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Patient Education
1. What is Arthroscopic Surgery?

Arthroscopic surgery involves the use of a small telescope, called an arthroscope, to look inside joints. The joints typically amenable to arthroscopic surgery include the knee, the shoulder, the elbow, the ankle, and the hip.


The arthroscope is about the size of a pencil and is inserted into the joint through an incision, usually about ½ inch long (referred to as a portal.) Other instruments of the same size are also inserted into the knee in order to probe, excise, or repair injured tissues. The viewing of the joint through such small instruments requires more than one angle of approach. Therefore, most arthroscopic procedures require two or more portals. Sometimes people mistake arthroscopic surgery for laser surgery. Although lasers have been used in arthroscopic surgery, they currently offer little benefit compared to other techniques. Actually, several complications have been associated with the use of lasers in arthroscopic procedures.


Arthroscopic surgery has many advantages over traditional open surgery. It allows for excellent illumination and magnification of structures deep inside the joints. The small incisions leave much smaller scars than traditional open surgical procedures. Because a large open wound is avoided, patients typically have less pain and can more often be treated as outpatients, allowing them to return to their normal activities quicker. However, arthroscopic surgery does not change the biology of the healing process. As a result, any repair still takes the same amount of time to heal. Although the pain may be less, restrictions on activity may not be different just because someone has had arthroscopic surgery as opposed to traditional open surgery. Also, there are some procedures that cannot be done arthroscopically and do require an open approach. A surgeon who is skilled in arthroscopic surgery can best make the determination of whether the patient is best-suited to an arthroscopic or open surgical procedure.



Standard portals for knee arthroscopy

Arthroscopic removal of a shoulder joint loose body

2. What are some common Knee Conditions?

The knee joint is one of the most often injured joints in the body. It consists of three main bones. The femur (thigh bone) articulates against the tibia (shin bone). The patella (kneecap) also articulates against the femur. An intricate system of ligaments and muscles provides stability to the knee and allows for painless range of motion in order to flex and extend this joint. Also, a structure called a meniscus is present in the knee to act as a shock absorber. There are actually two menisci in each knee. One is the medial (inside) meniscus and the other is the lateral (outside) meniscus.


These menisci are situated between the end of the femur and the top of the tibia and serve to absorb the shock of weight bearing activity, and thereby lessen the forces on the joint surface of both the femur and tibia. The joint surfaces of the bones are covered with a very important layer of articular cartilage that allows for smooth gliding.


3. What is Articular Cartilage?

Articular cartilage is an extremely important component of joints. It is the smooth covering of the end of the bones that allows for frictionless gliding of one bone against another. Most people are probably most familiar with the articular cartilage on the end of a chicken drumstick.


Wearing away of this cartilage or damage by injury causes the joint surface to become rough and irregular leading to friction. This roughening of the articular cartilage is referred to as chondromalacia, which can be painful. This leads to further wear and tear and inflammation and eventually results in the most common type of arthritis, osteoarthritis (also known as degenerative joint disease).


Unfortunately, articular cartilage in adults has extremely poor ability to heal after injury. A lot of research is being done to find a way to stimulate the repair of articular cartilage with medications, injections, open surgery, or arthroscopic procedures. All have met with limited success. Although we do not have a perfect solution to this problem, many new promising techniques are currently available. Unfortunately, each technique has limitations and is indicated for only specific types of problems. Only a surgeon experienced and skilled in various different techniques to address injury to the articular cartilage can give you an accurate assessment of options for treating a particular joint.


If the entire joint’s articular cartilage is worn, the only procedure expected to give lasting pain relief with good joint function is a total joint replacement. However, these artificial joints themselves wear out with time and use. Consequently, a young adult or middle-aged person should try to postpone this surgery for as long as possible due to the fact that they tend to be more active than older individuals and consequently the artificial joint wears out more quickly. Furthermore, results of revision artificial joint surgeries are generally not as good as those of the first-time implantation.



Arthroscopic picture of the articular cartilage of a patella (knee cap) with roughening and irregularity of the surface

Same patella after arthroscopic chondroplasty (smoothening of the cartilage)

4. What are Knee Ligament Injuries?

The knee joint is stabilized primarily by four very strong ligaments. Three of them, the anterior cruciate ligament, the posterior cruciate ligament, and the medial collateral ligament, connect the end of the femur (thigh bone) to the top of the tibia (shin bone). The lateral collateral ligament actually connects the end of the femur to the top of the fibula, which is a much smaller bone in the shin. The fibula and tibia are connected to each other by very strong bindings, so the effect of the lateral collateral ligament is to control the motion between the femur and tibia, just like the other three ligaments that connect these bones directly to each other.


