Welcome to the Orthopaedic Center

Transcription

1 Welcome to the Orthopaedic Center We are one of the pioneer orthopaedic sports medicine rehab group in india The Orthopaedic Sports Medicine and Rehabilitation Center brings together a unique combination of specialists in orthopaedic surgery. Our orthopaedic physicians consist of fellowship trained Spine, joint replacement, sports medicine, upper extremity, and hand surgery specialties, as well as all general orthopaedic and fracture care. We also have a team of Board Certified Physiatrists performing a wide range of chronic pain treatments. Our Physicians and therapists work together to bring you the very best medical expertise available, assuring a rapid recovery from your surgery or injury through our total TEAM approach! We strive to provide the highest quality of diagnosis, care and rehabilitation for patients with orthopaedic problems. Specialties Anatomical Arm, Elbow, Foot and Ankle, Hand and Wrist, Hip, Knee, Low Back, Neck, Shoulder, Spine Treatment Arthritis, Arthroscopic Surgery, Disability, Joint Replacement, Osteoporosis, Pain, Rehabilitation, Sports Medicine, Trauma/Fractures, Comprehensive Musculoskeletal Care More about Specialties» Approach to treating patients The goal of our practice is to provide comprehensive musculokeletal care for our patients. We are leaders in specialty orthopaedic care. We have extended office hours for our patients' convenience, and an exceptional team of highly subspecialized physicians who focus their practices on different areas of the body.

2 Other specialties in our practice are PHYSICAL MEDICINE & REHABILITATION, RHEUMATOLOGY, and PODIATRY. We have full-service ORTHOTICS departments Patient education library Orthopaedic information you can trust from Your Orthopaedic Connection, a service provided by the American Academy of Orthopaedic Surgeons. About Orthopaedics Arthritis Broken Bones and Injury Children Diseases and Syndromes Foot and Ankle Hand and Wrist Hip Joint Replacement Knee and Leg Prevention and Safety Seniors Shoulder, Arm, Elbow Spine and Neck Sports and Exercise Treatment and Rehabilitation What is a Hand Surgeon? What do hand surgeons do? Print this article Our hands serve many purposes. Hands help us eat, dress, write, earn a living, create art, and do many other activities. To do these activities, our hands require sensation

3 and movement, such as joint motion, tendon gliding, and muscle contraction. When a problem takes place in the hand, care must be given to all the different types of tissues that make function of the hand possible. What do hand surgeons do? This drawing was made from a photograph taken in 1946 of two founding members of the American Society for Surgery of the Hand. Sterling Bunnell, MD, and J. William Littler, MD, are examining the hand of a patient. Hand surgery is the field of medicine that deals with problems of the hand, wrist, and forearm. Hand surgeons care for these problems with and without surgery. They are specially trained to operate when necessary. Many hand surgeons are also experts in diagnosing and caring for shoulder and elbow problems. Hand surgeons are orthopaedic, plastic, or general surgeons who have additional training in surgery of the hand. To become members of the American Society for Surgery of the Hand, hand surgeons must take a full year of additional training and must pass a rigorous certifying examination. Some hand surgeons treat only children, some treat only adults, and some treat both. Because many hand surgeons devote most of their time to examining, treating and studying the hand, they are specialists in hand care. Why visit a hand surgeon? When a problem takes place in the hand, care must be given to all the different types of tissues that make function of the hand possible. Not every visit to a hand surgeon results in hand surgery. Hand surgeons often recommend non-surgical treatment options to assist you. Sometimes, they may refer you to a hand therapist for more treatment.

4 Hand surgeons are specialists in hand care. If you have pain in your fingers, hand, wrist or arm, or have other upper-extremity related concerns, you may want to consult a hand surgeon. Examples of conditions treated by a hand surgeon are: Carpal tunnel syndrome Wrist pain Cuts on the fingers and hand Sports injuries to the hand and wrist Creating fingers from toes and other joints The mission of American Society for Surgery of the Hand is to advance the science and practice of hand surgery through education, research and advocacy on behalf of patients and practitioners North River Road, Suite 600 Rosemont, IL Phone : Fax: info@hand-surg.org Last reviewed: October 2007 Co-developed with the American Society for Surgery of the Hand AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist"program on this website.

