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Issues of tissues

Tuesday, May 08, 2018

In the first of a two-part article, Dr Naresh Shivdasani discusses dealing with soft tissue lesions and limb pain

Joint problems are one aspect of limb pain. Many patients have painful muscles, tendons, ligament or joint capsule pain. Once an exact diagnosis is made, it is possible to target the damaged tissue for treatment. There are many degenerative lesions which occur and cause immense suffering. Many of our patients go to bone setters for treatment, a practice which should be deplored.

A few common issues of tissues, will be discussed here, in two parts.

A word about local steroid injections would not be amiss. Steroids are powerful anti-inflammatory drugs. There is a phobia among many patients that steroids like cortisone have serious side effects. Yes, they do if used over a long period and systemically. However, the intra-lesional steroids used by Orthopaedic surgeons are suspensions, hence do not have significant systemic effects, as they remain at the site of injection, working their magic locally.

Carpal Tunnel Syndrome
This is common in those who work long hours on the computer. There is a strong ligament holding the wrist bones together. Beneath this, the structures going to the hand, including the median nerve, pass. Repetitive Stress Injury (RSI) occurs in those who work on keyboards. Compression of the Median Nerve at the wrist due to swelling in the enclosed space at the wrist causes tingling and numbness in the fingers. It may mimic the pain of cervical spondylosis.

The pain is worse at night and relieved by hanging the arm from the side of the bed. Pregnancy, Rheumatoid Arthritis (RA) and Hypothyroidism may be contributing factors. Early cases may respond to splintage, NSAIDs, or steroid injection. In late cases surgery is a must, to allow the damaged muscles of the hand to recover. Special tests (EMG, NCV) may be needed to confirm the diagnosis.

Trigger finger or Thumb
There are several pulleys in the hands and fingers which hold the tendons in place while allowing smooth gliding of the tendons within their sheaths. Due to constant movements, these pulleys get thickened, preventing the smooth movement of the tendons. The impediment to the movement results in pain and restriction of movement of the digits—‘triggering', hence the term. One should rule out systemic disease like Diabetes or RA. The middle finger is commonly involved. This condition may respond to anti-inflammatory drugs (NSAIDs). Some patients try ultrasonic treatment given by Physiotherapists, in an attempt to break the fibrosis. Often steroid injection locally helps. Occasionally surgery is required to release the thickened band.

Frozen Shoulder
The shoulder is a ‘ball and socket’ joint, but the ‘ball’ is much bigger than the ‘socket'. It is stabilised by muscles and ligaments, unlike the hip joint, which is constrained by bone. It is very sensitive to any trauma.

There is severe pain and restriction of the shoulder movement over a period of time. Many patients delay seeking treatment as they feel that it would resolve ‘by itself’. The precipitating factors include injury, fracture, surgery, diabetes and stroke. The pain and suffering can last a year-and-a-half. X-rays may show subtle changes. MRIs or sonography of the shoulder may be done to confirm if any tear is found in the rotator cuff. Damage to the tendons (rotator cuff) around the shoulder may be detected on MRI. Management would include analgesics (NSAIDs), physiotherapy, heat, liniments and home remedies! Many cases respond to local steroid injections or even to acupuncture. Some cases need arthroscopic surgery to release the adhesions.

Dr Naresh Shivdasani (D.Orth, M.S. (Orth) is a Senior Orthopaedic Surgeon, with interest in Acupuncture and Spinal Manipulation. He believes that most disease originates from stress and lifestyle issues.

Short Takes

  • Joint problems are one aspect of limb pain. Many patients have painful muscles, tendons, ligament or joint capsule pain. There are also many degenerative lesions that can cause suffering
  • Once an exact diagnosis is made, it is possible to target the damaged tissue.

To be continued

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