The medial collateral ligament (MCL) is located outside of the joint space and on the inner aspect of the knee. Likewise, the lateral collateral ligament (LCL) is located outside of the joint and on the outer aspect of the knee. The two cruciate ligaments are located in the center of the knee joint itself. These cross each other, hence the name “cruciate.” The insertion of these ligaments onto the tibia is such that the anterior cruciate ligament (ACL) inserts on the anterior (front) aspect of the top of the tibia and the posterior cruciate ligament (PCL) inserts on the posterior (back) aspect of the top of the tibia.


The end of the femur being round and the top of the tibia being relatively flat, there is very little intrinsic stability imparted by the bony architecture. Rather, the stability of the knee is fundamentally dependent upon the ligamentous structures. Disruption of these ligaments can lead to instability of the knee joint. The degree of instability depends on the number of ligaments that have been injured and their capacity to heal. The medial collateral ligament and the lateral collateral ligament do have significant capacity to heal after injury. Therefore, isolated injuries to these ligaments can often be treated by bracing and activity modification and rehabilitation. Once the ligaments have healed, normal activity can be resumed. In contrast, the cruciate ligaments, being inside the joint, have very poor capacity to heal. Restoring function of torn cruciate ligaments therefore requires surgical intervention.


Posterior cruciate ligament (PCL) injury is generally well tolerated by the knee. With appropriate rehabilitation, people can typically return to activity after an isolated posterior cruciate ligament injury. In fact, an estimated 2% of NFL players are playing on knees without posterior cruciate ligaments. A strong quadriceps muscles is thought to be able to take over some of the duties of the posterior cruciate ligament and thereby compensate for its absence or incompetence. As a result, most isolated PCL injuries can be successfully treated without surgery. In some severe cases, however, the PCL does require reconstruction to decrease severe laxity.


In contrast to the PCL, anterior cruciate ligament (ACL) deficiency is less well compensated for by rehabilitation. Although one can restore motion and strength to the knee, the instability that results from ACL-deficiency limits one’s ability to do cutting, pivoting, twisting, and jumping-type activities. Straight-ahead activities like jogging or bicycling are unaffected. However, sports such as basketball, soccer, or football are usually not possible for patients with ACL-deficient knees. An analogy can be made of a four-wheel vehicle vs. a three-wheel vehicle. A four-wheel vehicle can take corners a lot faster than a three-wheel vehicle due to the inherent stability provided by four wheels. However, on a straight track, both vehicles may perform similarly.


The ACL has such a poor ability to heal, that even surgical repair has not been very successful. In order to restore it’s function, we must reconstruct it. This means replacing the torn ligament with tissue to act as a new ligament. Many synthetic grafts have been tried and have uniformly met with failure. However, a high degree of success has been achieved by the use of tendons to act as the new anterior cruciate ligament. Traditionally, a portion of the patellar tendon (which connects the kneecap to the tibia) is used. The central third of this tendon is taken along with a small piece of the kneecap and a small piece of the tibia. This is then put through drill holes in the top of the tibia and the end of the femur to take the place of the torn anterior cruciate ligament. More recently, techniques have been developed to take a couple of the small hamstring tendons from the medical (inside) aspect of the knee to act as a new ACL. Also, tendinous tissue from organ donors has also been used to reconstruct the ACL. All three methods have a high degree of success and each one has advantages and disadvantages. Discussing these options with a surgeon skilled in all these various techniques is the best way of deciding which graft source is the best choice for your knee.



Arthroscopic picture of a normal ACL

Acute ACL Tear

Same knee after ACL Reconstruction

5. What are Meniscal Injuries?

The knee joint is stabilized primarily by four very strong ligaments. Three of them, the anterior cruciate ligament, the posterior cruciate ligament, and the medial collateral ligament, connect the end of the femur (thigh bone) to the top of the tibia (shin bone). The lateral collateral ligament actually connects the end of the femur to the top of the fibula, which is a much smaller bone in the shin. The fibula and tibia are connected to each other by very strong bindings, so the effect of the lateral collateral ligament is to control the motion between the femur and tibia, just like the other three ligaments that connect these bones directly to each other.


