Monday, April 2, 2012

Getting Ahead of Knee Pain


Malaysians are getting increasingly active as the benefits of sports and exercise for general health and chronic disease control becomes apparent.

Sports and exercise no longer remains the bastion of the younger population with older age groups getting increasingly involved. The term ‘recreational athlete’ was coined particularly to refer to the weekend athlete who exercises at a more social or leisurely level, though not less competitively.

Whether it is the young elite athlete, the older athlete or the recreational athlete, knee pain is a common complaint found in sports’ forums and discussion groups. Fortunately, knee pain can be well managed by understanding the possible causes, particularly those causing the most potential damage; scenarios in which immediate medical attention is prudent and most importantly, preventive strategies to avoid recurrences.

Causes of knee pain are multiple and varied. They differ between the younger and older patients. The common causes in the young active person usually involve the ligaments, meniscus and tendons – both occurring after an acute injury or overuse of the knee. In the older patients, arthritis is a common cause - both degenerative arthritis or traumatic.

Knee pain produces mind-boggling symptoms for patients and clinicians alike. For a treatment to be effective, an accurate diagnosis is crucial. This requires accurate clinical history, thorough examination and appropriate imaging.

More often than not, the clinical history points to the most obvious diagnosis.

Pain occurring acutely after sporting activity often points to a ligament, cartilage or meniscal injury. Knee swelling often confirms this diagnosis. Associated symptoms of instability – often described as a wobbly knee - denotes severe injury and warrants immediate specialist consultation. The inability to straighten the knee adequately is also a worrying symptom – the locked knee and is a surgical emergency.

Knee pain progressing and worsening over a longer duration, especially in the older age group, particularly if associated with stiffness during inactivity, points to arthritis as a possible cause of the problem. Pain associated with stair climbing or standing up from a seated position suggests the patella femoral (knee-cap joint) as a target pain generator.

Inability to place one’s weight (weight-bearing) on the painful limb warrants immediate medical attention. However, in children, any type of knee pain would warrant an early visit to the treating physician.

It is also prudent to keep in mind that knee pain can even result from problems of the lower back or hip joint.

A good examination of the patient in general and knee in particular is done to evaluate the severity of the knee pain or injury, confirm the structures involved and rule out possible associated conditions which modify treatment decisions.

Imaging is guided by a clinical diagnosis and is best done after history taking and clinical evaluation. Radiographs are particularly effective in picking up fractures, evidence of overuse injuries and arthritis. The magnetic resonant imaging (MRI) allows for better delineation of cartilage, ligament and meniscal pathology.

Management of knee pain depends on diagnosis. Self-care techniques can be undertaken if the injury is mild.


Immediate care strategies include:
1.         Rest – to prevent worsening of pain.
2.      Cryotherapy – the use of cooling techniques – this aids pain relief and also reduces any associated swelling.
3.         Compression of the knee with a bandage – this offers some support to the knee.
4.         Elevation of the affected knee – keeping the knee above the level of the hip.
5.         Simple analgesics such as Paracetamol at a regular appropriate dosing.

Pain that is not resolving/getting better within the first 24 hours warrants a medical consult. Guidelines have been created to suggest immediate medical consult in the following instances:
1.         Persistent knee swelling in spite of appropriate rest and care.
2.         Instability symptoms – signifying possible major ligament injury.
3.         Locking of the joint.
4.         Inability to bear weight.
5.         Knee pain in children.
6.         Additional systemic signs such as fever, loss of appetite – which may signify an infection.


A torn meniscus is a common cause of knee pain. It occurs both, in the young and old, particularly following a sports injury or in the older patient as a degenerative tear in arthritis. It is at times associated with knee swelling or a locked knee.

Treatment in the young is generally operative. If picked up early, the meniscus is repairable with minimally invasive (key-hole) surgical techniques. When not repairable, the torn part is resected. Degenerative tear can be initially managed with pain relief and guided rehabilitation - including graduated weight-bearing and passive and active movements. Surgery may still be needed when the degenerative tear is large and presents with mechanical effect like knee locking. Improvement is indicated by cessation of swelling and pain – this permits a continuance of conservative non-operative care.

Postoperative rehabilitation is of utmost importance for optimum recovery and includes soft tissue management – care of swelling, progressive range of motion exercises and graduated weight bearing where appropriate.

Collateral Ligaments
The collateral ligaments are usually injured in a ‘twisting’ injury. When mild, they present with pain over the sides of the knee although severe injuries can present with instability.
High energy – severe injuries warrant surgical repair and reconstruction particularly that of the outer knee. Whereas, injuries on the inner knee, particularly if isolated, heal well with brace support and structured rehabilitation.

Cruciate Ligaments
The anterior cruciate ligament is the one of the most common ligament injuries. Management techniques are evolving and advances, particularly in surgical techniques and rehabilitation are rapid.

Excellent results occur when reconstructive surgeries are done well, with a target return to sports within 6 months being very much achievable. High demand patients – the young, the athletic (both the elite and the weekend warriors) benefit from surgery and the option for surgery must be strongly considered in them. Not all patients with anterior cruciate ligament ruptures are candidates for surgery with the more sedentary group of patients doing reasonably well following a non-surgical rehabilitation programme.

Treatment of the posterior cruciate ligament is conservative on the outset particularly when isolated. Surgery is considered when symptoms of instability or pain persist despite completion of a rehabilitation programme.

The old adage “cartilage–once destroyed is never replaced” is no longer easily accepted in modern orthopaedic care. Genetic engineering has spurred cartilage injury healing to the forefront of medical research, bringing about rapid change in care techniques. Surgical results for treatment of larger and painful lesions have improved with newer and newer techniques becoming available to the treating physician.

