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Manage the pain

Tuesday, May 15, 2018

Accurate diagnosis of soft tissue lesions is essential, says Dr Naresh Shivdasani, in the second of a two-part series

Heel Spur (Plantar Fasciitis) Many patients come with heel pain, where the x-ray shows an bony outgrowth in the front of the heel. The pain can be excruciating. It is important to rule out Diabetes in these patients.  It is commonly seen in peri-menopausal women and obese patients,  There is more pain in the morning or after a period of rest. On examination, there is severe to moderate tenderness (pain on touch) at the medial aspect of  Calcaneum (heel). Patients are told to use soft footwear and silicon heels. These don't give much relief, unfortunately. The heel spur is NOT the cause of the pain, and can be an incidental finding, where patients have no pain at the heel.

The treatment is adequate doses of analgesics, (I prefer giving a long-acting drug at night), the use of ultrasound or moist heat, and treatment of the underlying cause. A steroid injection in the tender spot helps most patients. If all else fails, surgery is required to release the fascia or entrapped nerves, if any.

Tennis Elbow  There is pain on the outer side of the elbow and difficulty even in doing the simplest of tasks, like holding a glass. This is more common in non-athletes. It is seen in an equal number in males and females, and often in the fifth decade. Many different theories are postulated about the cause; the 'god' of cricket suffered from tennis elbow!

There is severe tenderness about five mm from the outer elbow point (lateral epicondyle). There is, however, no redness, swelling or warmth. The x-ray is usually normal. The pain may be referred from the neck. Hence cervical spondylosis should be ruled out.

Flexor Tendinitis Every muscle in the body has an attachment at both ends.  The hand muscles have an attachment which allows smooth movement of the fingers. Those that help close the hand for making a fist  are commonly affected. The tendons are covered with a smooth envelope which has a bit of fluid in it. When there is 'tendinitis, these coverings (sheaths) get swollen and painful. The tendon itself doesn't get inflamed. There is severe pain and swelling on the front of the forearm and hand. This condition may be associated with Rheumatoid Arthritis. The treatment includes support with an aluminum or plastic splint (readily available) or crepe bandage. Anti-inflammatory drugs used judiciously and in therapeutic doses would help decrease the swelling. In severe cases, injection of local steroids or surgery would be needed.

Ganglion This is a fluid-filled swelling near the joint or tendon sheath. This occurs due to a protrusion of the joint lining due to a weak spot in it. The size may fluctuate and may cause mild pain. It can cause pressure on the nearby nerves, resulting in palsy of the muscles supplied by it. If it is growing rapidly, it can be excised, or if small, a local steroid injection would help.

Retrocalcaneal Bursitis There is pain,  swelling and tenderness at the posterior superior aspect of the heel. It is aggravated by walking; pain may be absent at rest. There is a protective lining or bursa between the tendon attachment and the bone. Swelling of this is called Bursitis. Inflammation of the tendon sheath is called Tenosynovitis. The  Tendo-Achilles tendon is usually injured due to repetitive movements of the foot. Tendon rupture should be ruled out, by careful examination.

Management  includes avoidance of sandals with straps and  tight shoes. A small raise in the heel helps relieve pain and swelling. Use of soft footwear, even at home helps to decrease the pain. This is one condition where I avoid steroid injection locally as there is a real danger of tendon rupture following the injection. If surgery is required, a fragment of the bone abutting the tendon is shaved off.

Soft tissue lesions can be quite debilitating and accurate diagnosis helps to successfully manage the outcomes.

(This is the second and concluding part of an article on soft tissue lesions.)

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.

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