The medial collateral ligament (MCL) is located outside of the joint space and on the inner aspect of the knee. Likewise, the lateral collateral ligament (LCL) is located outside of the joint and on the outer aspect of the knee. The two cruciate ligaments are located in the center of the knee joint itself. These cross each other, hence the name “cruciate.” The insertion of these ligaments onto the tibia is such that the anterior cruciate ligament (ACL) inserts on the anterior (front) aspect of the top of the tibia and the posterior cruciate ligament (PCL) inserts on the posterior (back) aspect of the top of the tibia.


The end of the femur being round and the top of the tibia being relatively flat, there is very little intrinsic stability imparted by the bony architecture. Rather, the stability of the knee is fundamentally dependent upon the ligamentous structures. Disruption of these ligaments can lead to instability of the knee joint. The degree of instability depends on the number of ligaments that have been injured and their capacity to heal. The medial collateral ligament and the lateral collateral ligament do have significant capacity to heal after injury. Therefore, isolated injuries to these ligaments can often be treated by bracing and activity modification and rehabilitation. Once the ligaments have healed, normal activity can be resumed. In contrast, the cruciate ligaments, being inside the joint, have very poor capacity to heal. Restoring function of torn cruciate ligaments therefore requires surgical intervention.


Posterior cruciate ligament (PCL) injury is generally well tolerated by the knee. With appropriate rehabilitation, people can typically return to activity after an isolated posterior cruciate ligament injury. In fact, an estimated 2% of NFL players are playing on knees without posterior cruciate ligaments. A strong quadriceps muscles is thought to be able to take over some of the duties of the posterior cruciate ligament and thereby compensate for its absence or incompetence. As a result, most isolated PCL injuries can be successfully treated without surgery. In some severe cases, however, the PCL does require reconstruction to decrease severe laxity.


In contrast to the PCL, anterior cruciate ligament (ACL) deficiency is less well compensated for by rehabilitation. Although one can restore motion and strength to the knee, the instability that results from ACL-deficiency limits one’s ability to do cutting, pivoting, twisting, and jumping-type activities. Straight-ahead activities like jogging or bicycling are unaffected. However, sports such as basketball, soccer, or football are usually not possible for patients with ACL-deficient knees. An analogy can be made of a four-wheel vehicle vs. a three-wheel vehicle. A four-wheel vehicle can take corners a lot faster than a three-wheel vehicle due to the inherent stability provided by four wheels. However, on a straight track, both vehicles may perform similarly.


The ACL has such a poor ability to heal, that even surgical repair has not been very successful. In order to restore it’s function, we must reconstruct it. This means replacing the torn ligament with tissue to act as a new ligament. Many synthetic grafts have been tried and have uniformly met with failure. However, a high degree of success has been achieved by the use of tendons to act as the new anterior cruciate ligament. Traditionally, a portion of the patellar tendon (which connects the kneecap to the tibia) is used. The central third of this tendon is taken along with a small piece of the kneecap and a small piece of the tibia. This is then put through drill holes in the top of the tibia and the end of the femur to take the place of the torn anterior cruciate ligament. More recently, techniques have been developed to take a couple of the small hamstring tendons from the medical (inside) aspect of the knee to act as a new ACL. Also, tendinous tissue from organ donors has also been used to reconstruct the ACL. All three methods have a high degree of success and each one has advantages and disadvantages. Discussing these options with a surgeon skilled in all these various techniques is the best way of deciding which graft source is the best choice for your knee.



Arthroscopic picture of a normal medial meniscus

Flap tear of the medial meniscus of the right knee

Same knee after arthroscopic excision of the torn portion of the medial meniscus


What if one loses an entire meniscus? A massive irreparable meniscal tear can lead to loss of the entire meniscus. Fortunately, technology has advanced to the point of allowing us to perform meniscal transplantations. In this procedure, a cadaveric meniscus is transplanted into a knee lacking that structure. Only certain knees are candidates for this promising technique, however. Dr. Ilahi is one of only a handful of surgeons in the Houston area with experience in this technically demanding operation.

6. What is Patellar Instability?

The patella, or knee cap, is an important component of the knee joint. It is a bone through which the tendon of the quadriceps, the largest muscle in the body, inserts onto the front aspect of the top of the tibia (shin bone). The back side of the patella is covered by thick articular cartilage and moves against the end of the femur (thigh bone) which is also covered by thick articular cartilage. The end of the femur has a small groove in which the patella tracks. Some people have a very shallow groove and some have a deeper groove. However, the groove is not enough to maintain the patella’s position. There are important soft tissue attachments that help control the patella’s motion. These can be torn by a traumatic event or stretched over time. Also, some people have soft tissue attachments that are genetically loose or thin and insufficient to keep the patella in its track, especially when exerting.


