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Orthopedic Institute
The Queen’s Medical Center
Level 8 via Queen Emma Elevator
1301 Punchbowl Street, Honolulu, Hawaii 96813
Phone:
808-691-8800
Queen’s Orthopedic Associates
Hale Pawa‘a
1401 South Beretania, Suite 750
Honolulu, Hawaii 96814
The two main bones of the shoulder are the humerus and the scapula (shoulder blade). The end of the scapula, called the glenoid, meets the head of the humerus to form a glenohumeral cavity that acts as a flexible ball-and-socket joint.
The joint cavity is cushioned by articular cartilage covering the head of the humerus and face of the glenoid. The scapula extends up and around the shoulder joint at the rear to form a roof called the acromion, and around the shoulder joint at the front to form the coracoid process.
A ring of fibrous cartilage surrounds the glenoid and stabilizes the joint. This is called the labrum.
Ligaments connect the bones of the shoulder and tendons join the bones to surrounding muscles.
The biceps tendon attaches the biceps muscle to the shoulder and helps to stabilize the joint.
Four short muscles originate on the scapula and pass around the shoulder where their tendons fuse together to form the rotator cuff.
All of these components of your shoulder, along with the muscles of your upper body, work together to manage the stress your shoulder receives as you extend, flex, lift and throw.
The biceps tendon is a long cord-like structure that is located in the front of the shoulder. It originates from the top of the shoulder socket (the glenoid) and exits the joint through a bony trough (the biceps groove). Below the shoulder, this tendon becomes the long head of the biceps muscle. The short head of the biceps is a continuation of the conjoined tendon that originates from a bony hook (the coracoid) at the front of the shoulder blade. Thus the biceps muscle, which functions to bend the elbow and rotate the forearm, has two anchor points in the shoulder region.
Age, inactivity, or over-activity can weaken a tendon, which may lead to injury due to the decreased ability to endure repetitive motions and sudden loads because of its location, from a direct blow to the front of the shoulder. Some individuals develop bone spurs in their biceps grooves or under the top of their shoulder blades (the acromion), which can lead to wear and tear of their tendons.
A less frequent injury is a dislocation of the biceps tendon from its groove. This is usually seen in combination with a tear of the subscapularis tendon or the rotator cuff tendon, which normally help hold the biceps tendon in it groove. The biceps tendon can also be injured at its attachment site on top of the glenoid. This usually involves an avulsion, where the tendon is pulled off the bone and rendered unstable.
Initially, rest, ice, and gentle anti-inflammatory medications are all that is usually needed. Sometimes an injection with a strong anti-inflammatory medication such as cortisone is needed to control the pain and swelling. Severe cases that fail to improve may require surgical treatment.
Plantar fasciitis is a condition defined by inflammation of the plantar fascia – a thick tissue that connects between the heel bone, across the bottom of the feet and to the toes. Healthy plantar fascia tissues absorb shock in the arch of the foot. But tension on the tissues can cause tearing, leading to inflammation. This inflammation usually causes throbbing pain in or near the heel.
People with plantar fasciitis often complain of heel pain – especially pain that is worse in the morning after waking or after sitting or standing for long periods of time. If you have a recurring stabbing pain in or near your heel, contact our office to schedule a consultation. Your surgeon can diagnose plantar fasciitis with a simple exam and imaging tests.
Your surgeon may recommend one or more of many different treatments for plantar fasciitis, depending on its severity. Often, treatment is conservative and may include stretching, physical therapy, and the use of foot orthotics. In most cases, pain is manageable using an over-the-counter anti-inflammatory, though your doctor may recommend steroid injections for the relief of severe pain.
Few people need to undergo surgery to treat plantar fasciitis. However, it is an option for patients with severe heel pain that has not responded to more conservative treatment measures, please ask your surgeon for more information regarding this.
Shoulder instability represents a spectrum of disorders, the successful management of which requires a correct diagnosis and treatment. The boundaries of this spectrum are represented by a subluxation event (a partial dislocation which spontaneously reduces), to a complete dislocation, which often requires anesthesia to reduce the shoulder. The majority of instabilities are traumatic in nature and the ball of the shoulder is unstable toward the front of the shoulder. It is this type of shoulder instability that we will concentrate on here.
In order for a shoulder to dislocate, the very important and delicate balance of soft tissues (ligaments, capsule and tendons) around the shoulder become damaged. These damaged tissues often don’t heal properly and the shoulder can develop recurrent dislocations and/or pain with certain types of activities.
The older a patient is at the time of initial injury the lower the chances are for developing recurrent instability. Patients under the age of 20 with traumatic dislocations have a substantially higher rate of recurrence (greater than 90%). It is for this reason we have become more aggressive in recent years in recommending early repair for this group of patients. We believe early repair reduces the likelihood of further injuring the shoulder with additional episodes of dislocation.
The treatment for recurrent shoulder instability is usually surgical. This surgery is aimed at repairing the damaged capsule and ligaments directly. This procedure can be done arthroscopically as an outpatient. The surgery is performed with a miniature lighted telescope and small instruments introduced into the shoulder joint through hollow cannulas. Advanced miniature anchors with suture attached are inserted precisely into the socket of the shoulder, and the torn ligaments are reattached to the socket. Complete healing from this procedure takes approximately 4-6 months.
Calcium deposits around the shoulder are a fairly common occurrence. Frequently they do not cause problems, but if they increase in size or become inflamed, then very severe pain may result. This collection of questions and answers is intended to explain this common shoulder problem and describe the methods we recommend for treatment in different situations.
In most situations, there is no known cause for calcium deposits. Many people ask if their diet should be changed to reduce calcium intake. This should never be used as a form of treatment, since a normal balanced diet with a calcium supplement up to 1000mg a day is healthy in a normal patient, particularly senior citizens and post-menopausal females.
