ARTHRITIS

All of the moving joints in our bodies have two smooth lubricated surfaces which glide easily over each other. These joints surfaces are covered with articular cartilage. The cartilage is a hard substance which is constructed of very large molecules densely intertwined with each other. When pressure is put on the joint surfaces a slick lubricating fluid is squeezed out much like you squeeze water out of a sponge. This ensures adequate lubrication even under high loads or stresses. The lining of the joint capsule or covering is called synovium. This is a thin layer of cells which secretes nutrients for the articular cartilage and performs other tasks to keep the joint healthy.

Inflammatory arthritis occurs when the joint lining becomes thickened and irritated. The cause is often unknown but may be due to an immune disorder or latent virus infection. Rheumatoid arthritis is a common cause of inflammatory arthritis. The medical treatment is usually directed by a rheumatologist (medical arthritis doctor). After a period of time the inflammatory arthritis may destroy the joint surfaces. This results in rough bone surfaces rubbing against each other. Osteoarthritis, degenerative arthritis or wear-and-tear arthritis is common in older patients and occasionally seen in younger patients. In many patients the cause is not known. In others the osteoarthritis results from previous injury or damage to the joint. Over a period of time the joint surface gradually erodes away until rough joint surfaces rub against each other.

The symptoms of arthritis include pain, limitation of motion, redness, swelling, fluid accumulation (e.g. water on the knee), warmth, deformity, instability and loss of function. For many patients pain is the most annoying and disabling symptom. Pain may arise from the actual swelling and inflammation of the joint lining. It may also arise from the rubbing of irregular joint surfaces on each other.

Non-operative treatment may include oral medication, rest, splints, physical therapy, cortisone injections and injections of special lubricating fluid. When these have failed surgery is the next treatment option. In certain situations arthroscopic (microscopic) surgery of the joint may allow the smoothing of the joint surfaces. This does not cure the problem but smoothing the gliding surfaces can lead to significantly decreased pain and increased function. This is most often used in the knee. The next step in treating a worn-out joint is a total joint replacement. This involves open surgery, the removal of the arthritic ends of the bones, careful carpentry to fashion the bone ends properly and the replacement of the joint surfaces with metal and plastic surfaces. This is commonly done for arthritis of the hip and knee and less commonly for other joints.

Total hip replacement and total knee replacement are big operations which often require two to three hours of surgery. Patients often stay in the hospital for 5 days after surgery and occasionally longer. Physical therapy is important after surgery to maximize function. Most patients experience dramatic relief of pain after a total joint replacement. The rubbing of the rough irregular joint surfaces has been replaced by the gliding of metal on hard plastic.

There are a number of potential problems associated with total joint surgery. The artificial joints can wear out. The ten year reoperation rate is approximately 20%. This means that one patient out of five will require a second operation within the first ten years following surgery. The metal can break from metal fatigue. The plastic can also wear away or break. The risk of infection is about 1 in 100. An infection in a total joint replacement is a serious problem. Sometimes antibiotics will cure the infection. Other times the entire prosthesis needs to be removed. If this happens it can sometimes be replaced later. The total risk of complications is relatively low and the majority of patients are pleased by their decreased pain and increased function.

Percutaneous Lumbar Discectomy and Arthroscopic Lumbar Discectomy

Arthroscopy is a technique which allows us to look inside your joints by inserting a long, narrow instrument through a puncture wound. Some people call this microsurgery of a joint. Arthroscopy can be used in the evaluation and treatment of knees, shoulders, ankles, elbows, wrists and occasionally other joints.

There is a 50-70% chance of decreased pain following this procedure. Occasional patients are completely free of pain. Those with good results may still have some pain, but they are considerably improved and no longer consider open surgery as a treatment option. Potential complications of this procedure include infection in the disc space, aggravation of the herniated disc, damage to the nerve roots, perforation of bowel, bleeding, increased pain, reactions to medication, etc. but these risks are uncommon.

Not all patients are suitable candidates for this procedure. Some patients have detached fragments of disc material in the spinal canal: percutaneous lumbar discectomy and arthroscopic lumbar discectomy cannot remove these fragments and open surgery is required. If these procedures are unsuccessful, open surgery can be performed at a later date. Patients may continue to have pain for up to three weeks after a percutaneous or arthroscopic lumbar discectomy and then get better. The results following open surgery do not seem to be compromised by a previous percutaneous lumbar discectomy.

Any of the above procedures work by relieving pressure on the nerves. These procedures do not magically cure the nerve. By eliminating the pressure, the nerve is relieved of the source of irritation and then has a chance to heal itself. The extent of improvement depends on the severity of damage to the nerve. Thus there may be rapid improvement in symptoms if the nerve is irritated, but not permanently damaged; slow improvement in symptoms for a nerve with greater damage; and no improvement if a nerve is more severely damaged.

ARTHROSCOPIC

Arthroscopy is a technique which allows us to look inside your joints by inserting a long, narrow instrument through a puncture wound. Some people call this microsurgery of a joint. Arthroscopy can be used in the evaluation and treatment of knees, shoulders, ankles, elbows, wrists and occasionally other joints.

General anesthesia is usually used, although occasionally in special circumstances local anesthesia with intravenous sedation is sufficient. The arthroscope is inserted through a small puncture wound and the joint is filled with fluid. There is a fiberoptic light and a small television camera attached to the arthroscope. Often a small drainage tube is inserted through another puncture wound to allow fluid to wash through the joint. The joint is carefully examined. Often a blunt probe is inserted through another puncture wound and the structures inside the joint are gently pushed and pulled with the probe while being examined. This allows for a more detailed examination.

If the structures are entirely normal, the arthroscope is removed and the procedure is over. In this situation we have not done any treatment which will improve your symptoms, however we know that your symptoms are not coming from any anatomic abnormality inside the joint. Further evaluation and treatment can then be considered with the knowledge gained by arthroscopy.

Occasionaly we see an abnormality that we are unable to correct. For example, in the early stages of degenerative arthritis, which is a mechanical wearing out of the gliding surfaces of the joint, we may see gliding surfaces which are abnormally soft and mushy. This is not something that can be corrected. In this situation we have not done anything to correct your joint, but can offer advice regarding further evaluation and treatment based on the information gained at the arthroscopy.

Usually we find some anatomic abnormality which can be improved by arthroscopic surgery. Common problems include torn menisci (joint cartilages), rough irregular joint gliding surfaces (degenerative arthritis or chondromalacia), loose bodies of cartilage floating in the joint, and torn ligaments. In these situations we insert various instruments into the joint through other puncture wounds and remove, smooth or repair the torn or irregular surfaces.

