A Patient’s Guide to Postsurgical Infection

One of the greatest advances in surgery during the twentieth century has been in understanding how to reduce the risk of infection during and after surgery. Any surgical procedure, no matter how small, carries the risk of infection. Simple procedures, such as placing a needle into a joint to remove fluid or inject medications, have a very low risk. More complex operations that require larger incisions and leave the skin open for longer have a higher risk. Operations done to insert something into the body, such as metal plates or artificial joints, must be done carefully to ensure that the foreign material that is left in the body does not carry infection with it. Preventing infection is one of the most important parts of any operation. All members of the health care team take preventing infection very seriously.

Infection prevention begins before surgery. Your doctor will make sure that no infections exist that may spread to cause problems with your surgery. If you have a skin infection, a bladder infection, or some other type of infection, your surgery may be postponed until the infection is treated and under control.

The morning before surgery, you may be asked to shower with antibacterial soap to reduce the number of bacteria on the skin. Before surgery begins, the skin around the incision site will be cleansed and prepped with a disinfectant, such as iodine. Before surgery, you may be given a dose of antibiotics. This is not true for all types of surgeries. Operations that have a low risk of infection usually do not require antibiotics as a precaution. Many orthopedic operations do require antibiotics, especially those operations where something artificial is left in the body.

During surgery, great care is taken to ensure that the entire operation is done under sterile conditions. Surgery is performed in a sterile room that is designed to prevent the spread of infection. All the items needed for surgery are sterilized.

Your wound dressing will also be applied under sterile conditions before you leave the operating room. The wound dressing is an important barrier against infection until the incision seals itself. This usually occurs in the first few days. If an incision is still seeping any type of drainage, this can be an avenue for germs to enter the wound. The dressing will be kept in place until all drainage stops and the incision seals itself.

After surgery, you may continue on antibiotics for 24 to 72 hours. This is to help reduce the chance of infection.

While you are in the hospital or surgery center, your health care team will make sure your bandage stays dry and clean. A bandage that has soaked through can create an entryway for germs to enter the wound. Alert your nurse if this occurs. Before leaving the hospital or surgery center, you will be taught how to take care of your incision. The same instructions apply if you see extra drainage after your return home. Change the dressing, and call to let your nurse know.

Notice that the health care team always washes their hands before changing the bandage. You should do the same. If you develop an infection anywhere else in your body after surgery, let your doctor know. Some infections can spread and cause problems with the surgery.

Follow these guidelines:

• Wash your hands before changing your bandage.
• Change your bandage as instructed.
• Don’t get the incision wet unless your doctor tells you to.
• Don’t put any medication on the incision unless your doctor tells you to.
• Don’t scratch or pick at the incision.

If you develop any of the following warning signs of infection, contact your doctor:

• fever
• increased redness around the incision
• increased swelling around the incision
• drainage from the wound for more than five days after surgery
• drainage from the wound that is cloudy, yellow, or foul smelling
• pain that increases and becomes constant.

A Patient’s Guide to Cumulative Trauma Disorder

Introduction

Cumulative trauma disorder (CTD) is a broad category that includes many common diseases that affect the soft tissues of the body. CTD in itself is not a disease. Doctors use the concept to understand and explain what may have caused, or contributed to, certain conditions. Examples of the conditions that may be caused or aggravated by cumulative trauma include carpal tunnel syndrome, tennis elbow, and low back pain.

Other terms are often used to describe the concept of CTD. These include repetitive stress injury (RSI), overuse strain (OS), and occupational overuse syndrome (OOS). This document will refer to these categories generally as CTD.

This guide will help you understand

• what factors may contribute to CTD
• how doctors diagnose conditions related to CTD
• what treatment options are available
• how to prevent CTD

Causes

What causes CTD?

Opinions abound as to what may cause CTD, but there is very little agreement. Some of the theories about how CTD starts are described below. The theories include

• overuse
• muscle tension
• nerve tension
• psychosocial factors
• mind-body interaction
• contributing factors

Overuse

Using muscles and joints after they have become fatigued, or overly tired, increases the likelihood of injury. Overloaded muscles and soft tissues without proper rest have no chance to recover fully. This problem often hampers athletes who have to throw, jump, or run repeatedly. It can also affect people who work in jobs where they keep doing the same action again and again, such as typing, gripping, and lifting.

All body tissues are in a constant state of change. Minor damage occurs continuously, which the body must repair in the normal course of a day. But the damage can occur faster than the repair mechanisms can keep up with it. When this happens, the tissues become weaker. They may begin to hurt. The weaker the tissues become, the more likely they will suffer even more damage. A cycle begins that looks like a spiral–constantly downward.

Muscle Tension

Some doctors think muscle tension causes CTD. To function, or work properly, the body and each of its parts needs a steady supply of blood, rich in oxygen and nutrients. Nutrients are the body’s fuel–glucose, for example. Cutting off or slowing the blood supply harms the tissues of the body.

Tense muscles are believed by some to actually squeeze off their own flow of energy and fuel. Muscles can get energy without oxygen, but the process produces a chemical called lactic acid. This chemical can be a potent pain-causing chemical. Lactic acid is a chemical that can produce a burning feeling when muscles are overexercised. Some physicians believe that lactic acid produced by tense muscles may cause some of the symptoms of CTD.

As pain develops, muscles tighten even further because they attempt to guard the surrounding area. Guarding is a term that is used to describe a reflex that all muscles in the body share. When pain occurs anywhere in the body, muscles around the painful area go into spasm (they tighten uncontrollably) to try to limit the movement in the area. As a result, blood flow is slowed down even more. The muscles begin to ache more. The nerves that have their blood supply reduced and squeezed by muscles begin to tingle or go numb.

Nerve Tension

This theory suggests that nerves become extra sensitive when they’ve become shortened and irritable. It is thought that poor postures used over long periods causes muscles to bulk up and interfere with blood flow. The nerves that course through the body then become shortened and may begin to stick to the nearby tissues. Moving the arm or leg puts tension on the nerve and can cause pain to radiate along the limb. The problem is thought to get worse from stress because the muscles and nerves tense up and become even tighter. Also, when the same activities are done over and over again, the tight nerve is pulled and strained to the point that it can’t heal and eventually becomes a chronic source of symptoms.

Psychosocial Factors

Problems with CTD tend to be more common among people who suffer from boredom, who have poor working relations, who aren’t satisfied with their jobs, and who have unhappy social circumstances. Reasons why this is so are unclear. The number of CTD cases reported may also be influenced by state worker’s compensation rules. States where claims are processed quickly and with greater benefits tend to have higher volumes of CTD cases. Both of these findings suggest that many cases of CTD may be highly influenced by the patient’s perception of the overall situation. Some patients may subconsciously, or consciously, rationalize their symptoms due to many factors that are not medical but have to do with their overall job and social situation.

Mind-Body Interaction

A newer theory suggests that there isn’t really an injury going on in the soft tissues where symptoms are felt. Instead, the problem is said to be coming from influences within the mind. It is theorized that the brain starts producing pain signals as a cover-up for deep-rooted feelings of past emotional pain or problems. Though the idea sounds hard to believe, practitioners using this approach claim they have had success rates as high as 95 percent. Their patients are reported to have gotten swift relief from treatments aimed at the underlying and unconscious emotional triggers.

Contributing Factors

The way people do their tasks can put them at risk for CTD. Some risk factors include

• force
• awkward or static postures
• poor tool and equipment design
• fatigue
• repetition
• temperature
• vibration

One of these risk factors alone may not cause a problem. But doing a task where several factors are present may pose a greater risk. And the longer a person is exposed to one or more risks, the greater the possibility of developing CTD. Many different symptoms can arise from the accumulation of small injuries or stresses to the body. CTD is not so much a disease as it is a response to excessive demands these factors can place on our bodies without giving them adequate time to recover between.

Symptoms

What does CTD feel like?

The symptoms of CTD usually start gradually. Patients usually don’t recall a single event that started their symptoms. They may report feelings of muscle tightness and fatigue at first. People commonly report feeling numbness, tingling, and vague pain. Others say they feel a sensation of swelling in the sore limb. Some patients with arm symptoms sense a loss of strength and may drop items because of problems with coordination. Symptoms often worsen with activity and ease with rest.

Diagnosis

How do doctors diagnose CTD?

Your doctor begins the evaluation by taking a history of the problem. You’ll probably be asked questions about your job, such as the type of work you do and how you do your job tasks. Other questions give your doctor information about your work conditions, such as the postures you use, the weights you have to lift or push, and whether you have to do repetitive tasks. You may be asked about how you like your job and whether you get along with your supervisors and coworkers.

Your doctor will do a thorough physical examination. Your description of the symptoms and the physical examination are the most important parts in the diagnosis of CTD. Your doctor will first try to determine what conditions are affecting you. For example you may have symptoms of carpal tunnel syndrome or tennis elbow that need to be treated. Second, your doctor will try and determine if cumulative trauma is playing a role in your condition. If so, part of the treatment will be to try and eliminate the source of the cumulative trauma.

There are no specific tests that can diagnose CTD. There are many tests that may be ordered as your doctor looks for specific conditions.

Treatment Options

What treatments are available?