Many calcium deposits are present for years without causing any symptoms. Only when the deposit becomes large enough to pinch between the bones when the shoulder is elevated, does it cause pain. Sometimes smaller deposits cause pain if they become acutely inflamed, especially when the calcium salts leak from the lesion into the sensitive bursal tissues.
When a calcium deposit becomes acutely inflamed, either because it ruptures and leaks calcium salts into the bursa, or because it pinches the bursa or rotator cuff, the symptoms can be quite severe. The acute inflammation can be treated with localized ice packs and rest in a sling, but oral anti-inflammatory medications are also helpful. A cortisone injection directly into the area of the calcium deposit may give relief within a few hours, when without it the acute severe pain may last for several days.
If a patient has two or three recurrent episodes of painful symptoms in the shoulder, or if the calcium deposit appears on x-ray to be enlarging, then it may be appropriate to consider arthroscopic surgery to remove it.
The top of the wing bone or scapula is the acromion. The joint formed where the acromion connects to the collarbone or clavicle is the AC joint. Usually there is a protuberance or bump in this area, which can be quite large in some people normally. This joint, like most joints in the body, has a cartilage disk or meniscus inside and the ends of the bones are covered with cartilage. A capsule holds the joint together, and the clavicle is held in the proper position by two heavy ligaments called coracoclavicular ligaments.
The AC joint is injured most often when one falls directly on the point of the shoulder. The trauma will separate the acromion away from the clavicle, causing a sprain or a true AC joint dislocation. In a mild injury, the ligaments that support the AC joint are simply stretched (Grade I), but with more severe injury, the ligaments can partially tear (Grade II) or completely tear (Grade III). In the most severe injury, the end of the clavicle protrudes beneath the skin and is visible as a prominent bump.
Most often the clinical exam will demonstrate tenderness or bruising around the top of the shoulder near the AC joint, and the suspected diagnosis can be confirmed using an x-ray, which compares the injured side with the patient’s other joint.
When a joint is first sprained, conservative treatment is certainly the best. Applying ice directly to the point of the shoulder is helpful to inhibit swelling and relieve pain. The arm can be supported with a sling that also relieves some of the weight from the shoulder. Gentle motion of the arm can be allowed to prevent stiffness, and exercise putty is very helpful to improve function of the elbow, wrist, and hand, but any attempts at vigorous shoulder mobilization early on will probably lead to more swelling and pain.
Usually surgery is reserved for those cases where there is residual pain or unacceptable deformity in the joint after several months of conservative treatment. The pain can occur with direct pressure on the joint, such as with straps from underwear or work clothing. Sometimes there will be catching, clicking, or pain with overhead activities, such as lifting, throwing, or reaching.
Finally, in some people with very thin skin and very little muscular and soft tissue padding above their shoulders, the prominent clavicle after the separation may be considered unattractive, since the shoulder can appear to be unbalanced.
Arthritis is a condition that occurs in various joints in the body, especially in the knees, hips, and spine. It can affect any joint, but the shoulder is affected infrequently. When arthritis occurs, the cartilage that covers the ends of the bones making up the joint breaks down and often flakes off into the joint. The joint becomes swollen and stiff, and the lining tissue of the joint (the synovium) becomes overgrown. Frequently, spurs will develop around the margins of the joint and can, sometimes, break off inside. The pain can vary from mild to very severe, depending upon many factors, including the severity of the disease, the type of arthritis (most are wear and tear, or degenerative arthritis, but some are caused by rheumatoid disease) and the activity level.
The shoulder joint becomes stiff, feels heavy, and fatigues easily when arthritis is present. The stiffness is usually worse in the morning, and can slowly improve with “warm up activities.” Also, grinding and catching in the shoulder is a common sign of arthritis.
Most advanced cases of arthritis can be diagnosed with an x-ray evaluation of the shoulder. Sometimes, with rheumatoid or other types of “inflammatory” arthritis, special blood tests or other evaluations are needed.
The treatment of shoulder arthritis depends on how disabling and painful the disease is. Often your doctor will refer you to a rheumatologist who specializes in treating arthritis with medications. Physical therapy, particularly hydrotherapy (swimming pool), is very soothing, and helps maintain or regain range of motion of the joint, and strengthen the surrounding muscles. If the arthritis is advanced, causing severe pain and disability, then your doctor may consider an operative procedure. Some early arthritis can be treated with arthroscopic (microsurgical) techniques. With this operation, the doctor will trim out the inflamed synovial lining tissue and remove debris and pieces of degenerated cartilage. Of course, this will not cure the arthritis, but frequently can relieve many of the symptoms, at least for a while. In severe disease, the only surgical treatment is joint replacement. This is a very good operation for pain relief and often will restore some motion, but it has its limitations. The joint surfaces are surgically replaced through a five-inch incision in the front of the shoulder, and a metal ball and plastic socket are inserted.
The hand is composed of many small bones called carpals, metacarpals and phalanges. The two bones of the lower arm — the radius and the ulna — meet at the hand to form the wrist. The median and ulnar nerves are the major nerves of the hand, running the length of the arm to transmit electrical impulses to and from the brain to create movement and sensation.
CTS is a compression neuropathy, i.e. a pinching of the median nerve within the wrist. The carpal tunnel is a bony canal within the palm side aspect of the wrist that allows for the passage of the median nerve to the hand. Pinching or compression of this nerve by the transverse carpal ligament sets into motion a progressively crippling disorder which eventually results in wrist pain, numbness and tingling in the hand, pain consisting of a “pins and needles” feeling at night, weakness in grip and a feeling of incoordination.
This disabling syndrome occurs more often in women than men, by a ratio of thee to one, usually between the ages of 30 and 50 years. Also, CTS is seen more frequently in people who tend to do forceful repetitive types of work, such as grocery store checkers, assembly line workers, meat packers, typist, accountants, writers, etc. Most patients generally visit their doctor with these complaints, and the diagnosis is confirmed after physical examination and appropriate nerve testing.