With patellar instability, one can have episodes of the patella coming partially out of the groove (called patellar subluxation) or completely coming out of the groove (dislocation). These can be very painful and debilitating. Treatment is aimed at restoring the patella’s position and trying to maintain it in its track.


Depending on the cause and severity of the patellar instability, one can control or correct it by either non-operative or operative means. Non-operative means include muscle strengthening exercises, as well as the use of certain braces (see also "Braces" in the "Treatment Modalities" section). Operative correction involves balancing the soft tissue attachments to the patella by surgical releases of overly tight structures and/or tightening of overly loose structures. Also, sometimes the insertion of the quadriceps tendon itself onto the shin bone needs to be altered surgically.


Successful treatment depends on correct diagnosis and intervention by the physician as well as a lot of effort in rehabilitation and compliance with exercises and activity modification by the patient.


7. What are some common Shoulder Conditions?

The shoulder joint is actually an intricate complex of four articulations that, working together, allow for more motion than any other joint in the human body. The main joint is called the glenohumeral joint. This is a ball and saucer joint. The ball portion of the proximal humerus (arm bone) articulates against the saucer-shaped glenoid portion of the scapula (shoulder blade). This is the joint that is injured in a shoulder dislocation. The scapula, in turn, rests against the upper posterior rib cage, and there is actually a fair amount of movement between the scapula and the rib cage normally. The scapula also articulates with the clavicle (collar bone) through the acromion process of the scapula. This joint is referred to as the acromioclavicular joint and is the joint that is injured during a shoulder separation.


An intricate complex of ligaments and muscles provides stability to these joints and allows for smooth, painless motion. Through injury or degeneration, portions of the shoulder complex can be damaged or wear out. This can result in pain and stiffness, as well as weakness, instability, and loss of function of the shoulder.


8. What is Shoulder Instability?

The shoulder joint has been described as a ball-and-saucer joint. Consequently, there is little stability imparted by the bony architecture. In order to maintain that consistent ball-and-saucer relationship (keep the ball from rolling off the saucer), ligaments are present that connect the ball (head of the humerus, or arm bone) directly to the saucer (glenoid process of the scapula, or shoulder blade). These ligaments allow some motion between these two structures, but limit the motion in order to prevent dislocation. Importantly, the muscles around the shoulder help to control this ball-and-saucer movement. These act in concert with the ligaments in order to allow smooth, pain-free, and stable motion of this important joint.


Traumatic dislocations, such as that during a tackle in football, invariably tear some of the stabilizing ligaments. Although the ligaments heal, they often heal looser than what they originally were. These loose ligaments do not provide as much stability as they did prior to injury. This increases the risk of having a further dislocations. With each subsequent re-dislocation, the ligaments are again injured and progressively get even looser. This can progress to the point where the dislocation happens from very trivial activities. At this stage, the only effective treatment is to surgically repair the torn ligaments in order to tighten them and prevent abnormal motion of this ball-and-saucer joint.


Sometimes the instability is not severe enough to allow a dislocation, but enough to allow the ball to move part way off the saucer. This is referred to as a subluxation. This can be thought of as a partial dislocation in that the ball and saucer are still touching, but the ball has moved off the center of the saucer. This abnormal position can cause discomfort. Because the amount that the ball has to move is less than in a complete dislocation, the amount that the ligaments have to be stretched is also less. This lesser degree of instability can therefore often be controlled by strengthening the muscles around the shoulder to help reduce some of the stress of stabilizing the joint from the ligaments. Therefore, these shoulders, although somewhat loose, can often be treated successfully without having to surgically tighten the ligaments.


9. What is a Shoulder Separation?

The term “shoulder separation” is not the same as the term “shoulder dislocation.” Dislocation of the shoulder implies that the main shoulder joint comes apart to where the “ball” (head of the humerus, or arm bone) is no longer on the “saucer” (glenoid process of the scapula, or shoulder blade). In contrast, shoulder separation indicates that a much smaller joint, called the acromioclavicular joint, has been injured. The acromioclavicular joint is basically the articulation of the clavicle (collarbone) and the acromion process of the scapula (shoulder blade). This small joint is located directly above the main shoulder joint and is often injured from direct blows to the top of the shoulder or from being thrown and landing on the top of the shoulder when one hits the ground. Such an injury drives the acromion process down while the collarbone maintains its position. This ruptures ligaments connecting the two bones and causes the collarbone to “rise up” compared to the acromion. Consequently, a bump on the top of the shoulder is often created with this injury.


