The knee is the largest joint of the body, and it is also the one most easily injured. The knee is made up of the lower end of the femur (the thigh bone), the upper end of the tibia (the shin bone), and the patella (the knee cap). Large ligaments support the knee, provide stability, and connect the bones. Other important structures include the meniscus (a cushion of cartilage), muscles, nerves, and blood vessels.

Knee injuries cause knee pain, especially for athletes. There are four major ligaments of the knee: the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the medial collateral ligament (MCL), and the lateral collateral ligament (LCL). Also, the meniscus is commonly injured, resulting in knee pain. Other causes of knee pain include Osgood-Schlatter Disease and Adolescent Anterior Knee Pain.

ACL Injury

The ACL extends from the front of the tibia and inserts on the back of the femur. This structure prevents excessive posterior movement of the femur on the tibia. The ACL is often torn when an athlete changes direction rapidly, slows down from running, or lands wrong from a jump. These types of injuries are common for athletes who ski, play basketball, or play football. The pain associated with a torn ACL is rated as moderate to severe and is typically described as sharp at first, and then throbbing or achy as the knee begins to swell. Most people report increased pain with bending or straightening of the knee.

PCL injury

PCL injuries are much less common compared to ACL injuries.  The PCL is often injured when an athlete receives a blow to the front of the lower leg, just below the knee or makes a simple misstep on the playing field. The PCL prevents the tibia from sliding backwards and works with the ACL to prevent pivoting of the knee. The symptoms of a PCL tear include knee pain, decreased motion, and swelling.

MCL Injury

Most injuries to the MCL are the result of a direct blow to the outside of the knee. Athletes who play soccer or football are at increased risk for this type of injury. The MCL spans the distance from the top of the tibia to the end of the femur on the inside of the knee. This structure prevents widening of the inside of the joint. A torn MCL causes swelling over the ligament, bruising, and feeling that the knee will give out or buckle.

LCL Injury

The LCL connects the end of the femur to the top of the fibula (the smaller shin bone). It is located on the outer aspect of the knee. The LCL helps to prevent unnecessary side-to-side movement of the knee joint. The LCL is usually torn from traumatic falls, motor vehicle accidents, or during sporting activities. Symptoms of a torn LCL depend on the severity of the tear and include pain, swelling, difficulty bending the knee, and instability of the joint.

Torn Meniscus

The meniscus is the rubbery, tough cartilage that sits between the femur and the tibia. This structure works as a shock absorber. Athletes are at risk for tears in this cartilage with cutting, pivoting, twisting, decelerating, or being tackled. There are two menisci of the knee and they lie between the femur and tibia, one on the inside and one on the outside of the joint. The symptoms of a meniscus tear include knee pain, swelling, popping sound within the knee, and limited motion of the joint.

Osgood-Schlatter Disease

Osgood-Schlatter disease is an overuse injury common among growing adolescents. This syndrome is caused by inflammation of the tendon below the patella. Athletes who participate in gymnastics, basketball, running, and soccer are at increased risk for this disease. The symptoms of Osgood-Schlatter disease include swelling, knee pain, and tenderness below the knee cap.

Adolescent Anterior Knee Pain

Young, active adolescents often complain of pain in the front and center region of the knee. This is called Adolescent Anterior Knee Pain, and it is not associated with any injury or damage to the knee structures. The cause of this syndrome is not clear, but experts believe that the complex anatomy of the knee joint contributes to the problem. The knee is extremely sensitive to problems of alignment and overuse. For teens, a number of factors are thought to be involved. These include poor flexibility, imbalance of the thigh muscles, problems with alignment, improper sports training techniques, improper use of equipment, and overdoing sports activities.

Symptoms of Adolescent Anterior Knee Pain include pain that begins gradually and is worse at night, popping sounds of the knee when climbing stairs or walking after prolonged sitting, pain during activities that repeatedly bend the knee, pain that causes the knee to buckle, and pain related to change in activity level or playing surface.

When to Seek Treatment

Seek medical attention immediately if you:

• Have severe knee pain
• Begin limping
• Notice swelling at the site of injury
• Hear a popping or clicking noise
• Feel that your knee is going to give out
• Cannot move your knee
• Cannot bear weight on your knee
• Have tenderness along any aspect of the knee or tibia
• Have pain with climbing stairs, walking, or running

Elbow and forearm tendon injury is common for overhead throwing athletes, such as baseball and softball players and those who play tennis. Acute tendon rupture can occur with repetitive, forceful overhead throwing. The biceps muscle is in the front portion of the upper arm, and it helps you rotate your forearm and bend your elbow. This structure is also necessary for shoulder stability.

