Overuse Injuries in Orthopaedics practice

INTRODUCTION

Overuse injuries are injuries of the musculoskeletal and nervous systems that may be caused by repetitive tasks, forceful exertions, vibrations, mechanical compression (pressing against hard surfaces), or sustained or awkward positions. It is also known as Repetitive Strain Injury or Cumulative Trauma Disorders. These are most commonly used to refer to patients in whom there is no discrete, objective, pathophysiology that corresponds with the pain complaints. Stress fracture is also a common overuse injury, which scientist already described it since 1855. Overuse injuries due to repetitive motion are common in occupational, recreational, habitual activities and elite athletes. [1] The examples of overuse injuries are Golfer's elbow, Tennis elbow, Baseball pitchers’ elbow, Javelin throwers’ elbow. These conditions have acquired names derived from activities in which they were encountered when they were first described.

PATHOPHYSIOLOGY
Normally, our tissues adapt to the stresses placed on them over time. Different types of stresses include shear, tension, compression, impingement, vibration, and contraction. Tendons, ligaments, neural tissue, and other soft tissues can undergo mechanical fatigue, resulting in characteristic changes depending on their individual properties. As a respond, the tissues attempt to adapt to the demands placed on them. In the process of adapting, they can incur injury unless they have appropriate time to heal. The rate of injury simply exceeds the rate of adaptation and healing in the tissue.
In stress fractures, it is resulted from recurrent and repetitive loading of bone. It differs from other types of fractures in that; most of them have no acute traumatic event preceding the symptoms. Usually, the patient has a history of an increase and/or change in the character of activity or athletic workouts, increase in frequency of doing activity, or change in posture during activity. Bones may be more prone to stress fractures if the bone is weakened, as in individuals with osteoporosis.
There are a lot of hypothesis as why does the injury happens in repetitive tasks. One of them is the depletion of adenosine 5’-triphosphate (ATP) in the muscle fibers, which leads to reduction of sarcoplasmic reuptake of Ca2+ resulting in high concentrations in the cytosol, allowing Ca2+ –dependent activation of phospholipase, the generation of free radicals, and damage to the muscle fibers involved. [1]
Other hypothesis involving Prostaglandin E2, which has been found to be present in high quantities in overuse tissues in rat and chicken models. [2] This mediator has been suggested to influence cell proliferation, increase collagenase, and decrease collagen synthesis. As the result of increasing loads on these tissues, nitric acid and prostaglandin amount are altered. However, a contradicting hypothesis based on rat-model observations shows that overuse of muscle may lead to an understimulation of tendon cells, rather than overstimulation.
In another study, alterations in regulation of genes within tendons undergoing overuse have been shown in the rat model, in which there is upregulation of genes associated with cartilage, and down-regulation of genes associated with tendon.[3] This might suggests that overuse may cause a morphologic alteration of tendon tissue, resulting in the cartilaginous changes in the tendons
From another point of view, psychosocial factors might play a role in overuse injuries for decades. This includes work satisfaction, perceived physical health, perceived mental health, coping mechanisms of the patient and his/her family, perception of work-readiness, and anxiety.
RISK FACTORS:
Risk factors for overuse injury are not only depends on the biomechanical changes of the action, but also intrinsic factor of the patient. Sex differences play a role in certain overuse injuries. For example, the incidence of carpal tunnel syndrome is higher among female compared to male. This has a variety of possible causes, including anatomical differences in the carpal tunnel, hormonal differences, differences in the activities performed by men and woman, biomechanical differences such as elbow carrying angles, Q-angles, femoral anteversion, and lean body mass. Stress fractures typically affect individuals who are more active, and the incidence probably increases with age due to age-related reduction in bone mineral density (BMD).
Although stress fractures result from repeated loading, some other causes such as menstrual disturbances and irregularities, lower dietary calcium intake, caloric restriction, less oral contraceptive use, muscle weakness, decreased testosterone level in male endurance athletes and leg-length differences are risk factors for stress fractures.[4] A study among military recruits has shown that recruits with stress fractures had significantly narrower tibiae and increased external rotation of the hip.
HISTORY:
It is important to obtaining complete information on the onset, timing, and frequency of symptoms; any associated symptoms; and alleviating and exacerbating factors. Information about specific activity or technique problem is also essential. Other relevant symptoms may include a history of popping, clicking, rubbing, erythema, or vascular phenomena. In athlete, specific attention must be paid to training details, equipment fit, and technique. The most salient historical feature in the diagnosis of stress fracture is the insidious onset of activity-related pain. In early stage, the pain is usually mild and felt toward the end of the inciting activity. As the disease progresses, the pain may worsen and occur earlier, limiting participation in sports activities. Rest may relief the pain in the early stages, but as the injury progresses, the pain may persist even after cessation of activity. Other than that, night pain is a frequent complaint. Usually, the patient has no recent history of trauma to the affected area.
Long-bone fractures usually lead to localized pain, while pain from injury of trabecular bone is more diffuse. Possible risk factors that precipitated or contributed to the injury should be identify. These include details of the athlete's training history both in terms of volume and intensity, intensive sustained muscular activity, muscle fatigue, structural malalignments, biomechanical inefficiencies, concurrent injury, or poor bone health status. Diagnosis is usually based on clinical findings and high index of suspicion because fracture site or new bone formation is visible on radiography maybe only after several weeks.
PHYSICAL EXAMINATION
The examination in case of overuse injury follows the basic method of orthopaedic examination; consist of inspection (including alignment and anatomical structure), palpation, and passive (including athlete's flexibility) and active range of motion (ROM). Usually, tenderness and guarding are present. During ROM examination, crepitus; painful or painless usually can be appreciated. On local examination, erythema, swelling, and anatomic derangement raise the possibility of an acute injury or infection, as well as the presence of an inflammatory disease. Some special test or maneuvers can be applied to help in making diagnosis, such as “Hop test” and “Fulcrum test”, or Tinel and Phalen tests at the wrist.[5] But, no single physical examination test is sufficiently sensitive and specific to permit the unequivocal diagnosis of a stress fracture. So, the doctor should correlate the history with examination, together with high clinical suspicion to consider the overuse injury as one of the possible diagnosis.

