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Patient Education about Knee Pain

The knee is one of the largest and most complex joints in the body. The knee joins the thigh bone (femur) to the shin bone (tibia). The smaller bone that runs alongside the tibia (fibula) and the kneecap (patella) are the other bones that make the knee joint.

Tendons connect the knee bones to the leg muscles that move the knee joint. Ligaments join the knee bones and provide stability to the knee:

  • The anterior cruciate ligament prevents the femur from sliding backward on the tibia (or the tibia sliding forward on the femur).
  • The posterior cruciate ligament prevents the femur from sliding forward on the tibia (or the tibia from sliding backward on the femur).
  • The medial and lateral collateral ligaments prevent the femur from sliding side to side.

Two C-shaped pieces of cartilage called the medial and lateral menisci act as shock absorbers between the femur and tibia.
Numerous bursae, or fluid-filled sacs, help the knee move smoothly.

Your knee joints serve a vital role holding up your bodyweight and are put through even more pressure when you walk, run or jump. Knee pain is very common, both from sport injuries and the wear and tear of day-to-day life.

Knee pain can come from injuries including sprains, swollen or torn ligaments (anterior cruciate ligament or ACL), meniscus or cartilage tears and runner’s knee.

Sports injuries tend to affect one knee at a time. Pain in both knees is more common with arthritis, osteoarthritis, gout or pseudogout, usually later in life.

Conditions that cause knee pain

  • Tendonitis. This is an overuse injury causing swelling of the tendons, the bands of tissue that connect your bones and muscles. This is sometimes called ‘jumper’s knee’ as it is common in sports involving jumping, such as basketball.
  • Bone chips. Sometimes, a knee injury can break off fragments from the bone or cartilage. These pieces can get stuck in the joint, causing it to freeze up. You may also have pain and swelling.
  • Housemaid’s knee or bursitis is caused by kneeling for long periods of time or repetitive knee movements. Fluid builds up in the bursa, the sac of fluid that cushions the knee joints. Swelling behind the knee is called a ‘Baker’s cyst’ and may be caused by injuries or arthritis.
  • Bleeding in the knee joint. This injury is also called haemarthrosis and affectsblood vessels around the knee ligaments causing the knee to feel warm, stiff, bruised and swollen. This may require hospital treatment in serious cases.
  • Iliotibial band syndrome. This is an overuse injury to the iliotibial band of tissue that runs from the hip to the shin past the knee.
  • Medial plica syndrome. This overuse injury affects the plica, a fold of tissue in the knee joint.
  • Osgood- Schlatter Disease. This overuse condition is common in teenagers playing sport and causes swelling and tenderness over the bony bump just below the knee.
  • Partially dislocated kneecap (or patellar subluxation). This is usually due to a physical condition with the legs rather than a sports injury. The kneecap slides out of position and causes pain and swelling.

Treatment for knee pain

Treatment will depend on the type and severity of the injury. Many knee injuries will get better on their own, or can be treated at home. Avoid putting weight on the injured knee as much as possible. Raise the leg with cushions and use an ice pack or bag of frozen veg wrapped in a towel held to the knee. Painkillers such asibuprofen can help with pain and swelling.

You may need to see your GP or seek medical advice if:

  • No weight can be put on the injured knee
  • There’s severe pain when no weight is put on the knee
  • The knee locks, clicks painfully or gives way
  • The knee looks deformed
  • There’s fever, redness or a feeling of heat around the knee, or there’s extensive swelling
  • The calf beneath the injured knee is painful, swollen, numb or tingling
  • Pain is still there after three days of home care treatment

A doctor will carry out a physical examination of the injured knee and may arrange some extra tests, including blood tests, an X-ray or MRI scan.

Treatment may involve physiotherapy, painkillers and sometimes an arthroscopy – a form of keyhole surgery that is used to look inside a joint and repair any damage that has occurred.

When will my knee pain feel better?

Recovery from knee pain will depend on the type and severity of the injury.

If recovery prevents you doing high impact sport such as running, try a low impact one like swimming.

Preventing knee pain

Knee pain cannot always be avoided, but good precautions include stretching, warming up and cooling down around a workout or playing sport. Having the right equipment, such as trainers designed for running and kneepads for jobs involving kneeling can help.

Stop exercising if you feel pain in your knee.

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Ganglion Cyst of Wrist and Hand

Ganglion cysts are the most common mass or lump in the hand. They are not cancerous and, in most cases, are harmless. They occur in various locations, but most frequently develop on the back of the wrist.

These fluid-filled cysts can quickly appear, disappear, and change size. Many ganglion cysts do not require treatment. However, if the cyst is painful, interferes with function, or has an unacceptable appearance, there are several treatment options available.

A ganglion rises out of a joint, like a balloon on a stalk. It grows out of the tissues surrounding a joint, such as ligaments, tendon sheaths, and joint linings. Inside the balloon is a thick, slippery fluid, similar to the fluid that lubricates your joints.

Ganglion cysts can develop in several of the joints in the hand and wrist, including both the top and underside of the wrist, as well as the end joint of a finger, and at the base of a finger. They vary in size, and in many cases, grow larger with increased wrist activity. With rest, the lump typically becomes smaller.

Ganglion Wrist Cyst

CAUSES

It is not known what triggers the formation of a ganglion. They are most common in younger people between the ages of 15 and 40 years, and women are more likely to be affected than men. These cysts are also common among gymnasts, who repeatedly apply stress to the wrist.

Ganglion cysts that develop at the end joint of a finger — also known as mucous cysts — are typically associated with arthritis in the finger joint, and are more common in women between the ages of 40 and 70 years.

SYMPTOMS

Most ganglions form a visible lump, however, smaller ganglions can remain hidden under the skin (occult ganglions). Although many ganglions produce no other symptoms, if a cyst puts pressure on the nerves that pass through the joint, it can cause pain, tingling, and muscle weakness.

Large cysts, even if they are not painful, can cause concerns about appearance.