The anterior cruciate ligament is one of the four main supporting ligaments in the knee. It is one frequently injured in sports either as the result of contact or sometimes from hyperextension without contact. If your doctor feels arthroscopic reconstruction of the anterior cruciate ligament is advisable, he will discuss the details with you.

Often arthroscopic surgery results in significant improvement in function and decrease in pain for the involved joint. Arthroscopic surgery does not 'cure' the joint. It is not possible to make the joint like there was never anything wrong with it. After the rough and irregular surfaces are smoother or torn structures repaired, the joint is usually able to glide more easily and the pain and stiffness are often relieved.

Not all joints are improved by these procedures. If there is a simple torn meniscus in the knee, the knee may be better in a matter of days. If there is degenerative arthritis, a good result may be decreased pain and increased function that lasts a few years. If the problem is severe, arthroscopic surgery may be of no benefit. Rarely, pain and stiffness are worse after arthroscopic surgery. Occasionally we find a problem which cannot be treated with arthroscopic surgery. In this situation we do not proceed to a larger operation unless we have obtained your permission ahead of time.

The risks of arthroscopy include medical and anesthetic complications, infection, damage to the arteries and nerves in the leg, damage to the gliding surfaces of the joint and increased pain.

If you have further questions regarding arthroscopy, please do not hesitate to ask us.

TENDONITIS AND BURSITIS

Cause

Tendonitis and bursitis are common causes of musculoskeletal pain in people between the ages of 30 and 60. They also occur in people who are both older and younger than that. These problems may occur in various parts of the body including the shoulder, elbow, wrist, hand, hip, knee, ankle and foot. The exact cause is not well understood. As you grow older, the different parts of your body do not tolerate stress as well as they used to. Rather than developing sore muscles which go away in a few days, your body appears to develop an inflammatory or irritatied response that can last for a long time and be quite painful. These problems often follow an episode of unaccustomed activity such as raking leaves or they may follow a specific incident of excessive stress or injury to your body.

Bursitis

Anywhere in your body that two surfaces need to glide over each other, there is a bursa. A bursa consists of two surfaces of slick tissue which face each other and glide over each other. The edges are sealed and they form essentially a collapsed sac. When inflamed, this sac fills with fluid, swells and becomes sore and tender. There is a bursa where the skin at the point of your elbow glides over the underlying bone. Another bursa lies under the skin which glides over your knee cap. There are bursae in the heel where the skin glides a little over the bone. There are also bursa deeper within your shoulders and your hips. Inflammation of these structures is called bursitis.

Tendonitis

Detailed studies of the blood supply to the tendons that surround the shoulder indicate that the amount of blood supply decreases significantly as we age through the 30's, 40's and 50's. It is likely that a similar steady decrease in blood supply occurs in other tendons and muscle-tendon junctions of the body. This may explain why our tendons are less able to withstand stress and are more likely to become inflamed. Inflammation of the tendons, their attachments to bone and the muscle-tendon junctions is called tendonitis. An acute injury or multiple small injuries from chronic stress can lead to small tears in the tendons, at their attachments to bone, or at the muscle-tendon junction. These small tears can result in an area of chronic inflammation. This process is called tendonitis.

Deposits of calcium are sometimes laid down in areas of the tendons which develop decreased blood supply. The calcium crystals are very irritating to the tissues and cause pain and inflammation. This is called calcific tendonitis and often is the cause of the acute tendonitis that appears suddenly without cause. The pain may be severe enough to interfere with sleep.

Treatment

The mainstays of treatment for tendonitis and bursitis are non-steroidal anti-inflammatory medications (Motrin, Naprosyn, Dolobid, Ansaid, Orudis, Indocin, Clinoril, Feldene, Celebrex and Vioxx) and cortisone shots. Neither cures all cases. Some types of tendonitis and bursitis seem to respond better to medication and others are more amenable to cortisone shots. Both treatments have low risks associated with them. Anti-inflammatory medications can cause ulcer problems. Cortisone shots rarely cause a temporary increase in inflammation, rupture of tendons or depigmentation of the skin. Too many cortisone shots (usually more than six in one place) can increase the risk of rupture of a tendon. Rest and avoidance of repetitive stress to the inflamed area are also important.

CALCANEAL BURSITIS (HEEL PAIN) (Plantar Fasciitis)

The soft tissue which pads your heel takes a considerable amount of abuse during your daily activities of walking, running and playing sports. This tissue is well padded. Its structure is something like bubble packing. There are tiny compartments filled with fat rather than air and these tiny compartments act like individual shock absorbers. Between the heel bone (calcaneus) and the soft tissue is a bursa which allows easy gliding between the fatty tissue of the heel and the underlying bone.

Chronic repetitive stress or a direct blow to the heel can cause the onset of an acute bursitis in the heel. This can become quite painful, interfere with sleep and make walking unpleasant. Cortisone shots into the heel work more often than anti-inflammatory medications. Unfortunately shots in the heel often hurt alot. Cortisone shots, anti-inflammatory medications and heel pads are the mainstays of treatment. Only in rare situations is surgery performed for this problem. Sometimes one shot cures the problem. Other times calcaneal bursitis can take a long time to correct and can be a very difficult problem.

CARPAL TUNNEL SYNDROME

Cause

Where the wrist and hand meet, nine tendons and one large nerve pass together through a tight tunnel into the palm. This tunnel, called the carpal tunnel, is formed on three sides by the small bones of the wrist and on the fourth side by the very tough fibrous tissue that makes the heel of the hand firm. The nerve passing through the carpal tunnel is called the median nerve. This nerve gives feeling to the thumb, index, middle and part of the ring fingers, and it gives movement to the muscles that lift the thumb away from the palm. Anything that causes swelling within the narrow carpal tunnel can put pressure on the median nerve. A frequently repeated motion of the fingers or wrist can cause irritation and swelling, and a sudden injury, like a blow to the hand or a fractured wrist, can do the same. Pregnancy or arthritis can also cause swelling, and sometimes swelling occurs without any obvious cause. Whatever the cause, swelling and increased pressure in the carpal tunnel can interfere with the flow of blood to the median nerve. Over time the constriction in blood flow can lead to chronic irritation and eventual damage to the nerve. This problem is called carpal tunnel syndrome.

Symptoms

Chronic irritation of the median nerve can cause a variety of sensations in the hand and forearm including numbness, tingling, burning, sleepiness, pins and needles or even shock-like feelings. The patient's hand may cramp and tire easily or lose strength and dexterity. Feeling may be lost in the thumb, index and middle fingers, and patients may sometimes wake at night with numb or aching hands. Many patients feel they have arthritis and that nothing can be done. Symptoms often occur in both hands.

