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Lumbar Canal Stenosis

Management Team

Lumbar Canal Stenosis

Overview

Lumbar canal stenosis is the narrowing of the spinal canal in the lumbar region (lower back) causing compression of the spinal cord and nerve roots. It is caused by age-related degeneration of the spine, disc herniation, ligamentum flavum hypertrophy, rheumatoid arthritis, tumours of the spine and spinal cord, and fractures.

  • Pain in the lower back with or without radiation to the lower limbs that increases on standing or walking (claudication) and is relieved by resting.
  • Stiffness leads to decreased mobility in the lower back muscles.
  • Weakness in the lower limbs, and bowel and bladder problems in the advanced stage of the disease.

  • Taking a thorough medical history.
  • Palpation of the lower back to identify the impacted region.
  • Tests, such as straight leg raising tests and nerve compression signs.
  • Assessment of movements and neurological examination.
  • X-rays: To assess the disc space, degenerative (wear and tear) changes, fractures, or loss of curvatures.
  • Magnetic resonance imaging (MRI): To assess the canal size, disc condition, and nerve compression.
  • Nerve conduction velocity and electromyographical studies: To assess the nerve roots and involvement of the muscles.

Non-surgical treatment

  • Non-steroidal anti-inflammatory medications
  • Rest
  • Ice pack application
  • Physical therapy to strengthen the core and paraspinal muscles
  • Steroid injections

Surgical treatment

Spine surgery is usually advised for patients in whom the non-surgical line of management failed and the neurological symptoms worsened.

  • Decompression: This involves surgically releasing the pressure on the affected nerve roots by making small openings in the bone.
  • Decompression and fusion: This involves releasing the compression on the nerve and addressing the bony instability using screws and rods.

Spine rehabilitation services are recommended for rapid recovery in patients undergoing surgery.

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Limb Length Discrepancy

Management Team

Limb Length Discrepancy

Overview

Limb length discrepancy (LLD) refers to a condition where one limb is shorter than the other.

Congenital (since birth) conditions like:

  • Femoral deficiency (loss of the thigh bone)
  • Hip dislocation and genetic conditions like Down’s syndrome or Turner’s syndrome

Acquired conditions like:

  • Injuries to the limb growth plate
  • Bone infection
  • Post-traumatic malunion and tumours
  • Muscle weakness or contractures and joint contractures 

  • Uneven walking pattern
  • Limping
  • Difficulty in balance and coordination
  • Backpain

  • Measurement of true limb length, pelvic tilt, and shoulder drop.
  • Observation of the walking pattern.
  • X-ray of both lower limbs that should include pelvis and ankle joint.
  • Computed tomography to assess the bony involvement or childhood bone disorder
  • Magnetic resonance imaging (MRI) to assess the soft tissues around the bones and joint.

Non-surgical treatment

  • Observation in patients with a discrepancy of less than 2 cm.
  • Orthotic devices like heel raises, shoe lifts, and extension prostheses.

Surgical treatment

Available surgical approaches for limb deformity correction are as follows:

  • Epiphysiodesis: This involves putting plates or screws to restrict the growth either on one or both sides of a particular bone.
  • Osteotomy: This involves lengthening or shortening the bone surgically based on the indication and requirement.
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Knee Cartilage Damage

Management Team

Knee Cartilage Damage

Overview

Cartilage is a tough, flexible connective tissue that acts as a cushion between joints. It reduces friction while supporting weight. Knee cartilage damage can result in knee joint pain, stiffness, and inflammation. In severe cases, a piece of cartilage may even break off.

  • Elastic cartilage: Found in the ears and nose, known for its flexibility.
  • Fibrocartilage: The toughest type, found in spinal discs and the hip and pelvis.
  • Hyaline cartilage: Springy and tough, found in the ribs, windpipe, and joints.

  • Knee swelling, warmth, tenderness, and pain.
  • Knee stiffness and limited range of motion.
  • In severe cases where a piece of cartilage may break off, the knee joint may lock and bleed (hemarthrosis).

