What begins as a gradual onset of dull, achy pain in one knee, can also feel like the knee is giving way. Patients have also said that knee pain increases with prolonged sitting or when climbing the stairs, kneeling, squatting, or running up an incline.

Causes and precautions
Many doctors suspect that changes to the surface of the patella – the kneecap or bone at the front of the knee – cause the pain. Pain may also result from irritation to the tissue around the knee. While the precise mechanism of injury and pain remains unknown, several factors contribute to development of the condition. Overuse of the joint often leads to runner’s knee. In addition, the kneecap may be out of alignment; thigh muscles may be tight, out of balance, or weak; or the patient may have flat feet. Sometimes an injury will precipitate the pain.

To avoid runner’s knee, individuals should maintain a healthy weight. They should also warm up, and stretch before running or engaging in other physical activity. Runners should wear shoes with good shock absorption and train at a gradually increasing pace. They should also lean forward, keeping their knees bent as they run. Jogging on a smooth, resilient surface, such as a cushioned track rather than the road, is also a good idea, as is walking down steep hills or running downhill in a zigzag pattern to put less stress on the knee joint.

Diagnosis
When assessing runner’s knee, physicians inquire about the onset of symptoms, type of activities, and the types of running and playing surfaces. They perform a physical exam and watch how the patient walks, squats, sits, and moves. Often, individuals with runner’s knee favor the injured leg. Doctors also examine the knee and note any fluid or swelling; check joint alignment; evaluate muscle tone, strength, and flexibility; and assessfor tenderness when they touch or move the knee.

X-rays may be ordered to rule out other conditions such as arthritis. Doctors might also ask for a computed tomography (CT) or magnetic resonance imaging(MRI) scan to check for abnormalities.

Treatment
Treatment of runner’s knee aims to decrease pain and improve function. Initial therapy may involve elevating the knee, wrapping it in an elastic bandage, and applying cold packs several times a day to help decrease the pain and swelling. Physicians may have the patient tape the knee or wear a brace to support the joint. After the initial swelling goes down, doctors may suggest heat to relax muscles and increase blood flow. Alternating heat and cold can increase flexibility in a stiff joint. In addition, physicians may recommend a nonsteroidal anti-inflammatory medication. Once the pain and swelling decrease, doctors may also suggest a rehabilitation program to stretch and strengthen the supporting muscles and improve range of motion, agility, and coordination.

To aid in recovery, patients should avoid any activity that increases the pain until the action can be completed without discomfort. Patients may swim or try another low-impact activity instead of running or jumping until the problem resolves. Patients can participate in sports again once the injury heals and the doctor gives the go-ahead, but they should resume athletic pursuits gradually. It’s also important for runners to wear proper shoes to reduce or prevent knee pain. They can also place custom orthotics – or sometimes an off -the-shelf arch support – in their shoes to help relieve knee discomfort.

While most patients respond to conservative treatment with time, some cases may require surgery to remove debris from the knee or return the kneecap to proper alignment. Runner’s knee usually responds well to treatment and an active rehabilitation program. If athletes stick to sensible training schedules, wear supportive shoes, and use proper running technique, they can help alleviate the condition – and may even prevent its onset.

The relative risk for glenohumeral instability is explained by the joint’s anatomy. The humeral head is round and articulates with the flat glenoid fossa of the scapula (shoulder blade). Therefore, maintaining normal joint stability requires the interplay of both static restraints (the glenohumeral capsule ligaments, or capsulolabral complex) and dynamic forces (the musculature surrounding the shoulder, including the rotator cuff).

Initial Treatment
Initial management of shoulder dislocations requires recognition of the injury. Medical professionals (certifi ed athletic trainers, emergency medical personnel, or physicians) who are familiar with the injury may be able to perform an initial reduction of the injury with gentle, nonforced maneuvers. When early attempts are unsuccessful, prompt referral to an emergency room is appropriate. In this setting, a reduction can be performed either with conscious sedation or the use of an intra-articular anesthetic agent, such as lidocaine.² Radiographs should be obtained both before and after the reduction maneuver to confirm anatomic position of the joint, and to rule out associated bone injury, such as a fracture.

Problem Management
Once the joint is reduced, secondary management is initiated. First, the patient should be educated about the natural history and potential complications that might result from the injury. The secondary eff ects are generally age-dependent. In patients younger than 30 years, the primary concern is the development of recurrent joint instability. Recurrent instability may manifest itself as a spectrum of disability, from frank dislocation requiring repeated reduction, to painful “apprehension” or a sense of instability that interferes with daily or athletic activities.³

In patients older than 35, the concern is for associated injuries that occur at the time of dislocation, such as bone fracture, nerve injury, or rotator cuff tears.⁴ Evaluating for associated injuries and initiating prompt treatment often require secondary imaging studies, including magnetic resonance imaging (MRI) or occasionally computed tomography (CT) scanning. A variety of treatment options might exist. Orthopedic consultation after an initial glenohumeral dislocation is appropriate to help determine the optimal treatment plan, thereby improving recovery and functional outcome.