Treatment for CTS depends upon the stage of the disease. In the early stage, the syndrome can be reversible and is most often treated with appropriate modification in activities, a removable wrist brace, and antiinflammatory medicines. In moderate stages of the disorder, especially if the numbness and pain continues in the wrist and hand, a cortisone injection into the carpal tunnel can be extremely beneficial. Surgical intervention in CTS is only indicated in those patients in whom non-operative treatment has failed to eliminate their symptoms. In patients with advanced disease, and especially in those who have profound weakness or muscle atrophy, surgical intervention should be done early. CTS should not be left untreated because it can eventually cause permanent nerve damage.
This is a cartilage similar to the cartilage in the knee that is often torn and does not have an adequate blood supply to it. The reason it is causing discomfort is usually there is a flap of tissue that is flapping back and forth and causes irritation of the joint.
For this problem, there are three modes of treatment – no treatment, conservative, and surgical.
Conservative treatment would consist of resting the wrist in a wrist brace or a cortisone injection. Usually, antiinflammatory medications and physical therapy are not beneficial.
If there is persistent pain despite conservative treatment, arthroscopic surgery with debridement of the tear to give the tear smooth edges is usually very successful. This can be performed under local anesthesia on an outpatient basis with two or three small incisions on the wrist. Occasionally, the cartilage can be repaired.
This is the most common location for arthritis in the hand due to wear and tear with use of the thumb throughout the patient’s years.
There is no cure for arthritis but there is treatment falling into three categories; no treatment, conservative, and surgery. Surgery as the last resort, when conservative treatment has failed, consists of a joint replacement using the patient’s normal body tissues and involves excising the arthritic bone and replacing it with a tendon taken from the wrist which is rolled up into a ball and used as a spacer and a portion of it is used to reconstruct the ligament. This is done through a small incision at the base of the thumb and a smaller incision at the base of the wrist to harvest the tendon used for the graft. It is an outpatient procedure performed under an axillary block where only the arm goes to sleep. The patient is immobilized in a splint for two weeks, then a thumb spica cast for two weeks and then uses a removable custom-made splint for two months while they are undergoing therapy for their thumb. The first month is to regain range of motion and the second month to regain strength. This concludes a three-month postoperative rehabilitation protocol. Patients have a very good success rate with this surgery.
Before surgery is considered, conservative treatment is attempted which is aimed at alleviating the symptoms of arthritis. This consists of a splint, possible anti-inflammatory medications, possible icing, and occasionally a cortisone injection which usually provides good but temporary relief.
Dupuytren’s disease is a genetically inherited disorder that primarily involves the palmar aponeourosis and its digital prolongations. The primary pathological change is in the fascial tissues of the palm, which results in thickening, cord-like formation of contractile bands, and then eventual contractures at the level of the interphalangeal joints. On occasion, it can be associated with other diseases such as diabetes, epilepsy or alcoholism.
Certain contributing factors increase the likelihood of significant progression. These include a strong family history, early onset of disease, rather extensive bilateral involvement, and the presence of disease in other areas such as the plantar regions of the feet. These contributing factors may lead to a more aggressive course of the disease and possibly even an operation at an earlier age.\
The disease appears to be slightly different in women than men, has a tendency to usually appear between the ages of 40 and 60, is seen much more frequently in men than in women, has over a 65% chance of being bilateral, and can involve other areas such as the foot, the dorsum of the hand, and other fibrous tissues. It is a slowly progressive disorder that may have periods of temporary arrest, or even a rapid progression. After the nodules have formed, the tendency is for these to coalesce into a cord, which will lead to a flexion contracture at the MCP joints and the PIP joints. The disease can infiltrate the skin itself.
Initial treatment is always non-surgical. This would consist of continued observation for progression of the problem. As the disease does not involve any pain, there is no reason for the excision of the nodules or cords until contractures in digits have occurred. If a contracture becomes bothersome or a nodule becomes painful, or if the contracture in the MCPJ exceeds 30 degrees or any involvement at the PIP joint occurs, we would recommend surgical excision. This would consist of a palmar and digital fasciectomy utilizing an axillary block anesthetic. A skin graft taken from the forearm is almost always used. Long-term results are usually quite good. If contractures have developed at the MCPJ and PIP joint, they can usually be corrected to within half of the preoperative level. Recurrence of the disease is possible, but this is usually not associated with further contracture necessitating surgery.
The problem is a swelling of the tendon sheath around the tendons passing along the distal radial aspect of the wrist. This sheath runs through a tight tunnel holding the tendon down to bone and this swollen sheath passing through a tight tunnel results in significant pain. For this problem there are three modes of treatment, not treatment, conservative treatment and surgery.
As a last resort, when conservative treatment has failed, surgical decompression of the tendon by opening up the pulley can be performed as an outpatient procedure under local anesthesia with a small incision. This has a good success rate.
Conservative treatment consists of modification of activities, use of a thumb brace and occasional icing and then possible use of anti-inflammatory medications. If the pain still persists despite the above treatment a cortisone injection can be helpful. No more than three cortisone injections are recommended per year in any one location.
This is a hyperextension injury that is essentially a ligamentous injury, although it may involve a portion of bone avulsed off by a ligament. It usually involves a piece of bone avulsed off the base of the middle phalanx by the volar plate, which is usually not significantly displaced and usually will heal without problem. It also usually involves a collateral ligament tear which heals without problem but often heals with abundant scar tissue leading to an appearance of chronic swelling on one side of the joint, which is permanent.
No more than a few days of immobilization is necessary and is important to work on obtaining full range of motion of the joint. The middle joint of the fingers is the worst with regards to stiffness and early range of motion is very important. Range of motion exercises may be explained to the patient or therapy with a hand therapist may be necessary. “Buddy taping” of the fingers after the initial few days of immobilization is all that is necessary for finger support. At first, “buddy taping” will be necessary all the time, gradually progressing to “buddy taping” only with exertive or sporting activities with affected hand. If motion is begun early, full range of motion can be expected. For those who have been immobilized longer, permanent stiffness may result. Rarely, with severe stiffness, surgical release of the scarred tendons and joint capsule may be necessary. Also rarely, instability may result which may require reconstructive surgery. Most patients do extremely well, being able to progress to painless activity with full function, with minimal abnormal appearance.
