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ARTHRITIS
All of the moving joints in our bodies have two
smooth lubricated surfaces which glide easily over each other.
These joints surfaces are covered with articular cartilage.
The cartilage is a hard substance which is constructed of very
large molecules densely intertwined with each other. When pressure
is put on the joint surfaces a slick lubricating fluid is squeezed
out much like you squeeze water out of a sponge. This ensures
adequate lubrication even under high loads or stresses. The
lining of the joint capsule or covering is called synovium.
This is a thin layer of cells which secretes nutrients for the
articular cartilage and performs other tasks to keep the joint
healthy.
Inflammatory arthritis occurs when the joint lining
becomes thickened and irritated. The cause is often unknown
but may be due to an immune disorder or latent virus infection.
Rheumatoid arthritis is a common cause of inflammatory arthritis.
The medical treatment is usually directed by a rheumatologist
(medical arthritis doctor). After a period of time the inflammatory
arthritis may destroy the joint surfaces. This results in rough
bone surfaces rubbing against each other. Osteoarthritis, degenerative
arthritis or wear-and-tear arthritis is common in older patients
and occasionally seen in younger patients. In many patients
the cause is not known. In others the osteoarthritis results
from previous injury or damage to the joint. Over a period of
time the joint surface gradually erodes away until rough joint
surfaces rub against each other.
The symptoms of arthritis include pain, limitation
of motion, redness, swelling, fluid accumulation (e.g. water
on the knee), warmth, deformity, instability and loss of function.
For many patients pain is the most annoying and disabling symptom.
Pain may arise from the actual swelling and inflammation of
the joint lining. It may also arise from the rubbing of irregular
joint surfaces on each other.
Non-operative treatment may include oral medication,
rest, splints, physical therapy, cortisone injections and injections
of special lubricating fluid. When these have failed
surgery is the next treatment option. In certain situations
arthroscopic (microscopic) surgery of the joint may allow the
smoothing of the joint surfaces. This does not cure the problem
but smoothing the gliding surfaces can lead to significantly
decreased pain and increased function. This is most often used
in the knee. The next step in treating a worn-out joint is a
total joint replacement. This involves open surgery, the removal
of the arthritic ends of the bones, careful carpentry to fashion
the bone ends properly and the replacement of the joint surfaces
with metal and plastic surfaces. This is commonly done for arthritis
of the hip and knee and less commonly for other joints.
Total hip replacement and total knee replacement
are big operations which often require two to three hours of
surgery. Patients often stay in the hospital for 5 days
after surgery and occasionally longer. Physical therapy is important
after surgery to maximize function. Most patients experience
dramatic relief of pain after a total joint replacement. The
rubbing of the rough irregular joint surfaces has been replaced
by the gliding of metal on hard plastic.
There are a number of potential problems associated
with total joint surgery. The artificial joints can wear out.
The ten year reoperation rate is approximately 20%. This means
that one patient out of five will require a second operation
within the first ten years following surgery. The metal can
break from metal fatigue. The plastic can also wear away or
break. The risk of infection is about 1 in 100. An infection
in a total joint replacement is a serious problem. Sometimes
antibiotics will cure the infection. Other times the entire
prosthesis needs to be removed. If this happens it can sometimes
be replaced later. The total risk of complications is relatively
low and the majority of patients are pleased by their decreased
pain and increased function.
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ARTHROSCOPY
Arthroscopy is a technique which allows us to
look inside your joints by inserting a long, narrow instrument
through a puncture wound. Some people call this microsurgery
of a joint. Arthroscopy can be used in the evaluation and treatment
of knees, shoulders, ankles, elbows, wrists and occasionally
other joints.
General anesthesia is usually used, although occasionally
in special circumstances local anesthesia with intravenous sedation
is sufficient. The arthroscope is inserted through a small puncture
wound and the joint is filled with fluid. There is a fiberoptic
light and a small television camera attached to the arthroscope.
Often a small drainage tube is inserted through another puncture
wound to allow fluid to wash through the joint. The joint is
carefully examined. Often a blunt probe is inserted through
another puncture wound and the structures inside the joint are
gently pushed and pulled with the probe while being examined.
This allows for a more detailed examination.
If the structures are entirely normal, the arthroscope
is removed and the procedure is over. In this situation we have
not done any treatment which will improve your symptoms, however
we know that your symptoms are not coming from any anatomic
abnormality inside the joint. Further evaluation and treatment
can then be considered with the knowledge gained by arthroscopy.
Occasionaly we see an abnormality that we are
unable to correct. For example, in the early stages of degenerative
arthritis, which is a mechanical wearing out of the gliding
surfaces of the joint, we may see gliding surfaces which are
abnormally soft and mushy. This is not something that can be
corrected. In this situation we have not done anything
to correct your joint, but can offer advice regarding further
evaluation and treatment based on the information gained at
the arthroscopy.
Usually we find some anatomic abnormality which
can be improved by arthroscopic surgery. Common problems include
torn menisci (joint cartilages), rough irregular joint gliding
surfaces (degenerative arthritis or chondromalacia), loose bodies
of cartilage floating in the joint, and torn ligaments. In these
situations we insert various instruments into the joint through
other puncture wounds and remove, smooth or repair the torn
or irregular surfaces.
The anterior cruciate ligament is one of the four
main supporting ligaments in the knee. It is one frequently
injured in sports either as the result of contact or sometimes
from hyperextension without contact. If your doctor feels arthroscopic
reconstruction of the anterior cruciate ligament is advisable,
he will discuss the details with you.
Often arthroscopic surgery results in significant
improvement in function and decrease in pain for the involved
joint. Arthroscopic surgery does not 'cure' the joint. It is
not possible to make the joint like there was never anything
wrong with it. After the rough and irregular surfaces are smoother
or torn structures repaired, the joint is usually able to glide
more easily and the pain and stiffness are often relieved.
Not all joints are improved by these procedures.
If there is a simple torn meniscus in the knee, the knee may
be better in a matter of days. If there is degenerative arthritis,
a good result may be decreased pain and increased function that
lasts a few years. If the problem is severe, arthroscopic surgery
may be of no benefit. Rarely, pain and stiffness are worse after
arthroscopic surgery. Occasionally we find a problem which cannot
be treated with arthroscopic surgery. In this situation we do
not proceed to a larger operation unless we have obtained your
permission ahead of time.
The risks of arthroscopy include medical and anesthetic
complications, infection, damage to the arteries and nerves
in the leg, damage to the gliding surfaces of the joint and
increased pain.
If you have further questions regarding arthroscopy,
please do not hesitate to ask us.
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THE
LOW BACK
Back pain is a very common problem, so common
that as many as nine out of ten people will experience serious
back trouble at some time in their lives. The area of the back
usually affected is the lower back or lumbar region. You may
feel an ache or pain in that area, or the pain can radiate to
your buttocks, thighs, legs or feet. Your symptoms can include
weakness, numbness, tingling and even burning or pins and needles
sensations.