  • Falls, accidents, or sports.
  • Chronic joint stress, especially in obese individuals or individuals with osteoarthritis.
  • Prolonged inactivity increases the risk of cartilage damage.

  • Physical examination for initial assessment by a clinician.
  • Magnetic resonance imaging (MRI) to identify the extent of cartilage damage.
  • Arthroscopy procedures: inserting a tube-like instrument into the joint for examination and repair.

Non-surgical treatment

  • Exercise and advanced physiotherapy techniques for strengthening the joints
  • Non-steroidal anti-inflammatory drugs (NSAIDs) and sometimes, steroid injections to alleviate pain and inflammation
  • Awareness regarding injury prevention can also help patients adopt a healthy, low-risk lifestyle.

Surgical treatment

  • Surgical treatment depends on the severity and specifics of the damage and includes:
  • Debridement
  • Marrow stimulation
  • Mosaicplasty
  • Autologous chondrocyte implantation

Furthermore, in recent years, several advanced surgical options, such as partial knee replacement, total knee replacement, knee implant technology, robotic-assisted surgery, knee joint replacement, and advanced knee surgery, have become available, which are associated with rapid recovery and improved outcomes for patients with damaged knee cartilage.

If left untreated, cartilage damage can lead to severe joint impairment and chronic pain, potentially resulting in conditions like osteoarthritis.

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Knee Bursitis

Management Team

Knee Bursitis

Overview

Knee bursitis is defined as inflammation of bursae, tiny fluid-filled sacs that minimise friction. It serves as a cushion between bones, tendons, muscles, and skin around joints, absorbing pressure and protecting the joints. This condition frequently affects the region above the kneecap or the inner region of the knee (beneath the joint); it limits knee movement and causes pain and discomfort.

Knee bursitis can result from prolonged pressure on the knees (e.g., kneeling), overuse of the knee joint, direct blows, bacterial infections, or medical conditions like osteoarthritis, rheumatoid arthritis, or gout.

  • Extended pressure on the knee from activities like prolonged kneeling (common in carpet layers and plumbers).
  • Repetitive knee strain associated with specific sports (e.g., wrestling and football) or from direct impact.
  • Underlying health conditions, including bacterial infections, osteoarthritis, rheumatoid arthritis, gout, or obesity.

Preventive measures include wearing kneepads, taking breaks between intense physical activities, and maintaining a healthy body weight.

Symptoms differ depending on the bursa involved and the cause of inflammation.  

  • Common symptoms include warmth, soreness, swelling, and pain while moving or resting the knee.
  • Sudden symptoms may occur after a direct hit.
  • Kneeling on hard surfaces can cause chronic symptoms.
  • Fever, bruising, swelling and skin changes near the knee, along with difficulties moving the knee, may also be observed.

  • Reviewing medical history.
  • Conducting physical examinations.
  • Performing imaging tests (e.g., X-ray, MRI, and/or ultrasound) or fluid aspiration.

Non-surgical treatment

Non-surgical options include medications, such as antibiotics for infections, and physical therapy. At-home care may involve rest, over-the-counter pain relievers, applying ice, compression, elevation, and, if necessary, weight management.

Surgical treatment

In some cases, corticosteroid injections or fluid drainage through aspiration may be recommended; this enables outpatient recovery. Surgery to remove the bursa is rarely needed. Following treatment, patients are advised to engage in basic or advanced physiotherapy. However, returning to normal activities should be discussed with an orthopaedic specialist for injury prevention (especially, reinjuries) and ensure a faster recovery.

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K

Acute Pain Management

Management Team

Acute Pain Management

Overview

Acute pain is a sudden onset of pain that serves as a warning signal to the body regarding injury, illness, or another problem requiring attention. It typically lasts less than six months and resolves once the underlying cause is treated. Acute pain management is crucial for promoting comfort, enhancing recovery, and preventing complications for patients suffering from acute pain. While it offers numerous benefits, it is essential to tailor techniques to the individual’s condition and carefully manage associated risks. Multimodal approaches, combining pharmacological and non-pharmacological strategies, are often the most effective and safest for managing acute pain. Multimodal approaches, combining pharmacological and non-pharmacological strategies, are often the most effective and safest for managing acute pain.