Diagnosis

Carpal tunnel syndrome is diagnosed by evaluating the patient's symptoms, examining the hand and forearm and performing two tests of the electrical functioning of the affected nerves. EMGs (electromyography) detect the irritability of muscles in the hand and arm, and NCVs (nerve conduction velocities) measure the speed of electrical impulses traveling along the median nerve and its branches. EMGs and NCVs can detect significant changes in nerve function and thus confirm a diagnosis of carpal tunnel syndrome. However, patients with milder irritation of the median nerve will sometimes have normal electrical tests because their problem has not progressed far enough to be detected by electrical changes.

Treatment

Many patients have mild carpal tunnel syndrome. They never develop abnormal EMGs or NCVs, and their symptoms are not seriously bothersome or disabling. Treatment in these mild cases may include putting the wrists in splints at night or during the day. People often sleep with their wrists bent forward, which increases the pressure on the nerve by narrowing the size of the carpal canal. Wearing the splints at night and occasionally during the day prevents this. Most patients with more severe carpal tunnel syndrome have abnormal EMGs and/or NCVs though their symptoms may vary from mild to disabling. Some patients with normal electrical tests nevertheless have severe symptoms that persist for months. Because nerve damage can be progressive, the appropriate treatment for most patients with abnormal tests or persistent symptoms is carpal tunnel release surgery. In this operation, the tough tissue forming the palmar side of the carpal canal is opened to relieve the pressure on the median nerve. The increased space for the median nerve and tendons results in decreased pressure in the carpal canal and increased blood supply to the median nerve. The nerve then has a chance to heal itself. The surgery itself does not `cure' the nerve. The pattern of symptom relief after carpal tunnel release surgery depends on which of three types of injury the nerve has sustained. In the first type of injury, the nerve is in a sense stunned or `knocked out'. The nerve can `come to' in days or weeks. In the second type of injury, the nerve cell itself has died back, but the small nerve canals remain intact. After surgery relieves the pressure, the nerve cells begin growing down the small nerve canals at the rate of about one inch per month. Since the distance from the site of injury to the tips of the fingers is six or seven inches, recovery can take six to eight months after carpal tunnel release surgery. Occasional patients note recovery over one to two years. In the third type of nerve injury, the nerve cell has died back and the small nerve canals have collapsed as well. No nerve recovery is possible in this situation. There is no way to determine before surgery how much of each type of injury any individual patient has. Thus after carpal tunnel release surgery, recovery may occur almost immediately, may occur over six to eight months or more, or may never occur. Partial recovery often occurs. About 80 to 90 percent of patients experience good relief from their symptoms after carpal tunnel release surgery. Even those, whose symptoms are not relieved, are still helped because reducing the pressure on the median nerve prevents the problem from becoming worse in most cases. Carpal tunnel release surgery is done on an out-patient basis. No overnight stay in the hospital is necessary. In the procedure most commonly used, an anesthesiologist administers intravenous sedation and the surgeon gives a local anesthesia. This method reduces the risk of the nausea sometimes caused by general anesthesia, and the sedation keeps even very nervous patients comfortable. Sutures remain in the skin for two to three weeks, and patients begin using their hand shortly after surgery.

Risks

When surgery is indicated, the principal risk of not operating to relieve the pressure in the carpal tunnel, is progressive permanent damage to the median nerve. The risks of carpal tunnel release surgery itself include the risks related to all surgery: infection, anesthetic complications and allergic reactions to medications. A small percentage of patients can have an unpleasant flare of pain after surgery which may last for a few months and in rare cases much longer. This problem occurs when the nerve has been extremely irritated by the increased pressure in the carpal canal and then reacts to the increased blood supply with increased irritation. There may also be some tenderness in the palm after surgery, but it usually goes away within six months.

There is a technique for performing a carpal tunnel release using small incisions and an endoscope. We do not recommend this procedure. There have been a number of reports indicating that the endoscopic procedure has a one in a hundred risk of damage to or cutting of one of the major nerves at the wrist. This is such a serious complication that we do not recommend this procedure.

CERVICAL STRAIN

Cause

Cervical strain is often caused by excessive stress such as heavy lifting, unusual strenuous activity or an injury such as an automobile accident or a fall in which the neck is exposed to sudden excessive forces. There may be some tearing of the muscles and/or ligaments about the neck.

Treatment

The treatment of cervical strain depends on how severe your pain is. If your pain is not too disabling, no specific treatment may be indicated. You should simply avoid any activity or movement that puts stress on your neck. Lifting should be minimized; it is better to carry small loads for several trips rather than one heavy load in one trip. Strenuous activity should be avoided. The constant jerking of long car rides may also aggravate a cervical strain and should be avoided. Sleeping on your stomach can force your neck backwards and to the side. This can increase your pain and sleeping on your stomach should be avoided. If your pain is worse in the morning, your sleeping position may be the cause. Eliminating these potential causes of strain often allows your body to gradually heal itself. Gentle stretching exercises are also helpful. If your pain is more severe, medication may be necessary in addition to reduced activity. Muscle relaxants, like Flexeril, taken three times a day, or Soma, taken four times a day. can help alleviate the muscle spasms that contribute to your pain. Muscle relaxants can make you drowsy, so you should not drive or operate machinery while taking them. If they make you feel too sleepy or "spacey" you should stop taking them. Some patients only take them at night or on weekends. Others try half of a pill. Anti-inflammatory pain medications such as Motrin, Indocin, Naprosyn, Dolobid, Easprin, Nalfon, Clinoril, Voltaren, Feldene, Celebrex and Vioxx are also frequently prescribed.. These are taken with meals, one to four times a day depending on the specific medication, and should be stopped if they upset your stomach or cause other side effects. These medications can increase your risk of developing bleeding stomach ulcers. No medication should be taken if there is a chance that you are pregnant. Physical therapy also helps some patients with cervical strain. Our therapists use heat, massage, intermittent traction, transcutaneous nerve stimulation, ultrasound, electrical stimulation and other modalities to help reduce the spasm and pain in your neck and shoulders. The therapist may teach you specific exercises and may also show you how to put yourself in a mild form of traction at home. Soft or hard neck collars are sometimes recommended to help patients reduce everyday stress on the neck.

It is important to analyze the way you position and use your body at work and in other activities. Computer screens should be directly in front of you when using them and at or slightly below eye level. Activities requiring moving or holding the head at extremes of motion should be avoided. If you have to do work above your shoulders, it is less stressful to stand on a stool or ladder to raise your body so that the work is at a more comfortable level.

