Transcript OFFICE ORTHOPAEDICS

OFFICE
ORTHOPAEDICS
ANATOMICAL FACTS AND
MANAGEMENT GUIDELINES
THE NON-SPECIFIC
ACHES AND PAIN
SYNDROMES
COMMONEST
 Low back pain
 Interscapular pain
 Shoulder pain
 Anterior knee pain
 Multiple bony pains
LESS COMMON PAINFUL
AREAS
 Elbow
 Heel
and back of ankle
 Wrist, first carpometacarpal joint
 Neck
 Coccyx
Your bones reflect what you
eat and what you do for a
lifetime!
(Nutrition and activity are the
key points of musculoskeletal
health.)
ALL ACHES AND PAINS
DIRECTLY RELATED TO
1.Lifetime and current status of
nutrition
 ( Poor nutrition related pains)
 (obesity related pains)
2.Lifetime and current status of
physical activity
3.Medical illness/Psychological
make up
EFFECTS OF THE THREE
FACTORSfavourable/unfavourable

Long standing alteration in the
strength and mechanics of the bones,
joints and muscles.

range of movement of joints.

Changes in the attitude towards
physical activity (‘ I can’t move’)
Understanding the basic
muscle development
The upright human posture has best
of extensors developed as compared
to the quadrupeds.
 All placed on the dorsal side except
quadriceps and tibialis anterior.
 Need active, full and lifetime use to
prevent disuse and loss of ROM of
concerned joints

KEY MUSCLES OF UPPER LIMB
Trapezius
Levator scapulae
The rhomboids
Extensors of the wrist
Flexor pollicis longus
Abductor pollicis longus and extensor
pollicis brevis
Key muscles of non
specific aches and pains
BACK and LOWER LIMB
 Erector spinae
 Gluteus maximus
 Rectus femoris
 Vastus medialis
 Tendo achilis
THE COMMON FACTOR
Remember the motor milestones of a
child? Flexors are fetal
muscles,extensors develop later from
head to toe.(Neck holding to tiptoe
standing)
If you do not use ALL extensors daily,
fully, they can cause pain due to
disuse and subsequent fibrosis.
PATHOLOGY OF
FIBROSIS
Normal healing response,leading to scar
formation.
NOT a part of normal aging or
degeneration.
BUT can occur due to disuse of joints
and muscles.
Loss of intermediate gliding tissue
planes due to fibrosis.
Pathophysiology of
stiffness/contracture
Disuse- obliteration of gliding planesfibrosis of intermediate ‘white’ tissues
i.e.loose areolar tissue, joint capsule,
ligaments, tendons, fascia etc.Gradual loss of mobility- permanent
stiffness
RED tissue does not lead to contracture
by itself
WHAT ABOUT
DEGENERATION?
Natural aging process is NOT
painful normally.
Lifestyle throughout the life makes
it painful.
Diet and activity related.
Contractures are not normal with
age.
WHAT IS SPONDYLOSIS
AND OSTEOARTHROSIS?
 Symptom
complex originating
from a combination of factors
including aging
 But not solely blamed on aging
 Radiological changes only?
 ‘Dustbin diagnosis’ for aches and
pains
When to consider
radiological degeneration
really seriously?
 A)
In the spine- When it shows
OBJECTIVE neural signs (
Cervical spondylotic myelopathy,
Lumbar canal stenosis)and gross
malalingment.
Contd.
 B)
In other joints- When it causes
MECHANICAL MALALIGNMENT
of the joint( Scoliosis,
kyphosis,Genu varum,
Planovalgus foot, Hallux valgus
etc.)
Clinical or radiological
entity?
Changes in the alignment of a joint
make it painful.
 Localized sclerosis an indirect
indicator.
 Osteophytes alone are NOT a cause
of pain.
 Careful correlation needed between
symptoms and x-ray findings.
 Mostly mismatching.

TWO BROAD
CATEGORIES OF
PATIENTS
1.Nutritionally low, manual worker
or housewife with multiple
pregnancies.
2.Well to do, well-fed, comfort
loving urban patient living a
mechanized life.
NOTE BEFORE
EXAMINATION
Is it a child? Adult?Old person?Male?
Female?
 Where does the pt come from? Urban
area? Rural area? hilly area?
 What has been the occupation of the
patient? Play? Sports?Table
work?Manual work?
housewife?Machine worker?
computer worker?

