Musculo skeletal problems in the community Dr.A.K.Venkatachalam, MS, DNB,FRCS,MCH orth Consultant Orthopaedic surgeon, Besant nagar,Chennai
Atruamatic knee painCauses Patello femoral pain syndrome Plica Degenerative meniscal tears Osteoarthritis of the tibiofemoral joints( Knee joint) Pes anserinus bursitis
Patello femoral pain syndrome• Common cause of knee pain, account for 30% of visits to a knee surgeon• Mechanism of pain is related to maltracking of patella.• Common in women• Main clinical feature is “Pain on walking upstairs” or rising from the squatting position which increases the load on the knees to 7 times that of body weight
Patello femoral pain cont’d• Diagnosis- “Grind test”- done by squeezing patella against the femur. Sky line views to document mal- tracking• Associated with knee osteoarthritis but can also appear in isolation in patients with mal-tracking of patella• Treatment- Quadriceps strengthening and patellar mobilisation.• If pain not relieved after three months- arthroscopic or open patellar realignment surgery.• If no mal alignment then debridement with a shaver
Normal and abnormal patellaralignment seen on sky line views
Lateral release for mal alignment of patella • Arthroscopic lateral release with LASER
Debridement of patella for idiopathic softening of cartilage
Plica syndrome• Plica are embryological remnants in the synovium of the knee joint• Medial plica is the commonest cause of knee pain.• Plica alone is a rare cause of pain, associated with patello femoral arthritis and knee OA.• Clinical diagnosis – clicking on the medial aspect of the knee when knee is flexed to 90 degrees as the hypertrophied plica rubs against the medial condyle.
Degenerative meniscal tears• Mensici transmit 30%- 70% of the load of the knee, Lateral meniscus > medial meniscus.• Tears of the menisci are common- 35% on MRI scans of people > 65 years of age.• Clinically – cause more pain than pure arthritic pain-due to displaced tears causing capsular stretching.• No effusion seen usually.• Diagnosis- grinding of the knee in hyper flexion and circumduction- clicking sound.
Degenerative tears of menisci• Conservative treatment consisting of quadriceps strengthening.• Tears producing symptoms mechanical symptoms like locking, catching need arthroscopic menisectomy.
Cartilage lesions• Articular cartilage lesions are pre cursors of osteo-arthritis.Causes-• Traumatic knee injury after sports or two wheeler accidents• Obesity• Mal alignment• Ligament injury like ACL injury.
Articular cartilage defect seen at operation Normal cartilage Damag ed cartilag e Damaged cartilage
Mal alignment of lower limbs• Common cause of unicompartmental secondary osteoarthritis• Patients will require a major surgical procedure within 10 years• Corrective osteotomy for active individuals can postpone a knee replacement by 10 years.• Costs are lower as no implants are used.
Unicompartmental osteoarthritis• Similar to wear of car tyre when wheel balancing not proper.• Usually medial compartment arthritis in genu varum and lateral in Genu valgum.• Treatment methods- a) Outer heel raise or float.• Osteotomy/ Unicompartmental replacement. Good results for 5 -10 years
Deformities of knee are main cause of secondary unicompartmental arthritis
Shoulder problems in the community• Shoulder instability.• Subacromial impingement• Adhesive capsulitis.• Rotator cuff tendonitis & tears
Shoulder instability• The shoulder joint has the maximum range of movement.• Anatomy similar to a golf ball perched on a tee- explains its vulnerability.• Dislocation or subluxation called instability.• 98 % of dislocations are anterior.• Dislocations should be reduced promptly to maximize function.
Instability cont’d• Clinical features can be remembered by the mnemonics- TUBS and AMBRI.• T-Traumatic etiology• U-Uni directional instability- mainly anterior• B-Bankart’s lesion (capsular detachment of anterior part)• S-Surgical stabilization is the treatment of choice- Open or arthroscopic stabilization.
Traumatic instability prognosis• 80-90% of persons with an anterior dislocation will have a recurrent dislocation.• First aid is reduction,• Later rehabilitation and referral
Atraumatic Instability• A-Atraumatic• M-Multi directional• B-Bilateral• R-Rehabilitation by muscular strengthening• I-Inferior capsular tightening is the surgical procedure for failed conservative treatment.
Atraumatic or multi directional instability (MDI)• Difficult to manage by general practitioners.• Subtle tests are needed diagnose this multi directional instability.- “Sulcus sign”• Failure to recognize the multidirectional component, is the cause of surgical failures by many surgeons.
