Ganglion

Ganglion (Cyst) of the Wrist 

A wrist ganglion can appear on the A, back (dorsum) of the hand or B, on the underside.
Ganglion cysts arise from the capsule of a joint or the sheath of a tendon. They can be found at different places on the wrist. A ganglion cyst that grows on the top of the wrist is called a dorsal ganglion. Others are found on the underside of the wrist between the thumb and your pulse point, at the end joint of a finger, or at the base of a finger. Most of the time, these are harmless and will often disappear in time.

Cause 

A ganglion cyst contains a thick, clear, mucus-like fluid similar to the fluid found in the joint. No one knows what triggers the formation of a ganglion. Women are more likely to be affected than men. Ganglia are common among gymnasts, who repeatedly apply stress to the wrist.



Symptoms

Wrist ganglion. 

Because the fluid-filled sac puts pressure on the nerves that pass through the joint, some ganglion cysts may be painful. Large ganglia, even if they are not painful, are unattractive. Smaller ganglions that remain hidden under the skin (occult ganglions) may be quite painful.

A ganglion grows out of a joint, like a balloon on a stalk. It rises out of the connective tissues between bones and muscles. Inside the balloon is a thick, slippery fluid similar to the fluid in your joints. Usually, the more active the wrist, the larger the cyst becomes. With rest, the lump generally decreases in size.


Diagnosis 

Your doctor may ask you how long you have had the ganglion, whether it changes in size, and whether it is painful. Pressure may be applied to identify any tenderness. A penlight may be held up to the cyst to see whether light shines through. X-rays may be taken to rule out other conditions, such as arthritis or a bone tumor. Sometimes, an MRI or ultrasound is needed to find a ganglion cyst that is not visible.



Treatment 

Initial treatment is not surgical.

• Observation.
Because the ganglion is not cancerous and may disappear in time, just
waiting and watching may be enough to make sure that no unusual changes occur.
• Immobilization.
Activity often causes the ganglion to increase in size. This is because
activity increases pressure on nerves, causing pain. A wrist brace or splint may relieve symptoms, letting the ganglion decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.
• Aspiration.
If the ganglion causes a great deal of pain or severely limits activities, the
fluid may be drained from it. This procedure is called "aspiration." The area around the ganglion cyst is numbed and the cyst is punctured with a needle so that the fluid drains away.

Nonsurgical treatment leaves the outer shell and the stalk of the ganglion intact, so it may reform and reappear.

The ganglion cyst can be removed through outpatient surgery, but this is no guarantee that the cyst will not grow again. Surgery may also include removing part of the involved joint capsule or tendon sheath. There may be some tenderness, discomfort, and swelling after surgery. Normal activities usually may be resumed two to six weeks after surgery.

Frozen Shoulder

Frozen shoulder is characterized by pain and loss of motion or stiffness in the shoulder. It affects about two percent of the general population. Frozen shoulder most commonly affects patients between the ages of 40 and 60 years, with no clear predisposition based on sex, arm dominance, or occupation.

Cause 

Anatomy of the shoulder, showing the ligaments and bones.

The causes of frozen shoulder are not fully understood. The process involves thickening and contracture of the capsule surrounding the shoulder joint.

Frozen shoulder occurs much more commonly in individuals with diabetes, affecting 10 percent to 20 percent of these individuals. Other medical problems associated with increased risk of frozen shoulder include: hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease or surgery.

Frozen shoulder can develop after a shoulder is immobilized for a period of time. Attempts to prevent frozen shoulder include early motion of the shoulder after it has been injured.

Symptoms 

Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. The pain is usually located over the outer shoulder area and sometimes the upper arm.


The hallmark of the disorder is restricted motion or stiffness in the shoulder. The affected individual cannot move the shoulder normally. Motion is also limited when someone else attempts to move the shoulder for the patient.

Some physicians have described the normal course of a frozen shoulder as having three stages:

• Stage one: In the "freezing" stage, the patient develops a slow onset of pain. As the pain worsens, the shoulder loses motion. This stage may last from six weeks to nine months.
• Stage two: The "frozen" stage is marked by a slow improvement in pain, but the stiffness remains. This stage generally lasts four months to nine months.
• Stage three: The final stage is the "thawing," during which shoulder motion slowly returns toward normal. This generally lasts five months to 26 months.


Diagnosis 

A doctor can diagnose frozen shoulder based on the patient's symptoms and a physical examination.

X-rays or MRI (magnetic resonance imaging) studies are sometimes used to rule out other causes of shoulder stiffness and pain, such as a rotator cuff tear.

Treatment 

Frozen shoulder will generally get better on its own. However, this takes some time, occasionally up to two to three years. Treatment is aimed at pain control and restoring motion.


Nonsurgical Treatment 

Pain control can be achieved with anti-inflammatory medications. These can include pills taken by mouth, such as ibuprofen, or by injection, such as corticosteroids.


Physical therapy is used to restore motion. This may be under the direct supervision of a physical therapist or via a home program. Therapy includes stretching or range-of-motion exercises for the shoulder. Sometimes, heat is used to help decrease pain. Examples of some of the exercises that might be recommended can be seen in the following figures.

If these methods fail, nerve blocks are sometimes used to limit pain and allow more aggressive physical therapy.


More than 90 percent of patients improve with these relatively simple treatments. Usually, the pain resolves and motion improves. However, in some cases, even after several years the motion does not return completely and a small amount of stiffness remains.


Surgical Treatment 

Surgical intervention is considered when there is no improvement in pain or shoulder motion after an appropriate course of physical therapy and anti-inflammatory medications. When more invasive measures are considered, the patient must always consider that most individuals will get better if given sufficient time and that surgery always has risk involved.

Surgical intervention is aimed at stretching or releasing the contracted joint capsule of the shoulder. The most common methods include manipulation under anesthesia and shoulder arthroscopy:

Manipulation under anesthesia involves putting the patient to sleep and forcing the shoulder to move. This process causes the capsule to stretch or tear.

With shoulder arthroscopy, the surgeon makes several small incisions around the shoulder. A small camera and instruments are inserted through the incisions. These instruments are used to cut through the tight portions of the joint capsule.

Often, manipulation and arthroscopy are used together in combination to obtain maximum results. Most patients have very good results with these procedures.

After surgery, physical therapy is important to maintain the motion that was achieved with surgery. Recovery time varies, from six weeks to three months.

