Duke Ahn, M.D.(Board Certified in Orthopaedic Surgery)

  • Monday - Friday: 8:00 AM - 5:00 PM
  • (562) 583-2250

Welcome to My blog Sites. This is your first post. Edit or delete it, then start blogging!

Information on adolescent anterior knee pain is also available in Spanish: Dolor de rodilla anterior en adolescentes.

This article addresses pain in the front and center of the knee. Pain located in the upper shinbone area, just below the kneecap, is a different condition and is discussed in Osgood-Schlatter Disease (Knee Pain).

A teenager or young adult who is physically active and participates in sports may sometimes experience pain in the front and center of the knee, usually underneath the kneecap (patella). This condition—called adolescent anterior knee pain—commonly occurs in many healthy young athletes, especially girls.

Adolescent anterior knee pain is not usually caused by a physical abnormality in the knee, but by overuse or a training routine that does not include adequate stretching or strengthening exercises. In most cases, simple measures like rest, over-the-counter medication, and strengthening exercises will relieve anterior knee pain and allow the young athlete to return to his or her favorite sports.

Anatomy

aakp-img1

The knee is the largest and strongest joint in your body. It is made up of the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap). The ends of the bones where they touch are covered with articular cartilage, a smooth slippery substance that protects the bones as you bend and straighten your knee.

Ligaments and tendons connect the thighbone to the bones of the lower leg. The four ligaments in the knee attach to the bones and act like strong ropes to hold the bones together.

Muscles are connected to bones by tendons. The quadriceps tendon connects the muscles in the front of the thigh to the kneecap. Stretching from your kneecap to your shinbone is the patellar tendon.

Causes

In many cases, the true cause of anterior knee pain may not be clear. The complex anatomy of the knee joint, which allows it to bend while supporting heavy loads, is extremely sensitive to small problems in alignment, activity, training, and overuse.

aakp-img2
The patella of this adolescent’s right knee is out of alignment and shifted toward the inside of her leg.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

For example, weakness in the quadriceps muscles at the front of the thigh may lead to anterior knee pain. When the knee bends and straightens, the quadriceps muscles help to keep the kneecap within a groove at the end of the femur. Weak quadriceps can cause poor tracking of the kneecap within the groove. This can place extra stress on tendons (potentially leading to tendinitis), or irritate the cartilage lining on the underside of the kneecap (chondromalacia patella).

There are other factors that may contribute to adolescent anterior knee pain:

Symptoms

The most common symptom of anterior knee pain is a dull, achy pain that begins gradually and is frequently activity related. Other common symptoms include:

Adolescent anterior knee pain syndrome does not usually cause swelling around the knee. Symptoms like clicking, locking, snapping, or giving way of the knee are also uncommon. These symptoms suggest a mechanical problem in the knee and are reasons to see your doctor.

Doctor Examination

If your knee pain will not go away and interferes with activity, visit your doctor.

Physical Examination

Your doctor will examine your knee to determine the cause of pain behind your kneecap and rule out other problems. He or she may ask you to stand, walk, jump, squat, sit, and lie down.

During the physical examination, your doctor will also check:

  • Alignment of the lower leg and the position of the kneecap
  • Knee stability, hip rotation, and range of motion of knees and hips
  • The kneecap for signs of tenderness
  • The attachment of thigh muscles to the kneecap
  • Strength, flexibility, firmness, tone, and circumference of front thigh muscles (quadriceps) and the back thigh muscles (hamstrings)
  • Tightness of the heel cord and flexibility of the feet
Tests
aakp-img3
In this x-ray of a bent knee taken from above, the patella is clearly out of alignment within the groove in the femur.
Reproduced from Schepsis AA: Patellar instability. Orthopaedic Knowledge Online Journal 2003; 1(12). Accessed February 2014.

X-rays. Plain x-rays provide detailed pictures of dense structures, like bone. Special x-ray views will help your doctor determine if there are any problems in the shape or position of the kneecap. Your doctor may x-ray both of your legs to look for differences between them.

Magnetic resonance imaging (MRI) scans. This imaging study can create better images of the soft tissues around your knee. Unless you are suffering from symptoms like locking or catching of the knee, an MRI is not usually ordered during the initial evaluation and work-up of anterior knee pain. However, if your symptoms persist and do not improve with treatment, your doctor may order an MRI at a follow-up visit. This imaging study will help your doctor determine if there is an internal problem within the knee joint, such as damage to the cartilage or ligaments.

Treatment

There are simple changes you can make to help relieve anterior knee pain.

Activity Changes

Stop doing the activities that make your knee hurt until the pain has resolved. This probably means changing your training routine. Switching to low-impact activities during this time will put less stress on your knee joint. Biking and swimming are good low-impact options. If you are overweight, losing weight will also help to reduce pressure on your knee.

Your knee pain may be related to your exercise technique. A trainer at school may be able to help you evaluate and improve upon your technique-such as how you land from a jump or push off from the starting block.

Resume running and other higher impact sports activities gradually.

Physical Therapy Exercises

Specific exercises will help you improve range of motion, strength, and endurance. It is especially important to focus on stretching and strengthening your quadriceps as these muscles are the main stabilizers of your kneecap. Your doctor may provide you with exercises or may recommend you visit a physical therapist who can develop an exercise program to improve your thigh muscle flexibility and strength.

It is very important to stick with the therapeutic exercise program for as long as your doctor or physical therapist prescribes. Anterior knee pain can return.

aakp-img4
Straight-leg raises are an effective exercise for strengthening the quadriceps muscles.
Ice

Applying ice after physical activity may relieve some discomfort. Do not apply ice directly to the skin. Use an ice pack or wrap a towel around the ice or a package of frozen vegetables. Apply ice for about 20 minutes at a time.

Orthotics and Footwear

Your doctor may recommend shoe inserts. Soft-, firm- and hard-molded arch supports can help prevent the foot from overpronating and relieve pain and fatigue. Different types of arch supports can be purchased at your local drugstore.

Be sure that your athletic shoes provide the correct support for your activities.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Over-the-counter medications such as ibuprofen and naproxen may help to relieve your pain. Always take these medicines with some food in order to avoid the potential side effect of stomach upset. If NSAIDs do not provide relief from the discomfort, consult your doctor for a more thorough evaluation.

Recovery

Adolescent anterior knee pain is usually fully relieved with simple measures. It may recur, however, if you do not make adjustments to your training routine or activity level. It is essential to maintain appropriate conditioning of the muscles around the knee, particularly the quadriceps and hamstrings.

There are additional steps that you can take to prevent recurrence of anterior knee pain. They include:

Last reviewed: October 2014

posna-logo

Reviewed by members of POSNA (Pediatric Orthopaedic Society of North America)

The Pediatric Orthopaedic Society of North America (POSNA) is a group of board eligible/board certified orthopaedic surgeons who have specialized training in the care of children’s musculoskeletal health. One of our goals is to continue to be the authoritative source for patients and families on children’s orthopaedic conditions. Our Public Education and Media Relations Committee works with the AAOS to develop, review, and update the pediatric topics within OrthoInfo, so we ensure that patients, families and other healthcare professionals have the latest information and practice guidelines at the click of a link.
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Knee arthroscopy is a surgical procedure that allows doctors to view the knee joint without making a large incision (cut) through the skin and other soft tissues. Arthroscopy is used to diagnose and treat a wide range of knee problems.

During knee arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your knee joint. The camera displays pictures on a video monitor, and your surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions, rather than the larger incision needed for open surgery. This results in less pain for patients, less joint stiffness, and often shortens the time it takes to recover and return to favorite activities.

KneeArthroscopy_img1

During arthroscopy, your surgeon can see the structures of your knee in great detail on a video monitor.

Anatomy


Your knee is the largest joint in your body and one of the most complex. The bones that make up the knee include the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap).

Other important structures that make up the knee joint include:

KneeArthroscopy_img2

The normal anatomy of the knee.

Anatomy


Your doctor may recommend knee arthroscopy if you have a painful condition that does not respond to nonsurgical treatment. Nonsurgical treatment includes rest, physical therapy, and medications or injections that can reduce inflammation.

Knee arthroscopy may relieve painful symptoms of many problems that damage the cartilage surfaces and other soft tissues surrounding the joint.

Common arthroscopic procedures for the knee include:

KneeArthroscopy_img3

(Left) A large meniscal tear called a “flap” tear. (Right) Arthroscopic removal of the damaged meniscal tissue.

 

Preparing for Surgery


Evaluations and Tests

Your orthopaedic surgeon may recommend that you see your primary doctor to assess your general health before your surgery. He or she will identify any problems that may interfere with the procedure. If you have certain health risks, a more extensive evaluation may be necessary before your surgery.

To help plan your procedure, your orthopaedic surgeon may order preoperative tests. These may include blood tests or an electrocardiogram (EKG).

Admissions Instructions

If you are generally healthy, your knee arthroscopy will most likely be performed as an outpatient. This means you will not need to stay overnight at the hospital.

Be sure to inform your orthopaedic surgeon of any medications or supplements that you take. You may need to stop taking some of these before surgery.

The hospital or surgery center will contact you ahead of time to provide specific details of your procedure. Make sure to follow the instructions on when to arrive and especially on when to stop eating or drinking prior to your procedure.

Anesthesia

Before your surgery, a member of the anesthesia team will talk with you. Knee arthroscopy can be performed under local, regional, or general anesthesia:

  • Local anesthesia numbs just your knee
  • Regional anesthesia numbs you below the waist
  • General anesthesia puts you to sleep

Your orthopaedic surgeon and your anesthesiologist will talk to you about which method is best for you.

Surgical Procedure


Positioning

Once you are moved into the operating room, you will be given anesthesia. To help prevent surgical site infection, the skin on your knee will be cleaned. Your leg will be covered with surgical draping that exposes the prepared incision site.

At this point, a positioning device is sometimes placed on the leg to help stabilize the knee while the arthroscopic procedure takes place.

Procedure

To begin the procedure, the surgeon will make a few small incisions, called “portals,” in your knee. A sterile solution will be used to fill the knee joint and rinse away any cloudy fluid. This helps your orthopaedic surgeon see the structures inside your knee clearly and in great detail.

KneeArthroscopy_img4

Your surgeon will insert the arthroscope and surgical instruments through small incisions called “portals.”

Your surgeon’s first task is to properly diagnose your problem. He or she will insert the arthroscope and use the image projected on the screen to guide it. If surgical treatment is needed, your surgeon will insert tiny instruments through other small incisions.

Specialized instruments are used for tasks like shaving, cutting, grasping, and meniscal repair. In many cases, special devices are used to anchor stitches into bone.

KneeArthroscopy_img5

(Left) A common type of meniscal tear is a “bucket handle” tear. (Right) A photo of a bucket handle tear taken through an arthroscope. Click the image below to watch a video of arthroscopic treatment for a bucket handle tear.

<iframe width=”520″ height=”360″ class=”youtube-embed” src=”http://www.youtube.com/embed/RPGOg0mBJIE?wmode=opaque&amp;rel=0″ frameborder=”0″ wmode=”opaque” allowfullscreen=””></iframe>

Closure

Most knee arthroscopy procedures last less than an hour. The length of the surgery will depend upon the findings and the treatment necessary.

Your surgeon may close each incision with a stitch or steri-strips (small bandaids), and then cover your knee with a soft bandage.

KneeArthroscopy_img6

A soft bandage will protect the incisions while they heal.

 

Complications


The complication rate after arthroscopic surgery is very low. If complications occur, they are usually minor and are treated easily. Possible postoperative problems with knee arthroscopy include:

  • Infection
  • Blood clots
  • Knee stiffness
  • Accumulation of blood in the knee

Recovery


After surgery, you will be moved to the recovery room and should be able to go home within 1 or 2 hours. Be sure to have someone with you to drive you home and check on you that first evening.

While recovery from knee arthroscopy is faster than recovery from traditional open knee surgery, it is important to follow your doctor’s instructions carefully after you return home.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Medications

In addition to medicines for pain relief, your doctor may also recommend medication such as aspirin to lessen the risk of blood clots.

Swelling

Keep your leg elevated as much as possible for the first few days after surgery. Apply ice as recommended by your doctor to relieve swelling and pain.

Dressing Care

You will leave the hospital with a dressing covering your knee. Keep your incisions clean and dry. Your surgeon will tell you when you can shower or bathe, and when you should change the dressing.

KneeArthroscopy_img7

Working with a physical therapist can help you achieve your best recovery.

Your surgeon will see you in the office a few days after surgery to check your progress, review the surgical findings, and begin your postoperative treatment program.

Bearing Weight

Most patients need crutches or other assistance after arthroscopic surgery. Your surgeon will tell you when it is safe to put weight on your foot and leg. If you have any questions about bearing weight, call your surgeon.

Rehabilitation Exercise

You should exercise your knee regularly for several weeks after surgery. This will restore motion and strengthen the muscles of your leg and knee.

Therapeutic exercise will play an important role in how well you recover. A formal physical therapy program may improve your final result.

Driving

Your doctor will discuss with you when you may drive. Typically, patients are able to drive from 1 to 3 weeks after the procedure.

Outcome


Many people return to full, unrestricted activities after arthroscopy. Your recovery will depend on the type of damage that was present in your knee.

Unless you have had a ligament reconstruction, you should be able to return to most physical activities after 6 to 8 weeks, or sometimes much sooner. Higher impact activities may need to be avoided for a longer time.

If your job involves heavy work, it may be longer before you can return to your job. Discuss when you can safely return to work with your doctor.

For some people, lifestyle changes are necessary to protect the joint. An example might be changing from high impact exercise (such as running) to lower impact activities (such as swimming or cycling). These are decisions you will make with the guidance of your surgeon.

Sometimes, the damage to your knee can be severe enough that it cannot be completely reversed with surgery.

If you found this article helpful, you may also be interested in Knee Arthroscopy Exercise Guide Knee Arthroscopy Exercise Guide.

Instructions: Select your height and weight and press the “Compute BMI” button. Your BMI and rating will be displayed in the results table.

While every orthopaedic evaluation is different, there are many commonly used tests that an orthopaedic surgeon may consider in evaluating a patient’s condition.

In general, the orthopaedic evaluation usually consists of:

Your medical history is taken to assist the orthopaedic surgeon in evaluating your overall health and the possible causes of your joint pain. In addition, it will help your orthopaedic surgeon determine to what degree your joint pain is interfering with your ability to perform everyday activities.

What the physician sees during the physical examination — which includes examination of standing posture, gait analysis (watching how you walk), sitting down, and lying down — helps to confirm (or to rule out) the possible diagnosis. The physical exam will also enable the orthopaedic surgeon to evaluate other important aspects of your hips and knees, including:

If you are experiencing pain in your hip joint, your back may be examined because hip pain may actually be the result of problems in the lower spine.

After the physical examination, X-ray evaluation is usually the next step in making the diagnosis. The X-rays help show how much joint damage or deformity exists. An abnormal X-ray may reveal:

Occasionally, additional tests may be needed to confirm the diagnosis. Laboratory testing of your blood, urine, or joint fluid can be helpful in identifying specific types of arthritis and in ruling out certain diseases. Specialized X-rays of the back can help confirm that hip pain isn’t being caused by a back problem. Magnetic Resonance Imaging (MRI) or a bone scan may be needed to determine the condition of the bone and soft tissues of the affected joint.

In order to assist the orthopaedic surgeon in making a diagnosis, it may be helpful to write down your answers to the following questions before the appointment:

The questions below provide a way to discuss your joint pain with your doctor or specialist, and whether you’re a joint replacement candidate. Take them with you to your doctor, and be sure to ask any additional questions you may have to address your concerns:

Ready to see an orthopaedic specialist about joint replacement to relieve your pain? Before you go, consider how you’d answer certain questions he or she may ask. Your specialist should also ask questions about your medical and health history. Of course, you should be as thorough as possible when answering.

Definition of Osteoporosis

Bone is a living tissue, comprising mainly calcium and protein. Healthy bone is always being remodeled; that is, small amounts are being absorbed in your body and small amounts are being replaced.

If more bone calcium is absorbed than is replaced, the density or the mass of the bone is reduced. The bone becomes progressively weaker, increasing the risk that it may break.

Osteoporosis means “porous bone.” This condition develops when bone is no longer replaced as quickly as it is removed.

Cause

More than 2 million fractures occur related to osteoporosis each year. Most people are unaware that they have osteoporosis until a fracture occurs.

The exact medical cause for osteoporosis is not known, but a number of factors are known to cause osteoporosis, including

The loss of bone tends to occur most in the spine, lower forearm above the wrist, and upper femur or thigh-the site of hip fractures. Spine fractures, wrist fractures, and hip fractures are common injuries in older persons.

A gradual loss of bone mass, generally beginning about age 35, is a fact of life for everyone. After growth is complete, women ultimately lose 30% to 50% of their bone density, and men lose 20% to 30%.

Women lose bone calcium at an accelerated pace once they go through menopause. Menstrual periods cease because a woman’s body produces less estrogen hormone, which is important for the maintenance of bone mass or bone strength. Your family doctor or gynecologist may evaluate and recommend a treatment program of estrogen replacement therapy, calcitonin or other medications. To be most effective, the treatment program should begin at menopause.

Prevention

Although osteoporosis will occur in all persons as they age, the rate of progression and the effects can be modified with proper early diagnosis and treatment.

During growth and young adulthood, adequate calcium nutrition and Vitamin D and regular weightbearing exercises, such as walking, jogging, and dancing, three to four hours a week, build strong bones and are investments in future bone health.

Smoking and consuming excessive amounts of alcohol should be avoided because they increase bone loss. As people age, appropriate intake of calcium and Vitamin D and regular exercise, as well as avoidance of smoking and excessive alcohol use, are necessary to reduce loss of bone mass.

Treatment

Family doctors working with your orthopaedic surgeon can evaluate whether your bone density has been reduced, and can evaluate the cause for the reduction. Early treatment for osteoporosis is the most effective way to reduce bone loss and prevent fractures. However, treatment programs after a fracture also are of value and may help to prevent future fractures.

Current treatment methods can reduce bone loss, but there are no proven methods of restoring lost bone. Building bones through adequate calcium intake and exercise when you are young is an investment that will pay off years later with a reduced risk of hip and other fractures.

Last reviewed: August 2009
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Transient osteoporosis of the hip is an uncommon condition that causes temporary bone loss in the upper portion of the thighbone (femur).

People with transient osteoporosis of the hip will experience a sudden onset of pain that intensifies with walking or other weight-bearing activities. In many cases, the pain increases over time and may become disabling.

Painful symptoms gradually subside and usually end within 6 to 12 months. Bone strength in the hip also returns to normal in the majority of people.

Despite the name, transient osteoporosis of the hip is very different from the more common age-related osteoporosis. Age-related osteoporosis is a painless, progressive condition that leads to a weakening of the bones throughout the body. Unlike transient osteoporosis, it can put people at greater long-term risk for fractures in different areas of the body.

For more information about age-related osteoporosis: Osteoporosis

Anatomy

The hip is one of the body’s largest joints. It is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

In transient osteoporosis of the hip, the femoral head loses density and strength.

toh-img1
Normal hip anatomy.

Description

Transient osteoporosis of the hip is an uncommon condition that most often occurs in young or middle-aged men (between ages 30 and 60), and in women in the late stages of pregnancy (the last 3 months) or in the early post-partum period.

Transient osteoporosis most often occurs in the hip joint, but can also affect other joints in the leg, such as the knee, ankle and foot.

During the time that the bone is weakened, it is at greater risk for breaking.

Cause

Currently, there is no clear explanation for what causes this condition. Researchers are studying this disease and several theories have been proposed, although none are proven.

Some of the causes that have been suggested include:

Symptoms

Doctor Examination

Because transient osteoporosis of the hip is not a common condition, doctors often diagnose it by ruling out other, more frequent sources of hip pain. Arthritis, osteonecrosis, stress fracture, muscle injury, and tumor are all conditions that your doctor may consider during your evaluation.

Medical History and Physical Examination
toh-img2

 

Your doctor will test the range of motion in your hip.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

 

Your doctor will talk to you about your symptoms and when they first began. He or she may ask you whether you can remember any injury to the joint.

During the physical examination, your doctor will have you move your leg in different directions to assess your range of motion and try to replicate the pain. Most patients with transient osteoporosis of the hip have more pain when they move the hip themselves (active range of motion) as opposed to when the doctor moves the hip for them (passive range of motion). In addition, pain is often felt only with extremes of hip movements, and it usually worsens with any weight bearing. This discrepancy (severe pain with weight bearing, but minimal pain with passive range of motion) is one of the clues to the diagnosis of transient osteoporosis.

Tests
    • X-rays. In the early course of the disease (the first 6 weeks), x-ray images may show a subtle decrease in the bone density of the femoral head, but this may be hard to see. Several months later, x-rays may show a dramatic loss of bone density with a near complete disappearance of the femoral head. This temporary loss of bone density is why the disease is termed “transient osteoporosis of the hip.”
toh-img3

 

This x-ray of the pelvis shows early changes in bone density in the affected hip (white arrows).
Reproduced with permission from Korompilias AV, Karantanas AH, Lykissas MG, Beris AE: Transient osteoporosis. J Am Acad Orthop Surg 2008; 16:480-489.
    • Other imaging scans. Because x-rays may not show bone loss until the condition is well-advanced, your doctor may order other types of imaging tests to identify the cause of your symptoms. Computed tomography (CT) scans and magnetic resonance imaging (MRI) scans can provide more detailed images. MRI scans provide clear images of the soft tissues surrounding the hip. A nuclear medicine bone scan can more clearly show changes in bone caused by infection or injury. (A nuclear medicine bone scan should not be confused with a Dual Energy X-ray Absortiometry (DEXA) scan. A DEXA scan is a study that tests for generalized bone density, and while it is the gold-standard in testing for age-related osteoporosis, it is not effective in diagnosising transient osteoporosis of the hip.)

If you are pregnant, your doctor may decide to delay imaging studies until the last stages of your pregnancy, or even until after the delivery. Generally, MRI is safe to obtain in pregnancy, although you should discuss this with your orthopaedic surgeon, your primary doctor, and your obstetrician if you are considering this test.

  • Laboratory tests. Currently there is no blood test that helps to diagnose this disorder. However, blood tests are often very helpful in ruling out other causes of hip pain, such as metabolic (nutritional) disorders, endocrine (hormonal) disorders, and metastatic disease (cancer).
Bone Marrow Edema

One of the most common signs of transient osteoporosis of the hip is bone marrow edema. Bone marrow is a spongy substance that produces blood cells and is located in the hollow of long bones. In bone marrow edema, the bone marrow is inflamed and full of fluid.

An MRI scan of a hip affected by transient osteoporosis will usually reveal bone marrow edema. Because of this, MRI is one of the most useful studies to help diagnose the condition.

 

toh-img4

 

This MRI image shows edema surrounding the affected hip. Edema causes the bone to appear white in the MRI image.
Reproduced with permission from Korompilias AV, Karantanas AH, Lykissas MG, Beris AE: Transient osteoporosis. J Am Acad Orthop Surg 2008; 16:480-489.

Treatment

Because transient osteoporosis resolves on its own, treatment focuses on minimizing symptoms and preventing any damage to the bones while they are weakened by the disorder.

Outcomes

With proper diagnosis and treatment, most patients with transient osteoporosis of the hip can expect complete resolution of symptoms within 6 to 12 months. Bone strength in the hip also will return to normal in the majority of cases.

In a small percentage of patients, transient osteoporosis recurs later in life. It can return to the same hip or even in the opposite hip. Whether the condition will recur is difficult to predict.

Last reviewed: July 2013
Contributed and/or Updated by: Jared R. H. Foran, MD
Peer-Reviewed by: Stuart J. Fischer, MD
Contributor Disclosure Information

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Bursae are small, jelly-like sacs that are located throughout the body, including around the shoulder, elbow, hip, knee, and heel. They contain a small amount of fluid, and are positioned between bones and soft tissues, acting as cushions to help reduce friction.

Pes anserine bursitis is an inflammation of the bursa located between the shinbone (tibia) and three tendons of the hamstring muscle at the inside of the knee. It occurs when the bursa becomes irritated and produces too much fluid, which causes it to swell and put pressure on the adjacent parts of the knee.

Pain and tenderness on the inside of your knee, approximately 2 to 3 inches below the joint, are common symptoms of pes anserine bursitis of the knee.

Knee Tendon Bursitis_img1

Pain from pes anserine bursitis is located on the inside of the knee, just below the joint.

Cause


Bursitis usually develops as the result of overuse or constant friction and stress on the bursa. Pes anserine bursitis is common in athletes, particularly runners. People with osteoarthritis of the knee are also susceptible.

Several factors can contribute to the development of pes anserine bursitis, including:

Symptoms


The symptoms of pes anserine bursitis include:

Doctor Examination


Your doctor will examine your knee and talk to you about your symptoms.

Symptoms of pes anserine bursitis may mimic those of a stress fracture, so an x-ray is usually required for diagnosis.

Treatment


Athletes with pes anserine bursitis should take steps to modify their workout program so that the inflammation does not recur. Other treatments include:

If your symptoms continue, your orthopaedic surgeon may recommend surgical removal of the bursa. This is typically performed as an outpatient (same-day) procedure. If putting weight on your leg causes discomfort after the procedure, your doctor will recommend using crutches for a short time. Normal activities can typically be resumed within 3 weeks of the procedure.

 

Osteoporosis is a disease of progressive bone loss associated with an increased risk of fractures. The term osteoporosis literally means “porous bone.” Diagnosis of osteoporosis involves a measurement of bone mineral density (BMD).

Radiographic Measurement

The history of BMD measurement dates back to the 1940s. At that time, bone density was measured on plain radiographs (X-rays). However, because loss of bone density is not apparent on a plain X-ray until approximately 40% of the bone is lost, different methods of BMD measurement have been developed.

Singh Index

The Singh index describes the trabecular patterns in the bone at the top of the thighbone (femur). X-rays are graded 1 through 6 according to the disappearance of the normal trabecular pattern. Studies have shown a link between a Singh index of less than 3 and fractures of the hip, wrist, and spine.

Radiographic Absorptiometry

Radiographic absorptiometry was developed during the late 1980s as an easy way to determine BMD with plain X-ray. An X-ray of the hand is taken, incorporating an aluminum reference wedge. The X-ray is then analyzed, and the density of the bone is compared to the density of the reference wedge.

Single-Photon Absorptiometry

In the early 1960s, a new method of measuring BMD, called single-photon absorptiometry (SPA), was developed. In this method, a single-energy photon beam is passed through bone and soft tissue to a detector. The amount of mineral in the path is then quantified. The distal radius (wrist) is usually used as the site of measurement because the amount of soft tissue in this area is small.

SPA measurements are accurate, and the test usually takes about 10 minutes. The radioactive source gradually decays, however, and must be replaced after some time.

Dual-Photon Absorptiometry

Dual-photon absorptiometry (DPA) uses a photon beam that has two distinct energy peaks. One energy peak is absorbed more by the soft tissue. The other energy peak is absorbed more by bone. The soft-tissue component is subtracted to determine the BMD.

DPA allowed for the first time BMD measurements of the spine and proximal femur. However, although DPA is accurate for predicting fracture risk, the precision is poor because of decay of the isotope. In addition, the machine has limited usefulness in monitoring BMD changes over time.

Dual-Energy X-ray Absorptiometry

Dual-energy X-ray absorptiometry (DXA) works in a similar fashion to DPA, but uses an X-ray source instead of a radioactive isotope. This measurement technique is superior to DPA because the radiation source does not decay and the energy stays constant over time. DXA has become the “gold standard” for BMD measurement today.

Scan times for DXA are much shorter than for DPA, and the radiation dose is very low. The skin dose for an anteroposterior spine scan is in the range of 3 mrem.

DXA scans are extremely precise. Precision in the range of 1% to 2% has been reported. DXA can be used as an accurate and precise method to monitor changes in bone density in patients undergoing treatments.

The first generation DXA machines used a pencil beam-type scanner. The X-ray source moved with a single detector. Second-generation machines use a fan-beam scanner that incorporates a group of detectors instead of a single detector. These machines are considerably faster and produce a higher resolution image.

Quantitative Computed Tomography

Measurement of BMD by quantitative computed tomography (QCT) can be performed with most standard CT scanners. QCT is unique in that it provides for true three-dimensional imaging and reports BMD as true volume density measurements.

The advantage of QCT is the ability to isolate an area of interest from surrounding tissues. QCT can, therefore, localize an area in a vertebral body of only trabecular bone, leaving out the elements most affected by degenerative change and sclerosis.

The radiation dose with QCT is about ten times that of DXA, and QCT tests may be more expensive than DXA.

Peripheral Bone Density Testing

Lower cost portable devices that can determine BMD at peripheral sites such as the radius, phalanges, or calcaneus are increasingly being used for osteoporosis screening. The advantage of using a portable device is the ability to bring BMD assessment to a population who otherwise would not be able to have the test. These machines are considerably less expensive than those that measure BMD in the hip and spine.

One of the problems with peripheral testing is that only one site is tested; thus, low bone density in the hip or spine may be missed. This may be a problem because of differences in bone density between different skeletal sites.

Although peripheral machines are considered accurate, doubts have been raised about their precision. Peripheral machines may not be good enough to monitor patients undergoing treatment for osteoporosis.

In postmenopausal women, differences in BMD between different skeletal sites is more common. BMD may be normal at one site and low at another site. In the early postmenopausal years, bone density in the spine decreases first because the bone turnover in this highly trabecular bone is greater than at other skeletal sites. Bone density becomes similar across the skeleton at approximately 70 years of age.

In early postmenopausal women–therefore, up to the age of 65 years–the most accurate site to measure BMD is probably the spine. In women older than 65 years, BMD is similar across the skeleton; therefore, it may not make much difference which site is measured.

Caution must be used when interpreting spine scans in elderly patients because degenerative changes may falsely elevate BMD values. BMD measurements are, however, mostly site specific, and the most accurate predictor of fracture risk at any site is a BMD measurement of the spine.

At present, peripheral BMD testing machines are good screening devices because of their portability, availability, and lower cost. However, the following patients may still need central testing, even if peripheral testing is normal:

Interpreting a Bone Density Report

The main purpose of obtaining a bone density test is to determine fracture risk. BMD correlates very well with risk of fracture. It is more powerful in predicting fractures than cholesterol is in predicting myocardial infarction or blood pressure in predicting stroke.

T-score

The T-score is the number of standard deviations (SD) above or below the young adult mean. The young adult mean is the expected normal value for the patient compared to others of the same sex and ethnicity. It is approximately what the patient should have been at their peak bone density at about age 20 years.

As a general rule, for every SD below normal the fracture risk doubles. Thus, a patient with a BMD of 1 SD below normal (a T-score of -1) has twice the risk of fracture as a person with a normal BMD. If the T-score is -2, the risk of fracture is four times normal. A T-score of -3 is eight times the normal fracture risk. Patients with a high fracture risk can be treated to prevent future fractures.

Other risk factors for fracture include a person’s eyesight, balance, leg strength, and physical agility. Age itself is an independent risk factor for fracture, independent of bone density. Osteoporosis patients that have had a previous fragility fracture are considered to have severe osteoporosis and have a high risk for future fractures.

Z-score

The Z-score is the number of SD the bone density measurement is above or below the value expected for the patient’s age.

Primary osteoporosis is age-related osteoporosis, with no secondary causes.

Secondary osteoporosis occurs when underlying agents or conditions induce bone loss. Some common causes of secondary osteoporosis are thyroid or parathyroid abnormalities, malabsorption, alcoholism, smoking, and the use of certain medications especially corticosteriods.

A Z-score lower then -1.5 is suggestive of secondary osteoporosis. If secondary causes are suspected, laboratory testing should be performed to find out if there is an underlying reason for the osteoporosis. This is important because treating the underlying condition may be necessary to correct the low bone density.

Last reviewed: August 2007
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Weightbearing Exercise for Women and Girls

If you want strong bones, you have to use them! Everyone needs lifelong weight-bearing exercise to build and maintain healthy bones. Girls and young women especially should concentrate on building strong bones now to cut their risk of osteoporosis later in life.

A bone thinning disease that can lead to devastating fractures, osteoporosis afflicts many women after menopause and some men in older age. Osteoporosis is responsible for almost all the hip fractures in older people.

The disease is largely preventable if you get enough weight-bearing exercise when you’re young, stay active and continue other healthy habits as you age.

Bone Mass and Young Females

The maximum size and density of your bones (peak bone mass) is determined by genetics but you need weightbearing exercise to reach top strength. The best time to build bone density is during years of rapid growth.

Osteoporosis prevention is a special concern for females for a number of reasons:

Doing regular weightbearing exercise for the rest of your life can help maintain your bone strength.

What is “Weightbearing”?

Weightbearing describes any activity you do on your feet that works your bones and muscles against gravity. Bone is living tissue that constantly breaks down and reforms. When you do regular weightbearing exercise, your bone adapts to the impact of weight and pull of muscle by building more cells and becoming stronger.

Some activities recommended to build strong bones include:

Although they are excellent cardiovascular exercise choices, swimming and bicycling are not weightbearing activities, so are not as effective as the above activities in adding bone mass. If musculoskeletal conditions prevent weight-bearing exercise, then swimming and cycling are good alternatives. They do have some bone-building capacity.

You should exercise for at least 30 minutes a day, four or more days a week. Besides improving bone strength, regular exercise also increases muscle strength, improves coordination and balance, and leads to better overall health. To sustain the bone strengthening benefit of weightbearing activity, you must increase the intensity, duration and amount of stress applied to bone over time.

Additional Information

In addition to doing weightbearing exercise, to protect yourself from osteoporosis, you should also:

Premenopausal women who exercise too much or suffer from the eating disorder anorexia nervosa can also develop long term problems with weak bones if low body weight stops normal menstrual periods (amenorrhea). If this happens during rapid growth years, you could lose bone mass at a time when your body needs to be building it. See your doctor right away for diagnosis and treatment.

For more information, see the web site of national bone health campaign, Powerful Bones, Powerful Girls by the Department of Health and Human Services, Centers for Disease Control and Prevention and the National Osteoporosis Foundation:

The AAOS Women’s Health Issues Committee strongly supports the campaign.

Last reviewed: October 2007
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

As people age, their bones may become very weak and fragile — a condition called osteoporosis. It often develops unnoticed over many years, with no symptoms or discomfort until a bone breaks.

Fortunately, there are many things that people at all stages of life can do to build strong, healthy bones. Childhood and adolescence are especially important times for building bones and developing habits that support good bone health for life.

Healthy Bones Begin in Childhood

Bones grow in size during childhood, gaining mass and strength. The amount of bone mass you obtain while you are young determines your skeletal health for the rest of your life. The more bone mass you have after adolescence, the more protection you have against losing bone mass later.

Calcium and Nutrition

Good nutrition is vital for normal growth. Like all tissues, bone needs a balanced diet, enough calories, and appropriate nutrients, such as calcium. But not everyone follows a diet that is best for bone health. For example, the Institute of Medicine recommends a calcium intake for children ages 9 to 18 years of 1,300 mg/day (1,000 mg/day for children ages 4 to 8 years). Many children, however, have diets that do not meet this recommendation.

Calcium is the most important nutrient for reaching peak bone mass. It prevents and treats osteoporosis. Calcium is not made in the body — it must be absorbed from the foods we eat. To effectively absorb calcium from food, our bodies need Vitamin D.

Vitamin D can come from diet or exposure to sunlight. Before the development of fortified milk, lack of dietary Vitamin D caused rickets—a softening of the bones. Although rare in Western societies today, some children still develop rickets.

Most infants and young children in the United States get enough Vitamin D from fortified milk, but adolescents typically do not consume as many dairy products, and few foods contain substantial levels of the vitamin. Although exposure to sunlight can help our bodies make Vitamin D, it is not a practical or safe way for children to obtain the vitamin. To reduce the risk for skin cancer, it is important for children to wear sunscreen when playing outdoors. Because sunscreen blocks the absorption of Vitamin D, even children who spend a great deal of time outdoors may not meet their Vitamin D needs.

In addition, dieting and fasting to be thin may also harm nutrition and bone health. As a result, many children — especially adolescents — may not get adequate levels of Vitamin D. For children and teens to safely get the Vitamin D their bodies need, it may be helpful to take Vitamin D supplements. Talk to your doctor about whether Vitamin D supplements are needed.

Exercise

Sports and exercise are healthy activities for people of all ages. Weight-bearing exercise during the teen years is essential to reach maximum bone strength. Examples of weight-bearing exercise include walking and running, as well as team sports like soccer and basketball.

Occasionally, a female athlete who focuses on being thin or lightweight may eat too little or exercise too much. Young women who exercise excessively can lose enough weight to cause hormonal changes that stop menstrual periods (amenorrhea). This loss of estrogen can cause bone loss at a time when young women should be adding to their peak bone mass. It is important to see a doctor if there have been any menstrual cycle changes or interruptions.

Risk Factors for Poor Bone Health

Several groups of children and adolescents are at greater risk for poor bone health, including:

Childhood obesity may also play a role in reducing bone density, but more research is needed to separate the roles of other factors including diet, race, ethnicity, lifestyle, and sun exposure.

Prevention

Research is currently being done on ways to maximize peak bone mass in children but, for now, parents and children alike can benefit from the following suggestions:

Source: Recommended Dietary Allowance for calcium from the Food and Nutrition Board (FNB) at the Institute of Medicine of the National Academies (formerly National Academy of Sciences).

Last reviewed: April 2014
posna-logo
Reviewed by members of POSNA (Pediatric Orthopaedic Society of North America)

The Pediatric Orthopaedic Society of North America (POSNA) is a group of board eligible/board certified orthopaedic surgeons who have specialized training in the care of children’s musculoskeletal health. One of our goals is to continue to be the authoritative source for patients and families on children’s orthopaedic conditions. Our Public Education and Media Relations Committee works with the AAOS to develop, review, and update the pediatric topics within OrthoInfo, so we ensure that patients, families and other healthcare professionals have the latest information and practice guidelines at the click of a link.
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Definition of Osteoporosis

Bone is a living tissue, comprising mainly calcium and protein. Healthy bone is always being remodeled; that is, small amounts are being absorbed in your body and small amounts are being replaced.

If more bone calcium is absorbed than is replaced, the density or the mass of the bone is reduced. The bone becomes progressively weaker, increasing the risk that it may break.

Osteoporosis means “porous bone.” This condition develops when bone is no longer replaced as quickly as it is removed.

Cause

More than 2 million fractures occur related to osteoporosis each year. Most people are unaware that they have osteoporosis until a fracture occurs.

The exact medical cause for osteoporosis is not known, but a number of factors are known to cause osteoporosis, including

The loss of bone tends to occur most in the spine, lower forearm above the wrist, and upper femur or thigh-the site of hip fractures. Spine fractures, wrist fractures, and hip fractures are common injuries in older persons.

A gradual loss of bone mass, generally beginning about age 35, is a fact of life for everyone. After growth is complete, women ultimately lose 30% to 50% of their bone density, and men lose 20% to 30%.

Women lose bone calcium at an accelerated pace once they go through menopause. Menstrual periods cease because a woman’s body produces less estrogen hormone, which is important for the maintenance of bone mass or bone strength. Your family doctor or gynecologist may evaluate and recommend a treatment program of estrogen replacement therapy, calcitonin or other medications. To be most effective, the treatment program should begin at menopause.

Prevention

Although osteoporosis will occur in all persons as they age, the rate of progression and the effects can be modified with proper early diagnosis and treatment.

During growth and young adulthood, adequate calcium nutrition and Vitamin D and regular weightbearing exercises, such as walking, jogging, and dancing, three to four hours a week, build strong bones and are investments in future bone health.

Smoking and consuming excessive amounts of alcohol should be avoided because they increase bone loss. As people age, appropriate intake of calcium and Vitamin D and regular exercise, as well as avoidance of smoking and excessive alcohol use, are necessary to reduce loss of bone mass.

Treatment

Family doctors working with your orthopaedic surgeon can evaluate whether your bone density has been reduced, and can evaluate the cause for the reduction. Early treatment for osteoporosis is the most effective way to reduce bone loss and prevent fractures. However, treatment programs after a fracture also are of value and may help to prevent future fractures.

Current treatment methods can reduce bone loss, but there are no proven methods of restoring lost bone. Building bones through adequate calcium intake and exercise when you are young is an investment that will pay off years later with a reduced risk of hip and other fractures.

Last reviewed: August 2009
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Information on osteoporosis is also available in Spanish: Osteoporosis.

What is osteoporosis?

Osteoporosis is a disease of progressive bone loss associated with an increased risk of fractures. The term osteoporosis literally means porous bone. The disease often develops unnoticed over many years, with no symptoms or discomfort until a fracture occurs. Osteoporosis often causes a loss of height and dowager’s hump (a severely rounded upper back).

Why should I be concerned about osteoporosis?

Osteoporosis is a major health problem, affecting more than 44 million Americans and contributing to an estimated 2 million bone fractures per year. According to the National Osteoporosis Foundation, the number of fractures due to osteoporosis may rise to over 3 million by the year 2025.

 

osteoporosis-img1
Vertebrae showing signs of osteoporosis. Normal vertebrae (left), vertebrae with mild osteoporosis (center), and vertebrae with severe osteoporosis (right).

 

One in two women and one in four men older than 50 years will sustain bone fractures caused by osteoporosis. Many of these are painful fractures of the hip, spine, wrist, arm, and leg, which often occur as a result of a fall. However, performing even simple household tasks can result in a fracture of the spine if the bones have been weakened by osteoporosis.

The most serious and debilitating osteoporotic fracture is a hip fracture. Most patients who experience a hip fracture and previously lived independently will require help from their family or home care. All patients who experience a hip fracture will require walking aids for several months, and nearly half will permanently need canes or walkers to move around their house or outdoors. Hip fractures are expensive. Health care costs from hip fractures total more than $11 billion annually, or about $37,000 per patient.

What causes osteoporosis?

Doctors do not know the exact medical causes of osteoporosis, but they have identified many of the major factors that can lead to the disease.

Aging

Everyone loses bone with age. After 35 years of age, the body builds less new bone to replace the loss of old bone. In general, the older you are, the lower your total bone mass and the greater your risk for osteoporosis.

Heredity

A family history of fractures; a small, slender body build; fair skin; and Caucasian or Asian ethnicity can increase the risk for osteoporosis. Heredity also may help explain why some people develop osteoporosis early in life.

Nutrition and Lifestyle

Poor nutrition, including a low calcium diet, low body weight, and a sedentary lifestyle have been linked to osteoporosis, as have smoking and excessive alcohol use.

