Conditions Treated

FOOT CONDITIONS

The Foot

The foot is composed of 26 bones, 4 arches, and countless muscles, veins, arteries, nerves, joints, and fascia. Beyond that, we rely on the foot repeatedly throughout the day to walk, run and stand. The feet take a lot of abuse, it’s easy to understand why they’re so prone to injury. We’ve outlined some of the most common injuries we see and treat in our clinic.

Achilles Tendonitis/Tendonosis: The Achilles tendon is made up of the tendons from two muscles in the lower leg, the gastrocnemius and the soleus. It attaches onto the top/back portion of the calcaneus (heel bone) and is the largest tendon in the body, being able to withstand over 1,000 lbs. of pressure. Although it is strong, it is also the most commonly ruptured tendon. Micro tears occur in the tendon causing inflammation in the area. The patient feels pain at the back of the heel, typically after periods of rest or during jumping, and starting/stopping activities. Inflexible lower leg muscles, over pronation of the feet, and changes in footwear and training schedules are all causes of this condition.

Bunions: Bunions are seen at the side of the base of the big toe. It looks like an enlargement of the joint. They form when the big toe bends laterally towards the other toes, a condition also known as Hallux Abducto Valgus. Bunions can result from abnormal bone formation in the first metatarsalphalangeal joint. Poor foot mechanics are often genetic and can lead to this problem. Other things such as injuries to the foot and 1st toe, flat/pronated feet, and poor footwear can also be a cause. People with bunions complain of pain from the pressure of their footwear, redness and swelling in and around the joint, the motion of the first toe is very restricted, and their other toes are affected either by hammer toes, calluses or corns.

Compartment Syndrome: Compartments are seen in the limbs of the body and are made of muscles, nerves, and blood vessels all bundled up by fascia. Compartment syndrome occurs when pressure builds up inside a compartment (usually one of the two in the lower leg), this pressure prevents nourishment (oxygen etc.) from reaching the tissues. There are two different types of CS, acute and chronic.

Acute Compartment Syndrome:

• can take several hours to develop
• when the pressure exceeds the blood pressure within the compartment, the blood vessels collapse
• without nutrients the tissues can die within hours
• common causes of ACS include badly bruised muscles, complications after surgery, circulation blockage, crushed foot, and major changes in activity levels.

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Chronic Compartment Syndrome:

• pain and swelling typically due to exercise
• improves with rest
• numbness and difficulty moving foot
• muscles feel “tight” or “full”
• the pain stops relatively quickly after ending activity but the pressure can remain elevated for some time

Corns: The formation of dead skin cells that develop on the top, sides and tips of the toes. The core of the corn is usually cone shaped with the point facing down. With pressure, the tip can press onto a nerve, making it even more painful. Corns may also become inflamed due to friction from footwear.

Gout: Gout occurs most often in the big toe but can affect any joint of t he body. It usually occurs overnight (within 12-24 hours). It involves painful swelling of one joint at a time, sometimes two. After the first attack a person may go anywhere from one week to years without having another, growing more frequent and more severe with every attack. Without treatment, gout may cause chronic or continuous joint problems and damage.

Uric acid is a natural chemical produced by the kidneys and is key in breaking down and building up food and body tissues. It is normally dissolved in the blood, but in the case of gout, crystal deposits form in the joint causing an inflammatory response.

Genetics play a role in this disease as well as obesity, sudden weight gain, abnormal kidney function, excessive alcohol consumption, and some cancers. The relationship between uric acid levels in the blood stream and gout is unclear. People with high levels of uric acid in their blood do not always have gout and visa versa.

Hammer Toes: Hammer toes can affect any of the toes except the big toe and is most commonly seen in the second toe. It happens when the ligaments and tendons tighten and pull the toe downwards. The bend occurs in the proximal inter phalangeal joint (PIP) with the base of the toe pointing up and the bottom of the toe pointing down. Most people will not notice the inital signs of a hammer toe until a corn appears on the top of the bend in the toe. The corn develops due to the pressure and friction on the joint, typically from footwear. It will be noticeably painful while wearing tight fitting shoes. There are two seperate types of Hammer Toes. a) Flexible – can move actively and straighten passively (with help from fingers) and b) Rigid – movement in this case would be limited and painful. Hammer Toes can be hereditary but tight shoes are mostly the cause. Weak muscles in the foot and ankle can also be a factor.

Morton’s Neuroma: A condition where nerve(s) are being “squeezed” by the toes and surrounding tissues of the foot, typically between the 3rd and 4th toe. Symptoms of this condition include sharp pain, burning, and even a lack of feeling in the affected area. Morton’s Neuroma may also cause numbness, tingling, or cramping in the forefoot. You may experience this after prolonged walking or standing.

Metatarsalgia: A painful condition in the metatarsal area of the foot (the ball of the foot). Pain is typically located under the 2nd, 3rd and 4th toes and is most prominent under the 1st toe (big toe). One or more of the metatarsal heads become inflamed due to extended pressure on the forefoot. Improper fitting shoes are a common cause.