Flexible Flatfoot

Flexible Flatfoot in Children 

Flexible flatfoot is a condition in which the arch of the foot shrinks or disappears upon standing. Upon sitting or when the child is on tiptoes, the arch reappears. Parents and other family members often worry needlessly that an abnormally low or absent arch in a child's foot will lead to permanent deformities or disabilities. Most children eventually outgrow flexible flatfoot without any problems. The condition usually is painless and does not interfere with walking or sports participation.

Flexible flatfoot, showing the absence of an arch when standing.

Symptoms 

A flexible flatfoot has normal muscle function and good joint mobility and is considered to be a variation of normal. As the child grows and walks on it, the foot's soft tissues tighten, shaping its arch gradually. Flexible flatfoot often continues until the child is at least age 5 years or older. If flexible flatfoot continues into adolescence, the child may experience aching pain along the
bottom of the foot. A doctor should be consulted if the child's flatfeet cause pain.


Diagnosis 

To make the diagnosis, the doctor will examine the child to rule out other types of flatfeet that may require treatment. These include flexible flatfoot with a tight heel cord, or rigid flatfoot, which is a more serious condition.

The doctor will look for patterns of wear on the child's everyday shoes. Tell the doctor if anyone else in the family is flatfooted, as this may be an inherited condition. It is important to know about any known neurological or muscular disease in the child.

The arch disappears when standing (left) and reappears when the child is on tiptoes (right).

The doctor may ask the child to sit, stand, raise the toes while standing, and stand on tiptoe. He or she will probably examine the child's heel cord (Achilles tendon) for tightness and may check the bottom of the foot for calluses.

Treatment 

Nonsurgical Treatment 

Treatment for flexible flatfoot is required only if the child is experiencing symptoms of discomfort from the condition.

If the child has activity-related pain or tiredness in the foot/ankle or leg, the doctor may recommend stretching exercises for the heel cord.

A child at age 3 years (left) with flexible flatfoot. The same child at age 15 years (right) has a normal arch despite having received no treatment.

If discomfort continues, the doctor may recommend shoe inserts. Soft-, firm-, and hard-molded arch supports may relieve the child's foot pain and fatigue in many cases. They can also extend the life of his or her shoes, which may otherwise wear unevenly. Sometimes a doctor may prescribe physical therapy or casting if your child has flexible flatfoot with tight heel cords.


Surgical Treatment 

Occasionally, surgical treatment will be necessary for an adolescent with persistent pain. A small number of flexible flatfeet become rigid instead of correcting with growth. These cases may need further medical evaluation.

Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a condition where the bones of the hip are abnormally shaped. Because they do not fit together perfectly, the hip bones rub against each other and cause damage to the joint.

Anatomy 

The hip is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

A slippery tissue called articular cartilage covers the surface of the ball and the socket. It creates a smooth, low friction surface that helps the bones glide easily across each other.

The acetabulum is ringed by strong fibrocartilage called the labrum. The labrum forms a gasket around the socket, creating a tight seal and helping to provide stability to the joint.

In a healthy hip, the femoral head fits perfectly into the acetabulum.

Description 

In FAI, bone spurs develop around the femoral head and/or along the acetabulum. The bone overgrowth causes the hip bones to hit against each other, rather than to move smoothly. Over time, this can result in the tearing of the labrum and breakdown of articular cartilage (osteoarthritis).


Types of FAI 

There are three types of FAI: pincer, cam, and combined impingement.

Pincer. This type of impingement occurs because extra bone extends out over the normal rim of the acetabulum. The labrum can be crushed under the prominent rim of the acetabulum.

Cam. In cam impingement the femoral head is not round and cannot rotate smoothly inside the acetabulum. A bump forms on the edge of the femoral head that grinds the cartilage inside the acetabulum.

Combined. Combined impingement just means that both the pincer and cam types are present.
(Left) Pincer impingement. (Right) Cam impingement.



How FAI Progresses 

It is not known how many people may have FAI. Some people may live long, active lives with FAI and never have problems. When symptoms develop, however, it usually indicates that there is damage to the cartilage or labrum and the disease is likely to progress. Symptoms may include pain, stiffness, and limping.



Cause 

FAI occurs because the hip bones do not form normally during the childhood growing years. It is the deformity of a cam bone spur, pincer bone spur, or both, that leads to joint damage and pain. When the hip bones are shaped abnormally, there is little that can be done to prevent FAI.

Because athletically active people may work the hip joint more vigorously, they may begin to experience pain earlier than those who are less active. However, exercise does not cause FAI.



Symptoms 

People with FAI usually have pain in the groin area, although the pain sometimes may be more toward the outside of the hip. Sharp stabbing pain may occur with turning, twisting, and squatting, but sometimes, it is just a dull ache.


Home Remedies 

When symptoms first occur, it is helpful to try and identify an activity or something you may have done that could have caused the pain. Sometimes, you can just back off on your activities, let your hip rest, and see if the pain will settle down. Over-the-counter anti-inflammatory medicines (ibuprofen, naproxen) may help.


If your symptoms persist, you will need to see a doctor to determine the exact cause of your pain and provide treatment options. The longer painful symptoms go untreated, the more damage FAI can cause in the hip.


Doctor Examination 

During your first appointment, your doctor will discuss your general health and your hip symptoms. He or she will also examine your hip.


Impingement Test 

As part of the physical examination, your doctor will likely conduct the impingement test. For this test, your doctor will bring your knee up towards your chest and then rotate it inward towards your opposite shoulder. If this recreates your hip pain, the test result is positive for impingement.


Imaging Tests 

Your doctor may order imaging tests to help determine whether you have FAI.

X-rays. These provide good images of bone, and will show whether your hip has abnormally shaped bones of FAI. X-rays can also show signs of arthritis.

Computed tomography (CT) scans. More detailed than a plain x-ray, CT scans help your doctor see the exact abnormal shape of your hip.

Magnetic resonance imaging (MRI) scans. These studies can create better images of soft tissue. They will help your doctor find damage to the labrum and articular cartilage. Injecting dye into the joint during the MRI may make the damage show up more clearly. Your doctor may also inject a numbing medicine into the joint as a diagnostic test. If the numbing medicine provides temporary pain relief, it confirms that FAI is the problem.


Treatment 

Nonsurgical Treatment 

Activity changes. Your doctor may first recommend simply changing your daily routine and avoiding activities that cause symptoms.

