Mobility & Flexibility - Joint Movement

Stretching is often an outstanding complement to chiropractic care. Blood flow to the muscles is increased and it helps lower the risk of injury and improves physical performance. More importantly, stretching is good for the joints, helping them function through their full range of motion.

Additionally, some studies show that muscles work and move more effectively when they are stretched regularly. These benefits of stretching make it a great practice to incorporate into your daily routine, especially between chiropractic treatments.

The muscles all along the spine respond well to stretching. However, sometimes it is difficult to manipulate specific muscle groups and get a thorough stretch.

The cervical spine is a prime example. Although the neck turns in so many ways, finding positions that provide an effective stretch are surprisingly difficult.

These three stretches effectively work the muscles through the neck and shoulders and are simple enough to do at home whether you are between chiropractic appointments or if you wake up with a crick in your neck.

Before You Stretch

If you are under a chiropractor’s care, you should check with him or her before you start a stretching program. This is especially important if you have a neck injury or have a spinal condition that causes deterioration or pain.

When you begin stretching, you may feel a little discomfort, but it is important to note that it should never cause pain or worsen it. If this occurs, or if it just doesn’t feel “right,” you should stop immediately and call your chiropractor.

Neck and Trap Stretch

If standing: Stand up straight with your pelvis slightly tucked (not swayback), feet shoulder’s width apart, knees soft.

If sitting: Sit up straight with your feet flat on the floor.

1. Drop your shoulders and roll them slightly back. Let your arms hang down.

2. Reach behind your back and, with your left hand, grasp your right wrist. If you can’t reach to grasp your wrist, grab your fingers. If you can’t reach your fingers, sit in a straight back chair and put your right arm as far behind you as you can and slide your right hand under your right buttock to provide stability.

3. If clasping your hands behind you, gently pull your arm behind you to the left. If unable to reach behind you, drop your right shoulder.

4. At the same time, tilt your head to the left, bringing your ear to your shoulder but don’t raise your left shoulder. You will feel the stretch all along the right muscles of the neck.

5. Hold the stretch for 15 to 30 seconds.

6. Do the same movement for the left side.

7. Repeat the full move 3 to 5 times.

Gentle Neck Extension

If standing: Stand up straight with your pelvis slightly tucked (not swayback), feet shoulder’s width apart, knees soft, hands relaxed and at your sides.

If sitting: Sit up straight with your feet flat on the floor, hands relaxed and at your sides.

If lying down: Lie flat on the floor. If necessary, put a pillow under your knees to take pressure off of the lower back. Stretch your arms down by your side.

1. Push your shoulders down towards your feet.

2. Tuck your chin to your chest but don’t let your shoulders lift.

3. Slowly raise your chin, feeling the stretch along the front of your neck. Hold the position for 20 to 

30 seconds.

4. Return your head to its normal, upright position for 30 seconds. Repeat the entire movement 5 to 7 times.

Stretch for Traps

If standing: Stand up straight with your pelvis slightly tucked (not swayback), feet shoulder’s width apart, knees soft, hands relaxed and at your sides.

If sitting: Sit up straight with your feet flat on the floor, hands relaxed and at your sides.

If lying down: Lie flat on the floor. If necessary, put a pillow under your knees to take pressure off of the lower back. Stretch your arms down by your side.

1. Start with your head in the normal, upright position.

2. Bend your neck to the right side, moving your ear towards your shoulder.

3. Raise your left hand to your head and apply gentle pressure to facilitate the stretch while drawing 

up your left shoulder. Hold for 20 seconds.

4. Return to your starting position.

5. Repeat the same movement on the right side.

6. Do 3 to 5 sets.

Chiropractic Neck Pain Treatment

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Wrist & Hand Trauma

• Distal Radius & Ulnar Fractures (Colles, Smith's, Barton's, Chauffeur's, DiePunch)- complicated by 50% ulnar styloid Fx, TFC path, DRUJ dislocation, scapholunate lig dissociation, lunate/perilunate dislocation )
• Carpal bones Fracture & dislocations (scaphoid, triquetrum, hamate Fx &Lunate/perilunate dislocation)
• Ligaments dissociation (Scapholunate dissociation, Lunotriquetral instability) 
• Metacarpal & Phalangeal fractures (Bennett, Rolando, Game keeperFx/Stener lesion, Boxer Fx) 
• Pediatric wrist injury (green-stick Fx, Torus Fx, Bowing/plastic deformity, Salter-Harris injuries) 
• In all cases, Orthopedic hand surgical referral is required

• Colles fx: m/c d/t FOOSH+pronation. m/c inOSP/elder women. Rare in men and if occurs need DEXA to avoid hip Fx etc. Young pts: high-energy trauma. Typically extra-articular.50%-cases show Ulna styloid (US) Fx. 
• Complications: dinner fork deform, CRPS, DJD, nerve entrapment. 
• Imaging: x-rad is sufficient, CT in complex Fx, MRI helps with ligament tears and TFC. 
• Rx: if extra-articular and <5-mm distal radius shortening and <5-degree dorsal angulation closed reduction+casting is sufficient. ORIF in complex cases. 
•  Image Dx: distal rad impaction/shortening,dorsal angulation of distal fragment, carefully examine if intra-articular extension, 50% US Fx

• Smith Fx: Goyrand in French literature. Considered as reversed Colles, otherwise almost identical, I.e., 85% extra-articular, 50%US Fx, OSP/elderly women, young pts-high-energy trauma. Differences: mechanismFOOSHwith flexed wrist thus m. Less frequent.
• Imaging steps: (see Colles Fx) C
• Complications: similar to Colles Fx 
• Rad Dx: 85% extra-articular with volar(anterior) angulation of the distal fragment,radial shortening. Carefully examine cortical breach suspecting intra-articular extension that can be named as Smith type 2 or Reversed Barton Fx (next) 
• Rx: similar approach as in Colles.

• Barton fx: FOOSH, impaction of distal radius similar to Colles but the Fx line extends from the dorsal radial aspect into radiocarpal joint resulting with dorsal slip/dislocation of the carpus. 
• Imaging: 1st sept x-radiography often with CTto examine intra-articular Fx extension and operative planning 
• Rad Dx: distal radius Fx extending from dorsal into the radiocarpal joint with a variable degree of displacement, the proximal slip of the carpus 
• If Fx line extends from the volar aspect into the wrist joint named Reversed Barton aka Smith type 2 (above bottom image)
• Complications: similar to all distal radius Fx 
• Rx: operative with ORIF

• Chauffeur's/backfire Fx aka Hutchinson Fx: intra-articular Fx of Radial styloid. The name derives from the time when the car had to be started with a hand crank that could backfire inducing wrist dorsiflexion and radial deviation.
• Imaging: x-radiography is sufficient. CT may be helpful if Fx not readily shown by x-rays.
• Complications: non-union, malunion, DJD,scapholunate dissociation,lunate/perilunate dislocation 
• Rx: operative with percutaneous lagscrewin all cases d/t intra-articularnature

• Die-Punch Fx: impaction Fx by the Lunate bone into distal articularLunate fossa of the Radius. IntraarticularFx. Derives its name from a technique to shape (impress) a hole in industrial machining "die-punch."FOOSH injury.
• Imaging: 1st step x-rays, may be equivocal d/t subtle depression of the Lunate fossa then CT scanning is most informative. 
• Rad Dx: impacted lunate fossa region with intra-articular Fx extension. This can present as a comminuted Fxarticular Fx of the Distal Radius. 
• Rx: operative d/t intra-articular Fx

Construct arcs of Gilula when evaluating carpal injuries. An Important step required to avoid missing subtle changes in carpal alignment and cortical continuity

• Scaphoid bone Fx: m/c Fx carpal bone. D/tFOOSH wrist extended radially deviated. Location of Fx is most important to prognosis: Waist-m/c location (70%). May have 70-100%chance of AVN. Proximal pole Fx: 20-30% with a high risk of non-union. Distal pole-10%shows better prognosis. Distal pole Fx is m/c in children. Key clinical sign; pain in the snuffbox.
• Imaging: 1st step-x-radiography but 15-20%missed d/t occult Fx. Special views required. Thus MRI is the most sensitive and specific for early occult Fx. Bone scintigraphy has98/100% specificity & sensitivity esp. 2-3 days after the onset. Key rad. Dx: Fx line if evident, displacement and obscuration of scaphoid(navicular) fat pad, examine for scapholunate dissociation. If proximal bone appears sclerotic-AVN occurred. MRI: low on T1 & high on T2/STIR/FSPD d/t bone edema, a low signalFx line can be noted. 
• Rx: Spica cast should be applied if clinically suspected even w/o x-ray findings. For waistFx-cast for 3-mo for prox pole 5-mo immobilization. ORIF or percutaneous pinning with a Herbert screw.

Scapholunate Ligaments Dissociation

• SNAC wrist: scaphoid non-union advanced collapse. Often d/t non-union and dissociation of scapholunate ligaments (SLL)with progressive radiocarpal and intercarpalDJD. The Proximal scaphoid fragment is attached to Lunate with distal dissociating and rotating‘signet ring” sign on x-rays.
• SNAC wrist may often result in DISI
• Rx: progressive DJD may lead to four-corner arthrodesis

• Scapholunate advanced collapse (SLAC wrist): SLLdissociation with progressive intercarpal and radiocarpal DJD and volar or dorsal carpal displacement (DISI & VISI). Causes: trauma, CPPD, DJD, Kienboch disease (AVN of Lunate), Preiserdisease (AVN of Scaphoid).
• SLL dissociation will lead to Dorsal or VolarIntercarlate aka Intercarpal Segmental Instability (DISIor VISI).
• Rad Dx: Dx underlying cause. X-rays demonstrate dorsal or volar angulation of the Lunate with increased or decreased scapholunate angle on the lateral view. On frontal view: Terry Thomas sign or widening of scapholunate distance 3-4-mm as the upper limit of normal.
•  MRI may help with ligament evaluation and pre-surgical planning
• Rx: often operative with late DJD. Four-corner arthrodesis

• Triquetrum Fx: 2nd m/c carpal bone Fx. M/C dorsal aspect is avulsed by the tough Dorsal radiocarpal ligament. Cause: FOOSH.
• Imaging: x-radiography wrist series is sufficient. Best revealed on the lateral view as an avulsed bone fragment adjacent to the dorsum of the Triquetrum. CT may help if radiographically equivocal. 
• Rx: conservative care 
• Complications: rare, may persist as pain on the dorsum of the wrist

• Hook of the Hamate Fx: m/c occurs in batting sports (cricket, baseball, hockey, impact by a golf club, etc.) 2% of carpusFx.
• Imaging: x-radiography may fail to detect an Fx unless "carpal tunnel view" is used. CT may help if x-rays unrewarding.
• Clinically: pain, positive pull test, weak, painful grip. Deep ulnar n. Branch may be affected by the Guyon canal. 
• Rx: usually non-operative, but chronic non-union may require excision. 
• DDx: bipartite hamate

•  Lunate vs. Perilunate dislocation: Lunate is m/c dislocated carpal bone. Overall infrequent carpal injury. However, often missed!
• Occurs with FOOSH and wrist extended and ulnar deviated. Imaging: 1st step x-rays. Ifunrewarding or require more complex injury evaluation CT scanning.
• Key Rad DDx: DDx Lunate from perilunate dislocation. Lunate dislocation: lunate lost its contact with distal radius ‘spilled teacup” on the lateral. Perilunate dislocation: Lunate maintains its contact with distal radius despite the Capitatedorsally dislocated. Lunate dislocation is additionally helped to identify a “pie sign” d/t Lunate overlapping the Capitate
• Rx: emergency reduction and operative repair of torn ligaments

Metacarpal & Phalangeal Injuries

• Bennett Fx: intra-articular but noncomminuted impact-type Fx of the base of 1st MC bone of the thumb. X-radiography is sufficient.
• Rad Dx: characteristic triangular fragment of bone on the ulnar aspect of the 1st MCbase, often with radial subluxation of the remaining radial aspect of the 1st MC 
• Complications: DJD, non-union, etc. 
• Rx: prone to instability/non-union requiring an operative care 
• Rolando Fx: aka comminuted Bennett with Y or T-configuration. More complex injury. It is unstable requiring operative care

• Gamekeeper thumb: traditionally described as a chronic tear of the ulnar (medial) collateral ligament at 1stMCP in English Gamekeepers' who performed neck twisting/killing of small game. An acute injury may also be named as Skier's thumb. This injury can be ligamentous w/o a fracture and/or an avulsion injury at the 1st proximal phalanx base. 
• Complication: Stener lesion or displacement of torn ligament over Adductor pollicis muscle that cannot heal w/o surgical repair. MRI Dx is required. 
• Avoid thumb stress views that can induce a Stenerlesion
• Imaging: x-radiography followed by MRI to Dx Stenerlesion. MSK US can be used if MRI is unavailable. 
•  Stener lesion on MRI & MSUS: ulnar collateral stump is more superficial to Adductor pollicis aponeurosis and appears like a low signal mass-like stump forming so-called "yo-yo on the string sign" reported both on MRI and MSK US. 
• Rx: often operative

• Boxer Fx: m/c MC Fx. An extra-articular usually non-comminuted or minimal comminuted Fx through m/c the 5th and sometimes the 4th MCneck-head junction (occasionally through the shaft) resulting in volar head angulation. Mechanism: direct impact as in clenched fist punching hard surface (e.g., facial bones/wall punching) hence 95% in young males. 
• Imaging: x-radiography hand series is sufficient 
• Rad Dx: Fx line transverse or oblique through MCneck with volar head angulation. Evaluate the degree of displacement, critical to report. 
• Rx: typically non-operative with short –arm gutter splint and digits flexed. (https://www.aafp.org/afp/2009/0101/p16.html)
• N.B. If the same mechanism fractures the 2ndand 3d MC in the same anatomic area, it may require operative care.

• Phalangeal hand Fx: m/c skeleton Fx (10% of all Fx). Sports and industrial injuries dominate
• Imaging: x-radiography with hand series or PA/lateral finger views will suffice
• Rad Dx: if prox phalanx Fx, distal fragment is angled volarly with prox fragment dorsally. Distal phalanx may be angled dorsally. Key observation: nail bed injury, which considered an open Fx with a risk of infection. 
• Rx: if <10-degree angulation-buddy-taping with motion rehab. CRPP vs. ORIF can be considered in complex cases-Orthopedic hand surgeon referral
• Complication: loss of motion, necrosis, infection.May result with amputation 
• For additional common injuries: PIP is m/c dislocated joint. Mullet (Baseball) finger, Jersey finger and other injury refer to: 
• https://www.aafp.org/afp/2012/0415/p805.html

• Felon: septic infection of the fingertip pulp typically with Staph.Aureus. Causes: needle prick(diabetics), paronychia, nail splinters, etc. m/c in index and thumb, presenting with pain, swelling, etc. 
• D/t specific pulp anatomy theinfection>swelling leads to pulp compartment syndrome-pressure and necrosis. 
• Rx: operative with incision distal to DIP, irrigation/debridement

Pediatric Wrist Injury 

• Incomplete Fx: Greenstick Fx, Torus (Buckle)Fx, Bowing (Plastic) deformity/Fx. D/t FOSHe.g. fell off the monkey bar. m/c affects <10-years-old.
• Key Imaging diagnosis: degree of angulation/displacement, epiphyseal growth plate injury (Salter-Harris classification)
• Rx: usually non-operative (closed reduction and casting)

• Distal Radioulnar Joint (DRUJ) Instability-common injury following trauma as in FOOSHwith wrist hyperextension and rotation and disruption of DRUJ ligaments and TFCcomplex. Avulsion of ulnar styloid with the dorsal or volar displacement of distal ulnar should be noted.
• Imaging steps: x-rays initially, MRI may identify ligaments and TFC damage, MSKUScan help with ligaments tearing.
• Note: isolated DRUJ volar (top image) and dorsal (bottom image) dislocation.

Wrist & Hand Arthritis

• Wrist DJD-typically is secondary to trauma, scapholunate dissociation, SLAC, SNAC wrist, CPPD, Keinboch or Preiser Disease and others.
• May lead to major functional loss
• Imaging: typically presents as radiocarpal JSL, subchondral sclerosis,osteophytosis, subcortical cysts, and loose bodies. Typically additional induces intercarpal degeneration and particularly Tri-scaphe joint.
• MRI may be helpful with early recognition of scapholunate dissociation, Lunate/Navicular AVN.
• Rx: conservative vs. operative.