Plantar Fasciitis: The plantar fascia is a band of connective tissue running from the heel into the toes and serves to support the bottom of the foot. It takes a bulk of the load when you are weight bearing. When the fascia and surrounding tissues aren’t stretched/used regularly there are allowed to shorten. A shortened plantar fascia is more likely to tear when asked to stretch past it’s capacity (sometimes all it takes is weight bearing). The most common symptom of this condition is pain in the heel on 1st step, in the morning or after a period of rest.

The calcaneus is the largest bone in your foot and takes the most pressure when weight bearing. A heel spur can develop at the lower frontal area of the calcaneus, where the plantar fascia attaches. When under stress, the plantar fascia pulls away from the bone causing your body to lay down calcium (building block for bone) in an attempt to strengthen the area.

Many people have a spur and don’t know it because a spur alone does not cause pain. Rarely are there cases of the spur “poking” into tissue resulting in pain. A spur is mainly just evidence that you may have plantar fasciitis.

Sever’s Disease (Calcaneal Apophysitis): The bones of the body start out as cartilage during fetal development. As we age they ossify into the bones we have as adults. The heel bone is no exception. It is made up of two bones with cartilage in the middle. The bones fuse together at around 16 years of age. Sever’s Disease occurs when there is a disturbance of growth in this area and therefore is common in adolescents age 10 to 14. Pain in the heel is usually present during sports, especially ones that involve running and jumping. Common risks are obesity, over activity, tight calf muscles and over pronated feet.

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Shin Splints: Characterized by inflammation of the sheath of the periosteum (bone) of the tibia (shin bone). This may happen on the outer side (lateral) or the inside/back of the tibia. Most describe the onset of pain as gradual, starting as a dull ache after walking or running. The area of pain is typically localized, being 4-6 inches in length on the mid region of the bone. The muscles that attach to the tibia (soleus, flexor digitorum longus, tibialis anterior) often feel sore as well. Causes may include overuse, running on hard surfaces, tip toe running, high arches, and bad shoes and arch support. There is an increased risk of stress fractures occurring if this condition is left untreated.

Sprains: An overstretching or tearing of a ligament. The most commonly damaged ligament is the anterior talo-fibular ligament of the ankle. Risks of injury include poor rehabilitation of a previous sprain, poor proprioception of a previously sprained ankle, and weak ankle muscles. There are three different types of sprains:

1. 1st Degree Sprain: There is some overstretching and tearing of the ligament and little or no functional loss of the ankle. There is mild pain on weight bearing and some swelling and stiffness.

2. 2nd Degree Sprain: There is more tearing than a first degree sprain, moderate instability, moderate to severe pain on rest and severe pain on weight bearing. Swelling and stiffness are also present.

3. 3rd Degree Sprain: The ligament is completely ruptured, there is functional loss and gross instability. Many times there is severe pain right after the injury followed by no pain at all. Swelling is typically severe.

Tarsal Tunnel Syndrome: Signified by the entrapment of the tibial nerve inside the ankle. Patient has tingling and numbness in the sole of the foot that worsens throughout the day. Rest and elevation lessen the symptoms. The tibial nerve BENDS around behind the medial malleolus, making it more prone to injury. Surrounding structures can also impinge the nerve if they are swollen or inflamed. Things like flat pronated feet, a cyst or lesion in the area, Rheumatoid Arthritis, fractures or other misalignments to a joint can cause this condition.

PLANTAR FASCIITIS

Plantar Fasciitis is characterized by the inflammation of the plantar fascia, although inflammation is not always present which we’ll get into shortly. Stress, strain and or trauma can cause micro tears in the fascial tissue leading to heel pain, arch pain and potential lower leg pain.

Although the condition seems to be abundant in athletes, they are not the only ones at risk. Any activity that promotes excessive or extreme dorsi/plantar flexion such as running or jumping could potentially lead to plantar fa sciitis. Sudden weight gain, tight muscles in the lower leg, commencing exercise after a long period of dormancy, even structural problems such as flat feet or high arches play a role.

We all know that when an elastic is stretched with force that it will tear at a certain point, imagine that same force being put on a shorter elastic. The breaking point would be much sooner. When the muscles of your lower leg become “tight” they shorten, causing your foot to rest in a more flexed position.This flexed position puts strain on the surrounding tissues of the foot and allows them, along with your plantar fascia to shorten.  As a result the tissue is more susceptible to injury. One of your best defenses is stretching.

The most common symptom of plantar fasciitis is pain in the heel or arch of the foot with the first few steps taken in the morning or after a long rest period (first-step pain). This is because the tissue is being forcefully stretched after it’s  had time to shorten. Other symptoms may include; localized pain at the front of the heel, pain in and around the achilled tendon area, the pain typically starts gradually, worsening as the condition becomes chronic.

The conventional treatment for plantar fasciitis tends to involve the use of non steroidal anti-inflammatory drugs (NSAID’s). As previously mentioned, this condition doesn’t always involve inflammation, that may seem strange because the suffix “itis” pertains to inflammation. The tissue may receive tears that are not traumatic enough to cause a vascular disruption necessary for an inflammatory response and should end in the suffix “osis” meaning condition of. So why give anti-inflammatory medication when inflammation isn’t present? Good question. Unfortunately, plantar fasciitis is very often mistreated and misdiagnosed.

