Symptoms and Pain Management of Spinal Stenosis

Spinal stenosis is characterized by the narrowing of the open spaces within the spine.

This narrowing can result to pressure on the spinal cord and on the nerves that pass through the spine to the legs and arms.

The condition often occurs in the neck and the lower back.

In some people, spinal stenosis will not manifest any symptoms.

However, others may experience numbness, pain, muscle weakness, tingling, and issues with bowel or bladder function.

The condition is often caused by wear-and-tear changes in the spine secondary to osteoarthritis.

In cases that are severe, surgery may be recommended in order to create additional space for the nerves or the spinal cord.

Causes

While some are born with a small spinal canal, most cases of spinal stenosis occur when the amount of space within the spine is reduced.

Other possible causes can include the following:

  • Bone overgrowth – wear-and-tear damage due to osteoarthritis can result to the formation of bone spurs which can form in the spinal canal. Paget’s disease, a bone condition common among adults can also result to bone overgrowth in the spine.
  • Thickened ligaments – the tough cords that help hold the bones of the spine can thicken and become stiff over time. The ligaments that are thickened may end up bulging into the spinal canal.
  • Herniated disk – as one ages, the soft cushions that function as shock absorbers between the vertebrae can dry out. The cracks in the exterior of the disk may cause some of the inner material to escape, causing it to press on the nerves or the spinal cord.
  • Spinal injuries – vehicle accidents (and other traumas) can result to fracture or dislocation of one or more vertebrae. Bones displaced from spinal fractures can end up damaging the contents of the spinal canal. When adjacent tissues swell following back surgery, it can also cause pressure on the nerves or the spinal cord.
  • Tumors – abnormal growths can also develop inside the spinal cord (in the space between the vertebrae and the spinal cord or within the membranes covering the spinal cord).

Symptoms

While spinal stenosis may be evident on X-rays, it is possible that no symptoms or signs will manifest.

However, when symptoms occur, they usually start gradually and get worse as time goes on.

Depending on the location, symptoms of the condition can vary.

  • Lower back (lumbar spine) – when the nerves in the lumbar spine are compressed, it can result to leg pain or cramping (especially when walking or standing for prolonged periods). In most cases, discomfort is eased when the patient sits down or bends forward.
  • Neck (cervical spine) – weakness, tingling, and numbness in the foot, arm, hand, or leg are some of the most common symptoms that signal cervical stenosis. While tingling in the hand is considered the most prevalent, many patients also report balance and walking issues. Bowel or bladder nerves may also become affected, resulting to incontinence.

Visiting an orthopaedic specialist is recommended if there is persistent numbness, weakness, and pain in the legs, back, and arms.

Complications

While rare, untreated cases of spinal stenosis may cause long-term:

  • Weakness
  • Numbness
  • Balance issues
  • Paralysis
  • Incontinence

Pain Management and Treatment

Treatment intervention and pain management for spinal stenosis will vary and will depend on the severity of the symptoms and the location of the stenosis.

Medications

To help ease pain caused by spinal stenosis, the following may be prescribed:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) – minimizes inflammation and relieves pain associated with osteoarthritis.
  • Antidepressants – to help alleviate chronic pain, nightly doses of tricyclic antidepressants may be recommended.
  • Muscle relaxants – cyclobenzaprine (Fexmid, Amrix) can help calm muscle spasms associated with spinal stenosis.
  • Anti-seizure drugs – to ease pain due to damaged nerves, anti-seizure drugs such as pregabalin (Lyrica) and gabapentin (Horizant, Gralise, Neurontin) may be prescribed.

Physiotherapy

There is a tendency for some patients with spinal stenosis to become less active in an effort to alleviate the pain.

However, it can prove counterproductive as it can result to muscle weakness which causes more pain.

Fortunately, a physical therapist can recommend exercises that can help:

  • Build up the patient’s endurance and strength
  • Retain the stability and flexibility of the spine
  • Improve the patient’s balance

Surgery

Surgery might be recommended if conservative treatment interventions have proved futile or if the patient has been disabled by the symptoms.

The primary goal of the procedure would be to relieve nerve roots or spinal cord pressure by creating space within the spinal canal.