 What
is the patient’s social/nutritional
status?
 What is the duration of complaints?
 Any relation to the obstretic history in
case of a young female pt?
 Alcoholic?
 Medical illness? Diabetic? On
steroids?
 Already treated and no relief?
 What is most difficult to do?
TRY TO ASSESS
Mentality of the patient Doctor should give a medicine that works
like magic!
 Investigate me by all possible modalities
including MRI
 I am a very sick patient and cannot
improve.
 I can do anything that you tell me.
DIFFERENTIATE THE SINISTER FROM
THE NON SPECIFIC PAINS
‘NO FINDINGS, ONLY PAIN’
Early sign of an infection or a
pathological fracture?
 Missing a significant injury?
 Deep seated neoplasm?
 Reflection of a medical condition?

Low back pain

Commonest problem in office
orthopedics faced by adults.

Sinister in children and adolescents.

Most confusing symptom for decision
making.
THE first look
examination
SPEND TIME ON INSPECTION
 Show
 Can
me how you walk.
you hold your arms up in the
air?
 Look
up to the ceiling.
The Real Physical
examination

All back and lower limb patients must
be examined first standing and then
made to lie down.

Upper limbs, neck and hands can be
examined with the patient sitting and
you standing at the back of the
patient.
The Standing patient
CURVES OF THE BACK
(especially the lumbar curve)
Flat back
Hyperlordotic curve
Kyphotic dorsal spine
Scoliotic list
Prominence of sacrococcygeal junction
What Importance is to the
curve?
 Major
cause of mechanical back
pain
 Indicative of inner problems like
acute or chronic disc prolapse
 Developmental anomalies of the
spine
Functions of the spinal
curves
Spring loading effect in vertical
posture- not a loaded pillar.
 Permits elongation and shortening of
the stature to some extent.
 Acts like a shock absorber for every
activity

The Evolution of The BackTheirs and Ours
The primitive backA loading surface on four
pillars.
 No axial loading.
 Very stable design
 Permits speed in
mobility
 Compromised mobility of
the spine per se.
 No true vertical posture.
The Human spine-Broad based
vertical pillar with spring effect
Looks like a minaret but has
tremendous flexibility and load
carrying capacity under bent
positions.
 Efficient protective mechanism by
the strong front and back muscles
that spare the bony column from
excessive loading.

Review of basic concepts

Human spine- Phylogenetically the
best evolved, vertical spine amongst
all vertebrates.

Basic function- Painless axial loading
an all positions of movements WITHOUT
ACTUAL OR POTENTIAL RISK TO THE NUERAL
ELEMENTS.
The built-in protectors
The IAR and the neutral
zone
The line of weight transmission
in spineCer. Spine- lateral mass and partly
posterior elements
 Dorsal spine- vertebral bodies
 Lumbar spine- posterior elements
(facet joints are not a part of normal
weight bearing)
 Change over in juctional areas

Effects of Sedentary life
style
Loss of in built protectors
 Lets the stresses pass on to areas
that are not meant for.
 Sets in degeneration that encroaches
on to the neural space- nerve roots.
 Loss of compressile strength of the
vertebral bone.

THE ‘RADIATING’ LEG
PAIN
Anatomical-Pertains to a definite
neural segment, extends up to or distal to
ankle
with signs of root compression.
Non-anatomical- confusion of the
sensory cortex due to limb bud rotation.
Extends only up to the back of the thigh and
knee.
No neural signs
The diffuse back pain- from the
superficial layer of muscles
• Not related to spine if not in the DEAD
midline.
• Pain that spreads along the top of
posterior iliac crest – disuse of
latissimus dorsi.
 Pain in the dorsolumbar and
interscapular area- disuse of
trapezius.
INTERSCAPULAR AND
SHOULDER PAINS
Different from NECK PAIN- midline
location
(Neck pain is a much more sinister sign.
Pain in the area of upper trapezius,
Levator scapulae and the rhomboids)
‘Radiation’ to the arm -Truly
anatomical?
 Non- anatomical ‘Drag pain’ all over
the limb

Investigations
Mostly required to check the bone quality
1. Nutritional osteoporosis
2. Disuse osteoporosis
3. Drug or disease related
osteoporosis
Good quality x rays of spine and pelvis,
DEXA, biochemical investigations
X rays of the affected
joints/spine

Mechanical alignment of the bones in
weight bearing areas-Lumbosacral inclination
-cervical curvature
-knee alignment-genu
varum/valgum
-foot arches
-sacrococcygeal junction
Ask for
X ray pelvis AP view
 Lumbosacral spine AP and Lateral
views
 Ultrasonographic bone densitometry
 Biochemical investigations not very
useful
 Blood sugar
in relevant cases.

Remember!
No investigation will give you a
diagnosis or a cause of pain
that you have not clinically
suspected.
Management
Aim at definitive treatment i.e.
permanent and lasting relief by
treating the root cause if possible.
NSAIDs ARE NOT A
DEFINITIVE TREATMENT!
IT MAY BE LIFESTYLE ITSELF!
The link must be treated
together
Muscles and bones cannot be treated
separately for aches and pains.
 Each area has a key muscle that
needs to be specifically targeted.
 Identify that.

