The vertebral column (backbone) is made up of 33 vertebrae separated by spongy disks and classified into four distinct areas. The cervical area consists of seven bony parts in the neck; the thoracic spine consists of 12 bony parts in the back area; the lumbar spine consists of five bony segments in the lower back area; five sacral bones (fused into one bone, the sacrum); and four coccygeal bones (fused into one bone, the coccyx).
Between each vertebra is a fibrous disc with a jelly-like core. These cushions of cartilage allow the body to accept and dissipate load across multiple levels in the spine and still allow for the flexibility required for performing normal activities of daily living. As the body twists, bends, flexes and extends, the intervertebral discs are constantly changing their shape.
Causes
When discs degenerate, becoming less supple due to age or back strain, the disc may prolapse — squeezing out some of the soft core. This loss of cushioning may cause pressure on local nerves and cause back or neck pain, numbness or tingling in the arms, or searing pain down one or both legs. If the prolapse is severe it can damage the spinal cord. As a part of the aging process the discs lose their high water content and their ability to cushion the vertebrae. This is called degenerative disc disease. As the discs deteriorate, the spine can initially become less stable. Bony spurs can develop as a result of this instability and can cause pressure on nearby nerves leading to leg or arm pain. Narrowing of the neural canal by these bony spurs is known as degenerative spinal stenosis.
By the age of 35, approximately 30% of people will show evidence of disc degeneration at one or more levels. By the age of 60, greater than 90% of people will show evidence of disc degeneration at one or more levels on MRI. In some patients, this disc degeneration can be nearly asymptomatic; in others, disc degeneration can lead to intractable back pain.
The outer layer of the discs themselves can also tear. When this occurs, the inner, gelatinous layer can herniate out (a “herniated” or “ruptured” disc) and also cause pressure on an adjacent nerve. If the herniation occurs in the neck and causes pressure there, it can cause pain that radiates into the shoulder and arm; if it occurs in the lower back, the pain produced can radiate down into the hip and leg.
Symptoms
Patients with disc disease in the cervical, thoracic, or lumbar spine experience variable symptoms depending on where the disc has herniated and what nerve root it is pushing on. The following are the most common symptoms of lumbar disc disease:
•Intermittent or continuous back pain (this may be made worse by movement, coughing, sneezing, or standing for long periods of time)
•Spasm of the back muscles
•Sciatica — pain that starts near the back or buttock and travels down the leg to the calf or into the foot.
•Muscle weakness in the legs
•Numbness in the leg or foot
•Decreased reflexes at the knee or ankle
•Changes in bladder or bowel function
The symptoms of lumbar disc disease may resemble other conditions or medical problems. Always consult your physician for a diagnosis.
In rare cases, patients with large disc herniations may experience weakness in an extremity or signs of spinal cord compression such as difficulty with gait, incoordination, or loss of bowel/bladder control.
Diagnosis
•Spine x-rays are commonly taken after a neck injury in order to rule out a fracture, dislocation or instability. If the x-rays show degenerative changes right after the injury, then we assume they were present prior to the injury. Cervical spine x-rays may reveal congenital narrowing of the cervical spinal canal when present. Thoracic and lumbar x-rays may also show evidence of degenerative disease such as bone spurs and disc space narrowing.
•CT scan of the spine is valuable in assessing bone injury, such as fracture and/or dislocation. Bulging or herniated discs may or may not be visible on CT scan, and may or may not be related to the patient’s symptoms. CT scan is most useful in showing bone structures, and is not as good as MRI in showing spinal cord, nerve roots or discs. CT scan does not show torn ligaments or minor tears of discs.
•MR scanning (MRI) of the spine is the best method of imaging the spinal cord and nerve roots, the intervertebral discs, and the ligaments. However, MRI findings can only be of value when they are interpreted together with and in the light of the entire clinical picture, and exactly match the clinical findings.
•Cervical myelography consists of x-rays taken after the injection of radio-opaque contrast material into the spinal fluid via a lumbar puncture, and is followed by post-myelogram CT scan of the spine (myelo-CT). It may provide useful images of the interior of the spinal canal, and can reveal indentations of the spinal fluid sac caused by bulging or herniated discs or bone spurs that might be pressing on the spinal cord or nerves. MRI provides superior images of the spinal cord, nerve roots and discs.
•Electrodiagnostic studies(EMG and nerve-conduction velocities) are useful in evaluating weakness of hand and arm or leg muscles, and can indicate whether the weakness is due to abnormality or compression of a nerve root, or to some other cause.
Treatment
Treatment for disc disorders must be closely tailored to the patient, based on:
•The history and severity of their pain
•Whether or not they have had prior treatments for this problem and how effective they have been and
•Whether or not there is any evidence of neurologic damage such as weakness of an extremity or the loss of reflexes
Some of the treatments used include
•Activity modification
•Patient education on proper body mechanics (to help decrease the chance of worsening pain or damage to the disc)
•Physical therapy, which may include ultrasound, massage, conditioning, and exercise programs
Weight control
•Medications (to control pain and/or to relax muscles)
Surgery for patients with disc disorders of the spine is usually reserved for those who have failed exhaustive attempts at conservative treatment over a period of 6-12 weeks. An exception to this is the patient with a neurologic deficit; in this patient, it is wise to consider early surgical decompression to maximize the likelihood of neurologic recovery.
Surgery is done under general anesthesia. An incision is placed in the lower back over the area where the disc is herniated. Some bone from the back of the spine is removed to gain access to the area where the disc is located. Typically, the herniated part of the disc and any extra loose pieces of disc are removed from the disc space.
After surgery, restrictions may be placed on the patient’s activities for several weeks while healing is taking place to prevent another disc herniation from occurring. Your physician will discuss any restrictions with you.
Sunday, October 24, 2010
Patient handouts for BKA and AKA
Below the Knee Amputation and Above the Knee Amputation
PVS
--------------------------------------------------------------------------------
Our Services
Heart and Vascular Care
This handout will tell you how to take care of yourself at home after your Below the Knee Amputation (BKA) or Above the Knee Amputation (AKA). Your nurse will review this sheet with you before you go home.
Care of the Incision
There are several layers of stitches holding your incision together on the inside and outside. You may get the stitches wet in the shower. Do not swim or take tub baths. Clean the area gently with mild soap and water. Do not rub. Remove any dried drainage. Gently pat the incision dry. Leave the incision open to air unless told otherwise by your health care team.
At your first clinic visit or even before you leave the hospital, your stitches may be removed. Small pieces of tape called Steri-Strips® may be placed along the incision to help the edges of the incision heal. You may shower with the Steri-Strips® in place. Do not soak them in water for any length of time. Do not rub the incision; just allow the water to flow gently over the site. Gently pat the incision dry. After 2 – 3 days, as your wound heals, the Steri-Strips® will begin to curl up at the ends. You may trim the curled ends with a scissors. In time the Steri-Strips® will fall off on their own. If they do not, you can remove them after one week by gently peeling back the strips.
When to Call Your Doctor
At least twice each day you should look at your incision site for signs of infection or breakdown.
Call your doctor if you have these signs of infection or skin breakdown.
•An increase in redness at the site or red streaks on your skin that extend from the site.
•Increased warmth around the site.
•Increased pain that becomes constant or tenderness around the site.
•Bulging or swelling at the site.
•New drainage or bleeding from your site (drainage may be cloudy, yellow, or foul-smelling).
•Open spots between the stitches where the skin is pulling apart.
•A temperature of more than 101.5° F (38.5° C), by mouth; taken twice a day 4 hours apart.
•If you notice the skin along the site is getting darker or turning black.
With these symptoms you should contact a doctor right away (go to the emergency room if your doctor cannot be reached).
•Sudden increase in pain that is not controlled by your pain medicine.
•Uncontrollable bleeding from incision or anywhere else.
•Sudden increase in tenderness or swelling in leg.
•Sudden increase in redness, warmth, or even a bluish skin discoloration in leg.
•Please refer to Health Facts For You: Deep Vein Thrombosis and Pulmonary Embolism.
Care of the Residual Leg
•Look at your entire leg, front and back, each day. Use a mirror to look for skin abrasions, blisters, or red marks.
•Wash your leg everyday. It is very important to keep the leg clean. This prevents skin problems and bacteria from growing.
•Do not soak the leg.
•Use warm water.
•Use mild soaps without fragrance (Example: Dial® soap).
•Wear ace wraps or a shrinker sock at all times. This will reduce swelling, unless you are wearing a prosthesis.
•Reduce the swelling to speed up the amount of time it takes to heal the incision.
•Reduce the swelling to keep the stump the right shape when finding a prosthesis to use.
•If you are using ace wraps, rewrap every 2 – 4 hours while awake to compress the stump. Make sure there are no creases.
•Wear a leg protector when out of bed.
•Do not put too much weight or clothing on one side of the residual leg and not the other. Keep it equal.
•Avoid rubbing the leg against other surfaces or clothing.
Activity
Your doctor would like you to keep doing your exercises the way you learned in Physical Therapy. If you are able, you should also walk with your walker as much as you can. Inspect your walker to be sure it is safe. Check the rubber stoppers for signs of wear. All of the walker legs should be same height. You may notice that you tire quickly as you do more. This is normal. It should lessen as you get your strength and energy back. Take rest periods as needed but be as active as you can be to maintain your strength.
•Do not sit with your legs crossed.
•Do not place pillows under the stump to increase comfort; this can increase the chance that the muscles will shrink.
Pain Control
It is normal to have pain at the incision site, but not all people have this. Your doctor may have prescribed pain medicine for you to use at home. If you needed pain medicine in the hospital, this is often the same. If you have pain, your pain should in time lessen and may be managed with something you can buy over-the-counter. Be sure to ask your doctor which is best for you.
You may also have one or both of the problems listed here.
•Phantom sensation: This is the feeling that you still have the amputated part (leg or toe). Often, only the farthest part is felt, and although not painful, there may be tingling, numbness, or pressure. It may disappear as you get stronger, or it may last throughout life. Almost all people who have had an amputation have phantom sensation.
•Phantom pain: This is actual pain (most often the burning, cramping, squeezing, or shooting type) in the amputated part. It may be present all the time or it may come and go. Phantom pain may be relieved with pain medicine. If severe phantom pain is a problem for you, talk to your doctor about something else for pain relief. Many people report they have more relief from the medicine called Neurontin, which your doctor can discuss with you.
•(Please refer to Health Facts For You: Neuropathic Pain)
Diet
You may resume your regular diet when you return home. You should avoid constipation Decreased activity as well as some prescription pain medicines can cause constipation.
You can try to prevent constipation by trying these methods:
•Drink several glasses of fluids (8-10 8-oz. glasses of water or fruit juice per day)
•Eat foods high in fiber (whole grain breads and cereals, fresh fruit and vegetables)
•(Please refer to Health Facts For You: Suggestions For Relieving Constipation).
If these do not work, an over-the-counter stool softener or laxative (something that loosens and softens bowels) may be used. If the problems do not go away, call your doctor.
Maintain a stable body weight; this is very important for overall success.
Care of Your Other Leg
If you have diabetes or have peripheral vascular disease it is even more important now to take good care of your other leg and foot and protect it from being damaged in any way.
Ways to care for other leg:
•Look at legs and feet daily for sores, scratches, cracks, blisters or reddened areas. Report them to your doctor or nurse.
•Wash your legs and feet daily with mild soap and water. Avoid soaking. Dry well.
•Put lotion on dry skin daily.
•Let a doctor or nurse clip your toenails or show you how to clip toenails.
•Wear shoes that fit well.
•Wear white cotton or wool socks.
•Check shoes and socks for stones, sharp things, or holes.
•Do not use heating pads or hot water bottles on legs or feet.
•Never go barefoot.
Are You at Risk for Poor Blood Flow to the Legs and Feet?
You are more likely to have poor blood flow to the legs if you:
•Smoke
•Have high blood pressure
•Have high cholesterol
•Have diabetes
•Are over age 50
•Do not exercise
•Have heart disease in your family
PVS
--------------------------------------------------------------------------------
Our Services
Heart and Vascular Care
This handout will tell you how to take care of yourself at home after your Below the Knee Amputation (BKA) or Above the Knee Amputation (AKA). Your nurse will review this sheet with you before you go home.
Care of the Incision
There are several layers of stitches holding your incision together on the inside and outside. You may get the stitches wet in the shower. Do not swim or take tub baths. Clean the area gently with mild soap and water. Do not rub. Remove any dried drainage. Gently pat the incision dry. Leave the incision open to air unless told otherwise by your health care team.
At your first clinic visit or even before you leave the hospital, your stitches may be removed. Small pieces of tape called Steri-Strips® may be placed along the incision to help the edges of the incision heal. You may shower with the Steri-Strips® in place. Do not soak them in water for any length of time. Do not rub the incision; just allow the water to flow gently over the site. Gently pat the incision dry. After 2 – 3 days, as your wound heals, the Steri-Strips® will begin to curl up at the ends. You may trim the curled ends with a scissors. In time the Steri-Strips® will fall off on their own. If they do not, you can remove them after one week by gently peeling back the strips.
When to Call Your Doctor
At least twice each day you should look at your incision site for signs of infection or breakdown.
Call your doctor if you have these signs of infection or skin breakdown.
•An increase in redness at the site or red streaks on your skin that extend from the site.
•Increased warmth around the site.
•Increased pain that becomes constant or tenderness around the site.
•Bulging or swelling at the site.
•New drainage or bleeding from your site (drainage may be cloudy, yellow, or foul-smelling).
•Open spots between the stitches where the skin is pulling apart.
•A temperature of more than 101.5° F (38.5° C), by mouth; taken twice a day 4 hours apart.
•If you notice the skin along the site is getting darker or turning black.
With these symptoms you should contact a doctor right away (go to the emergency room if your doctor cannot be reached).
•Sudden increase in pain that is not controlled by your pain medicine.
•Uncontrollable bleeding from incision or anywhere else.
•Sudden increase in tenderness or swelling in leg.
•Sudden increase in redness, warmth, or even a bluish skin discoloration in leg.
•Please refer to Health Facts For You: Deep Vein Thrombosis and Pulmonary Embolism.
Care of the Residual Leg
•Look at your entire leg, front and back, each day. Use a mirror to look for skin abrasions, blisters, or red marks.
•Wash your leg everyday. It is very important to keep the leg clean. This prevents skin problems and bacteria from growing.
•Do not soak the leg.
•Use warm water.
•Use mild soaps without fragrance (Example: Dial® soap).
•Wear ace wraps or a shrinker sock at all times. This will reduce swelling, unless you are wearing a prosthesis.
•Reduce the swelling to speed up the amount of time it takes to heal the incision.
•Reduce the swelling to keep the stump the right shape when finding a prosthesis to use.
•If you are using ace wraps, rewrap every 2 – 4 hours while awake to compress the stump. Make sure there are no creases.
•Wear a leg protector when out of bed.
•Do not put too much weight or clothing on one side of the residual leg and not the other. Keep it equal.
•Avoid rubbing the leg against other surfaces or clothing.
Activity
Your doctor would like you to keep doing your exercises the way you learned in Physical Therapy. If you are able, you should also walk with your walker as much as you can. Inspect your walker to be sure it is safe. Check the rubber stoppers for signs of wear. All of the walker legs should be same height. You may notice that you tire quickly as you do more. This is normal. It should lessen as you get your strength and energy back. Take rest periods as needed but be as active as you can be to maintain your strength.
•Do not sit with your legs crossed.
•Do not place pillows under the stump to increase comfort; this can increase the chance that the muscles will shrink.
Pain Control
It is normal to have pain at the incision site, but not all people have this. Your doctor may have prescribed pain medicine for you to use at home. If you needed pain medicine in the hospital, this is often the same. If you have pain, your pain should in time lessen and may be managed with something you can buy over-the-counter. Be sure to ask your doctor which is best for you.
You may also have one or both of the problems listed here.
•Phantom sensation: This is the feeling that you still have the amputated part (leg or toe). Often, only the farthest part is felt, and although not painful, there may be tingling, numbness, or pressure. It may disappear as you get stronger, or it may last throughout life. Almost all people who have had an amputation have phantom sensation.
•Phantom pain: This is actual pain (most often the burning, cramping, squeezing, or shooting type) in the amputated part. It may be present all the time or it may come and go. Phantom pain may be relieved with pain medicine. If severe phantom pain is a problem for you, talk to your doctor about something else for pain relief. Many people report they have more relief from the medicine called Neurontin, which your doctor can discuss with you.
