Common Injuries & Conditions

Upper Extremity:
- Elbow
- Shoulder
Lower Extremity:
- Foot & Ankle
- Knee
- Hip & Upper Leg

Fractures & Dislocations
Arthritis

Common Orthopedic Injuries & Conditions
Upper Extremity: Elbow

Bursitis of the Elbow

Bursitis is the painful inflammation of the bursa, a synovial fluid-filled sac found in areas subject to friction such as joints. With over 150 in the human body, the bursae serve as a lubricant and cushion movement between the muscles, tendons and bones at and around the joints.

Generally caused by repetitive movement and stress, Bursitis can affect the heel (achilles) and toes as well as the knee, elbow, and shoulder joints. The most common site for bursitis, though, is the shoulder.

The inflammation associated with bursitis causes pain during movement and limits range of motion in the affected limb. Pain and tenderness, particularly at the affected joints, are common symptoms. There may also be swelling and redness, with some warmth to the touch. At the hip joint, the bursae are deeper and swelling is not as visible. In the shoulder, bursitis hinders arm movement - making it difficult to raise the arm outward from the side of the body and affect such activities as putting on a jacket and combing the hair.

Bursitis symptoms tend to appear suddenly in acute bursitis cases, though are brought on gradually with exercise or activity in chronic bursitis cases.

Those at Risk
Those most often affected by bursitis are athletes subjecting their limbs and joints to repetitive movements. Those involved in laborious jobs subjecting the same joints to the same physical movement day after day are also affected.

Bursitis can also be the result of a trauma, rheumatoid arthritis and a chronic or acute infection.

Treatment
A physical assessment of pain, limited range of movement and any associated swelling in the affected limb will help determine the diagnosis and best bursitis of the elbow treatment plan. X-rays are not effective tools in identifying bursitis. Inserting a thin needle into the affected bursa and removing (aspirating) some of the synovial fluid for further examination will confirm the diagnosis. In such cases, the fluid is generally not clear. It can be tested for the presence of microorganisms, which would indicate an infection, as well as for crystals, which could indicate gout.

Bursitis responds well to conservative treatment, which usually entails heat, rest, and immobilization of the affected joint area. A sling may also be used for a shoulder injury.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen may be indicated for pain and inflammation. Rehabilitation exercises of the affected area begin after the period of rest. If the nearby muscles have become weak as a result of the condition or the immobility, then rehabilitation exercises designed to rebuild strength and range of motion become part of the treatment plan.

If the bursitis is related to an inflammatory condition such as arthritis or gout, then treatment entails management of that disease first in order to control the bursitis.

When bursitis fails to respond to an initial conservative treatment plan, an injection into the joint of a long-acting corticosteroid can have positive results. Usually one injection is all that is needed.

If the bursitis persists, surgery to remove the damaged bursa may be indicated.

If the bursitis is caused by an infection, additional treatment may be needed. Septic bursitis is caused by the presence of an organism, Staphylococcus aureus. Septic bursitis requires treatment with antibiotics that can be administered by mouth, injected into a muscle, or injected intravenously. The bursa will also need to be drained by needle two or three times over the first week of treatment.

Contusions

Contusions are often seen in contact sports and are the result of a strong force or fall. Affecting the forearm muscles and elbow bone, they are frequently accompanied by a fracture and present with bruising and possibly some bleeding. Shortly after the injury, stiffness can occur during activities requiring range of motion of the elbow.

They can also produce an actute hemorrhagic bursitis or a common chronic olecranon bursitis, depending on the area sustaining the force. A contusion to the ulnar nerve (an area often referred to as the "funny bone") can be very painful and send burning sensations down the ulnar side of the forearm to the ring and little fingers.

Those at Risk
Contusions are common injuries in sports, particularly contact sports such as football, baseball and basketball. Individuals and athletes involved in full contact sports or other types of extreme sports such as motocross and BMX are more likely to experience this type of injury. Contusions can also result from an accident as well.

Treatment
The best course for contusion treatment is determined following a full examination of the injured area and assessment of the severity and any other related injuries. The patient's history and the cause of the injury are also assessed. Often times an X-ray can help determine the presence of an associated fracture and probability of other soft tissue damage. If a fracture is present, the best form of reduction and stabilization is determined based on the type of break - followed by a period of rest then rehabilitation exercises in order to reduce the risk of permanent stiffness in the limb.

Elbow Instability

Elbow instability is generally created from overuse activities or excessive force placed on the elbow joint, which causes progressive weakening and possible detachment of an elbow ligament further jeopardizing the joint environment. The instability can affect the outer, or lateral, portion of the elbow, or the inner, or medial, portion.