Medications and Other Illnesses

Osteoporosis has been linked to the use of some medications, including steroids, and to other illnesses, including some thyroid problems.

What can I do to prevent osteoporosis or keep it from getting worse?

osteoporosis-img2

 

To prevent osteoporosis, slow its progression, and protect yourself from fractures you should include adequate amounts of calcium and Vitamin D in your diet and exercise regularly.

Calcium

During the growing years, your body needs calcium to build strong bones and to create a supply of calcium reserves. Building bone mass when you are young is a good investment for your future. Inadequate calcium during growth can contribute to the development of osteoporosis later in life.

Whatever your age or health status, you need calcium to keep your bones healthy. Calcium continues to be an essential nutrient after growth because the body loses calcium every day. Although calcium cannot prevent gradual bone loss after menopause, it continues to play an essential role in maintaining bone quality. Even if women have gone through menopause or already have osteoporosis, increasing intake of calcium and Vitamin D can decrease the risk of fracture.

How much calcium you need will vary depending on your age and other factors. The National Academy of Sciences makes the following recommendations regarding daily intake of calcium:

  • Males and females 9 to 18 years: 1,300 mg per day
  • Women and men 19 to 50 years: 1,000 mg per day
  • Pregnant or nursing women up to age 18: 1,300 mg per day
  • Pregnant or nursing women 19 to 50 years: 1,000 mg per day
  • Women and men over 50: 1,200 mg per day

Dairy products, including yogurt and cheese, are excellent sources of calcium. An eight-ounce glass of milk contains about 300 mg of calcium. Other calcium-rich foods include sardines with bones and green leafy vegetables, including broccoli and collard greens.

If your diet does not contain enough calcium, dietary supplements can help. Talk to your doctor before taking a calcium supplement.

Vitamin D

Vitamin D helps your body absorb calcium. The recommendation for Vitamin D is 200-600 IU (international units) daily. Supplemented dairy products are an excellent source of Vitamin D. (A cup of milk contains 100 IU of Vitamin D. A multivitamin contains 400 IU of Vitamin D.) Vitamin supplements can be taken if your diet does not contain enough of this nutrient. Again, consult with your doctor before taking a vitamin supplement. Too much Vitamin D can be toxic.

Exercise Regularly

Like muscles, bones need exercise to stay strong. No matter what your age, exercise can help minimize bone loss while providing many additional health benefits. Doctors believe that a program of moderate, regular exercise (3 to 4 times a week) is effective for the prevention and management of osteoporosis. Weight-bearing exercises such as walking, jogging, hiking, climbing stairs, dancing, treadmill exercises, and weight lifting are probably best. Falls account for 50% of fractures; therefore, even if you have low bone density, you can prevent fractures if you avoid falls. Programs that emphasize balance training, especially tai chi, should be emphasized. Consult with your doctor before beginning any exercise program.

 

How is osteoporosis diagnosed?

osteoporosis-img3
Loss of height and a stooped appearance of a person with osteoporosis results from partial collapse of weakened vertebrae.

 

The diagnosis of osteoporosis is usually made by your doctor using a combination of a complete medical history and physical examination, skeletal x-rays, bone densitometry, and specialized laboratory tests. If your doctor diagnoses low bone mass, he or she may want to perform additional tests to rule out the possibility of other diseases that can cause bone loss, including osteomalacia (a metabolic bone disease characterized by abnormal mineralization of bone) or hyperparathyroidism (overactivity of the parathyroid glands).

Bone densitometry is a safe, painless x-ray technique that compares your bone density to the peak bone density that someone of your same sex and ethnicity should have reached at 20 to 25 years of age.

Bone densitometry is often performed in women at the time of menopause. Several types of bone densitometry are used today to detect bone loss in different areas of the body. Dual-energy x-ray absorptiometry (DEXA) is one of the most accurate methods, but other techniques can also identify osteoporosis, including single photon absorptiometry (SPA), quantitative computed tomography (QCT), radiographic absorptiometry, and ultrasound. Your doctor can determine which method is best suited for you.

How is osteoporosis treated?

Because lost bone cannot be replaced, treatment for osteoporosis focuses on the prevention of further bone loss. Treatment is often a team effort involving a physician or internist, an orthopaedist, a gynecologist, and an endocrinologist.

Although exercise and nutrition therapy are often key components of a treatment plan for osteoporosis, there are other treatments as well.

Estrogen Replacement Therapy

Estrogen replacement therapy (ERT) is often recommended for women at high risk for osteoporosis to prevent bone loss and reduce fracture risk. A measurement of bone density when menopause begins may help you decide whether ERT is right for you. Hormones also prevent heart disease, improve cognitive functioning, and improve urinary function. ERT is not without some risk, including enhanced risk of breast cancer; the risks and benefits of ERT should be discussed with your doctor.

Selective Estrogen Receptor Modulators

New anti-estrogens known as SERMs (selective estrogen receptor modulators) can increase bone mass, decrease the risk of spine fractures, and lower the risk of breast cancer.

Calcitonin

Calcitonin is another medication used to decrease bone loss. A nasal spray form of this medication increases bone mass, limits spine fractures, and may offer some pain relief.

Bisphosphonates

Bisphosphonates, including alendronate, markedly increase bone mass and prevent both spine and hip fractures.

ERT, SERMs, calcitonin, and bisphosphonates all offer patient with osteoporosis an opportunity to not only increase bone mass, but also to significantly reduce fracture risk. Prevention is preferable to waiting until treatment is necessary.

Your orthopaedist is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves. This has been prepared by the American Academy of Orthopaedic Surgeons and is intended to contain current information on the subject from recognized authorities. However, it does not represent official policy of the Academy and its text should not be construed as excluding other acceptable viewpoints.

Last reviewed: August 2009
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Information on osteoporosis is also available in Spanish: Osteoporosis.

What is osteoporosis?

Osteoporosis is a disease of progressive bone loss associated with an increased risk of fractures. The term osteoporosis literally means porous bone. The disease often develops unnoticed over many years, with no symptoms or discomfort until a fracture occurs. Osteoporosis often causes a loss of height and dowager’s hump (a severely rounded upper back).

Why should I be concerned about osteoporosis?

Osteoporosis is a major health problem, affecting more than 44 million Americans and contributing to an estimated 2 million bone fractures per year. According to the National Osteoporosis Foundation, the number of fractures due to osteoporosis may rise to over 3 million by the year 2025.

 

osteoporosis-img1
Vertebrae showing signs of osteoporosis. Normal vertebrae (left), vertebrae with mild osteoporosis (center), and vertebrae with severe osteoporosis (right).

 

One in two women and one in four men older than 50 years will sustain bone fractures caused by osteoporosis. Many of these are painful fractures of the hip, spine, wrist, arm, and leg, which often occur as a result of a fall. However, performing even simple household tasks can result in a fracture of the spine if the bones have been weakened by osteoporosis.

The most serious and debilitating osteoporotic fracture is a hip fracture. Most patients who experience a hip fracture and previously lived independently will require help from their family or home care. All patients who experience a hip fracture will require walking aids for several months, and nearly half will permanently need canes or walkers to move around their house or outdoors. Hip fractures are expensive. Health care costs from hip fractures total more than $11 billion annually, or about $37,000 per patient.

What causes osteoporosis?

Doctors do not know the exact medical causes of osteoporosis, but they have identified many of the major factors that can lead to the disease.

Aging

Everyone loses bone with age. After 35 years of age, the body builds less new bone to replace the loss of old bone. In general, the older you are, the lower your total bone mass and the greater your risk for osteoporosis.

Heredity

A family history of fractures; a small, slender body build; fair skin; and Caucasian or Asian ethnicity can increase the risk for osteoporosis. Heredity also may help explain why some people develop osteoporosis early in life.

Nutrition and Lifestyle

Poor nutrition, including a low calcium diet, low body weight, and a sedentary lifestyle have been linked to osteoporosis, as have smoking and excessive alcohol use.

Medications and Other Illnesses

Osteoporosis has been linked to the use of some medications, including steroids, and to other illnesses, including some thyroid problems.

What can I do to prevent osteoporosis or keep it from getting worse?

osteoporosis-img2

 

To prevent osteoporosis, slow its progression, and protect yourself from fractures you should include adequate amounts of calcium and Vitamin D in your diet and exercise regularly.

Calcium

During the growing years, your body needs calcium to build strong bones and to create a supply of calcium reserves. Building bone mass when you are young is a good investment for your future. Inadequate calcium during growth can contribute to the development of osteoporosis later in life.

Whatever your age or health status, you need calcium to keep your bones healthy. Calcium continues to be an essential nutrient after growth because the body loses calcium every day. Although calcium cannot prevent gradual bone loss after menopause, it continues to play an essential role in maintaining bone quality. Even if women have gone through menopause or already have osteoporosis, increasing intake of calcium and Vitamin D can decrease the risk of fracture.

How much calcium you need will vary depending on your age and other factors. The National Academy of Sciences makes the following recommendations regarding daily intake of calcium:

  • Males and females 9 to 18 years: 1,300 mg per day
  • Women and men 19 to 50 years: 1,000 mg per day
  • Pregnant or nursing women up to age 18: 1,300 mg per day
  • Pregnant or nursing women 19 to 50 years: 1,000 mg per day
  • Women and men over 50: 1,200 mg per day

Dairy products, including yogurt and cheese, are excellent sources of calcium. An eight-ounce glass of milk contains about 300 mg of calcium. Other calcium-rich foods include sardines with bones and green leafy vegetables, including broccoli and collard greens.

If your diet does not contain enough calcium, dietary supplements can help. Talk to your doctor before taking a calcium supplement.

Vitamin D

Vitamin D helps your body absorb calcium. The recommendation for Vitamin D is 200-600 IU (international units) daily. Supplemented dairy products are an excellent source of Vitamin D. (A cup of milk contains 100 IU of Vitamin D. A multivitamin contains 400 IU of Vitamin D.) Vitamin supplements can be taken if your diet does not contain enough of this nutrient. Again, consult with your doctor before taking a vitamin supplement. Too much Vitamin D can be toxic.

Exercise Regularly

Like muscles, bones need exercise to stay strong. No matter what your age, exercise can help minimize bone loss while providing many additional health benefits. Doctors believe that a program of moderate, regular exercise (3 to 4 times a week) is effective for the prevention and management of osteoporosis. Weight-bearing exercises such as walking, jogging, hiking, climbing stairs, dancing, treadmill exercises, and weight lifting are probably best. Falls account for 50% of fractures; therefore, even if you have low bone density, you can prevent fractures if you avoid falls. Programs that emphasize balance training, especially tai chi, should be emphasized. Consult with your doctor before beginning any exercise program.

 

How is osteoporosis diagnosed?

osteoporosis-img3
Loss of height and a stooped appearance of a person with osteoporosis results from partial collapse of weakened vertebrae.

 

The diagnosis of osteoporosis is usually made by your doctor using a combination of a complete medical history and physical examination, skeletal x-rays, bone densitometry, and specialized laboratory tests. If your doctor diagnoses low bone mass, he or she may want to perform additional tests to rule out the possibility of other diseases that can cause bone loss, including osteomalacia (a metabolic bone disease characterized by abnormal mineralization of bone) or hyperparathyroidism (overactivity of the parathyroid glands).

Bone densitometry is a safe, painless x-ray technique that compares your bone density to the peak bone density that someone of your same sex and ethnicity should have reached at 20 to 25 years of age.

Bone densitometry is often performed in women at the time of menopause. Several types of bone densitometry are used today to detect bone loss in different areas of the body. Dual-energy x-ray absorptiometry (DEXA) is one of the most accurate methods, but other techniques can also identify osteoporosis, including single photon absorptiometry (SPA), quantitative computed tomography (QCT), radiographic absorptiometry, and ultrasound. Your doctor can determine which method is best suited for you.

How is osteoporosis treated?

Because lost bone cannot be replaced, treatment for osteoporosis focuses on the prevention of further bone loss. Treatment is often a team effort involving a physician or internist, an orthopaedist, a gynecologist, and an endocrinologist.

Although exercise and nutrition therapy are often key components of a treatment plan for osteoporosis, there are other treatments as well.

Estrogen Replacement Therapy

Estrogen replacement therapy (ERT) is often recommended for women at high risk for osteoporosis to prevent bone loss and reduce fracture risk. A measurement of bone density when menopause begins may help you decide whether ERT is right for you. Hormones also prevent heart disease, improve cognitive functioning, and improve urinary function. ERT is not without some risk, including enhanced risk of breast cancer; the risks and benefits of ERT should be discussed with your doctor.

Selective Estrogen Receptor Modulators

New anti-estrogens known as SERMs (selective estrogen receptor modulators) can increase bone mass, decrease the risk of spine fractures, and lower the risk of breast cancer.

Calcitonin

Calcitonin is another medication used to decrease bone loss. A nasal spray form of this medication increases bone mass, limits spine fractures, and may offer some pain relief.

Bisphosphonates

Bisphosphonates, including alendronate, markedly increase bone mass and prevent both spine and hip fractures.

ERT, SERMs, calcitonin, and bisphosphonates all offer patient with osteoporosis an opportunity to not only increase bone mass, but also to significantly reduce fracture risk. Prevention is preferable to waiting until treatment is necessary.

Your orthopaedist is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves. This has been prepared by the American Academy of Orthopaedic Surgeons and is intended to contain current information on the subject from recognized authorities. However, it does not represent official policy of the Academy and its text should not be construed as excluding other acceptable viewpoints.

Last reviewed: August 2009
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Deep vein thrombosis, or DVT, occurs when a blood clot forms in one of the deep veins of the body. This can happen if a vein becomes damaged or if the blood flow within a vein slows down or stops. While there are a number of risk factors for developing a DVT, two of the most common are experiencing an injury to your lower body and having surgery that involves your hips or legs.

A DVT can have serious consequences. If a blood clot breaks free, it may travel through the bloodstream and block blood flow to the lungs. Although rare, this complication—called a pulmonary embolism—can be fatal. Even if a blood clot does not break free, it may cause permanent damage to the valves in the vein. This damage can lead to long-term problems in the leg such as pain, swelling, and leg sores.

In many cases, DVT occurs without noticeable symptoms and is very difficult to detect. For this reason, doctors focus on preventing the development of DVT using different types of therapies, depending upon a patient’s needs. Your doctor will take steps to prevent DVT if you have a major fracture or are having lower extremity surgery—including total hip or total knee replacement.

Deep Vein_img1

Blood clots may form in one of the deep veins of the body.

Description


Arteries are the blood vessels that carry oxygen-rich blood from the heart to all other parts of the body. Veins return the oxygen-depleted blood back to the heart. There are two types of veins in the body:

Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms within one of the deep veins. While DVT can occur in any deep vein, it most commonly occurs in the veins of the pelvis, calf, or thigh.

<iframe width=”520″ height=”360″ class=”youtube-embed” src=”http://www.youtube.com/embed/xM44LqJDNXA?wmode=opaque&amp;rel=0″ frameborder=”0″ wmode=”opaque” allowfullscreen=””></iframe>

Cause


Several factors can affect blood flow in the deep veins and increase the risk for developing blood clots. These include:

A broken hip or leg, or having major surgery on your hip, knee or lower leg can affect normal blood flow and clotting. In these orthopaedic situations, three primary factors contribute to the formation of blood clots in veins: slow blood flow, hypercoagulation, and damage to the veins.

Blood that Flows Slowly through Veins (Stasis)

The walls of the veins are smooth. This helps blood flow freely and mix with naturally occurring agents (anticoagulants) in the blood that keep the blood cells from clotting. Blood that does not flow freely and does not mix with anticoagulants may be more likely to lead to blood clots. This is why it is important to watch for signs of DVT in people who are on bed rest, immobilized in a splint or cast, or not able to move for long periods of time.

Hypercoagulation

Blood thickens, or coagulates, around matter that does not belong in the veins. During surgery, matter such as tissue debris, collagen, or fat may be released into the blood system and can cause the blood to coagulate. In addition, during total hip replacement, reaming and preparing the bone to receive the prosthesis may cause the body to release chemical substances called antigens into the blood system. These antigens can also stimulate clot formation.

Damage to the Vein Walls

During surgery, the doctor must move, or retract, soft tissues such as ligaments, muscles, and tendons to reach the area being operated on. In some cases, this can release naturally occurring substances that promote blood clotting.

Complications


Pulmonary Embolism

A pulmonary embolism is a blood clot that breaks free and travels through the veins. This can happen right after the formation of the blood clot or it may happen days later. If the blood clot reaches the lungs, it can block the flow of blood to the lungs and heart.

A pulmonary embolism is a serious medical emergency and can lead to death.

<iframe width=”520″ height=”360″ class=”youtube-embed” src=”http://www.youtube.com/embed/teDMDE3CUfM?wmode=opaque&amp;rel=0″ frameborder=”0″ wmode=”opaque” allowfullscreen=””></iframe>

Post-thrombotic Syndrome

Some people who have a DVT develop long-term symptoms in the calf, a condition called post-thrombotic syndrome. Post-thrombotic syndrome is caused when damage to the veins results in venous hypertension—or higher than normal blood pressure in the veins. This increased pressure can damage the valves that control blood flow through the veins. This allows blood to pool at the site—sometimes causing lasting impairment.

Patients with post-thrombotic syndrome may experience symptoms that can greatly impact the quality of life, including pain, swelling, skin changes, and leg sores.

Symptoms


Symptoms of DVT occur in the leg affected by the blood clot and include:

Many patients, however, experience no symptoms at all.

In some cases, a pulmonary embolism may be the first sign of DVT. Symptoms of pulmonary embolism include:

Doctor Examination


If your doctor suspects DVT, he or she will order diagnostic tests.

Tests

 Duplex ultrasound. This is the most common test for DVT. Ultrasound uses high-frequency sound waves that echo off the body—much like the technology used to check fetal well-being. This creates a picture of the blood vessels. Duplex ultrasound combines traditional ultrasound technology with Doppler technology, which generates a color image showing blood as it flows through the body.Ultrasound is both noninvasive and painless. It can be repeated regularly because it does not require radiation. If you do not have a blood clot, duplex ultrasound may be helpful in revealing other causes for your symptoms.

Deep Vein_img2

(Left) In an ultrasound, the technician places a noninvasive probe called a “transducer” over the patient’s leg. (Right) The transducer sends images to the ultrasound machine and screen.

Magnetic resonance imaging (MRI) scan. An MRI produces detailed, cross-sectional images of structures inside the body, including blood vessels and veins. The test is painless and noninvasive. Although used infrequently, some doctors may use an MRI to locate blood clots in the pelvis and thigh.

MRI allows both legs to be viewed at the same time. However, it cannot be used for patients with certain implanted devices, such as pacemakers.

Venography. In venography, the doctor injects a contrast solution (or dye) into a vein on the top of the foot. The solution mixes with the blood and flows throughout the veins. An x-ray of the affected leg will then show whether there are any blockages in the veins of the calf and thigh.

Venography is rarely used because it is invasive and requires radiation.

Treatment


Since DVT may occur after a major fracture or surgery, many patients are already hospitalized when the condition is diagnosed. The goals of treatment for DVT are to:

  • Stop the blood clot from getting bigger
  • Prevent the clot from breaking off and traveling to the lungs where it could lead to pulmonary embolism
  • Reduce the chance of developing another clot
  • Minimize the risk of developing other complications

Most often, treatment for DVT is nonsurgical.

Nonsurgical Treatment

Anticoagulants. Nonsurgical treatment usually consists of taking anticoagulants—blood thinning medications that will prevent further clotting and help dissolve existing clots. Anticoagulant medications are started immediately after the clot is diagnosed.

Anticoagulants can cause bleeding problems if the dosage is too high so their use must be monitored closely whether you are in the hospital or at home. Depending upon the medication you are taking, your doctor may order frequent blood tests to check how long it takes for your blood to clot. It is important to make sure that the medication level in your blood is high enough to prevent clots, but not too high to cause excessive bleeding.

The most common anticoagulants used to treat DVT are heparin, warfarin (Coumadin), and Xa inhibitors. In some cases, low molecular weight heparin (LMWH) may be used. LMWH is a type of anticoagulant derived from standard unfractionated heparin.

    • Heparin. Treatment for DVT usually begins with heparin (or LMWH) therapy. Standard heparin is given intravenously (injection into a vein) while LMWH is given by subcutaneous injection under the skin. LMWH has a short half life and is eliminated from the body in 12 hours. Dosing is based on body weight. For most adults, each dose is the same—unlike for standard heparin, where doses are frequently changed based on clotting times.

Since LMWH does not require an intravenous line or dose monitoring it can be given on an outpatient basis. The injections are given either by a visiting nurse or performed by the patients themselves.

  • Warfarin. Heparin (or LMWH) therapy is usually followed by 3 to 6 months of warfarin, which is taken orally. Warfarin takes at least 36 hours to start working, and from 4 to 5 days to reach its maximum effectiveness. For this reason, both heparin and warfarin are given at the start of treatment; the heparin protects the patient, keeping his or her blood anticoagulated until the warfarin “kicks in.”
  • Xa inhibitors. These newer anticoagulants, taken orally, may work as well as warfarin in some patients. Because they do not require regular blood test monitoring or frequent adjustments in dosing, they are becoming more widely prescribed. There are risks and benefits to all types of anticoagulants. Your doctor will discuss which medication will work best for you.

Observation and serial ultrasound. Depending on your individual risk factors, your doctor may manage an isolated, below the knee or calf DVT with observation and monitoring through serial duplex ultrasound scans, rather than anticoagulant therapy. Your doctor will discuss which type of treatment is right for you.

Thrombolytics. In some cases, your doctor may recommend using thrombolytics. These clot-dissolving medications are injected via a catheter directly into the blood clot and are used only when there is an extremely high risk for pulmonary embolism.

Surgical Treatment

If anticoagulants do not stop your blood clot from increasing in size, or if you have a medical condition that does not allow you to take anticoagulation medications, your doctor may recommend surgery to insert a small device called a vena cava filter into the main vein leading to your heart. This filter is designed to capture most blood clots traveling through your blood stream before they reach your lungs and cause a pulmonary embolism.

Prevention


If you are having orthopaedic surgery, your risk for developing DVT is highest from 2 to 10 days after surgery and includes the time after you have been discharged from the hospital. You remain at risk for about 3 months.

The measures your doctor uses to help prevent DVT are called prophylaxis. He or she will use several preventive measures in combination. For example, if you are having total knee or total hip replacement, your doctor may prescribe early movement and exercise, compression stockings, and medications that thin the blood and reduce the body’s ability to form blood clots.

Early Movement and Physical Therapy

Most patients begin walking or doing other leg exercises as soon as possible after surgery. Performing simple leg lifts while lying in bed will help increase blood flow through the veins. In addition, a physical therapist will teach you specific exercises to restore joint range of motion, strengthen your lower body, and improve circulation in your deep veins. If pain after surgery makes it difficult for you to move, you may be given pain medication so that you can move more comfortably.

In some cases, your doctor may also use a knee support that slowly moves your knee while you are in bed. This device is called a continuous passive motion (CPM) machine. Some doctors believe the device decreases leg swelling by elevating your leg and improves blood circulation by moving the muscles of your leg.

Compression Devices

Graded elastic compression stockings are tight at the ankle and become looser as they go up the leg. The compression they provide may help circulation by preventing blood from pooling in the veins.

In addition, your doctor may recommend that you use an external pneumatic compression device after surgery. This device, which is worn like a boot, applies pulsing pressures to the calf. This pressure is similar to that which you experience while you are walking. Compression devices not only improve venous blood flow but also stimulate the body’s own ability to prevent blood clots.

Deep Vein_img3

A pneumatic compression device.

Anticoagulants

Anticoagulants, or blood thinners, are used to stop blood clots from getting bigger and to prevent new blood clots from forming. If you are having joint replacement surgery, you will start anticoagulants the day after surgery and continue in the hospital and at home. The length of time that you take the medication will vary, depending on the type of surgery you have had, as well as other risk factors.

Additional Measures

If you have experienced a traumatic lower body injury, you may be treated with additional prophylactic measures. If you are unable to take anticoagulants, your doctor may implant a vena cava filter in the main vein leading to your heart. This is done to help prevent a potential DVT from reaching your heart and lungs and causing a pulmonary embolism.

Bone Health Basics

Bones. They give our bodies structure, allowing us to walk, ride a bike, and hold a child. They protect our organs and store our supply of calcium, a mineral necessary for building and maintaining strong bones.

In the last 15 years, we have learned a great deal about bones — the way they work, grow, rebuild, weaken, and break. We now know that diet and exercise can grow strong healthy bones in children, and help maintain them as we age.

Most importantly, we have learned more about bone metabolism — which is how bone rebuilds itself and stays healthy throughout our lives. We have learned that some people are at higher risk for osteoporosis because their bone metabolism does not support sufficient rebuilding of bone. A healthy diet and exercise can help, but cannot solve this problem. However, doctors can now identify people at risk and provide treatments to correct problems with bone metabolism.

ffws-img1

 

Normal skeletal anatomy
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4.Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

 

What we have learned about bone health is especially important as Americans are living longer. By 2020, half of all Americans over age 50 will have weak bones, according to the National Institutes of Health (NIH). We can improve this outcome by making changes to our diet and lifestyle, and preventing bone loss in people who are most at risk.

The good news is, no matter what your age, there are many things you can do to improve your bone health.

Bone Basics

Importance of Bones

Bones and the skeleton play many important roles in the body. They:

    • Store and supply calcium as needed for all of the cells and organs of the body
    • Give our bodies support and muscle attachments which allow us to move and use our limbs
    • Enclose and protect our vital organs
    • Provide space for bone marrow, where all types of blood and bone cells are made
FracturePrincipals1

 

In general, bones are made up of spongy, mesh-like cancellous bone covered by hard, compact cortical bone. At the center of many bones is soft bone marrow.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

 

In addition, bone cells respond to their environment to strengthen the structure of individual bones to resist fracture.

These complex functions occur within what appears to be a solid structure. And yet, while the outside of a bone looks like a rock, the inside more closely resembles lacy coral surrounded by a hard thick shell. Unlike a rock, a bone is living tissue that is constantly changing.

Bone Remodeling

After the body’s skeleton forms and grows to its adult size, it completely regenerates itself about every 10 years, through a process called remodeling. Remodeling removes old pieces of bone and replaces them with new, fresh bone. This keeps the bone and its cells healthy and strong, and allows the bones to supply calcium to the body.

Keeping the skeleton in good repair requires a balance between the removal and replacement of bone tissue. In young healthy adults, the amount of bone removed and replaced is about the same. This is called balanced bone remodeling and is controlled by your bone metabolism. As we age, the remodeling process may shift out of balance, resulting in loss of bone structure and strength, and lead to bone disease, such as osteoporosis.

ffws-img3

 

Enlarged photographs of the cancellous bone inside a vertebral bone in the spine. (Top) Healthy cancellous bone. (Bottom) Cancellous bone loss caused by osteoporosis. This weakened bone is at an increased risk for fracture.
Reproduced from Einhorn TA: The structural properties of normal and osteoporotic bone. Instr Course Lect 2003; 52: 533-539.

Nutrition and Bone Health

 

Sources of Calcium

 

Good sources of calcium include milk, cheeses, leafy green vegetables, and almonds.
© Thinkstock, 2012

 

Good nutrition is essential to ensuring that the body has the protein, minerals, and vitamins needed to make and regenerate bone.

Calcium, phosphorus, zinc, and magnesium are necessary minerals that must come from our diets. Vitamins D, K, and A are needed for normal bone metabolism. Without these nutrients, our bones can become weak and more likely to break.

Calcium and Vitamin D are well known for the important role they play in building strong bones. The skeleton is our body’s major storage bank for calcium, and Vitamin D helps our bodies effectively absorb calcium from our diets.

If we do not have enough calcium in our diets, calcium is removed from the skeleton, causing our bones to become weaker. Osteoporosis, the most common bone disease, can be worsened by a loss of calcium and other minerals.

Great sources of calcium are dairy products like yogurt and cheese, as well as cereals, soy products, and green leafy vegetables. Calcium supplements can also help if you generally avoid dairy products.

Physical Activity and Bone Health

Being active and following a regular exercise program are important to maintaining healthy bones. Weight-bearing exercise is especially important for maintaining bone strength and preventing osteoporosis.

Weight-bearing physical activity can slow bone loss in older people. Maintaining muscle mass also preserves and strengthens surrounding bone and helps prevent falls. Weight-bearing describes any activity you do on your feet that works your bones and muscles against gravity. Regular weight-bearing exercises — such as brisk walking, jogging, or team sports — turns on your body’s bone-forming cells and helps bones become stronger.

Maintaining Bone Health as You Age

As we age, our bones are affected by genetics, nutrition, exercise, and hormonal loss. We cannot change our genes but we can control our nutrition and activity level, and if necessary, take osteoporosis medications. You are never too old or too young to improve your bone health.

Bone can definitely get stronger or weaker over time depending on how we take care of it.

Tips for Healthy Bones

Each year, approximately 1.5 million older Americans suffer fractures because of weak bones, leading to temporary or permanent disability, and even death.

There are things you can do to maintain and even improve your bone strength.

  • Understand your individual risk for fracture. This is based on any risk factors you have for fracture and your bone density. Ask your doctor if you need a bone density test.
  • Understand your individual risk for bone loss. Genetics plays a role in bone health, and some people have genetically determined high rates of bone turnover after menopause or with aging. Talk to your doctor about bone metabolism testing. Bone metabolism testing can provide additional information about your risk for fracture.
  • Be active every day. Strength-building and weight-bearing activities help build strong bones. Children should exercise at least an hour each day, and adults should total 30 minutes of daily activity.
  • Maintain a healthy weight. Older adults who are overweight have a higher risk for falling. Being underweight raises the risk of bone loss.
  • Get enough calcium and Vitamin D.
  • Do not smoke. Smoking can reduce bone mass and increase your risk for a broken bone.
  • Limit alcohol use. Heavy alcohol use reduces bone mass and increases your risk for broken bones.
  • Reduce your risk of falling. There are many changes your can make in your home to help prevent a fall. Remove obstacles and add safety features — such as grab bars and non-slip mats — where needed.
  • Consider bone-boosting medications. In addition to calcium and Vitamin D supplements, there are many drug options that slow bone loss and increase bone strength. Talk to your doctor about these methods for protecting your bones.
Last reviewed: May 2012
Contributed and/or Updated by: Barbara J. Campbell, MD
Peer-Reviewed by: Stuart J. Fischer, MD
Contributor Disclosure Information

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

The health and strength of our bones rely on a balanced diet and a steady stream of nutrients, most importantly, calcium and Vitamin D.

Calcium is a mineral that people need to build and maintain strong bones and teeth. It is also very important for other physical functions, such as muscle control and blood circulation.

Calcium is not made in the body — it must be absorbed from the foods we eat. To effectively absorb calcium from food, our bodies need Vitamin D.

If we do not have enough calcium in our diets to keep our bodies functioning, calcium is removed from where it is stored in our bones. Over time, this causes our bones to grow weaker and may lead to osteoporosis — a disorder in which bones become very fragile.

Postmenopausal women are most vulnerable to osteoporosis. Although loss of estrogen is the primary reason for this, poor lifelong calcium and Vitamin D intake, as well as lack of exercise, play a role in the development of osteoporosis.

Note that men also are at risk for osteoporosis — typically later in life than women — and it is important for them to keep track of calcium intakes, as well.

Calcium

Calcium needs vary with age. The Food and Nutrition Board (FNB) of the Institute of Medicine of the National Academies provides guidelines on the amount of calcium needed each day.

Recommended Daily Allowance in Milligrams (mg)
Life Stage Group Recommended Daily Calcium Intake
Women and men 9 to 18 years 1,300 mg
Women and men 19 to 50 years 1,000 mg
Women 51 to 70 years 1,200 mg
Men 51 to 70 years 1,000 mg
Women and men > 70 years 1,200 mg
Pregnant or nursing women 14 to 18 years 1,300 mg
Pregnant or nursing women 19 to 50 years 1,000 mg
Reprinted and adapted with permission from Tables S-1 and S-2, Dietary Reference Intakes for Calcium and Vitamin D, 2011 by the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.
Dietary Sources of Calcium

People can get the recommended daily amount of calcium by eating a healthy diet that includes a variety of calcium-rich foods. Milk, yogurt, cheese, and other dairy products are the biggest food sources of calcium. Other high-calcium foods include:

  • Kale, broccoli, Chinese cabbage (bok choy) and other green leafy vegetables
  • Sardines, salmon, and other soft-bone fish
  • Tofu
  • Breads, pastas and grains
  • Calcium-fortified cereals, juices, and other beverages.

Sources of Calcium

Good sources of calcium include milk, cheeses, leafy green vegetables, and almonds.
© Thinkstock, 2012

A more complete listing of calcium-rich foods is included at the end of this article.

Some foods make it harder for the body to absorb calcium. In particular, sodas and carbonated beverages should be avoided, not just for bone health but for many nutritional reasons, including preventing obesity. Sodas decrease calcium absorption in the intestines and contain empty calories. Milk, calcium-fortified juices, and water are better beverage alternatives for all age groups.

Calcium Supplements

Although adequate calcium can be obtained through your diet, it is difficult for many people, particularly for those who avoid dairy products. People who are lactose-intolerant or vegetarians who do not eat dairy products have a harder time getting enough calcium from foods.

It is also hard to get enough calcium from the diet during certain times of our lives, such as in adolescence when our bodies require more calcium to build strong bones for life. Postmenopausal women and men older than age 70 also require more calcium to slow down bone loss.

Doctors recommend calcium supplements to those who do not get enough calcium from the foods they eat. Although calcium is sometimes found in multivitamins, it is typically not in significant amounts. Many people need to take separate calcium supplements to ensure they reach the Recommended Dietary Allowance for their life stage.

Not all the calcium consumed — whether through food or supplement — is actually absorbed in the intestines. Research shows that calcium is absorbed most efficiently when it is taken in doses less than 500 mg. Because many calcium supplements come in 500 mg doses, people who require 1,000 mg of supplementation each day should take their doses at separate times. Newer daily slow release formulations of calcium citrate that supply 1200 mg have recently become available.

Most calcium supplements also contain Vitamin D, which helps the body absorb calcium.

Vitamin D

Without Vitamin D, our bodies cannot effectively absorb calcium, which is essential to good bone health.

Children who lack Vitamin D develop the condition called rickets, which causes bone weakness, bowed legs, and other skeletal deformities, such as stooped posture. Adults with very low Vitamin D can develop a condition called osteomalacia (soft bone). Like rickets, osteomalacia can also cause bone pain and deformities of long bones.

Vitamin D Recommended Dietary Allowance

The FNB recommends 400 International Units (IU) of Vitamin D for infants during the first year of life. The RDA for everyone from age 1 through 70 years is 600 IU. Recent research, however, supports that the body needs at least 1000 IU per day for good bone health, starting at age 5 years.

Many foods contain some Vitamin D, however, few contain enough to meet the daily recommended levels for optimal bone health.

 

childrens supplements

 

The American Academy of Pediatrics recommends that all children take Vitamin D supplements.
© Thinkstock, 2012

 

In the 19th and early 20th centuries, children were routinely given cod liver oil for a range of medicinal purposes. When cod liver oil was tied to the prevention and treatment of rickets, Vitamin D was discovered. Soon after, Vitamin D was added to milk — one glass of milk contains about 100 IU of Vitamin D. As a result, parents stopped using cod liver oil. Because today’s children do not drink as much milk as in the past, it is difficult for them to get enough Vitamin D from milk. In addition, other dairy products are not typically supplemented with Vitamin D. Getting enough Vitamin D from what we eat is very difficult.

Although our bodies can make Vitamin D in our skin when it is exposed to good sunlight, it is very important to protect our skin by using sunscreen when we are outdoors. This blocks the excessive UV radiation that can cause skin cancer. Sunscreen does, however, also block our skin’s ability to make Vitamin D. This is why doctors often recommend Vitamin D supplements for both adults and children. The American Academy of Pediatrics recommends that all children — from infancy through adolescence — take Vitamin D supplements.

Safe Levels of Calcium and Vitamin D

Too much calcium and/or Vitamin D can be harmful and cause serious side effects. In addition to establishing RDA guidelines, the FNB has established Tolerable Upper Intake Levels (ULs). These represent the highest levels of calcium and Vitamin D that can be consumed by the average individual and still be safe.

These ULs are important guidelines for people who may require different dosages of these supplements. For example, people who live in areas with little sun, those with darker skin, and people who are obese may need more Vitamin D than the recommended daily amount.

Note that ULs are not levels that people should try to reach — they are the safe limits based on current research. When intake goes beyond the ULs listed below, the risk for serious side effects increases.

Upper Safe Limit for Calcium Intake
Life Stage Upper Safe Limit
Birth to 6 months 1,000 mg
Infants 7-12 months 1,500 mg
Children 1-8 years 2,500 mg
Children 9-18 years 3,000 mg
Adults 19-50 years 2,500 mg
Adults 51 years and older 2,000 mg
Pregnant and breastfeeding teens 3,000 mg
Pregnant and breastfeeding adults 2,500 mg
Upper Safe Limit for Vitamin D Intake
Age Male Female Pregnancy Lactation
0-6 months 1,000 IU 1,000 IU
7-12 months 1,500 IU 1,500 IU
1-3 years 2,500 IU 2,500 IU
4-8 years 3,000 IU 3,000 IU
≥9 years 4,000 IU 4,000 IU 4,000 IU 4,000 IU
Reprinted and adapted with permission from Tables S-1 and S-2, Dietary Reference Intakes for Calcium and Vitamin D, 2011 by the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.

More foods in the U.S. are being fortified with calcium and Vitamin D, and awareness of the importance of these nutrients for bone health is growing. In recent years, the media has reported on the potential health benefits of taking high levels of Vitamin D, such as in the areas of cancer prevention, diabetes management, and heart health. As a result, it is becoming more likely that people may consume unsafe quantities of these nutrients.

The FNB conducted an extensive review of the medical literature and found enough evidence of bone health benefits to support raising the UL levels on Vitamin D in adults from 2000 IU to 4000 IU. What was also determined, however, is that very high levels of Vitamin D (above 10,000 IUs per day) can cause kidney damage and dangerously high serum calcium levels. Too much calcium from dietary supplements can also cause adverse health effects, including kidney stones, higher risks for heart problems, and possibly increased risk for prostate cancer.

Calcium and Vitamin D are essential for good bone health, but must be consumed safely. If you are not sure what intake levels are right for you and your health needs, be sure to talk to your doctor.

Other Key Nutrients in Bone Health

Many other nutrients — most found naturally and at sufficient levels in a typical diet — contribute to bone health and growth. They include:

Dietary Sources of Calcium

Selecting foods high in calcium is one way to help you achieve your targeted daily calcium intake. Here are some major food sources of calcium to assist your meal planning.

Selected Food Sources of Calcium
Food Milligrams (mg) per serving Percent DV*
Yogurt, plain, low fat, 8 ounces 415 42
Orange juice, calcium-fortified, 6 ounces 375 38
Yogurt, fruit, low fat, 8 ounces 338-384 34-38
Mozzarella, part skim, 1.5 ounces 333 33
Sardines, canned in oil, with bones, 3 ounces 325 33
Cheddar cheese, 1.5 ounces 307 31
Milk, nonfat, 8 ounces** 299 30
Milk, reduced-fat (2% milk fat), 8 ounces 293 29
Milk, buttermilk, 8 ounces 282-350 28-35
Milk, whole (3.25% milk fat), 8 ounces 276 28
Tofu, firm, made with calcium sulfate, 1/2 cup*** 253 25
Salmon, pink, canned, solids with bone, 3 ounces 181 18
Cottage cheese, 1% milk fat, 1 cup 138 14
Tofu, soft, made with calcium sulfate, 1/2 cup*** 138 14
Instant breakfast drink, various flavors and brands, powder prepared with water, 8 ounces 105-250 10-25
Frozen yogurt, vanilla, soft serve, 1/2 cup 103 10
Ready-to-eat cereal, calcium-fortified, 1 cup 100-1,000 10-100
Turnip greens, fresh, boiled, 1/2 cup 99 10
Kale, fresh, cooked, 1 cup 94 9
Kale, raw, chopped, 1 cup 90 9
Ice cream, vanilla, 1/2 cup 84 8
Soy beverage, calcium-fortified, 8 ounces 80-500 8-50
Chinese cabbage (bok choy) raw, shredded, 1 cup 74 7
Bread, white, 1 slice 73 7
Pudding, chocolate, ready to eat, refrigerated, 4 ounces 55 6
Tortilla, corn, ready-to-bake/fry, one 6″ diameter 46 5
Tortilla, flour, ready-to-bake/fry, one 6″ diameter 32 3
Sour cream, reduced fat, cultured, 2 tablespoons 31 3
Bread, whole-wheat, 1 slice 30 3
Broccoli, raw, 1/2 cup 21 2
Cheese, cream, regular, 1 tablespoon 14 1

* DV = Daily Value. DVs were developed by the U.S. Food and Drug Administration to help consumers compare the nutrient contents among products within the context of a total daily diet. The DV for calcium is 1,000 mg for adults and children aged 4 years and older. Foods providing 20% of more of the DV are considered to be high sources of a nutrient, but foods providing lower percentages of the DV also contribute to a healthful diet. The U.S. Department of Agriculture’s Nutrient Database Web site lists the nutrient content of many foods. It also provides a comprehensive list of foods containing calcium.

** Calcium content varies slightly by fat content; the more fat, the less calcium the food contains.

*** Calcium content is for tofu that is processed with a calcium salt. Tofu processed with other salts does not provide significant amounts of calcium.

Source: National Institutes of Health (NIH) (Dietary Supplement Fact Sheet: Calcium): U.S. Department of Agriculture, Agricultural Research Service. 2011. USDA National Nutrient Database for Standard Reference, Release 24. Nutrient Data Laboratory Home Page; Institute of Medicine of the National Academies Dietary Reference Intakes for Calcium and Vitamin D.

Last reviewed: July 2012
Contributed and/or Updated by: Barbara J. Campbell, MD
Peer-Reviewed by: Stuart J. Fischer, MD
Contributor Disclosure Information

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

In 2010, there were roughly 10.4 million patient visits to doctors’ offices because of common knee injuries such as fractures, dislocations, sprains, and ligament tears. Knee injury is one of the most common reasons people see their doctors.

Your knee is a complex joint with many components, making it vulnerable to a variety of injuries. Many knee injuries can be successfully treated with simple measures, such as bracing and rehabilitation exercises. Other injuries may require surgery to correct.

Anatomy


The knee is the largest joint in the body, and one of the most easily injured. It is made up of four main things: bones, cartilage, ligaments, and tendons.