DOCTOR EXAMINATION

Medical History and Physical Examination

During the initial appointment, your doctor will discuss your medical history and symptoms. He or she may ask you how long you have had the ganglion, whether it changes in size, and whether it is painful.

Pressure may be applied to identify any tenderness. Because a ganglion is filled with fluid, it is translucent. Your doctor may shine a penlight up to the cyst to see whether light shines through.

Imaging Tests

X-rays. These tests create clear pictures of dense structures, like bone. Although x-rays will not show a ganglion cyst, they can be used to rule out other conditions, such as arthritis or a bone tumor.

Magnetic resonance imaging (MRI) scans or ultrasounds. These imaging tests can better show soft tissues like a ganglion. Sometimes, an MRI or ultrasound is needed to find an occult ganglion that is not visible, or to distinguish the cyst from other tumors.

TREATMENT

Nonsurgical Treatment

Initial treatment of a ganglion cyst is not surgical.

    • Observation. Because the ganglion is not cancerous and may disappear in time, if you do not have symptoms, your doctor may recommend just waiting and watching to make sure that no unusual changes occur.
    • Immobilization. Activity often causes the ganglion to increase in size and also increases pressure on nerves, causing pain. A wrist brace or splint may relieve symptoms and cause the ganglion to decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.
    • Aspiration. If the ganglion causes a great deal of pain or severely limits activities, the fluid may be drained from it.

This procedure is called an aspiration.

The area around the ganglion cyst is numbed and the cyst is punctured with a needle so that the fluid can be withdrawn.

Aspiration frequently fails to eliminate the ganglion because the “root” or connection to the joint or tendon sheath is not removed. A ganglion can be like a weed which will grow back if the root is not removed. In many cases, the ganglion cyst returns after an aspiration procedure.

Aspiration procedures are most frequently recommended for ganglions located on the top of the wrist.

Nonsurgical Treatment

Initial treatment of a ganglion cyst is not surgical.

    • Observation. Because the ganglion is not cancerous and may disappear in time, if you do not have symptoms, your doctor may recommend just waiting and watching to make sure that no unusual changes occur.
    • Immobilization. Activity often causes the ganglion to increase in size and also increases pressure on nerves, causing pain. A wrist brace or splint may relieve symptoms and cause the ganglion to decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.
    • Aspiration. If the ganglion causes a great deal of pain or severely limits activities, the fluid may be drained from it.

This procedure is called an aspiration.

The area around the ganglion cyst is numbed and the cyst is punctured with a needle so that the fluid can be withdrawn.

Aspiration frequently fails to eliminate the ganglion because the “root” or connection to the joint or tendon sheath is not removed. A ganglion can be like a weed which will grow back if the root is not removed. In many cases, the ganglion cyst returns after an aspiration procedure.

Aspiration procedures are most frequently recommended for ganglions located on the top of the wrist.

Surgical Treatment

Your doctor may recommend surgery if your symptoms are not relieved by nonsurgical methods, or if the ganglion returns after aspiration. The procedure to remove a ganglion cyst is called an excision.

Surgery involves removing the cyst as well as part of the involved joint capsule or tendon sheath, which is considered the root of the ganglion. Even after excision, there is a small chance the ganglion will return.

Excision is typically an outpatient procedure and patients are able to go home after a period of observation in the recovery area. There may be some tenderness, discomfort, and swelling after surgery. Normal activities usually may be resumed 2 to 6 weeks after surgery.

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Achilles Tendon Pain

What is the Achilles tendon?

The Achilles tendon connects the calf muscle to the heel bone. It lets you rise up on your toes and push off when you walk or run.

What are common Achilles tendon problems?

The two main problems found in the Achilles tendon are:

  • Achilles tendinopathy. Achilles tendinopathy includes one of two conditions:
    • Tendinitis. This actually means “inflammation of the tendon,” but inflammation is rarely the cause of tendon pain.
    • Tendinosis. This refers to tiny tears (microtears) in the tissue in and around the tendon caused by overuse. In most cases Achilles tendon pain is the result of tendinosis, not tendinitis. Some experts now use the term tendinopathy to include both inflammation and microtears. But many doctors may still use the term tendinitis to describe a tendon injury.
  • Achilles tendon tear or rupture. An Achilles tendon also can partially tear orcompletely tear (rupture) camera. A partial tear may cause mild or no symptoms. But a complete rupture causes pain and sudden loss of strength and movement.

Problems with the Achilles tendon may seem to happen suddenly. But usually they are the result of many tiny tears to the tendon that have happened over time.

What causes Achilles tendon problems?

Achilles tendon problems are most often caused by overuse or repeated movements. These movements can happen during sports, work, or other activities. For example, if you do a lot of pushing off or stop-and-go motions when you play sports, you can get microtears in the tendon. Microtears can also happen with a change in how long, hard, or often you exercise. Microtears in the tendon may not be able to heal quickly or completely.

Being out of shape or not warming up before exercising may also cause Achilles tendon problems. So can shoes with poor arch supports or rigid heels.

An Achilles rupture is most often caused by a sudden, forceful motion that stresses the calf muscle. This can happen during an intense athletic activity or even during simple running or jumping. Middle-aged adults are especially likely to get this kind of injury.

A rupture most often occurs in sports such as basketball, racquet sports (including tennis), soccer, and softball. A tendon already weakened by overstretching, inflammation, or small tears is more likely to rupture.

What are the symptoms?

Symptoms of Achilles tendon problems include swelling in the ankle area and mild or severe pain. The pain may come on gradually or may only occur when you walk or run. You may have less strength and range of movement in the ankle.

A rupture of the Achilles tendon may cause a sudden, sharp pain. Most people feel or hear a pop at the same time. Swelling and bruising may occur, and you may not be able to point your foot down or stand on your toes.

How are Achilles tendon problems diagnosed?

