Lateral Elbow Pain: Causes, Symptoms And Treatment

Use of the upper limb in sport demands a well functioning elbow. In addition, injuries in this region may interfere with the patient’s everyday activities. The clinical approach to elbow pain is considered under the following headings:

• Lateral Elbow Pain, with a particular focus on
• Extensor Tendinopathy
• Medial Elbow Pain
• Posterior Elbow Pain
• Acute Elbow Injuries
• Forearm Pain
• Upper Arm Pain.

Lateral Elbow Pain

Lateral elbow pain is an extremely common presentation among sportspeople and manual workers. The most common cause is an overuse syndrome related to excessive wrist extension. This condition has traditionally been known as ‘tennis elbow‘. This is an unsatisfactory term as it gives little indication of the pathological processes involved. In fact, the condition is more common in non-tennis players than in tennis players. It has also been referred to as ‘lateral epicondylitis’. This is also inappropriate as the site of the abnormality is usually just below the lateral epicondyle and the primary pathology is due to collagen disarray rather than inflammation.

The primary pathological process involved in this condition is tendinosis of the extensor carpiradials brevis (ECRB) tendon, usually within 1-2 cm of its attachment to the common extensor origin at the lateral epicondyle. This condition will be referred to as extensor tendinopathy.

Other conditions that may cause lateral elbow pain include synovitis of the radio humeral joint, radiohumeralbursitis and entrapment of the posterior interosseous branch of the radial nerve (radial tunnel syndrome). These conditions may exist by themselves or in conjunction with extensor tendinopathy.

There is often a contribution to lateral elbow pain from the cervical and upper thoracic spines and neural structures. This may be a relatively minor contribution or, in some cases, the main cause of the patients elbow pain. A full assessment of the cervical spine and neural structures is essential in examination of the patient with lateral elbow pain.

History

The characteristics of the patients lateral elbow pain should be elicited. The diffuse pain of extensor tendinopathy typically radiates from the lateral epicondyle into the proximal forearm extensor muscle mass. Occasionally the pain may be more localized. The onset of pain may be either acute or insidious. There may have been recent changes in training or technique, note-taking or equipment used in sport or work.

The severity of pain ranges from relatively trivial pain to an almost incapacitating pain that may keep the patient awake at night. It is important to note whether the pain is aggravated by relatively minor everyday activities, such as picking up a cup, or whether it requires repeated activity, such as playing tennis or bricklaying, to become painful.

Pain may radiate into the lateral aspect of the forearm. This may be consistent with posterior interosseous nerve entrapment or irritation of other neural structures. If pain is closely related to the activity level, it is more likely to be of a mechanical origin. If pain is persistent, unpredictable or related to posture, referred pain should be considered.

Certain movements, usually those involving wrist extension or gripping, will aggravate mechanical pain. Referred pain is affected by prolonged posture, such as lengthy periods seated at a desk or in a car. Associated sensory symptoms, such as pins and needles, may indicate a neural component. Presence of neck, upper thoracic or shoulder pain should also be noted.

Often by the time the patient presents to the sports medicine clinician, he or she will already have undergone a variety of treatments. It is important to note the response to each of these treatments.

An activity history should also be taken, noting any recent change in the level of activity. In tennis players, note any change in racquet size, grip size or string tension and whether or not any comment has been made regarding his or her technique.

Examination

Examination involves:

1. Observation from the front

2. Active movements

• elbow flexion/extension
• supination/pronation
• wrist flexion (forearm pronated)
• wrist extension

3. Passive movements

• as above

4. Resisted movements

• wrist extension
• extension at the third metacarpophalangaI-joint
• grip test

5. Palpation

• lateral epicondyle
• extensor muscles

6. Special tests

• neural tension
• cervical spine examination
• thoracic spine examination
• periscapular soft tissues

Investigations

Investigations are usually not performed in the straightforward case of lateral elbow pain. However, in longstanding cases, plain X-ray (AP and lateral views) of the elbow may show osteochondritis dissecans, degenerative joint changes or evidence of heterotopic calcification.

Ultrasound examination may prove to be a useful diagnostic tool in the investigation of patients with lateral elbow pain. Ultrasound may demonstrate the degree of tendon damage as well as the presence of a bursa.

Extensor tendinopathy

For this major sports medicine condition, we review the pathology, outline the clinical presentation, and then discuss evidence based and clinically founded treatment.

Clinical Features

Extensor tendinopathy occurs in association with any activity involving repeated wrist extension against resistance. This includes sporting activities, such as tennis ,squash and badminton, as well as occupational and leisure activities, such as carpentry, bricklaying, sewing and knitting. Computer use has been shown to be associated with the development of this condition. The peak incidence is between the ages of 40 and 50 years but this condition may affect any age group.

There are two distinct clinical presentations of this condition. The most common is an insidious onset of pain, which occurs 24-72 hours after unaccustomed activity involving repeated wrist extension. This occurs typically after a person spends the weekend laying bricks or using a screwdriver. It is also seen after prolonged sewing or knitting .In the tennis player, it may occur after the use of a new racquet, playing with wet, heavy balls or over hitting, especially hitting into the wind. It also occurs when the player is hitting ‘late’(getting the position slowly), so that body weight is not transferred correctly and the player relies on the forearm muscles exclusively for power.

Treatment

No single treatment has proven to be totally effective in the treatment of this condition. A combination of the different treatments mentioned below will result in resolution of the symptoms in nearly all cases.

The basic principles of treatment of soft tissues injuries apply. There must be control of pain, encouragement of the healing process, restoration of flexibility and strength, treatment of associated factors (e.g. increased neural tension, referred pain),gradual return to activity with added support and correction of the predisposing factors.

Control of Pain

It remains unclear as to how much pain is ideal in the treatment of tendinopathies. Clinical experience suggests that a low level of pain, which does not worsen with training, is likely to not be harmful for tendon healing. However, some patients require relative rest, application of ice and analgesia for comfort.

CEREBRAL PALSY: Causes, Methods And Treatment

This is a disorder of movement and posture caused by a non-progressive lesion in the immature brain, leading to global dysfunction.

Lesions

In cerebral palsy, the lesion could be in either the brain or the upper cervical cord, and the lesion is static.

