Tuesday, June 9, 2009
So I am a little over two weeks out now, and these past couple of days, my knee seems to have made a sudden improvement with an increase in ROM and reduced swelling. I still can't kneel on the knee, but each day it is getting easier to do ordinary things.
I plan to start rowing again next week since my range is essentially sufficient enough to do that, and because it is an unloaded activity.
The tear I had in the Medial meniscus was more like the radial tear shown in the Lateral Meniscus above. The surgery involved trimming it out and smoothing the remaining meniscus.
Because there was no blood supply or bleeding inside the knee in general, the recovery is fairly quick and there is little opportunity to scar. I do feel the impact of the scar tissue and the fact that the scar tissue is contracting where the arthroscopic tools penetrated the knee during surgery though, especially the scar in my distal Quadriceps muscle - but again, not a big scar and almost a non issue day to day now.
Monday, June 8, 2009
Question: How do you know if you have nerver root compression from a herniated cervical disc?
Answer: You have pain AND weakness in the arm .
Click the "play" button to listen:
In the image adjacent, you can see how a cervical spine disc herniation compresses the anterior nerve root of the spinal nerve causing motor weakness. Because the disc is anterior to the spinal cord, and because the anterior nerve root is the motor nerve root, compression leads to weakness and this is always the first consideration when motor weakness is the primary sign along with pain as a symptom.
As in this image, the herniation might or might not be an indication for a cervical discectomy. The reality is that you should allow time to pass before committing to a surgical solution. The reason I say this is that the decision largely depends on what tissue is compressing the nerve root.
If the nucleus is the primary culprit, then allow time to pass because the nucleus is made up of glucosaminoglycans (GAG's) and GAG's decay fairly rapidly, which means that they biind less water. As they decay, they dehydrate, and as they dehydrate, the pressure comes off the nerver root, and strength should return.
On the other hand, if the material pressing against the nerve root is part of the fibrous shell of the disc - the Annulus, then surgery mught in fact be the best option. In this case, the Annulus does not decay, and it is sort of like the reality of having a pin stuck in your arm - it hurts till you take it out. But that said, cervical traction is a good idea to try. If traction is successful, great, if not, the next level of intervention worth trying is potentially selective injection techniques. Often, the combination of selective injections with cervical traction along with aerobic exercise and other gapping activities (to gap the cerival spine, forward bend, side bend the head away from the pain, and GENTLY rotate toward the pain) would offer the best course of action.
Acutely, the position of comfort is to place the same side forearm on the forehead to achieve temporary relief of pain.
So acutely try this:
- Aerobic exercise for a half hour to soften and relax the accessory muscles of respiration
- Gapping exercises to relieve the nerve root
- Cervical traction to relieve the pressure
- Forearm on the forehead to unload the tension on the nerve and reduce arm pain
- If all else fails, then see the doc for evaluation and consideration of a selective injection
Depending on which side the herniated disc is affecting, you could position the head in alight side bending to further provide relief while under traction. It is key though, if you use this device, to allow your neck to relax before you pick up your head when you are done with the traction. as for how much traction, I suggest that the traction is pain free, but you should try to use at least 20# of traction for a few minutes when you do use the machine.
Saturday, June 6, 2009
Occasionally, and typically following trauma, but not always, one can sustain an injury to the juncture between the ribs and the cartilage between the breast bone (the sternum) and the ribs. Alternatively, the irritation can arise between the sternum and the cartilage. I usually see these sorts of injuries after a motor vehicle accident where the seat belt coming across the rib cage creates the injury or when the chest is driven into the steering wheel is the cause. I have one recent case where the irritability was not traumatic at all, but came on after a case of severe and persistent coughing. Patients following open heart surgery often have to deal with this injury.
This is a difficult injury to manage because there is not much blood supply, and it is made more difficult to treat in hitting and throwing athletes because the rib cage needs to be able to rotate forcefully in those situations.
The pain is felt on the outer third of the chest wall, and is seemingly irritated with breathing deeply. Palpation of the joint line can illicit pain. The pain can be bilateral, but is most often unilateral.
The best treatment for this condition is a combination of aerobic exercise, even though it might hurt to breath at first, ice on the irritated chest wall, and a therapeutic dose of NSAID's on board as tolerated. Physical therapy in the form of manual therapy is valuable to oscillate the joints to promote healing, but this is tricky and needs to be done very carefully. Also, mobilizing the thoracic spine through exercise is key. I really like the TRX as a tool here.
The bottom line is that this is an injury that takes a long time to heal, and is easily irritated again, so the return to sport must be managed on a gradient. For example, in the case of a baseball player returning to practice, I would suggest short toss until that was pain free, then gradually working their way to long toss before trying any hitting drills or throwing in form the outfield. As for hitting drills, swing next to a fence until that was pain free before hitting off a tee, before hitting any soft toss pitches, before hitting any regularly pitched balls, before throwing in from the outfield. In the case of tennis for example, ground strokes before overhead strokes and so on.
Wednesday, June 3, 2009
I recently saw a patient who suffered a ankle severe sprain wake boarding. The sprain recovered, but the ankle continued to "snap". on closer examination, the snapping sensation was actually the peroneal tendon snapping around the lateral malleolus.
You can see how the tendons (in the image to the left) are held in place by connective tissue. When this connective tissue is stretched sufficiently, it will allow the tendons to "snap" over the lateral malleolus. It really is a snapping sensation and it is often painful. You can almost see this snapping in the following two images.
While is it is possible to treat this condition conservatively, in a cast boot for example, when the tendons snap over the ankle repeatedly, then sadly, surgery is the only option. The post surgical course is pretty much the same as it would be for any ankle surgery - the repair has to heal, then the joints and muscles need to be rehabilitated for the athlete to return to their sport.
It is important to repair this injury though, because the peroneal muscles play a very important role in normal foot mechanics. Peronus longus, for example, crosses over the bottom of the foot and inserts at the base of the big toe, while the brevis attaches on the lateral border of the mid foot at the base of the fifth metatarsal. Both plantar flexion, eversion and plantar flexion with eversion are impacted by this injury.
My patient who suffered the injury had a surgical repair and is back on the water without restriction.