The elbow is a hinge joint made up of the humerus, ulna, and radius.
The unique positioning and interaction of the bones in the joint allow for a small amount of rotation as well as hinge action. This rotation is easily noticed during activities such as hand-to-mouth eating motions. The primary stability of the elbow is provided by the ulnar collateral ligament, on the medial (inner) side of the elbow.
However, one of the most common injuries to the elbow occurs on the lateral, or outer, side of the elbow — it is called “lateral epicondylitis” or “tennis elbow.”
Tennis elbow, or lateral epicondylitis, is one of the most common elbow problems seen by an orthopedic surgeon. It is actually a tendinitis of the muscle called the extensor carpi radialis brevis, which attaches to the lateral epicondyle of the humerus.
It may be caused by a sudden injury or by repetitive use of the arm. Many doctors feel that micro tears in the tendon lead to a hyper-vascular phenomenon resulting in pain. The pain is usually worse with strong gripping with the elbow in an extended position, as in a tennis back hand stroke, but this problem can occur in golf and other sports as well as with repetitive use of tools.
Before surgery is considered a trial of at least six months of conservative treatment is indicated and may consists of rest, application of a brace or splint, anti-inflammatory medications, and/or modification of elbow activities. If the above treatment is not helpful, a cortisone injection can be beneficial but no more than three injections are recommended in any one location in a year.
Conservative treatment is in two phases and after Phase I (Pain relief) has been successful, Phase II, (Prevention of recurrence) is equally as important and involves stretching and then later strengthening exercises, so the micro tears will not occur in the future.
When conservative treatment has failed, then surgery is indicated. Many procedures have been described. Procedures as simple as percutaneous release of the tendon off of the bone have been described and more recently arthroscopic procedures or other procedures involving the joint and resection of a ligament as well have been described.
The most popular procedure today is a simple excision of diseased tissue from within the tendon, shaving down the bone and re-attachment of the tendon. This can be performed as an outpatient procedure with regional anesthesia (where only the arm goes to sleep) and through a relatively small incision of approximately 3″ long. 85-90% of patients with this technique are typically able to perform full activities without pain after a recuperation of two to three months. Approximately 10-12% of patients have improvement but with some pain during aggressive activities and only 2-3% of patients have no improvement.
Cubital tunnel syndrome is a pinched nerve at the elbow commonly known as the “funny bone.” This might be caused by trauma or repetitive use of the elbow and may be caused by continuous use of the elbow in a flexed position. This causes the nerve to become stretched and irritated as opposed to when the arm is extended and the nerve is in a relaxed position. The diagnosis can be confirmed with electrodiagnostic testing including nerve conduction velocity and the electromyogram. Nerve conduction velocity studies, the speed of the nerve across the elbow, will be slowed when there is nerve compression and electromyogram studies, the innervation of the muscles, might be affected by the pinched nerve.
For this problem there are three modes of treatment – no treatment, conservative and surgical. Unfortunately with conservative treatment, only splinting with the arm in an extended position has been found to be helpful. Cortisone injection, physical therapy, and anti-inflammatory medications, have not been seen as beneficial. Nighttime splinting is achieved with a custom made long arm splint that the patient will wear at nighttime and as often as possible during the day. Unfortunately it is cumbersome to keep the arm out straight all the time and therefore this is usually used only at night. If the patient has persistent complaints despite conservative treatment surgery would be recommended. There are three types of procedures, one is to cut the medial epicondyle which is the bone pinching the nerve or the other two operations are to actually move the nerve out of the cubital tunnel either above or below the muscles of the forearm. This can be performed as an outpatient procedure with an axillary block where only the arm is put to sleep and it has a high success rate.
Hip impingement is when there is abnormal contact between the femur and acetabulum during normal movements of the hip joint. This can be caused by a femoral head that is not perfectly round (Cam type impingement) or an acetabulum that is too deep (Pincer type impingement). Often both the head and the socket have slight abnormalities. This is called mixed-type impingement.
In general, young athletes involved in sports that require forceful and repetitive hip movements are at the greatest risk of hip impingement. However, patients of all ages can have hip impingement depending on their anatomy and activities.
Like most orthopedic conditions, a trial of rest, activity modification, and anti-inflammatory medication is recommended. Guided rehabilitation with an experienced therapist can often quiet down and eliminate many symptoms of hip impingement. Changes in body mechanics and flexibility can be extremely helpful. If conservative treatment is not helpful and your hip pain continues to interfere with your day-to-day activities, surgery may be recommended.
The hip abductor is a group of muscles, similar to the rotator cuff in the shoulder, that allow the pelvis to remain level with the ground as we walk. It also helps stabilize the hip joint during movement, and is extremely important in the normal movement and functioning of the hip joint.
Most abductor tears occur through overused and chronic inflammation and tendonitis of the abductor tendon. On rare occasion, a fall or traumatic even can case an acute hip abductor tear or injury.
Pain over the lateral (outside) side of the hip that is worse with weight bearing and walking is typical. The pain can be worsened with pressure over the area.
Most cases of abductor tears are mistaken as bursitis over the “trochanter” – the bony part of the hip that you can feel on the outside of your hip. The only way to identify an abductor tear is with an MRI; however, it is important to get plain xrays first to evaluate for arthritis and other abnormalities of the hip.
Depending on the sized of the tear, it can be repaired arthroscopically through 2-3 small (1cm) incisions, or, if warranted, through an open incision over the hip. The tear is identified and it is fixed back to bone using specialized suturing tools and suture anchors.
