Bell's Palsy: Cause, Symptoms, and Treatment

Bell's palsy is a type of facial paralysis that involve the cranial nerve VII (Facial nerve) resulting in loss of control of facial muscles on the affected side or ,rarely, both sides resulting in total facial paralysis. The paralysis is of the infranuclear/lower motor neuron type. The nerve that controls muscles on one side of the face damaged by inflammation or compression. This facial condition is common to occur in people between 15 and 60 years of age, but people outside this age group can also have Bell's palsy. They can affect men and women equally. Facial nerve
Facial nerve's nuclei are from the brainstem. Inflammation of the facial nerve within its bony canal (fallopian canal) will block in transmitting neural signals or even damage the nerve. The interruption in the messages the brain sends to the facial muscles results in facial weakness or paralysis. Because of that interruption, one may lose the ability to control over eye blinking, closing of the eyes, frowning, raising eyebrows, smiling, salivation, and lacrimation (production of tears). Facial nerve also supply the taste sensation in the anterior two-thirds of the tongue, via the chorda tympani nerve. Again, damage to this nerve will affect the taste sensation in the anterior two-third of the tongue on the affected side. Additionally, the facial nerve carries nerve impulses to the lacrimal glands, the saliva glands, and the muscles of a small bone in the middle of the ear called the stapes.


Causes


Like many other diseases, the exact cause of Bell's palsy is unknown. Studies suggest that this medical condition could be triggered by:

• Herpes Simplex that causes cold sores and genital herpes.
• Herpes zoster virus that causes chickenpox and shingles. They are less common cause of Bell's palsy compared to herpes simplex.
• Epstein-Barr virus that causes mononshingles.
• Brain tumors. An abnormal tissue growth.
• Meningitis that causes meninges inflammation.
• Sarcoidosis that causes organ inflammation.
• HIV that attack the immune system.
• Stroke.
• Diabetes mellitus.
• Ramsay Hunt syndrome from varicella-zoster virus.
• Lyme disease. A bacterial infection caused by ticks.
• Head trauma from an accident.
• An accident from surgery.
• Congenital facial palsy.

Symptoms Symptoms can vary from mild to severe and typically come on over 48 hours. They usually appear abruptly, and you will just notice drooping of your face on the affected side or when you have difficulty eating or drinking. In most cases of Bell's palsy, improvement seen within two to three weeks and full recovery expected within nine months. Common symptoms include:

• Headache.
• Sudden weakness or total paralysis of the facial muscles that causes your face to droop
• Drooping of the eyelid which causes difficulty in closing the eyelid.
• Drooling from the mouth on the affected side.
• Loss of ability to taste.
• Difficulty in eating and drinking.
• Inability to make facial expressions.
• Impaired speech.
• Pain around the ear on the affected side.
• Dry eye from inability to blink the eye.
• Increased tear production.
• Increased sensitivity to sound (hyperacusis).
• Numbness on the affected side of the face.

Risk factors

• More likely to occur in pregnant women than in nonpregnant women.
• More likely to occur in diabetic people.
• Familial inheritance.
• Recent upper respiratory tract infection.
• Viral infection that results in swelling.

Differential diagnosis

Here are some medical conditions that produce facial paralysis and are mistaken as Bell's palsy.

• Stroke. They are accompanied by weakness in the arms and legs. Also has control in the upper part of the face, like wrinkling of the forehead.
• Infection with herpes zoster virus. Presence of small blisters on the external ear and hearing disturbance.
• Lyme disease, caused by ticks, produce facial paralysis.

Diagnosis

There is no routine laboratory or imaging tests required to make the diagnosis of Bell's palsy. Diagnosis is usually done by eliminating the other reasonable possibilities.

• A physical examination conducted by your doctor to include all questions about the symptoms.
• A neurologic examination to check the facial nerve integrity.
• Imaging test like CT scan or MRI to check the facial nerve.
• Blood test can check the presence of bacterial or viral infection.
• Electromyography (EMG) can confirm the presence of nerve damage and to determine the severity and extent of nerve involvement.
• The degree of nerve damage assessment, using the House-Brackmann Facial Nerve Grading System.

Treatment

Usually, the condition gets better by itself with normal or near-normal function. Signs of improvement will show within two weeks, with complete recovery within six to nine months.

Corticosteroids medicines, such prednisone, have been found to improve outcomes and are thus recommended. They work best if taken within 3 days after symptoms start. Corticosteroid works on reducing inflammation.

Antiviral medications, when added in steroids, is of a small added benefit in the treatment. One review found antivirals alone are ineffective in improving recovery from Bell's palsy. They are usually prescribed if Bell's palsy caused by a virus.

Mild pain relieved by some over-the-counter pain medications, such as ibuprofen or acetaminophen.

Dry eye protection from drying up by using eye drops or an eye patch.

Surgery is generally not recommended, but may improve the outcome for those who have not recovered from severe facial nerve paralysis.

Physical therapy

• A series of facial exercises will promote muscle re-education. These exercises will strengthen your facial muscles and promote faster recovery.
• Applying heat can help reduce pain. An infrared radiation applied to the affected side of the face or a warm, moist towel placed over the face will help relieve pain.
• Electrical stimulation to stimulate the facial nerve, but there is no concrete evidence to support its efficiency.
• Soft tissue mobilization or massaging your face will promote relaxation and increase circulation.

