Disorders of the Soft Tissues
Your muscles, tendons, ligaments, and bursa are all susceptible to damage from daily stress and sports activities. These tissues can be stressed by an imbalance in muscle strength (when one muscle is much stronger than its opposing muscle), lack of ﬂexibility, or weakness caused by a previous injury. A fall, a sudden twisting motion, or a blow to the body is sufﬁcient to cause any of the following problems. Using the injured part before it has healed completely often leads to reinjury.
A bursa is a ﬂuid-ﬁlled sac between a bone and a tendon or muscle that allows the tendon to slide smoothly over the bone. Bursitis occurs when repeated stress and overuse cause the bursa to become inﬂamed and swollen with excess ﬂuid. Bursitis also can result from injury, rheumatoid arthritis, gout, or infection. Bursitis most often occurs in the shoulder but also can affect the hip, knee, elbow, Achilles tendon, or ankle. Often the nearby tendon also becomes swollen. Bursitis usually can be treated with rest, ice, and nonsteroidal anti-inﬂammatory medication. Occasionally it is necessary for a doctor to withdraw excess ﬂuid from the bursa using a needle and syringe. If an infection is present, the doctor will prescribe antibiotics. If there is no infection, the doctor may inject a
corticosteroid drug to relieve symptoms. Even with successful treatment, how- ever, the condition may recur. If bursitis recurs frequently, the affected bursa may be removed in a minor surgical procedure called bursectomy.
A contusion refers to a bruised muscle, tendon, or ligament. Following injury, blood pools (collects) in the injured area and discolors the skin. Most contusions respond well to RICE: rest, ice, compression, and elevation (see page 65). How- ever, if you do not see improvement or if the pain worsens, contact your doctor as soon as possible so he or she can take steps to prevent permanent damage to the soft tissues.
Sprain versus Strain
Many people use the terms “sprain” and “strain” inter- changea bly. However, a sprain refers to stretching or tearing of ligaments (which connect bone to bone), while a strain refers to stretching or tearing of tendons (which connect muscle to bone) and their attached muscles. Sprains most often occur as a result of excessive twisting motion in the ankle, knee, or wrist. Strains often occur in the foot or leg. Mild sprains and strains are treated with RICE (see page 65) followed by gentle exercises to relieve the pain and restore mobility.
Tendons are cordlike tissues that connect muscle to bone. Inﬂammation of a tendon is called tendinitis. The condition usually results from excess friction between a tendon and a bone. Tendinitis usually occurs after long-term stress that aggravates a speciﬁc tendon. Profes- sional athletes and workers engaged in repetitive job activities are at high risk for tendinitis. Although any ten- don can become inﬂamed, the tendons of the shoulder, wrist, heel (Achilles tendon), and elbow are most sus- ceptible to overuse injuries.
Symptoms of tendinitis include pain, tenderness, and, in some cases, restricted movement of the attached muscle.
Treatment of tendinitis may include making changes in your activities or routine, receiving corticosteroid injections, taking nonsteroidal anti-inﬂammatory med- ications such as aspirin or ibuprofen, splinting (immobi- lizing the tendon), and performing exercises to correct muscle strength imbalance and improve ﬂexibility. Persistent inﬂammation that does not respond to other forms of treatment may require surgery.
Only the common cold causes more missed days of work than low back pain. The lower (or lumbar) region of the spine connects your upper body (chest and abdomen) to your lower body (hips and legs) and provides tremendous mobility and strength. Twisting, turning, bending, standing, lifting, and walking all rely on the lower back.
Back pain may range from a mild ache or stiffness to severe pain that prevents movement of any sort. Stress on or injury to the muscles and ligaments that
support the spine are a common source of back pain. A sedentary lifestyle and being overweight increase the back’s vulnerability to stress and injury. Strenuous sports activities and physically demanding jobs can also cause stress and injury to the back. In addition, aging increases the risk of back injury due to age-related changes, osteoporosis, and arthritis. A prolapsed disk (when one of the pads of cartilage between the vertebrae of the spine protrudes and presses on a ligament or a nerve, causing back pain) also is more likely to occur in older adults.