  • Laminectomy – this procedure involves the removal of the lamina (back part) of the vertebra affected. To maintain spine strength, the vertebra may have to be linked to the adjoining vertebrae with a bone graft (spinal fusion) or a metal hardware.
  • Laminoplasty – this procedure is only carried out on the vertebrae found in the neck. By creating a hinge on the lamina, the space within the spinal canal is opened up. The gap in the spine’s opened section is bridged using metal hardware.
  • Laminotomy – this procedure involves removal of just a portion of the lamina, with a hole carved just big enough to relieve pressure in a certain spot.
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Recognising the Potential Signs of Bone Tumours

Bone tumours occur when the cells within the bone divide uncontrollably and form a mass of abnormal tissue or lump.

Most bone tumours are benign (not cancerous).

Benign tumours are not life-threatening and will not spread to other parts of the body.

Depending on the type, treatment interventions for benign bone tumours can range from simple observation to surgical removal.

Unfortunately, not all bone tumours are benign.

Some bone tumours can be malignant or cancerous.

Malignant bone tumours can cause the cancer cells to spread to other parts of the body (metastasise).

Typically, the treatment approach for malignant bone tumours include a combination of radiation, chemotherapy, and surgery.

Bone tumours can develop in any part of the bone (from the surface to the bone marrow) and can affect any bone in the body.

A growing bone tumour, even a benign one can weaken the bone and destroy healthy tissues, making it more prone to fractures.

Malignant bone tumours are either primary or secondary bone cancer.

Primary bone cancers originally begin in the bone while secondary bone cancers began somewhere else in the body and spread to the bone.

Cancer types that begin elsewhere that often spreads to the bone include:

  • Renal
  • Prostate
  • Lung
  • Breast
  • Thyroid

Benign Bone Tumors

While there are many types of benign bone tumours, there are also conditions and diseases that may resemble bone tumours. Although some of these conditions are not really classified as tumouur of the bone, in most cases, they will require the same treatment.

Some of the most common benign bone tumors and the conditions that resemble them include:

  • Giant cell tumour
  • Enchondroma
  • Non-ossifying fibroma
  • Unicameral (simple) bone cyst
  • Chondroblastoma
  • Fibrous dysplasia
  • Osteoid osteoma
  • Aneurysmal bone cyst
  • Osteoid osteoma

Symptoms

Oftentimes, people with bone tumour will experience pain in the affected area.

In most cases, the pain is described as dull and aching.

It also has the tendency to worsen at night and during activity.

Other typical indicators include night sweats and fever.

While bone tumours are not attributed to trauma, an injury may cause a tumour to become painful.

Injury may also cause a bone already weakened by the tumour to break.

In some cases, benign tumours are discovered incidentally, when an X-ray is taken for another reason like knee injury or a sprained ankle.

Diagnosis

Stress fractures, infections, and other non-tumour conditions can closely resemble bone tumours.

To ensure the diagnosis is accurate, a thorough evaluation and a number of tests may be ordered.

Medical history – patients will be asked about their current symptoms, their general health, and their complete medical history. Oftentimes, the doctor would also check if the patient or any member of the family has had a history of tumours or cancer.

Physical examination – when conducting a thorough physical examination, the doctor will look for the following signs:

  • Tenderness or swelling (in the tumour area)
  • Changes in the overlying skin
  • Presence of mass
  • Effects the tumour might have on the joints that are nearby

Tests – X-rays are used to provide images of dense structures like the bone. In most cases, an X-ray will be ordered to help confirm the diagnosis. When further evaluation is necessary, the doctor may also order magnetic resonance imaging (MRI) or computed tomography (CT) scan.

Treatment

Nonsurgical Options

Benign tumours

If benign, the doctor may just recommend a close monitoring of the tumour to check for any changes. In line with this, periodic X-rays, tests, and follow-ups may be required. Fortunately, some benign tumours will respond well to medication. Others may disappear over time as the case of osteoid osteoma.

Malignant tumors

In the case of bone cancers, treatment is often provided by a team of doctors from different medical specialties (i.e. orthopaedic oncologist, radiologist, pathologist, medical oncologist, etc.). Generally, malignant tumours are treated using a combination of radiation therapy, chemotherapy, and surgery.

Surgical Treatment

Benign tumours

In some cases, excision (removal of the tumour) or other surgical techniques may be recommended to help minimize disability and fracture risk. However, some tumours may return, even with appropriate treatment. Fortunately, it is very rare that they become cancerous or metastasize.