Your doctor can tell if you have an Achilles tendon problem by asking questions about your past health and checking the back of your leg for pain and swelling. The doctor may ask: How much pain do you have? How did your injury happen? Have you had other injuries in the ankle area?

If your symptoms are severe or do not improve with treatment, your doctor may want you to get an X-ray, ultrasound scan, or MRI.

How are they treated?

Treatment for mild Achilles tendon problems includes rest, over-the-counter pain medicine, and stretching exercises. You may need to wear well-cushioned shoes and change the way you play sports so that you reduce stress on the tendon. Early treatment works best and can prevent more injury.

Even in mild cases, it can take weeks to months of rest for the tendon to repair itself. It’s important to be patient and not return too soon to sports and activities that stress the tendon.

Treatment for severe problems, such as a torn or ruptured tendon, may include surgery or a cast, splint, brace, walking boot, or other device that keeps the lower leg from moving. Exercise, either in physical therapy or in a rehab program, can help the lower leg get strong and flexible again. The tendon will take weeks to months to heal.

Although treatment for Achilles tendon problems takes time, it usually works. Most people can return to sports and other activities.

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Know More About GOUT

Gout causes attacks of pain and swelling in one or more joints. An anti-inflammatory painkiller usually eases an attack quickly. Lifestyle factors may reduce the risk of having gout attacks. These include losing weight (if overweight), eating a healthy diet, and not drinking much alcohol or sugar-sweetened soft drinks. If gout attacks recur, then taking vitamin C supplements and/or allopurinol each day can prevent them.

Gout causes attacks of painful inflammation in one or more joints. It is a type of arthritis (although it is very different to the more common rheumatoid arthritis and osteoarthritis). The pain of a gout attack can be severe.

Gout is caused by a chemical in the blood called uric acid (urate). Uric acid is usually harmless and is made in the body. Most is passed out with the urine and some from the gut with the stools (faeces). In people with gout the amount of uric acid in the blood builds up. From time to time the level may become too high and tiny grit-like crystals of uric acid may form. The crystals typically collect in a joint. The crystals irritate the tissues in the joint to cause inflammation, swelling and pain – a gout attack.

Note: some people have a high level of uric acid but do not form crystals or have gout. Also, rarely, some people with a normal level of uric acid have gout attacks. However, as a rule, the higher the level of uric acid, the greater the chance of developing gout.

Why does uric acid build up?

Normally, there is a fine balance between the amount of uric acid (urate) that you make and the amount that you pass out in the urine and faeces. This keeps the level of uric acid in the blood in check. However, in most people with gout, their kidneys do not pass out enough uric acid and the blood level may rise. They are said to be under-excreters of uric acid. Their kidneys usually work otherwise normally.

In some people, the build-up of uric acid may due to other factors. For example:

  • Drinking too much alcohol can cause uric acid to build up.
  • If you do not have enough vitamin C in your diet.
  • If you drink sugar-sweetened soft drinks high in fructose it can cause uric acid to build up. A recent research study found that having two drinks a day of a sugar-sweetened soft drink increased the risk of developing gout by 85%. (Drinks labelled as ‘diet’ or drinks containing artificial sweeteners were not found to increase the risk.) Fructose-rich fruits and fruit juices may also increase the risk.
  • Certain foods may ‘tip the balance’ to raise your uric acid higher than normal. In particular, eating a lot of heart, herring, sardines, yeast extracts, or mussels may increase the level of uric acid. However, eating a normal balanced diet should not have much effect on the uric acid level.
  • Some medicines may raise the level of uric acid. For example, ‘water’ tablets (diuretics) such as bendroflumethiazide, aspirin (at full painkiller dose – not low-dose aspirin used to prevent blood clots), and some chemotherapy medicines.
  • More uric acid is made than usual in illnesses where the cells of the body have a rapid turnover. For example, severe psoriasis and some blood disorders.
  • People with certain other conditions have an increased risk of developing gout. These include:
  • Obesity.
  • High blood pressure.
  • Kidney damage.
  • Diabetes mellitus.
  • Bone marrow disorders.
  • Lipid disorders (especially hypertriglyceridaemia).
  • Vascular disease.
  • Enzyme defects such as hypoxanthine guanine phosphoribosyltransferase (HGPRT) deficiency and glucose-6-phosphate dehydrogenase (G6PD) deficiency.

Gout affects about 1 in 200 adults. Men are more commonly affected than women. A first attack of gout typically develops in middle age but it sometimes occurs in younger people. It tends to run in some families, as there is a family history of gout in about 1 in 5 cases. It may be that the genetic make-up that you inherit from your family may be a factor in becoming an under-excreter of uric acid (urate).

Gout usually occurs in attacks. An attack typically develops quickly over a few hours. It usually causes severe pain in one joint. The base of the big toe is the most commonly affected joint. Walking can be very painful and even the weight of bedclothes can hurt.

However, any joint can be affected. Sometimes two or more joints are affected. Affected joints usually swell and the nearby skin may look red and inflamed. If left untreated, a gout attack may last several days but usually goes completely within 7-10 days. Less severe attacks can occur which may be mistaken at first for other forms of arthritis. Weeks, months or even years may go by between attacks. Some people only ever have one attack.

A gout attack can be very painful. However, other effects from gout are uncommon. Joint damage may occur if you have recurring attacks. In a few people, uric acid crystals form kidney stones or may cause some kidney damage. Sometimes the crystals form bumps (tophi) under the skin. These are usually harmless and painless but sometimes form in awkward places such as at the end of fingers. Tophi occasionally become infected.

Gout is usually diagnosed if you have the typical gout symptoms and a raised blood level of uric acid. If there is doubt as to the cause of the pain and swelling, your doctor may take some fluid out of a swollen joint. This is done with a needle and syringe. The fluid is looked at under the microscope. Crystals of uric acid (urate) can be seen in the fluid to confirm the diagnosis of gout.