There are several possible causes of these symptoms.
You may have strained or injured the muscles and ligaments in
the lumbar region, or you may have a problem with a disc in
the lumbar spine. Another possible cause is a narrowing of the
spinal canal in your back.
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LUMBAR
STRAIN
Causes and Symptoms
Lumbar strain is frequently caused by heavy lifting,
strenuous activity, a fall or an injury such as an automobile
accident, which subjects your back to a sudden, excessive force.
The pain you experience is probably caused by tearing of the
muscles or ligaments in your back, but it may also be caused
by increased pressure on or injury to the discs which act as
cushions between the bones of the spine. The symptoms
of lumbar strain are pain, stiffness and muscle spasm in the
low back. The pain can spread to the buttocks and to the back
of the thighs. Some patients feel as though their back "locks"
or "freezes" occasionally, making movement impossible. This
sensation is caused by a brief period of severe muscle spasm.
Treatment
The treatment of lumbar strain depends on the
severity of the symptoms. If your pain is not too disabling,
no specific medical treatment may be indicated. But there are
many changes you should make in your daily activities to reduce
the stress on your back and to allow your body to gradually
heal itself.
The amount of lifting and carrying you do each
day must be minimized. It is better to carry small loads for
several trips than to carry a single, heavy load for one trip.
If your job involves lifting, especially heavy lifting, you
and your co-workers should get in the habit of helping each
other, thus protecting all of your backs.
When you want to bend over to do something or
pick something off the floor, don't bend over at the waist.
It is less stressful on your back to lower yourself by bending
one or both knees (holding on to something if possible) while
keeping your back straight. Avoid working in awkward positions.
Analyze the work you have to do and figure out ways to perform
your work in a more relaxed, less stressful way.
You should avoid all strenuous activity while
your back is healing and generally decrease the number of hours
you are on the go each day. When you are at work all day, lying
down during your lunch hour can help you get through the day,
or lying on the floor for a short time, with your legs up on
a chair, can be a good position for resting your back.
Shifting position frequently during the day is
also useful. If your job involves a lot of sitting, you should
try to find or create occasions for standing. You might stand
while on the telephone, or you might stand now and then while
using your computer by raising the keyboard. Prolonged car rides,
when the back has poor support, should also be avoided. None
of these changes in the usual way of doing things is easy to
make, but the corresponding benefits for your back can be significant.
Bed rest during the evenings and on the weekends
will also help your back to heal. The most comfortable positions
are on your back with two pillows under your knees and a small
pillow under your head, or on your side with your knees drawn
up. Sometimes placing pillows between your legs and arms makes
lying on your side more comfortable.
Back braces help some people with lumbar strain,
but not everyone. Some patients swear by them; others swear
at them. But if you find that your pain increases as the day
progresses and the normal daily stresses take their toll, a
back brace can be helpful. It decreases the stress the back
receives by providing external support. Reduced stress means
decreased back pain and increased ability to function.
A patient who is under significant emotional or
mental stress, at home or at work, is more likely to develop
muscle spasm in the back. Once a lumbar strain has developed,
a patient under stress has a much harder time getting better.
In these situations, it is important to decrease the amount
of stress or to learn to manage it. Biofeedback techniques or
psychotherapy may be helpful in these circumstances.
Medication
For more severe pain, medication may be necessary
in addition to changes in activity. We often prescribe muscle
relaxants such as Flexeril, taken three times a day, or Soma,
taken four times a day. Muscle relaxants may make you drowsy,
so you should not drive or operate machinery while taking them.
If they make you too sleepy or "spacey," you can try taking
half a pill or you can stop taking them.
Frequently we also prescribe anti-inflammatory
pain medication such as Ibuprofen (Motrin, Advil, Mediprin,
Nuprin), Indocin, Naprosyn, Dolobid, Easprin, Nalfon, Feldene,
Clinoril, Ansaid, Voltaren, Celebrex, Vioxx, etc. These are
taken one to four times a day depending on the specific medication.
They should be taken with meals and should be stopped if you
have any stomach upset or other side effects. Occasionally these
medications can cause bleeding ulcers; they should not be taken
if you have a history of ulcers.
If you are taking any other medications or have
any other illnesses, please inform us so that we can evaluate
the possibility of cross reactions between medications. You
should not take any medication if there is a chance that you
are pregnant.
Physical Therapy
Physical therapy often is helpful in relieving
pain and muscle spasm. Our therapists use a variety of modalities
including traction, heat, massage, ultrasound, electrical stimulation
and exercise. They will tailor a program to your specific problem.
For patients who do heavy work, a work hardening program to
build strength, endurance and confidence is often useful.
Exercise
Once your pain has subsided, you can begin a program
of protective exercise to help decrease your risk of back flare-ups.
Protective exercise includes low stress, rhythmical activities
such as brisk walking, lap swimming or bike riding (regular
or stationary). You should gradually work your way up to twenty
minutes of any of these exercises each day. Stomach crunches
and gentle stretching are also useful. None of these exercises
should be done if you are having acute pain. Avoid exercises
which stress the back such as contact sports, aerobics and weight
lifting until you are painfree for a few months.
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HERNIATED
LUMBAR DISC
Causes
and Symptoms
The lumbar spine consists of a series of cylinder-like
bones, called vertebrae, stacked on top of each other. Between
each pair of vertebrae is a cushion or shock absorber of softer
tissue called a disc. The disc itself consists of an outer ring
of tough, layered tissue (like the tread on a radial tire) and
an inner core of soft pulpy material like crab meat.
With increasing age and accumulated stress to
the back, the discs in the lower back frequently begin to degenerate,
wear out and even break up into fragments. This same process
can be caused by an injury which exerts sudden pressure on the
disc. Such injuries include heavy lifting, automobile accidents
and falls from heights.
A weakened or injured disc can bulge out of alignment
with the vertebrae above and below it. This bulging can cause
pain by pressing on the ligaments that encase the spine. If
the bulge is large, it can put pressure on one or more nerves
in the spinal canal behind the disc. At times, fragments of
disc material can push their way through the ligaments at the
back of the disc and into the spinal canal. Herniated discs
are also called slipped discs or ruptured discs. It does not
act like a poker chip which slips in and out of place but more
like toothpaste squeezed from a tube.
A herniated disc can cause all the symptoms of
lumbar strain. In addition there can be pain, numbness and tingling
and other odd sensations radiating down the legs to the feet
and toes. These symptoms may occur in one leg or both legs.
Pressure on the nerves in the spinal canal can also cause weakness
of the muscles in the legs, and in rare cases, can interfere
with bowel and bladder control. Pain radiating from the back
down the leg is sometimes called sciatica. Sciatica is often,
but not always, caused by a herniated lumber disc.