Classification

Cerebral palsy is classified based on various clinical types and based on the degree of severity.

Lesions in the Brain

In cerebral palsy, the lesions in the brain can occur in the following four areas:

• Cerebral  cortex (spastic  type)
• Midbrain  (dyskinesia)
• Cerebellum  (ataxic)
• Widespread brain involvement (rigidity and mixed).

Causes

In cerebral palsy, the causes are different in pre-natal, natal, postnatal and perinatal period.

Clinical Features

This depends on the location of lesions in the brain. Single muscle involvement is rare as in polio and entire portion of the body supplied by that area of brain is involved, the patients show delayed mile stones and primitive reflexes are usually preserved.

Other clinical features depend on the geographic distribution of cerebral palsy and the associated handicapping situations.

Orthopedic Deformities

The following are the common orthopedic deformities encountered in cerebral palsy.

Upper Limb

• Pronation contracture of the forearm.
• Flexion deformities of the wrist and fingers.
• Thumb in palm deformity.
• Swan neck deformity.
• Shoulder adduction and internal rotation deformity.

Lower Limb

• Adduction deformity (most common).
• Flexion and internal rotation deformity.
• Dysplastic and subluxated hip.
• Dislocated  hip
• Pelvic obliquity.

Spine

• Scoliosis
• Kyphoscoliosis.

Knee

• Genu  recurvatum
• Genu valgum
• Patella  alta
• Subluxation or dislocation of patella.
• Knee flexion contracture-(most common).

Foot

• Equinus deformity
• Varus or valgus
• Talipes equinovarus
• Calcaneus deformity
• Talipes cavus
• Hallux valgus

Order of preference to improve the quality of life in cerebral palsy is as follows:

• Education and communication is the first priority
• Activities of daily life
• Mobility
• Ambulation

The role of orthopedic surgeon starts when the child is 12 months of age and seldom before.

Methods

• Motor age test
• Physiotherapy, occupational  therapy, speech therapy, etc
• Use of braces to:

1. Improve function
2. Control unnecessary movements
3. Prevent and correct deformities

• Drug therapy:  The role of drug therapy is disappointing. Muscle relaxants, antiepileptic may have a role.

Treatment

Broad Principles of the treatment:

• To prevent deformities from developing.
• To assist returning of muscle power by graduated exercises.
• To reduce disability by appropriate appliance or by operations on joints and muscles.

Surgery:

• Not done till the child reaches five years of age.
• Indicated to correct deformity in an ambulatory patient and to make him or her socially more acceptable.
• Commonly indicated in spastic type of cerebral palsy.

Choice of Surgery

Operation on nervous system:

• Sympathectomy, rhizotomy (anterior or posterior).

Operation on muscles and tendons:

• Tenotomy, tendon lengthening and tendon transfers.
• Myotomy and  muscle transposition.

Operation on bones and joints:

• Bone lengthening or bone shortening to equalize the limb lengths.
• Osteotomies to correct knock knee, and other bone deformities.
• Arthrodesis of wrist, hip, and foot to correct deformity, provide stability and to improve functions.

 Sports Rehabilitation :

A dictionary definition of rehabilitation is the restoration to a former capacity or standing, or to rank, rights and privileges lost or forfeited.  This is the essence of sports medicine rehabilitation. While the treatment described in may lead to an athlete becoming pain-free and able to return to activities of daily living, rehabilitation is required to return the athlete to the previous level of function.

All musculoskeletal injuries require active rehabilitation. Rehabilitation is also necessary following surgery. The primary aim of injury rehabilitation is to enable the athlete to return to sport with full function in the shortest possible time. If rehabilitation is inadequate the athlete is:

• prone to reinjury of the affected area.
• incapable of performing at pre-injury standard.
• predisposed to injuring another part of the body.

The Rehabilitation Program

Although sports medicine is readily classified as a science, devising a successful rehabilitation program should be considered an art. Skilful rehabilitation cannot be replaced by a recipe approach as each athlete is an individual who brings very different personality and lifestyle factors to the therapy room. Furthermore, each athlete has different post-injury sporting goals, levels of skill and degrees of competitiveness, all of which influence the rehabilitation program. Several general principles should underpin every rehabilitation program.

Every Athlete is an Individual

To prescribe rehabilitation requires high-level people skills as the psychological make-up of each athlete is different. As some athletes are highly motivated and become overzealous, they may need to be held back throughout rehabilitation. Other athletes are hesitant and lack confidence and require considerable psychological support and encouragement.

Each athlete has a different lifestyle. Some have considerable career or job commitments whereas others are full-time professionals. Some athletes have good support from their family and peers, whereas others are loners. The therapist must establish a caring, trusting relationship with the patient and be aware of the psychological effects of the patient’s injury throughout the rehabilitation period. It may also be appropriate for the therapist to communicate regularly with the athletes coach or parent and keep them informed of progress.

Because of the individual differences between athletes, and also to improve compliance, the therapist must customize each rehabilitation program. The program should be monitored and may need to be modified throughout the rehabilitation period, based on subjective and objective assessment findings.

Once the diagnosis has been made and initial therapy instituted, the therapist performs a comprehensive baseline assessment from which to measure progress. An appropriate, individualized rehabilitation plan is then formulated.

Keys to a Successful Rehabilitation Program

Explanation

The rehabilitation plan should be explained to the patient with realistic, approximate time frames. It should be emphasized that the time frames are only approximate and not promises It is important to set short-term goals, for example, the removal of a brace or the commencement of jogging, and long-term goals, such as a return to sport.

It is also important to explain the rationale behind the program .This is only possible if the therapist has first formulated a hypothesis as to why the injury occured.  For Example, if lack of flexibility contributed to injury, the therapist should include an ongoing program to gradually improve the athlete’s flexibility beyond the pre-injury level. If dynamic joint instability was a precipitating factor, or a precipitating factor or a result of injury, rehabilitation should emphasize muscle control and strengthening. If incorrect biomechanics and poor muscle control were important factors in the etiology of the injury, these components should be addressed.

Provide Precise Prescription

During the rehabilitation program, the therapist must emphasize correct exercise technique and carefully apply principles for the progression and limitation of exercises and activities. The therapist must also constantly monitor and, if necessary, modify the program as required. This requires one-to-one attention, and cannot be ‘supervised‘ while attending to several other patients.

