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Quadrilateral Space Syndrome

A Patient’s Guide to Quadrilateral Space Syndrome

Introduction

Quadrilateral space syndrome (QSS) happens when the axillary nerve is compressed, or injured in the back of the shoulder. Sometimes the symptoms are caused by the compression of an artery in the same area.

Quadrilateral space syndrome usually happens from overuse, especially with overhead sports like throwing and swimming. The syndrome can also be caused by an injury, like a shoulder dislocation.

This guide will help you understand

what parts of the shoulder are involved
what causes this condition
how doctors diagnose the condition
what treatment options are available

Anatomy

What parts of the shoulder are involved?

A quadrilateral is a four-sided shape. The quadrilateral space of the shoulder is in the upper back, where the shoulder meets the body. Three of the sides of the quadrilateral space are formed by muscles. The top of the quadrilateral is bordered by a muscle called the teres minor. The teres major muscle forms the bottom border. Part of the triceps muscle forms the inside border. The long bone of the upper arm, called the humerus, makes up the outer border.

In addition to these muscles, the axillary nerve and the posterior circumflex humeral artery are in the quadrilateral space. When either the nerve or the artery is compressed or injured in this area it can cause problems such as quadrilateral space syndrome.

The axillary nerve is considered a peripheral nerve. There are several peripheral nerves in the shoulder that can be injured. The spinal cord in the neck, or cervical area, has branches that are called nerve roots. The nerve roots in the neck come together to form a large peripheral nerve called the brachial plexus. The axillary nerve is one of the branches off the brachial plexus. The axillary nerve is mainly formed from the fifth (C5) and sixth (C6) cervical nerve roots. The axillary nerve gives strength to the teres minor muscle and the deltoid muscle. It gives sensation to the shoulder joint.

The shoulder joint is also known as the glenohumeral joint. It is a ball and socket joint. The glenoid is the cup portion of the shoulder joint. The upper end of the humerus forms the ball portion.

The shoulder joint is supported by many muscles. The most famous are the four rotator cuff muscles.They combine at the shoulder to form a thick cuff. They are also referred to as the SITS muscles. Each letter stands for one

of the rotator cuff muscles; supraspinatus, infraspinatus, teres minor, and subscapularis. Sometimes injury to the quadrilateral space is mistaken as rotator cuff injury.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

What causes this condition?

Repetitive stress or overuse is a major cause of quadrilateral space syndrome. Some of the more common causes of overuse are seen in overhead sports like throwing and swimming. Children specializing in certain sports at early ages, have increased risk of getting quadrilateral space syndrome. Sometimes poor training techniques are to blame. Bands of extra fibers are usually what cause the compression of the axillary nerve, or the small artery in the quadrilateral space.

There are varying degrees of nerve injury. Most commonly, injury to the axillary nerve is a more mild form of injury called neuropraxia. This means that it typically recovers fully. The axillary nerve is very short, so even a severe injury can heal rather quickly.

An acute axillary nerve injury can also happen from carrying a heavy backpack. The misuse of crutches can also cause compression of the nerve.

The most common traumatic injury that causes quadrilateral space syndrome (QSS) is a shoulder dislocation. Some reports show that quadrilateral space syndrome can happen 10 to 60 percent of the time after a shoulder dislocation. There is a greater risk depending on the type of dislocation.

A blunt force injury to the back of the shoulder can also cause quadrilateral space syndrome.

Symptoms

What does quadrilateral space syndrome feel like?

Symptoms of quadrilateral space syndrome usually include vague shoulder pain, numbness or tingling in the arm, and tenderness to pressure over the area of the quadrilateral space. A dull ache in the shoulder may worsen when the arm is moved overhead repeatedly.

Weakness and instability can sometimes be noted. The diagnosis of quadrilateral space syndrome is often missed since symptoms can be similar to other shoulder problems.

Diagnosis

How will my doctor diagnose this condition?

Your doctor will complete a history and physical examination.

Your doctor will ask questions about activity, possible traumatic injury, and the symptoms you are having. The physical examination usually includes evaluating range of motion, strength testing, checking reflexes and sensation. During this examination pressure will be applied over various areas of the shoulder to see where it may be painful.

Weakness and instability can sometimes be noted. The diagnosis of quadrilateral space syndrome is often missed since symptoms can be similar to other shoulder problems. Often there will be wasting of the teres minor muscle, and sometimes the deltoid muscle. Subluxation (instability) of the glenohumeral joint is sometimes noted as well.

Your doctor may want you to have some special tests done in order to better evaluate what is causing your problems.

Electromyelogram (EMG) is a valuable tool in the diagnosis of quadrilateral space syndrome (QSS) and other peripheral injuries around the shoulder. The doctor will place small needle electrodes into various muscles to see how well they are functioning. Since different nerves make different muscles work, it help to narrow down where the problem is coming from.

Magnetic resonance imaging (MRI) scans can sometimes identify the muscle wasting of the teres minor and deltoid muscles. MRI does not use x-rays. It uses magnetic waves. It allows the doctor to see your tissues and bones in thin slices.

Computed tomography angiography (CTA) is sometimes used to identify problems with the artery or vein within the quadrilateral space. Computed tomography uses special X-rays. The CTA requires that contrast dye be injected into a vein. Your arm will likely be in a throwing position while being scanned. Computed tomography also allows your doctor to see your bones and tissues in thin slices.

Some doctors do an axillary nerve block. The area of the axillary nerve is injected with a numbing medication like lidocaine. If the pain goes away when the nerve is numb, it is considered a postitive test. This helps the doctor determine whether or not it is the axillary nerve causing your symptoms.

Treatment

What treatment options are available?

Nonsurgical Treatment

Most of the time, quadrilateral space syndrome will improve with nonsurgical treatment.

There are varying degrees of nerve injury. Most commonly, injury to the axillary nerve is a more mild form of an injury called neuropraxia. This means that it typically recovers fully. The axillary nerve is very short, so even a severe injury can heal rather quickly.

It is important to rest your shoulder. Your doctor may suggest taking a break from the activity that may be causing your symptoms. Changing throwing or sport mechanics may be helpful.

Anti-inflammatories (NSAIDs) such as ibuprofen or naprosyn may be suggested. Heat or cold packs to your shoulder may be beneficial.

Your doctor will likely prescribe physical therapy.

Surgery

If there is no improvement after six weeks of conservative care, surgery is usually recommended.

Bands of extra fibers in the quadrilateral space are usually what cause the compression of the axillary nerve or the small artery or vein. These bands of fibers are clipped or removed during surgery. This type of surgery is called decompression. It is quite effective.

Occasionally, after high-energy trauma, or during surgery, the axillary nerve will be over-stretched, or even cut. This type of injury is called neurotomesis. The axillary nerve may need to be repaired. The injured portion is replaced with another nerve. This is called a nerve graft.

Your surgeon will operate from the back of the shoulder, making a small incision. In the case of nerve grafting, there will be a small incision where the other portion of nerve is removed. You will be allowed to go home the same day. Your arm will likely be in a sling.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Physical therapy is helpful for maintaining shoulder range of motion, or flexibility. Posture training may also be helpful. Your physical therapist or trainer may have you change the way you do your overhead sport when overuse is a problem. Electrical muscle stimulation (EMS) may be beneficial when there is muscle weakness or wasting. EMS is a battery operated device that sends electrical current to your muscles to make them contract. This will help maintain strength and decrease wasting of the muscle. There are units that can be used at home.

After about four weeks, you may be able to do more exercise on your own. Usually by six weeks, exercises specific to your sport are introduced. In most cases, you can expect to be pain free, have full range of motion, and be able to resume activity in 12 weeks.

Return to sports varies. Your doctor may want to have the EMG repeated monthly to see if the axillary nerve is improving. Improvement in the EMG should be seen. Near full recovery of deltoid muscle strength is recommended before return to your sport.
Most of the time, conservative care such as physical therapy is all that is needed. Return to activity is the goal of treatment. Rarely is surgery needed.

After Surgery

Most shoulder rehabilitation includes three phases.

Phase I is to limit pain, and allow range of motion at the shoulder. Gentle motion is started to keep scar tissue from forming again. This also keeps the nerve and blood vessels moving freely. During the first four weeks after surgery, it is important not to overuse your arm. Working on posture may also be a part of your therapy.

Phase II includes gentle strengthening of the shoulder and upper extremity. Total body conditioning is also important. This often means riding a bike, walking on a treadmill, and even strengthening of the core muscles in your trunk.

Phase III is usually started six weeks after surgery. This includes sport specific activities, functional activities, and continued conditioning. Your physical therapist or trainer may have you change the way you do your overhead sport when overuse has been the problem.

Your doctor may want to have the EMG repeated at monthly intervals to see if the axillary nerve is improving, especially after surgery to graft the nerve. By twelve weeks, you should be pain free. You should have full range of motion of the shoulder. Return to sports varies. However, in general, it is recommended there be improvement in the EMG, and that the muscle strength of the operated shoulder is at least 80 percent of the muscle strength of nonoperated shoulder.

Adult Degenerative Scoliosis

A Patient’s Guide to Adult Degenerative Scoliosis

Introduction

A normal healthy spine will be straight when seen from the front or the back. When seen from the side, the normal spine forms a gentle “S” curve, which is known as adult degenerative scoliosis.

Scoliosis is an abnormal or exaggerated curve of the spine from the side or from the front or back. Adult degenerative scoliosis is different from the type of scoliosis that occurs in teenagers. Adult degenerative scoliosis occurs after the spine has stopped growing and results from wear and tear of the spine. The condition most often affects the lumbar spine.

This guide will help you understand

what parts make up the spine
what causes adult degenerative scoliosis
how your doctor will diagnose this condition
what treatment options are available

Anatomy

What parts make up the spine?

The spine is made up of 24 moveable bone segments called vertebrae. The spine is divided into three distinct portions. There are seven cervical or neck vertebrae, 12 thoracic or mid-back vertebrae and five lumbar or low back vertebrae.

The spine is made up of three general parts. The top portion is the cervical spine and connects with the skull or cranium. The middle portion is the thoracic spine and is identified by the ribs that attach to each of the vertebrae. The lower portion is the lumbar spine. It connects with the pelvis at the sacrum.

The vertebra stack on top of one another and are separated by discs. The spine has normal curves. When looking at the spine from the side, the spinal column is not straight up and down, but forms an “S” curve. The cervical spine has an inward curve called a lordosis. The thoracic spine curves outward. This curve is called a kyphosis. The lumbar spine usually has an inward curve or a lordosis. The “S” curve seen in the side view allows for shock-absorption and acts as a spring when the spine is loaded with weight. This “S” curve maintains balance of the spine in a forward and backward plane.

The spinal cord travels within a canal made by the vertebra. Branching off of the spinal cord are nerve roots. These nerves then supply arm, trunk, and leg muscles for movement. They also supply muscles of organs such as the bladder.

Discs are fluid-filled cushions between the vertebrae. Facet joints are small joints in the back that allow movement. Facet joints are lined with cartilage. The cartilage is a covering of the joint surface that gives some cushion and protects the bone. It is also slippery which helps with motion.

Causes

What causes adult degenerative scoliosis?

Adult degenerative scoliosis can be a result of scoliosis from childhood. The curvature may increase during adulthood and become painful. Scoliosis that happens in childhood is usually idiopathic, meaning there is no known reason for it.

Any part of the spine can be affected by scoliosis including the cervical, thoracic, or lumbar vertebrae. Most often the lumbar spine is affected. The vertebrae curve to one side and may rotate, which makes the waist, hips, or shoulders appear uneven.

The most common cause of adult degenerative scoliosis is from degeneration, known as wear and tear. It usually occurs after the age of 40. In older women, it is often related to osteoporosis. Osteoporosis is the loss of calcium in the supporting bone. This makes the vertebrae weak.

In adult degenerative scoliosis, the spine loses its structural stability and becomes unbalanced. This imbalance of the spine causes changes in the way the forces of the spine are directed. The larger the scoliotic curve becomes, the faster these changes cause degeneration of the spine. This creates a vicious cycle where increasing deformity causes more imbalance, that in turn causes more deformity. While this process occurs very slowly, it usually continues to slowly progress until something is done to restore the balance in the spine.

When there is an “S” curve when viewing the spine from the front, the condition is called scoliosis. The scoliotic deformity may also affect the normal “S” curve that the spine has when vised from the side. These curves are normal and required to maintain the proper balance of the spine. Many patients with scoliosis actually lose the normal curves of the spine.

Our body has a natural tendency to try to maintain a balance where the head is straight above the middle of the pelvis. If one leg is longer that the other, and the pelvis tilts, the spine will curve in the opposite direction to place the head above the center of the pelvis. If there is a curve in a portion of the spine, then the remainder of the spine will bend in the opposite direction to try and keep the head above the middle of the pelvis.

The scoliotic curve has a convex and concave side. The convex side is simply the outside of the curve where concave is the inside of the curve. The spine above and below the curve will tend to bend in the opposite direction in an attempt to balance the spine. Remember, the body will always try to place the head immediately above the middle of the pelvis. The concave side will tend to have more compression of the facet joints and possibly the nerve roots. This can lead to more pain from arthritis on the concave side of the curve and may lead to pain, weakness and numbness into the legs from the compressed nerve roots. These nerve changes are called radiculopathy.

In adult degenerative scoliosis, there is gradual narrowing of the discs that cushion between the vertebrae. The cartilage and joint surfaces of the facet joints in the spine can wear out, causing arthritis. This can cause back pain.

Stenosis is a term meaning narrowing. There are times when the canal for the spinal cord is narrowed. The openings for the nerve roots may also be narrowed. This will usually cause compression of the nerve structures. When the spinal cord or spinal nerves are compressed, pain, changes in feeling and/or motor function of the muscles can happen.

Sometimes spondylolisthesis occurs. This is slippage of one vertebra on the other. This can happen in adult degenerative scoliosis when the vertebrae do not stack on top of one another like they are supposed to. One vertebra may be shifted sideways, not lining up as it should. The slippage is graded from I to IV, one being mild, IV often causing neurological symptoms.

In rare and severe cases, the chest may become deformed because of scoliosis. This may affect the lungs and heart. This can lead to breathing problems, fatigue, and even heart failure.

Degenerative scoliosis is more common the older we get. As our population ages, adult scoliosis will be even more common. It will be an increasing source of deformity, pain, and disability.

Related Document: A Patient’s Guide to Scoliosis

Symptoms

What does adult degenerative scoliosis feel like?

Most people who have scoliosis will notice the deformity it can cause. There is usually a hump (rib hump) in the back. One shoulder and/or side of the pelvis may be lower than the other. You may have noticed that you have shrunk in height. You may not be able to stand up straight. For many, there is no significant pain caused by the scoliosis. Other symptoms may include:

Decreased range of motion or stiffness in the back
Pain involving the spine
Stiffness and pain after prolonged sitting or standing
Pain when lifting and carrying
Pain may travel to areas away from the spine itself. It may cause pain in the buttocks or legs
Spasm of the nearby muscles
Difficulty walking
Difficulty breathing

Diagnosis

How will my doctor know if I have adult degenerative scoliosis?

Your doctor will ask you several questions about your pain, function, what makes your pain better and worse, when it started, bowel or bladder function, motor function, and whether you have had previous surgery.

Your doctor will perform a physical examination that will include observation of your posture in standing position both sideways and from the front and back to assess for scoliosis. Mobility of your spine and hips, as well as walking ability will be evaluated.

A neurological exam that includes testing reflexes with a small rubber hammer, and testing of sensation will likely be included.

Your doctor will want to start with x-rays to measure the degree of the scoliosis. X-rays provide pictures of the alignment of the vertebra. Using a device to measure angles held up to the x-ray image, the degree of curvature of the spine can be measured. These measurements are referred to as the Cobb angles. Diagnosis of scoliosis is made when a curve measures greater than 10 degrees. X-rays can also give your doctor information about how much degeneration has occurred in the spine. They show the amount of space between the vertebrae. They can also show the degree of fusion of the spine following surgery.

If you are having pain into your leg(s), or difficulty with bowel or bladder function, your doctor will likely order a magnetic resonance imaging (MRI) scan. The MRI scan provides a better image of the soft tissues such as discs, nerves, and the spinal cord. The MRI machine uses magnetic waves rather than x-rays to show the soft tissues of the spine. The pictures show slices of the area imaged. The test does not require a needle or dye.

A computed tomography (CT) scan may be ordered. It is best for evaluating problems with the vertebral bones. It is a form of x-ray. Sometimes, it may require dye into the spinal canal fluid so that the spinal cord and nerve root anatomy is identified better. When dye is injected for this purpose, the technique is called a myelogram.

SPECT stands for Single Photon Emission Computed Tomography. It is a nuclear scan because it uses a radioactive tracer, Technetium. Technetium is injected into your vein. Where there is increase in metabolic activity, such as in the case with inflammation (arthritis), fracture, infection, or tumor the Technetium will be more concentrated.

Electromyogram (EMG) and/or or nerve conduction velocity (NCV) tests are performed by the placement of small needles in extremities where there is concern about change in motor function, or sensation. By using low-level electrical current, the device measures whether or not a motor nerve is being compressed. It can also help determine the source of changes in sensation. The EMG tests the muscles to see whether they are working properly. If they aren’t, it may be because the nerve is not working well. The NCV test measures the speed of the impulses traveling along the nerve. Impulses are slowed when the nerve is compressed or constricted.

Treatment

What treatment options are available?

Most of the time treatment of adult degenerative scoliosis is conservative care, meaning non-surgical. Rarely is surgery necessary. Treatment decisions for adult degenerative scoliosis are based on how much pain you are experiencing, how much the condition is affecting your ability to function and whether or not you are having symptoms of nerve compression.

Nonsurgical Treatment

Whenever possible, doctors prefer treatment other than surgery. The first goal of nonsurgical treatment is to ease pain and other symptoms so the patient can resume and maintain normal activities as soon as possible.

Your doctor may prescribe treatment from a physical therapist. Much of the pain from adult degenerative scoliosis is the result of muscle spasm. This spams occurs when the normal muscles must work harder than normal try to restore the balance to the spine. The muscles become fatigued and begin to spasm. This causes pain.

The physical therapist can help you with positions and exercises to ease these symptoms. The therapist can design an exercise program to improve flexibility of tight muscles, to strengthen the back and abdominal muscles, and to help you move safely and with less pain.

You may also be prescribed medication to help you gain better control of your symptoms so you can resume normal activity swiftly. Over-the-counter anti-inflammatory medications such as Ibuprofen or Aleve may be helpful. There are also many prescription anti-inflammatories available. Narcotic medication may be considered to make you more comfortable.

Bracing may provide some help especially when the scoliosis is painful or unstable. Braces that are made to fit may be more comfortable and effective but they are more expensive than off-the-shelf braces or supports. There are also unloading braces to help relieve pressure on the discs, nerves and joints of the spine.

If symptoms continue to limit your ability to function normally, your doctor may suggest an injection into the spine to help with pain. Your doctor may recommend facet injections into the joints of the spine. A procedure called radiofrequency ablation may provide more lasting benefit. Epidural or transforaminal injections into the spine can also be helpful. A series of injections may be more helpful to provide temporary decrease in pain.

If you have osteoporosis, discuss with your doctor how you can optimize your treatment for this condition to slow the progression of osteoporosis. Adequately treating the osteoporosis can help reduce the progression of the scoliosis.

Surgery

Surgery is usually considered when non-surgical treatments have not provided enough relief from pain – or when the nerves of the spine are being damaged. Surgery is more common when the curvature is continuing to increase and the imbalance of the spine is clearly getting worse. Surgery to correct adult degenerative scoliosis is both complex and difficult. Most surgeons would not suggest surgical intervention except as a last resort when all conservative measures have failed and the pain is intolerable.

Adult degenerative scoliosis is a disease of older people. As a result, the overall health of the individual is important when making decisions about whether or not to consider surgery. Other illnesses, such as heart disease, lung disease or diabetes, may increase the risk of medical complications either during or after the operation and make surgery too risky.

Surgeons must consider the quality of the bone of the spine as well. Older individuals are more likely to have some degree of osteoporosis. This makes the bone weaker. Weaker bone may not be able to hold the instrumentation, the rods and screws necessary to correct the spine. If the bone weakened by osteoporosis cannot hold the screws necessary to hold the spine aligned as it fuses, this can lead to failure of the entire operation.

The goal of surgery is to improve the balance of the spine and remove pressure on any of the nerves of the spine. Surgery to relieve pressure on the nerves is called a decompression. Surgery to reinforce the area that is unstable is called a fusion. To accomplish the goals of the surgery requires several steps.

First, the surgeon must be able to adequately see the area of spine to be corrected. This is called the exposure. The surgery usually requires an incision in the back. In some cases, surgery will also need to be performed on the front of the spine. This may require an incision in the abdomen or from the side of the body to allow the surgeon to reach the front of the spine. Sometimes a combination of both is necessary.

Next, the surgeon must perform a decompression so that all nerves are free of any pressure. This is accomplished by removing any bone spurs or disc material that is causing pressure on the spinal nerves.

The surgeon must then mobilize the spine. Usually after the decompression is finished, the spine is mobilized a great deal. Removing bone spurs and disc material also loosens the contracted scar tissue around the spine and allows the surgeon to straighten the spine back toward normal.

Finally, the surgeon must insert the screws and rods that will hold the spine in the new position while the fusion occurs. Two special screws called pedicle screws are inserted into each vertebra. These special screws are then attached to metal rods that hold the vertebrae in alignment.

Bone graft is placed between each vertebra. This bone graft will form a solid bone bridge between each vertebra and allow the spine to grow together – or fuse. The combination of the pedicle screws and the metal rods is called the instrumentation. This instrumentation forms the strut that will hold the spine in the correct alignment until the spine fuses.

Once the spine has fused, it will remain in the balanced position. The instrumentation is no longer really necessary, as the fused bone of the spine is now what is keeping the spine from collapsing again. The instrumentation is rarely removed and only removed when it is causing a problem. Restoring balance to the spine should decrease pain and reduce the risk of future problems.

Rehabilitation

What can I expect during recovery and treatment?

Nonsurgical Rehabilitation

Physical therapy is important for strengthening muscles of the spine, abdomen, hip girdle, and legs. Stretching of certain muscles may also be recommended. Stretching or traction applied to the sides of the curve is sometimes used by physical therapists and chiropractors. Exercises must be done on a regular, ongoing basis. It may be possible to improve posture and motion.

Your physical therapist may be instructed by your physician to place a battery operated electrical device (TENS unit) over the area of pain. This reduces painful input to the brain from your back.

Traction devices may be tried by your physical therapist or chiropractor. These are often available for home use.

Muscle stimulators are battery-powered electrical devices that cause muscle contraction. The electrodes or patches are placed over a muscle such as along the spine. There are wires that then attach the electrodes to the device. The current is given for a limited period of time, controlled by a timer. This can help train the muscles to contract on their own.

Activity modification such as limited lifting or avoidance of prolonged sitting or standing may be helpful. Occasional use of a cane or walker to improve walking tolerance may be recommended.

Use of ice or heat may prove beneficial. Your doctor or physical therapist can provide you with guidelines.

Your physical therapist may advise you to participate in weight bearing exercises to help strengthen your bones and muscles. These may include activities such as walking, toning with the use of weights or other resistance, and tai chi.

After Surgery

If surgery was necessary for your adult scoliosis you will likely be hospitalized for several days following surgery. Some patients prefer to extend their stay in a transitional care unit in the hospital, or even a skilled nursing facility (nursing home).

Your surgeon may suggest a brace following surgery, to ensure that you do not bend too far and to support your spine.

You will be allowed to get in and out of bed and walk shortly after surgery. Lifting is usually limited during the initial recovery period. You will gradually be allowed to resume your usual activities after several weeks or months.

It may be recommended that you have physical and occupational therapy after your surgery to help you regain strength and independence with daily activity. They also will help you with activity modification. They can recommend equipment for use in your home that may be helpful.

Your surgeon will want to see you periodically to monitor your progress. Repeat imaging with X-ray, MRI or CT scan is usually done to follow the progress of your spine as it heals.

Triangular Fibrocartilage Complex (TFCC) Injuries

A Patient’s Guide to Triangular Fibrocartilage Complex (TFCC) Injuries

Introduction

Triangular fibrocartilage complex (TFCC) injuries of the wrist affect the ulnar (little finger) side of the wrist. Mild injuries of the TFCC may be referred to as a wrist sprain. As the name suggests, the soft tissues of the wrist are complex. They work together to stabilize the very mobile wrist joint. Disruption of this area through injury or degeneration can cause more than just a wrist sprain. A TFCC injury can be a very disabling wrist condition.

This guide will help you understand

what parts if the wrist are involved
how these injuries occur
how doctors diagnose the condition
what treatment options are available

Anatomy

What parts of the wrist are involved?

The wrist is actually a collection of many bones and joints. It is probably the most complex of all the joints in the body. There are 15 bones that form connections from the end of the forearm to the hand.

The wrist itself contains eight small bones, called carpal bones. These bones are grouped in two rows across the wrist. The proximal row is where the wrist creases when you bend it. The second row of carpal bones, called the distal row, meets the proximal row a little further toward the fingers.

The proximal row of carpal bones connects the two bones of the forearm, the radius and the ulna, to the bones of the hand. On the ulnar side of the wrist, the end of the ulna bone of the forearm moves with two carpal bones, the lunate and the triquetrum.

The triangular fibrocartilage complex (TFCC) suspends the ends of the radius and ulna bones over the wrist. It is triangular in shape and made up of several ligaments and cartilage. The TFCC makes it possible for the wrist to move in six different directions (bending, straightening, twisting, side-to-side).

