Orthopaedics
General orthopaedic conditions and treatment
Achilles Tendon Disorders
Who does this affect? This is the heel cord. It is a crucial tendon at the back of the ankle that allows the patient to “toe-off” when walking or running. The blood supply comes from above and below and so the portion in the middle becomes vulnerable, as you get older.
Symptoms It can become inflamed (tendonitis) or even rupture during activity, especially sports involving rapid acceleration such as tennis or squash.
Investigations A careful examination is essential. Scans are sometimes used to help plan surgery.
Non-surgical Treatment Treatment Initially, physiotherapy and orthotics (insoles) are used for tendonitis. Specialised splints are used to treat ruptures and this avoids an operation, but recovery is slower than with surgery, and the re-rupture rates are slightly higher.
Surgical Treatment In some patients, early surgical repair of ruptured Achilles tendon with functional aftercare has the lowest rates of re-rupture. Surgery can also be used for chronic tendonitis.
Ankle Pain and Arthroscopy
Who does this affect? This condition can affect all age groups. It is often seen after a sprain or bad twist to the ankle.
Symptoms There are a number of conditions within the ankle that may cause pain or limitation of movement. The pain may be caused by inflamed tissue catching within the joint or areas of worn or loose bone or cartilage.
Investigations A careful clinical assessment and X-rays are done firstly. Often scans (CT/MRI) are used to obtain more information prior to surgery.
Non-surgical Treatment Physiotherapy and splints may be tried at first.
Surgical Treatment An ankle arthroscopy is becoming more and more useful. This is a procedure where a small incision is made over the joint and a specialized camera and instruments are inserted. Many abnormalities can be treated using this special equipment and techniques.
Anterior Cruciate Ligament Reconstruction
Who does this affect? Sportsmen and women are at risk of this injury. It is usually due to a twist or change of direction whilst running. The patient often hears or feels a “pop” and their knee swells within minutes becoming very painful.
Symptoms The anterior cruciate ligament is one of two main ligaments within the knee joint. It can lead to feelings of knee instability, “giving way” pain and long-term knee problems
Investigations Often a careful assessment by the surgeon is all that is required. MRI Scans are undertaken if there is any doubt.
Non-surgical Treatment Initially, physiotherapy is helpful to stop the knee stiffness and muscle wasting i.e. rehabilitation starts before surgery. If the patient wishes to maintain their pre-injury lifestyle, surgery is recommended. Also, avoiding surgery can result in long-term knee problems of cartilage tears, instability and early arthritis.
Surgical Treatment It cannot be repaired and so is replaced using either hamstring tendons or part of the patellar tendon. Normally, this is undertaken with “keyhole” techniques. Surgery is undertaken in combination with a supervised rehabilitation program designed to return the knee and patient to a high level of activity.
Arthritis of the Hand and Wrist
Who does this affect? Like arthritis elsewhere in the body, it is usually seen in middle age and onwards.
Symptoms This is commonly seen at the base of the thumb, but can be in any of the joints in the hand and wrist. It can be painful and very restricting. It may be due to a previous injury, however, often it is just “wear & tear”.
Investigations Careful clinical examination and X-ray is necessary.
Non-surgical Treatment Initially, injection and splints are the usual treatments.
Surgical Treatment Surgery is usually offered if symptoms do not settle following non-surgical. For base of thumb arthritis, Trapeziectomy is very beneficial. This is done under a general anaesthetic as either a day case or overnight stay.
Arthritis of the knee
Who does this affect? This condition is more common in the older patient and in most cases is due to osteoarthritis. However, it can occur earlier if there has been a history of previous injury, surgery or other rare conditions.
Symptoms Knee pain is typical, worse on walking or standing. This can progress to pain at rest or night. Knee stiffness is common. Difficulty walking up or down stairs is another common complaint.
Investigations X-rays of the knee are essential.
Non-surgical Treatment Initially this condition is treated with simple measures such as painkillers, weight loss, physiotherapy and activity modification.
Surgical Treatment If non-surgical treatment is unsuccessful, knee replacement is very successful in relieving pain and improving the patient’s quality of life.
Bunion (Hallux Valgus)
Who does this affect? Generally, bunions are more common in women. Bunions can be hereditary; however, they are more commonly associated with modern footwear.