Promote mouth care. Food may stick in the mouth that may cause gum problems or tooth decay. Brushing or using dental floss will help prevent these problems.

Swallowing problems, prevention by eating slowly and chewing your food well. A soft diet will also help you.

Acupuncture is given, but the efficiency of using this alternative medicine remains unknown.



Prognosis

The prognosis is generally very good. Most people with Bell's palsy start to regain normal facial function in as early as 3 weeks, even without treatment. Studies show complete recovery achieved in at least 1 year.



Complications

Most people recover from Bell's palsy without complication. However, complications are possible for severe cases of Bell's palsy. These may include:

• Chronic loss of taste (ageusia).
• Chronic facial spasm.
• Facial pain.
• Persistent facial weakness.
• Reduced sense of taste.
• Incomplete or faulty regeneration of facial nerve, such as synkinesis.
• Difficulties in speech, eating, and drinking.
• Twitching of facial muscles.
• Eye problems, such as corneal infections

Shin Splints: Causes, Symptoms, and Treatment

Shin Splints, medically known as Medial Tibial Stress Syndrome, refers to a pain along  long bone in the lower leg (Tibia). This condition is a physical activity-related problem that is usually common to athletes(runners), dancers, and military recruits. We often experience this pain, even on a simple activity such as morning jog, brisk walking, or even catching a bus to take a ride to work.

Causes:

Shin splints develop after a vigorous, repetitive physical activity, compromising the bones, muscles, and tendons in the lower leg. As a result of overworked, pain and inflammation will soon be experienced. This condition is common to anyone who just started an activity or a sudden change in the level of activity. A sudden change and/or increase in the frequency, duration, and intensity of an activity will likely cause shin splints. 

Symptoms:

The most common complaint is a dull, throbbing pain and tenderness along the border of the tibia. Pain usually occurs during and after exercise. Mild swelling will also occur in the lower leg.

Risk Factors:

Anyone will likely have shin splints if:

• You are wearing an improper or a worn-out shoes during an activity or exercise.
• You have some foot deformities, such as flat feet and high arches.
• You are a new participant in a sports activity.
• You suddenly increase the frequency, duration, or intensity of an activity.
• You are into military training.

Diagnosis:

We often do home remedies to manage shin splints. If the symptoms continue to persist, it would be better to see your doctor. 

The doctor usually does physical examination and patient interview on symptoms and medical history. X-rays will also be done to rule out other problems that cause the pain, such as stress fractures.




Treatment:

We often do home remedies to manage shin splints. If the symptoms continue to persist, it would be better to see your doctor. 

• Rest. If would be best if you take some time off from an activity or exercise that causes the pain. This will promote faster recovery. Instead, try to engage in low-impact activities that don't give too much stress on your lower leg such as swimming.
• Ice. Never apply ice directly over the skin. Wrap around the ice with layers of towelling.
• Apply icing for 20 minutes, four to six times a day for several days. This will help in reducing pain and swelling.
• Ultrasound, iontophoresis, phonophoresis, and electrical stimulation  can help reduce pain and inflammation.
• Elastic compression bandage will help against swelling.
• Take some over-the-counter pain reliever to reduce pain and swelling, such ibuprofen, Aspirin, Naproxen, or Acetaminophen.
• Range of motion and flexibility exercises to the lower leg muscles helps a lot. See your physical therapist to help you with pain management and your return to sports. Here are some exercises you can do at home.
• Wear shoes with good cushioning to reduce stress on the lower leg.
• Orthotic shoe insert provides foot alignment and stability of your foot and ankle.
• Surgical treatment done in very severe cases. 

Here are some exercises you can do at home.

Toe Curls.

• Standing. Spread the towel in front of you. Place your one foot at the edge of the towel. Slowly bring or pull the towel towards you using your toes. Repeat this procedure with the other foot.

Calf Stretching

• Long sitting on the floor. Loop a towel or resistance band at the bottom of your one foot. Gently pull them towards you into dorsiflexion. Hold it for a few seconds and repeat three times on each leg. Do the same stretching on the other leg.

Shin Resistance Exercise

• Sitting on the floor. Loop a resistance band around the front of your one foot while the other end of the resistance band looped around a stationary object like a table. Dorsiflex the foot against the resistance band. Do this with 10 to 15 reps. Progress with heavier band later on.

Prevention:

• Start a new exercise or activity slowly. Gradually increase the frequency, duration, and intensity as you go along with your exercise or activity. Don't rush.
• Start an exercise with warm up and light stretching to prepare your muscles.
• Stop an exercise the moment you feel pain in your shinbone.
• Try to develop strength in your lower leg before going into high-impact activities.
• Cross training is effective in improving fitness and performance. Incorporate low-impact activities such as jogging and swimming, with your main activity or sports.
• Avoid overdoing an exercise or an activity.
• Wear the right shoes that give comfort and safety.

Frozen Shoulder: Causes, Symptoms, Treatments - All About Physical Therapy

Frozen shoulder, otherwise known as adhesive capsulitis, is a condition in the shoulder characterized by stiffness, pain, and limitation of motion. It is typical in frozen shoulder to involve only one, although, few cases affect both shoulders. 

Causes:

Frozen shoulder usually happen after a recent injury or after a medical procedure or from, a medical condition such as stroke, diabetes, or mastectomy. The inability of moving the shoulder into its full range of motion because of pain results in stiffness of the tissues around the joint. Later on, shoulder movement becomes more difficult and painful.