CUBITAL TUNNEL SYNDROME

When you hit your "crazy bone" on the inside of your elbow, you often feel pain, numbness and tingling radiating down the inside of your forearm into the ring and little finger. The "crazy bone" is actually one of the three big nerves in your arm called the ulnar nerve. This nerve travels down the inside of the upper arm, crosses the elbow behind the bony bump on the inside of the elbow (called the medial epicondyle) and continues down the forearm on the little finger side of the forearm.

The ulnar nerve usually passes through a tight tunnel at the elbow just behind that bony bump on the inside of the elbow. This nerve can develop chronic irritation due to a number of factors. Certain repetitive activities which involve frequent bending and straightening of the elbow are a common source of problems. Frequent positioning of the elbow in a bent position can increase pressure on the nerve. Habitual positioning the of elbow on a desk or table can put pressure on the nerve as can sleeping on your stomach with your arms up over your head.

The tunnel at the elbow is not tight in all people. There are some people in whom the nerve can slide or sublux forward so that it rests directly over the bump on the inside of the elbow. This subjects the nerve easily to pressure if the inside of the elbow rests on anything. In other people the nerve can dislocate completely to the front of the arm with flexion of the elbow and then it returns to the back of the arm with extension of the elbow. Repetitive snapping backwards and forwards can cause chronic irritation of the nerve.

If the nerve becomes chronically irritated, it can cause vague aches or pains at the inside of the elbow, forearm or in the hand. It may also cause numbness, tingling, pins and needles feeling or burning type of feelings in the elbow, forearm or hand. Often these symptoms are in the ring and little fingers.

The diagnosis is made by examining the nerve for evidence of irritation. The nerve is palpated and tapped to see if it is more irritable than normal. The examination also looks for slippage, subluxation or dislocation of the nerve. Electrical studies of the nerve are also useful. These are called electromyography and nerve conduction velocities. If the irritation of the nerve reaches a sufficient level of severity, the speed of conduction of the nerve impulses will slow at the elbow. This alteration in the speed of conduction of the nerve can be detected by the electrical studies. Not all patients who have cubital tunnel syndrome have positive electrical tests. Positive electrical tests suggest that the severity of the condition is greater than if the tests are normal.

Initial treatment consists of trying to eliminate or reduce the amount of chronic irritation of the nerve. This involves changing the way you use and position your arm. If you use a computer keyboard a lot or drive a car or truck frequently, you should position yourself further back from the keyboard or steering wheel so that your arms are held straighter most of the time rather than bent most of the time. If you rest your elbows on a desk or table frequently, you need to break yourself of this habit. If you sleep on your stomach with your arms over your head, you need to change your sleeping position. This is not easy to do. It can take months of effort to become accustomed to falling asleep in a different position. The best position for sleeping is lying on your side with your elbows straight.

Anti-inflammatory medications occasionally are helpful, but not often. Cortisone shots are dangerous because of the risk of damage to the nerve by injecting the nerve itself. If symptoms remain sufficiently severe or if the electrical studies are markedly abnormal, then surgical release of the nerve is indicated. The purpose of the surgical release is to open up the tunnel and remove pressure from the nerve. Sometimes the nerve is permanently moved to the front of the elbow to remove it from the position where is receives repetitive trauma. Sometimes the bony bump on the inside of the elbow (medial epicondyle) is partly removed as a way of relieving pressure on the nerve and protecting it from chronic irritation.

Most patients who have a surgical release of the nerve have improved symptoms with decreased pain, numbness and tingling. In some patients there is only partial relief, depending on how much damage the nerve has suffered. Occasional patients have tenderness on the inside of the elbow due to continuing irritation of the nerve despite the release of the pressure. Rare patients have flares of pain which can last months or rarely for a long time. This is an unusual response to irritation or injury which nerves can develop. About four out of five patients get good improvement in their symptoms following surgery.

DEQUERVAIN'S STENOSING TENOSYNOVITIS

This tendonitis with an impossibly long name occurs on the thumb side of the wrist. The tendons which pull the thumb out into the hitchhiking position pass through a tight tunnel at the bony prominence on the thumb side of the wrist. Repetitive motion activities involving the wrist or trauma to the wrist or hand can initiate a process of swelling and inflammation of this tendon and its tendon sheath. As the tendon swells it rubs more, which irritates it more, which causes it to swell more, which causes it to rub more, etc. This can become a self perpetuating process.

This problem usually presents with pain on the thumb side of the wrist, aggravated by use of the wrist. The pain can be mild and chronic or severe and acute. The diagnosis is made by noting tenderness to palpation of this tendon sheath. A diagnostic test called the Finkelstein's Test is often used. This involves placing your thumb in the palm, making a fist around the thumb and then angling the wrist toward the little finger side. In DeQuervain's tendinitis this is often quite painful.

Treatment includes the injection of cortisone medicine into the tendon sheath. Anti-inflammatory medications help occasional patients, but are generally not as helpful. If the cortisone shots are not helpful, then surgical release of the tendon sheath is indicated. This relieves the continual rubbing which is preventing the problem from resolving. The surgery is done under local anesthesia and on an ambulatory surgery basis. Often an anesthesiologist gives intravenous sedation. Sutures remain in two to three weeks. The majority of patients get good relief from the surgery. There is a very sensitive nerve called the superficial radial nerve which passes across the wrist in this area. Rare patients develop an irritation or injury to this nerve which can cause very unpleasant pain on a long term basis. Every effort is made during surgery to minimize this risk.

HERNIATED CERVICAL DISC

Cause

The Neck or Cervical Spine has seven vertebrae (bones) stacked on top of each other. Between each pair of vertebrae is a cushion or shock absorber of softer tissue called an intervertebral disc or just a disc. This combination of vertebrae and discs gives your neck its unique combination of strength and flexibility. With increased age and accumulated stress, the discs between the vertebrae may begin to degenerate, wear out, and even break up into separate fragments. Disc material may eventually protrude out of alignment with the vertebrae above and below the disc and bulge against the nerves in the spinal canal. This same protrusion or herniation can be caused by a sudden, acute stress like that suffered in an automobile accident or in a fall. Pressure from disc material bulging against the nerves can cause pain, numbness and/or tingling that is felt across the shoulders, down the arms and even in the fingers. In older people, degeneration of the discs can lead to a narrowing of the space between the neck vertebrae and sometimes to the development of bone spurs which can also push against the nerves causing similar pain. This condition is called cervical spondylosis, degenerative arthritis, or degenerative disc disease of the cervical spine.