There are many different grades of shoulder separation. Most can heal in the sense that the swelling and discomfort go away and function returns, even if the relationship between the collar bone and the acromion is not restored. However, if there is a wide degree of separation, patients often have persistent pain and weakness. These wider degrees of separation often require surgical reconstruction in order to bring the collarbone back down to a more normal position in relation to the scapula.


10. What are Labral Tears?

The labrum is a lip of cartilage that goes around the rim of the glenoid, or saucer portion of the ball-and-saucer shoulder joint. The presence of the labrum helps to deepen the saucer and therefore provide some stability to the joint. Also, this is the structure through which ligaments that connect the ball and saucer to each other pass. Consequently, when there is a tear in the labrum, the shoulder joint can become unstable. Also, the labral tear can itself be painful.


Labral tears can be difficult to diagnose, even with the latest imaging techniques such as MRI. Sometimes they can only be suspected and not reliably diagnosed until actual inspection of the joint through arthroscopic surgery. Fortunately, most labral tears are amenable to being addressed through arthroscopic surgical techniques, in the hands of those surgeons skilled in arthroscopic surgery.


11. What is Shoulder Impingement?

Shoulder impingement is a common cause of shoulder pain. Usually, a bone spur on the undersurface of the acromion (a portion of the shoulder blade) develops slowly over time for unknown reasons in some individuals. If big enough, this spur can pinch or "impinge" on the underlying soft tissues, especially the subacromial bursa and the rotator cuff tendons. Raising the arm above shoulder level can bring these structures against the undersurface of the acromion to where a bone spur can rub on them ("impinge") and cause inflammation such as bursitis and tendinitis. Eventually, this repetitive impingement can lead to a rotator cuff tear (see section on rotator cuff tears).


If no rotator cuff tear exists, the symptoms of impingement syndrome can usually be controlled without surgical intervention. Exercises, activity modification, and time can often lead to resolution of the impingement syndrome. Sometimes, an injection of cortisone-type medication may be required for resolution.


If the spur is very large, or if conservative treatment does not work, surgical excision of the bone spur may be required. This can be done arthroscopically on an outpatient basis.



X-ray of a patient with a very large acromial spur

X-ray of same shoulder after arthroscopic spur excision. Note the increased space above the round humeral head

12. What is a Rotator Cuff?

The rotator cuff is actually a set of four important muscles about the shoulder. These muscle are normally difficult to see, being covered by both the much larger deltoid and trapezius muscles. However, they are extremely important stabilizers of the shoulder ball-and-saucer joint. Deconditioning of the rotator cuff muscles can lead to abnormal motions of the shoulder joint and result in pain and weakness. Therefore, much of the therapy for shoulder injuries is focused on restoring strength and stamina to these important muscles.


The tendons of the rotator cuff can be injured either by a one-time severe injury or slowly tear by chronic overuse and inflammation. Once completely torn, these tendons cannot heal without surgical repair. If no repair is performed, the size of the tear often increases and the ends of the torn tendons get drawn further and further apart with shortening and scarring of the tendons, as well as irreversible atrophy of the corresponding muscles. As a result, rotator cuff tears that have not been repaired for many years often become irreparable - the ends of the tendons are just too short and scarred far apart from each other to be brought back to each other to be repaired. In order to prevent this from occurring, consideration should be given to surgical repair of symptomatic full thickness rotator cuff tears when they are diagnosed. In the past, repair of rotator cuff tears required an open procedure. Now, however, techniques have evolved to allow this repair to be done arthroscopically through small incisions and the use of a telescope by surgeons skilled in the techniques of arthroscopic rotator cuff repair.



Example of intact rotator cuff viewed through the arthroscope. The broad white tendon has no defect.

Example of rotator cuff tear viewed through the arthroscope. The hole or defect in the tendon substance is the tear

Same view after arthroscopic rotator cuff repair. Note that the defect is now closed with suture material


13. What is a Frozen Shoulder?

The term “frozen shoulder” is a lay-term to describe a condition whose medical name is “adhesive capsulitis.” Although a lay-term, “frozen shoulder” accurately describes this condition. For incompletely understood reasons, the glenohumeral capsule (the soft tissue lining of the shoulder ball-and-saucer joint) becomes inflamed and contracted. As a result, there is severe restriction of motion of this joint. Patients with this condition have pain when moving their shoulder in any direction. This can be very limiting. Fortunately, however, most often the frozen shoulder thaws and motion and function of this joint are regained. However, this can take up to two years to occur. The thawing process can sometimes be hastened somewhat with physical therapy exercises to try and stretch the contracted joint capsule.