Non-steroidal anti-inflammatory medications. Drugs like ibuprofen can be provided in a prescription-strength form to help reduce pain and inflammation.


Physical therapy. Specific exercises can improve the range of motion in your hip and strengthen the muscles that support the joint. This can relieve some stress on the injured labrum or cartilage.


Surgical Treatment 

If tests show joint damage caused by FAI and your pain is not relieved by nonsurgical treatment, your doctor may recommend surgery.

Many FAI problems can be treated with arthroscopic surgery. Arthroscopic procedures are done with small incisions and thin instruments. The surgeon uses a small camera, called an arthroscope, to view inside the hip.

During arthroscopy, your doctor can repair or clean out any damage to the labrum and articular cartilage. He or she can correct the FAI by trimming the bony rim of the acetabulum and also shaving down the bump on the femoral head. Some severe cases may require an open operation with a larger incision to accomplish this.


(Left) During arthroscopy, your surgeon inserts an arthroscope through a small incision about the size of a buttonhole. (Right) Other instruments are
inserted through separate incisions to treat the problem.


Long-Term Outcomes 

Surgery can successfully reduce symptoms caused by impingement. Correcting the impingement can prevent future damage to the hip joint. However, not all of the damage can be completely fixed by surgery, especially if treatment has been put off and the damage is severe. It is possible that more problems may develop in the future.

While there is a small chance that surgery might not help, it is currently the best way to treat painful FAI.

Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) is an unusual disorder of the adolescent hip. It is not rare. For reasons that are not well understood, the ball at the upper end of the femur (thigh bone) slips off in a backward direction. This is due to weakness of the growth plate. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty.

The patient's left hip (arrow) shows that a slight shift of the head of the femur occurred through the growth plate.


The condition is diagnosed based on a careful history, physical examination, observation of the gait/walking pattern, and X-rays of the hip. The X-rays help confirm the diagnosis by demonstrating that the upper end of the thigh bone does not line up with the portion called the femoral neck.


Risk Factors 

The cause of SCFE is unknown. It occurs two to three times more often in males than females. A large number of patients are overweight for their height. In most cases, slipping of the epiphysis is a slow and gradual process. However, it may occur suddenly and be associated with a minor fall or trauma. Symptomatic SCFE, treated early and well, allows for good long-term hip function.

Symptoms 

The typical patient has a history of several weeks or months of hip or knee pain and an intermittent limp. The appearance of the adolescent is characteristic. He or she walks with a limp. In certain severe cases, the adolescent will be unable to bear any weight on the affected leg. The affected leg is usually turned outward in comparison to the normal leg. The affected leg may also appear to be shorter.



Diagnosis 

The physical examination will show that the hip does not have full and normal range of motion. There is often a loss of complete hip flexion and ability to fully rotate the hip inward. Because of inflammation in the hip, there is often pain at the extremes of motion and involuntary muscle guarding and spasm.



Treatment 

The goal of treatment, which requires surgery, is to prevent any additional slipping of the femoral head until the growth plate closes. If the head is allowed to slip farther, hip motion could be limited. Premature osteoarthritis could develop. Treatment should be immediate. In most cases, treatment begins within 24 to 48 hours.

Early diagnosis of SCFE provides the best chance to achieve the treatment goal of stabilizing the hip.
A screw is inserted to prevent any further slip of the femoral head through the growth plate.
Fixing the femoral head with pins or screws has been the treatment of choice for decades.
Depending on the severity of he child's condition, the surgeon will recommend one of three surgical options.

• Placing a single screw into the thighbone and femoral epiphysis.
• Reducing the displacement and placing one or two screws into the femoral head.
• Removing the abnormal growth plate and inserting screws to aid in preventing    any further displacement.


Complications 

There are several potential complications associated with a slipped capital femoral epiphysis. The most common are avascular necrosis (AVN) of the femoral head and chondrolysis.

Avascular necrosis means that the blood supply to the femoral head has been permanently altered by the femoral head slipping. There is no way to identify children at risk for avascular necrosis or to prevent this complication. Evidence of avascular necrosis may not be seen on X-rays for as long as 6 to 24 months following surgery.
Chondrolysis, or loss of articular cartilage of the hip joint, is a major complication of SCFE. It may cause the hip to stiffen with a permanent loss of motion, flexion contracture, and pain. The loss of motion may be a result of an inflammation in the hip joint. This is still not fully understood by surgeons. Aggressive physical therapy and anti-inflammatory medications may be prescribed for this rare complication. There may be some return of motion.



Care After Surgery 

Most likely, the child will be admitted to the hospital by a pediatric orthopaedist. Surgery is usually performed within 24 to 48 hours. After surgery, the child will be on crutches for weeks to months. A physical therapist will demonstrate how to use crutches. The doctor will give you specific instruction about your child's weight-bearing status and activity restrictions. Follow the instructions closely.

It is important that your child be followed closely for 18 to 24 months after surgery. After the immediate postoperative period, X-rays every 3 to 4 months are needed to ensure that the abnormal growth plate has fused.

Your child may be restricted from certain sports and activities during this time of recuperation. This helps to minimize the chance of further complications. The fusion must be mature enough to prevent further slippage. Then, vigorous physical activities can begin.

Elbow (Olecranon) Bursitis

Description 

The bursa is a slippery sac between the loose skin and the bones of the elbow. It is located at the tip of the elbow. The bursa allows the skin to move freely over the underlying bone. Normally, the bursa is flat. If it becomes irritated or inflamed, a condition known as bursitis develops.

Cause 

Elbow bursitis can occur for a number of reasons.

• Trauma: A hard blow to the tip of the elbow could cause the bursa to produce    excess fluid and swell.
• Prolonged Pressure: Leaning on the tip of the elbow for long periods of time on    hard surfaces, such as a tabletop, may cause the bursa to swell. Typically, this    type of bursitis would develop over several months.
• Infection: If the tip of the elbow has an injury that breaks the skin, such as an    insect bite or a scrape, bacteria may get inside the bursa and cause an infection.    The infected bursa produces fluid, redness, and swelling. If the infection goes    untreated, the fluid may turn to pus.
• Medical Conditions: Certain conditions such as rheumatoid arthritis and gout are
   associated with development of elbow bursitis.


Symptoms 

Swelling is often the first symptom. The skin on the back of the elbow is loose, which means that a small amount of swelling may not be noticed right away. As the swelling continues, the bursa grows. This causes pain as the bursa is stretched, because the bursa contains nerve endings. The swelling may grow large enough to restrict motion of the elbow.