5 Diseases and Syndromes Arthritis: An Overview Carpal Tunnel Syndrome Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy) dequervain's Tendinitis Low Back Pain Neck Pain Osteoporosis Scoliosis Shoulder Pain and Common Shoulder Problems Arthritis: An Overview Anatomy Cause Natural History Diagnosis Medications Exercise and Therapy Surgery Long-Term Management Research Print this article Arthritis literally means "inflammation of a joint." In some forms of arthritis, such as osteoarthritis, the inflammation arises because the smooth covering (articular cartilage) on the ends of bones become damaged or worn. Osteoarthritis is usually found in one, usually weightbearing, joint.

6 In other forms of arthritis, such as rheumatoid arthritis, the joint lining becomes inflamed as part of a disease process that affects the entire body. Some other types of arthritis are: seronegative spondyloarthropathies, crytalline deposition diseases, and septic arthritis. Arthritis is a major cause of lost work time and serious disability for many people. Although arthritis is mainly a disease of adults, children may also have it. Anatomy Arthritis is a disease of the joint. A joint is where the ends of two or more bones meet. The knee joint, for example, is formed between the bones of the lower leg (the tibia and the fibula) and the thighbone (the femur). The hip joint is where the top of the thighbone (femoral head) meets a concave portion of the pelvis (the acetabulum). A smooth tissue of cartilage covers the ends of bones in a joint. Cartilage cushions the bone and allows the joint to move easily without the friction that would come with bone-on-bone contact. A joint is enclosed by a fibrous envelope, called the synovium, which produces a fluid that also helps to reduce friction and wear in a joint. Ligaments connect the bones and keep the joint stable. Muscles and tendons power the joint and enable it to move. Cause There are two major categories of arthritis.

7 The first type is caused by wear and tear on the articular cartilage (osteoarthritis) through the natural aging process, through constant use, or through trauma (posttraumatic arthritis). The second type is caused by one of a number of inflammatory processes. Regardless of whether the cause is from injury, normal wear and tear, or disease, the joint becomes inflamed, causing swelling, pain and stiffness. This is usually temporary. Inflammation is one of the body's normal reactions to injury or disease. In arthritic joints, however, inflammation may cause long-lasting or permanent disability. Natural History

8 Osteoarthritis This drawing of an arthritic hip shows how the cartilage covering the leg bone (femur) and the acetabulum of the hip become damaged over time. The most common type of arthritis is osteoarthritis. It results from overuse, trauma, or the degeneration of the joint cartilage that takes place with age. Osteoarthritis is often more painful in joints that bear weight, such as the knee, hip, and spine, rather than in the wrist, elbow, and shoulder joints. However, joints that are used extensively in work or sports or joints that have been damaged from fractures or other injuries may show signs of osteoarthritis. Other disorders that injure or overload the articular cartilage may lead to osteoarthritis. In osteoarthritis, the cartilage covering the bone ends gradually wears away. In many cases, bone growths called "spurs" develop at the edges of osteoarthritic joints. The bone can become hard and firm (sclerosis). The joint becomes inflamed, causing pain and swelling. Continued use of the joint is painful.

9 Rheumatoid Arthritis Rheumatoid arthritis is a long-lasting disease. It is estimated that 1% of the population throughout the world have rheumatoid arthritis. Women are three times more likely than men to have rheumatoid arthritis. The development of rheumatoid arthritis slows with age. Rheumatoid arthritis affects many parts of the body, but mainly the joints. The body's immune system, which normally protects the body, begins to produce substances that attack the body. In rheumatoid arthritis, the joint lining swells, invading surrounding tissues. Chemical substances are produced that attack and destroy the joint surface. Rheumatoid arthritis may affect both large and small joints in the body and also the spine. Swelling, pain, and stiffness usually develop, even when the joint is not used. In some circumstances, juvenile arthritis may cause similar symptoms in children. Diagnosis Arthritis is diagnosed through a careful evaluation of symptoms and a physical examination. X-rays are important to show the extent of any damage to the joint. Blood tests and other laboratory tests may help to determine the type of arthritis. Some of the findings of arthritis include: Weakness (atrophy) in the muscles Tenderness to touch