Make the Most of the Available Facilities

If facilities such as a gymnasium, pool or biofeedback devices are available, the program may take advantage of these facilities. If sophisticated equipment is not available, however, simple equipment, such as an exercise bike, rubber tubes, steps, free weights, and the use of appropriate functional exercises incorporating body position and body weight, can all be incorporated in the program.

Begin as soon as possible

The rehabilitation program should start as early as possible following injury or surgery. Pain, inflammation swelling or joint effusion must be controlled in the early stages as they inhibit optimal function. Rest from aggravating activities, ice, electrotherapeutic modalities and anti-inflammatory medications will help reduce these factors.

In the past, it has been customary to begin rehabilitation with range of motion exercises (e.g. stretching) and introduce strength training later. A variation to this approach has recently been presented in acute hamstring strains, indicating that a rehabilitation program consisting of progressive agility and trunk stabilization exercises is more effective than a program that consists of hamstring stretching and strengthening in regards to promote return to sport and preventing recurrence of injury. This approach may well be the way of the future, but more research is required into this area.

The Important Components of Rehabilitation are:

• Muscle conditioning
• Flexibility
• Neuromuscular control (balance, proprioception)
• Functional Exercises
• Sport Skills
• Correction of abnormal biomechanics
• Maintenance of cardiovascular fitness
• Psychology
• These components are incorporated into the overall rehabilitation program.

Gets Relief in Peripheral Spinal Nerve Pain :

The dorsal and ventral  nerve  roots  arising  from  the spinal cord join at the intervertebral foremen to form a spinal nerve. In the thoracic  segments,  these  mixed spinal nerves retain their  autonomy  and  supply  one intercostals segment both  dermatome  and  myotomal. In virtually all others segments,  spinal  nerves  join with others to form a plexus.  There  are 31 pairs  of  spinal nerves consisting of 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal.

A spinal nerve has three  components:  motor, sensory and sympathetic. The sympathetic components of all 31 mixed spinal nerves leave along the 14 motor roots (12 thoracic and  2  lumbar  roots).  Each  spinal  nerve now divides into anterior and posterior rami. The anterior rami of the upper four cervical nerves form the cervical plexus and the  lower  four  cervical  together with upper thoracic nerves  form  the  brachial plexus. The anterior rami of  the first  three lumbar  nerves and part of the fourth nerve form the lumbar plexus .The saspinal rami except for upper three cervical posterior rami. The sacral anterior rami along with the anterior rami of the fifth lumbar and part of fourth lumbar form the lumbosacral plexus. The posterior rami supply the para spinal muscles and the skin of the back. They are smaller than anterior rami except for upper three cervical posterior rami.The spinal nerves are then distributed to the limb buds through several peripheral nerves. Therefore, a peripheral nerve is a/so a mixed nerve like the spinal nerve .

Dermatome is an area of skin supplied by a single spinal root. Myotome represents a muscle uni supplied by a single spinal root.

PRINCIPLES OF NERVE INJURY

NERVE DEGENERATION

Any part of the neuron detached from its nucleus degenerates and .is destroyed by phagocytosis. This process of degeneration distal to a point of injury is called secondary or wallerian degeneration. Reaction in proximal end is called primary or retrograde degeneration. Time required for degeneration varies between sensory, motor, and is related to the size and myelination. In secondary degeneration, response is obtained to faradic stimulation up to 18-72 hours. After 2-3 days, distal segment is fragmented and the myelin sheath starts degenerating. By seven days, macrophages clear the axon or debris and are completed within 15-30 days. Schwann cells undergo mitosis from seventh day onwards and start filling the areas previously occupied by axon and its myelin sheath. Primary retrograde degeneration proceeds for at least one internodes or more. Histological, its indentical to wallerian degeneration. More proximal the site of injury , more pronounced will be the changes.

NERVE REGENERATION

Axonal sprouting starts from 24 hours after injury. Unmyelinated initially but later on it  myelinated. Now if the endoneurium is int sprouts will readily pass along their former courses and after regeneration may innervate their previous end organs. If the endoneurium is interrupted, then the sprouting axons may migrate aimlessly throughout the damaged area into the epineurial, perineurial regions forming a stump neuroma or neuroma in continuity or they may enter into the other empty endoneural tubes or newly formed endoneural tubes only to terminate in myotomal or dermatomal areas of their own. Hence, recovery is difficult if entire axon is transected and filled with scar tissue.

TYPES OF NERVE INJURIES

Primary: This is due to injury of a peripheral nerve resulting from the same trauma that has injured a bone or joint.

Secondary: This is due to involvement of the nerve in infection, scar, callus, etc.

CLINICAL DIAGNOSIS

It is difficult to evaluate a nerve injury immediately after a severe trauma. The diagnostic approach towards a peripheral nerve injury should essentially consists of the following steps:

Listen: Carefully listen to what the patient has got to tell you about the history of the injury. Many a times mere listening can help clinch you the diagnosis. Here are  some samples:

History                                          

• I’m suffering from leprosy
• I took an injection in the arm or buttocks
• I traveled in a bus overnight
• 1 cut my wrist by a glass piece.
• I suffered from arm bone fracture
• I broke my elbow in a fall
• I have suffered a hip dislocation due to dashboard injury

Look: This is the second step in the diagnosis of PNI. After listening to the story, look for the typical tell tale evidences. Each nerve injury is associated with a particular attitude.

Feel and touch: This helps you to detect damage to the sensory component of a nerve. The affected skin could be cold or clammy. Patient may not be able to feel the temperature touch, vibrations, pressure in the affected areas. Loss of sweating is an ominous sign.

Move: Instruct the patient to move the limb and joints distal to the site of injury. Inability to do so totally reveals complete nerve damage, slight movements possible suggests less than complete damage to the Beware of the trick movements a patient may resort to overcome the loss of a particular muscle function. This is a diagnostic “pitfall” one should carefully avoid.

Knock: Using a knee hammer, knock over the knee, ankle, elbow, etc. to elicit the appropriate reflexes. They are normally absent in peripheral nerve injuries.

Measure: With a measuring tape, measure the muscle girth of the limbs for wasting.