If the bursitis is infected, the skin becomes red and warm. If the infection is not treated right away, it may spread to other parts of the arm or move into the bloodstream. This can cause serious illness.


Diagnosis 

An X-ray may be taken to look for a foreign body or a bone spur. Bone spurs are often found on the tip of the bone of the elbow in patients who repeatedly have elbow bursitis.


Treatment 

Nonsurgical Treatment 

Elbow bursitis due to infection. 

If the doctor suspects that bursitis is due to an infection, he or she may remove fluid (aspirate) from the swollen area. This is commonly performed as an office procedure. Fluid removal helps relieve symptoms and gives the doctor a sample that can be looked at in a laboratory to identify if any bacteria are growing. This also lets the doctor know if a specific antibiotic is needed to fight the infection.

Often, the doctor may prescribe antibiotics before the exact bacterium can be identified. This is done to prevent infection from progressing. The antibiotic that the doctor uses at this point will cover a number of possible infections.

If the bursitis is not from an infection, it is treated through a number of options. The elbow is elevated and ice is applied. An elbow pad may be used to cushion the elbow. Direct pressure to the swollen elbow should be avoided. Oral medications such as ibuprofen or other antiinflammatories may also be used.

If swelling and pain do not respond to these measures, the doctor may recommend removing fluid from the bursa and inject a corticosteroid medication into the bursa. The steroid medication is an anti-inflammatory drug that is stronger than the medication that can be taken without a prescription.



Surgical Treatment 

If the bursa is infected and it does not improve with antibiotics or by removing fluid from the elbow, surgery may be needed. This is an inpatient procedure.

If elbow bursitis is not a result of infection, surgery may still be needed if nonsurgical treatments don't work. Surgery to remove the bursa is usually performed as an outpatient procedure. The surgery does not disturb any muscle, ligament, or joint structure.


Rehabilitation 

Physical therapy after surgery is not always needed. Postoperative casting or prolonged immobilization is not typically required.

Developmental Dislocation

Developmental Dislocation (Dysplasia) of the Hip (DDH) 

Developmental dysplasia (dislocation) of the hip (DDH) is an abnormal formation of the hip joint in which the ball on top of the thighbone (femur) is not held firmly in the socket. In some instances, the ligaments of the hip joint may be loose and stretched.

The degree of hip looseness, or instability, varies in DDH. In some children, the thighbone is simply loose in the socket at birth. In other children, the bone is completely out of the socket. In still other children, the looseness worsens as the child grows and becomes more active.

In a normal hip, the head of the femur is firmly inside the hip socket. In some cases of DDH, the thighbone is completely out of the hip socket.

Pediatricians screen for DDH at a newborn's first examination and at every well-baby checkup thereafter. When the condition is detected at birth, it can usually be corrected. But if the hip is not dislocated at birth, the condition may not be noticed until the child begins walking. At this time, treatment is more complicated and uncertain.

Left untreated, DDH can lead to pain and osteoarthritis by early adulthood. It may produce a difference in leg length or a "duck-like" gait and decreased agility. If treated successfully (and the earlier the better), children regain normal hip joint function. However, even with appropriate treatment, especially in children 2 years or older, hip deformity and osteoarthritis may develop later in life.

Cause 

DDH tends to run in families. It can be present in either hip and in any individual. It usually affects the left hip and is predominant in:

• Girls
• First-born children
• Babies born in the breech position (especially with feet up by the shoulders).

The American Academy of Pediatrics now recommends ultrasound DDH screening of all female breech babies.

Symptoms 

Some babies born with a dislocated hip will show no outward signs.

Contact a pediatrician if your baby has:

• Legs of different lengths
• Uneven skin folds on the thigh
• Less mobility or flexibility on one side
• Limping, toe walking, or a waddling, duck-like gait


Doctor Examination 

In addition to visual clues, the doctor will use careful physical examination tests to check for DDH, such as listening and feeling for "clunks" as the hip is manipulated. For older infants and children, X-rays of the hip may be taken.



Nonsurgical Treatment 

Treatment methods depend on the child's age.

Newborns 

Newborns are placed in a Pavlik harness for 1 to 2 months to treat DDH.

Newborns are placed in a Pavlik harness for 1 to 2 months to treat DDH. The baby is placed in a soft positioning device, a Pavlik harness, for 1 to 2 months to keep the thighbone in the socket. This will help tighten the ligaments around the hip joint and promote normal hip socket formation.



1 to 6 months 

The baby's thighbone is repositioned in the socket using a harness or similar device. The method is usually successful. But if it is not, the doctor may have to anesthetize the baby and move the thighbone into proper position, and then put the baby into a body cast (spica).


Surgical Treatment 


6 months to 2 years 

The child is placed under anesthesia, and the thigh bone is manipulated into the proper position in the socket. Open surgery is sometimes necessary. Afterwards, the child is placed into a body cast (spica) to maintain the hip position.


Older than 2 years 

Deformities may worsen, making open surgery necessary to realign the hip. Afterwards, the child is placed into a body cast (spica) to maintain the hip in the socket.

In many children with DDH, a body cast and/or brace is required to keep the hip bone in the joint during healing. X-rays and other regular follow-up monitoring are needed after DDH treatment until the child's growth is complete.


Complications 

Complications of treatment may include a delay in walking if the child was placed in a body cast. The Pavlik harness and other positioning devices may cause skin irritation, and a difference in leg length may remain. Growth disturbances of the upper thigh rarely occur.

Dupuytren's Contracture

Dupuytren's contracture is a thickening of the fibrous tissue layer underneath the skin of the palm and fingers. Although painless, the thickening and tightening (contracture) of this fibrous tissue can cause the fingers to curl (flex).

Dupuytren's contracture is more common in men than in women.

Cause 


Symptoms of Dupuytren's contracture include painful bumps (nodules) under the skin that develop into tight bands of tissue, causing the
fingers to curl.

The cause of Dupuytren's contracture is not known. It is not caused by an injury or heavy hand use.

There are factors that put people at greater risk for developing Dupuytren's contracture.

• It is most common in people of Northern European (English, Irish, Scottish,    French, Dutch) or Scandinavian (Swedish, Norwegian, Finnish) ancestry.
• It often runs in families (hereditary).
• It may be associated with drinking alcohol.
• It is associated with certain medical conditions, such as diabetes and seizures.
• It increases in frequency with age.