Most often seen in repetitive throwing activities, or a trauma that resulted in a dislocation, the severity of the instability is based on a number of factors:

The acute nature of the condition - chronic, recurring
Area of impact and irritation
The direction of the displacement
The degree of displacement
Presence of associated fractures

Those at Risk
Individuals engaging in repeated throwing activities in either work or sports are at greater risk for medial (inner) elbow instability. Lateral (outer) elbow instability is most often diagnosed in those suffering from a trauma resultant of an earlier repair of a dislocated elbow.

Treatment
Following a thorough examination and assessment of patient history some imaging may be required in order to confirm diagnose, assess the degree of disruption and other related damage before determining the best treatment plan.

The most common elbow instability treatment is generally conservative and may include a course of anti-inflammatory medication and temporary refrain from the activity responsible for prompting the condition. When elbow instability fails to respond to conservative treatment, other treatment such as joint reconstruction may be indicated in order to repair the ligaments and restore joint stability. Restoring joint stability is very important in deterring other degenerative conditions such as osteoarthritis.

Medial Collateral Ligament (MCL) Injury - Baseball Elbow

Baseball elbow, otherwise known as, medial collateral ligament (MCL) injury, is an uncommon injury for a non athlete. Seen most often in sports medicine, the injury occurs when the elbow becomes weakened over time by the high velocity motion of pitches performed in amateur and professional baseball. The type of force required for balls to reach the extremely high rates of speed that they do over time weakens the elbow joint and results in this type of ligament injury.

The MCL is part of a network of ligaments and tendons that help stabilize the ulna and the humerus at the elbow joint. When this network experiences continuous and excessive force, it becomes irritated - compromising the integrity of the elbow joint. The resulting inflammation and stress can result in the formation of bone spurs, as well as cartilage and ligament tears.

A MCL tear can compromise the stability of the elbow joint and result in more serious degenerative conditions if not properly address.

Patients experiencing a MCL tear may not initially be aware of the injury, as there is relatively little pain and no loss of range of motion. Though the strength of the arm and force with which a ball can be thrown is greatly reduced. A MCL tear can happen suddenly or gradually over time.

Those at Risk
Those most at risk for a medial collateral ligament injury are athletes involved in a throwing sport such as pitchers in Baseball. The continuous force required in pitching, particularly at the professional level, places stress on the elbow joint and increases the likelihood of an MCL tear.

Treatment
A physical examination and assessment of the patient’s history, as well as a discussion regarding how the injury occurred will help determine the best treatment plan. An X-ray and/or MRI (magnetic resonance imaging) may be employed to better identify the extent of the injury. Depending on the severity of the injury, treatment may entail a period of rest, refraining from the activity that caused the injury - followed by rehabilitation exercises and physical therapy.

Exploratory arthroscopy and surgical repair may be required for more extensive tears. The surgical procedure used to repair this type of injury is named after a former professional baseball player who was among the first professional athletes to resume his sport following such an injury once believed to be a career ender. The Tommy John surgery, also known medically as medial collateral ligament reconstruction, has effectively addressed these types of ligament tears - quickly restoring strength by using a ligament-tendon exchange.

Medial Epicondylitis (Golfer's Elbow)

Categorized as an overuse tendinopathy, medical epicondylities, also known as Golfer's Elbow, is a fairly common overuse condition affecting the avid and casual tennis player, volley ball player and golfer alike. Unlike Tennis Elbow Syndrome, the pain experienced in medial epicondylitis is felt at the inside rather than the outside of the elbow – though impacts similarly the tendon located around the bony portion of the elbow and within this joint.

Medial epicondylitis affects the inner portion of the elbow and is caused by the excessive and repeated force used to bend the wrist toward the palm. This occurs in such activity as pitching a baseball, swinging a golf club or serving a tennis ball. The repetitive movement placed at the elbow joint eventually causes irritation at the joint and subsequent inflammation of the tendon.

The repeated force of the activity also causes damage to the tendons responsible for this bending action and can result in pain that generates from the elbow to the wrist, on the palmar side of the forearm.

While the condition may also result from a number of other everyday activities, it has become popularized by golfers and is most often referred to as Golfer's Elbow.

The amount of pain associated with golfer’s elbow varies on the severity of the condition and can be mild to moderate. Over time, it can become increasingly more evident and persistent - spreading down the forearm. If left untreated, the pain can eventually become debilitating, disrupting sleep and causing progressive weakness in the arm. Activities such as reaching and grasping may become painful and pain may become chronic.