Conditions that are acute and involve inflammation are typically “easy” to treat and patients recover in a relatively short period of time (4-6 weeks), where as non-inflammatory conditions tend to take longer (3-12 months).

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Definitions

Plantar Fascia: A fibrous aponeurosis (ligament-like) structure that extends from the front of the heel into the base of the toes. It provides static support to the longitudinal arch of the foot and aids in shock absorption.

Gastrocnemius: A large, superficial (close to the surface) muscle of the lower leg which serves to plantar flex the foot and flex the leg at the  knee. 
Soleus : A flat, broad muscle of the lower leg that serves to plantar flex the foot. Deep muscle compared to the gastrocnemius.

Achilles Tendon: The tendon of the gastrocnemius and the soleus muscles of the lower leg.

Plantar flexion: The motion of pointing the toes away from the body (towards the floor)

Dorsi flexion : The motion of pointing the toes towards the body (upwards)

Plantar Fasciitis Facts

• One disturbing fact about plantar fasciitis is that it sometimes takes many months to resolve. Indeed, it takes approximately 6 months for 75% of people to recover from this problem. 98% of people seem to be better at 12 months.
• Studies suggest that approximately 10% of individuals who see a doctor for plantar fasciitis have the problem for more than a year. Chronics plantar fasciitis is defined as plantar fasciitis symptoms persisting for 6 months or more.
• An estimated 10% of all running injuries are inflammations of the fascia, an incidence rate which in the U.S. would produce more than 200,000 cases of plantar fasciitis per year, just from the running population.
• A recent study determined that 77% of its sample of 411 plantar fasciitis (heel spurs) patients were overweight. Another study found that 23% of overweight women had plantar fasciitis (heel spurs) compared to 8% of the normal body-weight group.

Heel Spurs

The calcaneus is the largest bone in your foot and takes the most pressure when weight bearing. A heel spur can develop at the lower frontal area of the calcaneus, where the plantar fascia attaches. When under stress, the plantar fascia pulls away from the bone causing your body to lay down calcium (building block for bone) in an attempt to strengthen the area.

Many people have a spur and don’t know it because a spur alone does not cause pain. Rarely are there cases of the spur “poking” into tissue resulting in pain. A spur is mainly just evidence that you may have plantar fasciitis.

KNEE CONDITIONS

Knee Anatomy:

There are four bones in the knee, the tibia (shin bone), fibula (outside of the lower leg), femur (upper leg bone) and patella (knee cap). They are held together by four main ligaments, your anterior and posterior cruciate ligaments (ACL,PCL), and your lateral and medial collateral ligaments (MCL, LCL).

A meniscus is a cresent shaped, cartilagagenous struture of the inner knee, that lies in between the tibia and femur. It is made up of two parts, the medial (inside) and lateral (outside) meniscus. The menesci serve to absorb shock and to stabilize the knee.

Articular cartilage is found in all joints of the body. It covers the ends of “articulating” bones, allowing then to glide smoothly across one another. In the case of the knee, it is found on the end of the tibia and femur and on the back of the knee cap.

Bursa are fluid filled sacs located around joints in order to reduce friction between the tissues and bone. There are four major bursea of the knee: the prepatellar (most commonly injured), suprapetellar, superficial infrapatellar, and deep infrapatellar.

Tendons are abundant when talking about the knee. The patellar tendon is a combination of all four of your quadriceps muscles. It surrounds the back of the knee cap and attaches into the front of the shin bone (just below the knee cap). The adductor group serve to bring the knee towards the body and attach at various points on the inner knee. The idiotically band is a major part of the outside of the knee. It starts at the hip and ends on the side of the tibia. Your idiotically band is actually made up of fascia and therefore cannot contract. It does however work closely with your tensor fascia Plata muscle. Your hamstrings, which start from the bone in your bum and end on the medial and lateral sides of your tibia.

The iliotibial band is a major part of the outside of the knee. It starts at the hip and ends on the side of the tibia. Your iliotibial band is actually made up of fascia and therefore cannot contract. It does however work closely with your tensor fascia lata muscle. When the TFL contracts, it pulls on the IT band, which in turn moves the knee.

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LIGAMENT DAMAGE

ACL Injury:

Your ACL is a ligament that runs from the the front of the tibia to the back of the femur. It protects against excessive forward pressure of the tibia and rotation of the knee. It is most commonly injured as a result of a twisting motion or a hard blow to the side or back of the knee. The ligament can either receive a small tear or completely rupture. Recovery time depends on the severity of the tear.

PCL Injury:

Your PCL is also a ligament in the knee but it runs from the back of the tibia to the front of the femur. It protects against excessive backward pressure of the tibia. It is most commonly injured by a hard blow to the front of the shin bone. The ligament can either receive a small tear or completely rupture. Recovery time depends on the severity of the tear.

MCL Injury:

A ligament located on the inside of the knee, the most commonly injured ligament of the knee. It protects the knee against excessive valgus force (pressure placed on the outer side of the knee, causing the knee to bend inwards). It is ost commonly injured by a hard blow to the outer side of the knee. The ligament can either receive a small tear or completely rupture. Recovery time depends on the severity of the tear.

