Frozen Shoulder: Expert Treatment Recommendations by Dr. A. Mohan Krishna, Consultant Orthopedic Surgeon at Apollo Hospital

 

Introduction

Are you experiencing stiffness and pain in your shoulder that's making it difficult to perform day-to-day activities? Welcome to the club of frozen shoulder sufferers. Frozen shoulder, also known as adhesive capsulitis, is a condition that affects the shoulder joint. It occurs when the tissues in your shoulder joint become thicker and tighter, which eventually makes it difficult to move your shoulder. The causes of frozen shoulder aren't always clear, but it usually affects people who've had an injury, surgery, or conditions that limit shoulder movement. Initially, you may only feel a dull ache in your shoulder before it progresses to severe pain. As the condition worsens, night pain and stiffness, combined with limited movement, make it outright unbearable. Frozen shoulder can last for several years before it completely heals. In the next sections, we'll discuss how to diagnose and treat frozen shoulder, including the different surgical procedures available.

Diagnosis of Frozen Shoulder

Frozen shoulder can be diagnosed through physical examination and imaging tests. During a physical examination, the doctor will assess the mobility of your shoulder, look for any visible deformities, and apply pressure to determine the level of pain. Imaging tests such as X-rays, Ultrasound, and MRI scans may be conducted to rule out other possible conditions. The doctor may also ask about your medical history to determine any underlying medical conditions that may be causing the frozen shoulder. The diagnostic process helps the doctor ascertain the severity and stage of the condition and develop a personalized treatment plan that is best suited for your individual needs. Remember, the earlier the diagnosis, the better the chances of effective treatment.

Treatment Options for Frozen Shoulder

Frozen Shoulder: Expert Treatment Recommendations by Dr. A. Mohan Krishna, Consultant Orthopedic Surgeon at Apollo Hospital. Treatment Options for Frozen Shoulder So you’ve been diagnosed with a frozen shoulder? That’s tough luck, but the good news is that there are several treatment options that can help you recover much faster than you thought. Let’s take a look at the various ways you can get your frozen shoulder treated. Medications There are several pain relief medications that your doctor may prescribe to you. These include over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen to help reduce inflammation in the shoulder joint. Additionally, your doctor may also prescribe stronger medications if necessary. Physical therapy Physical therapy can help you regain mobility and restore function in your shoulder joint. Your therapist will work with you to design a treatment plan that involves gentle exercises to help stretch and strengthen the joint. Regular physical therapy sessions can go a long way in reducing the pain and stiffness associated with frozen shoulder. Minimally invasive procedures If physical therapy and medications don’t work, you may want to consider minimally invasive procedures such as arthroscopy, where a small camera is inserted into the joint and used to guide the surgeon while removing scar tissues and adhesions. Other minimally invasive procedures include hydrodilatation which involves the injection of a sterile fluid into the joint capsule to help stretch it. Surgical Procedures When all else fails, surgery may be the only option left. Your doctor may recommend surgery if you do not experience any relief from non-invasive treatments or the mobility of your shoulder is severely limited. Surgical procedures for frozen shoulder may include manipulation under anesthesia, where the surgeon moves the shoulder joint in different directions while the patient is under anesthesia. Other procedures include shoulder arthroscopy and shoulder replacement surgery. In a nutshell, there are many treatment options available to you if you are suffering from frozen shoulder. Medications can help with pain relief, physical therapy can help restore mobility, and minimally invasive procedures and surgery can help in severe cases. The key is to work closely with your doctor and therapist to find the best treatment plan that works for you.

Surgery for Frozen Shoulder

Having exhausted all non-surgical approaches to treat frozen shoulder, surgery remains the only viable alternative. Surgery for frozen shoulder is typically a last resort option in the event all other interventions fail. There are two different surgeries that may be performed to address frozen shoulder, namely manipulation under anesthesia and arthroscopic capsular release. Manipulation under anesthesia involves you being put under anesthesia while your doctor forcibly manipulates your arm to remove the adhesions causing the frozen shoulder. On the other hand, arthroscopic capsular release entails your doctor making small incisions in your shoulder and inserting a camera and tools to detach the adhesions, allowing for improved movement. Following surgery, you may have to wear a sling for a while as you convalesce. You may also need to undergo physical therapy as part of your rehabilitation process, which may last between six weeks and six months.