CAUSES

The primary factor leading to overuse injury is repetitive activity, although the specific type of force leads to different outcomes. Repetition is part of the definition of overuse injury. The concept is that overuse injury is associated with repeated challenge without sufficient recovery time. Another terms to describe repeated activities are cycles and fundamental cycles. While cycle is a large-scale activity that is repeated throughout the day, fundamental cycle is a small component of a cycle that may be repeated several times during the performance of a cycle. Repetitiveness and force exerted are features of a task that increase the risk of sustaining an overuse injury.

However, some studies have shown that cycle times and repetitive motions do not specifically lead to overuse injury in the upper extremity, but as possible causes for injury.[1] It is shown that vibration; especially over long periods is a factor in increasing the risk of many injuries such as lower back pain, intervertebral disk injury, and wrist injury. Apart from the above, malpositioning of limbs away from their neutral position increases the risk for overuse injury.


DIFFERENTIAL DIAGNOSIS
Differential diagnoses vary and depend on location, symptoms, history and physical examination.
o Shin splints (medial tibial stress syndrome) can mimic stress fractures ot the tibia. Shin splint pain tends to be present at the start of activity, while overuse injury at the end. Tenderness to palpation over a wide region of the tibia and the tibialis muscle, whereas the pain from stress fractures tends to be localized to a specific area on the tibia.
o True fractures can be differentiated from overuse injury by an obvious history, with a traumatic event being recalled by the patient with acute onset of pain.
• Muscle strains; may be acute or chronic. Chronic muscle strains can be differentiated from overuse injury by the location and by factors that exacerbate or worsen the injury.
• Costochondritis may mimic the pain seen in stress fractures of the ribs. Rib stress fractures should be suspected in athletes who participate in rowing sports, such as crew rowing. The pain of costochondritis may be more diffuse or widespread than the pain from stress fractures of the ribs. .[4]
• Nerve entrapment syndromes can also mimic overuse injury, but can be differentiated by presence of numbness in the former.[4]
• Popliteal artery entrapment syndrome is another cause of lower extremity pain. This also present with increased pain and/or swelling with exercise, which is more diffuse than the pain associated with stress fractures. Measurement of ankle blood pressures before and during exercise or an angiogram may help with the diagnosis.
DIAGNOSIS AND INVESTIGATIONS