  • Improved patient comfort:
    • Reduces physical distress and enhances overall well-being.
    • Allows patients to engage more comfortably in daily activities or rehabilitation.
  • Enhanced healing and recovery:
    • Alleviates pain that might otherwise impair mobility or cause muscle tension.
    • Promotes faster recovery by reducing stress on the body.
  • Prevention of chronic pain: Properly managed acute pain reduces the risk of developing chronic pain syndromes, such as post-surgical pain or nerve sensitisation.
  • Reduced physiological stress: Mitigates the body’s stress response (e.g., high blood pressure, increased heart rate), minimising complications like cardiac strain or respiratory issues.
  • Improved mobility: Effective pain control supports early mobilisation, especially after surgeries or injuries, preventing complications like deep vein thrombosis or muscle atrophy.
  • Better outcomes in surgery and recovery: Patients with well-managed pain post-surgery are more likely to adhere to physiotherapy and achieve optimal recovery.

  • Pharmacological methods:
    • Analgesics (pain killers): Over-the-counter pain relief medications (e.g., paracetamol) and non-steroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen, aspirin) for general pain, and prescription drugs (stronger opioids; e.g., morphine, fentanyl) for severe pain.
    • Local anaesthetics: Lidocaine or bupivacaine, delivered as injections or as topical creams (to be applied on the skin) to block pain signals.
    • Adjunctive medications: Steroids, anticonvulsants, or antidepressants to enhance pain relief in specific cases.
    • Regional anaesthesia:
      1. Nerve blocks: Targeted injections near specific nerves (e.g., intercostal or sciatic blocks) to block pain sensation.
      2. Epidural/spinal anaesthesia: Used in surgeries or childbirth to block pain in larger regions of the body.
  • Non-pharmacological methods:
    • Physical therapy: Techniques like massage, stretching, or exercise to relieve pain and improve mobility.
    • Cold or heat therapy: For inflammation or muscle spasms.
    • Acupuncture: Stimulating pressure points to reduce pain perception.
    • Cognitive-behavioural therapy (CBT): Psychological techniques to manage pain perception.
  • Advanced interventions:
    • Patient-controlled analgesia (PCA): A pump allows patients to self-administer a controlled amount of pain medication.
    • Intravenous (IV) therapy: For immediate and sustained pain relief, often in a hospital setting.
    • Multimodal analgesia: Combines different drug classes and techniques to target multiple pain pathways, enhancing efficacy while minimising side effects.

  • Medication-related risks:
    • Opioids: Risks of dependency, respiratory depression, and constipation.
    • NSAIDs: Prolonged use can cause gastrointestinal irritation, ulcers, or kidney damage.
  • Allergic reactions: Hypersensitivity to medications, such as anaphylaxis.
  • Regional anaesthesia risks:
    • Nerve Injury: Rare but possible during nerve block procedures.
    • Infection(s) or hematoma: Complications associated with needle insertion in spinal or epidural anaesthesia.
    • Cardiovascular effects: Hypotension (low blood pressure) can be caused due to sympathetic blockade.
  • Psychological and behavioural risks:
    • Inadequate pain relief: Failure to address the pain adequately may lead to frustration or mistrust in medical providers.
    • Fear of dependence: Anxiety about becoming reliant on pain medications.
  • Procedural risks:
    • Misplacement of injection: Misguided injections can lead to nerve damage, paralysis (rare), or ineffective pain control.
    • Overmedication: Excessive doses may result in toxicity or systemic complications.
  • Non-pharmacological risks:
    • Cold or heat therapy: Improper application may cause skin burns or frostbite.
    • Physical therapy: Overzealous exercise can aggravate pain or delay healing.
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A