Symptoms

The symptoms of a herniated cervical disc include all the symptoms of a cervical strain such as pain and stiffness in the neck, shoulders and between the shoulder blades. The pain can radiate up the back of the head. There can be pain, numbness, tingling or other odd sensations going across the shoulders, down the arm and into the fingers. Less commonly there may be weakness of a specific muscle or group of muscles in your shoulders or arms. These symptoms frequently occur only on one side. Rarely there may be interference with the control of your bowel and bladder.

Treatment

All the methods used to treat a cervical strain (reduced activity, medication, physical therapy and/or neck collars) can be used to treat a herniated cervical disc. However, a herniated cervical disc can be a serious problem. Distinct muscle weakness indicates a compressed nerve; if the pressure is not reduced or relieved, the nerve can be permanently damaged. In cases of severe pain and muscle weakness, patients are frequently prescribed bed rest to immobilize the affected area as much as possible. If your pain and other symptoms continue despite conservative treatment, further diagnostic tests are recommended such as magnetic resonance imaging (MRI scan), computer assisted tomography (CAT scan), electromyography (EMG) or a myelogram. These tests provide more precise information about your condition. An MRI scan produces an image of body tissues by recording the energy given off by hydrogen atoms in a shifting magnetic field. CAT scans produce images by a series of precisely controlled and enhanced low level x-rays. Both of these procedures require that you lie very still inside a hollow tube inside the machine while the scanning takes place. EMGs detect the electrical impulses in your muscles and nerves with tiny needles. A myelogram is performed by injecting a special dye, which shows up on x-rays, into the spinal canal of the lower back. You are then tilted head down on a table and the dye runs down to the neck. X-rays taken with the dye in the spinal canal allow us to look for evidence of disc material pressing on the nerves. If you have disabling pain which has not improved with conservative care, and if one or more of the above tests confirms the diagnosis of a herniated cervical disc, then surgery is indicated.

Surgery

The purpose of surgery is to remove the herniated disc material which is pressing on the nerves. A small piece of bone is then removed from the side of your pelvic bone and placed between the two involved vertebral bones to allow the bone to grow across the involved disc space and fuse it solid. A neck collar is worn for three months after surgery and strenuous activity must be avoided during that time. About 80 to 90% of patients experience relief of their symptoms. Some achieve full relief and some partial relief. Unfortunately, 10% to 20% do not get significant relief of their symptoms. The risks of surgery include medical and anesthetic complications, infection, injury to the carotid artery or esophagus, slippage or collapse of the bone graft, failure of the fusion to heal and continued or increased pain. Damage to the spinal cord and paralysis have occurred, but this is extremely rare.

HERNIATED LUMBAR DISC

Causes and Symptoms

The lumbar spine consists of a series of cylinder-like bones, called vertebrae, stacked on top of each other. Between each pair of vertebrae is a cushion or shock absorber of softer tissue called a disc. The disc itself consists of an outer ring of tough, layered tissue (like the tread on a radial tire) and an inner core of soft pulpy material like crab meat.

With increasing age and accumulated stress to the back, the discs in the lower back frequently begin to degenerate, wear out and even break up into fragments. This same process can be caused by an injury which exerts sudden pressure on the disc. Such injuries include heavy lifting, automobile accidents and falls from heights.

A weakened or injured disc can bulge out of alignment with the vertebrae above and below it. This bulging can cause pain by pressing on the ligaments that encase the spine. If the bulge is large, it can put pressure on one or more nerves in the spinal canal behind the disc. At times, fragments of disc material can push their way through the ligaments at the back of the disc and into the spinal canal. Herniated discs are also called slipped discs or ruptured discs. It does not act like a poker chip which slips in and out of place but more like toothpaste squeezed from a tube.

A herniated disc can cause all the symptoms of lumbar strain. In addition there can be pain, numbness and tingling and other odd sensations radiating down the legs to the feet and toes. These symptoms may occur in one leg or both legs. Pressure on the nerves in the spinal canal can also cause weakness of the muscles in the legs, and in rare cases, can interfere with bowel and bladder control. Pain radiating from the back down the leg is sometimes called sciatica. Sciatica is often, but not always, caused by a herniated lumber disc.

Treatment

The methods used to treat lumbar strain (reduced activity, medication and physical therapy followed by the gradual resumption of activity) can also be used to treat a herniated lumbar disc. However, a herniated disc can be a serious problem requiring more aggressive treatment. Sometimes we treat patients with strict bed rest and medication at home. Approximately three out of four patients will improve with medication, rest, physical therapy and the gradual resumption of activity.Those patients who continue to experience severe pain need further diagnostic tests such as magnetic resonance imaging (MRI), computerized axial tomography (CAT scan), electromyography (EMGs) or a myelogram. These tests provide more detailed information about the discs and nerves inside the lumbar spine.

An MRI scan produces images of internal tissues by detecting the energy given off by hydrogen atoms in your body in a shifting magnetic field. CAT scans produce images by a series of precisely controlled and enhanced low-level x-rays. Both of these procedures require nothing of the patient other than lying in a tube-like hollow inside a machine while the scanning takes place. There are no known complications from MRI scans. CAT scans use x-rays, but at low levels: the possibility of finding out useful information outweighs the very small risk from low level x-ray exposure.

EMGS require putting small needles into the muscles of the back and legs to measure the electrical activity of the muscles. A myelogram provides an x-ray outlining the nerve roots, spinal canal and lumbar discs. A myelogram requires the injection of a dye into the spinal canal in the lower back followed by multiple x-rays. The most common side effect from a myelogram is a headache which can be quite severe and last for several days or more. Very rarely, allergic reactions to the dye can cause nerve damage.

If a patient has not improved with bed rest, medication, and physical therapy, and if a diagnostic test confirms the presence of a herniated lumbar disc there are new methods that can often be tried before surgery is considered. Epidural and Foraminal blocks are often an option that is very common and has proven very effective. These "blocks" are basically the injection of pain relieving medication combined with an anti-inflammatory medicine into the space closest to the area of herniation. This is usually done as an outpatient procedure in the hospital so that the doctor has an x-ray machine available to him that enables him to view the area where the needle is placed. Many patients require two to three of these injections to completely recover, but most patients do recover and require no further intervention. If the herniation is too large or does not respond to blocks, then surgery may be indicated. The most common reasons for a patient deciding to have back surgery is PAIN which is of a disabling severity...PAIN which has not diminished despite conservative treatment, and the existence of a herniated disc documented by one or more of the diagnostic tests described above. Severe muscle weakness and numbness in the legs or loss of bowel and bladder control are more urgent reasons for surgery.

