Common
Problems
Anatomy of the Back
Ankle Anatomy
Anterior Cruciate Ligament
Cervical Disc Disease
Lumbar Disc Disease
Lumbar Strain
MCL and LCL Injuries
Meniscal Injuries
Achille’s Tendinitis
ITB Syndrome
Hip (Trochanteric) Bursitis
Lateral/Medial Epicondylitis
(Tennis/Golfer’s Elbow)
Patellofemoral Pain Syndrome
Rotator Cuff Tears
Plantar Fasciitis (Heel Spur
Syndrome)
Shoulder Impingement Syndrome
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
The normal anatomy of the spine is divided into three
regions. Each region is made up of individual bones
referred to as vertebrae. The upper region is referred
to as the cervical region and usually consists of
seven vertebrae. The middle region is referred to
as the thoracic spine and is made up of 12 vertebrae.
Finally, the lower region is known as the lumbar spine
and is made up of 5 vertebrae. Beneath the lumbar
spine is a fused bone known as the sacrum. Attached
to the sacrum is another fused bone known as the coccyx,
or the tailbone.
The spine is vitally important because it provides
both stability and flexibility, while protecting the
spinal cord. Many people will experience some form
of back pain in their lifetime, so knowledge of the
anatomy is important in understanding where your pain
is coming from.
Each vertebra can be divided further into individual
parts. The body of the vertebra provides the weight-bearing
area of the spine. Vertebrae have holes in them known
as the spinal canal, which allows the spinal cord
to pass down the spine. They also consist of spinous
processes, which are the “bumps” that
you can feel when you run your hands down your back.
Transverse processes are oriented 90 degrees to the
spinous processes and provide a place for muscles
to attach. The vertebrae also come together at facet
joints, giving further stability to the spine.
The vertebrae are separated by intervertebral discs,
which act as cushions between the bones. The disc
can be further separated into the outer fibrous ring
(annulus fibrosis) and the inner “watery”
centre, called the nucleus pulposis. When a disc protrudes
out, or herniates, this can cause pain in the back
and legs.
Your doctor uses his or her knowledge of the anatomy
of the spine, your symptoms, your physical examination,
and occasionally further investigations to diagnose
which part of your back is causing the problem. Then
an appropriate treatment plan can be instituted so
you are able to return to the activities you enjoy!
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
The ankle joint is composed of three bones: the tibia,
fibula and talus, and three ligamentous complexes
that join the bones together: lateral, medial and
syndesmotic. The ankle, along with the joints in the
foot, allow for both up and down and side to side
foot motion. Injuries to the ligaments are called
sprains and are very common around the ankle. Fractures
also occur frequently about the ankle.
Ankle Sprains
The ankle is one of the most commonly sprained joints.
The most common ankle sprain is a lateral ankle sprain,
which occurs when the sole of the foot turns inward,
resulting in stretching or tearing of ligaments on
the outside of the ankle. Another type is the high
ankle sprain, which is more common in high velocity
contact collision sports like football and hockey.
This is an injury to the ligaments that connect the
tibia and fibula, the two bones in the lower leg.
Common symptoms include pain, swelling, and sometimes
difficulty putting weight on the affected leg. Ankle
sprains are graded 1 through 3, with 3 being most
severe. Your doctor will determine if x-rays of the
ankle are required based on the severity of the symptoms.
Ankle sprains are treated with rest, ice, elevation,
anti-inflammatory medications, physiotherapy, activity
and exercise progression back to full weight bearing
as tolerated, and often taping or protective bracing
once the patient is ready to return to sports.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
The anterior cruciate ligament (ACL) is a stabilizing
structure in the knee that connects the femur (thigh
bone) to the tibia (shin bone). It prevents abnormal
anterior motion and shifting forward of the tibia
with respect to the femur and provides stability with
twisting, turning and pivoting type activities.
This ligament is one of the most commonly injured
structures around the knee. People may tear the ACL
through a noncontact injury such as changing directions
rapidly, landing from a jump, or rapidly decelerating
while running. The ACL may also be torn from a contact
injury such as being tackled. A torn ACL should be
suspected if you injured your knee and felt as though
the knee shifted abnormally or feeling or hearing
a “pop”. Often the knee swells within
a few hours after injury.