The entire triangular fibrocartilage complex (TFCC) sits between the ulna and two carpal bones (the lunate and the triquetrum). The TFCC inserts into the lunate and triquetrum via the ulnolunate and ulnotriquetral ligaments. It stabilizes the distal radioulnar joint while improving the range of motion and gliding action within the wrist.

There is a small cartilage pad called the articular disc in the center of the complex that cushions this part of the wrist joint. Other parts of the complex include the dorsal radioulnar ligament, the volar radioulnar ligament, the meniscus homologue (ulnocarpal meniscus), the ulnar collateral ligament, the subsheath of the extensor carpi ulnaris, and the ulnolunate and ulnotriquetral ligaments.

Injury to the triangular fibrocartilage complex involves tears of the fibrocartilage articular disc and meniscal homologue. The homologue refers to the piece of tissue that connects the disc to the triquetrum bone in the wrist. The homologue acts like a sling or leash between these two structures.

Another important structure to understand with TFCC injuries is the ulnar fovea. The fovea is a groove that separates the ulnar styloid from the ulnar head. The groove is at the junction of the ulnar bone and wrist. The styloid is a small bump on the edge of the wrist (on the side away from the thumb) where the ulna meets the wrist joint. Later we will talk about the fovea test to diagnose TFCC injuries.

Related Document: A Patient’s Guide to Wrist Anatomy

Causes

What causes this problem?

The triangular fibrocartilage complex stabilizes the wrist at the distal radioulnar joint. It also acts as a focal point for force transmitted across the wrist to the ulnar side. Traumatic injury or a fall onto an outstretched hand is the most common mechanism of injury. The hand is usually in a pronated or palm down position. Tearing or rupture of the TFCC occurs when there is enough force through the ulnar side of the hyperextended wrist to overcome the tensile strength of this structure.

High-demand athletes such as tennis players or gymnasts (including children and teens) are at greatest risk for TFCC injuries. TFCC injuries in children and adolescents occur more often after an ulnar styloid fracture that doesn’t heal.

Power drill injuries can also cause triangular fibrocartilage complex rupture when the drill binds and the wrist rotates instead of the drill bit. Triangular fibrocartilage complex
(TFCC) tears can also occur with degenerative changes. Repetitive pronation (palm down position) and gripping with load or force through the wrist are risk factors for tissue degeneration. Degenerative changes in the TFCC structure also increase in frequency and severity as we get older. Thinning soft tissue structures can result in a TFCC tear with minor force or minimal trauma.

There may be some anatomical risk factors. Studies show that patients with a torn TFCC often have ulnar variance and a greater forward curve in the ulnar bone. Ulnar variance means the ulna is longer than the radius because of congenital (present at birth) shortening of the radius bone in the forearm.

Symptoms

What does the condition feel like?

Wrist pain along the ulnar side is the main symptom. Some patients report diffuse pain. This means the pain is throughout the entire wrist area. It can’t be pinpointed to one area. The pain is made worse by any activity or position that requires forearm rotation and movement in the ulnar direction. This includes simple activities like turning a doorknob or key in the door, using a can opener, or lifting a heavy pan or gallon of milk with one hand.

Other symptoms include swelling; clicking, snapping, or crackling called crepitus; and weakness. Some patients report a feeling of instability, like the wrist is going to give out on them. You may feel as if something is catching inside the joint. There is usually tenderness along the ulnar side of the wrist.

If a fracture at the distal end of the ulna bone (at the wrist) is present along with soft tissue instability, then forearm rotation may be limited. The direction of limitation (palm up or palm down) depends on which direction the ulna dislocates.

Diagnosis

How do doctors diagnose the problem?

Your physician relies on the history (how, when, and what happened), symptoms, and physical examination to make the diagnosis. Tests of joint stability can be conducted. Special tests such as stress testing of the wrist radioulnar and ulnocarpal joints help define specific areas of injury.

An accurate diagnosis and grading of the injury (degree of severity) is important. Usually, the grade is based on how much disruption of the ligament has occurred (minimal, partial, or complete tear). There are two basic grades of triangular fibrocartilage complex injuries. Class 1 is for traumatic injuries. Class 2 is used to label or describe degenerative conditions.

Other tests may be done to provoke the symptoms and test for excess movement. These include hypersupination (overly rotating the forearm in a palm-up position) and loading the wrist in a position of ulnar deviation (moving hand away from the thumb) and wrist extension.

A new test called the fovea sign applies external pressure to the area of the fovea. The examiner compares the involved wrist with the wrist on the other side. Tenderness and pain during this test is a sign that there is a split-tear injury (down the middle length-wise).

Split tears are more common with lower energy, repetitive torque injuries such as from bowling or golf. This type of ligament injury was first discovered when a surgeon pushed on the area of pain while using an arthroscope to look inside the joint. The surgeon saw the ligament open up like a book.

X-rays may show disruption of the triangular fibrocartilage complex when there is a bone fracture present. Ligamentous instability without bone fracture appears normal on standard X-rays. X-rays with a dye injected is called a wrist arthrography. Arthrography is positive for a TFCC tear if the dye leaks into any of the joints. There are three specific joint areas tested, so this test is called a triple injection wrist arthrogram.

Acute injuries can be painfully swollen preventing proper examination. In such cases, more advanced imaging such as MRI (with or without a contrast dye) can be used to detect ligamentous or other soft tissue damage. When MRI is done with a dye injected into the area, the testing procedure is still called arthrography. The test itself is an MRI arthrogram. If the dye moves from one joint compartment to another, a tear of the soft tissues is suspected. But studies show that almost half the patients with a true triangular fibrocartilage complex tear have normal arthrograms.

Wrist arthroscopy is really the best way to accurately assess the severity of damage. At the same time, the surgeon looks for other associated injuries of ligaments and cartilage. The surgeon performs the test by inserting a long thin needle into the joint. A tiny TV camera on the end of the instrument allows the surgeon to look directly at the ligaments.

Using a probe, the surgeon tests the integrity of the soft tissues. A special trampoline test can be done to see if the fibrocartilage disk is okay. The surgeon presses the center of the disk with the probe. Good tension and an ability to bounce back show that the disk is attached normally and is not torn or damaged. If the probe sinks as if on a feather bed, the test is positive (indicates a tear). One advantage of an arthroscopic exam is that treatment can be done at the same time.

Treatment

What treatment options are available?

Nonsurgical Treatment

If the wrist is still stable, then conservative (nonoperative) care is advised. You may be given a temporary splint to wear for four to six weeks. The splint will immobilize (hold still) your wrist and allow scar tissue to help heal it. Anti-inflammatory drugs and physical therapy may be prescribed. You may benefit from one or two steroid injections spaced apart by several weeks.

If the wrist is unstable but you don’t want surgery, then the surgeon may put a cast on your wrist and forearm. It may be possible to use a splint for six weeks (instead of casting) and then start physical therapy. Your doctor will help you decide what would be best for your particular injury.

Surgery

Surgical treatment is based on the specific injury present. Instability as a result of complete ligamentous ruptures, especially with bone fracture, requires surgery as soon as possible.

The outside perimeter of the triangular fibrocartilage complex has a good blood supply. Tears in this area can be repaired. But there is no potential for healing when tears occur in the central area where there is no blood supply. Arthroscopic debridement (smoothing or shaving) of the damaged tissue is then required.

The surgeon debrides any tears of the disc or meniscal homologue that might catch against other joint surfaces. Then the surgeon looks for any problems with the foveal ligament. A probe is used to detect tension or laxity (looseness) of the ligaments. Laxity is a sign of injury.

Arthroscopic debridement works well for simple tears. Much of the damaged tissue can be removed while still keeping a stable wrist joint. The torn structures can be reattached with repair sutures. Some surgeons perform an arthroscopic wafer procedure in addition to the TFCC debridement especially when both TFCC disruption and positive ulnar variance are present. Further studies are needed to see if the combined procedure results in a more satisfactory outcome than current methods and to evaluate a rotational loss that can occur with this combined procedure.

Some ligamentous ruptures with fracture can also be repaired arthroscopically with reattachment and instrumentation. Instrumentation refers to the use of hardware such as wires and screws to help hold the repaired tissue in place until healing occurs.

Triangular Fibrocartilage Complex Injuries

Although they are few, there are some complex tears that require open repair. Open repair means the surgeon makes an incision and opens the tissues to perform the operation. This gives the surgeon a better view and better access of the area. The specific procedure depends on the tissues injured and the extent of the injury. For example, detachment of the radioulnar ligaments usually requires open repair. Instability of the distal radioulnar joint may require the use of wires to hold the area together until healing occurs.

In other cases, surgery has been delayed long enough that the torn ligament has retracted (pulled back) so far that direct repair can’t be done. In these cases, a tendon graft may be needed to help strengthen the repair.

Chronic and degenerative TFCC may require a different surgical approach. Debridement is not as successful with this group as it is with acute TFCC injuries. Sometimes it is necessary to shorten the ulnar bone at the wrist to obtain pain relief. There are two procedures used to shorten the ulna and unload the ulnocarpal joint. These are the ulnar (diaphyseal) shortening method and the distal ulnar head shortening osteotomy (Feldon wafer method). If lunate-triquetrum instability is present, ulnar shortening can be done to tighten the ulnocarpal ligaments and decrease the motion between the lunate and triquetrum.

When making the decision as to which procedure, the surgeon weighs the amount of shortening needed and the conformation of the distal radioulnar joint. (DRUJ) – which will affect the joint loading.

Diaphyseal Shortening method (using internal fixation – plate/screws) – higher complication rate (delayed union, nonunion, hardware removal).

Distal Ulnar head shortening osteotomy (ie, Feldon wafer method) arthroscopic or open method (only 2-3mm of shortening ) – less invasive and equal relief to diaphyseal shortening

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Many patients with a mild triangular fibrocartilage complex injury are able to return to work and/or return to sports at a preinjury level. Pain-free movement and full strength are possible.

Residual laxity may remain after nonoperative treatment of a TFCC injury. If conservative care is unsuccessful, persistent joint laxity and instability can lead to degeneration of the articular cartilage. Too much force or compression on either side of the joint can lead to pain and altered movement patterns. Surgery may be needed to restore normal wrist movement.

After Surgery

Your wrist will be immobilized in a bulky dressing or cast. The type of immobilizing device used and the position your wrist is placed in depends on the type of surgery you had. Motion exercises are usually started five to seven days after the operation.

Pain relief, improved motion, and increased function are the main goals of surgery for most patients. The surgeon is also interested in restoring wrist stability and the load bearing function of the wrist. After the initial soreness from the surgery is gone, you should experience a significant decrease in pain. Many patients report being pain free.

The follow-up plan after surgery may vary depending on the type of procedure used by your surgeon. Newer and improved methods have made it possible for some patients to return to full, unrestricted activity as early as six weeks post-op.

The standard result usually follows a typical course. One week after surgery, the splint will be replaced with a fiberglass type cast (still in a supinated position). The elbow is left free to move fully. The cast will be removed six weeks after the operation. Cast removal is followed by physical therapy for six to eight weeks.

Physical therapy may be needed to help you regain full joint motion, strength, and normal movement patterns. Some patients have difficulty regaining pinch and grip strength. The therapist will help you get back specific motions lost such as ulnar deviation (moving hand at the wrist away from the thumb and toward the little finger) and supination (palm up motion) or pronation (palm down motion). The therapist will help make sure you do not use compensatory shoulder motions to make up the difference.

The goal is to restore full motion, strength, and function. The rehab program will be geared toward your needs at home, work, and play. Many patients are able to return to work with no restrictions. A small number may require some work restrictions or changes in work tasks.

Complications may occur such as persistent pain and stiffness. Infection or delayed union or nonunion of bone fractures may be a problem. Further surgery may be needed to revise the first operation. Some patients need another surgery to remove any hardware used to stabilize the joint. The bottom of the ulna called the styloid may have to be removed. In rare cases, the procedure fails to provide the desired results. A wrist fusion may be the next step.

Shoulder Dislocations

A Patient’s Guide to Shoulder Dislocations

Introduction

A shoulder dislocation is a painful and disabling injury of the glenohumeral joint. Most dislocations are anterior (forward) but the shoulder can dislocate posteriorly (backwards). Inferior and posterolateral dislocations are possible but occur much less often. The specific type of dislocation is based on the position of the humeral head in relation to the glenoid (shoulder socket) at the time of the diagnosis.

This guide will help you understand

what parts of the shoulder are involved
how the problem develops
how doctors diagnose the condition
what treatment options are available

Anatomy

What parts of the body are involved?

The shoulder has unique and complex anatomy that allows range of motion and coordination needed for reaching, lifting, throwing, and many other movements. The bones of the shoulder are the humerus (the upper arm bone), the scapula (the shoulder blade), and the clavicle

(the collar bone).The roof of the shoulder is formed by a part of the scapula called the acromion.

There are actually four joints that make up the shoulder. The main shoulder joint, called the glenohumeral joint, is formed where the ball of the humerus fits into a shallow socket on the scapula. This shallow socket is called the glenoid. Understanding the remaining anatomical structures

discussed will help you understand why your shoulder dislocated.

The acromioclavicular (AC) joint is where the clavicle meets the acromion. The sternoclavicular (SC) joint supports the connection of the arms and shoulders to the main skeleton on the front of the chest. The scapulothoracic joint is formed where the shoulder blade glides against the thorax (the rib cage). This joint is important because it requires that the muscles surrounding the shoulder blade work together to keep the socket lined up during shoulder movements.

Ligaments, Joint Capsule, and Labrum

There are several important ligaments in the shoulder. Ligaments are soft tissue structures that connect bones to bones. A joint capsule is a watertight sac that surrounds a joint. In the shoulder, the joint capsule is formed by a group of ligaments that connect the humerus to the glenoid. These ligaments are the main source of stability for the shoulder. They help hold the shoulder in place and keep it from dislocating.

The labrum is a special cartilaginous structure inside the shoulder. It is attached almost completely around the edge of the glenoid. When viewed in cross section, the labrum is wedge-shaped. The shape and the way the labrum is attached create a deeper cup for the glenoid socket. This is important because the glenoid socket is so flat and shallow that the ball of the humerus does not fit tightly. The labrum creates a deeper cup for the ball of the humerus to fit into and helps prevent dislocation.

The labrum is also where the biceps tendon attaches to the glenoid. Tendons are much like ligaments, except that tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The biceps tendon runs from the biceps muscle, up the front of the upper arm, to the glenoid. At the very top of the glenoid, the biceps tendon attaches to the bone and actually becomes part of the labrum. This connection can be a source of problems when the biceps tendon is damaged and pulls away from its attachment to the glenoid.

The Rotator Cuff

The tendons of the rotator cuff are the next layer in the shoulder joint. Four rotator cuff tendons connect the deepest layer of muscles to the humerus. This group of muscles lies just outside the shoulder joint. These muscles help raise the arm from the side and rotate the shoulder in the many directions. They are involved in many day-to-day activities. The rotator cuff muscles and tendons also help keep the shoulder joint stable by holding the humeral head in the glenoid socket.

The large deltoid muscle is the outer layer of shoulder muscle. The deltoid is the largest, strongest muscle of the shoulder. The deltoid muscle takes over lifting the arm once the arm is away from the side.

Types of Shoulder Dislocations

Anterior Dislocation

With an anterior dislocation, the head of the humerus is driven forward from inside the glenoid cavity to a place under the coracoid process. This type of dislocation is sometimes referred to as a subcoracoid dislocation. The joint capsule is usually avulsed (torn away) from the margin of the glenoid cavity.

Anterior shoulder dislocation can also be the result of a detached labrum. When both the labrum and the capsule along the anterior margin of the glenoid cavity are avulsed, the injury is called a Bankart lesion. Compression fracture of the humeral head from the force of hitting the hard glenoid is called a Hill-Sach’s lesion. Three-fourths of the patients with a Bankart lesion will also have a Hill-Sach’s lesion.

Posterior and Inferior Dislocations

When the shoulder dislocates posteriorly, the head of the humerus moves backward behind the glenoid. An inferior dislocation describes the position of the humeral head down below the glenoid cavity. Posterior and inferior shoulder dislocations only account for about five to 10 per cent of all shoulder dislocations. Most shoulder dislocations are in the anterior direction.

Related Document: A Patient’s Guide to Shoulder Anatomy

Causes

What causes this problem?

The shoulder is a very mobile joint and more vulnerable to dislocation than other joints. The glenoid cavity is small in relation to the head of the humerus. Muscles, ligaments, and the bony anatomy of the shoulder all work together to maintain shoulder stability and prevent dislocation. Dislocation can occur when any of these structures are injured or altered in any way.

Tears or ruptures of the rotator cuff are the most common injuries that lead to shoulder dislocation. Fractures of the humerus and damage to any of the nerves (e.g., axillary, brachial plexus) supplying the rotator cuff can also result in shoulder dislocation. A fall on an outstretched hand or directly on the posterolateral aspect (back and side) of the shoulder can cause an anterior dislocation. Violent uncoordinated muscle contractions during a grand mal seizure can also cause shoulder dislocations.

Forceful motions that cause soft tissue structures to tear or rupture lead to dislocation. Forceful abduction, external rotation, and extension are the most common load resulting in shoulder dislocation. The joint capsule may be lifted off the bone and the head of the humerus gets lodged between the capsule and the bone.

Once the shoulder has been dislocated the first time, there is a high probability (90 per cent chance) of a second shoulder dislocation (recurrence). The force of the first dislocation dislodging the head of the humerus forward leaves a pocket formed by sagging soft tissues that the humeral head can slip back into. Some people with very lax ligaments can dislocate the shoulder and reduce it over and over. This is referred to as habitual dislocation and should be discouraged.

The highest incidence of recurrence is in young people (under the age of 20 at the time of the injury). Sixty per cent of patients between 20 and 40 years will have a recurrence. Only 10 per cent of patients over 40 years will have another shoulder dislocation. Participation in contact sports activity increases the risk of reinjury. After a second dislocation, frequent recurrence of shoulder dislocation can occur with less and less force, load, or stress.

Symptoms

What does the condition feel like?

Most people with a shoulder dislocation experience sudden, severe pain in the shoulder after a fall, injury, or other traumatic event. It’s a natural response to hold and support the arm against the body with the other hand.

Pain and a feeling of extreme apprehension with any movement of the arm are common. This type of apprehension is present when instability remains after the shoulder has been reduced (manually put back in place). You may be constantly aware that if you move the arm in just the right way, it will pop out again.

With an inferior dislocation, it is difficult (and sometimes impossible) to bring the arm down to the side. This is because the head of the humerus is caught under the glenoid cavity.

Diagnosis

How do doctors diagnose the problem?

The history and physical examination are probably the most important tools the physician uses to diagnose a ruptured or deficient rotator cuff and/or bone fracture. Any of these injuries in the shoulder complex can lead to (and will be present along with) shoulder dislocation.

Your physician will visually inspect the shoulder. When there is a shoulder dislocation, the normal rounded contour of the shoulder and upper arm is lost. Instead, the outside edge of the shoulder looks flat or square. There are changes in the appearance of the surface anatomy. For example, instead of the greater tuberosity (bony bump along top of shoulder), there is a gap under the acromion. The head of the humerus may be observed and felt as a large bump in front or behind the shoulder. The area is usually extremely tender to palpation.

Range of motion, strength, and sensation will be tested if possible. Any changes or loss of sensation may point to nerve damage. The physician will also check the pulses in your arm in order to detect the possibility of vascular complications.

There are many clinical tests that can be performed to identify which soft tissue structures have been damaged or ruptured. A positive apprehension test is very diagnostic of an unstable shoulder that might dislocate again after a first dislocation injury. The arm is abducted (moved away from the body) and externally (outwardly) rotated. Just before the joint is about to dislocate, the patient becomes extremely anxious. At that point, the test is considered positive for shoulder instability and therefore discontinued.

X-rays are an important diagnostic tool to show the displaced head of the humerus and any bone fractures. Several views may be needed to reveal the exact direction of the dislocation and fracture lines when present. Magnetic resonance imaging (MRI) is used to diagnose and define the extent of the lesion. MRIs are very accurate in detecting Hill-Sach’s lesions.

If surgery is being considered, then the surgeon may perform a diagnostic arthroscopic exam. A log, thin scope with a tiny fiber-optic TV camera on the end is inserted into the shoulder joint, allowing the orthopedic surgeon to look at the structures inside the joint directly.

Treatment

What treatment options are available?

Nonsurgical Treatment

In many cases, the shoulder can be reduced without surgery. This is called a closed reduction. Many health care professionals (especially those trained in emergency procedures) know how to manipulate the shoulder back into the socket. However, without the aid of a general anesthetic, this maneuver can be very painful.

One simple technique to reduce an anterior shoulder dislocation is done in the prone (face down) position. The injured arm is supported at the edge of the table. The arm is allowed to dangle over the edge of the table with a weight attached. As the shoulder muscles relax, the humeral head slips back to its normal position. This may take several minutes.

If passive positioning doesn’t work for an anterior dislocation, then a general anesthetic is administered and traction is applied to the upper limb. The arm is held in a position of shoulder abduction (away from the body) while lateral (sideways) and backward pressure is applied to the head of the humerus. Posterior shoulder dislocation can be treated in a similar fashion. Under anesthesia, the shoulder is rotated outwardly and forward pressure is applied on the dislocated humeral head.

Some patients who have recurrent dislocations know how to pop the joint back in place without help. When performed by someone else, the procedure is done quickly in order to prevent further pain or soft tissue damage. Functional outcome is better if the dislocation is reduced early.

Following closed reduction, X-rays are used to confirm correct placement of the humeral head in the glenoid cavity. After reduction, immobilization of the arm in a sling against the chest is usually recommended. Immobilization of the reduced shoulder is applied for several weeks up to a month. This approach will give the soft tissues a chance to heal. For older adults, passive exercises called Codman’s or pendulum exercises may be prescribed to prevent stiffness. These are usually done once or twice a day with the sling removed.

Recurrent dislocation is the most common complication after dislocation, especially in young people. Older adults are more likely to experience chronic pain and stiffness. When conservative care is unable to restore shoulder stability and normal function, then surgical intervention may be needed.

Surgery

If the shoulder can’t be reduced manually or if a sling and rehabilitation program does not control symptoms of instability, then surgery may be suggested. The main goal of surgery is to reduce and/or stabilize the shoulder. Restoring normal motion and function and preventing recurrent dislocations are important outcomes of surgical intervention.

Even when surgery is needed, your surgeon may have you see a physical therapist for several visits before the surgery. This is done to reduce swelling, strengthen the muscles, and stabilize the shoulder as much as possible before surgery. This practice also reduces the chances of scarring inside the joint and can speed recovery after surgery.

There are many different ways to repair a chronically unstable shoulder following a first dislocation or after many recurrent shoulder dislocations. The direction of instability (anterior, posterior, inferior, or some combination) is taken into consideration when choosing the best reconstructive technique. The site, type, and extent of damage are major determining factors in how the surgeon approaches the repair.

One of the most common procedures is the Bankart operation. During the Bankart reconstruction procedure, the labrum and capsule are reattached to the anterior margin of the glenoid cavity.

Shoulder reconstruction surgery may be done with an open incision method or with the aid of an arthroscope. Incisions are usually still required with arthroscopic technique, but the surgery doesn’t require the surgeon to open the joint. The arthroscope is used to view the inside of the shoulder joint as the surgeon performs the work.

Older adults who have a fracture and shoulder dislocation may need a shoulder replacement instead of shoulder reconstructive surgery to reduce the dislocation and repair the fracture.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Patients may receive physical therapy after having a dislocation. Therapists treat swelling and pain and help minimize tension on inflamed structures with the use of ice, supportive taping, electrical stimulation, and rest periods. Symptoms are addressed in the acute phase but restoring normal function rather than eliminating symptoms is the focus for chronic shoulder instability.

Exercises are used to help you regain normal movement of joints and muscles. Range-of-motion exercises should be started right away with the goal of helping you swiftly regain full movement in your shoulder. This includes the use of gentle stretching and motion through the full range available.

As your symptoms ease and strength improves, you will be guided in specialized exercises to improve posture, shoulder stability, and normal motor control. The desired final outcome is a return to full function. For athletes, this means full participation in sports activities.

In the later phase of rehab, the therapist will use a combination of kinetic chain exercises to decrease shear forces on the joint while enhancing strength. Plyometrics, a specific type of exercise to produce fast, powerful movements needed for sports performance will also be included.

You can return to your sporting activities when your muscles are back to nearly their full strength and control, you are not having swelling that comes and goes, and you aren’t having problems with the shoulder popping out of the joint.

After Surgery

Many shoulder reconstructive surgeries are now done on an outpatient basis. Patients go home the same day as the surgery. Some patients stay one or two nights in the hospital if necessary.

After any surgery to stabilize the shoulder your shoulder will be immobilized. You will probably wear a sling or hard brace for three to six weeks. A large abduction wedge under the armpit holds the arm in just the right position. The soft tissues must be given enough time to heal and form scar tissue to support and stabilize the shoulder joint.

Some studies are being done to investigate the use of early motion (within two to three days) after the operation. This accelerated rehab protocol has not been adopted routinely by all surgeons. Athletes may be most likely to try early rehab in order to return to sports participation as soon as possible. Functional recovery without immobilization has been proven possible. There is less postoperative pain with early motion.

Most doctors have their patients take part in formal physical therapy after shoulder reconstruction. You will probably be involved in a progressive functional rehabilitation program. The phases of rehabilitation include acute, early recovery, late recovery, and functional phase.