Nonsurgical Treatments

Many nonsurgical treatment approaches are used by physicians, physical and occupational therapists, and other health providers to reduce the symptoms of CTD-related conditions. A splint may be suggested initially to protect and rest the sore area. Anti-inflammatory drugs are often used together with therapy treatments such as ultrasound, cold packs, or electrical stimulation. A series of exercises may be suggested to help tissues move safely while healing.

Surgical Treatment

Surgery is rarely indicated for CTD. Specific conditions that can occur as a result of CTD may require surgery. Unless the doctor is quite sure there is a structural problem, such as a pinched nerve or severely inflamed tendon, then surgery is not usually suggested.

Prevention

How can I help prevent problems of CTD?

The best medicine for treating CTD is to prevent the problem from occurring in the first place. Key items to consider when attempting to prevent problems with CTD are listed below.

Use healthy work postures and body alignment. Posture can have a significant role in CTD. Faulty alignment of the spine or limbs can be a source of symptoms. Using healthy posture and body alignment in all activities decreases the possibility that CTD will strike. Incorrect posture may lead to muscle imbalances or nerve and soft tissue pressure, leading to pain or other symptoms. Most people spend many hours at their work place, and using unhealthy posture during these long hours increases the likelihood that CTD will develop.

Ergonomics

Assessing where and how a person does work is called ergonomics. Even subtle changes in the way a work station is designed or how a job is done can lead to pain or injury.

Rest and Relax

Rest and relaxation (R and R) have recently become front-line defenses in the prevention of CTD. Methods can be as simple as deep breathing, walking, napping, or exercising.

This strategy is useful during work and off hours. Whether at home or work, our bodies need time to recover, which simply means giving them a chance to heal. Rest and relaxation allow the body to recover and provide a way of repairing these injured tissues along the way, keeping them healthy.

The following ideas may be used to foster rest and relaxation at work:

• Be relaxed. Try to work with your muscles relaxed by pacing your work schedule, staying well ahead of deadlines, and taking frequent breaks.
• Stop to exercise. Gentle exercise performed routinely through the day helps keep soft tissues flexible and can ease tension.
• Change positions. Plan ways to change positions during work tasks. This could include using a chair rather than standing or simply readjusting your approach to your job activity.
• Rotate jobs or share work duties. This can be fun by offering a new work setting, and it allows the body to recover from the demands of the previous job task.
• Avoid caffeine and tobacco. These can heighten stress, reduce blood flow, and elevate your perception of pain.

Rehabilitation

What can I expect with treatment?

Getting treated right away for symptoms of CTD can shorten the time it takes to heal. Symptoms can sometimes go away within two to four weeks when steps are taken quickly to address the factors that may be causing your symptoms. However, people who keep doing activities when they have symptoms and don’t seek help right away may be headed for a long and frustrating recovery time, perhaps as long as a year or more.

Your doctor may have you work with a physical or occupational therapist to speed your recovery. Your therapist will want to gather more information and will further evaluate your condition. The answers you give and the results of the examination will guide the therapist in tailoring a treatment program that is right for you.

Therapists often teach patients ways to relax. Relaxation ideas often include helping you learn to breathe deeply by using your diaphragm muscle. Taking the time to relax and breathe deeply eases tense muscles and speeds nutrients and oxygen to sore tissues.

Your therapist may apply treatments such as heat, ice, ultrasound, or gentle hands-on stretches to reduce pain or other symptoms. Muscle stretching may be used to restore muscle balance and to improve your posture and alignment. Therapists sometimes apply stretches that are designed to help nerves glide where they course from the spine to the arms or legs.

Strengthening exercises are used to restore muscle balance and to improve your ability to use healthy postures throughout the day.

Therapists pay close attention to your posture and movement patterns. You may receive verbal instruction and hands-on guidance to improve your alignment and movement habits. Helping you see and feel normal alignment improves your awareness about healthy postures and movements, allowing you to release tension and perform your activities with greater ease.

Your therapist will spend time helping you understand more about CTD and why you are feeling symptoms. You may be given tips on how to combat symptoms at work using rest and relaxation. You may also be given specific stretches and exercises to do at work. Your therapist may visit your work place to analyze your job site and to watch how you do your job tasks. Afterward, your therapist can recommend changes to help you do your job with less strain and less chance of injury. These changes are usually inexpensive and can make a big difference in helping you be more productive with less risk of pain or injury.

Your therapist’s goal is to help you understand your condition, to look for and change factors that may be causing your symptoms, and to help you learn how to avoid future problems. When patients are well underway, regular visits to the therapist’s office will end. Your therapist will continue to be a resource, but you will be in charge of practicing the strategies and exercises you’ve learned as part of an ongoing program.

Taking Care of Your New Cast

Cast Care Instructions

Unless you have a waterproof cast, you should keep your cast dry. However, even waterproof casts should be dried out thoroughly after getting them wet. If you don’t dry your cast out after getting it wet, the skin underneath stays damp and can become moldy and smelly. Also, don’t swim with your cast on unless you have the waterproof kind.

To keep your cast dry in the shower, you can enclose it in a plastic garbage bag. Tape the open end of the bag so that water can’t get in. You can also buy a special cast protector.

Casts don’t completely harden for about two days. Be especially careful with your cast during this time. Don’t rest the full weight of the cast on a hard surface during these first two days. Doing so can dent the cast and can cause pressure sores on the skin under the cast. If the cast involves your foot, don’t walk on it for forty-eight hours, even if you have what is known as a walking cast. Walking on a soft cast may cause it to crack or dent.

Keep the casted or splinted limb elevated (propped up) above the level of your heart when you’re able to do so. This will reduce the swelling and help to keep the cast from becoming too tight.

Avoid too much activity and situations that may re-injure you or damage your cast. Remember your cast is there to help your arm or leg heal. It can’t do its job without your cooperation.

Warning Signs

If you have any of the following warning signs after your cast is placed or changed, you should consult your doctor.

Severe Pain

Your injury will probably cause some pain, but if the pain becomes steadily worse after the cast has been placed or changed, that may be a sign that the cast is too tight.

Bluish Nailbeds

The area under the fingernails and toenails is called the nailbed. Normally the nailbeds are pink. When the nailbed is pinched and released, it turns white for a few seconds and then pink again. This is because small blood vessels under the nail are squeezed shut. When you release the pressure, the blood vessels quickly open back up, turning the nail bed pink once again. This is called blanching. If the nailbed has a blue color and doesn’t turn pink again after being pinched and released, this may be a warning sign that the cast is too tight.

Numbness or Tingling

You may feel some numbness after a broken bone has been straightened or fixed if any type of anesthesia (such as a regional block or local anesthesia) was used. This should wear off in a few hours. But if you feel constant numbness or tingling in the fingers or toes of the casted arm or leg, this may indicate that the cast is too tight or that a nerve has been injured.

Immobility of Fingers or Toes

Because of your injury, you may have pain that makes it difficult for you to move your fingers or toes. But if you have no ability to move the fingers or toes of the casted arm or leg, it may be a signal that the cast is too tight and the muscles or nerves aren’t working properly.

Severe Coolness of Fingers or Toes

Many people notice a difference in the temperature of the casted arm or leg. Usually, this difference is minor. But if you have any other problems mentioned here that suggest that the circulation is not good, and the hand or foot is cool, it may be a sign that the cast is too tight.

Severe Swelling

If you have severe swelling above or below your cast, try keeping the casted limb propped up above the level of your heart. Most injuries cause at least some swelling. But if the swelling continues to get worse after the cast is put on, it may be either a sign that the cast is too tight or that something is going on under the cast that needs to be checked.

Dented or Cracked Cast

If your cast is dented or cracked, or starts falling apart before you are due for a checkup, this could lead to problems with healing. Small cracks are probably alright, but if the cast isn’t doing what it is supposed to, it could affect the healing of the injury. You should also check with your doctor if you think the cast isn’t holding the arm or leg still enough.

A Patient’s Guide to Arthroscopy

Introduction

Until recently, surgery on the inside of any joint meant making a large incision and opening the joint to do even the most minor procedure. Twenty years ago, fiber optics began changing all that and is continuing to change how orthopedic surgeons operate on joints in the body.

• What is arthroscopy?
• How is it used?
• Why is it better?
• What joints are being scoped?
• What goes on during an arthroscopy?
• What are the risks of arthroscopy?
• What should I do after my arthroscopy?

What is it?

The term arthroscopy basically means to look into the joint. (Arthro means joint, and scopy means look.) So the common phrase scope the joint means to insert an arthroscope into the joint and have a look. In the early days before the development of miniature video cameras, about all the surgeon could do was take a look.

Over the past several years, the development of very small video cameras and specialized instruments have allowed surgeons to do more than simply take a look into the joint. The arthroscope is now used more and more for actual surgical procedures.

How is it used?

Using the arthroscope to assist with joint surgery usually involves making smaller incisions into the joint than those made in a regular open-incision surgery. Once the arthroscope is inserted into the joint, it is used first to try to see the problem. In this way, the problem can be confirmed before making any large incisions and causing any damage unnecessarily. Using the arthroscope as his eyes the surgeon can then use small specialized instruments inserted into the joint through other small incisions to perform the operation. As surgeons have become familiar with this type of surgery, more surgical procedures that were once done with large incisions are now being done arthroscopically.

Why is it better?