Recovery can be prolonged after an abductor tear, and most patients will require the use of an abductor brace (large brace over the thigh and pelvis) for the first 4-6 weeks. Return to most activities can be expected by 6 months.
When conservative treatments fail to help with your hip arthritis, fracture, or other injury to the area you may be a candidate for a total hip replacement depending on certain risk factors like age and health condition.
In a total hip replacement, the surgeon removes the damaged bone and cartilage and replaces the femoral head with a prosthetic implant.
The bones of the knee, the femur and the tibia, meet to form a hinge joint. The joint is protected in front by the patella (kneecap). The joint is cushioned by articular cartilage that covers the ends of the tibia and femur, as well as the underside of the patella. The lateral meniscus and medial meniscus are pads of cartilage that further cushion the joint, acting as shock absorbers between the bones.
Ligaments help to stabilize the knee. The collateral ligaments run along the sides of the knee and limit sideways motion. The anterior cruciate ligament, or ACL, connects the tibia to the femur at the center of the knee. Its function is to limit rotation and forward motion of the tibia. The medial collateral ligament, or MCL, connects the top of the tibia to the bottom of the femur. It is located on the inner part of the knee and functions to limit side to side movement. The posterior cruciate ligament, or PCL (located just behind the ACL) limits backward motion of the tibia.
These components of your knee, along with the muscles of your leg, work together to manage the stress your knee receives as you walk, run and jump.
The Anterior Cruciate Ligament (ACL) is a ligament in the center of your knee that becomes damaged when twisted too far, such as in a skiing injury. ACL reconstruction is performed using a combination of open surgery and arthroscopic surgery.
Before the ACL reconstruction process begins, your surgeon will examine your knee arthroscopically, and repair any additional damage to the knee, such as a torn meniscus, or worn articular cartilage.
Reconstruction of the ACL begins with a small incision in your leg where small tunnels are drilled in the bone.
Next your new ACL is brought through these tunnels, and then secured with a staple and buckle system.
As healing occurs, the bone tunnels fill in to secure the tendon.
Arthritis of the knees can be mechanical (osteoarthritis) in which the surfaces of the knee gradually “wear out.” This may be due to age, angular deformity or old fractures. Systemic arthritis such as rheumatoid arthritis or gout affects the synovium (the membrane tissue in the joint that normally lubricates the joint), becomes pathologic and the surface of the joint is destroyed.
In either case when the surface of the joint is worn away, at a certain point in time walking and activities of daily living become very difficult. Standardized treatment such as weight loss, anti-inflammatory medication, braces, orthotics, steroid injections, physical therapy, etc. are all forms of non-surgical treatment.
In many cases, however, despite the above non-surgical treatments, functional limitations persist. Most people who are considering knee replacement are limited to walking less than three to six blocks, or less than 15 to 20 minutes. They have a difficult time getting up out of a chair. They have pain even while resting. They are taking anti-inflammatory medication and/or pain medicine on a regular basis and the pain is generally progressive.
It is important to realize that a knee “replacement” is actually just a “resurfacing” of the knee joint. The femur or thigh bone is covered with a metal covering and plastic is placed on the tibia so that instead of irregular arthritic surfaces, one has metal and plastic articulating which produces a smooth non-patent surface. In most cases the under-surface of the kneecap is also replaced with a plastic surface so that this articulates with the femoral surface.
Knee replacements have been done since the early 1970s and our most recent designs appear to have 85% to 90% survival at twenty years.
The actual procedure involving knee replacement involves either general or epidural anesthesia with a one to three day hospitalization. The surgery itself takes between 1-1/2 and 2-1/2 hours. In most cases patients donate two units of autologous blood to be used in the postoperative period. Weight-bearing begins immediately the first postoperative day. Patients usually use a walker for a period of one to two weeks, going to crutches and then a cane. People are off all walking aids anywhere from three weeks to two months.
Success rates in knee replacements are approximately 90% with 10% not doing as well. This can be due to either stiffness or ache or swelling in and about the knee. The most significant complications, aside from general medical complications (heart and lung) involve infection of the prosthesis. If this occurs, in some cases the prosthesis can be saved and the patient taken back to the operating room, the knee irrigated with antibiotic irrigation and then be on antibiotics. In some cases if this does not respond, then the entire prosthesis must be taken out and antibodies given for six weeks and then another attempt at re-implantation of the of the prosthesis must occur. In an extremely small percentage of cases, conceivably if the infection could not be controlled, then one is left a knee fusion in which the femur and tibia are fused in one bone.
Activities after knee replacement that should produce no difficulty are simple walking, bicycling, golfing, and swimming. The prosthesis is not designed form impact loading sports such as skiing, basketball, or racquetball.
Normal knee function requires a smooth gliding articular cartilage surface on the ends of the bones. This surface is composed of a thin layer of slippery, tough tissue called hyaline cartilage. This cartilage also acts to distribute force during repetitive pounding-like movements such as jumping or running.
A severe knee cartilage injury can radically change an active adult’s lifestyle. Symptoms such as locking, catching localized pain and swelling often affect your ability to work, play, and even perform normal activities.
A cartilage lesion appears as a hole or divot in the cartilage surface. Since cartilage has minimal ability to repair itself, even shat may seem like a small lesion (ranging from the size of a dime to a quarter), if left untreated, can hinder your ability to move free from pain, and cause deterioration to the joint surface.
The true ankle joint is composed of three bones: the tibia which forms the inside, or medial, portion of the ankle; the fibula which forms the lateral, or outside portion of the ankle; and the talus underneath. The true ankle joint is responsible for up and down motion of the foot.
Beneath the true ankle joint is the second part of the ankle, the subtalar joint, which consists of the talus on top and calcaneus on the bottom. The subtalar joint allows side-to-side motion of the foot.