Rehabilitation and Prevention

The road to recovery from frozen shoulder doesn't end after treatments or procedures. Post-treatment rehabilitation is fundamental in restoring your shoulder's mobility and functionality. As you may have noticed, frozen shoulder can restrict you from your daily activities and generally impact your quality of life. But don't worry, it's not the end of the world. Physical therapy is crucial in post-treatment rehabilitation. It gradually progresses by reducing pain and stiffness, restoring function, and improving strength and range of motion. It may include exercises such as stretching, low-impact aerobic conditioning, and weight-bearing exercises. The exercises help you reach behind your back, up above your head, and across your body. Sounds easy, right? Well, it's not a walk in the park because some exercises can be painful, but, hey, you got this! Prevention is always better than cure, and in the case of frozen shoulder, the saying stands. It would be best if you made some lifestyle adjustments. Specifically, everyone should have periodic check-ins with their doctors. Secondly, stretching exercises can be beneficial to prevent frozen shoulder. Still, ensure you don't force your shoulder too much during the exercises as this may lead to injury. Lastly, try not to have sedentary days but remain active with activities such as swimming, cycling, and walking. Overall, post-treatment rehabilitation and prevention of frozen shoulder are crucial components for maintaining your shoulder's functionality and mobility after treatment. Don't be afraid to take it slow and steady, and remember to make those lifestyle adjustments to avoid future episodes of a frozen shoulder.

Conclusion

Frozen shoulder is a common problem that affects a significant number of people. Fortunately, with the right treatment and management, you can alleviate symptoms, restore function and reduce pain. Treatment options for the frozen shoulder include medications, physical therapy, minimally invasive procedures, and surgical procedures if required. If conservative treatments don't work, surgery may be necessary. Following surgery, careful rehabilitation is necessary to restore full m

PLANTAR FASCIITIS

 PLANTAR FASCIITIS

Plantar Fasciitis:  It is the most common condition that causes heel pain. Plantar fasciitis is due to irritation and inflammation of the tight tissue that forms the arch of the foot. The most common symptom is pain under the heel after a period of rest, i.e. severe pain and inability to walk in the morning after getting up from sleep. The same might happen after sitting for a long time and then trying to walk. Interestingly the pain gets better after a few steps though it may not go away completely.  Again, the pain may get worse with prolonged walking and standing. X ray may show a bony spur which may develop in long standing cases of heel pain due to plantar fasciitis, but it may not cause the symptoms.

Treatment Options:

Not all of these treatments are appropriate for every condition, but they may be helpful in your situation.

1.Rest - Avoiding the precipitating activity; for example, take a few day off jogging or prolonged standing/walking.  Rest can reduce the severity of pain and will allow the inflammation to begin to cool down.

2.Ice Packs - Icing will help to diminish some of the symptoms and control the heel pain. Icing is especially helpful after an acute exacerbation of symptoms.

3.Exercises and Stretches - Are designed to relax the tissues that surround the heel bone. Some simple exercises performed in the morning and evening, often help patients feel better quickly.

4.Anti-Inflammatory Medications - Help to both control heel pain and decrease inflammation.

5.Shoe Inserts - Are often the key to successful treatment of heel pain. The shoe inserts often permit patients to continue their routine activities without heel pain.

6.Injection therapy - In some cases, corticosteroid injections are used to help reduce the inflammation and relieve pain.

7.Removable walking cast - May be used to keep your foot immobile for a few weeks to allow it to rest and heal and is used only for severe cases.

8.Night splint - Wearing a night splint allows you to maintain an extended stretch of the plantar fascia while sleeping. This may help reduce the morning pain experienced by some patients.