Symptoms:

This shoulder condition usually develops gradually, becomes worse over time and then slowly resolve over the course of 1 year up to 3 years. Persistent pain and limitation of motion from joint stiffness are the most obvious symptoms seen in people with frozen shoulder. This condition develops in 3 stages and each stage can last up to several months.

Freezing Stage 

• The painful stage. More and more pain is experienced when you do any movement of the shoulder. Limitation of motion starts to become limited.

Frozen Stage

• Pain begins to diminish at this stage, but the stiffness still remain making shoulder movement difficult affecting daily activities.

Thawing Stage

• Shoulder movement slowly improves at this stage.

Risk Factors:

• Age. Common to people aged 40 to 70 years
• Gender.More often to women than in men
• After surgical procedure 
• Recent injury such as fracture
• Medical problems such as stroke, hyperthyroidism, hypothyroidism, diabetes, Parkinson's disease, or cardiac disease

Diagnosis and Test:

• Medical History to include a detailed description of the symptoms, present and past medical conditions, and medications and/or supplements taken.
• Physical Examination to include testing the range of motion of both shoulder joints. The affected shoulder will show limited motion, both active and passive.
• Imaging Test
• X-rays, which shows a clear image of the bone, help find other problems in the shoulder.
• Ultrasound and MRI give a better view of the soft tissues to rule out other problems.

Treatment

The aim of treatment for frozen shoulder is to ease pain and keep the mobility and flexibility of the shoulder. Here are some of the recommended treatment approaches of frozen shoulder.

• Medications. Over the counter pain-relieving and antiinflammatory drugs, such as aspirin and ibuprofen to cut pain and swelling.
• Heat application followed by gentle stretching to increase range of motion.
• Range of motion exercises, given by a physical therapist, to recover shoulder joint mobility.
• Ice and corticosteroid injection will help reduce pain and swelling.
• Transcutaneous Electrical Nerve Stimulation (TENS) give pain relief by blocking pain fiber that carries pain impulses.
• Joint Distention. A sterile water is injected into a joint to stretch the tissue so that movement is easier
• Shoulder Manipulation under anesthesia. You will receive general anesthesia and the doctor do manipulation to break adhesion.
• Shoulder Arthroscopy. This procedure is rarely done. The doctor uses a lighted, tubular instrument inserted into a small incision around the joint to remove scar tissue and adhesions.

Plantar Fasciitis: All About Physical Therapy

Plantar fasciitis is an overuse injury involving the plantar fascia, a strong, thick band of tissue that runs from the heel(calcaneum) up to the toes. An overstretched or overused injury of the plantar fascia will lead to pain and inflammation at the bottom of the foot which makes walking more difficult. This band of tissue provides arch support as well as a shock-absorber of your foot. Plantar fasciitis affect both men and women, but more to active men aged 40 to 70. The involvement can either be one foot or both.

Possible Causes and Risk Factors:

This foot condition develops as the result of repeated small tears in the plantar fascia resulting to inflammation and degeneration of the connective tissues in the fascia. Plantar fasciitis is more likely to develop if you have:

• Flat feet and high arches of the foot.
• Certain occupations that requires prolonged standing.
• Obesity or a sudden weight gain.
• Engaged in long distance running and other intense activities or exercise.
• Tight TA will raise the arches of the foot.
• Incorrect shoe fitting that doesn't support the arch of the foot because this puts more stress on heel.
• A sedentary lifestyle and you do lots running, walking, and jumping.
• Certain type of arthritis, particularly among the elderly people.

Symptoms:

Anyone with plantar fasciitis will likely experience:

• Pain and tenderness at the bottom of the heel with the first step in the morning or even after standing/sitting for a while.
• Limited ankle dorsiflexion secondary to tight TA.
• Mild swelling or redness of the foot.
• Limping or may attempt toe walking to decrease pain which might also develop foot, knee, hip or back problems later on.
• Painful with barefoot walking on hard surface or even stair climbing.
• Pain after an intense activity such as running, jumping, and other related activities that repeatedly put stress or pressure on the tissues.

Diagnosis:

• Physical examination should include patient interview.
• An x-ray may be taken to rule out other problems.
• An ultrasound scan usually shows thickening and swelling of the fascia.

Treatment:

Start your treatment as early as possible before it gets worse. Go and see your doctor. Here are some recommended treatment approach if you have plantar fasciitis.

• Take time to rest your feet , at least for a week. Limiting or even stopping an exercise or activity allows better healing of the tissues
• Apply ice for 15 minutes, at least twice a day, to relieve pain and inflammation.
• Avoid any form of the heating your foot during the first 2 to 3 days.
• Flexibility and strengthening exercises to ankle and calf muscles.

1. Standing with both hands touching the wall at shoulder level. Feet slightly apart, with one foot in front of the other foot.Begin by bending your front knee while keeping your back knee in a straight position and then move forward by leaning on the wall. Hold it for a few seconds and then release. This exercise will stretch your calf muscles. Do this again by switching the position of the two feet to stretch the other calf muscles.
2. Long sitting on the floor. Loop a towel around the ball of your one foot. Pull the toes towards you while keeping your knee straight. Hold this for a few seconds. Do this exercise with the other foot.
3. While sitting on a chair, place a water bottle, a tennis ball, or a drink can under the arch of your foot. Slowly roll the bottle from the ball of the foot to the heel. The massage effect helps reduce pain in the bottom of your foot.