LCL Injury:

A ligament located on the outside of the knee. It protects the knee against excessive varus force (pressure placed on the inside of the knee, causing the knee to bend outwards). It is most commonly injured by a hard blow to the inside of the knee. The ligament can either receive a small tear or a complete rupture. Recovery time depends on the severity of the tear.

Meniscal Tear:

Injuries to the meniscus are common and typically as a result of twisting the knee while weight bearing. A tear to one or more of the ligaments in the knee can result in a torn meniscus. It is important to remember that it can also degenerate with age, making it more susceptible to injury. The medial aspect of the meniscus is most often injured.

Symptoms include pain on the medial and lateral aspects of the knee when bending or twisting. A piece of the meniscus may rip off and create problems such as locking, clicking or catching within the joint.

Patellofemoral Pain:

The word patellofemoral refers to the area made up of the patella (patello) and the femur (femoral). Pain occurs in this area when the knee cap is compressed against the groove of the femur (femoral groove). Increased or repetitive bending of the knee will in turn increase the pain. Activities such as climbing or descending stairs after a period of rest often aggravate this problem.

Causes of this condition may include poor patellar tracking, flat feet, weak thigh muscles or ligaments, a previous injury to the area and/or overuse.

Iliotibial Band Syndrome:

Iliotibial band syndrome is a condition of the band of fascia located at the side of the hip, running down into the side of the knee. Your IT band connects to many muscles, a major one being the tensor fascia lata (TFL), which literally means to tense your lateral fascia (your IT band). When the fascia is tensed, it pulls the leg away from the body. The IT band also serves to stabilize the outside of the knee.

A bursa lies underneath the IT band to prevent friction between the IT band and the femur. Repetitive flexion and extension of the knee causes the IT band to slip back and forth across the condyle of the femur (bony projection on the outside of the knee), this motion can irritate the bursa, potentially making it inflamed and irritated.Another problem seen with the IT band is when it adheres to one of the quadriceps muscles called vastus lateralis. It is important to address both issues when treating a patient for IT band syndrome.

Prepatellar Bursitis:

The prepatellar bursa is a thin, fluid filled sac, used to reduce friction between the patella and the overlying skin. Of thenumerous bursa surrounding the knee, the prepatellar bursa is the most likely to be inflamed. A blow to the front of the knee is most likely to be the cause.

Most people notice that the front of the knee is painful during movement and painful to the touch. There may also be swelling and heat in the area. Chronic cases may have scar tissue build up on the walls of the bursa.

Osgood-Schlatter’s Knee Pain:

This disease is often seen in young people who are still in the growing stages. It is usually as a result of over activity of the legs. Repetitive flexion and extension of the knee will place stress on the growing bones, creating pain where the patellar tendon inserts (about 3 fingers below the kneecap). The pain may also radiate to the outside of the knee and into the knee cap. Jumping, starting, stopping and running can aggravate this problem.

Osteoarthritis:

Osteoarthritis involves the breakdown of the cartilage in a joint. It is one of the most common forms of arthritis and is very often seen in the knees. When the cartilage used to help bones slide easily against one another deteriorates, the joint may become weak, painful and stiff.

OA typically starts gradually as a casual pain or stiffness of the joint. It may then progress, making it difficult to climb and descend stairs and perform daily activities. Rarely will you see inflammation (pain, swelling, redness) as you might in other inflammatory or erosive osteoarthritis’. Some common symptoms of OA are joint soreness following overuse activities, morning stiffness lasting around 30 minutes, pain that is worse at the end of the day, knee catching or locking, and weakened thigh muscles.

Middle aged people are mostly affected, women more so than men. This is thought to be because of the broadness of women’s hips, creating more torsion on the knees. Age does increase the risk for developing OA.

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Patellar Tendonitis/Tendonosis:

The patellar tendon may receive micro-tears in the tissue that can a) cause inflammation in the area which would be referred to as a tendonitis or b) heal improperly, but not cause an inflammatory effect, which we would then call a tendonosis. Treatment for these conditions are profoundly different in that all inflammatory conditions are treated with non steroidal anti-inflammatory drugs (NSAID’s), an approach you cannot take to a non inflammatory condition.

Patellar tendonitis occurs in people who are placing too much stress on the patellar tendon and quadriceps muscles. Pain will be felt at the bottom of the knee cap and can be accompanied by swelling and sensitivity.

Chondromalacia:

Articular cartilage covers the back of the knee cap, and the ends of the tibia a femur. Chondromalacia occurs when the cartilage on the underside of the knee cap becomes irritated. The knee cap tends to rub against the knee joint, causing pain in the front of the knee. It most often occurs in young, athletic individuals, women are more common than men.

Baker’s Cyst:

Also known as a popliteal cyst, a baker’s cyst is most often a symptom of another underlying problem. Fluid builds up inthe back of the knee joint, one cause is when the joint capsule herniates into the back of the knee. Conditions like arthritis and tissue tears can cause swelling of the knee, often leading to a baker’s cysts. You must treat the primary problem if you wish to treat the cyst.