9.Weight reduction – It helps to reduce stress on foot and heel and thus help to reduce the severity of pain.

Gout - Gouty Arthritis

Gout:

Gout is a medical condition, a metabolic disease in which crystals of Uric acid (Monosodium urate) gets deposited in joints and tissues. These crystals are the by-product of body’s Protein degradation.

Causes:

The proteins that we consume in our diet get digested and undergo various steps of degradation in our body. Uric acid is produced during this process is usually excreted from intestine and kidneys.

High levels of Uric acid can be produced due to

Intake of protein rich diet- high purine dietAbnormalities in chemical pathways that leads to excessive production of uric acidCertain drugs like Aspirin (Salicylates), Diuretics (Kidney drugs) interfere with the excretion of uric acid thereby raising its level in blood.

The body’s own overproduction of uric acid is an inherited condition and is present from birth.

Symptoms :

Uric acid is deposited in the form of crystals (Monosodium urate) in joints and tendon. This result in intense irritation, inflammation and pain in the joints and tendon tissues. The joint becomes hot, red and swollen.

Classically the big toe joint of the foot is affected, but ankles, knees, elbows and joints of hand and feet can be involved. Large joints like hip and shoulder joints tend to be spared.

Predisposing factors:

Men are more likely to be affected than women.The commonest age for the first attack is between 30 and 60.

Risk factors include.

A high alcohol intake. Alcohol by itself  does not cause gout, but it will stimulate gout attacks in those who are affectedA protein rich diet.Certain races, like Maoris and Polynesian- who have higher blood levels of uric acid are more susceptible to goutObesity,Conditions that cause high cell turnover, such as polycythaemia (increased red cells), lymphomas and various other cancers can increase blood uric acid levels.A family history of gout,Drugs like Diuretics (drugs increasing urine flow) or low dose salicylates,Kidney diseases,

Some percentage of patients suffering from Gout can have renal colic due to deposition on uric acid crystals in the kidneys.

Diagnosis:

History and complaints

Sudden onset of severe pain, swelling and redness of joint in great to of the foot.Sometimes swelling of joints of foot, ankles and handsHistory of similar episodes in the past.

Examination:

Red, tender, swelling of joint of great toe or other involved joints.Long standing cases uric acid crystals deposit in tendons, tissues appear as swellings called Gout tophi. More common around the elbow, wrists, finger and toe joints and sometimes on the earlobe.

Investigations:

Blood tests: Raised blood uric acid levelsDoubtful cases: Fluid examination from Gout swelling for Uric acid crystals.X rays: in long standing cases shows joint destruction

Treatment:

Acute attack:

Acute attack of gout is characterised by hot, swollen, red and painful joint of great to of foot.

Non-steroidal anti-inflammatory drugs in acute attacks help in reducing the pain and swelling. They should be given in high doses initially.Colchicine is one of the oldest known drugs and can be taken during acute painful phase.New drugs are available that can be given during acute attacks which can reduce blood levels of Uric acid.

Drug treatment:

Drugs in the treatment of gout are given to control the levels of uric acid in blood and to prevent long term complications. Drug dosage should be adjusted according to the levels of uric acid in the blood.

Allopurinol is one of the oldest and common drug used to control the levels of uric acid in blood. This drug inhibits xanthine oxidase which converts xanthine into uric acid.Probenicid and Sulphinpyrazone – Promotes excretion of uric acid through kidneys.

Prevention:

Once you are diagnosed with Gout, you’re a patient of gout for your life.

Avoid Protein rich diet – High Purine foodsAvoid Dehydration: especially in hot weathersAvoid unaccustomed strenuous exercise.Care should be taken in patients on long term diuretics and low dose aspirin.

Regular medications to control the uric acid levels by the advice of physician or orthopedician.

Complications of untreated Gout:

Long term complications of uncontrolled gout can cause

Joint damage (Arthritis),Formation of gout tophi (swellings around the joint) andRare complication of chronic kidney disease.

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).

Synovial fluid replacement therapy

 

 

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