The ends of the bones in these joints are covered by articular cartilage. The major ligaments of the ankle are: the anterior tibiofibular ligament, which connects the tibia to the fibula; the lateral collateral ligaments, which attach the fibula to the calcaneus and gives the ankle lateral stability; and, on the medial side of the ankle, the deltoid ligaments, which connect the tibia to the talus and calcaneus and provide medial stability.
These components of your ankle, along with the muscles and tendons of your lower leg, work together to handle the stress your ankle receives as you walk, run and jump.
Plantar fasciitis is a condition defined by inflammation of the plantar fascia – a thick tissue that connects between the heel bone, across the bottom of the feet and to the toes. Healthy plantar fascia tissues absorb shock in the arch of the foot. But tension on the tissues can cause tearing, leading to inflammation. This inflammation usually causes throbbing pain in or near the heel.
People with plantar fasciitis often complain of heel pain – especially pain that is worse in the morning after waking or after sitting or standing for long periods of time. If you have a recurring stabbing pain in or near your heel, contact our office to schedule a consultation. Your surgeon can diagnose plantar fasciitis with a simple exam and imaging tests.
Your surgeon may recommend one or more of many different treatments for plantar fasciitis, depending on its severity. Often, treatment is conservative and may include stretching, physical therapy, and the use of foot orthotics. In most cases, pain is manageable using an over-the-counter anti-inflammatory, though your doctor may recommend steroid injections for the relief of severe pain.
Few people need to undergo surgery to treat plantar fasciitis. However, it is an option for patients with severe heel pain that has not responded to more conservative treatment measures, please ask your surgeon for more information regarding this.
The heel is the largest bone in the foot and responsible for bearing the weight of the entire body. Many people develop heel pain at some point in their lives, whether on the underside or back of the heel. In most cases, heel pain is not a symptom of a serious underlying health condition. However, it can affect a person’s quality of life, including the ability to stand, walk or exercise without discomfort.
Heel pain can be caused by many different conditions, some more common than others. Often, patients who visit a doctor for heel pain are suffering from Achilles tendonitis or plantar fasciitis. However, other conditions can also cause heel pain, including bone fractures, excessive pronation, gout, bursitis, fibromyalgia, arthritis, and peripheral neuropathy.
You should see a doctor for heel pain that persists for several weeks despite efforts to rest, ice, and elevate your feet at home. You should also contact your doctor about heel pain that continues when you are not standing or pain that is severe and occurs with swelling.
Your doctor will examine your foot and may use diagnostic imaging to determine the cause of your heel pain. Depending on your diagnosis, you may be instructed to rest the heel, wear different shoes, use foot orthotics, or undergo physical therapy. In some cases, patients require additional interventions, such as surgery.
Hammertoe is easily identified by the abnormal bend it causes in one or more toes. The bent is found in the middle joint and usually affects the toe closest to the big toe. The symptoms are very similar to mallet toe, which instead causes an abnormal bend in the joint closest to the nailed. A Hammertoe may cause skin irritation, corns and calluses, as well as chronic pain.
Schedule an appointment with us if hammertoe is making you uncomfortable or affecting your ability to walk. It is important to seek treatment while the toe is still flexible and more easily treated. Left untreated, hammertoe may progress to a permanent condition that requires more extensive treatment.
Treatment for hammertoe may include the use of foot orthotics and/or devices, as well as physical therapy exercises that strengthen and elongate the affected toe. When conservative treatment measures are ineffective, patients may require surgical intervention to treat hammertoe.
Arthritis is a common, yet painful disease that causes joint inflammation in the body. Though it can affect any joint, many people have arthritis of the foot and ankle, where tiny joints are responsible for supporting the body’s weight and absorbing shock. Arthritis causes the joints to swell and become inflamed, leading to severe pain. Often, a person with advanced stages of arthritis will experience sensations of bone rubbing on bone as the cartilage deteriorates resulting in bone spurs.
A person with foot and ankle arthritis will have varying degrees of symptoms depending on how advanced the disease is. However, this condition typically causes stiffness and pain when walking or standing, as well as tenderness when pressure is applied to the joints. The joint may also swell or become warm to the touch, and in many cases, it is worse in the mornings or when participating in vigorous activity.
There are many different ways of treating foot and ankle arthritis. Though there is no cure, the focus is often on symptom management and slowing the progression of the disease. At our office, we emphasize a non-surgical and minimally invasive approach, which may include lifestyle modifications, orthotics, and the use of advanced and alternative therapies. For more information about foot and ankle arthritis treatment, contact our office to schedule a consultation. For recalcitrant cases, surgery may be indicated, which includes fusion and in some cases, total ankle replacement. Please consult with us for more information.
Flatfeet is a condition defined by the lack of an arch on the inside of the feet. Instead, the foot is flat and touches the floor entirely while standing. Often, the condition causes no symptoms, allowing most people with flatfeet to live normal, pain-free lives. However, some people have pain or discomfort associated with flatfeet and may experience knee or ankle complications as a result of the condition due to degeneration of the tendon that primarily supports the arch of the foot.
Adults can identify flatfeet by a lack of arch on the inside of the feet. In children, the condition is less obvious, as arches normally develop over time during childhood. In fact, it is normal for infants and toddlers to have flatfeet. Many parents notice flatfeet by ages three to five if the arches have not begun to develop yet.
Many people with flatfeet live their lives symptom-free and without complications. However, you should see your doctor about flatfeet or fallen arches if you have swelling, foot pain, ankle pain or knee pain related to flatfeet.
A doctor may visually examine your foot for flat arches and order imaging tests to determine the underlying cause of the condition. Initially, foot orthotics and/or devices and physical therapy may be helpful for alleviating symptoms associated with the condition. However, some patients require surgery for flatfeet – especially if the condition is caused by a degenerative or ruptured tendon (Posterior Tibial Tendon Dysfunction).