Hip Dislocation

Management Team

Hip Dislocation

Overview

A dislocated hip occurs when the ball of the hip joint (the femoral head) emerges from its socket (the acetabulum). Dislocations are categorised based on the direction of displacement:

  • Anterior dislocated hip: The femoral head dislocates towards the front of the body. It is less common and usually results from trauma or injury. It can be associated with certain positions or injuries, such as during a car accident or high-impact sports.
  • Posterior dislocated hip: The femoral head dislocates towards the back of the body. This is more common than anterior dislocation and often results from trauma, such as a car accident, fall, or direct impact. It is frequently associated with hip fractures.

  • Severe pain in the hip or groin area.
  • Difficulty or inability to move the affected leg.
  • The leg may appear to be positioned abnormally or out of alignment.
  • Swelling and bruising around the hip or groin area.
  • Difficulty in moving the hip joint or leg.

  • Trauma, such as car accidents, falls, or high-impact sports.
  • Hip dysplasia, which is an abnormal hip joint by birth.
  • Old age.
  • Sports or activities that involve sudden movements or collisions.
  • Previous hip replacement or other surgeries that might alter joint stability.
  • Bone weakness and conditions like osteoporosis that increase the susceptibility to bone dislocation.
  • Improper use of assistive devices, such as crutches or walkers can increase the risk of hip dislocation.

  • Physical examination to assess the position of the leg, range of motion, and pain level. The healthcare provider will also check for signs of swelling and bruising. 
  • Medical history recording to discuss how the injury occurred, previous hip problems, and overall health. 
  • Imaging studies:
    • Radiography (X-rays) to confirm the dislocation and check for associated fractures or other injuries.
    • Computed tomography (CT) or magnetic resonance imaging (MRI) to assess the extent of soft tissue damage or to get a more detailed view of the joint and surrounding structures.

Non-surgical treatment

  • The primary treatment is to relocate the femoral head back into the acetabulum. This procedure is called ‘reduction’ and is usually performed under anaesthesia.
  • Medications to manage pain and inflammation.

Post-reduction care

  • The hip may be immobilised using a brace or splint to keep it stable during the healing process.
  • Rehabilitation and physical therapy to restore strength, range of motion, and function. This may include exercises and mobility training.

Surgical treatment

  • For cases where there are associated fractures, severe joint damage, or recurrent dislocations, complex joint revision surgery may be necessary to repair the hip joint or stabilise it.
  • Prompt and appropriate treatment is crucial for a dislocated hip to prevent long-term complications, joint preservation, and to restore normal function.
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H

Hip Bursitis

Management Team

Hip Bursitis

Overview

Hip bursitis is a common hip problem involving inflammation of the bursa, which is a small fluid-filled sac that reduces friction and cushioning between bones and soft tissues. In the hip, bursae are located around the greater trochanter (the bony prominence on the side of the hip) and the ischial tuberosity (the bony part you sit on).

  • Greater trochanteric bursitis: Inflammation of the bursa located on the outer side of the hip. It is the most common type.
  • Ischial bursitis: Inflammation of the bursa located under the ischial tuberosity.
  • Iliopsoas bursitis: Inflammation of the bursa located in front of the hip joint near the iliopsoas muscle.

  • Pain on the outer side of the hip may worsen with activities like walking, climbing stairs, or prolonged sitting.
  • Tenderness over the bursa when pressed.
  • Swelling around the hip area (less common but possible).
  • Difficulty moving the hip or feeling of stiffness.
  • Pain that worsens at night, particularly when lying on the affected side.

  • Repetitive activities or sports that put stress on the hip.
  • Old age, especially age-related wear and tear.
  • Activities that involve repetitive hip movements or prolonged sitting.
  • Trauma or a fall onto the hip.
  • Excessive physical activity, especially without proper conditioning or warm-up.
  • Incorrect posture or gait issues can place extra stress on the hip bursae.
  • Underlying conditions, such as osteoarthritis, rheumatoid arthritis, or gout.