Symptoms 

Dupuytren's contracture symptoms usually occur very gradually.

Nodules. One or more small, tender lumps (nodules) form in the palm. Over time, the tenderness usually goes away.

Bands of tissue. The nodules may thicken and contract, forming tough bands of tissue under the  skin.

Curled fingers. One or more fingers bend (flex) toward the palm. The ring and little fingers are  most commonly affected, but any or all fingers can be involved. As the bend in the finger  increases, it may be hard to straighten your finger. Grasping large objects and putting your hand  in a pocket becomes difficult.



Doctor Examination 

Your doctor will examine your hand and test the feeling in your thumb and fingers. Your grip and pinch strength may also be tested.

During the examination, your doctor will record the locations of nodules and bands on your palm. Using a special device, he or she will measure the amount of contracture in your fingers.
Your doctor may also measure the range of motion in your fingers to determine whether there is limitation in your flexion.


Your doctor will measure the bend in your finger, and note where the bands of tissue and nodules are.

Your doctor will refer back to these measurements throughout your treatment to determine whether the disease is progressing.



Treatment 

There is no way to stop or cure Dupuytren's contracture. However, it is not dangerous.
Dupuytren's contracture usually progresses very slowly and may not become troublesome for years. It may never progress beyond lumps in the palm.

If the condition progresses, nonsurgical treatment may help to slow the disease.



Nonsurgical Treatment 

Steroid injection. If a lump is painful, an injection of corticosteroid -a powerful antiinflammatory medication -may help relieve the pain. In some cases, it may prevent the progression of contracture. Several injections may be needed for a lasting effect.

Splints. Splinting does not prevent increased bend in the finger. Forceful stretching of the contracted finger will not help either, and may speed the progression of contracture.


Surgical Treatment 

Surgery is recommended when your doctor has confirmed through measurements over time that the disease is progressing. Some patients turn to surgical treatment when hand function is limited; they have trouble grasping objects or putting their hands in their pockets.

Surgical procedure. Surgery for Dupuytren's contracture divides or removes the thickened bands to help restore finger motion. Sometimes the wound is left open and allowed to heal gradually. Skin grafting may be needed.

Complications. Although rare, risks of surgery include injury to nerves and blood vessels, and infection. Permanent stiffness of the fingers may occur, although this is also rare.

Recovery. Some swelling and soreness are expected after surgery, but severe problems are rare.

After surgery, elevating your hand above your heart and gently moving your fingers help to  relieve pain, swelling, and stiffness.

Physical therapy may be helpful during recovery after surgery. Specific exercises can help strengthen your hands and help you move your fingers.

Most people will be able to move their fingers better after surgery.

Recurrence. Approximately 20% of patients experience some degree of recurrence. This may require further surgery.


New Developments 

Experiments are being performed with enzyme injections that may be able to break down the tough bands and improve motion without surgery. Early results are promising, but these injections are not available for general use at this time.

A new, less invasive procedure called needle aponeurotomy is being performed by some hand surgeons. Recovery is much faster, but long-term outcome is unknown. The procedure requires special technical expertise and has greater risk of nerve and/or vessel damage.

Down Syndrome: Musculoskeletal Effects

Down syndrome is one of the most common genetic disorders. According to the Centers for Disease Control and Prevention, it affects about 13 babies in every 10,000 births. Its primary  effect is mental retardation and a number of physical abnormalities.

The child may have special medical problems of the heart, stomach, eyes and other parts of the  body. Some problems in Down syndrome involve the bones and joints (musculoskeletal system).

Symptoms 


X-ray of the pelvis shows that the patient's left hip is dislocated.

A child with Down syndrome may have weak muscle tone (hypotonia). He or she may also have  ligaments that are too loose (ligament laxity). This leads to excessive joint flexibility.

Associated  findings include:

•  Developmental delays. A child with Down syndrome will eventually reach the same  growth milestones as other children. But, he or she may be slow learning to turn over, sit,  stand, walk or do other physical activities.
•  Joint instability. Children with Down syndrome may have joints, such as the hip or  knee, which slip out of place or become dislocated. Joint laxity in the neck may be  excessive. This can lead to compression of the spinal cord.
•  Other Problems. Down syndrome may also lead to other problems, such as flat feet and  bunions.


Nonsurgical Treatment 

Getting early medical care and treatment (intervention) can improve the health of a child with  Down syndrome and address some musculoskeletal problems.

Because children grow most rapidly during the first three years of life, it is important that the  child have a comprehensive medical examination at birth.


Physical Therapy 

The doctor may recommend a special program of physical therapy, exercise, and other activities  early on. Early intervention can help a child with Down syndrome achieve developmental skills  and build muscle tone and coordination. It can also give extra stimulation and encouragement to  help the child achieve his or her full potential in life. Many children with Down syndrome go on  to hold jobs and live independently well into middle age and beyond.

Early diagnosis and treatment is also important for managing orthopaedic problems in children with Down syndrome. Some children may need splints or other devices for physical activity.  Sometimes your doctor may refer you to a pediatric orthopaedist for specialized help or surgery.



Neck Instability 

In some people with Down syndrome, the upper part of the spine (cervical) is abnormal under  the base of the skull. Muscles are weak and ligaments may be looser than they should be.
Potentially, this can cause bones (vertebrae) in the neck to press on the spinal cord, leading to an inability to coordinate muscle movement and weakness.

Any progressive changes in a child with Down syndrome should be brought to the doctor's  attention. These changes may include:

•  Weakness, clumsiness and tripping
•  Walking with stiff legs
•  Having a stiff neck, neck pain, and headaches
•  The doctor may recommend taking X-rays of your child's neck to look for joint laxity. In  some cases, a child may be kept out of contact sports or other activities that put stress on  the neck, such as high jumping, diving, gymnastics, and using a trampoline.


Staying Active 

A child with Down syndrome should be encouraged to be physically active and consume a  healthy diet. This will help them avoid excess weight gain and other physical problems. Your  doctor can help develop a well-rounded exercise routine that includes aerobic activity, strength  training, and stretching exercises.


Surgical Treatment 

Occasionally, a child with Down syndrome may need a type of surgery called spinal fusion to  hold the bones in the neck together. This will prevent excessive pressure on the spinal cord.

Surgery may also occasionally be needed to manage looseness of the hip and knee joints and  looseness of the joints in the feet.