Initial treatment often includes ice, a knee immobilizer
to limit knee motion and crutches. Sports activities
should not be resumed until you are evaluated by a
Sports Medicine Specialist or Orthopedic Surgeon.
During your evaluation, the doctor will examine your
knee to determine if there is abnormal movement, indicating
a torn anterior cruciate ligament. Your doctor may
obtain x-rays and/or magnetic resonance imaging (MRI)
of the knee to help evaluate your injury.
A torn ACL can be treated surgically or nonsurgically.
Your activity level, symptoms, age and other associated
injured structures in the knee will help determine
if your injury should be treated with or without surgery.
The ACL rarely heals on its own due to the nature
of its structure. Nonsurgical treatment for less active
people often includes muscle strengthening exercises
and the use of a brace to try to help provide stability.
Surgical treatment replaces the damaged ACL with another
strong tissue, such as autologous hamstring or patellar
tendon. Successful reconstruction of the ACL provides
stability to the knee and often allows return to full
pivoting, jumping and contact sports and activities.
After surgery, there is a rehabilitation period to
work on regaining your knee motion, strengthening
your leg and allowing the new tissue to heal into
the bones in your leg. The recovery period usually
lasts between 6 and 12 months.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
The spine is made up of vertebrae, which are separated
by intervertebral discs. The disc is a combination
of a hard outer layer, known as the annulus fibrosis,
and a soft inner layer, known as the nucleus pulposus.
The disc acts a cushion or “shock-absorber”
for the spine. As you age, the disc starts to lose
some of its water content and becomes less effective
in terms of shock absorption. This may lead to the
center of disc “rupturing” or “herniating”
through the annulus fibrosis.
Occasionally when the disc herniates, it may “impinge”
or touch the spinal nerves that travel nearby. This
may lead to neck pain as well as pain, numbness, tingling
or weakness in the arms.
Your sports medicine physician will determine if
you have this problem after discussing your symptoms
and performing a physical examination. Depending on
your symptoms, further investigations may be ordered
(xrays, CT, MRI) to help the physician make the appropriate
diagnosis and determine what the best treatment plan
is for each individual patient.
While a herniated disc sounds serious, most people
are able to return to their normal activities within
several weeks or months with only conservative treatment.
This includes the use of anti-inflammatory medications,
physical therapy and the avoidance of activities that
increase the neck pain. In addition you may consider
seeing a practitioner that specializes in “manual”
medicine. Occasionally, a trial of steroid injections
into the neck may help decrease ongoing inflammation.
Surgical treatment is indicated for some patients,
especially those with symptoms not responding to conservative
treatment. This often helps relieve the pain in the
arm, though it may not relieve the symptoms in the
neck. The goal of the surgery is to remove the part
of the disc that is “pressing” on the
spinal nerve. This is often accomplished via a “discectomy”.
Sometimes the physician may have to remove some of
the bone as well. After surgery, many physicians will
still recommend physical therapy to strengthen the
spine and relieve pain.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
The spine is made up of vertebrae, which are separated
by intervertebral discs. The disc is a combination
of a hard outer layer, known as the annulus fibrosis,
and a soft inner layer, known as the nucleus pulposus.
The disc acts a cushion or “shock-absorber”
for the spine. As you age, the disc starts to lose
some of its water content and becomes less effective
in terms of shock absorption. This may lead to the
center of the disc “rupturing” or “herniating”
through the annulus fibrosis. This most commonly occurs
at the lowest levels in the lumbar spine, typically
L4-5 and L5-S1.
Occasionally when the disc herniates, it may “impinge”
or touch the spinal nerves that travel nearby. This
may lead to back pain as well as pain, numbness, tingling
or weakness in the legs.
Your sports medicine physician will determine if
you have this problem after discussing your symptoms
and performing a physical examination. Depending on
your symptoms, further investigations may be ordered
(xrays, CT, MRI) to help the physician make the appropriate
diagnosis and determine what the best treatment plan
is for each individual patient.
While a herniated lumbar disc sounds serious, most
people are able to return to their normal activities
within several weeks or months with only conservative
treatment. This includes the use of anti-inflammatory
medications, physical therapy, and the avoidance of
activities that increase the back pain. In addition
you may consider seeing a practitioner that specializes
in “manual” medicine. Occasionally, a
trial of steroid injections into the back may help
decrease ongoing inflammation.