Surgery

The traditional method of surgical treatment is called a lumbar laminectomy or lumbar discectomy. During this surgery, the muscle layer covering the spine is peeled back and the spine is exposed. An opening is made into the spinal canal and the nerve roots and lumbar discs are directly examined. If the herniated disc seen in the diagnostic tests is confirmed, then the abnormal disc material is removed with small instruments and the pressure on the spinal nerves is relieved. Sometimes bone is removed from the back of the spine or the hole between the bones through which the nerves pass is widened to relieve pressure on the nerves. One or more discs may be removed depending on how many are involved.

Positive results from surgery cannot be guaranteed, but the majority of patients with herniated lumber discs are better after surgery. If a patient has more leg pain than back pain and a relatively large herniation, there is a 70% chance of a good result from surgery. Occasional patients are completely pain free after surgery, but most patients still have some back or leg pain after recovery. Often some leg numbness persists. Some patients get only temporary relief or no relief. Rare patients have increased pain, muscle weakness, paralysis, increased numbness or tingling or difficulty controlling bowel and bladder function after surgery. The risk of these more severe complications is one in one thousand. Like all surgery, back surgery also involves risks of infection and of medical and anesthetic complications.

Surgery on one area of the back does not prevent problems from occurring in other areas. It is possible to get recurrence of back pain after surgery from herniation of discs at new levels. Further herniation of disc material at the same level is also possible. Scar tissue or adhesions can form around the nerves after surgery causing pain.

Generally patients are out of work for three months following back surgery. Some patients can return to light work earlier, but only perhaps half of the patients with strenuous jobs requiring heavy lifting will be able to return to their former occupations. A back brace may be prescribed for six weeks following surgery. During recovery, we recommend an exercise regimen that includes gentle stretching exercises, stomach strengthening exercises and regular rhythmical exercises such as brisk walking, lap swimming or bicycling (regular or stationary).

KNEE CAP PAIN (CHONDROMALACIA PATELLAE)

Causes and Symptoms

Three bones contribute to the structure of your knee. The femur or thigh bone forms two rounded surfaces which form the top portion of your knee. The tibia or shin bone consists of a weight-bearing platform which forms the bottom of the knee. The patella, or knee cap, is a disc shaped bone which is in front of the knee and glides up and down in a groove in the femur during bending and straightening of the knee. Everyday activities, like kneeling and stair climbing, cause significant compressive stresses between the knee cap and the underlying femur. Strenuous activities, like running and jumping, can generate forces as much as six times your body weight pushing the patella against the underlying femur. So if you weigh 120 pounds, the force across your knee cap can equal 700 pounds at times. If you weigh 200 pounds, the force can reach 1200 pounds. All of these stresses can cause softening and irregularity of the cartilage (the gliding surface) on the undersurface of your knee cap. Pain arising from the underside of the knee cap is one of the more common problems we see in our office. This condition is sometimes called chondromalacia patella from chondro for cartilage, malacia for softening and patella for knee cap. So the name simply means softening of the cartilage under the knee cap. It is also called patellofemoral pain syndrome because not everyone with this problem has obvious irregularities of the kneecap. Pain under the knee cap often becomes a problem in teenagers who are active in sports, but it is also seen in young and middle-aged adults. It occurs more commonly in women than in men, more commonly in people with loose ligaments (so-called double jointed) and more commonly in people who are overweight. Quite often pain in the knee cap develops in people who have become more active in sports or at work. Running, jumping and climbing activities tend to be common aggravators. Other aggravators include squatting, kneeling, and leg extension against weight from a fully bent position. Falling on the knee or hitting the knee hard (eg. hitting the knee against the dashboard in an automobile accident or following a fall) can cause the same condition. In a mild case of chondromalacia patellae, your knees may crack or grind after you have been seated for a long time, or your knees make hurt when you kneel, squat or go up and down stairs. You may also feel a sensation of rubbing or grating under your knee cap. In a moderate case you may be comfortable at rest but develop pain with strenuous running and jumping types of activities. In severe cases the pain may be constant and interfere with walking and normal daily activities.

Treatment

Chondromalacia is rarely "cured", but short-term treatment can relieve the pain of a flare-up and long-term treatment can help prevent flare-ups from recurring. In the short term you should avoid activities that aggravate your knee such as running, kneeling, squatting and climbing. If your knee is very painful, treatment may include a splint to rest the knee and one of a number of anti-inflammatory medications. Once the acute pain of a flare-up has subsided, specific exercises are very important. Proper exercise includes bicycling (regular or stationary) and/or lap swimming. Patients who ride an exercise bicycle 20 minutes a day seems to do much better than those who do not. Short arc quadriceps (front thigh muscle) exercises are also useful. To do this lie on a bed or sit on a chair with a small rolled towel or toilet tissue roll under the knee so that the knee is bent at about a 20 degree angle. Straighten the knee and lift the heel off the bed and hold it for the count of ten and then relax. Repeat this exercise 30 times, three times a day. As your muscles grow stronger, you can add weights to your ankle. You can use ankle weights purchased from a sporting goods store, or use a purse with books in it and put the strap over your ankle. Other exercises, called McConnell exercises, work on strengthening the inner portion of your thigh muscle and are usually taught by our physcial therapists. At no time should you do any exercise in which you are straightening your knee from a fully bent position against resistance. Examples of exercises you should not do include squats, squats with weights on your shoulders, working at a weight bench with the starting position having the knee hanging straight down, and pushing against weights with your feet starting with the knees fully bent. In the long term, after your knee has settled down and protective exercises have strengthened the knee joint, you can gradually increase your level of activity. In time you will find the level of activity you can tolerate without causing your knee to flare up. You may, however, have to change sports. This will be your decision. Not everyone can continue in the strenuous running and jumping sports at the level they desire. If your job requires a lot of stair or ladder climbing, you may have to alter the way you work to reduce the number of times you go up and down. On occasion it is necessary to change jobs to minimize stress on the knee cap. If your problem is severe and you live in a house with stairs, especially a townhouse, it may be wish to move to a one floor house or apartment.

Surgery

When pain remains severe and activity is unacceptably restricted, surgery is sometimes recommended. In one surgical procedure, an attempt is made to release soft tissue structures on the outside of the knee cap to allow it to glide in a different manner over the underlying bone. In another procedure, the rough undersurface of the knee cap is mechanically smoothed. These procedures may be performed using the arthroscope or during open surgery. Your surgeon will recommend the procedure and method best for you. The results of these operations vary. They do help some patients, but there are many patients who are not helped. Thus these operations are usually done only as a last resort.

