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Treatment generally includes the following:
- Sometimes pharmacologic therapy for initial disease treatment
- Physical therapy
- Occupational therapy
- Use of appropriate assistive devices such as orthoses
- Surgical treatment
Two types of treatment options are typically available:
- Surgery
- Conservative treatment (rehabilitation and physical therapy)
Surgery may impede normal growth of structures in the knee, so doctors generally do not recommend knee operations for young people who are still growing. There are also risks of complications, such as an adverse reaction to anesthesia or an infection.
When designing a rehabilitation program, clinicians consider associated injuries such as chipped bones or soft tissue tears. Clinicians take into account the person's age, activity level, and time needed to return to work and/or athletics. Doctors generally only recommend surgery when other structures in the knee have sustained severe damage, or specifically when there is:
- Concurrent osteochondral injury
- Continued gross instability
- Palpable disruption of the medial patellofemoral ligament and the vastus medialis obliquus
- High-level athletic demands coupled with mechanical risk factors and an initial injury mechanism not related to contact
Supplements like glucosamine and NSAIDs can be used to minimize bothersome symptoms.
An effective rehabilitation program reduces the chances of reinjury and of other knee-related problems such as patellofemoral pain syndrome and osteoarthritis. Rehabilitation focuses on maintaining strength and range of motion to reduce pain and maintain the health of the muscles and tissues around the knee joint.
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat PFPS, however there is only very limited evidence that they are effective. NSAIDs may reduce pain in the short term, overall however, after three months pain is not improved. There is no evidence that one type of NSAID is superior to another in PFPS, and therefore some authors have recommended that the NSAID with fewest side effects and which is cheapest should be used.
Glycosaminoglycan polysulfate (GAGPS) inhibits proteolytic enzymes and increases synthesis and degree of polymerization of hyaluronic acid in synovial fluid. There is contradictory evidence that it is effective in PFPS.
With prompt treatment, particularly open reduction, and early mobilisation the outcome is generally good. High energy injuries and associated fractures worsen the outcome.
Prompt medical treatment should be sought for suspected dislocation.
Usually, the shoulder is kept in its current position by use of a splint or sling. A pillow between the arm and torso may provide support and increase comfort. Strong analgesics are needed to allay the pain of a dislocation and the distress associated with it.
Shoulder reduction may be accomplished with a number of techniques including traction-countertraction, external rotation, scapular manipulation, Stimson technique, Cunningham technique, or Milch technique. Pain can be managed during the procedures either by procedural sedation and analgesia or injected lidocaine into the shoulder joint. Injecting lidocaine into the joint may be less expensive and faster. If a shoulder cannot be relocated in the emergency room, relocation in the operating room maybe required. This situation occurs in about 7% of cases.
Magnetic resonance imaging rarely can give useful information for managing patellofemoral pain syndrome and treatment should focus on an appropriate rehabilitation program including correcting strength and flexibility concerns. In the uncommon cases where a patient has mechanical symptoms like a locked knee, knee effusion, or failure to improve following physical therapy, then an MRI may give more insight into diagnosis and treatment.
In the absence of cartilage damage, pain at the front of the knee due to overuse can be managed with a combination of RICE (rest, ice, compression, elevation), anti-inflammatory medications, and physiotherapy.
Usually chondromalacia develops without swelling or bruising and most individuals benefit from rest and adherence to an appropriate physical therapy program. Allowing inflammation to subside while avoiding irritating activities for several weeks is followed by a gradual resumption. Cross-training activities such as swimming, strokes other than the breaststroke, can help to maintain general fitness and body composition. This is beneficial until a physical therapy program emphasizing strengthening and flexibility of the hip and thigh muscles can be undertaken. Use of nonsteroidal anti-inflammatory medication is also helpful to minimize the swelling amplifying patellar pain. Treatment with surgery is declining in popularity due to positive non-surgical outcomes and the relative ineffectiveness of surgical intervention.
Depending on the severity of the deformities, the treatment may include the amputation of the foot or part of the leg, lengthening of the femur, extension prosthesis, or custom shoe lifts. Amputation usually requires the use of prosthesis. Another alternative is a rotationplasty procedure, also known as Van Ness surgery. In this situation the foot and ankle are surgically removed, then attached to the femur. This creates a functional "knee joint". This allows the patient to be fit with a below knee prosthesis vs a traditional above knee prosthesis.
In less severe cases, the use of an Ilizarov apparatus can be successful in conjunction with hip and knee surgeries (depending on the status of the femoral head/kneecap) to extend the femur length to normal ranges. This method of treatment can be problematic in that the Ilizarov might need to be applied both during early childhood (to keep the femur from being extremely short at the onset of growth) and after puberty (to match leg lengths after growth has ended). The clear benefit of this approach, however, is that no prosthetics are needed and at the conclusion of surgical procedures the patient will not be biologically or anatomically different from a person born without PFFD.