10 Limited ability to move the joint passively (with assistance) and actively (without assistance). Signs that other joints are painful or swollen (an indication of rheumatoid arthritis) A grating feeling or sound (crepitus) with movement Pain when pressure is placed on the joint or the joint is moved Medications Over-the-counter medications can be used to control pain and inflammation in the joints. These medications, called anti-inflammatory drugs, include aspirin, ibuprofen, and naproxen. Acetaminophen can be effective in controlling pain. Prescription medications also are available. A physician will choose a medication by taking into account the type of arthritis, its severity, and the patient's general physical health. Patients with ulcers, asthma, kidney, or liver disease, for example, may not be able to safely take anti-inflammatory medications. Injections of cortisone into the joint may temporarily help to relieve pain and swelling. It is important to know that repeated, frequent injections into the same joint can damage it, causing undesirable side effects. Viscosupplementation or injection of hyaluronic acid preparations can also be helpful in lubricating the joint. This is typically perfomed in the knee. Exercise and Therapy Canes, crutches, walkers, or splints may help relieve the stress and strain on arthritic joints. Learning methods of performing daily activities that are the less stressful to painful joints also may be helpful.

11 Certain exercises and physical therapy may be used to decrease stiffness and to strengthen the weakened muscles around the joint. Surgery In general, an orthopaedic surgeon will perform surgery for arthritis when other methods of nonsurgical treatment have failed to relieve pain and other symptoms. When deciding on the type of surgery, the physician and patient will take into account the type of arthritis, its severity, and the patient's physical condition. There are a number of surgical procedures. These include: Removing the diseased or damaged joint lining Realignment of the joints Fusing the ends of the bones in the joint together, to prevent joint motion and relieve joint pain Replacing the entire joint (total joint replacement) Long-Term Management In most cases, persons with arthritis can continue to perform normal activities of daily living. Exercise programs, anti-inflammatory drugs, and weight reduction for obese persons are common measures to reduce pain, stiffness, and improve function. In persons with severe cases of arthritis, orthopaedic surgery can often provide dramatic pain relief and restore lost joint function.

12 Some types of arthritis, such as rheumatoid arthritis, are often treated by a team of health care professionals. These professionals may include rheumatologists, physical and occupational therapists, social workers, rehabilitation specialists, and orthopaedic surgeons. Research At present, most types of arthritis cannot be cured. Researchers continue to make progress in finding the underlying causes for the major types of arthritis. In the meantime, orthopaedic surgeons, working with other physicians and scientists, have developed many effective treatments for arthritis. Last reviewed: October 2007 AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist"program on this website. Carpal Tunnel Syndrome Anatomy Cause Symptoms Doctor Examination Tests Treatment Print this article

13 Carpal tunnel syndrome is a common source of hand numbness and pain. It is more common in women than men. Anatomy The carpal tunnel is a narrow, tunnel-like structure in the wrist. The bottom and sides of this tunnel are formed by wrist (carpal) bones. The top of the tunnel is covered by a strong band of connective tissue called the transverse carpal ligament. The median nerve travels from the forearm into the hand through this tunnel in the wrist. The median nerve controls feeling in the palm side of the thumb, index finger, and long fingers. The nerve also controls the muscles around the base of the thumb. The tendons that bend the fingers and thumb also travel through the carpal tunnel. These tendons are called flexor tendons. The carpal tunnel protects the median nerve and flexor tendons that bend the fingers and thumb. Reproduced and adapted from Rodner C, Raissis A, Akelman E: Carpal Tunnel Syndrome. Orthopaedic Knowledge Online. Rosemont, IL, American Academy of Orthopaedic Surgeons, Cause Carpal tunnel syndrome occurs when the tissues surrounding the flexor tendons in the wrist swell and put pressure on the median nerve. These tissues are called the

14 synovium. The synovium lubricates the tendons and makes it easier to move the fingers. This swelling of the synovium narrows the confined space of the carpal tunnel, and over time, crowds the nerve. Carpal tunnel syndrome is caused by pressure on the median nerve traveling through the carpal tunnel. Many things contribute to the development of carpal tunnel syndrome: Heredity is the most important factor - carpal tunnels are smaller in some people, and this trait can run in families. Hand use over time can play a role. Hormonal changes related to pregnancy can play a role. Age the disease occurs more frequently in older people. Medical conditions, including diabetes, rheumatoid arthritis, and thyroid gland imbalance can play a role. In most cases of carpal tunnel syndrome, there is no single cause. Symptoms The most common symptoms of carpal tunnel syndrome include:

15 Numbness, tingling, and pain in the hand An electric shock-like feeling mostly in the thumb, index, and long fingers Strange sensations and pain traveling up the arm toward the shoulder Symptoms usually begin gradually, without a specific injury. In most people, symptoms are more severe on the thumb side of the hand. Symptoms may occur at any time. Because many people sleep with their wrists curled, symptoms at night are common and may awaken you from sleep. During the day, symptoms frequently occur when holding something, like a phone, or when reading or driving. Moving or shaking the hands often helps decrease symptoms. Symptoms initially come and go, but over time they may become constant. A feeling of clumsiness or weakness can make delicate motions, like buttoning your shirt, difficult. These feelings may cause you to drop things. If the condition is very severe, muscles at the base of the thumb may become visibly wasted. Doctor Examination To determine whether you have carpal tunnel syndrome, your doctor will discuss your symptoms and medical history. He or she will also examine your hand and perform a number of physical tests, such as: Checking for weakness in the muscles around the base of your thumb Bending and holding your wrists in positions to test for numbness or tingling in your hands Pressing down on the median nerve in the wrist to see if it causes any numbness or tingling Tapping along the median nerve in the wrist to see whether tingling is produced in any of the fingers Testing the feeling in your fingers by lightly touching them when your eyes are closed

16 Tests Electrophysiological tests. Electrical testing of median nerve function is often done to help confirm the diagnosis and clarify the best treatment option in your case. X-rays. If you have limited wrist motion, your doctor may order x-rays of your wrist. Treatment For most people, carpal tunnel syndrome will progressively worsen without some form of treatment. It may, however, be modified or stopped in the early stages. For example, if symptoms are clearly related to an activity or occupation, the condition may not progress if the occupation or activity is stopped or modified. Nonsurgical Treatment If diagnosed and treated early, carpal tunnel syndrome can be relieved without surgery. In cases where the diagnosis is uncertain or the condition is mild to moderate, your doctor will always try simple treatment measures first. Bracing or splinting. A brace or splint worn at night keeps the wrist in a neutral position. This prevents the nightly irritation to the median nerve that occurs when wrists are curled during sleep. Splints can also be worn during activities that aggravate symptoms. Medications. Simple medications can help relieve pain. These medications include anti-inflammatory drugs (NSAIDs), such as ibuprofen. Activity changes. Changing patterns of hand use to avoid positions and activities that aggravate the symptoms may be helpful. If work requirements cause symptoms, changing or modifying jobs may slow or stop progression of the disease. Steroid injections. A corticosteroid injection will often provide relief, but symptoms may come back.

17 Surgical Treatment Surgery may be considered if you do not gain relief from nonsurgical treatments. The decision whether to have surgery is based mostly on the severity of your symptoms. In more severe cases, surgery is considered sooner because other nonsurgical treatment options are unlikely to help. In very severe, long-standing cases with constant numbness and wasting of your thumb muscles, surgery may be recommended to prevent irreversible damage. The ligament is cut during surgery. When it heals, there is more room for the nerve and tendons. Surgical technique. In most cases, carpal tunnel surgery is done on an outpatient basis under local anesthesia. During surgery, a cut is made in your palm. The roof (transverse carpal ligament) of the carpal tunnel is divided. This increases the size of the tunnel and decreases pressure on the nerve. Once the skin is closed, the ligament begins to heal and grow across the division. The new growth heals the ligament, and allows more space for the nerve and flexor tendons.

18 Endoscopic method. Some surgeons make a smaller skin incision and use a small camera, called an endoscope, to cut the ligament from the inside of the carpal tunnel. This may speed up recovery. The end results of traditional and endoscopic procedures are the same. Your doctor will discuss the surgical procedure that best meets your needs. Recovery. Right after surgery, you will be instructed to frequently elevate your hand above your heart and move your fingers. This reduces swelling and prevents stiffness. Some pain, swelling, and stiffness can be expected after surgery. You may be required to wear a wrist brace for up to 3 weeks. You may use your hand normally, taking care to avoid significant discomfort. Minor soreness in the palm is common for several months after surgery. Weakness of pinch and grip may persist for up to 6 months. Driving, self-care activities, and light lifting and gripping may be permitted soon after surgery. Your doctor will determine when you should return to work and whether there should be any restrictions on your work activities. Complications. The most common risks from surgery for carpal tunnel syndrome include: Bleeding Infection Nerve injury Long-term outcomes. Most patients' symptoms improve after surgery, but recovery may be gradual. On average, grip and pinch strength return by about 2 months after surgery.