•(Please refer to Health Facts For You: Neuropathic Pain)
Diet
You may resume your regular diet when you return home. You should avoid constipation Decreased activity as well as some prescription pain medicines can cause constipation.
You can try to prevent constipation by trying these methods:
•Drink several glasses of fluids (8-10 8-oz. glasses of water or fruit juice per day)
•Eat foods high in fiber (whole grain breads and cereals, fresh fruit and vegetables)
•(Please refer to Health Facts For You: Suggestions For Relieving Constipation).
If these do not work, an over-the-counter stool softener or laxative (something that loosens and softens bowels) may be used. If the problems do not go away, call your doctor.
Maintain a stable body weight; this is very important for overall success.
Care of Your Other Leg
If you have diabetes or have peripheral vascular disease it is even more important now to take good care of your other leg and foot and protect it from being damaged in any way.
Ways to care for other leg:
•Look at legs and feet daily for sores, scratches, cracks, blisters or reddened areas. Report them to your doctor or nurse.
•Wash your legs and feet daily with mild soap and water. Avoid soaking. Dry well.
•Put lotion on dry skin daily.
•Let a doctor or nurse clip your toenails or show you how to clip toenails.
•Wear shoes that fit well.
•Wear white cotton or wool socks.
•Check shoes and socks for stones, sharp things, or holes.
•Do not use heating pads or hot water bottles on legs or feet.
•Never go barefoot.
Are You at Risk for Poor Blood Flow to the Legs and Feet?
You are more likely to have poor blood flow to the legs if you:
•Smoke
•Have high blood pressure
•Have high cholesterol
•Have diabetes
•Are over age 50
•Do not exercise
•Have heart disease in your family
Osteosarcoma
Osteosarcoma is a common type of bone cancer that affects mostly children and teens between the ages of 10 to 19. It occurs during periods of rapid bone growth and is more common boys than in girls. Osteosarcoma cab diagnosed in adults, but it extremely rare.
Symptoms of Osteosarcoma
The shin, thigh, and upper arm are common tumor sites in children and adolescents with osteosarcoma. It is in these areas that pain and swelling occur with the disease. Osteosarcoma can develop in other bones, but it is much less common.
Bone pain is a common symptom of osteosarcoma that may become worse during exercise or at night. Bone pain is more often related to a benign condition, like an injury, than it is to cancer. Keep in mind that not all bone tumors are cancerous as some are benign.
Other symptoms of osteosarcoma include:
•joint tenderness or inflammation
•fractures due to bone weakness
•limited range of motion
Non-specific symptoms like fever, unintentional weight loss, fatigue, and anemia can also be symptoms of osteosarcoma. But they are also indicators of other less severe conditions.
Diagnosing Osteosarcoma
Symptoms combined with other findings during a physical exam may suggest the presence of osteosarcoma, but additional tests are needed to confirm any suspicion.
Imaging tests, like x-rays, MRIs, and CT scans help identify any bone abnormalities. Other tests may include a bone scan, a specialized nuclear imaging test that allows doctors to see the metabolic activity of the bone. Bone scans identify areas in the bone that have new growth or have broken down -- excellent indicators of conditions.
Ultimately, it is a bone biopsy that will rule out or confirm the presence of cancer. A bone biopsy involves the removal of a small amount of bone tissue to be examined under a microscope. It usually takes less than an hour and can be done as an outpatient or surgical procedure.
Doing a biopsy on someone with primary bone cancer can be complex because there is a risk of spreading the cancer during the procedure. The procedure should be done by a surgeon who has experience performing bone biopsies on those with suspected bone cancer. Note that biopsies a common way to worsen these cancers and potentially spread into other tissues.
If cancer is detected, it is then graded and staged by a pathologist. Grading and staging classifications vary based on the type of bone cancer. Ideally, the pathologist examining the sample will be experienced in diagnosing bone cancer.
Treatment of Bone Cancer
The key to successful treatment is having a treatment team that is experienced in bone cancer. Many types of bone cancer are very rare, and having a team that is highly experienced in managing bone cancer is a necessity. Several types of doctors make up these unique treatment teams and include medical oncologists, radiation oncologists, radiologists, surgical oncologists, orthopedic oncologists, and specialized pathologists.
•Find a Bone Cancer Physician
There are three standard forms of treatment for osteosarcoma: surgery, radiation therapy, and chemotherapy. Many times, more than one treatment method is required, such as surgery along with radiation therapy. Treatment varies based on type of bone cancer, if it has spread (metastasized), and other general health factors.
Surgery: Osteosarcoma is most commonly treated with surgery. Surgical treatment for bone cancer that has not spread involves removing the cancerous tissue and a small margin of healthy bone tissue surrounding it. Some tumors may require chemotherapy or radiation therapy in addition to surgical treatment.
Radiation Therapy: Radiation therapy uses specific types high energy beams of radiation to shrink tumors or eliminate cancer cells. Radiation therapy works by damaging a cancer cell's DNA, making it unable to multiply. Although radiation therapy can damage nearby healthy cells, cancer cells are highly sensitive to radiation and typically die when treated. Healthy cells that are damaged during radiation are resilient and are often able to fully recover.
Chemotherapy: Chemotherapy is often prescribed to treat osteosarcoma. Chemotherapy drugs work by eliminating rapidly multiplying cancer cells. However, other healthy cells in the body multiply just as quickly, such as hair follicle cells. Unfortunately, many chemotherapy drugs may not be able to discern the two, attacking healthy cells and causing side effects like hair loss.
Note that most teams offer neoadjuvant therapy for the sarcomas and there is adjuvant therapy, too.
Symptoms of Osteosarcoma
The shin, thigh, and upper arm are common tumor sites in children and adolescents with osteosarcoma. It is in these areas that pain and swelling occur with the disease. Osteosarcoma can develop in other bones, but it is much less common.
Bone pain is a common symptom of osteosarcoma that may become worse during exercise or at night. Bone pain is more often related to a benign condition, like an injury, than it is to cancer. Keep in mind that not all bone tumors are cancerous as some are benign.
Other symptoms of osteosarcoma include:
•joint tenderness or inflammation
•fractures due to bone weakness
•limited range of motion
Non-specific symptoms like fever, unintentional weight loss, fatigue, and anemia can also be symptoms of osteosarcoma. But they are also indicators of other less severe conditions.
Diagnosing Osteosarcoma
Symptoms combined with other findings during a physical exam may suggest the presence of osteosarcoma, but additional tests are needed to confirm any suspicion.
Imaging tests, like x-rays, MRIs, and CT scans help identify any bone abnormalities. Other tests may include a bone scan, a specialized nuclear imaging test that allows doctors to see the metabolic activity of the bone. Bone scans identify areas in the bone that have new growth or have broken down -- excellent indicators of conditions.
Ultimately, it is a bone biopsy that will rule out or confirm the presence of cancer. A bone biopsy involves the removal of a small amount of bone tissue to be examined under a microscope. It usually takes less than an hour and can be done as an outpatient or surgical procedure.
Doing a biopsy on someone with primary bone cancer can be complex because there is a risk of spreading the cancer during the procedure. The procedure should be done by a surgeon who has experience performing bone biopsies on those with suspected bone cancer. Note that biopsies a common way to worsen these cancers and potentially spread into other tissues.
If cancer is detected, it is then graded and staged by a pathologist. Grading and staging classifications vary based on the type of bone cancer. Ideally, the pathologist examining the sample will be experienced in diagnosing bone cancer.
Treatment of Bone Cancer
The key to successful treatment is having a treatment team that is experienced in bone cancer. Many types of bone cancer are very rare, and having a team that is highly experienced in managing bone cancer is a necessity. Several types of doctors make up these unique treatment teams and include medical oncologists, radiation oncologists, radiologists, surgical oncologists, orthopedic oncologists, and specialized pathologists.
•Find a Bone Cancer Physician
There are three standard forms of treatment for osteosarcoma: surgery, radiation therapy, and chemotherapy. Many times, more than one treatment method is required, such as surgery along with radiation therapy. Treatment varies based on type of bone cancer, if it has spread (metastasized), and other general health factors.
Surgery: Osteosarcoma is most commonly treated with surgery. Surgical treatment for bone cancer that has not spread involves removing the cancerous tissue and a small margin of healthy bone tissue surrounding it. Some tumors may require chemotherapy or radiation therapy in addition to surgical treatment.
Radiation Therapy: Radiation therapy uses specific types high energy beams of radiation to shrink tumors or eliminate cancer cells. Radiation therapy works by damaging a cancer cell's DNA, making it unable to multiply. Although radiation therapy can damage nearby healthy cells, cancer cells are highly sensitive to radiation and typically die when treated. Healthy cells that are damaged during radiation are resilient and are often able to fully recover.
Chemotherapy: Chemotherapy is often prescribed to treat osteosarcoma. Chemotherapy drugs work by eliminating rapidly multiplying cancer cells. However, other healthy cells in the body multiply just as quickly, such as hair follicle cells. Unfortunately, many chemotherapy drugs may not be able to discern the two, attacking healthy cells and causing side effects like hair loss.
Note that most teams offer neoadjuvant therapy for the sarcomas and there is adjuvant therapy, too.
Osteomyelitis
Osteomyelitis is an acute or chronic bone infection.
Symptoms
•Bone pain
•Fever
•General discomfort, uneasiness, or ill-feeling (malaise)
•Local swelling, redness, and warmth
•Nausea
Additional symptoms that may be associated with this disease:
•Chills
•Excessive sweating
•Low back pain
•Swelling of the ankles, feet, and legs
Treatment
The objective of treatment is to eliminate the infection and prevent it from getting worse.
Antibiotics will be given to destroy the bacteria that are causing the infection. You may be given more than one antibiotic at a time. Often, the antibiotics are given through an IV (intravenously, meaning through a vein) rather than by mouth. Antibiotics are taken for at least 4-6 weeks, sometimes longer.
Surgery may be needed to remove dead bone tissue if you have an infection that does not go away. If there are metal plates near the infection, they may be removed. The open space left by the removed bone tissue may be filled with bone graft or packing material that promotes the growth of new bone tissue.
Infection of an orthopedic prosthesis may require surgical removal of the prosthesis and infected tissue surrounding the area. A new prosthesis may be implanted in the same operation or delayed until the infection has gone away.
If the patient has diabetes, it will need to be well controlled. If there are problems with blood supply, surgery to improve blood flow may be needed.
Causes
Bone infection can be caused by bacteria or fungi.
•Infection may also spread to a bone from infected skin, muscles, or tendons next to the bone, as in osteomyelitis that occurs under a chronic skin ulcer (sore).
•The infection that causes osteomyelitis can also start in another part of the body and spread to the bone through the blood.
•A current or past injury may have made the affected bone more likely to develop the infection. A bone infection can also start after bone surgery, especially if the surgery is done after an injury or if metal rods or plates are placed in the bone.
In children, the long bones are usually affected. In adults, the feet, spine bones (vertebrae), and the hips (pelvis) are most commonly affected.
Risk factors are recent trauma, diabetes, hemodialysis, poor blood supply, and IV drug abuse. People who have had their spleen removed are also at higher risk for osteomyelitis.
Tests & diagnosis
A physical examination shows bone tenderness and possibly swelling and redness.
Tests may include:
•Blood cultures
•Bone biopsy (which is then cultured)
•Bone scan
•Bone x-ray
•C-reactive protein (CRP)
•Erythrocyte sedimentation rate (ESR)
•MRI
•Needle aspiration of the area around affected bones
Prognosis
When treatment is received, the outcome for acute osteomyelitis is usually good.
The outlook is worse for those with long-term (chronic) osteomyelitis, even with surgery. Amputation may be needed, especially in those with diabetes or poor blood circulation.
The outlook is guarded in those who have an infection of a prosthesis.
Prevention
Prompt and complete treatment of infections is helpful. High-risk people should see a health care provider promptly if they have signs of an infection anywhere in the body.
Complications
When the bone is infected, pus is produced within the bone, which may result in an abscess. The abscess steals the bone's blood supply. The lost blood supply can result in a complication called chronic osteomyelitis. This chronic infection can cause symptoms that come and go for years.
Other complications include:
•Need for amputation
•Reduced limb or joint function
•Spread of infection
Symptoms
•Bone pain
•Fever
•General discomfort, uneasiness, or ill-feeling (malaise)
•Local swelling, redness, and warmth
•Nausea
Additional symptoms that may be associated with this disease:
•Chills
•Excessive sweating
•Low back pain
•Swelling of the ankles, feet, and legs
Treatment
The objective of treatment is to eliminate the infection and prevent it from getting worse.
Antibiotics will be given to destroy the bacteria that are causing the infection. You may be given more than one antibiotic at a time. Often, the antibiotics are given through an IV (intravenously, meaning through a vein) rather than by mouth. Antibiotics are taken for at least 4-6 weeks, sometimes longer.
Surgery may be needed to remove dead bone tissue if you have an infection that does not go away. If there are metal plates near the infection, they may be removed. The open space left by the removed bone tissue may be filled with bone graft or packing material that promotes the growth of new bone tissue.
Infection of an orthopedic prosthesis may require surgical removal of the prosthesis and infected tissue surrounding the area. A new prosthesis may be implanted in the same operation or delayed until the infection has gone away.
If the patient has diabetes, it will need to be well controlled. If there are problems with blood supply, surgery to improve blood flow may be needed.
Causes
Bone infection can be caused by bacteria or fungi.
•Infection may also spread to a bone from infected skin, muscles, or tendons next to the bone, as in osteomyelitis that occurs under a chronic skin ulcer (sore).
•The infection that causes osteomyelitis can also start in another part of the body and spread to the bone through the blood.
•A current or past injury may have made the affected bone more likely to develop the infection. A bone infection can also start after bone surgery, especially if the surgery is done after an injury or if metal rods or plates are placed in the bone.
In children, the long bones are usually affected. In adults, the feet, spine bones (vertebrae), and the hips (pelvis) are most commonly affected.
Risk factors are recent trauma, diabetes, hemodialysis, poor blood supply, and IV drug abuse. People who have had their spleen removed are also at higher risk for osteomyelitis.
Tests & diagnosis
A physical examination shows bone tenderness and possibly swelling and redness.
Tests may include:
•Blood cultures
•Bone biopsy (which is then cultured)
•Bone scan
•Bone x-ray
•C-reactive protein (CRP)
•Erythrocyte sedimentation rate (ESR)
•MRI
•Needle aspiration of the area around affected bones
Prognosis
When treatment is received, the outcome for acute osteomyelitis is usually good.
The outlook is worse for those with long-term (chronic) osteomyelitis, even with surgery. Amputation may be needed, especially in those with diabetes or poor blood circulation.
The outlook is guarded in those who have an infection of a prosthesis.
Prevention
Prompt and complete treatment of infections is helpful. High-risk people should see a health care provider promptly if they have signs of an infection anywhere in the body.
Complications
When the bone is infected, pus is produced within the bone, which may result in an abscess. The abscess steals the bone's blood supply. The lost blood supply can result in a complication called chronic osteomyelitis. This chronic infection can cause symptoms that come and go for years.
Other complications include:
•Need for amputation
•Reduced limb or joint function
•Spread of infection
Treating an acute gout attack
Medication Choices
Medication treatment for gout usually involves some combination of:
Short-term treatment, using medicines that relieve pain and reduce inflammation during an acute attack or prevent a recurrence of an acute attack. These medicines may include:
Nonsteroidal anti-inflammatory drugs (NSAIDs), except for aspirin, which should never be used to relieve pain during a gout attack. Aspirin may change uric acid levels in the blood and may make the attack worse.
Colchicine, which may also be used for long-term treatment.
Corticosteroids, which may be given in pills or by a shot for cases of gout that do not respond to NSAIDs or colchicines. They may also be given to people who cannot take NSAIDs for other reasons, such as those with chronic kidney failure, heart failure, gastrointestinal bleeding or those using a blood-thinner, such as warfarin.
Long-term treatment, using medicines to lower uric acid levels in the blood, which can reduce the frequency and severity of gout attacks in the future. This may include:
Uricosuric agents, to increase elimination of uric acid by the kidneys.
Allopurinol or a newer medicine called febuxostat, to decrease production of uric acid by the body.
Colchicine, to prevent flare-ups during the first months that you are taking uric acid-lowering medicines
Medication treatment for gout usually involves some combination of:
Short-term treatment, using medicines that relieve pain and reduce inflammation during an acute attack or prevent a recurrence of an acute attack. These medicines may include:
Nonsteroidal anti-inflammatory drugs (NSAIDs), except for aspirin, which should never be used to relieve pain during a gout attack. Aspirin may change uric acid levels in the blood and may make the attack worse.
