Category Archives: Tendonitis and bursitis

Some of the more common conditions we see that are due to soft tissue injury

What are my options for shoulder pain?

The shoulder has the honor of being is the largest, most complex, and most mobile joint in the body.  And it is this reason that makes it the most vulnerable to overuse.

The shoulder consists of three bones: the humerus (upper arm bone), clavicle (collarbone), and scapula (shoulder blade).

The rotator cuff muscles and tendons are responsible for movement and stabilization of the shoulder.

In addition, there are other muscles and a complex array of ligaments that also serve to ensure stability.

Another tendon, the biceps tendon, originates from the glenoid (the cup of the shoulder blade where the humerus sits) and extends down the humerus.  It is responsible for certain arm and shoulder movements.

The ironic fact is that a patient who complains of shoulder pain may have nothing wrong with the shoulder!shoulder-pain

For example, many medical conditions such as gall bladder disease, pneumonia, and ectopic pregnancies can present with shoulder pain.  Also, neck conditions often cause referred pain to the shoulder.  Patients with heart disease who are experiencing a heart attack may complain of pain in the left shoulder and arm.

Shoulder ailments fall into three major groups.  The first is trauma.  An example may be a skier who falls on an extended arm.  The impact can drive the head of the arm bone into the socket and cause damage to the cartilage, the bone, as well as the rotator cuff tendons. If the ligaments are stretched or torn, the shoulder can dislocate.  While the shoulder can be “relocated”, once dislocation occurs, the patient is at increased risk for another dislocation. Significant impact can cause damage to the cartilage that cushions the head of the femur as well as the “cup” of the scapula.  This cup is referred to as the glenoid.  The glenoid also has a lip of tougher cartilage that can be torn with impact injuries.

Trauma, if significant enough, can cause dislocation of the joint joining the collar bone to the shoulder blade. The common term for this is a “separated shoulder.”

A related but different type of ailment is wear and tear.  Because so many of the structures that permit shoulder movement and provide stability are made of connective tissue, it stands to reason that over time, they can begin to wear out.  And that is exactly what happens.  Tendons- the ropes that connect muscles to bone-, ligaments, and bursae (fluid filled sacks that cushion joint movement) all are prone to injury as a result of overuse.

When this occurs, conditions such as tendinopathy (previously known as tendonitis), bursitis, and ligament strain ensue.

While inflammation may be present, the overwhelming problem is tissue breakdown.

The last ailment that affects the shoulder is arthritis.  The three bones that make up the shoulder interact with each other at two specific points.  At these two points, there is a joint where two bones whose ends are covered with cartilage articulate.  The two joints are the glenohumeral joint- the joint that joins the shoulder blade and the humerus and the acromioclavicular joint that joins the collarbone to the shoulder blade.

Arthritis at these two areas can develop as a result of systemic disease such as rheumatoid arthritis or as a result of wear and tear- osteoarthritis.

The treatment of shoulder disorders depends upon both the underlying problem as well as the amount of patient discomfort and the impact on quality of life.

For traumatic disorder where there is obvious tissue disruption, surgery is usually required.  The type of surgery will be up to both the surgeon as well as to the individual who has the problem. The shoulder is a complex joint so it’s important to ensure whoever works on the shoulder is an expert.

For most wear and tear problems, non-steroidal anti-inflammatory medicines (NSAIDS) are sometimes, but not always, helpful. Ice and rest also can be useful.

Patients may require a steroid injection. For people who don’t respond to medicines, injections, and physical therapy, surgery may be an option. Ultrasound guidance is important.

Regenerative medicine techniques can be used for shoulder issues.  An example would be a procedure called percutaneous needle tenotomy which can be used to treat rotator cuff tendinopathy and tears.

In this procedure, a small needle is introduced using local anesthetic and ultrasound guidance. The needle is used to irritate the tendons of the rotator cuff and induce inflammation. Then, platelet-rich plasma, obtained from the patient’s whole blood is injected into the area where the tendons have been irritated. Ultrasound guidance here is mandatory. Platelets are cells in the blood that contain many growth and healing factors. This stimulates the production of new strong tendon tissue.