  • Physical examination to assess pain, tenderness, range of motion, and functional limitations. The healthcare provider will also evaluate the hip joint for signs of swelling or other issues.
  • Medical history to discuss symptoms, activities, injuries, and any previous treatments or underlying conditions.
  • Imaging studies:
    • Radiographs (X-rays) to rule out other conditions like fractures or arthritis, which may have similar symptoms.
    • Ultrasonography to visualise inflammation of the bursa and guide treatment regimens, such as injections.
    • Magnetic resonance imaging (MRI) for detailed images of soft tissues and to help identify bursitis and other hip joint issues.
  • If there is significant swelling, fluid can be aspirated (withdrawn) from the bursa and analysed to rule out infection or other conditions.

Non-surgical treatment

  • Resting and reducing activities that exacerbate symptoms.
  • Applying ice to the affected area to reduce pain and swelling.
  • Medications such as:
    • Non-steroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation.
    • For severe inflammation, corticosteroids can be injected directly into the bursa for relief.
  • Physical therapy exercises to strengthen the muscles around the hip, improve flexibility, and correct any gait or posture issues contributing to the bursitis.
  • Changing activities or using supportive devices like cushions or orthotics to reduce stress on the hip.

Surgical treatment

Surgery is rarely needed but may be considered if conservative treatments fail. It may involve bursectomy (removal of the bursa) or other procedures to address underlying issues.

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H

Hip Arthritis

Management Team

Hip Arthritis

Overview

Hip arthritis is an umbrella term for various types of arthritis affecting the hip joint. It is characterised by inflammation of the hip joint, leading to pain, stiffness, and decreased mobility. It involves the breakdown of cartilage within the hip joint, which can affect its function and cause discomfort.

  • Osteoarthritis (OA): The most prevalent form that is characterised by the gradual wear of cartilage, causing the bones to rub together.
  • Avascular necrosis with secondary arthritis: This occurs when blood flow to the hip bone is disrupted, leading to bone death and arthritis.
  • Rheumatoid arthritis (RA): It is an autoimmune disorder where the body’s immune system attacks the synovial lining of the joint, leading to inflammation and pain.
  • Psoriatic arthritis: It is associated with psoriasis, and can affect the hip joint and cause pain and swelling.
  • Post-traumatic arthritis: Develops after a hip injury or fracture that leads to joint damage and arthritis.

  • Persistent pain in the hip joint or groin area, which may worsen with activity.
  • Stiffness, especially noticeable in the morning or after sitting for long periods.
  • Reduced range of hip joint motion.
  • Difficulty walking or performing daily activities due to pain and stiffness.
  • Difficulty in squatting and sitting cross-legged.

  • Ageing, especially for OA.
  • Autoimmune diseases, especially for types, such as RA or psoriatic arthritis.
  • Family history of arthritis.
  • Obesity.
  • Previous hip injuries or fractures.
  • Female sex, especially for developing OA and RA.
  • Jobs or activities that add repetitive stress to the hip.

  • Physical examination to assess the hip joint for pain, swelling, range of motion, and functional limitations.
  • Medical history recording through discussion of symptoms, their duration, and any previous treatments or hip injuries.
  • Imaging studies include:
    • Radiography (X-ray) to assess joint damage, cartilage loss, and bone changes.
    • Magnetic resonance imaging (MRI) for detailed images of the soft tissues around the hip and assessing cartilage and bone marrow changes.
    • Computed tomography (CT) to evaluate complex cases or assess the extent of joint damage.
  • Blood tests to identify inflammatory or autoimmune conditions (e.g., rheumatoid factor for RA and markers of inflammation).