Colchicine, which may also be used for long-term treatment.
Corticosteroids, which may be given in pills or by a shot for cases of gout that do not respond to NSAIDs or colchicines. They may also be given to people who cannot take NSAIDs for other reasons, such as those with chronic kidney failure, heart failure, gastrointestinal bleeding or those using a blood-thinner, such as warfarin.
Long-term treatment, using medicines to lower uric acid levels in the blood, which can reduce the frequency and severity of gout attacks in the future. This may include:
Uricosuric agents, to increase elimination of uric acid by the kidneys.
Allopurinol or a newer medicine called febuxostat, to decrease production of uric acid by the body.
Colchicine, to prevent flare-ups during the first months that you are taking uric acid-lowering medicines
laminectomy
Laminectomy.
This procedure involves removing the bone, bone spurs, and ligaments that are compressing the nerves. This procedure may also be called a "decompression." Laminectomy can be performed as open surgery, where your doctor uses a single, larger incision to access your spine. The procedure can also be done using a minimally invasive method, where several smaller incisions are made. Your doctor will discuss with you the right option for you.
To access the spine, muscles are pulled back to expose the bone. After the laminectomy, bone graft material and screws are placed along the sides of the vertebrae to help with healing.Spinal fusion. If arthritis has progressed to spinal instability, a combination of decompression and stabilization or spinal fusion may be recommended.
In a spinal fusion, two or more vertebrae are permanently healed or fused together. A bone graft taken from the pelvis or hip bone is used to fuse the vertebrae.
Fusion eliminates motion between vertebrae and prevents the slippage from worsening after surgery. The surgeon may also use rods and screws to hold the spine in place while the bones fuse together. The use of rods and screws makes the fusion of the bones happen faster and speeds recovery.
Rehabilitation. After surgery, you may stay in the hospital for a short time, depending on your health and the procedure performed. Healthy patients who undergo just decompression may go home the same or next day, and may return to normal activities after only a few weeks. Fusion generally adds 2 to 3 days to the hospital stay.
Your surgeon may give you a brace or corset to wear for comfort. He or she will likely encourage you to begin walking as soon as possible. Most patients do not need physical therapy except to learn how to strengthen their backs.
Your physical therapist may show you exercises to help you build and maintain strength, endurance, and flexibility for spinal stability. Some of these exercises will help strengthen your abdominal muscles, which help support your back. Your physical therapist will create an individualized program, taking into consideration your health and history.
Most people can go back to a desk job within a few days to a few weeks after surgery. They may return to normal activities after 2 to 3 months. Older patients who need more care and assistance may be transferred from the hospital to a rehabilitation facility prior to going home.
Surgical risks. There are minor risks associated with every surgical procedure. These include bleeding, infection, blood clots, and reaction to anesthesia. These risks are usually very low.
Elderly patients have higher rates of complications from surgery. So do overweight patients, diabetics, smokers, and patients with multiple medical problems.
Specific complications from surgery for spinal stenosis include:
•Tear of the sac covering the nerves (dural tear)
•Failure of the bone fusion to heal
•Failure of screws or rods
•Nerve injury
•Need for further surgery
•Failure to relieve symptoms
•Return of symptoms
Surgical outcomes. Overall, the results of laminectomy with or without spinal fusion for lumbar stenosis are good to excellent in approximately 80% of patients. Patients tend to see more improvement of leg pain than back pain. Most patients are able to resume a normal lifestyle after a period of recovery from surgery
This procedure involves removing the bone, bone spurs, and ligaments that are compressing the nerves. This procedure may also be called a "decompression." Laminectomy can be performed as open surgery, where your doctor uses a single, larger incision to access your spine. The procedure can also be done using a minimally invasive method, where several smaller incisions are made. Your doctor will discuss with you the right option for you.
To access the spine, muscles are pulled back to expose the bone. After the laminectomy, bone graft material and screws are placed along the sides of the vertebrae to help with healing.Spinal fusion. If arthritis has progressed to spinal instability, a combination of decompression and stabilization or spinal fusion may be recommended.
In a spinal fusion, two or more vertebrae are permanently healed or fused together. A bone graft taken from the pelvis or hip bone is used to fuse the vertebrae.
Fusion eliminates motion between vertebrae and prevents the slippage from worsening after surgery. The surgeon may also use rods and screws to hold the spine in place while the bones fuse together. The use of rods and screws makes the fusion of the bones happen faster and speeds recovery.
Rehabilitation. After surgery, you may stay in the hospital for a short time, depending on your health and the procedure performed. Healthy patients who undergo just decompression may go home the same or next day, and may return to normal activities after only a few weeks. Fusion generally adds 2 to 3 days to the hospital stay.
Your surgeon may give you a brace or corset to wear for comfort. He or she will likely encourage you to begin walking as soon as possible. Most patients do not need physical therapy except to learn how to strengthen their backs.
Your physical therapist may show you exercises to help you build and maintain strength, endurance, and flexibility for spinal stability. Some of these exercises will help strengthen your abdominal muscles, which help support your back. Your physical therapist will create an individualized program, taking into consideration your health and history.
Most people can go back to a desk job within a few days to a few weeks after surgery. They may return to normal activities after 2 to 3 months. Older patients who need more care and assistance may be transferred from the hospital to a rehabilitation facility prior to going home.
Surgical risks. There are minor risks associated with every surgical procedure. These include bleeding, infection, blood clots, and reaction to anesthesia. These risks are usually very low.
Elderly patients have higher rates of complications from surgery. So do overweight patients, diabetics, smokers, and patients with multiple medical problems.
Specific complications from surgery for spinal stenosis include:
•Tear of the sac covering the nerves (dural tear)
•Failure of the bone fusion to heal
•Failure of screws or rods
•Nerve injury
•Need for further surgery
•Failure to relieve symptoms
•Return of symptoms
Surgical outcomes. Overall, the results of laminectomy with or without spinal fusion for lumbar stenosis are good to excellent in approximately 80% of patients. Patients tend to see more improvement of leg pain than back pain. Most patients are able to resume a normal lifestyle after a period of recovery from surgery
Low Back Pain
Low Back PainAnatomy
Description
Cause
Symptoms
Tests and Diagnosis
Treatment
Prevention Almost everyone will experience low back pain at some point in their lives. This pain can vary from mild to severe. It can be short-lived or long-lasting. However it happens, low back pain can make many everyday activities difficult to do.
AnatomyUnderstanding your spine and how it works can help you understand why you have low back pain.
Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine.
Vertebrae
Parts of the lumbar spine. These bones connect to create a canal that protects the spinal cord. The spinal column is made up of three sections that create three natural curves in your back: the curves of the neck area (cervical), chest area (thoracic), and lower back (lumbar). The lower section of your spine (sacrum and coccyx) is made up of vertebrae that are fused together.
Five lumbar vertebrae connect the upper spine to the pelvis.
Spinal Cord and Nerves
These "electrical cables" travel through the spinal canal carrying messages between your brain and muscles. Nerves branch out from the spinal cord through openings in the vertebrae.
Muscles and Ligaments
These provide support and stability for your spine and upper body. Strong ligaments connect your vertebrae and help keep the spinal column in position.
Facet Joints
Between vertebrae are small joints that help your spine move.
Intervertebral Disks
Intervertebral disks sit in between the vertebrae.
When you walk or run, the disks act as shock absorbers and prevent the vertebrae from bumping against one another. They work with your facet joints to help your spine move, twist, and bend.
Intervertebral disks are flat and round, and about a half inch thick. They are made up of two components.
Annulus fibrosus. This is the tough, flexible outer ring of the disk. It helps connect to the vertebrae.
Nucleus pulposus. This is the soft, jelly-like center of the annulus fibrosus. It gives the disk its shock-absorbing capabilities.
Healthy intervertebral disk (cross-section view). Top of page
DescriptionBack pain is different from one person to the next. The pain can have a slow onset or come on suddenly. The pain may be intermittent or constant. In most cases, back pain resolves on its own within a few weeks.
Cause
Lumbar ligament tear. There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.
As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger — and can make us prone to back pain, especially if we overdo our activities.
These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in her back!
Over-activity
One of the more common causes of low back pain is muscle soreness from over-activity. Muscles and ligament fibers can be overstretched or injured.
This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this "stiffness" and soreness in the low back — and other areas of the body — that usually goes away within a few days.
Disk Injury
Some people develop low back pain that does not go away within days. This may mean there is an injury to a disk.
Disk tear. Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood.
Disk herniation. Another common type of disk injury is a "slipped" or herniated disc.
Herniated disk. A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain.
Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is sciatica.
A herniated disk often occurs with lifting, pulling, bending, or twisting movements.
Disk degeneration. Disk Degeneration
With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints in the vertebrae to rub against one another. Pain and stiffness result.
This "wear and tear" on the facet joints is referred to as osteoarthritis. It can lead to further back problems, including spinal stenosis.
Spondylolisthesis. Degenerative Spondylolisthesis
(Spon-dee-low-lis-THEE-sis). Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.
Spinal Stenosis
Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves.
Spinal stenosis. When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth - called spurs - can lead to a narrowing of the spinal canal. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal.
Scoliosis
This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly leg symptoms, if pressure on the nerves is involved.
Additional Causes
There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position, you should consult your primary care doctor.
SymptomsBack pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain.
Most people find that reclining or lying down will improve low back pain, no matter the underlying cause.
People with low back pain may experience some of the following:
•Back pain may be worse with bending and lifting.
•Sitting may worsen pain.
•Standing and walking may worsen pain
•Back pain comes and goes, and often follows an up and down course with good days and bad days.
•Pain may extend from the back into the buttock or outer hip area, but not down the leg.
•Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain.
Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.
Tests and Diagnosis
Medical History and Physical Examination
After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain.
Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.
Imaging Tests
Other tests which may help your doctor confirm your diagnosis include:
X-rays. Although they only visualize bones, simple X-rays can help determine if you have the most obvious causes of back pain. It will show broken bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves.
Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible in an MRI scan.
Computerized axial tomography (CAT) scans. If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three-dimensional X-ray and focuses on the bones.
Bone scan. A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection.
Bone density test. If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.
Treatment
In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.
Nonsurgical Treatment
Medications. Several medications may be used to help relieve your pain.
•Aspirin or acetaminophen can relieve pain with few side effects.
•Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
•Narcotic pain medications, such as codeine or morphine, may help.
•Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.
Physical medicine. Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do.
•Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.
•Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
•Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.
•Traction is often used, but without scientific evidence for effectiveness.
•Other exercise-based programs, such as Pilates or yoga are helpful for some patients.
Surgical Treatment
Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.
In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.
Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply can not be treated with surgery.
Spinal Fusion. This is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a bad curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is if the painful spine segments do not move, they should not hurt.
Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals.
The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.
The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.
Disc Replacement. This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.
The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.
The surgery is done through your abdomen, usually on the lower two disks of the spine.
Prevention
It may not be possible to prevent low back pain. We cannot avoid the normal wear and tear on our spines that goes along with aging. But there are things we can do to lessen the impact of low back problems. Having a healthy lifestyle is a good start.
Exercise
Combine aerobic exercise, like walking or swimming, with specific exercises to keep the muscles in your back and abdomen strong and flexible.
Proper Lifting
Be sure to lift heavy items with your legs, not your back. Do not bend over to pick something up. Keep your back straight and bend at your knees.
Weight
Maintain a healthy weight. Being overweight puts added stress on your lower back.
Avoid Smoking
Both the smoke and the nicotine cause your spine to age faster than normal.
Proper Posture
Good posture is important for avoiding future problems. A therapist can teach you how to safely stand, sit, and lift.
Description
Cause
Symptoms
Tests and Diagnosis
Treatment
Prevention Almost everyone will experience low back pain at some point in their lives. This pain can vary from mild to severe. It can be short-lived or long-lasting. However it happens, low back pain can make many everyday activities difficult to do.
AnatomyUnderstanding your spine and how it works can help you understand why you have low back pain.
Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine.
Vertebrae
Parts of the lumbar spine. These bones connect to create a canal that protects the spinal cord. The spinal column is made up of three sections that create three natural curves in your back: the curves of the neck area (cervical), chest area (thoracic), and lower back (lumbar). The lower section of your spine (sacrum and coccyx) is made up of vertebrae that are fused together.
Five lumbar vertebrae connect the upper spine to the pelvis.
Spinal Cord and Nerves
These "electrical cables" travel through the spinal canal carrying messages between your brain and muscles. Nerves branch out from the spinal cord through openings in the vertebrae.
Muscles and Ligaments
These provide support and stability for your spine and upper body. Strong ligaments connect your vertebrae and help keep the spinal column in position.
Facet Joints
Between vertebrae are small joints that help your spine move.
Intervertebral Disks
Intervertebral disks sit in between the vertebrae.
When you walk or run, the disks act as shock absorbers and prevent the vertebrae from bumping against one another. They work with your facet joints to help your spine move, twist, and bend.
Intervertebral disks are flat and round, and about a half inch thick. They are made up of two components.
Annulus fibrosus. This is the tough, flexible outer ring of the disk. It helps connect to the vertebrae.
Nucleus pulposus. This is the soft, jelly-like center of the annulus fibrosus. It gives the disk its shock-absorbing capabilities.
Healthy intervertebral disk (cross-section view). Top of page
DescriptionBack pain is different from one person to the next. The pain can have a slow onset or come on suddenly. The pain may be intermittent or constant. In most cases, back pain resolves on its own within a few weeks.
Cause
Lumbar ligament tear. There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.
As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger — and can make us prone to back pain, especially if we overdo our activities.
These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in her back!
Over-activity
One of the more common causes of low back pain is muscle soreness from over-activity. Muscles and ligament fibers can be overstretched or injured.
This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this "stiffness" and soreness in the low back — and other areas of the body — that usually goes away within a few days.
Disk Injury
Some people develop low back pain that does not go away within days. This may mean there is an injury to a disk.
Disk tear. Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood.
Disk herniation. Another common type of disk injury is a "slipped" or herniated disc.
Herniated disk. A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain.
Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is sciatica.
A herniated disk often occurs with lifting, pulling, bending, or twisting movements.
Disk degeneration. Disk Degeneration
With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints in the vertebrae to rub against one another. Pain and stiffness result.
This "wear and tear" on the facet joints is referred to as osteoarthritis. It can lead to further back problems, including spinal stenosis.
Spondylolisthesis. Degenerative Spondylolisthesis
(Spon-dee-low-lis-THEE-sis). Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.
Spinal Stenosis
Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves.
Spinal stenosis. When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth - called spurs - can lead to a narrowing of the spinal canal. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal.
Scoliosis
This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly leg symptoms, if pressure on the nerves is involved.
Additional Causes
There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position, you should consult your primary care doctor.
SymptomsBack pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain.
Most people find that reclining or lying down will improve low back pain, no matter the underlying cause.
People with low back pain may experience some of the following:
•Back pain may be worse with bending and lifting.
•Sitting may worsen pain.
•Standing and walking may worsen pain
•Back pain comes and goes, and often follows an up and down course with good days and bad days.
•Pain may extend from the back into the buttock or outer hip area, but not down the leg.
•Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain.
Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.
Tests and Diagnosis
Medical History and Physical Examination
After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain.
Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.
Imaging Tests
Other tests which may help your doctor confirm your diagnosis include:
X-rays. Although they only visualize bones, simple X-rays can help determine if you have the most obvious causes of back pain. It will show broken bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves.
Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible in an MRI scan.
Computerized axial tomography (CAT) scans. If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three-dimensional X-ray and focuses on the bones.
Bone scan. A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection.
Bone density test. If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.
Treatment
In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.
Nonsurgical Treatment
Medications. Several medications may be used to help relieve your pain.
•Aspirin or acetaminophen can relieve pain with few side effects.
•Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
•Narcotic pain medications, such as codeine or morphine, may help.
•Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.
Physical medicine. Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do.
•Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.
•Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
•Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.
•Traction is often used, but without scientific evidence for effectiveness.
•Other exercise-based programs, such as Pilates or yoga are helpful for some patients.
Surgical Treatment
Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.
In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.
Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply can not be treated with surgery.
Spinal Fusion. This is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a bad curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is if the painful spine segments do not move, they should not hurt.
Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals.
The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.
The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.
Disc Replacement. This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.
The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.
The surgery is done through your abdomen, usually on the lower two disks of the spine.
Prevention
It may not be possible to prevent low back pain. We cannot avoid the normal wear and tear on our spines that goes along with aging. But there are things we can do to lessen the impact of low back problems. Having a healthy lifestyle is a good start.