Symptoms This is a condition where the patient develops painful lumps over the joints of the front of the foot. It usually affects the big toe and can be associated with painful, stiff arthritis of the big toe. Investigations X-ray of the foot.
Non-surgical Treatment If mild the condition can be treated with insoles or shoe modifications.
Surgical Treatment Depending on the severity of the condition, it usually requires surgery to straighten the toe and remove the bunion. This is most often done as a day case under general anaesthetic.
Carpal Tunnel
Who does this affect? It is seen usually seen in the over 40s. Women are more commonly affected than men. It is associated with pregnancy, diabetes and thyroid disorders.
Symptoms This is a very common condition causing tingling, “pins & needles” or even pain in the fingers. It is often worse at night or on activity. It can be quite disabling and is caused by a trapped nerve in the wrist.
Investigations We recommend prompt examination to make an early diagnosis. This minimizes the risk of permanent nerve damage. Special tests (nerve conduction studies) may be required to confirm the diagnosis.
Non-surgical Treatment Initially, splints and injections can be used as an alternative to surgery.
Surgical Treatment Treatment is a minor operation under local anaesthetic and undertaken as a day case. The procedure is very successful and injections are used for short-term improvement only.
Cartilage tears
Who does this affect? The knee is a complex joint and is commonly injured during activity. It can happen in both sportsmen and women, and in less active patients especially in association with early arthritis.
Symptoms Within the knee are ligaments (ACL) and semi-circular pieces of soft cartilage (meniscus). These can be torn and this can cause persistent pain as well as mechanical symptoms such as clicking or locking.
Investigations X-ray of the knee is usual. MRI scan is often used to help confirm the diagnosis.
Non-surgical Treatment Rest and physiotherapy may help settle symptoms. Injections are used occasionally.
Surgical Treatment This condition can be relieved by a day case “keyhole” operation known as arthroscopy. Here the knee joint is inspected via small incisions using a camera. Suitable tears are repaired and those that are not are removed.
Dislocation of the Shoulder
Who does this affect? There are two main groups, young athletes, and older patients, often following a fall.
Symptoms In young patients, the lining of the shoulder joint becomes torn. This is the Bankart lesion. It often does not heal correctly and becomes a weak spot, resulting in easier and easier dislocations. In older patients, it is more usual for the rotator cuff to tear, again, often making the shoulder weak.
Investigations Specific scans e.g. MRI or CT are sometimes used in younger patients. In older patients it is more likely that an MRI or ultrasound scan would be undertaken to assess the tear.
Non-surgical Treatment First-time young dislocators are treated with a special (Itoi) brace and physiotherapy in order to reduce the instance of further dislocations.
Surgical Treatment Should dislocation occur twice or more, surgery is then recommended to re-attach the torn lining. If there is a repairable tear to the cuff, then early surgery is recommended.
Dupuytren’s Contracture
Who does this affect? Patients are usually over 35 years of age and men are far more commonly affected than women.
Symptoms It is largely an inherited condition, running in families. It is also more common in diabetics and causes thickening under the skin of the palm and fingers. Often the fingers often get more and more curled over. This can be awkward and affect hand function. We recommend an early assessment to plan any need for surgery.
Investigations Careful assessment with the surgeon is necessary.
Surgical Treatment If the fingers have become crooked / curled then surgery is recommended to remove the thickened tissue and straighten the fingers. This is usually undertaken as a day case procedure under a general anaesthetic. Specialist after-care is important in order to obtain the best results of surgery.
Elbow Pain
Who does this affect? This includes tendon problems such as tennis and golfer’s elbow, which benefit from early diagnosis and treatment. This approach reduces the need for surgery for chronic problems. These usually affect those aged between 35-60.
Symptoms It is an over-use disorder, with micro-tears and a chronic healing process in the affected tendon. This causes pain and loss of function in the elbow. Symptoms are usually felt on activity, but can even occur at rest Investigations A focused clinical examination is usually sufficient to make the diagnosis.
Non-surgical Treatment The earlier the condition is treated, the better the outcome. Treatment starts with a cortisone injection, rest and physiotherapy. Forearm clasps can also be used.