Once, labeled a degenerative disease, osteoarthritis is now postulated as a disease of cartilage overload. Multimodal therapeutic strategies are available and treatment should be individualized from patient to patient. Treatment options include – nutriceuticals such as glucosamine and chondroitin, newer immunomodulator drugs, intraarticular injections of viscosupplements and stimulant substances including stem cells and minimally invasive techniques. Joint replacement – whether partial or total is a solution for advanced diseases to allow for a pain-free stable joint.

Knee pain continues to excite and baffle clinicians. Accurate diagnosis and appropriate care brings about good recovery. It is necessary to individualize treatment from patient to patient to allow for optimum recovery. Minimally invasive techniques have resulted in less tissue trauma in care and speedy recovery and return to pre-disease level of activity.

Thursday, March 15, 2012

Children - The Pulled Elbow.

Pulled Elbow – The wailing child with no fracture

With the school holiday on, I though this topic would be appropriate.
The pulled elbow occurs in children following a peculiar type of mechanism to the injury.
It usually involves a tug to the elbow of a child – which usually happens say when the caregiver – parent/nanny is trying to prevent the child from falling or preventing the child from crossing the street.
The child classically holds the elbow straight or slightly bent and particularly resists movement at the affected elbow. This often mimics a fracture at the elbow.
What happens?
The elbow joint consists of 3 bones – the arm bone, the humerus; the two forearm bone, the radius and ulna. The forearm bones are linked at the elbow by the annular ligament and it is the slipping of the head of the radius from this ligament which brings about the condition.
A good history – if classical and clinical evaluation is all that is required for a diagnosis. Often an x-ray is not necessary. I request for an x-ray to rule out a fracture around the elbow if the examination of the child me doubt the diagnosis of a pure pulled elbow – this usually is the case if the elbow is unduly swollen.
Manipulation is done in the clinic-emergency room. If done correctly - with reduction of the radial head, the child is comfortable within minutes and often starts using the limb. It is therefore important to review the child after 15-20 minutes. An arm sling is often used but often unnecessary with the child often discarding it within hours.
Note – Pictures from Netter’s Atlas of Orthopaedics

Monday, January 9, 2012

Carpal Tunnel Syndrome

Recently, Avtar Ji came over after his jog and told me ‘Doctor Saab – I’ve been having some pins and needles over my right hand la. My Sinseh said it’s due to ‘angin’ but it has not gone off with massages la’
Chatting a while more and gleaning out some more information, I possibly felt it was median nerve compression at the carpal tunnel – the Carpal Tunnel Syndrome. Examination and work up confirmed this and over 1 week I was able to get him better.
The carpal tunnel is located in the hand and not the wrist. Compression of the median nerve as it runs under the transverse carpal ligament forming the roof of the tunnel is a common cause of numbness of the outer 3 fingers (thumb, index and middle) and pain over the hand.
Many conditions can cause increased pressure within the carpal tunnel and lead to carpal tunnel syndrome although there is often no identifiable cause in spite of detailed evaluation.
At the early stage, patients usually complain of numbness, pain (usually a burning pain), and tingling in the thumb, index, and middle fingers although some patient feel it moving from hand to the lower forearm. As the condition progresses, Some claim to being clumsy and often dropping objects – especially claiming to find it difficult to feel and handle small objects while others complain of frank weakness.
The relationship between work and carpal tunnel syndrome is unclear. Positions of extreme wrist flexion and extension  - this in movement of the wrist to its limit upwards and downwards are known to increase pressures within the carpal canal and apply pressure on the nerve. Poor office ergonomics particularly with computer use are described as predisposing.
Diagnosis is made easy by a good history. Clinical examination centers on confirming that the level of compression is at the hand as occasionally the compression of the nerve may be at the elbow and at times neck problems can cause symptoms that mimic carpal tunnel syndrome. A trained doctor would comfortably make a diagnosis from examination alone. Confirmatory tests include nerve conduction studies that track and test the speed of conduction of impulses along the nerve.  
I often teach simple exercises to glide the median nerve. This involves movement of the wrist from one extreme to the other – from dorsiflexion to palmar flexion.
Usage of a splint keeping the wrist in a neutral position is also helpful. Early symptoms are predominant at night and splints are often used during sleep.
Office ergonomics and proper wrist positioning while at the computer often improves symptoms. The wrist should never be kept in extremes of flexion or extension while typing – simple gadgets such as a silicon rest pad or an ergonomically designed keyboard may help.
Medications and Injectables
Anti inflammatories are often used to combat acute pain although carpal tunnel syndrome is not inflammatory by definition.

Steroid injection into the carpal tunnel is often helpful in early cases where splints and exercises have failed.
More advanced cases, particularly those that involve muscle weakness and loss of dexterity and also in cases where conservative management have failed usually require surgery.
The goal of surgery is to take pressure off the nerve at the wrist. This involves releasing the carpal tunnel ligament which form the roof of the tunnel. Post surgery  movement of the fingers and wrist is encouraged and I often advise the use of a splint at night for 2 weeks. Return to heavy activity is at 6 weeks althought basic activities can be done based on comfort of hand use. Some people experience immediate relief in their hand once the pressure on the nerve is eliminated with surgery – these are often those who have had a short duration of symptoms. Other people do not experience immediate relief due to more long-standing and severe pressure on the nerve.
Risks following surgery is rare. The ones documented in literature include wound infection, stiffness at the wrist and residual pain. There are minimized further by rehabilitation and pain relief medication post operation.