Exercise
Combine aerobic exercise, like walking or swimming, with specific exercises to keep the muscles in your back and abdomen strong and flexible.
Proper Lifting
Be sure to lift heavy items with your legs, not your back. Do not bend over to pick something up. Keep your back straight and bend at your knees.
Weight
Maintain a healthy weight. Being overweight puts added stress on your lower back.
Avoid Smoking
Both the smoke and the nicotine cause your spine to age faster than normal.
Proper Posture
Good posture is important for avoiding future problems. A therapist can teach you how to safely stand, sit, and lift.
Osteoporosis and treatment
Osteoporosis
What is osteoporosis?
Why should I be concerned about osteoporosis?
What causes osteoporosis?
What can I do to prevent osteoporosis or keep it from getting worse?
How is osteoporosis diagnosed?
How is osteoporosis treated?
What is osteoporosis?
Osteoporosis is a disease of progressive bone loss associated with an increased risk of fractures. The term osteoporosis literally means porous bone. The disease often develops unnoticed over many years, with no symptoms or discomfort until a fracture occurs. Osteoporosis often causes a loss of height and dowager's hump (a severely rounded upper back).
Why should I be concerned about osteoporosis?
Osteoporosis is a major health problem, affecting 28 million Americans and contributing to an estimated 1.5 million bone fractures per year.
Vertebrae showing signs of osteoporosis. Normal vertebrae (left), vertebrae with mild osteoporosis (center), and vertebrae with severe osteoporosis (right).One in two women and one in five men older than 65 years will sustain bone fractures caused by osteoporosis. Many of these are painful fractures of the hip, spine, wrist, arm, and leg, which often occur as a result of a fall. However, performing even simple household tasks can result in a fracture of the spine if the bones have been weakened by osteoporosis.
The most serious and debilitating osteoporotic fracture is a hip fracture. Most patient who experience a hip fracture and previously lived independently will require help from their family or home care. All patients who experience a hip fracture will require walking aids for several months, and nearly half will permanently need canes or walkers to move around their house or outdoors. Hip fractures are expensive. Health care costs from hip fractures total more than $10 billion annually-$35,000 per patient.
What causes osteoporosis?
Doctors do not know the exact medical causes of osteoporosis, but they have identified many of the major factors that can lead to the disease.
Aging
Everyone loses bone with age. After 35 years of age, the body builds less new bone to replace the loss of old bone. In general, the older you are, the lower your total bone mass and the greater your risk for osteoporosis.
Heredity
A family history of fractures; a small, slender body build; fair skin; and Caucasian or Asian ethnicity can increase the risk for osteoporosis. Heredity also may help explain why some people develop osteoporosis early in life.
Nutrition and Lifestyle
Poor nutrition, including a low calcium diet, low body weight, and a sedentary lifestyle have been linked to osteoporosis, as have smoking and excessive alcohol use.
Medications and Other Illnesses
Osteoporosis has been linked to the use of some medications, including steroids, and to other illnesses, including some thyroid problems.
What can I do to prevent osteoporosis or keep it from getting worse?
To prevent osteoporosis, slow its progression, and protect yourself from fractures you should include adequate amounts of calcium and vitamin D in your diet and exercise regularly.
Calcium
During the growing years, your body needs calcium to build strong bones and to create a supply of calcium reserves. Building bone mass when you are young is a good investment for your future. Inadequate calcium during growth can contribute to the development of osteoporosis later in life.
Whatever your age or health status, you need calcium to keep your bones healthy. Calcium continues to be an essential nutrient after growth because the body loses calcium every day. Although calcium cannot prevent gradual bone loss after menopause, it continues to play an essential role in maintaining bone quality. Even if women have gone through menopause or already have osteoporosis, increasing intake of calcium and vitamin D can decrease the risk of fracture.
How much calcium you need will vary depending on your age and other factors. The National Academy of Sciences makes the following recommendations regarding daily intake of calcium:
•Males and females 9 to 18 years: 1,300 mg per day
•Women and men 19 to 50 years: 1,000 mg per day
•Pregnant or nursing women up to age 18: 1,300 mg per day
•Pregnant or nursing women 19 to 50 years: 1,000 mg per day
•Women and men over 50: 1,200 mg per day
Dairy products, including yogurt and cheese, are excellent sources of calcium. An eight-ounce glass of milk contains about 300 mg of calcium. Other calcium-rich foods include sardines with bones and green leafy vegetables, including broccoli and collard greens.
If your diet does not contain enough calcium, dietary supplements can help. Talk to your doctor before taking a calcium supplement.
Vitamin D
Vitamin D helps your body absorb calcium. The recommendation for vitamin D is 200-600 IU (international units) daily. Supplemented dairy products are an excellent source of vitamin D. (A cup of milk contains 100 IU of vitamin D. A multivitamin contains 400 IU of vitamin D.) Vitamin supplements can be taken if your diet does not contain enough of this nutrient. Again, consult with your doctor before taking a vitamin supplement. Too much vitamin D can be toxic.
Exercise Regularly
Like muscles, bones need exercise to stay strong. No matter what your age, exercise can help minimize bone loss while providing many additional health benefits. Doctors believe that a program of moderate, regular exercise (3 to 4 times a week) is effective for the prevention and management of osteoporosis. Weight-bearing exercises such as walking, jogging, hiking, climbing stairs, dancing, treadmill exercises, and weight lifting are probably best. Falls account for 50% of fractures; therefore, even if you have low bone density, you can prevent fractures if you avoid falls. Programs that emphasize balance training, especially tai chi, should be emphasized. Consult with your doctor before beginning any exercise program.
How is osteoporosis diagnosed?
Loss of height and a stooped appearance of a person with osteoporosis results from partial collapse of weakened vertebrae.The diagnosis of osteoporosis is usually made by your doctor using a combination of a complete medical history and physical examination, skeletal x-rays, bone densitometry, and specialized laboratory tests. If your doctor diagnoses low bone mass, he or she may want to perform additional tests to rule out the possibility of other diseases that can cause bone loss, including osteomalacia (a metabolic bone disease characterized by abnormal mineralization of bone) or hyperparathyroidism (overactivity of the parathyroid glands).
Bone densitometry is a safe, painless x-ray technique that compares your bone density to the peak bone density that someone of your same sex and ethnicity should have reached at 20 to 25 years of age.
Bone densitometry is often performed in women at the time of menopause. Several types of bone densitometry are used today to detect bone loss in different areas of the body. Dual-energy x-ray absorptiometry (DEXA) is one of the most accurate methods, but other techniques can also identify osteoporosis, including single photon absorptiometry (SPA), quantitative computed tomography (QCT), radiographic absorptiometry, and ultrasound. Your doctor can determine which method is best suited for you.
How is osteoporosis treated?
Because lost bone cannot be replaced, treatment for osteoporosis focuses on the prevention of further bone loss. Treatment is often a team effort involving a physician or internist, an orthopaedist, a gynecologist, and an endocrinologist.
Although exercise and nutrition therapy are often key components of a treatment plan for osteoporosis, there are other treatments as well.
Estrogen Replacement Therapy
Estrogen replacement therapy (ERT) is often recommended for women at high risk for osteoporosis to prevent bone loss and reduce fracture risk. A measurement of bone density when menopause begins may help you decide whether ERT is right for you. Hormones also prevent heart disease, improve cognitive functioning, and improve urinary function. ERT is not without some risk, including enhanced risk of breast cancer; the risks and benefits of ERT should be discussed with your doctor.
Selective Estrogen Receptor Modulators
New anti-estrogens known as SERMs (selective estrogen receptor modulators) can increase bone mass, decrease the risk of spine fractures, and lower the risk of breast cancer.
Calcitonin
Calcitonin is another medication used to decrease bone loss. A nasal spray form of this medication increases bone mass, limits spine fractures, and may offer some pain relief.
Bisphosphonates
Bisphosphonates, including alendronate, markedly increase bone mass and prevent both spine and hip fractures.
ERT, SERMs, calcitonin, and bisphosphonates all offer patient with osteoporosis an opportunity to not only increase bone mass, but also to significantly reduce fracture risk. Prevention is preferable to waiting until treatment is necessary.
Your orthopaedist is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves. This has been prepared by the American Academy of Orthopaedic Surgeons and is intended to contain current information on the subject from recognized authorities. However, it does not represent official policy of the Academy and its text should not be construed as excluding other acceptable viewpoints.
What is osteoporosis?
Why should I be concerned about osteoporosis?
What causes osteoporosis?
What can I do to prevent osteoporosis or keep it from getting worse?
How is osteoporosis diagnosed?
How is osteoporosis treated?
What is osteoporosis?
Osteoporosis is a disease of progressive bone loss associated with an increased risk of fractures. The term osteoporosis literally means porous bone. The disease often develops unnoticed over many years, with no symptoms or discomfort until a fracture occurs. Osteoporosis often causes a loss of height and dowager's hump (a severely rounded upper back).
Why should I be concerned about osteoporosis?
Osteoporosis is a major health problem, affecting 28 million Americans and contributing to an estimated 1.5 million bone fractures per year.
Vertebrae showing signs of osteoporosis. Normal vertebrae (left), vertebrae with mild osteoporosis (center), and vertebrae with severe osteoporosis (right).One in two women and one in five men older than 65 years will sustain bone fractures caused by osteoporosis. Many of these are painful fractures of the hip, spine, wrist, arm, and leg, which often occur as a result of a fall. However, performing even simple household tasks can result in a fracture of the spine if the bones have been weakened by osteoporosis.
The most serious and debilitating osteoporotic fracture is a hip fracture. Most patient who experience a hip fracture and previously lived independently will require help from their family or home care. All patients who experience a hip fracture will require walking aids for several months, and nearly half will permanently need canes or walkers to move around their house or outdoors. Hip fractures are expensive. Health care costs from hip fractures total more than $10 billion annually-$35,000 per patient.
What causes osteoporosis?
Doctors do not know the exact medical causes of osteoporosis, but they have identified many of the major factors that can lead to the disease.
Aging
Everyone loses bone with age. After 35 years of age, the body builds less new bone to replace the loss of old bone. In general, the older you are, the lower your total bone mass and the greater your risk for osteoporosis.
Heredity
A family history of fractures; a small, slender body build; fair skin; and Caucasian or Asian ethnicity can increase the risk for osteoporosis. Heredity also may help explain why some people develop osteoporosis early in life.
Nutrition and Lifestyle
Poor nutrition, including a low calcium diet, low body weight, and a sedentary lifestyle have been linked to osteoporosis, as have smoking and excessive alcohol use.
Medications and Other Illnesses
Osteoporosis has been linked to the use of some medications, including steroids, and to other illnesses, including some thyroid problems.
What can I do to prevent osteoporosis or keep it from getting worse?
To prevent osteoporosis, slow its progression, and protect yourself from fractures you should include adequate amounts of calcium and vitamin D in your diet and exercise regularly.
Calcium
During the growing years, your body needs calcium to build strong bones and to create a supply of calcium reserves. Building bone mass when you are young is a good investment for your future. Inadequate calcium during growth can contribute to the development of osteoporosis later in life.
Whatever your age or health status, you need calcium to keep your bones healthy. Calcium continues to be an essential nutrient after growth because the body loses calcium every day. Although calcium cannot prevent gradual bone loss after menopause, it continues to play an essential role in maintaining bone quality. Even if women have gone through menopause or already have osteoporosis, increasing intake of calcium and vitamin D can decrease the risk of fracture.
How much calcium you need will vary depending on your age and other factors. The National Academy of Sciences makes the following recommendations regarding daily intake of calcium:
•Males and females 9 to 18 years: 1,300 mg per day
•Women and men 19 to 50 years: 1,000 mg per day
•Pregnant or nursing women up to age 18: 1,300 mg per day
•Pregnant or nursing women 19 to 50 years: 1,000 mg per day
•Women and men over 50: 1,200 mg per day
Dairy products, including yogurt and cheese, are excellent sources of calcium. An eight-ounce glass of milk contains about 300 mg of calcium. Other calcium-rich foods include sardines with bones and green leafy vegetables, including broccoli and collard greens.
If your diet does not contain enough calcium, dietary supplements can help. Talk to your doctor before taking a calcium supplement.
Vitamin D
Vitamin D helps your body absorb calcium. The recommendation for vitamin D is 200-600 IU (international units) daily. Supplemented dairy products are an excellent source of vitamin D. (A cup of milk contains 100 IU of vitamin D. A multivitamin contains 400 IU of vitamin D.) Vitamin supplements can be taken if your diet does not contain enough of this nutrient. Again, consult with your doctor before taking a vitamin supplement. Too much vitamin D can be toxic.
Exercise Regularly
Like muscles, bones need exercise to stay strong. No matter what your age, exercise can help minimize bone loss while providing many additional health benefits. Doctors believe that a program of moderate, regular exercise (3 to 4 times a week) is effective for the prevention and management of osteoporosis. Weight-bearing exercises such as walking, jogging, hiking, climbing stairs, dancing, treadmill exercises, and weight lifting are probably best. Falls account for 50% of fractures; therefore, even if you have low bone density, you can prevent fractures if you avoid falls. Programs that emphasize balance training, especially tai chi, should be emphasized. Consult with your doctor before beginning any exercise program.
How is osteoporosis diagnosed?
Loss of height and a stooped appearance of a person with osteoporosis results from partial collapse of weakened vertebrae.The diagnosis of osteoporosis is usually made by your doctor using a combination of a complete medical history and physical examination, skeletal x-rays, bone densitometry, and specialized laboratory tests. If your doctor diagnoses low bone mass, he or she may want to perform additional tests to rule out the possibility of other diseases that can cause bone loss, including osteomalacia (a metabolic bone disease characterized by abnormal mineralization of bone) or hyperparathyroidism (overactivity of the parathyroid glands).
Bone densitometry is a safe, painless x-ray technique that compares your bone density to the peak bone density that someone of your same sex and ethnicity should have reached at 20 to 25 years of age.
Bone densitometry is often performed in women at the time of menopause. Several types of bone densitometry are used today to detect bone loss in different areas of the body. Dual-energy x-ray absorptiometry (DEXA) is one of the most accurate methods, but other techniques can also identify osteoporosis, including single photon absorptiometry (SPA), quantitative computed tomography (QCT), radiographic absorptiometry, and ultrasound. Your doctor can determine which method is best suited for you.
How is osteoporosis treated?
Because lost bone cannot be replaced, treatment for osteoporosis focuses on the prevention of further bone loss. Treatment is often a team effort involving a physician or internist, an orthopaedist, a gynecologist, and an endocrinologist.
Although exercise and nutrition therapy are often key components of a treatment plan for osteoporosis, there are other treatments as well.
Estrogen Replacement Therapy
Estrogen replacement therapy (ERT) is often recommended for women at high risk for osteoporosis to prevent bone loss and reduce fracture risk. A measurement of bone density when menopause begins may help you decide whether ERT is right for you. Hormones also prevent heart disease, improve cognitive functioning, and improve urinary function. ERT is not without some risk, including enhanced risk of breast cancer; the risks and benefits of ERT should be discussed with your doctor.
Selective Estrogen Receptor Modulators
New anti-estrogens known as SERMs (selective estrogen receptor modulators) can increase bone mass, decrease the risk of spine fractures, and lower the risk of breast cancer.
Calcitonin
Calcitonin is another medication used to decrease bone loss. A nasal spray form of this medication increases bone mass, limits spine fractures, and may offer some pain relief.
Bisphosphonates
Bisphosphonates, including alendronate, markedly increase bone mass and prevent both spine and hip fractures.
ERT, SERMs, calcitonin, and bisphosphonates all offer patient with osteoporosis an opportunity to not only increase bone mass, but also to significantly reduce fracture risk. Prevention is preferable to waiting until treatment is necessary.
Your orthopaedist is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves. This has been prepared by the American Academy of Orthopaedic Surgeons and is intended to contain current information on the subject from recognized authorities. However, it does not represent official policy of the Academy and its text should not be construed as excluding other acceptable viewpoints.
Hammer Time, I mean Hammer Toe
A hammer toe is a deformity of the second, third or fourth toes. In this condition, the toe is bent at the middle joint, so that it resembles a hammer. Initially, hammer toes are flexible and can be corrected with simple measures but, if left untreated, they can become fixed and require surgery.
People with hammer toe may have corns or calluses on the top of the middle joint of the toe or on the tip of the toe. They may also feel pain in their toes or feet and have difficulty finding comfortable shoes.