Investigate: After following this various clinical steps, certain investigations needs to be done to confirm the diagnosis and plan the appropriate line of treatment.

Typical Deformities:

• Wrist drop -  Radial nerve injury.
• Claw hand -  Ulnar nerve injury.
• Foot drop -  Lateral poplifeal nerve injury,
• Ape thumb – Median nerve injury.
• Winging of  scapula -  Thoracodorsal nerve injury.
• Pointing index – Median nerve injury.             ‘   _
• Policeman tip – Brachia! plexus injury.

DIAGNOSTIC TESTS

Electromyography:

Electromyography (EMG) helps to record the electrical activity of a muscle at rest and during activity .

Intact muscle: There is no electrical activity in an intact muscle at rest. During a weak contraction, the electrodes record a single action potential. In powerful muscle contractions, these motor action potentials superimpose to give an interference pattern.

Injured or denervated muscle: These muscles show electrical activity at rest. These are primitive responses which is normally suppressed by the stronger nerve action potentials. These denervation potentials normally appear by 1-2 weeks after injury.  If they have not appeared by 15-20 days after muscle denervation, it indicates a good prognostic sign.

Uses and limitations of EMG:  Electromyograph, helps to detect the presence or absence of nerve inury if present whether it is complete or incomplete and whether any regeneration is taking place or not. EMG does not give the level of injury or the degree of injury accurately.

Sweat Test (Starch Test): Presence of sweating within autonomous zone suggests that complete interruption of the nerve has not occurred.

Skin Resistance Test: It is another method of evaluating autonomic interruption by using Richter’s thermometer.

Electrical Stimulation: Faradic stimulation :is of little value (because even normally innervated muscles may fail to respond).

Galvanic stimulation: Recording of chronaxie and strength duration curve by galvanic stimulation is more helpful in evaluating nerve injuries.

MANAGEMENT

General Principles:

Resuscitation is carried out first, if the patient is in shock. General condition is improved by the emergency management measures. A thorough debridement of the wound is carried out; and if the wound is clean, direct suturing of the perineurium or epineurium or epiperineurium of both the cut ends carries out primary repair of the nerve. If the wound is contaminated, nerve is repaired after 3-6 weeks. In closed fractures with peripheral nerve injuries, conservative management is the treatment of choice. Careful assessment of the recovery is made and early surgical exploration is done if the recovery is not satisfactory.

Conservative Management:

This consists of the following essential  steps:

Splinting of the limbs.  Different splints are required to immobilize the limbs in various nerve injuries.

*   Upper limb

• Brachial plexus injury-aeroplane splint.
• Axillary  nerve injury-shoulder  abduction splint.
• Radial nerve injury–cock-up splint.

*    Lower limb..

• Common  peroneal  nerve injury-foot drop splint .
• Passive movements of all joints are done to prevent contractures.

Physiotherapy:  Massage, exercises, stimulation, etc.

Care of the skin, etc.

Operative Management

This consists of various types of nerve repair , tendon transfers, arthrodesis, etc.

TYPES OF NERVE REPAIR

Primary Repair : is done within 6-8 hours after injury and if the wound is clean cut.

Delayed Primary Repair : is done between 7 and 18 days after injury and if the wound is contaminated.

Secondary Repair : is carried out 18 days after injury, if the injury is seen late, failure of conservative treatment, incomplete injury, etc.

TECHNIQUES

Endoneurolysis: It is freeing of the nerve entrapped within the scar tissue either external scar (external neurologsis) or within nerve (internal neurolysis).

Partial Neurorrhaphy: This is advisable if one-half of a large nerve is disrupted, e.g. sciatic nerve injury.

Neurorrhaphy and Nerve Grafting:  if there is a gap after injury.

Methods of closing the gaps between the nerve ends if the nerves cannot be approximated end to end.

• Mobilization of the nerves by sectioning its cutaneous branches  and freeing it from  the fibrous tissue around.
• Positioning of the extremities in functional position.
• Transposition of the nerves, e.g. ulnar net transposition.
• Bone resection.
• Nerve grafting by using sural nerve.
• Nerve crossing.

By these above  methods,  the  cut  ends  of  the nerves can be brought together and sutured by a one of  the techniques mentioned  above.

Tendon transfers are contemplated after 18 months injury when there is no recovery after various net repair techniques or if the patient presents late.

Arthrodesis is considered if no tendons are available for transfers and if there is no hope of recovery.

TREATMENT OF NERVE INJURY

It is critically important that a person with a nerve injury receive medical care as soon as possible. Without timely, appropriate medical care (within nine to 12 months of the injury, preferably earlier), the injured nerves may no longer be repairable.

• Peripheral nerves have a remarkable ability to regenerate themselves.
• Patients with nerve injuries may be treated at physioline at any stage: at the time of the injury, later, for evaluation and treatment, or for secondary treatment, where people have not recovered adequate function after previous treatment.
• The management of a peripheral nerve injury varies depending on the cause, type and degree of the nerve injury.
• Physiotherapy is very important to promote the recovery of peripheral nerve injuries regardless of whether surgery is required.
• Physical therapy is started in the early stages following nerve injury to maintain passive range of motion in the affected joints and to maintain muscle strength in the unaffected muscles.
• Physioline provides specialized treatment programmes  and bracing or splinting.
• increase muscle strength
• increase sensation
• manage neuropathic pain
• maintain range muscle length / joint range of movement
• maintain nerve integrity

Pubic-Bone-Stress-Related Longstanding Groin Pain

It has been well accepted that athletic groin pain can arise from bony stress around the pubic symphysis, hence the term “osteitis pubis”. That ‘diagnosis’ is confirmed by typical radionuclide imaging appearances. The radiographic features are the typical ‘moth-eaten’ appearance along the margins of the pubic symphysis with asymmetrical bony erosions, osteophytes, sclerotic bony margins and subchondral bone cysts. The radionuclide bone scan shows increased uptake on the delayed static images over the pubic tubercle.

CT scanning is also a sensitive investigation  for displaying abnormalities of the bony architecture, such as cystic changes and perisymphysis erosions. In more recent times, MRI has shown bone marrow edema in the body of the pubis.