• DJD Hand: Extremely common. True primary OA. MCP-never affected w/o DIP & PIP
• If isolated MCP OA noted considerCPPD & Hemochromatosis (Hook-like osteophytes)
• Clinically:
• Mid-age females
• Typically painless except 1st CMC OA
• DIPs-Heberden nodes, PIPs-Bouchard nodes
• Erosive OA (occasionally called“inflammatory OA”)
• A Spectrum of OA but producing central proximal erosions at DIPs and PIPsresulting with very characteristic “gullwing” appearance. No systemic inflammation (no CRP, RF, Anti-CCP Ab)typically in middle-aged/elderly females, like Hand OA, often seen in families

Rheumatoid Arthritis

• Rheumatoid Arthritis (RA)-chronic systemic inflammatory disease of unknown etiology, targeting synovial joints, tendons with multiple systemic involvement (lung, CVS, Ocular, Skin, etc.) Pathology: Tcell>Macrophage/APC>mediatedautoimmune process resulting in pannus formation and gradual destruction of ST, cartilage, bone, and other tissues. 3% FemalesVS.1% Males. Environmental triggers: infection, trauma, smoking, and others in a genetically susceptible individual. 20-30%may be disabled after 10-years.
• Dx: clinical, labs, imaging.Symmetrical Polyarthritis esp. in MCP, wrists (2nd & 3RD MCP)

Overview of Shoulder Anatomy

Acute Trauma

• Proximal humeral Fx account for 4-6% of all Fxs. Osteoporotic (OSP) Fx in >60 y.o associated with minimal trauma with F: M 2:1 ratio. In young patients, acute high energy trauma predominates.
• Complications: AVN humeral head, Axillary N paralysis.
• Neer Classification: considers fractures along 4-anatomical lines with or w/o displacement >1-cm & 45-degree angulation
• One part Neer Fx- no displacement or very minimal <1-cm/45-degree. Can affect 1-4 lines and M/C at greater tuberosity. 80% of proximal humeral Fx are one-part Neer.
• Two-part Fx: 1-part is displaced >1-cm/45-degrees. m/c involves the surgical neck
• Three-part Fx: 2-parts are displaced >1-cm/45-degrees.
• Four-part Fx: all 4-parts can be displaced. Uncommon <1%
• Imaging: 1st step-radiography, CT may be used in more complex cases. Orthopedic referral
• Management: Neer one-part Fx is treated with Sling Immobilisation and progressive rehab
• The vast majority of Fx in the elderly are treated non-operatively
• Younger patients (40-65) may occasionally require hemiarthroplasty if 3 or 4-part Neer Fx present. Greater risk of AVN

Proximal Humerus Fractures

• Note: Left image: Fx involving the anatomical neck and the greater tuberosity with minimal displacement <1-cm/45-degree thus Dx as one-part Fx. Right image: Small avulsion Fx of the greater tuberosity with significant displacement (>45-degrees & 1-cm) thus Dx as two-part Fx

• Note: three-part Neer Fx (left) and four-part Neer Fx (right)> Management: operative in most cases in younger (40-65) patients

Shoulder Dislocation aka Glenohumeral Joint dislocation (GHJD)

• Refers to complete separation of the humerus from scapula glenoid. In 20-40s M: F 9:1 ratio, in60-80S M: F 3:1
• Anatomy: Shoulder stability is sacrificed for mobility, and overall GHJD is the m/c among large joints in the body
• Protective falls (e.g., FOOSH) and MVA are m/c causes. GHJ is most vulnerable in abduction, extension and external rotation. Anatomical factors: shallow glenoid, laxed ant-inferior capsule and GH ligaments. GHJD will induce severe tearing of major GHJ restraints. Associated osseous and labral injuries are common and may lead to chronic instability, DJD, and functional changes
• 3-types: Anterior GHJD (95%)
• Posterior GHJD (4%) especially associated with epileptic seizures, electrocution and can occur b/l
• Inferior GHJD aka Laxatio Erecta (<1%) associated with severe trauma
• Clinically: AGHJD presents with severe pain, the arm is externally rotated and adducted, severe limitation of movement. GHJD may persist as chronic dislocation.
• Management: prompt reduction in ED under anesthesia or heavy sedation with Kocher technique top image (not used), External rotation method (middle) or Milch technique (can be used w/o anesthesia) and a few other methods. Delay in reduction correlates with greater risk of immediate and long-term complications

Diagnostic Imaging Approach

• Shoulder series x-radiography is sufficient. Additional Imaging with CT scanning and MRI may be helpful to Dx osseous, cartilage, labral/ligaments pathology
• Anterior GHJD (95%). Subcoracoid position(top right) of the humerus is the m/c
• Anterior GHJD may also occur as subglenoid(bottom left)and infrequently as subclavicular
• Key to radiographic search is to evaluate associated Bankart and Hill-Sachs injuries

Bankart Lesion

• Occurs during anterior GHJD d/t impaction of the head into anterior-inferior glenoid. Variations exist (see next slide). BonyBankart can be seen on x-rays. So-called soft tissue Bankart requires MRI. Cartilage (soft)Bankart is the m/c.
• Hill-Sachs aka Hatchet deformity (arrow postreduction)occurs during the same mechanism as Bankart, i.e., compression and impaction of posterolateral aspect of the head against the glenoid producing wedge-shape Fx. Hill-Sachs lesion may predispose to recurrent/chronic GHJD.
• Bankart lesion may heal, but operative suture anchors are needed sometimes
• CT arthrogram and MRI may be helpful

Types of Bankart Lesion

• Note different types of Bankart lesion. Onlyosseous Bankart can be seen radiographically. Soft tissue Bankart requires MRI with and without intra-articular gadolinium(arthrogram).

Posterior Dislocation

• Note: posterior GHJD with its characteristic signs:
• Trough sign aka reverse Hill-Sachs. Occurs d/t anterolateral head impaction Fx
• Rim sign: only occurs in the PGHJD d/t posterior position of the head and anterior glenoid-to humeral head distance 6-mm or greater
• Light-bulb sign: d/t acute internal rotation of the humerus (head)

Inferior GHJD

• Inferior GHJD aka Laxatio Erecta
• Severe hyperabduction and inferior displacement of the humerus. Greater chances of severe neurovascular injury and acromial Fx
• The dislocated arm is hyperabducted and fixed with the elbow flexed and the arm above the head

ACJ Dislocation (ACJD) 

• ACJD: common injury, 9% of shoulder girdle injuries esp. in male athletes by a direct blow
• Rockwood classification (left) evaluates tearing of AC and CC ligaments and regional muscles
• Type1, 2, 3 among the m/c
• Type 1: sprain of ACL w/o tearing
• Type 2: tear of ACL and sprain of CCL
• Type 3: tear of AC & CCL. The clavicle is elevated above the acromion. If <2-cm good results with conservative Rx.
• Imaging: x-radiography with b/l ACJ views with and w/o weights to compare both ACJs. In complex cases CT scanning esp. if Fx is considered
• Management: Type 3 (>2-cm) & Types 4-6Operative

Type 3 ACJ Separation 

• Type 3 ACJ separation (top left)
• More significant ACJD (bottom images) with clinical sign of acromion under the skin and resultant ORIF

Rotator Cuff Muscles (RCM) Pathology

• RCM tendinopathy: collagenous degeneration of RCM particularly Supraspinatus M. tendon(SSMT) d/t overuse/degeneration-micro tearing with collagenous replacement. Impingement syndrome is a 2nd extrinsic cause. Presented clinically as pain and limited ROM
• Imaging Dx: MSK US can be as accurate as MRI and better in some cases d/t dynamic evaluation v. cost effective
• Key MRI clue is thickened inhomogeneous SSMTwith increased signal on all pulse sequences d/t fatty degeneration and inflammation (left images: T1 & T2 FS)
• MSKUS findings: thickening of the SSMTsubstance with a change in normal echogenicity.MSKUS is good to DDx with SSMT tears. US advantages are that it allows dynamic evaluation of painful structures

• Partial tear of SSMT: partial (incomplete) tear ofSSMT may occur at the bursal and articular surface or interstitial, i.e., intra-substance/noncommunicating. Etiology: sub-acromial impingement, acute strain, and chronic microtrauma tendinosis
• Clinically: pain on abd and flexion, impingement tests, Hawkins-Kennedy tests, etc. Pearls: partial tears can be more painful than complete tears
• Imaging Dx: MSKUS is as good as MRI (N.B.some studies indicated MSKUS is more superior to MRI). Key MRI findings: gap/incomplete tear of SSMT filled with joint fluid +/- granulation tissue
• MSKUS: decreased echogenicity of SSMT, thinning and partial tearing filled with fluid(anechoic areas arrows). Lost convexity of tendon bursal or articular interface.

• Full Thickness SSMT (rot cuff) tear: degeneration/tearing of rot cuff. 2nd to impingement by Hooked acromion, overhead overuse or acute trauma. 7-25% of shoulder pain in the general population. Clinically: pain on impingement tests.
• Imaging Dx: MSKUS is as good as MRI.Limitations: poor Dx of labral pathology. Key USDx: focal tendon interruption, an anechoic gap (fluid filled), hypoechoic tendon, tendon retraction, uncovered cartilage sign (bottom left, A: US B: MRI)
• MRI: key Dx: insertional tear extending through entire SSMT crescent, retraction with fatty degeneration of SSMT and the muscle. If retraction is at 12 o’clock or greater (top images), it may not be anchored operatively

• Rotator Cuff (RTC) Calcific Tendinitis: usually d/t calcium HADD crystals. Middle-aged women are most affected. Ranges from asymptomatic imaging finding to severe destructive arthropathy or Milwaukee shoulder(infrequent)
• HADD has 3-pathological phases: formation resting-resorption.Mild-to-moderate pain esp.in resting phase.
• Imaging: x-radiography: homogenous ovoid mineralization within RTCMT, m/c in SSMT. MRI: ovoid/globular decreased signal on all pulse sequences often with surrounding edema (bottom left)
• Rx: self-resolution occurs. Advanced cases: operative aspiration etc.

Superior Labrum Anterior to Posterior (SLAP) Lesions/Tears

• SLAP tears: FOOSH and throwing sports or chronic shoulder instability aka Multidirectional shoulder instability (in 20%). Type 1-9 exist but the M/C areType 1-4
• In all 4-types superior labrum is affected with or w/oLHBMT anchor tear (see pictures). Clinically: pain, limitation of AROM with active compression tests, typically non-specific findings mimicking RTCpathology
• Imaging is crucial: best imaging is MRI arthrography. Key signs: hyperintense linear fluid signal within superior labrum +/- extending along the LHBT on fat-suppressed fluid sensitive imaging and FS T1arthrogramme. Best observed on coronal slices.
• Rx: small tears may heal, but unstable tears require operative care.
• Key DDx: anatomical variants like Buford complex andSub-labral foramen

• SLAP tear with a paralabral cyst (bottom right)
• Normal variant DDx: sub labral foramen(bottom left) note: MR arthrography with contrast undercutting the labrum but w/o extending posteriorly to the LHBT

Shoulder Arthritis

• GHJ DJD: usually associated with a 2nd cause: trauma, instability, AVN, CPPD, etc. Presented with pain, crepitus and decreased ROM/function. Associated RTC disease may be present. Imaging; x-radiography is sufficient and provides grading/care planning.Major findings: joint narrowing, osteophytosis esp. at the inferior-medial head (orange arrow), subchondral sclerosis/cysts. Often noted superior head migration d/t RTC disease.
• ACJ OA: common and typically primary with aging. Presents with ACJ loss and osteophytes. Osteophytes along the undersurface of the ACJ “keel osteophytes”(blue arrow) may lead to RTC muscle tear. Regional bursitis is another clinical feature of ACJ arthrosis.
• Management: usually conservative depending on clinical signs/symptoms

• Rheumatoid Arthritis GHJ: RA is a multisystem inflammatory disease affecting multiple joints lined by the synovium. GHJ RA is common (m/c large joints in RA knees/shoulders). Clinically: pain, limited ROM and instability, muscle weakness/wasting. Hands, feet, and wrists are m/c affected. Imaging: x-radiography reveals periarticular erosions, uniform joint space loss, juxta-articular osteoporosis, subluxations, and soft tissue swelling. MRI can help detect commonly associated RTC tearing and instability. Early changes can be detected by MSKUS esp. with power Doppler use indicating hyperemia/inflammation.
• Note: L shoulder x-ray revealing cartilage destruction and symmetrical joint loss, multiple erosions, and likely loss of RTCM support with superior head migration, ST effusion present.
• Note: PDFS coronal and axial MRI slices of GHJ RA indicating marked inflammatory joint effusion, bone erosion/edema, synovial pannus formation and likely tear in RTC m. Management: Rheumatological referral and pharmacotherapy with DMARD. Operative care asRTCM repair. 10% of patients are disabled d/t RA

• Neuropathic Osteoarthropathy aka Charcot's shoulder: d/t neurovascular and neural periarticular damage. Multiple causes exist.M/c develops in diabetics in midfoot. Shoulder Charcot is m/c in Syringomyelia (25%), trauma paralysis, MS, etc. Dx: clinical(50% pain/swelling 50% painless destruction). Imaging is crucial. X-radiography is sufficient in well-established cases, but early Dx is challenging. MRI may help with early Dx and delayed complications. Rad Dx: Shoulder Charcot is m/c presented as atrophic type destructive arthropathy with humeral head appearing as if surgically amputated along with intra-articular debris, density, distention, dislocation, and other key features

• Septic Shoulder: shoulder is the 3rd m/c followingknee>hips. Patients at risk: diabetics, RA pts, immunocompromised, I.V. drug users, indwelling catheters, etc. Routes: hematogenous (m/c), direct inoculation (iatrogenic, trauma etc.) adjacent spread(e.g. OM). Staph. Aureus (>50%) m/c.
• Clinically: joint pain and dec. ROM, fever 60% only, toxemia, inc. ESR/CRP. Dx: imaging and joint aspiration/culture. RadDx: early x-rays often unremarkable except ST effusion/fat planes obscuration, joint widening. Later7-12 days patchy osteopenia, moth-eaten/permeating bone resorption, articular destruction, joint narrowing. May progress to severe joint destruction and ankyloses. Early Dx & I.V. antibiotics are crucial even before culture. Operative irrigation and joint drainage in some cases. Complications are possible esp. if Rx is delayed. MSKUS with needle aspiration may help. Note: (top image) non-traumatic joint widening with inferolateral head displacement d/t septic A dx: by needle aspiration Staph. Aures.

Ischemic Osteonecrosis

• Ischemic Osteonecrosis of the humeral head may occur d/t trauma (Neer four-part Fx), Steroids, Lupus, Sickle cell, Alcoholism, Diabetes, and many other conditions. Imaging is crucial: MRI detects earliest changes as intraosseous edema. X-ray features are late, presented as a collapse of subchondral bone with sclerosis “snow cap” sign, fragmentation, and progressive severe DJD
• Management: orthopedic referral, core decompression in early cases, hemiarthroplasty in moderate and total arthroplasty in severe cases.

Shoulder Neoplasms

• In adults >40, bone Mets d/t lung, breast, renal cell, thyroid CA & prostate are the m/c causes. Clinically: may mimic pain resemblingRTC/joint changes. Should be evaluated carefully. Key to Dx: Hx, PE and Imaging esp.in pts with known primary
• Imaging: 1st step x-rays, MRI can help, Tc99bone scintigraphy helps to detect regional and distant disease. X-ray features: destructive lytic changes typically in prox humerus(red marrow) with or w/o path Fx. DDx: Mets, MM, lymphoma
• Clinically: night pain, pain at rest, etc. Lab tests: unrewarding, in severe cases hypercalcemia may be noted.

• Primary Malignant bone neoplasms (shoulder) Adults: M. Myeloma or Solitary plasmacytoma, Chondrosarcoma may transform from an enchondroma and some others. In children/teenagers: OSA vs. Ewing’s
• Primary benign bone neoplasms (shoulder). Adults: Enchondroma (patients in their 20-30s)GCT. In children: Simple bone cyst (Unicameral Bone cyst), Osteochondroma, Aneurysmal Bone Cyst, Chondroblastoma (rare)
• Imaging: 1st step x-radiography
• MRI is essential to Dx. Especially in cases of primary malignant neoplasms Evaluate extent, soft tissue invasion, preoperative planning, staging, etc.

Ankle Fractures

• 10% of all fractures. 2nd m/c following femoral neck Fx. Demographics: active young males and older osteoporotic females
• Stable Fx: overall prognosis is good
• Unstable Fx: require ORIF. 15%-20% chances of 2nd OA.
• Role of imaging is to determine the complexity, stability and care planning (i.e., operative vs. conservative)
• Weber classification considers tearing of distal tibial-fibular syndesmosis and potential instability
• Weber A - below syndesmosis. Stable, typically avulsion of the distal fibular malleolus
• Weber B - at the level of syndesmosis: may be outside syndesmosis and stable or tearing syndesmosis and unstable
• Weber C - above syndesmosis. Always unstable d/t tearing of syndesmosis
• Variations of fractures may involve the position/role of the talus bone during Fx (e.g., abduction, adduction, rotation, etc.) this is known as Lauge-Hanson classification

Tibiofibular Syndesmosis & Ankle Stability

• Denis-Weber classification of ankle fractures

Clinical Dx Accuracy

• Ankle Fractures could be facilitated by the "Ottawa Rule."