Another example of a regenerative medicine technique is the use of autologous stem cells (a patient’s own stem cells) for glenohumeral arthritis.

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“Ooohhh, My Aching Knee!” Insider Secrets on How You Can Get Relief Quickly and Easily!

When your knee hurts, getting relief is all that’s on your mind. Getting the right relief, though, depends on knowing what’s wrong. The correct diagnosis will lead to the correct treatment.

Know Your Knee!knee-arthritis

The knee is the largest joint in the body. It’s also one of the most complicated. The knee joint is made up of four bones that are connected by muscles, ligaments, and tendons. The femur (large thigh bone) interacts with the two shin bones, the tibia (the larger one) located towards the inside and the fibula (the smaller one) located towards the outside. Where the femur meets the tibia is termed the joint line. The patella, (the knee cap) is the bone that sits in the front of the knee. It slides up and down in a groove in the lower part of the femur (the femoral groove) as the knee bends and straightens.

Ligaments are the strong rope-like structures that help connect bones and provide stability. In the knee, there are four major ligaments. On the inner (medial) aspect of the knee is the medial collateral ligament (MCL) and on the outer (lateral) aspect of the knee is the lateral collateral ligament (LCL). The other two main ligaments are found in the center of the knee. These ligaments are called the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). They are called cruciate ligaments because the ACL crosses in front of the PCL. Other smaller ligaments help hold the patella in place in the center of the femoral groove.

Two structures called menisci sit between the femur and the tibia. These structures act as cushions or shock absorbers. They also help provide stability for the knee. The menisci are made of a tough material called fibrocartilage. There is a medial meniscus and a lateral meniscus. When either meniscus is damaged it is called a “torn cartilage”.

There is another type of cartilage in the knee called hyaline cartilage. This cartilage is a smooth shiny material that covers the bones in the knee joint. In the knee, hyaline cartilage covers the ends of the femur, the femoral groove, the top of the tibia and the underside of the patella. Hyaline cartilage allows the knee bones to move easily as the knee bends and straightens.

Tendons connect muscles to bone. The large quadriceps muscles on the front of the thigh attach to the top of the patella via the quadriceps tendon. This tendon inserts on the patella and then continues down to form the rope-like patellar tendon. The patellar tendon in turn, attaches to the front of the tibia. The hamstring muscles on the back of the thigh attach to the tibia at the back of the knee. The quadriceps muscles are the muscles that straighten the knee. The hamstring muscles are the main muscles that bend the knee.

Bursae are small fluid filled sacs that decrease the friction between two tissues. Bursae also protect bony structures. There are many different bursae around the knee but the ones that are most important are the prepatellar bursa in front of the knee cap, the infrapatellar bursa just below the kneecap, the anserine bursa, just below the joint line and to the inner side of the tibia, and the semimembranous bursa in the back of the knee. Normally, a bursa has very little fluid in it but if it becomes irritated it can fill with fluid and become very large.

Is it bursitis… or tendonitis…or arthritis?

Tendonitis generally affects either the quadriceps tendon or patellar tendon. Repetitive jumping or trauma may set off tendonitis. The pain is felt in the front of the knee and there is tenderness as well as swelling involving the tendon. With patellar tendonitis, the infrapatellar bursa will often be inflamed also. Treatment involves rest, ice, and anti-inflammatory medication. Injections are rarely used. Physical therapy with ultrasound and iontopheresis may help.

Bursitis pain is common. The prepatellar bursa may become inflamed particularly in patients who spend a lot of time on their knees (carpet layers). The bursa will become swollen. The major concern here is to make sure the bursa is not infected. The bursa should be aspirated (fluid withdrawn by needle) by a specialist. The fluid should be cultured. If there is no infection, the bursitis may be treated with anti-jnflammatory medicines, ice, and physical therapy. Knee pads should be worn to prevent a recurrence once the initial bursitis is cleared up.

Anserine bursitis often occurs in overweight people who also have osteoarthritis of the knee. Pain and some swelling is noted in the anserine bursa. Treatment consists of steroid injection, ice, physical therapy, and weight loss.