Those at Risk
Golfer's Elbow is generally found in those involved in repetitive positions within sporting activities or manual labor work. They are often between the ages of 20 and 40 years of age.

The condition may also be prompted by a random activity that is awkward for the limb and out of the ordinary - lifting heavy objects overhead and yard work. But, generally, those activities placing continuous strain on the muscles and tendons of the forearm and elbow are likely to prompt the condition.

Treatment
A complete physical examination and possibly x-rays will help confirm the diagnosis and determine the severity of the condition and best golfer's elbow treatment plan. Generally conservative, non surgical, treatment plan are used to address this type of tendinopathy. This may entail anti-inflammatory medication and rest in order to address the associated inflammation and relieve the pressure within the elbow joint.

Other conservative, less invasive procedures may be indicated if symptoms continue after a period of rest and anti inflammatory medications - including ultrasound therapy and rehabilitation exercises.

Chronic lateral epicondylitis failing to respond to nonsurgical treatment may require a lateral epicondyle release, which is also performed as an outpatient procedure

Radial Tunnel Syndrome

Also called resistant tennis elbow, Radial Tunnel syndrome, is the compression of the radial nerve that runs along the forearm. Playing a large role in the function of several muscles around the wrist and hand, the radial nerve can become compressed or pinched at the forearm or elbow and cause muscles down the arm to become weak.

While the symptoms of radial tunnel syndrome are similar to those of tennis elbow syndrome, they are prompted by completely different activities affecting different nerves and tendons. Radial tunnel syndrome is caused when the nerve that controls muscles around the wrist and hand (the posterior interosseous nerve) is pinched or compressed - resulting in muscle weakness and pain over the elbow at the point of compression.

The pain generated from radial tunnel syndrome usually causes pain approximately four centimeters beyond the bony prominence (funny bone) on the outside of the elbow.

Symptoms are similar to those experienced in Tennis Elbow and can include pain at the top of the forearm and back of hand when the wrist and fingers are spread. Though, the similarities between the two conditions stop there.

Since the radial nerve connects primarily to muscle, there is no loss of sensation. Beginning at the side of the neck where individual nerve roots leave the spine and exit through small openings (called foramen) between the vertebrae, the radial nerve is one of three joining at the nerve roots. Together with the ulnar and median nerves, they are responsible for arm and hand function, traveling down the arm to the hand and passing down the back of the upper arm, around the outside of the lateral portion of the elbow and down the forearm and hand.

Those at Risk
Individuals most seen with radial tunnel syndrome are engaged in repetitive activities (perhaps temporarily with a project or ongoing with a job or sport activity). Though, this type of nerve compression can also result from an injury - surfacing as a ganglia, lipoma, bone tumor and inflammation of the surrounding bursa or muscles. Aggravating movements include forceful and repetitive pushing, pulling, gripping, bending and twisting.

Though the condition is classified as a repetitive stress, or overuse condition, it can also result from a single direct blow to the outside of the elbow.

Treatment
A physical examination and patient assessment may be followed by an electromyogram (EMG), which helps assess muscle function. A nerve conduction velocity (NCV) test may also be indicated in order to help determine if nerve compression exist.

Treatment options for nerve compression conditions such as radial tunnel syndrome are generally conservative and may entail a period of rest from the activity responsible for the irritation, as well as a removable arm splint and rehabilitative exercises.

Chronic cases failing to respond to conservative treatment may require surgical repair. The nerve decompression procedure performed is an outpatient procedure followed by a rehabilitation program at our Houston rehabiliation center that helps change hand and arm position and movement during activities, in order to reduce the chance of a recurrence

Tennis Elbow Syndrome

A common overuse condition experienced by tennis players and the everyday active alike, Tennis Elbow Syndrome, is a condition that affects the tendon and median nerve located around the lateral epicondyle (the bony bump located at the back or outside of the elbow).

Also known medically as lateral epicondylitis, the condition is prompted by a repetitive movement that eventually causes irritation at the elbow joint, constriction of the carpal tunnel through which the median nerve must travel and subsequent inflammation of the tendon.

The median nerve is a significant nerve connecting the brain and spinal cord, down to the finger tips. When the median nerve is pinched or constricted as it passes through the carpal tunnel of the wrist it does not function properly and can cause a number of problems as a result.

Symptoms associated with Tennis Elbow may be mild to moderate pain located towards the outer portion of the elbow, which over time becomes increasingly more evident and persistent - spreading down the forearm and to the back of the middle and ring fingers. The pain can eventually become debilitating if the condition goes untreated, causing progressive weakness in the arm. Reaching and grasping activities may become painful, and persistent discomfort may be present while at rest following activities.