The significance of the bone marrow edema in sportspeople (mainly men) with longstanding groin pain is presently a topic of great interest and vigorous debate. As we know, Verrall et al have that bone marrow edema is present  in a large percentage (77%) of footballers presenting with longstanding groin pain that is associated with pubic symphysis tenderness and a positive squeeze test. They proposed that pubic bone stress was a possible cause of the symptoms and signs such as the squeeze test but their subsequent research showed only moderate levels of sensitivityof the squeeze test when correlated with clinical and MRI criteria.

Abnormalities in all imaging modalities are seen in athletes who have no history of groin pain; nevertheless, the presence of bone marrow edema elsewhere in the body is significant. For example, on MRI it is characteristic of the bone bruises associated with serious knee injuries.

The pubic bones are subjected to considerable forces by the various pelvic structures mentioned above. It may be that pubic bone abnormalities are the cause of pain in a small group of patients or they may simply be a sign of increased bone stress when the other clinical entities are affected.

Treatment of Groin Pain

A variety of treatments have focused on the symphysis pubis and bony abnormalities.

The use of corticosteroids both as a local injection into the symphysis pubis and in oral form (25-50 mg/day for 7 days) has been anecdotally helpful, but no controlled trial has been reported. We have found a short (5-7 days) course of oral prednisolone (50 mg/day)to be helpful in settling pain, thus enabling the patient to commence the rehabilitation program earlier.

Dextrose prolotherapy injections have been shown to be helpful in one study. Monthly injections of 12.5% dextrose and 0.5% lignocaine (lidocaine) into the adductor origins, suprapubic abdominal insertions and symphysis pubis were given until resolution of symptoms. An average of 2.8 treatments were required.

Three-to six-monthly courses of intravenous injections of the bisphosphonate pamidronate were found to be helpful in one report of three cases. Some physicians are advocating the use of extracorporeal shock wave therapy but there is no evidence to support this.

Surgery has been advocated by some clinicians. In the chronic stage of the condition, where imaging shows erosions and cystic changes in the pubic symphysis, surgical exploration and debridement of the symphysis may be indicated. Symphyseal wedge resection is out of favor as it can give rise to progressive sacroiliac arthrosis and ultimately posterior pelvic instability requiring major pelvic stabilization. Arthrodesis of the pubic symphysis by bone grafting and a compression plate has been used successfully in patients with proven pubic instability.

 Physical therapy is the best way to get relief of groin pain .Physical Therapy are to promotes body strength, function and mobility and prevent future physical injury. Physical Therapists design individualized treatment plans to achieve the specific goals for each patient per your doctor’s expectation. Its a unique rehabilitation technique and art that utilizes a wide variety of procedures such as restoring original functionality and movement to the body, but not limited to eliminating various kinds of pain including lower back pain, neck pain (cervical) leg pain (sciatica), groin pain and post-operative procedures. Typically after being thoroughly evaluated by your physician they generate a specific diagnosis and prescribe physical therapy. But in case of certical and serious chronic Groin pain then Surgery is the best way.

Osteoporosis: Definition, Causes, Types and Treatments

Definition

It is a generic term referring to a state of decreased mass per unit volume of a normally mineralized bone due to loss of bone proteins. It is called as silent epidemic and usually remains undetected till the patient sustains a hip, rib or spine fracture.

Most common cause is involutional bone loss in premenopausal age group.

Dexa criteria for osteoporosis as determined by WHO, are BMO of spine and hip of 2-5 50′s or more below the mean for heal thy young women and osteopenia between 1 to 2.5 SD’s or more below the mean.

Causes

Disuse

• Prolonged bed rest or inactivity.
• Prolonged casting or splinting.
• Paralysis, space travel, etc.

Diet

• Calcium, protein, vitamin C low in the diet.
• Chronic alcoholism.
• Anorexia nervosa.

Drugs: Whose prolonged use causes osteoporosis is heparin, methotrexate, ethanol, glucocorticoids, etc.

Idiopathic variety is seen in adolescent and middle aged male population.

Genetic role is seen is osteogenesis imperfecta.

Chronic illness like rheumatoid arthritis, cirrhosis, sarcoidosis, renal tubular acidosis, etc.

Neoplasm like bone marrow tumors (myeloma, lymphoma, leukemia).

Endocrine abnormalities: Hyperparathyroidism, increased levels of glucocorticoids, estrogens, etc.

Criteria for screening: The following group of people needs to be screened:

• All women > 65 years of age
• All men > 70 years of age
• Selected post-menopausal men and women who are 50-69 years with risk factors for fractures.

Types

There are two types of osteoporosis. Type 1 is postmenopausal and type 2 age related shows the features in these two types of osteoporosis.

Clinical Features

Early symptoms: The patient complains of acute pain in middle or low thoracic or high lumbar region. Sudden movement, sitting, sneezing, cough, etc. increases pain. Rest relieves it.

Most common symptom of osteoporosis is back pain secondary to vertebral compression. However, in some cases, fractures of axial skeleton may be seen with trivial trauma. Round type of gibbous due to compression of thoracic vertebrae is commonly seen. Other features of osteoporosis.

Investigation

Radiographs

Radiographs changes seen in the spine are:

• Loss of vertebral height due to symmetric transverse compression.
• Biconcave central compression (Cod fish spine) due to the pressure of the bulging disk into the bodies.
• Anterior wedge compression.
• The bone density of the vertebra is reduced.

Other bones

• Ground glass appearance due to generalized rarefaction.
• Singh’s index is the grading of the trabecula pattern of the neck of femur.
• Metacarpal index, etc.
• Pathological fractures.

Densitometry

Techniques for bone mass measurement-

• Single photon absorptiometry is used to asses, the amount of cortical bone mineral in appendicular skeleton.
• Mineral status of axial skeleton is assessed by dual photon absorptiometry (DEXA) and quantative CT scan.
• Total body neutron activation analysis to determine calcium content to the entire body.

Transiliac bone biopsy: It is an important diagnostic tool in patients of more than 50 years in postmenopausal diseases.

Blood chemistry: Serum calcium, phosphorus and alkaline phosphatase levels are usually normal.

Management of Osteoporosis

Preventing osteoporosis is lot easier than treating it. The treatment plan consists of general measures exercises and drug therapy.

General measures

• High protein and calcium rich diet.
• Rest that is adequate.
• Muscle relaxants and supports like belt, collar, etc. for symptomatic relief of pain.