Anti-inflammatory medicines such as aspirin, naproxen or ibuprofen among others can be taken to help with pain. In some cases the physical therapist will use ultrasound and electrical stimulation, as well as manipulation. Gentle stretching and strengthening exercises are added gradually. If there is no improvement, the doctor may inject a corticosteroid medicine into the space under the acromion. However, recent level one evidence showed limited efficacy of corticosteroid injections for pain relief. While steroid injections are a common treatment, they must be used with caution because they may lead to tendon rupture. If there is still no improvement after 6 to 12 months, the doctor may perform either arthroscopic or open surgery to repair damage and relieve pressure on the tendons and bursae.
In those with calcific tendinitis of the shoulder high energy extracorporeal shock-wave therapy can be useful. It is not useful in other types of tendonitis.
Non-septic prepatellar bursitis can be treated with rest, the application of ice to the affected area, and anti-inflammatory drugs, particularly ibuprofen. Elevation of the affected leg during rest may also expedite the recovery process. Severe cases may require fine-needle aspiration of the bursa fluid, sometimes coupled with cortisone injections. However, some studies have shown that steroid injections may not be an effective treatment option. After the bursitis has been treated, rehabilitative exercise may help improve joint mechanics and reduce chronic pain.
Opinions vary as to which treatment options are most effective for septic prepatellar bursitis. McAfee and Smith recommend a course of oral antibiotics, usually oxacillin sodium or cephradine, and assert that surgery and drainage are unnecessary. Wilson-MacDonald argues that oral antibiotics are "inadequate", and recommends intravenous antibiotics for managing the infection. Some authors suggest surgical irrigation of the bursa by means of a subcutaneous tube. Others suggest that bursectomy may be necessary for intractable cases; the operation is an outpatient procedure that can be performed in less than half an hour.
If the dislocated hip cannot be reduced by manipulation alone, an immediate open (surgical) reduction is necessary. A CT scan or Judet views should be obtained prior to transfer to the surgical suite.
Presently, treatments make it possible for quicker recovery. If the tear is not serious, physical therapy, compression, elevation and icing the knee can heal the meniscus. More serious tears may require surgical procedures. Surgery, however, does not appear to be better than non surgical care.
The term for non-surgical treatment for ACL rupture is "conservative management", and it often includes physical therapy and using a knee brace. Instability associated with ACL deficiency increases the risk of other knee injuries such as a torn meniscus, so sports with cutting and twisting motions are problematic and surgery is often recommended in those circumstances.
Patients who have suffered an ACL injury should be evaluated for other injuries that often occur in combination with an ACL tear and include cartilage/meniscus injuries, bone bruises, PCL tears, posterolateral injuries and collateral ligament injuries. When a combination injury occurs, surgical treatment is usually advised.
Depending on the stability achieved via initial treatment, the patient may be allowed to stand and walk with help of support within about six to eight weeks. Full function may return in about three months.
Early on arthritis of the shoulder can be managed with mild analgesics and gentle exercises.
Known gentle exercises include warm water therapy pool exercises that are provided by a trained and licensed physical therapist; approved land exercises to assure free movement of the arthritic area; cortisone injections (administered at the minimum of every six months according to orthopedic physicians) to reduce inflammation; ice and hot moist pact application are very effective. Moist heat is preferred over ice whereas ice is preferred if inflammation occurs during the daytime hours. Local analgesics along with ice or moist heat are adequate treatments for acute pain.
In the case of rheumatoid arthritis, specific medications selected by a rheumatologist may offer substantial relief.
When exercise and medication are no longer effective, shoulder replacement surgery for arthritis may be considered. In this operation, a surgeon replaces the shoulder joint with an artificial ball for the top of the humerus and a cap (glenoid) for the scapula. Passive shoulder exercises (where someone else moves the arm to rotate the shoulder joint) are started soon after surgery. Patients begin exercising on their own about 3 to 6 weeks after surgery. Eventually, stretching and strengthening exercises become a major part of the rehabilitation programme. The success of the operation often depends on the condition of rotator cuff muscles prior to surgery and the degree to which the patient follows the exercise programme.
In young and active patients a partial shoulder replacement with a non-prosthetic glenoid arthroplasty may also be a consideration .
First options for treatment are conservative, using hot or cold packs, rest and NSAID's at first. If no improvement is made, a splint or brace can be used to keep the deviated arm straight. When none of the conservative treatments work surgical intervention is designated.
If the femur head is dislocated, it should be reduced as soon as possible, to prevent damage to its blood supply. This is preferably done under anaesthesia, following which, leg is kept pulled by applying traction to prevent joint from dislocating.