Treatment
The methods used to treat lumbar strain (reduced
activity, medication and physical therapy followed by the gradual
resumption of activity) can also be used to treat a herniated
lumbar disc. However, a herniated disc can be a serious problem
requiring more aggressive treatment. Sometimes we treat patients
with strict bed rest and medication at home. Approximately three
out of four patients will improve with medication, rest, physical
therapy and the gradual resumption of activity.
Those patients who continue to experience severe pain need further
diagnostic tests such as magnetic resonance imaging (MRI), computerized
axial tomography (CAT scan), electromyography (EMGs) or a myelogram.
These tests provide more detailed information about the discs
and nerves inside the lumbar spine.
An MRI scan produces images of internal tissues
by detecting the energy given off by hydrogen atoms in your
body in a shifting magnetic field. CAT scans produce images
by a series of precisely controlled and enhanced low-level x-rays.
Both of these procedures require nothing of the patient other
than lying in a tube-like hollow inside a machine while the
scanning takes place. There are no known complications from
MRI scans. CAT scans use x-rays, but at low levels: the possibility
of finding out useful information outweighs the very small risk
from low level x-ray exposure.
EMGS require putting small needles into the muscles
of the back and legs to measure the electrical activity of the
muscles. A myelogram provides an x-ray outlining the nerve roots,
spinal canal and lumbar discs. A myelogram requires the injection
of a dye into the spinal canal in the lower back followed by
multiple x-rays. The most common side effect from a myelogram
is a headache which can be quite severe and last for several
days or more. Very rarely, allergic reactions to the dye can
cause nerve damage.
If a patient has not improved with bed rest, medication,
and physical therapy, and if a diagnostic test confirms the
presence of a herniated lumbar disc there are new methods that
can often be tried before surgery is considered. Epidural
and Foraminal blocks are often an option that is
very common and has proven very effective. These "blocks"
are basically the injection of pain relieving medication combined
with an anti-inflammatory medicine into the space closest to
the area of herniation. This is usually done as an outpatient
procedure in the hospital so that the doctor has an x-ray machine
available to him that enables him to view the area where the
needle is placed. Many patients require two to three of
these injections to completely recover, but most patients do
recover and require no further intervention. If the herniation
is too large or does not respond to blocks, then surgery may
be indicated. The most common reasons for a patient deciding
to have back surgery is PAIN which is of a disabling severity...PAIN
which has not diminished despite conservative treatment, and
the existence of a herniated disc documented by one or more
of the diagnostic tests described above. Severe muscle weakness
and numbness in the legs or loss of bowel and bladder control
are more urgent reasons for surgery.
Surgery
The traditional method of surgical treatment is
called a lumbar laminectomy or lumbar discectomy. During this
surgery, the muscle layer covering the spine is peeled back
and the spine is exposed. An opening is made into the spinal
canal and the nerve roots and lumbar discs are directly examined.
If the herniated disc seen in the diagnostic tests is confirmed,
then the abnormal disc material is removed with small instruments
and the pressure on the spinal nerves is relieved. Sometimes
bone is removed from the back of the spine or the hole between
the bones through which the nerves pass is widened to relieve
pressure on the nerves. One or more discs may be removed depending
on how many are involved.
Positive results from surgery cannot be guaranteed,
but the majority of patients with herniated lumber discs are
better after surgery. If a patient has more leg pain than back
pain and a relatively large herniation, there is a 70% chance
of a good result from surgery. Occasional patients are completely
pain free after surgery, but most patients still have some back
or leg pain after recovery. Often some leg numbness persists.
Some patients get only temporary relief or no relief. Rare patients
have increased pain, muscle weakness, paralysis, increased numbness
or tingling or difficulty controlling bowel and bladder function
after surgery. The risk of these more severe complications is
one in one thousand. Like all surgery, back surgery also involves
risks of infection and of medical and anesthetic complications.
Surgery on one area of the back does not prevent
problems from occurring in other areas. It is possible to get
recurrence of back pain after surgery from herniation of discs
at new levels. Further herniation of disc material at the same
level is also possible. Scar tissue or adhesions can form around
the nerves after surgery causing pain.
Generally patients are out of work for three months
following back surgery. Some patients can return to light work
earlier, but only perhaps half of the patients with strenuous
jobs requiring heavy lifting will be able to return to their
former occupations. A back brace may be prescribed for six weeks
following surgery. During recovery, we recommend an exercise
regimen that includes gentle stretching exercises, stomach strengthening
exercises and regular rhythmical exercises such as brisk walking,
lap swimming or bicycling (regular or stationary).
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Percutaneous
Lumbar Discectomy and
Arthroscopic Lumbar Discectomy
Other procedures for treating herniated lumbar
discs are called percutaneous lumbar discectomy and arthroscopic
lumbar discectomy. In these procedures the surgeon inserts a
long, narrow metal tube into the disc using x-rays to guide
its path or the metal tube is inserted using arthroscopic visualization.
Instruments inserted through the tube can then either suction
out the disc material or mechanically remove the disc material
decompressing the disc and allowing the bulging or herniation
to retract away from the compressed nerves. These procedures
are performed under local anesthesia with intravenous sedation
and do not usually require an overnight stay in the hospital.
There is a 50-70% chance of decreased pain following
this procedure. Occasional patients are completely free of pain.
Those with good results may still have some pain, but they are
considerably improved and no longer consider open surgery as
a treatment option. Potential complications of this procedure
include infection in the disc space, aggravation of the herniated
disc, damage to the nerve roots, perforation of bowel, bleeding,
increased pain, reactions to medication, etc. but these risks
are uncommon.
Not all patients are suitable candidates for this
procedure. Some patients have detached fragments of disc material
in the spinal canal: percutaneous lumbar discectomy and arthroscopic
lumbar discectomy cannot remove these fragments and open surgery
is required. If these procedures are unsuccessful, open surgery
can be performed at a later date. Patients may continue to have
pain for up to three weeks after a percutaneous or arthroscopic
lumbar discectomy and then get better. The results following
open surgery do not seem to be compromised by a previous percutaneous
lumbar discectomy.
Any of the above procedures work by relieving
pressure on the nerves. These procedures do not magically cure
the nerve. By eliminating the pressure, the nerve is relieved
of the source of irritation and then has a chance to heal itself.
The extent of improvement depends on the severity of damage
to the nerve. Thus there may be rapid improvement in symptoms
if the nerve is irritated, but not permanently damaged; slow
improvement in symptoms for a nerve with greater damage; and
no improvement if a nerve is more severely damaged.
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SPINAL STENOSIS
Causes
and Symptoms
Another cause of lower back pain and related problems
is spinal stenosis. In this condition, the diameter of the spinal
canal is narrower than normal because of overgrowth of bone
spurs which have formed as a result of degenerative arthritis
of the spine. Occasionally the spinal canal is narrow because
of congenital undergrowth of the spine.