Malignant tumors

Limb salvage surgery – this procedure involves removal of the cancerous section of the bone while keeping the nearby tendons, nerves, blood vessels, and muscles intact where possible. However, the surgeon will remove the tumour as well as a portion of the healthy surrounding tissues. The bone excised will be replaced with a prosthesis (metallic implant) or bone taken from the patient’s own body or from a donor.

Amputation – this procedure involves removal of all or a part of the affected extremity. It is considered the ideal treatment option when the tumour is large or when the blood vessels or nerves are involved. A prosthetic limb may be used to aid function after the procedure.

Managing Knee Osteoarthritis Through Physiotherapy

Also referred to as wear-and-tear arthritis, osteoarthritis (OA) is a condition characterised by the wearing away of the cartilage (the joint’s natural cushion).

When the cartilage wears away, the bones will rub against each other resulting in stiffness, swelling, and reduced movement.

In some cases, osteoarthritis can also result in the development of bone spurs.

Knee Osteoarthritis

While age is considered a primary risk factor for knee osteoarthritis, for some it can be hereditary.

Although the chance of developing the condition significantly increases after the age of 55 years, knee osteoarthritis can also occur even in young individuals.

For others, the condition can develop from infection, injury, or from being overweight.

Osteoarthritis is also more prevalent in women than in men.

Cause

Knee osteoarthritis can be attributed to some of the following factors:

  • Weight – weight can increase pressure placed on the joints, especially the knees. Every excess pound that is gained can translate to additional 3 to 4 pounds of extra weight on the knees.
  • Heredity – certain genetic mutations can make an individual more susceptible to developing osteoarthritis in the knee. In some cases, knee OA is also attributed to inherited abnormalities in the bones surrounding the knee joint.
  • Gender – women aged 45 (or older) are more prone to developing knee OA compared to men.
  • Stress injuries – individuals with jobs that require repetitive activities that can stress the joint (i.e. lifting weights, squatting, or kneeling) are more likely to develop the condition due to constant joint pressure.
  • Athletics – people involved in physically demanding sports like tennis, soccer, and long-distance running have a higher risk of developing knee osteoarthritis.
  • Other illnesses – those suffering from other conditions like rheumatoid arthritis become more prone to also developing knee OA. In addition, those with certain metabolic disorders (i.e. excess growth hormone or iron overload) also have a higher risk of developing the condition.

Symptoms

Common symptoms of knee osteoarthritis can include:

  • Pain (often increases with activity and gets better with rest)
  • Feeling of warmth (in the affected joint)
  • Swelling
  • Knee stiffness (especially noticeable in the mornings)
  • Decreased knee mobility (makes even the most routine of tasks like walking, climbing the stairs, and getting in and out of chairs challenging)
  • Creaking sound can often be heard when the affected knee is moved

Treatment Options

Treatment plan for knee osteoarthritis will often include a combination of the following:

  • Weight loss
  • Exercise
  • Anti-inflammatory drugs and pain relievers
  • Corticosteroid injections
  • Braces
  • Alternative therapies
  • Surgery
  • Physiotherapy

Physiotherapy for Knee OA

While nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to help provide pain relief and can assist in the initial management of the condition, more natural options may be used in conjunction with medication to help manage the condition more effectively.

However, following generalized exercise programs without sufficient instruction, education, or warnings can be counterproductive as it may only aggravate the inflammation and increase the pain.

In line with this, seeking the help and guidance of a competent and trained physiotherapist is recommended as they have a thorough knowledge and understanding of osteoarthritis and its management.

A physiotherapist will do a series of clinical tests to assess the extent of the condition.

In most cases, an X-ray is required to confirm the diagnosis.

Once thorough assessment has been carried out, physiotherapists will establish management goals and create a tailored treatment plan.

In most cases, treatment will include hands-on therapies like stretching, massage, and passive joint mobilization to decrease muscle tightness and spasm and to encourage full motion range.

Other potential treatment modalities (i.e. acupuncture, dry needling, and hydrotherapy) may also be recommended when necessary.

Physiotherapy treatment interventions provide conservative but effective results when it comes to damaged arthritic joints.

A comprehensive assessment is conducted so the apt treatment prescription can be given.