De Quervain's Tendinitis

De Quervain's tendinitis occurs when the tendons around the base of the thumb are irritated or constricted. The word "tendinitis" refers to a swelling of the tendons. Thickening of the tendons can cause pain and tenderness along the thumb side of the wrist. This is particularly noticeable when forming a fist, grasping or gripping things, or when turning the wrist.

Anatomy
Two of the main tendons to the thumb pass through a tunnel (or series of pulleys) located on the thumb side of the wrist. Tendons are rope-like structures that attach muscle to bone. Tendons are covered by a slippery thin soft-tissue layer, called synovium. This layer allows the tendons to slide easily through the tunnel. Any swelling of the tendons located near these nerves can put pressure on the nerves. This can cause wrist pain or numbness in the fingers. De Quervain tenosynovitis of the first extensor compartment.



Causes
De Quervain's tendinitis is caused when tendons on the thumb side of the wrist are swollen or irritated. The irritation causes the lining (synovium) around the tendon to swell, which changes the shape of the compartment. This makes it difficult for the tendons to move as they should.
Tendinitis may be caused by overuse. It can be seen in association with pregnancy. It may befound in inflammatory arthritis, such as rheumatoid disease. De Quervain's tendinitis is usually most common in middle-aged women.

Symptoms
Signs of De Quervain's tendinitis:
• Pain may be felt over the thumb side of the wrist. This is the main symptom. The    pain may appear either gradually or suddenly. Pain is felt in the wrist and can    travel up the forearm. The pain is usually worse when the hand and thumb are in     use. This is especially true when forcefully grasping objects or twisting the wrist.
• Swelling may be seen over the thumb side of the wrist. This swelling may occur    together with a fluid-filled cyst in this region.
• A "catching" or "snapping" sensation may be felt when moving the thumb.
• Pain and swelling may make it difficult to move the thumb and wrist.
• Numbness may be experienced on the back of the thumb and index finger. This    is caused as the nerve lying on top of the tendon sheath is irritated.



Diagnosis
The Finkelstein test is conducted by making a fist with the fingers closed over the thumb and the wrist is bent toward the little finger. Finkelstein test. Arrow indicates location of pain when test is positive.

The Finkelstein test can be quite painful for the person with De Quervain's tendinitis. Tenderness directly over the tendons on the thumb side of the wrist is a common finding with this test.

Treatment
The goal in treating de Quervain's tendinitis is to relieve the pain caused by irritation and swelling.

Nonsurgical Treatment
• Splints. Splints may be used to rest the thumb and wrist.
• Anti-inflammatory medication (NSAIDs). These medications can be taken by
mouth or injected into that tendon compartment. They may help reduce the swelling and relieve the pain.
• Avoiding activities that cause pain and swelling. This may allow the symptoms to
go away on their own.
• Corticosteroids. Injection of corticosteroids into the tendon sheath may help reduce swelling and pain.


Surgical Treatment
Surgery may be recommended if symptoms are severe or do not improve. The goal of surgery is to open the compartment (covering) to make more room for the irritated tendons. Normal use of the hand usually can be resumed once comfort and strength have returned. Your orthopaedic surgeon can advise you on the best treatment for your situation.

Corns

Every day, the average person spends several hours on their feet and takes several thousand steps. Walking puts pressure on your feet that's equivalent to 2-3 times your body weight. No wonder your feet hurt!

Actually, most foot problems can be blamed not on walking but on your walking shoes. Corns, for example, are calluses that form on the toes because the bones push up against the shoe and put pressure on the skin. The surface layer of the skin thickens and builds up, irritating the tissues underneath. Hard corns are usually located on the top of the toe or on the side of the small
toe. Soft corns resemble open sores and develop between the toes as they rub against each other.

Cause

• Shoes that don't fit properly. If shoes are too tight, they squeeze the foot, increasing pressure. If they are too loose, the foot may slide and rub against the shoe, creating friction.
• Toe deformities, such as hammer toe or claw toe.
• High heeled shoes because they increase the pressure on the forefoot.
• Rubbing against a seam or stitch inside the shoe.
• Socks that don't fit properly.

Diagnosis and Treatment

Corns can usually be easily seen. They may have a tender spot in the middle, surrounded by yellowish dead skin. Treating foot problems like corns is a team effort. You will need to work with your physician to ensure that problems don't recur.

During your office visit

• To restore the normal contour of the skin and relieve pain, your doctor may trim the corn by shaving the dead layers of skin off with a scalpel. This procedure should be done by a professional, and not by yourself, particularly if you have poor circulation, poor eyesight, or a lack of feeling in your feet.
• If the doctor discovers an underlying problem, such as a toe deformity, he or she can correct it. Most surgeries can be done on an outpatient basis.
At home
• You can soak your feet regularly and use a pumice stone or callus file to soften and reduce the size of corns and calluses.
• Wearing a donut-shaped foam pad over the corn will also help relieve the pressure. Use non-medicated corn pads; medicated pads may increase irritation and result in infection.
• Use a bit of lamb's wool (not cotton) between your toes to help cushion soft corns.
• Wear shoes that fit properly and have a roomy toe area.

Congenital Scoliosis

Congenital scoliosis is a sideways curvature of the spine that is caused by a
defect that was present at birth. It occurs in only 1 in 10,000 newborns and is
much less common than the type of scoliosis that begins in adolescence.
Children with congenital scoliosis sometimes have other health issues, such as
kidney or bladder problems.

Even though congenital scoliosis is present at birth, it is sometimes impossible to
see any spine problems until a child reaches adolescence.

Types of Congenital Scoliosis

A single hemivertebra in the lower back shown in a 3-D image from a computed
tomography (CT) scan. Note the four normal rectangular vertebra below the
single triangular-shaped hemivertebra (arrow). This wedged vertebra creates the
deformity that would not have otherwise been there.


Incomplete Formation of Vertebrae

As the spine forms before birth, part of one vertebra (or more) may not form
completely. When this occurs, the abnormality is called a hemivertebra and can
produce a sharp angle in the spine. The angle can get worse as the child grows.
This abnormality can happen in just one vertebra or in many throughout the
spine. When there is more than one hemivertebra, they will sometimes balance
each other out and make the spine more stable.

Failure of Separation of Vertebrae

During fetal development, the spine forms first as a single column of tissue that
later separates into segments that become the bony vertebrae. If this separation
is not complete, the result may be a partial fusion (boney bar) joining two or
more vertebrae together.
Such a bar prevents the spine from growing on one side after a child is born.
This results in a spinal curve that increases as a child grows.