Exercises

Exercises like walking and light aerobics are beneficial.

• Posture exercise: Wall arch, back bending and wall sliding postural exercises help to improve posture and overcome hunched back.
• Fall prevention is of utmost importance.
• Spinal orthosis when patient is erect and mobile.

Thigh contusions, resulting from a direct blow, can be a very disabling injury.  Contusions of the anterior portion of the thigh muscle are usually more serious than those involving the lateral portion of the quadriceps muscle, because of the differences in muscle mass percent in the two areas.  As with other regions of the body, contusions are graded according to the severity of the injury.

Growth Disorder of Thigh Bone

Fractures involving the shaft of femur are commonly seen in young adults involved in high velocity, high-energy trauma as occurs in a road traffic accident (RTA). Therefore it is usually associated with other skeletal injuries or injuries to the visceral organs.

Applied Anatomy of Femur

• Femur is the strongest bone in the body, being involved in transmission of weight.

• Weight transmission occurs through the medial cortex hence the medial cortex bears compressive stresses.

• Blood supply to the femur comes from one or two nutrient vessels arising from the cruciate anastomosis.

• End steal blood supply is the prominent source supplying the inner 3/4 th of the cortex. And this is disrupted during fractures.

• The femur is acted upon by strong muscles as follows:

Gluteus medius =>abduction

Iliopsoas — flexion, external rotation- proximally

Adductors —Adduction

Gastrocnemius — Posterior

Angulation—distally.

FRACTURE OF SHAFT OF FEMUR

Shaft of the femur is defined as part of the femur from the lower border of the lesser trochanter till the upper border of a square fitting the femoral condyles. Fractures involving the shaft of femur are usually caused by high-energy injuries, usually in young adult individuals. This is often associated with multiple bone fractures and multiple system injuries. Fracture femur is associated with significant morbidity and hospital stay.

Pathology

Fracture may occur at any site along the entire shaft, i.e. in the upper, middle or lower third region. The fracture may be transverse, oblique, spiral or comminuted. The femur gives attachment to bulky powerful muscles; therefore displacement of the fractured ends is very common. The glutei and Iliopsoas attached on to the proximal femur produce abduction, flexion and external rotation of the proximal fragment. The adductor muscles produce adduction of the distal fragment. The bulky muscles may interpose between fracture ends and interfere with the union of the fracture.

Clinical Features

Clinical features in a patient having fracture shaft of femur are always prominent. There will be pain, swelling, abnormal mobility and an obvious angular deformity of the thigh following an accident of trauma. Bony crepitus is also present.The examination must include looking for abnormalities in the hip and knee joints which may be missed. Systematic examination of all the long bones and visceral systems must be carried out to rute out other major injuries.

Injury to the popliteal vessels and sciatic nerve must also be ruled out.

Investigations

Radiograph of the femur should be taken both in AP and lateral view. This should also include radiographs of the hip and knee joint, so that injuries to these joints are not missed.

Management

Fractures involving the shaft of femur usually unite, but Malunion is quite common. Since femur involved in the weight bearing axis, the aim of the treatment is:

1. Proper alignment of the bone to avoid limb length discrepancies.

2. Early and adequate bony union to allow for early mobilization.

Immediate treatment

Fractures of the shaft of femur are usually associated with a blood loss to the amount of 1500 ml into the neighboring tissues without appreciable swelling. Therefore immediate treatment for these fractures involves:

• Adequate replacement of the lost blood volume.

• Proper immobilization and reduction with traction, A patient with fracture shaft of the femur should be splinted immediately in the casualty room. Splinting reduces the pain and prevents injury to the surrounding muscles and neurovascular bundles by the sharp edge of the fractured bone ends,

• Treatment of systemic and visceral injuries.

Definitive treatment

Definitive treatment for fractures of the shaft of femur can be done by conservative methods or by surgical interventions.

Conservative treatment: This can be achieved by the following means:

• Skin traction and immobilization of the limb in abduction and external rotation.

• Skeletal traction using upper tibial pin traction and immobilization.

This mode of treatment most often results in union but it is commonly associated with:

• Shortening and angular deformities of femur

• The prolonged period of recumbency resulting in complications like bed sore, pneumonia, contractures of knee joint etc.

Surgical intervention: Internal fixation is the best method of treatment for fracture shaft of the femur. Internal fixation can be achieved by following techniques: .

1. Standard intramedullary nails-Kuntscher’s nails: The Kuntscher’s nails (commonly called K-nails) have a clover leaf cross-section with a slot on one side with an eye at both ends. This is ideal for fracture at the level of the isthmus. The isthmus is located at the junction of the upper and middle thirds of the shaft where the medullary canal is the narrowest. In this technique after open reduction, the nail is inserted in a retrograde manner. If the facilities of radiographic control or image intensifier exist, then closed nailing can also be done in antegrade manner without opening the fracture site. The principle of fixation of the nail is three point fixation achieved at

• Pyriform fossa,

• Isthmus

• Medial cortex at the lower end of the nail.

The advantages of Kuntscher’s nailing are that it can be done without the image intensifier, and it is less expensive. The disadvantage, however, is that it cannot be performed in comminuted fractures and in fractures of the distal third of the femur.

2. Inter locking nails: Interlocking nails are an improvement over the conventional (Kuntscher’s) in tramedullary nails. These are provided with interlocking screws with slots for these screws at the proximal and distal end. The interlocking screws can be applied at both proximal and distal ends; they provide rotational stability at the fracture site. The screws pass through both the cortices and through the intervening nail. They are inserted under the control of image intensifier, without opening the fracture site. Thus they prevent the loss of fracture haernatoma as well as avoid stripping of the periosteum. They have expanded the indications of intramedullary nailing to involve the:

i. Comminuted fractures, and

ii. Segmental fractures.

iii. Further advancement in interlocking techniques have resulted in newer system Gamma nails, reconstructions nails etc.

3. Plating: Dynamic compression plates are used for fixation of oblique fractures. These plates are applied on the lateral cortex of femur producing compressive force at the fracture site. The disadvantages of plate fixation are that it involves

• Extensive stripping of the periosteum which may delay the fracture union.

• Delayed weight bearing and therefore problems of recumbency.