19 Complete recovery may take up to a year. If significant pain and weakness continue for more than 2 months, your physician may instruct you to work with a hand therapist. In long-standing carpal tunnel syndrome, with severe loss of feeling and/or muscle wasting around the base of your thumb, recovery is slower and might not be complete. Carpal tunnel syndrome can occasionally recur and may require additional surgery. Last reviewed: December 2009 AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist"program on this website. Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy) Description Cause Doctor Examination Tests Treatment Print this article Complex regional pain syndrome (CRPS) is a condition of intense burning pain, stiffness, swelling, and discoloration that most often affects the hand. Arms, legs, and feet can also be affected by CRPS.

20 This condition was previously known as reflex sympathetic dystrophy, Sudeck's atrophy, shoulder-hand syndrome, or causalgia. Description There are two types of CRPS: Type 1 occurs after an illness or injury that did not directly damage a nerve in the affected area Type 2 follows a distinct nerve injury Although the triggers vary, both types of CRPS have the same symptoms and go through the same three stages of disease. Stage I: Acute Stage I may last up to 3 months. Burning pain and increased sensitivity to touch are the most common early symptom of CRPS. This pain is different more constant and longer lasting than would be expected with a given injury. Swelling and joint stiffness usually follow, along with increased warmth and redness in the affected limb. There may be faster-than-normal nail and hair growth and excessive sweating. Acute stage CRPS, 2 months after injury Stage II: Dystrophic Stage II can last 3 to 12 months. Swelling is more constant and skin wrinkles disappear. Skin temperature becomes cooler. Fingernails become brittle. Pain is more widespread, stiffness increases, and the affected area becomes more sensitive to touch.

21 Stage III: Atrophic Stage III occurs after 1 year. The skin of the affected area becomes pale, dry, tightly stretched, and shiny. The area is stiff and there is less hope of getting motion back. Pain may decrease and the condition may spread to other areas of the body. Cause Although the two types of CRPS can be tied to injury or illness, the exact cause of CRPS is unknown. One theory is that a "short circuit" in the nervous system is responsible. This "short circuit" causes overactivity of the sympathetic (unconscious) nervous system which affects blood flow and sweat glands in the affected area. Symptoms most commonly occur after injury or surgery. Other causes include pressure on a nerve, infection, cancer, neck problems, stroke, or heart attack. Doctor Examination After discussing your medical history and symptoms, your doctor will carefully examine your hand or affected limb. People with CRPS are unusually protective of the involved limb. Even a light touch may evoke expressions of severe pain. Tests There is no single test that can make the diagnosis of CRPS. Some imaging studies, such as x-rays, bone scans, and magnetic resonance imaging (MRI) scans can help your doctor make a firm diagnosis. Treatment

22 Early diagnosis and treatment are important in order to prevent CRPS from developing into the later stages. It is also important that these patients not be told that the pain is "in their heads." CRPS is a physiological condition. Even though it is not fully understood, CRPS is treatable. After 6 months of treatment, this patient's hands have regained normal color and are no longer swollen. Nonsurgical Treatment Medications. Non-steroidal anti-inflammatory drugs (NSAIDs), oral corticosteroids, anti-depressants, blood pressure medications, anti-convulsants, and opioid analgesics are medications recommended to relieve symptoms. Injection therapy. Injecting an anesthetic (numbing medicine) near the affected sympathetic nerves can reduce symptoms. This is usually recommended early in the course of CRPS in order to avoid progression to the later stages. Biofeedback. Increased body awareness and relaxation techniques may help with pain relief. Therapy. Active exercise that emphasizes normal use of the affected limb is essential to permanent relief of this condition. Physical and/or occupational therapy are important in helping patients regain normal use patterns. Medications and other treatment options can reduce pain, allowing the patient to engage in active exercise.