To treat knee osteoarthritis, a range of physiotherapy modalities may be used, including:

  • Exercise prescriptions
  • Electrotherapy modalities
  • Joint mobilization
  • Hydrotherapy
  • Acupuncture
  • Education
  • Support aids

Physiotherapy modalities are designed to help reduce pain, strengthen key muscle groups, and improve the patient’s range of movement.

It will also give the patient the luxury to take control of the condition and perform daily tasks with less pain, disruption, and discomfort.

In addition, certain exercise programs may also be taught to assist with weight loss, which can be vital in significantly reducing the load placed on the joint.

Home exercise programs taught by physiotherapists have also been known to help reduce osteoarthritis flare-ups.

However, long-term compliance must be observed.

Unfortunately, some patients discontinue the exercises once function has been partially restored and pain has subsided and only starts exercising again when the next flare-up occurs.

While not everyone may be aware of it, the repetitive cycle of exercise and inactivity may only cause more joint deterioration and damage.

Ideally, a physiotherapy visit every 4 to 6 weeks is recommended.

The setup will allow the physiotherapist time to review, reinforce, and modify prescribed exercises when the need arises.

Limb Salvage Surgery Overview

The surgery performed to remove soft-tissue and bone cancer in the limbs while retaining the affected parts is called limb salvage surgery.

The procedure is done to remove the cancer and avoid amputation (while retaining the greatest possible degree of function and preserving the patient’s appearance).

Limb salvage surgery is a common procedure to treat bone sarcomas and tumors and soft tissue sarcomas that affect the extremities.

In essence, limb salvage surgery has become an alternative to amputation and is performed to treat cancers that originate in the limb and those cancers that have not invaded the soft tissues yet.

Decades ago, the standard treatment route for patients with cancer in the limb was amputation of the affected extremity.

Fortunately, thanks to dramatic improvements in surgical techniques (resection and reconstruction ), imaging methods (CT scans and MRIs), and high survival rates of patients treated using chemotherapy, limb cancer treatment will no longer always involve losing the extremity affected.

Otherwise known as limb-sparing surgery, limb salvage surgery entails removing the cancer and a margin of the surrounding healthy tissues.

Once removed, the bone will be replaced.

The replacement can be in the form of synthetic metal implant (prosthesis) or a piece of bone (graft).

The graft can be taken from the patient’s own body (autologous transplant) or it can come from a donor body (cadaver) and frozen until needed for the transplant (allograft).

In time, the transplanted bone will eventually grow into the patient’s remaining bone.

Radiation, chemotherapy, or a combination of both may be used to shrink the tumor before surgery is carried out.

Limb-sparing surgery is done in three stages.

  1. Surgeons remove the cancer (and a margin of the surrounding healthy tissues)
  2. A prosthesis or a bone graft is implanted (whichever is necessary)
  3. The wound is closed (by transferring muscle and soft tissue from other parts of the patient’s body to the surgical site)

Techniques Used in Limb Salvage Surgery

Bone Tumors – to treat low-grade bone tumors or its components, surgeons will remove the malignant lesion and a cuff of normal tissue (wide excision). In the case of high-grade tumors, the bone, muscle, and other tissues that have been affected by the tumor (radical resection) will be removed.

Soft Tissue Sarcomas – limb salvage surgery is used to treat around 80 percent of soft tissue sarcomas that affect the extremities. The tumor, lymph nodes, other tissues where the cancer has spread, and at least 2.54 cm of healthy tissues surrounding the tumor will also be removed.

Chemotherapy or radiation may be administered pre- or post-surgery.

Radiation may also be administered during the procedure. External beam (linear accelerator) is most commonly used. In brachytherapy, a special applicator will be placed against the bed where the tumor has been removed and tubes containing radioactive pellets will be inserted at the tumor site. The tubes will only be removed several days later.

Preparation

Before deciding if limb-sparing surgery is the best option for a patient, doctors will take into consideration several key factors—the type of cancer, the location and size of the tumor, the progression of the condition, and the patient’s general health and age.

Candidates for limb salvage surgery will be given insights on the likely surgery outcome. They will also be informed that should the implant fail, additional surgery (and even amputation) might be necessary.

Occupational and physical therapists will also help prepare the patient for the procedure by teaching ambulation (walking), range of motion (ROM), and muscle-strengthening exercises the patient will begin performing post-surgery.