The biceps tendons attach the biceps muscle to the bones of the shoulder and elbow. If you tear this tendon at the elbow, you lose strength in your arm and have significant weakness in supination (turning hand from palm down to palm up). Unless the biceps tendon is surgically repaired, there will be significant loss of arm function. The biceps tendon at the elbow region is the distal biceps tendon. The biceps tendon that attaches to the shoulder is the proximal biceps tendon.

Rupture of the proximal portion of the biceps tendon occurs often when there is a degenerative change within the tendon leading to structure failure. However, this tendon region could rupture during trivial activity. The primary cause of a distal biceps tendon tear is sudden injury.

Risk Factors

Those at risk for distal biceps tendon tears include men, age 30 or older. Smoking and the use of corticosteroids also increase the risk of these tears.

Symptoms

A distal biceps tendon tear causes the muscle to ball up near the shoulder, sometimes called the “popeye deformity”. Oftentimes, there is bruising at the elbow. If you tear this tendon, you may hear a “pop” at the elbow region. Pain is usually severe at first, but subsides after a couple of weeks. Other symptoms include weakness in twisting the forearm, swelling in the front of the elbow, and a gap in the front of the elbow.

Usually patients will have sudden pain associated with an audible snap in the area of their shoulder. The pain is usually not significant, and, as mentioned previously, some patients may experience pain relief after the rupture. After the ruptured tendon retracts, patients may notice a bulge in their arm at the biceps muscle. This is the retracted muscle bunched up in the arm, and is sometime referred to as a “Popeye Muscle,” because the muscle is more pronounced than normal.

Distal biceps tendon rupture is characterized by sudden pain over the front of the elbow after a forceful effort against a flexed elbow. Usually the patient will hear a snap and have pain where the tendon rupture occurs. Swelling and bruising around the elbow are also common symptoms of distal biceps tendon rupture.

Diagnosis

Medical History and Physical Examination

After discussing your symptoms, your doctor will review the events of the injury to determine how it occurred. During the physical examination, your doctor will feel the front of your elbow, looking for a gap in the tendon. He or she will test the supination strength of your forearm by asking you to rotate your forearm against resistance.

Your doctor will compare the supination strength to the strength of your opposite, uninjured forearm. In addition to the examination, your doctor may recommend imaging tests to help confirm a diagnosis.

Imaging Tests

X-rays. Although X-rays cannot show soft tissues like the biceps tendon, they can be useful in ruling out other problems that can cause elbow pain.
Magnetic resonance imaging (MRI). These scans create better images of soft tissues. They can show both partial and complete tears.

Treatment

Patients usually do not notice any loss of arm or shoulder function following a proximal biceps tendon rupture. A slight bulge in the arm, and some twitching of the retracted muscle are usually the most significant symptoms. Surgical repair of the proximal biceps tendon is usually only considered in the case of a younger patient who is more active.

The reason there is little functional loss following a proximal biceps tendon rupture is that there are actually two tendinous attachments of the biceps at the shoulder joint (that is why the muscle is named “bi-ceps,” meaning two heads). When the rupture occurs at the distal biceps tendon at the elbow, where there is only one attachment, surgical repair is much more commonly needed.

If pain persists following a proximal biceps tendon rupture, other causes of shoulder pain should be considered. These include impingement syndrome (rotator cuff bursitis), rotator cuff tears, or fractures around the shoulder.

Rupture of the distal biceps tendon at the elbow joint is much less common and accounts for less than 5% of biceps tendon ruptures. This injury is also usually found in middle-aged patients, although not always. There is usually some degree of tendinosus, or degenerative changes within the tendon, that predisposes the patient to rupture of the tendon.

The significance of a distal biceps tendon rupture is that without surgical repair, patients who experience complete rupture of the distal biceps tendon will notice loss of strength at the elbow. The strength will affect both the ability to bend the elbow against resistance, and the ability to turn the forearm to the palm-up position against resistance (for example, turning a doorknob or screwdriver).

Nonsurgical Treatment

Nonsurgical treatment may be considered for patients who are elderly and inactive, or who have medical problems that make them high-risk for modest surgery.

Patients must weigh the decision to proceed with nonsurgical treatment carefully, because restoring arm function with later surgery may not be possible.

The tendon should be repaired during the first 2 to 3 weeks after injury. After this time, the tendon and biceps muscle begin to scar and shorten.
While other options are available for patients requesting late surgical treatment for this injury, they are more complicated and generally less successful.

Surgical Treatment

If you and your doctor decide upon elbow surgery,the surgery is performed as an outpatient procedure under either regional or general anesthesia. Your procedure will most likely take between one and two hours. Following surgery, your arm will be placed in a splint for several days to immobilize the elbow and allow the wound to heal. During this time gentle wrist, hand and shoulder exercises are performed.

Early range of motion is begun within three to seven days after surgery depending on the type and extent of the reconstruction. You will be able to remove the splint and use a range of motion brace in order to avoid elbow stiffness. It is particularly important to achieve elbow extension (that is to be able to straighten the elbow fully).