Surgical treatment is indicated for some patients,
especially those with symptoms not responding to conservative
treatments. This often helps relieve the pain in the
leg, though it may not relieve the symptoms in the
back. Rarely, a patient will complain of bowel or
bladder incontinence. This may be a sign of “cauda
equina syndrome” and is a surgical emergency.
The goal of the surgery is to remove the part of the
disc that is “pressing” on the spinal
nerve. This is often accomplished via a “discectomy”.
Sometimes the physician may have to remove some of
the bone as well. After surgery, many physicians will
still recommend physical therapy to strengthen the
spine and relieve pain.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
A lumbar strain is an injury to the lower back that
results in stretching or tearing of the lumbar muscle
and damage to the tendons. This often results in muscle
“spasm” and is a very common cause of
low back pain. Many people will experience this at
some point in their lifetime.
Lumbar muscle strains most commonly occur with some
sort of pushing, pulling, lifting or twisting injury.
Usually the patient can recall when it happened and
it is sometimes described as “my back went out”.
Pain usually remains in the low back without radiation
down the legs.
Your sports medicine physician makes the diagnosis
after discussing your symptoms and performing a physical
examination. Occasionally, further investigation may
be necessary (xray, CT, MRI) in order to rule out
other, more serious conditions. The doctor may provide
a prescription for anti-inflammatory medication or
muscle relaxants and recommend physical therapy. A
manual practitioner may also help speed the resolution
of your symptoms. Your doctor may recommend short-term
rest (up to 48 hrs), though being more active seems
to help people return to their activities more quickly
than those with complete rest.
The goal of the physician is to have their patients
return to sports or work as quickly and as safely
as possible. Most people will have complete resolution
of their symptoms and return to their normal activities
in several weeks to several months.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
The medial and lateral collateral ligaments (MCL
and LCL) are stabilizing structures on the inner and
outer sides of the knee that connect the femur (thigh
bone) to the lower leg. They prevent abnormal side-to-side
motion and shifting of the tibia with respect to the
femur and provide stability with twisting, turning
and pivoting type activities.
The medial collateral ligament is one of the most
commonly injured structures around the knee. People
usually injure the MCL through a contact injury when
the knee is struck from the outside (lateral side).
Injuries to the MCL occur often in contact sports
such as football, hockey and soccer. Injuries to the
lateral side of the knee are much less common and
often involve more severe trauma to the knee.
The signs of a significant knee injury that may include
an injury to the collateral ligaments are pain and
difficulty walking after injury. Swelling of the knee,
pain with motion and a sense that the knee will give
out are signs of a knee injury that should be further
evaluated by a health care provider. Initial treatment
often includes ice, a knee immobilizer to limit knee
motion, anti-inflammatory medications and crutches.
Sports activities should not be resumed until you
are evaluated by a sports medicine physician or an
orthopedic surgeon. During your evaluation, the doctor
will examine your knee to determine if there is abnormal
movement indicating a torn collateral ligament. Your
doctor may order further tests of the knee (xrays,
MRI) to help evaluate your injury.
Isolated MCL injuries are usually treated without
surgery. Your doctor may recommend a hinged knee brace
to limit side-to-side motion of the knee to allow
the injured tissue to heal. Your doctor will also
typically recommend a course of rehabilitation with
a physical therapist. Sometimes when the MCL is severely
injured or damaged in combination with other structures
of the knee, surgery may be necessary. Isolated LCL
injuries occur rarely and are often combined with
injuries to other structures around the knee. Mild
injuries may be amenable to nonoperative treatment
including brace wear and rehabilitation exercises.
More severe LCL injuries or LCL injuries in combination
with other ligament injuries often require surgical
treatment. After any surgery, there is a rehabilitation
period to work on regaining your knee motion, strengthen
your leg and allow the tissue to heal. The recovery
period usually lasts between six and 12 months.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
The menisci are C-shaped fibrocartilage shock absorbers,
important for stabilizing and cushioning the knee.
Injury to the individual meniscus is considered to
be either traumatic or degenerative in origin, each
with unique characteristics.