Synovial Plica Syndrome:

This conditions occurs when a piece of fetal tissue (plica) remains in the knee. During development, the plica (membranes) separate the knee into it’s compartments and become smaller during the second trimester. As we age, they are referred to as synovial folds. In some people, the plica is more prominent, leaving it vulnerable to irritation and inflammation. The medial shelf plica is common in these cases, usually as a result of other overuse injuries.

Gout:

Gout is typically seen in the big toe of males over the age of 40. With 75 years being the peak age. Although it is not very common in the knee, it can happen. It causes sudden, severe pain of the joint, accompanied by swelling and redness.

The kidneys produce a substance called uric acid. It helps our body to excrete waste products. Gout occurs when there is an impairment of the transportation of uric acid. There is an abundance of uric acid in the blood stream, which travels into the joints and creates crystal deposits.

Genetics play a role in this disease as well as obesity, sudden weight gain, abnormal kidney function, excessive alcohol consumption, and some cancers. The relationship between uric acid levels in the blood stream and gout is unclear. People with high levels of uric acid in their blood do not always have gout and visa versa.

SHOULDER INJURIES

ROTATOR CUFF INJURIES

The shoulder is one of the most complex joints in the body, therefore shoulder pain is difficult to diagnose properly. It is easily subject to injury because the ball of the upper arm is larger than the shoulder socket that holds it. To remain stable, the shoulder must be anchored by its muscles, tendons, and ligaments. We’ve outlined most of the components of the shoulder to help you get a better understanding of what may be involved in a shoulder pathology.

Bones & Joints

Scapula: Also called the shoulder blade. Triangular shaped bone located behind the rib cage

Clavicle: Also known as the collar bone. The most breakable bone in the body. The distal end (furthest from the body) is called the acromion.

Humerus: Bone of the upper arm

Acromioclavicular (AC) joint: is located between the acromion (part of the scapula that forms the highest point of the shoulder) and the clavicle.

Glenohumeral joint: also called the shoulder joint, helps move the shoulder forward and backward and allows the arm to rotate in a circular fashion or hinge out and up away from the body. The capsule is a soft tissue envelope that encircles the glenohumeral joint. It is lined by a thin, smooth synovial membrane.

Muscles

The rotator cuff is a group of tendons which fuse together and surround the shoulder joint for stability and movement. These tendons connect to muscles which originate from the front and back of the scapula (shoulder blade). When the muscles contract, they pull on the rotator cuff tendon, causing the shoulder to move. The following fours muscles, often referred to as the S.I.T.S. muscles, make up the rotator cuff.

Supraspinatus: Lies on the top of the scapular spine, main movement is abduction

Infraspinatus: Lies below the spine of the scapula, aides in external rotation and adduction of the arm

Teres Minor: Small but powerful muscle that externally rotates, extends and adducts arm

Subscapularis: Lies on the front on the scapula, main movement is internal rotation

What is a Rotator Cuff Tear?

Some shoulder problems arise from the disruption of  soft tissues as a result of injury or from overuse or under use of the shoulder. Other problems arise from a degenerative process in which tissues break down and no longer function well. Symptoms may appear gradually or acutely (quickly).Symptoms include pain with overhead activities, combing hair, fastening buttons on the back of clothing, stiffness and loss of motion. If there is a tendonitis of the biceps tendon,  you may see pain on the front side of the shoulder that radiates down to the elbow and forearm. Pain may also occur when the arm is forcefully pushed upward overhead.

Shoulder pain may be localized or may be referred to areas around the shoulder or down the arm. Disease within the body (such as gallbladder, liver, or heart disease, or disease of the cervical spine of the neck) also may generate pain that travels along nerves to the shoulder.

A healthy tendon is made up of parallel cells (striated tissue) resembling many strings lined up next to each other. When a tear occurs it can range from one or several  of those strings being torn. In medical terminology the words “micro tears” are used to describe a tendon that has received a small amount of damage. Micro tears can lead to either a tendonitis or a tendinosis.

A tear in a rotator cuff tendon may occur after trauma, such as a fall on the shoulder, or in people  who are continually performing overhead activities i.e. swimmers, painters, construction, pitchers and tennis players. Acute tears are commonly signified by a “snapping” sensation, with immediate pain and weakness in the arm. Gradual tears are typically as a result of  rotator cuff degeneration over time. In fact, autopsy studies have shown rotator cuff tears in up to 70% of people over the age of 80 and 30% of the population under the age of 70. Most patients notice that at first the pain may be mild and only present with overhead activities such as reaching or lifting. It may be relieved by over-the-counter medication such as aspirin or ibuprofen. Over time the pain may become noticeable at rest or with no activity at all. There may be pain when you lie on the affected side and at night.

Tendon’itis’ is characterized by the presence of inflammation (redness, swelling, heat, pain) within a tendon. When the rotator cuff or the bicepital tendon become inflamed they may get “squeezed” by the aromion and the humerus, leading to a condition called impingement syndrome.

Tendono’sis refers to a pathology within the tendon in which the vascular response to the tear was not significant enough to cause inflammation.  Research has proven that most patients diagnosed with tendonitis show no signs of inflammation, and therefore do not respond to treatment to reduce inflammation (anti-inflammatories).