Spinal stenosis can cause back pain, leg pain
or numbness and tingling in the legs. Often there is little
or no back pain and the patient does not realize the problem
is in the back. The most serious symptom often is an inability
to walk for any significant distance. When the patient tries
to walk, pain, aching and weakness in the legs increase, forcing
the patient to stop. After a few minutes rest, the patient can
then walk a similar distance before the symptoms recur. Symptoms
are often vague and difficult to describe. The physical examination
may be normal and patients are sometimes accused of exaggerating
their symptoms.
Diagnosis of spinal stenosis requires an MRI scan,
CAT scan or myelogram (described above). Since similar symptoms
can sometimes be caused by an insufficient supply of blood to
the legs, further tests may be necessary to evaluate this possibility.
Treatment
When the pain and difficulty of walking are so
severe that the patient is incapacitated, the only effective
treatment is surgery. During surgery the bone at the back of
the spinal canal is removed in order to open up the spinal canal
and relieve the pressure on the nerves. Herniated lumbar discs
which frequently accompany this condition may have to be removed
at the same time. The length of spine which has to be decompressed
is determined by the diagnostic studies. One to four levels
are often involved. The risks of surgery are similar to those
listed for lumbar laminectomy above. In addition, if a patient
has little back pain before decompression laminectomy for spinal
stenosis, after surgery he may find significant improvement
in function and ability to walk, but increased back pain. Most
patients find that the improvement in function outweighs the
increase in back pain.
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CARPAL
TUNNEL SYNDROME
Causes
Where the wrist and hand meet, nine tendons and
one large nerve pass together through a tight tunnel into the
palm. This tunnel, called the carpal tunnel, is formed on three
sides by the small bones of the wrist and on the fourth side
by the very tough fibrous tissue that makes the heel of the
hand firm. The nerve passing through the carpal tunnel is called
the median nerve. This nerve gives feeling to the thumb, index,
middle and part of the ring fingers, and it gives movement to
the muscles that lift the thumb away from the palm. Anything
that causes swelling within the narrow carpal tunnel can put
pressure on the median nerve. A frequently repeated motion of
the fingers or wrist can cause irritation and swelling, and
a sudden injury, like a blow to the hand or a fractured wrist,
can do the same. Pregnancy or arthritis can also cause swelling,
and sometimes swelling occurs without any obvious cause. Whatever
the cause, swelling and increased pressure in the carpal tunnel
can interfere with the flow of blood to the median nerve. Over
time the constriction in blood flow can lead to chronic irritation
and eventual damage to the nerve. This problem is called carpal
tunnel syndrome.
Symptoms
Chronic irritation of the median nerve can cause
a variety of sensations in the hand and forearm including numbness,
tingling, burning, sleepiness, pins and needles or even shock-like
feelings. The patient's hand may cramp and tire easily or lose
strength and dexterity. Feeling may be lost in the thumb, index
and middle fingers, and patients may sometimes wake at night
with numb or aching hands. Many patients feel they have arthritis
and that nothing can be done. Symptoms often occur in both hands.
Diagnosis
Carpal tunnel syndrome is diagnosed by evaluating
the patient's symptoms, examining the hand and forearm and performing
two tests of the electrical functioning of the affected nerves.
EMGs (electromyography) detect the irritability of muscles in
the hand and arm, and NCVs (nerve conduction velocities) measure
the speed of electrical impulses traveling along the median
nerve and its branches. EMGs and NCVs can detect significant
changes in nerve function and thus confirm a diagnosis of carpal
tunnel syndrome. However, patients with milder irritation of
the median nerve will sometimes have normal electrical tests
because their problem has not progressed far enough to be detected
by electrical changes.
Treatment
Many patients have mild carpal tunnel syndrome.
They never develop abnormal EMGs or NCVs, and their symptoms
are not seriously bothersome or disabling. Treatment in these
mild cases may include putting the wrists in splints at night
or during the day. People often sleep with their wrists bent
forward, which increases the pressure on the nerve by narrowing
the size of the carpal canal. Wearing the splints at night and
occasionally during the day prevents this. Most patients with
more severe carpal tunnel syndrome have abnormal EMGs and/or
NCVs though their symptoms may vary from mild to disabling.
Some patients with normal electrical tests nevertheless have
severe symptoms that persist for months. Because nerve damage
can be progressive, the appropriate treatment for most patients
with abnormal tests or persistent symptoms is carpal tunnel
release surgery. In this operation, the tough tissue forming
the palmar side of the carpal canal is opened to relieve the
pressure on the median nerve. The increased space for the median
nerve and tendons results in decreased pressure in the carpal
canal and increased blood supply to the median nerve. The nerve
then has a chance to heal itself. The surgery itself does not
`cure' the nerve. The pattern of symptom relief after carpal
tunnel release surgery depends on which of three types of injury
the nerve has sustained. In the first type of injury, the nerve
is in a sense stunned or `knocked out'. The nerve can `come
to' in days or weeks. In the second type of injury, the nerve
cell itself has died back, but the small nerve canals remain
intact. After surgery relieves the pressure, the nerve cells
begin growing down the small nerve canals at the rate of about
one inch per month. Since the distance from the site of injury
to the tips of the fingers is six or seven inches, recovery
can take six to eight months after carpal tunnel release surgery.
Occasional patients note recovery over one to two years. In
the third type of nerve injury, the nerve cell has died back
and the small nerve canals have collapsed as well. No nerve
recovery is possible in this situation. There is no way to determine
before surgery how much of each type of injury any individual
patient has. Thus after carpal tunnel release surgery, recovery
may occur almost immediately, may occur over six to eight months
or more, or may never occur. Partial recovery often occurs.
About 80 to 90 percent of patients experience good relief from
their symptoms after carpal tunnel release surgery. Even those,
whose symptoms are not relieved, are still helped because reducing
the pressure on the median nerve prevents the problem from becoming
worse in most cases. Carpal tunnel release surgery is done on
an out-patient basis. No overnight stay in the hospital is necessary.
In the procedure most commonly used, an anesthesiologist
administers intravenous sedation and the surgeon gives a local
anesthesia. This method reduces the risk of the nausea sometimes
caused by general anesthesia, and the sedation keeps even very
nervous patients comfortable. Sutures remain in the skin for
two to three weeks, and patients begin using their hand shortly
after surgery.
Risks
When surgery is indicated, the principal risk
of not operating to relieve the pressure in the carpal tunnel,
is progressive permanent damage to the median nerve. The risks
of carpal tunnel release surgery itself include the risks related
to all surgery: infection, anesthetic complications and allergic
reactions to medications. A small percentage of patients can
have an unpleasant flare of pain after surgery which may last
for a few months and in rare cases much longer. This problem
occurs when the nerve has been extremely irritated by the increased
pressure in the carpal canal and then reacts to the increased
blood supply with increased irritation. There may also be some
tenderness in the palm after surgery, but it usually goes away
within six months.