Common Knee Injuries_img1

Common Knee Injuries


Your knee is made up of many important structures, any of which can be injured. The most common knee injuries include fractures around the knee, dislocation, and sprains and tears of soft tissues, like ligaments. In many cases, injuries involve more than one structure in the knee.

Pain and swelling are the most common signs of knee injury. In addition, your knee may catch or lock up. Many knee injuries cause instability — the feeling that your knee is giving way.

Fractures

The most common bone broken around the knee is the patella. The ends of the femur and tibia where they meet to form the knee joint can also be fractured. Many fractures around the knee are caused by high energy trauma, such as falls from significant heights and motor vehicle collisions.

Common Knee Injuries_img2

Patellar fracture.

For more information about common fractures of the knee:

Patellar (Kneecap) Fractures
Distal Femur (Thighbone) Fractures of the Knee
Fractures of the Proximal Tibia (Shinbone)

Dislocation

A dislocation occurs when the bones of the knee are out of place, either completely or partially. For example, the femur and tibia can be forced out of alignment, and the patella can also slip out of place. Dislocations can be caused by an abnormality in the structure of a person’s knee. In people who have normal knee structure, dislocations are most often caused by high energy trauma, such as falls, motor vehicle crashes, and sports-related contact.

Common Knee Injuries_img3

Patellar dislocation.
Reproduced with permission from The Body Almanac. © American Academy of Orthopaedic Surgeons, 2003.

For more information about knee dislocation:

Unstable Kneecap
Patellar Dislocation and Instability in Children (Unstable Kneecap)

Anterior Cruciate Ligament (ACL) Injuries

The anterior cruciate ligament is often injured during sports activities. Athletes who participate in high demand sports like soccer, football, and basketball are more likely to injure their anterior cruciate ligaments. Changing direction rapidly or landing from a jump incorrectly can tear the ACL. About half of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments.

Common Knee Injuries_img4

Anterior cruciate ligament tear.

For more information about ACL injuries:

Anterior Cruciate Ligament (ACL) Injuries
ACL Injury: Does It Require Surgery?

Posterior Cruciate Ligament Injuries

The posterior cruciate ligament is often injured from a blow to the front of the knee while the knee is bent. This often occurs in motor vehicle crashes and sports-related contact. Posterior cruciate ligament tears tend to be partial tears with the potential to heal on their own.

Common Knee Injuries_img5

Posterior cruciate ligament tear (shown from back of knee).

For more information about PCL injuries:

Posterior Cruciate Ligament Injuries

Collateral Ligament Injuries

Injuries to the collateral ligaments are usually caused by a force that pushes the knee sideways. These are often contact injuries. Injuries to the MCL are usually caused by a direct blow to the outside of the knee, and are often sports-related. Blows to the inside of the knee that push the knee outwards may injure the lateral collateral ligament. Lateral collateral ligament tears occur less frequently than other knee injuries.

Common Knee Injuries_img6

Tears of the medial and lateral collateral ligaments.

For more information about collateral ligament injuries:

Collateral Ligament Injuries

Meniscal Tears

Sudden meniscal tears often happen during sports. Tears in the meniscus can occur when twisting, cutting, pivoting, or being tackled. Meniscal tears may also occur as a result of arthritis or aging. Just an awkward twist when getting up from a chair may be enough to cause a tear, if the menisci have weakened with age.

Common Knee Injuries_img7

Meniscal tear.

For more information about meniscal tears:

Meniscus Tears

Tendon Tears

The quadriceps and patellar tendons can be stretched and torn. Although anyone can injure these tendons, tears are more common among middle-aged people who play running or jumping sports. Falls, direct force to the front of the knee, and landing awkwardly from a jump are common causes of knee tendon injuries.

Common Knee Injuries_img8

For more information about tendon tears:

Patellar Tendon Tear
Quadriceps Tendon Tear

Treatment of Knee Injuries


When you are first injured, the RICE method — rest, ice, gentle compression and elevation – can help speed your recovery.

Be sure to seek treatment as soon as possible, especially if you:

  • Hear a popping noise and feel your knee give out at the time of injury
  • Have severe pain
  • Cannot move the knee
  • Begin limping
  • Have swelling at the injury site

The type of treatment your doctor recommends will depend on several factors, such as the severity of your injury, your age, general health, and activity level.

Common Knee Injuries_img9

Nonsurgical Treatment

Many knee injuries can be treated with simple measures, such as:

  • Immobilization. Your doctor may recommend a brace to prevent your knee from moving. If you have fractured a bone, a cast or brace may hold the bones in place while they heal. To further protect your knee, you may be given crutches to keep you from putting weight on your leg.
  • Physical therapy. Specific exercises will restore function to your knee and strengthen the leg muscles that support it.
  • Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.

Surgical Treatment

Many fractures and injuries around the knee require surgery to fully restore function to your leg. In some cases – such as many ACL tears — surgery can be done arthroscopically using miniature instruments and small incisions. Many injuries require open surgery with a larger incision that provides your surgeon with a more direct view and easier access to the injured structures.

Common Knee Injuries_img10

(Left) Knee arthroscopy. (Right) Close-up of an arthroscopic meniscal surgery.

SOURCE: Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL: AAOS; February 2014. Based on data from the National Ambulatory Medical Care Survey, 2010; Centers for Disease Control and Prevention.

This article is also available in Spanish: Huesos saludables en todas las edades (Healthy Bones at Every Age).

Bone health is important at every age and stage of life. The skeleton is our body’s storage bank for calcium — a mineral that is necessary for our bodies to function. Calcium is especially important as a building block of bone tissue.

We must get calcium from the foods we eat. If we do not have enough calcium in our diets to keep our bodies functioning, calcium is removed from where it is stored in our bones. Over time, this causes our bones to grow weaker.

Loss of bone strength can lead to osteoporosis — a disorder in which bones become very fragile and more likely to break. Older adults with osteoporosis are most vulnerable to breaks in the wrist, hip, and spine. These fractures can seriously limit mobility and independence.

Fortunately, there are many things we can do at every age to keep our bones strong and healthy.

Peak Bone Mass

Our maximum bone size and strength is called peak bone mass. Genes play a large role in how much peak bone we have. For example, the actual size and structure of a person’s skeleton is determined by genetic factors.

 

Teenage boy drinking milk

 

Between the ages of 10 and 20 we can greatly increase our peak bone mass with a calcium-rich diet and regular weightbearing exercise.
© Thinkstock, 2012

 

Although peak bone mass is largely determined by our genes, there are lifestyle factors — such as diet and exercise — that can influence whether we reach our full bone mass potential.

There is a limited time that we can influence our peak bone mass. The best time to build bone density is during years of rapid growth. Childhood, adolescence, and early adulthood are the times when we can significantly increase our peak bone mass through diet and exercise. Not surprisingly, we can also make choices that decrease peak bone mass, such as smoking, poor nutrition, inactivity, and excessive alcohol intake.

Most people will reach their peak bone mass between the ages of 25 and 30. By the time we reach age 40, however, we slowly begin to lose bone mass. We can, however, take steps to avoid severe bone loss over time. For most of us, bone loss can be significantly slowed through proper nutrition and regular exercise.

Although everyone will lose bone with age, people who developed a higher peak bone mass when young are better protected against osteoporosis and related fractures later in life.

Some people, however, are at higher risk for bone loss and osteoporosis because of problems with the way their bodies remodel bone. A healthy diet and exercise can help, but bone will still be lost at a faster rate. The good news is that in recent years, medications have been developed to treat this metabolic problem. In severe cases, bone loss may even be reversed with newer, bone-forming medications.

Gender and Peak Bone Mass

Men have a higher peak bone mass than women. Men accumulate more skeletal mass than women do during growth, and their bone width and size is greater. Because women have smaller bones with a thinner cortex and smaller diameter, they are more vulnerable to developing osteoporosis. Although men have a higher peak bone mass, they also are at risk for osteoporosis, especially after age 70 when bone loss and fracture risk increases significantly.

 

hbea-img2

 

This chart shows bone mass in women as it relates to age.
Reproduced from J Bernstein, ed: Musculoskeletal Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003.

Bone Health at Every Stage

There are things we can do at every stage of life to ensure good bone health. Especially important is making sure we get enough calcium and Vitamin D. The sections below provide guidelines from the Food and Nutrition Board (FNB) at the Institute of Medicine of the National Academies on calcium and Vitamin D daily intake at every age for the general public.

Please note that some people may require different dosages of these supplements. For example, people who live in areas with little sun, those with darker skin, and people who are obese may need more Vitamin D than the recommended daily amount. The upper safe limit for people older than 9 years of daily Vitamin D is 4000 IU, but talk to your doctor about the best dose for you. Also, be aware that taking calcium and Vitamin D at higher than recommended levels may cause adverse side effects.

For a complete overview of calcium and Vitamin D Recommended Dietary Allowances (RDAs), as well as Tolerable Upper Intake Levels (ULs), refer to “Calcium, Nutrition, and Bone Health

Birth to Age 9

Calcium is an essential mineral for babies and young children to ensure they are able to grow strong bones and teeth. Because our bodies need Vitamin D to absorb calcium from our diets, getting enough Vitamin D goes hand-in-hand with getting enough calcium. Young children who do not get enough Vitamin D are at risk for rickets, a disease that can cause bone weakness, bowed legs, and other skeletal deformities.

First year. According to the FNB, infants, age birth to 6 months, need 200 milligrams (mg) of calcium each day, and infants, ages 7 to 12 months, 260 mg. During this first year, both breast milk and infant formula provide sufficient calcium.

The FNB daily recommendation of Vitamin D for infants birth to 12 months is 400 International Units (IU). Although Vitamin D can be found in breast milk and infant formula, it is not in sufficient amounts. The American Academy of Pediatrics now recommends that babies take daily Vitamin D supplement drops, unless they are drinking 32 oz. of infant formula each day.

Ages 1 to 3 years. The amount of calcium and Vitamin D that a young child needs increases with age.

The FNB recommended dietary allowance (RDA) for children ages 1 to 3 are 700 mg of calcium and 600 IU of Vitamin D. Milk is one of the best sources of calcium for children — plus a cup of milk is fortified with 100 IU of Vitamin D. Doctors recommend whole milk for children between the ages of 1 and 2 years. Lowfat and skim milk are good options after age 2.

 

childrens supplements

 

The American Academy of Pediatrics recommends that all children take Vitamin D supplements.
© Thinkstock, 2012

 

Because very few foods contain substantial levels of Vitamin D, the American Academy of Pediatrics recommends that all children — from infancy through adolescence — take Vitamin D supplements.

Ages 4 to 8 years. Children ages 4 through 8 need 1,000 mg of calcium each day, or the equivalent of about two cups of yogurt and one glass of milk.

The FNB recommends 600 IU of Vitamin D for everyone from age 1 through 70 years. Recent research, however, supports that the body needs at least 1000 IU per day for good bone health, starting at age 5 years. Taking a Vitamin D supplement is the most effective way for your child to get 1000 IU of Vitamin D every day.

Between 10 and 20 Years of Age

This is the stage of life when peak bone mass is established.

Puberty. Puberty is a very important time in the development of the skeleton and peak bone mass. Half of total body calcium stores in women and up to 2/3 of calcium stores in men are made during puberty. At the end of puberty, men have about 50% more body calcium than women.

 

Nurse measuring height of teenage girl

 

Adolescents grow rapidly and need 1,300 mg of calcium each day for the best possiblle development of the skeleton.
© Thinkstock, 2012

 

On average, girls begin puberty at age 10 and start having menstrual periods about age 12. Having a regular period is important to girls’ and women’s bone health because it indicates that sufficient estrogen is being produced. Estrogen is a hormone that improves calcium absorption in the kidneys and intestines.

The average girl grows the fastest in height between the ages of 11 and 12 years, and stops growing between the ages of 14 and 15 years. About 95% of a young woman’s peak bone mass is present by age 20, and some overall gains in mass often continue until age 30.

The average boy has his fastest rate of growth in height between ages 13 and 14, and stops growing between ages 17 and 18. Peak bone mass occurs 9 to 12 months after the peak rate in height growth.

Early or late onset of puberty affects peak bone mass. Boys with late puberty generally have less bone mass for life than those who start puberty at the typical time, about age 11 1/2. Obesity delays the start of puberty in boys and, therefore, may have a negative effect on peak bone mass.

Obesity in girls, however, accelerates the onset of puberty. The effect that obesity and early puberty have on the peak bone mass is variable in girls.

Nutrional requirements. Many adolescents and young adults do not get enough calcium. Both boys and girls age 10 to 20 years need at least 1,300 mg of calcium each day, the equivalent of:

  • One cup of orange juice with added calcium
  • Two cups of milk
  • One cup of yogurt

Other dairy products, green leafy vegetables, fish, and tofu are also good sources of calcium.

A Vitamin D supplement is necessary to ensure the calcium that adolescents do take in is absorbed in the intestines. Sodas and carbonated beverages should be avoided for many nutritional reasons, including for bone health and to prevent obesity. Sodas decrease calcium absorption in the intestines and contain empty calories. Milk, calcium-fortified juices, and water are better beverage alternatives for all age groups.

Adolescent pregnancy. Like other adolescents, young women who are pregnant and/or breastfeeding between the ages of 14 and 18 should have 1300 mg of calcium each day. The RDA for Vitamin D remains 600 IU, although as mentioned above, recent research supports a daily dosage of 1000 IU for better bone health.

Exercise. Weightbearing exercise during the teen years is essential to reach maximum bone strength. Examples of weightbearing exercise include walking and running, as well as team sports like soccer and basketball.

Young women who exercise excessively can lose enough weight to cause hormonal changes that stop menstrual periods (amenorrhea). This loss of estrogen can cause bone loss at a time when young women should be adding to their peak bone mass. It is important to see a doctor if there have been any menstrual cycle changes or interruptions.

Between 20 and 30 Years of Age

Although your body is no longer forming new bone as readily as before, your bones will reach their peak strength during these years. It is important to get adequate calcium and exercise to help achieve peak bone density. Both men and women need at least 1,000 mg of calcium each day, and probably a Vitamin D supplement because it is difficult to get 1000 IU of Vitamin D even from a healthy diet.

To promote good bone health, adults need at least 30 minutes of weightbearing activity (such as a brisk walk), 4 or more days per week. Muscle-strengthening activities at least two days of the week are also recommended.

Pregnancy and breastfeeding. The calcium requirement for pregnant or breastfeeding women is the same for any adult in this age range: 1,000 mg. Of course, getting the recommended calcium and Vitamin D daily allowance is especially important when you are pregnant or breastfeeding. Without it, a growing baby in the womb may pull calcium out of the mother’s bones in order to build its own skeleton. A nursing baby also requires calcium, and a mother can lose bone mass during the time she breastfeeds. In most cases, once breastfeeding ends, a healthy diet and exercise will help a mother regain any bone lost.

Between 30 and 50 Years of Age

After you reach your peak bone mass, you will begin to gradually lose bone. All through your life, your body is continually removing old bone and replacing it with fresh bone. This process is called remodeling. Up until about age 40, all the bone removed is replaced. After age 40, however, less bone is replaced. At this stage in life, getting enough exercise and calcium (1,000 mg) and Vitamin D (1,000 IU) every day, are crucial to minimizing bone loss. Exercise is also important for maintaining your muscle mass, which preserves and strengthens surrounding bone and helps prevent falls.

Older Than 50 Years of Age

The daily calcium recommendation for men over 50 remains the same at 1,000 mg. Many women over 50 are entering or have gone through menopause, and the FNB recommends that women over 50 increase their daily calcium intake to 1,200 mg.

Menopause. Most women enter menopause between the ages of 42 and 55. As the levels of estrogen drop dramatically, women undergo rapid bone loss. In fact, in the 10 years after menopause, women can lose 40% of their spongy, inner bone and 10% of their hard, outer bone. This reduces bone strength and increases a woman’s risk for fracture. It also helps explain why osteoporosis is much more common in women than in men (who do not experience this acute loss of hormone in middle age).

In the past, estrogen replacement therapy was frequently used to protect aging women from bone loss. Research has since shown that there are significant risks in taking estrogen long-term after menopause. These include increased risk of serious blood clots, stroke, heart attack, breast and ovarian cancers, gall bladder disease, and possibly dementia.

If your period becomes irregular, or, if you develop signs of menopause, such as hot flashes, talk with your doctor. You also may want to ask about bone density testing. This is a safe, painless, x-ray technique that compares your current bone density with the peak bone mass someone your same gender and ethnicity should have reached at 20 to 25 years of age.

 

hbea-img5

 

A duel-energy x-ray absorptiometry (DXA) scan is the “gold standard” of bone mineral density testing.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010

Age 70 and above. Both men and women should get 1,200 mg of calcium each day. The RDA for Vitamin D at this age is 800 IU.

After they reach the age of 70, men are more likely to experience low bone mass and fractures. Men over age 70 should discuss bone density testing with a doctor.

Fall prevention becomes especially important for people over age 70. Falls are the leading cause of injury to elderly people in the United States. Falls cause many seniors to lose their independence, requiring a change in living arrangements, such as moving to a nursing home or assisted living facility. Fortunately, many falls can be prevented, and having strong bones can help prevent fractures.

No matter your age, adequate calcium intake and exercise can limit bone loss and increase bone and muscle strength.

Source: National Institutes of Health (NIH) (Dietary Supplement Fact Sheet: Calcium) ; Institute of Medicine of the National Academies (Dietary Reference Intakes for Calcium and Vitamin D).

Last reviewed: July 2012
Contributed and/or Updated by: Barbara J. Campbell, MD
Peer-Reviewed by: Stuart J. Fischer, MD
Contributor Disclosure Information

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Osteoarthritis of the knee is one of the leading causes of disability in the United States. It develops slowly and the pain it causes worsens over time. Although there is no cure for osteoarthritis, there are many treatment options available to help people manage pain and stay active.

In its early stages, arthritis of the knee is treated with nonsurgical methods. Your doctor may recommend a range of treatments, including:

Changes in activity level
Weight loss
Pain relievers, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen
Physical therapy
Corticosteroid injections
Another treatment option is a procedure called viscosupplementation. If you have tried all other nonsurgical treatment methods and your pain continues to limit your activities, viscosupplementation may be an option.

In this procedure, a gel-like fluid called hyaluronic acid is injected into the knee joint. Hyaluronic acid is a naturally occurring substance found in the synovial fluid surrounding joints. It acts as a lubricant to enable bones to move smoothly over each other and as a shock absorber for joint loads. People with osteoarthritis have a lower-than-normal concentration of hyaluronic acid in their joints. The theory is that adding hyaluronic acid to the arthritic joint will facilitate movement and reduce pain.

The most recent research, however, has not found viscosupplementation to be effective at significantly reducing pain or improving function. Although some patients report pain relief with the procedure, some people are not helped by the injections.

Viscosupplementation was first used in Europe and Asia, and was approved by the U.S. Food and Drug Administration in 1997. Several preparations of hyaluronic acid are now commercially available.

Procedure

Depending on the product used, you will receive one to five shots over several weeks.

During the procedure, if there is any swelling in your knee, your doctor will remove (aspirate) the excess fluids before injecting the hyaluronic acid. Usually, the aspiration and the injection are done using only one needle injected into the joint, Some doctors may prefer to use two separate syringes.

For the first 48 hours after the shot, you should avoid excessive weight bearing on the leg, such as standing for long periods, jogging or heavy lifting.

Side Effects

You may notice a local reaction, such as pain, warmth, and slight swelling immediately after the shot. These symptoms generally do not last long. You may want to apply an ice pack to help ease them.

Complications

Rarely, patients may develop a local allergy-like reaction in the knee. In these cases, the knee may become full of fluid, red, warm, and painful. If this occurs, contact your doctor immediately.

Infection and bleeding are also very rare complications of this procedure.

Outcomes

As is noted above, some patients will not be helped by viscosupplementation. For those who report pain relief with the procedure, it may take several weeks to notice an improvement. How long the effects last varies. Some patients report pain relieving effects for several months following the injections.

If the injections are effective they may be repeated after a period of time, usually 6 months.

Although some patients report relief of arthritis symptoms with viscosupplementation, the procedure has never been shown to reverse the arthritic process or re-grow cartilage.

The effectiveness of viscosupplementation in treating arthritis is not clear. It has been proposed that viscosupplementation is most effective if the arthritis is in its early stages (mild to moderate), but more research is needed to support this. Research in viscosupplementation and its long-term effects continues.
Last reviewed: June 2015
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Rheumatoid arthritis is a chronic disease that attacks multiple joints throughout the body. It most often starts in the small joints of the hands and feet, and usually affects the same joints on both sides of the body.

More than 90% of people with rheumatoid arthritis (RA) develop symptoms in the foot and ankle over the course of the disease.

Description

Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In RA, the defenses that protect the body from infection instead damage normal tissue (such as cartilage and ligaments) and soften bone.

How It Happens

The joints of your body are covered with a lining — called synovium — that lubricates the joint and makes it easier to move. Rheumatoid arthritis causes an overactivity of this lining. It swells and becomes inflamed, destroying the joint, as well as the ligaments and other tissues that support it. Weakened ligaments can cause joint deformities — such as claw toe or hammer toe. Softening of the bone (osteopenia) can result in stress fractures and collapse of bone.

Rheumatoid arthritis is not an isolated disease of the bones and joints. It affects tissues throughout the body, causing damage to the blood vessels, nerves, and tendons. Deformities of the hands and feet are the more obvious signs of RA. In about 20% of patients, foot and ankle symptoms are the first signs of the disease.

 

rafa-img1

 

In RA, the lining of the joint swells and becomes inflamed. This slowly destroys the joint.
Reproduced with permission from The Body Almanac. © American Academy of Orthopaedic Surgeons, 2003.
Statistics

Rheumatoid arthritis affects approximately 1% of the population. Women are affected more often than men, with a ratio of up to 3 to 1. Symptoms most commonly develop between the ages of 40 and 60.

Cause

The exact cause of RA is not known. There may be a genetic reason — some people may be more likely to develop the disease because of family heredity. However, doctors suspect that it takes a chemical or environmental “trigger” to activate the disease in people who genetically inherit RA.

Symptoms

The most common symptoms are pain, swelling, and stiffness. Unlike osteoarthritis, which typically affects one specific joint, symptoms of RA usually appear in both feet, affecting the same joints on each foot.

 

rafa-img2

 

Anatomy of the foot and ankle.
Ankle

Difficulty with inclines (ramps) and stairs are the early signs of ankle involvement. As the disease progresses, simple walking and standing can become painful.

Hindfoot (Heel Region of the Foot)

The main function of the hindfoot is to perform the side-to-side motion of the foot. Difficulty walking on uneven ground, grass, or gravel are the initial signs. Pain is common just beneath the fibula (the smaller lower leg bone) on the outside of the foot.

As the disease progresses, the alignment of the foot may shift as the bones move out of their normal positions. This can result in a flatfoot deformity. Pain and discomfort may be felt along the posterior tibial tendon (main tendon that supports the arch) on the inside of the ankle, or on the outside of the ankle beneath the fibula.

Midfoot (Top of the Foot)

With RA, the ligaments that support the midfoot become weakened and the arch collapses. With loss of the arch, the foot commonly collapses and the front of the foot points outward. RA also damages the cartilage, causing arthritic pain that is present with or without shoes. Over time, the shape of the foot can change because the structures that support it degenerate. This can create a large bony prominence (bump) on the arch. All of these changes in the shape of the foot can make it very difficult to wear shoes.

 

rafa-img3

 

This x-ray shows signs of RA of the midfoot. Note that the front of the foot points outward and there is a large bump on the inside and bottom of the foot.
Forefoot (Toes and Ball of the Foot)

The changes that occur to the front of the foot are unique to patients with RA. These problems include bunions, claw toes, and pain under the ball of the foot (metatarsalgia). Although, each individual deformity is common, it is the combination of deformities that compounds the problem.

 

rafa-img4

 

People with RA can experience a combination of common foot problems, such as bunions and clawtoe.

 

The bunion is typically severe and the big toe commonly crosses over the second toe.

There can also be very painful bumps on the ball of the foot, creating calluses. The bumps develop when bones in the middle of the foot (midfoot) are pushed down from joint dislocations in the toes. The dislocations of the lesser toes (toes two through five) cause them to become very prominent on the top of the foot. This creates clawtoes and makes it very difficult to wear shoes. In severe situations, ulcers can form from the abnormal pressure.

 

rafa-img5

 

Severe claw toes can become fixed and rigid. They do not move when in a shoe. The extra pressure from the top of the shoe can cause severe pain and can damage the skin.

Doctor Examination

Medical History and Physical Examination

After listening to your symptoms and discussing your general health and medical history, your doctor will examine your foot and ankle.

Skin. The location of callouses indicate areas of abnormal pressure on the foot. The most common location is on the ball of the foot (the underside of the forefoot). If the middle of the foot is involved, there may be a large prominence on the inside and bottom of the foot. This can cause callouses.

Foot shape. Your doctor will look for specific deformities, such as bunions, claw toes, and flat feet.

Flexibility. In the early stages of RA, the joints will typically still have movement. As arthritis progresses and there is a total loss of cartilage, the joints become very stiff. Whether there is motion within the joints will influence treatment options.

Tenderness to pressure. Although applying pressure to an already sensitive foot can be very uncomfortable, it is critical that your doctor identify the areas of the foot and ankle that are causing the pain. By applying gentle pressure at specific joints your doctor can determine which joints have symptoms and need treatment. The areas on the x-ray that look abnormal are not always the same ones that are causing the pain.

Imaging Tests

Other tests that your doctor may order to help confirm your diagnosis include:

X-rays. This test creates images of dense structures, like bone. It will show your doctor the position of the bones. The x-rays can be used by your doctor to make measurements of the alignment of the bones and joint spaces, which will help your doctor determine what surgery would best.

Computerized tomography (CT) scan. When the deformity is severe, the shape of the foot can be abnormal enough to make it difficult to determine which joints have been affected and the extent of the disease. CT scans allow your doctor to more closely examine each joint for the presence of arthritis.

Magnetic resonance imaging (MRI) scan. An MRI scan will show the soft tissues, including the ligaments and tendons. Your doctor can assess whether the tendon is inflamed (tendonitis) or torn (ruptured).

Rheumatology Referral

Your doctor may refer you to a rheumatologist if he or she suspects RA. Although your symptoms and the results from a physical examination and tests may be consistent with RA, a rheumatologist will be able to determine the specific diagnosis. There are other less common types of inflammatory arthritis that will be considered.

Nonsurgical Treatment

Although there is no cure for RA, there are many treatment options available to help people manage pain, stay active, and live fulfilling lives.

Rheumatoid arthritis is often treated by a team of healthcare professionals. These professionals may include rheumatologists, physical and occupational therapists, social workers, rehabilitation specialists, and orthopaedic surgeons.

Although orthopaedic treatment may relieve symptoms, it will not stop the progression of the disease. Specific medicines called disease-modifying anti-rheumatic drugs are designed to stop the immune system from destroying the joints. The appropriate use of these medications is directed by a rheumatologist.

Orthopaedic treatment of RA depends on the location of the pain and the extent of cartilage damage. Many patients will have some symptom relief with appropriate nonsurgical treatment.

Rest

Limiting or stopping activities that make the pain worse is the first step in minimizing the pain. Biking, elliptical training machines, or swimming are exercise activities that allow patients to maintain their health without placing a large impact load on the foot.

Ice

Placing ice on the most painful area of the foot for 20 minutes is effective. This can be done 3 or 4 times a day. Ice application is best done right after you are done with a physical activity. Do not apply ice directly to your skin.

Nonsteroidal Anti-inflammatory Medication

Drugs, such as ibuprofen or naproxen, reduce pain and inflammation. In patients with RA, the use of these types of medications should be reviewed with your rheumatologist or medical doctor.

Orthotics

An orthotic (shoe insert) is a very effective tool to minimize the pressure from prominent bones in the foot. The orthotic will not be able to correct the shape of your foot. The primary goal is to minimize the pressure and decrease the pain and callous formation. This is more effective for deformity in the front and middle of the foot.

 

rafa-img6

 

A custom-molded leather brace can be effective in minimizing the pain and discomfort from ankle and hindfoot arthritis.

For people with RA, hard or rigid orthotics generally cause too much pressure on the bone prominences, creating more pain. A custom orthotic is generally made of softer material and relieves pressure on the foot.

Braces

A lace-up ankle brace can be an effective treatment for mild to moderate pain in the back of the foot and the ankle. The brace supports the joints of the back of the foot and ankle. In patients with a severe flatfoot or a very stiff arthritic ankle, a custom-molded plastic or leather brace is needed. The brace can be a very effective device for some patients, allowing them to avoid surgery.

Steroid Injection

An injection of cortisone into the affected joint can help in the early stages of the disease. In many cases, a rheumatologist or medical doctor may also perform these injections. The steroid helps to reduce inflammation within the joint. The steroid injection is normally a temporary measure and will not stop the progression of the disease.

Surgical Treatment

Your doctor may recommend surgery depending upon the extent of cartilage damage and your response to nonsurgical options.

Fusion. Fusion of the affected joints is the most common type of surgery performed for RA. Fusion takes the two bones that form a joint and fuses them together to make one bone.

During the surgery, the joints are exposed and the remaining cartilage is removed. The two bones are then held together with screws or a combination of screws and plates. This prevents the bones from moving. During the healing process, the body grows new bone between the bones in these joints.

Because the joint is no longer intact, this surgery does limit joint motion. Limited joint motion may not be felt by the patient, depending on the joints fused. The midfoot joints often do not have much motion to begin with, and fusing them does not create increased stiffness. The ankle joint normally does have a lot of motion, and fusing it will be noticeable to the patient. By limiting motion, fusion reduces the pain.

Fusion can be a successful technique. However, because patients with RA also show damaged cartilage and loose ligaments, the success rate of this type of surgery is lower in patients with RA than in patients without RA. The use of newer generation medication can slow the progression of the disease and impact the type of surgeries that can be performed successfully.

Other surgeries. The front of the foot is where there are more surgical options for some patients. Surgeons can now perform joint sparing operations to correct the bunion and hammertoes in some patients. Your surgeon will review the most appropriate options for your case.

Ankle

Ankle fusion and total ankle replacement are the two primary surgical options for treating RA of the ankle. Both treatment options can be successful in minimizing the pain and discomfort in the ankle. The appropriate surgery is based upon multiple factors and is individualized for every patient.

 

rafa-img7

 

The patient shown in these x-rays had arthritis of the hindfoot. It was treated by fusing all three joints of the hindfoot (triple fusion). An ankle replacement was also done in order to improve mobility and avoid the severe stiffness that would result from another ankle fusion. The ankle replacement implants can be seen here from the front and the side.

Patients with severe involvement of other joints around the heel or patients who have previously undergone a fusion on the other leg, may be more suited for ankle replacement. In addition, patients who have fusions within the same foot may be more suited for an ankle replacement.

Newer generation ankle replacement implants have shown promising early results. Ankle replacement implants have not yet been shown to be as long-lasting as those for the hip or knee, due to the fact that the newer generation of implants have not been available long enough to determine how long they will last.

 

rafa-img8

 

These x-rays show an ankle fusion from the front and the side. The number and placement of screws and the use of a plate are dependent upon the surgeon’s technique.

Following ankle fusion, there is a loss of the up and down motion of the ankle. The up and down motion is transferred to the joints near the ankle. This creates a potential for pain in those joints, and possibly arthritis.

Patients are able to walk in shoes on flat, level ground without much difficulty after an ankle fusion, despite the loss of ankle motion. The joints in the foot next to the ankle joint allow for motion similar to the ankle joint, and help patients with fused ankle joints walk more normally.

 

rafa-img9

 

Over time, the increased stress that is placed on the rest of the foot after an ankle fusion can lead to arthritis of the joints surrounding the ankle. This patient had pain in the subtalar joint (arrow) and required an additional fusion of that joint to minimize the pain. Increased stress on other joints is the most concerning problem following ankle fusion.
Hindfoot (Heel Region of the Foot)

A fusion of the affected joints of the hindfoot is the most common surgery used to treat patients with flatfoot or arthritis of the hindfoot. A triple arthrodesis is a fusion that involves all three joints in the back of the foot. Occasionally, the joint on the outside of the foot is not fused if there is minimal to no involvement of that joint (this is at the surgeon’s discretion). This type of fusion eliminates the side-to-side motion of the foot, while preserving most of the up and down movement.

If RA is only in one joint, then a fusion of just that affected joint may be all that is needed.

 

rafa-img10

 

(Left) In this x-ray, two of the three joints in the hindfoot have been fused. (Right) Just the subtalar joint is fused in this x-ray.

Any fusion of the hindfoot will limit side-to-side motion of the foot. This will affect walking on uneven ground, grass, or gravel. There is no method to replace the joints of the hindfoot.

Midfoot (Middle of the Foot)

Fusion is the most reliable surgical method to treat RA of the midfoot joints. If the shape of the foot is not normal, surgery is designed to help restore the arch and minimize the prominences on the foot.

There are joint replacement implants available for joints on the outside of the midfoot. This may preserve some midfoot motion. However, the use of these implants is at the surgeon’s discretion. These implants are not available for the joints on the inside of the midfoot.

Although the foot cannot be returned to a normal shape, the goals are to reduce pain in the foot and improve the potential for the patient to wear more normal shoes.

 

rafa-img11

 

(Top) This x-ray shows RA of the midfoot that has collapsed the arch. (Bottom) The surgical reconstruction involved a fusion of the middle of the foot with plates and screws.
Forefoot (Toes and Ball of the Foot)

The choice of treatment for patients with a bunion or lesser toe deformities (hammer or claw toes) depends on a number of factors.

If the disease is very mild, joint-sparing procedures that preserve motion can be considered. The decision is dependent on the medication that the patient is taking and the amount of damaged cartilage that is present. A fusion of the great toe may be recommended despite that fact the bunion is very mild. If there is damage to the cartilage of the great toe joint, correcting the bunion will not minimize the arthritic pain.

If the RA has progressed and the lesser toes (two through five) have dislocated, a complex operation to minimize the pain and restore the shape of the foot may be recommended. The operation involves fusion of the big toe and removing a portion of bone of each of the metatarsals. This surgery removes the prominent bone on the bottom of the foot that is a source of the pain and allows the toes to re-align into a better position.

Occasionally, the lesser toe metatarsals can be preserved by shortening them to allow the toes to resume their position within the joints. This is not always possible, however, and the joint may have to be removed.

 

rafa-img12

 

(Left) RA of the forefoot. The big toe is deviated and crosses over the second toe, a typical appearance of a bunion. The lesser toes (two through five) are dislocated, resulting in painful and severe claw toes. (Right) This x-ray taken immediately after fusion of the big toe shows that the prominent bones on the ball of the foot were removed and the claw toes were corrected. The pins hold the toes in place while the soft tissues heal. The pins are removed in the office after 4 to 6 weeks with minimal discomfort.

To fix the bend in the toes themselves, the surgeon may suggest cutting a tendon or removing a small portion of bone of the toes to allow them to straighten. Pins that stick out of the foot are temporarily required and will be removed in the office after healing takes place.

There are some newer implants available that can be buried within the toes, which avoid the need for pins sticking out of the foot. These implants may not work if the bone is soft, or if significant destruction of the joints has occurred.

This operation puts a lot of stress on the blood vessels and skin of the foot. In severe cases, the toes may not survive the operation and may require amputation of a portion or the entire toe. This operation can provide the patient with a high level of function and the ability to enjoy a wider variety of shoewear.

 

rafa-img13

 

Reconstruction of the foot does not mean that a patient will be required to wear bulky and unappealing shoes every day. The patient shown here had both feet reconstructed. She is able to wear sandals and mild heels without difficulty. Although these types of shoes are not recommended all the time, they can be worn from time to time. Not all patients will achieve such an excellent result.
Preparing for Surgery

Many of the medications that help with RA also affect the ability of the body to heal wounds and fight infection. Your surgeon will work with your rheumatologist or medical doctor to review which of your medications will need to be stopped prior to surgery. Once the wounds are healed, the medication is typically resumed.

This period of time can be very difficult for patients with other areas of the body that are affected by RA. Many fusions require at least 6 weeks of time where no pressure can be placed on the foot. Making appropriate preparations to ensure you have help at home is crucial for success after surgery.

Last reviewed: December 2011
Contributed and/or Updated by: Anish R. Kadakia, MD
Peer-Reviewed by: Stuart J. Fischer, MD; Steven L. Haddad, MD
Contributor Disclosure Information

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

If your knee is severely damaged by arthritis or injury, it may be hard for you to perform simple activities, such as walking or climbing stairs. You may even begin to feel pain while you are sitting or lying down.

If nonsurgical treatments like medications and using walking supports are no longer helpful, you may want to consider total knee replacement surgery. Joint replacement surgery is a safe and effective procedure to relieve pain, correct leg deformity, and help you resume normal activities.

Knee replacement surgery was first performed in 1968. Since then, improvements in surgical materials and techniques have greatly increased its effectiveness. Total knee replacements are one of the most successful procedures in all of medicine. According to the Agency for Healthcare Research and Quality, more than 600,000 knee replacements are performed each year in the United States.

Whether you have just begun exploring treatment options or have already decided to have total knee replacement surgery, this article will help you understand more about this valuable procedure.

Anatomy


The knee is the largest joint in the body and having healthy knees is required to perform most everyday activities.

The knee is made up of the lower end of the thighbone (femur), the upper end of the shinbone (tibia), and the kneecap (patella). The ends of these three bones where they touch are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily.

The menisci are located between the femur and tibia. These C-shaped wedges act as “shock absorbers” that cushion the joint.

Large ligaments hold the femur and tibia together and provide stability. The long thigh muscles give the knee strength.

All remaining surfaces of the knee are covered by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage, reducing friction to nearly zero in a healthy knee.

Normally, all of these components work in harmony. But disease or injury can disrupt this harmony, resulting in pain, muscle weakness, and reduced function.

 Anatomy
Normal knee anatomy.

Cause


The most common cause of chronic knee pain and disability is arthritis. Although there are many types of arthritis, most knee pain is caused by just three types: osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis.

Total Knee_causes

Osteoarthritis often results in bone rubbing on bone. Bone spurs are a common feature of this form of arthritis.

<iframe width=”520″ height=”360″ class=”youtube-embed” src=”http://www.youtube.com/embed/OXGx4jK_q3k?wmode=opaque&amp;rel=0″ frameborder=”0″ wmode=”opaque” allowfullscreen=””></iframe>

Description


A knee replacement (also called knee arthroplasty) might be more accurately termed a knee “resurfacing” because only the surface of the bones are actually replaced.

There are four basic steps to a knee replacement procedure.

Total Knee_Desc

(Left) Severe osteoarthritis. (Right) The arthritic cartilage and underlying bone has been removed and resurfaced with metal implants on the femur and tibia. A plastic spacer has been placed in between the implants. The patellar component is not shown for clarity.

<iframe width=”520″ height=”360″ class=”youtube-embed” src=”http://www.youtube.com/embed/kAMuP2MNqUo?wmode=opaque&amp;rel=0″ frameborder=”0″ wmode=”opaque” allowfullscreen=””></iframe>

Animation courtesy Visual Health Solutions, Inc.

 

Is Total Knee Replacement for You?


The decision to have total knee replacement surgery should be a cooperative one between you, your family, your family physician, and your orthopaedic surgeon. Your physician may refer you to an orthopaedic surgeon for a thorough evaluation to determine if you might benefit from this surgery.

When Surgery Is Recommended

There are several reasons why your doctor may recommend knee replacement surgery. People who benefit from total knee replacement often have:

  • Severe knee pain or stiffness that limits your everyday activities, including walking, climbing stairs, and getting in and out of chairs. You may find it hard to walk more than a few blocks without significant pain and you may need to use a cane or walker
  • Moderate or severe knee pain while resting, either day or night
  • Chronic knee inflammation and swelling that does not improve with rest or medications
  • Knee deformity — a bowing in or out of your knee
  • Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries

OLYMPUS DIGITAL CAMERA

A knee that has become bowed as a result of severe arthritis.

Candidates for Surgery

There are no absolute age or weight restrictions for total knee replacement surgery.

Recommendations for surgery are based on a patient’s pain and disability, not age. Most patients who undergo total knee replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total knee replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.

Orthopaedic Evaluation


An evaluation with an orthopaedic surgeon consists of several components:

  • A medical history. Your orthopaedic surgeon will gather information about your general health and ask you about the extent of your knee pain and your ability to function.
  • A physical examination. This will assess knee motion, stability, strength, and overall leg alignment.
  • X-rays. These images help to determine the extent of damage and deformity in your knee.
  • Other tests. Occasionally blood tests, or advanced imaging such as a magnetic resonance imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your knee.

Total Knee_Orthopaedic

(Left) In this x-ray of a normal knee, the space between the bones indicates healthy cartilage (arrows). (Right) This x-ray of a knee that has become bowed from arthritis shows severe loss of joint space (arrows).

Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether total knee replacement is the best method to relieve your pain and improve your function. Other treatment options — including medications, injections, physical therapy, or other types of surgery — will also be considered and discussed.

In addition, your orthopaedic surgeon will explain the potential risks and complications of total knee replacement, including those related to the surgery itself and those that can occur over time after your surgery.

Deciding to Have Knee Replacement Surgery


Realistic Expectations

An important factor in deciding whether to have total knee replacement surgery is understanding what the procedure can and cannot do.

More than 90% of people who have total knee replacement surgery experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living. But total knee replacement will not allow you to do more than you could before you developed arthritis.

With normal use and activity, every knee replacement implant begins to wear in its plastic spacer. Excessive activity or weight may speed up this normal wear and may cause the knee replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports for the rest of your life after surgery.

Realistic activities following total knee replacement include unlimited walking, swimming, golf, driving, light hiking, biking, ballroom dancing, and other low-impact sports.

With appropriate activity modification, knee replacements can last for many years.

Possible Complications of Surgery

Total Knee_possible Comp

Blood clots may develop in leg veins.

The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in fewer than 2% of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit full recovery.

Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.

Infection. Infection may occur in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.

Blood clots. Blood clots in the leg veins are one of the most common complications of knee replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program, which may include periodic elevation of your legs, lower leg exercises to increase circulation, support stockings, and medication to thin your blood.

Implant problems. Although implant designs and materials, as well as surgical techniques, continue to advance, implant surfaces may wear down and the components may loosen. Additionally, although an average of 115° of motion is generally anticipated after surgery, scarring of the knee can occasionally occur, and motion may be more limited, particularly in patients with limited motion before surgery.

Continued pain. A small number of patients continue to have pain after a knee replacement. This complication is rare, however, and the vast majority of patients experience excellent pain relief following knee replacement.