Traumatic meniscal tears are usually seen in young,
athletic individuals and may occur during either contact
or noncontact activities, particularly during sports
that require aggressive pivoting and twisting maneuvers.
There is a frequent association with injuries to the
anterior cruciate ligament (ACL). Most traumatic tears
are oriented in a vertical/longitudinal fashion.
In patients older than 40 years of age, degenerative
tears of the meniscus tend to be more common. There
is usually no history of prior trauma. Degenerative
tears tend to coexist with other degenerative knee
conditions, such as osteoarthritis. They have little
to no ability to heal on their own. Arthroscopically,
degenerative tears most commonly demonstrate a horizontal
cleavage or complex orientation or pattern.
Based upon relative blood supply, different meniscal
zones of vascularity have been demonstrated. The most
well vascularized, peripheral 25-30 percent of the
meniscus is referred to as the “red-red zone.”
The middle portion of the meniscus is known as the
“red-white zone,” with vascularity peripherally,
but not centrally. Finally, the most central portion
is the “white-white zone,” which is essentially
avascular. This classification of meniscal vascular
zones has implications for meniscal healing. Therefore,
peripheral (vascular) tears are more likely to heal
than central (avascular) tears.
Initial treatment in most instances consists of conservative,
nonoperative treatments. These include nonsteroidal
anti-inflammatory medications to reduce pain and inflammation,
physical therapy to reduce inflammation and preserve
knee strength and motion, and occasionally intra-articular
steroid injections, to calm local inflammation. If,
however, these modalities are ineffective, arthroscopic
surgical intervention may be required.
The choice to proceed with partial meniscectomy versus
meniscal repair depends upon several factors. Specifically,
the pathology, location and direction of the tear
must be considered, as well as the stability of the
knee itself. The ideal situation that would favor
repair over meniscectomy would be a traumatic, acute
tear, in the outer one-third of the meniscus, either
longitudinal or horizontal, in a ligamentously stable
knee. Otherwise, partial meniscectomy would be a better
choice, particularly for degenerative, complex tears.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
What is it?
Achilles tendonitis is inflammation of the Achilles
tendon, often an overuse injury. Micro-tears to the
tendon can result from repetitive stress to the area.
Rapid increase in activity level, improper warm-up,
altered running terrain, inappropriate footwear, biomechanical
factors and generalized overuse may increase one’s
risk of developing this condition.
How does it present?
Achilles tendonitis presents as pain or stiffness
in the lower calf or heel. Pain is worse with activity,
especially running and jumping. Swelling and tenderness
to touch may also be present. Achilles tendonitis
may develop over weeks to months or be of short-onset.
How do we evaluate it?
Evaluation of Achilles tendonitis is based on history
and physical exam. Exam may reveal poor calf flexibility,
tenderness and/or swelling over the Achilles tendon,
and decreased calf strength. Occasionally further
investigations may be necessary to rule out other
associated conditions.
Treatment?
Treatment of Achilles tendonitis includes relative
rest, with modification of activity initially. Ice
and NSAIDS (non-steroidal anti-inflammatory medication)
may help control pain symptoms. Heel lifts can effectively
shorten the tendon and may reduce stress or stretch
to the tendon with activity. Rehabilitation, through
physical therapy modalities and therapeutic exercises
involving calf stretching and strengthening, may take
weeks to months to resolve. Treatment is essential
as this may become chronic or, with repeated trauma
and decreased strength of the tendon, predispose to
tendon rupture.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
What is it?
Iliotibial Band Friction Syndrome of the knee is a
common overuse injury which presents as pain located
along the outside of the knee, usually just above
the joint. The iliotibial band is a broad tendon that
runs from the pelvis to the tibia (shin bone) and
helps support the leg in walking and running. Friction
from constant rubbing of this tendon along the bones
of the knee may produce a burning pain or ache along
the side of the knee. Bursitis of the underlying supportive
cushion may also be associated with this condition.
How does it present?
Iliotibial Band Friction Syndrome of the knee generally
presents as gradual onset of lateral knee pain. Pain
is worse with activity such as running, cycling and
descending stairs. There may be associated painful
snapping or popping felt on the outside of the knee.
This syndrome is common among runners.
How do we evaluate it?