Mortise & AP Views

AP, Medial Oblique & Lateral Views

• Reveal infrasyndesmotic Fx of fibular malleolus (Weber A)
• Stable Injury
• Conservative care in the form of short-leg walking cast/boot can be used. Good recovery. If no evidence of osteochondral injury, relatively low chances of post-traumatic OA
• No further imaging required. MRI may help to reveal bone contusion and osteochondral injury

Weber B at Level of Syndesmosis

• Can be stable or unstable. On occasions, the decision is made during operative exploration.
• CT scanning may help with further evaluation
• Management: depends on stability. Additional stabilization required if syndesmosis is ruptured

Weber C

• AP, medial oblique and lateral views reveal Weber C - suprasyndesmotic injury with abnormal joint widening d/t disruption of the tib-fib syndesmosis. Very unstable injury.
• Occasionally, when Weber C Fx positioned 6-cm from the tip of the lateral malleolus, it may be termed as Pott's ankle Fx (name after Percival Pott's who has proposed the original classification of ankle fractures based on their stability and degree of rotation). The term is somewhat outdated.
• Management: operative with additional stabilization of the syndesmosis

Maisonneuve Fracture

• Often spiral fracture of the proximal fibula combined with an unstable ankle injury
• No immediate ankle fracture is noted radiographically, thus can be missed on ankle views and require tibia and fibula views
• Rad features: widening of the ankle d/t syndesmosis tear and sometimes deltoid ligament disruption. Interosseous membrane is torn with proximal fibular Fx caused by pronation with external-rotation force
• Management: operative

Bimalleolar & Trimalleolar Fx

• Above top images Bimalleolar Fx v. unstable, the result of pronation and abduction/external rotation. Rx: ORIF.
• Trimalleolar Fx: 3-parts ankle Fx. Medial and lateral malleolus and avulsion of the posterior aspect of tibial plafond. More unstable. Rx: operative

Tillaux Fx

• Pediatric Fx affecting older child when the medial side of the physis is closed or about to close with lateral side till open. Avulsion by the anterior tibi-fibular ligament. Complications: 2nd dry/premature OA. Rx: can be conservative if stable by boot cast immobilization.

Pediatric Growth Plate Injuries

• Salter-Harris classification helps to diagnose and prognosticate physeal injuries.
• Helpful mnemonic: SALTR
• S: type 1-slip through the growth plate
• A: type 2-above, Fx extends into the metaphysis
• L: type 3-lower, intra-articular Fx extends through the epiphysis
• T: type4, "through" Fx extends through all: physis, metaphysis and epiphysis.
• R: type 5, "ruined." Crush injury to physis leading to complete death of the growth plate
• Type 1 and 5: present with no fracture
• Type 2: has the best prognosis and considered the most common.
• Management: referral to a pediatric orthopedic surgeon
• Complications: early physis closure, limb shortening, premature OA and others.

Calcaneal Fracture

• Most frequent tarsal Fx. 17% open Fx
• Mechanisms: axial loading (intra-articular Fx into sub-talar and calcaneal-cuboid joints in 75% cases). Avulsion by Achilles tendon (m/c in osteoporotic bone). Stress (fatigue) Fx.
• Intra-articular Fx carries a poor prognosis. Typically comminuted. Rx: operative.
• B/I calcaneal intra-articular fx with associated vertebra compression Fx with associated vertebral compression Fx (T10-L2) often termed Casanova aka Don Juan (Lover's) fx.
• Imaging: x-radiography with added "heel view" 1st step. CT scanning is best for Dx and pre-op planning.
• Radiography: Bohler's angle (<20-degrees) Gissane angle >130-degrees. Indicate Calcan, Fx.

Tarsal Bones

• M/C fractured tarsal bone is the Talus. M/C region: talar neck (30-50%). Mechanism: Axial loading in dorsiflexion. Complications: Ischemic osteonecrosis (AVN) of the talus. Premature (2nd OA). Imaging: 1st step: radiographs, CT can be helpful with further delineation
• Hawkins classification helps with Dx, prognosis & treatment. "Hawkins sign' on plain film/CT scan may help with AVN Dx. (above blue arrows indicate good prognosis d/t radiolucent line indicating no AVN because the bone is vascularized and hence resorbed)
• Rx: Type 1: conservative with short leg cast or boot (risk of AVN-0-15%), Type 2-4-ORIF (risk of AVN 50%-100%)

Bone Neoplasms Tumor-Like Conditions

• Bone neoplasms and tumor-like conditions affecting the knee can be benign or malignant. Age at Dx is crucial for DDx
• In patients <40: Benign bone neoplasms: Osteochondroma, Enchondroma are relatively frequent
• Fibrous cortical defect (FCD) & Non-ossifying fibroma (NOF) are particularly frequent in children
• Giant cell tumor (GCT) is the m/c benign neoplasm of the knee in patients between 20-40 years of age
• Malignant bone neoplasms in <40: m/c Osteosarcoma and 2nd m/c Ewing sarcoma
• In patients >40: malignant neoplasms: m/c are secondaries d/t bone metastasis. Primary bone malignancy: the m/c
• Multiple Myeloma (MM). Less frequently: a 2nd peak of Osteosarcoma (post-radiation or Paget’s), Fibrosarcoma or Malignant Fibrous Histiocytoma (MFH) of bone.
• Clinically: knee pain, pathological fracture
• Some tumor-like conditions like FCD/Non-ossifying fibroma are asymptomatic and may regress spontaneously. 
  Occasionally NOF may present with pathologic fracture. N.B. any knee/bone pain in a child/adolescents should be treated with clinical suspicion and adequately investigated.
• Imaging: 1st step: radiography
• MRI with T1+C is crucial for lesion characterization/regional extent, staging and pre-operative planning. CT may help with pathologic Fxs detection. If malignant bone neoplasms considered, CXR/CT, PET-CT to investigate metastatic spread and staging are important

Imaging Approach Bone Neoplasms

• Approach to imaging Dx of bone neoplasms includes age, bone location (epiphysis vs. metaphysis vs. diaphysis), a zone of transition surrounding the lesion, periosteal response, type of matrix, permeating or moth-eaten destruction vs. sclerotic, ground-glass, osteoid, cartilaginous matrix, soft tissue invasion, etc.
• Key x-radiography features to DDx benign vs. malignant bone neoplasm:
• Zone of transition: lesion is geographic with a narrow zone of transition vs. ill-defined wide zone of transition suggesting aggressive bone resorption
• What type of bone destruction occurred: soap-bubbly appearance vs. osteolytic vs. osteosclerotic changes
• Is there a round-glass matrix? Is there a well-defined rim of the sclerotic border with septations potentially suggesting slow growth and encapsulation like most benign processes.
• Periosteal proliferation: solid vs. aggressive spiculated/sunburst/hair-on-end with local soft tissue invasion and Codman triangle (study next slide)

FCD & NOF

• FCD & NOF or more appropriately Fibroxanthoma of the bone are benign bone processes that m/c seen in children. DDx based on the size with FCD presenting as <3-cm and NOF >3cm lesion composed of a fibrous heterogeneous matrix. FCD are asymptomatic and may regress in many cases. Some may progress to NOF. Location: identified in the knee region as an eccentric cortical based lesion.
• FCD must be DDx from an avulsive irregularity d/t repeated stress along Linea Aspera by extensors muscles
• Dx: radiography
• Management: leave-me-alone lesion. Occasionally NOF may progress and lead to pathologic fracture requiring an orthopedic consult

Osteochondroma

• Osteochondroma: m/c benign bone neoplasm. The knee is the m/c location. Contains all bone elements with a cartilaginous cap. Presented as pedunculated or sessile bone exostosis pointing away from the joint.
• 1% malignant degeneration to chondrosarcoma if solitary lesion and 10-15% in cases of HME
• Other complications: fracture (top left image) pseudoaneurysm of the Popliteal artery, adventitious bursa formation
• Hereditary Multiple Exostosis (HME)- autosomal dominant process. Presents with multiple osteochondromas (sessile-type dominates). May lead to limb deformities (Madelung deformity, coxa valga) reactive ST pressure, malignant degeneration
• Dx: radiography, MRI helps to Dx malignant degeneration to chondrosarcoma by changes in size and activity of cartilaginous cap (>2-cm in adults may manifest malignant degeneration). MRI will also help with Dx of regional complications

HME & Knee Pain

• 37-y.o male with HME and knee pain. Axial T1, T2 and STIR MRI slices at the popliteal region. Large cartilaginous cap and possible compression of the popliteal artery by osteochondroma. MRA was performed to evaluate popliteal A. pseudoaneurysm (large arrow). Pathology specimen obtained from the cartilaginous cap showed increased cellularity suggestive of malignant degeneration. Operative care was planned

Giant Cell Tumor (GCT) aka Osteoclastoma

• GCT- is a relatively common primary benign bone neoplasm. Age 25-40. M>F slightly.
• M/C location: Distal femur>proximal tibia>distal radius>sacrum
• GCT is the M/C benign sacral tumor. In 50% of cases, GCT occurs about the knee.
• GCT is histologically benign, but lung Mets may develop esp. if in distal radius and hands, often termed Malignant GCT
• <1% unresponsive/recurring GCTs may undergo malignant transformation to high-grade bone sarcoma
• Pathology: histologically composed of osteoclasts-multinucleated giant cells with stromal cells derived from precursors monocyte-macrophage type. Produces cytokines and osteolytic enzymes. GCT may contain blood and associated with secondary Aneurysmal Bone Cyst (ABC)
• Clinically: knee pain unresponsive to conservative care. Pathologic Fx may occur
• Imaging: always begins with radiography followed by MRI and surgical biopsy that are crucial to Dx.
• Rx: operative with curettage and cementing, a surgical appliance may be used if pathological fx present and cortical breach. In more severe cases other options available

Radiologic-Pathologic Dx

• Radiologic-pathologic Dx: osteolytic and/or soap-bubbly lesion typically involving metaphysis and into epiphysis (classic key feature) with subarticular extension. Zone of transition is generally narrow but occasionally in aggressive lesions wide zone of transition may be seen.
• MRI: low T1, highT2/STIR, characteristic fluid-fluid levels noted that are present in GCT and ABC. Histology is crucial to Dx.
• DDx: ABC, Brown cell tumor of HPT (osteoclastoma), Telangiectatic Osteosarcoma
• Radiological rule: if the physeal growth plate is present Dx of GCT is taken off the list in favor of chondroblastoma and vice versa.

Primarily Soap-Bubbly Appearance of GCT 

Coronal, Fat-Sat Sagittal & Axial MRI Slices of GCT

• T1 coronal, T2 fat-sat sagittal and T2 axial MRI slices of GCT. Typically: low T1, highT2/STIR and fluid-fluid levels

Characteristic MRI Appearance of GCT

• Fluid-fluid levels d/t different composition of blood degradation products
• Important DDx: ABC

Malignant Neoplasms About the Knee

• In children and very young adults, the m/c primary malignant neoplasm is central aka intramedullary (osteogenic) osteosarcoma (OSA). Second peak of OS: >70 y.o d/t Paget’s (1%) and/or post radiation OSA.
• The knee is the m/c location of OSA (distal femur, prox. Tibia)
• The 2nd m/c malignant pediatric primary is Ewing sarcoma.
• In adults >40 y.o. the m/c primary is Multiple Myeloma (MM) or Solitary Plasmacytoma
• Overall m/c bone neoplasms in adults d/t bone Mets from lung, breast, prostate, renal cell, thyroid (discussed)
• Dx: clinical and radiological with surgical biopsy
• Imaging is crucial to Dx. 1st step x-radiography. MRI+ gad C is vital
• CT scanning occasionally helps to evaluate pathological fracture

Central (Intramedullary) Osteosarcoma (OSA)

• m/c age: 10-20. M/c location: knee, males>females. Increased risk in some
• congenital syndromes and mutation of the retinoblastoma gene: Rothmund-Thompson AR syndrome.
• Early Dx is important d/t 10-20% present with Lung Mets at Dx. Prognosis depends on stages. Early stages with local bone invasion and no
• mets 76% of survival.
• Rx: limb salvage procedures preferred with 8-12 weeks of chemo, amputation if encased neurovascular tissue, path Fx, etc.
• Imaging: radiography and MRI.
• Clinically: bone pain, Inc. Alkaline Phosphatase
• Chest CT if lung Mets considered

Classic Rad Features of OSA 

• Osteoid forming a sclerotic mass with aggressive hair-on-end/speculated/sun-burst periosteal reaction, Codman's triangle and soft tissue invasion. Order MRI for staging and extent. Chest CT is crucial for Lung Mets dx.

MRI is Crucial for Dx/Staging

• Note sagittal T1 (left) and STIR (right) MR slices: large mass extending from distal femoral metaphysis to remaining shaft. A low signal on T1 and high on STIR d/t marrow invasion with edema, hemorrhaging and tumor invasion. Local ST invasion was seen (white arrows). Periosteal lifting and Codman’s triangle (green arrow) are additional signs of aggressive neoplasm.
• Note an interesting feature that the epiphysis is spared d/t physeal plate serving temporarily as an additional barrier to the tumor spread.

Ewing Sarcoma

• Ewing sarcoma: age: 2-20, uncommon in black patients. 2nd m/c highly malignant bone neoplasm in children that typically arises from the medullary cavity (Round cell tumors). Key symptom: bone pain that may mimic infection (ESR/CRP/WBC) Considered PNET
• Key Rad Dx: aggressive moth-eaten/permeative lucent lesions in the shaft of long bones with large soft tissue invasion/typical onion skin periostitis. May produce saucerisation
• May affect flat bones. May appear as sclerotic in 33%. Early lung Mets (25-30%) bone-to-bone Mets
• Poor prognosis if delayed Dx. Imaging steps: 1st step x-rad, MRI is v. important followed by a biopsy. CXR/CT PET-CT
• Rx: combined rad-chemo, operative.

M/C Malignant Knee Neoplasms in Adults

• 66-y.o. male with knee pain
• Note aggressive expansile osteolytic lesion in the distal femur metaphysis into epiphysis. No periosteal reaction present. Following further work up with abdominal and chest CT scanning, Dx of Renal cell carcinoma was established
• Distal Mets into lower extremity are more common with lung, renal cell, thyroid and breast CA.
• Renal cell and Thyroid will typically present with aggressive osteolytic expansile mass aka “blowout Mets.”
• In general, imaging approach should consist of Radiographic knee series, followed by MRI if x-rays are unrewarding
• Tc99 Bone scintigraphy is the modality of choice to evaluate metastatic bone disease

Soft Tissue Neoplasms About the Knee  

• Malignant fibrous histiocytoma (MFH) reclassified as Pleomorphic Undifferentiated Sarcoma (PUS) is the m/c S.T. sarcoma. MFH is aggressive biologically with poor prognosis
• M>F (1.2:1) 30-80 with a peak in a 6th decade. 25-40% of all adults sarcomas m/c extremities. Retroperitoneum next (worst prognosis d/t late Dx and large growth w/o symptoms)
• Clinically: painful, hard mass typically about the knee or thigh. Histology: poorly differentiated/undifferentiated malignant fibroblasts, myofibroblasts and other mesenchymal cells
• Imaging: MRI is the modality of choice with T1, T2, T1+C. Typically appears as an aggressive heterogeneous mass intermediate to low signal on T1 and high signal on T2 with areas of necrosis and enhancement on T1+C. May appear misleadingly encapsulated w/o true capsule
• Management: operative with radiation and chemotherapy. Tumour depth is crucial for prognosis. 80% 5-year survival if <5cm deep in ST and 50% if >5-cm deep in ST.

Synovial Sarcoma

• Synovial sarcoma: common malignant ST neoplasm esp. in younger patients or older children/adolescents. M/C found in the knee area
• Clinically: can present slowly as a palpable mass in the extremity often ignored the d/t slow growth
• Imaging is the key: radiography may reveal ST. density/mass. Some synovial sarcomas may show calcification and mistaken for Myositis Ossificanse or heterotopic bone formation
• MRI with T1, T2, and T1+C are Dx modality of choice. Other modalities: US, CT are non-specific
• DDx: MFH
• Management: operative, chemo-radiation
• Prognosis: variable depending on size, invasion, metastasis

For Complete List Of Bone & Soft Tissue Neoplasms

• http://bonetumor.org
• Further reading:
• https://emedicine.medscape.com/article/988516-differential
• https://www.ajronline.org/doi/10.2214/AJR.16.17434
• For further review of common childhood malignancies refer to:
• https://www.aafp.org/afp/2000/0401/p2144.html

Tibial Plateau Fractures

• Impaction type fractures predominate
• Result from valgus or varus stress with or w/o axial loading
• Associated with periarticular soft tissues injury
• High-stress injury m/c due to jumps falls and axial loading, often with the splitting of the tibial plateau. Men>women. Patients are in their 30s
• Low impact or no trauma in patients with osteoporosis d/t insufficiency fractures
• Impaction injury is more common with depression of tibial plateau. Women>men. Patients are in their 70s

Lateral Tibial Plateau Fractures More Common

• Functional anatomy plays a significant role
• 60% of weight bearing is by the medial plateau
• The medial plateau is more concave
• The lateral plateau is slightly higher and more convex. Valgus stress impacts lateral plateau.
• Tibial plateau fractures considered intra-articular and prone to delayed healing, non-union, meniscal injury (m/c lateral) ACL tear, secondary OA. Other complications: compartment syndrome, vascular injury.
• Management: operative in many cases especially if >3-mm step-off at the plateau
• If medial plateau or bicondylar Fxs present, ORIF will be required.