LUMBAR STRAIN

Causes and Symptoms

Lumbar strain is frequently caused by heavy lifting, strenuous activity, a fall or an injury such as an automobile accident, which subjects your back to a sudden, excessive force. The pain you experience is probably caused by tearing of the muscles or ligaments in your back, but it may also be caused by increased pressure on or injury to the discs which act as cushions between the bones of the spine. The symptoms of lumbar strain are pain, stiffness and muscle spasm in the low back. The pain can spread to the buttocks and to the back of the thighs. Some patients feel as though their back "locks" or "freezes" occasionally, making movement impossible. This sensation is caused by a brief period of severe muscle spasm.

Treatment

The treatment of lumbar strain depends on the severity of the symptoms. If your pain is not too disabling, no specific medical treatment may be indicated. But there are many changes you should make in your daily activities to reduce the stress on your back and to allow your body to gradually heal itself.

The amount of lifting and carrying you do each day must be minimized. It is better to carry small loads for several trips than to carry a single, heavy load for one trip. If your job involves lifting, especially heavy lifting, you and your co-workers should get in the habit of helping each other, thus protecting all of your backs.

When you want to bend over to do something or pick something off the floor, don't bend over at the waist. It is less stressful on your back to lower yourself by bending one or both knees (holding on to something if possible) while keeping your back straight. Avoid working in awkward positions. Analyze the work you have to do and figure out ways to perform your work in a more relaxed, less stressful way.

You should avoid all strenuous activity while your back is healing and generally decrease the number of hours you are on the go each day. When you are at work all day, lying down during your lunch hour can help you get through the day, or lying on the floor for a short time, with your legs up on a chair, can be a good position for resting your back.

Shifting position frequently during the day is also useful. If your job involves a lot of sitting, you should try to find or create occasions for standing. You might stand while on the telephone, or you might stand now and then while using your computer by raising the keyboard. Prolonged car rides, when the back has poor support, should also be avoided. None of these changes in the usual way of doing things is easy to make, but the corresponding benefits for your back can be significant.

Bed rest during the evenings and on the weekends will also help your back to heal. The most comfortable positions are on your back with two pillows under your knees and a small pillow under your head, or on your side with your knees drawn up. Sometimes placing pillows between your legs and arms makes lying on your side more comfortable.

Back braces help some people with lumbar strain, but not everyone. Some patients swear by them; others swear at them. But if you find that your pain increases as the day progresses and the normal daily stresses take their toll, a back brace can be helpful. It decreases the stress the back receives by providing external support. Reduced stress means decreased back pain and increased ability to function.

A patient who is under significant emotional or mental stress, at home or at work, is more likely to develop muscle spasm in the back. Once a lumbar strain has developed, a patient under stress has a much harder time getting better. In these situations, it is important to decrease the amount of stress or to learn to manage it. Biofeedback techniques or psychotherapy may be helpful in these circumstances.

Medication

For more severe pain, medication may be necessary in addition to changes in activity. We often prescribe muscle relaxants such as Flexeril, taken three times a day, or Soma, taken four times a day. Muscle relaxants may make you drowsy, so you should not drive or operate machinery while taking them. If they make you too sleepy or "spacey," you can try taking half a pill or you can stop taking them.

Frequently we also prescribe anti-inflammatory pain medication such as Ibuprofen (Motrin, Advil, Mediprin, Nuprin), Indocin, Naprosyn, Dolobid, Easprin, Nalfon, Feldene, Clinoril, Ansaid, Voltaren, Celebrex, Vioxx, etc. These are taken one to four times a day depending on the specific medication. They should be taken with meals and should be stopped if you have any stomach upset or other side effects. Occasionally these medications can cause bleeding ulcers; they should not be taken if you have a history of ulcers.

If you are taking any other medications or have any other illnesses, please inform us so that we can evaluate the possibility of cross reactions between medications. You should not take any medication if there is a chance that you are pregnant.

Physical Therapy

Physical therapy often is helpful in relieving pain and muscle spasm. Our therapists use a variety of modalities including traction, heat, massage, ultrasound, electrical stimulation and exercise. They will tailor a program to your specific problem. For patients who do heavy work, a work hardening program to build strength, endurance and confidence is often useful.

Exercise

Once your pain has subsided, you can begin a program of protective exercise to help decrease your risk of back flare-ups. Protective exercise includes low stress, rhythmical activities such as brisk walking, lap swimming or bike riding (regular or stationary). You should gradually work your way up to twenty minutes of any of these exercises each day. Stomach crunches and gentle stretching are also useful. None of these exercises should be done if you are having acute pain. Avoid exercises which stress the back such as contact sports, aerobics and weight lifting until you are painfree for a few months.

MRI

What Is It?

A magnetic resonance imaging scanner produces an image of the structures inside your body. When you are being scanned, your body is placed inside of a very strong magnet. When the magnet is turned on, the strong magnetic field causes the protons inside the atoms of your body to line up and spin in the same direction. A radio signal then nudges the spinning protons out of their alignment. When the radio frequency signal stops, the protons move back to their previous position and release an electronic signal. These signals are recorded by instruments and processed by a computer to provide an image of the part of your body being scanned. There are no x-rays and no radiation involved in an MRI scan. No side effects or risks of an MRI scan are known. Though the use of magnetic fields is not thought to be harmful, long-term side effects are unknown. Scans take between 30 and 90 minutes to complete. Often they take about 45 minutes. There are no known risks of an MRI scan in pregnancy, but we still do not advise them in pregnancy unless there is a critical situation in which an MRI scan would be safer than x-rays or surgery. People with cardiac pacemakers and patients with some metal implants cannot be scanned.

The Scan Itself

There is usually no specific preparation required before an MRI scan. You may eat, take medication, etc. Before your scan you may be asked about your medical history, asked to sign a consent form, asked to remove all metallic objects such as jewelry, hair pins, removable dentures etc. You may change into a hospital smock and be checked with a metal detector. Some patients are injected with a contrast agent to improve the images for certain problems. Young children may be sedated to help them lie still. You will be placed on the scanning table, positioned comfortably and the table will slide inside the giant magnet. It is important to lie as still as you can for the entire scan. Don't worry about breathing. During the scan you will not feel anything. You may, however, hear the hum of the machine, thumps, whirring, grating and other machine-like noises.