Neurovascular injury. While rare, injury to the nerves or blood vessels around the knee can occur during surgery.

Preparing for Surgery


Medical Evaluation

If you decide to have total knee replacement surgery, your orthopaedic surgeon may ask you to schedule a complete physical examination with your family physician several weeks before the operation. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such as a cardiologist, before the surgery.

Tests

Several tests, such as blood and urine samples, and an electrocardiogram, may be needed to help your orthopaedic surgeon plan your surgery.

Medications

Tell your orthopaedic surgeon about the medications you are taking. He or she will tell you which medications you should stop taking and which you should continue to take before surgery.

Dental Evaluation

Although the incidence of infection after knee replacement is very low, an infection can occur if bacteria enter your bloodstream. To reduce the risk of infection, major dental procedures (such as tooth extractions and periodontal work) should be completed before your total knee replacement surgery.

Urinary Evaluations

People with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before undertaking knee replacement surgery.

Social Planning

Although you will be able to walk on crutches or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing, and doing laundry.

If you live alone, your orthopaedic surgeon’s office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at home. They also can help you arrange for a short stay in an extended care facility during your recovery, if this option works best for you.

Home Planning

Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:

  • Safety bars or a secure handrail in your shower or bath
  • Secure handrails along your stairways
  • A stable chair for your early recovery with a firm seat cushion (and a height of 18 to 20 inches), a firm back, two arms, and a footstool for intermittent leg elevation
  • A toilet seat riser with arms, if you have a low toilet
  • A stable shower bench or chair for bathing
  • Removing all loose carpets and cords
  • A temporary living space on the same floor because walking up or down stairs will be more difficult during your early recovery

Your Surgery


You will most likely be admitted to the hospital on the day of your surgery.

Anesthesia

After admission, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down). The anesthesia team, with your input, will determine which type of anesthesia will be best for you.

Procedure

The procedure itself takes approximately 1 to 2 hours. Your orthopaedic surgeon will remove the damaged cartilage and bone, and then position the new metal and plastic implants to restore the alignment and function of your knee.

After surgery, you will be moved to the recovery room, where you will remain for several hours while your recovery from anesthesia is monitored. After you wake up, you will be taken to your hospital room.

Total Knee_surgery_Img1

Different types of knee implants are used to meet each patient’s individual needs.

Total Knee_surgery_Img2

(Left) An x-ray of a severely arthritic knee. (Right) The x-ray appearance of a total knee replacement. Note that the plastic spacer inserted between the components does not show up in an x-ray.

Preparing for Surgery


You will most likely stay in the hospital for several days.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Blood Clot Prevention

Your orthopaedic surgeon may prescribe one or more measures to prevent blood clots and decrease leg swelling. These may include special support hose, inflatable leg coverings (compression boots), and blood thinners.

Foot and ankle movement also is encouraged immediately following surgery to increase blood flow in your leg muscles to help prevent leg swelling and blood clots.

Physical Therapy

Total Knee_hospital_Says
A continuous passive motion (CPM) machine.

Most patients begin exercising their knee the day after surgery. In some cases, patients begin moving their knee on the actual day of surgery. A physical therapist will teach you specific exercises to strengthen your leg and restore knee movement to allow walking and other normal daily activities soon after your surgery.

To restore movement in your knee and leg, your surgeon may use a knee support that slowly moves your knee while you are in bed. The device is called a continuous passive motion (CPM) exercise machine. Some surgeons believe that a CPM machine decreases leg swelling by elevating your leg and improves your blood circulation by moving the muscles of your leg.

Preventing Pneumonia

It is common for patients to have shallow breathing in the early postoperative period. This is usually due to the effects of anesthesia, pain medications, and increased time spent in bed. This shallow breathing can lead to a partial collapse of the lungs (termed “atelectasis”) which can make patients susceptible to pneumonia. To help prevent this, it is important to take frequent deep breaths. Your nurse may provide a simple breathing apparatus called a spirometer to encourage you to take deep breaths.

Your Recovery at Home


The success of your surgery will depend largely on how well you follow your orthopaedic surgeon’s instructions at home during the first few weeks after surgery.

Wound Care

You will have stitches or staples running along your wound or a suture beneath your skin on the front of your knee. The stitches or staples will be removed several weeks after surgery. A suture beneath your skin will not require removal.

Avoid soaking the wound in water until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.

Diet

Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to help your wound heal and to restore muscle strength.

Activity

Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal activities of daily living within 3 to 6 weeks following surgery. Some pain with activity and at night is common for several weeks after surgery.

Your activity program should include:

  • A graduated walking program to slowly increase your mobility, initially in your home and later outside
  • Resuming other normal household activities, such as sitting, standing, and climbing stairs
  • Specific exercises several times a day to restore movement and strengthen your knee. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy center the first few weeks after surgery.

You will most likely be able to resume driving when your knee bends enough that you can enter and sit comfortably in your car, and when your muscle control provides adequate reaction time for braking and acceleration. Most people resume driving approximately 4 to 6 weeks after surgery.

Ablestock

Avoiding Problems After Surgery


Blood Clot Prevention

Follow your orthopaedic surgeon’s instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.

Warning signs of blood clots. The warning signs of possible blood clots in your leg include:

  • Increasing pain in your calf
  • Tenderness or redness above or below your knee
  • New or increasing swelling in your calf, ankle, and foot

Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:

  • Sudden shortness of breath
  • Sudden onset of chest pain
  • Localized chest pain with coughing

Preventing Infection

A common cause of infection following total knee replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your knee replacement and cause an infection.

After knee replacement, patients with certain risk factors may need to take antibiotics prior to dental work, including dental cleanings, or before any surgical procedure that could allow bacteria to enter the bloodstream. Your orthopaedic surgeon will discuss with you whether taking preventive antibiotics before dental procedures is needed in your situation.

Warning signs of infection. Notify your doctor immediately if you develop any of the following signs of a possible knee replacement infection:

  • Persistent fever (higher than 100°F orally)
  • Shaking chills
  • Increasing redness, tenderness, or swelling of the knee wound
  • Drainage from the knee wound
  • Increasing knee pain with both activity and rest

Avoiding Falls

A fall during the first few weeks after surgery can damage your new knee and may result in a need for further surgery. Stairs are a particular hazard until your knee is strong and mobile. You should use a cane, crutches, a walker, hand rails, or have someone to help you until you have improved your balance, flexibility, and strength.

Your surgeon and physical therapist will help you decide what assistive aides will be required following surgery and when those aides can safely be discontinued.

Outcomes


How Your New Knee Is Different

Improvement of knee motion is a goal of total knee replacement, but restoration of full motion is uncommon. The motion of your knee replacement after surgery can be predicted by the range of motion you have in your knee before surgery. Most patients can expect to be able to almost fully straighten the replaced knee and to bend the knee sufficiently to climb stairs and get in and out of a car. Kneeling is sometimes uncomfortable, but it is not harmful.

Most people feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending activities.

Most people also feel or hear some clicking of the metal and plastic with knee bending or walking. This is a normal. These differences often diminish with time and most patients find them to be tolerable when compared with the pain and limited function they experienced prior to surgery.

Your new knee may activate metal detectors required for security in airports and some buildings. Tell the security agent about your knee replacement if the alarm is activated.

Protecting Your Knee Replacement

After surgery, make sure you also do the following:

  • Participate in regular light exercise programs to maintain proper strength and mobility of your new knee.
  • Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery.
  • Make sure your dentist knows that you have a knee replacement. Talk with your orthopaedic surgeon about whether you need to take antibiotics prior to dental procedures.
  • See your orthopaedic surgeon periodically for a routine follow-up examination and x-rays, usually once a year.

Extending the Life of Your Knee Implant

Currently, more than 90% of modern total knee replacements are still functioning well 15 years after the surgery. Following your orthopaedic surgeon’s instructions after surgery and taking care to protect your knee replacement and your general health are important ways you can contribute to the final success of your surgery.

To learn more about the full value of total knee replacement surgery: Beyond Surgery Day: The Full Impact of Knee Replacement

If you found this article helpful, you may also be interested in Activities After Knee Replacement.

Aching joints are common in arthritis. In rheumatoid arthritis, the joint lining swells, invades surrounding tissues, and produces chemical substances that attack and destroy the joint surface.

People of all ages may be affected. The disease usually begins in middle age.

Rheumatoid arthritis usually affects joints on both sides of the body in the hands and feet, as well as the hips, knees, and elbows. Without proper treatment, rheumatoid arthritis can become a chronic, disabling condition.

Cause

ra-img1

 

Rheumatoid arthritis of the hand

 

Reproduced with permission from Abboud JA, Pedro BK, Bozentka DJ: Metacarpophalangeal Joint Arthroplasty in Rheumatoid Arthritis. J Am Acad Orthop Surg 2003; 11: 184-191.

Rheumatoid arthritis is not an inherited disease. Researchers believe that some people have genes that make them susceptible to the disease. People with these genes will not automatically develop rheumatoid arthritis. There is usually a “trigger,” such as an infection or environmental factor, which activates the genes. When the body is exposed to this trigger, the immune system responds inappropriately. Instead of protecting the joint, the immune system begins to produce substances that attack the joint. This is what may lead to the development of rheumatoid arthritis.

Ligaments and joint capsules become less effective supporting structures. Erosion of the articular cartilage, together with ligamentous changes, result in deformity and contractures. As the disease progresses, pain and deformity increase.

Symptoms

Pain, morning stiffness, swelling, and systemic symptoms are common. Other rheumatoid symptoms include:

Patients with severe rheumatoid arthritis typically have multiple affected joints in the hands, arms, legs, and feet. Joints of the cervical spine may be involved as well.

Diagnosis

Rheumatoid arthritis is diagnosed using a medical history and a physical examination. Some of the conditions the doctor looks for include swelling and warmth around the joint, painful motion, lumps under the skin, joint deformities, and joint contractures (inability to fully stretch or bend the joint).

A blood test may reveal an antibody called rheumatoid factor. This is an indicator of rheumatoid arthritis. X-rays can help show the progression of the disease.

The American College of Rheumatology requires at least four of the following seven criteria to confirm the diagnosis:

Treatment

Although there is no cure for rheumatoid arthritis, there are a number of treatment options that can help relieve joint pain and improve functioning. The treatment plan is tailored to the patient’s needs and lifestyle. Rheumatoid arthritis is often treated by a team of health care professionals. These professionals may include rheumatologists, physical and occupational therapists, social workers, rehabilitation specialists, and orthopaedic surgeons.

 

ra-img2

 

Feet with rheumatoid arthritis and special shoes used in treatment
Reproduced with permission from Cohen BE, James WC, Lee S, Davis WH, Anderson R: Rheumatoid Foot Deformity, Pathophysiology & Etiology: Incidence. Orthopaedic Knowledge Online
Medication

Medications used to control rheumatoid arthritis fall into two categories: those that relieve symptoms and those that have the potential to modify the course of the disease. Often, they are used together. Aspirin and ibuprofen can help reduce the pain and inflammation of rheumatoid arthritis. Disease-modifying drugs include methotrexate and sulfasalazine and gold injections.

Researchers are also working on biologic agents that can interrupt the progress of the disease. These agents target specific chemicals in the body to prevent them from acting on the joints.

Exercise and Therapy
ra-img3

 

X-ray of hip with rheumatoid arthritis and total hip replacement
Reproduced with permission from Lachiewicz PF: Rheumatoid Arthritis of the Hip. J Am Acad Orthop Surg 1997; 5: 332-338.

Exercise is an important part of a treatment program. The physician and physical therapist may work with patients to develop an exercise program that helps strengthen the joints without stressing them. In some cases, a splint or corrective footwear may be required.

Surgery

Joint replacement surgery is also an option and is often effective in restoring function.

Last reviewed: October 2007
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Achilles tendinitis is a common condition that causes pain along the back of the leg near the heel.

 A00147F01

The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, and jump.

Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration.

Description

Simply defined, tendinitis is inflammation of a tendon. Inflammation is the body’s natural response to injury or disease, and often causes swelling, pain, or irritation. There are two types of Achilles tendinitis, based upon which part of the tendon is inflamed.

A00147F02

 

Noninsertional Achilles Tendinitis

In noninsertional Achilles tendinitis, fibers in the middle portion of the tendon have begun to break down with tiny tears (degenerate), swell, and thicken.

Tendinitis of the middle portion of the tendon more commonly affects younger, active people.

Insertional Achilles Tendinitis

Insertional Achilles tendinitis involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone.

In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify (harden). Bone spurs (extra bone growth) often form with insertional Achilles tendinitis.

Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active.

 

 

A00147F03Insertional Achilles tendinitis
Cause

Achilles tendinitis is typically not related to a specific injury. The problem results from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too soon, but other factors can make it more likely to develop tendinitis, including:

A00147F04A bone spur that has developed where the tendon attaches to the heel bone.
Symptoms

Common symptoms of Achilles tendinitis include:

If you have experienced a sudden “pop” in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. See your doctor immediately if you think you may have torn your tendon.

Doctor Examination

After you describe your symptoms and discuss your concerns, the doctor will examine your foot and ankle. The doctor will look for these signs:

Tests

Your doctor may order imaging tests to make sure your symptoms are caused by Achilles tendinitis.

X-rays

X-ray tests provide clear images of bones. X-rays can show whether the lower part of the Achilles tendon has calcified, or become hardened. This calcification indicates insertional Achilles tendinitis. In cases of severe noninsertional Achilles tendinitis, there can be calcification in the middle portion of the tendon, as well.

Magnetic Resonance Imaging (MRI)

Although magnetic resonance imaging (MRI) is not necessary to diagnose Achilles tendinitis, it is important for planning surgery. An MRI scan can show how severe the damage is in the tendon. If surgery is needed, your doctor will select the procedure based on the amount of tendon damage.

Treatment

Nonsurgical Treatment

In most cases, nonsurgical treatment options will provide pain relief, although it may take a few months for symptoms to completely subside. Even with early treatment, the pain may last longer than 3 months. If you have had pain for several months before seeking treatment, it may take 6 months before treatment methods take effect.

Rest. The first step in reducing pain is to decrease or even stop the activities that make the pain worse. If you regularly do high-impact exercises (such as running), switching to low-impact activities will put less stress on the Achilles tendon. Cross-training activities such as biking, elliptical exercise, and swimming are low-impact options to help you stay active.

Ice. Placing ice on the most painful area of the Achilles tendon is helpful and can be done as needed throughout the day. This can be done for up to 20 minutes and should be stopped earlier if the skin becomes numb. A foam cup filled with water and then frozen creates a simple, reusable ice pack. After the water has frozen in the cup, tear off the rim of the cup. Then rub the ice on the Achilles tendon. With repeated use, a groove that fits the Achilles tendon will appear, creating a “custom-fit” ice pack.

Non-steroidal anti-inflammatory medication. Drugs such as ibuprofen and naproxen reduce pain and swelling. They do not, however, reduce the thickening of the degenerated tendon. Using the medication for more than 1 month should be reviewed with your primary care doctor.

Exercise. The following exercise can help to strengthen the calf muscles and reduce stress on the Achilles tendon.

 A00149F04
  • Calf stretch
    Lean forward against a wall with one knee straight and the heel on the ground. Place the other leg in front, with the knee bent. To stretch the calf muscles and the heel cord, push your hips toward the wall in a controlled fashion. Hold the position for 10 seconds and relax. Repeat this exercise 20 times for each foot. A strong pull in the calf should be felt during the stretch.

Physical Therapy. Physical therapy is very helpful in treating Achilles tendinitis. It has proven to work better for noninsertional tendinitis than for insertional tendinitis.

Eccentric Strengthening Protocol. Eccentric strengthening is defined as contracting (tightening) a muscle while it is getting longer. Eccentric strengthening exercises can cause damage to the Achilles tendon if they are not done correctly. At first, they should be performed under the supervision of a physical therapist. Once mastered with a therapist, the exercises can then be done at home. These exercises may cause some discomfort, however, it should not be unbearable.

 fig21 [Converted]
    • Bilateral heel drop
      Stand at the edge of a stair, or a raised platform that is stable, with just the front half of your foot on the stair. This position will allow your heel to move up and down without hitting the stair. Care must be taken to ensure that you are balanced correctly to prevent falling and injury. Be sure to hold onto a railing to help you balance.

Lift your heels off the ground then slowly lower your heels to the lowest point possible. Repeat this step 20 times. This exercise should be done in a slow, controlled fashion. Rapid movement can create the risk of damage to the tendon. As the pain improves, you can increase the difficulty level of the exercise by holding a small weight in each hand.

  • Single leg heel drop
    This exercise is performed similarly to the bilateral heel drop, except that all your weight is focused on one leg. This should be done only after the bilateral heel drop has been mastered.

Cortisone injections. Cortisone, a type of steroid, is a powerful anti-inflammatory medication. Cortisone injections into the Achilles tendon are rarely recommended because they can cause the tendon to rupture (tear).

Supportive shoes and orthotics. Pain from insertional Achilles tendinitis is often helped by certain shoes, as well as orthotic devices. For example, shoes that are softer at the back of the heel can reduce irritation of the tendon. In addition, heel lifts can take some strain off the tendon.

Heel lifts are also very helpful for patients with insertional tendinitis because they can move the heel away from the back of the shoe, where rubbing can occur. They also take some strain off the tendon. Like a heel lift, a silicone Achilles sleeve can reduce irritation from the back of a shoe.

If your pain is severe, your doctor may recommend a walking boot for a short time. This gives the tendon a chance to rest before any therapy is begun. Extended use of a boot is discouraged, though, because it can weaken your calf muscle.

Extracorporeal shockwave therapy (ESWT). During this procedure, high-energy shockwave impulses stimulate the healing process in damaged tendon tissue. ESWT has not shown consistent results and, therefore, is not commonly performed.

ESWT is noninvasive—it does not require a surgical incision. Because of the minimal risk involved, ESWT is sometimes tried before surgery is considered.

Surgical Treatment

Surgery should be considered to relieve Achilles tendinitis only if the pain does not improve after 6 months of nonsurgical treatment. The specific type of surgery depends on the location of the tendinitis and the amount of damage to the tendon.

Gastrocnemius recession. This is a surgical lengthening of the calf (gastrocnemius) muscles. Because tight calf muscles place increased stress on the Achilles tendon, this procedure is useful for patients who still have difficulty flexing their feet, despite consistent stretching.

In gastrocnemius recession, one of the two muscles that make up the calf is lengthened to increase the motion of the ankle. The procedure can be performed with a traditional, open incision or with a smaller incision and an endoscope—an instrument that contains a small camera. Your doctor will discuss the procedure that best meets your needs.

Complication rates for gastrocnemius recession are low, but can include nerve damage.

Gastrocnemius recession can be performed with or without débridement, which is removal of damaged tissue.

Débridement and repair (tendon has less than 50% damage). The goal of this operation is to remove the damaged part of the Achilles tendon. Once the unhealthy portion of the tendon has been removed, the remaining tendon is repaired with sutures, or stitches to complete the repair.

In insertional tendinitis, the bone spur is also removed. Repair of the tendon in these instances may require the use of metal or plastic anchors to help hold the Achilles tendon to the heel bone, where it attaches.

After débridement and repair, most patients are allowed to walk in a removable boot or cast within 2 weeks, although this period depends upon the amount of damage to the tendon.

Débridement with tendon transfer (tendon has greater than 50% damage). In cases where more than 50% of the Achilles tendon is not healthy and requires removal, the remaining portion of the tendon is not strong enough to function alone. To prevent the remaining tendon from rupturing with activity, an Achilles tendon transfer is performed. The tendon that helps the big toe point down is moved to the heel bone to add strength to the damaged tendon. Although this sounds severe, the big toe will still be able to move, and most patients will not notice a change in the way they walk or run.

Depending on the extent of damage to the tendon, some patients may not be able to return to competitive sports or running.

Recovery. Most patients have good results from surgery. The main factor in surgical recovery is the amount of damage to the tendon. The greater the amount of tendon involved, the longer the recovery period, and the less likely a patient will be able to return to sports activity.

Physical therapy is an important part of recovery. Many patients require 12 months of rehabilitation before they are pain-free.

Complications. Moderate to severe pain after surgery is noted in 20% to 30% of patients and is the most common complication. In addition, a wound infection can occur and the infection is very difficult to treat in this location.

For More Information

If you found this article helpful, you may also be interested in Achilles Tendon Rupture (Tear).

In order to assist doctors in the diagnosis and treatment of achilles tendon rupture, the American Academy of Orthopaedic Surgeons has done research to provide some useful guidelines. These are recommendations only and may not apply to each and every individual case. For more information: AAOS Clinical Practice Guideline: Diagnosis and Treatment of Acute Achilles Tendon Rupture.

Last reviewed: June 2010
Contributed and/or Updated by: Anish R. Kadakia, MD
Peer-Reviewed by: Stuart J. Fischer, MD; Steven L. Haddad, MD
Contributor Disclosure Information

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Preserving Life and Limb

Diabetes is a worldwide epidemic. Although the cause of diabetes is still unknown, we are learning more and more every day about this disease and the health problems it can create when not managed properly. According to the American Diabetes Association, nearly 7% of Americans have diabetes — that’s 20 million people. Many don’t even know they have it.

 

To understand diabetes is to understand a complex system of causes and effects — a lot like a row of dominoes standing on end. A person with diabetes cannot properly process food into energy. Their bodies just don’t produce enough of the hormone insulin to convert sugar into energy. This results in high blood sugar levels that can compromise the body’s intricate system of veins and arteries. The resulting poor circulation causes a host of serious conditions including the potential for blindness, kidney failure, heart disease and nerve damage, especially in the feet. Nerve damage desensitizes feet, leaving room for problems that go undetected so long that they cannot heal. In severe cases, the only option for some foot infections and other diabetic foot disorders is amputation.

 

How Can You Prevent the Domino Effect?

This website will answer some of the questions you may have about how diabetes may affect your feet and how you can help to protect yourself from serious foot problems. It also will help you better understand what to expect if you do develop foot disorders.

 

Why Focus on the Foot?

Normal, healthy feet will show wear and tear as we age. Our feet change over time, losing some of the padding that once cushioned our steps. For those with diabetes, there really is no such thing as normal wear and tear. If you or a loved one has been diagnosed with diabetes, you should be aware of potential problems and how to avoid them. Together, we can minimize the chances of a diabetic foot disorder from getting a “toehold” in your life.

 

What Are the Most Common Diabetic Foot Disorders?

Peripheral Neuropathy

Diabetes damages the nerves that help you detect sensations like pain. This nerve damage, or neuropathy, often affects peripheral body tissue first. Peripheral neuropathy may first appear as tingling or numbness in your fingers and toes. Over time, the nerve damage causes a lack of feeling in the toes and feet. The lack of feeling in the foot opens the door for many problems — ulcers of the foot tissue, infections, and, in severe cases, amputations of the toes, feet and legs.

As part of your diabetes management, be sure to have your physician carefully examine your feet every year. For some patients, feeling in the feet can be restored through new surgical techniques that alleviate pressure on compressed nerves.

Foot Ulcers

Diabetic ulcers are sores that develop in the soft tissue of the foot usually as a result of minor skin trauma or cumulative trauma in patients with loss of sensation in the foot. The lack of normal feeling in the foot means that these sores can exist without your feeling them. Ulcers are a leading cause of diabetic infections that if unresolved can lead to amputation of the affected limb. These ulcers will not heal on their own. If left untreated, the resulting infection may progress and can lead to increasingly extensive amputation the longer it goes untreated. Unfortunately, in many patients an amputation on one leg is followed within just a few years by amputation of the other.

Early detection of these ulcers can be critical in helping to prevent these amputations. By regularly visiting your foot and ankle specialist, frequently checking yourself, and seeking quick treatment for ulcers, you will be helping to prevent foot ulcers from compromising your mobility and your quality of life.

Information on hip osteoarthritis is also available in Spanish: Osteoartritis de cadera.

Sometimes called “wear-and-tear” arthritis, osteoarthritis is a common condition that many people develop during middle age or older. In 2011, more than 28 million people in the United States were estimated to have osteoarthritis. It can occur in any joint in the body, but most often develops in weight-bearing joints, such as the hip.

Osteoarthritis of the hip causes pain and stiffness. It can make it hard to do everyday activities like bending over to tie a shoe, rising from a chair, or taking a short walk.

Because osteoarthritis gradually worsens over time, the sooner you start treatment, the more likely it is that you can lessen its impact on your life. Although there is no cure for osteoarthritis, there are many treatment options to help you manage pain and stay active.

Anatomy

The hip is one of the body’s largest joints. It is a “ball-and-socket” joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

The bone surfaces of the ball and socket are covered with articular cartilage, a smooth, slippery substance that protects and cushions the bones and enables them to move easily.

The surface of the joint is covered by a thin lining called the synovium. In a healthy hip, the synovium produces a small amount of fluid that lubricates the cartilage and aids in movement.

 

img1osteoarthritis
The anatomy of the hip.

Description

Osteoarthritis is a degenerative type of arthritis that occurs most often in people 50 years of age and older, though it may occur in younger people, too.

In osteoarthritis, the cartilage in the hip joint gradually wears away over time. As the cartilage wears away, it becomes frayed and rough, and the protective joint space between the bones decreases. This can result in bone rubbing on bone. To make up for the lost cartilage, the damaged bones may start to grow outward and form bone spurs (osteophytes).

Osteoarthritis develops slowly and the pain it causes worsens over time.

img2osteoarthritis
A hip damaged by osteoarthritis.

Animation courtesy Visual Health Solutions, Inc.

Cause

Osteoarthritis has no single specific cause, but there are certain factors that may make you more likely to develop the disease, including:

Even if you do not have any of the risk factors listed above, you can still develop osteoarthritis.

Symptoms

The most common symptom of hip osteoarthritis is pain around the hip joint. Usually, the pain develops slowly and worsens over time, although sudden onset is also possible. Pain and stiffness may be worse in the morning, or after sitting or resting for a while. Over time, painful symptoms may occur more frequently, including during rest or at night. Additional symptoms may include:

Doctor Examination

During your appointment, your doctor will talk with you about your symptoms and medical history, conduct a physical examination, and possibly order diagnostic tests, such as x-rays.

Physical Examination

During the physical examination, your doctor will look for:

  • Tenderness about the hip
  • Range of passive (assisted) and active (self-directed) motion
  • Crepitus (a grating sensation inside the joint) with movement
  • Pain when pressure is placed on the hip
  • Problems with your gait (the way you walk)
  • Any signs of injury to the muscles, tendons, and ligaments surrounding the hip
Imaging Tests

X-rays. These imaging tests create detailed pictures of dense structures, like bones. X-rays of an arthritic hip may show a narrowing of the joint space, changes in the bone, and the formation of bone spurs (osteophytes).

 

img3osteoarthritis

 

(Left) In this x-ray of a normal hip, the space between the ball and socket indicates healthy cartilage. (Right) This x-ray of an arthritic hip shows severe loss of joint space and bone spurs.

Other imaging tests. Occasionally, a magnetic resonance imaging (MRI) scan, a computed tomography (CT) scan, or a bone scan may be needed to better determine the condition of the bone and soft tissues of your hip.

Treatment

Although there is no cure for osteoarthritis, there are a number of treatment options that will help relieve pain and improve mobility.

Nonsurgical Treatment

As with other arthritic conditions, early treatment of osteoarthritis of the hip is nonsurgical. Your doctor may recommend a range of treatment options.

Lifestyle modifications. Some changes in your daily life can protect your hip joint and slow the progress of osteoarthritis.

  • Minimizing activities that aggravate the condition, such as climbing stairs.
  • Switching from high-impact activities (like jogging or tennis) to lower impact activities (like swimming or cycling) will put less stress on your hip.
  • Losing weight can reduce stress on the hip joint, resulting in less pain and increased function.

Physical therapy. Specific exercises can help increase range of motion and flexibility, as well as strengthen the muscles in your hip and leg. Your doctor or physical therapist can help develop an individualized exercise program that meets your needs and lifestyle.

Assistive devices. Using walking supports like a cane, crutches, or a walker can improve mobility and independence. Using assistive aids like a long-handled reacher to pick up low-lying things will help you avoid movements that may cause pain.

Medications. If your pain affects your daily routine, or is not relieved by other nonsurgical methods, your doctor may add medication to your treatment plan.

  • Acetaminophen is an over-the-counter pain reliever that can be effective in reducing mild arthritis pain. Like all medications, however, over-the-counter pain relievers can cause side effects and interact with other medications you are taking. Be sure to discuss potential side effects with your doctor.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) may relieve pain and reduce inflammation. Over-the-counter NSAIDs include naproxen and ibuprofen. Other NSAIDs are available by prescription.
  • Corticosteroids (also known as cortisone) are powerful anti-inflammatory agents that can be taken by mouth or injected into the painful joint.
Surgical Treatment

Your doctor may recommend surgery if your pain from arthritis causes disability and is not relieved with nonsurgical treatment.

Osteotomy. Either the head of the thighbone or the socket is cut and realigned to take pressure off of the hip joint. This procedure is used only rarely to treat osteoarthritis of the hip.

Hip resurfacing. In this hip replacement procedure, the damaged bone and cartilage in the acetabulum (hip socket) is removed and replaced with a metal shell. The head of the femur, however, is not removed, but instead capped with a smooth metal covering.

Total hip replacement. Your doctor will remove both the damaged acetabulum and femoral head, and then position new metal, plastic or ceramic joint surfaces to restore the function of your hip.

img4osteoarthritis
In total hip replacement, both the head of the femur and the socket are replaced with an artificial device.

Animation courtesy Visual Health Solutions, Inc.

Complications. Although complications are possible with any surgery, your doctor will take steps to minimize the risks. The most common complications of surgery include:

  • Infection
  • Excessive bleeding
  • Blood clots
  • Hip dislocation
  • Limb length inequality
  • Damage to blood vessels or arteries

Your doctor will discuss possible complications with you before your surgery.

Recovery

After any type of surgery for osteoarthritis of the hip, there is a period of recovery. Recovery time and rehabilitation depends on the type of surgery performed.

Your doctor may recommend physical therapy to help you regain strength in your hip and to restore range of motion. After your procedure, you may need to use a cane, crutches, or a walker for a time.

In most cases, surgery relieves the pain of osteoarthritis and makes it possible to perform daily activities more easily.

Source: National Estimates: Osteoarthritis. Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL: AAOS; January 2013. Based on Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum 2008;58(1):26-35 and U.S. Census Bureau, Population Division, 2011.

Last reviewed: July 2014
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Osteoarthritis, also known as “wear and tear” arthritis, is a progressive disease of the joints.

Cause

With osteoarthritis, the articular cartilage that covers the ends of bones in the joints gradually wears away. Where there was once smooth articular cartilage that made the bones move easily against each other when the joint bent and straightened, there is now a frayed, rough surface. Joint motion along this exposed surface is painful.

Osteoarthritis usually develops after many years of use. It affects people who are middle-aged or older. Other risk factors for osteoarthritis include obesity, previous injury to the affected joint, and family history of osteoarthritis.

Anatomy

A joint is where the ends of two or more bones meet. The knee joint, for example, is formed between the bones of the lower leg (the tibia and the fibula) and the thighbone (the femur). The hip joint is where the top of the thighbone (femoral head) meets a concave portion of the pelvis (the acetabulum).

A healthy joint glides easily without pain because a smooth, elastic tissue called articular cartilage covers the ends of the bones that make up the joint.

Symptoms

Osteoarthritis can affect any joint in the body, with symptoms ranging from mild to disabling.

A joint affected by osteoarthritis may be painful and inflamed. Without cartilage, bones rub directly against each other when the joint moves. This is what causes the pain and inflammation. Pain or a dull ache usually develops gradually over time. Pain may be worse in the morning and feel better with activity. Vigorous activity may cause pain to flare up.

 

img1-osteoarthritis

 

Hands of a patient with osteoarthritis. Bone growths on the little finger are typical of osteoarthritis.

 

The joint may stiffen and look swollen, enlarged or “out of joint.” A bump may develop over the joint.

If bending the joint becomes difficult, motion may be limited.

Loose fragments of cartilage and other tissue can interfere with the smooth motion of joints. The joint may lock or “stick” when used. It may creak, click, snap, or make a grinding noise (crepitus). The joint may become weak and buckle.

Although osteoarthritis cannot be cured, early identification and treatment can slow progression of the disease, relieve pain and restore function.

Diagnosis

img2-osteoarthritis

 

(Reproduced with permission from Griffin LY(ed): Essentials of Musculoskeletal Care 3rd edition. Rosemont, IL. American Academy of Orthopaedic Surgeons. 2005.)

 

A complete medical history, physical examination, X-rays, and possibly laboratory tests will be done.

The doctor will want to know if the joint has ever been injured. He or she will want to know when the joint pain began and what the pain feels like: Is the pain continuous, or does it come and go? Does it occur in other parts of the body? It is important to know when the pain occurs: Is it worse at night? Does it occur with walking, running or at rest?

The doctor will examine the affected joint in various positions to see if there is pain or restricted motion. He or she will look for creaking or grinding noises (crepitus) that indicate bone-on-bone friction. muscle loss (atrophy), and signs that other joints are involved. The doctor will look for signs of injury to muscles, tendons, and ligaments.

X-rays can show the extent of joint deterioration, including narrowing of joint space, thinning or erosion of bone, excess fluid in the joint, and bone spurs or other abnormalities. They can help the doctor distinguish various forms of arthritis.

Sometimes laboratory tests can help rule out other diseases that cause symptoms similar to osteoarthritis.

Treatment

Nonsurgical Treatment

Early, nonsurgical treatment can slow progression of osteoarthritis, increase motion, and improve strength. Most treatment programs combine lifestyle modifications, medication, and physical therapy.

Lifestyle Modifications
The doctor may recommend rest or a change in activities to avoid provoking osteoarthritis pain. This may include modifications in work or sports activities. It may mean switching from high-impact activities (such as aerobics, running, jumping, or competitive sports) to low-impact exercises (such as stretching, walking, swimming, or cycling). A weight loss program may be recommended, if needed, particularly if osteoarthritis affects weight-bearing joints (such as the knee, hip, spine, or ankle)

Medications
Non-steroidal anti-inflammatory drugs can help reduce inflammation. Sometimes, the doctor may recommend strong anti-inflammatory agents called corticosteroids, which are injected directly into the joint. Corticosteroids provide temporary relief of pain and swelling.

Dietary supplements called glucosamine and chondroitin sulfate may help relieve pain from osteoarthritis. (Caution: The U.S. Food and Drug Administration does not test or analyze dietary supplements. Always consult your doctor before taking dietary supplements. )

Physical Therapy
A balanced fitness program, physical therapy, and/or occupational therapy may improve joint flexibility, increase range of motion, reduce pain, and strengthen muscle, bone, and cartilage tissues. Supportive or assistive devices (such as a brace, splint, elastic bandage, cane, crutches, or walker) may be needed. Ice or heat may need to be applied to the affected joint for short periods, several times a day.

Surgical Treatment

If early treatments do not stop the pain or if they lose their effectiveness, surgery may be considered. The decision to treat surgically depends upon the age and activity level of the patient, the condition of the affected joint, and the extent to which osteoarthritis has progressed.

Surgical options for osteoarthritis include arthroscopy, osteotomy, joint fusion, and joint replacement.

Arthroscopy
A surgeon uses a pencil-sized, flexible, fiberoptic instrument (arthroscope) to make two or three small incisions to remove bone spurs, cysts, damaged lining, or loose fragments in the joint.

Osteotomy
The long bones of the arm or leg are realigned to take pressure off of the joint.

Joint fusion
A surgeon eliminates the joint by fastening together the ends of bone (fusion). Pins, plates, screws, or rods may hold bones in place while they heal. This procedure eliminates the joint’s flexibility.

Joint replacement
A surgeon removes parts of the bones and creates an artificial joint with metal or plastic components (total joint replacement or arthroplasty).

Last reviewed: July 2007
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Arthritis is inflammation of one or more of your joints. Pain, swelling, and stiffness are the primary symptoms of arthritis. Any joint in the body may be affected by the disease, but it is particularly common in the knee.

Knee arthritis can make it hard to do many everyday activities, such as walking or climbing stairs. It is a major cause of lost work time and a serious disability for many people.

The most common types of arthritis are osteoarthritis and rheumatoid arthritis, but there are more than 100 different forms. In 2012, more than 51 million people reported that they had been diagnosed with some form of arthritis, according to the National Health Interview Survey. While arthritis is mainly an adult disease, some forms affect children.

Although there is no cure for arthritis, there are many treatment options available to help manage pain and keep people staying active.

 

Anatomy


The knee is the largest and strongest joint in your body. It is made up of the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap). The ends of the three bones where they touch are covered with articular cartilage, a smooth, slippery substance that protects and cushions the bones as you bend and straighten your knee.

Two wedge-shaped pieces of cartilage called meniscus act as “shock absorbers” between your thighbone and shinbone. They are tough and rubbery to help cushion the joint and keep it stable.

The knee joint is surrounded by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage and reduces friction.
Arthritis_Anatomy
Normal anatomy of the knee.

 

Description


The major types of arthritis that affect the knee are osteoarthritis, rheumatoid arthritis, and posttraumatic arthritis.

Osteoarthritis

Osteoarthritis is the most common form of arthritis in the knee. It is a degenerative,”wear-and-tear” type of arthritis that occurs most often in people 50 years of age and older, but may occur in younger people, too.

In osteoarthritis, the cartilage in the knee joint gradually wears away. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone, and produce painful bone spurs.

Osteoarthritis develops slowly and the pain it causes worsens over time.

Arthritis_osteoarthritis

(Left) Normal joint space between the femur and the tibia. (Right) Decreased joint space due to damaged cartilage and bone spurs.

<i frame src=”https://i.ytimg.com/vi/OXGx4jK_q3k/sddefault.jpg”></iframe>

Animation courtesy Visual Health Solutions, Inc.

Rheumatoid Arthritis

Rheumatoid arthritis is a chronic disease that attacks multiple joints throughout the body, including the knee joint. It is symmetrical, meaning that it usually affects the same joint on both sides of the body.

In rheumatoid arthritis the synovial membrane that covers the knee joint begins to swell, This results in knee pain and stiffness.

Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. The immune system damages normal tissue (such as cartilage and ligaments) and softens the bone.

Posttraumatic Arthritis

Posttraumatic arthritis is form of arthritis that develops after an injury to the knee. For example, a broken bone may damage the joint surface and lead to arthritis years after the injury. Meniscal tears and ligament injuries can cause instability and additional wear on the knee joint, which over time can result in arthritis.

 

 

Symptoms


A knee joint affected by arthritis may be painful and inflamed. Generally, the pain develops gradually over time, although sudden onset is also possible. There are other symptoms, as well:

 

Doctor Examination


During your appointment, your doctor will talk with you about your symptoms and medical history, conduct a physical examination, and possibly order diagnostic tests, such as x-rays or blood tests.

Physical Examination

During the physical examination, your doctor will look for:

  • Joint swelling, warmth, or redness
  • Tenderness about the knee
  • Range of passive (assisted) and active (self-directed) motion
  • Instability of the joint
  • Crepitus (a grating sensation inside the joint) with movement
  • Pain when weight is placed on the knee
  • Problems with your gait (the way you walk)
  • Any signs of injury to the muscles, tendons, and ligaments surrounding the knee
  • Involvement of other joints (an indication of rheumatoid arthritis)

Imaging Tests

  • X-rays. These imaging tests create detailed pictures of dense structures, like bone. They can help distinguish among various forms of arthritis. X-rays of an arthritic knee may show a narrowing of the joint space, changes in the bone and the formation of bone spurs (osteophytes).
  • Other tests. Occasionally, a magnetic resonance imaging (MRI) scan, a computed tomography (CT) scan, or a bone scan may be needed to determine the condition of the bone and soft tissues of your knee.

Arthritis_Doc_Exam

(Left) In this x-ray of a normal knee, the space between the bones indicates healthy cartilage (arrows). (Right) This x-ray of an arthritic knee shows severe loss of joint space.

Laboratory Tests

Your doctor may also recommend blood tests to determine which type of arthritis you have. With some types of arthritis, including rheumatoid arthritis, blood tests will help with a proper diagnosis.

Treatment


There is no cure for arthritis but there are a number of treatments that may help relieve the pain and disability it can cause.

Nonsurgical Treatment

As with other arthritic conditions, initial treatment of arthritis of the knee is nonsurgical. Your doctor may recommend a range of treatment options.

Lifestyle modifications. Some changes in your daily life can protect your knee joint and slow the progress of arthritis.

  • Minimize activities that aggravate the condition, such as climbing stairs.
  • Switching from high impact activities (like jogging or tennis) to lower impact activities (like swimming or cycling) will put less stress on your knee.
  • Losing weight can reduce stress on the knee joint, resulting in less pain and increased function.

Physical therapy. Specific exercises can help increase range of motion and flexibility, as well as help strengthen the muscles in your leg. Your doctor or a physical therapist can help develop an individualized exercise program that meets your needs and lifestyle.

Assistive devices. Using devices such as a cane, wearing shock-absorbing shoes or inserts, or wearing a brace or knee sleeve can be helpful. A brace assists with stability and function, and may be especially helpful if the arthritis is centered on one side of the knee. There are two types of braces that are often used for knee arthritis: An “unloader” brace shifts weight away from the affected portion of the knee, while a “support” brace helps support the entire knee load.

Other remedies. Applying heat or ice, using pain-relieving ointments or creams, or wearing elastic bandages to provide support to the knee may provide some relief from pain.

Medications. Several types of drugs are useful in treating arthritis of the knee. Because people respond differently to medications, your doctor will work closely with you to determine the medications and dosages that are safe and effective for you.

    • Over-the-counter, non-narcotic pain relievers and anti-inflammatory medications are usually the first choice of therapy for arthritis of the knee. Acetaminophen is a simple, over-the-counter pain reliever that can be effective in reducing arthritis pain.

Like all medications, over-the-counter pain relievers can cause side effects and interact with other medications you are taking. Be sure to discuss potential side effects with your doctor.

    • Another type of pain reliever is a nonsteroidal anti-inflammatory drug, or NSAID (pronounced “en-said”). NSAIDs, such as ibuprofen and naproxen, are available both over-the-counter and by prescription.
    • A COX-2 inhibitor is a special type of NSAID that may cause fewer gastrointestinal side effects. Common brand names of COX-2 inhibitors include Celebrex (celecoxib) and Mobic (meloxicam, which is a partial COX-2 inhibitor). A COX-2 inhibitor reduces pain and inflammation so that you can function better. If you are taking a COX-2 inhibitor, you should not use a traditional NSAID (prescription or over-the-counter). Be sure to tell your doctor if you have had a heart attack, stroke, angina, blood clot, hypertension, or if you are sensitive to aspirin, sulfa drugs or other NSAIDs.
    • Corticosteroids (also known as cortisone) are powerful anti-inflammatory agents that can be injected into the joint These injections provide pain relief and reduce inflammation; however, the effects do not last indefinitely. Your doctor may recommend limiting the number of injections to three or four per year, per joint, due to possible side effects.