• Athletic shoes or shoe with a well-cushioned sole are usually good choices.
• Heel cups or shoes inserts give added cushion and comfort to your foot.
• Resting night splint may be used to stretch the TA while sleeping.
• Try to reduce weight. Enrolling in a weight-reduction program helps a lot.
• Acetaminophen and Ibuprofen will help reduce pain and inflammation.
• Extracorporeal shock-wave therapy. Better discuss this procedure with you doctor.
• Foot surgery may be needed if all nonsurgical treatment didn't work out.

Preventive Measures:

• Do stretching prior to any activities or exercises.
• Avoid doing exercises on hard surfaces.
• Try to lose some weight if you are obese.
• Change your type of sport. Go into low-impact sports like swimming instead of running or jogging.
• Always check your shoe physical condition. Don't wear worn out shoes.

Morton's Neuroma

Morton's neuroma, also known as Morton's metatarsalgia or interdigital neuroma, is a painful foot condition affecting the nerve passing under the ligament that connect the metatarsals. This foot condition often affects the third and fourth toes, may sometimes develop in the second and third toes. Also, it either affects one foot or both feet. A constant irritation or an excessive pressure on those areas of the foot or both feet develops a thickening of the tissues that surround the nerves leading to the toes. As a result, one may experience a sharp, burning pain at the ball of the foot. The sensation is feeling like as if you are walking on a pebble, a common description of this foot condition. Although it can occur at any age, the condition is more notable in runners and in middle-aged women who loves to wear high-heeled shoes. Besides, the incidence is higher in women than in men.

Causes

Although the exact cause remained unclear, many experts believed that Morton's neuroma is usually associated with irritation or pressure of the nerves between the toes. Aside from wearing high-heeled shoes and participating in high-impact sports like running, anyone with foot deformities such hammertoes and flat feet will also have this foot condition.






Symptoms

A sharp, burning pain felt at the ball of the foot often worsen with activity and wearing tight shoes.
Unpleasant tingling sensation at the toe.
Pain increases over time.

Diagnosis

Examination may show a palpable mass at the toes, which is tender when pressed.
X-ray may help to rule out bone fracture.
A test on the range of motion to find any arthritic or an inflammatory condition of the joints.
Ultrasound and Magnetic Resonance Imaging are both good in visualizing the soft tissues, though quite expensive.

Treatment

The treatment is towards the symptoms. A conservative treatment is the first approach before going into an invasive intervention.

Wearing a orthotic device, those with foot deformities, will help relieve pressure on the toes.
Shoe change will help reduce pressure on the nerves, particularly the athletes.
Avoid high-heeled and tight shoes as well.
Foot massage provides pain relief.
Placing an ice pack at the sole provides pain relief.
Weight reduction  for obese persons to reduce strain on the feet.
Over the counter pain relievers and injections of steroids may help ease the pain and inflammation.
Surgical removal of the thickened tissues deemed necessary if all conservative treatments haven't worked. Although the surgery is successful in most cases, one may still experience the permanent sensation of numbness but not painful.

Gouty Arthritis

Gout is an inflammatory form of arthritis that develop from excess build up of uric acid in the tissues and blood because of too much production and/or the inability of the kidneys to remove them. These needle-like uric acid crystals deposited in the joints which in turn leads to a sudden, severe episodes of pain, tenderness, swelling, redness, warmth and stiffness of joints. In addition, it may also lead to kidney stone formation, tophi deposits in the skin and other tissues, or urate nephropathy.

The most common affectation is the joint at the base of the big toe. It will also affect many other joints together with or without big toe involvement. Gout typically occurs in the middle age, usually over the age of 40. It is more common in men and in persons with diet problem due high standards of living. Women are usually affected after menopause.





I. Stages of Gout

1. Asymptomatic Hyperuricemia

• This stage appears with higher uric acid level in the blood, but does not manifest  any symptoms. Treatment is usually not required.

2. Acute Gout

• With existing hyperuricemia, a gout attack  is triggered after a series of alcohol or drug intake, eating too much high-purine food such as liver, dried beans and peas. Pain and inflammation usually occurs at night and may last for a few days up to 10 days.

3. Interval Gout

• This stage shows no more symptoms, but gout is still there. This is the ideal time to manage gout to prevent future attacks.

4. Chronic Gout

• The uric acid remained at high level over a long time. Gout attack is more frequent and pain to last longer compared to earlier attacks.

II. Causes:

Uric acid are normally formed by our body and stays in our bloodstream in a dissolved form and end up being flushed out by the kidneys. Having too much uric acid in our blood (hyperuricemia) create a condition called gout. A high level of uric acid or the inability of our kidneys to remove them quickly, uric acid crystals begin to form and deposited in the joints. A longstanding hyperuricemia create tophi (tophus) formation. Tophi are large deposits of uric acid crystals, in the form of monosodium urate crystals, at the surface of joints, or in skin or cartilage.