Imaging Plays A Crucial Role

• Begins with x-radiography. X-radiography may not reveal the complexity and extent of this injury.
• CT scanning w/o contrast will further delineate fracture complexity and pre-operative planning
• MR imaging may be considered to evaluate for internal derangement: meniscal, ACL injuries.
• Shatzke classification may help to evaluate the complexity of this injury

Key Diagnostic Sign

• AP and lateral horizontal beam (cross table) left knee radiograph. Note subtle depression of the lateral plateau manifested by the lateral plateau appearing at the same level or lower as the medial. A critical diagnostic sign is the presence of fat-blood-interphase or FBI sign on cross-table lateral (above arrow) indicating intra-articular knee fracture

Lipohemarthorosis aka FBI Sign

• Can be detected by radiography, CT or MR imaging
• FBI sign is a reliable secondary radiographic sign of intra-articular knee fractures, regardless of how small they are
• Mechanism: fracture results with acute hemarthrosis
• Hemarthrosis will also occur w/o Fx. However, Fx will result with a fatty marrow being released into the joint cavity. Fat is a less dense medium (lighter) and will appear on the top of the hemorrhage if the patient is held in the supine position for 5-10-minutes before the cross-table radiograph is taken
• FBI sign confirms the intra-articular Fx.
• ACL/PCL, meniscal tears will not result in FBI sign

Lateral Tibial Plateau Fx

• Lateral tibial plateau Fx that was managed operatively
• Most common complication: premature secondary OA
• More complex injuries may result in more extensive operative care

Knee Internal Derangement

• Acute or chronic injuries of meniscal fibrocartilages and ligamentous restraints
• Tears of the ACL and posterior horn of the medial meniscus are the most common
• Acute ACL tears, however, often result with a lateral meniscus tear
• Acute ACL tear may occur as a combined injury of the ACL, MCL, and medial meniscus
• Functional anatomy: ACL prevents anterior displacement of the tibia and secondary varus stress
• MCL functions together with ACL in resisting external rotation of the tibia especially when the foot is planted (closed chain position)
• MCL is firmly attached to the medial meniscus, explaining the classic triad of ACL, MCL and medial meniscal tear (O'Donahue terrible triad)
• Cruciate ligaments (ACL/PCL) are intra-articular but extra-synovial. Less likely to be torn in closed pack position (full extension). When all articular facets of tibia and femur are in full contact, the ACL/PCL are at least tension and stable
• When the knee is flexed 20-30-degrees or more ACL is taut and remains unstable
• ACL is a significant mechanoreceptor that feeds the info to CNS about the joint position. Thus the majority of previous ACL tears will lead to some degree of knee instability

Functional Anatomy of ACL 

Diagnosis of ACL Tear

• Diagnosis of ACL tear requires MR imaging
• Concerns exist of not only ligamentous injuries but injuries to the articular cartilage and menisci.
• Most vendors will perform at least: one T1 WI in coronal or sagittal planes. Sagittal and coronal Proton-density slices to evaluate cartilaginous structures. Fast spin-echo sagittal, axial and coronal T2 fat-saturated or sagittal and coronal STIR images are crucial to demonstrate edema within the substance of knee ligaments
• Note sagittal proton-density MRI slice showing intact ACL (above)
• ACL is aligned along the Blumensaat line or oblique line corresponding the intercondylar roof of Femoral condyles. Lack of such alignment by the ACL is significant for ACL tear

Imaging Dx of Internal Derangement

• MRI shows 78-100% sensitivity and 78-100% specificity
• Primary signs of ACL tear: non-visualization of ACL (above green arrow), loss of its axis along the Blumensaat line (above triangle heads), wavy appearance and substance tear (above white arrow) or edema and cloud-like indistinctness (above yellow arrow)

Reliable Secondary Signs of ACL Tear 

• May be observed on the radiographs and MRI
• Segond avulsion fracture (80% specificity for ACL tear) (next slide)
• Deep femoral notch sign indicating osteochondral fracture (above bottom images) and
• Pivot -shift bone marrow edema in the posterolateral tibial condyle d/t external rotation and often valgus impact by the lateral femoral condyles (above top image)

Segond Fracture (Avulsion by ITB)

• Segond fracture at Gerdy's tubercle. A vital sign of the ACL tear seen on both radiographs and MRI

Management of ACL Tears

• In acute cases, usually operative using cadaveric or autograft (patella ligament or hamstring) ACL reconstruction
• Complications: graft tear, instability and premature DJD, joint stiffness d/t lack of postoperative rehab or gaft shortening. More rare, infection, the formation of intraosseous synovial cysts etc

Degenerative Joint Disease (DJD)

Macroscopic & Microscopic Appearance of Normal vs. Damaged Articular Hyaline Cartilage by DJD

Hip Osteoarthritis (OA) aka Osteoarthrosis 

• Symptomatic and potentially disabling DJD
• Progressive damage and loss of the articular cartilage causing denudation and eburnation of articular bone
• Cystic changes, osteophytes, and gradual joint destruction
• Develops d/t repeated joint loading and microtrauma
• Obesity, metabolic/genetic factors
• Secondary Causes: trauma, FAI syndrome, osteonecrosis, pyrophosphate crystal deposition, previous inflammatory arthritis, Slipped Capital Femoral Epiphysis, Leg-Calves-Perthes disease in children, etc.
• Hip OA, 2nd m/c after knee OA. Women>men
• 88-100 symptomatic cases per 100000

Radiography is the Modality of Choice for the Dx and Grading of DJD

• Special imaging is not required unless other complicating factors exist
• The acetabular-femoral joint is divided into superior, axial and medial compartments/spaces
• Normal joint space at the superior compartment should be 3-4-mm on the AP hip/pelvis view
• Understanding the pattern of hip joint narrowing/migration helps with the DDx of DJD vs. Inflammatory arthritis
• In DJD, m/c hip narrowing is superior-lateral (non-uniform) vs. inflammatory axial (uniform)

AP Hip Radiograph Demonstrates DJD

• With a non-uniform loss of joint space (superior migration), large subcortical cysts and subchondral sclerosis
• Radiographic features:
• Like with any DJD changes: radiography will reveal L.O.S.S.
• L: loss of joint space (non-uniform or asymmetrical)
• O: osteophytes aka bony proliferation/spurs
• S: Subchondral sclerosis/thickening
• S: Subcortical aka subchondral cysts "geodes."
• Hip migration is m/c superior resulting in a "tilt deformity."

Radiographic Presentation of Hip OA May Vary Depending On Severity

• Mild OA: mild reduction of joint space often w/o marked osteophytes and cystic changes
• During further changes, collar osteophytes may affect femoral head-neck junction with more significant joint space loss and subchondral bone sclerosis (eburnation)
• Cyst formation will often occur along the acetabular and femoral head subarticular/subchondral bone "geodes" and usually filled with joint fluid and some intra-articular gas
• Subchondral cysts may occasionally be very large and DDx from neoplasms or infection or other pathology

Coronal Reconstructed CT Slices in Bone Window

• Note moderate joint narrowing that appears non-uniform
• Sub-chondral cysts formation (geodes) are noted along the acetabular and femoral head subchondral bone
• Other features include collar osteophytes along head-neck junction
• Dx: DJD of moderate intensity
• Referral to the Orthopedic surgeon will be helpful for this patient

AP Pelvis (below the first image), AP Hip Spot (below the second image) CT Coronal Slice

• Note multiple subchondral cysts, severe non-uniform joint narrowing (superior-lateral) and subchondral sclerosis with osteophytes
• Advanced hip arthrosis

Severe DJD, Left Hip

• When reading radiological reports pay particular attention to the grading of hip OA
• Most severe (advanced) OA cases require total hip arthroplasty (THA)
• Refer your patients to the Orthopedic surgeon for a consultation
• Most mild cases are a good candidate for conservative care

Hip Arthroplasty aka Hip Replacement

• Can be total or hemiarthroplasty
• THA can be metal on metal, metal on polyethylene and ceramic on ceramic
• A hybrid acetabular component with polyethylene and metal backing is also used (above right image)
• THA can be cemented (above right image) and non-cemented (above-left image)
• Non-cemented arthroplasty is used on younger patients utilizing porous metallic parts allowing good fusion and bone ingrowth into the prosthesis

Failed THA May Develop

• Most develop within the first year and require revision
• Femoral stem may fracture (above left)
• Postsurgical infection (above right)
• Fracture adjacent to the prosthesis (stress riser)
• Particle disease

Femoroacetabular Impingement Syndrome

• (FAI): abnormality of normal morphology of the hip leading to eventual  cartilage damage and premature DJD
• Clinically: hip/groin pain aggravated by sitting (e.g., hip flexed & externally rotated). Activity related pain on axial loading esp. with hip flexion (e.g., walking uphill)
• Pincer-type acetabulum: > in middle age women potentially  many causes
• CAM-type deformity: > in men in 20-50 m/c 30s
• Mixed type (pincer-CAM) is most frequent
• Up until the 90s, FAI was not well-recognized

FAI Syndrome

• CAM-type FAI syndrome
• Radiography can be a reliable Dx tool
• X-radiography findings: osseous bump on the lateral aspect of femoral head-neck junction. Pistol-grip deformity. Loss of normal head sphericity. Associated features: os acetabule, synovial herniation pit (Pit's pit). Evidence of DJD in advanced cases
• MRI and MR arthrography (most accurate Dx of labral tear) can aid the diagnosis of labral tear and other changes of FAI
• Referral to the Orthopedic surgeon is necessary to prevent DJD progression and repair labral abnormalities. Late Dx may lead to irreversible changes of DJD

AP Pelvis: B/L CAM-type FAI syndrome

Pincer-Type FAI with Acetabula Over-Coverage 

• Key radiographic signs: "Cross-over sign" and abnormal center-edge and Alfa-angle evaluation methods

Dx of FAI 

• Center-edge angle (above the first image) and Alfa-angle (above the second image)
• B/L CAM-type FAI with os acetabule (above right image)

MR Arthrography

• Labral tear and CAM-type FAI syndrome on axial (above left) and coronal T2 W (above right) MR arthrography
• Note acetabula labral tear. Referral to an orthopedic surgeon is required. For more information: 
• https://radiopaedia.org/articles/femoroacetabular-impingment-1

Hip Pelvis Arthritis & Neoplasms

Pelvic Fractures Can Be Stable & Unstable

• Unstable Fx: a result of high energy trauma with >50% d/t MVA
• 20% closed Fx and 50% of open Fx result in mortality
• Mortality is associated with vascular and internal organs injuries
• Vascular injury: 20% arterial 80% venous
• Chronic morbidity/disability and prolonged pain
• Unstable Fx are rarely seen in the outpatient setting and typically and present to the ED
• Stable pelvic Fx are usually caused by muscles/tendons avulsions and more often seen in pediatric cases 

Understanding Pelvic Anatomy Is The Key To Successful Imaging Dx

• The bony pelvis is a continuous ring of bone held by strong ligaments
• During significant impact, pelvic fractures may occur in more than one location because forces applied to one region of the ring will also correspond to injury on the other, usually the opposite side of the ring (above image)
• Thus the majority of unstable pelvic Fx will typically demonstrate more than one break

• Pelvic is seen as a ring of  bone connected by some of the strongest ligaments in the body
• The pelvic ring comprises 2-semirings: anterior to the acetabulum and posterior to the acetabulum
• The bony pelvis is in close proximity to major vessels carrying a greater chance of vascular injury

• Anatomical Differences of The Female and Male Pelvis

Post-Traumatic Pelvic Views May Vary and Include:

• Standard AP Pelvis (above images)
• Judet views evaluating the acetabulo-pelvic region
• Inlet/Outlet views helping with the symphysis and SIJ regions
• Rad survey of the pelvis should include evaluation of the continuity of pelvic rings:
• Inlet/outlet, obturator rings (above the first image)
• Symphysis pubis and SIJ for diastasis and post-trauma separation (above the second image)
• Lumbosacral spine and hips should also be carefully examined

• Pelvic inlet (above top left) and Outlet (above bottom left)
• Judet views: left and right posterior oblique views 

Additional Survey:

• Iliopectineal, ilioischial, Shenton and Sacral arcuate lines will help detection of sacral, acetabular and hip fracture/dislocations 

Stable Pelvic Fractures aka Avulsion Injury

• Appreciating anatomical sites of pelvic origin/insertion of different muscles will help Dx of pelvic avulsion Fx

• Avulsion Fx of the AllS (origin of the direct head of Rectus femoris M)
• Pelvic avulsions occur by sudden eccentric contraction especially during kicking or jumping
• Imaging: x-radiography will suffice
• Clinically: sudden snap or pop followed by local pain. Pt can weight bear
• Care: non-operative with rest for 4-weeks. Non-union is rare. No major complications
• DDx: key rad DDx feature is not to mistake an avulsion from an aggressive pediatric bone tumor-like osteosarcoma that may show some exuberant new bone formation d/t healing and bone callus 

Commonly Encountered Unstable Pelvic Fractures

• Malgaigne Fx: d/t vertical shear injury to the ipsilateral pelvis
• Rad Dx: ipsilateral superior and inferior pubic rami Fx (anterior ring) with ipsilateral SIJ separation/Fx of the sacrum and adjacent ilium (posterior ring). Symphysis pubis diastasis can be seen. An additional clue is an avulsion of L4 and/or L5 TP that often signifies serious pelvic injury
• Clinically: marked leg shortening, shock, inability to weight bear.
• Damage to Superior Gluteal Artery can occur
• Imaging: x-radiography followed by CT scanning w/o and with IV contrast esp. if visceral injury present
• Care: surgical in most cases d/t significant instability. ORIF. Hemostasis, Pelvic stabilization
• Prognosis: depends on the complexity, rate of visceral complications and stability. 10% Superior glut artery bleed requiring rapid hemostasis 

Open Book Pelvis (major instability)

• Mechanism: AP compression of different force magnitude (picture depiction)
• Rad Dx: diastasis of symphysis pubis with diastasis of SIJ with and w/o adjacent Fx of the ala
• Imaging steps: x-radiographic, CT scanning with and w/o contrast for vascular injury, cystography for acute urinary bladder rupture
• Immediate and delayed complications may occur: vascular injury, urethral/bladder injury 

Straddle Injury: Unstable Fx

• Mechanism: direct impact/collision
• High risk of urinary bladder/urethral injury
• Imaging: bilateral superior and inferior pubic rami Fx with or w/o diastasis and Fx of SIJ
• CT with and w/o contrast for vascular injury
• Cystourethrogram additionally evaluates a urogenital injury
• Complications: urethral strictures, bleeding, bladder rupture
• Note: Straddle Fx with right SIJ separation

Hip Fractures (Femoral Neck)

• Common injury
• Occurs in:
• 1) Young adults due to high energy trauma
• 2) Osteoporotic patients with low impact, trivial or no trauma (i.e., insufficiency Fx)
• X-radiography is crucial to early Dx and prevention of complications which include:
• Dx: intra-capsular vs. extra-capsular Fx
• Ischemic osteonecrosis aka avascular necrosis (AVN) of the femoral head and rapid disabling DJD
• Epidemiology: USA has some of the highest rates of OSP hip Fx worldwide. Highest healthcare cost Fx to treat overall
• Women>men, Caucasians>African-Americans
• 25-30% mortality within the 1st year. Mortality depends on co-morbidities and stat of activity prior Fx
• Pathophys: the femoral neck is intra-capsular and transmits arterial flow to the head. The neck is uncovered by the periosteum and unable to develop a good callus. The neck transmits maximum tensile forces through the proximal femur and prone to Fx and non-union

Acute Pelvis & Hip Trauma

Everyone knows that exercise is great for overall wellness, better health, and a healthy body. Many chiropractors will often recommend regular exercise to their patients who need to lose weight, want better mobility, or are seeking relief from depression. Some chiropractors are turning to Pilates to help their patients get stronger, more flexible, and more mobile. 

What is Pilates?

In the early 20th century Joseph Pilates developed the exercise program to help World War I soldiers improve their physical fitness. It was used to rehabilitate patients who had been injured. By incorporating resistance, stretching, and target strengthening exercise, Pilates uses resistance bands, individual machines, and floor work to reshape and rehabilitate the body. Dancers, gymnasts, athletes, and celebrities use Pilates to stay in shape. However, anyone can do it for a healthier, more supple spine.

Care of the spine is at the core of Pilates. By keeping it in a neutral, or natural, position, this exercise can prevent back pain as well as help ease it. When done correctly, Pilates can:

• Improve muscle control and movement efficiency through mental focus.
• Make you more mindful of your body’s position, specifically, remaining aware of the spine’s position and keeping it neutral
• Improve centering and mental focus through special, breathing techniques
• Support and improve posture by strengthening the abdominal and back muscles.

Benefits of Pilates for Chiropractic Patients

The benefits of Pilates tremendous, but for chiropractic patients, it is even more so. By regularly incorporating Pilates into your exercise routine, you can enjoy these incredible benefits.

You can adapt Pilates to your fitness level and needs. Whether you are just starting a fitness program or you’ve been working out for years, Pilates can be tailored to your fitness needs and level.