A tendon receives the most stress at the tenoperiosteal junction, meaning where the tendon attaches to the bone. Imagine that area as the “weakest link”. Your body will lay down calcium deposits, in order prevent further damage and strengthen the attachment. A condition called calcific tendonitis occurs, a similar thing happens in plantar fasciitis patients (bone spurs).

ELBOW CONDITIONS

Golfers Elbow

Inside of Elbow - The cause of golfer’s elbow is similar to tennis elbow, the difference: pain and tenderness are felt on the inside (medial) of the elbow, on or around the joint’s bony prominence.

Medial Epicondyle – The bony prominence felt on the inside of the elbow, serves as an attachment site for the flexor tendons.

Extensor – A muscle that extends a part.

Flexor – A muscle that brings two bones closer together, causing flexion of the part or a decreased angle of the joint.

Humerus – Upper bone of the arm from the elbow to the shoulder joint.

Tendon – Fibrous connective tissue serving for the attachment of muscles to bones and other parts.

Tendonitis – Inflammation of a tendon.

Tendonosis – Condition of the tendon.

Ulna – The inner and larger bone of the forearm, between the wrist and the elbow, on the side opposite that of the thumb.

Tennis Elbow is also known as lateral epicondylitis (inflammation of the lateral epicondyle)even though inflammation is not always present, a point we’ll discuss later on. A common source of pain is damage to one or more of the extensor tendons, within the group of the common extensor tendon (see diagram above).

Although the name may refer to a tennis related injury, tennis players are not the only ones suffering. Any activity or sport, whether it be recreational or work related, can cause this injury. Repetitive stress and strain of the extensors can cause micro tears to form in the tendons. The result is restriction of movement, inflammation and pain. Even if the original injury heals, these areas are weak and prone to tear again, which may lead to hemorrhaging and the formation of rough, granulated tissue and calcium deposits in the surrounding tissues. In an acute injury, inflammation forms when the body releases collagen into the injured area. The pressure that results from this process can cut off blood flow and pinch the radial nerve , a major nerves that supplies the muscles of the forearm and hand. Tingling and numbness can be felt in the forearm and hand and many people complain that their hands are continually cold.

A fundamental factor in Tennis Elbow injuries are tight, inflexible muscles, and fascial restrictions. Muscle connect to tendons which then attach to bone. When a muscle contracts, it shortens, pulling on the tendons at both ends. Fascia is a connective tissue seen throughout the body. Muscles and surrounding tissues are meant to glide freely on top of one another. When they are restricted, the joint they supply won’t have it’s optimal range of motion. When muscles are tight they are already putting load on the tendon from a resting position!

Of interest is how the grip mechanism plays a vital role in both tennis and golfer’s elbow. When gripping an object we are contracting the flexors of the hand and slightly stretching the extensors. Then we ask our muscles to extend or flex the hand at the wrist. You can imagine why a tendon would tear when

a.) the muscles are tight putting load on the tendon 
b.) the tendons tighten when gripping 
c.) the tendons are then ask to stretch past their extreme when extending the wrist

Think of the tendon/bone attachment as the “weakest link”, most injuries occur in that area.

Conventional treatment for tennis elbow may include non-steroidal anti-inflammatory drugs (NSAIDS). As previously mentioned, inflammation is not always present. That may sound strange because the suffix “itis” pertains to inflammation. Tissue can receive tears that are not traumatic enough to cause the vascular disruption necessary for an inflammatory response, in that case a more appropriate suffix would be “osis”, meaning condition of (tendonOSIS). So why give anti-inflammatory medication when inflammation isn’t present? Good question. Unfortunately, tennis elbow is often mistreated and misdiagnosed. These conditions can linger on for several months, even years, if not properly treated.

Conditions that are acute and involve inflammation are typically “easy” to treat and patients recover in a relatively short period of time (4-6 weeks), where as non-inflammatory conditions tend to take longer (3-12 months).

Facts About Tennis Elbow

• Tennis players actually account for less then 5% of reported cases
• Half of all tennis players will suffer from this condition at some point
• Each year, approximately one person in every 25 will seek medical help for a “sports” injury, but not all of those injuries are sustained while playing sports. Any repetitive physical activity even walking, can injure muscles and joints
• Sports injuries are most commonly caused by poor training methods, structural abnormalities, weakness in muscles, tendons, ligaments, and unsafe exercising environments.

Golfers Elbow

Golfer’s Elbow is also known as medial epicondylitis (inflammation of the medial epicondyle) even though inflammation is not always present, a point we’ll discuss later on. A common source of pain is damage to one or more of the flexor tendons, of the common flexor tendon.

One must realize that Golfer’s Elbow is not strictly a golf related injury. Any activity or sport, whether it be recreational or work related, can cause this injury. Repetitive stress and strain of the flexors can cause micro tears to form in the tendons. The result is restriction of movement, inflammation and pain. Even if the original injury heals, these areas are weak and prone to tear again, which may lead to hemorrhaging and the formation of rough, granulated tissue and calcium deposits in the surrounding tissues. In an acute injury, inflammation forms when the body releases collagen into the injured area. The pressure that results from this process can cut off blood flow and pinch the radial nerve , one of the major nerves that supply the muscles of the forearm and hand. Tingling and numbness can be felt in the forearm and hand and many people complain that their hands are continually cold.