General measures

If you are able to, raise the affected limb (usually a leg) to help reduce the swelling. The easiest way to raise your leg is to recline on a sofa with your leg up on a cushion. An ice pack (or pack of frozen peas) held against the inflamed joint may ease the pain until the gout treatment medicines (below) start to work:

  • Wrap the ice pack (or peas) in a towel to avoid direct skin contact and ice burn.
  • Apply for about 20 minutes, and then stop. (It should not be applied for long periods.)
  • Repeat as often as required BUT make sure the temperature of the affected part has returned to normal before applying again.

Anti-inflammatory painkillers

A short course of an anti-inflammatory painkiller will quickly ease most gout attacks (within 12-24 hours). There are several types and brands, such as diclofenac,indometacin and naproxen. Your doctor will prescribe one. Many people with gout like to have a supply of tablets on standby in the home just in case an attack occurs. They are usually needed only for a few days until the inflammation and pain go.

Most people can take short courses of anti-inflammatory painkillers without any problem, although side-effects occur in some people:

  • Bleeding from the stomach is the most serious possible side-effect. This is more of a risk if you are aged over 65, or have had a duodenal or stomach ulcer. Stop the tablets and see a doctor if you develop indigestion, have upper tummy (abdominal) pain, pass black stools (black faeces), or if you are sick (vomit) or pass blood. Read the leaflet that comes with the tablets for a list of other possible side-effects.
  • Some people with asthma, high blood pressure, certain kidney problems and heart failure may not be able to take anti-inflammatory painkillers.
  • Some people taking certain other medicines should not take anti-inflammatory painkillers. This is because of a possible risk of the two medicines interacting. Therefore, check with your doctor or pharmacist if you are taking other medication, before taking anti-inflammatory painkillers.

Also, don’t take more than one anti-inflammatory painkiller at a time unless specified by a doctor. For example, some people take low-dose aspirin every day (which is classed as an anti-inflammatory medicine) to prevent blood clots. Aspirin plus another anti-inflammatory medicine increases the risk of bleeding from the stomach.

Therefore, if you are already taking aspirin and develop gout, you need to discuss the options with your doctor. For example, your doctor may advise that you take another medicine to ‘protect the stomach’ if you need to take aspirin and another anti-inflammatory medicine. Remember – some painkillers that you can buy from pharmacies contain aspirin.

Other treatments

Colchicine is an alternative medicine that eases gout attacks. It is usually only used if you have problems or side-effects with anti-inflammatory painkillers. Steroid tablets or injections can also reduce the pain and inflammation. They are another alternative if there are problems or side-effects with anti-inflammatory painkillers and colchicine.

Canakinumab is another option that has recently been introduced.

Lifestyle measures and medicines can help to prevent gout attacks.

Lifestyle suggestions

  • If you are overweight, try to lose some weight. This can help to lower the uric acid (urate) level. However, do not use diets that increase uric acid levels, such as high-protein diets or starvation diets.
  • Eat sensibly. A high uric acid level may be lowered a bit by avoiding a high protein intake and foods rich in purines, such as liver, kidneys and seafood. Also avoid eating foods high in yeast extracts, such as Marmite®. See separate Gout Diet Sheet for more details.
  • If you drink a lot of alcohol then it may help if you reduced the amount that you drink. You do not need to stop drinking alcohol altogether but cutting down may help if you drink a lot. In particular, avoid binge drinking. Keep to within the recommended levels of alcohol – these are 21 units per week for men and 14 units per week for women.
  • If you drink a lot of sugar-sweetened soft drinks, especially those containing fructose, it may help to reduce the number or cut them out all together.
  • If you are taking any medicines, check whether they are a cause of gout (see above). An alternative medicine may be available. Your doctor will advise.
  • Avoid lack of fluid in the body (dehydration) by drinking plenty of water (up to two litres per day unless there is a medical reason why not to).
  • Have your blood pressure checked at least once a year. High blood pressure is more common in people with gout.

With the help of lifestyle changes, many people only have an attack of gout every now and then. All you may need is to have some anti-inflammatory painkillers on standby to treat each attack.

For some people, attacks occur more often. In this situation, you can take a medicine to prevent attacks.

Allopurinol is used to prevent gout attacks

Allopurinol is a commonly used medicine to prevent gout attacks. Allopurinol does not have any effect during a gout attack and it is not a painkiller. It works by lowering the level of uric acid in the blood. It takes 2-3 months to become fully effective. You need to take it every day to keep the uric acid level normal to prevent gout attacks.

As a general rule, regular allopurinol may be advised by your doctor if you:

  • Have had two or more attacks of gout within a year.
  • Have one or more tophi (described above).
  • Have any joint or kidney damage due to gout.
  • Have one or more kidney stones made from uric acid.
  • Have had a gout attack and are taking long-term medication that can cause gout.

When you first take allopurinol, it can sometimes cause a gout attack. This is because it may cause the level of uric acid to rise slightly before it falls. For this reason it is not normally started during a gout attack. It is best to start it about 3-4 weeks after an attack has settled. Also, an anti-inflammatory painkiller is often prescribed for the first 2-3 months after you start allopurinol, just in case the allopurinol causes a gout attack. Once the level of uric acid has been brought down, taking allopurinol each day usually works well to prevent gout attacks.

The dose of allopurinol needed varies from person to person. Treatment is usually started with a low dose. A blood test is often done after a month or so to check that the level of uric acid has come down. If not, the dose may need to be increased. Most people end up taking about 100-300 mg each day to stop gout attacks.

If a gout attack occurs while you are taking allopurinol, you can still take an anti-inflammatory painkiller to relieve the pain. However, this may indicate that you need an increased dose of allopurinol. Side-effects are uncommon with allopurinol. Read the information that comes with the packet of tablets for details about possible side-effects. If side-effects do occur, other medicines with a similar action are sometimes prescribed. For example, a medicine called febuxostat may be an option if you cannot take allopurinol for medical reasons or due to side-effects.