It helps you strengthen your core. The deep muscles of your abdomen, back, and pelvic floor make up the core muscles of your body. Many of the movements focus on these muscles, making a body that is strong and the frame is supported.

Allows you to strengthen your muscles without bulking up. With Pilates your muscles get strong, but it also stretches the muscles so that they are lean and long. You will look toned and tight but not bulky and muscular.

It focuses on whole body fitness. Many types of exercise only work certain parts of the body, but this focuses on entire body fitness. It works every part of the body so that the muscle development is balanced.

It helps to improve your posture. It strengthens your body and helps to keep your spine in proper alignment due to a strong core. As a result, your posture naturally improves. By incorporating it into your exercise routine, you will find yourself standing taller, stronger, and more graceful.

You can become more connected through your mind and body by increased awareness. Pilates engages your mind and increases body awareness. It unites the mind, body, and spirit for complete coordination. Each movement is done with full attention.

It improves your flexibility. Pilates is a gentle but powerful exercise that works to safely stretch the muscles, making them longer, and increasing the range of motion in the joints.

It can protect you from injuries. By strengthening your body, Pilates can help protect you against injury. It conditions your whole body so that your muscles and strength are balanced. This reduces your risk of injury.

You get a natural energy boost. Just like with any exercise, it will give you an energy boost. However, it is increased even more thanks to the focused breathing and increase in circulation stimulating the muscles and spine.

It can help you lose weight and attain a lean, long, healthy body. It tones and strengthens the body, and if you do it regularly, it will reshape you. The body is more muscular and more balanced. It also helps you move with more grace and ease.

Chiropractic Care & PUSH as Rx

Hypermobility Syndrome is a condition of the joints. Characterized by the ability of the joint to move beyond its normal range of motion and is sometimes called “loose joints” or “double jointed.” It is typically a genetic disorder and often identified in children. The gene passes from parent to child, so the condition tends to run in families. It is estimated that 10 to 15 percent of children who are otherwise considered to be normal have joints that are hypermobile. However, it can be found in all ages and does not seem to be confined to a particular age group, ethnic group, or population although there are more cases of girls being hypermobile than boys.

Hypermobility Signs and Symptoms

The signs and symptoms of hypermobility can vary widely from person to person. Some people may not experience any symptoms while others have muscle and joint pain along with mild swelling. Usually noted in the evening or later afternoon as well as after moderate physical activity or exercise. The most common areas for pain and achiness are the elbows, knees, thigh muscle, and calf muscle. Often rest will provide relief.

A person who is hypermobile is usually more prone to soft tissue injuries and sprains. Additionally, the affected joints may be more inclined to become dislocated. It can also cause back pain, impaired joint position sense, and even flat feet, osteoarthritis, and nerve compression disorders. Other symptoms include increased bruising, chronic pain, loose skin, and thin scars. Children and young people who are hypermobile often experience growing pains more often than other children.

Most children will grow out of hypermobility; their joints will lose some of their flexibility as they get older along with the symptoms of rarely persist beyond childhood although some adults do find that they get dislocations and sprains much easier.

Causes of Hypermobility

The exact cause of hypermobility is not known, although it does seem to run in families. Genes play a large part in the process, particularly those involved in collagen production which is a vital protein for tendon, joint, and ligament development and function. There are also several associated conditions. Genetic disorders like Ehlers-Danlos and Marfan have hypermobility as a component as does Down Syndrome.

Hypermobility Treatment

Treatment for hypermobility depends on the patient. It depends on the symptoms that they are experiencing as well as the severity and how much of an impact the condition has on their quality of life. Mild symptoms may not require any treatment while more moderate to severe symptoms may warrant medication like naproxen, ibuprofen, or acetaminophen for pain. All of which, can be bought over the counter.

Patients can ward off many of the symptoms or eliminate them by engaging in regular exercise, protecting the joints, practicing good posture, muscle strengthening exercises, and balancing techniques. Orthotics to correct flat feet can also be beneficial.

Chiropractic for Hypermobility

Many people use chiropractic for hypermobility pain and discomfort. The doctor will use adjustments to bring the joints into the appropriate movement pattern and the body into proper alignment, allowing the body to function as it should and relieves stress from joints that were compensating due to misalignment.

The patient may also be advised to do specific exercises at home, and get counseling on improving their posture. Because chiropractic treats the entire body, the patient will find that they learn how to best live with the condition without medication and manage pain naturally. Patients report dramatic improvement in their distress and mobility after regular, consistent chiropractic visits.

Chiropractic Care & Crossfit Rehabilitation

Ever since he started chiropractic care with Dr. Alex Jimenez and continued rehabilitation at Push, Bobby Gomez has experienced great improvements on his back and hip pain. Since birth, Bobby had problems walking due to an uneven pelvic tilt. However, treatment has helped him gain more muscle on his legs, giving him more strength, flexibility and mobility to further improve his gait. Thanks to chiropractic care and rehabilitation, Bobby Gomez has become more confident and at peace with himself, highly recommending Dr. Alex Jimenez as the non-surgical choice for hip pain.

Hip Pain Chiropractic Treatment

Pain in the hip is the experience of pain from the joints or muscles in the hip region, a condition arising from any of a number of variables. Occasionally it is associated with back pain. Causes of pain around the hip joint may be extra-articular, or referred pain from neighboring structures, including the sacroiliac joint, spine, symphysis pubis, or the inguinal canal. Clinical tests are accommodated to identify the source of pain as intra-articular or extra-articular. The flexion-abduction-external spinning (FABER), internal range of motion with overpressure (IROP), and scour tests reveal sensitivity worth in identifying individuals with intra-articular pathology.

We are blessed to present to you El Paso’s Premier Wellness & Injury Care Clinic.

Our services are specialized and focused on injuries and the complete recovery process. Our areas of practice include: Wellness & Nutrition, Chronic Pain, Personal Injury, Auto Accident Care, Work Injuries, Back Injury, Low Back Pain, Neck Pain, Migraine Treatment, Sport Injuries, Severe Sciatica, Scoliosis, Complex Herniated Discs, Fibromyalgia, Chronic Pain, Stress Management, and Complex Injuries.

As El Paso’s Chiropractic Rehabilitation Clinic & Integrated Medicine Center, we passionately are focused treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.

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Posterior tibial tendon dysfunction is a very common ankle and foot problem that occurs when there is a tear or inflammation in the posterior tibial tendon – the tendon that is at the back of the ankle and is the key player in stabilizing the foot. The inflammation or tear affects the integrity of the tendon, weakening it so that is no longer provides the support or stability of the arch of the foot. This results in what is commonly known as flatfoot.

While this condition rarely requires surgery, there is pain, sometimes severe, swelling, and impaired mobility associated with it. Chiropractic for flatfoot has been found to be very effective for most patients, helping them heal faster and manage their pain.

What Causes Posterior Tibial Tendon Dysfunction?

The most common causes of flatfoot are overuse and injury. Falls are common culprits, causing injury to the tendon so that it tears or becomes inflamed.

Overtraining, particularly in high impact exercise or sports like basketball, dancing, soccer, and high impact aerobics can get tears due to the repetitive motion and constant pressure on the foot. Once the tendon is torn or inflamed, the arch begins to collapse until eventually the foot is flat.

This condition occurs more often in women than men. Also, people over 40 seem to be more prone to posterior tibial tendon dysfunction, although it can occur in younger people who overtrain or have any of the other risk factors including diabetes, obesity, and hypertension.

What Are The Symptoms Of Posterior Tibial Tendon Dysfunction?

Pain is the first and most common indicator of flatfoot. It typically is located where the tendon lies; along the inner portion of the ankle and foot. Sometimes swelling may be present.

The patient will also notice that the pain increases with activity. High impact or high intensity activities can be excruciating and quite difficult. It can get to the point where standing or walking for extended periods of time are very painful.

In advanced stages, the pain may shift to the outer portion of the ankle. As the arch collapses, the movement may cause the heel bone to shift outward. This, in turn, puts pressure on the outer ankle bone.

How Is Posterior Tibial Tendon Dysfunction Treated?

The treatment for flatfoot depends on the severity of the condition. Most patients can avoid surgery, but it is still a long healing process.

Typically, the patient will be advised to rest and ice the area, switch to low impact exercise, and take nonsteroidal anti-inflammatory medication for the pain. In moderate to severe cases, the patient may be put in a walking boot or short leg cast for 6 to 8 weeks in order to immobilize the foot and ankle, letting the tendon rest and heal. The downside of this is that the other muscles around the ankle will also “rest” and atrophy as a result.

Shoe inserts, or orthotics, as well as braces are also common treatments for flatfoot. However, any type of immobilization of the ankle and foot is usually accompanied by physical therapy either while the brace is worn or after a cast has been removed.

In more severe cases, the doctor may recommend a steroid injection directly into the tendon although there is an increased risk of the tendon rupturing. Surgery is usually a last resort and it is much more complex. Patients who undergo surgery for flatfoot rarely regain all of the mobility they had prior to the operation.

Chiropractic For Posterior Tibial Tendon Dysfunction

There has been a great deal of success in using chiropractic to treat flatfoot. The chiropractor will typically recommend rest and ice as well as chiropractic manipulations to help bring the ankle, foot, and leg back into alignment to counteract the weakened tendon. Often the ankle will lose mobility as the arch collapses and the bones in the foot and ankle shift. This, in turn, causes the arch to collapse even more.

By using chiropractic techniques to bring the ankle back into alignment, thus restoring the forward glide of the joint, they can alleviate the pain and help heal the condition. They may also recommend an air brace to stabilize the ankle when the patient will be doing a lot of walking as well as advise on lifestyle changes such as weight loss and a healthy diet. Often patients who have tried working with medical doctors to cure their flatfoot but were unsuccessful, were finally able to gain relief and improvement when they started working with their chiropractor.

Injury Medical Clinic: Chiropractic Injury Treatment

You try to stand up from a seated position and feel a stab of pain in your lower back. It may even shoot through your hip, buttock, or down the back of your thigh. The pain may even get worse then you walk uphill or sit for a long period of time. While these symptoms could mean a pinched nerve, lumbar disc herniation, hip bursitis, or degenerative hip disease, it could also be sacroiliac joint dysfunction.

What Is Sacroiliac Joint Dysfunction?

The sacroiliac (SI) joint is located in the pelvis. It is very strong as it is a weight bearing joint connecting the pelvis to the sacrum. It is surrounded by tough ligaments that reinforce it, providing added support.

There is an SI joint located on each side of the sacrum and they work together, moving as a single unit to act as a shock absorber for the spine and for transmitting force of the upper body. Just like any other joint in the body, the SI joint can be injured or diseased, causing it to become unstable and inflamed, causing pain and limited mobility.

What Causes SI Joint Inflammation?

While doctors have not established how the pain is generated, it is believed that it is due to a change in the normal motion of the joint. This could occur due to:

• Hypermobility (Instability or Too Much Movement) – This can cause the pain to reside in the lower back. It can also be felt in the hip or both the hip and lower back and may even radiate into the groin.
• Hypomobility (Fixation or Too Little Movement) – This can cause the pain to reside in the lower back or buttocks and may radiate down one leg, usually in the back of the thigh. It usually doesn’t reach the knee, but sometimes can even reach the ankle and foot. In this way, the condition mimics sciatica.

Sacroiliac joint dysfunction typically affects women who are young or middle aged. Older women and men are rarely affected although it does happen.

What Are Treatment Options For Sacroiliac Joint Pain?

When SI joint pain is initially diagnosed the treatment is usually fairly conservative. Medication, physical therapy, and injections are used by doctors for pain management.

NSAIDs and other similar medications decrease inflammation and reduce pain, while physical therapy can readjust the SI joint in cases where it is dislocated or immobilized. It also includes exercises that stabilize the joint for pain management over the long term.

Steroid injections directly into the sacroiliac joint can help with the reduction of inflammation and pain while making physical therapy more effective. When steroid injections are effective but the effects are temporary there is another non-surgical treatment that is sometimes used called RFA, or radiofrequency ablation.

In cases where the conservative methods do not achieve the desired results there are surgical options that provide pain reduction and stabilization on a more permanent scale. SI fusion involves fusing the joint, providing relief.

However, there is a treatment option that is non-invasive, doesn’t involve steroids or medications that could have harmful side effects – chiropractic.

Chiropractic For Sacroiliac Joint Pain

There are two chiropractic treatments that are typically used to treat SI joint pain:

• Spinal manipulation – This is the traditional chiropractic adjustment that is also known as high-velocity, low-amplitude (HVLA) thrust.
• Spinal mobilization – This is a less forceful, gentle chiropractic adjustment also known as low-velocity, low-amplitude thrust.

Chiropractic is proven to be an effective, non-invasive, gentle method for relieving the pain and inflammation of SI joint dysfunction. No medication, no surgery, just relief.

So if you’ve been suffering from sacroiliac joint dysfunction, give us a call! Our Doctor of Chiropractic is here to help!

Injury Medical Clinic: Sciatica Treatment

De Quervain's Tenosynovitis, also called “washerwoman sprain,” is a condition of the hand that typically affects people who do continuous, fast, repetitive movements. The patient can experience a sudden onset of the condition, or it can be gradual, beginning with tenderness in the thumb area and slowly progressing. It can restrict activity, but it doesn’t have to be a long-term disability. Chiropractic care can help relieve the symptoms of De Quervain’s Tenosynovitis and the hand can return to normal function.

What Is De Quervain's Tenosynovitis?

De Quervain's Tenosynovitis is a condition affecting the thumb side of the wrist. It is a very painful condition that makes many everyday activities difficult or impossible. Many events like playing golf, lifting a child, garden work, and racket sports can worsen the condition.

What are the Symptoms of De Quervain's Tenosynovitis?

There are several characteristic symptoms of De Quervain’s tenosynovitis which include:

• Pain near or at the base of the thumb
• Difficulty moving or controlling the thumb and wrist when doing activities that involve pinching or grasping
• Swelling near or at the bottom of the thumb
• A “catch” or “sticking” sensation when moving the thumb

If the condition is allowed to progress or goes untreated, it can involve the forearm and entire thumb, causing pain and swelling in those areas. The pain and symptoms can be exacerbated by movements that require the wrist and thumb. The symptoms can last for a long time, weeks or even months. 

What causes De Quervain's Tenosynovitis?

The exact cause of De Quervain’s Tenosynovitis is not known, but the condition is commonly associated with chronic overuse of the wrist. Some tendons connect the wrist and lower thumb, enabling movement like grasping, gripping, pinching, and wringing. The tendons slide through a sheath as they facilitate the movement. Over time, the sheath can swell and thicken which inhibits the amount of the tendon’s movement. When the actions are repetitive, they can cause irritation of the sheath, resulting in inflammation.

Who is at Risk for De Quervain's Tenosynovitis?

Research has identified several groups that are at risk for developing De Quervain’s Tenosynovitis:

• 30 to 50 years of age with a higher concentration statistically around 40
• Female
• African ethnicity or descent
• Pregnant
• Caring for a child or baby
• Works at a job that involves repetitive wrist and hand motions
• Excessive text messaging on a smartphone or cell phone (can include younger

This condition has typically been considered to be one that affects people who are middle-aged. However, with the popularity of texting, many young people experience symptoms of De Quervain’s. In one study, more than half of students who texted extensively were labeled positive for De Quervain’s.

What are the Treatments for De Quervain's Tenosynovitis?

Treatment for De Quervain’s Tenosynovitis include:

• Resting the affected thumb and wrist
• Bracing or immobilization
• Ice to the affected area
• Anti-inflammatory medications like ibuprofen and naproxen

If standard treatment is not sufficient,t it may be necessary to seek medical attention. If the condition is severe or chronic, the doctor may inject corticosteroid directly into the tendon sheath. Surgery for De Quervain’s is not common, but it may be deemed necessary to release the thumb. The speed of healing and the degree of normal use of the thumb depends on the treatment chosen and if the activity that exacerbates the condition is stopped.

Can Chiropractic Help De Quervain's Tenosynovitis?

A chiropractor may recommend rest, ice, and bracing for a patient with De Quervain’s Tenosynovitis. Upon reviewing the patient’s lifestyle and habits, he or she may also advise ergonomic changes, modification of activity, and reduce exposure to positions that exacerbate the symptoms. Soft tissue therapies may be used to quickly bring relief to the soft tissue, minimizing the inflammation and pain. As the pain decreases, the chiropractor will recommend specific strengthening and stretching exercises that involve the wrist, thumb, and forearm.

With regular care and modification to activities, the condition can be healed, and full mobility of the thumb and wrist can be restored.