Radiography
Stress fractures may not show up on radiographs for the first 2-4 weeks after injury. The first radiographic finding may be a localized periosteal reaction or an endosteal cortical thickening. The low sensitivity of radiographs for stress fractures gives advantage to bone scanning, magnetic resonance imaging (MRI), and computed tomography (CT).
Magnetic resonance imaging (MRI)
MRI not only provides information about bone integrity and fracture orientation, but also can demonstrate focal tissue damage and edema.
Technetium-99m bone scanning
It took 72 hours for Technetium bone scan findings to be positive in the case of a stress fracture. However, a positive bone scan finding is nonspecific, and it may be indicative of another diagnosis, such as an infection or a neoplastic process. In a study which compare conventional radiography and bone scanning for the initial detection of stress fractures, positive findings were reported in 96% of bone scans, whereas only 42% positive findings were reported on radiographs.
Electrodiagnostic testing
Electrodiagnostic testing (such as EMG, nerve conduction studies) can be very useful in cases of peripheral nerve compression or injury; such testing can provide evidence of the location and severity of the injury. However, EMG and nerve conduction studies are not tests with high specificity, although they can provide much-needed information when vague symptoms are the chief complaint. They are also very useful for documenting work-related injuries.
Laboratory Tests
These tests are relevant if the individual is discovered to have metabolic bone disease or another comorbidity such as inadequate nutritional status.

TREATMENT
Physical Therapy
Patient should have rest, particularly avoidance of the inciting activity. Total bed rest is virtually never advisable for these patients. Instead, participation in a carefully planned physical therapy program is important. The physical therapy program also offers the patient the chance to see that movement will not lead to ongoing tissue damage, thus preventing significant "sick behaviors" or kinesophobia. Ill-fitting equipment, overtraining, or technique flaws commonly cause overuse injury in athletes. So, specialized fitted equipments hould be provided, while sports psychology is worthwhile in combating overtraining, and sport-specific coaching is often invaluable. Coaches, athletes, and physicians must work together to correct these problems.
Occupational Therapy
Occupational therapists can help to identify workplace modifications. In cases of individuals who develop overuse injuries as a result of the interface with adaptive equipment, occupational therapy may be of great benefit. Simple modifications in the manner in which the patient performs activities of daily living or modifications in the equipment itself can provide relief.


Surgical Intervention
Surgical intervention is required only if conservative approaches fail, or if the injury is amenable to surgery. Most common problems that lead to surgery in overuse injury are decompression of nerves and repair of lax or failed ligaments. Surgical procedures most typically involve open-reduction internal fixation and pinning of the associated fracture sites. Surgeries that are performed solely to relieve pain in the absence of objective findings are notorious for suboptimal outcomes.
Medication
Combined injection of corticosteroids and local anesthetics is quite helpful in persons with overuse injury.[1] Pain relief enables more effective participation in therapy, and it may help to limit the likelihood that the patient will develop a chronic pain syndrome. Usually, injections should be performed after less invasive measures fail. In some rare condition, immediate relief of pain may be necessary to allow participation in an athletic or performing arts event, and this can be achieved through injection therapy.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are mainstays in the treatment of overuse injuries. However, there are evidences that revealed that true inflammation is rarely a component of these disorders, especially tendinopathies. So, the use of simple analgesics has become more prevalent in the treatment of such disorders. Muscle relaxants, opiates, corticosteroids, tricyclic antidepressants, and sleep medications have a role in the specific treatment of individuals with overuse injury.

PREVENTION
Nutritional measures: calcium supplementation
A study by Schwellnus and Jordaan found that there is no benefit with calcium supplementation (500 mg/d) beyond the usual dietary intake in male military recruits.[6]
Biomechanical measures: orthotics and shoe inserts
The use of orthotic devices and shoe inserts has been studied as a preventive measure for lower-extremity stress fractures. It is found that the incidence of lower-extremity stress fractures was lower in the group using semirigid orthoses (15.7%) or soft biomechanical orthoses (10.7%) than in the control group (27%). Additionally, the recruits better tolerated the soft biomechanical orthoses than the semirigid orthoses.[7]
In a prospective study of stress fractures, shock-absorbing orthotic device worn within military boots decreases the incidence of stress fractures. [8] There is a statistically significant decrease in the incidence of femoral stress fractures in the orthotic device group.
COMPLICATION
High-risk stress fractures
Even though nonunion of stress fractures is uncommon, but it can occur. To prevent this, stress injuries should be closely followed up for early surgical intervention. These include stress fractures of the neck of the femur, the anterior cortex of the tibia, the tarsal navicular, and the bases of the second and fifth metatarsals. Other high-risk stress fractures include stress fractures of the patella and medial malleolus.
Low-risk stress fractures
Low-risk stress fractures include most upper-extremity stress fractures, except for the fractures through the physis of the humeral head (little leaguer's shoulder) and fractures through the medial epicondyle (little leaguer's elbow), which may have complications due to the involvement of the growth plate.[9] Other low-risk stress fractures include stress fractures of the ribs, pelvis, femoral shaft, fibula, calcaneus, and the metatarsal shafts.














REFERENCES:
1. eMedicine. Scott R Laker, MD. Overuse Injury, Mar 12, 2008.

