Scott M. Evans, PA-C was featured on WMUR Sunday night (November 24th) discussing concussion testing ... Read More
Scott M. Evans, PA-C was featured on WMUR Sunday night (November 24th) discussing concussion testing ... Read More
We are hosting our 4th Annual Food Drive! New Hampshire Orthopaedic Center is participating again ... Read More
... Read More
© 2013 New Hampshire Orthopaedic Center
Knee pain is a common complaint in patients presenting to the orthopedist. The kneecap is often the culprit. To understand why this bone plays such a prominent role in knee pain, a review of anatomy is in order.
The knee cap, known as the patella, is a fig newton size bone, triangular in cross section and located at the end of the quadriceps, the powerful muscle-tendon structure that runs down the front of the thigh and is responsible for extending the lower leg.
When our knee bends, the patella slides into a groove in the front of the femur (the thigh bone) called the patello-femoral groove. This V shaped groove perfectly matches the two sides of the triangular (V-shaped) patella. When the quadriceps contracts, pulling the lower leg to the straight (i.e. extended) position, the undersurface of the kneecap is subjected to compression stresses (pressure): the stronger the contracture (intensified in running or stair climbing, for example), the greater the stress.
The knee joint, like all joints in the body, is lined with a smooth, slippery white material called cartilage. The cartilage on both sides of the patella-femoral joint can tolerate the high pressures of intense quadriceps activity if the patella glides in the groove perfectly centered, thereby absorbing equally the compression stresses on both of its V-shaped sides (facets). And, “therein lies the rub”.
For the patella to stay perfectly centered in the groove during activity, many things have to be in place: the pull of the quadriceps has to be equal (symmetrical) on both sides of the patella; the rotation of the thigh must be aligned with that of the lower leg; the muscles around the knee, foot and ankle must be balanced and strong enough to perform their function; and the individual muscles in the entire leg must be of the right tension, not too tight and not too loose.
If the forces around the patella and the whole limb are not balanced, the patella glides asymmetrically in the groove (i.e. slips out of place) during quadriceps contracture predominantly loading one (usually the outside i.e. lateral) facet over the other. This concentrated pressure over just half the usual surface area causes the cartilage to fail resulting in pain, buckling and stiffness. If this continues unchecked, arthritis occurs.
Often a person has a slipping patella, but doesn’t know it. The knee has no symptoms because the person’s lifestyle does not include activities with intense demands on the quadriceps. The knee remains symptom free as long as the activities of daily living (ADL) are not stressful enough to cause symptoms.
All is well until the person embarks on a new activity (running, biking, hiking, lifting, etc.) that markedly increases the load on the knee. This new load is concentrated on the slipping patella and is more than a single lateral facet can bear. Pain occurs in the front of the knee and occasionally behind the knee. Simple every day activities like squatting, climbing stairs and getting up from a chair now are painful. Swelling, cracking and stiffness become daily occurrences. It is at this point the patient seeks medical help.
Orthopaedic treatment must be tailored to the specific mechanical abnormality, with the goal being to balance the forces acting on the patello-femoral joint so that the patella remains centered in the femoral groove during quadriceps contracture. Conservative therapy involving physical therapy, orthotics, and bracing (individually or in combination) is successful in most cases. When rehabilitation efforts fail, surgery is used to balance the forces around the kneecap so that the patella stays in its groove.
When a patient`s chief complaint is knee pain, orthopedists must first find the site of the pain and then the reason it exists. When the pain site is the knee cap, we must identify the mechanical abnormalities, educate the patient as to why they exist and then correct them with rehabilitation and, if necessary, surgery. This, plus a lifelong commitment by the patient to a maintenance exercise program gives us our best chance at a successful and lasting outcome.
Recommended: A Healthy Orthopaedic Lifestyle
Strains, sprains, overuse injuries, fractures, and arthritis: it`s a rare person who has not experienced one of these orthopaedic problems.
Practicing good orthopaedic health habits can minimize the risk of incurring one or more of these common musculoskeletal conditions.
Strong muscles protect our joints from injury by absorbing the energy of impact and torsion. Also, a strong muscle with its attached tendon is less likely to tear, a condition that can lead to painful tendinopathy(1) such as “tennis elbow” or shoulder bursitis.