Surgical Treatment For resistant cases day case surgery is offered.
Flat Feet
Who does this affect? This is a common condition where there is collapse of the normal arch of the foot. It occurs in 30% of the population and usually causes no symptoms. It is more common in older women.
Symptoms Occasionally it can cause pain across the sole of the foot, often made worse by standing or walking.
Investigations Sometimes, X-rays and an MRI scan are used to plan surgery.
Non-surgical Treatment In most cases supportive insoles relieve the discomfort.
Surgical Treatment Surgery is reserved for severe cases.
Frozen Shoulder
Who does this affect? Frozen shoulder is a common, under-diagnosed condition, causing a very painful and stiff shoulder. Without treatment, it can be disabling for years. Prompt treatment, often involving keyhole surgery, results in a much quicker and more complete recovery. Who does it affect? It is usually seen in middle years, and is more common in women. For example, In Japan, it is known as 50 year olds’ shoulder.
Symptoms In most people, the exact cause is not known, although there is a genetic part. It is common in diabetics and those with Dupuytren’s contracture. Frozen shoulder results in the lining of the shoulder joint (capsule) becoming very thickened and inflamed. Some people have a mild form whilst others have it more severely.
Investigations A careful examination and X-ray, in order to rule out other causes, is usually all that is necessary.
Non-surgical Treatment Initially, patients will receive a steroid injection and physiotherapy.
Surgical Treatment If non-surgical treatment is unsuccessful, manipulation under anaesthesia may be tried. Increasingly, surgery to release the thickened lining is recommended.
Hand and Wrist Conditions
Who does this affect? Any age group can be affected. Occasionally, these conditions can go in time by themselves.
Symptoms Ganglion, lumps, bumps and swellings around the hand and wrist are common and can be worrying, uncomfortable or unsightly. Often there is no cause. They can be associated with a previous wrist sprain or strain. On the finger, they are usually due to arthritis in the finger (knuckle joints).
Investigations Clinical assessment and an X-ray are often all that is required. If the lump is large or unusual, an MRI scan is used to confirm the diagnosis.
Non-surgical Treatment Aspiration (using a needle /syringe to suck out the contents) can often work to remove the swelling.
Surgical treatment A small surgical procedure is often used to remove the lump if it is troublesome.
Heel Pain & Planter Fasciitis
Who does this affect? Any age group, usually, between 30 to 60 years.
Symptoms This is a common condition caused by inflammation at the heel. It occurs where the soft-tissues of the arch of the foot insert into the heel bone. It can be due to over use.
Investigations Clinical examination is usually all that is needed.
Non-surgical Treatment It can take time to resolve and is often helped by local injections, physiotherapy and the use heel pad insoles.
Surgical Treatment For cases which have not been helped by non-surgical methods, surgery can be performed.
Hip and Groin Pain
Who does this affect? This can be a relatively common condition in active people and can be caused by a variety of problems.
Symptoms This condition can include inflamed areas on the side of the hip, soft tissue problems in the hip joint, bony catching (impingement) around the hip and early arthritis. Hip-related pain is not always felt directly over the hip; instead, you may feel pain in your groin. The pain you do feel in the hip may actually be the result a problem in your back, a hernia or other diagnoses.
Investigations X-ray of the hip is usual. Scans are used for complex cases.
Non-surgical Treatment Physiotherapy, painkillers, anti-inflammatory drugs and modification of activity can be tried.
Surgical Treatment Depending on the cause, surgery is becoming more and more widely used. Options include hip arthroscopy (keyhole surgery), hip resurfacing or replacement or open debridement. The options are best discussed with your surgeon.
Hip Replacement and Re-surfacing for Arthritis
Who does this affect? This condition is more common in the older patient. However, it can occur earlier due to abnormalities within the hip. This may be due to a previous injury, childhood hip disease or problems with the blood supply to the hip.
Symptoms Commonly, this causes groin pain often going down the thigh up to the knee. The hip is stiff, and the patient walks with a limp.
Investigations X-ray of the hip. Scans are used in complex cases
Non-surgical Treatment To begin with, simple measures are tried such as painkillers, weight loss and activity modification.