Results

A radiologist will interpret the scan and send a report to us. He will probably do this some time after you have left the scanning facility. They should give you a copy of the MRI scan to bring with you when you come back to our office. We also will interpret the scan to make sure that we agree with the radiologists report. If there are any questions, we will confer with the radiologist or ask other radiologists for their opinions. This increases the probability that we will get the maximum information from your scan.

NECK PAIN

Most people experience at least one serious episode of neck pain sometime in their lives. If you have a neck problem, you may feel pain, stiffness or muscle spasms in your neck itself, or the pain may radiate up the back of your head, causing headaches, or the pain may travel down between your shoulder blades, or spread out across your shoulders and even down your arms to your fingers. You may also feel numbness, tingling or pins and needles sensations in all these areas. Your arms may seem weak and grow tired easily. These symptoms often result from two causes: strain to the muscles and ligaments of your neck, called cervical strain, or bulging or herniation of the disc or shock absorber in your neck, called herniated cervical disc.

Percutaneous Lumbar Discectomy

Other procedures for treating herniated lumbar discs are called percutaneous lumbar discectomy and arthroscopic lumbar discectomy. In these procedures the surgeon inserts a long, narrow metal tube into the disc using x-rays to guide its path or the metal tube is inserted using arthroscopic visualization. Instruments inserted through the tube can then either suction out the disc material or mechanically remove the disc material decompressing the disc and allowing the bulging or herniation to retract away from the compressed nerves. These procedures are performed under local anesthesia with intravenous sedation and do not usually require an overnight stay in the hospital.

There is a 50-70% chance of decreased pain following this procedure. Occasional patients are completely free of pain. Those with good results may still have some pain, but they are considerably improved and no longer consider open surgery as a treatment option. Potential complications of this procedure include infection in the disc space, aggravation of the herniated disc, damage to the nerve roots, perforation of bowel, bleeding, increased pain, reactions to medication, etc. but these risks are uncommon.

Not all patients are suitable candidates for this procedure. Some patients have detached fragments of disc material in the spinal canal: percutaneous lumbar discectomy and arthroscopic lumbar discectomy cannot remove these fragments and open surgery is required. If these procedures are unsuccessful, open surgery can be performed at a later date. Patients may continue to have pain for up to three weeks after a percutaneous or arthroscopic lumbar discectomy and then get better. The results following open surgery do not seem to be compromised by a previous percutaneous lumbar discectomy.

Any of the above procedures work by relieving pressure on the nerves. These procedures do not magically cure the nerve. By eliminating the pressure, the nerve is relieved of the source of irritation and then has a chance to heal itself. The extent of improvement depends on the severity of damage to the nerve. Thus there may be rapid improvement in symptoms if the nerve is irritated, but not permanently damaged; slow improvement in symptoms for a nerve with greater damage; and no improvement if a nerve is more severely damaged.

SPINAL STENOSIS

Causes and Symptoms

Another cause of lower back pain and related problems is spinal stenosis. In this condition, the diameter of the spinal canal is narrower than normal because of overgrowth of bone spurs which have formed as a result of degenerative arthritis of the spine. Occasionally the spinal canal is narrow because of congenital undergrowth of the spine.

Diagnosis of spinal stenosis requires an MRI scan, CAT scan or myelogram (described above). Since similar symptoms can sometimes be caused by an insufficient supply of blood to the legs, further tests may be necessary to evaluate this possibility.

Treatment

When the pain and difficulty of walking are so severe that the patient is incapacitated, the only effective treatment is surgery. During surgery the bone at the back of the spinal canal is removed in order to open up the spinal canal and relieve the pressure on the nerves. Herniated lumbar discs which frequently accompany this condition may have to be removed at the same time. The length of spine which has to be decompressed is determined by the diagnostic studies. One to four levels are often involved. The risks of surgery are similar to those listed for lumbar laminectomy above. In addition, if a patient has little back pain before decompression laminectomy for spinal stenosis, after surgery he may find significant improvement in function and ability to walk, but increased back pain. Most patients find that the improvement in function outweighs the increase in back pain.

TENNIS ELBOW (LATERAL EPICONDYLITIS)

Tendinitis at the outside of the elbow is often called tennis elbow. The majority of patients whom we see with this problem do not play tennis excessively. Tennis elbow may be caused by a sudden, acute stress on the elbow or by repetitive motion activities involving picking up objects with the palm facing downwards or inwards.

The first line of treatment is to eliminate chronic stress on the tendon which attaches to the outside of the elbow. Whenever you pick something up with your palm facing downwards or inwards, the muscles on the back of the forearm contract and do most of the work. Most of the muscles on the back of the forearm attach to the tendon on the outside of the elbow. When these muscles contract they put stress on this tendon. It is important to change the way you pick up and carry things. You must think of carrying things with two hands rather than one. This decreases the stress on each arm. Carrying things with the palm up puts stress on the muscles on the palm side of the forearm. These muscle attach to the inside of the elbow. Containers of liquid such as milk, orange juice, etc. should be smaller (eg. quarts rather than half gallons) and should be picked up with both hands.

Cortisone shots are often effective in reducing the amount of pain and inflammation. Unfortunately cortisone shots in this area often hurt. Anti-inflammatory medication can also be of value. If several cortisone shots and anti-inflammatory medications are unsuccessful in curing this problem. There is a surgical option. The tendon on the outside of the elbow is explored. If the area of chronic inflammation is seen, it is removed. If no specific area of inflammation is found, the tendon is lengthened a small amount to decrease stress and tension on the tendon. The results from this operation are not universally good. Perhaps four out of five patients get good relief of symptoms. Unfortunately, approximately one in five does not.

TRIGGER FINGER (TENOSYNOVITIS)

In the hand and fingers mild inflammation of the tendons can cause swelling of the tendons and of the tendon sheaths in which they glide. This swelling causes the tendons to rub more as they glide. The rubbing causes increased inflammation and swelling, which causes more rubbing, which causes more swelling, etc. The swelling can reach a point at which the tendon cannot glide fully. In this situation the finger may pop or snap as it moves or even become stuck in one position. Sometimes it is impossible to pull the fingers into a full fist position. This is often called trigger finger (thumb) or tenosynovitis. It can occur spontaneously or can develop after injury to the palm or from chronic repetitive stress.

Injections of cortisone into the tendon sheath often help to decrease the swelling and allow freer gliding of the tendons. Anti-inflammatory medications are sometimes effective. If relief is not obtained with the shots, then a small operation is used to open up the tendon sheath at the area of tightness. This is performed under local anesthesia on an ambulatory surgery basis. 95% of patients get relief of symptoms and freer gliding of the tendons as a result of this operation.