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Sever’s Disease (Heel Pain in Children)

What Is Calcaneal Apophysitis?
Calcaneal apophysitis is a painful inflammation of the heel’s growth plate. It typically affects children between the ages of 8 and 14 years old, because the heel bone (calcaneus) is not fully developed until at least age 14. Until then, new bone is forming at the growth plate (physis), a weak area located at the back of the heel. When there is too much repetitive stress on the growth plate, inflammation can develop.

Calcaneal278Calcaneal apophysitis is also called Sever’s disease, although it is not a true “disease.” It is the most common cause of heel pain in children, and can occur in one or both feet.

Heel pain in children differs from the most common type of heel pain experienced by adults. While heel pain in adults usually subsides after a period of walking, pediatric heel pain generally doesn’t improve in this manner. In fact, walking typically makes the pain worse.

Causes
Overuse and stress on the heel bone through participation in sports is a major cause of calcaneal apophysitis. The heel’s growth plate is sensitive to repeated running and pounding on hard surfaces, resulting in muscle strain and inflamed tissue. For this reason, children and adolescents involved in soccer, track, or basketball are especially vulnerable.

Other potential causes of calcaneal apophysitis include obesity, a tight Achilles tendon, and biomechanical problems such as flatfoot or a high-arched foot.

Symptoms
Symptoms of calcaneal apophysitis may include:

  • Pain in the back or bottom of the heel
  • Limping
  • Walking on toes
  • Difficulty running, jumping, or participating in usual activities or sports
  • Pain when the sides of the heel are squeezed

Diagnosis
To diagnose the cause of the child’s heel pain and rule out other more serious conditions, the foot and ankle surgeon obtains a thorough medical history and asks questions about recent activities. The surgeon will also examine the child’s foot and leg. X-rays are often used to evaluate the condition. Other advanced imaging studies and laboratory tests may also be ordered.

Treatment
The surgeon may select one or more of the following options to treat calcaneal apophysitis:

  • Reduce activity. The child needs to reduce or stop any activity that causes pain.
  • Support the heel. Temporary shoe inserts or custom orthotic devices may provide support for the heel.
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation.
  • Physical therapy. Stretching or physical therapy modalities are sometimes used to promote healing of the inflamed issue.
  • Immobilization. In some severe cases of pediatric heel pain, a cast may be used to promote healing while keeping the foot and ankle totally immobile.

Often heel pain in children returns after it has been treated because the heel bone is still growing. Recurrence of heel pain may be a sign of calcaneal apophysitis, or it may indicate a different problem. If your child has a repeat bout of heel pain, be sure to make an appointment with your foot and ankle surgeon.

Can Calcaneal Apophysitis Be Prevented?
The chances of a child developing heel pain can be reduced by:

  • Avoiding obesity
  • Choosing well-constructed, supportive shoes that are appropriate for the child’s activity
  • Avoiding or limiting wearing of cleated athletic shoes
  • Avoiding activity beyond a child’s ability.

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Trigger Finger in Children / Babies

Trigger thumb means your child’s thumb pops, clicks or catches when they try to straighten it. Their thumb may lock in a bent position. If the thumb locks, your child can pull it straight using their other hand. (Or you can pull it straight for them.) But they can’t straighten the locked thumb using their thumb muscles.

The muscle that bends the tip of the thumb is called flexor pollicis longus (FLEX-er PAHL-i-sis LONG-us). This muscle starts in your child’s forearm. Near the wrist, the muscle turns into tendon. The tendon runs along the palm side of your child’s thumb and connects to the bone in the tip of the thumb.

When your child moves their thumb, this tendon should glide smoothly inside a wrapping called a tendon sheath. Near the base of the thumb, a tough band (ligament) crosses the tendon and tendon sheath, acting like a pulley. Doctors call this the A1 pulley.

Trigger thumb occurs when the tendon swells, forming a bump (nodule) near the A1 pulley. The nodule gets stuck at the pulley, so the tendon cannot glide inside the sheath. You may be able to feel this bump on your child’s palm at the base of their thumb.

Trigger Finger

Trigger Finger

Trigger Thumb in Children

In children, trigger thumb usually happens between the ages of 1 and 3 years old. It’s not thought to be due to injury or other medical problems.

Most children with trigger thumb have it in only one hand. About one-third of children have it in both hands. Triggering can happen in fingers, too. This is a different and more complex problem.

Trigger Thumb at Seattle Children’s

Trigger thumb is one of the most common conditions treated by the experts in our Hand and Upper Extremity Program. Each year we see many children with this condition in our clinics.

Our team is well versed in the treatment options for trigger thumb. For many children, treatment begins with stretching and splinting. This may be enough to cure the problem. If it’s not, we perform surgery to release the A1 pulley. Our surgeons are experienced at performing this type of surgery in children.

Symptoms of Trigger Thumb

If your child has trigger thumb, they will have one or both of these symptoms:

  • Popping, clicking or catching when they move their thumb
  • Thumb locked in a bent position

You child may also have these symptoms:

  • Pain and swelling in their thumb, usually near the base
  • Bump on the palm side of their thumb, near the base

Trigger Thumb Diagnosis

Doctors can diagnose trigger thumb by asking about your child’s symptoms and doing a physical exam.

If your child seems to have trigger thumb, the doctor will check to make sure they do not have some other problem, like a fractured bone or a joint that’s out of place (dislocated).

The doctor will also check for signs of broader health conditions that may affect the hands, like cerebral palsy orarthrogryposis. (Most children with trigger thumb do not have any other condition.)

Trigger Thumb Treatment Options

Stretching and splinting

If the doctor believes stretching and splinting will be enough to cure your child’s trigger thumb, they will start with these options.

They will teach you stretches and massage to do at home. This can help free the bump (nodule) from the tough band (ligament, A1 pulley) where it sticks.

Your child may also need to wear a thumb splint to stretch their thumb and hold it straight. Because this prevents the thumb from moving, it may keep the A1 pulley from bothering the tendon. The swelling may decrease, and the tendon may glide the way it should.