You should expect functional rehab to last four to six months after surgery. This will ensure the best result from your reconstruction. During the acute phase (one to three weeks), you may expect to see the physical therapist two to three times a week. The goal is to control pain and inflammation. The therapist will address any postural abnormalities and begin muscle re-education.

When you have minimal pain and adequate soft tissue healing, you’ll be advanced to the early recovery phase. This phase usually lasts from three to six weeks after the surgery. During this time, the therapist will work with you to increase motion, strength, and control.

When you have full, pain free motion and improved strength, then you’ll enter the late recovery phase. This phase extends from six to 12 weeks post-operatively. Improving strength, power, endurance, and dynamic kinetics (movement) is the main thrust of the late recovery phase.

The functional phase begins about three months after surgery. This phase is directed at the sports athlete. The therapist will put you through a series of drills designed to improve coordination, speed, and agility. In order to participate in this level of rehab, you must have normal range of motion, flexibility needed for your sport or activity, and 90 per cent of normal strength. You must also be free of symptoms during activities or sport-specific drills.

Ulnar Collateral Ligament Reconstruction (Tommy John Surgery)

A Patient’s Guide to Ulnar Collateral Ligament Reconstruction (Tommy John Surgery)

Introduction

The doctors call it a UCLR ulnar collateral ligament reconstruction. Baseball players and fans call it Tommy John surgery — named after the pitcher (Los Angeles Dodgers) who was the first to have the surgery in 1974. It is one of the major advancements in sports medicine in the last quarter century.

This guide will help you understand:

what your surgeon hopes to achieve
how do I prepare for this procedure
what happens during the procedure
what to expect as you recover

Anatomy

What’s the normal anatomy of the elbow?

The bones of the elbow are the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb).

There are several important ligaments in the elbow. Ligaments are soft tissue structures that connect bones to bones. The ligaments around a joint usually combine together to form a joint capsule. A joint capsule is a watertight sac that surrounds a joint and contains lubricating fluid called synovial fluid.

In the elbow, two of the most important ligaments are the ulnar collateral ligament (UCL) and the lateral collateral ligament. The UCL is also known as the medial collateral ligament. The ulnar collateral ligament is on the medial (the side of the elbow that’s next to the body) side of the elbow, and the lateral collateral is on the outside. The ulnar collateral ligament is a thick band of ligamentous tissue that forms a triangular shape along the medial elbow. It has an anterior bundle, posterior bundle, and a thinner, transverse ligament.

Together these two ligaments, the ulnar (or medial) collateral and the lateral collateral, connect the humerus to the ulna and keep it tightly in place as it slides through the groove at the end of the humerus. These ligaments are the main source of stability for the elbow. They can be torn when there is an injury or dislocation of the elbow. If they do not heal correctly the elbow can be too loose or unstable. The ulnar collateral ligament can also be damaged by overuse and repetitive stress, such as the throwing motion.

Rationale

What does my surgeon hope to achieve?

Surgical treatment is designed to restore medial stability of the elbow. Full return to previous activities is the main goal. This is especially true for those athletes who want to remain active and competitive in sports. Many throwing athletes who develop this condition have pain in the elbow during and after throwing activities. They may also develop numbness and tingling in the hand due to stretching of the ulnar nerve at the elbow. Successful treatment of the condition should improve or eliminate these symptoms.

Who can benefit from this procedure?

Throwing athletes (especially baseball pitchers) at the college and professional level are affected most often by this injury requiring surgery. Minor league athletes and younger sports participants may also develop this injury requiring surgical care. Anyone with this injury who has not benefited (gotten better) with conservative care is a candidate for surgery.

Preparation

How should I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the operation?

Reconstruction

If you are having problems that may be coming from inside the joint, such as arthritis and loose bodies, your surgeon may perform an arthroscopy before the actual reconstruction procedure is done. During this procedure, a small TV camera is inserted into the elbow joint through two or three small (1/4 inch) incisions. Using special instruments your surgeon will be able to evaluate the joint, remove any loose bodies and bone spurs that may be causing problems. Arthroscopy is not always necessary.

The reconstruction is performed through an incision on the medial (inside) side of the elbow joint. The damaged ulnar collateral ligament along the medial side of the elbow is replaced with a tendon harvested from somewhere else in the body. The tendon graft can come from the patient’s own forearm, hamstring, knee, or foot. This is called an autograft.

Over the years the way that surgeons perform this operation have improved. In the early days, the muscles on the inside of the elbow joint and forearm (the flexor muscles) were completely detached from the humerus and the ulnar nerve was re-routed from its normal position in the cubital tunnel on the back side of the elbow. This was done to be able to see the joint and protect the nerve. As surgeons have understood this problem more completely, these two parts of the operation have been eliminated. Now, the flexor muscles are not detached, but are split and retracted to allow the surgeon to see the areas of the elbow joint required to perform the operation successfully. The ulnar nerve is re-routed only if the patient was having symptoms of ulnar nerve damage before the operation. These improvements have resulted in a less invasive procedure with a decreased rate of complications.

One common technique used to replace the damaged ulnar collateral ligament is called the docking technique. The surgeon drills two holes in the ulna and three in the medial epicondyle (the small bump of bone on the inside of the elbow at the end of the humerus). The two holes in the ulna form a tunnel that the tendon graft will be looped through. The three holes in the medial epicondyle form a triangle. The bottom hole will be bigger than the top two holes, so that the surgeon can slide the end of the tendon graft into the bottom hole. The two top holes are used to pull the tendon graft into the tunnel using sutures that are attached to the graft and threaded through the two holes.

After the tendon is harvested, sutures are attached to both ends. The tendon is looped through the lower tunnel formed in the ulna, and stretched across the elbow joint. The two sutures attached to the ends of the graft are threaded into the larger bottom tunnel in the medial epicondyle and each is threaded out one of the upper, smaller holes.

Using these two sutures, the surgeon pulls the end of the graft farther into the upper tunnel until the amount of tension is correct to hold the joint in position. The surgeon carefully puts the elbow through its full arc of motion and readjusts the tension on the sutures until he is satisfied that the proper ligamentous tension is restored. The two sutures are tied together to hold the tendon graft in that position.

Another common technique to reconstruct the ulnar collateral ligament is the figure of eight technique. In this technique, the tendon graft is threaded through two pairs of holes – two drilled in the medial epicondye and two in the ulna. The graft is looped through the holes in a figure of eight fashion. The two ends of the tendon are sutured to the tendon itself.

If there is any concern that the ulnar nerve has been stretched and damaged due to the instability (as mentioned above), it may be re-routed so that it runs in front of the elbow joint rather than through the cubital tunnel in the back of the elbow. The incision is sutured together and the elbow is placed in a large bandage and splint.

There are several newer techniques being developed that hopefully will make the procedure even less invasive while retaining the success that the docking technique has enjoyed.

Complications

What might go wrong?

As with all surgical procedures, complications can occur. This topic doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications are

anesthesia complications
infection
nerve or blood vessel damage

Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Infection

Any operation carries a small risk of infection. You may be given antibiotics before the operation to reduce the risk of infection. If an infection occurs, you will most likely need more antibiotics to cure it.

Nerve or Blood Vessel Damage

Because the operation is performed so close to the nerves and vessels, it is possible to injure them during surgery. All of the nerves that travel down the arm pass across the elbow. The ulnar nerve is especially at risk for damage. Problems such as pain, numbness, and weakness in the arm and hand can be the consequences of nerve scarring, entrapment, or traction injury from the original trauma or from the procedure.

This condition is called a neuropathy. It may be temporary with gradual resolution of symptoms over a period of many months. If it doesn’t resolve on its own or with physical therapy, further surgery may be needed. In a small number of cases, this complication is permanent.

Studies show that up to half of the patients treated by ligament reconstruction are left with a loss of full motion. The main problem is a five to 10 degree loss of extension (the elbow doesn’t straighten all the way). This deformity does not affect strength or function. Earlier, more aggressive rehab may restore motion but at the risk of impaired healing of the graft.

Long-term complications can include chronic pain with throwing and chronic instability of the elbow.

After Surgery

What should I expect as I recover?

Repair or Reconstruction

The postoperative program is the same for repairs or reconstruction. At first your arm will be immobilized in a bulky dressing and a posterior splint for the first 10 days. It holds the elbow in a position of 90 degrees of flexion and neutral forearm rotation while leaving the wrist free to move. If non-absorbable sutures are used to close the incision, you may need these removed in 10 days.

You’ll have about a four-inch long incision along the inside of your elbow. There may be some discomfort after surgery. Your surgeon can give you pain medicine to control the discomfort. You should keep your elbow elevated above the level of your heart for several days to avoid swelling and throbbing. Keep your elbow propped up on a stack of pillows when sleeping or sitting.

Rehabilitation

What should I expect during my rehabilitation?

Gentle hand grip and shoulder and wrist mobilization exercises are allowed right away after surgery. Postoperative immobilization is discontinued in seven to 10 days at which time active range of motion for the elbow are started. Your surgeon may want you to wear a special hinged brace to protect the elbow.

Your therapist will instruct you in the active range of motion exercises to be done daily. Strengthening exercises for the entire upper quadrant (shoulder, arm, wrist, and hand) are included in the post-operative program. Specific strengthening exercises to help the athlete prepare for his or her particular sport begin around four months post-op. Up until this time, any stress to the medial elbow is avoided.

With careful adherence to the rehab program and completing the exercises daily, pitchers can get their full range of motion back in six to eight weeks. The program will progress to strength training with weight exercises. For the next four months, they can increase the weight they use and start doing exercises that emphasize all parts of their arm.

Flexibility, conditioning, coordination, and strengthening are part of the daily program. You may use ice after throwing sessions to help control inflammation. Plyometric exercises are used throughout the training period. An aerobic portion of the exercise program is also advised to help the athlete return to sports at the same level (or even higher level) as before the surgery. Good, overall physical condition is important to prevent injury as the athlete returns to sports activity.

At times in your rehab and recovery, you may find it necessary to move back to a previous level of training if symptoms of pain and swelling recur. Your therapist will guide you through the advancement (and regression) of your program. Additional training to restore normal joint proprioception (sense of joint position) and proper throwing mechanics is also provided.

Based on long-term studies of athletes over the years, the chances of a complete recovery after surgery are estimated at 85 to 90 percent. The process of rehabilitation to return to a level of playing equal to before the injury takes about a year for pitchers and about six months for position players.

The most often used criteria for resuming full (competitive) sports participation include 1) no pain with throwing, 2) full shoulder and elbow range of motion, 3) normal forearm strength, and 4) good throwing biomechanics.

The tendon graft is very weak immediately after the surgery. Transforming a tendon into a functioning ligament requires a very gradual rebuilding process. Athletes are encouraged to go slowly and not test the limits of the graft. The key to a successful UCLR (Tommy John) is to rehab for a long-term career, not to try for shortcuts during the first year of recovery.

Ulnar Collateral Ligament Injuries

A Patient’s Guide to Ulnar Collateral Ligament Injuries

Introduction

The ulnar collateral ligament (UCL) can become stretched, frayed or torn through the stress of repetitive throwing motions, causing ulnar collateral ligament injuries.

Professional pitchers have been the athletes treated most often for this problem. Javelin throwers and football, racquet sports, ice hockey, and water polo players have also been reported to injure the UCL. A fall on an outstretched arm can also lead to UCL rupture (often with elbow dislocation).

This guide will help you understand

how the problem develops
what causes this condition
how doctors diagnose the condition
what treatment options are available

Anatomy

What parts of the elbow are affected?

The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge. But there is a second joint where the end of the radius (the radial head) meets the humerus. This joint is complicated because the radius has to rotate so that you can turn your hand palm up and palm down (pronation/supination). At the same time, it has to slide against the end of the humerus as the elbow bends and straightens.

The joint is even more complex because the radius has to slide against the ulna as it rotates the wrist as well. As a result, the end of the radius at the elbow is shaped like a smooth knob with a cup at the end to fit on the end of the humerus. The edges are also smooth where it glides against the ulna.

There are several important ligaments in the elbow. Ligaments are soft tissue structures that connect bones to bones. The ligaments around a joint usually combine together to form a joint capsule. A joint capsule is a watertight sac that surrounds a joint and contains lubricating fluid called synovial fluid.

In the elbow, two of the most important ligaments are the ulnar collateral ligament (UCL) and the lateral collateral ligament. The UCL is also known as the medial collateral ligament. The ulnar collateral ligament is on the medial (the side of the elbow that’s next to the body) side of the elbow, and the lateral collateral is on the outside. The ulnar collateral ligament is a thick band of ligamentous tissue that forms a triangular shape along the medial elbow. It has an anterior bundle, posterior bundle, and a thinner, transverse ligament.

Causes

What causes ulnar collateral ligament (UCL) injuries?

The ulnar collateral ligament can become stretched, frayed or torn through the stress of repetitive throwing motions. If the force on the soft tissues is greater than the tensile strength of the structure, then tiny tears of the ligament can develop. Months (and even years) of throwing hard cause a process of microtears, degeneration, and finally, rupture of the ligament. The dominant arm is affected most often. Eventually the weakened tendon my rupture completely causing a pop and immediate pain. The athlete may report the injury occurred during a single throw, but the reality is usually that the ligament simply finally became weakened to the point that it finally ruptured.

However, the general profile associated with this injury may be changing. Today, more and more children ages 10 to 18 are affected. Longer seasons with extended practice time and more tournaments increase the risk of UCL injury. Throwing volume, pitch type, and throwing mechanics can all contribute to the problem.

Children have their own unique risk factor in that they have an open growth plate in the elbow called the medial epicondylar physis. Force along the inside of the elbow during throwing is more likely to cause failure at the area of the growth plate than at the UCL. This injury is often termed Little League Elbow. Reconstruction of the UCL may not be needed in this age group unless the injury to the UCL occurs after the growth plate is closed. Sometimes the ligament avulses or pulls away, taking a piece of the growth plate with it. When the condition has been present for some time, the ligament is not all that may be damaged. The entire elbow joint is at risk due to the abnormal forces caused by the repetitive stress injury.

Symptoms

What does the condition feel like?

Pain along the inside of the elbow is the main symptom of this condition. Throwing athletes report it occurs most often during the acceleration phase of throwing. If there are loose fragments or uneven joint surfaces, you may also notice popping, catching, or grinding.

Sometimes swelling can be seen along the inside of the elbow. If the ligament was ruptured, there may be bruising in the same area. Some patients have a slight loss of elbow motion. Closing the hand and clenching the fist reproduces the painful symptoms.

Diagnosis

How will my doctor diagnose this condition?

The diagnosis is based on your history and symptoms. Your physician will complete an examination of the shoulder and elbow, performing specific tests to look for areas of tightness or laxity (looseness). Most patients will report tenderness along the inside of the elbow to palpation of the UCL ligament.

Valgus stress tests are done at the elbow to test for joint stability. The examiner places force toward the inside of the elbow as the joint is moved from a position of slight flexion into full extension. Too much motion or opening of the joint at the medial joint line called gapping may be observed or felt by palpation. The examiner may also feel the crepitation (popping, crunching) as the joint moves.

Standard X-rays are taken to look for bone spurs, loose fragments, or calcification in the ulnar collateral ligament. If the joint is gapping enough to sublux (partially dislocate), valgus stress radiographs may be taken.

Magnetic resonance imaging (MRI) with contrast dye is used to diagnose ligamentous rupture. The test doesn’t always show a problem when there is one. This is called a false-negative result. Ultrasound and CT scans may be helpful. Some surgeons prefer to use arthroscopy to make the final diagnosis. The presence and severity of valgus gapping can be confirmed. Studies using these more advanced test methods to diagnose UCL injuries are being done. More data is needed before they become routine in the diagnosis of UCL injuries.

Treatment

What treatment options are available?

Nonsurgical Treatment

Many athletes with elbow instability from UCL injury can be treated successfully with rehabilitation and without invasive procedures. At first, symptoms may be treated with rest and/or activity modification (fewer pitches per game, per practice, per day). The athlete’s posture, strength, and release of the ball must be analyzed and corrected. The use of curve balls should be avoided during the early phases of rehabilitation.

Antiinflammatory drugs and analgesics may be used to reduce pain and inflammation. Icing may help but must be used with caution. Too much cold can cause a worsening of the swelling as the body sends more blood to the area to warm things up. And cold can be an irritant to the already damaged (and irritated) nerve.

Many athletes are able to return to play without further treatment. If conservative (nonoperative) care does not change the picture, then surgery may be needed.

Surgery

When the condition fails to respond to conservative care described above, surgery may be indicated. If pain is the primary symptom and there is no evidence that the elbow joint is grossly unstable, the surgeon may use an arthroscope (a tiny fiber-optic TV camera) to look inside the elbow and see the condition of the joint and the soft tissues. It may be possible to debride any tissue fragments or frayed edges. During debridement, the surgeon carefully cleans the area by removing any dead or damaged tissue. Any bone spurs or areas of calcium build-up are also removed.

If the ulnar collateral ligament has been injured acutely due to a fall on the outstretched arm, a direct repair of the ligament may be possible. If the ligament has pulled off the bone, it may be reattached with sutures through holes drilled in the bone. If the ligament is damaged by constant overuse and is not strong enough to restore stability to the elbow joint if it is simply re-attached or repaired, then the ligament must be replaced with a new ligament. This is termed a ligament reconstruction. During a reconstruction, the ulnar collateral ligament along the medial (inside) of the elbow is replaced with a tendon graft harvested from somewhere else in the body (autograft). One common technique used to replace the damaged ulnar collateral ligament is called the docking technique.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Other modalities such as electrical stimulation and ultrasound with cortisone (called phonophoresis) may be used by a physical therapist when needed. Steroid injections are not usually recommended for this condition.

The athlete will work with the physical therapist to develop a daily program of stretching and strengthening. Stretching exercises for the muscles of the forearm are included. A strengthening program for the entire elbow/arm complex will be prescribed. High repetition, low weight exercise training is used to increase endurance without placing additional stress across the joint.

The therapist will also address any problems with flexibility, strength, and conditioning at the shoulder. Plyometric strengthening of the entire arm starts with the forearm muscles (flexors and pronators) and progresses to include the biceps, triceps, and rotator cuff of the upper arm. Plyometrics refers to training the nerves to fire quickly and the muscles to contract strong and fast. Plyometrics help develop explosive movements to improve muscular power and force. The goal is to increase the speed of the pitch (or throw for other throwing athletes).

After Surgery

Arthroscopic Debridement

Gentle range of motion exercises are started right away. Full motion is restored as the pain and swelling resolve. Elbow strengthening exercises are begun within the first few days to week after the procedure. A rehabilitation program is started and progressed, including a gradual throwing program. Full sports participation can be anticipated within one to three months.

Repair or Reconstruction

The postoperative program is the same for repairs or reconstruction. At first your arm will be immobilized in a bulky dressing.

You will be referred to a physical therapist to begin a rehabilitation program.

Gentle handgrip and shoulder and wrist mobilization exercises are allowed right away after surgery. Postoperative immobilization is discontinued in seven to 10 days at which time active range of motion for the elbow is started. Your surgeon may want you to wear a special hinged brace to protect the elbow.

Chondromalacia Patella

A Patient’s Guide to Chondromalacia Patella

Introduction

The patella, or kneecap, can be a source of knee pain when it fails to function properly. Alignment or overuse problems of the patella can lead to wear and tear of the cartilage behind the patella. Chondromalacia patella is a common knee problem that affects the patella and the groove it slides in over the femur (thigh bone). This action takes place at the patellofemoral joint.

Chondromalacia is the term used to describe a patellofemoral joint that has been structurally damaged, while the term patellofemoral pain syndrome (PFPS) refers to the earlier stages of the condition. Symptoms are more likely to be reversible with PFPS.

This guide will help you understand

what parts of the knee are affected
how this condition develops
how doctors diagnose the condition
what treatment options are available

Anatomy

What is the patella, and what does it do?

The patella (kneecap) is the moveable bone on the front of the knee. This unique bone is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the lower leg bone. The large quadriceps tendon together with the patella is called the quadriceps mechanism. Though we think of it as a single device, the quadriceps mechanism has two separate tendons, the quadriceps tendon on top of the patella and the patellar tendon below the patella.

Tightening up the quadriceps muscles places a pull on the tendons of the quadriceps mechanism. This action causes the knee to straighten. The patella acts like a fulcrum to increase the force of the quadriceps muscles.

The underside of the patella is covered with articular cartilage, the smooth, slippery covering found on joint surfaces. This covering helps the patella glide (or track) in a special groove made by the thighbone, or femur. This groove is called the femoral groove.

Two muscles of the thigh attach to the patella and help control its position in the femoral groove as the leg straightens. These muscles are the vastus medialis obliquus (VMO) and the vastus lateralis (VL). The vastus medialis obliquus (VMO) runs along the inside of the thigh, and the vastus lateralis (VL) lies along the outside of the thigh. If the timing between these two muscles is off, the patella may be pulled off track.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

What causes this problem?

Problems commonly develop when the patella suffers wear and tear. The underlying cartilage begins to degenerate, a condition most common in young athletes. Soccer players, snowboarders, cyclists, rowers, tennis players, ballet dancers, and runners are affected most often. But anyone whose knees are under great stress is at increased risk of developing chondromalacia patella.

Wear and tear can develop for several reasons. Acute injury to the patella or chronic friction between the patella and the femur can result in the start of patellofemoral pain syndrome. Degeneration leading to chondromalacia may also develop as part of the aging process, like putting a lot of miles on a car.

The main cause of knee pain associated with patellofemoral pain syndrome is a problem in the way the patella tracks within the femoral groove as the knee moves. Physical and biomechanical changes alter the stress and load on the patellofemoral joint.

The quadriceps muscle helps control the patella so it stays within this groove. If part of the quadriceps is weak for any reason, a muscle imbalance can occur. When this happens, the pull of the quadriceps muscle may cause the patella to pull more to one side than the other. This in turn causes more pressure on the articular cartilage on one side than the other. In time, this pressure can damage the articular cartilage leading to chondromalacia patella.

Weakness of the muscles around the hip can also indirectly affect the patella and can lead to patellofemoral joint pain. Weakness of the muscles that pull the hip out and away from the other leg, the hip abductor muscles, can lead to imbalances to the alignment of the entire leg – including the knee joint and the muscle balance of the muscles around the knee. This causes abnormal tracking of the patella within the femoral groove and eventually pain around the patella. Many patients are confused when their physical therapist begins exercises to strengthen and balance the hip muscles, but there is a very good reason that the therapist is focusing on this area.

A similar problem can happen when the timing of the quadriceps muscles is off. There are four muscles that form the quadriceps muscle group. As mentioned earlier, the vastus medialis obliquus (the muscle on the inside of the front of the thigh) and the vastus lateralis ( the muscle that runs down the outside part of the thigh) are two of these four muscles. People with patellofemoral problems sometimes have problems in the timing between the VMO and the VL. The VL contracts first, before the VMO. This tends to pull the patella toward the outside edge of the knee. The result is abnormal pressure on the articular surface of the patella.

Another type of imbalance may exist due to differences in how the bones of the knee are shaped. These differences, or anatomic variations, are something people are born with. Doctors refer to this the “Q angle”. Some people are born with a greater than normal angle where the femur and the tibia (shinbone) come together at the knee joint. Women tend to have a greater angle here than men. The patella normally sits at the center of this angle within the femoral groove. When the quadriceps muscle contracts, the angle in the knee straightens, pushing the patella to the outside of the knee. In cases where this angle is increased, the patella tends to shift outward with greater pressure. This leads to a similar problem as that described above. As the patella slides through the groove, it shifts to the outside. This places more pressure on one side than the other, leading to damage to the underlying articular cartilage.

Finally, anatomic variations in the bones of the knee can occur such that one side of the femoral groove is smaller than normal. This creates a situation where the groove is too shallow, usually on the outside part of the knee. People who have a shallow groove sometimes have their patella slip sideways out of the groove, causing a patellar dislocation. This is not only painful when it occurs, but it can damage the articular cartilage underneath the patella. If this occurs repeatedly, degeneration of the patellofemoral joint occurs fairly rapidly.

Symptoms

What does chondromalacia patella feel like?

The most common symptom is pain underneath or around the edges of the patella. The pain is made worse by any activities that load the patellofemoral joint, such as running, squatting, or going up and down stairs. Kneeling is often too painful to even try. Keeping the knee bent for long periods, as in sitting in a car or movie theater, may cause pain.

There may be a sensation like the patella is slipping. This is thought to be a reflex response to pain and not because there is any instability in the knee. Others experience vague pain in the knee that isn’t centered in any one spot.

The knee may grind, or you may hear a crunching sound when you squat or go up and down stairs. If there is a considerable amount of wear and tear, you may feel popping or clicking as you bend your knee. This can happen when the uneven surface of the underside of the patella rubs against the femoral groove. The knee may swell with heavy use and become stiff and tight. This is usually because of fluid accumulating inside the knee joint, sometimes called ‘water on the knee’. This is not unique to problems of the patella but sometimes occurs when the knee becomes inflamed.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history of your knee problem followed by an examination of the knee, including the patella. X-rays may be ordered on the initial visit to your doctor. An X-ray can help determine if the patella is properly aligned in the femoral groove. Several X-rays taken with the knee bent at several different angles can help determine if the patella seems to be moving through the femoral groove in the correct alignment. The X-ray may show arthritis between the patella and thighbone, especially when the problems have been there for awhile.

Diagnosing problems with the patella can be confusing. The symptoms can be easily confused with other knee problems, because the symptoms are often similar. In these cases, other tests, such as magnetic resonance imaging (MRI), may be suggested. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. Usually, this test is done to look for injuries, such as tears in the menisci or ligaments of the knee. Recent advances in the quality of MRI scans have enabled doctors to see the articular cartilage on the scan and determine if it is damaged. This test does not require any needles or special dye and is painless.