Aftercare

Typically, limb salvage surgery patients will remain in the hospital for 5 to 10 days after the procedure.

Nurses will monitor the blood flow and sensation in the affected extremity and will check for signs of possible surgery complications like deep-vein thrombosis, pulmonary embolism, or pneumonia.

Broad spectrum antibiotics will be given in the first 48 hours after the surgery and medications (prophylactic anticoagulants) to prevent blood clots may also be prescribed.

A drainage tube will be placed in the wound (at least for the first 24 to 48 hours) to prevent hematoma (blood) and seroma (fluid) from accumulating in the surgical site.

Since limb salvage surgery requires extensive surgical incisions and loss of functional tissues, patients will also need extensive rehabilitation after.

The type of reconstruction done and the amount of bone removed will often dictate how much the patient can exercise and how soon.

However, most patients begin continuous passive motion (CPM), muscle-strengthening, and ROM exercises at least a day after the surgery and will continue to do them for the next 12 months or so.

Also, before the patient is sent home, the doctor will decide whether a brace, walker, cane, or other assistive device will be needed.

While salvaged limbs often function better than artificial ones, it may take at least a year before patients who have undergone lower-extremity limb salvage to learn to walk again.

Patients who have upper extremity salvage will also have to master new ways of using the affected extremity.

Surgical Treatment Options for Osteosarcoma

The bone cancer that often develops in the tibia (shinbone) near the knee, humerus (upper arm bone) near the shoulder, and the femur (thighbone) near the knee is called osteosarcoma.

Osteosarcoma is one of the most prevalent types of malignant bone cancer.

It accounts for at least 3 percent of the cancers that develop in children.

While other types of cancer can end up spreading to the bone, osteosarcoma is one of the few that begins in the bones and can spread (or metastasise) to other parts of the body.

Most cases of osteosarcoma often occur during growth spurts in adolescence.

This type of cancer is also more common among boys than in girls.

Symptoms

Osteosarcoma symptoms can vary depending on its location.

However, some of the most prevalent symptoms of the condition include:

  • Bone pain (when lifting objects, while in motion, and even at rest)
  • Limping
  • Swelling
  • Bone fractures
  • Limitation of joint motion

The severity of pain brought about by the condition can vary from one patient to another. While some will notice only dull pain, others may experience the kind that keeps them up at night.

In addition, people with osteosarcoma may notice that the muscles in the affected area may appear smaller (atrophy).

Some symptoms of the condition can mimic growing pains (i.e. leg pain secondary to normal bone growth).

However, if the pain persists past their initial growth spurts or if the pain is causing severe pain or discomfort, seeing a doctor is recommended.

Diagnosis

A variety of tests may be used to accurately diagnose the condition.

When conducting a physical examination, the doctor will look for signs of redness or swelling.

Medical history, previous illnesses, and past medical treatments of the patient will also be looked into.

A simple blood test may also be required to check for tumor markers (alkaline phosphatase).

Tumor markers are chemical readings in the blood that will indicate cancer presence.

Other tests that are used to help diagnose osteosarcoma can include:

  • X-ray – can produce images of the hard (calcified or ossified) tissues inside the body, including the bones
  • MRI scan – makes use of powerful magnets and radiofrequency waves to produce images of the internal organs
  • CT scan – a 3D X-ray used to examine the soft organs and bones
  • PET scan – a full body scan using a special tumour marker (usually used to detect cancer)
  • Bone scan – an imaging test that can show abnormalities in the bone that other imaging tools may miss. Bone scans are also used to check if the cancer has spread to other bones.
  • Biopsy – removal of a tissue sample from the bone for testing

Treatment

Treatment of osteosarcoma can include chemotherapy (drugs used to kill the cancer cells), followed by surgery to remove the tumor or cancerous cells.

In most cases, surgery can effectively remove the bone cancer while chemotherapy can help ensure the remaining microscopic cancer cells in the body are eliminated.

Surgical Treatment

Surgical treatment for osteosarcoma can be amputation or limb-salvage surgery.

Nowadays, osteosarcoma in the leg or arm is often treated with limb-salvage surgery instead of amputation.

In limb-salvage surgery, the bone and the muscle affected are removed.