All surgical procedures that are done result in damage to tissues that are otherwise normal, because an incision must be made to see the problem. This is particularly bothersome for joints because to enter a joint, the joint capsule and ligaments must be incised (cut into). For minor surgical procedures inside the joint, it is not unusual for the recovery time to be much longer. This is because the normal tissues that were cut must also heal. Also, large incisions into the joint to perform surgical procedures increase the chances for infection. Long procedures where the joint is open to the air can lead to injury to the articular cartilage (the smooth surface of all joints) because it dries the cartilage out.

Arthroscopy causes less damage to normal structures by requiring much smaller incisions through the joint capsule and ligaments around the joint. Arthroscopy also allows the joint to remain closed and reduces the risk of infection and drying out of the articular cartilage. Because of this, the healing time for most arthroscopic procedures is greatly reduced. Rehabilitation is faster, and unnecessary damage to normal structures is avoided.

Arthroscopy has also greatly expanded orthopedic surgeon’s understanding of problems around the joints. In many cases, conditions which were completely unknown before the invention of the arthroscope have been discovered and are now being treated very effectively with arthroscopic surgery.

What joints are being scoped?

Just about every joint in the body has been scoped, but the vast majority of surgical procedures done with the arthroscope are done on the knee and the shoulder. The knee was the primary site of arthroscopic procedures in the early days of arthroscopy and continues to be a common target of the scope.

Probably the most common use of the arthroscope initially was to remove loose bodies from the knee joint or to remove a torn cartilage or torn meniscus. A loose body is a fragment of bone or cartilage that moves around inside the joint and can get caught between the two bones of the joint and cause pain. The menisci (or cartilages) of the knee are two small pieces of tissue that sit between the two bones of the knee joint and act similar to a gasket. A torn meniscus is a common problem that involves these structures and can get caught between the knee and cause pain.

Very complex surgical procedures are now done inside the knee with the aid of the arthroscope. For example, the anterior and posterior cruciate ligaments inside the knee are now almost always reconstructed without opening the knee joint. The procedure is done by using the arthroscope to help see where to drill holes in the bone and to place the ligament graft. Even fractures that involve the joint surface of the lower leg bone (the tibia) are being fixed by watching the fracture through the arthroscope while screws are inserted through small incisions in the skin–a procedure that once required a large incision into the joint.

The arthroscope is continuing to change the way orthopaedic surgeons deal with shoulder surgery as well. The arthroscope is now being used to repair torn tendons around the shoulder, to reconstruct the shoulder in patients who dislocate their shoulder and have instability, and to identify problems in the shoulder that were unknown prior to shoulder arthroscopy.

Other common joints that may be treated with arthroscopy include the ankle, wrist, elbow, and hip.

What goes on during an arthroscopy?

Preoperative

Your doctor will meet with you to explain what the surgery is intending to accomplish and what you can expect. You will be asked to sign a surgical consent form that describes the operation and the potential risks. It is a record that you understand the procedure. If you have any questions, now is the time to ask.

You will also need to review your other medical problems with the doctor in case you have a medical problem that will require evaluation before surgery. If you have serious lung or heart problems, you may need to see your family physician to get medical clearance before the procedure.

Admission

Most arthroscopic surgical procedures are done on an outpatient basis, which means you will probably be able to go home the same day. (Some arthroscopically assisted procedures still require larger incisions to be made around the joint, and these larger procedures may require a night or two stay in the hospital.) Generally, you are asked to not eat or drink anything after midnight on the evening before surgery. If you commonly take medications in the morning, ask your doctor whether you should take them or not.

Anesthesia

There are many different types of anesthesia that can be done, depending on your wishes, your doctor’s recommendations, and, of course, which joint is involved. In general, anesthesia may be local, regional, or general. Each of these types of anesthesia has advantages and disadvantages, but all are quite safe.

Local Anesthesia

Local anesthesia involves injecting lidocaine (or a similar medication) into the joint and in the areas where the incisions are made. This is the same type of anesthesia that is typically used to sew up a laceration, for example. The benefits of this type of anesthesia are that it is relatively safe, has less effect on the rest of your body, and returns to normal quickly after the procedure. The disadvantages are that you may still feel some discomfort during the procedure. This type of anesthesia is not generally used for shoulders or hips.

Regional Anesthesia

Regional anesthesia is probably the most common type used for arthroscopy. It is often referred to as a block (for example, a spinal block). The block is done by injecting lidocaine around the nerves that go to an extremity (in a spinal block, these are the nerves that go to the legs). The advantages to this type of anesthesia are that it does not affect the function of the lungs (a concern if you have lung problems). It does not cause as much nausea as general anesthesia, and it is relatively safer than general anesthesia. You are also awake and can watch the procedure on the TV monitor. The disadvantages are that it takes longer to take affect than going to sleep, and the actual block involves an injection–which may be uncomfortable for a short period of time.

General Anesthesia

General anesthesia is commonly referred to as going to sleep. It is commonly used for arthroscopic procedures–especially procedures which may be long and complicated. The advantages of general anesthesia are that you are not aware of anything that occurs during surgery. The disadvantages are that you may have a hangover with nausea and vomiting due to the drugs used, and you may have a higher risk of lung problems after surgery.

Surgery

Once the anesthesia is working, the operating room nurses and your doctor will prepare the equipment for arthroscopy. There are lots of electronics and equipment that need to be assembled. The surgical limb will be positioned to make it easier for the surgeon to do the surgery. If the procedure is going to be done on the knee, ankle, elbow, or wrist, a tourniquet may be used to stop the blood flow temporarily during the procedure. This makes it easier to see inside the joint.

When the surgery starts, several small incisions are made into the joint. These are usually about one-quarter of an inch long. The number varies from one to about six depending on what will be done. The joint is then filled with clear fluid (usually similar to the salt solution used in intravenous fluids). This expands the joint and allows the camera to work better. The fluid flows through the joint continuously to wash away blood and other material that is present during the procedure.

Once the surgery is under way, various instruments are used to perform the procedure. The camera is used to view the inside of the joint while the other instruments are used to either remove or repair the problem. If you are awake, you can watch the TV monitor and see exactly what your doctor is seeing. Still pictures or video can be taken through the arthroscope to record the condition of the joint. Your doctor performs the procedure while watching the TV monitor and guiding the instruments by what he or she sees on the TV. That’s why arthroscopy is like a very sophisticated video game.

Recovery

After surgery you will be taken from the operating room into the recovery room. There you will be closely monitored by the nurses until they are sure you are not having any problems from either the surgery or the anesthesia. You will probably be able to have something to drink if you are not nauseated. Normally, you will remain in the recovery room thirty to sixty minutes.

Discharge

Once you are ready to be released from the recovery room, you will probably return to where you started–the outpatient surgery department. Here you can wait with your family or friends until you are ready to be released to go home. You can probably have something to eat at this point and prepare to go home. You will be given some instructions at this point about what you should expect and what you should, and should not, be doing at home.

What are the risks of arthroscopy?

Like all surgical procedures, arthroscopy has potential complications. (Some of the more complicated procedures have specific risks.)

In general, arthroscopy requires anesthesia, and there are risks associated with anesthesia. Different types of drugs are given during the procedure that may cause a reaction–even death in very rare instances.

The arthroscopy procedure itself can result in damage to the joint structures or damage to nerves and blood vessels around the joint. Infection of the joint or soft tissues around the joint can occur after arthroscopy and may require additional operations to drain or treat the infection. Infection rates are generally less after arthroscopic procedures due to smaller incisions, shorter operations, and the fact the joint is constantly being flushed out during the procedure.

View animation of pulmonary embolism

Thrombophlebitis (blood clots), sometimes called deep venous thrombosis (DVT), can occur after arthroscopy (usually after arthroscopy of the hip or lower extremity joints). DVT occurs when the blood in the large veins of the leg forms blood clots within the veins. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they get lodged in the small blood vessels of the lung and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible.

What should I do after my arthroscopy?

You will be given specific instructions about what to do after your arthroscopy depending on what type of procedure you had performed. In general, you should take it easy for several days following surgery. You should watch for any signs of infection such as fever or chills, redness around the incisions, or increasing swelling or fluid build-up around the joint. If you have nausea and vomiting that persists for more that twenty-four hours after returning home you may want to discuss a medication change with your doctor. For specific instructions for your procedure you should consult your doctor.

A Patient’s Guide to Osteoporosis

Introduction

Osteoporosis is a very common disorder affecting the skeleton. In a patient with osteoporosis, the bones begin losing their minerals and support beams, leaving the skeleton brittle and prone to fractures.

In the U.S., 10 million individuals are estimated to already have the disease and almost 34 million more have low bone mass, placing them at increased risk for osteoporosis. Of the 10 million Americans affected by osteoporosis, eight million are women and two million are men. Most of them over age 65.

Bone fractures caused by osteoporosis have become very costly. Half of all bone fractures are related to osteoporosis. More than 300,000 hip fractures occur in the United States every year. A person with a hip fracture has a 20 percent chance of dying within six months as a result of the fracture. Many people who have a fracture related to osteoporosis spend considerable time in the hospital and in rehabilitation. Often, they need to spend some time in a nursing home.

This guide will help you understand

• what happens to your bones when you have osteoporosis
• how doctors diagnose the condition
• what you can do to slow or stop bone loss

Anatomy

What happens to bones with osteoporosis?

Most people think of their bones as completely solid and unchanging. This is not true. Your bones are constantly changing as they respond to the way you use your body. As muscles get stronger, the bones underneath them get stronger, too. As muscles lose strength, the bones underneath them weaken. Changes in hormone levels or the immune system can also change the way the bones degenerate and rebuild themselves.

