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The primary treatment is rest. This does not mean bed rest or immobilizing the area but avoiding actions which result in aggravation of the pain. Icing the joint may help. A non-steroidal anti-inflammatory drug may relieve pain and reduce the inflammation. If these are ineffective, the definitive treatment is steroid injection into the inflamed area.
Physical therapy to strengthen the hip muscles and stretch the iliotibial band can relieve tension in the hip and reduce friction. The use of point ultrasound may be helpful, and is undergoing clinical trials.
In extreme cases, where the pain does not improve after physical therapy, cortisone shots, and anti-inflammatory medication, the inflamed bursa can be removed surgically. The procedure is known as a bursectomy. Tears in the muscles may also be repaired, and loose material from arthritic degeneration of the hip removed. (At the time of bursal surgery, a very close examination of the gluteal tendons will reveal sometimes subtle and sometimes very obvious degeneration and detachment of the gluteal tendons. If this detachment is not repaired, removal of the bursa alone will make little or no difference to the symptoms.)
The bursa is not required, so the main potential complication is potential reaction to anaesthetic. The surgery can be performed arthroscopically and, consequently, on an outpatient basis. Patients often have to use crutches for a few days following surgery up to a few weeks for more involved procedures.
There are numerous case reports in which surgery has relieved GTPS, but its effectiveness is not documented in clinical trials.
Injections are usually focused on the iliopsoas bursa. Corticosteroid injections are common, but usually only last weeks to months. In addition, corticosteroid side effects can include weight gain, weakening of the surrounding tissues, and more. Cellular based therapy may have a role in future injection based treatments, though there is no current research proving the effectiveness of these therapies.
A self-treatment recommended by the U.S. Army for a soft tissue injury of the iliopsoas muscle treatment, like for other soft tissue injuries, is a HI-RICE (Hydration, Ibuprofen, Rest, Ice, Compression, Elevation) regimen lasting for at least 48 to 72 hours after the onset of pain. "Rest" includes such commonsense prescriptions as avoiding running or hiking (especially on hills), and avoiding exercises such as jumping jacks, sit-ups or leg lifts/flutter kicks.
Stretching of the tight structures (piriformis, hip abductor, and hip flexor muscle) may alleviate the symptoms. The involved muscle is stretched (for 30 seconds), repeated three times separated by 30 second to 1 minute rest periods, in sets performed two times daily for six to eight weeks. This should allow one to progress back into jogging until symptoms disappear.
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.
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.
As patellofemoral pain syndrome is the most common cause of anterior knee pain in the outpatient, a variety of treatments for patellofemoral pain syndrome are implemented. Most patients with patellofemoral pain syndrome respond well to conservative therapy.
While ITBS pain can be acute, the iliotibial band can be rested, iced, compressed and elevated (RICE) to reduce pain and inflammation, followed by stretching. Massage therapy, and many of its modalities, can offer relief if symptoms arise.
Because wear on the hip joint traces to the structures that support it (the posture of the legs, and ultimately, the feet), proper fitting shoes with adequate support are important to preventing GTPS. For someone who has flat feet, wearing proper orthotic inserts and replacing them as often as recommended are also important preventive measures.
Strength in the core and legs is also important to posture, so physical training also helps to prevent GTPS. But it is equally important to avoid exercises that damage the hip.
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.
Surgical treatment is only initiated if there is severe pain, as the available operations can be difficult. Otherwise, high arches may be handled with care and proper treatment.
Suggested conservative management of patients with painful pes cavus typically involves strategies to reduce and redistribute plantar pressure loading with the use of foot orthoses and specialised cushioned footwear. Other non-surgical rehabilitation approaches include stretching and strengthening of tight and weak muscles, debridement of plantar callosities, osseous mobilization, massage, chiropractic manipulation of the foot and ankle, and strategies to improve balance. There are also numerous surgical approaches described in the literature that are aimed at correcting the deformity and rebalancing the foot. Surgical procedures fall into three main groups:
1. soft-tissue procedures (e.g. plantar fascia release, Achilles tendon lengthening, tendon transfer);
2. osteotomy (e.g. metatarsal, midfoot or calcaneal);
3. bone-stabilising procedures (e.g. triple arthrodesis).
Treatment of posterolateral corner injuries varies with the location and grade of severity of the injuries. Patients with grade I and II (partial) injuries to the posterolateral corner can usually be managed conservatively. Studies have reported that patients with grade III (complete) injuries do poorly with conservative management and typically will require surgical intervention followed by rehabilitation.
