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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.
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.
Many non-operative treatments have been advocated, including rest; oral administration of non-steroidal anti-inflammatory drugs; physical therapy; chiropractic; and local modalities such as cryotherapy, ultrasound, electromagnetic radiation, and subacromial injection of corticosteroids.
Shoulder bursitis rarely requires surgical intervention and generally responds favorably to conservative treatment. Surgery is reserved for patients who fail to respond to non-operative measures. Minimally invasive surgical procedures such as arthroscopic removal of the bursa allows for direct inspection of the shoulder structures and provides the opportunity for removal of bone spurs and repair of any rotator cuff tears that may be found.
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.
Post-traumatic wrist osteoarthritis can be treated conservatively or with a surgical intervention. In many patients, a conservative (non-surgical) approach is sufficient. Because osteoarthritis is progressive and symptoms may get worse, surgical treatment is advised in any stage.
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.
In general, anti-inflammatory drugs are prescribed initially. This medical treatment is usually accompanied by physiotherapy to increase back and stomach muscles. Thus, the spine can be both relieved and stabilized. If these conservative measures do not bring about betterment, minimally invasive procedures such as a facet infiltration can be conducted to offer relief. In this procedure, a local anesthetic is injected directly into the respective joint, usually in combination with a cortisone preparation (corticosteroid).
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
While acupuncture leads to improvements in pain relief, this improvement is small and may be of questionable importance. Waiting list-controlled trials for peripheral joint osteoarthritis do show clinically relevant benefits, but these may be due to placebo effects. Acupuncture does not seem to produce long-term benefits. While electrostimulation techniques such as TENS have been used for twenty years to treat osteoarthritis in the knee, there is no conclusive evidence to show that it reduces pain or disability.
A Cochrane review of low level laser therapy found unclear evidence of benefit. Another review found short term pain relief for osteoarthritic knees.
The effectiveness of glucosamine is controversial. Reviews have found it to be equal to or slightly better than placebo. A difference may exist between glucosamine sulfate and glucosamine hydrochloride, with glucosamine sulfate showing a benefit and glucosamine hydrochloride not. The evidence for glucosamine sulfate having an effect on osteoarthritis progression is somewhat unclear and if present likely modest. The Osteoarthritis Research Society International recommends that glucosamine be discontinued if no effect is observed after six months and the National Institute for Health and Care Excellence no longer recommends its use. Despite the difficulty in determining the efficacy of glucosamine, it remains a viable treatment option. The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) recommends glucosamine sulfate and chondroitin sulfate for knee osteoarthritis. Its use as a therapy for osteoarthritis is usually safe.
A 2015 Cochrane review of clinical trials of chondroitin found that most were of low quality, but that there was some evidence of short-term improvement in pain and few side effects; it does not appear to improve or maintain the health of affected joints.
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 .
For stage I, normally, nonsurgical treatment is sufficient. This type of therapy includes the use of splint or cast immobilization, injections of corticosteroid in the pain causing joints and the use of a systemic non-steroidal anti-inflammatory drug to reduce pain and improve the functional use of the affected joint. However, the amount of pain that can be suppressed by nonsurgical therapy is limited and with the progression of the wrist osteoarthritis surgical treatment is inevitable.
In stage I surgical treatment often consists of neurectomy of the posterior interosseous nerve and is often combined with other procedures. In the case of a SLAC, the scapholunate ligament can be reconstructed in combination with a radial styloidectomy, in which the radial styloid is surgically removed from the distal radius. In the case of a SNAC, the scaphoid can be reconstructed by fixating the scaphoid with a screw or by placing a bone graft(Matti-Russe procedure)to increase the stability of the scaphoid.
There is moderate quality evidence that manual therapy and therapeutic exercise improves pain in patients with thumb CMC
OA at both short- and intermediate-term follow-up, and low to moderate quality evidence that magneto therapy improves pain
and function at short-term follow-up. There is moderate evidence that orthoses (splints) can improve hand function at long-term follow-up. There is very low to low-quality evidence that other conservative interventions provide no significant improvement in pain and in function at short- and long-term follow-up. Some of the commonly performed conservative interventions performed in therapy have evidence to support their use to improve hand function and decrease hand pain in patients with CMC OA.
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.
If intraarticular trapeziometacarpal fractures (such as the Bennett or Rolando fractures) are allowed to heal in a displaced position, significant post-traumatic osteoarthritis of the base of the thumb is virtually assured. Some form of surgical treatment (typically either a CRPP or an ORIF) is nearly always recommended to ensure a satisfactory outcome for these fractures, if there is significant displacement.