In some cases, arthroscopy may be used to make the definitive diagnosis when there is still a question about what is causing your knee problem. Arthroscopy is an operation that involves placing a small fiber-optic TV camera into the knee joint, allowing the surgeon to look at the structures inside the joint directly. The arthroscope allows your doctor to see the condition of the articular cartilage on the back of your patella. The vast majority of patellofemoral problems are diagnosed without resorting to surgery, and arthroscopy is usually reserved to treat the problems identified by other means.

There is no clear link between the severity of symptoms and X-ray or arthroscopic findings. Most often, the doctor relies upon the history, symptoms, and results of the examination.

Treatment

What treatment options are available?

Nonsurgical Treatment

Nonoperative treatment is usually recommended for this problem. Getting the pain and inflammation under control is the first step. The overall goals for a rehab plan are to improve muscle function and flexibility while providing pain relief or pain control.

Your physician may suggest rest and anti-inflammatory medications, such as aspirin or ibuprofen, especially when the problem is coming from overuse. Acetaminophen (Tylenol®) may be used for pain control if you can’t take anti-inflammatory medications for any reason. Activity modification, flexibility, and strengthening are key parts of the rehab program. Physical therapy can help in the early stages by decreasing pain and inflammation. Your physical therapist may use ice massage and ultrasound to limit pain and swelling.

An alternative to bracing is to tape the patella in place. The therapist applies and adjusts the tape over the knee to help realign the patella. The idea is that by bracing or taping the knee, the patella stays in better alignment within the femoral groove. This in turn is thought to improve the pull of the quadriceps muscle so that the patella stays lined up in the groove. Patients report less pain and improved function with these forms of treatment.

As the pain and inflammation become controlled, your physical therapist will work with you to improve flexibility, strength, and muscle balance in the knee. Quadriceps strengthening exercises to address deficits in knee extension strength include non-weight-bearing single-joint (e.g., knee extension) and weight-bearing multiple-joint exercises (e.g., seated leg press).

Non-weight bearing exercises are also known as open kinetic chain exercise. Weight-bearing exercises are referred as closed-chain exercise. Closed-chain exercises place less stress on the patellofemoral joint and may be used first to achieve improved function before progressing to open kinetic chain exercises. Studies also show greater VMO activity with closed kinetic chain exercise. And a closed-chain exercise program also addresses hip muscle weakness at the same time as knee muscle deficits.

The therapist will adjust your rehab program to provide you with the most pain free and effective method of treatment. The overall rehab program will include a home exercise program of stretching, agility exercises, balance activities, and strengthening designed to return you to your former level of pain free participation in sports and other activities.

Surgery

If nonsurgical treatment fails to improve your condition, surgery may be suggested. The procedure used for patellofemoral problems varies. In severe cases a combination of one or more of the following procedures may be necessary.

Arthroscopic Method

Arthroscopy is sometimes useful in the treatment of patellofemoral problems of the knee. Looking directly at the articular cartilage surfaces of the patella and the femoral groove is the most accurate way of determining how much wear and tear there is in these areas. Your surgeon can also watch as the patella moves through the groove, and may be able to decide whether or not the patella is moving normally. If there are areas of articular cartilage damage behind the patella that are creating a rough surface, special tools can be used by the surgeon to smooth the surface and reduce your pain. This procedure is sometimes referred to as shaving the patella.

Cartilage Procedure

In more advanced cases of patellar arthritis, surgeons may operate to repair or restore the damaged cartilage. The type of surgery needed for articular cartilage is based on the size, type, and location of the damage. Along with surgical treatment to fix the cartilage, other procedures may also be done to help align the patella so less pressure is placed on the healing cartilage.

Lateral Release

If your patella problems appear to be caused by a misalignment problem, a procedure called a lateral release may be suggested. This procedure is done to allow the patella to shift back to a more normal position and relieve pressure on the articular cartilage.

In this operation, the tight ligaments on the outside (lateral side) of the patella are cut, or released, to allow the patella to slide more towards the center of the femoral groove. These ligaments eventually heal with scar tissue that fills in the gap created by the surgery, but they no longer pull the patella to the outside as strongly as before the surgery. This helps to balance the quadriceps mechanism and equalize the pressure on the articular cartilage behind the patella.

Ligament Tightening Procedure

In some cases of severe patellar misalignment, a lateral release alone may not be enough. For problems of repeated patellar dislocations, the surgeon may also need to realign the quadriceps mechanism. In addition to the lateral release, the tendons on the inside edge of the knee (the medial side) may have to be tightened as well.

Bony Realignment

If the misalignment is severe, the bony attachment of the patellar tendon may also have to be shifted to a new spot on the tibia bone. Remember that the patellar tendon attaches the patella to the lower leg bone (tibia) just below the knee. By moving a section of bone where the patellar tendon attaches to the tibia, surgeons can change the way the tendon pulls the patella through the femoral groove.

The surgeon removes a section of bone where the patellar tendon attaches on the tibia. This section of bone is then reattached on the tibia closer to the other knee.

Usually, the bone is reattached onto the tibia using screws. This procedure shifts the patella to the medial side. Once the surgery heals, the patella should track better within the center of the groove, spreading the pressure equally on the articular cartilage behind the patella.

Arthroscopic procedures to shave the patella or a simple lateral release can usually be done on an outpatient basis, meaning you can leave the hospital the same day. If your problem requires the more involved surgical procedure where bone must be cut to allow moving the patellar tendon attachment, you may need to spend one or two nights in the hospital.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Patients with chondromalacia may benefit from four to six weeks of physical therapy. The aim of treatment is to calm pain and inflammation, to correct muscle imbalances, and to improve function of the patella.

It is important to understand the need to keep your activity level below what will trigger more pain and tissue damage. You may need to ice your knee during the day and limit certain activities such as stairs, squatting, or running.

Good results can be expected when working slowly but steadily on flexibility and strengthening exercises. The moto of no pain, no gain does not apply to this problem. The most successful program is one of common sense. If an activity causes pain, then reduce the frequency, intensity, or duration of that activity until you are once again pain free. Gradually build up what you can do while maintaining your pain free status.

Muscle imbalances are commonly treated with stretching and strengthening exercises but improvement usually takes at least six to eight weeks. You may need to continue a modified program of flexibility and strengthening exercises to maximize control and strength of the quadriceps muscles. This type of program done two to three times each week may be needed for several more months (or longer if you continue to experience pain during progressive sports participation).

After Surgery

Many surgeons will have their patients take part in formal physical therapy after knee surgery for patellofemoral problems. Patients undergoing a patellar shaving usually begin rehabilitation right away. More involved surgeries for patellar realignment or restorative procedures for the articular cartilage require a delay before going to therapy. And rehabilitation may be slower to allow the bone or cartilage to heal before too much strain can be put on the knee.

The first few physical therapy treatments are designed to help control the pain and swelling from the surgery. The physical therapist will choose exercises to help improve knee motion and to get the quadriceps muscles toned and active again. Muscle stimulation, using electrodes over the quadriceps muscle, may be needed at first to get the muscle moving again.

As the program evolves, more challenging exercises are chosen to safely advance the knee’s strength and function. The key is to get the soft tissues in balance through safe stretching and gradual strengthening.

The physical therapist’s goal is to help you keep your pain under control, ensure you place only a safe amount of weight on the healing knee, and improve your strength and range of motion. When you are well under way, regular visits to the therapist’s office will end. The therapist will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Quadriceps Tendonitis

A Patient’s Guide to Quadriceps Tendonitis of the Knee

Introduction

Alignment or overuse problems of the knee structures can lead to strain, irritation, and/or injury of the quadriceps muscle and tendon. Quadriceps tendonitis produces pain, weakness, and swelling of the knee joint.

These problems can affect people of all ages but the majority of patients with overuse injuries of the knee (and specifically quadriceps tendonitis) are involved in soccer, volleyball, or running activities.

This guide will help you understand

how the problem develops
how doctors diagnose the condition
what treatment options are available

Anatomy

What is the quadriceps muscle/tendon, and what does it do?

The patella (kneecap) is the moveable bone on the front of the knee. This unique bone is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the lower leg bone.

The large quadriceps muscle ends in a tendon that inserts into the tibial tubercle, a bony bump at the top of the tibia (shin bone) just below the patella. The tendon together with the patella is called the quadriceps mechanism. Though we think of it as a single device, the quadriceps mechanism has two separate tendons, the quadriceps tendon on top of the patella and the patellar tendon below the patella.

The long bones of the femur and the tibia act as level arms, placing force or load on the knee joint and surrounding soft tissues. The amount of load can be quite significant. For example, the joint reaction forces of the lower extremity (including the knee) are two to three times the body weight during walking and up to five times the body weight when running.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

How does this problem develop

Quadriceps tendonitis occurs most often as a result of stresses placed on the supporting structures of the knee. Running, jumping, and quick starts and stops contribute to this condition. Overuse injuries from sports activities is the most common cause but anyone can be affected, even those who do not participate in sports or recreational activities.

There are extrinsic (outside) factors that are linked with overuse tendon injuries of the knee. These include inappropriate footwear, training errors (frequency, intensity, duration), and surface or ground (hard surface, cement) being used for the sport or event (such as running). Training errors are summed up by the rule of toos. This refers to training too much, too far, too fast, or too long. Advancing the training schedule forward too quickly is a major cause of quadriceps tendonitis.

Intrinsic (internal) factors such as age, flexibility, and joint laxity are also important. Malalignment of the foot, ankle, and leg can play a key role in tendonitis. Flat foot position, tracking abnormalities of the patella, rotation of the tibia, and a leg length difference can create increased and often uneven load on the quadriceps mechanism. Any muscle imbalance of the lower extremity (from the hip down to the toes) can impact the quadriceps muscle and affect the joint. Individuals who are overweight may have added issues with load and muscle imbalance leading to quadriceps tendonitis.

Strength of the patellar tendon is in direct proportion to the number, size, and orientation of the collagen fibers that make up the tendon. Overuse is simply a mismatch between load or stress on the tendon and the ability of that tendon to distribute the force. If the forces placed on the tendon are greater than the strength of the structure, then injury can occur. Repeated microtrauma at the muscle tendon junction may overcome the tendon’s ability to heal itself. Tissue breakdown occurs triggering an inflammatory response that leads to tendonitis and even partial tears.

Chronic quadriceps tendonitis is really a problem called tendonosis. Inflammation is not present. Instead, degeneration and/or scarring of the tendon has developed. Chronic tendon injuries are much more common in older athletes (30 to 50 years old).

Symptoms

What does the condition feel like?

Pain from quadriceps tendonitis is felt in the area at the bottom of the thigh, just above the patella. The pain is most noticeable when you move your knee. The more you move your knee, the more tenderness develops in the area of the tendon attachment above the kneecap.

There may be swelling in and around the quadriceps tendon. It may be tender or very sensitive to touch. You may feel a sense of warmth or burning pain. The pain can be mild or in some cases the pain can be severe enough to keep the runner from running or other athletes from participating in their sport. Stiffness of the knee is common when you first get up in the morning (or after a long period of rest or inactivity), and during and after exercise

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history of your knee problem followed by an examination of the knee, including the patella. There is usually tenderness with palpation of the inflamed tissues at the insertion of the tendon into the bone. The knee will be assessed for range of motion, strength, flexibility and joint stability.

The physician will look for intrinsic and extrinsic factors affecting the knee (especially sudden changes in training habits). Potential problems with lower extremity alignment are identified. The doctor will also check to see if the quadriceps tendon is partially torn or ruptured. Weakness of the extensor mechanism is a sign of such an injury.

X-rays may be ordered on the initial visit to your doctor. An X-ray can show fractures or the presence of calcium deposits in the quadriceps muscle but X-rays do not show soft tissue injuries. In these cases, other tests, such as ultrasonography or magnetic resonance imaging (MRI), may be suggested. Ultrasound uses sound waves to detect tendon tears. MRIs use magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. Usually, this test is done to look for injuries, such as tears in the quadriceps. This test does not require any needles or special dye and is painless.

Treatment

What treatment options are available?

Nonsurgical Treatment

The initial treatment for acute quadriceps tendonitis begins by decreasing the inflammation in the knee. Your physician may suggest relative rest and anti-inflammatory medications, such as aspirin or ibuprofen, especially when the problem is coming from overuse. Acetaminophen (Tylenol®) may be used for pain control if you can’t take anti-inflammatory medications for any reason.

Relative rest is a term used to describe a process of rest-to-recovery based on the severity of symptoms. Pain at rest means strict rest and a short time of immobilization in a splint or brace is required. When pain is no longer present at rest, then a gradual increase in activity is allowed so long as the resting pain doesn’t come back.

Physical therapy can help in the early stages by decreasing pain and inflammation. Your physical therapist may use ice massage, electrical stimulation, and ultrasound to limit pain and control (but not completely prevent) swelling. Some amount of inflammatory response is needed for a good healing response.

The therapist will prescribe stretching and strengthening exercises to correct any muscle imbalances. Eccentric muscle strength training helps prevent and treat injuries that occur when high stresses are placed on the tendon during closed kinetic chain activities. Eccentric contractions occur as the contracted muscle lengthens. Closed kinetic chain activities means the foot is planted on the floor as the knee bends or straightens.

Flexibility exercises are often designed for the thigh and calf muscles. Specific exercises are used to maximize control and strength of the quadriceps muscles. You will be shown how to ease back into jumping or running sports using good training techniques. Off-season strength training of the legs, particularly the quadriceps muscles is advised.

Bracing or taping the patella can help you do exercises and activities with less pain. Most braces for patellofemoral problems are made of soft fabric, such as cloth or neoprene. You slide them onto your knee like a sleeve. A small buttress pads the side of the patella to keep it lined up within the groove of the femur. An alternative to bracing is to tape the patella in place. The therapist applies and adjusts the tape over the knee to help realign the patella. The idea is that by bracing or taping the knee, the patella stays in better alignment within the femoral groove. This in turn is thought to improve the pull of the quadriceps muscle so that the patella stays lined up in the groove. Patients report less pain and improved function with these forms of treatment.

Therapists also design special shoe inserts, called orthotics, to improve knee alignment and function of the patella. Proper footwear for your sport is important. The therapist will advise you in this area.

Prevention of future injuries through patient education is a key component of the treatment program. This is true whether conservative care or surgical intervention is required. Modification of intrinsic and extrinsic risk factors is essential.

Coaches, trainers, and therapists can work together to design a training program that allows you to continue training without irritating the tendon and surrounding tissues. Remember to warm up and stretch before exercise. Some experts recommend a cool down and stretching after exercise as well. Know your limits and don’t overdo it.

Use ice after activity if indicated by pain or swelling. Icing should be limited to no more than 20 minutes to avoid reflex vasodilation (increased circulation to the area to rewarm it causing further swelling). Heat may be used in cases of chronic tendinosis to stimulate blood circulation and promote tissue healing.

Whenever you have to miss exercising for any reason or when training for a specific event, adjust your training schedule accordingly. Avoid the too training errors mentioned earlier.

Surgery

Surgery is rarely needed when a wide range of protective measures, relative rest, ice, support, and rehab are used. If nonsurgical treatment fails to improve your condition, then surgery may be suggested. Surgery is designed to stimulate healing through revascularization (restoring blood supply). Weak, damaged tissue is removed and the injured tendon is repaired. Tissue remodeling through surgery can restore function.

Arthroscopic procedures can usually be done on an outpatient basis. This means you can leave the hospital the same day. If your problem requires a more involved surgical procedure where bone must be cut to allow moving the quadriceps tendon attachment, you may need to spend one or two nights in the hospital.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Quadriceps tendonitis is usually self-limiting. That means the condition will resolve with rest, activity modification, and physical therapy. Recurrence of the problem is common for patients who fail to let the quadriceps tendon recover fully before resuming training or other aggravating activities.

Physical therapy for about four to six weeks is usually recommended. The aim of treatment is to calm pain and inflammation, to correct muscle imbalances, and to improve the function of the quadriceps mechanism.

With a well-planned rehabilitation program, most patients are able to return to their previous level of activity without recurring symptoms.

After Surgery

Many surgeons will have their patients take part in formal physical therapy after knee surgery for patellofemoral problems. More involved surgeries for patellar realignment or restorative procedures for tendon tissue require a delay before going to therapy. And rehabilitation may be slower to allow the tendon to heal before too much strain can be put on the knee.

Patellar Tendonitis

A Patient’s Guide to Patellar Tendonitis

Introduction

Alignment or overuse problems of the knee structures can lead to strain, irritation, and/or injury. This produces pain, weakness, and swelling of the knee joint. Patellar tendonitis (also known as jumper’s knee) is a common overuse condition associated with running, repeated jumping and landing, and kicking.

This guide will help you understand

what parts of the knee are involved
how the problem develops
how doctors diagnose the condition
what treatment options are available

Anatomy

What parts of the knee are involved?

The large quadriceps muscle ends in a tendon that inserts into the tibial tubercle, a bony bump at the top of the tibia (shin bone) just below the patella. The tendon together with the patella is called the quadriceps mechanism. Though we think of it as a single device, the quadriceps mechanism has two separate tendons, the quadriceps tendon on top of the patella and the infrapatellar tendon or patellar tendon below the patella.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

What causes this problem?

Patellar tendonitis occurs most often as a result of stresses placed on the supporting structures of the knee. Running, jumping, and repetitive knee flexion into extension (e.g., rising from a deep squat) contribute to this condition. Overuse injuries from sports activities is the most common cause but anyone can be affected, even those who do not participate in sports or recreational activities.

There are extrinsic (outside) factors that are linked with overuse tendon injuries of the knee. These include inappropriate footwear, training errors (frequency, intensity, duration), and surface or ground (hard surface, cement) being used for the sport or event (such as running). Training errors are summed up by the rule of “toos”. This refers to training too much, too far, too fast, or too long. Advancing the training schedule forward too quickly is a major cause of patellar tendonitis.

An increased Q-angle or femoral anteversion are two common types of malalignment that contribute to patellar tendonitis. The Q-angle is the angle formed by the patellar tendon and the axis of pull of the quadriceps muscle. This angle varies between the sexes. It is larger in women compared to men. The normal angle is usually less than 15 degrees. Angles more than 15 degrees create more of a pull on the tendon, creating painful inflammation.

Any muscle imbalance of the lower extremity (from the hip down to the toes) can impact the quadriceps muscle and affect the joint. Individuals who are overweight may have added issues with load and muscle imbalance leading to patellar tendonitis.

Chronic tendonitis is really a problem called tendonosis. Inflammation is not present. Instead, degeneration and/or scarring of the tendon has developed. Chronic tendon injuries are much more common in older athletes (30 to 50 years old).

Symptoms

What does the condition feel like?

Pain from patellar tendonitis is felt just below the patella. The pain is most noticeable when you move your knee or try to kneel. The more you move your knee, the more tenderness develops in the area of the tendon attachment below the kneecap.

There may be swelling in and around the patellar tendon. It may be tender or very sensitive to touch. You may feel a sense of warmth or burning pain. The pain can be mild or in some cases the pain can be severe enough to keep the runner from running or other athletes from participating in their sport. The pain is worse when rising from a deep squat position. Resisted quadriceps contraction with the knee straight also aggravates the condition.

Diagnosis

How do doctors diagnose the problem?

X-rays may be ordered on the initial visit to your doctor. An X-ray can show fractures of the tibia or patella but X-rays do not show soft tissue injuries. In these cases, other tests, such as ultrasonography or magnetic resonance imaging (MRI), may be suggested. Ultrasound uses sound waves to detect tendon tears. MRIs use magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. Usually, this test is done to look for injuries, such as tears in the quadriceps. This test does not require any needles or special dye and is painless.

Treatment

What treatment options are available?

Nonsurgical Treatment

The initial treatment for acute patellar tendonitis begins by decreasing the inflammation in the knee. Your physician may suggest relative rest and anti-inflammatory medications, such as aspirin or ibuprofen, especially when the problem is coming from overuse. Acetaminophen (Tylenol®) may be used for pain control if you can’t take anti-inflammatory medications for any reason.

Relative rest is a term used to describe a process of rest-to-recovery based on the severity of symptoms. Pain at rest means strict rest and a short time of immobilization in a splint or brace is required. When pain is no longer present at rest, then a gradual increase in activity is allowed so long as the resting pain doesn’t come back.

The therapist will prescribe stretching and strengthening exercises to correct any muscle imbalances. Eccentric muscle strength training helps prevent and treat injuries that occur when high stresses are placed on the tendon during closed kinetic chain activities. Eccentric contractions occur as the contracted muscle lengthens. Closed kinetic chain activities means the foot is planted on the floor as the knee bends or straightens.

A specific protocol of exercises may be needed when rehabilitating this injury. After a five-minute warm up period, stretches are performed. Next, in a standing position, the patient bends the knees and drops quickly into a squatting position, and then stands up again quickly. The goal is to do this exercise as quickly as possible. Eventually sandbags are added to the shoulders to increase the load on the tendon. All exercises must be done without pain.

Researchers have also discovered that patellar tendonitis responds to a concentric-eccentric program of exercises for the anterior tibialis muscle. The anterior tibialis muscle is located along the front of the lower leg. It is the muscle that helps you dorsiflex the ankle (pull your toes and ankle up toward the face).

You start with your foot in a position of full plantar flexion by rising up on your toes. Now drop down into a position of dorsiflexion. This is a concentric muscle contraction. Resistance of the foot and ankle from full dorsiflexion back into plantar flexion is the eccentric contraction. This exercise is repeated until the anterior tibialis fatigues. As your pain subsides, the program progresses so that eventually, you will just be doing the eccentric activities.

Whenever you have to miss exercising for any reason or when training for a specific event, adjust your training schedule accordingly. Avoid the “too” training errors mentioned earlier.

Surgery

Arthroscopic procedures can usually be done on an outpatient basis. This means you can leave the hospital the same day. If your problem requires a more involved surgical procedure where bone must be cut to allow moving the Patellar tendon attachment, you may need to spend one or two nights in the hospital.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Patellar tendonitis is usually self-limiting. That means the condition will resolve with rest, activity modification, and physical therapy. Recurrence of the problem is common for patients who fail to let the patellar tendon recover fully before resuming training or other aggravating activities.

With a well-planned rehabilitation program, most patients are able to return to their previous level of activity without recurring symptoms.

After Surgery

Many surgeons will have their patients take part in formal physical therapy after knee surgery. More involved surgeries for patellar realignment or restorative procedures for tendon tissue require a delay before going to therapy. And rehabilitation may be slower to allow the tendon to heal before too much strain can be put on the knee.

The first few physical therapy treatments are designed to help control the pain and swelling from the surgery. The physical therapist will choose exercises to help improve knee motion and to get the quadriceps muscles toned and active again. Muscle stimulation, using electrodes over the quadriceps muscle, may be needed at first to get the muscle moving again.

Diffuse Idiopathic Skeletal Hyperostosis

A Patient’s Guide to Diffuse Idiopathic Skeletal Hyperostosis

Introduction

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a phenomenon that more commonly affects older males. It is associated with stiffness and back pain, but often it causes no signs or symptoms.

The most common finding of Diffuse Idiopathic Skeletal Hyperostosis (DISH) is ligaments that turn into bone. It is also known as Forestier’s disease, after the name of the physician who recognized it. It is most often confirmed by x-ray.

This guide will help you understand

what parts of the spine are affected
what causes this condition
what does this condition feel like
how doctors diagnose the condition
what treatment options are available

Anatomy

What parts of the spine are involved?

The spine, or vertebral column, is made up of bones that stack on top of one another. These bones are called vertebrae. There are five sections of the spine. At the top is the neck, or cervical spine, which connects with the skull. Below the neck is the thoracic spine or mid-back, which has the ribs attached. The ribs form your chest. Below the thoracic spine is your lumbar spine or low back. The lumbar spine attaches to the sacrum which is part of the pelvis. The last section of the spine is the coccyx, also know as the tail bone.

There are ligaments that help stabilized the spine. The ligament along the front of the spine is called the anterior longitudinal ligament. There is another ligament that attaches to the back of the spine called the posterior longitudinal ligament. These are the spinal ligaments that can turn into bone in Diffuse Idiopathic Skeletal Hyperostosis (DISH).

Causes

What causes this problem?

Diffuse Idiopathic Skeletal Hyperostosis generally occurs in people between the ages of 50 and 60. It appears more often in men than women. While the cause is unknown, there seems to be a connection with having diabetes, high blood pressure, coronary artery disease, and being over weight.

Some researchers feel that the extra bone is made because of extra blood supply near the spine. Growth factors that effect the formation of calcium likely play a role.

DISH generally affects the ligament in front of the spine called the anterior longitudinal ligament. This is the most common ligament that turns into bone with DISH, but it can affect other ligaments as well. Another common feature of DISH is that it can cause syndesmophytes (a bony outgrowth attached to a ligament) and tendonitis at sites other than the spine. These calcification sites can lead to bone spurs in the heels, elbows, ankles, knees, and shoulders. Bone spurs and inflammation develop where the tendon attaches to the bones.

Although DISH is considered a form of osteoarthritis, it is not considered degenerative, from wear or tear. The disc heights and facet joints do not show wear and tear as with other forms of osteoarthritis.

Medications that are used to treat acne may increase your risk of having DISH. These medications are called retinoids. They are similar to vitamin A.

Symptoms

What does the condition feel like?