As a child, your bones are constantly growing and getting denser. At about age 25, you hit your peak bone mass. As an adult, you can help maintain this peak bone mass by staying active and eating a diet with enough calories, calcium, and vitamin D. But maintaining this bone mass gets more difficult as we get older. Age makes building bone mass more difficult. In women, the loss of estrogen at menopause can cause the bones to lose density very rapidly.

The bone cells responsible for building new bone are called osteoblasts. Stimulating the creation of osteoblasts helps your body build bone and improve bone density. The bone cells involved in degeneration of the bones are called osteoclasts. Interfering with the action of the osteoclasts can slow down bone loss.

In high-turnover osteoporosis, the osteoclasts reabsorb bone cells very quickly. The osteoblasts can’t produce bone cells fast enough to keep up with the osteoclasts. The result is a loss of bone mass, particularly trabecular bone–the spongy bone inside vertebral bones and at the end of long bones. Postmenopausal women tend to have high-turnover osteoporosis (also known as primary type one osteoporosis). This relates to their sudden decrease in production of estrogen after menopause. Bones weakened by this type of osteoporosis are most prone to spine and wrist fractures.

In low-turnover osteoporosis, osteoclasts are working at their normal rate, but the osteoblasts aren’t forming enough new bone. Aging adults tend to have low-turnover osteoporosis (also known as primary type two osteoporosis). Hip fractures are most common in people with this type of osteoporosis.

Secondary osteoporosis describes bone loss that is caused by, or secondary to, another medical problem. These other problems interfere with cell function of osteoblasts and from overactivity of osteoclasts. Examples include medical conditions that cause inactivity, imbalances in hormones, and certain bone diseases and cancers. Some medications, especially long term use of corticosteroids, are known to cause secondary osteoporosis due to their impact on bone turnover.

Osteoporosis creates weak bones. When these weak bones are stressed or injured, they often fracture. Fractures most often occur in the hip or the bones of the spine (the vertebrae). They can also occur in the upper arm, wrist, knee, and ankle.

Causes

What causes osteoporosis?

Aging is one of the main risk factors for osteoporosis and osteoporotic fractures. If you are lucky enough to live a long life, you are much more likely to develop weakened bones from osteoporosis. In women, the loss of estrogen in menopause causes bone loss of up to two percent per year. White women over age 50 have a lifetime risk of fracture of about 50 percent. This figure increases with increasing age.

A number of factors contribute to osteoporosis:

• advanced age
• female gender
• low body weight or a thin and slender build
• recent weight loss
• history of fractures
• family history of fractures
• tobacco use
• alcohol abuse
• lack of exercise
• extended use of certain medications (e.g., corticosteroids, anticonvulsants, and thyroid medicine)
• Asian or Caucasian race

These risk factors are just as important as a measurement of low bone mass in determining how likely you are to have a fracture. People with low bone mass but no additional risk factors often don’t develop fractures. People with small amounts of bone loss but many risk factors are more likely to eventually develop fractures.

Symptoms

What does osteoporosis feel like?

Fractures caused by osteoporosis are often painful. But osteoporosis itself has no symptoms. That is why it is especially important to get tested if you are a woman past menopause and have any of the above risk factors. Women over 65 should be tested whether or not they have other risk factors. People with other bone problems or who take drugs that weaken the bones should also be tested. An initial screening for osteoporosis is painless and easy.

Diagnosis

How do doctors diagnose osteoporosis?

Free osteoporosis screenings are available in many drug stores and malls. Most of these screenings use a machine that scans the bone in the heel of your foot. It is a fast and simple way to get an idea of your bone density. However, this test is not entirely accurate. Because the heel bears a lot of weight, the test may show normal bone in the heel, even though the hipbones or spine may have low bone density. If the foot scan shows a low bone mass, you should talk to your doctor.

Your doctor will take a detailed medical history to help weigh your risk factors for osteoporosis. Information about your lifestyle and diet will also help your doctor develop a plan to help you build or maintain bone density.

Your doctor may also recommend more precise testing. Dual-energy X-ray absorptiometry (DEXA) is the most common method of measuring bone mass. A DEXA test uses special X-rays of the bones of your hip and spine to show your bone mass in these areas. The bone mass is then compared to that of a healthy thirty-year-old, called a T score. If you are within one standard deviation (SD) for bone density, you have normal bone. (SD is a statistic to measure variations in how a group is distributed.) If you are between one and 2.5 SDs below ideal levels, you are considered to be osteopenic. This means you have a mild form of osteoporosis. If the bone mass is more than 2.5 SDs below ideal levels, you have osteoporosis.

Be aware that DEXA scans are not perfect. Different equipment or different technicians can get somewhat different readings. If you need to have more precise data, your doctor may recommend additional types of bone scans or ultrasound tests.

A single DEXA scan also can’t show your doctor whether your bone mass is stable, increasing, or decreasing. Your doctor may have you take certain medications that create markers in the blood or urine to show what is happening in your bones. These tests will tell your doctor if you have high-turnover or low-turnover osteoporosis.

If bone density tests show that you have weakened bones, your doctor will need to rule out other causes. In some cases, problems with bone marrow or hormone levels can cause bone loss. Blood tests can show these conditions.

In other cases the bone weakening is actually from a condition called osteomalacia. Osteomalacia involves a softening of the bones caused by a lack of vitamin D. Vitamin D in your body comes from food and sunlight. Due to a lack of sunlight, almost 10 percent of people with hip fractures in the northern parts of the world have osteomalacia rather than osteoporosis. Urine and blood tests can help rule out osteomalacia.

In some cases, your primary care physician may refer you to a specialist. If you still have significant bone loss while on medication to prevent bone resorption, you may need to see a specialist. Referral is also advised for patients who have recurring fractures during therapy or repeated, unexplained fractures. Your doctor will help you find the right specialist for your situation.

Treatment Options

What can be done for osteoporosis?

The goal of your treatment plan will be to prevent fractures. This is especially important if you’ve already suffered a fracture from osteoporosis. To prevent fractures, you need to increase your bone mass. If you have high-turnover osteoporosis, you also need to prevent rapid bone reabsorption.

You need to take several steps to increase your bone mass

• Make sure you get enough calcium and vitamin D. (Vitamin D helps your body absorb calcium.) Researchers think that increased calcium intake alone could reduce the number of fractures by 10 percent. More and more of us don’t get enough calcium and vitamin D, especially as we age. It is difficult to get recommended levels from the food we eat, so supplements are probably necessary. Talk to your doctor about what kind to buy. Calcium comes in many forms–for example, calcium carbonate, calcium citrate, calcium phosphate, and calcium from bone meal. Some forms of calcium need to be taken with food, and others need to be taken with certain types of food. Taking extra calcium and vitamin D improves the effectiveness of all other treatments for osteoporosis.
• Eat enough calories to maintain a healthy weight. Being too thin increases your risk of osteoporotic fractures. Weight loss can be a cause of bone loss.
• Exercise. Your bones are constantly adjusting to the demands you put on them. Even low levels of exercise can help you maintain better bone mass. Low-impact exercises like fast walking, stair climbing, and safe forms of dance help stimulate osteoblasts, slowing down reabsorption. Muscle-strengthening exercises, using light weights, can help keep the bones underneath the muscles strong. Balance training can help you prevent the falls that can cause fractures. Your doctor may recommend seeing a physical therapist to help you develop an exercise program with all three kinds of exercises. (See below.)
• Premenopausal women should avoid overtraining and certain eating disorders, which can cause missed periods (amenorrhea).
• If you smoke, quit immediately.
• If you drink alcohol, do so moderately.

Medication

If you follow these recommendations and still have significant bone loss, your doctor may prescribe medications to slow down your body’s reabsorption of bone.

Many drugs are now available for the prevention and/or treatment of osteoporosis. Finding the right drug for each patient takes into consideration benefits and risks of the drug. These are matched against specific patient characteristics and risk factors. Ultimately, the best drug is the one most likely to be taken consistently and/or correctly by the patient. Osteoporosis management is most effective when drugs are taken in such a way that they have their full benefit.

If you are past menopause, hormone replacement therapy can be very effective. Bisphosphonates and calcitonin can also slow your body’s reabsorption of bone.

Studies have shown that 80 percent of women actually build bone mass up to two percent per year while on estrogen replacement therapy. Estrogen has been shown to decrease the occurrence of fractures in the vertebrae by 50 percent and fractures in the hip by 25 percent. Studies have also shown that hormone replacement therapy can also lower rates of coronary artery disease, relieve some symptoms of menopause, and maybe even prevent or postpone Alzheimer’s disease.

Hormone replacement therapy worries many women. Studies have shown that it may increase the risk of breast cancer. For women with a family history of breast cancer or who have had a stroke or thrombophlebitis (blood clots), hormone replacement therapy is probably not appropriate. Other women should at least consider taking estrogen. Its effects on osteoporosis are dramatic. Researchers estimate that, if estrogen were widely used, it could reduce all osteoporotic fractures by 50 to 75 percent.

Hormone replacement therapy must be continued to be effective, however. When a woman stops taking estrogen, she’ll start to lose bone at a very fast rate again. Within seven years, her bone density will be as low as that of a woman who never took estrogen.

