ps, Author at 🩺Singapore Sports & Orthopaedic Surgeon

Sports Injuries of the Knee

ps Lower Limb Comments Off

The incidence of sports-related injuries has been increasing steadily over the recent years. It is estimated that doctors in the Unites States treat 3.5 million sports injuries in a year and in Singapore, over 16,000 sports injuries occur every year.

Sports injuries impact the sufferer on two fronts. In terms of sporting activity, the individual is unable to participate during the recovery phase. After recovery, the individual may not be able to return to sport at pre-injury level due to residual impairment of function. With respect to life outside of sport, time may have to be taken off work or school, depending on the severity of the injury. Difficulties may also be experienced in the performance of certain aspects of an individual’s job.

Sports injuries can be divided into acute sports injuries and overuse sports injuries. Acute sports injuries are associated, most commonly, with contact sports (eg. football or basketball) or sports involving sudden twisting or change in direction (racket sports). The onset of symptoms is sudden and treatment often involved surgery. Overuse sports injuries occur with sports of repetition (eg. running) where the same action is repeated many times over. The onset of symptoms is gradual and treatment usually involves physiotherapy and rehabilitation. In this article, we will focus on acute sports injuries of the knee.

Sports Injuries to Knee Ligament

The primary function of ligaments is to keep movement of the knee within the desired plane and within normal limits. Disruption of any of the knee ligaments allows abnormal knee movement. This, in turn, causes damage to other structures within the knee. The usual targets of this secondary damage are cartilage and the menisci.

There are four main knee ligaments and the most commonly damaged ligament is the anterior cruciate ligament (ACL).

Sports injuries involving the ACL are most often sustained with a twisting or hyperextension injury. With an ACL tear, immediate joint swelling is seen from bleeding within the knee. There will, of course, be pain. Some patients may experience a locked knee. In this condition, a fragment of the torn ligament gets trapped in the joint and the joint cannot be fully extended because of the mechanical obstruction. At the time of injury, the meniscus may also be damaged.

Immediate treatment with RICE (rest, ice, compression and elevation) therapy is instituted and crutches can be used if necessary. With symptoms of immediate joint swelling and pain after an injury, an early consultation with a doctor is prudent to ensure that there isn’t a fracture. Early rehabilitation is started to allow weight-bearing and regain range of motion of the knee. Further rehabilitation involves the strengthening and coordination / balance training. The most common complaint of a patient with an ACL tear is an unstable knee, which buckles with rapid change in the direction of walking or running. This prevents an individual from returning to sports and risks further damage to the knee.

Because of its position within the knee joint, ACL tears do not have the ability to heal. Once the ACL is torn, the torn ends remain separate and do not heal, even if stitched together. The objective of the surgery for an ACL tear is not to repair the damage but to replace the ACL. This is referred to as reconstruction of the ACL. Reconstruction of the ACL is performed using the patient’s own tissue to replace the torn ligament. The most common tissue used are the patella tendon (tendon connecting the kneecap to the shin bone) and hamstring tendons (tendons behind the knee). The current standard of treatment of an ACL reconstruction is with arthroscopic (keyhole) surgery.

The benefits of reconstructing a torn ACL are reducing the chances of abnormal twisting of the knee and reducing the risk of secondary damage to the menisci and joint cartilage, thus reducing the likelihood of knee arthritis. This procedure also allows the patient to return to sports requiring twisting.

It is important to seek medical attention at the early stages of the injury to reduce the change of secondary damage.

Sports Injuries to Meniscus

A meniscus is a piece of specialist cartilage shaped like the letter “C”. There are two menisci in each knee. They serve to absorb shock transmitted through the knee and to protect more fragile cartilage covering the surfaces of the knee joint.

A meniscus can be torn with a twisting or impact injury. There is associated knee swelling, which may be of a more gradual nature than in an ACL tear, together with pain. There may also be locking of the knee.

Surgery for a meniscus tear is performed arthroscopically (keyhole surgery). During the procedure, the meniscus is either repaired or debrided (torn fragments removed and remaining meniscus smoothed down). The decision whether to repair or debride is made based on the location, size and configuration of the tear.