Carpal Tunnel Pain Treatment

Acute Elbow Trauma

• In adults: Radial head Fx is the m/c (33%) and accounts for 1.5-4% of all fractures. Etiology: FOOSH with forearm pronated. Associated injuries: elbow collateral ligaments tears. EssexLoprestiFx with interosseous membrane tearing and dislocation of the Distal Radio-Ulnar Joint(DRUJ)
• Terrible triad: of the Radial head Fx, elbow dislocation and Coronoid process Fx (typically avulsed by the Brachialis M)
• Imaging: 1st step is x-radiography with elbow series, CT scanning may help in complex cases, MRIif ligamentous injury.
• In children: Supracondylar Fx of the distal humerus accounts for 90% of acute trauma. It is always d/t accidental trauma with FOOSH and elbow extended, rarely <5% with flexed elbow. MostSupracondylar Fx occur in children <10 y.o. Males>Females. Complications: malunion in cubitus varus aka Gunstock deformity, vascular injury and acute ischemic compartment syndrome with Volkmann contracture
• Imaging: 1st step x-radiography can be sufficient. CT occasionally used in complex cases.

• Radial head (RH) Fx: Mason classification helps to determine the degree of complexity and mode of treatment
• Type 1- undisplaced is the m/c and stable contained by ligaments. On radiographs can be very subtle and evaluation of abnormal elbow fat pads is critical and often the only diagnostic clue
• Type 2- displaced by 2-mm or > with rotational block
• Type 3- comminuted >2-3 fragments and
• Type4 is presented with RH fx, posterior elbow dislocation and sometimes Coronoid process fracture often d/t Brachialis M avulsion
• Rx: Type 1 managed non-operatively by immobilization and movement rehab. Type 2- ORIF if rotational block. Type 3 and 4, ORIF and RH resection or RH arthroplasty
• Note abnormally displaced anterior fat pad (orange arrow) and the emergence of the posterior fat pad (green arrow) that is usually deep in the olecranon fossa and not seen unless acute hemarthrosis or other effusiondevelopsFat pad signs are most reliable indicators of intra-articular elbow Fx

• Mason type 1 RH Fx can be v. subtle and missed. Radiographic search should involve a close evaluation of positive fat pad signs. Note anterior fat pad displacement aka Sail sign and the presence of the post fat pad d/t acute bleed

• Monteggia fracture-dislocations: prox 1/3ulnar shaft Fx. with concomitant dislocation of PRUJ (radial head). FOOSH injury. Children4-12 y.o. Infrequent in adults.
• X-rays readily reveal ulnar Fx, but radial head dislocation may be subtle and occasionally missed. This is a serious injury leading to elbow disability if Dx delayed 2-3 weeks or left untreated. X-rays are typically sufficient:Rx: casting vs. operative.

• Supracondylar Fx: this is the M/C elbow Fx in children.
• Especially, the un-displaced types 1(top right) is difficult to Dx. Abnormality of "fat pads" and anterior humeral line and radiocapitella line disturbance are often most reliable
• Type 3 carries a particularly high risk for Volkmann contracture (vascular ischemic-necrosis of the anterior forearm muscle compartment

Elbow complaints in a young athlete

• Epicondyle Fx: common pediatric injury, about 10%.Essentially an avulsion Fx and a MUCL tear. Medial epicondyle is m/c Fx. FOOSH is the m/c mechanism.M>F. If minimally displaced or undisplaced can be treated with casting esp. in non-dominant arm. If displaced as in this case, require ORIF.
• Medial epicondyle avulsive Fx in a young baseball pitcher was coined a “little league elbow” in the 60sand now should be avoided to avoid confusion
• OCD of the Capitellum is a common athletic injury induced by repeated compression/flexion. OCD must be DDx from Panner’s disease or osteochondritis typically presented in younger patients
• Difficulty in diagnosis may stem from multipleapophysis about the elbow (see CRITOE)
• Imaging: 1st step: x-rays followed by MRI and/or MRarthrogramme if indicated.
• CT may help with complex injury evaluation. MRI and/or MSKUS may help with a ligament injury.

Elbow Arthritis

• DJD of the elbow is uncommon and typically 2nd to trauma, occupation, CPPD, OCD of theCapitellum or other pathology. Clinically: pain, reduced ROM esp. in dominant arm, deterioration of ADL. Loss of terminal flexion and extension. 50% develop Ulnarcompressive neuropathy. Rx: conservative,arthroscopic debridement/osteophytes removal, capsular release. In older patients and not active patients Total Elbow Arthroplasty (TEA) can be used
• Imaging: x-radiography is sufficient, CT helps with pre-operative planning

• Inflammatory Arthritis: RA of the elbow is frequent (20-50%) and destructive d/t synovitis, pannus, bone/cartilage, and ligamentous destruction/laxity. Clinically: begins after the onset of hands symptoms with, symmetrical swelling, pain, reduced ROM, flexion contracture. Presence of rheumatoid nodules can be noted along the olecranon and posterior forearm. Rx: DMARD, operative tendons repair.
• Imaging: x-radiography with early non-specific effusion (fat pads),later: erosions, symmetric JSL, osteopenia. MSK US helps early Dx. MRI reveals synovitis, bone edema correlates with pre-erosive x-ray findings, synovial enhancement on FS T1+C.
• Gouty Arthritis: may affect the elbow but less than in the lower extremity. Olecranon bursitis causing a “rising sun sign” on x-rays with or w/o bone erosions. Aspiration and polarised microscopy revealing needle-shaped negatively birefringent monosodium urate crystals. Rx: colchicine, other meds.
• Septic Arthritis: consider in diabetics, IV drug users, concurrent RA, patients with active TB, gonococcal in young adults. Clinically presents as monoarthritis with or w/o constitutional signs. X-ray: poor detection in early stages. US may show effusion and high Doppler.MRI: effusion, osseous edema. Bone scintigraphy can help as well. Labs: CBC, ESR, CRP. Diagnostic arthrocentesis with gram staining and culture are crucial. Rx: Prompt IV antibiotics

• Juvenile Idiopathic Arthritis (JIA) considered M/C chronic disease of childhood and precedes IBD infrequency. Dx is clinical and imaging: Criteria: Joint pain and swelling in a child 0-16-years for 6-weeks or longer. Many forms exist M/C pauciarticular(oligoarticular) 40%, F>M, associated with ocular involvement (iridocyclitis) and potential blindness. Polyarticular and Systemic forms.
• Elbow is frequently affected along with the knee, wrists, and hands, especially in polyarticular dz.
• Labs: ESR/CRP RF-VE in most cases
• Imaging: early x-ray features are non-specific. Later: osseous erosion, destruction of joint cartilage, overgrowth of articular epiphyses, early closure of physis. Delayed features: 2nd DJD, joint ankyloses.DDx: hemophilic arthropathy. Cervical radiographs are crucial.
• Rx: DMARD, conservative care

Miscellaneous pathologies

• Supracondylar process: 2% of the population. Described by Sir JohnStruthers in 1854. Fibrous band(Ligament of Struthers) may lead to compression of the Median N. DDx fromOsteochondroma that typically points away from the joint
• Primary synovial chondrometaplasia (Reichel Syndrome): abnormalmetaplasia of synovial cells shedding cartilage into joint potentially causing DJD, extrinsic bone erosion, synovitis, nerve compressions, etc. Removedoperatively. Imaging: multiple osseocartilaginous loose bodies of relatively equal sizes in the joint cavityDDx with DJD and 2ndosteochondromatosis. MRI-low signal onT1 and T2 with potential joint effusion. Ina tight joint like the elbow may present with large joint distention.•
• Panner’s Disease: osteochondrosis of theCapitellum typically in 5-10 y.o. Young athlete DDX from OCD of Capitellum(discussed) that occurs in teenagers.Clinically: pain on activity. Recovery occurs in most cases by spontaneous healing. Imaging: x-rays reveal sclerosis and slight fragmentation of theCapitellum w/o loose body. MRI: low T1and high T2 signal in the entireCapitellum.
• Myositis Ossificance:

Soft Tissue & Bone Neoplasms about the Elbow

• Lipoma: intramuscular, subcutaneous. Most common soft tissue neoplasms. Composed of fat but a substantial number may undergo fat necrosis-calcification-fibrosis. Typically remains benign. Occasionally difficult to DDx from a well-differentiated liposarcoma. Imaging: x radiography: radiolucent lesion well-circumscribed with or w/o calcification. US and MRI are important. On MRIT1high, T2 low SI.
• Hemangioma: benign vascular lesion, often composed of multiple vascular channels. Capillary vs. cavernous. More common in children, but found in any age. May often form phleboliths (calcification). Imaging: x-rays reveal soft tissue mass containing phleboliths. MRI: T1-high or variable signal. T2-high signal in areas of slow flow. “bag of worms” sign. Biopsy best avoided. Rx: difficult: local excision vs. embolization vs. observation. High recurrence.
• Peripheral Nerve sheath tumor (PNST): benign vs.malignant. Greater incidence in NF1 with a higher risk of malignant PNST. Benign PNST: Schwannoma vs.Neurofibroma. Spinal vs. peripheral nerves. Histology: Schwann cells interspersed with fibroblast and vessels.Clinically: pts in 20s and 30s, palpable mass with or w/o local pressure. Imaging: MRI: T1: split-fat sign, T2: target sign. T1+C enhancement
• Soft Tissue Sarcomas: MFH, Synovial sarcoma,(discussed), Liposarcoma (more frequent in the retroperitoneum) Dx: MRI. Clinically: Dx is delayed d/t painless enlarging mass often ignored. Clinically palpable mass deserves MRI examination, US may be helpful. Biopsy confirms Dx.
• Malignant bone Neoplasms: Children: OSA, Ewing’s sarcoma (discussed) Adults: Mets, Myeloma (discussed)

Lisfranc Fracture-Dislocation

• M/C dislocation of the foot at tarsal-metatarsal articulation (Lisfranc joint). Direct impact or landing and plantar or dorsal flexing the foot. Lisfranc ligament holding 2nd MT base and 1st Cu is torn. Manifests with or w/o fracture-avulsion.
• Imaging: 1st step: foot radiography in most cases sufficient to Dx. MSK US may help: show disrupted Cu1-Cu2. Ligament and widened space > 2.5mm. MRI may help but not essential. Weight-bearing view aids Dx.
• 2-types: homolateral (1st MTP joint in contact) and divergent (2-5 MT displaced laterally and 1st MT medially)
• Management: operative fixation is crucial
• N.B. Atraumatic Lisfranc dislocation is a frequent complication of a diabetic Charcot foot

Osteochondral Injury of the Talus (OCD)

• Common. Non-traumatic found in superior-medial talar dome. Traumatic may affect supero-lateral dome.
• Clinically: pain/effusion/locking. Imaging is crucial.
• 1st step: radiography may reveal focal radiolucent concavity/halo, fragment.
• MRI helpful esp. if OCD is cartilaginous and to demonstrate bone edema.
• Management: non-operative: short-leg cast/immonbilization-4-6 wk. operative: arthrocsopic removal.
• Complications: premature 2nd DJD

Metatarsal Injuries

• Acute & Stress fractures are common: m/c 5th MT & 2nd, 3rd MT.
• Jones Fx: extra-articular Fx of proximal metaphysis of the 5th MT. Prone to non-union. Often fixed operatively.
• Pseudo-Jones: intra-articular avulsion of 5th MT styloid/base by eccentric contraction of Peroneus Brevis M. Managed conservatively: boot-cast immobilization. Both Jones & Pseudo-Jones Dx by foot series radiography.
• Stress Fx. Calcaneus, 2nd, 3rd, 5th MTs. Repeated loading (running) or "March foot" 2nd/3rd MT. Clinically: pain on activity, reduced by rest. Dx: x-rays often unrewarding earlier. MRI or MSK US may help. Managed: Conservatively. Complications; progress into complete Fx
• Turf toe: common athletic hyperextension of 1st MTP-sesamoid/plantar plate complex tearing. 1st MTP unstable/loose. Managed operatively.

Arthritis of the Foot & Ankle

• DJD of the ankle: uncommon a primary OA. Typically develops as 2nd to trauma/AVN, RA, CPPD, Hemophilic arthropathy, Juvenile Idiopathic Arthritis, etc. manifests as DJD: osteophytes, JSL, subchondral cysts all seen on x-rays
• Inflammatory Arthritis: RA may develop in the ankle or any synovial joint. Will typically presents with symmetrical Hands/feet RA initially (2nd, 3rd MCP, wrists, MTPs in feet) typically with erosion, uniform JSL, juxta-articular osteopenia, and delayed subluxations.
• HLA-B27 spondyloarthropathies: commonly affect lower extremity: heel, ankle esp in Reactive (Reiter). Erosive-productive bone proliferation is a crucial Dx.
• Gouty Arthritis: common in the lower extremity. Ankle, mid-foot foot esp 1st MTPs. Initial onset: acute gouty arthritis with ST effusion and no erosions/tophi. Chronic tophaceous gout: peri-articular, intra-osseous punched-out erosions with over-hanging edges, no initial JSL/osteopenia, ST. Tophi may be seen.
• Miscellaneous arthropathy: PVNS. Not common. Affects 3-4th decades of life. The result of synovial proliferation with Macrophages and multi-nucleated Giant Cells filled with hemosiderin and fatty accumulation may lead to inflammation, cartilage damage, extrinsic bone erosions. Dx: x-rays are insensity, MRI modality of choice. Synovial biopsy. Management: operative, can be difficult.

Neuropathic Osteoarthropathy

• (Charcot's joint) Common and on the rise d/t epidemic in type 2 DM. May present with pain initially (50% of cases) and painless destructive arthropathy as a late manifestation. Early Dx: delayed. Imaging is crucial: x-rays: initially unrewarding, some SF effusion is seen. MRI helps with early Dx and extremity off-loading. Late Dx: irreversible dislocations, collapse, disability. Note: Lisfrance dislocation in Charcot joint
• M/C mid-foot (TM joint) in 40% of cases, ankle 15%. Progression: Rocker-bottom foot, ulcerations, infections, increased morbidity, and mortality.
• Early Dx: by MRI is crucial. Suspect it in patients with type 2 DM especially if early non-traumatic foot/ankle pain reported.

Degenerative Knee Arthritis

• Knee Arthritis
• Knee OA (arthrosis) is the m/c symptomatic OA with 240 cases per 100,000, 12.5% of people >45 y.o.
• Modifiable risk factors: trauma, obesity, lack of fitness, muscle weakness
• Non-modifiable: women>men, aging, genetics, race/ethnicity
• Pathology: da disease of the articular cartilage. Continuing mechanical stimulation follows by an initial increase in water and cartilage thickness. Gradual loss of proteoglycans and ground substance. Fissuring/splitting. Chondrocytes are damaged and release enzymes into the joint. Cystic progression and further cartilage loss. Subchondral bone is denuded and exposed to mechanical stresses. It becomes hypervascular forming osteophytes. Subchondral cysts and bone thickening/sclerosis develop.
• Imaging plays a crucial role in Dx/grading and management
• Clinically: pain on walking/rest, crepitus, swelling d/t synovitis, locking/catching d/t osseocartilaginous fragments and gradual functional loss. Knee OA typically presents as mono and oligoarthritis. DDx: morning pain/stiffness is >30-min DDx from inflammatory arthritis
• Treatment: in mild to moderate cases-conservative care. Severe OA-total knee arthroplasty

OA: L.O.S.S. Radiologic Presentation

• Typical radiologic-pathologic presentation of  OA: L.O.S.S.
• Loss of joint space (non-uniform/asymmetrical)
• Osteophytes
• Subchondral sclerosis
• Subchondral cysts
• Bone deformity: Genu Varum- is the m/c deformity d/t medial knee compartment affected more severely
• In addition: a weakening of periarticular soft tissues, instability and other changes

Imaging

• Radiography is the modality of choice
• Views should include b/l weight bearing
• Evaluation of joint space is crucial. Normal joint space -3-mm
• Grading is based on the degree of joint space narrowing (JSN), osteophytes, bone deformation, etc.
• Grade 1: minimal JSN, suspicious osteophytes
• Grade 2: appreciable osteophytes and JSN on AP weight-bearing view
• Grade 3: multiple osteophytes, definite JSN, subchondral sclerosis
• Grade 4: severe JSN, large osteophytes, marked subchondral sclerosis and definite bony deformity
• Typical report language will state:
• Minor, mild, moderate or severe aka advanced arthrosis

Technique

• Radiography: AP weight-bearing knees: note severe JSN of the medial compartment more severely with lateral knee compartment. Osteophytes and marked genu varum deformity and bone deformation
• Typically medial femorotibial compartment is affected early and more severely
• The patellofemoral compartment is also affected and best visualized on the lateral and Sunrise views
• Impressions: severe tri-compartmental knee arthrosis
• Recommendations: referral to the orthopedic surgeon

Moderate JSN

• B/L AP weight-bearing view (above top image): Moderate JSN primarily of the medial femorotibial compartment. Osteophytosis, subchondral sclerosis and mild bone deformation (genu varum)
• Additional features: PF OA, intra-articular osteophytes, secondary osteocartilaginous loose bodies and subchondral cysts (above arrows)

Secondary Osteochondromatosis

• Intra-articular osteocartilaginous loose bodies known as secondary osteochondromatosis
• Typical in DJD especially of the large joints
• It may accelerate further cartilage destruction and progression of OA
• May worsen signs of synovitis
• Intra-articular locking, catching etc.