A gap will be left in the bone and is filled by a bone graft (often from a bone bank) or a special metallic tumour prosthesis.

These may be matched to the size of the bone defect.

However, since there is higher risk of fracture and infection with bank bone replacement, metal prostheses are often used when reconstructing the bone after the tumor removal.

If the cancer has spread to the blood vessels and the nerves surrounding the original tumor, amputation is often the likely option.

However, amputation can come with short and long-term side effects.

For instance, it will take at least 3 to 6 months before the patient will be able to learn to use a prosthetic (artificial) arm or leg proficiently.

And that is just the start of a long social and psychological rehabilitation.

Oftentimes, with limb-salvage surgery, the patient can already bend the knee (or the affected body part) almost immediately.

For children with tumors around the knee, a continuous passive motion (CPM) machine may be used to help improve motion.

Rehabilitation and physical therapy for 6 to 12 months after the surgery can help the patient walk (with crutches or walker, initially) and then without any assistive devices eventually.

Complications

Post-surgery complications can include slow healing of the surgical wound and infection.

In some cases, the bank bone or the metal prosthetic device may require replacing as the body grows, or when implants lose fixation after many years of use.

In addition, chemotherapy may also result to unpleasant side effects.

Some of the likely side effects can include:

  • Nausea
  • Vomiting
  • Pain
  • Constipation
  • Hair loss
  • Tingling in the arms and legs
  • Anemia
  • Fluid retention
  • Infections

Prognosis

Fortunately, survival rate for osteosarcoma that has not spread to other parts of the body is at 60 to 80 percent.

Also, osteosarcoma that develops in the leg or arm often has a better prognosis compared to those that develop in the shoulder blades, spine, ribs, or the pelvic bone.

Prevention and Treatment of Achilles Tendinitis

The largest tendon in the body is the Achilles tendon.

It is used when walking, jumping, or running.

The Achilles tendon also connects the calf muscles to the heel bone.

While the Achilles tendon can often withstand stress from jumping and running, it can become prone to tendinitis.

Achilles tendinitis is characterized by pain along the back of the leg (near the heel).

Essentially, the condition is attributed to both degeneration and overuse.

Types

Simply put, tendinitis is the inflammation of the tendon.

Inflammation is considered the body’s natural response to disease or injury and it often results in pain, swelling, or irritation.

There are two types of Achilles tendinitis, depending on the part of the tendon that is inflamed.

Noninsertional Achilles Tendinitis

This type of Achilles tendinitis occurs when the fibers found in the tendon’s middle portion thickens, swells, and has tiny (micro) tears.

This type of tendinitis often affects young and active individuals.

Insertional Achilles Tendinitis

This type of tendinitis develops in the heel’s lower portion (where the tendon is attached to the heel bone).

In both types of Achilles tendinitis, the damaged tendon fibers may also harden (calcify).

However, bone spurs can also develop in people with insertional Achilles tendinitis.

This type can affect anyone, even those patients who are not active.

Cause

In most cases, Achilles tendinitis is not associated with any specific injury.

The injury often occurs secondary to repetitive tendon stress.

In other words, it can develop when the tendon is made to do too much or too soon.

However, the condition can also be attributed to the following:

  • Drastic increase in the intensity or amount of exercise – for instance, increasing the distance you cover by a few miles without giving the body a chance to gradually adjust.
  • Calf muscles that are tight – individuals with tight muscles who start an aggressive exercise program drastically can put unnecessary stress and strain on the Achilles tendon.
  • Bone spur – extra bone growths can end up rubbing against the tendon and cause a lot of pain.

Symptoms

Telltale indicators of Achilles tendinitis can include:

  • Stiffness and pain along the Achilles tendon (especially noticeable in the mornings)
  • Pain at the back of the heel or along the tendon (often worsens with activity)
  • Severe pain (often manifests a day after exercising)
  • Pain on squatting
  • Thickening of the tendon
  • Swelling (can get worse with activity)
  • Bone spur (in the case of insertional tendinitis)

If a sudden “pop” is felt in the heel or the back of the calf, it can be due to a torn (ruptured) Achilles tendon. There is a weakness in pushing off with the foot.

In similar scenarios, getting immediate medical attention is recommended.

Diagnosis

To accurately diagnose the condition, the ankle and the foot will be examined.