• Extensive implant with high chances of infection.

Complications

Complications of fracture of femur can be divided into immediate and late complications.

Immediate complications

1. Shock: In patients with closed fracture of shaft of femur upto 1500 ml of blood can be lost into soft tissue without much swelling. Hence replacement of the lost blood volume is very important. An IV line should be started in every patient of fracture shaft of femur: and the pulse and blood pressure should be monitored.

2. Fat embolism: This is seen after 1-2 days following fracture shaft of femur.

3. Injury to the surrounding neurovascular structure is a very rare complication due to a bone spike causing damage to the neurovascular bundles. Injury to the blood vessels requires emergency exploration.

Late complications

1. Malunion: When the reduction is not satisfactory or if the fracture redisplaces, the fracture may go in for Malunion. This is the most common complication associated with fracture of femur. This occurs in a position of external and lateral angulation. A shortening of less than 3 cm can be treated with heel and sole raise in the shoes.

2. Knee stiffness: Follows prolonged immobilization. This is due to:

• Adhesions within the joint across the articular surfaces.

• Patello femoral adhesions.

• Quadriceps contracture.

3. Nonunion: This is diagnosed if there is no evidence of callus after 6 months following fracture.

• This is caused by soft tissue interposition at the fracture site.

• There is frank abnormal mobility, pain on stressing at the fracture site.

• Treatment is by open reduction and internal fixation with bone grafting.

Experiencing an injury to the inner thigh or groin can make each step more painful than the next. While you are rehabilitating a sports hernia, groin pull or groin strain, your physician may recommend physical therapy exercises to allow your inner thigh and groin muscles to strengthen properly without re-injuring the area. Always speak with your physician, however, before beginning any exercise or physical therapy program.

http://www.active-physicaltherapy.com/

Soft tissue injuries are those that occur to the muscles, skin and connective tissues in your body. These injuries include repetitive stress injuries such as carpal tunnel syndrome and tendinitis, but they can also occur as a result of a fall or car accident, to name just a couple of causes. While each case is different, treatments for soft tissue injuries can help reduce pain and swelling, and your therapy also can include treatments to help restore your previous activity level.

Contusions and lacerations to the face and scalp are a common occurrence, particularly in sports such as football, ice hockey, martial  arts and racquet sports. ‘Examination should include palpation of the underlying bone to detect bony tenderness. Neurological examination is required if there is a history of loss of consciousness or suspected skull fracture. Begin immediate management with ice and pressure to reduce local swelling. Control bleeding with direct pressure over the wound using sterile gauze. A player with a bleeding wound must be removed from the field of play immediately as there is concern that the presence of blood may increase the risk of hepatitis B or human immunodeficiency virus (HIV) infection for other players.

• Nose
• Ears
• Eyes
• Teeth
• Facial Bones

Our back is composed of 33 bones called vertebrae, 31 pairs of nerves, 40 muscles and numerous connecting tendons and ligaments running from the base of your skull to your tailbone. Between your vertebrae are fibrous, elastic cartilage called discs. These “shock absorbers” keep your spine flexible and cushion the hard vertebrae as you move.

Spinal cord could be damaged due to injuries of spine extending from cervical vertebrae to the thoracolumbar junction. Below this, the cord ends and the cauda equina begin.

Incidence

• Spinal cord injuries are seen in 10-25 percent of cases of spinal column injuries.
• They are more common at the cervical level (40%) than the lumbar level (20%).

Pathology

The pathology may vary from extradural hemorrhage to cord concussion, laceration to cord crushing. Lesion has longitudinal, sagittal and coronal dimensions. Amount of neural damage has no relationship to radiographic appearance

Clinical Classification of Neurological Damage

• Complete paralysis.
• Sensory paralysis.
• Motor paralysis useless.
• Motor paralysis useful.
• Recovery.

Injury at the cervical level: This has already been discussed and may vary from concussion, root injuries, incomplete and complete cord transection.

Injuries at the thoracic level: This could result in paraplegia.

Injuries at the thoracolumbar region: Due to injuries at the thoracolumbar junction, three things can occur:

• Complete cord division and nerves intact.
• Complete cord division and partial nerve division.
• Complete cord division and complete nerve division.

Clinical Assessment

General examination: This consists of examination of the head, chest, pelvis and other systems for incidence of injuries and recording the vital statistics

Neurological examination: Examine the level of vertebral injury and find out the level of the corresponding cord injury. Now each muscle group and dermatome has to be checked .In cases of cervical cord injury, survival is impossible if the cord is injured above. The level of lesion can easily be detected by examining the respective myotome dermatome and reflexes. In cases of injury at the thoracolumbar junction, a mixed picture of both cord and root lesion may emerge and there could be an UMN and LMN feature in the lower limbs. Below is the nerve roots which are damaged, and it is easy to identify the injured nerve root by a careful examination of myotome, dermatome and reflexes of the lower limb. Slightest voluntary movement and sensation below the level of cord lesion indicate cord continuity with better prognosis. If paralysis is complete even after 8 hours and if there is symmetrical returning of reflexes and priapism in male, it indicates an unfavorable prognosis.

Return of reflex activity (e.g. anal reflex, bulbocauernosus reflex and plantar response): Return of reflex activity below the lesion indicates that the spinal shock has passed off and remaining paralysis and anesthesia may be due to injury to the long tracts of cauda equina.

Total sensory and motor paralysis after 8 hours with return of reflex activity indicates that distal part spinal cord has been separated from cerebral control.

Investigation

This consists of plain radio-graph of the affected part and all three views- anteroposterior, lateral and oblique are done. MRI and CT scan are also done and their role has already been described.

Treatment

First aid as already discussed.

• Management of vertebral fracture and dislocations as discussed in individual injuries.
• Rehabilitation programs in neurological injury.

Physical Therapy: This consists of putting joints through all the range of movements by passive stretching and exercises. Parallel bar walking, walking with of walkers or crutches is encouraged. Wheel chair transfer activities are encouraged for injuries from C6 level onwards.

Occupational Therapy: If possible, the patient is to return to his original work with minor adjustments if necessary. Nevertheless, if the patient, however, is unable to return to his original work, an alternative employment depending upon his present status of health is suggested.