Combination of Bars and Hemivertebrae

The combination of a bar on one side of the spine and a hemivertebra on the
other causes the most severe growth problem. These cases can require surgery
at an early age to stop the increased curvature of the spine.

Compensatory Curves

In addition to scoliosis curves, a child's spine may also develop compensatory
curves in order to maintain an upright posture. This occurs when the spine tries
to make up for a scoliosis curve by creating other curves in the opposite
direction above, or below, the affected area. The vertebrae are shaped normally
in compensatory curves.

Symptoms

This 4-year-old girl's body shifts to the left. One hip looks higher than the other
and her waistline is not the same shape on the two sides.
Congenital scoliosis is often detected during the pediatrician's examination at
birth because of a slight abnormality of the back.
Scoliosis is not painful, so if the curvature is not detected at birth, it can go
undetected until there are obvious signs --which could be as late as
adolescence. A child may suspect that something is wrong when clothes do not
fit properly. Parents can discover the problem in early summer when they see
their child in a bathing suit.

The physical signs of scoliosis include:

• Tilted, uneven shoulders, with one shoulder blade protruding more than the other
• Prominence of the ribs on one side
• Uneven waistline
• One hip higher than the other
• Overall appearance of leaning to the side
• In rare cases there may be a problem with the spinal cord or nerves that
   produces weakness, numbness, or a loss of coordination.


Doctor Examination and Investigation

Physical Examination

The standard screening test for scoliosis is the forward bending test. Your child
will bend forward and your doctor will observe your child from the back, looking
for a difference in the shape of the ribs on each side. A spinal deformity will be
most noticeable when your child is in this position.
With your child standing upright, your doctor will check to see if the hips are
level, the shoulders are level, and that the position of the head is centered over
the hips. He or she will check the movement of the spine in all directions.
To rule out the presence of a spinal cord or nerve problem, your doctor may
check the strength in your child's legs and the reflexes in the abdomen and legs.

Tests

This adolescent girl's curve and the hemivertebra causing it show up clearly on
x-ray.
Although the forward bending test can detect scoliosis, it cannot detect the
presence of congenital abnormalities. Imaging tests can provide more
information.

X-rays. Images of your child's spine are taken from the back and the side. The
x-rays will show the abnormal vertebra(e) and how severe the curve is.
Once your doctor makes the diagnosis of congenital scoliosis, your child will be
referred to a pediatric orthopaedic surgeon for specialized care and further
tests.

Computed tomography (CT) scan. A CT scan can provide a detailed image of
your child's spine, showing the size, shape, and position of the vertebrae. To
see the vertebrae better, your doctor may have a 3-D image made from the CT
scan. This looks like a photograph of the bones.
This 3-D image from a CT scan shows hemivertebrae, as well as a fused, boney
block.

Ultrasound. Your doctor will do an ultrasound of your child's kidneys to detect
any problems.
Magnetic resonance imaging (MRI) scan. Because an MRI can evaluate soft tissues
better than a CT scan, an MRI will be done to check for abnormalities of the
spinal cord at least once for every patient.


Treatment
There are several treatment options for congenital scoliosis. In planning your
child's treatment, your doctor will take into account the type of vertebral
abnormality, the severity of the curve, and any other health problems your child
has.

Your doctor will determine how likely it is that your child's curve will get worse,
and then suggest treatment options to meet your child's specific needs.

Nonsurgical Treatment

Observation. A child with a small curve that seems to be unchanging will be
monitored to make sure the curve is not getting worse. Although it does not
happen in every patient, congenital scoliosis curves can get bigger as the spine
grows and the deformity of the back becomes more noticeable. It is likely that a
curve in a young child will get worse because younger children still have a lot of
growing to do.
Your doctor will follow the changes of your child's curve using x-rays taken at
6-to 12-month intervals during the growing years.
Physical activity does not increase the risk for curve progression. Children with
congenital scoliosis can participate in most sports and hobbies.
Bracing or casting. Braces or casts are not effective in treating the curvature
caused by the congenitally abnormal vertebrae, but they are sometimes used to
control compensatory curves where the vertebrae are normally shaped.


Surgical Treatment

Surgical treatment is reserved for patients who:

• have curves that have significantly worsened during the course of x-ray
  monitoring
• have severe curves
• have a large deformity of the spine or trunk
• are developing a neurological problem due to an abnormality in the spinal cord
An important goal of surgery is to allow the spine and chest to grow as much as
possible. There are several surgical options.

This x-ray was taken of the same patient after her surgery to remove the
hemivertebra and fuse the curved vertebrae with a metal implant.
Spinal fusion. In this procedure, the abnormal curved vertebrae are fused
together so that they heal into a single, solid bone. This will stop growth
completely in the abnormal segment of the spine and prevent the curve from
getting worse.

Hemivertebra removal. A single hemivertebra can be surgically removed. The
partial correction of the curve that is achieved by doing this can then be
maintained using metal implants. This procedure will only fuse two to three
vertebrae together.

Growing rod. Growing rods do not actually grow but can be lengthened with
minor surgery that is repeated every 6 to 8 months. The goal of a growing rod is
to allow continued growth while correcting the curve. One or two rods are
attached to the spine above and below the curve. Every 6 to 8 months, the child
returns to the doctor and the rod is lengthened to keep up with the child's
growth. When the child is full grown, the rod(s) are replaced and a spinal fusion
is performed.

Rehabilitation. Young children usually recover quickly from surgery and are
discharged from the hospital within 1 week. Depending on the operation, a child
may need to wear a cast or brace for 3 to 4 months.
Once they are healed, children are allowed to participate in most of the activities
that they had previously participated in.


Long-Term Outcomes

Congenital scoliosis detected at an early age is one of the most challenging
types of scoliosis to treat. The curves can be large to begin with and because
children have so much growth ahead of them, the chance of severe curve is
high.

Although fusion of vertebrae at an early age results in the spine and trunk being
shorter than they would have been, children can have outstanding results and
achieve normal, or near-normal, function.

Congenital Muscular Torticollis

Congenital Muscular Torticollis (Wryneck)

Congenital muscular torticollis, also called wryneck, is usually discovered in the first 6 to 8 weeks of life. The infant keeps his or her head tilted to one side and has difficulty turning the head to the opposite side.