2. Flick J, Devkota A, Tsuzaki M, et al. Cyclic loading alters biomechanical properties and secretion of PGE2 and NO from tendon explants. Clin Biomech (Bristol, Avon). Jan 2006; 21(1): 99-106.

3. Archambault JM, Jelinsky SA, Lake SP, et al. Rat supraspinatus tendon expresses cartilage markers with overuse. J Orthop Res. May 2007; 25(5): 617-24.

4. eMedicine. John M Martinez, MD. Stress Fractures, Apr 17, 2008.

5. eMedicine. Vincent N Disabella, DO, FAOASM. Elbow and Forearm Overuse Injury, Feb 12, 2008.

6. Schwellnus MP, Jordaan G. Does calcium supplementation prevents bone stress injuries? A clinical trial. Int J Sport Nutr. Jun 1992; 2(2): 165-74.

7. Finestone A, Giladi M, Elad H. Prevention of stress fractures using custom biomechanical shoe orthoses. Clin Orthop. Mar 1999;360: 182-90

8. Schwellnus MP, Jordaan G, Noakes TD. Prevention of common overuse injuries by the use of shock absorbing insoles – A prospective study. Am J Sports Med. December 1990; 18:636-641.

9. Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med. Jan-Feb 2001; 29(1): 100-11.


N.B. This article is excerpted from the Book : OVERUSE INJURIES IN ORTHOPEDIC PRACTICE: Diagnostic Enigma and Mananagement Principles

Editorial Reviews
Product Description
Overuse injuries are injuries of the musculoskeletal and nervous systems that may be caused by repetitive tasks, forceful exertions,vibrations,mechanical compression,or sustained or awkward positions.It is also known as Repetitive Strain Injury or Cumulative Trauma Disorders. These are most commonly used to refer to patients in whom there is no discrete,objective,pathophysiology that corresponds with the pain complaints.Physical activity is a great way for kids to build bone strength, prevent obesity and stay healthy,when paired with safety and prevention practices. With youth sports injuries rising at alarming rates,overuse injuries such as sore bones and muscles, and swollen or injured joints need prompt attention in child athletes to prevent chronic musculoskeletal problems later in life. Understanding overuse injuries can guide you to designing your training to reduce the risk of injury and help you to recognize and treat them as they inevitably occur.Overuse injuries can be defined as the product of "too much,too fast,too soon." The topics discussed in these chapters are conditions commonly seen by the author in his long stint as an orthopedic and sports medicine consultant.
About the Author
Prof Gourishankar Patnaik is internationally renowned orthopedic and Spinal surgeon. A topper throughout he has over two decades of teaching and research experience at various medical colleges in India, Oman, USA and Malaysia. A globe trotter he has authored many books. A gifted Surgeon his research interests include diabetes, Neurotrauma and E-learning.

FROZEN SHOULDER IN DIABETICS
When we ponder upon diabetes mellitus and its complications, we might be imagining conditions like diabetic foot, renal failure, atherosclerosis, diabetic retinopathy and so on. Shoulder problems are not what come to mind when most people think of diabetes. But studies have found a link between both types of diabetes and a condition known as frozen shoulder.
The incidence of frozen shoulder has been estimated to be from 3% to 5% in the general population, with a significantly increased incidence amongst diabetics, on the order of
10% to 20%. It appears to be most common in adults between the ages of 40 to 70 years. Women appear to be at a slightly increased risk (4:1) and the non-dominant arm is most commonly affected. Idiopathic frozen shoulder is most strongly associated with insulin-dependent diabetes, in which the lifetime risk of developing adhesive capsulitis may be as high as 36%, with the first episode occurring at a significantly younger age than in the general population. Non-insulin-dependent diabetics also have an increased incidence of frozen shoulder, but not as high as in insulin users. Diabetics also have a tendency to develop bilateral shoulder involvement. Therefore, patients who present with a somewhat atypical set of findings should be screened for diabetes as part of their initial workup.
So, what is a frozen shoulder actually? A frozen shoulder is a shoulder joint with significant loss of its range of motion in all directions. The range of motion is limited not only when the patient attempts motion, but also when the doctor attempts to move the joint fully while the patient relaxes. A frozen shoulder is also referred to as adhesive capsulitis. The modern English words "adhesive capsulitis" are derived from the Latin words adhaerens meaning "sticking to" and capsula meaning "little container" and the Greek word itis meaning "inflammation". The shoulder is the most mobile joint in the body. Its function is to position the arm in space to reach out to objects and deliver them for other actions. The shoulder is a ball and socket joint formed by the upper end of the humerus (arm bone) and the socket formed by the glenoid of the shoulder blade. It is lined by a bag like capsule. The capacity of this joint is about 15- 20 cc. In frozen shoulder the capacity is reduced to 2- 3 cc. The movements at the shoulder joint occur synchronously with that at joint between the shoulder blade and the torso and are compensated to some extent by this.