When back pain is chronic or severe or affects a person’s ability to func- tion normally, it requires treatment. Contact your doctor if the pain is not relieved within a few days, is severe and constant, recurs, or is accompanied by other symptoms, such as radiating pain, numbness, tingling, weakness, bowel or bladder incontinence, fever, or vomiting. Your doctor can assess the extent and seriousness of a back injury through a thorough physical examination (especially of the back and the legs). Depending on your symptoms and the results of the examination, you may need to undergo X rays, computed tomog- raphy (CT) scanning (see page 90), or magnetic resonance imaging (MRI; see page 90).
Most low back pain results from sprains or strains and will respond to self- treatment measures such as limited rest, anti-inﬂammatory drugs such as aspirin or ibuprofen, back stretching and strengthening exercises, and prevention (see box). In some cases the doctor may prescribe muscle relaxants to relieve symp- toms. Your doctor may recommend that you wear a lightweight brace to support your back. He or she also may recommend heat treatments and massage, or trac- tion (a treatment that stretches your spine with weights while you lie on your back). It is important to note that prolonged bed rest weakens the back muscles and is not recommended as a treatment for back pain.
Protecting Your Back
It is easier to prevent back injury than it is to treat it. If you injured your back in the past, you must be especially careful to avoid reinjury. You
can protect your back by doing the following:
• Exercise regularly.
• Stretch (especially before exercising).
• Strengthen your abdominal muscles (to support your back).
• Do not smoke.
• Maintain a healthy weight.
• Maintain correct posture (don’t slouch).
• Use straight-backed chairs and a ﬁrm mattress that support your back.
• Lift objects by bending at your knees rather than at your waist.
• Do not lift heavy objects.
• Avoid standing or sitting in one position for long periods.
• Support one leg on a small stool when standing, to ﬂatten and relax your lower back.
• Sleep on your back with a pillow supporting your bent knees.
• Manage your stress.
Disorders of the Joints
A joint is the point at which two or more bones meet. It is made up of the bones and muscles brought together at the joint, the ligaments (which connect bone to bone), the tendons (which connect muscle to bone), the bursae (which cushion the joint), and cartilage. The cartilage permits smooth movement of the joint and acts as a shock absorber between the bones. The entire joint is enclosed in a ﬁbrous capsule with a special lining (the synovium) that produces ﬂuid to reduce friction within the joint. Inﬂammation of or damage to any of these components affects the entire joint. This section describes some common problems that can affect the joints.
Arthritis is a general term that refers to inﬂammation of one or more joints. There are more than 100 arthritic disorders. Osteoarthritis, which most people refer to as simply arthritis, is a chronic joint disease that affects many middle- aged and older Americans. Osteoarthritis that has no obvious cause is called primary arthritis. Osteoarthritis that results from damage to the cartilage that covers the ends of the bones in a joint is called secondary arthritis. Injury and obesity are two factors that may be involved in the development of osteoarthritis. Heredity may also be a factor.
The symptoms of osteoarthritis include pain, tenderness, swelling, redness, and loss of motion or strength in the affected joint or joints. The pain tends to worsen toward the end of the day. In some people the joint may make cracking sounds when it is in motion. In osteoarthritis, joint cartilage gradually wears away, allowing adjoining bones to rub against each other. Painful outgrowths of bone (spurs) also may develop. Although symptoms usually do not appear until middle age, they can begin as early as between ages 20 and 30. Among adults under age 55, men and women are affected equally; after age 55, the incidence of osteoarthritis is higher in women. Joints in the hips, knees, spine, big toe, and ﬁngers are most commonly affected.
Osteoarthritis is diagnosed based on your symptoms and the results of a physical examination. X rays usually are taken to conﬁrm the diagnosis. There is no cure for osteoarthritis. Your doctor probably will prescribe a nonsteroidal anti-inﬂammatory drug to relieve symptoms. Severe episodes of inﬂammation may be treated by injecting a corticosteroid drug directly into the affected joint. Massage, heat treatments, and warm baths may help relieve symptoms. Regu- lar, gentle exercise (such as walking or swimming) will help your joints stay ﬂexible. Maintaining a healthy weight (see page 67) will reduce the strain on your joints. For some people doctors may recommend joint replacement (see page 310).
