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Treatment is generally conservative with rest, ice, and specific exercises being recommended. Simple pain killers may be used if required such as acetaminophen (paracetamol) or ibuprofen. Typically symptoms resolve as the growth plate closes. Physiotherapy is generally recommended once the initial symptoms have improved to prevent recurrence. Surgery may rarely be used in those who have stopped growing yet still have symptoms.
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.
One of the main ways to prevent OSD is to check the participant's flexibility in their quadriceps and hamstrings. Lack of flexibility in these muscles can be direct risk indicator for OSD. Muscles can shorten, which can cause pain but this is not permanent. Stretches can help reduce shortening of the muscles. The main stretches for prevention of OSD focus on the hamstrings and quadriceps.
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.
Impingement syndrome is usually treated conservatively, but sometimes it is treated with arthroscopic surgery or open surgery. Conservative treatment includes rest, cessation of painful activity, and physical therapy. Physical therapy treatments would typically focus at maintaining range of movement, improving posture, strengthening shoulder muscles, and reduction of pain. Physical therapists may employ the following treatment techniques to improve pain and function: joint mobilization, interferential therapy, accupuncture, soft tissue therapy, therapeutic taping, rotator cuff strengthening, and education regarding the cause and mechanism of the condition. NSAIDs and ice packs may be used for pain relief.
Therapeutic injections of corticosteroid and local anaesthetic may be used for persistent impingement syndrome. The total number of injections is generally limited to three due to possible side effects from the corticosteroid. A recent systematic review of level one evidence, showed corticoestroid injections only give small and transient pain relief.
A number of surgical interventions are available, depending on the nature and location of the pathology. Surgery may be done arthroscopically or as open surgery. The impinging structures may be removed in surgery, and the subacromial space may be widened by resection of the distal clavicle and excision of osteophytes on the under-surface of the acromioclavicular joint. Damaged rotator cuff muscles can be surgically repaired.
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.
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.
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 first-line treatment for a muscular strain in the acute phase include five steps commonly known as P.R.I.C.E.
- Protection: Apply soft padding to minimize impact with objects.
- Rest: Rest is necessary to accelerate healing and reduce the potential for re-injury.
- Ice: Apply ice to induce vasoconstriction, which will reduce blood flow to the site of injury. Never ice for more than 20 minutes at a time.
- Compression: Wrap the strained area with a soft-wrapped bandage to reduce further diapedesis and promote lymphatic drainage.
- Elevation: Keep the strained area as close to the level of the heart as is possible in order to promote venous blood return to the systemic circulation.
Immediate treatment is usually an adjunctive therapy of NSAID's and Cold compression therapy. Controlling the inflammation is critical to the healing process. Cold compression therapy acts to reduce swelling and pain by reducing leukocyte extravasation into the injured area. NSAID's such as Ibuprofen/paracetamol work to reduce the immediate inflammation by inhibiting Cox-1 & Cox-2 enzymes, which are the enzymes responsible for converting arachidonic acid into prostaglandin. However, NSAIDs, including aspirin and ibuprofen, affect platelet function (this is why they are known as "blood thinners") and should not be taken during the period when tissue is bleeding because they will tend to increase blood flow, inhibit clotting, and thereby increase bleeding and swelling. After the bleeding has stopped, NSAIDs can be used with some effectiveness to reduce inflammation and pain.
A new treatment for acute strains is the use of platelet rich plasma (PRP) injections which have been shown to accelerate recovery from non surgical muscular injuries.
It is recommended that the person injured should consult a medical provider if the injury is accompanied by severe pain, if the limb cannot be used, or if there is noticeable tenderness over an isolated spot. These can be signs of a broken or fractured bone, a sprain, or a complete muscle tear.
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.
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.
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.
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 .
Pelvic fractures that are treatable without surgery are treated with bed rest. Once the fracture has healed enough, rehabilitation can be started with first standing upright with the help of a physical therapist, followed by starting to walk using a walker and eventually progressing to a cane.
It is often seen as a repetitive stress injury, and thus lifestyle modification is typically the basic course of management strategies. For example, a person should begin doing foot and calf workouts. Strong muscles in the calves and lower legs will help take the stress off the bone and thus help cure or prevent heel spurs. Icing the area is an effective way to get immediate pain relief.
Treatment of ankle fractures is dictated by the stability of the ankle joint. Certain fractures patterns are deemed stable, and may be treated similar to ankle sprains. All other types require surgery, most often an open reduction and internal fixation (ORIF), which is usually performed with permanently implanted metal hardware that holds the bones in place while the natural healing process occurs. A cast or splint will be required to immobilize the ankle following surgery.
In children recovery may be faster with an ankle brace rather than a full cast in those with otherwise stable fractures.
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.
Surgery is often required for pelvic fractures. Many methods of pelvic stabilization are used including external fixation or internal fixation and traction. There are often other injuries associated with a pelvic fracture so the type of surgery involved must be thoroughly planned.
Steroid injections are helpful in the short term (first approximately 4 weeks) however, their long term effectiveness is not known, and quality of evidence for its use remains poor and controversial.