Aerobic activity that elevates your heart rate for at least 20 minutes a day is recommended for strengthening muscles. My favorite is brisk walking with two walking poles (2), because all four extremities are engaged in weight bearing exercise which is important for improving muscle and bone strength. Excellent substitutes for walking include swimming, riding a stationary bike or using an elliptical trainer.
Aging increases our need for regular exercise as the body`s “fitness memory” becomes shorter and shorter. Exercise more as you age, not less.
As we get older, our joints and muscles get stiffer. Stiffness lowers the threshold for incurring sprains, strains and tendon inflammation (“tendinitis”). A daily stretching program not only feels good, but minimizes the risk of injury by maintaining flexibility. A simple, but reasonably comprehensive program can be accomplished in 10 minutes (3).
Obesity is strongly liked to arthritis, not only mechanically (extra weight on joints), but also biochemically (fat cells secrete joint damaging inflammatory substances). A weight control plan I recommend includes eating three balanced meals a day with portion control, no snacking, and avoidance of processed foods and sugary drinks.
Smoking and Alcohol
Smoking and heavy drinking are both risk factors for fracture non-union, poor wound healing and osteoporosis. Stop smoking and drink only in moderation.
Calcium and Vitamin D
Vitamin D and Calcium are essential for optimal bone and muscle health. Adults should ingest 1200 mg of calcium (diary, supplements) and 800 IU of Vitamin D (supplements) per day.
Beware of “New” Sport or Activity Participation
Intense use of muscle groups that are not conditioned is an invitation for overuse injuries and tendinitis.
Daily exercise on the stationary bike, for instance, does not mean you are ready to play a game of racquetball, climb Mt Washington or even paint the kitchen.
Start slowly, identify the new muscle groups required for the activity and stretch and strengthen them regularly. The duration of this preparation phase will vary with your age, baseline fitness and type of desired activity, but plan on spending a few weeks to months in training before unrestricted participation.
Good Driving Habits
Motor vehicle accidents are a frequent cause of musculoskeletal injuries, many of them devastating. Minimize your risk by obeying traffic laws, wearing your seat belt, and avoiding distractions like texting. Never drive while intoxicated.
When an accident or arthritis happens, it is often viewed as just “bad luck”, but there is something to the old adage, “you make your own luck”. Practicing a healthy orthopaedic lifestyle minimizes the risk of musculoskeletal injury and prevents or at least lessens the debilitating symptoms of osteoarthritis.
(1) May 2012 blog
(2) July 2012 blog
Hip girdle pain is defined as pain in the buttock that radiates into the thigh. It is a common problem, particularly in the older person. Although there are many possible causes of this condition, most are found to be degenerative disease of the hip joint (osteoarthritis), the lumbar spine (facet arthritis, lumbar stenosis) or the buttock tendons (tendinopathy, “trochanteric bursitis”) at their attachment to the greater trochanter, the bony bump just forward of one`s pants pocket.
The history given by the patient is often similar in the three conditions: pain in the buttock radiating into the thigh and sometimes into the outer leg below the knee. This pain typically worsens with activity and improves with rest. The physical exam, though occasionally diagnostic, more often is non-specific, failing to implicate one specific area of pain generation more than another.
X-ray and MRI are often employed in the diagnostic testing and are excellent at showing degenerative disease of the hip and spine and, to a lesser extent, the tendons. Positive findings on the films, however, do not provide a definitive diagnosis, as those degenerative changes may be simply age related and not causing any of the symptoms experienced by the patient.
At this point in the systematic search for a diagnosis, the orthopedist must answer several questions:
To answer these questions we often turn to steroid/anesthetic injections in our quest for a specific diagnosis. The three sites of injection are the hip joint (osteoarthritis), the lumbar spine (facet arthritis, lumbar stenosis) and the greater trochanter (tendinopathy, trochanteric bursitis). We begin our injection sequence at the site that is the prime suspect and wait for several days to properly gauge a response. If the response is a 50% reduction in pain then injecting the other two sites is unnecessary, as the prime pain generator has been identified. If the injection response is equivocal we move on to the second site, and if that too is indecisive, on to the third. In the rare event that all three are non-diagnostic, we expand our search to include uncommon causes of hip girdle pain.
Once we have our diagnosis, the treatment is focused on that condition. Effective treatment for the primary condition often markedly diminishes the symptoms from the secondary sites.
Treatment for all three conditions initially involves physical therapy, each program tailored to the specific pathology or abnormality. In many cases, the injection used for diagnosis is therapeutic as well as diagnostic, with pain relief lasting months.