Stiffness and decreased range of motion are the most common symptoms of DISH. The stiffness usually happens in the morning upon waking. It also happens after a long period of rest. Often the decrease in motion in the spine is with side-bending. DISH most commonly affects the mid back, but can also affect the neck and low back. It also seems to affect the right side of the thoracic spine more often than the left side. Pain may be a symptom of DISH, but not always.

In addition to changes in the spine, DISH can also cause stiffness, pain, and inflammation in tendons throughout the body. When DISH affects areas other than the spine, it feels like tendonitis. Ligaments and tendons where they attach to the bone near the joints develop extra bone growth.

Difficulty swallowing (dysphagia), or a hoarse voice, can happen when people have DISH in the neck. The bone spurs can put pressure on your esophagus (tube connecting the throat with the stomach), making it difficult to swallow. The pressure can also cause a hoarse voice or difficulty in breathing. In rare cases, this can become serious. This may require surgery to remove the bone spurs.

Neurological problems are rare in DISH. In severe cases, the extra bone growth around the spine can cause problems with the spinal cord or nerves. Squeezing of the spinal cord can cause loss of feeling and paralysis.

Diagnosis

How do doctors diagnose the problem?

Your doctor will complete a history and physical examination. Your doctor will ask you questions about things such as activity, urination, bowel movements, weakness, and stiffness. Range of motion of the spine is usually evaluated, as well as tenderness of the spine or muscles next to the spine.

Neurological examination usually includes checking reflexes at the knees and ankles (elbows and wrists if your neck is involved), sensation, and muscle strength. Your doctor may ask you to walk on your heels and toes.

Your doctor may ask that you have x-rays of your spine, usually the mid-back. If you have signs of nerve problems, a magnetic resonance imaging (MRI) scan, or a computed tomography (CT) scan may be ordered.

The MRI allows your doctor to look at slices of the area in question. The MRI machine uses magnetic waves, not x-rays. It shows the soft tissues of the body. This includes the spinal cord, nerves, and discs. It can also show spinal bones.

Computed tomography (CT) is best for evaluating problems with the vertebral bones. It is usually tolerated well but exposes you to radiation.

Extra bone growth along the vertebral column can be identified with any of these imaging tests. The extra bone growth must involve three or more adjacent vertebrae to meet the criteria for DISH. The calcification along the spine has a very unique appearance. Some doctors call it cascading or flowing. It is also sometimes described as appearing like candle wax dripping and oozing down the spine.

Treatment

What treatment options are available?

Nonsurgical Treatment

While there is no cure for DISH, there are treatments that can help the symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDs) may help manage pain or tendonitis-like inflammation. Tylenol® which is also called acetaminophen may also help relieve pain. More severe pain may be treated with corticosteroid injections.

Surgery

Rarely is surgery necessary. However, if the extra bone growth compresses the spinal cord or nerve roots, surgery may be needed. Surgery is done to relieve pressure on the spinal cord or nerve roots. Surgery to take out the extra bone growth (spurs) in the neck may help with symptoms of difficulty swallowing. You should expect to be hospitalized for a brief stay. Initially you may be asked to wear a corset or brace for support.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Physical therapy may help delay the loss of motion in affected joints. Regular exercise such as walking or stretching is recommended. This helps with the stiffness and pain. Exercises help increase your range of motion in your joints. Heat may also be helpful to areas of your body affected by DISH.

After Surgery

Physical and/or occupational therapy can help you with getting in and out of bed properly, moving, walking, dressing, etc. Initially, you will not be allowed to lift more than 10 pounds. At first, using a walker may be more comfortable and safe. Gradually you will be able to return to your normal activities.

Regular exercise such as walking or stretching is recommended. This helps with the stiffness and pain. Exercises help increase your range of motion in your joints. Heat may also be helpful to areas of your body affected by DISH.

Your surgeon will want you to follow up on a regular basis. Repeat examination will include testing of the nerves and spinal cord. Imaging studies will also be repeated.

Dropped Head Syndrome

A Patient’s Guide to Dropped Head Syndrome

Introduction

Dropped Head Syndrome is characterized by severe weakness of the muscles of the back of the neck. This causes the chin to rest on the chest in standing or sitting. Floppy Head Syndrome and Head Ptosis are other names used to describe the syndrome.

Most of the time, Dropped Head Syndrome is caused by a specific generalized neuromuscular diagnosis. When the cause is not known, it is called isolated neck extensor myopathy, or INEM.

This guide will help you understand

what parts make up the cervical spine
what causes this condition
how doctors diagnose this condition
what treatment options are available

Anatomy

What parts make up the cervical spine?

The spine is made up of a column of bones. Each bone, or vertebra, is formed by a round block of bone, called a vertebral body. A bony ring attaches to the back of the vertebral body, forming a canal for the spinal cord. The spinal cord is a made up of nerve cells which grow to look like a rope or cord about one half inch in diameter. The spinal cord attaches to the base of the brain. The base of the brain is called the
brainstem.

The vertebral column is divided into three distinct portions. The cervical, or neck portion attaches to the base of the skull at the upper end. The lower end of the cervical portion connects with the thoracic spine. There are seven cervical vertebrae.

There are many muscles that lie in the neck region. Some attach from the base of the skull, others to the spine, ribs, collar bone, and shoulder blade. Extension of the neck happens when the top of the head tilts backward. This causes the face and eyes to look up. Flexion of the neck is when the top of the head tilts forward. This causes the eyes to look down. It also lowers the chin to the chest.

The vertebrae stack on top of one another. When looking at the spine from the side, or from the sagittal view, the vertebral column is not straight up and down, but forms an “S” curve. The cervical spine has an inward curve called a lordosis. The thoracic spine curves outward. This curve is called a kyphosis. The lumbar spine usually has an inward curve or a lordosis. The “S” curve seen in the sagittal or side view allows for shock-absorption and acts as a spring when the spine is loaded with weight.

Causes

What causes this condition?

Most of the time, Dropped Head Syndrome is caused by a specific generalized neuromuscular diagnosis. These include amyotrophic lateral sclerosis (ALS) also known as Lou Gehrig’s disease, Parkinson’s disease, myasthenia gravis, polymyositis, and genetic myopathies. Other specific causes can include motor neuron disease, hypothyroidism, disorders of the spine, and cancer.

When the cause of Dropped Head Syndrome is not known, it is called isolated neck extensor myopathy, or INEM.

The INEM form of Dropped Head Syndrome usually happens in older persons. The weakness of the muscles in the back of the neck usually occurs gradually over one week to three months.

Symptoms

What does the condition feel like?

The symptoms of dropped head syndrome are usually painless. It most often occurs in the elderly. The weakness is limited to the muscles that extend the neck. Dropped Head Syndrome usually develops over a period of one week to three months. The head is then tilted downward. Because of the weakness of the extensors of the neck, the chin rests on the chest. Lifting or raising the head in sitting or standing is impossible. When lying down however, the neck is able to extend.

Gaze is down at the floor, instead of forward. The face is downward. The neck appears elongated, and the curve at the base of the neck is accentuated. This can cause over stretching or pinching of the spinal cord. When this happens, there may be weakness and numbness of the arms or entire body.

Dropped head syndrome can also cause difficulty swallowing, speaking, and breathing.

Diagnosis

How will my doctor diagnose this condition?

Diagnosis begins with a complete history and physical exam. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities.

Your doctor will do a physical examination to test your reflexes, skin sensation, muscle strength.

Most of the time, loss of of neck extension occurs as part of a more generalized neurological disorder. Neurological conditions must be considered first because some are treatable. A neurologist will usually be involved to help decide what is causing the chin-on-chest deformity.

Your doctor will likely ask that you have magnetic resonance imaging (MRI) of your neck. The MRI machine uses magnetic waves rather than X-rays. It shows the anatomy of the neck. It is very good at showing the spinal cord and nerves. The test does not require a dye or a needle.

Electromygraphy (EMG) uses small diameter needles in the muscle belly being tested. It helps determine how well the nerve conducts signals to the muscles.

A muscle biopsy may be needed. A small piece of muscle is removed and examined under a microscope. A closer look at the muscle fibers can be helpful in making a diagnosis.

In isolated neck extensor myopathy (INEM), the muscle biopsy is non-specific. EMG shows some myopathic changes. Labs are normal.

If no other associated neurologic disorders are found, then the diagnosis of isolated neck extensor myopathy (INEM) is made. It is a diagnosis of exclusion, meaning that everything else that could caused it has been ruled out. It is not known what causes isolated neck extensor myopathy (INEM).

Some doctors feel that isolated neck extensor myopathy (INEM) is caused by either a non-specific non-inflammatory or inflammatory response that is restricted to the neck extensor muscles. Another possible cause is thoracic kyphosis. When the natural curve of the thoracic spine is increased, it may place the extensor muscles at a disadvantage given the weight of the head. This may cause over stretching and weakness of the extensor muscles.

Treatment

What treatment options are available?

Isolated neck extensor myopathy (INEM) is considered benign because it does not spread or get worse. Symptoms can improve in some cases. It is most often treated conservatively.

Nonsurgical Treatment

Treatment of Dropped Head Syndrome is mainly supportive. The weakness remains localized to the neck extensor muscles, physical therapy may help with this. There are some cases that improve dramatically, but most usually do not improve.

The most useful treatment is use of a neck collar. It can partially correct the chin-on-chest deformity. This improves the forward gaze and activities of daily living. It also can help prevent contractures of the neck in a fixed flexed posture. However, it can be uncomfortable and cause sores under the chin. Some use a baseball cap attached to straps around the trunk. This avoids the chin discomfort from using a collar.

Prednisone is a potent anti-inflammatory that may be prescribed. It may be beneficial when there is local myositis, or inflammation of the muscles. It can be taken in a pill form by mouth or intravenously.

Surgery

Unless fusion is necessary, surgery is usually not recommended in Dropped Head Syndrome.

When there is damage to the nerves in the neck or spinal cord, surgery to fuse the neck may be necessary. This usually requires a fusion from C2-T2. The loss of neck movement after fusion leaves patients unable to see the ground in front of their feet. This makes them at greater risk for falls. The inconvenience caused by having a rigid neck may prove to be a greater problem than the original dropped head deformity.

Osteoporosis, particularly in older females also poses a problem with surgery. The soft bone may allow the metal used to stabilize the spine to pull out.

Rehabilitation

What should I expect as I after treatment?

Nonsurgical Rehabilitation

Physical therapy is usually recommended. Neck extension strengthening exercises may provide some improvement. However, most patients will find the strengthening both tiring and frustrating. When lying down on your back you can move the neck to maintain range of motion. This helps to avoid unnecessary stiffness and shortening of the muscles in the front of the neck.

Range of motion exercises should be done on an ongoing basis to avoid contractures of the neck. Wearing a neck collar when up will likely improve activities of daily living.

Speech therapy may be recommended for swallowing, feeding, and breathing problems. Some people may need to have a feeding tube inserted through the stomach.

Your doctor may want to repeat imaging of the spine. There is the possibility of over stretching or pinching the spinal cord when the neck extensors are so weak. You will need to watch for symptoms such as weakness or numbness in the arms or other portions of the body. Bowel and bladder function could become a problem.

After Surgery

If surgery is recommended, you will probably require an overnight hospital stay or a few days stay. Initially, you will not be allowed to lift, and you will have to move carefully. Most likely your neck will be placed in a fairly rigid brace. You will eventually be able to resume your normal activities. You can expect healing of the fusion in three to nine months.

Physical therapy is usually recommended after surgery. Neck extension strengthening exercises are prescribed to prevent contracture of the neck. Occupational therapy may be recommended to help with arm strengthening. It can also help with dressing, and other activities of daily living. Equipment needs can be evaluated by the occupational therapist. Speech therapy may also be recommended after surgery.

Your surgeon will want to follow up with you on a regular basis. Imaging studies may need to be repeated on occasion. Assessment of the fusion is usually done with X-rays.

Cervical Burners and Stingers (Brachial Plexus Injuries)

A Patient’s Guide to Burners and Stingers (Brachial Plexus Injuries)

Introduction

Injury to the nerves of the neck and shoulder that cause a burning or stinging feeling are called burners or stingers. Another name for this type of nerve injury is brachial plexus injury. Football players are affected most often. Up to half of all college football players have had at least one burner or stinger. Many of these occurred during high school football. Fortunately, it’s not a serious neck injury.

This guide will help you understand

what parts of the body are involved
how the problem develops
how doctors diagnose the condition
what treatment options are available

Anatomy

What parts of the body are involved?

The brachial plexus is affected most often by a downward or backward force against the shoulder. A nerve plexus is an area where nerves branch and rejoin. The brachial plexus is a group of nerves in the cervical spine from C5 to C8-T1. This includes the lower half of the cervical nerve roots and the nerve root from the first thoracic vertebra.

The nerves leave the spinal cord, go through the neck, under the clavicle

(collar bone) and armpit, and then down the arm.

The brachial plexus begins with five roots that merge or join together to form three trunks. The three trunks are upper (C5-C6), middle (C7), and lower (C8-T1). Each trunk then splits in two, to form six divisions. These divisions then regroup to become three cords (posterior, lateral, and medial).

Finally, there are branches that result in three nerves to the skin and muscles of the arm and hand: the median, ulnar, and radial nerves.

Causes

What causes this condition?

Burners or stingers are the result of traction or compressive forces on the brachial plexus or cervical nerve roots. The usual mechanism of injury occurs when a direct blow or hard hit to the top of your shoulder pushes it down at the same time your head is forced to the opposite side.

In the process, the brachial plexus between the neck and shoulder gets stretched. The same injury can happen if a downward force hits the collarbone directly. In football, burners or stingers occur most often when you tackle or block another player. This motion overstretches the nerves of the brachial plexus.

It’s not clear exactly where in the brachial plexus the damage occurs. Some experts suggest the injury is most likely to be at the level of the trunks, rather than at the nerve root level. The results of other studies show that burners or stingers from compression forces cause nerve root damage while traction injuries result in plexus injuries. A nerve root injury would be much more serious than a burner or stinger from a trunk injury of the brachial plexus.

Other athletes who participate in wrestling, gymnastics, snow skiing, and martial arts can also experience burners or stingers. Some studies suggest that athletes with a narrow cervical canal may be at increased risk for this type of injury.

Symptoms

What does this condition feel like?

A burning or stinging feeling between the neck and shoulder is the hallmark finding in this condition. True neck pain is more likely to be an injury to the neck itself. With burners or stingers, the painful symptoms start above the shoulder and go down the arm and even into the hand.

The shoulder and arm may feel numb or weak. You may feel as if this area is tingling. Weakness may be present at the time of the injury. Some patients report the arm feels and appears to be “dead”. This paralysis and other symptoms may be transient or temporary. They may only last a few seconds or minutes. But for some patients, healing takes days or weeks. In rare cases, the damage can be permanent.

Diagnosis

How do doctors diagnose this condition?

A careful history and physical exam are needed to diagnose stingers or burners. By assessing areas of weakness, the examiner may be able to tell whether a stretch injury of the brachial plexus has occurred. Nerve function and reflexes are also evaluated. If the physician suspects a cervical spine injury, further testing may be needed.

X-rays, MRI, and electrodiagnostic studies such as an electromyogram (EMG) can help make the final diagnosis. The EMG will confirm a problem, pinpoint the area of damage, and give an idea of how long recovery will take for each individual.

Treatment

What treatment options are available?

Nonsurgical Treatment

Protecting the neck with a soft collar is the first step in the acute phase of burners or stingers. If the injury occurs on the playing field, the player is placed in a protective collar before being moved off the field. This is worn until X-rays are taken to rule out fracture, dislocation, or other more serious neck injury.

Rest and gentle neck and shoulder range of motion are advised until symptoms resolve. If this does not occur within a few days, then physical therapy may be needed. Your therapist will use modalities such as biofeedback, electrical nerve stimulation, and manual therapy to help restore the natural function of the nerves.

Range of motion and strengthening exercises will be added as tolerated. Posture is very important during the healing phase. A chest-out position helps open the spinal canal, thus giving more room for the spinal cord. This posture also decreases pressure on the nerve roots. Your therapist will provide sport-specific therapy when the symptoms resolve (go away).

Surgery

Surgery is not a treatment option for burners or stingers. Management remains conservative (nonsurgical). Patients are followed through the athletic season until recovery is complete.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Burners and stingers are self-limiting. This means that with treatment, they will resolve over time. You will likely be able to return to full sports participation when you no longer have any symptoms. Full neck and shoulder motion must be present. And you should be able to participate in practice without any problems before entering a game.

It is possible to get another burner or stinger but it could be something more serious. If you experience these types of symptoms again, slowly lie down on the ground. Wait for the team trainer or physician to examine you before moving your head and neck.

Some football players choose to wear extra padding, special shoulder pads, or a neck roll to protect the neck and avoid reinjury. All equipment should be in good condition and fit properly. Daily stretching of the neck is advised. Players should avoid using spearing or head tackling, which has been prohibited since 1979.

Sacral Insufficiency Fractures

A Patient’s Guide to Sacral Insufficiency Fractures

Introduction

The sacrum is a wedge shaped bone that makes up part of the pelvis. It transmits the weight of the body to the pelvic girdle. As the name suggests, sacral insufficiency fractures occur when the quality of the sacral bone has become insufficient to handle the stress of weight bearing. The bone has lost some of its supporting structure and has become weak. Since this is usually because of osteoporosis, sacral insufficiency fractures occur most often in older women.

This guide will help you understand

what parts make up the sacrum
what causes this condition
how doctors diagnose this condition
what treatment options are available

Anatomy

What makes up the sacrum?

The sacrum is the triangular bone just below the lumbar spine. The sacrum has five segments fused together into one large bone. The coccyx or tailbone attaches to the bottom of the sacrum.

The sacrum forms the base of the spine and the center of the pelvis. The sacrum transmits the weight of the body to the pelvic girdle. It is shorter and wider in the female than in the male. Its name means “sacred bone”.

At the top of the sacrum there are wings from each side called the sacral ala. At the ala, the sacrum fits between the two halves of the pelvis. These pelvic bones are called the iliac bones. This is where the sacroiliac joints are formed. Most everyone has two dimples in their low back where the sacroiliac joints form. These three bones of the pelvis, the sacrum and the two iliac bones, make a ring.

Each of the iliac bones has projections called the pubic rami. They meet together in the front of the pelvis, forming a joint called the symphysis pubis. The iliac bones also contain the cup or socket for the hip joint.

Nerves that leave the spine in the area of the sacrum help control the bowels and bladder and provide sensation to the crotch area.

There are three types of bone, woven bone, cortical bone, and cancellous bone. In adults, woven bone is found where there is a broken bone that is healing (callus formation). It can also be found with hyperparathyroidism and Paget’s disease. It is composed of randomly arranged collagen strands. It is normally remodeled by the body and replaced with cortical or cancellous bone.

Cortical bone is called compact or lamellar bone. It forms the inside and outside tables of flat bones and the outside surfaces of long bones. It is dense and makes up 80 percent of our bone mass. The radius (wrist bone), skull, and long bones are made of cortical bone.

Cancellous bone is also called trabecular bone. It lies between the cortical bone surfaces. It is the inner supporting structure and is spongy. It makes up 20 percent of our bone mass. Normal cancellous bone is always undergoing remodeling on the inside surfaces of bone. Cancellous bone is found in the hip, spine, and femur.

The three main cells that form and shape bones are osteoblasts, osteocytes, and osteoclasts. Osteoblasts are bone-forming cells. When calcium is deposited in the cells, they make bones strong and hard. Osteocytes are mature osteoblasts trapped within the bone. Osteoclasts are bone-resorbing cells. They dissolve bone surfaces by releasing a chemical called an enzyme. Their activity is in part controlled by hormones in the body.

It is normal for bones to have mini fractures from everyday wear and tear. They are healed by ongoing bone remodeling. Bone remodeling occurs in 120 day cycles. Normal bone has a balance of clearing away old bone and formation of new bone. Osteoclasts resorb or clear away the damaged bone for the first 20 days. Bone is then formed by osteoblasts over the last 100 days.

Sacral insufficiency fractures usually are parallel to the spine. They are most often in the ala, just beside the sacroiliac joint. At times there is also a transverse fracture that connects insufficiency fractures when they occur on both sides of the sacrum. The fracture lines then create an “H” pattern. Sacral fractures are classified into three zones, zone 1, zone 2, and zone 3. If the fracture involves just the ala, there is usually not a risk for nerve damage.

Causes

What causes sacral insufficiency fractures ?

A physician named Lourie first described sacral insufficiency fractures in 1982. These fractures can cause severe pain in the buttock, back, hip, groin, and/or pelvis. Walking is typically slow and painful. Many daily activities become painful, difficult, and in some cases impossible.

Sacral insufficiency fractures occur when the quality of the sacral bone has become insufficient to handle the stress of weight bearing. The bone has lost some of its supporting structure and has become weak.

Osteoporosis is the leading cause of sacral insufficiency fractures. Osteoporosis is defined as low bone mass (weight). There is a decrease in bone tissue and minerals such as calcium. This can make the bones fragile. This means they can break more easily. Bone mineral density is measured by a DEXA scan. DEXA involves scanning the lumbar spine, the hip, and sometimes, the wrist. Osteoporosis affects 25 million people in the United States. Of these, 80 percent are females.

Other risk factors that can weaken bone include radiation to the pelvis, steroid use, rheumatoid arthritis, hyperparathyroidism, anorexia nervosa, liver transplantation, osteopenia, Paget’s disease, hip joint replacement, and lumbosacral fusion. Sacral insufficiency fractures can also occur in pregnant or breastfeeding women due to temporary osteoporosis.

Sacral insufficiency fractures can occur spontaneously, meaning there does not need to be any trauma such as a fall. The fracture can just simply happen when the bone becomes too weak to handle the stress of weight bearing. When the sacrum is fractured, 60 percent of the time the bone in front of the pelvis will also fracture. This bone is called the pubic ramus.

Symptoms

What does a sacral insufficiency fracture feel like ?

Unfortunately, sacral insufficiency fractures are often an unsuspected and undiagnosed cause of low back pain in elderly women. It was not until 1982 that they were described by a physician named Lourie.

Symptoms can include severe pain in the buttock, back, hip, groin, and/or pelvis. If the pubic ramus has fractured, there may be pain in the front of the pelvis. Walking is typically slow and painful. It can be difficult to do other necessary activities. Your back or pelvis may be tender to touch. You may find that you have limited range of motion of your low back.

Rarely there is nerve damage with sacral insufficiency fractures. When nerve damage does occur, the symptoms are usually problems with bowel or bladder function, or decreased sensation or strength of the leg(s).

Diagnosis

How do doctors diagnose the problem?

Your doctor will want to ask questions about your general health, what your symptoms feel like, and if there was any trauma that could have caused your symptoms.

Your doctor will want to perform a physical exam. This will likely include checking your nerve and spinal cord function, checking your range of motion, and feeling or tapping your back and pelvis to check for tenderness.

Your doctor will want you to have imaging of your pelvis. Plain X-rays are often negative. However, a fracture will be seen on bone scan, Computed Tomography (CT), or Magnetic Resonance Imaging (MRI).

Your doctor may order a bone scan with technetium-99m medronate ethylene diphosphonate (MDP). The MDP is injected into your vein. This should be performed after a minimum of 48 to 72 hours after symptoms begin. Where there is a fracture, the MDP will be concentrated. Uptake patterns on the scan may include the “H”-shape, also called the Honda sign when there is a sacral insufficiency fracture.

Single Photon Emission Computed Tomography (SPECT) is a new, advanced diagnostic nuclear medicine procedure that uses the emission of a radioisotope that is carried in the blood to the tissues. SPECT imaging is often added to provide information that is not available on routine bone scan images. It provides three-dimensional (3-D) views of the area examined. Following a bone scan you will remain on the exam table and the camera will rotate around the table while it takes pictures. SPECT imaging adds 30 to 60 minutes to the time of the nuclear scan. Sedation may be needed.

CT scan may be used to confirm and complement a positive bone scan. The CT scan uses special Xrays.

MRI is the radiological examination of choice by some doctors. Bone marrow edema on an MRI suggests a fracture. The MRI machine uses magnetic waves, not X-rays to show the bone and soft tissues.

Your doctor may request that you give samples of blood for the laboratory. This is to see if there could be another cause for osteoporosis that can be treated.

Treatment

What treatment options are available?

Most of the time treatment for sacral insufficiency fractures is non-surgical.

Nonsurgical Treatment

Treatment consists of rest, pain medications, and gradual walking with a walker or crutches. Improvement of symptoms may begin after one to two weeks of treatment. Most people are pain free in six to 12 months. Complete healing may occur after nine months. Most patients should have a full recovery.

Water exercise may be recommended to allow movement.

Bracing with a corset is sometimes helpful.

Medications that are used to help the fracture heal include calcium (1200-1500mg) and Vitamin D (400-800 IU). Bisphoshonates such as Actonel, Fosamax and Boniva are used to treat osteoporosis. Calcitonin is also used to help with pain and healing of the bone when broken. Parathyroid hormone (PTH) replacement can also be beneficial. It increases both bone resorption and bone formation. Bone mineral density is increased, making the bone stronger.

For pain, narcotics or opioids can be helpful. Some doctors feel that nonsteroidal anti-inflammatories (NSAID) such as Aleve or Ibuprofen should not be used for at least three to four weeks after a new fracture. Some studies have shown that they can slow fracture healing.

Your doctor may want you to have physical therapy to help with your pain. Heat, gentle massage, and electrical stimulation, or TENS units may improve pain.

Surgery

Surgical treatment is rare with sacral insufficiency fractures. A newer treatment that shows some promise in relieving pain and allowing more normal activity sooner is called a sacroplasty.