Other, more conservative and non-surgical, treatment options available for the management and treatment of tendinopathy include: rest, ice, massage therapy, eccentric exercise, NSAIDs, ultrasound therapy, LIPUS, electrotherapy, taping, sclerosing injections, blood injection, glyceryl trinitrate patches, and (ESWT) extracorporeal shockwave therapy. Studies with a rat model of fatigue-damaged tendons suggested that delaying exercise until after the initial inflammatory stage of repair could promote remodelling more rapidly. There is insufficient evidence on the routine use of injection therapies (Autologous blood, Platelet-rich plasma, Deproteinised haemodialysate, Aprotinin, Polysulphated glycosaminoglycan, Corticosteroid, Skin derived fibroblasts etc.) for treating Achilles tendinopathy. As of 2014 there was insufficient evidence to support the use of platelet-rich therapies for treating musculoskeletal soft tissue injuries such as ligament, muscle and tendon tears and tendinopathies.
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.
Treatment of medial knee injuries varies depending on location and classification of the injuries. The consensus of many studies is that isolated grade I, II, and III injuries are usually well suited to non-operative treatment protocols. Acute grade III injuries with concomitant multiligament injuries or knee dislocation involving medial side injury should undergo surgical treatment. Chronic grade III injuries should also undergo surgical treatment if the patient is experiencing rotational instability or side-to-side instability.
The use of surgery to treat a Jefferson fracture is somewhat controversial. Non-surgical treatment varies depending on if the fracture is stable or unstable, defined by an intact or broken transverse ligament and degree of fracture of the anterior arch. An intact ligament requires the use of a soft or hard collar, while a ruptured ligament may require traction, a halo or surgery. The use of rigid halos can lead to intracranial infections and are often uncomfortable for individuals wearing them, and may be replaced with a more flexible alternative depending on the stability of the injured bones, but treatment of a stable injury with a halo collar can result in a full recovery. Surgical treatment of a Jefferson fracture involves fusion or fixation of the first three cervical vertebrae; fusion may occur immediately, or later during treatment in cases where non-surgical interventions are unsuccessful. A primary factor in deciding between surgical and non-surgical intervention is the degree of stability as well as the presence of damage to other cervical vertebrae.
Though a serious injury, the long-term consequences of a Jefferson's fracture are uncertain and may not impact longevity or abilities, even if untreated. Conservative treatment with an immobilization device can produce excellent long-term recovery.
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.
Treatment of the unhappy triad usually requires surgery. An ACL surgery is common and the meniscus can be treated during the surgery as well. The MCL is rehabilitated through time and immobilization. Physical therapy after the surgery and the use of a knee brace help speed up the healing process.
A typical surgery for a blown knee includes:
- Patellar tendon autograft (An autograft is a graft that comes from the patient)
- Hamstring tendon autograft
- Quadriceps tendon autograft
- Allograft (taken from a cadaver) patellar tendon, Achilles tendon, semitendinosus, gracilis, or posterior tibialis tendon
The goal of reconstruction surgery is to prevent instability and restore the function of the torn ligament, creating a stable knee. There are certain factors that the patient must consider when deciding for or against surgery.
UCL injuries may or may not require surgery. Non surgical treatment will primarily focus on strengthening the elbow joint to regain strength and stability. First a course of
RICE (Rest, ice, compression, elevation) is typically coupled with NSAIDS (Non-steroidal anti-inflammatory drugs) to help alleviate pain and swelling. When the swelling has subsided, individual exercises or physical therapy may be prescribed to strengthen muscles around the elbow joint to compensate for tearing in the UCL. These may include biceps curls (non resistance and resistance), pronating and supinating the forearm, and grip strengthening exercises, performed with low resistance and moderate repetitions no more than three times a week.
Surgical treatment may help restore the ability to perform the overhand throwing motions most commonly associated with UCL injuries. The reconstructive surgery, generally known as Tommy John surgery, was first performed by Dr. Frank Jobe in 1974 and has modified several times over the past 30 years. The surgery involves an autograft of the palmaris longus tendon (mostly seen as an accessory tendon) or an allograft of tissue from a cadaver or donor. The new tendon is attached by drilling holes in the medial epicondyle of the humerus and the sublime tubercle of the ulna and lacing the tendon through them in a figure eight. The patient may begin physical therapy shortly after. It usually takes about 15 months after the surgery for standard rehabilitation. In study conducted by Dr. Frederick Azar, 78 Tommy John surgeries were performed and analyzed after the surgeries. Of the 78 patients, 8 of them (8.8%) reported complications. Two patients had superficial infections that resolved with oral antibiotics, two patients reported tightness of tenderness at the surgery site, and one had a superficial wound infection at the elbow incision that resolved with oral antibiotics. One patient developed postoperative ulnar nerve damage. Two patients had damages to the posteromedial part of the olecranon and required to have reoperation.
Recent studies have shown that MLB pitchers who undergo Tommy John surgery return to pitch in the MLB 83% of the time and only 3% fail to return to pitch in the MLB or the minor league.
Recently, there has been a recorded increase of Tommy John surgery. The increase is related to the false perception that the surgery improves the stability of the UCL joint. Many athletes believe in this false perception and cause them to lie about their symptoms in hopes to undergo the surgery. In order to combat these rumors, physicians are motivated to educate the public that Tommy John surgeries are only for those who have severe UCL injuries. The surgery will have an insignificant effect if the patient does not have a severe UCL injury.
The tendon chosen is then woven in a figure eight pattern through the humerus and ulna, which holes were first drilled in the bones. After surgery occurs, rehabilitation comes into place and usually takes about a year because a tendon needs time to convert into a ligament.