Evaluation of iliotibial band friction syndrome is
based on history and physical exam. Tenderness may
be present along the distal (lower) iliotibial band.
Restriction or tightness may also be appreciated.
Sometimes, a snapping sensation can be palpated by
the examiner or felt by the patient as the band glides
along the bones of the knee.
Treatment?
Treatment includes ice, NSAIDS (anti-inflammatory
medications), and relative rest or modification of
training activities, especially running or hill training.
Stretching and strengthening is a mainstay of treatment
and often guided through physical therapy. Manual
therapy may also be effective to help in recovery.
Despite these treatments it may still take weeks to
months to improve and GRADUAL return to activity is
imperative.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
What is it?
Greater trochanteric bursitis is an inflammation of
the greater trochanteric bursa. The greater trochanter
is a bony prominence on the outside aspect of the
femur. It is covered with a bursa which is a closed
sac containing fluid usually found or formed in areas
subject to friction. Inflammation may occur secondary
to friction or trauma. The iliotibial band overlies
the bursa and a tight iliotibial band may often compress
the bursa or cause irritation as it slides over the
greater trochanter. Other biomechanical factors including
broad pelvis, leg length discrepancy, training errors
and excessive pronation of the foot may contribute
to the irritation.
How does it present?
Pain is usually localized over the greater trochanter.
Patients may have night pain preventing then from
sleeping on their affected side. The pain may increase
when rising from a seated position or after prolonged
walking. Pain may radiate to the thigh, knee or buttocks.
How do we evaluate it?
Evaluation of greater trochanteric bursitis is based
upon history and physical examination. The patient
will be tender to palpation over the greater trochanter.
Iliotibial band tightness and flexibility are evaluated.
Biomechanics of the hip, knee, ankle and leg length
discrepancies are evaluated which may all be contributing
to the pain. Further investigations (xrays, CT, Bone
Scan, MRI) are usually not necessary to make the diagnosis
but can help exclude other causes of hip pain including
stress fracture and arthritis.
Treatment?
Treatment of greater trochanteric bursitis includes
the use of NSAIDS, ice, activity modification, and
physical therapy. Patients may be prescribed a home
exercise program to help stretch both hamstrings,
hip flexors, external rotators and the iliotibial
band. Custom orthotics may be helpful if there are
any biomechanical abnormalities found. Training may
need to be modified to assist with treatment. Sometimes
a corticosteroid injection into the bursa can help
relieve symptoms by decreasing inflammation over and
around the bursa. Rarely surgery is indicated for
treatment.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
What is it?
The lateral epicondyle is the bony prominence located
on the outer aspect of the elbow, whereas the medial
epicondyle is located on the medial side. These are
important structures because here multiple tendons
originate. The tendons of muscles that help extend
and supinate the wrist originate at the lateral epicondyle,
whereas the tendons of muscles that flex and pronate
the wrist originate at the medial epicondyle. Either
of these can become inflamed, torn or begin to degenerate
through activities that cause repetitive motions or
direct trauma. The most common muscle involved is
the extensor carpi radialis brevis. Wrist extensor/flexor
overload, poor flexibility, poorly fitted equipment
and improper hitting techniques may contribute to
lateral/medial epicondylitis. Repetitive motions including
the use of keyboards can be a major contributing factor.
Lateral epicondylitis (tennis elbow) is ten times
more common than medial epicondylitis (golfer’s
elbow).
How does it present?
Patients will develop pain over the lateral (outer)
or medial (inner) aspect of their elbow, which can
occur both gradually and acutely. This pain may start
in the elbow and move into the forearm. Activities
that involve wrist extension such typing, lifting
weights in extension or even picking up a full cup
of coffee usually aggravate tennis elbow, whereas
flexion / pronation activities typically aggravate
golfer’s elbow. Usually a history of overuse
is established and activities that require repetitive
movements will usually aggravate the pain.
How do we evaluate it?
Evaluation of lateral / medial epicondylitis is based
upon history and physical examination. Pain is present
with palpation of the outer (lateral) or medial (inner)
aspect of the elbow. Pain can be reproduced with certain
resistive movements performed by the physician. Further
investigations are usually not necessary, but may
be useful to help rule out other diseases.
Treatment?