There is a technique for performing a carpal tunnel
release using small incisions and an endoscope. We do not recommend
this procedure. There have been a number of reports indicating
that the endoscopic procedure has a one in a hundred risk of
damage to or cutting of one of the major nerves at the wrist.
This is such a serious complication that we do not recommend
this procedure.
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CUBITAL
TUNNEL SYNDROME
When you hit your "crazy bone" on the inside of
your elbow, you often feel pain, numbness and tingling radiating
down the inside of your forearm into the ring and little finger.
The "crazy bone" is actually one of the three big nerves in
your arm called the ulnar nerve. This nerve travels down the
inside of the upper arm, crosses the elbow behind the bony bump
on the inside of the elbow (called the medial epicondyle) and
continues down the forearm on the little finger side of the
forearm.
The ulnar nerve usually passes through a tight
tunnel at the elbow just behind that bony bump on the inside
of the elbow. This nerve can develop chronic irritation due
to a number of factors. Certain repetitive activities which
involve frequent bending and straightening of the elbow are
a common source of problems. Frequent positioning of the elbow
in a bent position can increase pressure on the nerve. Habitual
positioning the of elbow on a desk or table can put pressure
on the nerve as can sleeping on your stomach with your arms
up over your head.
The tunnel at the elbow is not tight in all people.
There are some people in whom the nerve can slide or sublux
forward so that it rests directly over the bump on the inside
of the elbow. This subjects the nerve easily to pressure if
the inside of the elbow rests on anything. In other people the
nerve can dislocate completely to the front of the arm with
flexion of the elbow and then it returns to the back of the
arm with extension of the elbow. Repetitive snapping backwards
and forwards can cause chronic irritation of the nerve.
If the nerve becomes chronically irritated, it
can cause vague aches or pains at the inside of the elbow, forearm
or in the hand. It may also cause numbness, tingling, pins and
needles feeling or burning type of feelings in the elbow, forearm
or hand. Often these symptoms are in the ring and little fingers.
The diagnosis is made by examining the nerve for
evidence of irritation. The nerve is palpated and tapped to
see if it is more irritable than normal. The examination also
looks for slippage, subluxation or dislocation of the nerve.
Electrical studies of the nerve are also useful. These are called
electromyography and nerve conduction velocities. If the irritation
of the nerve reaches a sufficient level of severity, the speed
of conduction of the nerve impulses will slow at the elbow.
This alteration in the speed of conduction of the nerve can
be detected by the electrical studies. Not all patients who
have cubital tunnel syndrome have positive electrical tests.
Positive electrical tests suggest that the severity of the condition
is greater than if the tests are normal.
Initial treatment consists of trying to eliminate
or reduce the amount of chronic irritation of the nerve. This
involves changing the way you use and position your arm. If
you use a computer keyboard a lot or drive a car or truck frequently,
you should position yourself further back from the keyboard
or steering wheel so that your arms are held straighter most
of the time rather than bent most of the time. If you rest your
elbows on a desk or table frequently, you need to break yourself
of this habit. If you sleep on your stomach with your arms over
your head, you need to change your sleeping position. This is
not easy to do. It can take months of effort to become accustomed
to falling asleep in a different position. The best position
for sleeping is lying on your side with your elbows straight.
Anti-inflammatory medications occasionally are
helpful, but not often. Cortisone shots are dangerous because
of the risk of damage to the nerve by injecting the nerve itself.
If symptoms remain sufficiently severe or if the electrical
studies are markedly abnormal, then surgical release of the
nerve is indicated. The purpose of the surgical release is to
open up the tunnel and remove pressure from the nerve. Sometimes
the nerve is permanently moved to the front of the elbow to
remove it from the position where is receives repetitive trauma.
Sometimes the bony bump on the inside of the elbow (medial epicondyle)
is partly removed as a way of relieving pressure on the nerve
and protecting it from chronic irritation.
Most patients who have a surgical release of the
nerve have improved symptoms with decreased pain, numbness and
tingling. In some patients there is only partial relief, depending
on how much damage the nerve has suffered. Occasional patients
have tenderness on the inside of the elbow due to continuing
irritation of the nerve despite the release of the pressure.
Rare patients have flares of pain which can last months or rarely
for a long time. This is an unusual response to irritation or
injury which nerves can develop. About four out of five patients
get good improvement in their symptoms following surgery.
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KNEE CAP PAIN (CHONDROMALACIA
PATELLAE)
Causes and Symptoms
Three bones contribute to the structure of your
knee. The femur or thigh bone forms two rounded surfaces which
form the top portion of your knee. The tibia or shin bone consists
of a weight-bearing platform which forms the bottom of the knee.
The patella, or knee cap, is a disc shaped bone which is in
front of the knee and glides up and down in a groove in the
femur during bending and straightening of the knee. Everyday
activities, like kneeling and stair climbing, cause significant
compressive stresses between the knee cap and the underlying
femur. Strenuous activities, like running and jumping, can generate
forces as much as six times your body weight pushing the patella
against the underlying femur. So if you weigh 120 pounds, the
force across your knee cap can equal 700 pounds at times. If
you weigh 200 pounds, the force can reach 1200 pounds. All of
these stresses can cause softening and irregularity of the cartilage
(the gliding surface) on the undersurface of your knee cap.
Pain arising from the underside of the knee cap is one of the
more common problems we see in our office. This condition is
sometimes called chondromalacia patella from chondro for cartilage,
malacia for softening and patella for knee cap. So the name
simply means softening of the cartilage under the knee cap.
It is also called patellofemoral pain syndrome because not everyone
with this problem has obvious irregularities of the kneecap.
Pain under the knee cap often becomes a problem in teenagers
who are active in sports, but it is also seen in young and middle-aged
adults. It occurs more commonly in women than in men, more commonly
in people with loose ligaments (so-called double jointed) and
more commonly in people who are overweight. Quite often pain
in the knee cap develops in people who have become more active
in sports or at work. Running, jumping and climbing activities
tend to be common aggravators. Other aggravators include squatting,
kneeling, and leg extension against weight from a fully bent
position. Falling on the knee or hitting the knee hard
(eg. hitting the knee against the dashboard in an automobile
accident or following a fall) can cause the same condition.
In a mild case of chondromalacia patellae, your knees may crack
or grind after you have been seated for a long time, or your
knees make hurt when you kneel, squat or go up and down stairs.
You may also feel a sensation of rubbing or grating under your
knee cap. In a moderate case you may be comfortable at rest
but develop pain with strenuous running and jumping types of
activities. In severe cases the pain may be constant and interfere
with walking and normal daily activities.