The aim of the meniscal surgery is to obtain a stable meniscus, which will not displace into the joint to cause locking. To restore the normal configuration or smoothen out the damaged surfaces also reduces the risk of further damage and consequent arthritis.

Although the occurrence of acute sports injury of the knee is increasing, treatment outcomes are good and many patients do return to playing their chose sport. It is important to seek medical attention at the early stages of the injury to reduce the chance of secondary damage. With early treatment and arthroscopic (minimally-invasive, keyhole) surgery, when needed, the down-time from sports and daily activities can be minimised.

Do

Seek early medical attention after an acute sports injury of the knee (especially if associated with swelling)

Don’t

Neglect a locked knee. This requires urgent attention to “unlock” it. Walking on a locked knee will result in irreversible cartilage damage of the knee.

Ignore an unstable knee. Frequent twisting of an unstable knee may cause meniscal or cartilage injuries.

Test for Post-Menopausal Osteoporosis

ps General Comments Off

Osteoporosis Screening Package @ $379

(Includes Specialist Consultation & BMD Screening).

Drinking Milk is Not Enough to Prevent Osteoporosis!

Women, as they grow older, and especially after menopause, lose up to 20 percent of their bone mass in the five to seven years after menopause! Although osteoporosis affects men as well, in the last three decades since 1960s, the number of osteoporotic hip fractures in Singapore rose five-fold per 100k population in women over the age of 50.

In April, the Osteoporosis Society of Singapore [OSS] launched a campaign encouraging postmenopausal women to take early action to protect their bone health, instead of delaying to after their first bone fracture.

Singapore has the highest number of osteoporotic fractures in Asia yet many postmenopausal women, to the frustration of doctors here, are leaving it to after they have had their first fracture before taking preventive action.

Studies show that one in every five patients usually dies within the first year after a hip fracture. Of those who survive, more than half will lose their ability to walk and will end up bedridden or wheelchair-bound.

Drinking your calcium in the form of milk while good for bone health is not enough for those at risk of postmenopausal osteoporosis.

You Might be of High Fracture Risk due to Osteoporosis

Once you have menopaused, the OSS is encouraging postmenopausal women to undergo bone mineral density (BMD) screening.

The OSTA test will determine if a postmenopausal woman is at high, moderate or low risk of having a low BMD. Those who are at high risk or moderate risk with other risk factors should have their BMD tested.

Patients with pre-existing osteoporotic fractures may heighten their risk of further fractures by two to four times. Therefore it will be prudent for patients with high risk of fractures to seek medical attention before their first fracture. The situation is expected to worsen when the proportion of Singapore population aged above 65 triples by 2030.

Too Late for More Milk to Prevent Osteoporosis

For osteoporotic patients, where the bone density has begun degenerating, medication is necessary as osteoporosis is a progressive one.

In a normal situation, drinking your milk and eating your cheese and sunning yourself for vitamin D will be good measures to build bone health but will not be sufficient when you identified with the bone degenerative condition – osteoporosis.

When faced with this, you need to medicate under your doctor’s supervision.

The International Osteoporosis Foundation reports that patients on medication reduce their risk for fracture by about 30-70%. But not all patients are found to be compliant.

Many stop taking their prescribed medication or fail to take it regularly. This is largely because osteoporosis is not associated with any visible to the eye symptoms. As a result, many fail to realise the hidden severity of osteoporosis until it is too late – after a fracture.

Patient compliance with prescribed treatment is most important whether they take oral medication or opt for the convenience of injections.

Patients who find it hard to comply with the regime of taking oral medication regularly, can consider other options such as yearly intravenous infusions.

Those with previous fractures, high-risk scores on OSTA should seek their doctor’s advice right away. Without medication, their risks of further fractures double or rise as high as four times.

9 Strategies to Fight Back Pain

ps Neck and Back Comments Off

The Back Pain Battle

Fundamental Strategies for Managing Back Pain

IF YOU SUFFER from low back pain, you are in good company because most people experience back pain at least once in their lives. Over any given one year period, more than one third of the population will experience back pain. Of these people, most who experience activity-limiting back pain will go on to have recurring episodes.

