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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HEEL AND FOOT PAIN

HEEL & FOOT PAIN

Heel pain is an extremely common complaint, and there are several common causes.

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.

Posterior Heel Pain:  Posterior heel pain causes symptoms behind the foot, rather than underneath. Posterior heel pain causes include Achilles tendinitis and retrocalcaneal bursitis. These patients may also develop bony growth behind the heel bone and when they are large may lead to rupture of Achilles tendon. Patients may have difficulty to walk comfortably on the affected side and pain that occurs at night or while resting.

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.

If, after several months of non-surgical treatment, you continue to have heel pain, surgery will be considered.

Healthy Joint Club says:

Not being able to take first step out of bed in the morning can be frightening. More over severe pain from the heel may force you to restrict several day time activities. Except for a handful of cases and some uncommon conditions, most cases improve with treatment and time. Even though the time taken for the recovery may vary from person to person there is a natural tendency for these conditions to get better spontaneously.

STRETCHING EXERCISES

     

1.PLANTAR FASCIA STRETCH:

Sit in a chair and cross one foot over your other knee. Grab the base of your toes and pull them back toward your leg until you feel a comfortable stretch. Hold for 10 seconds and repeat 5 to 10 times.

2.ACHILLES STRETCH:

Stand on forefoot at the edge of stair, reach the step below with your heel, until you feel the stretch in the arch of the foot. Hold this position for 10 seconds and repeat 5 to 10 times.          

3.HEEL RAISE:

Stand behind the chair or any support and raise your body up onto your toes and hold for 5 seconds. Then slowly lower down yourself. Repeat 5 to 10 times.

4.TOWEL PICK:

Drop a towel on the ground and pick up the towel with your toes. Release and repeat 5 to 10 times.

5.FROZEN CAN ROLL:

Take a frozen juice can or tin, roll your feet on the can from front to back. Do it for 3 to 5 minutes.

6.TOWEL STRETCH:

Loop a towel around your toes and pull the foot towards your body keeping your leg straight. Hold this for 10 seconds and relax. Repeat 5 to 10 times.

Dr.A.Mohan Krishna
M.S.Ortho.,MCh orth (U.K)
Consultant Orthopedic surgeon,
Apollo Hospital
Appointments
Cell: 9247258989
         9441184590
email: bonesandjointsclinic@gmail.com
online appointments: 
www.drmohankrishna.com
www.bonesandjointsclinic.com

TAIL BONE PAIN - COCCYDYNIA

Pain in the tail bone can frustrate, irritate and embrace many patients for getting the treatment. This condition can be curable and prevented if proper care is taken.

Any irritation (inflammation) of the bony area (tail bone) situated between the folds of the buttocks is referred as Coccydynia.

The usual complaint is pain at the bottom region of the back on sitting. It is usually caused by injury, during pregnancy, chronic pressure on the tail bone due to sitting for long hours as of in those involved in driving occupation. Sometimes tail bone pain occurs in patients with chronic constipation. In one third of the cases the cause is not known.

Coccydynia is usually diagnosed based on the typical complaints and sometimes by an x-ray. Clinician can diagnose by examination and eliciting tenderness at the local region. It is necessary to directly visualize the tailbone region to rule out other causes and any infection. Sometimes infection of the hair follicles at the tailbone region can mimic coccydynia.

This condition usually frustrate patients and impair the quality of life.  Sometimes patients feel embarrassed to get the treatment. Treatment is usually by activity modification, anti inflammatory medications and local injections. Surgery is rarely indicated in non responsive cases.

Since long hours of sitting may aggravate the condition, a modified padded cushion with cut out at the back could relieve the pressure on the coccyx. (Doughnut cushion). Pelvic floor exercises could help to get relief from pain. Use of stool softeners and laxatives in cases of constipated patients could help to relive pain. Seitz bath by sitting in tub of hot water may provide pain relief. 

Oral anti inflammatory medications and local application of pain gels may tries to relive the symptoms. Local trigger injections with low dose steroid preparations will aid in complete relief in majority of cases. These local injections can be given by the doctor in the outpatient department.  In rare case surgical treatment by removal of coccyx may be required in those cases not responding to conservative methods.

Dr.A.Mohan Krishna
M.S.Ortho.,MCh orth (U.K)
Consultant Orthopedic surgeon,
Apollo Hospital
Appointments
Cell: 9247258989
         9441184590
email: bonesandjointsclinic@gmail.com
online appointments: 
www.drmohankrishna.com
www.bonesandjointsclinic.com

BACK PAIN IN PREGENACY

BACK PAIN IN PREGNANCY

Back pain is the most common orthopedic complaint in most of the pregnant women. According to the scientific literature 50% to 80% of the pregnant women complain of back pain at sometime during their pregnancy. Out of the different back pains it is the lower back pain which most of the pregnant mothers suffer.

Number of factors can be attributed for the cause of low back pain in the pregnancy. Hormonal and postural changes play a major role in the cause.

During pregnancy many hormones are produced out of which Relaxin is the one which is of our concern. The function of hormone Relaxin is to loosen the joints and ligaments in your body. This helps to relax the ligaments in the pelvis which in turn makes room for your baby inside and also helps during delivery of your baby.

Since the hormone have no selective role in relaxing the ligaments and joints of the pelvis only, all the ligaments and joints in the body are stretched. Laxity of the ligaments which support the spine results in the instability which can cause back pain.

As the baby grows and size of the uterus expands, the posture of your body is altered resulting in forward bending of lower spine and compensatory backward bending of upper spine. Abdomen shifts forwards and downwards altering the normal biomechanics of the spine. This in turn adds on strain to back muscles which may become sore and tired.