The final management depends on the size of the fragment(s), stability and congruence of the joint. In some cases traction for six to eight weeks may be the only treatment required; however, surgical fixation using screw(s) and plate(s) may be required if the injury is more complex. The latter treatment will be called for if bone fragments do not fall into place, or if they are found in the joint, or if the joint itself is unstable.
Initial treatment may include physical therapy, bracing, anti-inflammatory drugs, or corticosteroid injections to increase flexibility, endurance, and strength.
Exercises can strengthen the muscles around the knee, especially the quadriceps. Stronger and bigger muscles will protect the meniscus cartilage by absorbing a part of the weight. The patient may be given paracetamol or anti-inflammatory medications.
For patients with non-surgical treatment, physical therapy program is designed to reduce symptoms of pain and swelling at the affected joint. This type of rehabilitation focuses on maintenance of full range of motion and functional progression without aggravating the symptoms. Physical therapists can utilize modalities such as electric stimulation, cold therapy and ultrasonography, etc.
Recently, accelerated rehabilitation programs have been used and show to be as successful as the conservative program. The program reduces the time the patient spends using crutches and allows weight bearing activities. The less conservative approach allows the patient to apply a small amount of stress and prevent range of motion losses. It is likely that a patient with a peripheral tear may pursue the accelerated program and a patient with a larger tear will use the conservative program.
Hip dislocation rehabilitation can take anywhere from two to three months, depending on the patient. Complications to nearby nerves and blood vessels can sometimes cause loss of blood supply to the bone, also known as osteonecrosis. The protective cartilage on the bone can also be disturbed from this type of injury. For this reason, it is important for patients to contact a physician and get treatment immediately following injury.
- The first step to recovering from a hip dislocation is reduction. This refers to putting the bones back into their intended positions. Normally, this is done by a physician while the patient is under a sedative. Other times, a surgical procedure is required to reduce the hip bones back into their natural state.
- Next, rest, ice, and take anti-inflammatory medication to reduce swelling at the hip.
- Weight bearing is allowed for the type one posterior dislocation, but should only be done as pain allows and patient is comfortable.
- Within 5–7 days of the injury occurrence, patients may perform passive range of motion exercises to increase flexibility.
- A walking aid should be used until the patient is comfortable with both weight bearing and range of motion.
In the original description by Hume, where the olecranon fractures were not displaced, treatment consisted of closed reduction of the radial head dislocation under general anaesthesia by supination of the forearm. This was followed by immobilisation of the arm in a plaster cast with the elbow flexed at 90° and the forearm in supination for 6 weeks.
Where the olecranon fracture is displaced, open reduction internal fixation is recommended. Once the olecranon has been repaired, closed reduction of the radial head dislocation is usually possible. This is followed by immobilisation with the elbow flexed to 90° and the forearm in the neutral position. The duration of immobilisation depends on clinical assessment of the joint, and mobilisation may be possible after as little as 4 weeks.
In children, the results of early treatment are always good, typically normal or nearly so. If diagnosis is delayed, reconstructive surgery is needed and complications are much more common and results poorer. In adults, the healing is slower and results usually not as good.
Complications of ORIF surgery for Monteggia fractures can include non-union, malunion, nerve palsy and damage, muscle damage, arthritis, tendonitis, infection, stiffness and loss of range of motion, compartment syndrome, audible popping or snapping, deformity, and chronic pain associated with surgical hardware such as pins, screws, and plates. Several surgeries may be needed to correct this type of fracture as it is almost always a very complex fracture that requires a skilled orthopedic surgeon, usually a 'specialist', familiar with this type of injury.
Medication is not the primary treatment for hypermobility, but can be used as an adjuct treatment for related joint pain. NSAIDS are the primary medications of choice. Narcotics are not recommended for primary or long term treatment and are reserved for short term use after acute injury.
Early stages may be treated conservatively using the R.I.C.E methods.
1. Rest
2. Ice
3. Compression
4. Elevation
Exercises involving eccentric muscle contractions of the quadriceps on a decline board are strongly supported by extant literature. A physical therapist may also recommend specific exercises and stretches to strengthen the muscles and tendons, eg. cycling or swimming. Use of a strap for jumper's knee and suspension inlays for shoes may also reduce the problems.
Should this fail, autologous blood injection, or platelet-rich plasma injection may be performed and is typically successful though not as successful as high volume saline injection (Crisp "et al."). Uncommonly it may require surgery to remove myxoid degeneration in the tendon. This is reserved for patients with debilitating pain for 6–12 months despite conservative measures. Novel treatment modalities targeting the abnormal blood vessel growth which occurs in the condition are currently being investigated.
New research shows that knee operations in most cases have no better effects than exercise programs, and that most knee operations thus can be avoided.