Risk Factors

The most common ages for patients to suffer back pain is between 20 and 30 years and again in the 60s. Females tend to suffer from low back pain more than males. Being overweight increases the risk of someone developing back pain. Psychological factors such as stress, anxiety and depression are factors linked to back pain. Interestingly, degeneration of the lower spine (lumbar spine) is more related to heredity (genes) than heavy physical loading, which was thought to be a major contributor.

Causes of Back Pain

There are a multitude of causes of low back pain. It may arise from numerous anatomical locations such as bones, intervertebral discs, joints, ligaments, muscles, nerves and blood vessels. In each of these locations, conditions such as degeneration, infection, tumour and trauma may result in back pain.

Assessment of Back Pain

The aims of assessment of back pain by healthcare professional include:

Ruling out potentially serious spinal conditions such as fractures, tumours and infection
Identifying the cause of the back pain
Detecting significant nerve damage caused by the disorder

In order to achieve these aims, in addition to obtaining a history of the pain and examining the patient, the doctor may need X-rays and specialised tests such as a MRI scan may be required.

Managing Back Pain

Specific causes of back pain require targeted treatment (which is beyond the scope of this article). As such, we will highlight general measures used to control back pain.

REST

While rest is intuitively enforced with a patient suffering from back pain, prolonged bed rest is associated with a longer recovery period. Current recommendation is for bed rest to be limited to 48-hours. Normal activities should be resumed as soon as possible.

MEDICATION

Anti-inflammatory medications are commonly prescribed for the control of back pain. Paracetamol is similarly effective. Topical medications such as heating rubs have not been proven to be useful.

ICE/HEAT TREATMENT

Although there is no conclusive evidence that the use of these measures reduce back pain, because the potential for harm is low and some patients do find that they give relief, ice/heat treatment can be attempted.

BACK EXERCISE

No specific back exercise improves pain during the episode of acute pain. In fact, stretching and other activities that put an additional strain on the back are discouraged. Back exercises, though, help patients with chronic back pain (lasting more than 3 months).

Preventing Back Pain

GENERAL EXERCISE

exercise is important for general health and need not be avoided. High-impact activities, though, can aggravate back pain. Low-impact activities such as swimming, cycling and walking are recommended. Regular exercise has the added benefit of reducing obesity, which is a risk factor for back pain.

SPECIFIC EXERCISE / PHYSIOTHERAPY

Exercises that strengthen the core muscles (abdominals and back muscles) may decrease the tendency for one to suffer back pain. Specific exercises can be recommended by a physiotherapist. Pilates and yoga help with back pain by strengthening these muscles.

LUMBAR SUPPORT BELTS

Workers who frequently perform heavy lifting wear these belts but there is no evidence that they work to prevent back pain. On the contrary, there is evidence to suggest that they may increase the risk of a back injury!

STANDING

While standing, the head should be kept upright and the stomach pulled in. High heels should be avoided.

SITTING

Chairs should be at an appropriate height for working. In addition, they should have good lumbar support, as should car seats. If this is found to be lacking, a rolled-towel or small pillow should be employed.

SLEEPING

Individual needs vary but an excessively soft or hard mattress can cause back pain. In general, a moderately firm mattress is recommended but some trial and error may be required.

LIFTING

Avoid lifting objects that are too heavy. Good lifting technique is paramount whatever the weight of the object. The back should be kept straight and upright while the lifting is performed with the knees. The object is close to the body to reduce stress on the spine.

Dos for Back Pain Sufferers

Do see a doctor immediately (these are emergencies) if:

There is sudden bladder or bowel dysfunction.
Back pain is associated with fever and chills.
Back pain is caused by a severe injury.
There is a history of cancer with recent weight-loss associated with the back pain.

Don’ts for Back Pain Sufferers

Don’t neglect a back pain. If a back pain lasts longer than two weeks, the back muscles start to weaken.

Since using the muscle hurts, there is tendency to avoid using them. This leads to muscle wasting and weakness. This, in turn, causes more back pain because the muscles are not able to hold up the spine.