The long-term outcome after surgical treatment appears to be similar, whether the CRPP or the ORIF approach is used. Specifically, the overall strength of the affected hand is typically diminished, and post-traumatic osteoarthritis tends to develop in almost all cases. The degree of weakness and the severity of osteoarthritis does however appear to correlate with the quality of reduction of the fracture. Therefore, the goal of treatment of Bennett fracture should be to achieve the most precise reduction possible, whether by the CRPP or the ORIF approach.
For some people with hypermobility, lifestyle changes decrease symptom severity. In general activity that increases pain is to be avoided. For example:
- Typing can reduce pain from writing.
- Voice control software or a more ergonomic keyboard can reduce pain from typing.
- Bent knees or sitting can reduce pain from standing.
- Unwanted symptoms are frequently produced by some forms of yoga and weightlifting.
- Use of low impact elliptical training machines can replace high-impact running.
- Pain-free swimming may require a kickboard or extra care to avoid hyperextending elbow and other joints.
- Weakened ligaments and muscles contribute to poor posture, which may contribute to other medical conditions.
- Isometric exercise avoids hyperextension and contributes to strength.
Manual therapy is another commonly used treatment modality in which the joints or muscles of patients are manipulated with the intention of restoring the range of motion of the joint or increasing the flexibility of the muscles around the joint. Intervention techniques:
- Kaltenborn Mobilization Technique
- Maitland's Mobilization
- Neurodynamic Techniques
Though these fractures commonly appear quite subtle or even inconsequential on radiographs, they can result in severe long-term dysfunction of the hand if left untreated. In his original description of this type of fracture in 1882, Bennett stressed the need for early diagnosis and treatment in order to prevent loss of function of the thumb CMC joint, which is critical to the overall function of the hand.
- In the most minor cases of Bennett fracture, there may be only small avulsion fractures, relatively little joint instability, and minimal subluxation of the CMC joint (less than 1 mm). In such cases, closed reduction followed by immobilization in a thumb spica cast and serial radiography may be all that is required for effective treatment.
- For Bennett fractures where there is between 1 mm and 3 mm of displacement at the trapeziometacarpal joint, closed reduction and percutaneous pin fixation (CRPP) with Kirschner wires is often sufficient to ensure a satisfactory functional outcome. The wires are not employed to connect the two fracture fragments together, but rather to secure the first or second metacarpal to the trapezium.
- For Bennett fractures where there is more than 3 mm of displacement at the trapeziometacarpal joint, open reduction and internal fixation (ORIF) is typically recommended.
Regardless of which approach is employed (nonsurgical, CRPP, or ORIF), immobilization in a cast or thumb spica splint is required for four to six weeks.
In patients with bursitis who have rheumatoid arthritis, short term improvements are not taken as a sign of resolution and may require long term treatment to ensure recurrence is minimized. Joint contracture of the shoulder has also been found to be at a higher incidence in type two diabetics, which may lead to frozen shoulder (Donatelli, 2004).
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.
Ice is often used to reduce swelling in cycles of 15–20 minutes on and 20–30 minutes off. Icing an ankle too long can cause cold injuries, indicated if the area turns white.
In uncomplicated lateral ankle sprains, swelling of the soft tissue can be prevented with compression around both malleoli, elevation of the injured ankle higher than the heart, and pain-free exercises.
An orthopedic walking boot is often used for the treatment of a sprained ankle injury. Braces and crutches are also used to help alleviate the pain so the injured ankle can heal as quickly and painlessly as possible.
Although found to be less effective than casts, compression bandages are used to provide support and compression for sprained ankles. Wrapping is started at the ball of the foot and slowly continued up to the base of the calf muscle, which pushes the swelling up toward the center of the body so that it does not gather in the foot.
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.
Since there is a variety of classifications of winged scapula, there is also more than one type of treatment. Massage Therapy is an effective initial approach to relax the damaged muscles. In more severe cases, Physical Therapy can help by strengthening affected and surrounding muscles. Physical therapy constitutes treatment options if there is weakness of the glenohumeral joint muscles, but if the muscles do not contract clinically and symptoms continue to be severe for more than 3–6 months, surgery may be the next choice. Surgery by fixation of the scapula to the rib cage can be done for those with isolated scapular winging. Some options are neurolysis (chordotomy), intercostal nerve transfer, scapulothoracic fusion, arthrodesis (scapulodesis), or scapulothoracis fixation without arthrodesis (scapulopexy).