Surgery or not?
Historically, surgical treatment has been reserved for patients who have developed recurring shoulder dislocation. Advancements with arthroscopic shoulder surgery in the past fi ve to 10 years have led to increased interest in early surgical treatment to correct
the anatomic lesion (tear of the labrum, or Bankart-Perthes lesion) that occurs with shoulder dislocations. For cadets at the United States Military Academy, such treatment has provided improved shoulder stability when compared to rehabilitation alone.⁵

When managing young inseason athletes, treatment with brief immobilization and early rehabilitation remains a good option. Surgery can be delayed until the off season for those athletes with persistent instability despite appropriate rehabilitation, or those who desire to minimize risk of recurrent instability over time.

References
1. Matsen FA III, Titelman RM, Lippitt SB, Rockwood CA Jr., Wirth MA. In: Rockwood CA Jr., Matsen FA III, Wirth MA, Lippitt SB, eds., The Shoulder, 3rd ed., 2004.
2. Miller SL, Cleeman E, Auerbach J, Flatow EL. Comparison of intra-articular lidocaine and intravenous sedation for reduction of shoulder dislocations: a randomized, prospective study. J Bone Joint Surg Am. 2002;84A:2135-9.
3. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996;78(11):1677-84.
4. Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orth Rel Res. 1993;291:103-6.
5. Bottoni CR, Wilckens JH, DeBerardino TM, D’Alleyrand JC, Rooeny RC, Harpstrite JK, Arciero RA. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, fi rst-time shoulder dislocations. Am J Sports Med. 2002;30(4):576-80.

Although some occupations requiring repetitive hand use and/or exposure to vibration seem to increase the risk of carpal tunnel syndrome, the majority of individuals in such jobs do not get carpal tunnel syndrome, unless they are anatomically predisposed to it.

Diagnosing Carpal Tunnel
Physical exam findings in the patient who has carpal tunnel consist primarily of median nerve irritability, which is identified by sensitivity to tapping at the wrist level. An examiner can test for sensitivity to pressure by holding the wrist in a flexed position or placing direct pressure on it for a short period of time. Examination of the neck and proximal forearm to rule out other causes of nerve compression are also done as part of the examination.

In most cases, the patient’s history and a physical exam are enough for a diagnosis, but in some cases, it may be necessary to provide additional objective confirmation of nerve dysfunction. This can be done by doing an electromyogram (EMG), which is a nerve test to evaluate the electrical conductivity of the nerve. The EMG is not infallible and fails to diagnose about 10 percent of confirmed carpal tunnel syndrome cases. It may also produce a false positive.

Another way of obtaining objective information is to inject adrenal corticosteroids into the carpal canal to shrink swelling, thus diminishing pressure. A steroid injection will decrease pressure and invariably improve true carpal tunnel syndrome symptoms, unless permanent median nerve damage has occurred. The benefit is usually temporary, but temporary improvement confirms the carpal canal as the source of the symptoms.

Other tests such as X-rays and magnetic resonance imaging (MRI) scans might be useful to rule out other causes of wrist pain, but these tests cannot confirm a diagnosis.

Exploring treatments for Carpal Tunnel
Treatments to decrease swelling in the carpal canal include activity modification, stabilizing the wrist, physical therapy, use of antiinflammatory medication, and occasional injections of corticosteroids. These measures are effective in mild cases; but once symptoms begin occurring on a frequent or continuous basis, these treatments are rarely effective in providing any significant longterm or permanent relief.

For those patients with significant symptoms, the only permanent solution is carpal tunnel release, a surgery that will increase the size of the carpal tunnel. This procedure is performed frequently with a high success rate and a relatively low rate of repeat surgery.

Transverse carpal ligament surgery, a traditional method of relieving carpal tunnel syndrome, consisted of an open incision along the transverse carpal ligament and distal forearm fascia. Historically, this operation required a 2- to 3-inch incision beginning at the narrowest part of the wrist in the midline continuing out into the palm of the hand; and it was recommended to dissect around the tendons and nerves to remove inflammatory tissue and scarring. However, various studies have identified that in most cases dissection of the nerve and removal of synovial tissue is not necessary and is perhaps detrimental to recovery from carpal tunnel syndrome, because it may cause the formation of additional scar tissue.

After this type of surgery, “pillar pain” has been recognized as the most likely side effect. This pain is an ongoing tenderness in the palm of the hand usually associated with grasping, which is present in all patients for the first four to six weeks. In a few individuals individuals, however, it lasts for several months and even permanently. Unfortunately most of those at risk cannot be identified preoperatively; but it usually can be treated successfully with physical therapy.