During sacroplasty, a bone glue called polymethylmethacrylate (PMMA) is injected into the fracture. Serious complications can occur if it is not performed correctly.

Sacroplasty may be considered in those with a severe decrease in functional ability and quality of life. It may provide faster relief of pain than typical conservative care. It is usually done in a surgery suite.

The area that is to be injected is cleaned and sterilized. This helps to decrease the possibility of an infection. A needle is placed in the area over the fracture. This is monitored with an X-ray machine. Bone glue is then injected and hardens rather quickly. This stabilizes the fracture. You are usually allowed to go home the same day.

If there are neurological symptoms from the sacral fracture, The sacrum may need to be stabilized. Hardware such as screws and plates may be used.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Previously, bedrest was the recommended treatment for sacral insufficiency fractures. There are many complications of prolonged bedrest, especially in the elderly.

Medical management presently allows limited weight bearing. This can be tolerated with a wheeled walker or crutches in most cases. Limited weight bearing actually helps to stimulate new bone growth.

In six to nine months, you should be able to return to your previous activity level.

If you have a sacroplasty, the fracture will be considered healed much more quickly. This allows you to return to your previous activity level sooner also. Your doctor will likely repeat imaging studies to check the progress of the healing fracture(s).

Treating osteoporosis is crucial in an attempt to decrease the risk of another insufficiency fracture. Your doctor will likely recommend additional calcium, vitamin D. A prescription medication to help prevent mineral loss from your bones is also commonly used. Regular follow up with your doctor is important. DEXA scans are usually repeated to ensure that the treatments for your osteoporosis are working.

Weight bearing activities such as walking, and lifting light weights can be helpful. Avoiding excessive caffeine, alcohol, and smoking is important.

After Surgery

You will likely have to remain non-weight bearing for a period of time before being allowed to walk with a walker or crutches. You will need assistance for daily activities initially. This may mean that you will have to have live-in help, or stay in an extended care facility or nursing home.

Once allowed, your surgeon may want a physical therapist to help with walking and maintaining strength. Your surgeon may want an occupational therapist to help you with equipment that may be helpful, showering, dressing, and other daily activities.

Your surgeon will want you to follow up with him or her on a regular basis to check on how the fracture is healing. Imaging studies will be repeated. Healing should occur in six to 12 months. If the fracture heals properly, you should be able to return to your usual activities.

Treating osteoporosis is crucial in an attempt to decrease the risk of another insufficiency fracture. Your surgeon will likely recommend additional calcium, vitamin D. A prescription medication to help prevent mineral loss from your bones is also commonly used. Regular follow up with your doctor is important. DEXA scans are usually repeated to ensure that the treatments for your osteoporosis are working.

When allowed, weight bearing activities such as walking, and lifting light weights can help keep your bones strong. Avoiding too much caffeine, alcohol, and smoking is important.

Pes Anserine Bursitis of the Knee

A Patient’s Guide to Pes Anserine (Goosefoot) Bursitis

Introduction

Bursitis of the knee occurs when constant friction on the bursa causes inflammation. The bursa is a small sac that cushions the bone from tendons that rub over the bone. Bursae can also protect other tendons as tissues glide over one another. Bursae can become inflamed and irritated causing pain and tenderness.

This guide will help you understand

what part of the knee is affected
what causes this condition
how doctors diagnose this condition
what treatment options are available

Anatomy

What parts of the body are involved?

The pes anserine bursa is the main area affected by this condition. The pes anserine bursa is a small lubricating sac between the tibia (shinbone) and the hamstring muscle. The hamstring muscle is located along the back of the thigh.

There are three tendons of the hamstring: the semitendinosus, semimembranosus, and the biceps femoris. The semitendinosus wraps around from the back of the leg to the front. It inserts into the medial surface of the tibia and deep connective tissue of the lower leg. Medial refers to the inside of the knee or the side closest to the other knee.

Just above the insertion of the semitendinosus tendon is the gracilis tendon. The gracilis muscle adducts or moves the leg toward the body. The semitendinosus tendon is also just behind the attachment of the sartorius muscle. The sartorius muscle bends and externally rotates the hip. Together, these three tendons splay out on the tibia and look like a goosefoot. This area is called the pes anserine or pes anserinus.

The pes anserine bursa provides a buffer or lubricant for motion that occurs between these three tendons and the medial collateral ligament (MCL). The MCL is underneath the semitendinosus tendon.

Related Document: A Patient’s Guide to Knee Anatomy

Causes

What causes this problem?

Overuse of the hamstrings, especially in athletes with tight hamstrings is a common cause of goosefoot. Runners are affected most often. Improper training, sudden increases in distance run, and running up hills can contribute to this condition.

It can also be caused by trauma such as a direct blow to this part of the knee. A contusion to this area results in an increased release of synovial fluid in the lining of the bursa. The bursa then becomes inflamed and tender or painful.

Anyone with osteoarthritis of the knee is also at increased risk for this condition. And alignment of the lower extremity can be a risk factor for some individuals. A turned out position of the knee or tibia, genu valgum (knock knees), or a flatfoot position can lead to pes anserine bursitis.

Symptoms

What does the condition feel like?

The patient often points to the pes anserine as the area of pain or tenderness. The pes anserine is located about two to three inches below the joint on the inside of the knee. This is referred to as the anterior knee or proximedia tibia. Proximedia is short for proximal and medial. This term refers to the front inside edge of the tibia.

Some patients also have pain in the center of the tibia. This occurs when other structures are also damaged such as the meniscus (cartilage). The pain is made worse by exercise, climbing stairs, or activities that cause resistance to any of these tendons.

Diagnosis

How do doctors diagnose this problem?

A history and clinical exam will help the physician differentiate pes anserine bursitis from other causes of anterior knee pain, such as patellofemoral syndrome or arthritis. An X-ray is needed to rule out a stress fracture or arthritis. An MRI may be needed to look for damage to other areas of the medial compartment of the knee. Fluid from the bursa may be removed and tested if infection is suspected.

The examiner will also assess hamstring tightness. This is done in the supine position (lying on your back). Your hip is flexed (bent) to 90 degrees. The knee is straightened as far as possible. The amount of knee flexion is an indication of how tight the hamstrings are. If you can straighten your knee all the way in this position, then you do not have tight hamstrings.

Treatment

What treatment options are available?

Nonsurgical Treatment

The goal of treatment for overuse injuries such as pes anserine bursitis is to reduce the strain on the injured tissues. Stopping the activity that brings on or aggravates the symptoms is the first step toward pain reduction.

Bedrest is not required but it may be necessary to modify some of your activities. This will give time for the bursa to quiet down and for the pain to subside. Patients are advised to avoid stairs, climbing, or other irritating activities. This type of approach is called relative rest

Ice and antiinflammatory medications can be used in the early, inflammatory phase. The ice is applied three or four times each day for 20 minutes at a time. Ice cubes wrapped in a thin layer of toweling or a bag of frozen vegetables applied to the area works well.

Athletes are often instructed by their physical therapist or athletic trainer to perform an ice massage. A cup of water is frozen in a Styrofoam container. The top edge of the container is torn away leaving a one-inch surface of ice that can be rubbed around the area. The Styrofoam protects the hand of the person holding the cup while applying the ice massage. The pes anserine area is massaged with the ice for 10 minutes or until the skin is numb. Caution is advised to avoid frostbite.

Over-the-counter nonsteroidal antiinflammatory drugs (NSAIDs) such as Ibuprofen may be advised. In some cases, the physician will prescribe stronger NSAIDs. Your physical therapist can also use a process called iontophoresis. Using an electric charge, an antiinflammatory drug can be pushed through the skin to the inflamed area. This method is called transdermal drug delivery. Iontophoresis puts a higher concentration of the drug directly in the area compared to taking medications by mouth. This process does not deliver as much drug as a local injection.

Improving flexibility is a key part of the prevention and treatment of this condition. Hamstring stretching is performed at least twice a day for a minimum of 30 seconds each time. Holding the stretch for a full minute has been proven even more effective. Some patients must perform this stretch more often, even once an hour if necessary.

Do not bounce during the stretch. Hold the position at a point of feeling the stretch but not so far that it is painful or uncomfortable. Deep breathing can help ease the discomfort. Try to stretch a little more as you breathe out.

Quadriceps strengthening is also important. This is especially true if there are other areas of the knee affected. The quadriceps muscle along the front of the thigh extends the knee and helps balance the pull of the hamstrings.

A special type of exercise program called closed kinetic chain (CKC) is performed for six to eight weeks to assist with quadriceps strengthening. The CKC may include single-knee dips, squats and leg presses. Resisted leg-pulls using elastic tubing are also included. The exercise program is prescribed by a physical therapist and gradually progressed during the eight-week session.

If these measures are not enough, your physician may inject the bursa with a solution of lidocaine (an anesthetic or numbing agent) combined with a steroid (an antiinflammatory). The steroid injection can be diagnostic as well. If the symptoms are improved, it is assumed the problem was coming from the pes anserine bursa.

Surgery

Surgery is rarely needed for pes anserine bursitis. The bursa may be removed if chronic infection cannot be cleared up with antibiotics.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Pes anserine bursitis is considered a self-limiting condition. This means it usually responds well to treatment and will resolve without further intervention. Athletes may have to continue a program of hamstring stretching and CKC quadriceps strengthening on a regular basis.

Athletes may return to sports or play when the symptoms are gone and are no longer aggravated by certain activities. Protective gear for the knee may be needed for those individuals who participate in contact sports. During the rehab process, activity level and duration are gradually increased. If the symptoms don’t come back, the athlete can continue to progress to full participation in all activities.

After Surgery

If the bursa is removed, you follow the same steps of rehab and recovery outlined under Nonsurgical Treatment.

Treatment Guidelines for Low Back Pain

A Patient’s Guide to Treatment Guidelines for Low Back Pain

Introduction

In the United States low back pain is ranked number five among the most common reasons for physician office visits. Of the patients who get medical care, they usually improve rapidly in the first month. However, up to one-third of patients report chronic back pain of at least moderate severity.

Many diagnostic tests and treatments have been tried for low back pain. Many things may be suggested, but have little evidence to show their worth. Diagnostic tests and treatments for low back pain can also be costly. In 1998, it is estimated that 26.3 million dollars were spent in the U.S. On health care for low back pain.

What to do about back pain can be confusing for both you and your provider. The American College of Physicians (ACP) and the American Pain Society (APS) recently had a panel review and analyzed available research on acute and chronic low back pain in adults.

The panel’s recommendations were considered proven only when they were supported by at least fair-quality evidence. They also had to have at least moderate benefits. Some were considered proven even with small benefits if there were no significant harms, costs, or burdens.

This guide will give you a general overview of the newly recommended
guidelines for the evaluation, diagnosis, and treatment of acute and chronic low back pain in adults.

This guide will help you understand

how your doctor will evaluate your low back pain
what diagnostic tests are recommended
what treatment options are recommended based on evidence

Recommendation 1:

Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).1

Your doctor will want to do a history and physical examination to determine if there is a specific reason for your low back pain. It is important for your doctor to determine if there is neurologic (nerve) involvement. Your back pain can then be placed into one of three categories:

non-specific back pain
back pain with radiculopathy (leg pain)
back pain from another specific source (fracture, infection, tumor, etc.)

The most common category is non-specific back pain. This means that the cause of the pain is unknown. More than 85% of patients evaluated in the primary care setting with low back pain have non-specific low back pain. This means there are no findings of a specific disease or spinal abnormality.

Another category is back pain with leg pain. Leg pain is called radiculopathy or sciatica. This may be caused by a problem with a disc between the bones of the spine. Discs may be torn (annular tear), bulged (protruded), or ruptured (herniated). Leg pain can also be caused by stenosis. Stenosis happens when the hollowed out portion of the bones of the spine become narrowed. The spinal cord lies in the hollowed out portion. When it becomes narrow, the spinal cord can become pinched. Stenosis can also happen when there is narrowing of the opening for the nerve root. The nerve root branches off the spinal cord.

Other specific spinal causes of low back pain include fracture, infection, tumor, cancer, and inflammatory arthritis.

Spinal cord and nerve function can be evaluated in several ways. Straight leg raise (SLR) test is when your doctor lifts your leg up while the knee is kept straight. This can be useful in diagnosing a herniated disc. Your doctor will want to check the strength of various muscles in the legs. Reflexes at the knees and ankles should be evaluated also. Sensation of the leg also evaluates nerve function.

Other signs that there may be a neurological problem include loss of bowel or bladder function.

Your doctor will ask questions about the possibility of low back pain that comes from problems outside the back. Sometimes pain is from the pancreas, kidneys, or bulging of the large blood vessel in the abdomen called the aorta. Your doctor will also want to know about risk factors for cancer and infection.

Your doctor will ask about any problems with your mood, stress, or problems at home or on the job. Psychosocial factors are known to make your back pain worse, or interfere with your back pain getting better. These include depression, passive coping strategies, job dissatisfaction, disputed compensation claims, and being overly focused on physical symptoms. These problems can predict the course of low back pain even more so than findings on the physical exam, or the severity of your pain.

Recommendation 2:

Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).1

There is no evidence that routine plain x-rays in patients with nonspecific low back pain improve patient outcomes. They subject you to a significant amount of radiation. The amount of radiation to reproductive (sperm and egg) cells from two views of the lumbar spine is equivalent to being exposed to a daily chest x-ray for more than one year.

Plain x-rays are recommended when there is the possibility of compression fracture of the vertebra bone. High-risk patients are those with a history of osteoporosis or steroid use.

Your doctor may want you to have imaging when nonspecific low back pain (without symptoms of radiculopathy or spinal stenosis) becomes persistent (lasting more than four to eight weeks). There is no optimal evidence to make a recommendation as to which imaging study is most useful in this case.

Recommendation 3:

Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).1

Neurologic deficits or the suspicion of a serious underlying condition such as cancer or infection merit a prompt work-up with Magnetic Resonance Imaging (MRI) or Computed Tomography (CT). Delayed diagnosis is linked to worse outcomes.

MRI allows your doctor to look at slices of the area in question. The MRI machine uses magnetic waves, not x-rays to show the soft tissues of the body. This includes the spinal cord, nerves, and discs. It can also evaluate spinal bones. The test may require that a dye be injected intravenously (through a vein).

CT scans are a form of x-ray. MRIs are generally preferred over CTs since it does not use radiation.

If you have risk factors for cancer, the recommendations are for either x-rays, blood work to measure erythrocyte sedimentation rate (ESR), or an MRI.

Recommendation 4:

Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with MRI (preferred) or CT only if they are potential candidates for surgery or epidural steroid injection (strong recommendation, moderate-quality evidence).1

Most patients with lumbar disc herniations with radiculopathy improve with noninvasive therapy (treatments other than spinal injections or surgery) within the first four weeks.

If symptoms of radiculopathy become persistent after noninvasive therapies, the panel recommends surgical removal of the disc or epidural steroid injections as possible treatment options. Surgery is also a treatment option for spinal stenosis with persistent symptoms.

Recommendation 5:

Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).1

Your doctor should inform you that an acute episode of low back pain with or without radiculopathy or sciatica should more than likely improve in the first month.

The evidence shows that staying active is more effective than resting in bed. Return to normal activities as soon as possible should be encouraged. Self-care education books are inexpensive and have shown to be helpful. Their benefits are similar to costlier therapies such as supervised exercise, acupuncture, massage, and spinal manipulation.

The panel authors did not find sufficient evidence to guide specific recommendations about modified work on the job. Factors to consider are your age, general health, and physical demands of your required job tasks.

Use of heating pads may provide short-term relief of acute low back pain. There is not adequate evidence to recommend lumbar supports and cold packs.

Recommendation 6:

For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs).1

Medications from several classes have been shown to have moderate, mostly short-term benefits for patients with low back pain.

Acetaminophen (Tylenol®) is a slightly weaker pain medication than non-steroidal anti-inflammatories (NSAIDs). However, acetaminophen is generally safer and less costly. Acetaminophen can cause liver enzyme elevations at dosages of 4 g (4,000 mg)/day even in healthy adults. The clinical significance of the liver enzyme elevation is uncertain.

NSAIDs can be selective, or non-selective. Advil® and Motrin® (ibuprofen); and Aleve® (naproxen) are examples of over-the-counter non-selective NSAIDs. Celebrex® is the only selective NSAID available in the United States. Nonselective NSAIDs, while more effective than acetaminophen, are known to cause stomach and kidney problems. Selective NSAIDs such as Celebrex® and most non-selective NSAIDS also increase risk for heart attack. The lowest effective doses for the shortest periods necessary are recommended. If you benefit from nonselective NSAIDs, taking a medication to protect the stomach lining may be beneficial and more cost-effective than a selective NSAID. It was also recommended that doctors remain alert for new evidence about the safety of NSAIDs. There is not enough evidence to recommend for or against aspirin to treat low back pain.

When used carefully opioid analgesics (Tramadol) are an option in the management of acute or chronic severe, disabling low back pain. Potential risks such as addiction and abuse should be considered before starting them. There is not enough evidence to recommend one opioid over another.

Skeletal muscle relaxants may provide short term relief of acute low back pain. There is no convincing evidence that skeletal muscle relaxants differ in effectiveness or safety. Sedation can be a problem with any of the muscle relaxants.

Tricyclic antidepressants such as Pamelor® have demonstrated effectiveness in the management of chronic low back pain. Selective serotonin reuptake inhibitors (SSRIs) such as Prozac®, Zoloft®, Celexa® and Lexapro®, and trazodone have not shown that they are effective for low back pain. Serotonin-norepinephrine reuptake inhibitors (SNRIs) have not yet been evaluated for low back pain. Since depression is common in patients with chronic low back pain, it should be properly treated.

Small, short-term benefits for the treatment of leg pain or radiculopathy have been found with gabapentin (Neurontin®). There is not adequate evidence to recommend for or against other similar drugs for radiculopathy.

Benzodiazepines such as Valium® (diazepam) provide short-term pain relief for acute or chronic low back pain. However, they can be abused, cause addiction, and require more of them to get the same result. When benzodiazepines are used, a time-limited course is recommended.

Herbal therapies including devil’s claw, willow bark, and capsicum seem to be safe options for acute exacerbations of chronic low back pain.

Systemic corticosteroids have not been shown to be helpful in the treatment of low back pain with or without sciatica.

Overall, evidence is limited on the benefits and risks when medications are used long-term for low back pain.

Recommendation 7:

For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).1

Spinal manipulation may provide small to moderate short-term benefits for acute low back pain. Supervised exercise therapy, home exercise regimens, and other non-medication treatments have not been proven to be effective for acute low back pain.

For subacute low back pain (lasting four to eight weeks), intensive interdisciplinary rehabilitation is moderately effective. This usually includes the services of a physician, psychologist, physical therapist, social worker, or vocational counselor. Active physical therapy to restore function and a form of psychological treatment called cognitive-behavioral therapy (CBT) are shown to reduce time off work due to low back pain.

For chronic low back pain there are non-medication treatments with fair to good supporting evidence and moderate benefit. These include acupuncture, massage therapy, and Viniyoga-style yoga. Exercise therapy has also shown fair to good supporting evidence. This includes individualized, supervised stretching, and strengthening therapy. Cognitive-behavioral therapy (CBT) or progressive relaxation, spinal manipulation, and intensive interdisciplinary rehabilitation have also shown moderate benefit. Short-term benefits may be obtained with back schools, but the evidence is inconsistent.

Transcutaneous electrical nerve stimulation (TENS) and intermittent or continuous traction have not been proven effective for chronic low back pain. There is insufficient evidence to recommend interferential therapy, low-level laser, shortwave diathermy, or ultrasound for chronic low back pain.

Lastly, the panel recommends that patient expectations of benefit from a treatment be considered when choosing therapies. They found that this seems to positively influence outcomes.

1. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine 2007. Vol. 147, No. 7. Pp. 478–491.

Intraoperative Monitoring

A Patient’s Guide to Intraoperative Monitoring

Introduction

Spine surgery can be unpredictable and potentially dangerous because it can involve areas near nerves and the spinal cord. During spinal surgery, there is a risk that damage to the nervous system can occur. This is especially true when hardware or instrumentation is used and inserted near nerves, or when a curvature of the spine is corrected. It is important for surgeons to be able to have someone experienced to monitor nerve tissue while doing the operation.

The nervous system can be monitored during spine surgery to make it safer. The term commonly used for monitoring the nervous system during surgery is intraoperative monitoring, or intraoperative neurophysiologic monitoring (IOM). Intraoperative monitoring is not only being used for complex spinal surgeries but is widely used for other surgeries too. Some of these include brain surgery, ear surgery, and surgery involving arteries.

This guide will help you understand

what is intraoperative monitoring
why is intraoperative monitoring important
when is intraoperative monitoring used
what happens during surgery
what are possible complications

Anatomy

What parts of the spine are involved?

The spine is divided into various parts. The upper portion is the cervical spine, or neck. The middle portion is the thoracic spine, or trunk. The lower portion is the lumbar spine, or low back. There are bony blocks called vertebrae that make up the spine. They are stacked on top of one another. There are discs that separate the vertebrae and provide cushion. The spinal cord is protected by the bony spine. It lies in a hollowed area, or arch made by the bony spine. This is called the spinal canal.

Projecting from the spinal cord are nerves that travel to limbs, the trunk, and internal organs. The spinal cord is similar to a tree trunk. The nerves are like branches. The portion of the nerve as it branches off of the spinal cord is called the nerve root. The spinal cord sends and receives messages to and from the body and the brain. The nerves that branch off of the spinal cord go to various body parts to provide sensation and motor function or movement.

Nerve tissue is delicate and can be damaged relatively easily. When damage is done to the spinal cord or nerve, it may cause sensory and/or motor changes in the affected body part. The damage may be permanent.

What is intraoperative monitoring?

Intraoperative neurophysiological monitoring (IOM) uses equipment to evaluate the function of the spinal cord and nerves during spine surgery. Its role is to provide the surgeon with immediate feedback and warning before permanent nerve injury has occurred. This has been shown to increase safety and improve outcomes in complex spine surgery.

Intraoperative neurophysiological monitoring (IOM) began with the use of somatosensory evoked potentials (SSEPs). This measures the conduction of sensation above and below the area of surgery. During spinal surgery, electrodes are placed on limbs that could be affected by the surgery. Electrodes are also placed on the surface of the skull over the area of the brain where the impulse from the limb is received. A machine is used to monitor the electrical activity in the brain just like an electroencephalogram (EEG). The electrical activity is recorded as waves. When the limb is stimulated with an electrical current by the surgeon or technician, there should be a response in the brain. This checks the function of the sensory portion of the nerves and spinal cord.

Somatosensory evoked potentials (SSEPs) are the most widely used intraoperative neurophysiological monitoring during surgery. However, SSEP monitoring may not detect injuries to individual nerve roots.

In the 1980’s surgeons began using electromyography (EMG) to monitor the motor portion of the nerves during spinal surgery. It is becoming more commonly used. During surgery, while the patient is asleep, needle electrodes are placed in the muscle groups that correspond to the area where the surgeon will be working. Electrical activity from the muscle can be monitored by a machine. The activity is recorded as waves, similar to the SSEP monitor. It is also similar to the waves that are recorded from the heart muscle during an electrocardiogram (ECG). Baseline recordings are taken before the surgery begins. Recordings are then repeated throughout the procedure. A significant change in the wave alerts the surgeon or technician that the nerve in the area could be damaged. The surgeon can then take action to prevent permanent damage.

EMG seems to be more accurate in identifying potential neurological damage than other methods of monitoring that have been used. However, it is not useful when muscle paralyzing agents are used for anesthesia. It is also not useful if a nerve root has been cut completely.

Studies show that the use of both SSEPs and EMG monitoring during spinal surgery is most ideal but not always available.

Other monitoring available includes rectal and urinary sphincter electromyography, motor-evoked potentials (MEPs), transcranial electrical stimulation (TES), brainstem auditory evoked potential (BAEP), dermatomal evoked potentials (DEP), facial nerve monitoring, and spinal cord mapping.

Why is intraoperative monitoring important?

Spine surgery can be unpredictable and dangerous because it can involve areas near nerves and the spinal cord. During spinal surgery there is a risk that damage to the nervous system can occur. Intraoperative neurophysiological monitoring allows the surgeon to know, during the surgery, if/when nerve tissue is being injured or is at risk for being injured. The problem can be corrected immediately. Intraoperative neurophysiological monitoring (IOM) allows assessment of nerve tissue function while the surgery is taking place. Many complications involving the nervous system can be avoided with careful monitoring during surgery. This makes spine surgery safer. It is also proven to improve the outcomes of spinal surgery. It is being used more commonly, especially during complicated spinal surgery.

Spine surgery often involves the use of instrumentation (hardware). This hardware may include screws, rods, plates, and cages. The complication rate from instrumentation with lumbar spine fusion varies from one to 33 per cent. Possible complications from placement of hardware include damage to the spinal cord and nerve roots. Up to 10 per cent of the time, pain and sensory changes in the portion of the limb affected can result. This is called radiculopathy. One per cent of the time, motor change or weakness in the portion of the limb affected at that surgical level can occur. This is called myelopathy. Neither of these outcomes is desirable after spine surgery.

Surgeons have relied on imaging, most usually X-rays and computed tomography (CT) scans to check the placement of hardware during surgery. However, there are times when these do not show improperly placed hardware, fracture of spinal bone, or damage to nerve tissue.

Intraoperative neurophysiological monitoring (IOM) is more effective in sensing neurological damage, and misplacement of hardware. In fact, some studies show that it is one-third more effective than imaging with X-ray or CT scan.