The doctor will look for the following signs:

  • Swelling (at the back of the heel) along the Achilles tendon
  • Enlargement or thickening of the Achilles tendon
  • Bony spurs (at the back of the heel or at the lower part of the tendon)
  • Maximum tenderness
  • Pain in the middle of tendon (in noninsertional tendinitis)
  • Limited motion range of the ankle (a noticeable decrease in the ability to flex the foot)

To rule out other possible underlying conditions, the following imaging tests might be required:

  • Magnetic Resonance Imaging (MRI) – while an MRI scan will not be used to diagnose Achilles tendinitis, it is considered vital when planning surgery. An MRI scan can also show the severity of the tendon damage. If surgery is required, the procedure will be based on the tendon damage severity.
  • Ultrasound scan can detect the fluid or small tears within the tendon.
  • X-rays – X-rays can be used to check if the lower part of the Achilles tendon has hardened or calcified or there may be visible bone spurs.

Treatment

Nonsurgical Treatment Options

Basically, nonsurgical treatment interventions can help alleviate the pain.

However, it will usually take months before the symptoms subside completely.

  • Rest – the first step to effectively reduce the pain is to minimize (or completely stop) doing activities that will only make the pain worse. For instance, those who do high-impact exercises should switch to low-impact, non-repetitive ones at least for the time being to lessen tendon stress.
  • Ice – placing ice on the painful area can be beneficial and can be done as needed. This can be done for at least 20 minutes each time and should be stopped when the skin starts to feel numb.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) – medications like naproxen and ibuprofen can help reduce the swelling and alleviate the pain. However, NSAIDs can’t minimize the thickening of the tendon.
  • Physical therapy – physical therapy such as ultrasound treatment is considered beneficial for patients with Achilles tendinitis although it has been proven to work better for noninsertional tendinitis than insertional tendinitis.
  • Supportive shoes and orthotics – pain from insertional Achilles tendinitis will often get better with the help of orthotic devices and supportive shoes. However, if the pain is severe, a walking boot to immobilize the ankle joint might be recommended. It will give the tendon a chance to rest before any therapy can commence.
  • Judicious injections or platelet-rich plasma (PRP) have been known to improve healing of partial tears associated with Achilles tendinitis.

Surgical Treatment

Surgery is often considered when the pain does not subside even after 6 months of conservative treatment.

In addition, the specific type of surgery that will be carried out will depend on the severity of the tendon damage and the location of the tendinitis.

  • Gastrocnemius recession – this procedure is surgical lengthening of the gastrocnemius (calf) muscles. Since tight calf muscles can increase strain on the Achilles tendon, this surgery is beneficial for those who have difficulty flexing their feet even after consistent stretching.
  • Debridement and repair – this is often the procedure done when there is less than 50 percent tendon damage. The primary goal of the procedure is to remove the tendon’s unhealthy portion which may delay healing.
  • Debridement with tendon transfer – this procedure is carried out when there is more than 50 percent tendon damage. In some cases, when more than 50 percent of the tendon requires removal, the remaining portion is no longer strong enough to function on its own. To ensure the remaining tendon does not rupture with activity, an Achilles tendon transfer is done using part of the big toe (flexor halluces) tendon.

Prevention

While there is no foolproof way to prevent Achilles tendinitis, the following measures can help reduce one’s risk significantly:

  • Gradually increase activity level – when starting an exercise regimen, start slowly and ensure any increase in the duration or intensity of training is gradual.
  • Take it easy – when possible, refrain from doing activities that will put excessive stress on the tendon. When participating in any strenuous activity, ensure to warm up first.
  • Choose proper fitting footwear – shoes worn during exercise should provide adequate heel cushioning and should come with a firm arch support to minimize tension in the Achilles tendon.
  • Stretch daily – the calf muscles and the Achilles tendon should be stretched before and after exercise in order to maintain flexibility.
  • Cross-train – to help reduce one’s risk, consider alternating between high-impact activities (i.e. running and jumping) and low-impact ones (i.e. swimming and cycling).

ACL Injuries: What are the Possible Causes?

The tough bands of fibrous tissues that connect two bones across a joint is called a ligament.

Inside the knee joint, you can find the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL).

The two ligaments connect the femur (thigh bone) to the tibia (the lower leg bone).