Treatment
Chondromalacia is rarely "cured", but short-term
treatment can relieve the pain of a flare-up and long-term treatment
can help prevent flare-ups from recurring. In the short term
you should avoid activities that aggravate your knee such as
running, kneeling, squatting and climbing. If your knee is very
painful, treatment may include a splint to rest the knee and
one of a number of anti-inflammatory medications. Once the acute
pain of a flare-up has subsided, specific exercises are very
important. Proper exercise includes bicycling (regular or stationary)
and/or lap swimming. Patients who ride an exercise bicycle 20
minutes a day seems to do much better than those who do not.
Short arc quadriceps (front thigh muscle) exercises are also
useful. To do this lie on a bed or sit on a chair with a small
rolled towel or toilet tissue roll under the knee so that the
knee is bent at about a 20 degree angle. Straighten the knee
and lift the heel off the bed and hold it for the count of ten
and then relax. Repeat this exercise 30 times, three times a
day. As your muscles grow stronger, you can add weights to your
ankle. You can use ankle weights purchased from a sporting goods
store, or use a purse with books in it and put the strap over
your ankle. Other exercises, called McConnell exercises, work
on strengthening the inner portion of your thigh muscle and
are usually taught by our physcial therapists. At no time should
you do any exercise in which you are straightening your knee
from a fully bent position against resistance. Examples of exercises
you should not do include squats, squats with weights on your
shoulders, working at a weight bench with the starting position
having the knee hanging straight down, and pushing against weights
with your feet starting with the knees fully bent. In the long
term, after your knee has settled down and protective exercises
have strengthened the knee joint, you can gradually increase
your level of activity. In time you will find the level of activity
you can tolerate without causing your knee to flare up. You
may, however, have to change sports. This will be your decision.
Not everyone can continue in the strenuous running and jumping
sports at the level they desire. If your job requires a lot
of stair or ladder climbing, you may have to alter the way you
work to reduce the number of times you go up and down. On occasion
it is necessary to change jobs to minimize stress on the knee
cap. If your problem is severe and you live in a house with
stairs, especially a townhouse, it may be wish to move to a
one floor house or apartment.
Surgery
When pain remains severe and activity is unacceptably
restricted, surgery is sometimes recommended. In one surgical
procedure, an attempt is made to release soft tissue structures
on the outside of the knee cap to allow it to glide in a different
manner over the underlying bone. In another procedure, the rough
undersurface of the knee cap is mechanically smoothed. These
procedures may be performed using the arthroscope or during
open surgery. Your surgeon will recommend the procedure and
method best for you. The results of these operations vary. They
do help some patients, but there are many patients who are not
helped. Thus these operations are usually done only as a last
resort.
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MRI (Magnetic Resonance Imaging)
What
Is It?
A magnetic resonance imaging scanner produces
an image of the structures inside your body. When you are being
scanned, your body is placed inside of a very strong magnet.
When the magnet is turned on, the strong magnetic field causes
the protons inside the atoms of your body to line up and spin
in the same direction. A radio signal then nudges the spinning
protons out of their alignment. When the radio frequency signal
stops, the protons move back to their previous position and
release an electronic signal. These signals are recorded by
instruments and processed by a computer to provide an image
of the part of your body being scanned. There are no x-rays
and no radiation involved in an MRI scan. No side effects or
risks of an MRI scan are known. Though the use of magnetic fields
is not thought to be harmful, long-term side effects are unknown.
Scans take between 30 and 90 minutes to complete. Often they
take about 45 minutes. There are no known risks of an MRI scan
in pregnancy, but we still do not advise them in pregnancy unless
there is a critical situation in which an MRI scan would be
safer than x-rays or surgery. People with cardiac pacemakers
and patients with some metal implants cannot be scanned.
The
Scan Itself
There is usually no specific preparation required
before an MRI scan. You may eat, take medication, etc. Before
your scan you may be asked about your medical history, asked
to sign a consent form, asked to remove all metallic objects
such as jewelry, hair pins, removable dentures etc. You may
change into a hospital smock and be checked with a metal detector.
Some patients are injected with a contrast agent to improve
the images for certain problems. Young children may be sedated
to help them lie still. You will be placed on the scanning table,
positioned comfortably and the table will slide inside the giant
magnet. It is important to lie as still as you can for the entire
scan. Don't worry about breathing. During the scan you will
not feel anything. You may, however, hear the hum of the machine,
thumps, whirring, grating and other machine-like noises.
Results
A radiologist will interpret the scan and send
a report to us. He will probably do this some time after you
have left the scanning facility. They should give you a copy
of the MRI scan to bring with you when you come back to our
office. We also will interpret the scan to make sure that we
agree with the radiologists report. If there are any questions,
we will confer with the radiologist or ask other radiologists
for their opinions. This increases the probability that we will
get the maximum information from your scan.
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NECK PAIN
Most people experience at least one serious episode
of neck pain sometime in their lives. If you have a neck problem,
you may feel pain, stiffness or muscle spasms in your neck itself,
or the pain may radiate up the back of your head, causing headaches,
or the pain may travel down between your shoulder blades, or
spread out across your shoulders and even down your arms to
your fingers. You may also feel numbness, tingling or pins and
needles sensations in all these areas. Your arms may seem weak
and grow tired easily. These symptoms often result from two
causes: strain to the muscles and ligaments of your neck, called
cervical strain, or bulging or herniation of the disc or shock
absorber in your neck, called herniated cervical disc.
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CERVICAL STRAIN
Cause
Cervical strain is often caused by excessive
stress such as heavy lifting, unusual strenuous activity or
an injury such as an automobile accident or a fall in which
the neck is exposed to sudden excessive forces. There may be
some tearing of the muscles and/or ligaments about the neck.
Treatment
The treatment of cervical strain depends on how
severe your pain is. If your pain is not too disabling, no specific
treatment may be indicated. You should simply avoid any activity
or movement that puts stress on your neck. Lifting should be
minimized; it is better to carry small loads for several trips
rather than one heavy load in one trip. Strenuous activity should
be avoided. The constant jerking of long car rides may also
aggravate a cervical strain and should be avoided. Sleeping
on your stomach can force your neck backwards and to the side.
This can increase your pain and sleeping on your stomach should
be avoided. If your pain is worse in the morning, your sleeping
position may be the cause. Eliminating these potential causes
of strain often allows your body to gradually heal itself. Gentle
stretching exercises are also helpful. If your pain is more
severe, medication may be necessary in addition to reduced activity.