Rehabilitation protocols for post-op patients with repaired or reconstructed posterolateral corner injuries focus on strengthening and achieving full range of motion. Similar to nonoperative treatments, the patient is non-weightbearing for 6 weeks followed by a return to partial weight-bearing on crutches. Range of motion exercises begin first at 1 to 2 days postoperatively, followed by progressive strength training. Patients can typically begin riding a stationary bike and using a quadriceps machine around 6 to 8 weeks, but isolated hamstring exercises should be avoided for a minimum of 4 months postoperatively. Patients can progress to leg presses after 6 weeks, but the weight should be very light. Jogging and more aggressive strength training can begin around 4 – 6 months at the surgeon and physical therapists discretion. Patients should not be casted after surgery unless absolutely necessary.
In rare cases, if diagnosed in utero, fetal surgery may be considered to save a limb which is in danger of amputation or other deformity. This typically would not be attempted if neither vital organs nor the umbilical cord were affected. This operation has been successfully performed on fetuses as young as 22 weeks. The surgery took place at Melbourne's Monash Medical Centre in Australia and is believed to be the earliest surgery of its type, as surgeons usually hold off on operating until the woman is in week 28 of gestation. There are also several facilities in the United States that have performed successful amniotic band release surgery.
Treatment usually occurs after birth and where plastic and reconstructive surgery is considered to treat the resulting deformity. Plastic surgery ranges from simple to complex depending on the extent of the deformity. Physical and occupational therapy may be needed long term.
Prosthetics may help some ABS sufferers to live more functional lives. The price and complexity of these prosthetics vary dramatically, but advances in 3-D printing have helped to increase the availability of artificial fingers while reducing their cost of production.
Iliotibial band syndrome (ITBS) is a common injury to the knee, generally associated with running, cycling, hiking or weight-lifting (especially squats).
There are several proposed methods of treatment. Interestingly the quality of reduction does not correlate with late symptoms and osteoarthritic changes. Despite this fact, the joint surface should be restored as close to its anatomical position as possible.
Some advocate fixation with Kirschner wires, or plate and screw constructions.
Another accepted treatment is an external fixator accompanied by the tension band wiring technique.
Tension band wiring is a technique in which the bone fragments are transfixed by Kirschner wires, which are then also used as an anchor for a loop of flexible wire. As the loop is tightened the bone fragments are compressed together.
Dead arm syndrome starts with repetitive motion and forces on the posterior capsule of the shoulder. The posterior capsule is a band of fibrous tissue that interconnects with tendons of the rotator cuff of the shoulder. Four muscles and their tendons make up the rotator cuff. They cover the outside of the shoulder to hold, protect and move the joint.
Overuse can lead to a buildup of tissue around the posterior capsule called hypertrophy. The next step is tightness of the posterior capsule called posterior capsular contracture. This type of problem reduces the amount the shoulder can rotate inwardly.
Over time, with enough force, a tear may develop in the labrum. The labrum is a rim of cartilage around the shoulder socket to help hold the head of the humerus (upper arm) in the joint. This condition is called a superior labrum anterior posterior (SLAP) lesion. The final outcome in all these steps is the dead arm phenomenon.
The shoulder is unstable and dislocation may come next. Dead arm syndrome will not go away on its own with rest—it must be treated. If there is a SLAP lesion, then surgery is needed to repair the problem. If the injury is caught before a SLAP tear, then physical therapy with stretching and exercise can restore it.
It is common among baseball pitchers as they age, and it can also occur with quarterbacks in football and handball players also as they age.
Surgical correction is recommended when a constriction ring results in a limb contour deformity, with or without lymphedema.
At the beginning of the surgery a tourniquet will be applied to the limb. A tourniquet compresses and control the arterial and venous circulation for about 2 hours. The constriction band must be dissected very carefully to avoid damaging the underlying neurovasculature. When the constriction band is excised, there will be a direct closure. This allows the fatty tissue to naturally reposition itself under the skin.
“With complete circumferential constriction bands, it is recommended that a two-stage correction approach be used. At the first operation, one-half of the circumference is excised and the other one-half can be excised after three to six months. This will avoid any problems to the distal circulation in the limb, which may already be compromised. Lymphedema, when present, will significantly improve within a few weeks of the first surgery.”
For the direct closure of the defect after dissecting a constriction band there are two different techniques:
1. Triangular flaps; For this technique the circumference between the two borders must be measured. Depending on the difference the number of triangular flaps can be decided. With a triangular flap you can create more skin.