The semimembranous bursa can be affected when a patient has fluid in the knee (a knee effusion). The fluid will push backwards and the bursa will become filled with fluid and cause a sensation of fullness and tightness in the back of the knee. This is called a Baker’s cyst. If the bursa ruptures, the fluid will dissect down into the calf. The danger here is that it may look like a blood clot in the calf. A venogram and ultrasound test will help differentiate a ruptured Baker’s cyst from a blood clot. The Baker’s cyst is treated with aspiration of the fluid from the knee along with steroid injection, ice, and elevation of the leg.

Knock out knee arthritis… simple steps you can take!

Younger people who have pain in the front of the knee have what is called patellofemoral syndrome (PFS). Two major conditions cause PFS. The first is chondromalacia patella. This is a condition where the cartilage on the underside of the knee cap softens and is particularly common in young women. Another cause of pain behind the knee cap in younger people may be a patella that doesn’t track normally in the femoral groove. For both chondromalacia as well as a poorly tracking patella, special exercises, taping, and anti-inflammatory medicines may be helpful. If the patellar tracking becomes a significant problem despite conservative measures, surgery is need.

While many types of arthritis may affect the knee, osteoarthritis is the most common. Osteoarthritis usually affects the joint between the femur and tibia in the medial (inner) compartment of the knee. Osteoarthritis may also involve the joint between the femur and tibia on the outer side of the knee as well as the joint between the femur and patella. Why osteoarthritis develops is still being scrutinized carefully. It seems to consist of a complex interaction of genetics, mechanical factors, and immune system involvement. The immune system attacks the joint through a combination of degradative enzymes and inflammatory chemical messengers called cytokines.

Patients will sometimes feel a sensation of rubbing or grinding. The knee will become stiff if the patient sits for any length of time. With local inflammation, the patient may experience pain at night and get relief from sleeping with a pillow between the knees. Occasionally, locking and clicking may be noticed. Patients with osteoarthritis may also tear the fibrocartilage cushions (menisci) in the knee more easily than people without osteoarthritis.

So how is the arthritis treated? An obvious place to start is weight reduction for patients who carry around too many pounds.

Strengthening exercises for the knee are also useful for many people. These should be done under the supervision of a physician or physical therapist.

Other therapies include ice, anti inflammatory medicines, and occasionally steroid injections. Glucosamine and chondroitin supplements may be helpful. A word of caution… make sure the preparation you buy is pure and contains what the label says it does. The supplement industry is unregulated… so buyer beware!

Injections of the knee with viscosupplements – lubricants- are particularly useful for many patients. Special braces may help to unload the part of the joint that is affected.

Arthroscopic techniques may be beneficial in special circumstances. Occasionally, a surgical procedure called an osteotomy, where a wedge of bone is removed from the tibia to “even things out,” may be recommended. Joint replacement surgery is required for end stage knee arthritis.

Research is being done to develop medicines that will slow down the rate of cartilage loss. Targets for these new therapies include the destructive enzymes and/or cytokines that degrade cartilage. It is hoped that by inhibiting these enzymes and cytokines and by boosting the ability of cartilage to repair itself, that therapies designed to actually reverse osteoarthritis may be created. These are referred to as disease-modifying osteoarthritis drugs or “DMOADs.” Genetic markers may identify high risk patients who need more aggressive therapies.

Newer compounds that are injected into the knee and provide healing as well as lubrication are also being developed. And finally, less invasive surgical techniques are also being looked at. Recent technological advances in “mini” knee replacement look very promising.

The technology that will revolutionize our approach to knee osteoarthritis is the use of mesenchymal stem cells.  These are stem cells derived from “non-blood” tissues such as fat, bone marrow, or even the lining of the joint. Studies in both animals as well as humans have shown great potential for these cells to regenerate cartilage.

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Another excellent study showing PRP works for tennis elbow!