Muscle relaxants, like Flexeril, taken three times a day, or
Soma, taken four times a day. can help alleviate the muscle
spasms that contribute to your pain. Muscle relaxants can make
you drowsy, so you should not drive or operate machinery while
taking them. If they make you feel too sleepy or "spacey" you
should stop taking them. Some patients only take them at night
or on weekends. Others try half of a pill. Anti-inflammatory
pain medications such as Motrin, Indocin, Naprosyn, Dolobid,
Easprin, Nalfon, Clinoril, Voltaren, Feldene, Celebrex and Vioxx
are also frequently prescribed.. These are taken with meals,
one to four times a day depending on the specific medication,
and should be stopped if they upset your stomach or cause other
side effects. These medications can increase your risk
of developing bleeding stomach ulcers. No medication should
be taken if there is a chance that you are pregnant. Physical
therapy also helps some patients with cervical strain. Our therapists
use heat, massage, intermittent traction, transcutaneous nerve
stimulation, ultrasound, electrical stimulation and other modalities
to help reduce the spasm and pain in your neck and shoulders.
The therapist may teach you specific exercises and may also
show you how to put yourself in a mild form of traction at home.
Soft or hard neck collars are sometimes recommended to help
patients reduce everyday stress on the neck.
It is important to analyze the way you position
and use your body at work and in other activities. Computer
screens should be directly in front of you when using them and
at or slightly below eye level. Activities requiring moving
or holding the head at extremes of motion should be avoided.
If you have to do work above your shoulders, it is less stressful
to stand on a stool or ladder to raise your body so that the
work is at a more comfortable level.
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HERNIATED
CERVICAL DISC
Cause
The Neck or Cervical Spine has seven vertebrae
(bones) stacked on top of each other. Between each pair of vertebrae
is a cushion or shock absorber of softer tissue called an intervertebral
disc or just a disc. This combination of vertebrae and discs
gives your neck its unique combination of strength and flexibility.
With increased age and accumulated stress, the discs between
the vertebrae may begin to degenerate, wear out, and even break
up into separate fragments. Disc material may eventually protrude
out of alignment with the vertebrae above and below the disc
and bulge against the nerves in the spinal canal. This same
protrusion or herniation can be caused by a sudden, acute stress
like that suffered in an automobile accident or in a fall. Pressure
from disc material bulging against the nerves can cause pain,
numbness and/or tingling that is felt across the shoulders,
down the arms and even in the fingers. In older people, degeneration
of the discs can lead to a narrowing of the space between the
neck vertebrae and sometimes to the development of bone spurs
which can also push against the nerves causing similar pain.
This condition is called cervical spondylosis, degenerative
arthritis, or degenerative disc disease of the cervical spine.
Symptoms
The symptoms of a herniated cervical disc include
all the symptoms of a cervical strain such as pain and stiffness
in the neck, shoulders and between the shoulder blades. The
pain can radiate up the back of the head. There can be pain,
numbness, tingling or other odd sensations going across the
shoulders, down the arm and into the fingers. Less commonly
there may be weakness of a specific muscle or group of muscles
in your shoulders or arms. These symptoms frequently occur only
on one side. Rarely there may be interference with the control
of your bowel and bladder.
Treatment
All the methods used to treat a cervical strain
(reduced activity, medication, physical therapy and/or neck
collars) can be used to treat a herniated cervical disc. However,
a herniated cervical disc can be a serious problem. Distinct
muscle weakness indicates a compressed nerve; if the pressure
is not reduced or relieved, the nerve can be permanently damaged.
In cases of severe pain and muscle weakness, patients are frequently
prescribed bed rest to immobilize the affected area as much
as possible. If your pain and other symptoms continue despite
conservative treatment, further diagnostic tests are recommended
such as magnetic resonance imaging (MRI scan), computer assisted
tomography (CAT scan), electromyography (EMG) or a myelogram.
These tests provide more precise information about your condition.
An MRI scan produces an image of body tissues by recording the
energy given off by hydrogen atoms in a shifting magnetic field.
CAT scans produce images by a series of precisely controlled
and enhanced low level x-rays. Both of these procedures require
that you lie very still inside a hollow tube inside the machine
while the scanning takes place. EMGs detect the electrical impulses
in your muscles and nerves with tiny needles. A myelogram is
performed by injecting a special dye, which shows up on x-rays,
into the spinal canal of the lower back. You are then tilted
head down on a table and the dye runs down to the neck. X-rays
taken with the dye in the spinal canal allow us to look for
evidence of disc material pressing on the nerves. If you have
disabling pain which has not improved with conservative care,
and if one or more of the above tests confirms the diagnosis
of a herniated cervical disc, then surgery is indicated.
Surgery
The purpose of surgery is to remove the herniated
disc material which is pressing on the nerves. A small piece
of bone is then removed from the side of your pelvic bone and
placed between the two involved vertebral bones to allow the
bone to grow across the involved disc space and fuse it solid.
A neck collar is worn for three months after surgery and strenuous
activity must be avoided during that time. About 80 to 90% of
patients experience relief of their symptoms. Some achieve full
relief and some partial relief. Unfortunately, 10% to 20% do
not get significant relief of their symptoms. The risks of surgery
include medical and anesthetic complications, infection, injury
to the carotid artery or esophagus, slippage or collapse of
the bone graft, failure of the fusion to heal and continued
or increased pain. Damage to the spinal cord and paralysis have
occurred, but this is extremely rare.
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TENDONITIS
AND BURSITIS
Cause
Tendonitis and bursitis are common causes of musculoskeletal
pain in people between the ages of 30 and 60. They also occur
in people who are both older and younger than that. These problems
may occur in various parts of the body including the shoulder,
elbow, wrist, hand, hip, knee, ankle and foot. The exact cause
is not well understood. As you grow older, the different parts
of your body do not tolerate stress as well as they used to.
Rather than developing sore muscles which go away in a few days,
your body appears to develop an inflammatory or irritatied response
that can last for a long time and be quite painful. These problems
often follow an episode of unaccustomed activity such as raking
leaves or they may follow a specific incident of excessive stress
or injury to your body.
Bursitis
Anywhere in your body that two surfaces need to
glide over each other, there is a bursa. A bursa consists of
two surfaces of slick tissue which face each other and glide
over each other. The edges are sealed and they form essentially
a collapsed sac. When inflamed, this sac fills with fluid, swells
and becomes sore and tender. There is a bursa where the skin
at the point of your elbow glides over the underlying bone.
Another bursa lies under the skin which glides over your knee
cap. There are bursae in the heel where the skin glides a little
over the bone. There are also bursa deeper within your shoulders
and your hips. Inflammation of these structures is called bursitis.
Tendonitis
Detailed studies of the blood supply to the tendons
that surround the shoulder indicate that the amount of blood
supply decreases significantly as we age through the 30's, 40's
and 50's. It is likely that a similar steady decrease in blood
supply occurs in other tendons and muscle-tendon junctions of
the body. This may explain why our tendons are less able to
withstand stress and are more likely to become inflamed. Inflammation
of the tendons, their attachments to bone and the muscle-tendon
junctions is called tendonitis. An acute injury or multiple
small injuries from chronic stress can lead to small tears in
the tendons, at their attachments to bone, or at the muscle-tendon
junction. These small tears can result in an area of chronic
inflammation. This process is called tendonitis.