Until intraoperative neurophysiological monitoring, surgeons commonly relied on the wake up test and the clonus test to evaluate nerve function during surgery. However, these are more difficult to repeat during the surgery, can lengthen the time of surgery, and do not fully evaluate nerve function. The wake up test involves allowing the patient to wake up from the anesthesia. The patient is then asked to move body parts that may be affected by the surgery. The clonus test involves the surgeon quickly jerking the foot towards the shin to see if the stretch reflex still works. This assesses the function of the spinal cord.

Intraoperative neurophysiological monitoring (IOM) is quick, painless, easy, and inexpensive. Recordings can be taken several times during surgery or even throughout the entire procedure. It does not cause harm to the patient. It also provides real-time feedback to the surgeon. It is safe and effective for reducing nerve tissue damage during surgery.

When is intraoperative monitoring used for spinal surgery?

Some spine surgeons may prefer to use intraoperative monitoring during most (if not all) of their surgeries. Others prefer to use it during complex surgeries. It is commonly used for the following spinal surgeries:

All spinal cord cases
Spinal instrumentation with hardware
Scoliosis
Discectomy with a neurological deficit
Decompression with a neurological deficit
Total disc replacement
Pain stimulator placement
Corpectomy
Vertebrectomy
Odontoid/Dens fractures

What happens during surgery?

After you are put to sleep by the anesthesiologist, small wire electrodes are placed in the muscles of your lower leg for lumbar surgery. They may be placed in the arms for neck surgery. For EMG monitoring, the electrodes are placed in specific muscles that correspond with a specific level in the spinal cord.

Technically, EMG monitoring is relatively easy, and the setup takes practically no additional time during positioning for the surgical procedure.

Intraoperative monitoring is technically done by a technician who is in the operating room during the entire procedure. A neurophysiologist may be involved in interpreting the recordings generally at a remote location where they observe the same data as seen by the technologist. This real-time interpretation by an experienced neurophysiologist is the standard of care in many regions in the United States.

If the spinal cord or nerve roots are damaged while drilling into bone, placing hardware in the spine, or decompressing the spine, the SSEP or EMG signal will change. This alerts the technician who can then alert the surgeon. Some monitoring units are equipped with a loudspeaker that allows immediate audio feedback. The surgeon can make a change at that time to avoid damage to nerve tissue.

When pedicle screws are used, the surgeon may use a handheld probe that can give an electrical stimulation to the pedicle screw once it has been placed. If the screw is where it is supposed to be, it will take a certain amount of current to cause a muscle contraction and wave on the monitor. If it is misplaced, it will take less. This is called an evoked EMG.

The surgeon can then re-evaluate the placement of the screw in order to avoid harm to the nerve root or spinal cord.

SSEPs and EMG recordings can be taken several times during the surgery if necessary without causing harm to the patient.

What are possible complications of intraoperative monitoring?

There really are none. The surgery need not be interrupted unnecessarily during surgery when neurophysiological monitoring is used. This is safer for the patient. Because the skin is penetrated with needle electrodes, there is a small risk for infection. This is minimal as the skin is disinfected before the needles are placed. The needles are sterile. They are thrown away after a single use. Mild soreness may be experienced where the needles were inserted.

Intraoperative monitoring is usually not costly. It is well worth it to avoid neurological complications during spinal surgery when possible.

Complementary and Alternative Medicine

A Patient’s Guide to Pain Management: Body Talk

Introduction

Complementary and alternative medicine (CAM) has become more and more popular as a way to maintain or regain health. CAM refers to a wide range of therapies that complement (go along with) traditional approaches. But when allopathic doctors (those who practice traditional medicine) combine efforts with others who provide alternative care, the practice is referred to as complementary and integrative medicine (CIM).

Body Talk is one of these CIM treatment methods offered by medical doctors and other health care professionals. Alternative or nontraditional care of this type tends to be more holistic in the way we view the whole patient.

This guide will help you understand

what body talk is
how body talk works
who can benefit from body talk
what to expect from body talk

Each individual is viewed as a whole including the mind, body, emotions, and spirit. Holistic reflects the idea that these parts can’t be separated. It is believed that they are held together by energy that flows throughout the body.

Anything that disrupts this energy force alters the balance of health and can result in distress, disease, and other unnatural conditions. By rebalancing the mind-body vital life force, the body can heal itself and restore natural health and an inner balance among all the systems.

What is Body Talk?

Body Talk is an alternative form of health care that allows the body’s energy systems to regain homeostasis. Homeostasis is the stable, normal state of any body system. Injuries, illness, surgery, and stress are just a few examples of things that can cause the body to function less optimally or become unbalanced.

Body Talk encompasses a wide range of knowledge from Western medicine, Chinese acupuncture, and osteopathic and chiropractic philosophy. It even incorporates up-to-date physics and mathematics concepts. The goal of Body Talk is to resynchronize or rebalance the body’s energy systems. It is considered a form of energy medicine designed to optimize the body’s internal communications.

How Body Talk Works

When the body is functioning normally and maintaining homeostasis, each system, organ, and microscopic cell are in constant communication with each other. Anything that disrupts this balance can compromise these lines of communication. When communication is altered, overloaded, or cut off, there can be a decline in holistic health. Again, this includes body function and/or emotional, psychologic, and spiritual health.

The Body Talk method relies on using neuromuscular biofeedback to reconnect and integrate communication pathways. The practitioner uses muscle testing and a series of “yes” or “no” questions to find imbalances that the innate wisdom of the body considers a priority.

Rather than treating the final signs and symptoms of dysfunction, the original layers of miscommunication or broken communication are restored first. Any area that is not communicating correctly or is out of balance with the rest of the body is linked back together.

The practitioner helps the body return to a state of homeostasis or balance by focusing on the areas that have been identified as a priority. Then the practitioner gently taps on the patient’s head (alerting the brain to the new communication pathways) and on the sternum (storing the new information in the heart to be passed on throughout the rest of the body).

Literally by tapping into the nervous system, Body Talk has been effective in turning off areas of physiologic function that are over working. Using this same method, Body Talk can turn on areas that may not be working at all or functioning less than optimally.

Likewise, for patients experiencing chronic pain, the nervous system may have set up a negative feedback loop involving stress, pain and emotion. As we respond to a stressor, our nervous system is aroused and we become tense and hyperalert.

This is called the fight, flight, or freeze response. Muscles contract and don’t relax even when we think we are at rest. The function of our organs and endocrine systems may be put on hold but don’t get turned back to a state of homeostasis.

The more tense and aroused we are in response to a stressor, the more uncomfortable we are emotionally, and the more we hurt. The more uncomfortable and sore we are, the tenser we become and so on. Body Talk helps re-establish normal patterns of energy flow and communication between the brain, nervous system, and body.

Who Can Benefit from Body Talk?

Anyone can benefit from the balancing Body Talk offers regardless of age, health, or diagnosis. Some rely on it to maintain a healthy balance, while others use it to restore health. Body Talk has provided benefits to many individuals with a wide range of problems including headaches, infections, viruses, back pain, allergies, digestive disorders, and chronic fatigue.

Athletes and sports participants may seek out the skills of a Body Talk practitioner to enhance performance or speed recovery from sports injuries. Other individuals with learning disorders, phobias, and emotional disorders have been helped by this method.

What You Can Expect from Body Talk

The Body Talk process restores function at optimal levels to speed up healing. Because communication pathways between cells, organs, and systems are balanced, the patient experiences more than just short-term relief from symptoms. The overall flow and balance of energy throughout the body is vastly improved.

The corrected energy patterns are stored in the body’s cellular memory. Long-term improvement in health is the expected result. Body Talk is a noninvasive technique that is safe and effective. Benefits can be seen immediately. It can be used alone or in conjunction with other CIM/CAM techniques.

Body Talk does not diagnose or treat specific diseases, conditions, or disorders. Some individuals may still need medical care from a traditional allopathic (medical) doctor.

Where Can I Go to Get Body Talk?

Certified Body Talk practitioners must undergo a rigorous series of steps in training before taking both a written and a practical test. This assures that you receive care from a practitioner who is adequately trained.

Many health care organizations and private clinics in the United States and around the world offer these services. You can find more information and the location of a practitioner near you by contacting the International Body Talk Association at www.bodytalksystem.com or by calling 1-877-519-9119 (U.S. only).

Back Pain in Children

A Patient’s Guide to Back Pain in Children

Introduction

Until recently, a complaint of back pain in a child or adolescent was considered uncommon. It was usually associated with a certain condition such as tumor, curvature of the spine, a broken spinal bone, inflammation, or infection.

However, more recently, reports of back pain is much more common among children. By the age of 15, 20 to 70 percent of children will report back pain. It is seldom associated with a serious condition, particularly as age increases. Even though the majority of children will not have a serious condition, there is still a small portion that do.

This guide will give you a general overview of back pain in children. It will help you understand:

What parts make up the spine
What causes back pain in children
How the diagnosis is made
What treatment options are available

Anatomy

What parts make up the spine?

The spine is made up of a column of bones. Each bone, or vertebrae, is formed by a round block of bone, called a vertebral body. A bony ring attaches to the back of the vertebral body, forming a canal for the spinal cord.

Facet joints are small joints on either side of the spine that allow motion. As the bones of the spine interlock, a facet joint is formed. Each vertebra will form two facet joints on either side. There is a pair at the top and a pair at the bottom of each vertebra. The area of the vertebrae bones that is between the upper and lower facet joints is called the pars articularis or pedicle.

Intervertebral discs form a cushion between the round blocks of bone making up the vertebral body. The area of the bone where the disc attaches to the vertebra is called an end plate. Discs are a collection of tough tissue similar to a ligament. They are filled with fluid when healthy.

There are three general portions of the spinal column. The cervical or neck portion, the thoracic portion making up the mid-back, and the lumbar or lower portion. The lumbar portion connects with the pelvis at the sacrum.

There are specific curves associated with each region of the spine. When looking from the side, the cervical spine has an inward curve called a lordosis. The thoracic spine curves outward and is called a kyphosis. The lumbar spine usually has a lordosis. These three curves maintain balance of the spine in a forward and backward plane.

When these curves are exaggerated or absent, the condition is called scoliosis.

Causes

What can cause back pain in children?

There are several red flag warning signs that may suggest a specific cause for back pain. Night pain, constant pain, or pain that spreads into the buttocks or legs are some of them. Leg weakness or bowel and bladder problems can indicate nerve or spinal cord problems.

Conditions that can cause back pain are grouped into nonspecific, meaning the cause is unknown; and specific back pain, meaning there is an identified cause for the back pain.

Nonspecific back pain means that there is no specific structural reason or cause for back pain. Approximately 60 to 75 percent of children reporting back pain will have non-specific back pain. Their physical exam and X-rays will be normal. It is usually considered a muscle strain or from poor posture.

In some cases, non-specific back pain may be related to mood problems such as depression or anxiety. It sometimes is related to problems at school or with peers. Visits with a school counselor or psychologist may be recommended.

Approximately 25 to 40 percent of children will have changes in imaging studies (such as X-ray or MRI) that indicate a pathological (specific) cause for their back pain. These include the following:

Spondylolysis is a fracture of the pars interarticularis or pedicle(s), usually of the L5 or last lumbar vertebrae. This is most likely caused by an injury. It may also be caused by repetitive activity. The activities that most likely cause spondylolysis include extension (bending backwards) and rotation. Sports that put athletes at higher risk include ballet, gymnastics, football, high jumping, diving, rowing, and weight lifting.

Spondylolysis is a common cause for back pain in children, especially those that are active in sports. It may happen in four to five percent of children by the age of six, and up to six percent of adults. Spondylolyis is three times more common in boys than girls. Growth spurts and involvement in contact sports may explain the difference between boys and girls.

Early on, X-rays may not show a fracture. Special imaging such as MRI, CT, or SPECT bone scan may show signs of a stress fracture. Spondylolysis may cause pain in a particular spot in the low back and spasm of the muscles along the spine. Often it will cause pain into the buttocks or thighs. Spondylolysis will likely heal with a change in activity, rest, and avoiding hyperextension and rotation. Bracing may be helpful if symptoms do not get better.

Spondylolisthesis occurs when spondylolysis worsens or does not heal. It can cause slippage of one vertebra on the other. This slippage is called spondylolisthesis. The slippage is graded from I through IV, one being mild, IV often causing neurological symptoms.

Scoliosis or curvature of the spine may be a source of back pain in children. Most cases of scoliosis only require watching for worsening. However, some may need bracing and even surgery. Sometimes a scoliosis is caused by tumor or infection of the spine.

Related Document: A Patient’s Guide to Scoliosis

Scheuermann’s kyphosis is a deformity where there is wedging of three or more vertebrae in a row in the thoracic region. Wedging means that the vertebra is wider towards the back, and narrower towards the front. The vertebra has lost its usual rectangular shape. This causes increased curvature or forward bending of the spine. This curvature is called kyphosis. The curve from a sideways view can be 50 degrees or more. If the curvature is greater than 75 degrees, surgery to straighten the spine may be necessary.

There may also be narrowing of the disc spaces between the vertebrae. Most of the time there are also Schmorl’s nodes seen in the endplate of a vertebral body or several vertebrae. On imaging studies these look like small hollowed areas.

Discitis and vertebral osteomyelitis are rare in children. When a disc becomes inflamed and possibly infected, the condition is called discitis. If the vertebral bone becomes infected, the condition is called vertebral osteomyelitis.

Common symptoms of these conditions include refusal to crawl, sit, or walk and back pain. A limp and forward bending while placing the hands on thighs for support are also common signs. Fever of 102 degrees Fahrenheit or greater is common in vertebral osteomyelitis.

With discitis, the disc will appear narrowed on an X-ray or an MRI. Discitis usually happens in children less than five years old.

In vertebral osteomyelitis, the vertebral bone and surrounding tissue including the disc can become infected. On X-ray or MRI the bone and/or tissue can show destruction. Vertebral osteomyelitis tends to affect older children and adolescents.

Both conditions are treated with rest, antibiotics by IV and by mouth. A brace to support the spine may be suggested. Surgery may be necessary in osteomyelitis, to clean out the infection and/or to stabilize the spine.

Tumors are a rare cause of back pain in children. A tumor of the spine is an abnormal growth of tissue in or around the spinal column. There are many different types of spinal tumors. They can be benign or malignant. Benign means that the tumor does not spread to other parts of the body. It can still cause destruction of vertebral bone or spinal tissue. Some benign tumors can come back after they have been removed. Benign tumors include osteoid osteoma, osteoblastoma, and aneurysmal bone cysts. Malignant tumors are tumors that can spread to other parts of the body. These include sarcoma, leukemia, and lymphoma.

Related Document: A Patient’s Guide to Spinal Tumors

Symptoms

Depending on the age of the child, they may or may not be able to tell you about their symptoms.

In a younger child, refusal to crawl, sit, or walk may indicate back pain.

In older children, symptoms may include:

Pain involving the spine
Spasm of the nearby muscles
Decreased range of motion or stiffness in the back
Stiffness and pain after prolonged sitting or standing
Pain with loading the spine as when lifting and carrying
Pain may refer to areas away from the spine itself. It may cause pain in the buttocks or legs
Leg weakness or bowel and bladder problems can indicate nerve or spinal cord problems
Difficulty walking
Fever
Diagnosis
How will my doctor diagnose this condition?
Your doctor will perform an examination that will include your history. It will include questions about activity, spinal injuries, urination, bowel movements, weakness, what makes the pain better and worse, when does the pain occur, etc. Your doctor may also ask questions about school, home, and your moods.
A physical examination will be done as well. This will include looking at the back to evaluate the curves of the spine, spasm of the muscles, and for unusual markings of the skin or soft tissue along the spine. Your doctor will also want to watch you move or walk, and evaluate the range of motion of the spine. Neurological examination may include checking reflexes, sensation, and muscle strength.
Imaging studies
X-rays are recommended for all children complaining of back pain. Views of the spine from the front, the side, and part way in between (oblique) should be taken. X-rays will show bone as well as the disc spaces.

Magnetic resonance imaging (MRI) allows your doctor to look at slices of the area in question. The MRI machine uses magnetic waves, not X-rays to show the soft tissues of the body. This includes the spinal cord, nerves, and discs. It can also evaluate spinal bones. The test may require the use of dye in an IV. Sedation or anesthesia may be needed to help you lie still for this test.
A computed tomography (CT) scan may be ordered. It is best for evaluating problems with the vertebral bones. It is usually tolerated by children, however, exposes them to radiation. Sometimes, it may require dye in the spinal canal fluid for easier identification of the spinal cord and nerve root anatomy. When dye is injected for this purpose, the technique is called a myelogram.
Bone Scans, also called nuclear scans can be used to detect fracture, bone infection, or tumor. A radioactive tracer, Technetium, is injected into your vein. Where there is increase in metabolic activity the Technetium will be more concentrated. This occurs when there is inflammation, fracture, infection, or tumor. Some tumors in the spine can spread to other parts of the body, or come from cancer somewhere else in the body. A scan can be helpful to see if there are other areas in the body where the cancer may be.
SPECT stands for Single Photon Emission Computed Tomography. SPECT imaging is often added to provide information that is not available on routine bone scan images. It provides three-dimensional (3-D) views of the area examined. Following a bone scan you will remain on the exam table and the camera will rotate around the table while it takes pictures. SPECT imaging adds 30 to 60 minutes to the time of the nuclear scan. Sedation may be needed.
A biopsy of the spine may be required if an infection or tumor is found. In some cases tissue samples can be taken with a needle. Sometimes tissue for a biopsy is taken during a minor surgery. This allows the doctor a better view of the area he neeeds to biopsy. The tissue is then looked at under a microscope.
Laboratory Studies
Blood tests may be requested to evaluate the blood for specific bacteria causing the infection. A complete blood count (CBC), especially in children under the age of 10 is important. There is a greater chance that back pain is from leukemia in children younger than 10. If there is an infection, the CBC may show an increase in the infection-fighting white blood cells. A C-reactive protein (C-RP) and erythrocyte sedimentation rate (ESR) may also show an increase when an infection is present. A blood culture may be necessary to help determine what bacteria are causing the infection in discitis or vertebral osteomyelitis.
A biopsy may be required to determine what bacteria are causing an infection. This will help your doctor choose the right antibiotic to treat the infection.
Treatment
What treatments are available?
Non-surgical treatment
Most treatment for back pain in children is non-surgical. Treatment of children with non-specific back pain includes change in activity and rest. Trunk strengthening and postural exercises with the help of a physical therapist may be useful. Short-term use of over-the-counter medications such as Ibuprofen (Advil, Motrin) may be beneficial. Weight loss may be recommended.

Carrying backpacks may sometimes be to blame for non-specific back pain. It is suggested that children wear their backpack using both shoulder straps. Making more frequent trips to the locker can decrease the weight of the backpack. Some children choose to use wheeled backpacks.
Treatment of non-specific back pain may include involving the school counselor or a psychologist. Children may complain of back pain when they are depressed or anxious. It may also indicate problems at home, in school, or with peers.
Bracing may also be required for proper treatment of some conditions.
Antibiotics either by IV and/or by mouth are necessary for the treatment of discitis and vertebral osteomyelitis.
Surgical treatment
Surgical treatment for back pain in children is rare.
If a tumor has been discovered as the source of your back pain, the treatment options will vary depending on the type of tumor found.
Some tumors are evaluated periodically on a watch and see basis. Surgery to remove the tumor is often recommended. If radiation or chemotherapy is required, you will be referred to an oncologist (cancer specialist). In the case of a tumor, radiation may begin as early as one to two weeks following surgery. Radiation usually lasts only 15 to 20 minutes per day for two to six weeks. Treatment options and the prognosis for many tumors have improved greatly in the past few years.
The spine may need to be stabilized due to scoliosis or kyphosis, or from the removal of a tumor or infection. Metal hardware such as screws, rods, plates, or cages may need to be used. The bone may also be supported by bone graft or bone cement.
Rehabilitation
What should I expect after treatment?
Non-surgical Rehabilitation
Periodic follow-up with your physician is required. Repeated or different imaging studies may be necessary, particularly if symptoms do not improve. Laboratory tests may need to be repeated.
Specific treatment by a physical therapist may be suggested. This treatment usually involves avoiding movements that could make the condition worse, posture training, as well as back and abdominal (core) strengthening. A physical therapist will also instruct you in safe lifting and proper body mechanics in other daily activities.
Surgical rehabilitation
If surgical intervention is required, your surgeon will require periodic follow-up visits. This could be on a long-term basis to watch for spinal deformity or recurrence of a tumor. Repeated or different imaging studies may be necessary. Laboratory tests may need to be repeated.
The amount of time you are hospitalized depends on the type of surgery required. After surgery, activity such as sitting, crawling, or walking are usually allowed as well as activities that do not require stretching of the spine or straining. Lifting is limited during the initial recovery period. You will likely be required to use a brace or corset after surgery to help with stability.
You may benefit from physical therapy and occupational therapy. Therapists can help with regaining strength, movement, coordination, and activities of daily living.

Chronic Pain and Sleep

A Patient’s Guide to Chronic Pain and Sleep

Introduction

Sleep and pain problems are among the most common complaints in our society. It is not surprising then that these conditions frequently occur in the same person. Painful diseases such as backache, osteoarthritis, rheumatoid arthritis, headache, and fibromyalgia may interfere with sleep. However, poor sleep may also promote pain, headaches, and fatigue. Studies have shown that several nights of disturbed sleep in healthy people may cause not only sleepiness, but also nonspecific generalized muscle aching and fatigue.

This guide will help you understand

the stages of sleep
the importance of sleep to your body
what can cause sleep disturbances
what treatment options are available

Sleep is defined as the natural periodic suspension of consciousness during which the powers of the body are restored. Sleep is a complex process involving several stages. There are changes in the chemistry and behavior of the body during sleep.

There are many processes in the body that rely on the sleep-wake cycle. These processes are important in fighting infection, healing our body, and allowing processing of new knowledge or information. It is believed that sleep is crucial to learning and intellectual function. Proper sleep is absolutely necessary for the normal function of the body. Sleep disturbances can have significant and serious consequences. Lab rats die after two to three weeks of sleep deprivation.

Anatomy of Sleep

Circadian Rhythm

The circadian rhythm is a built-in cycle of sleep and wake times. There are other cyclic changes that occur in your body. These include changes in temperature, heart rate, blood pressure, hormone secretions, and lung function. These internal cycles are controlled by a group of nerve cells called a circadian pacemaker. This pacemaker is closely related to parts of the retina (in the back of the eye) and a small organ in the brain called the hypothalamus. Humans have a biological clock that is represented by a 24-hour cycle. Sunlight appears to be the cue that resets this clock on a daily basis.

The Human Sleep Cycle

There is a lot of difference in mammals’ need for sleep. Daily sleep time for man is approximately seven to eight hours. An owl monkey needs 17 hours a day. A bat needs 20 hours a day. Sleeping too little or too much can be harmful to a person’s health.

Human sleep occurs in cycles that are generally about 90 minutes long. There are five stages of sleep within each sleep cycle. These stages are further divided into two separate states, non-rapid eye movements (NREM) and rapid eye movement (REM). These stages are defined by brain wave activity using an electroencephalogram (EEG).

NREM sleep is the lighter stage of sleep. Body movements occur, but the mind is quiet. NREM is divided into four stages, with each stage of sleep getting progressively deeper.

REM sleep is deep sleep that is more refreshing. This is because there is total muscle relaxation except for bursts of rapid eye movements. The brain is active in REM sleep, dreaming occurs in this stage of sleep. Ideally, 20 to 50 percent of an adult’s sleep should be in REM sleep. During this phase of sleep, there may be irregularities of the heart and breathing. These can be recognized by monitoring the heart with an electrocardiogram (ECG). REM sleep has been described as a highly activated brain in a paralyzed body.

As sleep continues, the time spent in NREM sleep is decreased and the amount of time in REM sleep increases. The last third of the night is mostly REM sleep. It is linked to the circadian rhythm of body temperature.

There are age-related changes that are predictable. Infants usually start the sleep cycle with REM sleep. As we approach age 65 and older, less time is spent in REM sleep.

Causes

What causes this problem?

Some sleep disorders are known to have genetic causes. Others are caused by illnesses such as Parkinson’s disease, depression, lung disease, or heart failure. Other sleep disorders have an unknown cause. There are several common sleep disorders.

Sleep-Related Breathing Disorders or Sleep Apnea. Apnea means without breath. While sleeping, when a person stops breathing for a minimum of 10 seconds it is called an apneic episode. If you have more than five apnea events in an hour, you are diagnosed with sleep apnea. Oxygen level in the blood or tissues is also important when making the diagnosis of sleep apnea. Oxygen levels at 95 percent and above are normal. In sleep apnea, levels may drop to 80 percent or lower. Levels below 70 percent are considered dangerously low. When this low, the heart may beat irregularly and may even cause death.

There are two main types of sleep apnea.

Central sleep apnea is the interruption of breathing during sleep. The cause may be unknown. Or it can be caused by medications such as opioids (narcotics). Other causes can be heart failure, stroke, renal failure, lung disease, or being at high altitudes.

Obstructive sleep apnea (OSA) is caused by closing of the airway when air should be moving into the nose, mouth, and lungs. It may be as common as two to four of every 100 adults, and three out of every 100 children.

Narcolepsy is a term that is used for excessive daytime sleepiness without troubled sleep during the night. It is diagnosed when a person can fall asleep with a short delay (usually eight minutes or less) to REM sleep. Falling asleep while driving, hallucinations while sleeping, and sleep paralysis may occur. Narcolepsy appears to be genetic. A substance called hypocretin/orexin is found to be decreased in persons with narcolepsy. Narcolepsy is treated with medications.