Social Therapy: The attitude of the people towards these patients should not be of sympathy, but of support and encouragement. The right attitude of the society towards these unfortunate victims will go a long way in rehabilitating them back to normal.

Your spinal cord is part of your central nervous system and carries messages from your brain to all the different parts of your body, controlling almost every one of your bodily functions. An injury to your spinal cord causes partial or complete loss of function and mobility below the point where the cord is damaged. Physical therapy is part of the rehabilitation for all injuries of this type, and will be tailored to your specific needs.

For physical therapy to be effective, it is important that the patient also responds positively to the treatment, and for that to happen he/she needs to be in a positive frame of mind and not in a saddened or dull mindset. By strengthening muscles, therapy can help compensate for damaged tendons and improve the mechanics of the Spinal Cord Injury. Physical therapy also includes efforts to motivate the patient to make sure that he/she indeed remains in a positive mindset all throughout the session.

EXAMINATION OF THE SPINE

Spinal disease is any pathology which affects the spinal column and the spinal cord and spinal nerves which are controlled there in. Spine disease is a large area of study because of the large number of diseases which can affect the spinal system, from purely skeletal to primary nervous system disorders. All types of spine disease can present with either or both spinal symptoms and neurological symptoms associated with injury or compression of the spinal cord or spinal nerves. Spine disease is very common, with many people undergoing spinal surgery every day. The bony spine is intended so that vertebral column “stacked” together can provide a wobbly support structure. The spine also protects the spinal cord (nervous tissue that extends down the spinal column from the brain) from injury. Each vertebra has a spinous process, which is a bony prominence behind the spinal cord that shields the cord’s nerve tissue. The vertebrae also have a strong bony “body” in front of the spinal cord to provide a platform suitable for weight-bearing. The discs are pads that serve as “cushions” between each vertebral body that serve to minimize the impact of movement on the spinal column. Each disc is designed like a jelly donut with a central softer component (nucleus pulposus). With injury or degeneration, this softer component can sometimes rupture (herniate) through the surrounding outer ring (annulus fibrosus) and irritate adjacent nervous tissue. Ligaments are strong fibrous soft tissues that firmly attach bones to bones. Ligaments attach each of the vertebrae and surround each of the discs. When ligaments are injured as the disc degenerates, localized pain in the area affected can result.

History

Pain: The patient with a spinal disease usually presents with pain; which is localized to the area of involvement in the spine. In cervical spondylosis the pain is in the cervical region while the pain is felt in the lumbosacral area in prolapsed intervertebral disc, spondylolisthesis or in osteoarthritis of the spine. Tuberculosis usually involves the dorsal or dorsolumbar spine producing pain in these areas of the spine.

Pain associated with stiffness in the back, especially in the morning in a young male is often seen in ankylosing spondylosis.

Pain in the low back, exaggerated on coughing or sneezing indicates a disc prolapse.

Radicular Pain: Pain in the spine may be associated with radiating pain into the extremities. For example, in cervical spondylosis the pain may radiate to the upper limbs; low backache may be associated with pain in the lower limbs in disc prolapse or in spondylolisthesis. In tuberculosis of the dorsal spine, the pain may radiate along the intercostalnerves to the front of the trunk. This type of pain is called girdle pain.

Paraesthesia: Back pain may be associated along with tingling or numbness in the extremities in conditions like discprolapse or spondylolisthesis. Back pain with paraesthesia and radicular pain in the lower limbs on walking in characteristic of lumbar canal stenosis. In this condition the symptoms are relieved temporarily if the patient gets an opportunity to set for a few minutes in the middle of walking. He can walk again for the same distance before the symptoms reappear. It is called intermittent claudication.

Weakness in the extremities may be seen in disc prolapse, spondylolisthesis, tuberculosis or spinal cord tumour. The patient may also develop paralysis distal to the involvement in the spine.

Examination

Inspection
Gait: The gait must be observed as the patient walks into the examination room. The patient with tuberculosis of the spine walks cautinuously, allowing little movement to the spine. A patient suffering from ankylosing spondylitis walks with a stiff gait, the spine is stiff and there is no movement of the head and neck. A patient with severe disc prolapse is bent forward slightly.
The patient’s back must be exposed completely and the patient must be examined from behind. A nurse or a female attendant must accompany the doctor while examining a female patient. The patient is examined in standing and spine lying position.
Deformity: In standing position, when the patient is examined from behind, the spine is in a straight vertical line from the nape of the neck to the natal cleft. Both the scapulae are symmetrically placed at the same level. Lateral curvature of the spine with asymmetry of the scapulae occurs in scoliosis. Normally there is mild kyphosis in the dorsalspine. Exaggerated generalized kyphosis occurs in Scheuermann’s disease in children and in osteoporosis in the elderly; in young males it is seen in ankylosing spondylitis. Localized kyphosis (“knuckle” due to collapse of one vertebra, and “gibbus” due to collapse of 2-3 vertebrae) is seen in tuberculosis.

Swelling in the paraspinal region or lumbar region may be seen as a “cold abscess” in tuberculosis. A soft cystic swelling in the paraspinal region in a child is seen in spina befida manifesta (or cystica).

Palpation
Tenderness in the spine is elicited initially by giving gentle blows to spine from dorsal spine to the sacral region, with a fist. Once the tender area in the spine is identified, tenderness is then elicted by pressing the spinous process of the vertebra with the thumb. When tuberculosis is suspected the thumb is used to apply pressure over the transverse process of the vertebra (rather than the spinous process). By this manoeuvre an attempt is made to rotate the vertebra to elicit tenderness.

Movements
The movements of the spine-forward flexion lateral bending and rotation-are tested systematically. Forward flexion may be restricted in tuberculosis, disc prolapse or due to muscle spasm in postural backache. In disc prolapse the trunk lists to one side on forward flexion. Flexion is grossly restricted in ankylosing spondylitis.

Neurological Examination
Examination of the spine is not complete unless a complete neurological examination of the extremities is performed systematically.

Physical Therapy is a unique rehabilitation technique and art that utilizes a wide variety of procedures such as restoring original functionality and movement to the body, but not limited to eliminating various kinds of pain including. Typically after being thoroughly evaluated by your physician they generate a specific diagnosis and prescribe physical therapy.