Those at Risk
While the condition is named after a particular sport, the vast majority of those diagnosed each year with Tennis Elbow are not tennis players at all. They are everyday individuals performing repetitive activities that place strain on the elbow joint. The condition may also be prompted by an activity that is awkward and out of the ordinary. The average age of Tennis Elbow Syndrome sufferers is between 40 and 60. The types of activities most often identified as prompting the condition include - gardening, frequently lifting children, painting, storing luggage in an overhead compartment or high closet shelf, painting with a brush or roller, using a chain saw or hand tools.

Generally, those activities placing continuous strain on the muscles and tendons of the forearm and elbow are likely to prompt the condition.

Treatment
A physical examination and assessment of the patient's medical history, lifestyle and activities help in initial diagnosis. Imaging scans may be indicated in order to determine the severity of the condition and the best treatment plan. Conservative treatment is used in mild to moderate cases, addressing inflammation and relieving stress on the affected area. Other minimally invasive procedures may be indicated if symptoms continue after a period of rest and anti inflammatory medications. Other nonsurgical treatment options may include ultrasound therapy and rehabilitation.

Chronic lateral epicondylitis failing to respond to nonsurgical treatment may require a lateral epicondyle release, which is also performed as an outpatient procedure

Triceps Tendon Inflammation and Rupture

The triceps tendon, which is located on the back side of the upper arm (opposite the biceps tendon) inserting into the back of the elbow, just as any other tendon subjected to excessive activity and stress, becomes inflamed. This generally occurs in athletes training hard for their sport and lifting weights beyond the point of muscle fatigue. This can also occur by pushing something that is too heavy or by breaking a fall on outstretched arms.

If the inflammation is not addressed and the activity temporary halted, the triceps tendon can rupture. The symptoms of inflammation or a rupture may include elbow pain at rest or during activity, reduced elbow function and painful swelling at the back of the elbow.

Those at Risk
Athletes over training the biceps muscle and under training the opposing triceps muscle while subjecting both muscles groups to strenuous workouts are most at risk for triceps tendon inflammation or rupture. Those involved in activities more frequently involving falls than others, such as skateboarding or roller bladding, are also at risk as the arms are used more often than not to break those falls.

Treatment
A complete examination and discussion of daily activities, followed by and MRI (magnetic resonance imaging) or arthrogram for those with resistant elbow pain, will help determine the severity of the problem and the best treatment plan.

Less invasive nonsurgical treatment has proven successful in treating triceps tendon inflammation or ruptures and may include cold compression to reduce swelling, nonsteroidal anti-inflammatory drugs (NSAIDs) and period of rest. Rehabilitative exercises and physical therapy may also be indicated to help the patient return to a competitive sports level of strength.

When the condition fails to improve with conservative treatment, surgery to repair the tendon may be indicatedc. This depends on the patient's history, age and level of activity that must be resumed.

Ulnar Collateral Ligament (UCL) Tear

Comprised of the anterior, posterior and transverse bands, the Ulnar Collateral Ligament (UCL) represents the main stabilization for the elbow joint. The anterior band most prominently impacts valgus stability and exposed to stress. When it is stressed, it can tear or rupture.

Sports involving constant extreme force, such as competitive overhead and throwing sports like baseball, football, volleyball and swimming, places stress on the UCL and over time causes damage. It is during the acceleration of the overhead throw or motion that the largest amount of valgus force is placed on the elbow - while the forearm disproportionately lags behind the upper arm causing valgus stress. The elbow becomes dependent on the anterior band of the UCL for stability. The extreme acceleration can cause the valgus force to overcome the tensile strength of the UCL and result in either chronic microscopic tears or an acute rupture.

Tears may cause a "popping" should and quickly accompanied by weakness and reduced arm function.

Once career-ending injuries for athletes, today better diagnostic techniques and treatment makes it no more than a minor set back.

Those at Risk
The competitive athlete engaging season after season in an overhead sport is at greatest rish for UCL injuries as their elbow joint endures an unusual amount of high acceleration flexion and extension.

Treatment
An imaging scan may be performed following a complete examination, review of patient history and discussion of the activity most likely responsible for causing the injury.

Based on the severity of the injury, treatment may require only a brief refrain from the activity responsible for the injury, followed by rehabilitative exercises. More severe tears and injuries that do not respond to conservative treatment may require exploratory arthroscopy to identify the severity of the damage and surgical repair.