Sleep-related movement disorders include restless legs syndrome (RLS) and periodic limb movement disorders (PLMD).

Restless legs syndrome (RLS) is described as a strong, nearly uncontrollable desire to move the legs. The sensations are worse at rest and occur more frequently in the evening or during the night. Walking or moving the legs relieves the sensation.

Periodic limb movement disorders (PLMD) is the involuntary limb movements which are often rhythmical that can fragment or interrupt sleep. Because they are rhythmical, they are thought to originate from a subcortical region of the brain. Possibly up to 40 percent of persons over 65 years of age may have PLMD.

Insomnia is difficulty falling asleep, staying asleep, or sleep that is not refreshing and restorative. It happens in as many as 30 percent of Americans. Symptoms of insomnia aside from difficulty sleeping include daytime exhaustion or fatigue, lack of energy, lack of concentration, forgetfulness, irritability, and depression. Insomnia can be caused by many different conditions. It happens more frequently as we age, particularly after 60. It may be caused by stress, depression and anxiety, or mental illness. Noise or extreme temperatures in the environment can also cause insomnia. Other causes of insomnia can be shift work, jet lag, nighttime activity schedules, and medication side effects. Use of alcohol, tobacco, and illicit drugs may interfere with sleep. A person with insomnia may also have one of the other sleep disorders such as sleep apnea, narcolepsy, or restless legs syndrome.

Unusual behaviors may occur during sleep. These behaviors include sleepwalking, sleep talking, tooth grinding, and other physical activities. These can cause arousals and get in the way of normal sleep cycles. Sleep related tooth grinding is called bruxism. Clenching of the teeth may cause tempomandibular joint pain and/or wearing down of the teeth. An appliance similar to a mouth guard or retainer may be used to treat bruxism.

Symptoms

What does the condition feel like?

Sleepiness is the most common symptom in people with a sleep disorder. Sleepiness is caused by the decrease in the amount, the quality of sleep, as well as the circadian rhythm of the body.

Fatigue and not feeling refreshed after sleeping, may be signs you have a sleep disorder.

Snoring and stopping breathing while sleeping are other symptoms of a possible sleep disorder.

Sleep disorders may be associated with many chronic illnesses such as high blood pressure, heart attacks, stroke, headache, or depression. There are many processes in the body that rely on the sleep-wake cycle. These processes are important in fighting infection, healing our body, and allowing processing of new knowledge or information. Sleep disturbances can have significant and serious consequences. Slower reaction times may decrease driving safety and cause auto accidents. Poor balance, decreased concentration, and forgetfulness are also noted in persons with sleep disorders. Mood disorders (irritability or depression), decreased motivation, and lack of energy may also be symptoms of chronic sleep problems.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical examination. Your doctor will ask you several questions to determine if your symptoms call for a sleep study. You may be asked to fill out a questionnaire about snoring, sleepiness, stopping breathing during sleep, unwanted leg movements, medications you are taking and such.

Your doctor may do a physical exam. An examination of your nose, mouth, throat, and lungs is usually included. Your doctor may request that you have a chest x-ray. The x-ray is to check for abnormalities of your lungs, or to measure your heart size.

There are doctors who specialize in sleep medicine. You may be asked to be evaluated by one of them.

Examination of your nose and mouth is done to determine if there is decrease in the size of your airway, or factors that may interfere with proper airflow. Swollen sinuses from dryness or allergies, or jaw deformity are examples. The doctor may also examine your teeth to see if there are signs of wear from bruxism.

Examination of the throat is done to find out if you have enlarged tonsils or extra or swollen tissue in the back of your mouth. The piece of tissue that dangles down from the top of the back of the mouth is called the uvula. Uvula means grape cluster, and is shaped similar to one. In some people, it can be enlarged and can get in the way of proper airflow.

If lung disease is possible, the specialist may want to assess your lung function. Some of the risk factors for lung disease include smoking, heart failure, or asthma. You may be asked to blow into a device that measures the force, and how much air you can blow. There are more complex machines that may also be used to monitor airflow in and out of your lungs. The specialist may also have you do hand-held reflex testing in the office. This also monitors your ability to stay alert.

Your doctor may want to monitor the oxygen or carbon dioxide levels in your blood. This is done with a machine called an oximeter. The part that measures the oxygen or carbon dioxide levels in your blood is similar to a clothes pin. It is worn over your finger or ear lobe. It is connected by a wire to the oximeter. It then measures and records your oxygen level when sleeping. Normal oxygenation is 95 to 100 percent. In sleep apnea, levels may drop to 80 percent or lower. Levels below 70 percent are considered dangerously low.

A polysomnogram is a procedure that is used to diagnose sleep disorders. It is done at a sleep laboratory or center. It is a way to record and measure what is going on during sleep. It can measure biological functions as well as body movement. Information is gathered from a set of electrodes taped to your skin. Wires from the electrodes carry signals to a monitoring device where they are recorded. The doctor then interprets the information. There are no needles. The electrodes measure electrical activity and do not cause an electrical shock.

The sleep laboratory consists of private rooms with beds. The sleep room is well insulated and temperature is kept comfortable. You may be allowed to wear your usual sleep clothes. You will be given a buzzer to alert the sleep study technician if you need to get up or get uncomfortable for any reason. Testing in the sleep study center may also involve seeing how long it takes to fall asleep while reading or resting.

Brain wave monitoring is done with several electrodes placed on the surface of the skull. These electrodes monitor and record brain wave activity. It can tell the different stages of sleep and when you are awake.

Other electrodes are placed near the outside corner of each eye in order to monitor eye movements. Electrodes on the chin or throat monitor jaw muscle tightening. Electrodes on the stomach monitor abdominal movements. Electrodes on the legs sense leg movements.

The heart rate and rhythm is monitored with an electrocardiogram (ECG). Sticky patches with electrodes are placed on the chest. There is an increase in cardiovascular events such as heart attack and stroke in persons with chronic sleep problems.

Another measuring device is called a strain gauge. It is a stretchy belt that is worn around the chest to measure chest movement.

Treatment

What treatment options are available?

Non-Surgical Treatment

Treatment of insomnia can include medication and behavioral therapy. Behavioral therapies are usually done with a psychologist or person with similar training. Talk therapy may be helpful in decreasing stress and anxiety.

Quite often, changes in habits are all that is needed to improve sleep. Poor sleep habits include spending too much time in bed or having an irregular sleep schedule. Not getting sufficient bright-light exposure during the day and poor physical functioning are known to interfere with proper sleep. Sleeping in an environment that is too bright, too noisy, or too hot or cold can cause sleep problems. Drinking alcohol or caffeinated beverages too close to bedtime can also interfere with sleep. Treatment of depression is also important to consider.

Some recommended sleep medications include some of the antidepressants. Drugs that stimulate the breathing reflex may be used for central sleep apnea. Specific medications are also used for narcolepsy. Medications that treat Parkinson’s disease can be beneficial for RLS and PLMD. Our bodies make melatonin that helps regulate the sleep cycle. It is also available as an over-the-counter medication. It is most helpful for shift work and jet lag. When soft tissue in the nose or throat is enlarged, it may be recommended that you use decongestants or other medications that help shrink soft tissue in your nose and throat.

Behavioral treatments often mean changing the way you act or think. You may need to learn how to decrease stimulation of the body’s system of alertness. This system is called fight or flight and can interfere with proper sleep. When your nervous system is on high alert, it is especially difficult to fall asleep. Reducing stress, doing relaxation exercises or other soothing activities can calm the nervous system. Changing negative attitudes about yourself and sleep can also be helpful. There are many simple ways that sleep can be improved.

he following tips may be helpful for anyone with sleep problems.

Exercise can increase the core body temperature, which promotes sleep. When vigorous enough, exercise can help the body release endorphins, which are chemicals that act like morphine, a pain medication.

Increase your body temperature. A hot bath, shower, or use of a hot tub can affect body temperature. A hot drink will also warm you. It is recommended that you try to increase your body temperature within two hours before bedtime.

Bedroom environment should be a comfortable temperature, quiet, and dark. If there are factors out of your control such as a noisy neighbor or animal, earplugs may be useful. Eyeshades may help with unwanted light.

Bedtime rituals such as a bath, reading for pleasure, or listening to soothing music may help decrease your body’s alertness.

Stress reduction and relaxation improve sleep. Relaxation can include deep breathing exercises. Progressive muscle relaxation involves slowly tensing and releasing muscles. You usually start with muscles of the face, then neck. You gradually work your way down until your toes feel fully relaxed. Meditation, prayer, imagery, and listening to soothing music are other methods to help reduce stress.

Regular sleep schedule is important. Wake and get up at the same time each morning, including weekends, even after a poor night’s sleep. This will help with the circadian rhythm.

Daytime naps should generally be avoided.

Get out of bed. If you are awake in bed for more than 20 minutes, get up and go to another room. Do not watch TV in bed. The bed should be used only for sleep and sex. Too much time in bed causes interrupted and shallow sleep.

Heavy meals late in the evening should be avoided. A warm drink or small snack may be beneficial before bedtime.

Exposure to sunlight is important for the circadian rhythm. Spend some time outdoors especially after awakening. Talk to your doctor about the use of bright light therapy to help regulate the circadian rhythm. There are also lighting devices available that imitate dawn. Light boxes and dawn stimulators may be available at medical supply stores or on the Internet. It is important to buy the appropriate light box and use only as directed.

Quit smoking. Withdrawal from nicotine begins two or three hours after smoking. This can interrupt sleep.

Avoid alcohol before bed. Although it may help you fall asleep, sleep is otherwise interrupted.

Avoid caffeine particularly after the middle of the afternoon. If at all possible, decrease or don’t drink caffeinated drinks altogether. You may have to taper off of caffeine. Most people will have symptoms of withdrawal. These could include headache and fatigue.

Avoid medications that may interfere with either falling asleep or staying asleep. Narcotics for pain may cause a decrease in the brain’s ability to keep breathing during sleep. This can cause a decrease in oxygen level in the blood.

Aromatherapy is the use of scents such as lavender, chamomile, or vanilla that help to quiet the nervous system. These may be sprayed on bedding. Oils may be placed under your nose, or on your chest, or used in the bath.

Allergies can cause swelling and narrowing of the airway. This can cause partial blockage of your airway and contribute to obstructive sleep apnea. Ask your doctor about treatment of allergies. A mixture of water with a little bit of salt can be used to rinse the lining of your nose and sinus tissue. This helps to shrink swollen tissue. It also helps to flush pollen and other allergens. Humidifiers in dry climates may also help sooth the lining of your nose and sinuses.

Lose weight particularly if you have sleep apnea. You may be asked to see a nutritionist to help with weight loss.

Change in sleep position can also make a difference. You may have more trouble breathing properly while lying on your back. Sleeping on your sides can relieve this. There are monitors and alarms available. Some people have sewn a small ball into the back of their pajamas.

Dental appliances or retainers may be useful in bringing the jaw and tongue forward during sleep. This helps to keep the airway open. Dental appliances are also used to treat bruxism (grinding the teeth at night).

Continuous positive airway pressure (CPAP) is the most common treatment for sleep apnea. It is a breathing device. A CPAP machine is a small machine that can sit on your nightstand. It has a hose that attaches to a mask that usually covers the nose. The mask is worn during sleep. Room air is blown through the nostrils, allowing the airway to remain open during sleep. Some people may also require oxygen at night. Your insurance will pay for most if not all of the cost. Typically they are obtained from oxygen or medical equipment companies.

Getting used to the CPAP machine is not always easy. Some people may experience anxiety from having the mask placed over the face. Others may not like the way it looks. It may take encouragement to help you continue with the changes necessary to improve sleep. If you still have sleepiness or insomnia after using CPAP or after making several lifestyle changes, your doctor may need to consider more aggressive treatment.

Surgery

Other treatments for sleep apnea include surgery. There are several surgeries that may be recommended. If you have trouble breathing through your nose, the surgeon may decide to cut away some of the soft tissue in the nose. Sometimes straightening the septum (cartilage) that divides the nose into two parts is also necessary.

If your airway is small, especially when the soft palate (top of the mouth) and the tongue relax during sleep, it may be recommended that you have reconstructive surgery. The most common type of reconstructive surgery is called uvulopalatopharyngoplasty or UPPP. Excess tissue such as the tonsils, adenoids, and uvula are removed. These surgeries are usually performed by an otolaryngologist, or ear, nose, and throat (ENT) surgeon.

Sometimes surgery to change the structure of the jaw or face is considered.

Ventilators or mechanical breathing machines are needed for some extreme cases of central sleep apnea. Air is blown from the ventilator through a hole in the neck called a tracheostomy. A tracheostomy is the operation used to make a small opening in the trachea or windpipe. A small cut is made by a surgeon in the front of the neck. This bypasses the causes for decreased airflow in the nose, mouth, and throat. During waking hours the tube is plugged to allow normal breathing. At night, a tube is inserted that is then connected to a ventilator or breathing machine.

Stomach banding or bypass is recommended if being overweight contributes to a sleep disorder.

Summary

Regular follow up with your doctor or therapist is recommended to help make transition into lifestyle changes easier. Trying different methods for relaxation and other changes in behavior may take some coaching.

The staff at the sleep center or the staff at the medical supply store is helpful in answering questions about equipment. They may also be able to help with making adjustments in equipment that make sleep better. It may take several weeks or months to adjust to using machines when sleeping. You may need a repeat polysomnography or a shortened version of one after you have used your equipment for a while. Adjustments may need to be made if you continue to experience fatigue or other symptoms.

Hopefully, treatment of your underlying sleep disorder will improve some of your other medical problems such as blood pressure, weight, fatigue, and lowered mood. Your doctor will want to monitor these.

A physical therapist or personal trainer may be able to help you start an exercise program. Pain and fatigue often lead to inactivity, which leads to de-conditioning. Starting an exercise program can cause increased pain at first. The support of a professional may help you continue with an exercise program.

A registered dietitian may be recommended by your doctor for weight loss.

Some cities have support groups for people with sleep disorders. Check with your physician or through your local hospital to see what support groups are available.

Muscle Cramps

A Patient’s Guide to Muscle Cramps

Introduction

You have over 600 muscles in your body. These muscles control everything you do, from breathing to putting food in your mouth to swallowing.

When it comes to muscle cramps, the most commonly affected muscles are the muscles of your upper arms, the muscles behind your thighs, and the muscles in the front of your thighs.

This guide will help you understand

what muscle cramps are
how the problem develops
what treatment options are available
how muscle cramps can be prevented

Anatomy

What parts of the body are involved?

Muscles are composed of many fibers bundled together; the bigger, more frequently used muscles have more fibers than the smaller, lesser used ones. Among the muscles are voluntary and involuntary muscles. Voluntary, or striated muscles are those that we move by choice (for example, the muscles in your arms and legs). These muscles are attached to bones by tendons, a sinewy type of tissue. Involuntary muscles, or smooth muscles, are the ones that move on their own (for example, the muscles that control your diaphragm and help you breathe). The muscles in your heart are called involuntary cardiac muscles.

When it comes to muscle cramps, the most commonly affected muscles are the gastrocnemius (calf muscles), triceps (the muscles in your upper arms), the hamstrings (the muscles behind your thighs), and the quadriceps (the muscles in front of your thighs).

Causes

What causes muscle cramps?

To move your muscles, your brain sends signals to the voluntary muscles and coordinates the movements that you want. The voluntary muscles contract as they’re being used and they become tighter. The muscles then relax when the movement is complete. When the contraction/relaxation cycles are done repeatedly, as in exercising, the fibers become stronger and the muscles get larger and stronger. However, sometimes the muscles, or just a few fibers within the muscle, contract on their own, causing a muscle spasm or cramp. The difference between a spasm and a cramp is the force of the contraction. If it’s a quick contraction and release of muscle, without pain, it’s a spasm. If the contraction is prolonged and painful, it’s a cramp. Occasionally, cramps are so intense that you can’t use your muscle because it’s so tight and painful. Cramps can be short-lived, a minute or less, or as long as a couple of days. When researchers tested the cramping muscles of some athletes, they found rapid repetitive muscle firing, which could be described as the muscle fibers being hyperactive, in a sense.

Cramps can happen in one muscle, like the hamstring, or they can happen in a number of muscles together, like in your hands if you have writer’s cramp. They can happen once and then not again, or there can be a series of on-again-off-again cramping.

There are several reasons why muscle cramps may occur, including the most common one that is seen in both professional and weekend athletes. These are called exercise-associated muscle cramping or EAMC. These types of cramps fall under the category of paraphysiologic cramps. Those are cramps that affect normally healthy people but are brought on by an event, such as exercise.

Researchers have estimated that marathon runners and triathletes may have a 30 to 67 percent lifetime risk of developing these cramps. Although the exact cause of the cramping isn’t known, researchers do believe that they can be caused by inadequate stretching, muscle fatigue, or lack of oxygen to the muscle. Other causes can also include heat, dehydration, and/or lack of salt and minerals (electrolytes). New research suggests that there may be abnormal motor neuron (nerve) activity at the level of the spine.

Researchers also have noticed that the athletes who suffer from a lot of cramping tend to be older, marathon runners, or have a high body mass index. They don’t stretch regularly, and have a family history of muscle cramps.

Cramps can also happen if you use the same muscles in the same way for too long a period. This could be as you crouch down to work in the garden, type on a keyboard, or write out long lists with paper and pen. The muscles contract and cause the pain.

Occasionally, these types of cramps seemingly come out of nowhere. For example, as we stretch, we often point our toes downward. This motion contracts the muscle in the calf of the leg and can cause a severe cramp or charley horse.

Women who are pregnant may also find that they get more muscle cramps during their pregnancy, but the reason why isn’t clear. Again, these are considered to be paraphysiologic cramps because they are brought on by the pregnancy. Along the same vein, seniors may also be prone to developing muscle cramps. Doctors believe this is due to loss of muscle mass as people age plus inactivity.

Muscle cramps can also occur as a side effect of medications. Diuretics, or water pills, cause you to eliminate fluid from your body. If too much fluid is eliminated too quickly, the resulting dehydration could cause muscle cramps. Other medications can also cause muscle cramps.

Skeletal problems can increase the chances of leg cramps. For example, people with problems like scoliosis (curvature of the spine) could have one leg longer than the other. This imbalance can cause cramping in the leg.

Symptomatic cramps are, as the name suggests, symptoms of an illness that may be causing the cramping. Examples of a few illnesses that can cause muscle cramping are: Parkinson’s disease, tetanus, diabetes, and heart disease. Atherosclerosis (hardening of the arteries) makes it hard for blood to circulate throughout the body as it should. Often, one of the first signs of atherosclerosis is a symptom called claudication or intermittent claudication. Someone who has atherosclerosis may start feeling cramping in one or both legs after walking for a while. At rest, the pain disappears, but it comes back when the person resumes walking.

Radiculopathy (irritation of the nerve root at the spine) is a known cause for muscle cramping, usually at night. Some other illnesses that can cause muscle cramping are cirrhosis of the liver, Black Widow spider bites, and malignant hyperthermia, among others.

Finally, idiopathic muscle cramps are cramps that have no known cause but they are symptoms of a disease, or can be inherited. Sudden nocturnal (occurring at night) leg cramps are an example of this type of cramping.

Symptoms

What do muscle cramps feel like?

Muscle cramps are painful, there’s no doubt about it. The symptoms of muscle cramps usually come on quickly and intensely. They can be so strong that you may have to stop what you’re doing, the discomfort of the cramping making it too difficult to continue. There are also cramps that occur after the fact. These delayed or nocturnal cramps can affect athletes.

The most obvious symptom of a muscle cramp is a sharp, acute pain in the affected muscle or muscles. If it’s a large muscle that is involved, like the one in the calf of your leg, you may be able to feel a knot or hard lump in the muscle, just under the skin.

Diagnosis

How do doctors identify muscle cramps?

Generally, people know what they are experiencing when they have a muscle cramp so they don’t seek medical help to find out what they are and what caused them. However, sometimes muscle cramps are more serious and they are frequent, lengthy, and unbearably painful. If they are caused by an illness, rather than overexertion, the reason for them will need to be found.

Your doctor will first do a physical examination and take your medical history. Let your doctor know is you have been ill recently with vomiting, diarrhea, or fever. Anything that may cause dehydration is important information and should be shared with the doctor.

You’ll be asked when the cramps began, how long have you been having them, how long they last, and what are you usually doing when they start. Other questions, such as are you pregnant, taking any medications (including over-the-counter and natural or herbal remedies), do you smoke, and how much alcohol do you drink, will be asked. Your doctor will also need to know how much and how often you exercise.

Your doctor will want to know exactly where the cramping is occurring. Let your doctor know if there are any other types of pain that happen at the same time. Your doctor will want to know if the cramps are always in the same place or if they occur elsewhere.

Further testing may recommended. Blood tests are usually first since muscle cramping may be caused by dehydration and depletion of salt and minerals (electrolytes). Since pregnant women can be more prone to muscle cramping, a pregnancy test may be ordered for women along with other blood tests.

Additional blood tests may be ordered to check if your thyroid and kidneys are working properly. Your thyroid is a small gland that is just below your voice box and is responsible for making and distributing hormones.

If the blood tests are all within normal range and negative for pregnancy, there are more tests that may be ordered. A vascular Doppler ultrasound uses ultrasound waves to make images on a screen. Using the Doppler (small machine), your doctor looks to see if there are any blockages in the blood vessels.

If your doctor thinks there may be a neurological (nervous system), disorder causing the cramping. One test that may be done is called an electromyography (EMG). To perform an EMG, your doctor will insert a needle into the muscle that has been cramping. The needle has an electrode that will relay to a recording device any electrical activity from your muscle. After the needle has been inserted, you’ll be asked to contract (flex, tighten) your muscle and then relax it.

A magnetic resonance imaging (MRI) scan may also be done. The MRI is a radiological test that uses magnetic waves and a computer to create pictures of the parts of the spine. To perform this test, you must lie in a tube for about an hour. No needles or dye are usually required. The machine takes pictures of the spine one slice at a time. It can do this in multiple directions. It allows the doctor to see the bones and soft tissues of the spine – including the nerves. Your doctor will be looking for anything that may show an injured disc, pinched nerve, or injured nerve that could represent a cause for the cramping.

Treatment

What can be done to relieve the pain from muscle cramps?

The type of treatments required for muscle cramps depends on what is causing them. If you’re having occasional muscle cramps from physical activity or overusing certain muscles, you can usually take care of the cramps yourself. Simply stopping the activity will stop the cramping. If the cramps continue, stretching the cramping muscle – although painful – should release the tension of the muscle. For example, if it is your calf muscle that is cramping, stand facing a wall or solid object that you can hold on to for balance. Keeping your heel of the sore leg as close to the floor as possible, tilt your body (slowly) to the wall or object, stretching the calf muscle. If you’re lying in bed when the cramping starts, you can try pointing your toes straight up towards the ceiling, or grab hold of your toes and pull your foot up towards you.

Some people find that using ice packs can help relax the tense muscles, others have better luck with heat such as from heating pads, warming packs, even warm towels. Be careful when applying ice or heat to a sore part of your body. Ice should never be held directly on the skin. Ice should always be buffered with at least one layer of cloth. Heating pads can get very warm and can cause burns, so be sure to monitor the heat level and keep a layer of fabric between the heat and the skin. Massage may help as well, although it can be painful as the knot is being worked out. If the cause of the cramping is dehydration, then fluids with electrolytes (sports drinks, for example) are essential to balance the fluid loss.

For athletes who experience a lot of cramping good nutrition is important. Adequate fluid and electrolytes may help limit the cramping. This could mean meeting with a dietitian to discuss diet and eating habits.

Some muscle cramps can be caused as a side effect of certain medications. Talk to your doctor. Adjusting the dosages or changing the medication may help the cramping problem. Don’t change any of your prescription drugs or stop taking them without your doctor’s knowledge and approval.

If the cramps are caused by an illness, they should subside by treating the illness. Medications are generally not recommended or used for muscle cramps because of their side effects. Most muscle cramps are short-lived. By the time the medication has started working the cramping has already stopped. There are some cases where doctors may use Botox® to stop cramping in certain muscles. This is decided on an individual basis and depends on the cause and the impact of the cramping.

Because muscle cramps come on so quickly and suddenly, usually resolving just as fast as they came, the best treatment is prevention. Anyone who is about to do something strenuous or athletic should warm up and stretch their muscles first. If you’re moving furniture, digging up a garden, painting, or doing general maintenance that you’re not used to, the muscles you will be using can get fatigued. By stretching them, this should be prevented.

It’s also important to stretch correctly. Don’t stretch quickly. Stretch slowly and hold each stretch for 30 seconds. Any shorter than 30 seconds and there’s no benefit. There is also no benefit for holding it longer than 30 seconds. Some experts suggest that athletes continue to stretch daily. This may keep the muscles flexible. Also remember to stretch after the activity to allow the muscles to cool down.

Other important tips include staying hydrated; drink enough fluids to keep your body’s electrolytes from depleting – but don’t overdo the fluids either. Finally, don’t overdo the exercising, especially in hot weather.

Summary

Since exercise-associated muscle cramping occurs most often in healthy individuals, the important issue is to control cramping frequency and intensity. This can be done through preventative measures, such as proper preparation and stretching, and ensuring adequate fluid intake before undertaking physical exercise or activity.

For those who experience muscle cramps due to illness, their frequency and intensity may be affected by the treatment for the illness. If side effects from medication are causing the cramps, this may be avoided by changing or adjusting medications, dosage, or medication combinations when possible. Ask your doctor if a change in your prescription medication may help.