A few theories had been put forth by a number of physicians and researchers to explain the link between frozen shoulder and diabetes mellitus. Dr. Aaron Vinik, MD, PhD who is the Director of Diabetes Research Institute in Eastern Virginia Medical School, Norfolk, Virginia said that certain compounds accumulate in the linings of joints in the collagen. The collagen fibers then stick together and limit the capacity for the joint and ligaments to stretch with movement. Ultimately this ends up as a frozen shoulder. Agreeing with the fact, Dr. Richard Bernstein of the Diabetes Center Mamaroneck, New York offers his perspective on frozen shoulder:
Muscular and skeletal problems are virtually universal among people with long-standing, poorly controlled diabetes. Sometimes the problems are very painful and even disabling. They probably stem from glycosylation of collagen (a protein in tendons).
Collagen fibers normally slide along one another during muscular movement. In glycosylation, they become glued together by glucose. This process can also occur in the skin, which becomes hard and tough (diabetic scleredema).
In another studies, Neviaser and Neviaser in 1945 coined the name "adhesive capsulitis" to suggest an adhesive process of the capsule to the humeral head and was first termed by. However, this name appears to be somewhat of a misnomer, as later shown by later arthroscopic evaluations. What has been found is a contracture that consists of thickening and fibrosis within the joint capsule itself. This process results in decreased intra-articular volume and diminished capsular compliance, so that glenohumeral motion is limited in all planes. Normal intra-articular volume is about 15 to 30 cc; in patients with adhesive capsulitis, the joint capacity is typically less than 10 cc.
Histologically there has been some controversy regarding the etiology of the fibrosis and contracture of the capsule. In original studies done by Neviaser there was evidence of synovial inflammation. In separate studies, however, Bunker suggested that the active pathologic process is that of fibroblastic proliferation. Interestingly, it appears that the histologic changes are very similar to Dupuytren's contracture, which is also associated with diabetes.
Meanwhile, recent advances discovered that the answer to frozen shoulder lies in the genes. These genes may also be associated with Diabetes mellitus. The alterations in these genes and chromosomes lead to a distorted response to wound healing and scar tissue formation. Exuberant scar tissue forms in response to trauma. The remodeling of scar tissue collagen is less. When more scar tissue forms in the capsule of the shoulder joint, the normally possible movements are grossly reduced. Diabetics also develop nodules in their palms and feet, another evidence of the exaggerated healing process.
Whatever it is, the pathophysiology of frozen shoulder in diabetics remains elusive. What can be said is that, there is a positive evidence to link the excessive level of glucose in the blood and the process of glycosylation of the collagen fibers to be responsible in the development of frozen shoulder.
Classically, the frozen shoulder has been described as occurring in 3 stages:
(1) painful, (2) stiff, and (3) resolving. The natural course of these phases
typically takes from 1 to 3 years to resolve. The first phase often begins
with pain in the shoulder. Patients will complain of pain while sleeping on
their side and will self-restrict the movement of their shoulder to their side
in order to avoid pain. They often complain of generalized pain in the deltoid
region. Often, patients will not seek medical attention during this phase,
expecting that the pain will resolve on its own. They may self-medicate with
analgesics, and will only present when the restriction of motion becomes problematic.
There is usually no inciting trauma or other event, although patients may remember
the specific moment when they were unable to do a particular activity due to
restricted motion. The painful phase may last from 2 to 9 months.
In the stiff or frozen phase, the shoulder is significantly
restricted, and patients note the inability to perform daily functions, especially
those that require significant internal or external rotation or elevation (e.g.
hair washing, reaching overhead). Patients often present at this point with
very specific complaints, such as an inability to scratch their back, fasten
their bra, or get an item from an overhead shelf. When moving within the limits
of their motion, the patient has little or no pain. It is only when the patient
attempts an activity that requires motion beyond their capability that they
develop "end-range pain." The frozen stage can last for 3 months
to 1 year.
In the resolution phase, the "thawing" begins and the patient gradually regains some range of motion. The ability to perform functional activities improves over 1 to 3 years; however, full range of motion is rarely recovered. On long-term follow-up (even up to 11 years later), up to 60% of patients appear to have persistent restriction. What is notable is that loss of less than 20% of the normal range of motion does not appear to affect activities of daily living, nor cause significant functional disability.
How a frozen shoulder is usually diagnosed? A frozen shoulder is suggested during examination when the shoulder range of motion is significantly limited, with either the patient or the examiner attempting the movement. Underlying diseases involving the shoulder can be diagnosed with the history, examination, blood testing to exclude any endocrine disorders e.g. hyperthyroidism, and x-ray examination of the shoulder.
If necessary, the diagnosis can be confirmed when an x-ray contrast dye is injected into the shoulder joint to demonstrate the characteristic shrunken shoulder capsule of a frozen shoulder. This x-ray test is called arthrography. Arthrogram contrasts are special x-rays that show details of the shoulder capsule, such as a decrease in size (in a normal shoulder the capsule is rounded, but in a frozen shoulder the capsule is squat, square and contracted).