Surgery

If stretching and splinting aren’t enough, your child will need a day surgery, called trigger thumb release or A1 pulley release.

The surgeon makes a small cut (incision) on your child’s palm in the crease of skin at the base of the thumb. Then the surgeon cuts through the A1 pulley. This takes pressure off the tendon and allows it to glide smoothly. (The surgeon doesn’t cut into the tendon or remove the nodule.)

After surgery, your child will need a bandage for one to two weeks to protect their thumb while it heals. Trigger thumb rarely comes back, and children rarely need any other treatment for it. You can expect your child to regain normal use of their thumb.

GET PROFESSIONAL OPINION AND TREATMENT FOR YOUR CHILD TRIGGER FINGER / THUMB TODAY. PLEASE CALL +65 6471 2744 FOR APPOINTMENT.

Prevent Back Pain with Good Posture

When it comes to posture, your mother did know best. Her reminders to stand up straight and stop slouching were good advice.

Your spine is strong and stable when you practice healthy posture. But when you stoop or slouch, your muscles and ligaments struggle to keep you balanced — which can lead to back pain, headaches and other problems.

A healthy back has three natural curves:

  • An inward or forward curve at the neck (cervical curve)
  • An outward or backward curve at the upper back (thoracic curve)
  • An inward curve at the lower back (lumbar curve)

Good posture helps maintain these natural curves, while poor posture does the opposite — which can stress or pull muscles and cause pain.

When standing, keep these tips in mind:

  • Keep your shoulders back and relaxed.
  • Pull in your abdomen.
  • Keep your feet about hip distance apart.
  • Balance your weight evenly on both feet.
  • Let your hands hang naturally at your sides.

Try not to tilt your head forward, backward or sideways, and make sure your knees are relaxed — not locked.

To test your standing posture, take the wall test. Stand with your head, shoulder blades and buttocks touching a wall, and have your heels about 2 to 4 inches (about 5 to 10 centimeters) away from the wall. Reach back and slide your hand behind the curve in your lower back, with your palm flat against the wall.

Ideally, you’ll feel about one hand’s thickness of space between your back and the wall. If there’s too much space, tighten your abdominal muscles to flatten the curve in your back. If there’s too little space, arch your back so that your hand fits comfortably behind you. Walk away from the wall while maintaining this posture. Keep it up throughout your daily activities.

When seated, keep these tips in mind:

  • Choose a chair that allows you to rest both feet flat on the floor while keeping your knees level with your hips. If necessary, prop up your feet with a footstool or other support.
  • Sit back in your chair. If the chair doesn’t support your lower back’s curve, place a rolled towel or small pillow behind your lower back.
  • Stretch the top of your head toward the ceiling, and tuck your chin in slightly.
  • Keep your upper back and neck comfortably straight.
  • Keep your shoulders relaxed — not elevated, rounded or pulled backward.

To see if you’re keeping your shoulders straight, stand in front of a mirror or ask someone else to evaluate your shoulder position. Aim to keep your shoulders in the same position as shown in the image on the left.

Although good posture should be natural, you might feel wooden or stiff at first if you’ve forgotten the sensation of sitting and standing up straight. The key is to practice good posture all the time. You can make improvements at any age. Stretching and core strengthening exercises can help, too.

Cure Your Back Pain Today! Call us for Appointment today +65 6471 2744 (24 Hours) or SMS to: +65 92357641.

Patient Guide to Lower Back Pain

Lower back pain can be acute or severely painful or can be a long term moderate pain from a chronic back injury.

We explain the differences between acute low back pain and moderate chronic low back and its management.

Often is not possible to completely diagnose the causes of low back pain. Below we also outline the most common diagnosable causes of low back pain, less common causes and other conditions which can cause low back pain.

Acute VS Chronic Low Back Pain

Acute low back pain is severe back pain and usually comes on suddenly caused by a movement such as bending or twisting. Pain in the lower back and buttocks may increase over a couple of hours as inflammation develops. Management of acute low back pain is to reduce pain as quickly as possible by getting the patient into a position of least pain which may be lying on the back, front or side. Whatever is most comfortable is the best and it will be different for each individual. See management of acute low back pain for more detailed information.

Mild or moderate lower back pain is associated with chronic or long term back problems which are usually caused initially by an injury, usually to the joints in the back but over time other structures in particular soft tissue such as muscles contribute to the pain. A range of symptoms include dull aching in the lower back which may come and go, be on one side or across the lower back. There will be reduced range of movement, tenderness at points on the spine, muscle spasms and pain may radiate into the buttocks and hamstrings.

Common Causes of Low Back Pain

Often the exact cause of low back pain is not possible to identify. Symptoms can be vague, come and go and there can be a number of tissues and structures causing the pain. However below are some injuries and conditions that can usually be diagnosed.

SciaticaSciatica or nerve route compression causes pain in the lower back which radiates down into the legs. There are a number of causes by a slipped disc is one of the more common causes.

Facet joint pain or zygapophysial joints as they are also know are synovial joints in the spine which allow movement and help support the spine. Symptoms of facet joint pain include muscle spasm at the side of the spine which pulls the vertibra out of line. Patients will often report a sudden pain when bending over or moving.

Spondylolysis or stress fracture of the pars interarticularis is an overuse injury more common in younger athletes who are involved in sports requiring a lot of bending backwards and rotation of the spine such as javelin throwing, tennis, baseball pitching and fast  bowling in cricket. Symptoms include lower back pain often on one side of the back. Pain is worse during activities requiring backwards bending of the spine or exaggerating the lumbar curve in the spine. Tenderness will be felt over the site of the fracture when pressing in.