III. Risk Factors:

1. Beverages, such as tea, coffee, may increase the level of uric acid. Drinking too much alcoholic drinks and fructose-rich sodas increases the risk.
2. Diet of high-purine content, such as red meat, internal organs, seafood, oily fish, dried pea and beans, lentils, or spinach, produces high level of uric acid.
3. Obesity or being overweight increases the risk of developing gout even at younger age.
4. Starvation and dehydration.
5. Certain medical conditions or illness, such as kidney failure, rapid weight loss, polycythemia, high blood pressure, and lead poisoning.
6. Regular intake of aspirin or diuretics.
7. Bypass surgery.
8. Family history of gout.
9. Age and gender. Most common in men over the age of 40. Women are usually affected after menopausal.

IV. Symptoms:

1. Sudden onset of a warmth, red, extreme pain and tenderness, swollen joints, usually the big toe joints (Podagra). Gouty attack usually happen during nighttime.
2. Usually it affect one joint at a time, but may involve other joints (heels, knees, wrist and fingers) if no treatment made.
3. First gout attack stop spontaneously within 1 to 2 weeks even without intervention.
4. With time, gout attack is more frequent and to last longer.
5. At the beginning, it will only involve one or two joints and then progress to affect multiple joints.
6. Tophi formation in skin and other tissues.

V. Diagnosis:

1. A detailed medical history and physical examination. This include:

• Diet
• Medications
• Intensity and causes of pain
• Presence of other symptoms
• Duration and description of attack
• Joints involved

2. Blood Test

• This measure the level of uric acid in the blood.

3. Joint Aspiration

• The most important diagnostic tool. This procedure is by extracting fluid from the affected joint for testing under a microscope. Presence of uric acid crystals suggest gout.

4. X-ray, Ultrasound , CT Scan, or a MRI to look at soft tissues involvement.

VI. Treatment:

Home Management:

1. Take the prescribed medicines, the antiinflamatory drugs during flare-up. Don't take aspirin or diuretics it may only aggravate the symptoms.
2. Elevate leg above the heart level.
3. Use ice packs to alleviate pain and swelling.
4. Use an assistive walking device to lessen weight-bearing on the affected joints.
5. Splinting to immobilize the affected joint(s) is helpful.
6. Stay hydrated.
7. Take a rest to relieve stress.

Medications:

Medicines are given during acute attack as well as to prevent future attack. Some of these medicines may work effectively on some people and some of them may just give problems from side effects. To stay safe, it is still best to call and see your doctor.

1. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin, ibuprofen, naproxen for pain and inflammation during acute attack.
2. Colchicine is an alternative medication. Side effects may include abdominal cramps and nausea.
3. Corticosteroids help control inflammation. Usually given if NSAIDs is not available or contraindicated. Administered either orally or directly injected to the joint.
4. Allopurinol and Probenecid both help to lower uric acid level and prevent future attack.
5. Febuxostat is another choice of medication to lower uric acid level.

Physical Therapy:

A management program formulated towards the maintenance or improvement of ROM, strength & endurance, and function. Physical therapy with medications is helpful for gouty sufferer. Begin with low-impact exercises and slowly progress to a more strenuous exercises as tolerated. Stop the exercise if it causes unusual, uncomfortable pain because this might to lead to injury or worsening of the symptoms. Avoid doing any exercises during flare-up instead do it in between flare-up.








Benefits of Regular Exercise:

1. Improve circulation.
2. Improve mobility and flexibility of joints.
3. Improve muscle strength and endurance.
4. Improve posture and balance.
5. Reduce stress and improve general well-being.
6. Alleviate pain and inflammation.
7. Maintain a healthy weight.
8. Lower the risk of gout.
9. Lower the risk of cardiac and pulmonary problems.

Management:

1. Modalities such as ice or a cold compress may help during flare-up to alleviate pain and inflammation.
2. Use a walking aid devices (a cane, walker, or crutches) to reduce weight-bearing of the painful joint and to help in maintaining a normal gait. Limping or incorrect gait may put stress on the other joints.
3. Rest and elevation of the affected joint during acute attack.
4. Range of motion and gentle stretching exercises improve flexibility and mobility of joints. A simple, light self-stretching help a lot to reduce joint stiffness and increase muscle blood flow.
5. Strengthening and endurance exercises, using a light dumbbell, will help your muscles to stay in shape. Slowly progress the exercises as tolerated.
6. Proprioception exercise keep up the joint sense of position.
7. Cardiovascular training recommended to keep a healthy lungs, heart, and circulation. Walking, swimming, and jogging are some of the activities that improve overall fitness.
8. Lifestyle change, such as diet control and avoiding other risk factors, is to consider.

Nursemaid Elbow (Pulled Elbow)

This common pediatric condition refers to radial head subluxation (radiocapitellar joint of the elbow complex) generally occurring between the ages of 1 and 4 years, although it can happen anytime until the age of 7. At that age, the soft tissues, including muscles and bones still continue to develop that even a mild sudden pulling force on the extended pronated forearm produce a partial dislocation. Children at this age are very active in their play activities such that tugging a child or by swinging them around or back and forth by the arms causes the bone to slip out of its normal place at the joint.