In some cases, pain and swelling may “flare” immediately after the injection, and the potential exists for long-term joint damage or infection. With frequent repeated injections, or injections over an extended period of time, joint damage can actually increase rather than decrease.

    • Disease-modifying anti-rheumatic drugs (DMARDs) are used to slow the progression of rheumatoid arthritis. Drugs like methotrexate, sulfasalazine, and hydroxychloroquine are commonly prescribed.

In addition, biologic DMARDs like etanercept (Embril) and adalimumab (Humira) may reduce the body’s overactive immune response. Because there are many different drugs today for rheumatoid arthritis, a rheumatology specialist is often required to effectively manage medications.

    • Viscosupplementation involves injecting substances into the joint to improve the quality of the joint fluid. For more information: Viscosupplementation Treatment for Arthritis
    • Glucosamine and chondroitin sulfate, substances found naturally in joint cartilage, can be taken as dietary supplements. Although patient reports indicate that these supplements may relieve pain, there is no evidence to support the use of glucosamine and chondroitin sulfate to decrease or reverse the progression of arthritis.

In addition, the U.S. Food and Drug Administration does not test dietary supplements before they are sold to consumers. These compounds may cause side effects, as well as negative interactions with other medications. Always consult your doctor before taking dietary supplements.

Alternative therapies. Many alternative forms of therapy are unproven, but may be helpful to try, provided you find a qualified practitioner and keep your doctor informed of your decision. Alternative therapies to treat pain include the use of acupuncture and magnetic pulse therapy.

Acupuncture uses fine needles to stimulate specific body areas to relieve pain or temporarily numb an area. Although it is used in many parts of the world and evidence suggests that it can help ease the pain of arthritis, there are few scientific studies of its effectiveness. Be sure your acupuncturist is certified, and do not hesitate to ask about his or her sterilization practices.

Magnetic pulse therapy is painless and works by applying a pulsed signal to the knee, which is placed in an electromagnetic field. Like many alternative therapies, magnetic pulse therapy has yet to be proven.

Surgical Treatment

Your doctor may recommend surgery if your pain from arthritis causes disability and is not relieved with nonsurgical treatment. As with all surgeries, there are some risks and possible complications with different knee procedures. Your doctor will discuss the possible complications with you before your operation.

Arthroscopy. During arthroscopy, doctors use small incisions and thin instruments to diagnose and treat joint problems.

Arthroscopic surgery is not often used to treat arthritis of the knee. In cases where osteoarthritis is accompanied by a degenerative meniscal tear, arthroscopic surgery may be recommended to treat the torn meniscus.

Cartilage grafting. Normal, healthy cartilage tissue may be taken from another part of the knee or from a tissue bank to fill a hole in the articular cartilage. This procedure is typically considered only for younger patients who have small areas of cartilage damage.

Synovectomy. The joint lining damaged by rheumatoid arthritis is removed to reduce pain and swelling.

Osteotomy. In a knee osteotomy, either the tibia (shinbone) or femur (thighbone) is cut and then reshaped to relieve pressure on the knee joint. Knee osteotomy is used when you have early-stage osteoarthritis that has damaged just one side of the knee joint. By shifting your weight off the damaged side of the joint, an osteotomy can relieve pain and significantly improve function in your arthritic knee.

Total or partial knee replacement (arthroplasty). Your doctor will remove the damaged cartilage and bone, and then position new metal or plastic joint surfaces to restore the function of your knee.

Arthritis_Treatment

Left) A partial knee replacement is an option when damage is limited to just one part of the knee. (Right) A total knee replacement prosthesis.

Recovery


After any type of surgery for arthritis of the knee, there is a period of recovery. Recovery time and rehabilitation depends on the type of surgery performed.

Your doctor may recommend physical therapy to help you regain strength in your knee and to restore range of motion. Depending upon your procedure, you may need to wear a knee brace, or use crutches or a cane for a time.

In most cases, surgery relieves pain and makes it possible to perform daily activities more easily.

Source: Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL: AAOS; April 2014. Based on data from the National Health Interview Survey, 2012; U.S. Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Health Statistics.

Articular cartilage is the smooth, white tissue that covers the ends of bones where they come together to form joints. Healthy cartilage in our joints makes it easier to move. It allows the bones to glide over each other with very little friction.

Articular cartilage can be damaged by injury or normal wear and tear. Because cartilage does not heal itself well, doctors have developed surgical techniques to stimulate the growth of new cartilage. Restoring articular cartilage can relieve pain and allow better function. Most importantly, it can delay or prevent the onset of arthritis.

Surgical techniques to repair damaged cartilage are still evolving. It is hoped that as more is learned about cartilage and the healing response, surgeons will be better able to restore an injured joint.

Cartilage Damage

Hyaline Cartilage

The main component of the joint surface is a special tissue called hyaline cartilage.When it is damaged, the joint surface may no longer be smooth. Moving bones along a tough, damaged joint surface is difficult and causes pain. Damaged cartilage can also lead to arthritis in the joint.

The goal of cartilage restoration procedures is to stimulate new hyaline cartilage growth.

Identifying Cartilage Damage

In many cases, patients who have joint injuries, such as meniscal or ligament tears, will also have cartilage damage. This damage may be hard to diagnose because hyaline cartilage does not contain calcium and cannot be seen on an X-ray.

If other injuries exist with cartilage damage, doctors will address all problems during surgery.

Patient Eligibility

acr-img1
Articular cartilage in the knee damaged in a single, or focal, location.

Most candidates for articular cartilage restoration are young adults with a single injury, or lesion. Older patients, or those with many lesions in one joint, are less likely to benefit from the surgery.

The knee is the most common area for cartilage restoration. Ankle and shoulder problems may also be treated.

Surgical Procedures

Many procedures to restore articular cartilage are done arthroscopically. During arthroscopy, your surgeon makes three small, puncture incisions around your joint using an arthroscope.

Some procedures require the surgeon to have more direct access to the affected area. Longer, open incisions are required. Sometimes it is necessary to address other problems in the joint, such as meniscal or ligament tears, when cartilage surgery is done.

In general, recovery from an arthroscopic procedure is quicker and less painful than a traditional, open surgery. Your doctor will discuss the options with you to determine what kind of procedure is right for you.

The most common procedures for cartilage restoration are:

Microfracture

acr-img2
Steps of the microfracture technique. Left: Damaged cartilage is removed. Center: Awl is used to make holes in the subchondral bone. Right: Healing response brings new, healthy cartilage cells.
(Reproduced with permission from Mithoefer K, Williams RJ III, Warren RF, et al: Chondral resurfacing of articular cartilage defects in the knee with the microfracture technique. J Bone Joint Surg Am 2006;88(suppl 1):294-304.

The goal of microfracture is to stimulate the growth of new articular cartilage by creating a new blood supply. A sharp tool called an awl is used to make multiple holes in the joint surface. The holes are made in the bone beneath the cartilage, called subchondral bone. This action creates a healing response. New blood supply can reach the joint surface, bringing with it new cells that will form the new cartilage.

The goal of microfracture is to stimulate the growth of new cartilage by creating a new blood supply.

A sharp tool called an awl is used to make multiple holes in the joint surface. The holes are made in the bone beneath the cartilage, called subchondral bone. This creates a healing response. New blood supply can reach the joint surface. This will bring new cells that will form cartilage.

Microfracture can be done with an arthroscope. The best candidates are young patients with single lesions and healthy subchondral bone.

acr-img3
Normal healthy articular cartilage in the knee (left). A large cartilage defect in the knee joint surface (center). During microfracture, an awl is used to penetrate the defect (right).

Drilling

Drilling, like microfracture, stimulates the production of healthy cartilage. Multiple holes are made through the injured area in the subchondral bone with a surgical drill or wire. The subchondral bone is penetrated to create a healing response.

Drilling can be done with an arthroscope. It is less precise than microfracture and the heat of the drill may cause injury to some of the tissues.

Abrasion Arthroplasty

Abrasion arthroplasty is similar to drilling. Instead of drills or wires, high speed burrs are used to remove the damaged cartilage and reach the subchondral bone.

Abrasion arthroplasty can be done with an arthroscope.

Autologous Chondrocyte Implantation (ACI)

ACI is a two-step procedure. New cartilage cells are grown and then implanted in the cartilage defect.

First, healthy cartilage tissue is removed from a non-weightbearing area of the bone. This step is done as an arthroscopic procedure. The tissue which contains healthy cartilage cells, or chondrocytes, is then sent to the laboratory. The cells are cultured and increase in number over a 3- to 5-week period.

An open surgical procedure, or arthrotomy, is then done to implant the newly grown cells. The cartilage defect is prepared. A layer of bone-lining tissue, called periosteum, is sewn over the area. This cover is sealed with fibrin glue. The newly grown cells are then injected into the defect under the periosteal cover.

ACI is most useful for younger patients who have single defects larger than 2 cm in diameter. ACI has the advantage of using the patient’s own cells, so there is no danger of a patient rejecting the tissue. It does have the disadvantage of being a two-stage procedure that requires an open incision. It also takes several weeks to complete.

Osteochondral Autograft Transplantation

In osteochondral autograft transplantation, cartilage is transferred from one part of the joint to another. Healthy cartilage tissue – a graft — is taken from an area of the bone that does not carry weight (non-weightbearing). The graft is taken as a cylindrical plug of cartilage and subchondral bone. It is then matched to the surface area of the defect and impacted into place. This leaves a smooth cartilage surface in the joint.

acr-img4
Mosaicplasty type osteochondral autograft transplantation procedure.
(Reproduced with permission from Hangody L, Rathonyi GK, Duska Z, et al: Autologous Osteochondral Mosaicplasty. Surgical Technique J Bone Joint Surg Am 2004;86(suppl 1):65-72.

A single plug of cartilage may be taken or a procedure using multiple plugs, called mosaicplasty, may be performed.

A single plug of cartilage may be transferred or a procedure with multiple plugs, called mosaicplasty, may be done.

Osteochondral autograft is used for smaller cartilage defects. This is because the healthy graft tissue can only be taken from a limited area of the same joint. It can be done with an arthroscope.

Osteochondral Allograft Transplantation

If a cartilage defect is too large for an autograft, an allograft may be considered. An allograft is a tissue graft taken from a cadaver donor. Like an autograft, it is a block of cartilage and bone. In the laboratory it is sterilized and prepared. It is tested for any possible disease transmission.

An allograft is typically larger than an autograft. It can be shaped to fit the exact contour of the defect and then press fit into place.

Allografts are typically done through an open incision.

Stem Cells and Tissue Engineering

Current research focuses on new ways to make the body grow healthy cartilage tissue. This is called tissue engineering. Growth factors that stimulate new tissue may be isolated and used to induce new cartilage formation.

The use of mesenchymal stem cells is also being investigated. Mesenchymal stem cells are basic human cells obtained from living human tissue, such as bone marrow. When stem cells are placed in a specific environment, they can give rise to cells that are similar to the host tissue.

The hope is that stem cells placed near a damaged joint surface will stimulate hyaline cartilage growth.

Tissue engineering procedures are still at an experimental stage. Most tissue engineering is performed at research centers as part of clinical trials.

Rehabilitation

After surgery, the joint surface must be protected while the cartilage heals. If the procedure was done on your knee or ankle, you may not be able to put weight on the affected leg. You will need to use crutches to move around for the first few weeks after surgery.

Your doctor may prescribe physical therapy. This will help restore mobility to the affected joint. During the first weeks after surgery, you may begin continuous passive motion therapy. A continuous passive motion machine constantly moves the joint through a controlled range of motion.

As healing progresses, your therapy will focus on strengthening the joint and the muscles that support it. It may be several months before you can safely return to sports activity.

Last reviewed: February 2009
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

There are more than 100 different forms of arthritis, a disease that can make it difficult to do everyday activities because of joint pain and stiffness.

Inflammatory arthritis occurs when the body’s immune system becomes overactive and attacks healthy tissues. It can affect several joints throughout the body at the same time, as well as many organs, such as the skin, eyes, and heart.

There are three types of inflammatory arthritis that most often cause symptoms in the hip joint:

Although there is no cure for inflammatory arthritis, there have been many advances in treatment, particularly in the development of new medications. Early diagnosis and treatment can help patients maintain mobility and function by preventing severe damage to the joint.

Anatomy

The hip is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

A slippery tissue called articular cartilage covers the surface of the ball and socket. It creates a smooth, low-friction surface that helps the bones glide easily across each other. The surface of the joint is covered by a thin lining called the synovium. In a healthy hip, the synovium produces a small amount of fluid that lubricates the cartilage and aids in movement.

iah-img1
The anatomy of the hip.

Description

The most common form of arthritis in the hip is osteoarthritis — the “wear-and-tear” arthritis that damages cartilage over time, typically causing painful symptoms in people after they reach middle age. Unlike osteoarthritis, inflammatory arthritis affects people of all ages, often showing signs in early adulthood.

Rheumatoid Arthritis

In rheumatoid arthritis, the synovium thickens, swells, and produces chemical substances that attack and destroy the articular cartilage covering the bone. Rheumatoid arthritis often involves the same joint on both sides of the body, so both hips may be affected.

Ankylosing Spondylitis

Ankylosing spondylitis is a chronic inflammation of the spine that most often causes lower back pain and stiffness. It may affect other joints, as well, including the hip.

Systemic Lupus Erythematosus

Systemic lupus erythematosus can cause inflammation in any part of the body, and most often affects the joints, skin, and nervous system. The disease occurs in young adult women in the majority of cases.

People with systemic lupus erythematosus have a higher incidence of osteonecrosis of the hip, a disease that causes bone cells to die, weakens bone structure, and leads to disabling arthritis.

Cause

The exact cause of inflammatory arthritis is not known, although there is evidence that genetics plays a role in the development of some forms of the disease.

Symptoms

Inflammatory arthritis may cause general symptoms throughout the body, such as fever, loss of appetite and fatigue. A hip affected by inflammatory arthritis will feel painful and stiff. There are other symptoms, as well:

Doctor Examination

Your doctor will ask questions about your medical history and your symptoms, then conduct a physical examination and order diagnostic tests.

Physical Examination

During the physical examination, your doctor will evaluate the range of motion in your hip. Increased pain during some movements may be a sign of inflammatory arthritis. He or she will also look for a limp or other problems with your gait (the way you walk) due to stiffness of the hip.

X-rays

X-rays are imaging tests that create detailed pictures of dense structures, like bone. X-rays of an arthritic hip will show whether there is any thinning or erosion in the bones, any loss of joint space, or any excess fluid in the joint.

Blood Tests

Blood tests may reveal whether a rheumatoid factor—or any other antibody indicative of inflammatory arthritis—is present.

 

iah-img2

 

(Left) This x-ray shows a normal hip. (Right) This x-ray shows inflammatory arthritis with decreased joint space.
Reproduced with permission from JF Sarwak, ed: Essentials of Musculoskeletal Care, ed. 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

 

Treatment

Although there is no cure for inflammatory arthritis, there are a number of treatment options that can help prevent joint destruction. Inflammatory arthritis is often treated by a team of healthcare professionals, including rheumatologists, physical and occupational therapists, social workers, rehabilitation specialists, and orthopaedic surgeons.

Nonsurgical Treatment

The treatment plan for managing your symptoms will depend upon your inflammatory disease. Most people find that some combination of treatment methods works best.

Non-steroidal anti-inflammatory drugs (NSAIDs). Drugs like naproxen and ibuprofen may relieve pain and help reduce inflammation. NSAIDs are available in both over-the-counter and prescription forms.

Corticosteroids. Medications like prednisone are potent anti-inflammatories. They can be taken by mouth, by injection, or used as creams that are applied directly to the skin.

Disease-modifying antirheumatic drugs (DMARDs). These drugs act on the immune system to help slow the progression of disease. Methotrexate and sulfasalazine are commonly prescribed DMARDs.

Physical therapy. Specific exercises may help increase the range of motion in your hip and strengthen the muscles that support the joint.

In addition, regular, moderate exercise may decrease stiffness and improve endurance. Swimming is a preferred exercise for people with ankylosing spondylitis because spinal motion may be limited.

Assistive devices. Using a cane, walker, long-handled shoehorn, or reacher may make it easier for you to perform the tasks of daily living.

Surgical Treatment

If nonsurgical treatments do not sufficiently relieve your pain, your doctor may recommend surgery. The type of surgery performed depends on several factors, including:

  • Your age
  • Condition of the hip joint
  • Which disease is causing your inflammatory arthritis
  • Progression of the disease

The most common surgical procedures performed for inflammatory arthritis of the hip include total hip replacement and synovectomy.

Total hip replacement. Your doctor will remove the damaged cartilage and bone, and then position new metal or plastic joint surfaces to restore the function of your hip. Total hip replacement is often recommended for patients with rheumatoid arthritis or ankylosing spondylitis to relieve pain and improve range of motion.

iah-img3

 

In total hip replacement, both the head of the femur and the socket are replaced with an artificial device.

 

Synovectomy. Synovectomy is done to remove part or all of the joint lining (synovium). It may be effective if the disease is limited to the joint lining and has not affected the articular cartilage that covers the bones. Generally, the procedure is used to treat only the early stages of inflammatory arthritis.

Your doctor will discuss the various surgical options with you. Do not hesitate to ask why a specific procedure is being recommended and what outcome you can expect.

Complications. Although complications are possible in any surgery, your doctor will take steps to minimize the risks. The most common complications of surgery include:

  • Infection
  • Excessive bleeding
  • Blood clots
  • Damage to blood vessels or arteries
  • Dislocation (in total hip replacement)
  • Limb length inequality (in total hip replacement)

Your doctor will discuss all the possible complications with you before your surgery.

Recovery. How long it takes to recover and resume your daily activities will depend on several factors, including your general health and the type of surgical procedure you have. Initially, you may need a cane, walker, or crutches to walk. Your doctor may recommend physical therapy to help you regain strength in your hip and to restore range of motion.

Outcomes

Inflammatory arthritis of the hip can cause a wide range of disabling symptoms. Today, new medications may prevent progression of disease and joint destruction. Early treatment can help preserve the hip joint.

In cases that progress to severe joint damage, surgery can relieve your pain, increase motion, and help you get back to enjoying everyday activities. Total hip replacement is one of the most successful operations in all of medicine.

Last reviewed: July 2014
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

A teenager or young adult who is physically active and participates in sports may sometimes experience pain in the front and center of the knee, usually underneath the kneecap (patella). This condition—called adolescent anterior knee pain—commonly occurs in many healthy young athletes, especially girls.

Adolescent anterior knee pain is not usually caused by a physical abnormality in the knee, but by overuse or a training routine that does not include adequate stretching or strengthening exercises. In most cases, simple measures like rest, over-the-counter medication, and strengthening exercises will relieve anterior knee pain and allow the young athlete to return to his or her favorite sports.

Anatomy


Adolescent Anterior Knee Pain
The knee is the largest and strongest joint in your body. It is made up of the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap). The ends of the bones where they touch are covered with articular cartilage, a smooth slippery substance that protects the bones as you bend and straighten your knee.

Ligaments and tendons connect the thighbone to the bones of the lower leg. The four ligaments in the knee attach to the bones and act like strong ropes to hold the bones together.

Muscles are connected to bones by tendons. The quadriceps tendon connects the muscles in the front of the thigh to the kneecap. Stretching from your kneecap to your shinbone is the patellar tendon.

Causes


In many cases, the true cause of anterior knee pain may not be clear. The complex anatomy of the knee joint, which allows it to bend while supporting heavy loads, is extremely sensitive to small problems in alignment, activity, training, and overuse.
For example, weakness in the quadriceps muscles at the front of the thigh may lead to anterior knee pain. When the knee bends and straightens, the quadriceps muscles help to keep the kneecap within a groove at the end of the femur. Weak quadriceps can cause poor tracking of the kneecap within the groove. This can place extra stress on tendons (potentially leading to tendinitis), or irritate the cartilage lining on the underside of the kneecap (chondromalacia patella).

There are other factors that may contribute to adolescent anterior knee pain:

Imbalance of thigh muscles (quadriceps and hamstrings) that support the knee joint
Tight quadriceps and hamstring muscles
Problems with alignment of the legs between the hips and the ankles
Using improper sports training techniques or equipment
Changes in footwear or playing surface
Overdoing sports activities, or changes in the type of training
Adolescent Anterior_Causes
The patella of this adolescent’s right knee is out of alignment and shifted toward the inside of her leg.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Symptoms


The most common symptom of anterior knee pain is a dull, achy pain that begins gradually and is frequently activity related. Other common symptoms include:

Popping or crackling sounds in the knee when you climb stairs or stand up and walk after prolonged sitting
Pain at night
Pain during activities that repeatedly bend the knee (jumping, squatting, running, and other exercise involving weight-lifting)
Pain related to a change in activity level or intensity, playing surface, or equipment.
Adolescent anterior knee pain syndrome does not usually cause swelling around the knee. Symptoms like clicking, locking, snapping, or giving way of the knee are also uncommon. These symptoms suggest a mechanical problem in the knee and are reasons to see your doctor.

Symptoms


If your knee pain will not go away and interferes with activity, visit your doctor.

Physical Examination
Your doctor will examine your knee to determine the cause of pain behind your kneecap and rule out other problems. He or she may ask you to stand, walk, jump, squat, sit, and lie down.

During the physical examination, your doctor will also check:

Alignment of the lower leg and the position of the kneecap
Knee stability, hip rotation, and range of motion of knees and hips
The kneecap for signs of tenderness
The attachment of thigh muscles to the kneecap
Strength, flexibility, firmness, tone, and circumference of front thigh muscles (quadriceps) and the back thigh muscles (hamstrings)
Tightness of the heel cord and flexibility of the feet

 

Tests

X-rays. Plain x-rays provide detailed pictures of dense structures, like bone. Special x-ray views will help your doctor determine if there are any problems in the shape or position of the kneecap. Your doctor may x-ray both of your legs to look for differences between them.

Magnetic resonance imaging (MRI) scans. This imaging study can create better images of the soft tissues around your knee. Unless you are suffering from symptoms like locking or catching of the knee, an MRI is not usually ordered during the initial evaluation and work-up of anterior knee pain. However, if your symptoms persist and do not improve with treatment, your doctor may order an MRI at a follow-up visit. This imaging study will help your doctor determine if there is an internal problem within the knee joint, such as damage to the cartilage or ligaments.

Adolescent Anterior_Test

In this x-ray of a bent knee taken from above, the patella is clearly out of alignment within the groove in the femur.
Reproduced from Schepsis AA: Patellar instability. Orthopaedic Knowledge Online Journal 2003; 1(12). Accessed February 2014.

Treatment


There are simple changes you can make to help relieve anterior knee pain.

Activity Changes

Stop doing the activities that make your knee hurt until the pain has resolved. This probably means changing your training routine. Switching to low-impact activities during this time will put less stress on your knee joint. Biking and swimming are good low-impact options. If you are overweight, losing weight will also help to reduce pressure on your knee.

Your knee pain may be related to your exercise technique. A trainer at school may be able to help you evaluate and improve upon your technique-such as how you land from a jump or push off from the starting block.

Resume running and other higher impact sports activities gradually.

Physical Therapy Exercises

Specific exercises will help you improve range of motion, strength, and endurance. It is especially important to focus on stretching and strengthening your quadriceps as these muscles are the main stabilizers of your kneecap. Your doctor may provide you with exercises or may recommend you visit a physical therapist who can develop an exercise program to improve your thigh muscle flexibility and strength.

It is very important to stick with the therapeutic exercise program for as long as your doctor or physical therapist prescribes. Anterior knee pain can return.

Adolescent Anterior_Treatment_physicalTherapy_Img

Straight-leg raises are an effective exercise for strengthening the quadriceps muscles.

Ice

Applying ice after physical activity may relieve some discomfort. Do not apply ice directly to the skin. Use an ice pack or wrap a towel around the ice or a package of frozen vegetables. Apply ice for about 20 minutes at a time.

Orthotics and Footwear

Your doctor may recommend shoe inserts. Soft-, firm- and hard-molded arch supports can help prevent the foot from overpronating and relieve pain and fatigue. Different types of arch supports can be purchased at your local drugstore.

Be sure that your athletic shoes provide the correct support for your activities.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Over-the-counter medications such as ibuprofen and naproxen may help to relieve your pain. Always take these medicines with some food in order to avoid the potential side effect of stomach upset. If NSAIDs do not provide relief from the discomfort, consult your doctor for a more thorough evaluation.

Recovery


Adolescent anterior knee pain is usually fully relieved with simple measures. It may recur, however, if you do not make adjustments to your training routine or activity level. It is essential to maintain appropriate conditioning of the muscles around the knee, particularly the quadriceps and hamstrings.

There are additional steps that you can take to prevent recurrence of anterior knee pain. They include:

  • Wearing shoes appropriate to your activities
  • Warming up thoroughly before physical activity
  • Incorporating stretching into your warm up routine, and stretching after physical activity
  • Reducing any activity that has hurt your knees in the past
  • Limiting the total number of miles you run in training and competition

Want more information? Try one of these websites. You will find information on musculoskeletal conditions relating to the knee, links to other websites, and information on other health conditions.

After having a knee replacement, you may expect your lifestyle to be a lot like it was before surgery— but without the pain. In many ways, you are right, but returning to your everyday activities takes time. Being an active participant in the healing process can help you get there sooner and ensure a more successful outcome.

Even though you will be able to resume most activities, you may have to avoid doing things that place excessive stress on your “new” knee, such as participating in high-impact sports like jogging. The suggestions here will help you enjoy your new knee while you safely resume your daily activities.

Hospital Discharge

Your hospital stay will typically last from 1 to 4 days, depending on the speed of your recovery. Before you are discharged from the hospital, you will need to accomplish several goals, such as:

If you are not able to accomplish these goals, it may be unsafe for you to go directly home after discharge. If this is the case, you may be temporarily transferred to a rehabilitation or skilled nursing center.

When you are discharged, your healthcare team will provide you with information to support your recovery at home. Although the complication rate after total knee replacement is low, when complications occur they can prolong or limit full recovery. Hospital staff will discuss possible complications, and review with you the warning signs of an infection or a blood clot.

Warning Signs of Infection

  • Persistent fever (higher than 100 degrees)
  • Shaking chills
  • Increasing redness, tenderness or swelling of your wound
  • Drainage of your wound
  • Increasing pain with both activity and rest

Warning Signs of a Blood Clot

  • Pain in your leg or calf unrelated to your incision
  • Tenderness or redness above or below your knee
  • Increasing swelling of your calf, ankle or foot

In very rare cases, a blood clot may travel to your lungs and become life-threatening. Signs that a blood clot has traveled to your lungs include:

  • Shortness of breath
  • Sudden onset of chest pain
  • Localized chest pain with coughing

Notify your doctor if you develop any of the above signs.

Recovery at Home


You will need some help at home for several days to several weeks after discharge. Before your surgery, arrange for a friend, family member or caregiver to provide help at home.

Preparing Your Home

The following tips can make your homecoming more comfortable, and can be addressed before your surgery:

  • Rearrange furniture so you can maneuver with a cane, walker, or crutches. You may temporarily change rooms (make the living room your bedroom, for example) to avoid using the stairs.
  • Remove any throw rugs or area rugs that could cause you to slip. Securely fasten electrical cords around the perimeter of the room.
  • Get a good chair—one that is firm with a higher-than-average seat and has a footstool for intermittent leg elevation.
  • Install a shower chair, gripping bar, and raised toilet seat in the bathroom.
  • Use assistive devices such as a long-handled shoehorn, a long-handled sponge, and a grabbing tool or reacher to avoid bending over too far.

fig40 [Converted]

Place items that you use frequently within easy reach.

Wound Care

During your recovery at home, follow these guidelines to take care of your wound and prevent infection:

  • Keep the wound area clean and dry. A dressing will be applied in the hospital and should be changed as necessary. Ask for instructions on how to change the dressing before you leave the hospital.
  • Follow your doctor’s instructions on how long to wait before you shower or bathe.
  • Notify your doctor immediately if the wound appears red or begins to drain. This could be a sign of infection.

Swelling

Mild to moderate swelling is normal for the first 3 to 6 months after surgery. To reduce swelling, elevate your leg slightly and apply ice. Wearing compression stockings may also help reduce swelling. Notify your doctor if you experience new or severe swelling, since this may be the warning sign of a blood clot.

Medication

Take all medications as directed by your doctor. Home medications may include narcotic and non-narcotic pain pills, oral or injectable blood thinners, stool softeners, and anti-nausea medications.

Be sure to talk to your doctor about all your medications—even over-the-counter drugs, supplements and vitamins. Your doctor will tell you which over-the-counter medicines are safe to take while using prescription pain medication.

It is especially important to prevent any bacterial infections from developing in your artificial joint. Your doctor may advise you to take antibiotics whenever there is the increased possibility of a bacterial infection, such as when you have dental work performed. Be sure to talk to your doctor before you have any dental work done and notify your dentist that you have had a knee replacement. You may also wish to carry a medical alert card so that, if an emergency arises, medical personnel will know that you have an artificial joint.

Diet

By the time you go home from the hospital, you should be eating a normal diet. Your doctor may recommend that you take iron and vitamin supplements. You may also be advised to avoid supplements that include vitamin K and foods rich in vitamin K if you taking certain blood thinner medications, such as warfarin (Coumadin). Foods rich in vitamin K include broccoli, cauliflower, brussel sprouts, liver, green beans, garbanzo beans, lentils, soybeans, soybean oil, spinach, kale, lettuce, turnip greens, cabbage, and onions.

Continue to drink plenty of fluids, but try to limit coffee intake and avoid alcohol. You should continue to watch your weight to avoid putting more stress on the joint.

Resuming Normal Activities


Once you get home, you should stay active. The key is to not do too much, too soon. While you can expect some good days and some bad days, you should notice a gradual improvement over time. Generally, the following guidelines will apply:

Driving
In most cases, it is safe to resume driving when you are no longer taking narcotic pain medication, and when your strength and reflexes have returned to a more normal state. Your doctor will help you determine when it is safe to resume driving.

Sexual Activity
Please consult your doctor about how soon you can safely resume sexual activity. Depending on your condition, you may be able to resume sexual activity within several weeks after surgery.

Sleeping Positions
You can safely sleep on your back, on either side, or on your stomach.

Return to Work
Depending on the type of activities you do on the job and the speed of your recovery, it may be several weeks before you are able to return to work. Your doctor will advise you when it is safe to resume your normal work activities.

Sports and Exercise
Continue to do the exercises prescribed by your physical therapist for at least 2 months after surgery. In some cases, your doctor may recommend riding a stationary bicycle to help maintain muscle tone and keep your knee flexible. When riding, try to achieve the maximum degree of bending and straightening possible.

As soon as your doctor gives you the go-ahead, you can return to many of the sports activities you enjoyed before your knee replacement.

Walk as much as you would like, but remember that walking is no substitute for the exercises prescribed by your doctor and physical therapist.
Swimming is an excellent low-impact activity after a total knee replacement; you can begin as soon as the sutures have been removed and the wound is healed.
In general, lower impact fitness activities such as golfing, bicycling, and light tennis will help increase the longevity of your knee and are preferable over high-impact activities such as jogging, racquetball and skiing.
Air Travel
Pressure changes and immobility may cause your knee joint to swell, especially if it is just healing. Ask your doctor before you travel on an airplane. When going through security, be aware that the sensitivity of metal detectors varies and your artificial joint may cause an alarm. Tell the screener about your artificial joint before going through the metal detector. You may also wish to carry a medical alert card to show to the airport screener.

Arthritis involves inflammation of one or more of your joints. Pain and stiffness are common symptoms of arthritis, and when these occur in your wrist, simple daily activities can become more difficult.

There are many types of arthritis, and most of these can affect the wrist. Although the severity of symptoms related to arthritis can vary, most arthritis-related diseases are chronic. This means that they are long-lasting—even permanent—and can eventually cause serious joint damage.

Your wrist is a complex joint—it is actually made up of multiple small joints. When healthy, the bones glide easily over each other during movement, protected by smooth cartilage that coats the joint surfaces. Arthritis damages this cartilage. As the disease progresses, there is a gradual loss of cartilage. Without a smooth joint surface, the bones rub against each other, leading to joint damage that cannot be repaired.

Although there is no cure for arthritis today, there are many treatment options available to help relieve your symptoms. Some options may also slow the progression of joint damage. With proper treatment, many people are able to manage their symptoms and stay active.

aow-img1

 

The bones of the wrist. Cartilage coats the ends of the bones to create a gliding joint.
Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Anatomy

The wrist is a complex joint that connects the hand to the forearm. It is formed by the two bones of the forearm—the radius and the ulna—and eight small carpal bones. The carpal bones are arranged in two rows at the base of the hand. There are four bones in each row.

The joint surface of each bone is covered with articular cartilage—a slippery substance that protects and cushions the bones as you move your hand and wrist.

Description

Although there are many types of arthritis, the three that most commonly affect the wrist are:

Osteoarthritis

Osteoarthritis can develop due to normal “wear-and-tear” in the wrist, particularly in people who have a family history of arthritis. It is a common problem for many people after they reach middle age, though it may occur in younger people, too.

In osteoarthritis, the smooth, slippery articular cartilage that covers the ends of the bones gradually wears away over time. Because the cartilage surface has little to no blood supply, it has little ability to heal or regenerate when it becomes injured or worn down.

As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone and lead to pain and stiffness in the joint.

aow-img2

 

(Left) This x-ray of a healthy wrist shows normal joint space. (Right) In this wrist with osteoarthritis, the cartilage is worn and the healthy space between bones is narrowed.
(Right) Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Osteoarthritis in the wrist can also develop from Kienböck’s disease. In Kienböck’s disease, the blood supply to one of the carpal bones—the lunate—is disrupted, causing the bone to die and slowly collapse. Over time, this collapse can lead to changes and arthritis in the joints around the lunate.

aow-img3

 

Surgical photo of the lunate bone in a patient with Kienböck’s disease. The cartilage in the center of the joint surface has worn down, exposing the bone underneath (red arrow). The black arrows indicate an area of healthy cartilage.
Rheumatoid Arthritis

Rheumatoid arthritis is a chronic disease that can affect multiple joints throughout the body. The condition often starts in smaller joints, such as those found in the hand and wrist. It is symmetrical, meaning that it usually affects the same joint on both sides of the body.

Rheumatoid arthritis is an autoimmune disease. This means that the body’s immune system attacks its own tissues. In rheumatoid arthritis, the defenses that normally protect the body from infection instead damage normal tissue (such as cartilage and ligaments) and can soften bone.

Rheumatoid arthritis often affects the joint between the two bones of the forearm, the radius and ulna. The deformity in the ulna can cause wearing and possible rupture of the tendons that straighten your fingers. This can cause more deformity and loss of function in your hand.

The exact cause of rheumatoid arthritis is not known—there are no clear genetic or environmental factors. Although it is not an inherited disease, researchers believe that some people have genes that could make them more likely to have rheumatoid disease.

aow-img4

 

In this wrist with advanced rheumatoid arthritis, the alignment of the carpal bones has collapsed, leading to a loss of joint space between the bones.
Posttraumatic Arthritis

Posttraumatic arthritis can develop after an injury, such as a broken wrist bone or a torn ligament. This trauma can cause a direct injury to the cartilage or a delayed wearing of the cartilage due to a change in the way the bones move together—such as after a ligament tear.

Posttraumatic arthritis can develop over many years from the initial injury. Despite proper treatment, an injured joint is more likely to become arthritic over time.

Symptoms

Not all patients with arthritis will experience symptoms. When they do occur, the severity varies greatly from patient to patient. For some patients, the symptoms are not constant—but may come and go depending on their level of activity and other factors.

Symptoms of arthritis may include:

Doctor Examination

Physical Examination

Your doctor will talk with you about your overall health and medical history and ask you to describe your symptoms. He or she will perform a careful examination of your hand and wrist, looking for:

aow-img5

 

During the examination, your doctor will measure the range of motion in your wrist.
  • Reduced range of motion
  • Any areas of pain or tenderness
  • Joint instability
  • Swelling or other changes in appearance

During the examination, your doctor may also evaluate:

  • Finger and thumb mobility—To determine how well your tendons and joints are functioning
  • Nerve function—To determine if you have another condition that may be affecting your wrist, such as carpal tunnel syndrome (nerve compression)
Tests

X-rays. X-rays provide detailed images of dense structures, such as bone. X-rays of your wrist will help your doctor learn more about the exact location and severity of your arthritis. They can also help your doctor distinguish between various types of arthritis.

Blood tests. Your doctor may recommend blood tests to determine which type of arthritis you have. With rheumatoid and other types of inflammatory arthritis, blood tests are important for an accurate diagnosis. Osteoarthritis is not associated with blood abnormalities.

Treatment

There is no cure for arthritis, but there are a number of treatments that may help reduce the frequency of your symptoms and relieve the pain and loss of function it can cause.

Nonsurgical Treatment

In general, initial treatment for arthritis is nonsurgical in nature and designed to help minimize your symptoms.

Nonsurgical treatment options may include:

  • Activity modification. Limiting or stopping the activities that make your pain worse is the first step in relieving symptoms.
  • Immobilization. Wearing a wrist splint for a short time will help support the joint and ease the stress placed on it by frequent use and activities.
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, naproxen, and ibuprofen can help reduce both pain and swelling. Topical NSAIDs can be applied directly to the skin in the area of the joint.
  • Exercise. Specific exercises will help improve range of motion and function in your wrist. Your doctor or a physical therapist can help develop an exercise program that meets your specific needs.
  • Steroid injection. Cortisone is a powerful anti-inflammatory agent that can be injected into an arthritic joint. Although an injection of cortisone can provide relief and reduce inflammation, the effects may be temporary.
  • Other therapies. This may include using “contrast soaks” of warm and cold water to help reduce swelling.

If your symptoms of rheumatoid arthritis are not adequately controlled by the above therapies, your doctor may prescribe additional medications. These medications—called disease-modifying anti-rheumatic drugs (DMARDs)—are designed to stop the immune system from attacking the joints.

Like all medications, DMARDs have both risks and benefits. Your use of DMARDs will be directed by a rheumatologist.

Surgical Treatment

If nonsurgical treatment does not relieve your pain and your quality of life has been significantly affected by arthritis, your doctor may recommend surgery.

The goal of surgery is to relieve pain while preserving or improving hand function. Typically, this is done by minimizing or eliminating bone-on-bone contact. There are a number of procedures for arthritis of the wrist. Your doctor will talk with you about which procedure will work best in your case.

Proximal row carpectomy. In this procedure, your doctor removes three carpal bones in the row of bones that is closest to the forearm. The procedure is designed to reduce your pain while maintaining some wrist motion.

 

aow-img6

 

(Left) The three wrist bones that are removed in a proximal row carpectomy. (Right) X-ray image of a wrist after the procedure.

Fusion. If motion is the source of your pain, your doctor may recommend fusion. Fusion is essentially a “welding” process. The basic idea is to fuse together the bones so that they heal into a single, solid bone. The theory behind fusion is that, if the painful bones do not move, they should not hurt.

During the procedure, your doctor removes the damaged cartilage and then uses pins, plates, or screws to hold the joint in a permanent position. Over time, the bones fuse or grow together— similar to the way the fractured ends of a bone heal together.

In some cases, your doctor can perform a partial fusion in which just some of the carpal bones are fused together. This addresses the damaged joint surfaces, but leaves the healthy joints intact to preserve some wrist motion.

 

aow-img7

 

In this partial wrist fusion, the scaphoid bone has been removed and screws have been used to hold four carpal bones in place.

If your arthritis is extensive, however, a complete wrist fusion may be necessary. In this procedure, all of the carpal bones are fused together, along with the radius (one of the bones in the forearm). Although all wrist motion is eliminated in a complete fusion, forearm rotation and finger/thumb motion are generally preserved.

 

aow-img8

 

In this complete wrist fusion, the bones are held together with a combination of plates, screws, and pins.

Total wrist replacement (arthroplasty). In total wrist replacement, your doctor removes the damaged cartilage and bone in your wrist and then positions new metal or plastic joint surfaces to restore the function of the joint. Replacing the wrist joint relieves the pain of arthritis while allowing more wrist movement than fusion.

 

aow-img9

 

In this total wrist replacement (arthroplasty), the worn-out bones have been replaced with an implant made of metal and plastic.

Living with Arthritis

It can be discouraging to learn that you have arthritis, but there are some things you can do to help lessen the impact the condition has on your life. These include:

If you found this article helpful, you may also be interested in Carpal Tunnel Syndrome.

Last reviewed: April 2016
Contributed and/or Updated by: Jacob W. Brubacher, MD; Charles D. Jennings , MD
Peer-Reviewed by: Stuart J. Fischer, MD; Fraser J. Leversedge, MD
Contributor Disclosure Information

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Arthritis is a condition that irritates or destroys a joint. Although there are several types of arthritis, the one that most often affects the joint at the base of the thumb (the basal joint) is osteoarthritis (degenerative or “wear-and-tear” arthritis).

Description

diseased-joint-img

Smooth cartilage covers the ends of the bones. It enables the bones to glide easily in the joint. Without it, bones rub against each other, causing friction and damage to the bones and the joint. Osteoarthritis occurs when the cartilage begins to wear away.

The joint at the base of the thumb, near the wrist and at the fleshy part of the thumb, enables the thumb to swivel, pivot, and pinch so that you can grip things in your hand.

Arthritis of the base of the thumb is more common in women than in men, and usually occurs after 40 years of age. Prior fractures or other injuries to the joint may increase the likelihood of developing this condition.

Symptoms

Doctor Examination

Your doctor will ask you about your symptoms, any prior injury, pain patterns, or activities that aggravate the condition.

One of the tests used during the examination involves holding the joint firmly while moving the thumb. If pain or a gritty feeling results, or if a grinding sound (crepitus) can be heard, the bones are rubbing directly against each other.

An x-ray may show deterioration of the joint as well as any bone spurs or calcium deposits that have developed.

Many people with arthritis at the base of the thumb also have symptoms of carpal tunnel syndrome, so your doctor may check for that, as well.

Treatment

Nonsurgical Treatment

In its early stages, arthritis at the base of the thumb will respond to nonsurgical treatment.