23 Surgical Treatment If nonsurgical treatment fails, there are surgical procedures that may help reduce symptoms. Spinal cord stimulator. Tiny electrodes are implanted along your spine and deliver mild electric impulses to the affected nerves. Pain pump implantation. A small device that delivers pain medication to the spinal cord is implanted near the abdomen. Results from surgical procedures may be disappointing. Many patients with chronic CRPS symptoms benefit from psychological evaluation and counseling. Last reviewed: June 2010 AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist"program on this website. De Quervain's Tendinitis (De Quervain's Tendinosis) Anatomy Causes Symptoms Diagnosis Treatment Print this article De Quervain's tendinitis occurs when the tendons around the base of the thumb are irritated or constricted. The word "tendinitis" refers to a swelling of the tendons. Thickening of the tendons can cause pain and tenderness along the thumb side of

24 the wrist. This is particularly noticeable when forming a fist, grasping or gripping things, or when turning the wrist. Anatomy Two of the main tendons to the thumb pass through a tunnel (or series of pulleys) located on the thumb side of the wrist. Tendons are rope-like structures that attach muscle to bone. Tendons are covered by a slippery thin soft-tissue layer, called synovium. This layer allows the tendons to slide easily through the tunnel. Any swelling of the tendons located near these nerves can put pressure on the nerves. This can cause wrist pain or numbness in the fingers. De Quervain tenosynovitis of the first extensor compartment. Reproduced with permission from: Griffin LY (ed): Essentials of Musculoskeletal Care, 3rd Edition. Rosemont, IL. American Academy of Orthopaedic Surgeons, Causes De Quervain's tendinitis is caused when tendons on the thumb side of the wrist are swollen or irritated. The irritation causes the lining (synovium) around the tendon to swell, which changes the shape of the compartment. This makes it difficult for the tendons to move as they should. Tendinitis may be caused by overuse. It can be seen in association with pregnancy. It may be found in inflammatory arthritis, such as rheumatoid disease. De Quervain's tendinitis is usually most common in middle-aged women.

25 Symptoms Signs of De Quervain's tendinitis: Pain may be felt over the thumb side of the wrist. This is the main symptom. The pain may appear either gradually or suddenly. Pain is felt in the wrist and can travel up the forearm. The pain is usually worse when the hand and thumb are in use. This is especially true when forcefully grasping objects or twisting the wrist. Swelling may be seen over the thumb side of the wrist. This swelling may occur together with a fluid-filled cyst in this region. A "catching" or "snapping" sensation may be felt when moving the thumb. Pain and swelling may make it difficult to move the thumb and wrist. Numbness may be experienced on the back of the thumb and index finger. This is caused as the nerve lying on top of the tendon sheath is irritated. Diagnosis The Finkelstein test is conducted by making a fist with the fingers closed over the thumb and the wrist is bent toward the little finger. Finkelstein test. Arrow indicates location of pain when test is positive. Adapted with permission from the American Society for Surgery of the Hand: Brochure: de Quervain's Stenosing Tenosynovitis. Engelwood, CO, The Finkelstein test can be quite painful for the person with De Quervain's tendinitis.

26 Tenderness directly over the tendons on the thumb side of the wrist is a common finding with this test. Treatment The goal in treating de Quervain's tendinitis is to relieve the pain caused by irritation and swelling. Nonsurgical Treatment Splints. Splints may be used to rest the thumb and wrist. Anti-inflammatory medication (NSAIDs). These medications can be taken by mouth or injected into that tendon compartment. They may help reduce the swelling and relieve the pain. Avoiding activities that cause pain and swelling. This may allow the symptoms to go away on their own. Corticosteroids. Injection of corticosteroids into the tendon sheath may help reduce swelling and pain. Surgical Treatment Surgery may be recommended if symptoms are severe or do not improve. The goal of surgery is to open the compartment (covering) to make more room for the irritated tendons.

27 Surgery opens the sheath over the inflamed tendons. Normal use of the hand usually can be resumed once comfort and strength have returned. Your orthopaedic surgeon can advise you on the best treatment for your situation. Last reviewed: October 2007 Co-developed with the American Society for Surgery of the Hand AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist"program on this website. Low Back Pain Anatomy Description Cause Symptoms Tests and Diagnosis Treatment Prevention Print this article Almost everyone will experience low back pain at some point in their lives. This pain can vary from mild to severe. It can be short-lived or long-lasting. However it happens, low back pain can make many everyday activities difficult to do.

28 Anatomy Understanding your spine and how it works can help you understand why you have low back pain. Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine. Vertebrae Parts of the lumbar spine. These bones connect to create a canal that protects the spinal cord. The spinal column is made up of three sections that create three natural curves in your back: the curves of the neck area (cervical), chest area (thoracic), and lower back (lumbar). The lower section of your spine (sacrum and coccyx) is made up of vertebrae that are fused together. Five lumbar vertebrae connect the upper spine to the pelvis. Spinal Cord and Nerves These "electrical cables" travel through the spinal canal carrying messages between your brain and muscles. Nerves branch out from the spinal cord through openings in the vertebrae.