Left elbow-joint Left: anterior and ulnar collateral ligaments Right: posterior and radial collateral ligaments (Photo credit: Wikipedia)





Causes:

• Catching a child by holding the hand or wrist to stop a fall.
• Pulling a child up by the hands or wrists to keep out of danger or lifting a child over a high step
• When an adult swing a child by holding the arms or hands.
• Quickly grabbing a child's hand or wrist to walk faster or even pulling a child hand along while walking
• Pulling a child hand through a long-sleeve jacket 
• An infant rolls over in an unusual way in a crib, bed, or in the floor

Signs and Symptoms:

• Moving the injured arm is painful, especially supination
• The child injured arm is kept on his/her side, usually held in flexion and pronation
• Minimal swelling

Differential Diagnoses:

• Elbow Fracture
• Soft Tissue, Hand or Wrist Injury
• Wrist Fracture 

Brief Anatomy:


The bone of the upper arm (humerus) and the two bones of the forearm (radius & ulna) made up the elbow complex. Medial collateral ligament, lateral collateral ligament, and the annular ligament holds the joint together to prevent dislocation. The joint complex has 2 joints namely, the proximal radioulnar joint for flexion & extension and the radiocapitellar joint for forearm pronation & supination.

Diagnosis:

• History of injury
• Physical examination
• A child is reluctant to move the injured arm because of pain
• The injured arm is kept on the side.
• The forearm is usually flexed and pronated
• Some tenderness at the radial head area

Imaging:

• X-ray to rule out possible fracture but are often unnecessary
• Ultrasonography and MRI performed to confirm ligament involvement

Treatment:

• A reduction is a gentle maneuver that allows the bone to go back into its normal place. If unsuccessful after 2-3 attempts, X-ray is needed to rule bone fracture. 
• Over-the-counter pain medicine, such as acetaminophen or ibuprofen may be given. Never give aspirin to a child under age 12.

Prognosis:

• It is usually excellent with treatment. If left untreated, the child may be permanently unable to fully move the elbow. 

Prevention:

• The most important thing is to know the risk 
• Avoid tugging or pulling a child's hand or wrist
• Never swing a child by holding the hand or wrist
• Never lift a child by holding the hand or wrist instead grasp under the arm
• Some children are more likely to get it again, a doctor may teach the family the reduction maneuver

Strain and Sprain

Aside from the other traumatic soft tissue injuries like contusions, sprain and strain are the two most common acute soft tissues injuries that involve muscles, tendons, and ligaments. These injuries often occur with our daily simple or complex activities like occupation, hobby, recreation, sports and exercise activities. These soft tissue injuries have two categories, the acute injuries and overuse injuries. Sprain and strain, together with contusions, belongs to the sudden traumatic acute injuries of the soft tissues. The overuse injuries, such as the tendinitis and bursitis, occur gradually over time and constantly injuring the soft tissue without allowing enough time to heal between occurrence.

            mild 2nd degree sprain, rotated inwards. (Photo credit: Wikipedia)
 

SPRAIN

A sprain is a sudden trauma involving one or more ligaments around a joint. The ligaments, similar to tendon and fascia which are connective tissues, are tough and fibrous connective tissues that connect one bone to another bone to maintain stability and resist mechanical stresses. Sprains can occur in any joint but are most common in the knee, ankle, wrist, and thumb. The injury can be minor that resolves in a few days or it can be a major injury requiring surgical intervention and a period of immobilization. Pain and rapid swelling follow after a sprain. In most cases, the severity of sprain depends on the pain and swelling. The greater it is, the more severe the injury is.

Causes

Risk factors that increase the occurrence of sprain include:

• Twisting, stretching or any excessive forces being applied to the joint that go beyond the functional range of motion 
• Fatigue of muscles predisposes to injury. A tired muscle doesn't give enough support to a joint
• A fall and landing on an outstretched arm, landing on the side of their foot, or twisting a knee with the foot planted firmly on the ground.
• Individuals with sedentary lifestyle, usually less or no physical activity
• Inadequate or no warm-up and cool-down regimen in an exercise or an activity  
• Bumping into a hard object or person such as contact sports
• Poor conditioning and poor techniques to an exercise or an activity

Signs and symptoms

• Pain around the affected joint
• Muscle pain and spasm
• Swelling follows soon after the injury
• Bruising may appear later sometimes at some distance from the affected joint (hematoma) or it may not appear at all
• Joint instability depends on the severity of the injury
• Sometimes may hear a popping sound or feel a tear 
• A loss of the ability to move and use of the affected extremity or to bear weight may lead to joint stiffness

Diagnosis

• Physical examination to demonstrate clinical presentation and method of injury
• X-ray for possible bone fracture
• Magnetic Resonance Imaging (MRI) performed for a detailed look at surrounding soft tissues and the ligament

Grading of injury

Grade I  

• Mild pain and swelling 
• Little to no instability, Little to no tear of the ligament 
• Stretched but intact with no loss of function

Grade II  

• Moderate pain and swelling, 
• Minimal instability of the joint 
• Partial tearing of the ligament from a third to almost all its fibers 
• Decrease in the ROM 

Grade III  

• Severe pain and swelling
• Significant instability of the joint
• Complete rupture of the ligament
• Significant decrease in ROM

                                                                        STRAIN                                                 

A strain is an injury involving the musculotendinous unit that involves a muscle, tendon or their attachment to bone.  Functionally, the tendons and muscles  tightly integrated to move bones.Tendons are fibrous cords of tissue with one end of the tendon connects to muscle and the other end of the tendon connects to a bone. The same with a sprain injury, any excessive forces that stretch or tear the muscle and/or tendons produce an injury. Muscle strains are particularly common in the legs and back, such as hamstring strains and lumbar (lower back) strains.