  • Ice the joint for 5 to 15 minutes several times a day.
  • Take an anti-inflammatory medication, such as aspirin or ibuprofen, to help reduce inflammation and swelling.
  • Wear a supportive splint to limit the movement of your thumb, and allow the joint to rest and heal. The splint may protect both the wrist and the thumb. It may be worn overnight or intermittently during the day.

Because arthritis is a progressive, degenerative disease, the condition may worsen over time. The next phase in treatment involves injecting a steroid solution injection directly into the joint. This will usually provide relief for several months. However, these injections cannot be repeated indefinitely.

Surgical Treatment

When nonsurgical treatment is no longer effective, surgery is an option. The operation can be performed on an outpatient basis, and several different procedures can be used.

One option involves fusing the bones of the joint together. This, however, will limit movement.

Another option is to remove part of the joint and reconstruct it using either a tendon graft or an artificial substance.

You and your physician will discuss the options and select the one that is best for you.

Rehabilitation

After surgery, you will have to wear a cast for 4 to 8 weeks, depending on which procedure is used. A rehabilitation program, often involving a physical therapist, helps you regain movement and strength in the hand. You may feel some discomfort during the initial stages of the rehabilitation program, but this will diminish over time. Full recovery from surgery takes several months. Most patients are able to resume normal activities.

Last reviewed: December 2013
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

This article is also available in Spanish: Artritis del hombro (Arthritis of the Shoulder).

In 2011, more than 50 million people in the United States reported that they had been diagnosed with some form of arthritis, according to the National Health Interview Survey. Simply defined, arthritis is inflammation of one or more of your joints. In a diseased shoulder, inflammation causes pain and stiffness.

Although there is no cure for arthritis of the shoulder, there are many treatment options available. Using these, most people with arthritis are able to manage pain and stay active.

Anatomy

aos-img1

 

The bones and joints of the shoulder.
Reproduced with permission from J Bernstein, ed: Musculoskeletal Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003.

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket. These tissues are called the rotator cuff.

There are two joints in the shoulder, and both may be affected by arthritis. One joint is located where the clavicle meets the tip of the shoulder blade (acromion). This is called the acromioclavicular (AC) joint.

Where the head of the humerus fits into the scapula is called the glenohumeral joint.

To provide you with effective treatment, your physician will need to determine which joint is affected and what type of arthritis you have.

Description

Five major types of arthritis typically affect the shoulder.

Osteoarthritis

Also known as “wear-and-tear” arthritis, osteoarthritis is a condition that destroys the smooth outer covering (articular cartilage) of bone. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. During movement, the bones of the joint rub against each other, causing pain.

Osteoarthritis usually affects people over 50 years of age and is more common in the acromioclavicular joint than in the glenohumeral shoulder joint.

aos-img2

 

(Left) An illustration of damaged cartilage in the glenohumeral joint. (Right) This x-ray of the shoulder shows osteoarthritis and decreased joint space (arrow).
Illustration on left reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.
Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic disease that attacks multiple joints throughout the body. It is symmetrical, meaning that it usually affects the same joint on both sides of the body.

The joints of your body are covered with a lining — called synovium — that lubricates the joint and makes it easier to move. Rheumatoid arthritis causes the lining to swell, which causes pain and stiffness in the joint.

Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In RA, the defenses that protect the body from infection instead damage normal tissue (such as cartilage and ligaments) and soften bone.

Rheumatoid arthritis is equally common in both joints of the shoulder.

Posttraumatic Arthritis

Posttraumatic arthritis is a form of osteoarthritis that develops after an injury, such as a fracture or dislocation of the shoulder.

Rotator Cuff Tear Arthropathy

aos-img3

 

Rotator cuff arthropathy.

 

Arthritis can also develop after a large, long-standing rotator cuff tendon tear. The torn rotator cuff can no longer hold the head of the humerus in the glenoid socket, and the humerus can move upward and rub against the acromion. This can damage the surfaces of the bones, causing arthritis to develop.

The combination of a large rotator cuff tear and advanced arthritis can lead to severe pain and weakness, and the patient may not be able to lift the arm away from the side.

Avascular Necrosis

Avascular necrosis (AVN) of the shoulder is a painful condition that occurs when the blood supply to the head of the humerus is disrupted. Because bone cells die without a blood supply, AVN can ultimately lead to destruction of the shoulder joint and arthritis.

Avascular necrosis develops in stages. As it progresses, the dead bone gradually collapses, which damages the articular cartilage covering the bone and leads to arthritis. At first, AVN affects only the head of the humerus, but as AVN progresses, the collapsed head of the humerus can damage the glenoid socket.

Causes of AVN include high dose steroid use, heavy alcohol consumption, sickle cell disease, and traumatic injury, such as fractures of the shoulder. In some cases, no cause can be identified; this is referred to as idiopathic AVN.

Symptoms

Pain. The most common symptom of arthritis of the shoulder is pain, which is aggravated by activity and progressively worsens.

Limited range of motion. Limited motion is another common symptom. It may become more difficult to lift your arm to comb your hair or reach up to a shelf. You may hear a grinding, clicking, or snapping sound (crepitus) as you move your shoulder.

As the disease progresses, any movement of the shoulder causes pain. Night pain is common and sleeping may be difficult.

Doctor Examination

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder.

During the physical examination, your doctor will look for:

  • Weakness (atrophy) in the muscles
  • Tenderness to touch
  • Extent of passive (assisted) and active (self-directed) range of motion
  • Any signs of injury to the muscles, tendons, and ligaments surrounding the joint
  • Signs of previous injuries
  • Involvement of other joints (an indication of rheumatoid arthritis)
  • Crepitus (a grating sensation inside the joint) with movement
  • Pain when pressure is placed on the joint
X-Rays

X-rays are imaging tests that create detailed pictures of dense structures, like bone. They can help distinguish among various forms of arthritis.

X-rays of an arthritic shoulder will show a narrowing of the joint space, changes in the bone, and the formation of bone spurs (osteophytes).

aos-img4

 

This x-ray shows severe osteoarthritis of the glenohumeral joint.
Reproduced with permission from Crosby LA (ed): Total Shoulder Arthoplasty. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 18.

To confirm the diagnosis, your doctor may inject a local anesthetic into the joint. If it temporarily relieves the pain, the diagnosis of arthritis is supported.

Treatment

Nonsurgical Treatment

As with other arthritic conditions, initial treatment of arthritis of the shoulder is nonsurgical. Your doctor may recommend the following treatment options:

  • Rest or change in activities to avoid provoking pain. You may need to change the way you move your arm to do things.
  • Physical therapy exercises may improve the range of motion in your shoulder.
  • Nonsteroidal anti-inflammatory medications (NSAIDs), such as aspirin or ibuprofen, may reduce inflammation and pain. These medications can irritate the stomach lining and cause internal bleeding. They should be taken with food. Consult with your doctor before taking over-the-counter NSAIDs if you have a history of ulcers or are taking blood thinning medication.
  • Corticosteroid injections in the shoulder can dramatically reduce the inflammation and pain. However, the effect is often temporary.
  • Moist heat
  • Ice your shoulder for 20 to 30 minutes two or three times a day to reduce inflammation and ease pain.
  • If you have rheumatoid arthritis, your doctor may prescribe a disease-modifying drug, such as methotrexate.
  • Dietary supplements, such as glucosamine and chondroitin sulfate may help relieve pain. (Note: There is little scientific evidence to support the use of glucosamine and chondroitin sulfate to treat arthritis. In addition, the U.S. Food and Drug Administration does not test dietary supplements. These compounds may cause negative interactions with other medications. Always consult your doctor before taking dietary supplements.)
Surgical Treatment

Your doctor may consider surgery if your pain causes disability and is not relieved with nonsurgical options.

Arthroscopy. Cases of mild glenohumeral arthritis may be treated with arthroscopy, During arthroscopy, the surgeon inserts a small camera, called an arthroscope, into the shoulder joint. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.

During the procedure, your surgeon can debride (clean out) the inside of the joint. Although the procedure provides pain relief, it will not eliminate the arthritis from the joint. If the arthritis progresses, further surgery may be needed in the future.

Shoulder joint replacement (arthroplasty). Advanced arthritis of the glenohumeral joint can be treated with shoulder replacement surgery, in which the damaged parts of the shoulder are removed and replaced with artificial components, called a prosthesis.

aos-img5

 

(Left) A conventional total shoulder replacement (arthroplasty) mimics the normal anatomy of the shoulder. (Right) In a reverse total shoulder replacement, the plastic cup inserts on the humerus, and the metal ball screws into the shoulder socket.

 

Replacement surgery options include:

  • Hemiarthroplasty. Just the head of the humerus is replaced by an artificial component.
  • Total shoulder arthroplasty. Both the head of the humerus and the glenoid are replaced. A plastic “cup” is fitted into the glenoid, and a metal “ball” is attached to the top of the humerus.
  • Reverse total shoulder arthroplasty. In a reverse total shoulder replacement, the socket and metal ball are opposite a conventional total shoulder arthroplasty. The metal ball is fixed to the glenoid and the plastic cup is fixed to the upper end of the humerus. A reverse total shoulder replacement works better for people with cuff tear arthropathy because it relies on different muscles — not the rotator cuff — to move the arm.

Resection arthroplasty. The most common surgical procedure used to treat arthritis of the acromioclavicular joint is a resection arthroplasty. Your surgeon may choose to do this arthroscopically.

In this procedure, a small amount of bone from the end of the collarbone is removed, leaving a space that gradually fills in with scar tissue.

Recovery. Surgical treatment of arthritis of the shoulder is generally very effective in reducing pain and restoring motion. Recovery time and rehabilitation plans depend upon the type of surgery performed.

Pain management. After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Complications. As with all surgeries, there are some risks and possible complications. Potential problems after shoulder surgery include infection, excessive bleeding, blood clots, and damage to blood vessels or nerves.

Your surgeon will discuss the possible complications with you before your operation.

Future Developments

Research is being conducted on shoulder arthritis and its treatment.

For More Information

If you found this article helpful, you may also be interested in Shoulder Joint Replacement.

In order to assist doctors in the treatment of arthritis of the shoulder, the American Academy of Orthopaedic Surgeons has done research to provide some useful guidelines. These are recommendations only and may not apply to each and every individual case. For more information: AAOS Clinical Practice Guideline: Treatment of Glenohumeral Joint Osteoarthritis.

SOURCE: Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL: AAOS; January 2013. Based on data from the National Health Interview Survey, 2008-2011; U.S. Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Health Statistics.

Last reviewed: January 2013
Contributed and/or Updated by: J. Michael Wiater, MD
Peer-Reviewed by: Stuart J. Fischer, MD
Contributor Disclosure Information

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

The following article provides in-depth information about treatment for anterior cruciate ligament injuries. The general article, Anterior Cruciate Ligament (ACL) Injuries, provides a good introduction to the topic and is recommended reading prior to this article.

The information that follows includes the details of anterior cruciate ligament (ACL) anatomy and the pathophysiology of an ACL tear, treatment options for ACL injuries along with a description of ACL surgical techniques and rehabilitation, potential complications, and outcomes. The information is intended to assist the patient in making the best-informed decision possible regarding the management of ACL injury.

 

Anatomy


Anatomy

The bone structure of the knee joint is formed by the femur, the tibia, and the patella. The ACL is one of the four main ligaments within the knee that connect the femur to the tibia.

The knee is essentially a hinged joint that is held together by the medial collateral (MCL), lateral collateral (LCL), anterior cruciate (ACL) and posterior cruciate (PCL) ligaments. The ACL runs diagonally in the middle of the knee, preventing the tibia from sliding out in front of the femur, as well as providing rotational stability to the knee.

The weight-bearing surface of the knee is covered by a layer of articular cartilage. On either side of the joint, between the cartilage surfaces of the femur and tibia, are the medial meniscus and lateral meniscus. The menisci act as shock absorbers and work with the cartilage to reduce the stresses between the tibia and the femur.

 

Description


The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee. The incidence of ACL injuries is currently estimated at approximately 200,000 annually, with 100,000 ACL reconstructions performed each year.1, 2 In general, the incidence of ACL injury is higher in people who participate in high-risk sports, such as basketball, football, skiing, and soccer.3, 4, 5
Approximately 50 percent of ACL injuries occur in combination with damage to the meniscus, articular cartilage, or other ligaments. Additionally, patients may have bruises of the bone beneath the cartilage surface. These may be seen on a magnetic resonance imaging (MRI) scan and may indicate injury to the overlying articular cartilage.

Anatomy_DescImg
Anatomy_DescImg2
(Left) Arthroscopic picture of the normal ACL. (Right) Arthroscopic picture of torn ACL [yellow star].

 

Cause


It is estimated that 70 percent of ACL injuries occur through non-contact mechanisms while 30 percent result from direct contact with another player or object.4
The mechanism of injury is often associated with deceleration coupled with cutting, pivoting or sidestepping maneuvers, awkward landings or “out of control” play.
Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sports.3, 10 It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Other hypothesized causes of this gender-related difference in ACL injury rates include pelvis and lower extremity (leg) alignment, increased ligamentous laxity, and the effects of estrogen on ligament properties.
Immediately after the injury, patients usually experience pain and swelling and the knee feels unstable. Within a few hours after a new ACL injury, patients often have a large amount of knee swelling, a loss of full range of motion, pain or tenderness along the joint line and discomfort while walking.

 

Doctor Examination


When a patient with an ACL injury is initially seen for evaluation in the clinic, the doctor may order X-rays to look for any possible fractures. He or she may also order a magnetic resonance imaging (MRI) scan to evaluate the ACL and to check for evidence of injury to other knee ligaments, meniscus cartilage, or articular cartilage.

In addition to performing special tests for identifying meniscus tears and injury to other ligaments of the knee, the physician will often perform the Lachman’s test to see if the ACL is intact.

Doctor_Exam

<iframe width=”520″ height=”360″ class=”youtube-embed” src=”http://www.youtube.com/embed/j6yuI59_yMM?wmode=opaque&amp;rel=0″ frameborder=”0″ wmode=”opaque” allowfullscreen=””></iframe>

If the ACL is torn, the examiner will feel increased forward (upward or anterior) movement of the tibia in relation to the femur (especially when compared to the normal leg) and a soft, mushy endpoint (because the ACL is torn) when this movement ends.

Another test for ACL injury is the pivot shift test. In this test, , the tibia will start forward when the knee is fully straight and then will shift back into the correct position in relation to the femur when the knee is bent past 30 degrees.

<iframe width=”520″ height=”360″ class=”youtube-embed” src=”http://www.youtube.com/embed/kDBCSNZX6w8?wmode=opaque&amp;rel=0″ frameborder=”0″ wmode=”opaque” allowfullscreen=””></iframe>

 

Natural History


The natural history of an ACL injury without surgical intervention varies from patient to patient and depends on the patient’s activity level, degree of injury and instability symptoms.

The prognosis for a partially torn ACL is often favorable, with the recovery and rehabilitation period usually at least three months. However, some patients with partial ACL tears may still have instability symptoms. Close clinical follow-up and a complete course of physical therapy helps identify those patients with unstable knees due to partial ACL tears.

Complete ACL ruptures have a much less favorable outcome. After a complete ACL tear, some patients are unable to participate in cutting or pivoting-type sports, while others have instability during even normal activities, such as walking. There are some rare individuals who can participate in sports without any symptoms of instability. This variability is related to the severity of the original knee injury, as well as the physical demands of the patient.

Natural_History_Img1

Arthroscopic picture of torn medial meniscus in chronically ACL-deficient knee. In this case, the torn meniscus is pushed forward [yellow star] and locked in front of the knee [called a “bucket handle” meniscus tear], so the patient could not straighten out the leg.

About half of ACL injuries occur in combination with damage to the meniscus, articular cartilage or other ligaments. Secondary damage may occur in patients who have repeated episodes of instability due to ACL injury. With chronic instability, up to 90 percent of patients will have meniscus damage when reassessed 10 or more years after the initial injury. Similarly, the prevalence of articular cartilage lesions increases up to 70 percent in patients who have a 10-year-old ACL deficiency.

Natural_History_Img2

 

Nonsurgical Treatment


In nonsurgical treatment, progressive physical therapy and rehabilitation can restore the knee to a condition close to its pre-injury state and educate the patient on how to prevent instability.37, 38 This may be supplemented with the use of a hinged knee brace. However, many people who choose not to have surgery may experience secondary injury to the knee due to repetitive instability episodes.

Surgical treatment is usually advised in dealing with combined injuries (ACL tears in combination with other injuries in the knee). However, deciding against surgery is reasonable for select patients. Nonsurgical management of isolated ACL tears is likely to be successful or may be indicated in patients:

With partial tears and no instability symptoms39
With complete tears and no symptoms of knee instability during low-demand sports who are willing to give up high-demand sports
Who do light manual work or live sedentary lifestyles
Whose growth plates are still open (children)

 

Surgical Treatment


ACL tears are not usually repaired using suture to sew it back together, because repaired ACLs have generally been shown to fail over time.31, 33, 34, 35, 36 Therefore, the torn ACL is generally replaced by a substitute graft made of tendon.

Animation courtesy Visual Health Solutions, Inc.

The grafts commonly used to replace the ACL include:

Patellar tendon autograft (autograft comes from the patient)
Hamstring tendon autograft
Quadriceps tendon autograft
Allograft (taken from a cadaver) patellar tendon, Achilles tendon, semitendinosus, gracilis, or posterior tibialis tendon
Patients treated with surgical reconstruction of the ACL have long-term success rates of 82 percent to 95 percent. Recurrent instability and graft failure are seen in approximately 8 percent of patients.

The goal of the ACL reconstruction surgery is to prevent instability and restore the function of the torn ligament, creating a stable knee. This allows the patient to return to sports. There are certain factors that the patient must consider when deciding for or against ACL surgery.

 

Patient Considerations
Active adult patients involved in sports or jobs that require pivoting, turning or hard-cutting as well as heavy manual work are encouraged to consider surgical treatment.This includes older patients who have previously been excluded from consideration for ACL surgery. Activity, not age, should determine if surgical intervention should be considered.

In young children or adolescents with ACL tears, early ACL reconstruction creates a possible risk of growth plate injury, leading to bone growth problems. The surgeon can delay ACL surgery until the child is closer to skeletal maturity or the surgeon may modify the ACL surgery technique to decrease the risk of growth plate injury.
A patient with a torn ACL and significant functional instability has a high risk of developing secondary knee damage and should therefore consider ACL reconstruction.

It is common to see ACL injuries combined with damage to the menisci (50 percent), articular cartilage (30 percent), collateral ligaments (30 percent), joint capsule, or a combination of the above. The “unhappy triad,” frequently seen in football players and skiers, consists of injuries to the ACL, the MCL, and the medial meniscus.
In cases of combined injuries, surgical treatment may be warranted and generally produces better outcomes. As many as 50 percent of meniscus tears may be repairable and may heal better if the repair is done in combination with the ACL reconstruction.

 

Surgical Choices
surgical_ChoicesImg
Patellar tendon autograft prepared for ACL reconstruction.

Patellar tendon autograft. The middle third of the patellar tendon of the patient, along with a bone plug from the shin and the kneecap is used in the patellar tendon autograft. Occasionally referred to by some surgeons as the “gold standard” for ACL reconstruction, it is often recommended for high-demand athletes and patients whose jobs do not require a significant amount of kneeling.57
In studies comparing outcomes of patellar tendon and hamstring autograft ACL reconstruction, the rate of graft failure was lower in the patellar tendon group (1.9 percent versus 4.9 percent).58 In addition, most studies show equal or better outcomes in terms of postoperative tests for knee laxity (Lachman’s, anterior drawer and instrumented tests) when this graft is compared to others. However, patellar tendon autografts have a greater incidence of postoperative patellofemoral pain (pain behind the kneecap) complaints and other problems.58, 59
The pitfalls of the patellar tendon autograft are:

Postoperative pain behind the kneecap
Pain with kneeling
Slightly increased risk of postoperative stiffness
Low risk of patella fracture

 

Hamstring tendon autograft.
The semitendinosus hamstring tendon on the inner side of the knee is used in creating the hamstring tendon autograft for ACL reconstruction. Some surgeons use an additional tendon, the gracilis, which is attached below the knee in the same area. This creates a two- or four-strand tendon graft. Hamstring graft proponents claim there are fewer problems associated with harvesting of the graft compared to the patellar tendon autograft including:

Fewer problems with anterior knee pain or kneecap pain after surgery
Less postoperative stiffness problems
Smaller incision
Faster recovery
hamstring_Img
Hamstring tendon autograft prepared for ACL reconstruction.

The graft function may be limited by the strength and type of fixation in the bone tunnels, as the graft does not have bone plugs.There have been conflicting results in research studies as to whether hamstring grafts are slightly more susceptible to graft elongation (stretching), which may lead to increased laxity during objective testing.Recently, some studies have demonstrated decreased hamstring strength in patients after surgery.
There are some indications that patients who have intrinsic ligamentous laxity and knee hyperextension of 10 degrees or more may have increased risk of postoperative hamstring graft laxity on clinical exam. Therefore, some clinicians recommend the use of patellar tendon autografts in these hypermobile patients.
Additionally, since the medial hamstrings often provide dynamic support against valgus stress and instability, some surgeons feel that chronic or residual medial collateral ligament laxity (grade 2 or more) at the time of ACL reconstruction may be a contra-indication for use of the patient’s own semitendinosus and gracilis tendons as an ACL graft.

 

Quadriceps tendon autograft.

Quadriceps_Img
Quadriceps tendon autograft prepared for ACL reconstruction.

The quadriceps tendon autograft is often used for patients who have already failed ACL reconstruction. The middle third of the patient’s quadriceps tendon and a bone plug from the upper end of the knee cap are used. This yields a larger graft for taller and heavier patients. Because there is a bone plug on one side only, the fixation is not as solid as for the patellar tendon graft. There is a high association with postoperative anterior knee pain and a low risk of patella fracture. Patients may find the incision is not cosmetically appealing.

Allografts. Allografts are grafts taken from cadavers and are becoming increasingly popular. These grafts are also used for patients who have failed ACL reconstruction before and in surgery to repair or reconstruct more than one knee ligament. Advantages of using allograft tissue include elimination of pain caused by obtaining the graft from the patient, decreased surgery time and smaller incisions. The patellar tendon allograft allows for strong bony fixation in the tibial and femoral bone tunnels with screws.

However, allografts are associated with a risk of infection, including viral transmission (HIV and Hepatitis C), despite careful screening and processing.Several deaths linked to bacterial infection from allograft tissue (due to improper procurement and sterilization techniques) have led to improvements in allograft tissue testing and processing techniques.There have also been conflicting results in research studies as to whether allografts are slightly more susceptible to graft elongation (stretching), which may lead to increased laxity during testing.

Recently published literature may point to a higher failure rate with the use of allografts for ACL reconstruction. Failure rates ranging from 23% to 34.4% have been reported in young, active patients returning to high-demand sporting activities after ACL reconstruction with allografts. This is compared to autograft failure rates ranging from 5% to 10%.

The reason for this higher failure rate is unclear. It could be due to graft material properties (sterilization processes used, graft donor age, storage of the graft). It could possibly be due to an ill-advised earlier return to sport by the athlete because of a faster perceived physiologic recovery, when the graft is not biologically ready to be loaded and stressed during sporting activities. Further research in this area is indicated and is ongoing.

 

Surgical Procedure

Before any surgical treatment, the patient is usually sent to physical therapy. Patients who have a stiff, swollen knee lacking full range of motion at the time of ACL surgery may have significant problems regaining motion after surgery. It usually takes three or more weeks from the time of injury to achieve full range of motion. It is also recommended that some ligament injuries be braced and allowed to heal prior to ACL surgery.

The patient, the surgeon, and the anesthesiologist select the anesthesia used for surgery. Patients may benefit from an anesthetic block of the nerves of the leg to decrease postoperative pain.

SurgicalProcedure_Img

Passage of patellar tendon graft into tibial tunnel of knee.

The surgery usually begins with an examination of the patient’s knee while the patient is relaxed due the effects of anesthesia. This final examination is used to verify that the ACL is torn and also to check for looseness of other knee ligaments that may need to be repaired during surgery or addressed postoperatively.

If the physical exam strongly suggests the ACL is torn, the selected tendon is harvested (for an autograft) or thawed (for an allograft) and the graft is prepared to the correct size for the patient.

After the graft has been prepared, the surgeon places an arthroscope into the joint. Small (one-centimeter) incisions called portals are made in the front of the knee to insert the arthroscope and instruments and the surgeon examines the condition of the knee. Meniscus and cartilage injuries are trimmed or repaired and the torn ACL stump is then removed.

SurgicalProcedure_Img2

Post-operative X-ray after ACL patellar tendon reconstruction (with picture of graft superimposed) shows graft position and bone plugs fixation with metal interference screws.

In the most common ACL reconstruction technique, bone tunnels are drilled into the tibia and the femur to place the ACL graft in almost the same position as the torn ACL. A long needle is then passed through the tunnel of the tibia, up through the femoral tunnel, and then out through the skin of the thigh. The sutures of the graft are placed through the eye of the needle and the graft is pulled into position up through the tibial tunnel and then up into the femoral tunnel. The graft is held under tension as it is fixed in place using interference screws, spiked washers, posts, or staples. The devices used to hold the graft in place are generally not removed.

Variations on this surgical technique include the “two-incision,” “over-the-top,” and “double-bundle” types of ACL reconstructions, which may be used because of the preference of the surgeon or special circumstances (revision ACL reconstruction, open growth plates).

Before the surgery is complete, the surgeon will probe the graft to make sure it has good tension, verify that the knee has full range of motion and perform tests such as the Lachman’s test to assess graft stability. The skin is closed and dressings (and perhaps a postoperative brace and cold therapy device, depending on surgeon preference) are applied. The patient will usually go home on the same day of the surgery.

SurgicalProcedure_Img3

Arthroscopic view of ACL graft [yellow star] in position.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

 

Rehabilitation

Physical therapy is a crucial part of successful ACL surgery, with exercises beginning immediately after the surgery. Much of the success of ACL reconstructive surgery depends on the patient’s dedication to rigorous physical therapy. With new surgical techniques and stronger graft fixation, current physical therapy uses an accelerated course of rehabilitation.

Postoperative Course. In the first 10 to 14 days after surgery, the wound is kept clean and dry, and early emphasis is placed on regaining the ability to fully straighten the knee and restore quadriceps control.

The knee is iced regularly to reduce swelling and pain. The surgeon may dictate the use of a postoperative brace and the use of a machine to move the knee through its range of motion.Weight-bearing status (use of crutches to keep some or all of the patient’s weight off of the surgical leg) is also determined by physician preference, as well as other injuries addressed at the time of surgery.

Rehabilitation. The goals for rehabilitation of ACL reconstruction include reducing knee swelling, maintaining mobility of the kneecap to prevent anterior knee pain problems, regaining full range of motion of the knee, as well as strengthening the quadriceps and hamstring muscles.

The patient may return to sports when there is no longer pain or swelling, when full knee range of motion has been achieved, and when muscle strength, endurance and functional use of the leg have been fully restored.

The patient’s sense of balance and control of the leg must also be restored through exercises designed to improve neuromuscular control.4 This usually takes four to six months. The use of a functional brace when returning to sports is ideally not needed after a successful ACL reconstruction, but some patients may feel a greater sense of security by wearing one.

 

Surgical Complications

Infection. The incidence of infection after arthroscopic ACL reconstruction has a reported range of 0.2 percent to 0.48 percent.There have also been several reported deaths linked to bacterial infection from allograft tissue due to improper procurement and sterilization techniques.

Viral transmission. Allografts specifically are associated with risk of viral transmission, including HIV and Hepatitis C, despite careful screening and processing. The chance of obtaining a bone allograft from an HIV-infected donor is calculated to be less than 1 in a million.

Bleeding, numbness. Rare risks include bleeding from acute injury to the popliteal artery (overall incidence is 0.01 percent) and weakness or paralysis of the leg or foot. It is not uncommon to have numbness of the outer part of the upper leg next to the incision, which may be temporary or permanent.

Blood clot. A blood clot in the veins of the calf or thigh is a potentially life-threatening complication. A blood clot may break off in the bloodstream and travel to the lungs, causing pulmonary embolism or to the brain, causing stroke. This risk of is reported to be approximately 0.12 percent.

Instability. Recurrent instability due to rupture or stretching of the reconstructed ligament or poor surgical technique (reported to be as low as 2.5 percent and as high as 34 percent) is possible.

Stiffness. Knee stiffness or loss of motion has been reported at between 5 percent and 25 percent.

Extensor mechanism failure. Rupture of the patellar tendon (patellar tendon autograft) or patella fracture (patellar tendon or quadriceps tendon autografts) may occur due to weakening at the site of graft harvest.

Growth plate injury. In young children or adolescents with ACL tears, early ACL reconstruction creates a possible risk of growth plate injury, leading to bone growth problems.The ACL surgery can be delayed until the child is closer to reaching skeletal maturity. Alternatively, the surgeon may be able to modify the technique of ACL reconstruction to decrease the risk of growth plate injury.

Kneecap pain. Postoperative anterior knee pain is especially common after patellar tendon autograft ACL reconstruction. The incidence of pain behind the kneecap varies between 4 percent and 56 percent in studies, whereas the incidence of kneeling pain may be as high as 42 percent after patellar tendon autograft ACL reconstruction.

nformation on total knee replacement is also available in Spanish: Reemplazo total de rodilla and Portuguese: Artroplastia total de joelho.

If your knee is severely damaged by arthritis or injury, it may be hard for you to perform simple activities, such as walking or climbing stairs. You may even begin to feel pain while you are sitting or lying down.

If nonsurgical treatments like medications and using walking supports are no longer helpful, you may want to consider total knee replacement surgery. Joint replacement surgery is a safe and effective procedure to relieve pain, correct leg deformity, and help you resume normal activities.

Knee replacement surgery was first performed in 1968. Since then, improvements in surgical materials and techniques have greatly increased its effectiveness. Total knee replacements are one of the most successful procedures in all of medicine. According to the Agency for Healthcare Research and Quality, more than 600,000 knee replacements are performed each year in the United States.

Whether you have just begun exploring treatment options or have already decided to have total knee replacement surgery, this article will help you understand more about this valuable procedure.

Anatomy
A00389F01TNormal knee anatomy.

The knee is the largest joint in the body and having healthy knees is required to perform most everyday activities.

The knee is made up of the lower end of the thighbone (femur), the upper end of the shinbone (tibia), and the kneecap (patella). The ends of these three bones where they touch are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily.

The menisci are located between the femur and tibia. These C-shaped wedges act as “shock absorbers” that cushion the joint.

Large ligaments hold the femur and tibia together and provide stability. The long thigh muscles give the knee strength.

All remaining surfaces of the knee are covered by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage, reducing friction to nearly zero in a healthy knee.

Normally, all of these components work in harmony. But disease or injury can disrupt this harmony, resulting in pain, muscle weakness, and reduced function.

Cause

The most common cause of chronic knee pain and disability is arthritis. Although there are many types of arthritis, most knee pain is caused by just three types: osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis.

A00389F02TOsteoarthritis often results in bone rubbing on bone. Bone spurs are a common feature of this form of arthritis.

Animation courtesy Visual Health Solutions, Inc.

Description

A knee replacement (also called knee arthroplasty) might be more accurately termed a knee “resurfacing” because only the surface of the bones are actually replaced.

There are four basic steps to a knee replacement procedure.

A00389F03T(Left) Severe osteoarthritis. (Right) The arthritic cartilage and underlying bone has been removed and resurfaced with metal implants on the femur and tibia. A plastic spacer has been placed in between the implants. The patellar component is not shown for clarity.

Animation courtesy Visual Health Solutions, Inc.

Is Total Knee Replacement for You?

The decision to have total knee replacement surgery should be a cooperative one between you, your family, your family physician, and your orthopaedic surgeon. Your physician may refer you to an orthopaedic surgeon for a thorough evaluation to determine if you might benefit from this surgery.

 

When Surgery Is Recommended

There are several reasons why your doctor may recommend knee replacement surgery. People who benefit from total knee replacement often have:

OLYMPUS DIGITAL CAMERA

OLYMPUS DIGITAL CAMERA

A knee that has become bowed as a result of severe arthritis.

  • Severe knee pain or stiffness that limits your everyday activities, including walking, climbing stairs, and getting in and out of chairs. You may find it hard to walk more than a few blocks without significant pain and you may need to use a cane or walker
  • Moderate or severe knee pain while resting, either day or night
  • Chronic knee inflammation and swelling that does not improve with rest or medications
  • Knee deformity — a bowing in or out of your knee
  • Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries

 

Candidates for Surgery

There are no absolute age or weight restrictions for total knee replacement surgery.

Recommendations for surgery are based on a patient’s pain and disability, not age. Most patients who undergo total knee replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total knee replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.

Orthopaedic Evaluation

An evaluation with an orthopaedic surgeon consists of several components:

A00389F04T(Left) In this x-ray of a normal knee, the space between the bones indicates healthy cartilage (arrows). (Right) This x-ray of a knee that has become bowed from arthritis shows severe loss of joint space (arrows).

Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether total knee replacement is the best method to relieve your pain and improve your function. Other treatment options — including medications, injections, physical therapy, or other types of surgery — will also be considered and discussed.

In addition, your orthopaedic surgeon will explain the potential risks and complications of total knee replacement, including those related to the surgery itself and those that can occur over time after your surgery.

Deciding to Have Knee Replacement Surgery

 

Realistic Expectations

An important factor in deciding whether to have total knee replacement surgery is understanding what the procedure can and cannot do.

More than 90% of people who have total knee replacement surgery experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living. But total knee replacement will not allow you to do more than you could before you developed arthritis.

With normal use and activity, every knee replacement implant begins to wear in its plastic spacer. Excessive activity or weight may speed up this normal wear and may cause the knee replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports for the rest of your life after surgery.

Realistic activities following total knee replacement include unlimited walking, swimming, golf, driving, light hiking, biking, ballroom dancing, and other low-impact sports.

With appropriate activity modification, knee replacements can last for many years.

 

Possible Complications of Surgery

The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in fewer than 2% of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit full recovery.

Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.

Blood clots may develop in leg veins.

A00219F01T (1)Infection. Infection may occur in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.

Blood clots. Blood clots in the leg veins are one of the most common complications of knee replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program, which may include periodic elevation of your legs, lower leg exercises to increase circulation, support stockings, and medication to thin your blood.

Implant problems. Although implant designs and materials, as well as surgical techniques, continue to advance, implant surfaces may wear down and the components may loosen. Additionally, although an average of 115° of motion is generally anticipated after surgery, scarring of the knee can occasionally occur, and motion may be more limited, particularly in patients with limited motion before surgery.

Continued pain. A small number of patients continue to have pain after a knee replacement. This complication is rare, however, and the vast majority of patients experience excellent pain relief following knee replacement.

Neurovascular injury. While rare, injury to the nerves or blood vessels around the knee can occur during surgery.

Preparing for Surgery

 

Medical Evaluation

If you decide to have total knee replacement surgery, your orthopaedic surgeon may ask you to schedule a complete physical examination with your family physician several weeks before the operation. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such as a cardiologist, before the surgery.

Tests

Several tests, such as blood and urine samples, and an electrocardiogram, may be needed to help your orthopaedic surgeon plan your surgery.

Medications

Tell your orthopaedic surgeon about the medications you are taking. He or she will tell you which medications you should stop taking and which you should continue to take before surgery.

Dental Evaluation

Although the incidence of infection after knee replacement is very low, an infection can occur if bacteria enter your bloodstream. To reduce the risk of infection, major dental procedures (such as tooth extractions and periodontal work) should be completed before your total knee replacement surgery.

Urinary Evaluations

People with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before undertaking knee replacement surgery.

Social Planning

Although you will be able to walk on crutches or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing, and doing laundry.

If you live alone, your orthopaedic surgeon’s office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at home. They also can help you arrange for a short stay in an extended care facility during your recovery, if this option works best for you.

Home Planning

Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:

  • Safety bars or a secure handrail in your shower or bath
  • Secure handrails along your stairways
  • A stable chair for your early recovery with a firm seat cushion (and a height of 18 to 20 inches), a firm back, two arms, and a footstool for intermittent leg elevation
  • A toilet seat riser with arms, if you have a low toilet
  • A stable shower bench or chair for bathing
  • Removing all loose carpets and cords
  • A temporary living space on the same floor because walking up or down stairs will be more difficult during your early recovery
Your Surgery

You will most likely be admitted to the hospital on the day of your surgery.

Anesthesia

After admission, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down). The anesthesia team, with your input, will determine which type of anesthesia will be best for you.

Procedure

The procedure itself takes approximately 1 to 2 hours. Your orthopaedic surgeon will remove the damaged cartilage and bone, and then position the new metal and plastic implants to restore the alignment and function of your knee.

A00389F09T

Different types of knee implants are used to meet each patient’s individual needs.
A00389F05T(Left) An x-ray of a severely arthritic knee. (Right) The x-ray appearance of a total knee replacement. Note that the plastic spacer inserted between the components does not show up in an x-ray.

After surgery, you will be moved to the recovery room, where you will remain for several hours while your recovery from anesthesia is monitored. After you wake up, you will be taken to your hospital room.

Your Hospital Stay

You will most likely stay in the hospital for several days.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Blood Clot Prevention

Your orthopaedic surgeon may prescribe one or more measures to prevent blood clots and decrease leg swelling. These may include special support hose, inflatable leg coverings (compression boots), and blood thinners.

Foot and ankle movement also is encouraged immediately following surgery to increase blood flow in your leg muscles to help prevent leg swelling and blood clots.

Physical Therapy

A00389F06TA continuous passive motion (CPM) machine.

Most patients begin exercising their knee the day after surgery. In some cases, patients begin moving their knee on the actual day of surgery. A physical therapist will teach you specific exercises to strengthen your leg and restore knee movement to allow walking and other normal daily activities soon after your surgery.

To restore movement in your knee and leg, your surgeon may use a knee support that slowly moves your knee while you are in bed. The device is called a continuous passive motion (CPM) exercise machine. Some surgeons believe that a CPM machine decreases leg swelling by elevating your leg and improves your blood circulation by moving the muscles of your leg.

Preventing Pneumonia

It is common for patients to have shallow breathing in the early postoperative period. This is usually due to the effects of anesthesia, pain medications, and increased time spent in bed. This shallow breathing can lead to a partial collapse of the lungs (termed “atelectasis”) which can make patients susceptible to pneumonia. To help prevent this, it is important to take frequent deep breaths. Your nurse may provide a simple breathing apparatus called a spirometer to encourage you to take deep breaths.

Your Recovery at Home

The success of your surgery will depend largely on how well you follow your orthopaedic surgeon’s instructions at home during the first few weeks after surgery.

Wound Care

You will have stitches or staples running along your wound or a suture beneath your skin on the front of your knee. The stitches or staples will be removed several weeks after surgery. A suture beneath your skin will not require removal.

Avoid soaking the wound in water until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.

Diet

Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to help your wound heal and to restore muscle strength.

Activity

Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal activities of daily living within 3 to 6 weeks following surgery. Some pain with activity and at night is common for several weeks after surgery.

Your activity program should include:

  • A graduated walking program to slowly increase your mobility, initially in your home and later outside
  • Resuming other normal household activities, such as sitting, standing, and climbing stairs
  • Specific exercises several times a day to restore movement and strengthen your knee. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy center the first few weeks after surgery.
Ablestock

Ablestock

Thinkstock © 2011

You will most likely be able to resume driving when your knee bends enough that you can enter and sit comfortably in your car, and when your muscle control provides adequate reaction time for braking and acceleration. Most people resume driving approximately 4 to 6 weeks after surgery.

Avoiding Problems After Surgery

Blood Clot Prevention

Follow your orthopaedic surgeon’s instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.

Warning signs of blood clots. The warning signs of possible blood clots in your leg include:

  • Increasing pain in your calf
  • Tenderness or redness above or below your knee
  • New or increasing swelling in your calf, ankle, and foot

Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:

  • Sudden shortness of breath
  • Sudden onset of chest pain
  • Localized chest pain with coughing

Preventing Infection

A common cause of infection following total knee replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your knee replacement and cause an infection.

After knee replacement, patients with certain risk factors may need to take antibiotics prior to dental work, including dental cleanings, or before any surgical procedure that could allow bacteria to enter the bloodstream. Your orthopaedic surgeon will discuss with you whether taking preventive antibiotics before dental procedures is needed in your situation.

Warning signs of infection. Notify your doctor immediately if you develop any of the following signs of a possible knee replacement infection:

  • Persistent fever (higher than 100°F orally)
  • Shaking chills
  • Increasing redness, tenderness, or swelling of the knee wound
  • Drainage from the knee wound
  • Increasing knee pain with both activity and rest

Avoiding Falls

A fall during the first few weeks after surgery can damage your new knee and may result in a need for further surgery. Stairs are a particular hazard until your knee is strong and mobile. You should use a cane, crutches, a walker, hand rails, or have someone to help you until you have improved your balance, flexibility, and strength.

Your surgeon and physical therapist will help you decide what assistive aides will be required following surgery and when those aides can safely be discontinued.

Outcomes

How Your New Knee Is Different

Improvement of knee motion is a goal of total knee replacement, but restoration of full motion is uncommon. The motion of your knee replacement after surgery can be predicted by the range of motion you have in your knee before surgery. Most patients can expect to be able to almost fully straighten the replaced knee and to bend the knee sufficiently to climb stairs and get in and out of a car. Kneeling is sometimes uncomfortable, but it is not harmful.

Most people feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending activities.

Most people also feel or hear some clicking of the metal and plastic with knee bending or walking. This is a normal. These differences often diminish with time and most patients find them to be tolerable when compared with the pain and limited function they experienced prior to surgery.

Your new knee may activate metal detectors required for security in airports and some buildings. Tell the security agent about your knee replacement if the alarm is activated.

Protecting Your Knee Replacement

After surgery, make sure you also do the following:

  • Participate in regular light exercise programs to maintain proper strength and mobility of your new knee.
  • Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery.
  • Make sure your dentist knows that you have a knee replacement. Talk with your orthopaedic surgeon about whether you need to take antibiotics prior to dental procedures.
  • See your orthopaedic surgeon periodically for a routine follow-up examination and x-rays, usually once a year.

Extending the Life of Your Knee Implant

Currently, more than 90% of modern total knee replacements are still functioning well 15 years after the surgery. Following your orthopaedic surgeon’s instructions after surgery and taking care to protect your knee replacement and your general health are important ways you can contribute to the final success of your surgery.

To learn more about the full value of total knee replacement surgery: Beyond Surgery Day: The Full Impact of Knee Replacement

If you found this article helpful, you may also be interested in Activities After Knee Replacement.