Subacromial impingement• Rubbing of the of the rotator cuff on the undersurface of the acromial arch.• Causes are extrinsic and intrinsic.• Extrinsic or primary causes are abnormal shape of the acromion, bony spurs from the acromio clavicular joint, displaced fractures of the greater tuberosity.
Clinical featuresPain on elevation of arm through the painful arc 30 – 110.
Intrinsic impingementDefinition- Impingement of the rotator cuff on the undersurface of the acromion on elevation due to superior migration of humerusCauses-• Weak rotator cuff tendons.• Can result from instability- disappears after correction of instability.
Adhesive capsulitis( frozenshoulder or Peri-arthritis• Multitude of causes-• Diabetes, Parkinsonism, depression, hypothyroidism, cervical spondylosis are the chief extrinsic causes.• Primary frozen shoulder occurs as a separate entity.
Adhesive capsulitisDiabetes is the chief cause of frozen shoulder in the community.3 phases in a protracted course Pain Progressive stiffness ResolutionEarlier thought to be a self limiting disease
Adhesive capsulitis cont’d• Even with appropriate treatment, it may take 6- 12 months to resolve.• Earlier thought that 90% of patients recover spontaneously, however studies have shown that 50% of patients can be left with a motion deficit.• No single treatment is available- frustrating to the patient as no rapid cure is available.
Adhesive capsulitis• Painful phase can be treated with NSAID’S failing which, intra articular steroid injection after checking glucose levels.• Stiff phase- physical therapy• MUA if no progress after self physiotherapy.• Failing which arthroscopic release of tight capsular structures, followed by CPM.
Rotator cuff tendonitis & tears• Commonest cause of chronic shoulder pain in middle age and elderly.• As common as grey hair.• Not all tears need surgical treatment, tears in younger patients need surgery.MRI scans are the best diagnostic modality in the absence of reliable Ultra sound radiologists.
TreatmentPhysical therapy is a waste as torn tissues cannot heal.If pain continues after 6 months of conservative treatment & steroid injections, surgical treatment is necessary.Steroid injections are a useful mode of therapy, but learning when and how much and where are important considerations.
ANKLE AND FOOT PROBLEMS• Ankle sprains• Sinus tarsi syndrome• Talar dome fracture• Plantar fascitis• Tendonitis of Tendo achilles and Tibialis posterior
• Ankle sprains are the commonest cause of sprain- injury to the components of the lateral ligament of the ankle occurs. • Always rule out a fracture by x rays. • Rule out fracture of the base of the fifth meta tarsal (Jones fracture)• Diagnose medial sprains early- Tibialis posterior tears – lead to commonest cause of acquired flat foot.
Treatment of ankle sprains• No POP casts.• R- Rest• Icing,
Treatment of ankle sprains• C- compression strapping• Elevation was the previous method.• Ankle stretching on the night of injury,. Cold treatment no longer preferred for ligament sprains as it decreases blood supply
Treatment of ankle sprains• M-movement• E-exercise• A- analgesics ( Not Brufen, but Chymoral to reduce inflammation and break adhesions• T- Treatment• Stationary bike cycling on day 2 – 3.
Achilles tendonitis• Pain 4- 6 cm above its insertion of the tendon.• Degeneration is the main etiology.• Steroid injection is contra indicated as it can lead to rupture of the tendon.
Plantar fascitis• Very common cause of heel pain.• Inflammation of the origin of the plantar fascia from the antero medial part of the calcaneus.• Tight Achilles tendon predisposes- patients lack dorsi flexion beyond 90 degrees.• Injection of steroid into the tender area followed by stretching of the heel cord to 15 degrees beyond neutral.• No bare feet.
Resistant causes of foot pain• Commonly seen after an ankle sprain. Consider if pain & effusion persists 6- 8 weeks after an ankle sprain.Causes-• Osteochondral fracures of the talus ( talar dome fractures)• Sinus tarsi syndrome• X rays are inconclusive for talar dome fracture. CT scans or MRI scans are useful.
Talar dome fractures• Initial treatment- walking casts• Surgery if pain persists.• Cartilage surgery regeneration of fibro cartilage by surgical means or by transfer of osteo-chondral plugs harvested from the knee.
Sinus tarsi syndrome• Sinus tarsi syndrome – Important cause of chronic ankle pain after an ankle sprain. May be due to subtle instability of the ankle. Pronated feet are predisposed-
Treatment of sinus tarsi syndrome• Try insoles at first• Steroid injection into the tender area after a trial of anti inflammatory drugs & foot wear (Arch support) modification.
Chronic foot and ankle conditions• Need early intervention as they can lead to biomechanical failure, chronic pain and disability.