In a small percentage of patients, the frozen shoulder never thaws and regaining motion requires surgical intervention. Current technology allows us to perform arthroscopic surgery in which the joint capsule is cut under direct vision of an arthroscope. Then the shoulder is gently manipulated in order to break up any adhesions or scar tissue which may have formed outside the joint. The resulting gains in motion can be dramatic. However, it takes a lot of effort doing physical therapy stretching exercises in order to maintain these gains in motion. People not willing to do these painful stretching exercises after such a surgical intervention will develop post-surgical scarring which will lead to the reformation of a tight capsule and loss of the motion gained at surgery.


14. What are some common Elbow Conditions?

The elbow joint is composed of three bones. The humerus (arm bone) articulates against both forearm bones, the radius and the ulna. The two forearm bones, in turn, rotate one around the other to allow rotation of the forearm. As a result, the elbow is responsible for flexion and extension, as well as rotation of the forearm. Rotating the forearm so that the palm is facing down is called pronation and rotating so that the palm is facing up is called supination. Stability of the joint is dependent upon the bony architecture as well as a system of ligaments and muscles. These also allow for painless motion.


Injuries or degenerative processes can lead to tearing and degeneration of these support structures of the elbow. This can result in pain, stiffness, weakness, instability, or loss of function.


15. What is Elbow Stiffness?

Stiffness of the elbow can be extremely problematic. Motion of this joint is vital to adequate positioning of the hand. Stiffness of the elbow after injury or due to arthritis can be very limiting.


If the stiffness is due to arthritis, it usually will not respond to anything short of surgical intervention. If the elbow stiffness is after an injury, however, it can often be treated successfully without surgery if treatment is initiated early and the patient is cooperative with the instructions.


As a result of the above, the goal after elbow injury and/or surgery is to try to move the elbow as soon as is it safely possible. Sometimes this means wearing a brace with hinges in order to give the elbow some support while doing motion exercises. One needs to work on bending (flexing) and straightening (extending) the elbow as well as keeping the elbow at the side and turning the forearm so that the palm faces up (supinate) and then the palm faces down (pronate). Like most stretches, these stretches should be held for about one minute. Bouncing should be avoided and the maneuver should not cause extreme pain, but one should feel a good stretch.


16. What is Golfer's Elbow?

The term “golfer’s elbow” is a lay-term for a condition whose medical name is medial epicondylitis of the elbow. Although often found in golfers, it can occur in individuals who never play golf. It is usually an overuse injury to the tendons on the inside aspect of the elbow. These are the same tendons that allow one to actively bend the wrist forward. If you lay your forearm on a counter with the palm facing up and then lift the clenched fist off the counter, you are using the muscles that we are talking about. These muscles originate as tendons from a small area of bone on the inside aspect of the elbow. If you extend your arm in front of you so that the palm is facing up to the ceiling, this is the part of the elbow on the same side as your little finger. In golfer's elbow this inside aspect of the elbow is the area of maximum pain. The pain can sometimes radiate down the forearm a little bit. There is usually no numbness or tingling involved with this condition.


What causes golfer’s elbow? The start of golfer’s elbow is thought to be an injury that causes a small tear in the origin of these muscles. Sometimes this is a one-time injury. More commonly, however, it is a repetitive overuse injury. Once the injury occurs, instead of a normal healing response, the body sometimes creates an ongoing process in which the tissue is not repaired but actually partially degenerates. This is why this problem can be so persistent.


Most of the time, this can be treated without surgical intervention. However, it can take up to two years in order for this to occur. In order to treat this successfully, we need to avoid the offending activity. If you are a golfer, you may need to modify your grip and/or correct abnormal mechanics in order to take the stress off the injured area. Some players might even need to restrict playing for a time, and then slowly return to those activities which do not cause them discomfort. Also, the way we grasp or lift things may need to be modified in order to decrease discomfort in this area.


Unlike lateral epicondylitis (tennis elbow), bracing is not typically used to decrease stress on the injured area. The reason for this is that medial epicondylitis occurs next to an important nerve (the ulnar nerve). Trying to take stress off the injured tendons by applying a brace here risks compressing this nerve.


The mainstay of treatment for golfer’s elbow consists of an exercise program. The exercises are designed to stretch and strengthen the injured area in order to stimulate a correct healing response. These exercises are done with high repetitions of about 20-25 per set and about 3-5 sets per workout. These should be done daily, and one should use very light weight. The average individual should use no more than 2 to 3 lbs. A very strong individual should use no more than 5 to 10 lbs.