Doctors often prescribe calcitonin to patients with fractures. Calcitonin is a non-sex, non-steroid hormone. Calcitonin binds to osteoclasts (the bone cells that reabsorb bone) and decreases their numbers and activity levels. Calcitonin used to be given only by injection, but now it is available in a nasal spray and a rectal suppository. Nasal calcitonin is used most often for women with osteoporosis who are five years or more past menopause and unable to take other approved agents. For unknown reasons, calcitonin seems to relieve pain. Calcitonin from salmon is much more effective than calcitonin from humans.

You and your doctor need to work together to monitor the effects of calcitonin. It is a new drug, and its long-term effects and benefits are still not fully known. More than 20 percent of patients develop a resistance to calcitonin over time, and it stops working for them.

Bisphosphonates also slow reabsorption by affecting the osteoclasts. The FDA has approved a variety of bisphosphonates for the treatment of osteoporosis. You may have heard the names of some of these such as Alendronate (Fosamax), Risedronate (Actonel), or Ibandronate (Boniva).

Some bisphosphonates are taken orally (pill form) on a daily basis. Others are available in weekly or monthly doses. A new injectable bisphosphonate (Zoledronate) can be given annually (once a year). Boniva comes in pill form and can also be injected once every three months. The injectable forms of this drug are used in the management of postmenopausal osteoporosis.

Studies have shown that bisphosphonates increase bone mass and prevent fractures. No one is sure how well bisphosphonates work when used for a long time. But stopping the drug doesn’t seem to cause the rapid bone loss that happens when someone stops taking estrogen. Because there can be some side effects with these medications, you need to work closely with your doctor if you take them.

The FDA is currently studying several drugs that may be used to treat osteoporosis. Some of these drugs, such as sodium fluoride, can be helpful in low-turnover osteoporosis. These drugs affect your osteoblasts in ways that cause them to create more bone. Sodium fluoride may be available in the near future. Other FDA-approved drugs are now available for the treatment of osteoporosis. For example, Raloxifene (Evista) is an anti-estrogen. Anti-estrogens are also called selective estrogen-receptor modifiers (SERMs). SERMs improve bone density and prevent fractures similar to estrogen, yet without increasing the chances of hormone-related cancer. Their main benefit over hormone replacement therapy is that they do not increase the risk of breast cancer.

Raloxifene is used most often for postmenopausal women younger than 65. They must not be at risk for blood clots or have cardiovascular disease. Men may be prescribed the only anabolic agent (Teriparatide/Forteo) approved for the management of osteoporosis. Anabolic usually refers to hormones that build up muscle or bone mass. Forteo is a form of parathyroid hormone used for patients at high risk of fracture. It is usually followed by an agent with antiresorptive effects such as a bisphosphonate.

Lifestyle changes, hormone replacement therapy, exercise prescription, and recent advances in drug therapy can help you take control of your osteoporosis. You and your doctor should be able to find ways to help you prevent the debilitating fractures of osteoporosis.

Physical Therapy

Many patients benefit from working with a physical therapist. People learn safe ways of moving, lifting, and exercising. Treatments also help people gain muscle strength and improved posture.

The physical therapist relies on your test results and the information received by you and your doctor. The therapist also looks at your body height, posture, body movements, strength, flexibility, balance, and your risk for having a fall.

Accurately measuring and recording your body height is a key part of the evaluation. It can give your therapist an idea of how osteoporosis is affecting your bones and posture, and comparing the recordings over a period of time can help track your success with treatments.

Posture exercises are used to help you “be tall”, regaining body height commonly lost with osteoporosis. This training can help patients who have stooped posture, called kyphosis, in the upper part of the spine. In healthy spine posture, the head is balanced on top of the spine rather than jutted forward.

In posture exercises, the goal is to get your body lined up from head to toe, with weight going through your hips. In people with advanced osteoporosis, the upper body is commonly bent forward at the hips. This prevents the hip bones from getting the right amount of stress and weight on them. As a result, the bones weaken and become more prone to fracture.

Your therapist will explain ways you can put good posture into practice. This is called body mechanics–the way you align your body when you do your activities. Remember that healthy posture is balanced with the body aligned from the head to toes. The same posture should be used when you bend forward to pick things up. Instead of rounding out your shoulders and upper back, keep the back in its healthy alignment as you bend forward at the hip joint. This keeps your back in a safe position and prevents the vertebrae from pinching forward. When bones are weakened from osteoporosis, rounding the spine forward when bending and lifting increases the risk of a spine fracture. As the back rounds forward, it pinches the front section of the vertebrae and can cause a fracture.

Your therapist will work with you in designing a safe program of exercise. Weight-bearing exercise strengthens existing bone and the muscles around joints. These types of exercises include walking outdoors or on a treadmill, doing safe forms of dance, and performing resistance training.

Some of the keys to safe exercise for osteoporosis include using good body alignment, avoiding bending or heavy twisting of the trunk, building up the amount of weight and number of repetitions gradually, and being consistent with your exercise program. Avoid exercises that curl your trunk forward such as stationary bike riding, sit-ups, toe-touches, and knee-to-chest exercises. Don’t exercise using abdominal crunch machines or rowing machines. Emphasize exercises that promote upright posture of the spine, such as walking. And do upper body exercises with your back supported in optimal alignment.

Your physical therapist will also check to make sure you have good balance. Poor balance can lead to a hazardous fall. When people with osteoporosis fall, they often end up fracturing a bone–a potentially life-threatening situation. Exercises to improve balance can be as simple as standing on one foot. As your balance gets better, more challenging types of exercises may be given.

People with balance problems can also benefit from practicing tai chi, an exercise form originating in China. In addition to gaining better balance, people who use the exercise movements show improved posture, flexibility, and strength.

Your therapist will continue to compare your test results of body height, posture, balance, and strength to see how well you are improving. The therapist’s goal is to help you become proficient and safe with your exercises, to improve you stature, strength, and flexibility, and to give you tips on how to avoid future problems.

When patients are well underway, regular visits to the therapist’s office will end. The therapist will continue to be a resource, but patients will be in charge of doing their exercises as part of an ongoing home program.

A Patient’s Guide to Viral Arthritis

Introduction

We know that some viruses cause joint pain and inflammation (swelling, redness, and heat). Researchers have wondered for a long time whether some kinds of arthritis with unexplained causes may be the result of a virus. So far no one knows, partly because the virus itself may be long gone before a patient ever develops the pain and inflammation of arthritis.

This guide will help you understand

• how viral arthritis develops
• how doctors diagnose viral arthritis
• what can be done for the condition

Anatomy

Where does viral arthritis develop?

Most viral infections in the body cause a limited illness. Then the body’s immune system destroys the virus, and the symptoms of the illness go away.

In viral arthritis, the immune system’s response to the virus causes inflammation in the joints. Even after the virus is eliminated from the body, the changes in the joint can continue to cause pain and swelling. The joint may even become permanently damaged.

Causes and Symptoms

Which viruses cause viral arthritis?

Several viruses are known to cause problems with joint inflammation and pain. Some of the most common are listed below.

Parvovirus B-19

Parvovirus B-19 is a common virus. About 60 percent of adults have been infected with it at some point in their lives. Parvovirus B-19 causes the illness called fifth disease, which causes a rash on the face and body. People usually get fifth disease as children. About 15 percent of children with fifth disease have some kind of joint pain, which usually goes away quickly. Almost 80 percent of adults who get fifth disease report sore joints within three weeks of the infection. Any joint can be involved, but usually it affects the foot, hand, knee, wrist, and ankle joints on both sides of the body. Most of the time the joint pain clears up in about two weeks, but it has been known to come and go for as long as ten years.

Hepatitis B

Hepatitis B infection, which causes severe inflammation of the liver, can cause a severe and sudden form of arthritis that affects many joints on both sides of the body. The hands and knees are the most common sites, but the wrists, ankles, elbows, shoulders, and other large joints are also affected. The arthritis often starts before the jaundice (yellowness of the skin) of hepatitis, and it may last for several weeks after the jaundice is gone. For patients with chronic (meaning long-lasting) hepatitis, joint pain may come and go.

Rubella

Rubella, a mild but highly infectious viral disease, causes joint pain in many adults, especially women. Joint symptoms tend to appear within a week of the rash common with this disease. The joints are usually not inflamed, but they are stiff and painful. The hands, knees, wrists, ankles, and elbows are most commonly affected. The joint pain of rubella usually goes away within two weeks, but in some cases it can last for several years.

The rubella vaccine also causes joint pain in about 15 percent of people. Joint stiffness occurs about two weeks after the shot and lasts for about a week. The vaccine has been known to cause more severe joint stiffness in some people, however, which can last for more than a year.

HIV

Human immunodeficiency virus (HIV) is the virus that causes AIDS. It is connected to several different forms of arthritis. When people are newly infected with HIV, they often have flu-like symptoms and joint pain. About 10 percent of HIV patients have severe joint pain that comes and goes, mostly in the shoulders, elbows, and knees. Patients with HIV are much more likely to develop reactive arthritis, Reiter’s syndrome, and psoriatic arthritis. In these cases, doctors aren’t sure whether HIV actually causes these forms of arthritis, or whether the arthritis occurs separately. Up to 30 percent of HIV patients also suffer from fibromyalgia.

In some cases, viruses that cause arthritis type symptoms can be carried by insects. Alphaviruses, one such family of viruses, are carried by mosquitoes in Africa, Australia, Europe, and Latin America. All can cause arthritis symptoms.