Treating Plantar Fasciitis

ps Lower Limb Comments Off

Plantar fasciitis, also known as heel-spur syndrome is a widespread problem amongst people who are active in sports, particularly runners. It starts as a dull, intermittent pain in the heel. If not treated correctly, it will progress to a sharp, persistent pain.

What is plantar fasciitis?

Plantar fasciitis is an inflammation of the plantar fascia, which is a thick band of tissue that runs from the heel of the foot to the toe. The pain is generally characterised as a dull, aching pain. In some cases, it can be a sharp, acute pain due to the inflammation.

What are the causes of plantar fasciitis?

The main cause of plantar fasciitis is due to overuse – such as running or standing all day. Teachers and factory supervisors who stand all day tend to get it due to increased pressure placed on the plantar fascia. We see it amongst long distance runners too. However, overuse is not enough to cause plantar fasciitis. We usually examine risk factors as well. One of them is the tightness of the calves, which is one of the leading causes of plantar fasciitis.

Another risk factor would be foot abnormalities. These include high arch foot (pes cavus) or flat-footedness (pes planus). In pes cavus, tension underneath the foot is going to be very high. With flat-footedness, the arch tends to collapse, creating a ‘windshield wiper’ effect. The bottom of the foot keeps rolling in, rendering it unstable.

Obesity is another reason – the extra weight can cause excess stress on the plantar fascia. Women may be more prone to develop plantar fasciitis due to long term use of high heels leading to tightening of the calves.

What are the signs and symptoms of plantar fasciitis?

Pain in the heel. This is most significantly felt in the mornings, during the first step of the day. Athletes, who run a lot, will feel it at the end of a run. The pain will be worse the following morning.

What can an athlete do to relieve the pain?

Painkillers can be taken or athletes can undergo the RICE therapy which is Rest, Ice Compression, Elevation therapy. It has an anti-inflammatory effect. The next step would be to reduce risk factors, which should be the highest priority. Daily stretching of the calves and the toes helps to stretch the plantar fascia, and bring some relief.

What are the other forms of treatment like for plantar fasciitis?

When the pain gets better. we start to strengthen the calves. Another way is to again look at reducing risk factors such as foot abnormalities.

Abnormal motion of the foot when walking such as overpronation, can be corrected with orthotic insoles, which we would get from a podiatrist to be custom made. A night splint is also used to keep the foot at 90 degrees angle to maintain the pressure on the plantar fascia. Cortisone injections are another form of approach in dealing with plantar fasciitis. It brings immediate relief but comes with side effects such as weakening of the tendons.

What is the rehabilitation process about for plantar fasciitis?

We start with the stretching and strengthening exercises. At more advanced levels, we move on to agility exercises like walking and running biomechanics as well as balance exercises. There has to be a certain degree of recovery before this stage can be reached.

What are the ways to prevent plantar fasciitis?

Regular stretching exercises and strengthening of the calves are crucial when it comes to preventing plantar fasciitis. Use of appropriate footwear is also important.

The Frozen Shoulder

ps Upper Limb Comments Off

The term “frozen shoulder” is used to describe a condition characterised by pain and gradual loss of range of motion of shoulder. It occurs in up to 5% of the population and is more common in females. Frozen shoulder affects patients between ages of 40 and 60 years and the non-dominant shoulder is more commonly affected. Up to a third of patients who have a frozen shoulder will develop the same condition in the opposite shoulder.

Pain and stiffness in frozen shoulder is due to inflammation and progressive fibrosis (or scarring) of the capsule of the shoulder joint.

This disorder can be subdivided into primary or secondary frozen shoulder.

Primary Frozen Shoulder

This is a frozen shoulder condition which develops in the absence of any other shoulder condition. There is, however, an association with diabetes and thyroid disease. This is more common than the secondary frozen shoulder.

Secondary Frozen Shoulder

The frozen shoulder progresses through four stages before it starts to improve.

Stage 1

Gradual onset of pain typically referred to the middle of the upper arm. Aching pain is experienced at rest and sharp pain on movement. Patient is unable to sleep on the affected side. This stage lasts less than three months.