Bunions are bone deformations that form on the foot where it joins the big toe. They develop over time, gradually getting bigger and sticking out from the rest of the foot. Bunions are caused by a combination of genetic and lifestyle factors, with many people predisposed to developing them due to a weakened foot structure. Others get bunions because of chronic stress on the big toe or a chronic condition like arthritis.
Bunions are easily identified by the large, protruding bump they cause at the base of the big toe. Usually, the big toe begins to angle away from the body, potentially leading to redness, soreness and swelling. The skin may also become thickened and develop calluses.
Many people live with bunions for years without any problems. However, they may lead to complications, such as ‘hammertoe’ or ‘bursitis’ if left untreated. Schedule an appointment to meet with an orthopedic surgeon if your bunions are worsening, causing chronic toe or foot pain, or if they are limiting your mobility. You may also wish to consult with a doctor about bunion treatment if your bunions are a source of embarrassment or affecting your ability to find shoes that fit.
Not everyone who has bunions requires treatment. However, your orthopedic surgeon may recommend addressing the symptoms of bunions by first changing shoes or using foot orthotics that support the big toe in a ‘normal’ position. Steroid injections or over-the-counter medications may also be used to reduce inflammation and temporarily manage pain. In some cases, surgery may be necessary to relieve pain and restore the toe’s natural position.
Bunions are a deformity in the mechanical structure of the foot. They form as bony structures at the base of the big toe. Bunions are often caused by a combination of weak foot structure and years of wearing poorly fitting or tight shoes, though they may also develop as a result of arthritis. An estimated 23 percent of adults under age 65 and 36 percent of adults over age 65 have bunions. Many live with them complication-free, while others experience pain associated with the condition. Though conservative treatments are often effective for reducing bunion discomfort, some people require surgery to gain relief.
Bunion surgery is not for everyone. We recommend first trying more conservative treatments, such as alternative footwear, before undergoing surgery to correct bunions. If conservative treatments fail, talk to your surgeon about whether surgery could be right for you.
You will be sedated and anesthetized for the duration of the procedure. Incisions are made around the surgical site, through which your doctor may cut the deformed bone and realign it with the rest of the foot. Since bunion surgery is typically an outpatient procedure, most patients can go home the same day as the operation.
Recovery from bunion surgery takes time. The initial 6 weeks after surgery are the time when patients must be most restrictive with activity. It is important to avoid putting too much weight on the treated foot and refrain from all high impact activities. Gradually, your surgeon will release you to begin increasing your activity levels over a period of several months. Keep in mind that recovery from bunion surgery may affect your ability to drive, work or bathe in the first several weeks post-op. It may help to arrange assistance with the activities you are limited in. Talk to your employer about how much time you can take off for recovery and whether you can use crutches or a motorized scooter at work.
It is normal to experience discomfort following a bunion operation. However, your surgeon may provide you with medications to help control pain while you heal. For more information about pain management after bunion surgery, contact our office or visit our surgery information page.
The ankles are complicated joints comprised of several different bones, tendons and ligaments. Together, these components facilitate movement and bear the weight of the entire body. However, ankles are also prone to conditions that cause pain and discomfort. In many cases, ankle pain goes away on its own – especially when it is the result of a minor injury. But sometimes medical intervention is necessary to relieve discomfort and restore mobility.
Ankle pain may be caused by one of many different conditions. Examples include arthritis, sprains, gout, bone spurs, tendonitis, and fractures. Ankle pain may also be caused by a condition known as ‘flatfeet’, in which the feet are missing arches.
You should see a doctor for any ankle pain that is severe or correlated with swelling. It is also important to schedule an appointment with your doctor if ankle pain persists for several weeks despite home treatment. For more information about ankle pain and when to seek treatment, contact our office today.
Treatment for ankle pain depends on the cause of the symptoms. A foot examination and diagnostic imaging can reveal underlying injuries and conditions responsible for your discomfort. Depending on your diagnosis, treatment may include physical therapy, rest, compression, or the use of foot orthotics. In some cases, patients may require surgery or other treatments to find relief from ankle pain.
At our office, limb preservation is of utmost importance when it comes to the care of our patients. Some of our patients – particularly those with diabetes – may be at risk for foot or leg amputation. Before amputating a foot or lower leg, we take every measure possible to salvage the limb and preserve its health. Our goal is to use advanced treatments and state-of-the-art surgical techniques to provide premium care for the conditions most often responsible for amputation.
There are several reasons why a leg or foot may need to be amputated, some of which include infections, wounds that will not heal, and peripheral artery disease.
What types of treatments are available to help salvage and preserve legs and feet?
Our team is highly skilled and trained in limb preservation. We employ many different treatments, some of which include:
The conditions that most commonly raise the risk of amputation are often asymptomatic or otherwise minimally perceptible to patients who may have lost sensation in their feet and legs. That is why everyone with a predisposition to potential foot health complications should undergo regular doctor check-ups and seek medical attention right away at the first sign of an abnormality.
Diabetes is a disease that affects multiple areas of the body – including the feet. Foot care should be an important part of every diabetic’s plan for preventing complications of high blood sugar. Approximately 70 percent of people with diabetes develop circulatory problems and peripheral nerve damage. Together, these conditions can lead to wounds that do not heal, resulting in infection and in some cases, the need for amputation. In fact, diabetic nerve damage (peripheral neuropathy) is a leading cause of foot and leg amputation in the United States.
Diabetic foot care is for anyone who has been diagnosed with diabetes, regardless of whether he or she has also been diagnosed with peripheral neuropathy. According The Diabetes Association, all diabetics need an annual foot exam. Those with peripheral neuropathy or other foot problems should undergo foot exams on a more frequent basis.
Your doctor will evaluate your foot circulation and sensitivity during each exam. You will also be checked for changes to your skin or any wounds on your feet. If you are experiencing discomfort caused by peripheral neuropathy, your doctor may be able to prescribe medication to reduce tingling, burning, or pins-and-needles sensations in your feet.
Can my doctor help me prevent diabetic foot complications?