Last reviewed: August 2015
Contributed and/or Updated by: Jared R. H. Foran, MD
Peer-Reviewed by: Stuart J. Fischer, MD
Contributor Disclosure Information

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

The goal of orthopaedic treatment is to relieve pain and restore function. In planning your treatment, your doctor will consider many things, including your age, activity level, and general health. If nonsurgical treatment methods, such as medication and physical therapy, do not relieve your symptoms, your doctor may recommend total joint replacement.

Your doctor and healthcare team will provide you with information to help you prepare for surgery. Never hesitate to ask questions. The following list of questions can help you in your discussions with your doctor before your surgery.

What are the major and/or most frequent complications of surgery?
Is the skill and experience of the orthopaedic surgeon more important than the device or procedure?
Can you give me any information on outcomes and complication rates?
If I do not have surgery, what is the risk?
How much pain can I expect, and how will it be managed in the hospital and after I go home?
How long will the device last, and what can I do to make it last as long as possible?
What are the pros and cons of minimally invasive (mini-incision) surgery? Does it really make a meaningful difference in the result, or does it pose unnecessary risks?
What will I be able to do/not do after my total joint replacement?
Is therapy necessary after surgery?
How long will I be in the hospital?
Will I be able to contact you after the surgery if I have a question or problem?

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Here are some exercises that your doctor may recommend to help speed your recovery:

Low Impact Aerobic Exercise – Swimming and riding a stationary bike are great low impact exercises that help build strength in your knee. Stop any exercise that causes increasing pain.

Short-Arc Knee Extensions – Roll up several towels in a roll 6-8 inches thick. Lay in bed with the towels under one knee. Bend the other knee. Keeping your knee on the towels, lift your foot to straighten the knee. Hold for a few seconds and lower the foot.

Ankle Pumps – While lying in bed, point your toes downward and then bring your toes back up towards your head, tightening your calf.

Heel Slides – Slide your heel along the bed pulling your foot towards you as your knee bends.

Straight Leg Raise – Start by tightening your quadriceps, the muscles in the front of your thigh. Then with toes toward the ceiling, lift your leg 6-12 inches from the bed.

Quadriceps Sets – Lie on your back, legs straight. Tighten the muscle in the front of your thigh as you press the back of your knee toward the bed. Hold for a few seconds, then relax the leg.

Standing Knee Bends – Stand while holding onto a steady surface, such as a table. Bend your knee as far as it will go comfortably. Hold for a few seconds and lower the leg.

Increasing upper body strength is also important because of the need to use a walker or crutches after knee replacement.

Bicep Curls – In a sitting position, keep you elbow close to your body and your wrist straight. Bend you arm, moving your hand up to your shoulder, then lower slowly.

Triceps Extensions – Sit, leaning forward from the waist. Bend your elbow so that your forearm is parallel to the floor. Then straighten your elbow as you extend your arm behind you.

Seated Press Ups – Sit in a sturdy chair with armrests. With palms on the armrests, press down to lift yourself from the chair. Hold for 3-5 seconds. Bend your elbows slowly to ease back down.

Talk to your doctor before starting any exercise program and remember to call your doctor if you experience increased pain or swelling in your knee after exercise.

This article is an introduction to total joint replacement surgery. Comprehensive information on specific types of joint replacement — such as for the hip, knee, shoulder, or wrist — can be found in separate articles devoted to those topics. Direct links to individual joint replacement topics are provided in the “Related Articles” section of this page.

Total joint replacement is a surgical procedure in which parts of an arthritic or damaged joint are removed and replaced with a metal, plastic or ceramic device called a prosthesis. The prosthesis is designed to replicate the movement of a normal, healthy joint.

In 2011, almost 1 million total joint replacements were performed in the United States. Hip and knee replacements are the most commonly performed joint replacements, but replacement surgery can be performed on other joints, as well, including the ankle, wrist, shoulder, and elbow.

 

Anatomy

A joint is where the ends of two or more bones meet. There are different types of joints within the body. For example, the knee is considered a “hinge” joint, because of its ability to bend and straighten like a hinged door. The hip and shoulder are “ball-and-socket” joints, in which the rounded end of one bone fits into a cup-shaped area of another bone.

 

When Is Total Joint Replacement Recommended?

Several conditions can cause joint pain and disability and lead patients to consider joint replacement surgery. In many cases, joint pain is caused by damage to the cartilage that lines the ends of the bones (articular cartilage)—either from arthritis, a fracture, or another condition.

If nonsurgical treatments like medications, physical therapy, and changes to your everyday activities do not relieve your pain and disability, your doctor may recommend total joint replacement.

 

Preparing for Surgery

In the weeks before your surgery, your surgical team and primary care doctor will spend time preparing you for your upcoming procedure. For example, your primary care doctor may check your general health, and your surgeon may require several tests — such as blood tests and a cardiogram — to help plan your surgery.

There are also many things you can do to prepare. Talk to your doctor and ask questions. Prepare yourself physically by eating right and exercising. Take steps to manage your first weeks at home by arranging for help and obtaining assistive items, such as a shower bench, handrails, or a long-handled reacher. By planning ahead, you can help ensure a smooth surgery and speedy recovery.

For a step-by-step guide to planning your joint replacement surgery:

Preparing for Joint Replacement Surgery

Additional information to help you prepare for surgery:

Total Joint Replacement: Questions Patients Should Ask Their Surgeon

Patient Safety

Before and After Total Joint Replacement (video)

 

Surgical Procedure

Total joint replacement surgery takes a few hours. The procedure is performed in a hospital or outpatient surgery center.

During the surgery, the damaged cartilage and bone is removed from your joint and replaced with prosthetic components made of metal, plastic, or ceramic. The prosthesis mimics the shape and movement of a natural joint. For example, in an arthritic hip, the damaged ball (the upper end of the femur) is replaced with a metal ball attached to a metal stem that is fitted into the femur, and a plastic socket is implanted into the pelvis, replacing the damaged socket.

A00233F01(Left) A hip with osteoarthritis. (Right) The head of the femur and the socket have been replaced with an artificial device.

Complications

Your doctor will explain the potential risks and complications of total joint replacement, including those related to the surgery itself and those that can occur over time after your surgery.

Most complications can be treated successfully. Some of the more common complications of joint replacement surgery include infection, blood clots, nerve injury, and prosthesis problems like loosening or dislocation.

 

 

Additional information on preventing complications:

Joint Replacement Infection

Deep Vein Thrombosis

Preventing Infection After Joint Replacement Surgery (video)

Preventing Blood Clots After Orthopaedic Surgery (video)

 

Recovery

Recovery and rehabilitation will be different for each person. In general, your doctor will encourage you to use your “new” joint shortly after your operation. Although it may be challenging at times, following your doctor’s instructions will speed your recovery.

Most patients will experience some temporary pain in the replaced joint because the surrounding muscles are weak from inactivity, the body is adjusting to the new joint, and the tissues are healing. This pain should resolve in a few months.

Exercise is an important part of the recovery process. Your doctor or physical therapist will provide you with specific exercises to help restore movement and strengthen the joint.

If you have any questions about limitations on your activities after total joint replacement, please consult your doctor.

 

Long-Term Outcomes

The majority of patients are able to perform daily activities more easily after joint replacement surgery. Most people can expect their joint replacement to last for many years, providing them with an improved quality of life that includes less pain, along with improved motion and strength that would not have been possible otherwise.

 

Joint Replacement Articles

For more comprehensive information about specific types of joint replacement:

Total Hip Replacement

Total Knee Replacement

Unicompartmental Knee Replacement

Shoulder Joint Replacement

Reverse Total Shoulder Replacement

Total Elbow Replacement

Wrist Joint Replacement (Wrist Arthroplasty)

Source: Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL; AAOS; May 2014. Based on data from the HCUP Nationwide Inpatient Sample, 2011; Agency for Healthcare Research and Quality.

Last reviewed: June 2014
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Regular exercises to restore your normal hip motion and strength and a gradual return to everyday activities are important for your full recovery. Your orthopaedic surgeon and physical therapist may recommend that you exercise 20 to 30 minutes 2 or 3 times a day during your early recovery. They may suggest some of the following exercises.

Early Postoperative Exercises

These exercises are important for increasing circulation to your legs and feet to prevent blood clots. They also are important to strengthen muscles and to improve your hip movement. You may begin these exercises in the recovery room shortly after surgery. It may feel uncomfortable at first, but these exercises will speed your recovery and reduce your postoperative pain. These exercises should be done as you lie on your back with your legs spread slightly apart.

Ankle Pumps

Slowly push your foot up and down. Do this exercise several times as often as every 5 or 10 minutes. This exercise can begin immediately after surgery and continue until you are fully recovered.

A00303F01

 

Ankle Rotations

A00303F02Move your ankle inward toward your other foot and then outward away from your other foot.

Repeat 5 times in each direction 3 or 4 times a day.

 

 

Bed-Supported Knee Bends

A00303F03Slide your heel toward your buttocks, bending your knee and keeping your heel on the bed. Do not let your knee roll inward.

Repeat 10 times 3 or 4 times a day.

 

 

Buttock Contractions

A00303F04Tighten buttock muscles and hold to a count of 5.

Repeat 10 times 3 or 4 times a day.

 

 

Abduction Exercise

A00303F05Slide your leg out to the side as far as you can and then back.

Repeat 10 times 3 or 4 times a day.

 

 

Quadriceps Set

A00303F06Tighten your thigh muscle. Try to straighten your knee. Hold for 5 to 10 seconds.

Repeat this exercise 10 times during a 10-minute period.

Continue until your thigh feels fatigued.

 

 

Straight Leg Raises

A00303F07Tighten your thigh muscle with your knee fully straightened on the bed. As your thigh muscle tightens, lift your leg several inches off the bed. Hold for 5 to 10 seconds. Slowly lower.

Repeat until your thigh feels fatigued.

 
 

Standing Exercises

Soon after your surgery, you will be out of bed and able to stand. You will require help since you may become dizzy the first several times you stand. As you regain your strength, you will be able to stand independently. While doing these standing exercises, make sure you are holding on to a firm surface such as a bar attached to your bed or a wall.

 

Standing Knee Raises

A00303F08Lift your operated leg toward your chest. Do not lift your knee higher than your waist. Hold for 2 or 3 counts and put your leg down.

Repeat 10 times 3 or 4 times a day.

 

 

 

 

 

Standing Hip Abduction

A00303F10Be sure your hip, knee and foot are pointing straight forward. Keep your body straight. With your knee straight, lift your leg out to the side. Slowly lower your leg so your foot is back on the floor.

Repeat 10 times 3 or 4 times a day.

 

 

 

 

 

Standing Hip Extensions

A00303F09Lift your operated leg backward slowly. Try to keep your back straight. Hold for 2 or 3 counts. Return your foot to the floor.

Repeat 10 times 3 or 4 times a day.

 

 

 

 

 

 

Walking and Early Activity

Soon after surgery, you will begin to walk short distances in your hospital room and perform light everyday activities. This early activity helps your recovery by helping your hip muscles regain strength and movement.

 

Walking with Walker, Full Weightbearing

Stand comfortably and erect with your weight evenly balanced on your walker or crutches. Move your walker or crutches forward a short distance. Then move forward, lifting your operated leg so that the heel of your foot will touch the floor first. As you move, your knee and ankle will bend and your entire foot will rest evenly on the floor. As you complete the step allow your toe to lift off the floor. Move the walker again and your knee and hip will again reach forward for your next step. Remember, touch your heel first, then flatten your foot, then lift your toes off the floor. Try to walk as smoothly as you can. Don’t hurry. As your muscle strength and endurance improve, you may spend more time walking. Gradually, you will put more and more weight on your leg.

 

Walking with Cane or Crutch

A walker is often used for the first several weeks to help your balance and to avoid falls. A cane or a crutch is then used for several more weeks until your full strength and balance skills have returned. Use the cane or crutch in the hand opposite the operated hip. You are ready to use a cane or single crutch when you can stand and balance without your walker, when your weight is placed fully on both feet, and when you are no longer leaning on your hands while using your walker.

 

Stair Climbing and Descending

A00303F11The ability to go up and down stairs requires both flexibility and strength. At first, you will need a handrail for support and you will only be able to go one step at a time. Always lead up the stairs with your good leg and down the stairs with your operated leg. Remember “up with the good” and “down with the bad.” You may want to have someone help you until you have regained most of your strength and mobility. Stair climbing is an excellent strengthening and endurance activity. Do not try to climb steps higher than those of the standard height of seven inches and always use the handrail for balance.

 

 

Advanced Exercises and Activities

A full recovery will take many months. The pain from your problem hip before your surgery and the pain and swelling after surgery have weakened your hip muscles. The following exercises and activities will help your hip muscles recover fully.

These exercises should be done in 10 repetitions four times a day with one end of the tubing around the ankle of your operated leg and the opposite end of the tubing attached to a stationary object such as a locked door or heavy furniture. Hold on to a chair or bar for balance.

 

Elastic Tube Exercises

Resistive Hip Flexion

A00303F13Stand with your feet slightly apart. Bring your operated leg forward keeping the knee straight. Allow your leg to return to its previous position.

Resistive Hip Abduction

A00303F12Stand sideways from the door and extend your operated leg out to the side. Allow your leg to return to its previous position.

Resistive Hip Extensions

A00303F14Face the door or heavy object to which the tubing is attached and pull your leg straight back. Allow your leg to return to its previous position.

Exercycling

Exercycling is an excellent activity to help you regain muscle strength and hip mobility. Adjust the seat height so that the bottom of your foot just touches the pedal with your knee almost straight. Pedal backwards at first. Pedal forward only after comfortable cycling motion is possible backwards. As you become stronger (at about 4 to 6 weeks) slowly increase the tension on the exercycle. Exercycle forward 10 to 15 minutes twice a day, gradually building up to 20 to 30 minutes 3 to 4 times a week.

Walking

Take a cane with you until you have regained your balance skills. In the beginning, walk 5 or 10 minutes 3 or 4 times a day. As your strength and endurance improves, you can walk for 20 or 30 minutes 2 or 3 times a day. Once you have fully recovered, regular walks, 20 or 30 minutes 3 or 4 times a week, will help maintain your strength.

Last reviewed: July 2007
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

What is knee replacement?

Knee joint replacement is a surgical procedure in which certain parts of an arthritic or damaged knee joint are removed and replaced with a prosthesis, or artificial joint. The artificial joint is designed to move just like a normal, healthy joint and allows you to get back to enjoying normal, everyday activities without pain.

How “bad” does my joint pain have to get before I should consider having joint replacement?

This is a very personal decision that only you can make with the help of an orthopaedic specialist’s evaluation of your pain and its effects on your daily life. For example, experiencing knee pain day after day without relief can lead to “staying off” the joint — which often weakens the muscles around it, so it becomes even more difficult to move.

When other more conservative treatment options — including medication and physical therapy — no longer provide pain relief, joint replacement may be recommended.

What is minimally invasive (MIS) knee joint replacement?

With a minimally invasive knee surgery, specialized techniques and instrumentation enable the physician to perform major surgery without as large an incision. In this respect, it is indeed “minimally invasive,” requiring a smaller incision and causing less trauma to the soft tissues. MIS knee replacement is considered a step forward in total knee replacement for a number of reasons, which include the following: potential for a shorter hospital stay, faster recovery, and less scarring. However, MIS surgery is not the right procedure for everyone. Only your orthopaedic specialist can determine its benefits for you.

Are there risks associated with MIS surgery?

The MIS knee replacement technique is significantly less invasive than conventional knee replacement surgery, but it is still a major surgery.

As with any major surgical procedure, patients who undergo total joint replacement are at risk for certain complications, the vast majority of which can be successfully avoided and/or treated.

What will I need to know about postoperative recovery in the hospital?

Following joint replacement surgery, hospital stays vary depending on insurance coverage and individual medical status. A total of four days (including the day of the surgery) is typical. On the first day after your surgery, you will likely get out of bed and begin physical and occupational therapy, typically several brief sessions a day.

Usually a case manager is assigned to work with you as you move through your rehabilitation routines. When you’re ready for discharge, the decision will be made concerning whether you can best continue to recover at home (the usual procedure) or in another facility where you may receive specialized rehabilitative help. If you do go to another facility, the goal will be to return you to your home, able to move about with a safe level of independence, within three to five days.

What can I expect in the first days after I’m discharged?

You shouldn’t be surprised if you feel a little shaky and uncertain for the first day or two after you’re discharged. But soon you may get a routine going and gain confidence in your new joint — the start of a new life with less pain. (As with any surgery, you’ll probably take pain medication for a few days while you are healing.) Be aware that you’ll probably need a walker and/or crutches for about six weeks, then use a cane for another six weeks or so. You’ll be in touch with your doctor or orthopaedic specialist as well as your case manager, so you’ll have plenty of opportunities to ask questions or discuss concerns as well as to report your progress.

When will I be able to go back to a normal daily routine, such as going to work or driving a car?

This is a decision that only you and your doctor or orthopaedic specialist can make. Be sure to follow your doctor’s or orthopaedic surgeon’s advice and recommendations. Individual results may vary.

How long does a knee replacement last?

As successful as most of these procedures are, over the years the artificial joint can become loose or wear out, requiring a revision (repeat) surgery. How long it will last depends not only on a person’s age, but also on a patient’s activity level. These issues — together with the fact that increasing numbers of younger and more active people are receiving total joint replacement — have challenged the orthopaedic industry to try to extend the life cycle of total joint replacements.

What happens during knee replacement surgery?

In surgery, the knee is flexed and the leg suspended. One muscle is separated to expose the femur (thighbone); later, the tibia (shinbone) is exposed. The damaged surfaces at the end of the thighbone are trimmed to shape it to fit inside the total knee prosthesis. The shinbone is cut flat across the top and a hole is created in the center to hold the stem of the tibial component. If needed, the knee cap is trimmed and the patellar component attached.

At various points during surgery, the alignment, function, and stability of the knee joint are evaluated and required adjustments are made. The prosthesis components are cemented into place, any contracted ligaments are released, the midvastus muscle is reconstructed, and the incision is closed.

Total knee replacement is one of the safest and most successful types of surgery; in well over 90% of cases, it is complication-free and results in significant pain relief and restoration of mobility.1

Stryker’s Triathlon® Knee System represents the contribution of over 30 years of clinical success in orthopaedic implants. It utilizes the latest in knee technology to help increase the extent to which you will be able to restore motion in your knee after surgery. The Triathlon® Knee is designed for natural knee movement, helping to relieve your pain and restore your independence.

Over 60% of total knee replacements are performed on women.2 Triathlon® was designed with women in mind.3 It’s a complete knee system designed to increase motion, decrease wear and fit a woman’s anatomy.

how much flexion

 

Increased Knee Motion

Restoring motion in your knee is likely one of the reasons you are considering knee replacement. Motion, the bending (flexing), straightening (extension) and rotation of your knee, affects your ability to perform everyday activities. The Triathlon® Knee System allows for natural knee motion and up to 150° of flexion.

totalkneewomen4


Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: Stryker and Triathlon. All other trademarks are trademarks of their respective owners or holders.

Are You Considering Knee Replacement Surgery?

Each patient is unique, but generally candidates for knee replacement surgery have:

The National Institutes of Health (NIH) has concluded that knee replacement surgery is “a safe and cost-effective treatment for alleviating pain and restoring function in patients who do not respond to non-surgical therapies. According to the American Academy of Orthopaedic Surgeons, knee replacement procedures have resulted in significant restoration of function and reduction of pain in about 90% of patients. As you read,make a note of anything you don’t understand. Your doctor will be happy to answer your questions so that you’ll feel comfortable and confident with your chosen treatment plan.

Information on total hip replacement is also available in Spanish: Reemplazo total de cadera and Portuguese: Artroplastia total de quadril.

Whether you have just begun exploring treatment options or have already decided to undergo hip replacement surgery, this information will help you understand the benefits and limitations of total hip replacement. This article describes how a normal hip works, the causes of hip pain, what to expect from hip replacement surgery, and what exercises and activities will help restore your mobility and strength, and enable you to return to everyday activities.

If your hip has been damaged by arthritis, a fracture, or other conditions, common activities such as walking or getting in and out of a chair may be painful and difficult. Your hip may be stiff, and it may be hard to put on your shoes and socks. You may even feel uncomfortable while resting.

If medications, changes in your everyday activities, and the use of walking supports do not adequately help your symptoms, you may consider hip replacement surgery. Hip replacement surgery is a safe and effective procedure that can relieve your pain, increase motion, and help you get back to enjoying normal, everyday activities.

First performed in 1960, hip replacement surgery is one of the most successful operations in all of medicine. Since 1960, improvements in joint replacement surgical techniques and technology have greatly increased the effectiveness of total hip replacement. According to the Agency for Healthcare Research and Quality, more than 300,000 total hip replacements are performed each year in the United States.

 

Anatomy

The hip is one of the body’s largest joints. It is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

The bone surfaces of the ball and socket are covered with articular cartilage, a smooth tissue that cushions the ends of the bones and enables them to move easily.

A thin tissue called synovial membrane surrounds the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost all friction during hip movement.

Bands of tissue called ligaments (the hip capsule) connect the ball to the socket and provide stability to the joint.

 

A00377F01T

 

Common Causes of Hip Pain

The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.

 

A00377F02T

Description

In a total hip replacement (also called total hip arthroplasty), the damaged bone and cartilage is removed and replaced with prosthetic components.

 

 

 

 

A00377F03

 

Is Hip Replacement Surgery for You?

The decision to have hip replacement surgery should be a cooperative one made by you, your family, your primary care doctor, and your orthopaedic surgeon. The process of making this decision typically begins with a referral by your doctor to an orthopaedic surgeon for an initial evaluation.

Candidates for Surgery

There are no absolute age or weight restrictions for total hip replacements.

Recommendations for surgery are based on a patient’s pain and disability, not age. Most patients who undergo total hip replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total hip replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.

When Surgery Is Recommended

There are several reasons why your doctor may recommend hip replacement surgery. People who benefit from hip replacement surgery often have:

  • Hip pain that limits everyday activities, such as walking or bending
  • Hip pain that continues while resting, either day or night
  • Stiffness in a hip that limits the ability to move or lift the leg
  • Inadequate pain relief from anti-inflammatory drugs, physical therapy, or walking supports

The Orthopaedic Evaluation

An evaluation with an orthopaedic surgeon consists of several components.

  • Medical history. Your orthopaedic surgeon will gather information about your general health and ask questions about the extent of your hip pain and how it affects your ability to perform everyday activities.
  • Physical examination. This will assess hip mobility, strength, and alignment.
  • X-rays. These images help to determine the extent of damage or deformity in your hip.
  • Other tests. Occasionally other tests, such as a magnetic resonance imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your hip.

A00377F04

A00377F12

Deciding to Have Hip Replacement Surgery

Talk With Your Doctor

Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether hip replacement surgery is the best method to relieve your pain and improve your mobility. Other treatment options — such as medications, physical therapy, or other types of surgery — also may be considered.

In addition, your orthopaedic surgeon will explain the potential risks and complications of hip replacement surgery, including those related to the surgery itself and those that can occur over time after your surgery.

Never hesitate to ask your doctor questions when you do not understand. The more you know, the better you will be able to manage the changes that hip replacement surgery will make in your life.

Realistic Expectations

An important factor in deciding whether to have hip replacement surgery is understanding what the procedure can and cannot do. Most people who undergo hip replacement surgery experience a dramatic reduction of hip pain and a significant improvement in their ability to perform the common activities of daily living.

With normal use and activity, the material between the head and the socket of every hip replacement implant begins to wear. Excessive activity or being overweight may speed up this normal wear and cause the hip replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports.

Realistic activities following total hip replacement include unlimited walking, swimming, golf, driving, hiking, biking, dancing, and other low-impact sports.

With appropriate activity modification, hip replacements can last for many years.

Preparing for Surgery

Medical Evaluation

If you decide to have hip replacement surgery, your orthopaedic surgeon may ask you to have a complete physical examination by your primary care doctor before your surgical procedure. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such a cardiologist, before the surgery.

Tests

Several tests, such as blood and urine samples, an electrocardiogram (EKG), and chest x-rays, may be needed to help plan your surgery.

Preparing Your Skin

Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for treatment to improve your skin before surgery.

Blood Donations

You may be advised to donate your own blood prior to surgery. It will be stored in the event you need blood after surgery.

Medications

Tell your orthopaedic surgeon about the medications you are taking. He or she or your primary care doctor will advise you which medications you should stop taking and which you can continue to take before surgery.

Weight Loss

If you are overweight, your doctor may ask you to lose some weight before surgery to minimize the stress on your new hip and possibly decrease the risks of surgery.

Dental Evaluation

Although infections after hip replacement are not common, an infection can occur if bacteria enter your bloodstream. Because bacteria can enter the bloodstream during dental procedures, major dental procedures (such as tooth extractions and periodontal work) should be completed before your hip replacement surgery. Routine cleaning of your teeth should be delayed for several weeks after surgery.

Urinary Evaluation

Individuals with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before having surgery.

Social Planning

Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry.

If you live alone, your orthopaedic surgeon’s office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended care facility during your recovery after surgery also may be arranged.

Home Planning

Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:

  • Securely fastened safety bars or handrails in your shower or bath
  • Secure handrails along all stairways
  • A stable chair for your early recovery with a firm seat cushion (that allows your knees to remain lower than your hips), a firm back, and two arms
  • A raised toilet seat
  • A stable shower bench or chair for bathing
  • A long-handled sponge and shower hose
  • A dressing stick, a sock aid, and a long-handled shoe horn for putting on and taking off shoes and socks without excessively bending your new hip
  • A reacher that will allow you to grab objects without excessive bending of your hips
  • Firm pillows for your chairs, sofas, and car that enable you to sit with your knees lower than your hips
  • Removal of all loose carpets and electrical cords from the areas where you walk in your home

 

fig40 [Converted]

Your Surgery

You will most likely be admitted to the hospital on the day of your surgery.

Anesthesia

After admission, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down). The anesthesia team, with your input, will determine which type of anesthesia will be best for you.

Implant Components

Many different types of designs and materials are currently used in artificial hip joints. All of them consist of two basic components: the ball component (made of highly polished strong metal or ceramic material) and the socket component (a durable cup of plastic, ceramic or metal, which may have an outer metal shell).

The prosthetic components may be “press fit” into the bone to allow your bone to grow onto the components or they may be cemented into place. The decision to press fit or to cement the components is based on a number of factors, such as the quality and strength of your bone. A combination of a cemented stem and a non-cemented socket may also be used.

Your orthopaedic surgeon will choose the type of prosthesis that best meets your needs.

 

OLYMPUS DIGITAL CAMERA

OLYMPUS DIGITAL CAMERA

OLYMPUS DIGITAL CAMERA

OLYMPUS DIGITAL CAMERA

 

 

 

 

 

 

 

 

A00377F08T

Procedure

The surgical procedure takes a few hours. Your orthopaedic surgeon will remove the damaged cartilage and bone and then position new metal, plastic, or ceramic implants to restore the alignment and function of your hip.

After surgery, you will be moved to the recovery room where you will remain for several hours while your recovery from anesthesia is monitored. After you wake up, you will be taken to your hospital room.

 

 

 

 

Your Stay in the Hospital

You will most likely stay in the hospital for a few days. To protect your hip during early recovery, a positioning splint, such as a foam pillow placed between your legs, may be used.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Physical Therapy
A spirometer measures the amount of air you breathe in and out.
Thinkstock © 2011

Walking and light activity are important to your recovery. Most patients who undergo total hip replacement begin standing and walking with the help of a walking support and a physical therapist the day after surgery. In some cases, patients begin standing and walking on the actual day of surgery. The physical therapist will teach you specific exercises to strengthen your hip and restore movement for walking and other normal daily activities.

Preventing Pneumonia

 

Home Health - Respiratory Therapy

Home Health – Respiratory Therapy

It is common for patients to have shallow breathing in the early postoperative period. This is usually due to the effects of anesthesia, pain medications, and increased time spent in bed. This shallow breathing can lead to a partial collapse of the lungs (termed “atelectasis”) which can make patients susceptible to pneumonia. To help prevent this, it is important to take frequent deep breaths. Your nurse may provide a simple breathing apparatus called a spirometer to encourage you to take deep breaths.

 

 

 

 

 

 

Recovery

The success of your surgery will depend in large measure on how well you follow your orthopaedic surgeon’s instructions regarding home care during the first few weeks after surgery.

Wound Care

 

Mature woman in physical therapy

Mature woman in physical therapy

You may have stitches or staples running along your wound or a suture beneath your skin. The stitches or staples will be removed approximately 2 weeks after surgery.

Avoid getting the wound wet until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.

Diet

Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength. Be sure to drink plenty of fluids.

Activity

Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal light activities of daily living within 3 to 6 weeks following surgery. Some discomfort with activity and at night is common for several weeks.

Your activity program should include:

  • A graduated walking program to slowly increase your mobility, initially in your home and later outside
  • Resuming other normal household activities, such as sitting, standing, and climbing stairs
  • Specific exercises several times a day to restore movement and strengthen your hip. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy center the first few weeks after surgery

Possible Complications of Surgery

The complication rate following hip replacement surgery is low. Serious complications, such as joint infection, occur in less than 2% of patients. Major medical complications, such as heart attack or stroke, occur even less frequently. However, chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur they can prolong or limit full recovery.

Infection

Infection may occur superficially in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later.

Minor infections of the wound are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.

Blood Clots

A00219F01T
Blood clots may form in the leg veins or pelvis.

Blood clots in the leg veins or pelvis are one of the most common complications of hip replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program which may include blood thinning medications, support hose, inflatable leg coverings, ankle pump exercises, and early mobilization.

Leg-length Inequality

Sometimes after a hip replacement, one leg may feel longer or shorter than the other. Your orthopaedic surgeon will make every effort to make your leg lengths even, but may lengthen or shorten your leg slightly in order to maximize the stability and biomechanics of the hip. Some patients may feel more comfortable with a shoe lift after surgery.

Dislocation

This occurs when the ball comes out of the socket. The risk for dislocation is greatest in the first few months after surgery while the tissues are healing. Dislocation is uncommon. If the ball does come out of the socket, a closed reduction usually can put it back into place without the need for more surgery. In situations in which the hip continues to dislocate, further surgery may be necessary.

A00377F06T

Loosening and Implant Wear

Over years, the hip prosthesis may wear out or loosen. This is most often due to everyday activity. It can also result from a biologic thinning of the bone called osteolysis. If loosening is painful, a second surgery called a revision may be necessary.

Other Complications

Nerve and blood vessel injury, bleeding, fracture, and stiffness can occur. In a small number of patients, some pain can continue or new pain can occur after surgery.

 

 

 

 

Avoiding Problems After Surgery

Recognizing the Signs of a Blood Clot

Follow your orthopaedic surgeon’s instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.

Warning signs of blood clots. The warning signs of possible blood clot in your leg include:

  • Pain in your calf and leg that is unrelated to your incision
  • Tenderness or redness of your calf
  • New or increasing swelling of your thigh, calf, ankle, or foot

Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:

  • Sudden shortness of breath
  • Sudden onset of chest pain
  • Localized chest pain with coughing

Preventing Infection

A common cause of infection following hip replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections.

Following surgery, patients with certain risk factors may need to take antibiotics prior to dental work, including dental cleanings, or before any surgical procedure that could allow bacteria to enter your bloodstream. Your orthopaedic surgeon will discuss with you whether taking preventive antibiotics before dental procedures is needed in your situation.

Warning signs of infection. Notify your doctor immediately if you develop any of the following signs of a possible hip replacement infection:

  • Persistent fever (higher than 100°F orally)
  • Shaking chills
  • Increasing redness, tenderness, or swelling of the hip wound
  • Drainage from the hip wound
  • Increasing hip pain with both activity and rest

Avoiding Falls

A fall during the first few weeks after surgery can damage your new hip and may result in a need for more surgery. Stairs are a particular hazard until your hip is strong and mobile. You should use a cane, crutches, a walker, or handrails or have someone help you until you improve your balance, flexibility, and strength.

Your orthopaedic surgeon and physical therapist will help you decide which assistive aides will be required following surgery, and when those aides can safely be discontinued.

Other Precautions

To assure proper recovery and prevent dislocation of the prosthesis, you may be asked to take special precautions when sitting, bending, or sleeping — usually for the first 6 weeks after surgery. These precautions will vary from patient to patient, depending on the surgical approach your surgeon used to perform your hip replacement.

Prior to discharge from the hospital, your surgeon and physical therapist will provide you with any specific precautions you should follow.

Outcomes

How Your New Hip Is Different

You may feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending. These differences often diminish with time, and most patients find these are minor compared with the pain and limited function they experienced prior to surgery.

Your new hip may activate metal detectors required for security in airports and some buildings. Tell the security agent about your hip replacement if the alarm is activated. You may ask your orthopaedic surgeon for a card confirming that you have an artificial hip.

Protecting Your Hip Replacement

There are many things you can do to protect your hip replacement and extend the life of your hip implant.

  • Participate in a regular light exercise program to maintain proper strength and mobility of your new hip.
  • Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery.
  • Make sure your dentist knows that you have a hip replacement. Talk with your orthopaedic surgeon about whether you need to take antibiotics prior to dental procedures.
  • See your orthopaedic surgeon periodically for routine follow-up examinations and x-rays, even if your hip replacement seems to be doing fine.
Contributed and/or Updated by: Jared R. H. Foran, MD
Peer-Reviewed by: Stuart J. Fischer, MD
Contributor Disclosure Information

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

pkr_Img1

 

Arthritis pain affects more than 40 million Americans.1 If you’re reading this website, you may be one of them. There are many causes of knee pain and there are a variety of treatment options. This website will review the causes and treatments of knee pain, highlighting more conservative knee treatment. Alleviating the pain and restoring mobility in your knee may allow you to do the simple things — from walking to gardening, even playing with your grandchildren, and most importantly, just enjoying life again. Information is the first step toward potential relief from joint pain.

Knee Anatomy and Function

The knee is the largest joint in the body and is central to nearly every routine activity. The knee joint is formed by the ends of 3 bones: the lower end of the thigh bone (femur), the upper end of the shin bone (tibia), and the knee cap (patella). Thick, tough tissue bands called ligaments connect the bones and stabilize the joint. A smooth, plastic-like lining called cartilage covers the ends of the bones and prevents them from rubbing against each other, allowing for flexible and nearly frictionless movement. Cartilage also serves as a shock absorber, cushioning the bones from the forces between them. Finally, a soft tissue called synovium lines the joint and produces a lubricating fluid that reduces friction and wear.

Regaining Mobility Safely, Slowly, Securely

At first

Most people experience reduction in joint pain and improvement in their quality of life following joint replacement surgery. While joint replacement surgery may allow you to resume many daily activities, don’t push your implant to do more than you could before your problem developed.

Give yourself at least six weeks following surgery to heal and recover from muscle stiffness, swelling and other discomfort. Some people continue to experience discomfort for 6-12 weeks following their joint replacement.

During visits to the physical therapist’s office, your therapist may use heat, ice or electrical stimulation to reduce any remaining swelling or pain. You should continue to use your walker or crutches as instructed.

Your physical therapist may use hands-on stretches for improving range of motion. Strength exercises address key muscle groups, including the buttock, hip, thigh and calf muscles. You can work on endurance through stationary biking, lap swimming and using an upper body ergometer (upper cycle). Physical therapists sometimes treat their patients in a pool. Exercising in a swimming pool puts less stress on your joints and the buoyancy lets you move and exercise easier.

When you are safe putting full weight through the leg, several types of balance exercises can help you further stabilize and control the hip or knee. Finally, you will work with a group of exercises to simulate day-to-day activities, such as going up and down steps, squatting, rising up on your toes, bending down and walking on uneven terrain. You may be given specific exercises to simulate your particular work or hobby demands.

By six weeks, you may be able to return to many normal activities such as driving, bicycling and golf. When you see your surgeon for follow-up two to six weeks after surgery, he or she can advise you on both short and long-term goals.

X-rays, CT Scans and MRIs

Diagnostic imaging techniques help narrow the causes of an injury or illness and ensure that the diagnosis is accurate. These techniques include X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI).

These imaging tools let your doctor “see” inside your body to get a “picture” of your bones, organs, muscles, tendons, nerves, and cartilage. This is a way the doctor can determine if there are any abnormalities.

X-rays

X-rays (radiographs) are the most common and widely available diagnostic imaging technique. Even if you also need more sophisticated tests, you will probably get an X-ray first.

The part of your body being pictured is positioned between the X-ray machine and photographic film. You have to hold still while the machine briefly sends electromagnetic waves (radiation) through your body, exposing the film to reflect your internal structure. The level of radiation exposure from X-rays is not harmful, but your doctor will take special precautions if you are pregnant.

Bones, tumors and other dense matter appear white or light because they absorb the radiation. Less dense soft tissues and breaks in bone let radiation pass through, making these parts look darker on the X-ray film. Sometimes, to make certain organs stand out in the picture, you are asked given barium sulfate or a dye.

You will probably be X-rayed from several angles. If you have a fracture in one limb, your doctor may want a comparison X-ray of your uninjured limb. Your X-ray session will probably be finished in about 10 minutes. The images are ready quickly.

X-rays may not show as much detail as an image produced using newer, more powerful techniques.

Computed Tomography (CT)

Computed tomography (CT) is a modern imaging tool that combines X-rays with computer technology to produce a more detailed, cross-sectional image of your body. A CT scan lets your doctor see the size, shape, and position of structures that are deep inside your body, such as organs, tissues, or tumors. Tell your doctor if you are pregnant before undergoing a CT scan.

You lie as motionless as possible on a table that slides into the center of the cylinder-like CT scanner. The process is painless. An X-ray tube slowly rotates around you, taking many pictures from all directions. A computer combines the images to produce a clear, two-dimensional view on a television screen.

You may need a CT scan if you have a problem with a small, bony structure or if you have severe trauma to the brain, spinal cord, chest, abdomen, or pelvis. As with a regular X-ray, sometimes you may be given barium sulfate or a dye to make certain parts of your body show up better.

A CT scan costs more and takes more time than a regular X-ray, and it is not always available in small hospitals and rural areas.

Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging (MRI) is another modern diagnostic imaging technique that produces cross-sectional images of your body. Unlike CT scans, MRI works without radiation. The MRI tool uses magnetic fields and a sophisticated computer to take high-resolution pictures of your bones and soft tissues. Tell your doctor if you have implants, metal clips, or other metal objects in your body before you undergo an MRI scan.

You lie as motionless as possible on a table that slides into the tube-shaped MRI scanner. The MRI creates a magnetic field around you and then pulses radio waves to the area of your body to be pictured. The radio waves cause your tissues to resonate.

A computer records the rate at which your body’s various parts (tendons, ligaments, nerves, etc.) give off these vibrations, and translates the data into a detailed, two-dimensional picture. You will not feel any pain while undergoing an MRI, but the machine may be noisy.

An MRI may help your doctor to diagnose your torn knee ligaments and cartilage, torn rotator cuffs, herniated disks, hip and pelvic problems, and other problems. An MRI may take 30 to 90 minutes. It is not available at all hospitals.

It may come as a surprise to you that total joint replacement patients are encouraged to get up and start moving around as soon as possible after surgery.

When you are medically stable, the physical therapist will recommend certain exercises for the affected joint. Physical therapy is a key part of recovery. The more quickly a joint replacement patient gets moving again, it is more likely that he or she will regain independence just as quickly. To ease the discomfort the activity will initially cause, pain medication is recommended prior to therapy. In addition, the physical therapist will discuss plans for rehabilitation following hospital discharge. Depending on your limitations, an occupational therapist may provide instruction on how to use certain devices that assist in performing daily activities, such as putting on socks, reaching for household items, and bathing. A case manager will discuss plans for your return home and will ensure that you have all the necessary help to support a successful recovery. If needed, the case manager can help arrange for you to have a home therapist.

 

The success of your joint replacement will strongly depend on how well you follow your orthopaedic surgeon’s instructions. As time passes, you will potentially experience a dramatic reduction in joint pain and a significant improvement in your ability to participate in daily activities. Remember, however, that joint replacement surgery will not allow you to do more than you could before you developed your joint problems!

When fully recovered, most patients can expect to return to work — unless your type of work is not advisable for people with artificial joints. Examples of these include construction work, certain types of carpentry, and occupations that involve repeated high climbing or lifting. You should discuss your situation with your doctor.

You may also be advised to avoid certain activities, including some athletics, as they may place excessive stress your new joint. Examples of these activities include:

 

Hip/Knee

 

Shoulder

 

After Joint Replacement, a Good Rule of Thumb is that Acceptable Physical Activities Should:

 

The success of your joint replacement will strongly depend on how well you follow your orthopaedic surgeon’s instructions. As time passes, you will potentially experience a dramatic reduction in joint pain and a significant improvement in your ability to participate in daily activities. Remember, however, that joint replacement surgery will not allow you to do more than you could before you developed your joint problems.

It’s important to have realistic expectations. For example, artificial joints have limitations:

You may be wondering how long you’ll need to be in the hospital after joint replacement. Every individual is different, and insurance coverage will differ as well. Generally speaking, a total of 4 days (including the day of the surgery) is typical. It is important to note that each patient experience differs and you will be discharged when you have achieved the goals outlined by your orthopaedic surgeon.

On the first day after your surgery, you may get out of bed and begin physical and occupational therapy, typically several brief sessions a day. These are first steps on your way to getting back into the routines of your life!

During your hospital stay, your orthopaedic surgeon works closely with nurses, physical therapists, and other healthcare professionals to ensure the success of your surgery and rehabilitation. Usually a case manager is assigned to work with you as you move through your rehabilitation routines. As the days progress, you should become more independent using two crutches or a walker.

If you need to work with a physical therapist after your joint replacement, the therapist may begin an exercise program to be performed in bed and in the therapy department. The physical therapist will work with you to help you:

The physical therapist (or nurses) will also show you:

 

Discharge from the hospital will depend, to some extent, on your progress in physical therapy. The physical therapist will likely give you a list of activities, exercises, and “do’s and don’ts” when you leave the hospital, and you may also have the assistance of an occupational therapist or nurse to help with special needs.

When you’re ready for discharge, your surgeon will determine whether you can best continue to recover at home (the usual procedure) or in a facility where you can receive specialized rehabilitation help. If you do go to another facility, the goal will be to return you to your home, able to move about with a safe level of independence, within 3 to 5 days.

You shouldn’t be surprised if you feel a little shaky and uncertain for the first day or two after you’re discharged. However, you should soon get a routine going and gain confidence in your new joint — the start of a new life with less pain. (As with many surgeries, pain medication may be prescribed while you are healing.)