Tara Haelle writing in Rheumatology News reported on a 24 week randomized controlled and double blind study looked at the effectiveness of platelet-rich plasma –PRP in treating tennis elbow. prp

The study  involved 230 patients who had failed physical therapy, non-steroidal anti-inflammatory drugs, and/or cortisone shots and was conducted at the Rothman Institute of Thomas Jefferson University.  The PRP group showed a 71.5% improvement in pain scores while the control group showed a 56.1% improvement.

tennis-elbow-on-fire

Comment: The differences weren’t huge but this still indicates PRP is the treatment of choice for this extremely painful disorder.

Cortisone shots should be avoided since they actually damage soft tissue and lead to more recurrence of tennis elbow and other forms of tendinopathy.

PRP should be administered using ultrasound guided needle tenotomy technique.

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The Agony of Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis or frozen shoulder syndrome, is a common painful disorder characterized by a relatively long duration and limited range of motion in the shoulder.  The length of time the frozen stage of the disease can last is anywhere from 1 to 3.5 years with a mean of 30 months.

frozen-shoulderIncreased capsular collagen thickening and capsular contraction in the shoulder joint causes restriction in both active and passive range of motion in the shoulder.   Adhesions also develop that tether the joint surfaces. As the condition gets worse, pain can become more severe and is accompanied by stiffness and decreased range of motion. The stiffening may increase to the point where even the natural arm swing that goes along with normal walking is lost.   Pain at night is often unbearable.

The diagnosis is made using a combination of history and physical diagnosis.  Confirmation can be made using magnetic resonance imaging or diagnostic ultrasound.

The most common treatments for frozen shoulder currently are long-term intensive and aggressive physical therapy, corticosteroids administered by injection, manipulation under anesthesia and arthroscopic surgery.  Depending on the series and studies cited, the results of the different treatment modalities vary widely. Also, each treatment has associated risks.

Drugs are often used to manage the pain, but none have been demonstrated to have an impact on the course of frozen shoulder.

Frozen shoulder is estimated to affect approximately two to five percent of the general adult population.  Certain conditions are associated with an increased occurrence of frozen shoulder.  These include diabetes, Dupuytren’s contracture, trauma, a previous history of frozen shoulder, and thyroid disease.

The condition tends to occur in a patient’s fourth to sixth decade of life.   Frozen shoulder occurs slightly more often in women than in men and often presents bilaterally.  Unfortunately, it may affect the opposite side years after onset of symptoms in the first shoulder; however, it does not typically affect the same shoulder twice.

Recently the use of an injectable drug called collagenase clostridium histolyticum has been studied in clinical trials.  This is the same drug used to treat Depuytren’s contracture. The theory is that this drug may digest the excess collagen that accounts for the adhesions that are the ostensible perpetrators of the frozen shoulder. However, there is concern that this substance may also affect the normal cartilage of the shoulder.

Spontaneous remission is the usual course for many patients. However, this remission may take several months or years to take place.

For more information on arthritis treatments and other arthritis problems,  go to:

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Light Treatment Doesn’t Work For Achilles Tendinopathy

Lynda Williams writing in MedWire reported research showing “that active intense pulsed light (ILP) does not benefit patients with chronic mid-body Achilles tendinopathy.” Investigators did not find a “significant difference in the achilles-tendinopathy6- and 12-week outcomes of 21 patients (27 tendons) who were randomly assigned to receive three weekly sessions with single pulse IPL designed to penetrate the and the 22 patients (27 tendons) given sham IPL.” The findings were published in the Bone and Joint Journal.

Comment: It is sometimes difficult to separate effective treatments vs those that don’t work.

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Steroid injections for tennis elbow make it worse

Genevra Pittman writing in Reuters reported that in an Australian study published in the Journal of the American Medical Association, researchers evaluated 165 adults with tennis elbow.

tennis-elbowThe participants were divided into four treatment groups: cortisone shots without physical therapy, cortisone shots with physical therapy, placebo shots without physical therapy, and placebo shots with physical therapy. After one year, 83% of the participants who received a cortisone shot reported that they had completely recovered, compared to 96% of those who received a placebo shot.

Steroid shots weaken tendons over the long haul.  A much more physiologic approach is to use ultrasound guided needle tenotomy and platelet-rich plasma (PRP).

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What the heck is “pseudosciatica”?