Cause Hammer toe results from shoes that don't fit properly or a muscle imbalance, usually in combination with one or more other factors. Muscles work in pairs to straighten and bend the toes. If the toe is bent and held in one position long enough, the muscles tighten and cannot stretch out.
Shoes that narrow toward the toe may make your forefoot look smaller. But they also push the smaller toes into a flexed (bent) position. The toes rub against the shoe, leading to the formation of corns and calluses, which further aggravate the condition. A higher heel forces the foot down and squishes the toes against the shoe, increasing the pressure and the bend in the toe. Eventually, the toe muscles become unable to straighten the toe, even when there is no confining shoe.
Treatment Conservative treatment starts with new shoes that have soft, roomy toe boxes. Shoes should be one-half inch longer than your longest toe. (Note: For many people, the second toe is longer than the big toe.) Avoid wearing tight, narrow, high-heeled shoes. You may also be able to find a shoe with a deep toe box that accommodates the hammer toe. Or, a shoe repair shop may be able to stretch the toe box so that it bulges out around the toe. Sandals may help, as long as they do not pinch or rub other areas of the foot.
Your doctor may also prescribe some toe exercises that you can do at home to stretch and strengthen the muscles. For example, you can gently stretch the toes manually. You can use your toes to pick things up off the floor. While you watch television or read, you can put a towel flat under your feet and use your toes to crumple it.
Finally, your doctor may recommend that you use commercially available straps, cushions or nonmedicated corn pads to relieve symptoms. If you have diabetes, poor circulation or a lack of feeling in your feet, talk to your doctor before attempting any self-treatment.
Hammer toe can be corrected by surgery if conservative measures fail. Usually, surgery is done on an outpatient basis with a local anesthetic. The actual procedure will depend on the type and extent of the deformity. After the surgery, there may be some stiffness, swelling and redness and the toe may be slightly longer or shorter than before. You will be able to walk, but should not plan any long hikes while the toe heals, and should keep your foot elevated as much as possible.
People with hammer toe may have corns or calluses on the top of the middle joint of the toe or on the tip of the toe. They may also feel pain in their toes or feet and have difficulty finding comfortable shoes.
Cause Hammer toe results from shoes that don't fit properly or a muscle imbalance, usually in combination with one or more other factors. Muscles work in pairs to straighten and bend the toes. If the toe is bent and held in one position long enough, the muscles tighten and cannot stretch out.
Shoes that narrow toward the toe may make your forefoot look smaller. But they also push the smaller toes into a flexed (bent) position. The toes rub against the shoe, leading to the formation of corns and calluses, which further aggravate the condition. A higher heel forces the foot down and squishes the toes against the shoe, increasing the pressure and the bend in the toe. Eventually, the toe muscles become unable to straighten the toe, even when there is no confining shoe.
Treatment Conservative treatment starts with new shoes that have soft, roomy toe boxes. Shoes should be one-half inch longer than your longest toe. (Note: For many people, the second toe is longer than the big toe.) Avoid wearing tight, narrow, high-heeled shoes. You may also be able to find a shoe with a deep toe box that accommodates the hammer toe. Or, a shoe repair shop may be able to stretch the toe box so that it bulges out around the toe. Sandals may help, as long as they do not pinch or rub other areas of the foot.
Your doctor may also prescribe some toe exercises that you can do at home to stretch and strengthen the muscles. For example, you can gently stretch the toes manually. You can use your toes to pick things up off the floor. While you watch television or read, you can put a towel flat under your feet and use your toes to crumple it.
Finally, your doctor may recommend that you use commercially available straps, cushions or nonmedicated corn pads to relieve symptoms. If you have diabetes, poor circulation or a lack of feeling in your feet, talk to your doctor before attempting any self-treatment.
Hammer toe can be corrected by surgery if conservative measures fail. Usually, surgery is done on an outpatient basis with a local anesthetic. The actual procedure will depend on the type and extent of the deformity. After the surgery, there may be some stiffness, swelling and redness and the toe may be slightly longer or shorter than before. You will be able to walk, but should not plan any long hikes while the toe heals, and should keep your foot elevated as much as possible.
Plantar Fasciitis and heel spurs
Plantar Fasciitis and Bone SpursAnatomy
Cause
Symptoms
Doctor Examination
Tests
Treatment Plantar fasciitis (fashee-EYE-tiss) is the most common cause of pain on the bottom of the heel. Approximately 2 million patients are treated for this condition every year.
Plantar fasciitis occurs when the strong band of tissue that supports the arch of your foot becomes irritated and inflamed.
AnatomyThe plantar fascia is a long, thin ligament that lies directly beneath the skin on the bottom of your foot. It connects the heel to the front of your foot, and supports the arch of your foot.
CauseThe plantar fascia is designed to absorb the high stresses and strains we place on our feet. But, sometimes, too much pressure damages or tears the tissues. The body's natural response to injury is inflammation, which results in the heel pain and stiffness of plantar fasciitis.
Risk Factors
In most cases, plantar fasciitis develops without a specific, identifiable reason. There are, however, many factors that can make you more prone to the condition:
•Tighter calf muscles that make it difficult to flex your foot and bring your toes up toward your shin
•Obesity
•Very high arch
•Repetitive impact activity (running/sports)
•New or increased activity
Heel Spurs
Although many people with plantar fasciitis have heel spurs, spurs are not the cause of plantar fasciitis pain. One out of 10 people has heel spurs, but only 1 out of 20 people (5%) with heel spurs has foot pain. Because the spur is not the cause of plantar fasciitis, the pain can be treated without removing the spur.
Heel spurs do not cause plantar fasciitis pain.Top of page
SymptomsThe most common symptoms of plantar fasciitis include:
•Pain on the bottom of the foot near the heel
•Pain with the first few steps after getting out of bed in the morning, or after a long period of rest, such as after a long car ride. The pain subsides after a few minutes of walking
•Greater pain after (not during) exercise or activity
Top of page
Doctor ExaminationAfter you describe your symptoms and discuss your concerns, your doctor will examine your foot. Your doctor will look for these signs:
•A high arch
•An area of maximum tenderness on the bottom of your foot, just in front of your heel bone
•Pain that gets worse when you flex your foot and the doctor pushes on the plantar fascia. The pain improves when you point your toes down
•Limited "up" motion of your ankle
Top of page
TestsYour doctor may order imaging tests to help make sure your heel pain is caused by plantar fasciitis and not another problem.
X-rays
X-rays provide clear images of bones. They are useful in ruling out other causes of heel pain, such as fractures or arthritis. Heel spurs can be seen on an x-ray.
Other Imaging Tests
Other imaging tests, such as magnetic resonance imaging (MRI) and ultrasound, are not routinely used to diagnose plantar fasciitis. They are rarely ordered. An MRI scan may be used if the heel pain is not relieved by initial treatment methods.
TreatmentNonsurgical Treatment
More than 90% of patients with plantar fasciitis will improve within 10 months of starting simple treatment methods.
Rest. Decreasing or even stopping the activities that make the pain worse is the first step in reducing the pain. You may need to stop athletic activities where your feet pound on hard surfaces (for example, running or step aerobics).
Ice. Rolling your foot over a cold water bottle or ice for 20 minutes is effective. This can be done 3 to 4 times a day.
Nonsteroidal anti-inflammatory medication. Drugs such as ibuprofen or naproxen reduce pain and inflammation. Using the medication for more than 1 month should be reviewed with your primary care doctor.
Exercise. Plantar fasciitis is aggravated by tight muscles in your feet and calves. Stretching your calves and plantar fascia is the most effective way to relieve the pain that comes with this condition.
•Calf stretch
Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.
•Plantar fascia stretch
This stretch is performed in the seated position. Cross your affected foot over the knee of your other leg. Grasp the toes of your painful foot and slowly pull them toward you in a controlled fashion. If it is difficult to reach your foot, wrap a towel around your big toe to help pull your toes toward you. Place your other hand along the plantar fascia. The fascia should feel like a tight band along the bottom of your foot when stretched. Hold the stretch for 10 seconds. Repeat it 20 times for each foot. This exercise is best done in the morning before standing or walking.
Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. It can be injected into the plantar fascia to reduce inflammation and pain. Your doctor may limit your injections. Multiple steroid injections can cause the plantar fascia to rupture (tear), which can lead to a flat foot and chronic pain.
Soft heel pads can provide extra support.Supportive shoes and orthotics. Shoes with thick soles and extra cushioning can reduce pain with standing and walking. As you step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension and the microtrauma that occurs with every step. Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel. Pre-made or custom orthotics (shoe inserts) are also helpful.
Night splints. Most people sleep with their feet pointed down. This relaxes the plantar fascia and is one of the reasons for morning heel pain. A night splint stretches the plantar fascia while you sleep. Although it can be difficult to sleep with, a night splint is very effective and does not have to be used once the pain is gone.
Physical therapy. Your doctor may suggest that you work with a physical therapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. In addition to exercises like the ones mentioned above, a physical therapy program may involve specialized ice treatments, massage, and medication to decrease inflammation around the plantar fascia.
Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged plantar fascia tissue. ESWT has not shown consistent results and, therefore, is not commonly performed.
ESWT is noninvasive—it does not require a surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered.
Surgical Treatment
Surgery is considered only after 12 months of aggressive nonsurgical treatment.
Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the plantar fascia, this procedure is useful for patients who still have difficulty flexing their feet, despite a year of calf stretches.
In gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope, an instrument that contains a small camera. Your doctor will discuss the procedure that best meets your needs.
Complication rates for gastrocnemius recession are low, but can include nerve damage.
Plantar fascia release. If you have a normal range of ankle motion and continued heel pain, your doctor may recommend a partial release procedure. During surgery, the plantar fascia ligament is partially cut to relieve tension in the tissue. If you have a large bone spur, it will be removed, as well. Although the surgery can be performed endoscopically, it is more difficult than with an open incision. In addition, endoscopy has a higher risk of nerve damage.
Complications. The most common complications of release surgery include incomplete relief of pain and nerve damage.
Recovery. Most patients have good results from surgery. However, because surgery can result in chronic pain and dissatisfaction, it is recommended only after all nonsurgical measures have been exhausted.
Cause
Symptoms
Doctor Examination
Tests
Treatment Plantar fasciitis (fashee-EYE-tiss) is the most common cause of pain on the bottom of the heel. Approximately 2 million patients are treated for this condition every year.
Plantar fasciitis occurs when the strong band of tissue that supports the arch of your foot becomes irritated and inflamed.
AnatomyThe plantar fascia is a long, thin ligament that lies directly beneath the skin on the bottom of your foot. It connects the heel to the front of your foot, and supports the arch of your foot.
CauseThe plantar fascia is designed to absorb the high stresses and strains we place on our feet. But, sometimes, too much pressure damages or tears the tissues. The body's natural response to injury is inflammation, which results in the heel pain and stiffness of plantar fasciitis.
Risk Factors
In most cases, plantar fasciitis develops without a specific, identifiable reason. There are, however, many factors that can make you more prone to the condition:
•Tighter calf muscles that make it difficult to flex your foot and bring your toes up toward your shin
•Obesity
•Very high arch
•Repetitive impact activity (running/sports)
•New or increased activity
Heel Spurs
Although many people with plantar fasciitis have heel spurs, spurs are not the cause of plantar fasciitis pain. One out of 10 people has heel spurs, but only 1 out of 20 people (5%) with heel spurs has foot pain. Because the spur is not the cause of plantar fasciitis, the pain can be treated without removing the spur.
Heel spurs do not cause plantar fasciitis pain.Top of page
SymptomsThe most common symptoms of plantar fasciitis include:
•Pain on the bottom of the foot near the heel
•Pain with the first few steps after getting out of bed in the morning, or after a long period of rest, such as after a long car ride. The pain subsides after a few minutes of walking
•Greater pain after (not during) exercise or activity
Top of page
Doctor ExaminationAfter you describe your symptoms and discuss your concerns, your doctor will examine your foot. Your doctor will look for these signs:
•A high arch
•An area of maximum tenderness on the bottom of your foot, just in front of your heel bone
•Pain that gets worse when you flex your foot and the doctor pushes on the plantar fascia. The pain improves when you point your toes down
•Limited "up" motion of your ankle
Top of page
TestsYour doctor may order imaging tests to help make sure your heel pain is caused by plantar fasciitis and not another problem.
X-rays
X-rays provide clear images of bones. They are useful in ruling out other causes of heel pain, such as fractures or arthritis. Heel spurs can be seen on an x-ray.
Other Imaging Tests
Other imaging tests, such as magnetic resonance imaging (MRI) and ultrasound, are not routinely used to diagnose plantar fasciitis. They are rarely ordered. An MRI scan may be used if the heel pain is not relieved by initial treatment methods.
TreatmentNonsurgical Treatment
More than 90% of patients with plantar fasciitis will improve within 10 months of starting simple treatment methods.
Rest. Decreasing or even stopping the activities that make the pain worse is the first step in reducing the pain. You may need to stop athletic activities where your feet pound on hard surfaces (for example, running or step aerobics).
Ice. Rolling your foot over a cold water bottle or ice for 20 minutes is effective. This can be done 3 to 4 times a day.
Nonsteroidal anti-inflammatory medication. Drugs such as ibuprofen or naproxen reduce pain and inflammation. Using the medication for more than 1 month should be reviewed with your primary care doctor.
Exercise. Plantar fasciitis is aggravated by tight muscles in your feet and calves. Stretching your calves and plantar fascia is the most effective way to relieve the pain that comes with this condition.
•Calf stretch
Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.
•Plantar fascia stretch
This stretch is performed in the seated position. Cross your affected foot over the knee of your other leg. Grasp the toes of your painful foot and slowly pull them toward you in a controlled fashion. If it is difficult to reach your foot, wrap a towel around your big toe to help pull your toes toward you. Place your other hand along the plantar fascia. The fascia should feel like a tight band along the bottom of your foot when stretched. Hold the stretch for 10 seconds. Repeat it 20 times for each foot. This exercise is best done in the morning before standing or walking.
Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. It can be injected into the plantar fascia to reduce inflammation and pain. Your doctor may limit your injections. Multiple steroid injections can cause the plantar fascia to rupture (tear), which can lead to a flat foot and chronic pain.
Soft heel pads can provide extra support.Supportive shoes and orthotics. Shoes with thick soles and extra cushioning can reduce pain with standing and walking. As you step and your heel strikes the ground, a significant amount of tension is placed on the fascia, which causes microtrauma (tiny tears in the tissue). A cushioned shoe or insert reduces this tension and the microtrauma that occurs with every step. Soft silicone heel pads are inexpensive and work by elevating and cushioning your heel. Pre-made or custom orthotics (shoe inserts) are also helpful.
Night splints. Most people sleep with their feet pointed down. This relaxes the plantar fascia and is one of the reasons for morning heel pain. A night splint stretches the plantar fascia while you sleep. Although it can be difficult to sleep with, a night splint is very effective and does not have to be used once the pain is gone.
Physical therapy. Your doctor may suggest that you work with a physical therapist on an exercise program that focuses on stretching your calf muscles and plantar fascia. In addition to exercises like the ones mentioned above, a physical therapy program may involve specialized ice treatments, massage, and medication to decrease inflammation around the plantar fascia.
Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged plantar fascia tissue. ESWT has not shown consistent results and, therefore, is not commonly performed.
ESWT is noninvasive—it does not require a surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered.
Surgical Treatment
Surgery is considered only after 12 months of aggressive nonsurgical treatment.
Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the plantar fascia, this procedure is useful for patients who still have difficulty flexing their feet, despite a year of calf stretches.
In gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope, an instrument that contains a small camera. Your doctor will discuss the procedure that best meets your needs.
Complication rates for gastrocnemius recession are low, but can include nerve damage.
Plantar fascia release. If you have a normal range of ankle motion and continued heel pain, your doctor may recommend a partial release procedure. During surgery, the plantar fascia ligament is partially cut to relieve tension in the tissue. If you have a large bone spur, it will be removed, as well. Although the surgery can be performed endoscopically, it is more difficult than with an open incision. In addition, endoscopy has a higher risk of nerve damage.
Complications. The most common complications of release surgery include incomplete relief of pain and nerve damage.
Recovery. Most patients have good results from surgery. However, because surgery can result in chronic pain and dissatisfaction, it is recommended only after all nonsurgical measures have been exhausted.
How to use crutches, canes, and walkers
How to Use Crutches, Canes, and Walkers General Guidelines
Crutches
Canes
Walkers If you ever break a bone in your leg or foot, have a surgical procedure on your lower limb, or suffer a stroke, you may need to use crutches, a cane, or a walker.