Two types of lower back pain are observed during pregnancy,

1. Lumbar pain
2. Posterior pelvic pain

Lumbar pain

It is similar to the kind of back pain that you may have experienced before the pregnancy. It is caused by sitting or standing for prolonged periods. It presents as pain in the lower back, just slightly above the waist line.

Posterior pelvic pain

It is the pain experienced at the back of the pelvis, below the waist line, across the buttocks and near the tail bone. It is the most common type experienced by pregnant women. It can be aggravated by bending twisting, climbing stairs, or leaning forwards.

Management

Back pain during pregnancy could be controlled and prevented by taking necessary precautions and following regular exercise protocol. Exercises help to strengthen, stretch the back muscle. These include pelvic tilt exercises, back stretches, hamstring stretches and kegel exercises.

Walking and swimming are the two preferred exercises during pregnancy to maintain the tone of back muscles. Walking helps to maintain flexibility of muscles of lower back, hips and knee. Swimming and other aquatic exercises allows full body work out with minimal stress and strain to the body. Prenatal yoga or pregnancy yoga helps to stretch and strengthen the back muscles and aid in relieving the pain.

It is not only exercises which help in controlling the back pain, but maintaining proper posture while standing and sitting will help. When you stand try to tuck your hips and pelvis, try resting one foot on a stool. Prolonged sitting can hurt you back, so take frequent breaks if you plan to sit for long times. Safe lifting and bending practices help you to prevent undue strain on your back. When bending over to lift any object, bend at the knees instead at waist and use your thigh muscles to push yourself up instead of back muscles. Try not to lift heavy objects. Wearing low heeled shoes with good arch support may help to alleviate back pain.

Sleeping posture most favorable for pregnant women is to sleep sideways, preferably on left side. Try sleeping with your knees and hip bent, with pillows between knees and one under the belly.

Note:

If you are pregnant with sever back pain, which is rhythmic and feels like menstrual cramps consult your doctor. If you have back pain with numbness or weakness in both lower limbs it needs urgent evaluation by your doctor. Dull back pain during late stages of pregnancy could be signs of preterm labor.

Dr.A.Mohan Krishna
M.S.Ortho.,MCh orth (U.K)
Consultant Orthopedic surgeon,
Apollo Hospital
Appointments
Cell: 9247258989
         9441184590
email: bonesandjointsclinic@gmail.com
online appointments: 
www.drmohankrishna.com
www.bonesandjointsclinic.com

Arthroscopy (keyhole surgery)

What is Arthroscopy?

Greek word for joints is “Arthros”, and Greek word for looking is “Scope”, so arthroscopy means looking in to the joints. Since this is done through a small cut it is commonly known as a minimally invasive surgery or a key hole surgery. It can be performed on many joints like shoulder, elbow, wrist, hip, knee and ankle joints, though shoulder and knee are the commonest.

Why Arthroscopy?

When investigating the conditions of the joints it is very helpful  to be able to look inside the joint in order to see exactly what is going on in addition to examining the joint from outside. It is done with special equipment. Operative procedures for any abnormalities can be done through a second small cut. It is routinely done as a planned procedure as a day case, but sometimes it is done as a matter of urgency, for example following injury to a joint like a twisted swollen knee joint.

What are the advantages?

a) Small incisions and small scares.

b) Less tissue damage and less chance of infection.

c) Less pain and disability after surgery and patient can return to sedentary work almost immediately and to more vigorous work within 1 to 2 weeks.

d) Better diagnosis of many joint problems.

e) Most procedures can be performed as outpatient basis. If hospitalization is required most procedures need 1-2 days of stay compared to several days of stay with open procedures.

f) Some procedures can be done better with arthroscopic surgery and perhaps for some that is the only way they can be done.

Preparation for surgery

After deciding to proceed with arthroscopy some basic blood tests are done and patient’s fitness is assessed. Like any other surgery patients would be asked not to eat or drink any for at least 6 hours prior to surgery. Patients can watch the surgery if it is done under regional anaesthesia.

 After surgery

Prescription would be given for pain killer tablets and other medicines as necessary. The joint needs to be rested a little for a couple of days but like in case of arthroscopy of the knee joint you can walk to and from the toilet with crutches but to avoid excessive use of the joint. One important aspect is physiotherapy to get full movement in the joint and to strengthen the muscles around the joints. Within the limits of pain these exercises can be started as soon as possible after surgery. The exercises can be carried out many times in a day.  Start with 4-6 repetitions of each exercise, increasing to as many as you feel able to do without getting any pain. When you had any other reconstructive surgery like ligament and meniscal surgery post operative care and advice will be different. Similarly arthroscopy of shoulder would be followed up by specific exercises depending upon the type surgery. You would be asked to visit the hospital after 2 days for a change of dressing.

 Common conditions needing Arthroscopy

Knee Arthroscopy:

A torn meniscus ( to repair or remove), a torn anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL), For removal or biopsy of inflamed or damaged lining of the joint(synovium), Misalignment of the kneecap (patella), Small pieces of broken cartilage and loose bodies in the knee joint, Removal of Baker's cyst(a swelling behind the knee that is filled with fluid), Some fractures of the bones of the knee. Washing the knee which is constantly sore due to arthritis can also be beneficial.

Shoulder Arthroscopy:

Arthroscopy of the shoulder may be recommended for infective arthritis(septic lesions), biceps tear, SLAP lesions, Rotator cuff lesions, impingement syndrome, recurrent dislocation of shoulder and other  instability problems with or without hyper laxity, Frozen shoulder, loose bodies etc. Problems associated with the other joints in shoulder joint complex i.e. subacromial joint, acromio-clavicular joint are also easily examined giving access to rotator cuff lesions, acromion pathology and  clavicular problems.