Sometimes conservative treatment yields only short-term relief. In these situations, depending on the diagnosis, total hip replacement for osteoarthritis or decompression of the lumbar spine for lumbar stenosis yields very good to excellent results. Surgery for trochanteric bursitis is less common, but would involve repair of a tear, if present, of the buttock tendons attachment to the greater trochanter.
“Pain in the butt” is a popular cliché with good reason, for the complaint is common and the symptoms annoying. The list of possible causes of hip girdle pain is long and complex, and making the diagnosis can be both challenging for the orthopedist and frustrating for the patient. Fortunately, most hip girdle pain is due to common degenerative changes about the hip and low back, conditions for which treatment is available and rewarding.
* This term refers to the overuse of a muscle that is compensating for the underuse of the injured area.
SHOULDER PAIN – The Big Three
“My shoulder hurts, Doc”. This is a common complaint heard by the orthopedist. The history is remarkably consistent: gradual onset of increasing shoulder and upper arm pain, with or without a preceding, usually minor, injury.
The diagnosis is most often one of three conditions we`ll call “the Big Three”: Rotator Cuff Tedinopathy, Adhesive Capsulitis, and Osteoarthritis of the Shoulder. Though similar in presentation, these conditions differ markedly in pathology (what is wrong anatomically and microscopically) and etiology or cause.
Initial treatment for each of the Big Three is conservative, consisting of physical therapy (stretching, strengthening, education on care of the shoulder for the particular diagnosis), a steroid injection and a measure of time, the latter based on knowledge of the natural history of the particular condition. In rotator cuff tendinopathy, surgery is considered if conservative therapy fails to bring relief after a few months or initially if there is suspicion that the cuff had been torn by a precipitating injury. An MRI is almost always used in the surgical decision making. Frozen shoulder is a self limiting disease, though its protracted course of 6-18 months can try the patience of both doctor and patient. Steroids injected into the shoulder joint within the first few months of onset can sometimes dramatically reduce pain and shorten the natural course. The shoulder joint afflicted with osteoarthritis often tolerates its burden surprisingly well. A regular program of stretching and strengthening is often all that is needed to maintain reasonable function and a pain level that is tolerable. For those patients with recalcitrant pain and stiffness, shoulder replacement offers an excellent alternative.
With the possible exception of low back pain, shoulder pain is the most common complaint heard in a general orthopedic practice. Although there are many causes, the vast majority are one of the Big Three, with rotator cuff dysfunction being by far the most common. Fortunately, in most cases, proper education and rehabilitation can return this complex but fascinating structure we call the shoulder to a high level of function.
This is an update on Osteoporosis (OP) and Fragility Fractures (FFs), conditions initially introduced in our October and December 2010 columns. I recommend a review of those earlier columns. A brief summary is as follows:
OP and its sequelae, FFs, are increasing at an alarming rate in the United States. There are more FFs each year than heart attacks, strokes and new cases of breast cancer combined.
A program of exercise, adequate calcium/Vitamin D intake (especially during the prime growth years of 8-18) and, when indicated, BPs, has been proven to reduce significantly the risk of OP and its complications. Despite this evidence, misconceptions and distrust abound, keeping compliance and participation low.
Let us review some fears, facts, and current thinking on OP.
Fear: “Bisphosphonates cause femur (thigh bone) fractures rather than prevent them.”
Fact: BPs can cause femur fractures, but it’s rare. Actually, BPs prevent as many as 100 femur fractures to every one they may cause. This rare event, moreover, seems to occur in persons taking BPs for longer than 5 years, the point at which many patients can safely stop the drug as their bone mass may well have stabilized.
Fear: “Calcium supplements can cause heart attacks”
Fact: This causal relationship, though implied in recent studies, has not been proven. Because of this possible connection, however, the recommendation is to obtain most of one’s daily calcium requirement through dietary means. Dietary calcium has not been linked to heart attacks.
Fear: “OP is the accepted cost of aging and FFs are relatively uncommon, especially if one is careful”
Fact: Fifty per cent of women over age 50 will have a FF in their lifetime. This serious complication of OP is largely a preventable condition if prophylactic recommendations are followed. Being careful is not enough.
Here are the current OP recommendations for all adults over 40:
OP, like Hypertension, is a silent disease, slowly progressing without causing symptoms. In both conditions proactive treatment will avert serious complications.
© 2013 New Hampshire Orthopaedic Center