Also unlike tennis elbow, injection of corticosteroids into the inflamed area is usually not undertaken. Again, the nearby ulnar nerve makes injections into this area of the elbow risky.


Very rarely, conservative treatment fails and painful golfer’s elbow persists causing discomfort and limited function. In these cases, surgical procedures can be performed. However, it can take many months to recover from this surgical intervention. During this time, activities performed with that arm are restricted.


Exercises for golfer's elbow and tennis elbow. The upper two figures demonstrates stretches that should each be held for one minute. The lower two figures depict strengthening exercises (reverse wrist curls and wrist curls, respectively). These should be done slowly and with control, using a light and very thin weight, aiming for a high number of repetitions, as described above. In severely symptomatic patients, these strengthening exercises should be initially performed with either no weight, or gripping a pencil.



17. What is Tennis Elbow?

The term “tennis elbow” is a lay-term for a condition whose medical name is lateral epicondylitis of the elbow. Although often found in tennis players, it can occur in individuals who never play tennis. It is usually an overuse injury to the tendons on the outside aspect of the elbow. These are the same tendons that allow one to actively bend the wrist back. If you lay your forearm on a counter with the palm facing down and then lift your clenched fist off the counter, you are using the muscles that we are talking about. These muscles originate as tendons from a small area of bone on the outside aspect of the elbow. If you extend your arm in front of you so that the palm is facing up to the ceiling, this is the part of the elbow on the same side as your thumb. In tennis elbow, this outside aspect of the elbow is the area of maximum pain. The pain can sometimes radiate on top of the forearm a little bit. There is usually no numbness or tingling involved with this condition.


What causes tennis elbow? The start of tennis elbow is thought to be an injury that causes a small tear in the origin of these muscles. Sometimes this is a one-time injury. More commonly, however, it is a repetitive overuse injury. Once the injury occurs, instead of a normal healing response, the body sometimes creates an ongoing process in which the tissue is not repaired but actually partially degenerates. This is why this problem can be so persistent.


Most of the time, this can be treated without surgical intervention. However, it can take up to two years in order for this to occur. In order to treat this successfully, we need to avoid the offending activity. If you are a tennis player, you may need to modify your grip size and/or correct swing mechanics in order to take the stress off the injured area. Some players might even need to restrict playing for a time, and then slowly return to those activities which do not cause them discomfort. Also, the way we grasp or lift things may need to be modified in order to decrease discomfort in this area.


In addition to activity modification, bracing can be used to decrease stress on the injured area. These are typically braces that look like thick bands that are wrapped around the forearm just below the elbow. They need to be worn only when doing activities that cause discomfort, such as playing tennis or grasping or typing.


The mainstay of treatment for tennis elbow consists of an exercise program. The exercises are designed to stretch and strengthen the injured area in order to stimulate a correct healing response. These exercises are done with high repetitions of about 20-25 per set and about 3-5 sets per workout. These should be done daily, and one should use very light weight. The average individual should use no more than 2 to 3 lbs. A very strong individual should use no more than 5 to 10 lbs.


Sometimes, however, the tennis elbow is too inflamed and painful to do much of the exercises or regular activities. In this situation, an injection of corticosteroids into the inflamed area can help decrease inflammation and pain to where the exercises can be performed. These injections can be repeated a couple of times, if needed. However, the cumulative effect of repeated steroid injections is detrimental to the health of tendons and can cause numerous local problems including complete tendon rupture. One must, therefore, be careful not to keep going back for repeated injections of steroids into the area of tennis elbow.


In a small percentage of individuals, conservative treatment fails and painful tennis elbow persists causing discomfort and limited function. In these cases, surgical procedures can be performed. The results of surgery can be dramatic. However, it can take many months to recover from this surgical intervention. During this time, activities performed with that arm are restricted.


Exercises for tennis elbow and golfer's elbow. The upper two figures demonstrates stretches that should each be held for one minute. The lower two figures depict strengthening exercises (reverse wrist curls and wrist curls, respectively). These should be done slowly and with control, using a light and very thin weight, aiming for a high number of repetitions, as described above. In severely symptomatic patients, these strengthening exercises should be initially performed with either no weight, or gripping a pencil.



18. What are some common Overuse Conditions?

The term “overuse injury” is frequently used in medicine when talking about the musculoskeletal system. Repetitive stress, without adequate time to allow for healing, will lead to the breakdown of the components that make up the musculoskeletal system. This is especially true for bones and tendons. Overuse injury of bones can lead to the development of stress fractures. Similarly, overuse injuries to tendons can lead to the development of tendinitis.