Procedure

Doctors use several procedures to reattach the distal biceps tendon to the forearm bone. Some doctors prefer to use two incisions, while others only one incision. There are pros and cons to each approach.
Sometimes the tendon is attached with stitches through holes drilled in the bone. Other times, small metal implants are used to attach the tendon to the bone.

Be sure to carefully discuss the options available with your doctor.
X-rays showing metal implants called suture anchors that have been used to secure the biceps tendon to the bone.

Rehabilitation

Right after surgery, your arm may be immobilized in a cast or splint.
Your doctor will soon begin having you move your arm, often with the protection of a brace. He or she may prescribe physical therapy to help you regain range of motion and strength.

Resistance exercises, such as lightly contracting the biceps or using elastic bands, may be gradually added to your rehabilitation plan.
Be sure to follow your doctor’s treatment plan. Since the biceps tendon takes 2 to 3 months to fully heal, it is important to protect the repair by restricting your activities.

Light work activities can begin soon after surgery. But heavy lifting and vigorous activity should be avoided for several months.

Although it is a slow process, your commitment to your rehabilitation plan is the most important factor in returning to all the activities you enjoy.

The physical therapy team at Hoag is orthopedic specialized, and they will work closely with your surgeon to establish a personalized rehabilitation plan for you. About six weeks after your surgery, elbow strengthening exercises may begin. For patients who remain dedicated to physical therapy the chances of complete recovery are very high, at above 90 percent.

Frozen shoulder, or adhesive capsulitis, is a disorder characterized by pain and stiffness in the shoulder joint. The symptoms generally begin gradually but worsen over time. As more time passes, the shoulder becomes very difficult to move. Around 2% of the general population is affected with this condition, and it typically occurs more often in women between the ages of 40 and 60.

The shoulder is a ball-and-socket joint that consists of the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). With frozen shoulder, the shoulder capsule thickens and gets tight due to stiff bands of tissue called adhesions.

To diagnose this condition, the orthopedic specialist will perform a complete physical examination and take an extensive medical history. Tests that will help the doctor rule out other shoulder disorders include X-rays, MRI, and ultrasound.

What are the stages of frozen shoulder?

Frozen shoulder develops in three stages: freezing, frozen, and thawing. The “freezing” stage occurs slowly and pain worsens gradually. With this stage, you lose range of motion of the shoulder joint, and it typically lasts from 6 weeks to 9 months. In the “frozen” stage, the painful symptoms actually improve – only the stiffness remains. This stage lasts around 4 to 6 months, and daily activities are troublesome during this time. The “thawing” stage is where shoulder motion slowly returns to normal. This stage lasts around 6 months to 2 years.

What are the symptoms of frozen shoulder?

During the “freezing” stage, the shoulder joint becomes quite painful. Any movement of the shoulder leads to discomfort during this time. Stiffness occurs in the “frozen” stage and there is decreased range of motion. These symptoms improve during the “thawing” stage.

What causes frozen shoulder?

Experts do not fully understand the causes of frozen shoulder. There is no distinct connection to arm dominance or occupation. With this condition, the capsule that encases the shoulder joint becomes thickened and tightens, restricting movement. There are some factors that can put you at risk for developing this condition. These include:

• Age and Sex: People over the age of 40 are more likely to experience frozen shoulder, and it is more common among women.
• Diabetes: Frozen shoulder has been found to occur more commonly in the diabetic patient, affecting around 15% of the diabetic population.
• Other Diseases: There are some additional medical problems associated with frozen shoulder like hyperthyroidism, hypothyroidism, tuberculosis, cardiac disease, and Parkinsons disease.
• Immobilization: When the shoulder is immobilized for an extended period of time, frozen shoulder can develop. Possible conditions requiring immobilization include a broken arm, a rotator cuff injury, a stroke, or recovery from surgery.

How is frozen shoulder treated?

Frozen shoulder typically resolves with time, although it can take as long as three years. The focus of treatment is to control pain and to restore strength and motion of the shoulder joint. Nonsurgical measures include non-steroidal anti-inflammatory medications (NSAIDS), steroid injections, and physical therapy. The orthopedic specialist can also inject sterile water into the joint capsule to stretch the tissue and enhance movement. This is called “joint distension.”

If these conservative measures do not improve the symptoms, the orthopedic specialist may find it necessary to operate on the shoulder. The surgeon can perform manipulation under anesthesia or shoulder arthroscopy. During the manipulation procedure, the doctor will force your shoulder to move under an anesthetic so it will not be painful to you, making the capsule and scar tissue stretch.

This is done to release the tightening and increase the range of motion. With shoulder arthroscopy, the doctor cuts through tight portions of the joint capsule to increase motion of the shoulder. This can be done with tiny instruments and a small camera.