Non-surgical treatment

  • Medications:
    • Analgesics, such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen) to reduce pain and inflammation.
    • Disease-modifying antirheumatic drugs (DMARDs) for RA or other inflammatory arthritis types.
    • Biologics for severe cases of RA or other inflammatory types.
  • Physical therapy for strengthening the muscles around the hip, improving flexibility, and enhancing overall function.
  • Lifestyle modifications, such as weight management, low-impact exercise (e.g., swimming and cycling), and joint protection strategies.
  • Assistive devices, such as canes, walkers, or braces to reduce strain on the hip joint and assist with mobility.

Surgical treatment

  • Hip arthroscopy procedure, which is a minimally invasive orthopaedic surgery to repair or clean out damaged tissue within the hip joint.
  • Hip replacement surgery
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H

Genu Varum (Bowed Legs)

Management Team

Genu Varum (Bowed Legs)

Overview

Genu varum is a paediatric orthopaedic condition involving leg deformity, which is also known as bowed legs. It is a skeletal disorder where the legs curve outward at the knees while the ankles are close together.

  • Usually symptomless, apart from cosmetic concerns.
  • Occasionally, in children, difficulty in walking and or pain in the outer part of the knees.

  • Bowing of the knees is normal till the age of 2 years.
  • Vitamin D deficiency.
  • Bone growth disorders like rickets, Blount disease, and osteogenesis imperfecta.
  • Genetic disorders, such as Carpenter syndrome.

  • Physical examination where the patient stands with both legs parallel to each other and both ankles together and the distance between both knees and ankles is measured.
  • A full-length radiograph (X-ray) of both legs (scanogram) to measure the extent of varus (deformity in the knees).
  • Radiograph of the knee joints at two different angles (anteroposterior and lateral views) to detect abnormality of the growth plates (ends of the bones in the knee joint).
  • Computed tomography (CT) for treatment planning.

Non-surgical treatment

Non-surgical treatment is the primary line of management. It includes:

  • Observation in cases of physiological (natural) varus.
  • Nutritional correction for vitamin D deficiency.
  • Bracing for minimal deformity.

Surgical treatment

Surgery is indicated in the advanced stage of the disease and when non-surgical management fails. Corrective osteotomy is required for severe deformities.

It involves placing small plates/screws to restrict the growth on the outer side of the knees, restricting the deformity. The implants are usually removed once the child achieves complete growth. However, growth may be restricted when the screw penetrates the growing region of the bone.

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G

Ganglion Cyst

Management Team

Ganglion Cyst

Overview

Ganglion cysts are small fluid-filled swellings usually over the tendon sheaths. They most commonly affect the wrist, ankle, or feet. The cause of ganglion cysts is unknown.

  • The patient usually presents with a soft painless swelling over the dorsum of the wrist joint (most common site).  
  • Dull aching pain with terminal movements at the wrist joint.
  • Rarely, the swelling compresses the underlying nerves, leading to tingling, numbness, and occasionally muscle weakness.

  • Women are more commonly affected than men.
  • High activity at young age (15–40 years).
  • Excessive friction and repetitive stress (like performing gymnastics).

  • Physical examination.
  • Radiography (X-ray) to assess the condition of the underlying joint and identify old pathologies.
  • Ultrasonography or magnetic resonance imaging (MRI) to rule out other causes of swelling and identify the exact anatomy, location, and extent of the cyst to plan treatment.

Non-surgical treatment

Conservative management is the initial treatment of choice. It includes:

  • Observation, if there is no pain.
  • Splints, such as a wrist brace to help immobilise the joint, alleviate pain, and decrease swelling.
  • Aspiration is recommended for large swellings affecting daily activities.

Surgical treatment

Surgical excision is recommended for patients for whom conservative management has failed. The surgical options are as follows:

  • Open excision to allow access to the complete cyst including the stalk and the wall. However, the chances of cyst recurrence can be up to 40%. A splint is advised for approximately 2 weeks after the surgery following which gradual movements are allowed.
  • Excision through arthroscopy procedure involves minimal incisions and less soft tissue damage and allows enhanced visualisation of the joint (most commonly the scapho-lunate joint) without jeopardising the articular cartilage. However, this technique requires extensive expertise.
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