Initial treatment involves rest from aggravating activities
that cause pain; ice, NSAIDS (non-steroidal anti-inflammatories)
and tennis / golfer’s elbow braces. Occasionally
wrist splints, which are worn at night and prevent
over extension, can reduce pain. Ergonomic aids around
the keyboard and good posture are important in preventing
recurrence of symptoms. Physical therapy involves
strength training and flexibility to aid in the rehabilitation
of patients with epicondylitis. Manual therapy may
also be effective in reducing the symptoms. Occasionally
corticosteroid injections are performed to reduce
ongoing pain and inflammation. Proper use of equipment
and using equipment that fits the individual needs
to be addressed in the racquet sport athlete. It may
take from two weeks to six months for patients to
become pain free. Rarely surgery is indicated for
refractory cases.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
Anterior (patellofemoral) knee pain is one of the
most common knee complaints seen by sports medicine
professionals. A diagnosis of patellofemoral pain
syndrome (PFPS) comprises several different clinical
entities, the common hallmark of which are anterior
knee pain.
Patellofemoral pain may be due to one (or a combination)
of the following reasons: 1) soft tissue abnormalities,
such as a muscle imbalance or a tight lateral retinaculum
2) patellar instability with subluxation/dislocation
of the kneecap or 3) patellar malalignment, such as
an excessive Q angle (the angle between the anterior
superior iliac spine (ASIS) and the center of the
patella). Each of these may contribute to an excessive
lateral pull on the patella, leading to symptomatic
wear of the underlying patellar cartilage.
In addition, Chondromalacia of the patella can be
a source of anterior knee pain, particularly in young
women. It represents softening or fissuring of the
cartilage underlying the patella. Certain factors
predispose individuals to such a phenomenon, such
as a weak VMO, an excessive Q angle, and patella alta
(a high-riding kneecap).
Treatment initially consists of specific exercises
to strengthen the quadriceps muscle, especially the
vastus medialis oblique (VMO), or inner quadriceps.
At the same time, stretching and releasing any tight
lateral soft tissues is instituted. This is usually
achieved with the help of an experienced physical
therapist. Other initial treatments may include using
an open patellar knee brace or the use of custom orthotics
in order to treat any associated biomechanical abnormalities.
If unsuccessful, an orthopedic consultation may be
sought to determine if further surgical intervention
may be required.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
Definition
Rotator cuff injury is a strain or tear of the rotator
cuff. The rotator cuff is made up of four separate
tendons that fuse together to surround the shoulder
joint. These muscles and tendons connect your upper
arm bone (humerus) with your shoulder blade. They
also help hold the ball of your upper arm bone firmly
in your shoulder socket, called the glenohumeral joint.
This combination results in the greatest range of
motion of any joint in your body.
Rotator cuff injuries are fairly common. Causes of
the injury may include poor posture, falling, lifting
and repetitive overhead arm activities. The injury
is common among people whose jobs, sports or hobbies
include heavy or repetitive lifting, especially with
the arm in overhead positions. As you get older, your
risk of a rotator cuff injury increases.
Signs and Symptoms
Symptoms may include recurrent pain, especially with
certain activities, pain that prevents sleeping on
the injured side, grating or cracking sounds when
moving the arm, decreased range of motion and/or muscle
weakness especially when lifting the arm.
Diagnosis
Evaluation of rotator cuff injuries is based upon
a thorough history and physical examination. Occasionally
further investigations (x-rays, ultrasound, MRI) help
to guide the physician in diagnosing a rotator cuff
injury and to rule out other problems. X-rays help
to rule out fractures and bone deformities, while
an MRI helps to determine the extent of the rotator
cuff injury/tear.
Treatment
The treatment plan will depend on the extent of the
injury, level of pain, amount of immobility and the
age of the patient. The initial treatment is typically
rest, ice and nonsteroidal anti-inflammatory medications,
modified activities, as well as physical therapy to
help regain normal motion. If pain persists after
several weeks, the physician may inject corticosteroid
into the affected area.