29 Muscles and Ligaments These provide support and stability for your spine and upper body. Strong ligaments connect your vertebrae and help keep the spinal column in position. Facet Joints Between vertebrae are small joints that help your spine move. Intervertebral Disks Intervertebral disks sit in between the vertebrae. When you walk or run, the disks act as shock absorbers and prevent the vertebrae from bumping against one another. They work with your facet joints to help your spine move, twist, and bend. Intervertebral disks are flat and round, and about a half inch thick. They are made up of two components. Annulus fibrosus. This is the tough, flexible outer ring of the disk. It helps connect to the vertebrae. Nucleus pulposus. This is the soft, jelly-like center of the annulus fibrosus. It gives the disk its shock-absorbing capabilities. Healthy intervertebral disk (cross-section view). Description Back pain is different from one person to the next. The pain can have a slow onset or come on suddenly. The pain may be intermittent or constant. In most cases, back pain resolves on its own within a few weeks.

30 Cause Lumbar ligament tear. There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions. As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s or even younger and can make us prone to back pain, especially if we overdo our activities. These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in her back! Over-activity One of the more common causes of low back pain is muscle soreness from overactivity. Muscles and ligament fibers can be overstretched or injured. This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this "stiffness" and soreness in the low back and other areas of the body that usually goes away within a few days.

31 Disk Injury Some people develop low back pain that does not go away within days. This may mean there is an injury to a disk. Disk tear. Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood. Disk herniation. Another common type of disk injury is a "slipped" or herniated disc. Herniated disk. A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain. Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is sciatica. A herniated disk often occurs with lifting, pulling, bending, or twisting movements. Disk degeneration.

32 Disk Degeneration With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints in the vertebrae to rub against one another. Pain and stiffness result. This "wear and tear" on the facet joints is referred to as osteoarthritis. It can lead to further back problems, including spinal stenosis. Spondylolisthesis. Degenerative Spondylolisthesis (Spon-dee-low-lis-THEE-sis). Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves. Spinal Stenosis Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves. Spinal stenosis. When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone in your facet joints to help support the vertebrae.

33 Over time, this bone overgrowth - called spurs - can lead to a narrowing of the spinal canal. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal. Scoliosis This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly leg symptoms, if pressure on the nerves is involved. Additional Causes There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position, you should consult your primary care doctor. Symptoms Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain. Most people find that reclining or lying down will improve low back pain, no matter the underlying cause. People with low back pain may experience some of the following: Back pain may be worse with bending and lifting. Sitting may worsen pain. Standing and walking may worsen pain Back pain comes and goes, and often follows an up and down course with good days and bad days. Pain may extend from the back into the buttock or outer hip area, but not down the leg.

34 Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain. Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor. Tests and Diagnosis Medical History and Physical Examination After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain. Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected. Imaging Tests Other tests which may help your doctor confirm your diagnosis include: X-rays. Although they only visualize bones, simple X-rays can help determine if you have the most obvious causes of back pain. It will show broken bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves. Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible in an MRI scan. Computerized axial tomography (CAT) scans. If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three-dimensional X- ray and focuses on the bones.

35 Bone scan. A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection. Bone density test. If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can. Treatment In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery. Nonsurgical Treatment Medications. Several medications may be used to help relieve your pain. Aspirin or acetaminophen can relieve pain with few side effects. Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling. Narcotic pain medications, such as codeine or morphine, may help. Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine. Physical medicine. Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do. Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.

36 Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them. Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments. Traction is often used, but without scientific evidence for effectiveness. Other exercise-based programs, such as Pilates or yoga are helpful for some patients. Surgical Treatment Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery. In addition, surgery should only be considered if you doctor can pinpoint the source of your pain. Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply can not be treated with surgery. Spinal Fusion. This is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone. Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a bad curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is if the painful spine segments do not move, they should not hurt. Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the

37 vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals. The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another. The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year. Disc Replacement. This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee. The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion. The surgery is done through your abdomen, usually on the lower two disks of the spine. Prevention It may not be possible to prevent low back pain. We cannot avoid the normal wear and tear on our spines that goes along with aging. But there are things we can do to lessen the impact of low back problems. Having a healthy lifestyle is a good start. Exercise Combine aerobic exercise, like walking or swimming, with specific exercises to keep the muscles in your back and abdomen strong and flexible. Proper Lifting Be sure to lift heavy items with your legs, not your back. Do not bend over to pick something up. Keep your back straight and bend at your knees.