Management of Severe Knee OA

• Conservative care: NSAID, exercise, weight loss etc.
• Operative care should be used if conservative care failed or symptoms progress despite conservative efforts in severe OA cases
• Review article
• https://www.aafp.org/afp/2018/0415/p523.html

Calcium Pyrophosphate Dehydrate Deposition Disease

• CPPD arthropathy common in the knee
• May present as asymptomatic chondrocalcinosis, CPPD arthropathy resembling DJD with pan predominance of large subchondral cysts. Often found as isolated PFJ DJD
• Pseudogout with an acute attack of knee pain resembling gouty arthritis
• Radiography is the 1st step and often reveals the Dx
• Arthrocentesis with polarized microscopy may be helpful to DDx between CPPD and Gouty arthritis

Rheumatoid Arthritis

• RA: an autoimmune systemic inflammatory disease that targets soft tissues of joints synovium, tendons/ligaments, bursae and extra-articular sites (e.g., eyes, lungs, cardiovascular system)
• RA is the m/c inflammatory arthritis, 3% of women and 1% of men. Age: 30-50 F>M 3:1, but may develop at any age. True RA is uncommon in children and should not be confused with Juvenile Idiopathic Arthritis
• RA most often affects small joints of the hands and feet as symmetrical arthritis (2nd 3rd MCP, 3rd PIPs, wrists & MTPs, sparing DIPs of fingers and toes)
• Radiographically: RA presents with joint effusion leading to hyperemia and marginal erosions and periarticular osteoporosis. In the knee, the lateral compartment is affected more frequently leading to valgus deformity. Uniform aka concentric/symmetrical JSN affects all compartments and remains a key Dx clue
• An absence of subchondral sclerosis and osteophytes. Popliteal cyst (Baker's cyst) may represent synovial pannus and inflammatory synovitis extending into the popliteal region that may rapture and extend into posterior leg compartment
• N.B. Following initial RA joint destruction, it is not unusual to note superimposed 2nd OA

• Radiography is the 1st step but early joint involvement may be undetectable by x-rays and can be helped by US and/or MRI.
• Lab tests: RF, CRP, anti-cyclic citrulline peptide antibodies (anti-CCP Ab). CBC
• Final Dx is based on Hx, clinical exam, labs, and radiology
• Clinical pearls: patients with RA may present with a single knee being affected
• Most patients are likely to have bilateral symmetrical hands/feet RA.
• Cervical spine, particularly C1-2 is affected in 75-90% of cases throughout the course of the disease
• N.B. Sudden exacerbation of joint pain in RA should not underestimate septic arthritis because patients with pre-existing RA are at higher risk of infectious arthritis. Joint aspiration may help with Dx.

Radiographic DDx

• RA (above left) vs. OA (above right)
• RA: concentric (uniform) joint space loss, lack of osteophytes and juxta-articular osteopenia.
• Clinical Pearls: patients with RA may present radiographically with subchondral sclerosis d/t superimposed DJD. The latter feature should not be interpreted as OA but instead considered as secondary OA

AP Knee Radiograph

• Note marked uniform JSN, juxta-articular osteopenia and subchondral cystic changes
• Clinical Pearls: subcortical cysts in RA will characteristically lack sclerotic rim noted in OA-associated subcortical cysts.

MRI Sensitivity

• MRI is very sensitive and may aid during early Dx of RA.
• T2 fat-sat or STIR and T1 + C gad contrast fat-suppressed sequences may be included
• MRI Dx of RA: synovial inflammation/effusion, synovial hyperplasia, and pannus formation decreased cartilage thickness, subchondral cysts, and bone erosions
• MRI is very sensitive to reveal juxt-articular bone marrow edema, a precursor to erosions
• Intra-articular fibrinoid fragments known as "Rice bodies" are characteristic MR sign of RA
• Note: T2 fat-sat sagittal MRI revealing large inflammatory joint effusion and pannus synovial proliferation (above arrowheads). No evidence of radiographic or MRI bone erosions present. Dx: RA

STIR MR Slices

• Note: STIR MR slices in the axial (above bottom image) and coronal planes (above top image) demonstrate extensive synovitis/effusion (above arrowheads) and multiple erosions in the medial and lateral tibial plateau (above arrows)
• Additionally, scattered patchy areas of bone marrow edema are noted (above asterisks) such marrow edema changes are indicative and predictive of future osseous erosions.
• Additional features: note thinning and destruction of joint cartilage

Meniscal Tears 

• Acute or chronic. Imaged with MRI (95% sensitivity & 81% specificity)
• Menisci are formed by a composition of radial and circumferential collagen fibers (97% type 1) mixed with cartilage, proteoglycans, etc. 65-75% H2O
• Aging can lead to meniscal attrition
• Acute tears are d/t rotational and compressive forces, ACL deficient knees show greater chances of meniscal tears
• Posterior horn of medial meniscus is m/c torn except in acute ACL tears when the lateral meniscus is m/c torn
• The meniscus is well vascularized in children. In adults, 3-zones exist: inner, middle and outer (above bottom image)
• Injury of the inner zone has no chance of healing
• Injury of the outer zone (25% in total) has some healing/repair

Clinical Presentation

• Pain, locking, swelling
• Most sensitive physical sign: pain on palpation at the joint line
• Tests: McMurry, Thessaly, Apply compression in prone
• Management: conservative vs. operative depends on location, stability, patient's age, and DJD and the type of tear
• Partial meniscectomy is performed. 80% proper functions on follow up. Less favorable if >40-y.o and DJD
• Total meniscectomy is not performed and only viewed historically. 70% OA 3-years after surgery 100% OA after 20 years post surgery.

Axial MR

• Appearance the medial (blue) and the lateral meniscus (red)

Menisci Play Significant Role

• One of the essential roles is "hoop-stress" mechanism.
• Particularly radial tears may significantly interfere with this mechanism.
• Further reading: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435920/

Types Location & Stability

• Types, location, and stability of tears are v. important during MRI Dx
• Vertical/longitudinal tears especially occur in acute ACL tears. Some longitudinal tears found at the periphery or "red zone" may heal
• Bucket handle tear: longitudinal tear in the inner edge that is deep and vertical extending through the long axis and may displace into a notch
• Oblique/flap/parrot-beak are complex tears
• Radial tear at 90-degree to plateau

Axial T2

• Axial T2 WI fat-sat and coronal STIR slices of the posterior horn of the medial meniscus.
• Note a radial tear of the posterior horn of the medial meniscus near the meniscal root. This is potentially an unstable lesion requiring operative care
• The meniscus, in this case, is unable to provide a "hoop-stress mechanism."

MRI Slices Coronal & Sagittal

• Fat-sat coronal and sagittal proton density MRI slices revealing horizontal (cleavage) tear that is more typical in the aged meniscus
• In some cases, when this tear does not contain a radial component, it may partially heal obviating the need for operative care

T2 w GRE Sagittal MRI Slice

• Complex tear with a horizontal oblique and radial component.
• This type of tear is very unstable and in most cases may need operative care

Bucket Handle Tear 

• Bucket handle tear are m/c in the medial meniscus esp. with acute ACL and MCL tear
• MRI signs; double PCL sign on sagittal slices
• Absent "bow-tie" sign and others
• Most cases require operative care

DDx From Meniscal Degeneration

• Occasionally meniscal tears need to be DDx from meniscal degeneration which may also appear bright (high signal) on fluid-sensitive MRI
• The simplest rule is that if there is a true meniscal tear aka Grade 3 lesion, it always reaches/extends to the tibial plateau surface

The Role of MSK Ultrasound (US) in Knee Examination

• MSK US of the knee permits high resolution and dynamic imaging of primarily superficial anatomy (tendons, bursae, capsular ligaments)
• MSK US cannot adequately evaluate cruciate ligaments and the menisci in their entirety
• Thus MR imaging remains modality of choice

Potential Pathologies Successfully Evaluated by MSK US

• Patellar tendionosis/patellar tendon rupture
• Quadriceps tendon tear 
• Prepatellar bursitis
• Infrapatellar bursitis
• Pes Anserine bursitis
• Popliteal cyst (Baker cyst)
• Inflammation/joint effusion with synovial thickening and hyperemia can be imaged with US (e.g., RA) especially with the addition of color power Doppler

Patient Presented With Atraumatic Knee Pain & Swelling

• Radiography revealed sizeable soft tissue density within the superficial pre-patella region along with mild-to-moderate OA
• MSK US demonstrated large septated heterogeneous fluid collection with mild positive Doppler activity on the periphery indicating inflammation d/t Dx of Superficial pre-patella bursitis

Long Axis US Images

• Note normal lateral meniscus and fibers of LCL (above bottom image) compared to
• Horizontal degenerative cleavage tear along with protrusion of lateral meniscus and LCL bulging (above top image)
• Major limitation: unable to visualize the entire meniscus and the ACL/PCL
• MRI referral is suggested

Rupture of Distal Tendon of Quadriceps

• Note rupture of distal tendon of the Quadriceps muscle presented as fiber separation and fluid (hypo to anechoic) fluid collection within the substance of the tendon
• Advantages of MSK US over MRI to evaluate superficial structures:
• Dynamic imaging
• Availability
• Cost-effective
• Patient's preparation
• Disadvantages: limited depth of structures, inability to evaluated bone and cartilage, etc.

Osteochondral Knee Injuries (OI)

• osteochondral knee injuries can occur in children 10-15 y.o presented as Osteochondritis Dissecance (OCD) and in mature skeleton m/c following hyperextension and rotation trauma, particularly in ACL tear.
• OCD-typically develops from repeated forces in immature bone and affects m/c postero-lateral portion of the medial femoral condyle.
• OI in mature bone occurs m/c during ACL tears mainly affecting so-called terminal sulcus of the lateral femoral condyle at the junction of the weight-bearing portion opposed to the tibial plateau and the part articulating with the patella
• Osteochondral injuries may potentially damage the articular cartilage causing secondary OA. Thus need to be evaluated surgically
• Imaging plays an important role and should begin with radiography often followed by MR imaging and orthopedic referral.

OCD Knee 

• 95% associated with some trauma. Other etiology: ischemic bone necrosis especially in adults
• Other common location for osteochondral injuries: elbow (capitellum), talus
• 1st step: radiography may detect osteochondral fragment potentially attached or detached
• Location: the posterior-lateral aspect of the medial femoral condyle. Tunnel (intercondylar notch) view is crucial
• MRI: modality of choice >90% specificity and sensitivity. Crucial for further management. T1-low signal demarcating line with T2 high signal demarcating line that signifies detachment and unlikely healing. Refer to orthopedic surgeon
• Management: stable lesion esp. in younger children>off weight-bearing-heals in 50-75%
• Unstable lesion and older child or impending physeal closure>operative fixation.

Ischemic Osteonecrosis

• Ischemic Osteonecrosis (More accurate term) aka avascular necrosis AVN: this term describes subarticular (subchondral) bone death
• Intramedullary bone infarct: depicts osteonecrosis within the medullary cavity of the bone (above x-ray image)
• Causes: m/c: trauma, systemic corticosteroids, diabetes, vasculitis in SLE. The list is long. Other vital causes: Sickle cell disease, Gaucher disease, alcohol, caisson disease, SCFE, LCP, etc.
• Pathology: ischemia and bone infarct with resultant devitalized center surrounded by ischemia and edema with normal bone on the outer periphery (MRI double line sign)
• Sub-articular necrotic bone eventually collapses and fragments leading to progressive bone and cartilage destruction and rapidly progressing DJD
• Early Dx often missed but crucial to prevent severe DJD

M/C Sites

• Hips, shoulders, talus, scaphoid bone. Many peripheral idiopathic AVN sites are known by their eponyms (e.g., Kienbock aka AVN of the lunate bone, Preisier aka scaphoid AVN)
• Radiography is insensitive to early AVN and may only present as subtle osteopenia
• Some of the early appreciable rad features are increased patchy bone sclerosis followed by sub-articular bone collapse or "crescent sign" signifying stage-3 on Ficat classification (above)
• Earliest detection and early intervention can be achieved by MRI (most sensitive modality)
• If MRI contraindicated or unavailable, 2nd most sensitive modality is radionuclide bone scan (scintigraphy)
• X-ray and CT scanning are of equal value

Coronal MRI Slice

• Fluid sensitive, sensitive coronal MRI slice revealing bill ischemic osteonecrosis of the femoral head
• MRI findings: l

Tc99-MMDP Radionuclide Bone 

• Bone scan reveals a central area of photopenia (cold spot) d/t necrotic fragment surrounded by increased osteoblastic activity as increased uptake of Tc-99 MDP in the right hip
• The patient is a 30-year-old female with breast cancer and chemotherapy treatment who suddenly presented with right hip pain

Radiographic Progression of AVN

• Later stages present with articular collapse, subarticular cysts, increased patchy sclerosis and complete flattening of the femoral head with resultant severe DJD. Rx: THA

Management

• Early imaging Dx with MRI or bone scintigraphy is essential
• Referral to the Orthopedic surgeon
• Core decompression (above) can be used to revascularize the affected bone during earlier stages but produces mixed results
• Delayed changes of AVN: THA as IN severe DJD cases

B/L THA 

• B/L THA in the patient with ischemic osteonecrosis of the right and later left hip
• When B/L hip AVN is present, typically consider systemic causes (corticosteroids, diabetes)

Inflammatory Arthritis Affecting the Hip

• Consider common systemic inflammatory condition such as RA and AS/EnA
• Hip RA may develop in 30% of patients with RA
• Key features to DDx inflammatory arthritis vs. DJD is symmetrical/uniform aka concentric joint loss often leading to axial migration and Protrusion Acetabule in advanced cases
• Key element between RA vs. AS: the presence of RA bone erosion w/o productive bone changes or enthesitis in AS d/t inflammatory subperiosteal bone proliferation, whiskering/fluffy periostitis (collar-type enthesitis circumferentially affecting head-neck junction)
• Dx: Hx, PE, labs: CRP, RH, anti-CCP Ab (RA)
• CRP, HLA-B27, RF- (AS)

Septic Arthritis

• Gonococcal infections, iatrogenic causes, I.V. drug use, and some others
• Routes: hematogenous, adjacent spread, direct inoculation (e.g., iatrogenic)
• Clinically: pain and reduced ROM presented as monoarthritis, generalized signs/symptoms. CBC, ESR, CRP changes. ARthrocentesis and culture are crucial
• M/C pathogen Staph. Aureus & Neisseria Gonorrhea
• 1st step: radiography, often unrewarding in the early stage. Later (4-10 days) indistinctness of the white cortical line at the femoral articular epiphysis, loss of joint space, effusion as a widening of the medial joint area (Waldenstrom sign)
• MRI - best at early DX: T1, T2, STIR, T1+C may help with early. Early I.V. antibiotics crucial to prevent rapid joint destruction

Slipped Capital Femoral Epiphysis (SCFE) 

• Important to diagnose but easily missed potentially leading to Ischemic Osteonecrosis of the femoral head aka AVN
• Presents typically in overweight children (more often boys), age over 8 years. Greater incidence in African-American boys
• 1st step: radiography, especially look for a widened physeal growth plate (so-called pre-slip). Later, slip and disturbed Klein's line (above image). MRI - best modality for early Dx and early intervention
• The frog lateral view often demonstrates the medial slip better than the AP view

Clinically Limping Child or Adolescent 

• M>F (10-18 years). African-Americans are at greater risk. 20% of cases of SCFE are B/L. Complications: AVN >>DJD
• Radiography: AP pelvis, spot, and frog leg may reveal slippage as Klein line failed to cross through the lateral aspect of the femoral head
• Additional features: physis may appear widened
• MRI w/o gad is required for the earliest Dx and prevention of complications (AVN)

Normal and Abnormal Klein Line

• Consistent with SCFE. The physis is also widened. Dx: SCFE
• Urgent referral to the Pediatric Orthopedic surgeon

Subtle Changes in Left Hip 

• Note suspected subtle changes in the left hip that may require MR examination to confirm the Dx
• Delay in care may result in significant complications

Perthes' Disease

• aka Legg-Calves-Perthes Disease (LCP)
• Refers to Osteochondritis of the femoral head with osteonecrosis likely d/t disturbed vascularization of the femoral head
• Presents typically in children (more often boys) aged under 8 years as atraumatic "limping child." 15% may have B/L Perthe's
• Imaging steps: 1st step x-radiography, followed by MRI especially in stage 1 (early) w/o x-ray abnormalities
• Unspecific signs: joint effusion with Waldenstrome sign+ (>2-mm increase in medial joint space compared to the opposite side). Past approach: Fluoroscopic Arthrography (replaced by MRI)
• Pathologic-Radiologic Correlation: in well-established cases, the femoral head characteristically becomes sclerotic, flattened and fragmented due to avascular necrosis (AVN). Later on, an occasional Coxa Magna changes may develop (>10% femoral head enlargement)
• Management: symptoms control, bracing. Boys at younger ate show better prognosis d/t more immaturity and better chances of bone/cartilage repair mechanisms. In advanced cases, operative care: osteotomy, hip arthroplasty in adulthood if advanced DJD develops