In the beginning, everything you do may seem difficult. But, with a few tips and some practice, you will gain confidence and learn to use your walking aid safely.
General Guidelines •Remove scatter rugs, electrical cords, spills, and anything else that may cause you to fall.
•In the bathroom, use nonslip bath mats, grab bars, a raised toilet seat, and a shower tub seat.
•Simplify your household to keep the items you need handy and everything else out of the way.
•Use a backpack, fanny pack, apron, or briefcase to help you carry things around.
Top of page
Crutches If an injury or surgical procedure requires you to keep your weight off your leg or foot, you may have to use crutches.
Proper Positioning
The top of your crutches should reach between 1 and 1.5 inches below your armpits while you stand up straight.
The handgrips of the crutches should be even with the top of your hip line.
Your elbows should bend a bit when you use the handgrips.
Hold the top of the crutches tightly to your sides, and use your hands to absorb the weight. Don't let the tops of the crutches press into your armpits.
Walking
Lean forward slightly and put your crutches about one foot ahead of you. Begin your step as if you were going to use the injured foot or leg, but shift your weight to the crutches instead of the injured foot. Your body swings forward between the crutches. Finish the step normally with your non-injured leg. When the non-injured leg is on the ground, move your crutches ahead in preparation for the next step. Keep focused on where you are walking, not on your feet.
Sitting
Back up to a sturdy chair. Put your injured foot in front of you and both crutches in one hand. Use the other hand to feel for the seat of your chair. Slowly lower yourself into it. Lean your crutches upside down in a handy location. (Crutches tend to fall over when they are stood on their tips.) To stand up, inch yourself to the front of the chair. Hold both crutches in the hand on your good leg side. Push yourself up and stand on the good leg.
Stairs
To walk up and down stairs with crutches, you need to be both strong and flexible. Facing the stairway, hold the handrail with one hand and tuck both crutches under your armpit on the other side. When you're going up, lead with your good foot, keeping the injured foot raised behind you. When you're going down, hold your injured foot up in front, and hop down each stair on your good foot. Take it one step at a time. You may want someone to help you, at least at first. If you're facing a stairway with no handrails, use the crutches under both arms and hop up or down each step on your good leg, using more strength. An easier way is to sit on the stairs and inch yourself up and down each step. Start by sitting on the lowest stair with your injured leg out in front. Hold both crutches flat against the stairs in your opposite hand. Scoot your bottom up to the next step, using your free hand and good leg for support. Face the same direction when you go down the stairs this way.
Canes
You may find it helpful to use a cane if you have a small problem with balance or instability, some weakness in your leg or trunk, an injury, or pain. If you are elderly, a single point cane may also help you to keep living independently.
Proper Positioning
The top of your cane should reach to the crease in your wrist when you stand up straight. Your elbow should bend a bit when you hold your cane. Hold the cane in the hand opposite the side that needs support.
Walking
When you walk, the cane and your injured leg swing and strike the ground at the same time. To start, position your cane about one small stride ahead and step off on your injured leg. Finish the step with your normal leg.
Stairs
To climb stairs, grasp the handrail (if possible) and step up on your good leg first, with your cane in the hand opposite the injured leg. Then step up on the injured leg. To come down stairs, put your cane on the step first, then your injured leg, and finally the good leg, which carries your body weight.
Walkers If you have had total knee or hip joint replacement surgery, or you have another significant problem, you may need more help with balance and walking than you can get with crutches or a cane. A pickup walker with four solid prongs on the bottom may give you the most stability. The walker lets you keep all or some of your weight off of your lower body as you take your steps. You use your arms to support some of the weight. The top of your walker should match the crease in your wrist when you stand up straight. Do not hurry when you use a walker. As your strength and endurance get better, you may gradually be able to carry more weight in your legs.
Walking
First, put your walker about one step ahead of you, making sure the legs of your walker are level to the ground. With both hands, grip the top of the walker for support and walk into it, stepping off on your injured leg. Touch the heel of this foot to the ground first, then flatten the foot and finally lift the toes off the ground as you complete your step with your good leg. Don't step all the way to the front bar of your walker. Take small steps when you turn.
Sitting
To sit, back up until your legs touch the chair. Reach back to feel the seat before you sit. To get up from a chair, push yourself up and grasp the walker's grips. Make sure the rubber tips on your walker's legs stay in good shape.
Stairs
Never try to climb stairs or use an escalator with your walker.
Crutches
Canes
Walkers If you ever break a bone in your leg or foot, have a surgical procedure on your lower limb, or suffer a stroke, you may need to use crutches, a cane, or a walker.
In the beginning, everything you do may seem difficult. But, with a few tips and some practice, you will gain confidence and learn to use your walking aid safely.
General Guidelines •Remove scatter rugs, electrical cords, spills, and anything else that may cause you to fall.
•In the bathroom, use nonslip bath mats, grab bars, a raised toilet seat, and a shower tub seat.
•Simplify your household to keep the items you need handy and everything else out of the way.
•Use a backpack, fanny pack, apron, or briefcase to help you carry things around.
Top of page
Crutches If an injury or surgical procedure requires you to keep your weight off your leg or foot, you may have to use crutches.
Proper Positioning
The top of your crutches should reach between 1 and 1.5 inches below your armpits while you stand up straight.
The handgrips of the crutches should be even with the top of your hip line.
Your elbows should bend a bit when you use the handgrips.
Hold the top of the crutches tightly to your sides, and use your hands to absorb the weight. Don't let the tops of the crutches press into your armpits.
Walking
Lean forward slightly and put your crutches about one foot ahead of you. Begin your step as if you were going to use the injured foot or leg, but shift your weight to the crutches instead of the injured foot. Your body swings forward between the crutches. Finish the step normally with your non-injured leg. When the non-injured leg is on the ground, move your crutches ahead in preparation for the next step. Keep focused on where you are walking, not on your feet.
Sitting
Back up to a sturdy chair. Put your injured foot in front of you and both crutches in one hand. Use the other hand to feel for the seat of your chair. Slowly lower yourself into it. Lean your crutches upside down in a handy location. (Crutches tend to fall over when they are stood on their tips.) To stand up, inch yourself to the front of the chair. Hold both crutches in the hand on your good leg side. Push yourself up and stand on the good leg.
Stairs
To walk up and down stairs with crutches, you need to be both strong and flexible. Facing the stairway, hold the handrail with one hand and tuck both crutches under your armpit on the other side. When you're going up, lead with your good foot, keeping the injured foot raised behind you. When you're going down, hold your injured foot up in front, and hop down each stair on your good foot. Take it one step at a time. You may want someone to help you, at least at first. If you're facing a stairway with no handrails, use the crutches under both arms and hop up or down each step on your good leg, using more strength. An easier way is to sit on the stairs and inch yourself up and down each step. Start by sitting on the lowest stair with your injured leg out in front. Hold both crutches flat against the stairs in your opposite hand. Scoot your bottom up to the next step, using your free hand and good leg for support. Face the same direction when you go down the stairs this way.
Canes
You may find it helpful to use a cane if you have a small problem with balance or instability, some weakness in your leg or trunk, an injury, or pain. If you are elderly, a single point cane may also help you to keep living independently.
Proper Positioning
The top of your cane should reach to the crease in your wrist when you stand up straight. Your elbow should bend a bit when you hold your cane. Hold the cane in the hand opposite the side that needs support.
Walking
When you walk, the cane and your injured leg swing and strike the ground at the same time. To start, position your cane about one small stride ahead and step off on your injured leg. Finish the step with your normal leg.
Stairs
To climb stairs, grasp the handrail (if possible) and step up on your good leg first, with your cane in the hand opposite the injured leg. Then step up on the injured leg. To come down stairs, put your cane on the step first, then your injured leg, and finally the good leg, which carries your body weight.
Walkers If you have had total knee or hip joint replacement surgery, or you have another significant problem, you may need more help with balance and walking than you can get with crutches or a cane. A pickup walker with four solid prongs on the bottom may give you the most stability. The walker lets you keep all or some of your weight off of your lower body as you take your steps. You use your arms to support some of the weight. The top of your walker should match the crease in your wrist when you stand up straight. Do not hurry when you use a walker. As your strength and endurance get better, you may gradually be able to carry more weight in your legs.
Walking
First, put your walker about one step ahead of you, making sure the legs of your walker are level to the ground. With both hands, grip the top of the walker for support and walk into it, stepping off on your injured leg. Touch the heel of this foot to the ground first, then flatten the foot and finally lift the toes off the ground as you complete your step with your good leg. Don't step all the way to the front bar of your walker. Take small steps when you turn.
Sitting
To sit, back up until your legs touch the chair. Reach back to feel the seat before you sit. To get up from a chair, push yourself up and grasp the walker's grips. Make sure the rubber tips on your walker's legs stay in good shape.
Stairs
Never try to climb stairs or use an escalator with your walker.
Answers to arthritis quiz
AnswersTrue or False
1. False. More than half of people affected by arthritis are under age 65. Rheumatoid arthritis can affect people of all ages, even children. However, the population is aging. The number of people with arthritis is expected to rise from the current 46 million as the baby boom generation ages. The Centers for Disease Control estimates this number to reach 67 million by the year 2030.
2. True, but joints may ache for several reasons. If the lining of the joint becomes inflamed, you may have rheumatoid arthritis. If the cushioning cartilage in the joint becomes damaged or worn away, you may have osteoarthritis or "wear and tear" arthritis.
3. False. There are interventions to prevent or reduce arthritis-related pain and disability. These interventions include early diagnosis, weight control, physical activity, physical and occupational therapy and joint replacement, when appropriate.
4. True. Post-traumatic arthritis can develop after an injury to the knee. This type of arthritis is similar to osteoarthritis and may develop years after a fracture or ligament injury in the knee.
5. True. Sudden onset of arthritis is possible, but, generally, the pain associated with arthritis develops gradually. The joint may become stiff and swollen, making it difficult to bend or straighten the knee. Pain and swelling are worse in the morning or after a period of inactivity. Pain also may increase after walking stair climbing or kneeling.
6. False. Researchers are making progress in finding the underlying causes for the major types of arthritis. In the meantime, orthopaedists, working with other physicians and scientists, have developed many effective treatments for arthritis.
7. True. However, arthritis can occur in other joints, too. For instance, arthritis at the base of the thumb is common. It occurs more in women than in men and usually after the age of 40.
8. False. Rheumatoid arthritis is not an inherited disease, although researchers believe that some people have genes that make them susceptible to the disease. People with these genes will not automatically develop rheumatoid arthritis.
9. True. However, research is underway to develop techniques to replace or "grow" cartilage in places where it has been worn away.
10. False. Regular exercise slows the loss of muscle mass, strengthens bones, and reduces joint and muscle pain. Inactivity can lead to weak muscles around the joint and result in joint instability.
Multiple Choice
1. D. More than 100 diseases that affect joint areas are called arthritis.
2. E. All listed. Nearly all vertebrates can suffer from osteoarthritis.
3. E. All listed. See your doctor for a complete medical evaluation.
4. B. Your doctor will prescribe a treatment program that meets your needs.
5. C. 46 million. The number is approximately one in five people.
6. E. $128 billion. The cost of arthritis equals a moderate recession.
1. False. More than half of people affected by arthritis are under age 65. Rheumatoid arthritis can affect people of all ages, even children. However, the population is aging. The number of people with arthritis is expected to rise from the current 46 million as the baby boom generation ages. The Centers for Disease Control estimates this number to reach 67 million by the year 2030.
2. True, but joints may ache for several reasons. If the lining of the joint becomes inflamed, you may have rheumatoid arthritis. If the cushioning cartilage in the joint becomes damaged or worn away, you may have osteoarthritis or "wear and tear" arthritis.
3. False. There are interventions to prevent or reduce arthritis-related pain and disability. These interventions include early diagnosis, weight control, physical activity, physical and occupational therapy and joint replacement, when appropriate.
4. True. Post-traumatic arthritis can develop after an injury to the knee. This type of arthritis is similar to osteoarthritis and may develop years after a fracture or ligament injury in the knee.
5. True. Sudden onset of arthritis is possible, but, generally, the pain associated with arthritis develops gradually. The joint may become stiff and swollen, making it difficult to bend or straighten the knee. Pain and swelling are worse in the morning or after a period of inactivity. Pain also may increase after walking stair climbing or kneeling.
6. False. Researchers are making progress in finding the underlying causes for the major types of arthritis. In the meantime, orthopaedists, working with other physicians and scientists, have developed many effective treatments for arthritis.
7. True. However, arthritis can occur in other joints, too. For instance, arthritis at the base of the thumb is common. It occurs more in women than in men and usually after the age of 40.
8. False. Rheumatoid arthritis is not an inherited disease, although researchers believe that some people have genes that make them susceptible to the disease. People with these genes will not automatically develop rheumatoid arthritis.
9. True. However, research is underway to develop techniques to replace or "grow" cartilage in places where it has been worn away.
10. False. Regular exercise slows the loss of muscle mass, strengthens bones, and reduces joint and muscle pain. Inactivity can lead to weak muscles around the joint and result in joint instability.
Multiple Choice
1. D. More than 100 diseases that affect joint areas are called arthritis.
2. E. All listed. Nearly all vertebrates can suffer from osteoarthritis.
3. E. All listed. See your doctor for a complete medical evaluation.
4. B. Your doctor will prescribe a treatment program that meets your needs.
5. C. 46 million. The number is approximately one in five people.
6. E. $128 billion. The cost of arthritis equals a moderate recession.
Arthritis quiz
QuestionsTrue or False
1. Arthritis is a disease of the elderly.
2. Aching joints are a common symptom of arthritis.
3. People with arthritis must learn to live with aching joints.
4. Arthritis can come from an injury.
5. Some people just wake up one morning and have painful arthritis in the knee joint.
6. The cause of arthritis is well known.
7. Arthritis occurs in major joints such as the hip and knee.
8. You can inherit rheumatoid arthritis.
9. Once the cartilage in the joint has worn away in osteoarthritis, your body will not grow new cartilage.
10. People with arthritis should avoid exercise because the activity will make the condition worse.
Multiple Choice
1. Arthritis includes how many different diseases?
a. One
b. 10
c. 25
d. 100+
e. None of the above
2. Which of the following vertebrates can suffer osteoarthritis?
a. Man
b. Porpoises
c. Whales
d. Dinosaurs
e. All of the above
3. Arthritis is diagnosed by:
a. The pattern of symptoms
b. Medical history
c. Physical exam, X-rays and lab tests
d. A and B only
e. All of the above
4. Arthritis treatment programs:
a. Are generally ineffective
b. Combine medication, exercise, rest and other techniques
c. Never include surgery
d. Avoid use of heat and cold
e. All of the above
5. How many Americans have arthritis?
a. 430,000
b. 70 million
c. 46 million
d. More than 50 million
e. None of the above
6. How much does arthritis cost the U.S. economy in medical care and lost wages?
a. $6.5 million
b. $65 million
c. $650 million
d. $6.5 billion
e. $128 billion
1. Arthritis is a disease of the elderly.
2. Aching joints are a common symptom of arthritis.
3. People with arthritis must learn to live with aching joints.
4. Arthritis can come from an injury.
5. Some people just wake up one morning and have painful arthritis in the knee joint.
6. The cause of arthritis is well known.
7. Arthritis occurs in major joints such as the hip and knee.
8. You can inherit rheumatoid arthritis.
9. Once the cartilage in the joint has worn away in osteoarthritis, your body will not grow new cartilage.
10. People with arthritis should avoid exercise because the activity will make the condition worse.
Multiple Choice
1. Arthritis includes how many different diseases?
a. One
b. 10
c. 25
d. 100+
e. None of the above
2. Which of the following vertebrates can suffer osteoarthritis?
a. Man
b. Porpoises
c. Whales
d. Dinosaurs
e. All of the above
3. Arthritis is diagnosed by:
a. The pattern of symptoms
b. Medical history
c. Physical exam, X-rays and lab tests
d. A and B only
e. All of the above
4. Arthritis treatment programs:
a. Are generally ineffective
b. Combine medication, exercise, rest and other techniques
c. Never include surgery
d. Avoid use of heat and cold
e. All of the above
5. How many Americans have arthritis?
a. 430,000
b. 70 million
c. 46 million
d. More than 50 million
e. None of the above
6. How much does arthritis cost the U.S. economy in medical care and lost wages?
a. $6.5 million
b. $65 million
c. $650 million
d. $6.5 billion
e. $128 billion
Rheumatoid Arthritis
Rheumatoid Arthritis Cause
Symptoms
Diagnosis
Treatment Aching joints are common in arthritis. In rheumatoid arthritis, the joint lining swells, invades surrounding tissues, and produces chemical substances that attack and destroy the joint surface.