Patient education and prevention are the foundations of our practice. Our team can provide you with helpful tips to reduce the risk of foot complications, such as keeping your feet clean and trimming your toenails straight across. We may also prescribe special shoes to protect your feet from developing sores
Charcot foot is a condition in which the bones and joints of the foot are weakened, resulting in deformity over time. The condition is progressive and may occur more rapidly in people who are overweight or obese. As the foot becomes increasingly misshapen, a Charcot foot can lead to severe disability, and in some cases, amputation. A person with the symptoms of Charcot foot should seek medical attention as soon as possible. Early diagnosis and treatment can lead to more successful outcomes than patients with advanced deformity. For some patients, reconstruction of a Charcot foot can help strengthen the bones and prevent more extreme treatments, such as amputation.
A person with Charcot foot may have a swollen or red foot that feels warm to the touch. This is often accompanied by pain or soreness, though people with neuropathy may not experience these sensations. Charcot foot causes deformity, fallen arches and in some cases, a foot that resembles the bottom of a rocking chair. Feet may also become weakened to the point of bone fracture.
Charcot foot reconstruction involves the use of an externally and/or internally fixed framework that secures bones of the foot in place. The external devices remains in place for a few months while the bones heal. After that time, the vast majority of people who have had a Charcot reconstructive surgery can regain walking independence and mobility. Ultimately, a successful Charcot reconstruction can prevent amputation, improve quality of life and even extend the longevity of a patient.
External fixation is a minimally invasive surgical procedure that has a high rate of success with a measurably low risk of complication. The procedure takes less time than internal fixation methods, and it requires smaller incisions. Furthermore, a surgeon can monitor the soft tissue healing process of a foot that has undergone external fixation Charcot reconstruction.
An athlete’s feet are under a lot of stress, making them especially susceptible to injury. When athletes push their bodies to perform, they put pressure on the feet. From training to competing, people who actively participate in athletic activity are constantly putting themselves at risk for injury. At our office, we aim to treat sports foot & ankle injuries as quickly and efficiently as possible, helping athletes to recover and return to their usual activities in as little time as possible.
Athletes can injure any part of their feet though certain types of injuries are more prevalent than others. Examples include:
Some sports-related foot injuries are obvious and occur suddenly. Others may develop gradually over time, progressively affecting your ability to train or compete comfortable and effectively. Signs of a sports-related foot injury include pain and swelling, as well as problems with mobility. If you notice any of these symptoms or have difficulty applying pressure to your foot or ankle, contact our office for an examination.
Sports foot injury treatment depends on how the injury is affecting the bones, joints and soft tissues. In many cases, treatments are non-invasive. This may include immobilization or the use of foot orthotic devices. Some people may benefit from anti-inflammatory treatments and in rare cases, surgical intervention. It is important that you facilitate recovery by allowing plenty of time for your injury to heal. Returning to sports too soon may worsen foot traumas, leading to an even longer treatment and recovery process.
The feet and ankles play a primary role in the support and mobility of a person’s body. Injuries to the feet or ankles can be debilitating and dramatically affect one’s ability to perform otherwise simple day-to-day tasks. At our office, we help our patients through the entire rehabilitative process. Our goal is to pinpoint the source of foot and ankle traumas, such as fractures and sprains, and see them through to recovery.
Pain and swelling are the most obvious signs of foot or ankle trauma. If you have fractured your foot, it is likely that you will experience some pain and swelling, as well as some bruising. Depending on the extent of the fracture and where it is located, you may be able to walk or limp, though doing so may worsen the pain. If you break your ankle, the pain will be sudden and severe, preventing you from putting any weight on the affected ankle. You may also notice a visible dislocation or deformity, as well as some swelling and bruising.
Treatment for an injury depends on the type and extent of the injury. The first step is always to rest the injury and apply ice while keeping it elevated until you can see a doctor. Some foot and ankle injuries require surgery, whereas others may only require a cast or compression. All foot and ankle injuries require a period of rest, during which time a patient must refrain from applying pressure to the affected foot or engaging in strenuous activity, such as exercise or sports. Rehabilitation may be necessary for injuries that have caused a tightening or inflammation of the muscles and ligaments.
It is impossible to prevent all foot and ankle traumas, but there are preventative measures you can take to avoid an injury. Start by wearing supportive and well-fitting shoes on a daily basis. Many people wear supportive shoes when exercising, but change into dangerous pumps or flip-flops for daily wear. It is just as possible to sustain a broken foot after tripping in high heels as it is to during a workout. Stretching and proper training are also important for preventing foot and ankle injuries. Talk to your surgeon before starting a new workout regimen or activity – especially if you have been inactive for a while. An exam can reveal whether your feet are healthy enough for activity.
The tendons are special tissues that connect the bones to the muscles. When tendons are put under repetitive stress or suffer a direct injury, they may become inflamed or begin to break down. This can lead to pain and limited mobility in the affected area. Tendonitis can affect nearly any tendon in the body, including the knees, elbow, hips and shoulder.
You may have tendonitis if you experience sudden and severe pain near a tendon caused by an injury. Tendonitis may often cause gradual pain that worsens over time – perhaps due to repetitive motions. Tendonitis in the shoulder may cause a loss of motion, which is also referred to as ‘frozen shoulder’.
If you think you may have developed tendonitis, administer immediate treatment using the acronym, ‘RICE’, which stands for rest, ice, compression and elevation. Then, contact your doctor to schedule an appointment.
Not all people with tendonitis require medical treatment. However, those who do may benefit from steroid injections, which help reduce inflammation and temporarily relieve pain. Physical therapy may also be beneficial for restoring lost mobility and range of motion. Tendonitis may persist for many weeks before fully improving. In rare cases, surgery may be required, but only when symptoms have not responded to more conservative treatments.
The Queen’s Health Systems
1301 Punchbowl Street
Honolulu, Hawaii 96813
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