Sciatica is a condition where nerve roots in the lower portion of the lumbar spine become irritated as a result of disc bulge, disc herniation, or osteoarthritis.

There is also a condition called “pseudosciatica” which mimics sciatica.  It can pose a real diagnostic challenge.  Conditions that cause pseudosciatica include

1. trochanteric bursitis: a form of bursitis that causes pain in the lateral hip.  The pain is aggravated by climbing stairs and by lying on the affected side.

2. pyriformis syndrome: a problem that occurs when a swollen pyriformis muscle places pressure on the sciatic nerve.  This occurs after over exertion or after a fall on the buttock.

3.iliotibial band syndrome. A problem that occurs in runners with pain in the lateral hip radiating down the side of the leg.sciatica2

The examining doctor needs to be aware of these “foolers” and perform a careful history and physical examination.

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What are some bad habits that lead to aches and pains in women?

Bad habits at any age can cause aches and pains in women.
Really young women often wear flip flops with no arch support.  This can lead to a nasty case of plantar fasciitis.
Young women who have infants often carry the infant on one hip using one hand.  This causes them to develop a form of tendonitis of the thumb called DeQuervain’s disease.  It’s very painful but can be fixed with a glucocorticoid injection, splinting, and rest.
Women who work in an office setting still often hold a phone in the crook of their neck and this can obviously cause problems with neck pain. The pain can radiate down between the shoulder blades.
High heels, particularly the fashionable stiletto heels can cause ankle sprains and eventual problems with arthritis/bursitis in the big toe (bunions).high-heels
Carrying big handbags are a recipe for disaster since they can cause strains of the shoulder and neck.
A really bad habit is eating too much.  This obviously leads to aches and pains in weight bearing joints. Obesity aggravates arthritis from a biomechanical perspective as well as an inflammatory one.  Fat cells make chemicals that aggravate inflammation.
Cigarette smoking is a risk factor for the development of rheumatoid arthritis.

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Why is PRP being used by athletes?

The use of regenerative treatments such as PRP and autologous stem cells have revolutionized our approach to athletic injuries and also to tendinopathies involving Boomer athletes.

PRP is an ultraconcentrate of blood that contains a large number of platelets, prpcells packed with growth and healing factors.

PRP ideally is administered using an ultrasound guided needle tenotomy injectingprptoankle-mmiller-13technique.  What this entails is using a small gauge needle to “pepper” the area of tendon damage to induce an acute inflammatory response.  Inflammation is the first step in healing. Inflammation causes the platelets to release their growth factors and initiate the healing of the damaged tendon.  The inflammatory phase lasts roughly about a week.  The healing phase lasts about 3-04 weeks.  The final stage is the reorganization phase where the tendon fibers are organized into a normal fiber pattern.  This can take up to a year.

Nonetheless, the ability to heal tendon damage withour having to resort to surgery is exciting.  In those patients who don’t respond to two PRP treatments, autologous stem cells are indicated.

 

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What’s a good exercise program for arthritis?

This is one of the most asked questions when it comes to arthritis.

Exercise is an often neglected form of treatment.  I consider it as important for an arthritis patient as medication.

exercise-clipartThe three types of exercise an arthritis patient should engage in are:
1. Low impact cardio (bike, swimming, elliptical trainer).  Cardio helps with overall conditioning as well as increasing blood flow to joints.
2. Resistance (weights). Resistance training strengthens muscles that help support joints.
3. Stretching . Stretching prevents injury and keeps joints flexible. One very good form of stretching is yoga.

Exercise should be done on a daily basis.  I know this runs counter to the idea that a day of rest is needed.  The day of rest should be devoted to stretching.

Now these are general guidelines since some patients are much more into exercise than others. There are quite a few people with arthritis who are competitive athletes.

Bottom line: If you are relatively sedentary, you should start out very slowly and know your limits.  Consultation with a physical therapist is a good idea.

If you already are an experienced athlete, then you will be able to design a program that incorporates the above three components.

As a rheumatologist who also has osteoarthritis, I exercise regularly but know what I can and cannot do. One last important point is to set some goals before you start.  That will help keep you on track.

For more information on  arthritis treatments and other arthritis problems go to:

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