People of all ages may be affected. The disease usually begins in middle age.
Rheumatoid arthritis usually affects joints on both sides of the body in the hands and feet, as well as the hips, knees, and elbows. Without proper treatment, rheumatoid arthritis can become a chronic, disabling condition.
Cause
Rheumatoid arthritis of the hand
Reproduced with permission from Abboud JA, Pedro BK, Bozentka DJ: Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis. J Am Acad Orthop Surg 2003; 11: 184-191.Rheumatoid arthritis is not an inherited disease. Researchers believe that some people have genes that make them susceptible to the disease. People with these genes will not automatically develop rheumatoid arthritis. There is usually a "trigger," such as an infection or environmental factor, which activates the genes. When the body is exposed to this trigger, the immune system responds inappropriately. Instead of protecting the joint, the immune system begins to produce substances that attack the joint. This is what may lead to the development of rheumatoid arthritis.
Ligaments and joint capsules become less effective supporting structures. Erosion of the articular cartilage, together with ligamentous changes, result in deformity and contractures. As the disease progresses, pain and deformity increase.
Symptoms
Pain, morning stiffness, swelling, and systemic symptoms are common. Other rheumatoid symptoms include:
•Swelling, pain, and stiffness in the joint, even when it is not being used
•A feeling of warmth around the joint
•Deformities and contractures of the joint
•Symptoms throughout the body, such as fever, loss of appetite and decreased energy
•Weakness due to a low red blood cell count (anemia)
•Nodules, or lumps, particularly around the elbow
•Foot pain, bunions, and hammer toes with long-standing disease
Patients with severe rheumatoid arthritis typically have multiple affected joints in the hands, arms, legs, and feet. Joints of the cervical spine may be involved as well.
DiagnosisRheumatoid arthritis is diagnosed using a medical history and a physical examination. Some of the conditions the doctor looks for include swelling and warmth around the joint, painful motion, lumps under the skin, joint deformities, and joint contractures (inability to fully stretch or bend the joint).
A blood test may reveal an antibody called rheumatoid factor. This is an indicator of rheumatoid arthritis. X-rays can help show the progression of the disease.
The American College of Rheumatology requires at least four of the following seven criteria to confirm the diagnosis:
•Morning stiffness around the joint that lasts at least 1 hour
•Arthritis of three or more joints for at least 6 weeks
•Arthritis of hand joints for at least 6 weeks
•Arthritis on both sides of the body for at least 6 weeks
•Rheumatoid nodules under the skin
•Rheumatoid factor present in blood testing
•Evidence of rheumatoid arthritis on X-rays
TreatmentAlthough there is no cure for rheumatoid arthritis, there are a number of treatment options that can help relieve joint pain and improve functioning. The treatment plan is tailored to the patient's needs and lifestyle. Rheumatoid arthritis is often treated by a team of health care professionals. These professionals may include rheumatologists, physical and occupational therapists, social workers, rehabilitation specialists, and orthopaedic surgeons.
Feet with rheumatoid arthritis and special shoes used in treatment
Reproduced with permission from Cohen BE, James WC, Lee S, Davis WH, Anderson R: Rheumatoid Foot Deformity, Pathophysiology & Etiology: Incidence. Orthopaedic Knowledge Online
Medication
Medications used to control rheumatoid arthritis fall into two categories: those that relieve symptoms and those that have the potential to modify the course of the disease. Often, they are used together. Aspirin and ibuprofen can help reduce the pain and inflammation of rheumatoid arthritis. Disease-modifying drugs include methotrexate and sulfasalazine and gold injections.
Researchers are also working on biologic agents that can interrupt the progress of the disease. These agents target specific chemicals in the body to prevent them from acting on the joints.
Exercise and Therapy
X-ray of hip with rheumatoid arthritis and total hip replacement
Reproduced with permission from Lachiewicz PF: Rheumatoid Arthritis of the Hip. J Am Acad Orthop Surg 1997; 5: 332-338.Exercise is an important part of a treatment program. The physician and physical therapist may work with patients to develop an exercise program that helps strengthen the joints without stressing them. In some cases, a splint or corrective footwear may be required.
Surgery
Joint replacement surgery is also an option and is often effective in restoring function.
Symptoms
Diagnosis
Treatment Aching joints are common in arthritis. In rheumatoid arthritis, the joint lining swells, invades surrounding tissues, and produces chemical substances that attack and destroy the joint surface.
People of all ages may be affected. The disease usually begins in middle age.
Rheumatoid arthritis usually affects joints on both sides of the body in the hands and feet, as well as the hips, knees, and elbows. Without proper treatment, rheumatoid arthritis can become a chronic, disabling condition.
Cause
Rheumatoid arthritis of the hand
Reproduced with permission from Abboud JA, Pedro BK, Bozentka DJ: Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis. J Am Acad Orthop Surg 2003; 11: 184-191.Rheumatoid arthritis is not an inherited disease. Researchers believe that some people have genes that make them susceptible to the disease. People with these genes will not automatically develop rheumatoid arthritis. There is usually a "trigger," such as an infection or environmental factor, which activates the genes. When the body is exposed to this trigger, the immune system responds inappropriately. Instead of protecting the joint, the immune system begins to produce substances that attack the joint. This is what may lead to the development of rheumatoid arthritis.
Ligaments and joint capsules become less effective supporting structures. Erosion of the articular cartilage, together with ligamentous changes, result in deformity and contractures. As the disease progresses, pain and deformity increase.
Symptoms
Pain, morning stiffness, swelling, and systemic symptoms are common. Other rheumatoid symptoms include:
•Swelling, pain, and stiffness in the joint, even when it is not being used
•A feeling of warmth around the joint
•Deformities and contractures of the joint
•Symptoms throughout the body, such as fever, loss of appetite and decreased energy
•Weakness due to a low red blood cell count (anemia)
•Nodules, or lumps, particularly around the elbow
•Foot pain, bunions, and hammer toes with long-standing disease
Patients with severe rheumatoid arthritis typically have multiple affected joints in the hands, arms, legs, and feet. Joints of the cervical spine may be involved as well.
DiagnosisRheumatoid arthritis is diagnosed using a medical history and a physical examination. Some of the conditions the doctor looks for include swelling and warmth around the joint, painful motion, lumps under the skin, joint deformities, and joint contractures (inability to fully stretch or bend the joint).
A blood test may reveal an antibody called rheumatoid factor. This is an indicator of rheumatoid arthritis. X-rays can help show the progression of the disease.
The American College of Rheumatology requires at least four of the following seven criteria to confirm the diagnosis:
•Morning stiffness around the joint that lasts at least 1 hour
•Arthritis of three or more joints for at least 6 weeks
•Arthritis of hand joints for at least 6 weeks
•Arthritis on both sides of the body for at least 6 weeks
•Rheumatoid nodules under the skin
•Rheumatoid factor present in blood testing
•Evidence of rheumatoid arthritis on X-rays
TreatmentAlthough there is no cure for rheumatoid arthritis, there are a number of treatment options that can help relieve joint pain and improve functioning. The treatment plan is tailored to the patient's needs and lifestyle. Rheumatoid arthritis is often treated by a team of health care professionals. These professionals may include rheumatologists, physical and occupational therapists, social workers, rehabilitation specialists, and orthopaedic surgeons.
Feet with rheumatoid arthritis and special shoes used in treatment
Reproduced with permission from Cohen BE, James WC, Lee S, Davis WH, Anderson R: Rheumatoid Foot Deformity, Pathophysiology & Etiology: Incidence. Orthopaedic Knowledge Online
Medication
Medications used to control rheumatoid arthritis fall into two categories: those that relieve symptoms and those that have the potential to modify the course of the disease. Often, they are used together. Aspirin and ibuprofen can help reduce the pain and inflammation of rheumatoid arthritis. Disease-modifying drugs include methotrexate and sulfasalazine and gold injections.
Researchers are also working on biologic agents that can interrupt the progress of the disease. These agents target specific chemicals in the body to prevent them from acting on the joints.
Exercise and Therapy
X-ray of hip with rheumatoid arthritis and total hip replacement
Reproduced with permission from Lachiewicz PF: Rheumatoid Arthritis of the Hip. J Am Acad Orthop Surg 1997; 5: 332-338.Exercise is an important part of a treatment program. The physician and physical therapist may work with patients to develop an exercise program that helps strengthen the joints without stressing them. In some cases, a splint or corrective footwear may be required.
Surgery
Joint replacement surgery is also an option and is often effective in restoring function.
Osteoarthritis
OsteoarthritisCause
Anatomy
Symptoms
Diagnosis
Treatment Osteoarthritis, also known as "wear and tear" arthritis, is a progressive disease of the joints.
CauseWith osteoarthritis, the articular cartilage that covers the ends of bones in the joints gradually wears away. Where there was once smooth articular cartilage that made the bones move easily against each other when the joint bent and straightened, there is now a frayed, rough surface. Joint motion along this exposed surface is painful.
Osteoarthritis usually develops after many years of use. It affects people who are middle-aged or older. Other risk factors for osteoarthritis include obesity, previous injury to the affected joint, and family history of osteoarthritis.
AnatomyA joint is where the ends of two or more bones meet. The knee joint, for example, is formed between the bones of the lower leg (the tibia and the fibula) and the thighbone (the femur). The hip joint is where the top of the thighbone (femoral head) meets a concave portion of the pelvis (the acetabulum).
A healthy joint glides easily without pain because a smooth, elastic tissue called articular cartilage covers the ends of the bones that make up the joint.
SymptomsOsteoarthritis can affect any joint in the body, with symptoms ranging from mild to disabling.
A joint affected by osteoarthritis may be painful and inflamed. Without cartilage, bones rub directly against each other when the joint moves. This is what causes the pain and inflammation. Pain or a dull ache usually develops gradually over time. Pain may be worse in the morning and feel better with activity. Vigorous activity may cause pain to flare up.
Hands of a patient with osteoarthritis. Bone growths on the little finger are typical of osteoarthritis.The joint may stiffen and look swollen, enlarged or "out of joint." A bump may develop over the joint.
If bending the joint becomes difficult, motion may be limited.
Loose fragments of cartilage and other tissue can interfere with the smooth motion of joints. The joint may lock or "stick" when used. It may creak, click, snap, or make a grinding noise (crepitus). The joint may become weak and buckle.
Although osteoarthritis cannot be cured, early identification and treatment can slow progression of the disease, relieve pain and restore function.
Diagnosis
(Reproduced with permission from Griffin LY(ed): Essentials of Musculoskeletal Care 3rd edition. Rosemont, IL. American Academy of Orthopaedic Surgeons. 2005.)A complete medical history, physical examination, X-rays, and possibly laboratory tests will be done.
The doctor will want to know if the joint has ever been injured. He or she will want to know when the joint pain began and what the pain feels like: Is the pain continuous, or does it come and go? Does it occur in other parts of the body? It is important to know when the pain occurs: Is it worse at night? Does it occur with walking, running or at rest?
The doctor will examine the affected joint in various positions to see if there is pain or restricted motion. He or she will look for creaking or grinding noises (crepitus) that indicate bone-on-bone friction. muscle loss (atrophy), and signs that other joints are involved. The doctor will look for signs of injury to muscles, tendons, and ligaments.
X-rays can show the extent of joint deterioration, including narrowing of joint space, thinning or erosion of bone, excess fluid in the joint, and bone spurs or other abnormalities. They can help the doctor distinguish various forms of arthritis.
Sometimes laboratory tests can help rule out other diseases that cause symptoms similar to osteoarthritis.
TreatmentNonsurgical Treatment
Early, nonsurgical treatment can slow progression of osteoarthritis, increase motion, and improve strength. Most treatment programs combine lifestyle modifications, medication, and physical therapy.
Lifestyle Modifications
The doctor may recommend rest or a change in activities to avoid provoking osteoarthritis pain. This may include modifications in work or sports activities. It may mean switching from high-impact activities (such as aerobics, running, jumping, or competitive sports) to low-impact exercises (such as stretching, walking, swimming, or cycling). A weight loss program may be recommended, if needed, particularly if osteoarthritis affects weight-bearing joints (such as the knee, hip, spine, or ankle)
Medications
Non-steroidal anti-inflammatory drugs can help reduce inflammation. Sometimes, the doctor may recommend strong anti-inflammatory agents called corticosteroids, which are injected directly into the joint. Corticosteroids provide temporary relief of pain and swelling.
Dietary supplements called glucosamine and chondroitin sulfate may help relieve pain from osteoarthritis. (Caution: The U.S. Food and Drug Administration does not test or analyze dietary supplements. Always consult your doctor before taking dietary supplements. )
Physical Therapy
A balanced fitness program, physical therapy, and/or occupational therapy may improve joint flexibility, increase range of motion, reduce pain, and strengthen muscle, bone, and cartilage tissues. Supportive or assistive devices (such as a brace, splint, elastic bandage, cane, crutches, or walker) may be needed. Ice or heat may need to be applied to the affected joint for short periods, several times a day.
Surgical Treatment
If early treatments do not stop the pain or if they lose their effectiveness, surgery may be considered. The decision to treat surgically depends upon the age and activity level of the patient, the condition of the affected joint, and the extent to which osteoarthritis has progressed.
Surgical options for osteoarthritis include arthroscopy, osteotomy, joint fusion, and joint replacement.
Arthroscopy
A surgeon uses a pencil-sized, flexible, fiberoptic instrument (arthroscope) to make two or three small incisions to remove bone spurs, cysts, damaged lining, or loose fragments in the joint.
Osteotomy
The long bones of the arm or leg are realigned to take pressure off of the joint.
Joint fusion
A surgeon eliminates the joint by fastening together the ends of bone (fusion). Pins, plates, screws, or rods may hold bones in place while they heal. This procedure eliminates the joint's flexibility.
Joint replacement
A surgeon removes parts of the bones and creates an artificial joint with metal or plastic components (total joint replacement or arthroplasty).
Anatomy
Symptoms
Diagnosis
Treatment Osteoarthritis, also known as "wear and tear" arthritis, is a progressive disease of the joints.
CauseWith osteoarthritis, the articular cartilage that covers the ends of bones in the joints gradually wears away. Where there was once smooth articular cartilage that made the bones move easily against each other when the joint bent and straightened, there is now a frayed, rough surface. Joint motion along this exposed surface is painful.
Osteoarthritis usually develops after many years of use. It affects people who are middle-aged or older. Other risk factors for osteoarthritis include obesity, previous injury to the affected joint, and family history of osteoarthritis.
AnatomyA joint is where the ends of two or more bones meet. The knee joint, for example, is formed between the bones of the lower leg (the tibia and the fibula) and the thighbone (the femur). The hip joint is where the top of the thighbone (femoral head) meets a concave portion of the pelvis (the acetabulum).
A healthy joint glides easily without pain because a smooth, elastic tissue called articular cartilage covers the ends of the bones that make up the joint.
SymptomsOsteoarthritis can affect any joint in the body, with symptoms ranging from mild to disabling.
A joint affected by osteoarthritis may be painful and inflamed. Without cartilage, bones rub directly against each other when the joint moves. This is what causes the pain and inflammation. Pain or a dull ache usually develops gradually over time. Pain may be worse in the morning and feel better with activity. Vigorous activity may cause pain to flare up.
Hands of a patient with osteoarthritis. Bone growths on the little finger are typical of osteoarthritis.The joint may stiffen and look swollen, enlarged or "out of joint." A bump may develop over the joint.
If bending the joint becomes difficult, motion may be limited.
Loose fragments of cartilage and other tissue can interfere with the smooth motion of joints. The joint may lock or "stick" when used. It may creak, click, snap, or make a grinding noise (crepitus). The joint may become weak and buckle.
Although osteoarthritis cannot be cured, early identification and treatment can slow progression of the disease, relieve pain and restore function.
Diagnosis
(Reproduced with permission from Griffin LY(ed): Essentials of Musculoskeletal Care 3rd edition. Rosemont, IL. American Academy of Orthopaedic Surgeons. 2005.)A complete medical history, physical examination, X-rays, and possibly laboratory tests will be done.
The doctor will want to know if the joint has ever been injured. He or she will want to know when the joint pain began and what the pain feels like: Is the pain continuous, or does it come and go? Does it occur in other parts of the body? It is important to know when the pain occurs: Is it worse at night? Does it occur with walking, running or at rest?