Sacroiliac jointSacroiliac joint pain occurs when the joint between the sacrum at the bottom of the spine and the ilium bone of the pelvis is not functioning correctly. It can be locked and not moving freely or it may be that there is too much movement in the joint. Symptoms of sacroiliac joint pain include pain located at either the left or right side of the lower back, not not usually both sides. The pain can vary from a dull ache to a sharp stabbing pain which can radiate into the buttocks. Occasionally sacroiliac joint dysfunction can cause pain in the testicles. Stiffness in the lower back when getting up after sitting for long periods and when getting up from bed in the morning is also common.

Muscular trigger points are tiny localized knots in the muscle which cause pain either at the location of the trigger point or referred elsewhere in the back. They are common in the errector spinae muscles which go up either side of the spine and the deep quadratus lumborum muscles either side of the lumbar spine. Deep tissue sports massage techniques are effective for releasing trigger points in the muscles and relieving muscular back pain.

Less Common Causes of Low Back Pain

Spondylolisthesis is most common in children aged between 9 and 14 years old and involves a slipping forward of one of the lumbar vertebra. Spondylolisthesis can vary in severity from a grade one where there may be no symptoms or pain at all and patients are unaware they have the condition to a grade two which may result in low back pain made worse by activity but not radiating into the legs. A grade three injury has greater than 50% forward movement of the vertebra and a grade 4 will be very debilitating with more than 75% movement in the bone.

Spinal canal stenosis is more common in older athletes and involves the spinal canal narrowing causing pressure on the nerves with symptoms of pain and numbness. Sciatic type symptoms may also be present along with weakness of the legs. An X-ray of the spine can confirm the diagnosis.

Fractured vertebra or compression fracture of the spine is a break or fracture of one of the vertebra bones and is usually due to compressive forces. Occurring most frequently in the lower back symptoms include pain at the site of the fracture which may radiate in the hips, buttocks or thighs. Numbness, tingling and weakness may also be experienced and bladder or bowel symptoms from the fracture pressing onto the spinal cord can occur.

Fibromyalgia is a widespread muscular fatigue and pain condition where pain and tenderness is felt throughout the body. Poor sleep patterns are common and the muscles may feel soft and doughy rather than toned and tight. Patients often complain that they ache all over or feel they have overworked the muscles. Irritable bowel syndrome, Dysmenorrhea (cramps or painful menstruation) and chronic headaches are also symptoms of fibromylagia.

Lumbar instability is where part of the spine is unstable or has too much movement. Most low back problems can be relieved by freeing up a hypomobile vertebra or one that has restricted movement, although mobilizing and already mobile joint is not going to be beneficial. In this case the surrounding structures and muscles should be strengthened to support the unstable back. Core strengthening exercises and Pilates exercises for the back are likely to be beneficial. It is possible to have a generally hypomobile spine but with one or two vertebra having restricted mobility. It is important to get an accurate diagnosis and treatment from a back specialist, Osteopath or Chiropractor as the wrong treatment or exercises can have a negative effect.

Other medical conditions and diseases that can have symptoms of lower back pain include rheumatological diseases, gynacologica, gastrointestinal as well as genitourinary problems. If in doubt seek advice from a doctor.

STOP YOUR BACK PAIN TODAY. CALL US AT 6471 2744 OR EMAIL TO: INFO@BONECLINIC.COM.SG TO SCHEDULE FOR AN APPOINTMENT

Patient Guide to Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis, is a condition characterized by stiffness and pain in your shoulder joint. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one or two years.

Your risk of developing frozen shoulder increases if you’re recovering from a medical condition or procedure that affects the mobility of your arm — such as a stroke or a mastectomy.

Treatment for frozen shoulder involves stretching exercises and, sometimes, the injection of corticosteroids and numbing medications into the joint capsule. In a small percentage of cases, surgery may be needed to loosen the joint capsule so that it can move more freely.

SYMPTOMS OF FROZEN SHOULDER

Frozen shoulder typically develops slowly, and in three stages. Each of these stages can last a number of months.

  • Painful stage. During this stage, pain occurs with any movement of your shoulder, and your shoulder’s range of motion starts to become limited.
  • Frozen stage. Pain may begin to diminish during this stage. However, your shoulder becomes stiffer, and your range of motion decreases notably.
  • Thawing stage. During the thawing stage, the range of motion in your shoulder begins to improve.

For some people, the pain worsens at night, sometimes disrupting normal sleep patterns.

CAUSES OF FROZEN SHOULDER

The bones, ligaments and tendons that make up your shoulder joint are encased in a capsule of connective tissue. Frozen shoulder occurs when this capsule thickens and tightens around the shoulder joint, restricting its movement.

Doctors aren’t sure why this happens to some people and not to others, although it’s more likely to occur in people who have recently experienced prolonged immobilization of their shoulder, such as after surgery or an arm fracture.

RISK FACTORS OF FROZEN SHOULDER

Although the exact cause is unknown, certain factors may increase your risk of developing frozen shoulder.

Age and sex
People 40 and older are more likely to experience frozen shoulder. Most of the people who develop the condition are women.

Immobility or reduced mobility
People who have experienced prolonged immobility or reduced mobility of their shoulder are at higher risk of developing frozen shoulder. Immobility may be the result of many factors, including:

  • Rotator cuff injury
  • Broken arm
  • Stroke
  • Recovery from surgery

Systemic diseases
People who have certain medical problems appear to be predisposed to develop frozen shoulder. Examples include:

  • Diabetes
  • Overactive thyroid (hyperthyroidism)
  • Underactive thyroid (hypothyroidism)
  • Cardiovascular disease
  • Tuberculosis
  • Parkinson’s disease

TESTS AND DIAGNOSIS:

During the physical exam, your doctor may ask you to perform certain actions, to check for pain and evaluate your range of motion. These may include:

  • Hands up. Raise both your hands straight up in the air, like a football referee calling a touchdown.
  • Opposite shoulder. Reach across your chest to touch your opposite shoulder.
  • Back scratch. Starting with the back of your hand against the small of your back, reach upward to touch your opposite shoulder blade.