Stage 2

“Freezing” stage characterised by increasing pain, especially at night, together with gradual limitation of shoulder motion.

Stage 3

“Frozen” stage where the predominant complaint is stiffness and pain is diminished. Symptoms have been present between 9 to 15 months at this point.

Stage 4

“Thawing” stage where pain is a minimal and gradual improvement is seen in the range of motion.

Treatment for Frozen Shoulder

Before treatment can be instituted, the diagnosis has to be confirmed and secondary frozen shoulder has to be excluded. This involves a history suggestive of the disorder with a physical examination by a healthcare professional to exclude other causes of shoulder pain and stiffness.

The physical examination may also be able to pick up causes of secondary frozen shoulder. Finally X-ray images, and in cases where other associated condition are suspected, an ultrasound scan or MRI scan may be obtained.

The treatment of a frozen shoulder involves several possible modalities.

Physiotherapy

This is the mainstay of treatment. Mobilisation exercises within the limits of pain improve symptoms and function while aggressive stretching is associated with a poorer outcome. The exercises recommended are dependent on the stage of the condition. In the later stages, strengthening exercises are also incorporated.

Oral Anti-inflammatory Medication

Because of the inflammation process involved in this disorder, this class of medication is useful to alleviate the pain component of symptoms and is routinely given.

Manipulation Under Anaesthesia

This procedure also known as MUA. In this procedure, you will be under general anaesthesia while the orthopaedic surgeon tries to move your shoulder to the full range of motion.

By doing this, the scar tissue around the shoulder capsule will break up and release your shoulder capsule. This procedure has a high success rate and many patients has high satisfaction with the result. The advantages of MUA is that it only requires half an hour’s time and there is no cut or wound to your skin.

Surgery

Surgery is an alternative for the patient who has failed non-operative measures. As a guideline, physiotherapy should be instituted for at least four to six months before it can be concluded that the patient has failed this modality of treatment. Surgery involved is an arthroscopic (keyhole surgery) release of the shoulder capsule.

Dos and Don’ts for Frozen Shoulder

Do

Seek medical opinion even if you are sure you have a frozen shoulder as a secondary frozen shoulder possibility needs to be excluded. The outcome of a secondary frozen shoulder, if left neglected, can be quite different from that of a primary frozen shoulder.

Don’t

Ignore a stiff and painful shoulder as appropriate early intervention results in a shorter duration of discomfort and inconvenience.
Aggressively stretch a stiff shoulder as it can result in worsening of the frozen shoulder.

Let our orthopaedic surgeon advise you personally on treatments to frozen shoulder.

Author: ps

Sports Injuries of the Knee

Sports Injuries to Knee Ligament

It is important to seek medical attention at the early stages of the injury to reduce the change of secondary damage.

Sports Injuries to Meniscus

Do

Don’t

Test for Post-Menopausal Osteoporosis

Osteoporosis Screening Package @ $379

(Includes Specialist Consultation & BMD Screening).

Drinking Milk is Not Enough to Prevent Osteoporosis!

You Might be of High Fracture Risk due to Osteoporosis

Too Late for More Milk to Prevent Osteoporosis

9 Strategies to Fight Back Pain

The Back Pain Battle

Fundamental Strategies for Managing Back Pain

Risk Factors

Causes of Back Pain

Assessment of Back Pain

Managing Back Pain

Preventing Back Pain

Dos for Back Pain Sufferers

Don’ts for Back Pain Sufferers

Treating Plantar Fasciitis

What is plantar fasciitis?

What are the causes of plantar fasciitis?

What are the signs and symptoms of plantar fasciitis?

What can an athlete do to relieve the pain?

What are the other forms of treatment like for plantar fasciitis?

What is the rehabilitation process about for plantar fasciitis?

What are the ways to prevent plantar fasciitis?

The Frozen Shoulder

Primary Frozen Shoulder

Secondary Frozen Shoulder

Treatment for Frozen Shoulder

Physiotherapy

Oral Anti-inflammatory Medication

Manipulation Under Anaesthesia

Surgery

Dos and Don’ts for Frozen Shoulder

Do

Don’t

Send us a Message