The doctor will examine the affected joint in various positions to see if there is pain or restricted motion. He or she will look for creaking or grinding noises (crepitus) that indicate bone-on-bone friction. muscle loss (atrophy), and signs that other joints are involved. The doctor will look for signs of injury to muscles, tendons, and ligaments.
X-rays can show the extent of joint deterioration, including narrowing of joint space, thinning or erosion of bone, excess fluid in the joint, and bone spurs or other abnormalities. They can help the doctor distinguish various forms of arthritis.
Sometimes laboratory tests can help rule out other diseases that cause symptoms similar to osteoarthritis.
TreatmentNonsurgical Treatment
Early, nonsurgical treatment can slow progression of osteoarthritis, increase motion, and improve strength. Most treatment programs combine lifestyle modifications, medication, and physical therapy.
Lifestyle Modifications
The doctor may recommend rest or a change in activities to avoid provoking osteoarthritis pain. This may include modifications in work or sports activities. It may mean switching from high-impact activities (such as aerobics, running, jumping, or competitive sports) to low-impact exercises (such as stretching, walking, swimming, or cycling). A weight loss program may be recommended, if needed, particularly if osteoarthritis affects weight-bearing joints (such as the knee, hip, spine, or ankle)
Medications
Non-steroidal anti-inflammatory drugs can help reduce inflammation. Sometimes, the doctor may recommend strong anti-inflammatory agents called corticosteroids, which are injected directly into the joint. Corticosteroids provide temporary relief of pain and swelling.
Dietary supplements called glucosamine and chondroitin sulfate may help relieve pain from osteoarthritis. (Caution: The U.S. Food and Drug Administration does not test or analyze dietary supplements. Always consult your doctor before taking dietary supplements. )
Physical Therapy
A balanced fitness program, physical therapy, and/or occupational therapy may improve joint flexibility, increase range of motion, reduce pain, and strengthen muscle, bone, and cartilage tissues. Supportive or assistive devices (such as a brace, splint, elastic bandage, cane, crutches, or walker) may be needed. Ice or heat may need to be applied to the affected joint for short periods, several times a day.
Surgical Treatment
If early treatments do not stop the pain or if they lose their effectiveness, surgery may be considered. The decision to treat surgically depends upon the age and activity level of the patient, the condition of the affected joint, and the extent to which osteoarthritis has progressed.
Surgical options for osteoarthritis include arthroscopy, osteotomy, joint fusion, and joint replacement.
Arthroscopy
A surgeon uses a pencil-sized, flexible, fiberoptic instrument (arthroscope) to make two or three small incisions to remove bone spurs, cysts, damaged lining, or loose fragments in the joint.
Osteotomy
The long bones of the arm or leg are realigned to take pressure off of the joint.
Joint fusion
A surgeon eliminates the joint by fastening together the ends of bone (fusion). Pins, plates, screws, or rods may hold bones in place while they heal. This procedure eliminates the joint's flexibility.
Joint replacement
A surgeon removes parts of the bones and creates an artificial joint with metal or plastic components (total joint replacement or arthroplasty).
Post-op Total knee activities
Activities in the HospitalThe knee is the largest joint in the body, and replacing it requires major surgery.
Early Mobilization
Although you will probably want to rest after surgery, early mobilization is important. If you had considerable pain in your knee, you probably cut back on your activities before surgery and your leg muscles may be weak. You will need to build up strength in your quadriceps muscles to develop control of your new joint. Early activity is also important to counteract the effects of the anesthesia and to encourage healing. Your doctor and a physical therapist will give you specific instructions on wound care, pain control, diet, and exercise.
Pain Management
Proper pain management is important in early recovery. Although pain after surgery is quite variable and not entirely predictable, it can be controlled with medication. Initially, you will probably receive pain control medication through an intravenous (IV) tube so that you can regulate the amount of medication you need. Remember that it is easier to prevent pain than to control it. You do not have to worry about becoming dependent on the medication; after a day or two, injections or pills will replace the IV tube.
Other Postoperative Activities
You will also have to take antibiotics and blood-thinning medication to help prevent blood clots from forming in the veins of your thighs and calves.
You may lose your appetite and feel nauseous or constipated for a couple of days. These are normal reactions. You may be fitted with a urinary catheter during surgery and be given stool softeners or laxatives to ease the constipation caused by the pain medication after surgery. You will be taught to do breathing exercises to prevent congestion from developing in your chest and lungs.
Initially, you will have a bulky dressing around the knee and a drain to remove any fluid build-up around the knee. The drain will be removed in a day or two. You may also be wearing elastic hose and, possibly, compression stocking sleeves. These plastic sleeves are connected to a machine that circulates air around your legs to help keep blood flowing normally.
Physical Therapy
A physical therapist will typically visit you on the day after your surgery and begin teaching you how to use your new knee. You may be fitted with a continuous passive motion exercise machine that will slowly and smoothly straighten and bend your knee. Even as you lie in bed, you can pedal your feet and pump your ankles on a regular basis to promote blood flow in your legs.
DischargeYour hospital stay may last from 3 to 7 days, depending on how well you heal after surgery. Before you go home, you will need to meet several goals:
•Get in and out of bed by yourself
•Bend your knee approximately 90° or show good progress in bending your knee
•Extend (straighten) your knee fully
•Walk with crutches or a walker on a level surface and to climb up and down 2 or 3 stairs
•Do the prescribed home exercises
You may experience mild swelling in your leg after you are discharged. Elevating the leg, wearing compression hose, and applying an ice pack for 15 to 20 minutes at a time will help reduce the swelling. You may be permitted to take the continuous passive motion exercise machine home with you for a few weeks, but this is not a substitute for the prescribed exercises.
Activities at HomeYou will probably need some help at home for several weeks. If you do not have sufficient help at home, you may be temporarily transferred to a rehabilitation center. The following tips can make your homecoming more comfortable:
•Rearrange furniture so you can maneuver with a walker or crutches. You may temporarily change rooms (make the living room your bedroom, for example) to avoid using the stairs.
•Remove any throw rugs or area rugs that could cause you to slip. Securely fasten electrical cords around the perimeter of the room.
•Install a shower chair, gripping bar, and raised toilet in the bathroom.
•Use assistive devices such as a long-handled shoehorn, a long-handled sponge, and a grabbing tool or reacher to avoid bending too far over.
Wound Care
General guidelines for wound care include:
•Keep the wound area clean and dry. A dressing will be applied in the hospital and should be changed as necessary. Ask for instructions on how to change the dressing before you leave the hospital.
•Do not shower or bathe until the sutures or staples are removed, usually a week to 10 days after surgery. Again, the wound should be kept clean and dry.
•Notify your doctor if the wound appears red or begins to drain.
•Take your temperature twice daily and notify your doctor if it exceeds 100.5°F.
•Swelling is normal for the first 3 to 6 months after surgery. Elevate your leg slightly and apply ice.
•Calf pain, chest pain, or shortness of breath are signs of a possible blood clot. Notify your doctor immediately if you notice any of these symptoms.
Medication
Take all medications as directed. You will probably be given a blood thinner to prevent clots from forming in the veins of your calf and thigh because these clots can be life-threatening. If a blood clot forms and then breaks free, it could travel to your lungs, resulting in a pulmonary embolism, a potentially fatal condition.
Because you have an artificial joint, it is especially important to prevent any bacterial infections from settling in your joint implant. You should get a medical alert card and take antibiotics whenever there is the possibility of a bacterial infection, such as when you have dental work. Be sure to notify your dentist that you have a joint implant and let your doctor know if your dentist schedules an extraction, periodontal work, dental implant, or root canal work.
Diet
By the time you go home from the hospital, you should be eating a normal diet. Your physician may recommend that you take iron and vitamin C supplements. Continue to drink plenty of fluids and avoid excessive intake of vitamin K while you are taking the blood thinner medication. Foods rich in vitamin K include broccoli, cauliflower, Brussels sprouts, liver, green beans, garbanzo beans, lentils, soybeans, soybean oil, spinach, kale, lettuce, turnip greens, cabbage, and onions. Try to limit coffee intake and avoid alcohol. You should continue to watch your weight to avoid putting more stress on the joint.
Resuming Normal Activities
Once home, you should continue to stay active. The key is to remember not to overdo it! While you can expect some good days and some bad days, you should notice a gradual improvement and a gradual increase in your endurance over the next 6 to 12 months. The following guidelines are generally applicable, but the final answer on each of these issues should come from your doctor.
•Physical Therapy Exercises - Continue to do the exercises prescribed for at least two months after surgery. Riding a stationary bicycle can help maintain muscle tone and keep your knee flexible. Try to achieve the maximum degree of bending and extension possible.
•Driving - If your left knee was replaced and you have an automatic transmission, you may be able to begin driving in a week or so, provided you are no longer taking narcotic pain medication. If your right knee was replaced, avoid driving for 6 to 8 weeks. Remember that your reflexes may not be as sharp as before your surgery.
•Airport Metal Detectors - The sensitivity of metal detectors varies and it is unlikely that your prosthesis will cause an alarm. You should carry a medic alert card indicating you have an artificial joint, just in case.
•Sexual Activity - can be safely resumed approximately 4 to 6 weeks after surgery.
•Sleeping Positions - You can safely sleep on your back, on either side, or on your stomach.
•Return to Work - Depending on the type of activities you perform, it may be 6 to 8 weeks before you return to work.
•Other Activities - Walk as much as you like, but remember that walking is no substitute for the exercises your doctor and physical therapist will prescribe. Swimming is also recommended; you can begin as soon as the sutures have been removed and the wound is healed, approximately 6 to 8 weeks after surgery. Acceptable activities include dancing, golfing (with spikeless shoes and a cart), and bicycling (on level surfaces). Avoid activities that put stress on the knee. These activities include: tennis, badminton, contact sports (such as football, baseball), squash or racquetball, jumping, squats, skiing, or jogging. Do not do any heavy lifting (more than 40 lb) or weight lifting.
Early Mobilization
Although you will probably want to rest after surgery, early mobilization is important. If you had considerable pain in your knee, you probably cut back on your activities before surgery and your leg muscles may be weak. You will need to build up strength in your quadriceps muscles to develop control of your new joint. Early activity is also important to counteract the effects of the anesthesia and to encourage healing. Your doctor and a physical therapist will give you specific instructions on wound care, pain control, diet, and exercise.
Pain Management
Proper pain management is important in early recovery. Although pain after surgery is quite variable and not entirely predictable, it can be controlled with medication. Initially, you will probably receive pain control medication through an intravenous (IV) tube so that you can regulate the amount of medication you need. Remember that it is easier to prevent pain than to control it. You do not have to worry about becoming dependent on the medication; after a day or two, injections or pills will replace the IV tube.
Other Postoperative Activities
You will also have to take antibiotics and blood-thinning medication to help prevent blood clots from forming in the veins of your thighs and calves.
You may lose your appetite and feel nauseous or constipated for a couple of days. These are normal reactions. You may be fitted with a urinary catheter during surgery and be given stool softeners or laxatives to ease the constipation caused by the pain medication after surgery. You will be taught to do breathing exercises to prevent congestion from developing in your chest and lungs.
Initially, you will have a bulky dressing around the knee and a drain to remove any fluid build-up around the knee. The drain will be removed in a day or two. You may also be wearing elastic hose and, possibly, compression stocking sleeves. These plastic sleeves are connected to a machine that circulates air around your legs to help keep blood flowing normally.
Physical Therapy
A physical therapist will typically visit you on the day after your surgery and begin teaching you how to use your new knee. You may be fitted with a continuous passive motion exercise machine that will slowly and smoothly straighten and bend your knee. Even as you lie in bed, you can pedal your feet and pump your ankles on a regular basis to promote blood flow in your legs.
DischargeYour hospital stay may last from 3 to 7 days, depending on how well you heal after surgery. Before you go home, you will need to meet several goals:
•Get in and out of bed by yourself
•Bend your knee approximately 90° or show good progress in bending your knee
•Extend (straighten) your knee fully
•Walk with crutches or a walker on a level surface and to climb up and down 2 or 3 stairs
•Do the prescribed home exercises
You may experience mild swelling in your leg after you are discharged. Elevating the leg, wearing compression hose, and applying an ice pack for 15 to 20 minutes at a time will help reduce the swelling. You may be permitted to take the continuous passive motion exercise machine home with you for a few weeks, but this is not a substitute for the prescribed exercises.
Activities at HomeYou will probably need some help at home for several weeks. If you do not have sufficient help at home, you may be temporarily transferred to a rehabilitation center. The following tips can make your homecoming more comfortable:
•Rearrange furniture so you can maneuver with a walker or crutches. You may temporarily change rooms (make the living room your bedroom, for example) to avoid using the stairs.
•Remove any throw rugs or area rugs that could cause you to slip. Securely fasten electrical cords around the perimeter of the room.
•Install a shower chair, gripping bar, and raised toilet in the bathroom.
•Use assistive devices such as a long-handled shoehorn, a long-handled sponge, and a grabbing tool or reacher to avoid bending too far over.
Wound Care
General guidelines for wound care include:
•Keep the wound area clean and dry. A dressing will be applied in the hospital and should be changed as necessary. Ask for instructions on how to change the dressing before you leave the hospital.
•Do not shower or bathe until the sutures or staples are removed, usually a week to 10 days after surgery. Again, the wound should be kept clean and dry.
•Notify your doctor if the wound appears red or begins to drain.
•Take your temperature twice daily and notify your doctor if it exceeds 100.5°F.
•Swelling is normal for the first 3 to 6 months after surgery. Elevate your leg slightly and apply ice.
•Calf pain, chest pain, or shortness of breath are signs of a possible blood clot. Notify your doctor immediately if you notice any of these symptoms.
Medication
Take all medications as directed. You will probably be given a blood thinner to prevent clots from forming in the veins of your calf and thigh because these clots can be life-threatening. If a blood clot forms and then breaks free, it could travel to your lungs, resulting in a pulmonary embolism, a potentially fatal condition.
Because you have an artificial joint, it is especially important to prevent any bacterial infections from settling in your joint implant. You should get a medical alert card and take antibiotics whenever there is the possibility of a bacterial infection, such as when you have dental work. Be sure to notify your dentist that you have a joint implant and let your doctor know if your dentist schedules an extraction, periodontal work, dental implant, or root canal work.
Diet
By the time you go home from the hospital, you should be eating a normal diet. Your physician may recommend that you take iron and vitamin C supplements. Continue to drink plenty of fluids and avoid excessive intake of vitamin K while you are taking the blood thinner medication. Foods rich in vitamin K include broccoli, cauliflower, Brussels sprouts, liver, green beans, garbanzo beans, lentils, soybeans, soybean oil, spinach, kale, lettuce, turnip greens, cabbage, and onions. Try to limit coffee intake and avoid alcohol. You should continue to watch your weight to avoid putting more stress on the joint.
Resuming Normal Activities
Once home, you should continue to stay active. The key is to remember not to overdo it! While you can expect some good days and some bad days, you should notice a gradual improvement and a gradual increase in your endurance over the next 6 to 12 months. The following guidelines are generally applicable, but the final answer on each of these issues should come from your doctor.
•Physical Therapy Exercises - Continue to do the exercises prescribed for at least two months after surgery. Riding a stationary bicycle can help maintain muscle tone and keep your knee flexible. Try to achieve the maximum degree of bending and extension possible.
•Driving - If your left knee was replaced and you have an automatic transmission, you may be able to begin driving in a week or so, provided you are no longer taking narcotic pain medication. If your right knee was replaced, avoid driving for 6 to 8 weeks. Remember that your reflexes may not be as sharp as before your surgery.
•Airport Metal Detectors - The sensitivity of metal detectors varies and it is unlikely that your prosthesis will cause an alarm. You should carry a medic alert card indicating you have an artificial joint, just in case.
•Sexual Activity - can be safely resumed approximately 4 to 6 weeks after surgery.
•Sleeping Positions - You can safely sleep on your back, on either side, or on your stomach.
•Return to Work - Depending on the type of activities you perform, it may be 6 to 8 weeks before you return to work.
•Other Activities - Walk as much as you like, but remember that walking is no substitute for the exercises your doctor and physical therapist will prescribe. Swimming is also recommended; you can begin as soon as the sutures have been removed and the wound is healed, approximately 6 to 8 weeks after surgery. Acceptable activities include dancing, golfing (with spikeless shoes and a cart), and bicycling (on level surfaces). Avoid activities that put stress on the knee. These activities include: tennis, badminton, contact sports (such as football, baseball), squash or racquetball, jumping, squats, skiing, or jogging. Do not do any heavy lifting (more than 40 lb) or weight lifting.
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