Your doctor may also ask you to relax your muscles while he or she moves your arm for you. This test can help distinguish between frozen shoulder and a rotator cuff injury.

Frozen shoulder can usually be diagnosed from signs and symptoms alone. But your doctor may suggest imaging tests — such as X-rays or an MRI — to rule out other structural problems.

TREATMENTS AND DRUGS:

Most frozen shoulder treatment involves controlling shoulder pain and preserving as much range of motion in the shoulder as possible.

Medications
Over-the-counter pain relievers, such as aspirin and ibuprofen (Advil, Motrin, others), can help reduce pain and inflammation associated with frozen shoulder. In some cases, your doctor may prescribe stronger pain-relieving and anti-inflammatory drugs.

Therapy
A physical therapist can teach you stretching exercises to help maintain as much mobility in your shoulder as possible.

Surgical and other procedures
Most frozen shoulders get better on their own within 12 to 18 months. For persistent symptoms, your doctor may suggest:

  • Steroid injections. Injecting corticosteroids into your shoulder joint may help decrease pain and improve shoulder mobility.
  • Joint distension. Injecting sterile water into the joint capsule can help stretch the tissue and make it easier to move the joint.
  • Shoulder manipulation. In this procedure, you receive a general anesthetic so you’ll be unconscious and feel no pain. Then the doctor moves your shoulder joint in different directions, to help loosen the tightened tissue. Depending on the amount of force used, this procedure can cause bone fractures.
  • Surgery. If nothing else has helped, you may be a candidate for surgery to remove scar tissue and adhesions from inside your shoulder joint. Doctors usually perform this surgery arthroscopically, with lighted, tubular instruments inserted through small incisions around your joint.

PREVENTION OF FROZEN SHOULDER:

One of the most common causes of frozen shoulder is the immobility that may result during recovery from a shoulder injury, broken arm or a stroke. If you’ve had an injury that makes it difficult to move your shoulder, talk to your doctor about what exercises would be best to maintain the range of motion in your shoulder joint.

CURE YOUR FROZEN SHOULDER TODAY! CALL +65 6471 2744 OR EMAIL TO: info@boneclinic.com.sg TO SCHEDULE FOR AN APPOINTMENT

Achilles Tendonitis

Achilles tendinitis

Achilles tendinitis is when the tendon that connects the back of your leg to your heel becomes swollen and painful near the bottom of the foot. This tendon is called the Achilles tendon. It is used for walking, running, and jumping.

Causes

There are two large muscles in the calf. These muscles are important for walking. They create the power needed to push off with the foot or go up on the toes. The large Achilles tendon connects these muscles to the heel.

Heel pain is most often due to overuse of the foot. Rarely it is caused by an injury.

Tendinitis due to overuse is most common in younger people. It can occur in walkers, runners, or other athletes.

Achilles tendinitis may be more likely to occur if:

  • Suddenly increase the amount or intensity of an activity
  • Your calf muscles are very tight (not stretched out)
  • You run on hard surfaces such as concrete
  • You run too often
  • You jump a lot (such as when playing basketball)
  • You do not have shoes with proper support
  • Your foot suddenly turns in or out

Tendinitis from arthritis is more common in middle-aged and elderly people. A bone spur or growth may form in the back of the heel bone. This may irritate the Achilles tendon and cause pain and swelling.

Symptoms

Symptoms include pain in the heel and along the tendon when walking or running. The area may feel painful and stiff in the morning.

The tendon may be painful to touch or move. The area may be swollen and warm. You may have trouble standing up on one toe.

Exams and Tests

The doctor will perform a physical exam. The doctor will look for tenderness along the tendon and pain in the area of the tendon when you stand on your toes.

X-rays can help diagnose bone problems.

An MRI scan may be done if your doctor is thinking about surgery or is worried about the tear in the Achilles tendon.

Treatment

The main treatments for Achilles tendinitis do not involve surgery. It is important to remember that it may take at least 2 to 3 months for the pain to go away.

Try putting ice over the Achilles tendon for 15 to 20 minutes, two to three times per day. Remove the ice if the area gets numb.

Changes in activity may help manage the symptoms:

  • Decrease or stop any activity that causes you pain.
  • Run or walk on smoother and softer surfaces.
  • Switch to biking, swimming, or other activities that put less stress on the Achilles tendon.

Your health care provider or physical therapist can show you stretching exercises for the Achilles tendon.

They may also suggest the following changes in your footwear:

  • A brace or boot or cast to keep the heel and tendon still and allow the swelling to go down
  • Heel lifts placed in the shoe under the heel
  • Shoes that are softer in the areas over and under the heel cushion

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen can help with pain or swelling. Talk with your health care provider.

If these treatments do not improve symptoms, you may need surgery to remove inflamed tissue and abnormal areas of the tendon. Surgery also can be used to remove the bone spur that is irritating the tendon.

Extracorporeal shock wave therapy (ESWT) may be an alternative to surgery for people who have not responded to other treatments. This treatment uses low-dose sound waves.

Outlook (Prognosis)

Lifestyle changes usually help improve symptoms. However, symptoms may return if you do not limit activities that cause pain, or if you do not maintain the strength and flexibility of the tendon.

Possible Complications

Achilles tendinitis may make you more likely to have an Achilles rupture. This condition usually causes a sharp pain, like someone hit you in the back of the heel with a stick. Surgical repair is necessary, but difficult because the tendon is not normal.

When to Contact a Medical Professional

If you have pain in the heel around the Achilles tendon that is worse with activity, contact your health care provider for evaluation and possible treatment for tendinitis.

Prevention

Maintaining strength and flexibility in the muscles of the calf will help reduce the risk of tendinitis. Overusing a weak or tight Achilles tendon makes you more likely to develop tendinitis.

CURE YOUR ACHILLES TENDINITIS TODAY! CALL +65 6471 2744 OR EMAIL TO: info@boneclinic.com.sg FOR APPOINTMENT

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