A fundamental factor in elbow injuries are tight, inflexible muscles, and fascial restrictions. Muscle connect to tendons which then attach to bone. When a muscle contracts, it shortens, pulling on the tendons at both ends. Fascia is a connective tissue seen throughout the body. Muscles and surrounding tissues are meant to glide freely on top of one another. When they are restricted, the joint they supply won’t have it’s optimal range of motion. When muscles are tight they are already putting load on the tendon from a resting position!

Of interest is how the grip mechanism plays a vital role in both tennis and golfer’s elbow. When gripping an object we are contracting the flexors of the hand and slightly stretching the extensors. Then we ask our muscles to extend or flex the hand at the wrist. You can imagine why a tendon would tear when

a.) the muscles are tight putting load on the tendon 
b.) the tendons tighten when gripping 
c.) the tendons are then ask to stretch past their extreme when flexing the wrist

Think of the tendon/bone attachment as the “weakest link”, most injuries occur in that area.

Conventional treatment for Golfer’s Elbow may include non-steroidal anti-inflammatory drugs (NSAIDS). As previously mentioned, inflammation is not always present. That may sound strange because the suffix “itis” pertains to inflammation. Tissue can receive tears that are not traumatic enough to cause the vascular disruption necessary for an inflammatory response, in that case a more appropriate suffix would be “osis”, meaning condition of (tendonOSIS). So why give anti-inflammatory medication when inflammation isn’t present? Good question. Unfortunately, tennis elbow is often mistreated and misdiagnosed. These conditions can linger on for several months, even years, if not properly treated.

Conditions that are acute and involve inflammation are typically “easy” to treat and patients recover in a relatively short period of time (4-6 weeks), where as non-inflammatory conditions tend to take longer (3-12 months).

Unexplained elbow pain may be as a result of crystal deposits which may form in the elbow joints as a result of conditions such as: gout and arthritis, or as a side effect from drugs or other medications. These individuals have a high density of impurity in their blood (may be caused improper digestion of uric acid). Over time the accumulation of such impurities can crystallize and form deposits in the elbow joint. Deposits then block the circulation to the attached tendons, which in turn causes pain and loss of elasticity in the tendons.

Bursa – A padlike sac or cavity found in connecting tissue usually in the vicinity of joints. It is lined with synovial membrane and contains a small amount of fluid (synovia) that acts to reduce friction between tendon and bone, tendon and ligament, or between other structures where friction is likely to occur.

BURSITIS

Bursa – A padlike sac or cavity found in connecting tissue usually in the vicinity of joints. It is lined with synovial membrane and contains a small amount of fluid (synovia) that acts to reduce friction between tendon and bone, tendon and ligament, or between other structures where friction is likely to occur.

Bursitis – Inflammation of the bursa, especially those located between bony prominences and muscle or tendon.

A – Bursitis of the shoulder

B – Bursitis of the knee or ‘Housemaid’s Knee’

C – Bursitis on the bone of the buttocks or ‘Weaver’s Bottom’

D – Bursitis of the elbow or ‘Miner’s Elbow’

There are over 150 Bursa in the human body. They act to lubricate and cushion pressure points between bones, tendons and muscles in and around joints. Bursitis occurs when a bursa becomes inflamed, making range of motion and pressure on the area painful. Bursitis is most prominant in areas around joints, i.e. shoulders, elbows, and hips. It is also possible to develop bursitis of the knee, heel, and even the big toe.

Bursitis is refered to as a repetitive strain injury (RSI), meaning that some sort of repetitive motion or strain on the joint/tissues has caused the injury. RSI’s can occur due to work or play related activities. As the illustration above depicts, many different forms of bursitis are named after a profession or trade in which you would repetitively use the affected joint. Other causes may include inflammatory arthritis (rheumatoid arthritis or gout), acute or chronic infections.

We’ve outlined the most commonly seen bursitis below.

Housemaid’s Knee (Prepatellar Bursitis): Results from kneeling on hard surfaces i.e. laying tile, scrubbing floors, gardening. Affects the prepatellar bursa. The inflamation is seen at the front of the knee and can grow quite large without treatment. Pain is present with activity and usually subsides at night. The swelling is rapid, being tender and wram to the touch.

Pes Anserine Bursitis: Other bursa in the knee can become inflammed such as the pes anserine bursa that lies between the the medial hamstring insertion point and the tibia. Pain with this condition is seen on the inside of the knee or the centre of the shin bone, 2 – 3 inches below the knee joint.

Miner’s Elbow (Olecranon Bursitis): Results from a back and forth motion of the elbow such as swinging a pick, vacuuming, throwing a baseball, swinging a tennis racket or golf club. Repetitive pressure or a hard blow to the elbow will also cause this problem. A lump may be seen on the back of the elbow due to the swelling.