THE TREATMENT
Prolonged, persistent and specific to the
cause.
Keystones
Initial pain relief
Calcium and its utilization
Antiosteoporotic drugs
Osteogenesis- Sureshot only by
exercise.
PHYSIOTHERAPY
Machines expected to do miracles?
Traction, diathermy
Ultrasound
TENS
LASER
(Acute phase relievers)
Exercises-active and
passive
 What
the patient does by himself
is the best physiotherapy.
 Can be taught to the patient
pertaining to his problem right in
the outdoor
 Should target the extensor of the
painful area.
The basic rule of muscle
activity
Full initial passive stretch before the
muscle begins an effective
contraction.
 Strengthening exercise must begin
with stretching exercises
 Two joint muscles like Rectus femoris
need special attention
 Daily floor level activity stretches
many muscles

Basic types of exercisesIsotonic and isometric
Repetitive exercise- cause muscle
hypertrophy, good for wasted
muscles.
 Endurance exercises- Sustaining the
contraction up to the level of fatigue.
 Increases the fatigue strength which
must come to normal.

FLAWS IN EXERCISE
PRESCRIPTIONS
Wrong muscle and wrong exercise
chosen
 Absence of initial stretching exercises
 Too little exercise
 Trick movements
 Reaching a static level of exercise
 Too short a period of exercise
 Organic pathology missed out-e.g.
stiff joint

How long to exercise?
Preferably for the rest of the life time.
Make it a routine.
 At least till the muscle gets back its full
length and strength(3-6 MONTHS),
progressively increasing.

WHAT ABOUT
ORTHOSES?
Collars, corsets, arch supports and
the like.
 Good for acute pain relief and doubtful
diagnosis under investigation.
 Prolonged use causes wasting of
muscles and aggravation of pain.
 Psychological dependency on the
orthosis both for the surgeon and the
patient.

Local applications and
fomentation






Only temporary, symptomatic treatment.
Good for initiation of exercises, hot packs
better.
Wean off quickly, if you prescribe .
Help in acute painful conditions with no skin
inflammation, for superficial areas.
No definite relief for deeper areas like back.
May help psychologically.
Specific exercises and target
muscles
 Lower
back- Lumbar fascia and
erector spinae stretching,
abdominal muscle strengthening.
 Interscapular area- Upper
trapezius, Rhomboids and levator
scapulae- Overhead abduction of
arms, shoulder bracing.
For the knee jointAnterior knee pain- Rectus femoris
stretching prone position, sustained
vastus medialis exercise.
 Straight leg raising- for vastus
medialis contraction.
 Hamstring stretching in specific
situations

Difficult areas- areas of ‘white
tissue abundance’
Red muscle fibers easy to stretch.
 Relative lack of elasticity in ‘white’
tissues-fascia, tendons, ligaments,
capsule, fibrous tissue
 Areas of loose areolar tissue
 Loss of gliding planes between
different tissues.

The more difficult areas
1.FROZEN SHOULDER-Extensive
fibrosis in the anteroinferior capsule
(an area full of ‘white’ tissues)
2.HAND- Abundant loose areolar tissue
right in the subcutaneous planes for
extensive skin mobility, lost by
fibrosis.
3.COCCYX- vestigial structure with ?
bilateral sensory cortical
representation.
Specific Physiotherapy for a
stiff shoulder
Daily passive stretching and active
assisted exercises in the direction
of first EXTERNAL ROTATION ,
then ABDUCTION in supine
position (Abduction essentially
involves external rotation).
Scapulothoracic rhythm
Abduction initiated by supraspinatus
 Taken over by deltoid upto 90
degrees
 Glenohumeral joint adducted by the
short muscles to make a single unit
 Scapulothoracic movement by
trapezius and other major muscles

Reversal of scapulothoracic
rhythm
Stiff glenohumeral joint moves as one
unit.
 No true abduction.
 Pt cannot do this movement on his
own.
 Needs passive/ active assisted
stretching of glenohumeral joint.

For the hand
Quick mobilization at the earliest
opportunity. Do not waste time.
 Devices like wax bath, under water
exercises help significantly.
 Passive assisted flexion of the MP
and IP joint helps initially.
 ‘Thumb in palm’ grip exercises for
CMC jt.

Heel pain
Entrapment neuropathy of medial
planter nerve under the flexor
retinaculum.
 Water logging during non activity.
(Arches normal, plum patients )
 Flat foot/planovalgus foot with
abnormal heel stresses- needs
correction.