19. What are Stress Fractures?

A stress fracture is a bony injury that is not caused by a single traumatic event (like a fall), but rather by repetitive loading (like running). An analogy can be made with that of a paper clip. If one straightens a paper clip and then bends it back to its original position, the clip remains apparently undamaged. However, if one repeats this dozens of times, the paper clip will break. Unlike a paper clip, our bones are living tissue and have the capacity for repair. However, this repair process takes time. If we overstress a bone and do not allow enough time for repair before we stress it again, there can be some damage to the bone. If this practice is continued, the damage can increase to the point where the bone can develop a crack. If one persists in activities even further, the bone can even break completely in two. Both the crack and complete break are considered fractures.


As you may expect, we typically see these injuries in individuals that do a lot of long distance walking and/or running, especially if they are not used to it. For example, military recruits are often forced to do a lot of marching in boot camp. As a result, they often develop what is called a “march fracture.” This is basically a stress fracture of one of the bones in the foot.


There are many different types of stress fractures. Fortunately, most of them can be treated simply by decreasing one’s activity to the point where it does not hurt. This allows the bone to repair itself. However, there are some stress fractures which should be treated more aggressively in order to achieve healing. Sometimes, this can mean being immobilized in a cast and/or being placed on crutches. Other times, this means surgical intervention.


20. What is Tendinitis?

The term “tendinitis” implies inflammation of a tendon. Tendons, in turn, are tough, soft tissue structures through which muscle attaches to the bone. In point of fact, the muscle tissue turns into tendinous tissue before it inserts onto a bone. As a result, the function of the tendon is to securely anchor muscles to the bones that those muscles move.


Inflammation of a tendon occurs as a result of an injury to the tendon. This injury can be a one-time traumatic injury, such as a contusion. However, more commonly, the injury is due to repetitive stresses on the tendon without sufficient rest and time between stresses in order for the tendon to heal. As a result, tendinitis is typically due to an overuse injury.


The most common areas of tendinitis are the rotator cuff tendons of the shoulder, the patellar tendon in the front of the knee, and tendons on the outside aspect of the elbow. Respectively, inflammation of these areas is referred to as rotator cuff tendinitis (“thrower’s shoulder”), patellar tendinitis ("jumper's knee"), and elbow lateral epicondylitis ("tennis elbow").


Tendinitis in any of these locations can be quite limiting. Fortunately, the inflamed tendon can usually be treated successfully with conservative means, including activity modification, physical therapy stretching and strengthening exercises, anti-inflammatory medication, and occasionally bracing. As a result, surgical treatment for tendinitis is usually not necessary. However, sometimes tendinitis does not respond to the conservative treatments outlined above and surgical intervention is necessary to resolve the problem.


21. What is Arthritis?

The term “arthritis” simply means inflammation of a joint. When doctors talk about arthritis in general, they are talking about degeneration of the joints, which can be a result of age, overuse, or injury. Basically, the smooth cartilage surfaces of the bones that allow gliding without any friction become rough and cause friction with motion. This leads to pain, swelling, stiffness, and loss of function of the affected joint. Some people have generalized arthritis, whereas others have arthritis limited to one or a few joints. This wear and tear form of arthritis is referred to as osteoarthritis, or degenerative joint disease. This is by far the most common form of arthritis. Other types of arthritis are grouped together under the term "inflammatory." An example of this type of arthritis is rheumatoid arthritis. This is a body-wide disease process in which the immune system starts attacking various joints throughout the body. Going unchecked, inflammatory arthritis conditions like rheumatoid arthritis can destroy joints and lead to significant disability.


The primary approach to treating osteoarthritis is with anti-inflammatory medications, therapy, activity modification, occasional bracing, and surgical intervention, when necessary. Rheumatoid arthritis, on the other hand, is primarily treated by powerful medications designed to control the body’s immune attack against itself. Sometimes surgery is also indicated to help particularly problematic joints in someone with rheumatoid arthritis.



A drawing of a normal knee joint is presented below. The surfaces of the bones that glide past each other are covered with a thick layer of ultra-smooth articular cartilage

Similar knee drawing representing moderate osteoarthritis, primarily involving the medial (inside) compartment. Notice that the smooth articular cartilage surface of the femur (thigh bone) has become rough due to the development of fissures and erosion. Osteophytes (bone spurs) may also develop

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