38 Weight Maintain a healthy weight. Being overweight puts added stress on your lower back. Avoid Smoking Both the smoke and the nicotine cause your spine to age faster than normal. Proper Posture Good posture is important for avoiding future problems. A therapist can teach you how to safely stand, sit, and lift. Last reviewed: May 2009 AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist"program on this website. Neck Pain Cause When Should You Seek Medical Care? Print this article The neck (cervical spine) is composed of vertebrae that begin in the upper torso and end at the base of the skull. The bony vertebrae along with the ligaments (which are comparable to thick rubber bands) provide stability to the spine. The muscles allow for support and motion. The neck has a significant amount of motion and supports the weight of the head. However, because it is less protected than the rest of the spine, the neck can be vulnerable to injury and disorders that produce pain and

39 restrict motion. For many people, neck pain is a temporary condition that disappears with time. Others need medical diagnosis and treatment to relieve their symptoms. Cause Neck pain may result from abnormalities in the soft tissues the muscles, ligaments, and nerves as well as in bones and joints of the spine. The most common causes of neck pain are soft-tissue abnormalities due to injury or prolonged wear and tear. In rare instances, infection or tumors may cause neck pain. In some people, neck problems may be the source of pain in the upper back, shoulders, or arms. Inflammatory Diseases The vertebral column. Rheumatoid arthritis can destroy joints in the neck and cause severe stiffness and pain. Rheumatoid arthritis typically occurs in the upper neck area. Cervical Disk Degeneration (Spondylosis) The disk acts as a shock absorber between the bones in the neck. In cervical disk degeneration (which typically occurs in people age 40 years and older), the normal gelatin-like center of the disk degenerates and the space between the vertebrae narrows. As the disk space narrows, added stress is applied to the joints of the spine causing further wear and degenerative disease. The cervical disk may also protrude and put pressure on the spinal cord or nerve roots when the rim of the disk weakens. This is known as a herniated cervical disk.

40 Injury Because the neck is so flexible and because it supports the head, it is extremely vulnerable to injury. Motor vehicle or diving accidents, contact sports, and falls may result in neck injury. The regular use of safety belts in motor vehicles can help to prevent or minimize neck injury. A "rear end" automobile collision may result in hyperextension, a backward motion of the neck beyond normal limits, or hyperflexion, a forward motion of the neck beyond normal limits. The most common neck injuries involve the soft tissues: the muscles and ligaments. Severe neck injuries with a fracture or dislocation of the neck may damage the spinal cord and cause paralysis. Other Causes Less common causes of neck pain include tumors, infections, or congenital abnormalities of the vertebrae. When Should You Seek Medical Care? If severe neck pain occurs following an injury (motor vehicle accident, diving accident, or fall), a trained professional, such as a paramedic, should immobilize the patient to avoid the risk of further injury and possible paralysis. Medical care should be sought immediately. Immediate medical care should also be sought when an injury causes pain in the neck that radiates down the arms and legs. Radiating pain or numbness in your arms or legs causing weakness in the arms or legs without significant neck pain should also be evaluated. If there has not been an injury, you should seek medical care when neck pain is: continuous and persistent severe accompanied by pain that radiates down the arms or legs accompanied by headaches, numbness, tingling, or weakness

41 Many patients seek orthopaedic care for neck pain because orthopaedists are specifically trained to diagnose, treat, and help prevent problems involving the muscles, bones, joints, ligaments, and tendons. Although some orthopaedists confine their practices to specific areas of the musculoskeletal system, most treat a wide variety of diseases, injuries, and other conditions, including neck pain. Last reviewed: November 2009 AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist"program on this website. Osteoporosis What is osteoporosis? Why should I be concerned about osteoporosis? What causes osteoporosis? What can I do to prevent osteoporosis or keep it from getting worse? How is osteoporosis diagnosed? How is osteoporosis treated? Japanese Translation Portuguese Translation Chinese Translation Print this article What is osteoporosis? Osteoporosis is a disease of progressive bone loss associated with an increased risk of fractures. The term osteoporosis literally means porous bone. The disease often develops unnoticed over many years, with no symptoms or discomfort until a