Diagnosis

How do doctors identify viral arthritis?

There is no specific test for any type of viral arthritis. Your doctor will make the diagnosis based on other symptoms. Usually blood work and X-rays don’t help. In many cases the diagnosis of viral arthritis is made after a search for other causes turns up negative and your symptoms or history suggest a virus as the cause.

Treatment

What can be done for the condition?

In most cases, viral arthritis runs its course fairly quickly. Your doctor may recommend a medication to help with the discomfort. Most of the time this will be an over-the-counter pain reducer like acetaminophen (Tylenol) or a nonsteroidal anti-inflammatory drug (NSAID), such as aspirin or ibuprofen. Your doctor may also recommend use of hot or cold packs on the inflamed joints and rest.

A Patient’s Guide to Tendonitis

Introduction

Chronic, or long-term, tendon problems are common. Tendon problems are especially common in people who play certain types of sports. Tendon problems account for almost 30 percent of all running injuries and 40 percent of all tennis injuries.

We use the term tendonitis, which means inflammation of the tendon, to refer to these chronic tendon problems. Doctors now know that the tendon does not always become inflamed when it is injured. Other changes in the tendon can cause tendon pain. However, tendonitis is still the most commonly used term.

This guide will help you understand

• how tendonitis develops
• how doctors diagnose the condition
• what can be done for tendonitis

Anatomy

Where does tendonitis develop?

Tendons connect muscle to bone. A tendon is made of material called collagen. Collagen is a key building block of the body. Collagen is considered a connective tissue because it forms tough strands that are like the strands of a nylon rope. Like the strands in a rope, the strands of collagen line up. The more strands, and the better they line up, the stronger they are. The tendon is wrapped in a thin, slippery covering called the tendon sheath. The tendon sheath allows the tendon to slide easily against the tissues around it.

Many parts of the tendon can be injured. Tendon problems can involve the area where the tendon attaches to the bone, the tissue that surrounds the tendon (the tendon sheath), or the main tissues of the tendon. Doctors use different terms to refer to injuries of different parts of the tendon.

Tendon injuries can show up anywhere in your body. Doctors see tendonitis most often in certain sites.

Achilles Tendonitis

The tendon sheath, the tissues of the tendon, and the attachment to the bone can all become injured in the Achilles tendon, found in the lower leg. Damaged Achilles tendons carry a higher risk of rupturing because of the weight they bear while standing and walking.

Related Document: A Patient’s Guide to Achilles Tendon Problems

Posterior Tibial Tendonitis

Tendonitis along the inside edge of the ankle and into the instep of the foot is called posterior tibial tendonitis. It is usually caused by age-related degeneration. If this tendon breaks, it can cause the arch of the foot to become flat and painful.

Related Document: A Patient’s Guide to Posterior Tibial Tendon Problems

Patellar and Quadriceps Tendonitis

Problems in the tendons of the knee occur mostly in people whose exercise involves running or jumping. Patellar tendonitis is also called jumper’s knee.

De Quervain’s Disease and Trigger Finger

Tendon problems are common in the hand and wrist. De Quervain’s disease causes pain in the wrist just above the thumb. Trigger finger generally causes pain in the palm just below the knuckles, but it eventually causes problems with movement.

Related Document: A Patient’s Guide to De Quervain’s Tenosynovitis

Related Document: A Patient’s Guide to Trigger Finger and Trigger Thumb

Lateral Epicondylitis

Lateral epicondylitis, also called tennis elbow, affects the area where the tendons of the elbow attach to bone on the outside of the elbow. It causes pain when using the wrist and hand.

Related Document: A Patient’s Guide to Lateral Epicondylitis

Medial Epicondylitis

Medial epicondylitis, also called Golfer’s elbow, affects the area where the tendons of the elbow attach to bone on the inside of the elbow. It causes pain when using the wrist and hand.

Related Document: A Patient’s Guide to Medial Epicondylitis

Rotator Cuff Tendonitis

Rotator cuff problems of the shoulder range from mild damage to complete tears. They can cause pain even when resting.

Related Document: A Patient’s Guide to Rotator Cuff Tears

Often, the muscles or other tissues of the joints become tight, misaligned, or weak around the area of tendon injury. Some of the pain and swelling of tendonitis may actually be in the surrounding tissues.

Causes

Why do I have this problem?

Doctors don’t know exactly what causes most tendon problems. They think that repetitive stress on the tendon is the most common cause. The tendon can be injured by the repetitive pounding of running and jumping, or by the stress caused by lifting heavy loads over and over again. Tendonitis usually builds up over weeks or months.

If the tendon is too damaged, or if it doesn’t get time to heal, the problem becomes chronic (long-lasting). In general, the heavier the load or the more often the stress is repeated, the more likely you are to develop tendonitis.

Too much stress on the tendons can be made worse by other factors. Lack of flexibility or weakness in your muscles can make tendonitis more likely. Shoes that don’t fit right, poor equipment, or incorrect technique can also increase your risk of tendon injury. Don’t underestimate the benefit of upgrading your equipment. The improved design of athletic shoes over the past few decades seems to have decreased tendon injuries.

Aging seems to cause tendon damage in some cases. As we age, the tissues of the tendon can break down, or degenerate. Age-related tendon problems do not seem to cause inflammation. The tendon material itself is more affected in these conditions and some surgeon’s refer to this type of tendon problem as tendonosis.

Some researchers think that a decreased blood supply to the tendons can cause the tendon damage in tendonosis. The decreased blood supply does not allow the tendon to get enough oxygen from the blood. This leads to a condition where the tendon degenerates. The collagen material that makes up the tendon actually becomes weaker and loses its nylon rope appearance. This type of degeneration has been noted in the rotator cuff around the shoulder, in the Achilles tendon in the heel and in the tendons of the elbow.

Many factors can work together to cause tendonitis. For instance, a woman in her forties who takes up running may have tendonitis caused jointly by the degeneration of aging and the mechanical stress of running.

Symptoms

What does tendonitis feel like?

Tendonitis causes pain. This is the primary symptom of tendonitis and tendonosis. The affected tendons are sometimes swollen. In some cases this swelling occurs from actual thickening of the tendon itself. In other cases the swelling comes from thickening or swelling of the tendon sheath. Tendon problems often cause pain after resting, such as when you first get up in the morning. This pain usually goes away within minutes, or even seconds.

The pain or swelling in your tendon may make your joint hard to move. Some types of tendon problems cause crepitus, a crackling feeling when the joint moves. In rare instances the weakened tendon may actually rupture, or break, with a sudden force. This may require surgery to repair.

Diagnosis

How do doctors identify tendonitis?

Your doctor will take a detailed medical history, including many questions about your activities, your job, and your symptoms. Your doctor will also physically examine the sore area. The probing and movement may cause pain, but it is important for your doctor to know exactly where it hurts.

X-rays do not usually show tendon damage. Your doctor may still ask you to get an X-ray or another imaging test to rule out other problems. Sometimes tendon injuries and other joint or muscle problems occur together. In some cases your doctor may recommend a magnetic resonance imaging (MRI) scan to look at the tendons. The MRI scan is a test that uses magnetic waves instead of X-rays. This test shows the tendons and other soft tissues of the body. It can show the damage in the material that makes up the tendon.

In rare cases it is difficult to find the exact source of your pain. In these cases, your doctor may ask you to go through more sophisticated imaging tests. Your doctor may also inject a local anesthetic into the tendon suspected of causing the pain. If the pain goes away, you have found the right tendon.

Treatment

What can be done for the problem?

Tendon problems can be difficult to treat effectively. They can last for many months to several years, even with treatment. You should expect your treatment to take from six to nine months. Even if treatment is effective, your pain may come back. The exact treatment your doctor recommends depends on which tendon is affected.

Your doctor will probably recommend nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, to help control the inflammation and pain. NSAIDs are usually used for a short time with tendon problems. Your doctor may also suggest ice or heat treatments.

If nothing helps relieve the pain, corticosteroid injections around the tendon are sometimes used. Doctors disagree on whether to use corticosteroid injections in tendons. Even if your doctor does use injections, they are not safe in all cases. Injections into tendons can cause more injury–in some cases, the tendons actually tear. It is generally recommended to give no more than three corticosteroid injections, at least three months apart. Patients need to avoid heavy activity for a few weeks after the injection.

You will need to rest to give your body time to heal. If playing tennis injured your tendon, stop playing tennis until it is completely healed. You should only take part in activities that don’t strain the injured tendon.

Your doctor may refer you to a physical or occupational therapist. A therapist will teach you stretches and exercises to help your tendon heal and regain its strength. A therapist can also assess your work site and athletic equipment and recommend changes to reduce the strain on your tendon. Depending on your type of injury, you may be asked to try such special equipment as arch supports, heel lifts, and splints.

Most people with chronic tendon problems can find ways to relieve the pain and take part in their normal activities, even if the problem doesn’t completely go away. In a few cases, patients can’t find ways to manage the pain even after six months. For these patients, surgery may be necessary. Surgery can be very successful in relieving the pain of chronic tendonitis.

A Patient’s Guide to Septic Arthritis

Introduction

Septic arthritis is an infection inside a joint that is caused by bacteria. (Septic describes an infection in the body caused by bacteria.) It comes on suddenly and causes very noticeable pain and swelling in the affected joint. It can affect anyone, including infants and children. But it is most likely to affect people over 60 and people with certain health or joint problems.