Causes

A strain caused by an excessive twisting or a pulling action to a muscle or tendon. This is common to contact sports and other sports that require extensive gripping and quick starts. 
The injury can be acute or chronic, just like in a sprain injury 

4 days after a pulled hamstring. Two images of the same leg. One of the pictures was shot through a mirror (Photo credit: Wikipedia)

Sign and Symptoms

• The severity is dependent on the extent of the injury.
• Pain and muscle spasm
• Localized swelling
• Loss of muscle function
• Limited joint range of motion

Grading of injury

Grade I  

• Localized pain, minimal swelling, and tender to touch

Grade II  

• Localized pain, moderate swelling, tenderness, and impaired motor function

Grade III  

• A palpable defect of the muscle, Severe pain, and poor motor function

Treatment of Sprain and Strain

In the acute phase, the focused is on the reduction of pain and swelling and further injury

• PRICE stands for protection, rest, ice, compression, and elevation 24 hours up to 72 hours to reduce pain and swelling or until swelling improves
• No heating such as hot baths or hot packs
• Refrain alcoholic beverages because it will increase bleeding and swelling, and slow down the healing process
• Massage may increase bleeding and swelling in the acute phase
• Don't avoid instead a reduction regular exercise or activities  
• Protection may include a non-weight bearing on the injured site using a crutch may help. A splint or brace may also be helpful for moderate injuries while a surgical repair required for severe injuries
• Apply an ice pack or a cold pack for 15 to 20 minutes to prevent frostbite, 6 to 8 times a day.
• Compression bandages to help reduces swelling
• Elevation of the injured extremity above heart level help also reduces swelling
• Prescription medication or over-the-counter pain relievers, such as ibuprofen (Advil, Motrin IB) and acetaminophen (Tylenol)  may be helpful to manage pain and inflammation during the healing process

Start the physical therapy programs early to prevent or minimize the effects of deconditioning. Depending on the patient's rate of recovery such as diminished pain and swelling, incorporate a series of exercises in the rehabilitation to help reduce swelling, prevent joint stiffness, and restore normal, pain-free range of motion. Exercises include: 

• Weight-bearing and balancing exercises
• Strengthening, endurance, and flexibility exercises to increase strength and regain flexibility
• Treatment modalities such as an Ultrasound, a soft-tissue massage or techniques, and a manual therapy techniques(Joint oscillation) help reduce pain and inflammation
• A  continuous passive motion (CPM) machine to maintain or promote flexibility of the joint.

As pain decreases and function improves, progression to functional training based on patient's occupation and/or recreational goals. Patient education and training/retraining for instrumental activities of daily living (IADL). A full recovery may allow a patient to return to full daily activities, including sports. Remind patient the potential danger in accelerating the rehabilitation program as it may lead to serious consequences.

Preventive measures

• Avoid exercising or doing sporting activities when you feel tired or in pain.
• Maintain a healthy, well-balanced diet to keep muscles strong and full of energy
• Wearing appropriate footwear designed for a specific activity such as sports shoes or a protective equipment. A high-heeled is more likely to sprain your ankle than if you wear flat shoes. 
• Practice safety measure to help prevent falls such as slippery floors, cluttered areas, and others
• Run on or walk on even surfaces may help
• A taping, strapping or wrapping your knees, ankles, wrists to protect joints. 
• Do regular stretching and strengthening exercises daily to maintain a healthy weight and promote general well-being
• Be in proper physical condition and in a high spirit to play a sport.
• A short warm-up and cool-down regimen that include stretching may help reduce injuries before engaging in any sports or exercise 

Lateral Epicondylitis (Tennis Elbow)

English: Lifting backpack (Photo credit: Wikipedia)

I. Overview

The most common overuse syndrome characterized by inflammation or degeneration at the common extensor tendon that joins the forearm muscles to the lateral epicondyle of the elbow. The forearm muscles and tendons become damaged from overuse leading to pain and tenderness on the outside of the elbow. It is a strain injury from playing tennis or other racquet sports. However, you can still get tennis elbow even if you are not a tennis player and is actually more common in non-tennis players. Any repetitive gripping activities or several other sports can also put you at risk. The structures primarily involved are the wrist extensors, particularly the extensor carpi radialis brevis. It also affect the extensor digitorum, extensor carpi radialis longus, and extensor carpi ulnaris.

II. Functional Anatomy

A synovial hinge joint formed between the distal end of the humerus in the upper arm and the proximal ends of the ulna and radius in the forearm. The elbow joint complex made up of four articulation,  the humeroulnar, humeroradial, superior radioulnar, and inferior radioulnar joints. Muscles, ligaments, and tendons hold the elbow joint together to provide functional movements and dynamic stabilization to perform skilled and precise motions. The coordination of multiple muscles allows two degrees of freedom of movements,  the combinations of flexion-extension and pronation-supination. The two epicondyles are actually the bony protuberance at the distal end of the humerus, the medial and lateral epicondyle. The forearm muscle tendons attach the muscle to bone. In lateral epicondylitis, the injury is on the tendon attachment on the lateral epicondyle of the humerus. The tendon usually involved is the Extensor Carpi Radialis Brevis (ECRB). Experiences pain and localized tenderness in the lateral side of the elbow.