If the infant is examined in the first month, a mass, or "tumor," may be felt in the neck. This is nontender and soft. It is attached to the muscle in the neck on the side to which the head is tilting. The mass gradually regresses so that by 4 to 6 months of age the "tumor" is gone.


A young child with a right-sided congenital muscular torticollis. Notice how the face turns away from the tight muscle. (Courtesy of Texas Scottish Rite Hospital for Children)

Congenital muscular torticollis can be associated with hip dysplasia (10% to 20%) so the hips should be examined in children with torticollis.

If you notice that your child holds the head tilted to one side, consult your physician. Other conditions can cause torticollis, and the physician will check for those during the physical examination. X-rays and/or an ultrasound of the neck and/or hips may be taken.

Ninety percent of children can be treated successfully with a stretching exercise program.

Cause

First-born children are more likely to have torticollis (and hip dislocation). This is likely from intrauterine "packing," resulting in injury to the muscle. The "tumor" is seen with response to the injury. As this resolves, the amount of scar in the muscle determines how tight the muscle is. There is no known prevention.

Symptoms

The head tilts to one side and the chin points to the opposite shoulder. The right side is involved 75% of the time. The lump is found in the muscle and it gradually goes away. There is limited range of motion of the neck. One side of the face and head may flatten as the child always sleeps on one side.

Treatment

The usual treatment consists of stretching exercises to turn the head so that the chin touches each shoulder and also so that the ear touches the shoulder.

There are other options that can help. Position toys where the infant has to turn his head to see them. Carry the child so that they have to look to the involved side. Place the child in bed with the involved side toward the wall so that they have to look the opposite way to see you outside the crib.

In 10% of children, surgery may be needed to correct the torticollis. This is an outpatient surgery to lengthen the short muscle.

Compartment Syndrome

Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.

Compartment syndrome can be either acute or chronic.

Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage.

Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion.

Anatomy

Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.


The area between the knee and ankle has four major muscle compartments: anterior, lateral, superficial posterior, deep posterior.

Description

Compartment syndrome develops when swelling or bleeding occurs within a compartment.
Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.

In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability and tissue death may result. This does not usually happen in chronic (exertional) compartment syndrome.

Compartment syndrome most often occurs in the anterior (front) compartment of the lower leg (calf). It can also occur in other compartments in the leg, as well as in the arms, hands, feet, and buttocks.

Cause

Acute Compartment Syndrome

Acute compartment syndrome usually develops after a severe injury, such as a car accident or a broken bone. Rarely, it develops after a relatively minor injury.

Conditions that may bring on acute compartment syndrome include:

• A fracture.
• A badly bruised muscle. This type of injury can occur when a motorcycle falls on the leg of the rider, or a football player is hit in the leg with another player's helmet.
• Reestablished blood flow after blocked circulation. This may occur after a surgeon repairs a damaged blood vessel that has been blocked for several hours. A blood vessel can also be blocked during sleep. Lying for too long in a position that blocks a blood vessel, then moving or waking up can cause this condition. Most healthy people will naturally move when blood flow to a limb is blocked during sleep. The development of compartment syndrome in this manner usually occurs in people who are neurologically compromised. This can happen after severe intoxication with alcohol or other drugs.
• Crush injuries.
• Anabolic steroid use. Taking steroids is a possible factor in compartment syndrome.
• Constricting bandages. Casts and tight bandages may lead to compartment
syndrome. If symptoms of compartment syndrome develop, remove or loosen any constricting bandages. If you have a cast, contact your doctor immediately.


Chronic (Exertional) Compartment Syndrome

The pain and swelling of chronic compartment syndrome is caused by exercise. Athletes who participate in activities with repetitive motions, such as running, biking, or swimming, are more likely to develop chronic compartment syndrome. This is usually relieved by discontinuing the exercise, and is usually not dangerous.


Symptoms

Acute Compartment Syndrome

The classic sign of acute compartment syndrome is pain, especially when the muscle within the compartment is stretched.

• The pain is more intense than what would be expected from the injury itself. Using or stretching the involved muscles increases the pain.
• There may also be tingling or burning sensations (paresthesias) in the skin.
• The muscle may feel tight or full.
• Numbness or paralysis are late signs of compartment syndrome. They usually indicate permanent tissue injury.

Chronic (Exertional) Compartment Syndrome

Chronic compartment syndrome causes pain or cramping during exercise. This pain subsides when activity stops. It most often occurs in the leg.

Symptoms may also include:

• Numbness
• Difficulty moving the foot
• Visible muscle bulging


Doctor Examination


Acute Compartment Syndrome

Go to an emergency room immediately if there is concern about acute compartment syndrome.
This is a medical emergency. Your doctor will measure the compartment pressure to determine whether you have acute compartment syndrome.

Chronic (Exertional) Compartment Syndrome

To diagnose chronic compartment syndrome, your doctor must rule out other conditions that could also cause pain in the lower leg. For example, your doctor may press on your tendons to make sure you do not have tendonitis. He or she may order an X-ray to make sure your shinbone (tibia) does not have a stress fracture.

To confirm chronic compartment syndrome, your doctor will measure the pressures in your compartment before and after exercise. If pressures remain high after exercise, you have chronic compartment syndrome.

Treatment


Acute Compartment Syndrome

Acute compartment syndrome is a surgical emergency. There is no effective nonsurgical treatment.

Your doctor will make an incision and cut open the skin and fascia covering the affected compartment. This procedure is called a fasciotomy.


Sometimes, the swelling can be severe enough that the skin incision cannot be closed immediately. The incision is surgically repaired when swelling subsides. Sometimes a skin graft is used.

Chronic (Exertional) Compartment Syndrome

Nonsurgical treatment. Physical therapy, orthotics (inserts for shoes), and anti-inflammatory medicines are sometimes suggested. They have had questionable results for relieving symptoms.

Your symptoms may subside if you avoid the activity that caused the condition. Cross-training with low-impact activities may be an option. Some athletes have symptoms that are worse on certain surfaces (concrete vs. running track, or artficial turf vs. grass). Symptoms may be relieved by switching surfaces.

Surgical treatment. If conservative measures fail, surgery may be an option. Similar to the surgery for acute compartment syndrome, the operation is designed to open the fascia so that there is more room for the muscles to swell.

Usually, the skin incision for chronic compartment syndrome is shorter than the incision for acute compartment syndrome. Also, this surgery is typically an elective procedure --not an emergency.