The PCL and the ACL form an “X” inside the knee and functions by stabilizing it against back-to-front and front-to-back (shear) forces.

When the ACL ligament is stretched beyond its normal limit or torn, an ACL injury occurs.

Causes

In majority of the cases, an ACL injury can be attributed to any of the following injury patterns:

  • A drastic stop, pivot, change in direction, and twist at the knee joint – these knee movements are often considered a routine part in sports like rugby, gymnastics, football, basketball, soccer, and skiing. Understandably, athletes who are involved in the aforementioned sports are highly susceptible to ACL tears.
  • Extreme knee hyperextension – in some cases, during athletic landings and jumps, the knee extends beyond its limit or is straightened more than it should. Similar scenarios may sometimes result in ACL tears. For instance, ACL tears can occur when landing awkwardly while playing basketball or missing a dismount when landing in gymnastics.
  • Direct contact – the ACL can get injured during contact sports especially when there is direct impact to the outside of the lower leg or the knee. A misdirected soccer kick that hits the knee, a sliding tackle while playing soccer, and a sideways football tackle are some of the likely ways the ACL can get injured. A sideways fall while skiing also commonly injures the ACL.

Just like sprains, ACL injuries are classified using the following grading system:

Grade I – this pertains to mild injuries (sprain) with only microscopic ACL tears. While the tiny tears may cause the ligament to stretch out of shape, the tears will not affect the knee joint’s overall ability to support the individual’s weight.

Grade II – this is considered a moderate injury where the ACL is partially torn or stretched. The knee can get a bit unstable and may even “give way” periodically when the person walks or stands up.

Grade III – this is considered a severe injury where the knee is very unstable and the ACL is completely torn and the knee feels unstable and wobbly.

Symptoms

Prevalent symptoms that indicate an ACL injury can include:

  • Feeling a “pop” in the knee (when the ACL tears)
  • Deformity and significant swelling (usually manifesting within a few hours after the injury)
  • Severe knee pain
  • Feeling unstable and unable to bear weight (especially if the ACL has been torn completely and there is no tension across the ligament injured)
  • A black and blue discoloration (around the affected knee secondary to bleeding from inside the knee joint)
  • A feeling that the injured knee will “give way,” “give out,” or buckle (especially when standing) many weeks or months later in untreated cases

Diagnosis

To accurately diagnose the condition, the doctor will need to physically examine the affected knee and look for signs of deformity, tenderness, discoloration, and swelling.

The knee’s range of motion will also be checked if it’s not too swollen or too painful.

The strength of the ligaments will also be assessed by the Lachman’s test or anterior drawer test. To do this, the doctor will ask the patient to bend the knee while the leg is gently pulled forward.

If the ACL is torn, a protruding “lower lip” of the knee or an “underbite” appearance will manifest.

If the physical exam of the knee will suggest a significant injury of the ACL, a magnetic resonance imaging (MRI) scan of the knee will be ordered.

In other cases, an arthroscopy (camera-guided surgery) might be required to inspect the ACL damage.

Treatment Interventions

For ACL sprains that are classified under Grade I and Grade II, the initial treatment will often follow the RICE rule:

  • Resting the affected joint
  • Icing the injured area (to minimize swelling)
  • Compressing the swelling (using an elastic bandage)
  • Elevating the injured knee

In some cases, wearing a knee brace may also be suggested.

To ease the pain and minimize the swelling, taking nonsteroidal anti-inflammatory drugs (NSAIDs) will be prescribed. Needle aspiration of the knee to remove blood from the joint also relieves pain very quickly.

When the pain has subsided, a rehabilitation program designed to strengthen the muscles around the knee will be recommended.

Generally, treatment for ACL injuries will depend on the patient’s activity level.

For instance, surgery might be the ideal treatment route for those who need to return to playing sports that will require jumping and pivoting.

Grade III injuries are also initially treated with RICE, bracing, and rehabilitation.

Once the swelling has subsided, the torn ACL is surgically reconstructed using a piece of the patient’s own tissue (autograft) or a donor tissue (allograft).

In the case of autografts, the torn tendon may be replaced by the patient’s own patellar tendon or a tendon section taken from a large leg muscle.

Recently, most knee reconstructions are carried out through arthroscopic surgery.

The procedure has become the preferred option since it will require smaller incisions and will cause less trauma and scarring.