Serious tears to the rotator cuff tendons usually
require surgical repair. An arthroscope is used to
view the shoulder joint and confirm the presence of
a tear. The arthroscope can also be used to remove
any bone spurs that may be present in the shoulder
and through this incision the torn rotator cuff edge
may be reattached to the humerus with stitches.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
Definition
Plantar fasciitis is a localized inflammation of the
plantar aponeurosis. The plantar fascia is a dense,
fibrous membrane that spans the entire length of the
foot, originating at the tubercle of the calcaneus
and attaching at the proximal phalanges. The fascia
protects the underside of the foot and helps support
the arches.
Predisposing factors for plantar fasciitis may include
anatomic or biomechanical abnormalities of the feet
or lower extremities, inappropriate footwear, muscle
tightness, obesity, overtraining or overuse. However,
because the condition is caused by repetitive microtrauma,
most people experience plantar fasciitis as part of
an overuse syndrome following changes in their usual
routines.
Signs and Symptoms
Patients often report severe heel pain upon weight
bearing. Pain is typically worse in the morning or
with the first steps after resting. Patients may note
that their pain gradually improves with activity.
Stretching with weight bearing causes increased pain.
On examination, the point of maximal tenderness is
usually on the medial calcaneal tuberosity. The pain
may be aggravated by passively dorsiflexing or actively
plantar flexing the foot.
Diagnosis
Evaluation of plantar fasciitis is usually based upon
history and physical examination. Occasionally further
investigations (xrays, US, CT, MRI) are performed
to determine if an associated heel spur is present
and to rule out other problems.
Treatment
Conservative treatments have long been the mainstay
of treating plantar fasciitis. Initial treatments
may include rest, ice, modified activity, and nonsteroidal
anti-inflammatory medications. Appropriate footwear
and/or custom orthotics addressing any anatomic or
biomechanical abnormalities may also be effective.
Physical therapy with an appropriate exercise program,
plantar fascia night splints, and occasionally corticosteroid
injections may also be prescribed by your physician
should your pain persist. A newer treatment called
Extracorporeal Shock Wave Therapy may also be effective
for some people. Rarely, surgical intervention may
be required for recalcitrant cases.
by Dr. M. Kramarchuk, MD, CCFP, Dip Sport Med.
Definition
Shoulder impingement syndrome is defined as a painful
entrapment of the supraspinatus tendon, subacromial-subdeltoid
bursa, and/or the biceps tendon between the humeral
head and the coracoacromial arch. Impingement most
often occurs in repetitive overhead activities such
as swimming, skiing, serving a tennis ball, spiking
a volleyball, throwing a ball, or jobs involving overhead
reaching.
Signs and Symptoms
The patient complains of pain around the top of the
shoulder over the acromion arch. Touching the area
with some pressure usually increases the pain and
the discomfort. There are also a number of examination
tests which the physician performs that help cofirm
that impingement exists.
Diagnosis
Evaluation of impingement syndrome is based upon a
thorough history and physical examination. Occasionally,
further investigations are necessary (xrays, ultrasound,
MRI) to distinguish between the various causes of
shoulder pain and help guide appropriate treatment.
Despite advanced imaging capabilities, impingement
remains a clinical diagnosis.
Treatments
The first step in treating these conditions is to
reduce pain and inflammation with rest, ice and anti-inflammatory
medicines such as aspirin, naproxen or ibuprofen.
Gentle stretching and strengthening exercises are
added gradually and quite often these are incorporated
into a formal course of physical therapy. If there
is no improvement, the doctor may inject a corticosteroid
medicine into the space under the acromion. If there
is still no improvement after six to 12 months, the
doctor may refer you to an orthopedic surgeon where
further surgical intervention may be necessary.
The primary aim of the surgical treatment of shoulder
impingement is to make more space available for the
tendons of the rotator cuff. Enlarging, or "decompressing"
the space between the acromion and the head of the
humerus can relieve the symptoms of impingement. Removing
a part of the acromion can stop the tendons of the
rotator cuff from rubbing on the bone. This type of
surgery is called an acromioplasty. Because inflammation
in the subacromial bursa contributes to the pain of
impingement syndrome, this lubricating sack is often
removed. This part of the procedure is called a bursectomy
or a debridement. These two procedures together are
called a sub-acromial decompression.
In general, the recovery from this surgery is usually
quite quick. Physical therapy exercises are started
very soon after surgery in order to speed up the rehabilitation
process.
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