Flat foot pain
Flexible flat foot- arch flattens on
weight bearing.
 Tib. Post. comes under undue
stretch.
 Leads to TP tendinitis or enthesitis.
 Walking in inversion, local heat and
arch support help.

General exercises for foot
problems
Tip toe walking, heel walking, walking
in inversion.
 Gripping small objects in toe- marbles,
cloth- for intrinsic muscle exercises.
 Must be weight bearing exercises.
 Activates the peripheral pump of calf
muscles.

Other useful modalities
For heel pain- Medial calcaneal nerve
block followed by inversion exercises,
intrinsic foot muscle exercises
 Multiple cutaneus branches supply the
heel pad.
 Point of exit of the nerves to be
blocked.

Elbow pain- Tennis/Golfer’s
elbow.
Lack of overhead, antigravity gripping
activity.
 Always acted upon by gravity, leads to
drag pain.
 Treated by overhead elbow extension
exercises with wrist dorsiflexion and
grip exercises.

Non specific wrist pain and
De’quervain’s disease
Lack of compressile loading of
radiocarpal joint.
 Grip exercises
 Stenosing tenosynovitis of thumb
abductors and extensors.
 ‘Thumb in palm’ grip exercises along
with sheath infiltration.

Coccydynia
Related to the pelvic diaphragm
musculature.
 Squatting stretches these muscles,
chair level activity may not.
 Small synovial joint at the sacrococcygial junction.


Too thin a patient with friction during
sitting- congenital exagg. of
curvature.
Treatment

Pelvic diaphragm exercises-levator
ani the key muscles.

Sphincter exercises

Carbamazepine 100 mgm t.i.d.. may
help
Therapeutics of aches and
pains
Do not depend on the NSAIDs. Just
begin and switch on to PT.
 Calcium alone is not a definitive
treatment.
 Utilization of calcium needs to be
improved with supplementation of vit.
D.
 Though fat soluble, the safety margin
of vit. D therapy is considerable.

Osteoporosis
Multifactorial origin
 Inactivity contributes.
 Sustained, combined treatment for
MONTHS, not days or weeks.
 Antiosteoporotic drugs –
bisphosphonates, dicerine and other
newer drugs.

‘The latest drug’

Newer drugs take time to prove their
efficacy.

Go slow on jumping into the use of a drug
that a MR is ‘teaching’ you!

Study the pharmacology well before use.
Useful in patients with strong psychological
overlay.

Remember!
There is no miracle drug for a
pain arising from the effects
of prolonged inactivity of a
muscle or a drug to change
the bone quality overnight!
SPECIAL MODALITIES
AVAILABLE
Nerve blocks- for Acute brachialgia
Acute disc pain
Steroids in acute neuralgic pains
Centrally acting drugs –Diazepam,
GABApen,carbamazepine etc.
Muscle relaxants- Methacarbamol
Microvasodilators- Xantinol nicotinateComplamina
Cinnerazine
Points to remember
The condition is not a short term
pathology.
 It reflects the lifestyle of an individual.
 Either nutrition or exercise or both -is
the missing link.
 That does not change in a short time.
 Have patience and persistence (like
ATT!)

For the paediatric age group




Growth pains in lower limbs very
common.
Improve the utilization and supply of
calcium, providing for reserves as well.
BACK PAIN IN A CHILD IS A SINISTER
SIGN, UNLESS PROVED OTHERWISE.
Investigate fully for any pathology.
CHILDREN DO NOT NEED
PHYSIOTHERAPY.
Role of quick relief?




Only in acute painful episodes, use a local
heating system and a short term, simple
NSAID, even paracetamol !
Do not expect miracles out of NSAIDs, any
combination is not the definitive treatment.
Keep drugs to minimum possible and
motivate the patient to be active.
Weight reduction.
Best to do
Do not restrict the patients normal
activities as far as possible.
Encourage him to be more active.
 Concentrate on the muscle which is
not used daily. Encourage floor level
activity.
 Target exercises against resistance
for the particular extensor muscle of
the area.

Can diet help?

YES!
1. More roughage rich diet,
whole grains better than ’factory
generated’, packed foods.
2. Diet advice quickly changes
the psychology due to traditional
values.
‘God made’ (natural) food always
better than ‘man-made’ (processed)
food!
Differentiate the following
Rheumatoid arthritis, Gouty arthritis
and nonspecific MULTIPLE JOINT
PAINS
 Acute or chronic disc prolapse.
 Spondylolisthesis
 Early infections of spine
 Malignancies/Tumors of spine
and LOW BACK PAIN

Summery
Aging is not a disease and is NOT
painful, inactivity and obesity can be.
 Bone stock is a reflection of an
individual’s life style.
 Full mobility is the key word to prevent
disuse of antigravity ‘human’ muscles
and also to maintain the bone quality.