Subacromial Bursitis: The subacromial bursa is located underneath the aromion of the shoulder and on top of the rotator cuff. This area is very small and can’t expand. Repetitive overhead movements such as swimming, painting, and construction work can agrevate the space causing the bursa and or the rotator cuff tendons to inflame. At first the shoulder begins to ache with activity and rest. It may radiate down the arm into the biceps and front of the arm. There may also be sudden pain with lifting, throwing and reaching.

Conventional treatment for bursitis may include anti-inflammatory and pain medications, as well as ice compresses and rest. Occasionally the aspiration of fluid is required, which involves removal of the bursa fluid with a needle and syringe, under a sterile environment. Many times anti-inflammatory and pain medications only tentatively relieve the symptoms, rather then cure. When not properly treated bursitis can linger for months.

TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMJ\TMD)

The temporomandibular joint is made up of the bone of the jaw (mandible) and the temporal bone (temples). The joint, along with the surrounding muscles, allow us to move the jaw from front to back, side to side and up and down. A soft disc like structure lies between the the condyles (rounded end of the mandible) and the temporal bones. It serves to absorb shock to the TMJ when chewing and talking.

There are three main categories to Temporomandibular Joint Dysfunction.

1. Muscle Disorders
– Consist of pain in the muscles that control the jaw, neck and shoulder. 
– Most common cause of TMD 
- Can also be called Myofascial pain 
– Can be as a result of a tear to one of the muscles surrounding the joint

2. Joint Derangement Disorders
– Dislocated jaw 
– Displaced disk 
– Injured bone (fractures etc.)

3. Degenerative Joint Disorders
– Wear and tear 
– Arthritis 
– Destruction of cartilage

CARPAL TUNNEL SYNDROME

The carpal tunnel is a small passage in the wrist that is made up of bones(carpals) on three sides and the transverse carpal ligament on top. The tunnel contains flexor tendons, that serve to flex the fingers, and it provides a pathway for the median nerve to supply the hand. Repetitive flexion and extension of the wrist may cause swelling of the tenosynovium, referred to as tenosynovitis. Due to the limited space in the carpal tunnel, the tenosynovitis applies increased pressure on the median nerve producing carpal tunnel symptoms.

Although it is widely accepted as THE cause for the syndrome, the carpal tunnel isn’t the only area of the body where the median nerve may be impinged. We must take into account that nerves travel directly from the spinal cord, bundle together to form part of the brachial plexus, and go all the way into the extremities. Therefore, the disturbance of the nerve could take place anywhere along that path.

To use an analogy, we all remember how a kink in a garden hose affects the water coming out the opening. The hose either expels less water or no water at all, depending on the ser verity of the kink. The same goes for your nerves. You can have a slight or extreme impingement that would affect the nerve and what it supplies, from that point forward. The following

Definitions:

Carpal: From the Latin word carpus meaning the wrist

Carpal Tunnel: A tunnel-like structure of the wrist formed by carpal bones and the transverse carpal ligament

Flexors (of the forearm): A group of muscles that serve to close the fist, flex the hand at the wrist and flex the arm at the elbow (see picture below)

Extensors (of the forearm): A group of muscles that serve to open the fist, extend the hand at the wrist and extend the arm at the elbow (see picture below)

Tenosynovium: A protective sheath that surrounds tendons

Median Nerve: A nerve that begins in the neck, travels down the arm to supply the palmar side of the thumb, pointer finger and half of the middle finger

Brachial Plexus: A bundle of nerves, veins and arteries which supply the arms

Areas Of Concern

Scalenes: Your scalenes are a group of three muscles originating on your vertebrae and inserting onto your collar bone, ribs and sternum (breast bone). They serve to rotate and flex the head at the neck. The brachial plexus passes through two of the scalenes, making it a common area for impingement.

Clavicle (collar bone) and First Rib: The plexus passes through this small area as well.

Pec Minor: The pectoralis minor muscle serves to depress the shoulder and aids in exhaling. The brachial plexus passes in between this muscle and the ribs.

Flexors & Extensors: The nerve travels under the biceps and into the forearm, where it is frequently trapped by tight flexor & extensor muscles.

Oponens Policus: A muscle that originates on the bridge of the carpal tunnel. It is responsible for drawing your thumb into the palm of your hand. When tight, it pulls on the transverse carpal ligament, creating pressure within the tunnel.

Facts About Carpal Tunnel Syndrome

• Carpal tunnel syndrome (CTS) results in more than two million visits to physicians’ offices each year.
• CTS strikes approximately three times as many women as men.
• CTS is one of the most common job-related injuries.
• Although it may be aggravated by work, CTS frequently occurs in people who are not working with their hands.
• Approximately 260,000 carpal tunnel surgeries are performed each year in the U.S., and 47% of these are considered to be work-related.
• According to data from the Bureau of Labor Statistics, in 1994, carpal tunnel syndrome accounted for 1.7% of workplace-related conditions in private industry that resulted in work loss.
• Almost half of CTS cases result in 31 days or more of work loss.
• If not properly treated, CTS can cause irreversible nerve damage and permanent disability of varying degrees.
• CTS accounts for roughly 10% to 17% of repetitive strain injuries.
• CTS is not a byproduct of the computer age. Meat packers complained of CTS symptoms as long ago as the mid-1800s.