Elbow - coude (Photo credit: Wikipedia)

III. Contributing factors

1. Overuse
Any repetitive wrist action against resistance during extension and supination may produce damage to the forearm muscle, particularly the extensor carpi radialis brevis muscle which stabilizes the wrist when the elbow is in extension. An example is ground stroke (backhand) in tennis.

2. Work and Activities 
There is a risk to any work or leisure activities that has no proper training, techniques, and equipment.

• Tennis/Racquetball/Squash - Check equipment for proper fit
• Fencing
• Weight Lifting
• Painters/Painting
• Carpenters/Bricklayers/Plumbers 
• Seamstresses/Tailors
• Cooks /Butchers
• Politicians (excessive handshaking)
• Musicians (pianists, drummers)
• Raking
• Knitting
• A lot of typing
• A lot of mouse work

3. Age
It is more common to individuals in their late 30's and 50's secondary to the normal loss of extensibility of connective tissue with age

4. Symptoms 
The symptoms of tennis elbow include pain and localized tenderness along the lateral aspect of the elbow especially over the lateral epicondyle that sometimes radiates into the dorsum of the hand although the damage is in the elbow. Pain usually increases with activity like picking up an object, holding a glass/cup, opening a door, or making shake hands. The elbow ROM is usually normal and involved only one side.

IV. Diagnosis

1. History Taking

• Information from patient
• Age of the patient (usual age group affected 30 to 50 years of age)
• How your current symptoms developed and medications
• Any occupational risk factors
• Recreational sports activities
• Family and Past medical history like an elbow injury before, history of rheumatoid arthritis or nerve disease

2. Physical Examination

• Inspections for swelling or ecchymosis.
• Palpation of the extremity for pain and tenderness at the lateral epicondyle
• The severity, the occurrence, and location of pain in relation to movement/activity
• Always examine ROM of the shoulder, elbow, and wrist on the affected side to evaluate for radiohumeral bursitis, osteochondritis of the capitellum, or PIN entrapment.

3. Tests

• Laboratory and imaging studies rarely needed
• X-ray or MRI (magnetic resonance imaging) to diagnose tennis elbow or rule out other problems like osteophytes, degenerative joint disease, or stress fracture
• Electromyography if there is radial nerve involvement
• Special orthopedic tests

Mills test

• The examiner palpates the patient’s lateral epicondyle with a thumb while passively pronating the forearm, flexing the wrist and extending the elbow.
• Positive test is reproduction of pain near the lateral epicondyle
• This test is also to use to indicate radial nerve involvement

Cozen’s test  

• Patient actively make a fist, pronate the forearm as well as radially deviate and extend the wrist against a counterforce that is being applied by the examiner.
• The positive test is the reproduction of pain near the lateral epicondyle.

Tennis elbow test

• The examiner resists the extension of the 3rd digit of the hand while stabilizing more proximal
• The positive test is the reproduction pain or discomfort in the region of the lateral epicondyle because it stress the extensor muscles and tendon

V. Differential Diagnoses

• Medial Epicondylitis
• Cervical Radiculopathy
• Plica Syndrome
• Elbow and Forearm Overuse Injuries
• Little League Elbow Syndrome
• Radial Nerve Entrapment 

Medical Intervention:
There are many treatment options for tennis elbow geared toward the goals of decreasing inflammation and analgesia. 

Nonsurgical Treatment
1. The patient is advice to avoid activities or work that aggravates the injury and treats pain and inflammation with protection, rest, ice, compression, and elevation.
2. Pharmacological intervention 

• Non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation such as ibuprofen, naproxen, or aspirin
• Monitor the effects on the gastrointestinal (GI) tract and renal function  with long-term use
• Topical NSAID such as diclofenac may offer some short-term relief.

3. Modalities

•  Ultrasound phonophoresis with hydrocortisone 
•  Electrical stimulation iontophoresis with NSAIDs and/or corticosteroid (dexamethasone) 

4. Counter-force bracing /Resting splints to relieve tension of the involved wrist extensor tendons
5. Physical therapy

•    Stretching to improve flexibility
•    Strengthening to increase functional activities
•    Progress from concentric to eccentric exercises and then resisted exercises as   tolerated
•   All exercise should be pain-free
•   Stretch and warm up before any sport or activity that will exercise your elbow or    arm.
•   Apply ice on your elbow after exercise

6. Steroid injections are very effective anti-inflammatory medicines to relieve symptoms.


Surgical Treatment
1. Recommended if the symptoms do not respond after 6 to 12 months of nonsurgical treatments
2. Surgical Option:
    a. Open surgery

• The most common approach to tennis elbow repair that involves making an incision over the elbow.

   b. Arthroscopic surgery

• This outpatient procedure involves using miniature instruments and small incisions. 

3. Rehabilitation

• Usually last 4 to 6 months postop
• Start the exercise with stretching and light, gradual strengthening exercise 2 months postop

4. Surgical risks

• Infection
• Nerve and blood vessel involvement
• Long-term rehabilitation process
• Loss of strength
• Loss of flexibility
• Possibility of another surgery

Home Care Program

• Give the same therapeutic program to the patient
• Patient education on modification of the activities that exacerbate the symptoms and use ice, elevation and rest as needed
• Advice patient about continued stretching and excercise to decrease the risk of recurrence
• Advice about the danger of rushing the recovery as it may worsen the damage

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