The tissues of the shoulder can also be evaluated with an MRI scan. The MRI findings that suggest adhesive capsulitis include soft tissue thickening in the rotator interval, which may encase the coracohumeral and superior glenohumeral ligaments, and soft tissue thickening adjacent to the biceps anchor. Other findings that can be demonstrated on MRI include thickening of the inferior glenohumeral ligament greater than 4 mm and loss of definition of the inferior capsule secondary to edema and synovitis.






The aim of treatment for frozen shoulder is to alleviate pain and preserve mobility and flexibility in the shoulder. However, recovery may be slow, as symptoms tend to persist for several years. Treatment options for frozen shoulder include painkillers to relieve symptoms of pain. Nonsteroidal anti - inflammatory drugs (NSAIDs), such as ibuprofen, are over - the - counter (OTC, no prescription required) painkillers and may reduce inflammation of the shoulder in addition to alleviating mild pain. Acetaminophen (paracetamol, Tylenol) is recommended for extended use. Prescription painkillers, such as codeine (an opiate - based painkiller) may also reduce pain. Not all painkillers are suitable for every patient; be sure to review options with doctor.
Exercise which is frequent and gentle can prevent and even reverse stiffness in the shoulder. Vigorous activity involving shoulder joint should be hindered to prevent more injury from occurring at the site and thus slowed down the healing. Hot or cold compression packs may help to reduce pain and swelling. It is often helpful to alternate between the two.
Corticosteroid injection is a type of steroid hormone that reduces pain and swelling. Corticosteroids may be injected into the shoulder joint to alleviate pain, especially in the 'painful stage' of symptoms. However, repeated corticosteroid injections are discouraged as they could cause damage to the shoulder. It is also a diabetogenic hormone which is not so preferably good choice of treatment for frozen shoulder in diabetics.
Transcutaneous electrical nerve stimulation (TENS) numbs the nerve endings in the spinal cord that control pain and sends small pulses of electricity from the TENS machine to electrodes (small electric pads) that are applied to the skin on the affected shoulder.
Physical therapy or physiotherapy session can teach exercises to maintain as much mobility and flexibility as possible without straining the shoulder or causing too much pain. Physiotherapy in the form of gentle, firm stretching exercises in various planes of motion has been proven to be effective in the relief of pain and in recovery of range of motion in up to 90% of patients with idiopathic frozen shoulder.
Ultrasound can speed the recovery of a frozen shoulder injury significantly by breaking down the scar tissue around the shoulder joint. Using ultrasound on a regular basis or throughout the day will help relax the shoulder muscles, tendons and tissues, diminish pain and inflammation, soften scar tissue and contribute greatly to the healing of injury.
For a resistant frozen shoulder or if patient has poor compliance to the aforementioned regiments, shoulder manipulation can be used as an alternative. The shoulder joint is gently moved while patient is under a general anesthetic. Another way is shoulder arthroscopy - a minimally invasive type of surgery used in a small percentage of cases. A small endoscope (tube) is inserted through a small incision into the shoulder joint to remove any scar tissue or adhesions.
As a conclusion, most patients who present with a restriction of shoulder motion with history of diabetes mellitus and no significant history of trauma to the shoulder may fall under the category of frozen shoulder. This fact can help the clinician to choose an appropriate treatment regimen. Patients diagnosed with the idiopathic form of adhesive capsulitis should be put on a gentle stretching regimen, and counseled about the natural history of the disease, which can take many months to resolve. All of the above treatments absolutely work if properly performed with the right equipment. But, if blood sugar remains elevated, such problems will in all likelihood recur.