Common Neoplasms & Other Conditions Affecting Hip/Pelvis 

• M/C hip & pelvis neoplasms in adults: bone metastasis ( above far left), 2nd m/c Multiple Myeloma (M/C primary bone malignancy in adults). Tips: remember Red Marrow distribution. Less frequent: Chondrosarcoma
• Paget's disease of bone (above-bottom left image) is m/c detected in the pelvis and Femurs
• Children and young adults 'limping child' benign neoplasms: Fibrous Dysplasia (above middle image), Solitary Bone Cyst (21%), Osteoid Osteoma, Chondroblastoma. Malignant pediatric neoplasms: m/c Ewing Sarcoma (above middle right and bottom images) vs. Osteosarcoma. >2y.o-consider Neuroblastoma
• Imaging: 1st step: radiography followed by MRI are most appropriate.
• If Mets are suspected: Tc99 bone scintigraphy is most sensitive

Multiple Myeloma

• Multiple Myeloma in a 75-y.o male (AP pelvis view)
• Chondrosarcoma in a 60-y.o male (axial and coronal reconstructed CT+C slices in the bone window)

Hip Pelvis Arthritis & Neoplasms

Hip Fractures

• Garden Classification (above) helps with Dx and correct management of patients
• M/C Fx are subcapital (80%)
• Fxs differentiated as intra-capsular (high risk of AVN) & extra-capsular (lower risk of AVN)
• Garden 1: incomplete undisplaced Fx typically impaction with valgus off-set of the head (15-20% AVN) patient able to ambulate
• Garden 2: complete, undisplaced Fx (30% AVN)
• Garden 3: complete, partially <50% displaced
• Garden 4: complete, 100% displaced Fx, pt collapsed with entire LE in ER (below image)
• Most osteoporotic Fx are intracapsular

Complete Displaced Femoral Neck Fracture Clinical Presentation

Imaging: Begins with X-radiography with Most Fxs

• CT scanning may help with further delineation of Fx complexity/displacement and Dx of additional regional Fxs
• MRI can be helpful if x-radiography fails to Dx fx
• X-radiography pitfalls: some undisplaced Garden 1 & 2 Fxs may be missed d/t pre-existing DJD and osteophytes along the femoral head-neck junction that may overly the Fx line
• Fx line is incomplete and too small/subtle especially if the study is read by non-radiologists
• Incomplete Fxs if left untreated will not heal and likely to progress to complete Fxs

• AP hip spot view: note valgus deformity of the head (above yellow arrow) with a small/subtle line of sclerosis in the sub-capital region representing Garden 1 Fx. MRI may help with Dx of subtle radiographic Fxs. If MRI contraindicated, Tc 99 radionuclide bone scan may help demonstrate high uptake of the radiopharmaceutical in Fx (below image)

Above - Tc99 Radionuclide Bone Scan Reveals Left Subcapital Femoral Neck Fx

• Garden 2 complete undisplaced (above green arrows) Fx

• AP hip: Garden 3 complete partially displaced Fx (above the first image)
• AP pelvis: complete displaced Garden 4 Fx (above the second image)
• Clinical pearls: in some cases of Garden 4 Fx, DDx may be difficult to differentiate from OSP vs. pathologic fx d/t to bone Mets of Multiple myeloma (MM)
• Management: depends on patients age and activity level
• Garden 3 & 4  require total hip arthroplasty in patients <85-y.o.
• Garden 1 & 2 may be treated with closed reduction of fx and open capsule and 3-cannulated fixating screws
• Pre-existing DJD may require total arthroplasty
• Occasionally observation may be performed on patients who are not active and significant risks of surgery and depends on surgical centers

• m/c Rx of Garden 1 & 2 undisplaced Fx with 3-screws. Screws proximity depends on the bone quality and Fx type

• THA aka hip replacement: cemented THA with bone cement (above the first image) vs. non-cemented (biologic) that is used mostly in younger patients
• 2-types: metal on metal vs. metal on polyethylene
• The femoral angle of the prosthesis should have slight valgus but never >140 degrees
• The non-cemented component uses porous metal allowing the bone to integrate sometimes coating in bone cement from osteoconduction
• THA has good outcome and prognosis
• Occasionally cement failure, fractures, and infections may complicate this procedure 

Supplemental Reading

• https://www.aafp.org/afp/2014/0615/p945.html
• https://emedicine.medscape.com/article/87043-overview
• https://radiopaedia.org/articles/proximal-femoral-fractures-summary

Acute Pelvis & Hip Trauma

Roberto Varela was always actively involved with chores at home before he started to experience neck, shoulder and leg pain. Due to his symptoms, Mr. Varela had difficulties engaging in regular physical activities, such as driving. However, after being recommended by his wife, he first received chiropractic care with Dr. Alex Jimenez, and Roberto Varela experienced tremendous relief from his neck, shoulder and leg pain, regaining his quality of life. Mr. Varela highly recommends Dr. Alex Jimenez and his staff for their services.

Chiropractic Treatment for Shoulder Pain

Shoulder pain or leg pain is common; however, sometimes these problems don't originate in the location of the symptoms. Shoulder and leg pain may also occur due to health issues in the neck or cervical spine. A variety of injuries and conditions can have their roots in improper posture, sports injuries or automobile accident injuries, causing misalignments, or subluxations, in the cervical spine or neck. Many healthcare professionals will discuss how damage to the cervical spine can be an underlying cause for shoulder pain and leg pain, among other symptoms.

We are blessed to present to you El Paso’s Premier Wellness & Injury Care Clinic.

Our services are specialized and focused on injuries and the complete recovery process. Our areas of practice include Wellness & Nutrition, Chronic Pain, Personal Injury, Auto Accident Care, Work Injuries, Back Injury, Low Back Pain, Neck Pain, Migraine Treatment, Sports Injuries, Severe Sciatica, Scoliosis, Complex Herniated Discs, Fibromyalgia, Chronic Pain, Stress Management, and Complex Injuries.

As El Paso’s Chiropractic Rehabilitation Clinic & Integrated Medicine Center, we passionately are focused on treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.

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If you sit behind a desk all day with little or no activity, you could be compromising your physical health, mental health, and brain health which could impact your productivity at work. From a physical standpoint, it isn’t healthy to remain in one position for too long. It can lead to various health conditions including diabetes, heart disease, and even cancer. Experts advise movement. By getting up and walking around every hour or so or do exercises at your desk.

Healthy brain function can be impacted by inactivity. If you sit at work without moving for long periods of time your brain could suffer. The lack of activity could cause it to enter into a state of slumber which can lead to a decrease in brain processing speed and short-term memory loss.

It can also impact a person’s ability to learn or retain new information. It is so important to create an organizational culture that encourages moving around as part of their workday.

There are four areas where you can incorporate movement into your workplace: policies, places, people, and permission.

Movement Policies

Create written policies that encourage and advocate movement during work hours. Incorporate moving workstations, moving meetings, flexible scheduling, more breaks when meetings run long, and a movement-friendly dress code.

Provide information and training to all employees and leadership underlining the importance of the policies and explaining the importance of movement as well as what they can do to support the initiative.

Places

Create workspaces that are conducive to movement, adjusting workstations so that they encourage active movement and incorporating dynamic change into current processes and workflows while minimizing the time employees spend sitting.

Seek out software and applications that encourage users to stretch or get up and move while they are working. Make stairwells more accessible and appealing, improve common areas, and promote collaboration that requires moving to various workstations or common areas.

People

Identify employees who are good role models for movement and train them for leadership roles so that they can encourage other employees to move a part of their workday. Train them in the policies regarding movement and task them with helping to create a culture of health and mobility within the organization.

Organize groups to walk during breaks or meet in common areas for light stretching and other types of movement. Sponsor contests and competitions with prizes for employees who achieve set goals.

Permission

Educate all employees and all levels of management or leadership on the benefits of movement and how it can positively impact personal production and performance as well as organizational outcomes. Stress that moving during the work day should become a regular activity and must be welcomed and allowed. Emphasize that it is the task of all employees to make a culture of movement the norm as opposed to the exception.

The benefits of moving around in the workplace extend far beyond healthier employees and increased production. Employees perceive themselves as valuable to the organization and morale is increased. Employee engagement improves on the job, and they invest more in their work as opposed to just doing a job. They are happier, empowered, and more productive at work and take more of an active role in business outcomes as well as their health.

Of course, employees will also enjoy individual benefits such as increased blood flow, as well as improved problem solving, better alertness, and enhanced creativity. A workplace that incorporates movement into its culture is a healthier, happier place to work with more robust, and more satisfied employees. You can’t afford to not implement this simple, effective strategy into your own organizational culture.

Chiropractic Care Hip Labral Tear Treatment

The human body is an intricate machine, and everything is connected so when something goes wrong in one area, it can cause problems in other areas. The back carries a lot of the stress in the body so when there is a problem with the hips, knees, or a foot dysfunction, the spine can bear at least some of the brunt of the pain and other effects.

Particularly true with foot dysfunction is when the mechanics of the foot are off, which can throw off the alignment of the entire body. Overpronation and oversupination in the foot can lead to severe and chronic back pain.

What is Pronation and Overpronation?

Pronation describes the way that the foot rolls inward during its normal motion. The foot turns inward, flattening out, as the heel’s outer edge strikes the ground.

For the foot to function correctly, there must be a significant degree of pronation. However, excessive pronation, or overpronation, can cause injury and damage to the foot and ankle. It creates the arch in the foot to flatten, and the ligaments, tendons, and muscles under the foot overstretch.

What is Supination and Oversupination

Supination describes the way the foot rolls outward during its normal motion. It occurs during the push off part of the gait, mainly when running when the heel lifts. The heel leaves the ground, and the action carries through as weight transfers to the forefront and toes. It moves the body in a forward direction.

When there is excessive supination or oversupination, it strains the tendons and muscles that provide stabilization for the ankle. Causing the ankle to roll, causing injury to the ankle including overpronation sprain, a torn tendon, or ligament rupture.

Conditions and Injuries Caused by Overpronation and Oversupination

Overpronation and oversupination can cause a variety of injuries and conditions that affect not only the feet and ankles, but also the knees, hips, and back as well. Some of the more common injuries and conditions include:

• Flat feet or posterior tibial tendon dysfunction
• Ankle Sprains
• Achilles tendinitis
• Arch pain
• Plantar fasciitis
• Corns
• Shin splints
• Heel pain
• Tight calves
• Calluses
• Knee pain
• Patellar tendonitis
• Hip pain
• Tight hip flexors
• Back pain
• Sciatica
• Herniated disks

How Foot Problems can Cause Back Pain

Foot Dysfunction can very easily cause a domino effect that extends all the way to the back. The feet are the foundation of the body and when there is a problem with the way they function it can cause the entire body to shift out of alignment.

For instance, overpronation of the foot causes a series of internal changes that extend up through the leg. The femur may rotate causing hip pain and inflammation of the sacroiliac joint which leads to back pain. Other misalignments in the body that are caused by foot problems can also lead to chronic lower back pain as well.

Chiropractic to Treat Foot Problems

Chiropractic seeks to find the cause of the conditions it is used to treat, including pain, instead of just treating symptoms. Because of this, the chiropractor will work to find the cause of the pain, in this case, overpronation and overpronation, and correct it – or the effects of the condition – in addition to treating the back pain.

Typically, overpronation and oversupination, are caused by muscle imbalances in the foot, ankle, and lower leg. Improper shoes, misalignment in the body, and other issues can cause these muscle imbalances. The chiropractor will work with the patient to find the cause of the foot problem so that can be corrected, then work to the damage or injury done.

Foot Dysfunction & Back Pain Treatment Chiropractor

Dealing with joint or muscle pain can be a daunting experience. It's important to work on maintaining mobility and flexibility. The more flexible, the less likely to be injured. One of the best ways to improve flexibility is through stretching.

First and foremost is the need to warm up your muscles before stretching. Stretching first can actually cause injury by pushing the joints too far. Spend a few minutes doing some light activity before stretching. This can be a quick walk or some basic calisthenics.

A chiropractor can recommend stretches, or you can use some of these basic techniques. There are two basic forms of stretching, static and dynamic.

Static Stretching & Dynamic Stretching

Static stretching involves holding a position for a certain period of time in order to loosen up the muscles. This is what most people think of when they think about stretching. However, dynamic stretching involves moving specific parts of the body to work on flexibility.

Effective Back Pain Stretches Can Be Done At Home. For example:

• Lie on your back with your knees bent
• Grasp one knee in both hands and pull it up towards your chest. Hold this position for 30 seconds
• Lower the knee to the starting pose
• Repeat with the other knee.
• Both knees can be done at the same time.

A Similar Stretch Begins In The Same Position As The Previous Stretch Except:

• Instead of lifting your knee to your chest
• Roll both legs to one side so that your knees are as close to the floor as possible
• Hold this position for 10 seconds, and then roll to the other side

Another Stretch Recommended By Chiropractors Comes From Yoga, Known As The "Cat Pose."

• On the floor hands and knees, with your hands directly under your shoulders.
• Let your abdomen drop down towards the floor
• Then, reverse this movement by arching your back
• Repeat this cycle three to five times

Other Dynamic Stretches Can Also Be Good For Muscle Pain. Try doing:

Hand walks to stretch your shoulders and abdominal muscles.

• Stand up straight and slowly lower your hands towards the floor.
• Walk your hands out in front of you until you are as far down as you can go.
• Then walk your hands back to the starting position.

A Final Stretch That Can Help Sore Back Muscles Known As The "Scorpion."

• Lie face-down and stretch your arms out to the sides
• First, slowly move your right foot towards your left arm
• Then, move your left foot towards your right arm
• Make sure to move in a slow and controlled fashion

When you are suffering from muscle or joint pain, it is a good idea to stretch both in the morning and the evening. By incorporating these exercises into your daily routine, you can avoid common injuries.

If you need further instruction regarding stretches, please give us a call so that you can schedule an appointment.

Injury Medical Clinic: Back Pain Specialist

TMJ dysfunction: The temporomandibular joints, TMJ, are the lower jaw hinges that sit on either side of the head in front of each ear. They are responsible for the lower jaw opening, closing, sliding, and rotating. The TMJs are the most body’s most complex joints. The typical person uses them more than 5,000 times a day by talking, laughing, yawning, chewing, eating, smiling, and swallowing.

What Is TMJ Dysfunction?

TMJ dysfunction occurs when one or both joints become inflamed or injured causing pain and immobility in the jaw area. Because these joints are used so often and tend to be far more mobile than most other joints in the body, they can be prone to pain.

It is important that both joints work together because if they don’t it could result in more pressure on one joint than the other and this could cause the pain and discomfort that is associated with TMJ dysfunction.

What Are The Symptoms Of TMJ Dysfunction?

There are many symptoms of TMJ dysfunction and they may vary depending on the patient, the extent of inflammation or injury, and the cause of the dysfunction. The symptoms may appear suddenly when there is injury to the joint, or they can gradually develop over a period of months or even years. They may be mild and barely noticeable or they can be severe and debilitating. The most common symptoms of TMJ dysfunction include:

• Jaw pain
• Jaw pain when moving the joint such as chewing or talking
• Popping or clicking of the joint
• Pain in the face or side of the neck
• Locking jaw
• Headaches
• Toothache
• Earache
• Clogged or “stopped up” ear
• Ringing in the ears (tinnitus)

TMJ dysfunction can significantly impact a person’s quality of life because the pain prevents them from doing many things they normally do, and often the jaw itself simply no longer functions as it should. 

What Causes TMJ Dysfunction?

Damage to the joint is the primary cause of pain associated with TMJ dysfunction. This can be the result of trauma such as:

• Dental work
• Sports injury
• Getting punched or hit
• Car accident
• Slip and fall accident

Subtle movements done repetitively can also cause TMJ dysfunction:

• Grinding teeth
• Holding a phone between the head and shoulder
• Clenching teeth
• Nail biting
• Gum chewing (excessive)
• Eating hard or tough foods

How Can Upper Neck Misalignment Cause TMJ Dysfunction?

When the upper neck sustains trauma such as whiplash it can cause a misalignment. This can also cause TMJ dysfunction in a couple of ways. It can cause one side to work harder or sustain more pressure than the other, or it can put excess pressure on the trigeminal nerve. This causes irritation and inflammation.

When left untreated, the condition can become severe. The misalignment keeps the joints from working as they should because opening and closing the jaw pinches the disc. This results in painful spasms in the shoulder and neck muscles when the patient does simple, everyday activities like talking, smiling, eating, or laughing.

Chiropractic For TMJ Dysfunction

Chiropractic can be a very effective treatment for TMJ dysfunction, especially if it is due to neck misalignment. A chiropractor will perform spinal adjustments in order to realign the spine and neck, bringing the body back into balance. This will allow the jaw to work as it should, minimizing rubbing or friction in the joint.

The patient may also be told to apply heat, massage, and do special exercises for TMJ dysfunction that will help the joints heal and help to minimize the pain.

This condition is not always easy to diagnose so it is wise to talk to your chiropractor and get a diagnosis before attempting any treatment or home remedies for TMJ. Regular chiropractic treatment can not only relieve the pain of TMJ and help to heal it, it can also help prevent it. Your chiropractor can be a great ally in this endeavor.

Injury Medical Clinic: Shoulder Pain Treatment