Rheumatoid arthritis is a chronic autoimmune disease in which the immune system attacks the synovial tissue, the membrane that lines the joints. It is the second most common form of arthritis and usually appears between ages 20 and
40. Although the cause of rheumatoid arthritis is unknown, there is a genetic component: if a close relative is affected, you are more likely to develop the dis- ease. There is no known cure.
In rheumatoid arthritis, the ﬂuid that lubricates the joints contains irritating chemicals that attack and damage the surfaces of the joints. The inﬂamed mem- brane swells and thickens, causing a wearing away of the joint cartilage, which leads to erosion of the bone and weakening of supporting tendons, ligaments, and muscles. The small joints in the hands, wrists, feet, ankles, and neck are most frequently affected, but the hips and the knees also can be affected. In most cases, more than one joint is affected and usually the same joints are affected on both sides, such as both hands.
Rheumatoid arthritis alternates between periods during which symptoms are present and periods with no symptoms. These periods can vary in length. When the disease is active, it causes redness, warmth, swelling, tenderness, pain, and stiffness in the affected joints. The severity of symptoms can vary from person to person. The joint damage resulting from the disease is not reversible; in advanced cases, the joints can become deformed.
A diagnosis of rheumatoid arthritis is based on the symptoms and an exami- nation of the joints. The doctor also can use X rays to detect damage—such as erosion of cartilage and bone—in the affected joints. A blood test also may be performed to check for a speciﬁc protein (an antibody called rheumatoid factor) that is present in most people who have rheumatoid arthritis.
Treatment of rheumatoid arthritis is similar to the treatment of osteoarthritis (see previous page). If treatment with nonsteroidal anti-inﬂammatory drugs is not effective, the doctor may prescribe other medications, including gold com- pounds such as auranoﬁn and aurothioglucose, and oral corticosteroids such as prednisolone and triamcinolone. The doctor also may prescribe antirheumatic drugs such as hydroxychloroquine and penicillamine. In severe cases, medica- tions such as azathioprine, cyclophosphamide, cyclosporine, and methotrexate sometimes are prescribed to suppress the inappropriate immune response.
For most people with rheumatoid arthritis, regular exercise can help main- tain ﬂexibility and strength in the joints. Your doctor can recommend suitable exercises and also may recommend that you work with a physical therapist to maintain or restore movement in your joints. For some people, surgery to remove the affected joint lining (a procedure called synovectomy) may provide relief. For severely damaged joints, a total joint replacement (see fol- lowing page) can reduce pain and restore movement, allowing a person to return to an active life.
Joint Replacement Because of engineering and medical advances, surgeons can now replace certain joints and restore their normal function. Joint replace- ment (called arthroplasty) has been used on the ankles, hands, wrists, and toes, but it is most often performed on the knee and the hip. With total joint replace- ment, the bone ends and cartilage are replaced with metal and plastic joint com- ponents. The metal component is inserted into the canal inside each long bone involved, while the plastic part covers or receives the metal “bone ends” as a car- tilagelike cushion, where bone meets bone. The joint components are usually attached to the bone tissue with an acrylic cement.
In hip replacement surgery, the end of the femur is replaced with a metal ball, and a plastic cup is cemented into the pelvis where the acetabulum (pelvic socket) would normally receive the end of the femur. In many patients, particularly younger ones, the plastic cup is not cemented into place to give time (with lim- ited activity) for the natural bone to grow and attach to it. In the knee, damaged bone ends are replaced with metal ends covered with plastic that can permit the same range of motion as a normal knee joint.
Joint replacement surgery lasts approximately 2 to 4 hours and requires a lengthy, structured recuperation period. The amount of recovery time required in the hospital depends on the nature of the surgery, your overall health, and whether you have any complications (such as infection, joint dislocation, or blood clots). You may be walking with support within a day of surgery, and you will start physical therapy immediately. You will probably be hospitalized for about a week, although full recovery can take up to 6 months. It is vital to main- tain an appropriate exercise and stretching program after the surgery to keep your new joint in good working order. Although replacement joints usually last at least 20 years, younger and more active patients may need to undergo revision surgery (surgery to repair or replace the artiﬁcial joint). Joint replacement sur- gery has an excellent success rate.