Trying an alternative
The problems recognized above led to the development of the endoscopic technique, which has been widely practiced for at least 10 years. Endoscopic carpal tunnel surgery makes up about 20 percent of the carpal tunnel releases done today. The technique is demanding, and may increase the risk of nerve injury. Published studies offer conflicting results with respect to this issue. Risk of nerve injury is dependent on the surgeon’s experience with the technique. There are few contraindications to endoscopic carpal surgery, except perhaps previous carpal tunnel surgery.

On the positive side, although studies are conflicting, the consensus seems to be that individuals who undergo endoscopic carpal tunnel surgery are able to recover more rapidly and return to activities sooner than those undergoing traditional open carpal tunnel surgery. In most cases individuals undergoing endoscopic carpal tunnel surgery recovered two to three weeks faster than their counterparts who had traditional carpal tunnel surgery. Long-term results between the two techniques have not been shown to be any different.

Joint replacement surgery has revolutionized the treatment of late-stage arthritis for most patients. Enhanced surgical techniques and modern care during and after the hospital stay have helped speed patients to quick recoveries back to near-normal function.

Designing engineers and orthopedic surgeons hope improvements of implants will allow longer lasting function of the replacements. These improvements may allow the replacement of joints in younger patients and provide an alternative to patients who fail to get adequate relief from more conservative treatments.

The hip is a good example of a large weight-bearing joint that is frequently replaced. It is made of two main parts: The ball at the top of the thighbone that fits perfectly into the round socket in the pelvis; and the shape of the bones and “ropes” of tissue between the bones, called ligaments that provide stability to the joint. The ball and socket are both covered with a smooth durable layer of cartilage that cushions the ends of the bones and enables them to move easily. It is this layer that “goes bad” in most forms of arthritis. Doctors and researchers continually try to find a way to replace healthy living cartilage effectively, but success is likely many years away.

Varied designs
At this time, the best medical science has to offer is to replace the entire joint. Many different designs and materials are currently used in artificial hip joints. All of them consist of two basic components: the ball component (usually made of polished metal) and the socket component (usually made of strong plastic). Both components are attached to the normal bone with either a rough surface (into which bone will grow) or bone cement.

The “weak link,” according to most studies of joint replacement, is the contact surface between the ball and socket. Just as the surface that nature makes can wear out with time (arthritis), the plastic surface of the joint slowly wears away with time and can eventually cause the metal parts to loosen from the bone. Even the most polished ball’s surface has tiny scratches that scrape against the plastic cup and cause the loss of tiny pieces of polyethylene plastic. These tiny pieces are recognized as foreign and stimulate the formation of cells that clean up the body. The cleanup cells in bone dissolve the bone (osteolysis) near the metal pieces of a joint replacement and can cause them to become completely loose and in need of rereplacement.

The second operation, or revision, is much more difficult and has higher risks of complications and lower rates of patient satisfaction.

It used to be that total hip replacement (arthroplasty) was the only option for these patients. Although the traditional surgery offers pain relief, it is often accompanied with limitations. Many patients are prevented from maintaining a more active lifestyle.

A new pain-relieving procedure known as hip resurfacing can be benefi cial for younger hip arthritis patients. Current studies show that after 10 years, 95 percent of patients with a resurfaced hip are functioning well.

Pluses and minuses
Compared with conventional total hip arthroplasty, hip resurfacing off ers distinctive advantages in the appropriate patient with end-stage hip arthritis. Th e most obvious advantage is bone preservation, because bone on the upper femur is maintained rather than resected, or removed. Another advantage is a more physiologic transfer of stress to the proximal thigh with activity.

These two advantages may make revision surgery at a later date less difficult because more femoral bone remains.

Another advantage is that with hip resurfacing the incidence of dislocation is lower. The larger diameter femoral head used reduces the dislocation rate when compared tothe smaller 28mm and 32mm heads used in a conventional total hip arthroplasty. For younger patients, the larger head also offers a greater range motion, which is essential for physical activities.

The risks of resurfacing are similar to those of total hip arthroplasty. They include infection, venothrombolic disease, neurovascular damage, wear, loosening, limb length inequality, and the physiologic stresses associated with surgical intervention. Hip resurfacing patients are also at risk for fractures of the femoral neck below the resurfacing, which occurs in roughly 2 to 3 percent of the procedures.

Dramatic changes
Hip resurfacing can produce dramatic changes in patients’ lives and activity levels. Several TCO patients have returned to skating, skiing, and bike riding. Some physicians will also allow patients to return to running and contact activities after the first year. There is hope for high activity and mobility after hip replacement surgery, even though patients might not feel as if they have returned to their athletic prime.