Surgical Treatment When a patient has severe arthritis and painkillers no longer effectively control the symptoms, hip joint replacement is advised. This has the benefit of relieving the pain and allowing the patient to return to a near normal level of activity. There are different forms of hip replacement (resurfacing, ceramic, hybrid and standard) and each one has a role to play depending on the patients’ age and activity level. The risks and benefits of each type are best discussed with your surgeon.
Metatarsalgia
Who does this affect? This condition is more common in older women. It is associated with other conditions such as rheumatoid arthritis.
Symptoms Metatarsalgia is a term describing pain in the area of the sole of the foot. Patients describe as though they are walking on a pebble. It often occurs in association with lesser toe deformities or bunions. It is due to a pressure overload in one area. They often have a skin callous in this area. Investigations X-rays can help confirm the diagnosis.
Non-surgical Treatment Correcting the underlying abnormality with insoles and podiatric care usually treats this condition well.
Surgical Treatment Surgery may be necessary to correct the toe deformities and relieve the area of the sole under pressure.
Rotator Cuff Problems & Shoulder Pain
Who does this affect? Any age group, particularly, in middle years. It can occur either from repetitive activity or a “one-off” movement, such as a fall. It can also be due to a shoulder dislocation.
Symptoms Shoulder pain due to muscle strains, particularly of the rotator cuff, are common. This is often known as “impingement” pain. Early assessment and treatment is crucial to avoid chronic symptoms Rotator cuff tendon tears are often not identified for a long time. These can cause shoulder pain often with muscle weakness. Prompt diagnosis and repair (surgery) gives the best chance of successful outcome and return to full activity.
Investigations A clinical exam and plain X-rays are essential. After this, usually an MRI scan is used to confirm the diagnosis.
Non-surgical Treatment If the tendons are strained, then a cortisone injection and physiotherapy is the first line of treatment. This is successful for over 50% of patients.
Surgical Treatment “Keyhole” surgery known as Arthroscopic Subacromial Decompression, is used for patients whose pain persists. If the rotator cuff tendon is torn, then prompt surgery to reattach the tendon gives the best outcome. Increasingly, this is done by keyhole methods too. Cuff repair does mean a period of recovery to regain full use, with physiotherapy.
Shoulder & Elbow Arthritis
Who does this affect? Just like hip and knee arthritis, it is usually seen in the over 50 age group.
Why does it occur? The exact cause is usually unknown. It is more common in those with a physical job or lifestyle, or previous injury, such as an untreated rotator cuff tear. Although not as common as arthritis of the hip and knee, the shoulder and elbow joints can also develop (osteo) arthritis causing pain, stiffness and reduced function.
Investigations Clinical assessment and X-rays are essential. Often, CT scans are used to help plan the surgery.
Non-surgical Treatment For mild cases, injection, painkillers and physiotherapy are tried in the first instance.
Surgical Treatment However, for more severe symptoms, modern shoulder joint replacement (resurfacing) is an excellent solution for pain control and restoring movement. Elbow arthritis often responds to a debridement operation in order to remove excess bone and release areas of stiffness. Increasingly, this is being undertaken using “keyhole” surgery. Elbow replacements are best reserved for lower demand patients.
Small Toe Deformities (Claw or Hammer Toes)
Who does it affect? This condition is more common in older women. These are commonly associated with other deformities of the foot such as bunions (Hallux Valgus) and are often made worse by tight footwear. Patients often complain of painful corns (callosities) and difficulty with shoes
Investigations X-ray
Non-surgical Treatment These are initially treated without surgery by modifying your shoes, introducing padding or the use of insoles.
Surgical Treatment Surgery is used to straighten and shorten claw or hammer toes. It is usually done a day-case under a general anaesthetic.
Trigger Finger
Who does it affect? Who does it affect? Patients notice a tender swelling below the finger or thumb with a “snap” when they try to bend it. Most are seen in older patients, but can occur at any age. It is common in diabetics.
Investigations An expert clinical examination is usually sufficient.
Non-surgical Treatment Initial treatment is by steroid injection and often this is all that is required.
Surgical Treatment If this is not successful, then a minor procedure performed under local anaesthetic is performed to free up the tendon. Diabetic patients do better with surgery straight away.
