CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome:

The carpal tunnel is the space between the bones and ligaments of the wrist through which median nerve passes. Carpal tunnel syndrome develops when the nerve becomes compressed. It is common condition of the hand that affects women more frequently than men.

The symptoms of carpal tunnel syndrome include:

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  Pins and needles or tingling sensations (Paraesthesias)

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Pain or numbness in the hand, typically worse at the night.

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Clumsiness and weakness of the hand.

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A weak grip and an impaired ability to bring the thumb across the palm to meet the other fingers.

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Pain in the wrist, forearm or shoulder.

Causes:

Any condition that narrows the carpal tunnel or produces swelling of or fluid retention by the contents of the tunnel can cause carpal tunnel syndrome. The many possible causes include

-          Hormonal changes.

-          Obesity,

-          Diabetes mellitus,

-          Rheumatoid arthritis,

-          Acromegaly – bone enlargement due to pituitary gland abnormality.

-          Under activity of thyroid (hypothyroidism)

-          Renal failure,

-          Alcoholism

-          Amyloidosis : rare condition in which abnormal proteins accumulate in tissues and organs.

-          Paget’s disease: a chronic bone disease that affects elderly people. The bones become deformed and thickened.

-          Tumors: such as lipoma (Fatty tumours), ganglions (fluid filled cysts formed in tendon), and deformities of wrist after the fractures.

-          The use of hand held vibrating tools – very rarely causes carpal tunnel syndrome.

Diagnosis:

The typical history of pain and weakness in the hands usually suggest the diagnosis of carpal tunnel syndrome, but it is important to exclude other conditions that may produce similar symptoms, such as a prolapsed cervical disc or arthritis of thumb joint.

Clinical examination:

This may reveal disturbances in sensation in the area supplied by the median nerve, wasting of the muscles at the base of thumb and poor grip.

Tinel’s sign: tapping the median nerve at the wrist may reproduce the pain and tingling of carpal tunnel syndrome in the affected person. Flexing the wrist against resistance has  a similar effect.

Imaging: an x-ray of the wrist may be used to rule out bony abnormalities, while MRI gives a clear picture of the soft tissues.

Nerve conduction studies: Nerve conduction studies are conducted to see the conduction and velocity of impulses across the median nerve. This test can be used for documentation of carpal tunnel syndrome.

Treatment:

Treat the underlying cause:

The underlying causes should be treated. For example overweight patients should be encouraged to lose some weight and patients with hypothyroidism should receive thyroid hormone replacement therapy.

Some patients recover without treatment, while others respond to rest or simple measures such as the use of wrist splint for week or so. In cases where the condition is persistent however several treatments are available.

-          Anti-inflammatory drugs: may help to relive tendon swelling and pressure on the wrist in rheumatoid arthritis.

-          Wearing night splints at night, which hold the wrist, slightly forward, may help night pain.

-          Diuretics (which increase the volume of urine) are sometimes prescribed to remove excess fluid from the body.

-          Steroid injections into the carpal may provide relief, but must be performed with utmost care. It is particularly important not to inject the median nerve itself any improvement may be temporary.

-          In persistent cases, surgery will be performed in order to reduce pressure on the large media nerve.

Surgery:

Surgery is usually advisable for persistent or worsening symptoms to prevent permanent loss of sensation and wasting of the muscles in the hand. In such cases without surgery, symptoms are likely to persist.

Surgical treatment usually involves dividing transverse carpal ligament in order to relieve the pressure on the median nerve. Freeing the nerve enables normal nerve conduction to resume. Traditionally, median nerve decompression was open surgical procedure, but also new technique of endoscopic carpal tunnel release is also being practiced.

Generally, both open and endoscopic techniques have excellent results although it may take few months for grip strength to return to normal.

KNEE PAIN IN YOUNG ADULTS - CHONDROMALACIA PATELLA

CHONDROMALACIA PATELLA (ANTERIOR KNEE PAIN)

Introduction:

The most common location of knee pain in young adults is at the front of the knee joint. The problem usually arises from patella (Knee cap bone) and surrounding soft tissue.

Knee cap (Patella) is a small bone which lies in front of lower end of thigh bone (Femur). The back side of knee cap is lined by smooth tissue called cartilage. This covering helps the patella to glide in a groove on the lower end of thigh bone. The knee cap is held on the top by thigh muscles (Quadriceps) and lower part is connected to the shin bone by Patellar tendon. Function of knee cap is to aid knee movement and stabilize knee joint while walking.

Causes:

There are many theories suggesting softening and micro injuries to this lining resulting in pain. It could be due to repetitive micro trauma during falls, or vigorous unaccustomed exercises etc. Abnormal position of knee cap over the knee joint with or without weak ligaments may also damage the cartilage lining. As cartilage lining gets softened and roughened it may cause pain and crepitus (clicks and sounds) over the knee cap. Obesity makes the condition worse.

Complaints:

• Pain in front of knee.
• Pain on climbing up and down the steps or ramps.
• Sudden ‘catch’ over the knee cap while getting up from the ground.
• Dull aching pain after sitting for long time.
• Discomfort during squatting (Using Indian toilet) and sitting cross legged.
• Ocassional clicks and sounds over the knee cap.
• Swelling.

Diagnosis:

Orthopaedician can make diagnosis based on your symptoms and examining the knee. Grating sensation behind knee cap might give us some idea of the roughness of patella when you tighten the knee cap muscles.

Some times there may be a little swelling the joint.

Tests:

Blood tests are normal.

X-rays are not helpful as the problem is with cartilage lining which cannot be seen on X-rays.

MRI (Magnetic resonance Imaging) scans can detect changes in the cartilage, but is used as last resort in unresponsive cases.

 Arthroscopy: It is possible to look inside the knee joint and back of the knee cap with pencil shaped camera (Arthroscope) to confirm the diagnosis. But arthroscopy is not done just for diagnosis and is only done if there is any need for surgery.

Treatment:

This condition generally improves over a period with some changes in the life style. But in some patients, symptoms persist for several years.

Analgesics (Pain Killers): Simple pain killers like Paracetomol and tramadol may be sufficient in most of the cases. Sometimes anti inflammatory medications (NSAIDS) may be necessary for a short period.

Nutritional supplements to cartilage lining like Glucosamine, Chondroitin, MSM and collagen peptides can be taken for 2 to 3 months which may relieve the symptoms.

Injections:

In some unresponsive cases Intra articualr Hyaluronic injections can help. They act by providing lubrication between joint surfaces and help to nourish cartilage lining of knee cap.

Physiotherapy:

Strengthening the anterior thigh muscles (Quadriceps) and muscles around the knee cap (VMO) helps to keep knee cap in right position.    

Surgery:

Surgical management is last resort in severe or unresponsive patients. It can be performed with arthroscope (Key hole surgery). The principle is to smoothen the rough surface of the back of knee cap. In some cases where there are large defects in the cartilage, multiple drill holes into the bone may help regrow some cartilage. Now a days we are combining this procedure with stem cell treatment in selective cases.

Do's & Dont's:

Please avoid any movement or position of which makes you feel the pain. It is better to avoid kneeling, squatting or sitting cross legged. One may go up and down the steps occasionally but avoid repeated stair climbing. Pain may get worse with exercise bicycle and walking on a treadmill with upward gradient (slope).