REFERENCES:
1. http://www.medicinenet.com/frozen_shoulder/article.htm
2. http://www.diabeteshealth.com/read/1999/11/01/1702/how-is-frozen-shoulder-associated-with-diabetes/
3. http://www.med.ucla.edu/modules/wfsection/article.php?articleid=233
4. http://EzineArticles.com/?expert=Alampallam_Venkatachalam
5. http://www.nlm.nih.gov/medlineplus/ency/article/000455.htm
6. http://www.deccanchronicle.com/health/diabetes-can-lead-frozen-shoulder-571
7. http://www.cnn.com/HEALTH/library/frozen-shoulder/DS00416.html
8. http://www.diabeteshealth.com/read/1999/11/01/1702/how-is-frozen-shoulder-associated-with-diabetes/
9. http://www.medicalnewstoday.com/articles/166186.php


This article is excerrpted from
: Orthopedic and Rheumatological afflictions in Diabetes Mellitus A review - Paperback (July 30, 2010) by Gourishankar Patnaikhttp://www.amazon.com/Musculoskeletal-Manifestations-Diabetes-Mellitus-Rheumatological/dp/363928089X/ref=sr_1_1?ie=UTF8&s=books&qid=1282478501&sr=8-1

Understand Your Fibromyalgia (By Mehraj sheikh)

Fibromyalgia syndrome affects the muscles and soft tissue. Fibromyalgia symptoms include chronic pain in the muscles, fatigue, sleep problems and painful tender points or trigger points at certain parts of the body. Fibromyalgia pain and other symptoms can be relieved through medications, lifestyle changes, stress management, and other fibromyalgia treatment.



Symptoms of Fibromyalgia
Symptoms of fibromyalgia include:
• Chronic muscle pain, muscle spasms or tightness, weakness in the limbs, and leg cramps
• Moderate or severe fatigue and decreased energy
• Insomnia or waking up feeling just as tired as when you went to sleep
• Stiffness upon waking or after staying in one position for too long
• Difficulty remembering, concentrating, and performing simple mental tasks
• Abdominal pain, bloating, nausea, and constipation alternating with diarrhea (irritable bowel syndrome)
• Tension or migraine headaches
• Jaw and facial tenderness
• Sensitivity to one or more of the following: odors, noise, bright lights, medications, certain foods, and cold
• Feeling anxious or depressed
• Numbness or tingling in the face, arms, hands, legs, or feet
• Increase in urinary urgency or frequency (irritable bladder)
• Reduced tolerance for exercise and muscle pain after exercise
• A feeling of swelling (without actual swelling) in the hands and feet
• Painful menstrual periods
• Dizziness
Diagnosis & Tests
Because there is no lab test or X-ray to diagnose fibromyalgia, oftentimes patients are misdiagnosed, which can delay good treatment. Find out how doctors make a fibromyalgia diagnosis and which doctors are experts in treating this common pain syndrome.
Diagnosis
Diagnosis and Misdiagnosis
Diagnosing fibromyalgia is oftentimes difficult -- and can be misdiagnosed. Learn the important steps you should go through to make sure you get an accurate diagnosis.
Finding the Right Doctor
Learn what to look for and steps to take to help you find the best fibromyalgia doctor for you.
Treatment & Care
Learn which fibromyalgia treatments work best, including treatments that target muscle pain and trigger points, treatments that help with sleep problems and depression, and treatments that help manage stress and anxiety.
Treatment
Fibromyalgia Treatments
Get up-to-date information on the latest fibromyalgia treatments -- from medications to ease pain, fatigue, and sleep problems to physical therapy, relaxation modalities, and regular exercises.
Medications
Fibromyalgia medications treat symptoms, such as the deep muscle pain, sleep problems, anxiety, and depression. Learn more to find out which medication might be right for you.
Cymbalta
Cymbalta helps people manage the unique symptoms of fibromyalgia. Is this medicine right for you?
Lyrica
Doctors think Lyrica may help fibromyalgia by calming overly excited nerves that cause pain. Learn more to see if this treatment may help you.
Savella
Doctors aren't exactly sure how Savella helps fibromyalgia but it's been shown to relieve pain and improve physical function. Learn more.
Physical Therapy
Physical therapy is often recommended to help ease fibromyalgia pain and teach self-management skills. Learn more about the different types of physical therapy for fibromyalgia.
Home Remedies
Many people turn to home remedies, including herbs, supplements, and alternative treatments, for relief of fibromyalgia symptoms. Discover which home remedies may help and which may not work at all.
Complementary Treatment
Herbs and Supplements
Can natural herbs and supplements help fibromyalgia symptoms? Review the different fibromyalgia herbs and supplements and learn how they might help manage symptoms.
Complementary Treatments
Complementary treatments for fibromyalgia include massage, acupuncture, meditation, and more. But are they safe and effective in ending fibromyalgia pain and fatigue? Discover the latest findings.
Diet
The Diet Connection
Can certain foods or nutrients ease symptoms of pain, stiffness, and fatigue? Can other foods actually trigger fibromyalgia symptoms? Learn more about the diet connection to fibromyalgia.