Deposits of calcium are sometimes laid down in
areas of the tendons which develop decreased blood supply. The
calcium crystals are very irritating to the tissues and cause
pain and inflammation. This is called calcific tendonitis and
often is the cause of the acute tendonitis that appears suddenly
without cause. The pain may be severe enough to interfere with
sleep.
Treatment
The mainstays of treatment for tendonitis and
bursitis are non-steroidal anti-inflammatory medications (Motrin,
Naprosyn, Dolobid, Ansaid, Orudis, Indocin, Clinoril, Feldene,
Celebrex and Vioxx) and cortisone shots. Neither cures all cases.
Some types of tendonitis and bursitis seem to respond better
to medication and others are more amenable to cortisone shots.
Both treatments have low risks associated with them. Anti-inflammatory
medications can cause ulcer problems. Cortisone shots rarely
cause a temporary increase in inflammation, rupture of tendons
or depigmentation of the skin. Too many cortisone shots (usually
more than six in one place) can increase the risk of rupture
of a tendon. Rest and avoidance of repetitive stress to the
inflamed area are also important.
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CALCANEAL BURSITIS (HEEL PAIN)
(Plantar Fasciitis)
The soft tissue which pads your heel takes a considerable
amount of abuse during your daily activities of walking, running
and playing sports. This tissue is well padded. Its structure
is something like bubble packing. There are tiny compartments
filled with fat rather than air and these tiny compartments
act like individual shock absorbers. Between the heel bone (calcaneus)
and the soft tissue is a bursa which allows easy gliding between
the fatty tissue of the heel and the underlying bone.
Chronic repetitive stress or a direct blow to
the heel can cause the onset of an acute bursitis in the heel.
This can become quite painful, interfere with sleep and make
walking unpleasant. Cortisone shots into the heel work more
often than anti-inflammatory medications. Unfortunately shots
in the heel often hurt alot. Cortisone shots, anti-inflammatory
medications and heel pads are the mainstays of treatment. Only
in rare situations is surgery performed for this problem. Sometimes
one shot cures the problem. Other times calcaneal bursitis can
take a long time to correct and can be a very difficult problem.
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DEQUERVAIN'S
STENOSING TENOSYNOVITIS
This tendonitis with an impossibly long name occurs
on the thumb side of the wrist. The tendons which pull the thumb
out into the hitchhiking position pass through a tight tunnel
at the bony prominence on the thumb side of the wrist. Repetitive
motion activities involving the wrist or trauma to the wrist
or hand can initiate a process of swelling and inflammation
of this tendon and its tendon sheath. As the tendon swells it
rubs more, which irritates it more, which causes it to swell
more, which causes it to rub more, etc. This can become a self
perpetuating process.
This problem usually presents with pain on the
thumb side of the wrist, aggravated by use of the wrist. The
pain can be mild and chronic or severe and acute. The diagnosis
is made by noting tenderness to palpation of this tendon sheath.
A diagnostic test called the Finkelstein's Test is often used.
This involves placing your thumb in the palm, making a fist
around the thumb and then angling the wrist toward the little
finger side. In DeQuervain's tendinitis this is often quite
painful.
Treatment includes the injection of cortisone
medicine into the tendon sheath. Anti-inflammatory medications
help occasional patients, but are generally not as helpful.
If the cortisone shots are not helpful, then surgical release
of the tendon sheath is indicated. This relieves the continual
rubbing which is preventing the problem from resolving. The
surgery is done under local anesthesia and on an ambulatory
surgery basis. Often an anesthesiologist gives intravenous sedation.
Sutures remain in two to three weeks. The majority of patients
get good relief from the surgery. There is a very sensitive
nerve called the superficial radial nerve which passes across
the wrist in this area. Rare patients develop an irritation
or injury to this nerve which can cause very unpleasant pain
on a long term basis. Every effort is made during surgery to
minimize this risk.
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TENNIS ELBOW (LATERAL EPICONDYLITIS)
Tendinitis at the outside of the elbow is often
called tennis elbow. The majority of patients whom we see with
this problem do not play tennis excessively. Tennis elbow may
be caused by a sudden, acute stress on the elbow or by repetitive
motion activities involving picking up objects with the palm
facing downwards or inwards.
The first line of treatment is to eliminate chronic
stress on the tendon which attaches to the outside of the elbow.
Whenever you pick something up with your palm facing downwards
or inwards, the muscles on the back of the forearm contract
and do most of the work. Most of the muscles on the back of
the forearm attach to the tendon on the outside of the elbow.
When these muscles contract they put stress on this tendon.
It is important to change the way you pick up and carry things.
You must think of carrying things with two hands rather than
one. This decreases the stress on each arm. Carrying things
with the palm up puts stress on the muscles on the palm side
of the forearm. These muscle attach to the inside of the elbow.
Containers of liquid such as milk, orange juice, etc. should
be smaller (eg. quarts rather than half gallons) and should
be picked up with both hands.
Cortisone shots are often effective in reducing
the amount of pain and inflammation. Unfortunately cortisone
shots in this area often hurt. Anti-inflammatory medication
can also be of value. If several cortisone shots and anti-inflammatory
medications are unsuccessful in curing this problem. There is
a surgical option. The tendon on the outside of the elbow is
explored. If the area of chronic inflammation is seen, it is
removed. If no specific area of inflammation is found, the tendon
is lengthened a small amount to decrease stress and tension
on the tendon. The results from this operation are not universally
good. Perhaps four out of five patients get good relief of symptoms.
Unfortunately, approximately one in five does not.
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TRIGGER FINGER (TENOSYNOVITIS)
In the hand and fingers mild inflammation of the
tendons can cause swelling of the tendons and of the tendon
sheaths in which they glide. This swelling causes the tendons
to rub more as they glide. The rubbing causes increased inflammation
and swelling, which causes more rubbing, which causes more swelling,
etc. The swelling can reach a point at which the tendon cannot
glide fully. In this situation the finger may pop or snap as
it moves or even become stuck in one position. Sometimes it
is impossible to pull the fingers into a full fist position.
This is often called trigger finger (thumb) or tenosynovitis.
It can occur spontaneously or can develop after injury to the
palm or from chronic repetitive stress.
Injections of cortisone into the tendon sheath
often help to decrease the swelling and allow freer gliding
of the tendons. Anti-inflammatory medications are sometimes
effective. If relief is not obtained with the shots, then a
small operation is used to open up the tendon sheath at the
area of tightness. This is performed under local anesthesia
on an ambulatory surgery basis. 95% of patients get relief of
symptoms and freer gliding of the tendons as a result of this
operation.
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© 2002 - 2005
Greater Washington Orthopaedic Group,
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