This guide will help you understand

• how septic arthritis develops
• how doctors diagnose the condition
• what can be done for septic arthritis

Anatomy

Where does septic arthritis develop?

In septic arthritis, the synovial fluid–the lubricating fluid inside a joint–becomes contaminated, or infected, with bacteria. In response to the infection, the body produces white blood cells that try to fight and kill the bacteria. This creates pus that mixes with the synovial fluid inside the joint. The white blood cells that fight infection produce chemicals that may not only kill the bacteria but may also damage the joint surfaces. Once this process begins, the breakdown of the joint can continue even after the infection goes away and the bacteria are all dead.

About 80 percent of cases of septic arthritis involve only one joint. Roughly half of the time a knee is affected. The other most common sites are the hip, shoulder, wrist, ankle, elbow, and small joints in the hands and feet. When more than one joint is affected, the knees are usually involved.

Causes

Why do I have this problem?

The cause of septic arthritis is known. It is caused by a bacterial infection in a joint. Bacteria can get into a joint in many ways. The bacteria may be introduced into the joint as a result of injury, such as a laceration that goes into the joint. Surgery on the joint can introduce bacteria into the joint. There is always a small chance of causing an infection if a needle is placed in the joint to either remove synovial fluid for testing or to inject medications into the joint. The joint infection can also come from infections in the skin around the joint or infections in the bones around the joint. The bacteria can also be carried by the blood from an area of infection somewhere else in the body. Once in the joint, synovial fluid provides a good place for the infection to lodge and grow.

Although they do not cause septic arthritis, several risk factors make it more likely to develop. These risk factors include a suppressed immune system, drug abuse, and other diseases. Other diseases that go along with septic arthritis include rheumatoid arthritis, diabetes, cancer, sickle cell disease, anemia, lupus, liver disease, skin infections, and hemophilia.

Artificial joints and recent joint surgery or arthrocentesis (inserting needles into the joint) are also risk factors for septic arthritis. However, the risk from these sources is small. The rate of septic arthritis from artificial joints is less than one percent. The rate following corticosteroid injections is less than 0.01 percent. Rates of septic arthritis following arthroscopy (surgery conducted using a small TV camera inserted into a joint) range from 0.04 percent to four percent. Septic arthritis caused by arthroscopy usually begins within two weeks of the procedure.

The biggest risk factor in septic arthritis is advanced age. Roughly half the cases of septic arthritis occur in people over age 60. In these patients, 75 percent of the infections occur in joints that have already been affected by arthritis, especially the hips, knees, and shoulders.

Symptoms

What does septic arthritis feel like?

Septic arthritis causes moderate to severe joint pain that comes on from a few hours to a few days. (Doctors refer to this as acute onset.) The pain is much worse when you move or touch the joint. The joint is usually warm and red, and it can’t move easily. You may have other evidence of infection, including a fever, chills, flu-like symptoms, and high white blood cell counts. However, 20 percent of patients with septic arthritis run no fever. Even fewer people over 60 run a fever or have high white blood cell counts when they have septic arthritis.

Diagnosis

How do doctors identify the condition?

The sooner a diagnosis of septic arthritis is made, the better. The more time the infection goes unchecked, the more damage it can do to the joint.

If you have acute onset in one joint and a risk factor of any kind, your doctor will probably test for septic arthritis. A needle will be inserted into the joint and synovial fluid removed and sent to the lab. Your doctor will perform several tests on the synovial fluid. The most important test is probably the measuring the white blood cell count in the fluid. An infection in the joint causes the white blood cell count to be extremely high. Other tests are also useful especially making sure there are no crystals in the fluid that could indicate the presence of gout. A gout attack can easily be mistaken for an infection, and vice versa.

The fluid will be examined under a microscope to look for bacteria. Your doctor will also have the lab perform a culture of the synovial fluid to try and grow the bacteria. In this test a small sample of the fluid is placed in a special container and allowed to incubate in a warm cabinet. The test usually takes from 24 to 36 hours to see if any bacteria grow. This test can also help determine the specific type of bacteria that is causing the infection. If bacteria grow in culture the lab can also test different antibiotics on the bacteria to see which antibiotic will work the best.

Your doctor may ask you to have an X-ray. The X-ray will be used to look for any problems in the joint. It will also provide a baseline of information so your doctor can see the changes in your joint over the course of the infection.

Treatment

What can be done for septic arthritis?

Your doctor will prescribe an antibiotic right away, taking into account your medical history, other diseases or infections you have, and the lab test results. The antibiotic may be changed as your doctor gets information from the testing of the synovial fluid. You will probably be started on intravenous (IV) antibiotics. You will need to continue on oral antibiotics for up to six weeks.

Antibiotics alone may not get rid of septic arthritis. The fluid in the joint may need to be drained at least once a day to remove the pus. This can be done using a large needle. In larger joints such as the knee, arthroscopy may also be used to wash the joint out and remove dead or damaged tissue. Surgery may be necessary to drain and clean joints such as the hip and shoulder. Surgery may also be necessary in joints with bone infections and in joints where the infection can’t be easily controlled.

As your infection begins to clear up, your doctor may suggest that you begin strengthening and range of motion exercises. They will help your joint regain its strength and flexibility. A physical or occupational therapist may oversee your exercise program.

How well your septic arthritis responds to treatment will depend on a number of factors. Most important is how soon you got treatment. Only about 25 percent of patients who wait a week to see a doctor can hope for a complete recovery. So you may feel as though your doctor is rushing you through tests and treatment, but it is for a very good reason.

A Patient’s Guide to Rheumatoid Arthritis

Introduction

Rheumatoid arthritis (RA) is a chronic, or long-term, inflammatory form of arthritis. RA is considered an autoimmune disease, in which your immune system attacks the tissues of your own body. In RA, the immune system mostly attacks tissues in the joints, but it can also affect other organs of your body. In some people, RA seems to run its course more or less by itself. In others, RA gets progressively worse and leads to the destruction of joints. RA can greatly affect your ability to move and do normal tasks. RA can appear at any age, but most patients are between the ages of 30 and 50. About two million Americans have RA, and most of them are women.

This guide will help you understand

• how RA develops
• how doctors diagnose the condition
• what can be done for RA

Anatomy

Where does RA develop?

In RA, two things are happening in the joints. First, the immune system causes inflammation in the synovial membrane, called synovitis. The synovial membrane is the thin tissue that lines the inside of all joints. At first this causes extra fluid, swelling, and oozing clots in the joint. The pain and swelling of synovitis can be reversed.

Second, the synovitis itself causes other problems in the joint. The blood cells and the swollen membranes release chemicals into the synovial fluid (the lubricating fluid of the joint) that can break down or damage the tissues of the joint. This breakdown can cause permanent damage to the cartilage, bone, ligaments, and tendons inside and around the joint. The structural damage usually happens in the first to third year of the disease. The synovitis can come and go, but the structural damage progresses. As a result, the joint becomes painful and very difficult to move.

RA usually affects many corresponding joints on both sides of body. (For example, both knees, both ankles, both wrists, and the same joints in both hands may be affected.) Research indicates that almost all the joints that will be affected show symptoms of RA in the first year of the disease. This means that each joint may continue to get worse, but you probably won’t have many more joints that will develop the symptoms of RA.

Most RA patients have inflammation in the tendons around the joint. (Tendons connect muscle to bone.) Nodules, or bumps, may form on the tendons, or the tendon sheath (the membrane that surrounds the tendon) may become inflamed. Inflammation can also occur in other parts of the body, like the lungs. In general, inflammation refers to symptoms of swelling, redness, heat, and pain.

Most people think of RA as a disease of the joints, but it is actually a systemic disease–it affects the whole body. That means that RA can show up in other organs, too, such as the heart, blood vessels, lungs, and eyes. Sometimes RA occurs in joints and other organs, and sometimes it occurs only in other organs. RA works somewhat differently outside the joints, but the underlying problems are still damage to the tissue and loss of function.

Causes

Why do I have this problem?

No one knows exactly what causes RA. There are probably different causes in different people. Many doctors and researchers think that a virus or bacteria might cause RA. So far studies haven’t proved this. However, researchers do know that bacteria can cause swelling in the synovial membrane.

Heredity–your genes–plays a part in RA. The disease tends to run in families. If a close relative has RA, you are 16 times more likely to develop the disease yourself.

Symptoms

What does RA feel like?

The primary symptom of RA is pain in corresponding joints (both elbows, both knees, and so on). In rare cases the pain is only in one joint. Most often the pain develops over several weeks. But the pain can come on suddenly. As the pain spreads to other joints, it becomes more symmetrical, meaning that it shows up in the same places on both sides of your body. The pain is directly related to the amount of swelling in the synovial membranes. When the swelling is at its worst, your joints themselves will feel warm and swollen. The pain can come and go with the swelling.

RA patients also describe severe morning stiffness that can last up to two hours. The stiffness can be so bad that it makes it hard for you to get dressed, make breakfast, or even get out of bed. This stiffness also corresponds to the synovitis. When the synovitis goes away for a time, so does the stiffness.