Exercise
Fibromyalgia & Exercise
Discover the importance of exercise for fibromyalgia. Find out which exercises are best for easing muscle pain and stiffness.
Coping
Tips for Coping
There's no doubt that fibromyalgia can be exhausting -- both physically and emotionally. Discover strategies to manage your symptoms so you can do the things you enjoy in life.
Fibromyalgia and Sex
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Total Knee replacement ( TKR) is indicated for End stage knee arthritis. Its roughly estimated that > 60% of people above the age of 60 require TKR. However the actual people who undergo this procedure are far less.
Advantages of TKR
The idea is to remain independent and mobile as one grows old. This ensures a good health with control of Hypertension, Diabetes and good psychosocial interaction. It has been proven time and again that a person restricted to bed or with limited mobility besides having many medical problems also suffers from depression and low self esteem.
Basic Protocol
Before undergoing this procedure a complete medical examination is done. This includes complete cardiac, renal check up with ECG, ECHO etc are done. An associated medical condition like hypertension or diabetes is never a contraindication. However such patients require extra care. It is advisable to plan for TKR in a Hospital with ICU/ CCU back up. Its been a case many patients to cut costs chose small nursing homes/ hospitals which do not have necessary medical/ cardiac back up.
Costs involved
It might range from 1.25 to 1.5 lacs per knee. A simultaneous bilateral TKR is little less, however this is subjected to medical fitness that patient can undergo this.
Post op care
The patient is mobile on 2nd post op day. The Hospital stay ranges from 5-7 days. The sutures are out by two weeks. Initially walking aids are used but later these can be discarded once good control is achieved
For more queries regarding Total knee or Hip replacement contact Dr. Harinder Batth, M.S ( PGI)..Mob-9888003333, Website – chandigarhortho.com , bonesetter.org

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Hip Resurfacing is Viable Alternative to Hip Replacement
Patients who had hip resurfacing surgery, such as the Birmingham Hip Resurfacing technique, reported a better quality of life, less pain and greater satisfaction a year after surgery.

Patients who had hip resurfacing surgery, such as the Birmingham Hip Resurfacing technique, reported a better quality of life, less pain and greater satisfaction a year after surgery than those who had a total hip replacement, according to a study presented at the American Academy of Orthopedic Surgeons (AAOS) 2009 Annual Meeting.

The study was based on data on the outcomes of 214 total hip replacement patients and 132 hip resurfacing patients that was recorded in a joint registry maintained at a single surgeon’s practice from 2003-2006. Orthopedic surgeon Dr. Elizabeth Anne Lingard of Freeman Hospital in Newcastle Upon Tyne, England, was the study’s lead researcher.

Each patient enrolled in the study completed a questionnaire preoperatively and one year after surgery. The questionnaire included the Western Ontario and MacMaster Universities Osteoarthritis Index (referred to as WOMAC, it is a 24-item questionnaire that is completed by the patient and focuses on joint pain, stiffness and loss of function related to osteoarthritis of the knee and hip) and the SF-36, a self-report questionnaire completed by the patient that measures health-related quality of life (and generates 8 subscales: physical functioning, role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role-limitations due to emotional problems, and mental health; and 2 summary scores: physical component and mental component). The patients also completed a questionnaire regarding satisfaction with their procedures and outcomes one year after surgery.

The study showed that one year after surgery both groups of patients experienced significant improvements in WOMAC and SF-36. Hip-resurfacing patients, however, posted significantly higher WOMAC scores for decreased pain symptoms. When asked about patient satisfaction with the surgery, a greater number of hip-resurfacing patients said they were satisfied with their ability to perform functional activities after surgery.

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For more information:
Keywords: hip resurfacing, hip replacement, joint replacement, orthopedic surgery, minimally invasive surgery
Dr.A.K.Venkatachalam, Consultant Orthopedic surgeon at the Madras Joint Replacement center opines that hip resurfacing allows excellent range of movements with least incidence of dislocation in males younger than 60 years. While choosing female patients who demand hip resurfacing, one has to be more selective says the surgeon. Females with small femoral head circumference less than 44 mm had a higher risk of complications like femoral neck fracture. Therefore female patients with large bone size in the appropriate age group with good bone density are also suitable candidates for Hip resurfacing.

Dr.A.K.Venkatachalam, consultant Orthopedic suregeon
Madras Joint Replacement center
Chennai, India
http://www.hipsurgery.in