2. Z/W-plasty; “Z-plasty is a plastic surgery technique that is used to improve the functional and cosmetic appearance of scars. It can elongate a contracted scar or rotate the scar tension line. The middle line of the Z-shaped incision (the central element) is made along the line of greatest tension or contraction, and triangular flaps are raised on opposite sides of the two ends and then transposed.”
In rare cases, if diagnosed in utero, fetal surgery may be considered to save a limb that is in danger of amputation or other deformity. This operation has been successfully performed on fetuses as young as 22 weeks. The Melbourne's Monash Medical Centre in Australia, as well as multiple facilities in the United States of America, have performed successful amniotic band release surgery.
Chondromalacia patellae (also known as CMP) is inflammation of the underside of the patella and softening of the cartilage.
The cartilage under the kneecap is a natural shock absorber, and overuse, injury, and many other factors can cause increased deterioration and breakdown of the cartilage. The cartilage is no longer smooth and therefore movement and use is painful. While it often affects young individuals engaged in active sports, it also afflicts older adults who overwork their knees.
"Chondromalacia patellae" is sometimes used synonymously with patellofemoral pain syndrome. However, there is general consensus that "patellofemoral pain syndrome" applies only to individuals without cartilage damage.
Running is a form of exercise and described as the one of the world's most accessible sport. However, its high-impact nature can lead to injury. Approximately 50% of runners are affected by some form of running injuries or running-related injuries (RRI) annually, and some estimates suggest an even higher frequency. The frequency of various RRI depend on the type of running, as runners vary significantly in factors such as speed and mileage. RRI can be both acute and chronic. Many of the common injuries that plague runners are chronic, developing over a longer period of time, as opposed to injury caused by sudden trauma, such as strains. These are often the result of overuse. Common overuse injuries include stress fractures, Achilles tendinitis, Iliotibial band syndrome, Patellofemoral pain (runners knee), and plantar fasciitis.
Proper running form is important in injury prevention. A major aspect of running form is foot strike pattern. The way in which the foot makes contact with the ground determines how the force of the impact is distributed throughout the body. Different types of modern running shoes are created to manipulate foot strike pattern in an effort to reduce the risk of injury. In recent years, barefoot running has increased in popularity in many western countries, because of claims that it reduces the risk of injury. However, this has not been proven and is still debated.
Amniotic band syndrome is considered an accidental event and it does not appear to be genetic or hereditary, so the likelihood of it occurring in another pregnancy is remote. The cause of amnion tearing is unknown and as such there are no known preventative measures.
Available hind limb IR animal model are either artery vein ligation or tourniquet application (by rubber band or O-ring).
Possible treatments are the application of IR related-pathway derived drug/inhibitor and cell therapy. The study has been done a role for p53 in activating necrosis. During oxidative stress, p53 accumulates in the mitochondrial matrix and triggers mitochondrial permeability transition pore (PTP) opening. To the end of this, necrosis occurs by physical interaction with the PTP regulator cyclophilin D (CypD). The mitochondrial p53-CypD axis as an important contributor to oxidative stress-induced necrosis and implicates in disease pathology and possible treatment. Cyclosporine A, known as a potent the mitochondrial permeability transition pore (mPTP) opening inhibitor and extremely powerful in protecting cardiomyocytes from IR, normalized ROS production, decreased inflammation, and restored mitochondrial coupling during aortic cross-clamping in Rat hind limb IR model.
The Segond fracture is a type of avulsion fracture (soft tissue structures tearing off bits of their bony attachment) of the lateral tibial condyle of the knee, immediately beyond the surface which articulates with the femur.
In general, overuse injuries are the result of repetitive impact between the foot and the ground. With improper running form, the force of the impact can be distributed abnormally throughout the feet and legs. Running form tends to worsen with fatigue. When moving at a constant pace, a symmetrical gait is considered to be normal. Asymmetry is considered to be a risk factor for injury. One study attempted to quantify the change in running form between a rested and fatigued state by measuring asymmetrical running gait in the lower limbs. The results showed that "knee internal rotation and knee stiffness became more asymmetrical with fatigue, increasing by 14% and 5.3%, respectively". These findings suggest that focusing on proper running form, particularly when fatigued, could reduce the risk of running related injuries. Running in worn out shoes may also increase the risk of injury and altering the footwear might be helpful. These injuries can also arise due to a sudden increase in the intensity or amount of exercise.