About half of RA patients have rheumatoid nodules. The nodules are hard knots, from the size of a pea to the size of a golf ball, that grow under the skin in three distinct layers. They are usually found on the outside of the elbow, the Achilles tendon on your heel, the underside of your fingers, the lower abdomen, and certain toe joints. They look like the kind of bump that grows around a splinter. They don’t usually hurt. Over time they tend to shrink or disappear.

Because RA is a systemic disease, most patients feel tired and weak during flare-ups. In patients who test positive for rheumatoid factor (RF) in their blood, other organ systems can also become inflamed when the joints do. About 50 percent of RA patients have systemic inflammation during joint outbreaks of RA.

Conjunctivitis, or inflammation of the eye, is common. It may be related to a disease of the eye called Sjogren’s syndrome, which often occurs along with RA. The main symptom is eye dryness, but patients often can’t even feel it.

RA can affect the lungs. Occasionally it can cause an inflammation of the membrane that surrounds the lungs (called the pleura), which causes pain in the side and sometimes coughing and problems breathing deeply.

RA commonly affects the nervous system, but it can be hard to tell from other symptoms of RA. Damage to the joints in the cervical spine (the neck) can eventually lead to weakness and instability between the cervical vertebrae. This damage can cause problems with the spinal cord as it travels through the neck.

Some symptoms depend on the affected joints:

• Cervical spine (the neck): Symptoms include neck stiffness, weakness, and loss of motion. Other symptoms often can’t be felt or seen in exams. Ligaments are often inflamed, and there may be problems with the spinal cord or nervous system. Neck pain alone tends to get better, even when the joints are damaged. Damage to the nervous system does not usually improve.
• Shoulders: The main symptom is loss of motion. Your body’s unconscious reaction to shoulder pain is simply not to use your shoulders. Since daily life doesn’t require much shoulder use, frozen shoulder syndrome can set in quickly.
• Hands and wrists: Almost everyone with RA has affected wrists. Joints in the middle of your hand and fingers are usually affected. The knuckles at the ends of your fingers usually are not. RA can cause joint deformities that freeze your fingers in unusual positions. Rheumatoid nodules and tendon inflammation can make it hard to bend the fingers. Nodules can cause a locking and catching action as your fingers bend.
• Knees: It is easy to feel the swelling in the knees. A fluid-filled lump called a Baker’s cyst often appears behind the knee. It can burst and leak fluid into the calf.
• Feet and ankles: RA commonly affects the joints in the middle of the toes and the ankle joints. The deformities and pain in the toes can cause problems with walking. The sole of the foot can feel tingly or numb.

The progression of RA is hard to predict. The swelling of RA flares up and dies down, and milder forms of the disease often don’t require much treatment. Mild RA may even go undiagnosed.

Diagnosis

How do doctors identify RA?

No single test can confirm a diagnosis of RA. Many findings over a period of time lead to the diagnosis. In fact, your doctor can’t even positively diagnose RA until you’ve had symptoms for at least several weeks. Early on, many characteristics of RA haven’t developed yet, such as the pattern of joints that are affected, X-ray findings, and blood test changes. And RA in its early stages can look a lot like other forms of arthritis, such as lupus, psoriatic arthritis, and diseases of the spine. Your doctor will need to consider each of these diagnoses and perhaps do tests to rule them out.

Your doctor will start with a detailed health history. You will need to describe your pain and be very specific about where your pain is located and when it came on. You will also need to tell your doctor about any other medical conditions you have had and drugs you are taking. Even if these other conditions are not related to your joint pain, your doctor will need to know these things to help you find effective treatment. Your doctor will also examine your joints closely. Your doctor will be looking for bone-on-bone crepitus, a high-pitched screech that you can feel or hear in the joint. It is the sound of bone rubbing on bone, and nothing else makes this sound.

Every patient with RA has inflammation of the synovial membranes. Your doctor can confirm this by checking the count of white blood cells (WBC) in your synovial fluid. This involves inserting a thin needle into your joint and drawing out a small amount of the fluid for testing. The fluid can also be tested for other things. The WBC alone doesn’t prove that you have RA. Your doctor will need to rule out other causes of synovitis.

Your doctor will also ask you to undergo a blood test. RF, or rheumatoid factor, is found in the blood of about 85 percent of RA patients. But this test alone can’t confirm RA either. Some patients with RA do not have RF, and people with RF can have other forms of arthritis.

Another blood test is the erythrocyte sedimentation rate (ESR, or sed rate), which measures how fast red blood cells settle in the test tube. Red blood cells that settle faster than normal indicate inflammation in the body. But the ESR varies greatly between people. It is even possible for a patient with RA to have a normal ESR. The ESR may be more useful in monitoring the progress of your disease than in diagnosing it. A higher ESR usually means that the inflammation is more severe.

The C-reactive protein test can also monitor inflammation. It is a newer test that may be more accurate than the ESR. This test measures the amount of a certain protein that is produced by the body due to inflammation. When inflammation is very active the amount of C-reactive protein is high, and when inflammation is brought under control the level of protein decreases.

At some point your doctor will probably ask you to get X-rays of your affected joints and organs. X-rays and other imaging techniques can show damage to the cartilage and bone and the swelling in the soft tissues of the joint.

In some cases your doctor may want to biopsy the rheumatoid nodules. A small amount of the nodule is removed and examined in a laboratory.

Treatment

What can be done for the condition?

Doctors have learned much about RA in recent years, but they still don’t know much more about how to truly cure the disease. They do have many strategies for treating the symptoms of RA. If you start treatment within a few months after your symptoms appear, the better you will probably do in the long-term. Early detection and treatment can help avoid the worst joint damage. Sudden remission does occur, but it’s unclear how often, and it appears to be more likely within the first two years of the disease. Patients who develop RA at a young age, are RF positive, have close relatives with RA, and have RA nodules tend to have a more difficult time managing the disease.

Your doctor will prescribe one or more medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, can help decrease the pain and swelling. Corticosteroids taken by mouth can also help with inflammation. Because steroid use can cause other problems in your body, they are usually not be used over long periods of time, if at all possible. Corticosteroid injections into the affected joints can ease the swelling and give you immediate, short-term relief. And your doctor may prescribe eye medications, even if you have no eye symptoms. Because eye inflammation is so common with RA and is hard to diagnose, the eye drops can help prevent it from developing or becoming severe.

Disease-modifying antirheumatic drugs (DMARDs) are important in treating RA. No one is sure exactly how well DMARDs actually slow or prevent the structural damage from RA. However, tests have shown all DMARDs to be effective for at least one year of treatment.

DMARDs can be very hard on your body and can interact with other drugs, so it is not always easy to find the best medication for you. Often more than one drug is taken at the same time. Several DMARDs are frequently prescribed:

• Hydroxychloroquine is a relatively nontoxic drug that was made to treat malaria. It can be safely used with other DMARDs. It is most useful in early, mild RA. You should get regular eye check-ups while taking this drug.
• Sulfasalazine is much like hydroxychloroquine. This drug requires regular blood monitoring.
• Gold salts can cause short-term remissions. Over the long-term, however, the RA does progress. Blood and urine monitoring is required.
• Methotrexate can help manage RA, but it is unclear how much it actually changes the course of the disease. Methotrexate can be very useful over the long-term, but there are problems with flare-ups when patients stop taking it.
• Azathioprine is used with moderate and severe RA.
• Penicillamine is only used in patients who have systemic disease that doesn’t respond well to other medications.
• Cyclosporine is expensive and hard on the kidneys, so it is most often used in severe RA.
• Cyclophosphamide is very effective but very toxic, so it is only used in specific cases.
• Certain antibiotics are somewhat effective in mild cases.

Combining methotrexate with another drug to get the desired results (decreased joint pain, swelling, and stiffness) is a popular and effective strategy for many patients. One group of disease modifying medications used along with methotrexate is called anti-tumor necrosis factor (TNF) agents.

Another term for the anti-TNF agents is TNF inhibitors. These are a special type of antibody also referred to as human monoclonal antibodies. They specifically target (and inhibit) tumor necrosis factor. Tumor necrosis factor (TNF) promotes the inflammatory response, which in turn causes many of the clinical problems associated with autoimmune disorders such as rheumatoid arthritis.

Anyone taking tumor necrosis inhibitors must be careful to report any signs of infection to the physician right away. There have been reports of deaths possibly associated with unrecognized or untreated infections in patients taking these immune suppressing drugs.

Symptoms of infection anywhere but commonly affecting skin, lungs, or urinary tract include fever, chills, fatigue, enlarged lymph nodes, skin rash or red streaks, cough, and/or sore throat. Upset stomach, painful urination or blood in the urine or stools are additional important symptoms that could be a signal of infection and should be reported to the physician as well.

In general, your doctor may recommend some of the following treatments that will require some effort and lifestyle changes from you:

• Patient education. RA is a frustrating and complex disease. The more you understand it, the better you can help treat your own symptoms and prevent flare-ups.
• Range-of-motion and strengthening exercises. These will most often be designed and monitored by a physical or occupational therapist.
• Equipment and gadgets, such as canes and jar openers that can help you go about your daily business without putting too much stress on affected joints.
• Gentle aerobic exercise.
• Support groups.

At least half of RA patients don’t find much relief from treatment and eventually need surgery on the affected joints. Surgery, including total joint replacement, can be a very effective way to help you overcome the pain and loss of movement of RA.

For most patients, RA is a disease that comes and goes throughout their lives. But it doesn’t have to be crippling. With your doctor’s help, you should be able to find treatment that works for you.