You may need a walker and/or crutches for about 6 weeks, then use a cane for another 6 weeks or so. You’ll be in touch with your doctor or orthopaedic surgeon as well as your case manager, so you’ll have plenty of opportunities to ask questions or discuss concerns as well as to report your progress.

 

Be aware that there are some things you should not do after joint surgery. It’s important to have realistic expectations. For example, artificial joints have limitations:

Your healthcare provider will instruct you about limiting your activities following the surgery. Remember: It is very important to follow these instructions!

 

The decision to resume a normal daily routine is one that only you and your doctor or orthopaedic surgeon can make. However, there are some general guidelines that your doctor may give you:

Call your doctor if you experience any of the following symptoms:

 

Consult your doctor regarding considerations before surgery, rehabilitation after surgery, and expectations for surgery. It is important to begin planning for your return home from the hospital before your surgical procedure. Your surgeon may suggest tips to prepare your home for after surgery. For example, get an apron or belt with pockets to carry things while you are on crutches, buy or borrow a cordless phone, remove scatter rugs and other obstacles, safe transport using crutches, have high chair and commode accessories available. Above all, during this time, treat yourself well, eat balanced meals, get plenty of rest, and if requested by your surgeon, donate your own blood in advance so it can be transfused during and after surgery.

 

After surgery you will need to rest your hip to allow proper healing. Your activity will be restricted during this healing period. During the first weeks after surgery, you may be advised to put a pillow between your legs when turning over in bed, wear elastic stockings, use raised toilet seat, take showers rather than baths, restrict activities such as sudden twisting or turning, crossing legs, exposing the scar to sunlight, and driving. Carefully follow your doctor’s instructions regarding progression to normal weight bearing and resumption of normal physical activity. Individual results will vary and all patients will experience different activity levels post-surgery.

 

Even after the healing period, excessive loads placed on the implants through sudden trauma or high impact activities, such as running and jumping, can damage the artificial joint. While the expected life of an artificial hip replacement system is difficult to estimate, it is finite. The components are made of foreign materials that will not indefinitely withstand the activity level and loads of normal, healthy bone. The hip joint may have to be replaced at some time in the future.

Every hospital has its own particular procedures, however, they often follow the basic routine outlined below. Your surgeon and hospital where the surgery will be performed will provide you with information detailing their specific procedures.

 

In the days following surgery, your condition and progress will continue to be closely monitored by your orthopaedic surgeon, nurses, and physical therapists. Much time will be given to exercising the new joint, as well as deep breathing exercises to prevent lung congestion. Gradually, pain medication will be reduced, the IV will be removed, diet will progress to solid food, and you will become increasingly mobile.

 

Joint replacement patients are generally discharged from the hospital when they are able to achieve certain rehabilitative milestones, such as getting in and out of bed unassisted or walking 100 feet. Whether you are sent directly home or to a facility that assists in rehabilitation will depend on your physician’s assessment of your abilities.

On the first day after your surgery, you may get out of bed and begin physical and occupational therapy — typically for several brief sessions a day. These are first steps on your way to getting back into the routines of your life!

In the days following surgery, your condition and progress will continue to be closely monitored by your orthopaedic specialist, nurses, and physical therapists. A good deal of time will be given to exercising the new joint, as well as deep-breathing exercises to prevent lung congestion. Gradually, pain medication will be reduced, the IV will be removed, diet will progress to solid food, and you will become increasingly mobile. Every individual is different, and insurance coverage will differ as well. Generally speaking, a total of four days (including the day of the surgery) in the hospital is typical.

Joint replacement patients are generally discharged from the hospital when they are able to achieve certain rehabilitative milestones, such as getting in and out of bed unassisted or walking 100 feet. Your physician will assess your progress and decide whether you are ready to go directly home or to a facility that will assist with your rehabilitation.

Usually a case manager is assigned to work with you as you move through your rehabilitation routines. As the days progress, expect to become more independent using two crutches or a walker.

If you need to work with a physical therapist after your joint replacement surgery, the therapist will begin an exercise program that you can perform in bed and in the therapy department. The physical therapist will work with you to help you gain confidence and increase your range of motion.

To help you gain confidence with your new joint, the physical therapist (or nurses) will also show you:

 

Leaving the hospital will depend on when you “graduate” from physical therapy. When you leave the hospital, the physical therapist should give you a list of activities, exercises, and “do’s and don’t’s” to follow. An occupational therapist or nurse may also be assigned to help with special needs. An occupational therapist may show you how to use certain devices that assist in performing daily activities, such as putting on socks, reaching for household items, and bathing.

You shouldn’t be surprised if you feel a little shaky and uncertain for the first day or two after you’re discharged. However, you should soon get a routine going and gain confidence in your new joint — the start of a new life with less pain. (As with any surgery, expect to take pain medication for a few days while you are healing.)

If you had a hip or knee replacement, you may need a walker and/or crutches for about six weeks, then a cane for another six weeks or so. Your doctor or orthopaedic specialist as well as your case manager will be in touch with you, so use these opportunities to ask questions or discuss concerns, and keep your team up-to-date on your progress.

 

The decision to resume a normal daily routine is one that only you and your doctor or orthopaedic surgeon can make. However, there are some general guidelines that your doctor may give you.

The complication rate following joint replacement surgery is very low. Serious complications, such as joint infection, occur in less than 2% of patients. Nevertheless, as with any major surgical procedure, patients who undergo total joint replacement are at risk for certain complications — many of which can be successfully avoided and/or treated.

 

Possible complications include:

Infection: Infection may occur in the wound or within the area around the new joint. It can occur in the hospital, after the patient returns home, or years later. Following surgery, joint replacement patients receive antibiotics to help prevent infection. Joint replacement patients may also need to take antibiotics before undergoing any medical procedures to reduce the chance of infection spreading to the artificial joint.

Blood Clots: Blood clots can result from several factors, including the patient’s decreased mobility following surgery, which slows the movement of the blood. There are a number of ways to reduce the possibility of blood clots, including:

  • Blood thinning medications (anticoagulants)
  • Elastic support stockings that improve blood circulation in the legs
  • Plastic boots that inflate with air to promote blood flow in the legs
  • Elevating the feet and legs to keep blood from pooling
  • Walking hourly

Lung Congestion: Pneumonia is always a risk following major surgery. To help keep the lungs clear of congestion, patients are assigned a series of deep breathing exercises.

Hip Replacement Surgery Understanding the Risks: Download Booklet

Knee Replacement Surgery Understanding the Risks: Download Booklet

If you’re reading this website, you are likely scheduled for joint replacement surgery. The information in this website is intended to help you prepare for the day of surgery and answer some questions that may be on your mind. This website will provide you with information so you know what to typically expect before, during and after your joint replacement. By better understanding the surgical experience, hopefully your mind will be put at ease.

This information was written by medical professionals. It provides general responses to frequently asked questions from patients like you. Each patient is unique and therefore patient needs may be unique. Please discuss your specific instructions with your orthopaedic specialist.

About Joint Replacement

About Hip Replacement

About Knee Replacement

About Arthritis

More Interesting Facts

Getting ready to undergo total joint replacement surgery begins weeks before the actual surgery date. Your doctor may request you take the following steps:

I. What to do Before you Check In

II. The Day of Surgery

III. When You Get Home

Are You Considering Shoulder Replacement Surgery?

Circumstances vary, but generally patients are considered for total joint replacement if:

Advancements in Shoulder Replacement

shoulder1
If you’re reading this website, chances are you’re considering or preparing for shoulder surgery. That’s good news — because shoulder replacement has been proven to relieve severe shoulder pain and restore function in the vast majority of patients.

And now there’s even better news. Advancements in the design of shoulder prosthesis allow the potential for you to restore your range of motion. Developed with patient comfort in mind, the Solar® Shoulder is designed for a more natural feel throughout range of motion.

The Solar® Shoulder is designed to replicate the natural anatomy of the patient and help provide you with maximum range of motion so you can get back to the activities you enjoy.*

As you read, make a note of anything you don’t understand. Your orthopaedic surgeon will be happy to answer your questions so that you’ll feel comfortable and confident with your chosen treatment plan.

According to the American Academy of Orthopaedic Surgeons, approximately 23,000 people have shoulder replacement surgery each year. Shoulder problems may arise because of injury to the soft tissues of the shoulder, overuse or underuse of the shoulder, or even because of damage to the tissues. Shoulder problems result in pain, which may be localized to the joint or travel to areas around the shoulder or down the arm.

*Individual results vary and not every patient will experience the same post-operative range of motion and results.

Are You Considering Knee Replacement Surgery?

Each patient is unique, but generally candidates for knee replacement surgery have:

The National Institutes of Health (NIH) has concluded that knee replacement surgery is “a safe and cost-effective treatment for alleviating pain and restoring function in patients who do not respond to non-surgical therapies.”1 According to the American Academy of Orthopaedic Surgeons, knee replacement procedures have resulted in significant restoration of function and reduction of pain in about 90% of patients.2 As you read,make a note of anything you don’t understand. Your doctor will be happy to answer your questions so that you’ll feel comfortable and confident with your chosen treatment plan.

 

You Don’t Have to Live with Joint Pain

Your joints are involved in almost every activity you do. Simple movements such as walking, bending, and turning require the use of your hip and knee joints. Normally, all parts of these joints work together and the joint moves easily without pain. But when the joint becomes diseased or injured, the resulting pain can severely limit your ability to move and work. Osteoarthritis, one of the most common forms of degenerative joint disease, affects an estimated 43 million people in the United States.1 Whether you are considering a total joint replacement, or are just beginning to explore available treatments, this website is for you. It will help you understand the causes of joint pain and treatment options. Most importantly, it will give you hope that you may be able to return to your favorite activities.

Once you’re through reading this website, be sure to ask your doctor any questions you may have. Gaining as much knowledge as possible will help you choose the best course of treatment to relieve your joint pain — and get you back into the swing of things.

 

Total joint replacement is a surgical procedure in which certain parts of an arthritic or damaged joint, such as a hip, knee or shoulder joints, are removed and replaced with a plastic or metal device called a prosthesis. The prosthesis is designed to enable the artificial joint to move just like a normal, healthy joint.

Hip replacement involves replacing the femur (head of the thighbone) and the acetabulum (hip socket). Typically, the artificial ball with its stem is made of a strong metal, and the artificial socket is made of polyethylene (a durable, medical grade plastic). In total knee replacement, the artificial joint is composed of metal and polyethylene and it is used to replace the diseased joint. The prosthesis is anchored into place with bone cement or is covered with an advanced material that allows bone tissue to grow into it.

In shoulder replacement surgery, the artificial shoulder joint can have either two or three parts, depending on the type of surgery required.

Total joint replacements of the hip, knee, and shoulder have been performed since the 1960s. Today, these procedures have been found to result in significant restoration of function and reduction of pain in 90% to 95% of patients. While the expected life of conventional joint replacements is difficult to estimate, it is not unlimited. Today’s patients can look forward to potentially benefiting from new advances that may increase the lifetime of the prostheses.

 

Total Joint Replacement

Total joint replacement is usually reserved for patients who have severe arthritic conditions. Most patients who have artificial hip or knee joints are over 55 years of age, but the operation is being performed in greater numbers on younger patients thanks to new advances in artificial joint technology.

Circumstances vary, but generally patients are considered for total joint replacement if:

Stress fractures are tiny cracks in a bone caused by the overuse and the repetition of movements during exercise. When your muscles are fatigued, they become unable to absorb additional shock during exercise and transfer the overload of stress to the bone. This constant process causes tiny “microcracks” in the bone.

Stress fractures are most common in the weight-bearing bones of your lower legs. They result from increasing the amount and intensity of activity or from an impact on unfamiliar surfaces. For example, a tennis player who changes from a soft to hard court may experience a stress fracture. Athletes participating in tennis, basketball, track and field, and gymnastics are most susceptible to stress fractures, especially if they are not resting enough between training sessions.

Studies have shown that women are more at risk for stress fractures than are men. This appears to be related to nutritional deficiencies and a woman’s propensity for decreased bone mass density.

The most common signs and symptoms include swelling and pain that decrease with rest, and increase with activity. Also, there may be a spot that feels tender or painful when pressure is applied. A stress fracture is sometimes mistaken for a shinsplint (an inflammation of the tibia or shinbone that commonly affects runners). However, stress fractures are more serious.

The most important factor in managing your pain and healing the fracture is rest, which may be needed for 4 to 12 weeks. You may also have to modify other daily activities during these weeks. The next step, rehabilitation, includes a program of muscle strengthening and generalized conditioning. If pain persists, careful use of nonsteroidal anti-inflammatory medications (NSAIDs) may be helpful. However, these medications may limit bone repair and are therefore should be used cautiously. In most cases, stress fractures can be managed with these conservative measures. However, more severe fractures may require surgery to fix and prevent further injury to the bone, as well as to ensure proper healing. Recovery from this kind of surgery is approximately six months.

You may be at risk for a stress fracture if you:

If you suspect that you have signs or symptoms of a stress fracture, if the pain is prolonged, or if there is no improvement with rest, please see your doctor for further evaluation and treatment.

The term “shinsplints” refers to the pain that develops along the inside of your shin (the tibia bone). Also known as medial tibial stress syndrome (MTSS), it commonly affects runners, aerobic dancers, and people in military boot camp because it is an exercise-related overuse injury. In such injuries, your repeated movements during exercise cause muscle fatigue. This fatigue leads to additional forces applied to the tissue (called the fascia) that attaches muscles to the bone. The muscles that attach to the tibia, which include the soleus muscle (ankle flexor) and the flexor digitorum longus (toe flexors), are what actually hurt during MTSS (injury to the bone itself does not cause pain).

Early in the condition, pain is experienced at the beginning of a training session and disappears as the exercising continues. As your injury progresses, the episodes of pain lengthen.

With repeated stress-related injuries, the bone itself can be affected and may eventually develop multiple microfractures — what is referred to as a stress fracture. The pain associated with a stress fracture will be sharp and focused on a very small area of your bone. Stress fractures are more serious and typically require you to restrict your activities to ensure proper healing.

Treatment of MTSS involves rest and often requires you to completely stop training for a period of time. It’s important to follow your doctor’s guidance and begin with lengthened rest time scheduled between training sessions. Your doctor may recommend that you take anti-inflammatory medications or use cold packs and mild compression to relieve the pain. For severe conditions that do not respond to the usual treatment, surgery may be an option. However, a full return to sports is not always achieved following surgery.

You may be more likely to develop MTSS if you:

If you suspect that you have signs or symptoms of MTSS, the pain is prolonged, or if there is no improvement with rest, see your doctor for further evaluation and treatment.

“Runner’s knee” is a blanket term to describe a number of conditions that cause pain at the front of the knee (patellofemoral pain). A common complaint of athletes, it is often the result of irritation in the soft tissues around the front of the knee. For some people, it is the result of their kneecap being out of alignment, which results in the wear and tear of the kneecap cartilage. This chronic wear and tear can eventually cause the cartilage to soften and break down, a condition identified as chondromalacia. As a result, the underlying bone and knee joint become irritated.

You may experience dull, aching pain around the front of the kneecap (the patella) where it connects to the lower end of the thighbone (the femur). The pain may worsen when going up or down stairs, squatting, or kneeling.

Treatment of patellofemoral pain depends on the underlying cause. The most important way to improve your condition is rest and rehabilitation. In some cases, surgery can correct the underlying condition and improve support to the knee. Arthroscopy, which involves the use of a small, pencil-sized camera, can be used to remove small fragments of kneecap cartilage. Realigning the kneecap is also an alternative, and this is done by opening the knee and reducing the abnormal pressures on the cartilage.

What causes “runner’s knee”?

At home, general care involves “RICE”:

A muscle cramp the sudden involuntary contraction of one or more muscle groups usually results in intense pain. The exact cause of muscle cramps is unknown. However, overuse, heat, dehydration, and salt and mineral depletion are considered triggers. In general, overuse, injury, and exercise in hot weather often lead to cramps. Occasionally, muscle cramps can signal other serious medical conditions, such as narrowing of the arteries to the legs (atherosclerosis), nerve compression because of lumbar spine narrowing (spinal stenosis), or potassium depletion.

Just about everyone experiences muscle cramps in their lifetime. They often occur when you’re exercising, although they can happen while you’re sitting or sleeping. They are very common in endurance athletes and other people who perform strenuous activities. Athletes most often experience muscle cramps in the preseason of their sport, when their bodies are not yet conditioned. The most commonly affected muscles are the lower leg (calf) and the thigh (hamstring and quadriceps).

Muscle cramps usually go away on their own and don’t require medical treatment. There are a few things you can do to help relieve the pain and even prevent the cramps. The most important home-care management technique is to stay hydrated with salt-replenishing fluids. Other methods you can use to get rid of your cramps include:

Regular flexibility exercises can also help you prevent cramps from starting. Flexibility exercises are best done before and after you work out to stretch muscle groups that are prone to cramping.

Please see your doctor if your muscle cramps are severe, occur often, respond poorly to treatment, or have no obvious cause. Your doctor may choose to evaluate for possible problems with circulation, nerves, medications, or nutrition.

A meniscal tear is a common injury of the knee. The meniscus is a wedge-like, shock-absorbing piece of cartilage found within your knee joint. It is shaped like a C and curves inside and outside the joint to stabilize your knee. It also allows your thigh (the femur) and your shin (the tibia) bones to glide and twist over each other with movement, as well as provide cushioning support for the weight-bearing job of your legs.

Injury to the meniscus often happens during sport activity, when a sudden twisting of the knee, pivoting, or deceleration causes a tear in your cartilage. A meniscal tear can also occur simultaneously with injury to other ligaments of the knee (in particular, the anterior cruciate ligament which helps to connect the upper and lower leg bones).

You may hear a popping sound at the time of injury to the meniscus, and you may still be able to bear weight and walk on the injured knee. Pain, swelling, and redness of the joint then develop over the next 12 to 24 hours. In some cases, a piece of cartilage can interfere with knee movement, and you may notice that your knee will “lock” or “pop” with attempted movement. Your doctor may choose to evaluate a possible tear with an MRI scan, a form of imaging that uses a large magnet to view changes in tissue.

Initial treatment of a meniscal tear follows basic home care management “RICE,” which stands for Rest, Ice, Compression, and Elevation. Nonsteroidal anti-inflammatory medications (NSAIDs) are helpful to relieve pain and inflammation. This may be all that is needed for minor tears that have occurred in the outer edges of the meniscus.

Surgery may be recommended for tears that are central, cause locking or instability of your knee, or for injuries that don’t heal on their own. Surgery may involve using a small, pen-sized camera (called an arthroscope) to trim torn flaps in the cartilage and repair any other damaged ligaments. Often, a brace or cast is needed after surgery, and physical therapy is an important part of recovery to relieve pain and strengthen and stabilize the muscles around your knee.

If you suspect that you have signs or symptoms of a meniscal tear, please see your doctor for further evaluation and treatment options.

The lower back is made up of five lumbar bones (vertebrae), all of which are separated by spinal discs composed of a gel-like substance and covered with cartilage. These discs act as shock absorbers and help your entire spinal column to move. The vertebrae themselves can be felt when you touch your back, and all the muscles that stabilize the spine attach to these bony points. The spinal canal, which holds the spinal cord and the nerves that branch off, runs the length of the spinal column. Because your lower back supports the majority of your body’s weight, it is very common to experience pain that comes from the muscles, the nerves, or the spine itself.

In fact, low back pain is the second most common reason people visit their doctor (cold and flu are number one).* There are many causes of back pain, and there is no single explanation for each person, although most people experience pain because of injury or trauma. The most common causes of back pain include:

Strains and sprains can occur for many reasons, and may not be caused by any single event. Using improper lifting techniques, being overweight, and having poor posture can cause enough strain on the structures of the lower back to cause injury. You are particularly at risk if you have a job that requires heavy lifting, don’t exercise, or have a history of osteoporosis or arthritis.

Most people find that low back pain improves with simple, at-home measures that include rest (limited to two days) and nonsteroidal anti-inflammatory medications (NSAIDs) or acetaminophen to relieve pain. Sometimes, stronger muscle relaxants and narcotics are used for a short period. Prolonged bedrest (longer than two or three days) is not recommended and may actually worsen the problem.

It is important to gradually resume activity after the first couple of days. Other methods of care include applying heat or cold packs, massage therapy, ultrasound, electrical stimulation, and traction and reduction (physically maneuvering the bones). Injection with local anesthetics or corticosteroids is also an option for short-term pain relief. With all causes of low back pain, one of the most important ways to improve your condition is with back strengthening and conditioning. This is done with specific exercises, as well as general aerobic conditioning.

Surgery for low back pain is an option when nonsurgical options have been unsuccessful. The most commonly performed back operation is spinal fusion, which limits movement of the most painful part of your back. Surgery is considered successful when pain is reduced; however, recovery can take longer than a year. Furthermore, it is rare for people to have complete recovery from pain. Surgery is not the right answer for everyone, and your doctor can best discuss the benefits and limitations of surgery for your particular condition.

How to prevent low back pain:

Home care for low back pain:

Back pain with a loss of bowel or bladder control, leg weakness, weight loss, or fever may suggest a more serious condition. If you experience these symptoms, please seek emergency care for further evaluation.


* American Academy of Orthopedic Surgeons – Low Back Pain Fact Sheet

Brief Evidence – Update: Primary Care Interventions to Prevent Low Back Pain – U.S. Preventive Services Task Force (USPSTF)

A bursa is a fluid-filled space that acts as a cushion between tendons, bone, and skin which helps your joints move with ease. There are over 150 bursae in your body, and several are found around the outer area of the hip, near the portion of your thighbone (the femur) called the greater trochanter. Bursitis occurs when a bursa becomes inflamed, and it is a common cause of pain to your hip.

Inflammation of a bursa is caused by repetitive-use injuries, prolonged pressure, lumbar spine diseases, rheumatoid arthritis, and sometimes infection. It can affect anyone at any age, but is most common in women and the middle-aged. The main symptom is aching pain over the part of the outer hip. The pain worsens with movement or pressure and may travel down the outside of the thigh toward the knee. Pain caused by pressure at night can make sleeping very difficult.

Your doctor will be able to diagnose bursitis when he or she physically examines the specific area causing pain and tenderness. However, an X-ray may be taken to rule out other causes.

Initial treatment of bursitis involves resting, immobilizing the area, and nonsteroidal anti-inflammatory medications (NSAIDs) to reduce inflammation and relieve pain, a regimen that is often effective. Exercise and physical therapy, especially for the hip and lower back, can be helpful to strengthen the surrounding muscles and help prevent further episodes. If these measures don’t relieve your pain, a doctor may recommend an injection of corticosteroids around the bursa, which usually brings rapid pain relief. Surgery to remove the damaged bursa may be an option in severe cases.

To help prevent bursitis, try:

If you suspect that you have signs or symptoms of hip bursitis, please see your doctor for evaluation and further discussion of treatment options.

Ligaments are tough, nonstretchable fibers that hold your bones together. A tear to the anterior cruciate ligament (ACL) of your knee joint is among the most common sport-related injuries. The ACL connects the thighbone (the femur) to the shinbone (the tibia) and acts to prevent your thighbone from moving too far forward over the knee joint. This ligament also helps stabilize the shinbone from rotating out of the knee joint.

The ACL can tear when it’s stretched beyond its normal range. This typically happens by sudden twisting movements, slowing down from running, or landing from a jump. You may hear a popping sound at the time of injury. Your knee may give way and begin to swell and hurt.

Because the ACL is not capable of healing itself (ligaments, unlike muscles, do not have their own blood supply), it can only be reconstructed (that is, replaced) surgically — it cannot simply be repaired. Less active people may choose to treat a torn ligament nonsurgically with a rehabilitation program focusing on muscle strengthening and lifestyle changes. Surgical reconstruction, however, may help many people recover full function after an ACL tear. Your doctor can discuss these different options with you and help choose what is right for you.

After ACL reconstruction, performing rehabilitative exercises may gradually return full flexibility and stability to your knee. Building strength in your thigh and calf muscles to support the reconstructed knee is a primary goal of rehabilitation. You may also need to use a knee brace for a short time, and it is important not to return to full activity too soon to prevent reinjury.

Transient osteoporosis of the hip is an uncommon condition that causes temporary bone loss in the upper portion of the thighbone (femur).

People with transient osteoporosis of the hip will experience a sudden onset of pain that intensifies with walking or other weight-bearing activities. In many cases, the pain increases over time and may become disabling.

Painful symptoms gradually subside and usually end within 6 to 12 months. Bone strength in the hip also returns to normal in the majority of people.

Despite the name, transient osteoporosis of the hip is very different from the more common age-related osteoporosis. Age-related osteoporosis is a painless, progressive condition that leads to a weakening of the bones throughout the body. Unlike transient osteoporosis, it can put people at greater long-term risk for fractures in different areas of the body.

For more information about age-related osteoporosis: Osteoporosis

Anatomy

The hip is one of the body’s largest joints. It is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

In transient osteoporosis of the hip, the femoral head loses density and strength.

 

toh-img1
Normal hip anatomy.

Description

Transient osteoporosis of the hip is an uncommon condition that most often occurs in young or middle-aged men (between ages 30 and 60), and in women in the late stages of pregnancy (the last 3 months) or in the early post-partum period.

Transient osteoporosis most often occurs in the hip joint, but can also affect other joints in the leg, such as the knee, ankle and foot.

During the time that the bone is weakened, it is at greater risk for breaking.

Cause

Currently, there is no clear explanation for what causes this condition. Researchers are studying this disease and several theories have been proposed, although none are proven.

Some of the causes that have been suggested include:

Symptoms

Doctor Examination

Because transient osteoporosis of the hip is not a common condition, doctors often diagnose it by ruling out other, more frequent sources of hip pain. Arthritis, osteonecrosis, stress fracture, muscle injury, and tumor are all conditions that your doctor may consider during your evaluation.

Medical History and Physical Examination
toh-img2

 

Your doctor will test the range of motion in your hip.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

 

Your doctor will talk to you about your symptoms and when they first began. He or she may ask you whether you can remember any injury to the joint.

During the physical examination, your doctor will have you move your leg in different directions to assess your range of motion and try to replicate the pain. Most patients with transient osteoporosis of the hip have more pain when they move the hip themselves (active range of motion) as opposed to when the doctor moves the hip for them (passive range of motion). In addition, pain is often felt only with extremes of hip movements, and it usually worsens with any weight bearing. This discrepancy (severe pain with weight bearing, but minimal pain with passive range of motion) is one of the clues to the diagnosis of transient osteoporosis.

Tests
  • X-rays. In the early course of the disease (the first 6 weeks), x-ray images may show a subtle decrease in the bone density of the femoral head, but this may be hard to see. Several months later, x-rays may show a dramatic loss of bone density with a near complete disappearance of the femoral head. This temporary loss of bone density is why the disease is termed “transient osteoporosis of the hip.”

 

toh-img3

 

This x-ray of the pelvis shows early changes in bone density in the affected hip (white arrows).
Reproduced with permission from Korompilias AV, Karantanas AH, Lykissas MG, Beris AE: Transient osteoporosis. J Am Acad Orthop Surg 2008; 16:480-489.

 

    • Other imaging scans. Because x-rays may not show bone loss until the condition is well-advanced, your doctor may order other types of imaging tests to identify the cause of your symptoms. Computed tomography (CT) scans and magnetic resonance imaging (MRI) scans can provide more detailed images. MRI scans provide clear images of the soft tissues surrounding the hip. A nuclear medicine bone scan can more clearly show changes in bone caused by infection or injury. (A nuclear medicine bone scan should not be confused with a Dual Energy X-ray Absortiometry (DEXA) scan. A DEXA scan is a study that tests for generalized bone density, and while it is the gold-standard in testing for age-related osteoporosis, it is not effective in diagnosising transient osteoporosis of the hip.)

If you are pregnant, your doctor may decide to delay imaging studies until the last stages of your pregnancy, or even until after the delivery. Generally, MRI is safe to obtain in pregnancy, although you should discuss this with your orthopaedic surgeon, your primary doctor, and your obstetrician if you are considering this test.

  • Laboratory tests. Currently there is no blood test that helps to diagnose this disorder. However, blood tests are often very helpful in ruling out other causes of hip pain, such as metabolic (nutritional) disorders, endocrine (hormonal) disorders, and metastatic disease (cancer).
Bone Marrow Edema

One of the most common signs of transient osteoporosis of the hip is bone marrow edema. Bone marrow is a spongy substance that produces blood cells and is located in the hollow of long bones. In bone marrow edema, the bone marrow is inflamed and full of fluid.

An MRI scan of a hip affected by transient osteoporosis will usually reveal bone marrow edema. Because of this, MRI is one of the most useful studies to help diagnose the condition.

 

toh-img4

 

This MRI image shows edema surrounding the affected hip. Edema causes the bone to appear white in the MRI image.
Reproduced with permission from Korompilias AV, Karantanas AH, Lykissas MG, Beris AE: Transient osteoporosis. J Am Acad Orthop Surg 2008; 16:480-489.

 

Treatment

Because transient osteoporosis resolves on its own, treatment focuses on minimizing symptoms and preventing any damage to the bones while they are weakened by the disorder.

Outcomes

With proper diagnosis and treatment, most patients with transient osteoporosis of the hip can expect complete resolution of symptoms within 6 to 12 months. Bone strength in the hip also will return to normal in the majority of cases.

In a small percentage of patients, transient osteoporosis recurs later in life. It can return to the same hip or even in the opposite hip. Whether the condition will recur is difficult to predict.

Last reviewed: July 2013
Contributed and/or Updated by: Jared R. H. Foran, MD
Peer-Reviewed by: Stuart J. Fischer, MD

Regular exercises to restore your normal hip motion and strength and a gradual return to everyday activities are important for your full recovery. Your orthopaedic surgeon and physical therapist may recommend that you exercise 20 to 30 minutes 2 or 3 times a day during your early recovery. They may suggest some of the following exercises.

Early Postoperative Exercises

These exercises are important for increasing circulation to your legs and feet to prevent blood clots. They also are important to strengthen muscles and to improve your hip movement. You may begin these exercises in the recovery room shortly after surgery. It may feel uncomfortable at first, but these exercises will speed your recovery and reduce your postoperative pain. These exercises should be done as you lie on your back with your legs spread slightly apart.

Ankle Pumps

Slowly push your foot up and down. Do this exercise several times as often as every 5 or 10 minutes. This exercise can begin immediately after surgery and continue until you are fully recovered.

threg-img1

Ankle Rotations

 

threg-img2

Move your ankle inward toward your other foot and then outward away from your other foot.

Repeat 5 times in each direction 3 or 4 times a day.

 

Bed-Supported Knee Bends

threg-img3

Slide your heel toward your buttocks, bending your knee and keeping your heel on the bed. Do not let your knee roll inward.

Repeat 10 times 3 or 4 times a day

 

Buttock Contractions

threg-img4

Tighten buttock muscles and hold to a count of 5.

Repeat 10 times 3 or 4 times a day

 

 

Abduction Exercise

threg-img5

Slide your leg out to the side as far as you can and then back.

Repeat 10 times 3 or 4 times a day

 

Quadriceps Set

threg-img6

Tighten your thigh muscle. Try to straighten your knee. Hold for 5 to 10 seconds.

Repeat this exercise 10 times during a 10-minute period.

Continue until your thigh feels fatigued.

 

Straight Leg Raises

threg-img7

Tighten your thigh muscle with your knee fully straightened on the bed. As your thigh muscle tightens, lift your leg several inches off the bed. Hold for 5 to 10 seconds. Slowly lower.

Repeat until your thigh feels fatigued.

Standing Exercises

Soon after your surgery, you will be out of bed and able to stand. You will require help since you may become dizzy the first several times you stand. As you regain your strength, you will be able to stand independently. While doing these standing exercises, make sure you are holding on to a firm surface such as a bar attached to your bed or a wall.

Standing Knee Raises

threg-img8

Lift your operated leg toward your chest. Do not lift your knee higher than your waist. Hold for 2 or 3 counts and put your leg down.Repeat 10 times 3 or 4 times a day

 

Standing Hip Abduction

threg-img9

Be sure your hip, knee and foot are pointing straight forward. Keep your body straight. With your knee straight, lift your leg out to the side. Slowly lower your leg so your foot is back on the floor.Repeat 10 times 3 or 4 times a day

 

Standing Hip Extensions

threg-img10

Lift your operated leg backward slowly. Try to keep your back straight. Hold for 2 or 3 counts. Return your foot to the floor.Repeat 10 times 3 or 4 times a day

 

Walking and Early Activity

Soon after surgery, you will begin to walk short distances in your hospital room and perform light everyday activities. This early activity helps your recovery by helping your hip muscles regain strength and movement.

Walking with Walker, Full Weightbearing

Stand comfortably and erect with your weight evenly balanced on your walker or crutches. Move your walker or crutches forward a short distance. Then move forward, lifting your operated leg so that the heel of your foot will touch the floor first. As you move, your knee and ankle will bend and your entire foot will rest evenly on the floor. As you complete the step allow your toe to lift off the floor. Move the walker again and your knee and hip will again reach forward for your next step. Remember, touch your heel first, then flatten your foot, then lift your toes off the floor. Try to walk as smoothly as you can. Don’t hurry. As your muscle strength and endurance improve, you may spend more time walking. Gradually, you will put more and more weight on your leg.

Walking with Cane or Crutch

A walker is often used for the first several weeks to help your balance and to avoid falls. A cane or a crutch is then used for several more weeks until your full strength and balance skills have returned. Use the cane or crutch in the hand opposite the operated hip. You are ready to use a cane or single crutch when you can stand and balance without your walker, when your weight is placed fully on both feet, and when you are no longer leaning on your hands while using your walker.

Stair Climbing and Descending

threg-img11

The ability to go up and down stairs requires both flexibility and strength. At first, you will need a handrail for support and you will only be able to go one step at a time. Always lead up the stairs with your good leg and down the stairs with your operated leg. Remember “up with the good” and “down with the bad.” You may want to have someone help you until you have regained most of your strength and mobility. Stair climbing is an excellent strengthening and endurance activity. Do not try to climb steps higher than those of the standard height of seven inches and always use the handrail for balance.

Advanced Exercises and Activities

A full recovery will take many months. The pain from your problem hip before your surgery and the pain and swelling after surgery have weakened your hip muscles. The following exercises and activities will help your hip muscles recover fully.

These exercises should be done in 10 repetitions four times a day with one end of the tubing around the ankle of your operated leg and the opposite end of the tubing attached to a stationary object such as a locked door or heavy furniture. Hold on to a chair or bar for balance.

Elastic Tube Exercises

Resistive Hip Flexion
threg-img12

 

Stand with your feet slightly apart. Bring your operated leg forward keeping the knee straight. Allow your leg to return to its previous position.

 

Resistive Hip Abduction
threg-img13

Stand sideways from the door and extend your operated leg out to the side. Allow your leg to return to its previous position.

 

Resistive Hip Extensions
threg-img14

Face the door or heavy object to which the tubing is attached and pull your leg straight back. Allow your leg to return to its previous position.

 

Exercycling

Exercycling is an excellent activity to help you regain muscle strength and hip mobility. Adjust the seat height so that the bottom of your foot just touches the pedal with your knee almost straight. Pedal backwards at first. Pedal forward only after comfortable cycling motion is possible backwards. As you become stronger (at about 4 to 6 weeks) slowly increase the tension on the exercycle. Exercycle forward 10 to 15 minutes twice a day, gradually building up to 20 to 30 minutes 3 to 4 times a week.

Walking

Take a cane with you until you have regained your balance skills. In the beginning, walk 5 or 10 minutes 3 or 4 times a day. As your strength and endurance improves, you can walk for 20 or 30 minutes 2 or 3 times a day. Once you have fully recovered, regular walks, 20 or 30 minutes 3 or 4 times a week, will help maintain your strength.

Last reviewed: July 2007
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Information on total hip replacement is also available in Spanish: Reemplazo total de cadera and Portuguese: Artroplastia total de quadril.

Whether you have just begun exploring treatment options or have already decided to undergo hip replacement surgery, this information will help you understand the benefits and limitations of total hip replacement. This article describes how a normal hip works, the causes of hip pain, what to expect from hip replacement surgery, and what exercises and activities will help restore your mobility and strength, and enable you to return to everyday activities.

If your hip has been damaged by arthritis, a fracture, or other conditions, common activities such as walking or getting in and out of a chair may be painful and difficult. Your hip may be stiff, and it may be hard to put on your shoes and socks. You may even feel uncomfortable while resting.

If medications, changes in your everyday activities, and the use of walking supports do not adequately help your symptoms, you may consider hip replacement surgery. Hip replacement surgery is a safe and effective procedure that can relieve your pain, increase motion, and help you get back to enjoying normal, everyday activities.

First performed in 1960, hip replacement surgery is one of the most successful operations in all of medicine. Since 1960, improvements in joint replacement surgical techniques and technology have greatly increased the effectiveness of total hip replacement. According to the Agency for Healthcare Research and Quality, more than 300,000 total hip replacements are performed each year in the United States.

Anatomy

The hip is one of the body’s largest joints. It is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

The bone surfaces of the ball and socket are covered with articular cartilage, a smooth tissue that cushions the ends of the bones and enables them to move easily.

A thin tissue called synovial membrane surrounds the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost all friction during hip movement.

Bands of tissue called ligaments (the hip capsule) connect the ball to the socket and provide stability to the joint.

thr-img1
Normal hip anatomy.

Common Causes of Hip Pain

The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.

thr-img2

 

A hip with osteoarthritis.

Animation courtesy Visual Health Solutions, Inc.

Description

In a total hip replacement (also called total hip arthroplasty), the damaged bone and cartilage is removed and replaced with prosthetic components.

 

thr-img3
(Left) The individual components of a total hip replacement. (Center) The components merged into an implant. (Right) The implant as it fits into the hip.

 

 

Animation courtesy Visual Health Solutions, Inc.

Is Hip Replacement Surgery for You?

The decision to have hip replacement surgery should be a cooperative one made by you, your family, your primary care doctor, and your orthopaedic surgeon. The process of making this decision typically begins with a referral by your doctor to an orthopaedic surgeon for an initial evaluation.

Candidates for Surgery

There are no absolute age or weight restrictions for total hip replacements.

Recommendations for surgery are based on a patient’s pain and disability, not age. Most patients who undergo total hip replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total hip replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.

When Surgery Is Recommended

There are several reasons why your doctor may recommend hip replacement surgery. People who benefit from hip replacement surgery often have:

  • Hip pain that limits everyday activities, such as walking or bending
  • Hip pain that continues while resting, either day or night
  • Stiffness in a hip that limits the ability to move or lift the leg
  • Inadequate pain relief from anti-inflammatory drugs, physical therapy, or walking supports

The Orthopaedic Evaluation

An evaluation with an orthopaedic surgeon consists of several components.

thr-img4
(Left) In this x-ray of a normal hip, the space between the ball and socket indicates healthy cartilage. (Right) This x-ray of an arthritic hip shows severe loss of joint space.

 

thr-img5
This x-ray shows a large bone spur that has developed on the ball of an arthritic hip.

Deciding to Have Hip Replacement Surgery

Talk With Your Doctor

Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether hip replacement surgery is the best method to relieve your pain and improve your mobility. Other treatment options — such as medications, physical therapy, or other types of surgery — also may be considered.

In addition, your orthopaedic surgeon will explain the potential risks and complications of hip replacement surgery, including those related to the surgery itself and those that can occur over time after your surgery.

Never hesitate to ask your doctor questions when you do not understand. The more you know, the better you will be able to manage the changes that hip replacement surgery will make in your life.

Realistic Expectations

An important factor in deciding whether to have hip replacement surgery is understanding what the procedure can and cannot do. Most people who undergo hip replacement surgery experience a dramatic reduction of hip pain and a significant improvement in their ability to perform the common activities of daily living.

With normal use and activity, the material between the head and the socket of every hip replacement implant begins to wear. Excessive activity or being overweight may speed up this normal wear and cause the hip replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports.

Realistic activities following total hip replacement include unlimited walking, swimming, golf, driving, hiking, biking, dancing, and other low-impact sports.

With appropriate activity modification, hip replacements can last for many years.

Preparing for Surgery

Medical Evaluation

If you decide to have hip replacement surgery, your orthopaedic surgeon may ask you to have a complete physical examination by your primary care doctor before your surgical procedure. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such a cardiologist, before the surgery.

Tests

Several tests, such as blood and urine samples, an electrocardiogram (EKG), and chest x-rays, may be needed to help plan your surgery.

Preparing Your Skin

Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for treatment to improve your skin before surgery.

Blood Donations

You may be advised to donate your own blood prior to surgery. It will be stored in the event you need blood after surgery.

Medications

Tell your orthopaedic surgeon about the medications you are taking. He or she or your primary care doctor will advise you which medications you should stop taking and which you can continue to take before surgery.

Weight Loss

If you are overweight, your doctor may ask you to lose some weight before surgery to minimize the stress on your new hip and possibly decrease the risks of surgery.

Dental Evaluation

Although infections after hip replacement are not common, an infection can occur if bacteria enter your bloodstream. Because bacteria can enter the bloodstream during dental procedures, major dental procedures (such as tooth extractions and periodontal work) should be completed before your hip replacement surgery. Routine cleaning of your teeth should be delayed for several weeks after surgery.

Urinary Evaluation

Individuals with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before having surgery.

Social Planning

Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry.

If you live alone, your orthopaedic surgeon’s office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended care facility during your recovery after surgery also may be arranged.

Home Planning

Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:

  • Securely fastened safety bars or handrails in your shower or bath
  • Secure handrails along all stairways
  • A stable chair for your early recovery with a firm seat cushion (that allows your knees to remain lower than your hips), a firm back, and two arms
  • A raised toilet seat
  • A stable shower bench or chair for bathing
  • A long-handled sponge and shower hose
  • A dressing stick, a sock aid, and a long-handled shoe horn for putting on and taking off shoes and socks without excessively bending your new hip
  • A reacher that will allow you to grab objects without excessive bending of your hips
  • Firm pillows for your chairs, sofas, and car that enable you to sit with your knees lower than your hips
  • Removal of all loose carpets and electrical cords from the areas where you walk in your home
fig40 [Converted]
Set up a “recovery center” where you will spend most of your time. Things like the phone, television remote control, reading materials, and medications should all be within reach.

Your Surgery

You will most likely be admitted to the hospital on the day of your surgery.

Anesthesia

After admission, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia (you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down). The anesthesia team, with your input, will determine which type of anesthesia will be best for you.

Implant Components

Many different types of designs and materials are currently used in artificial hip joints. All of them consist of two basic components: the ball component (made of highly polished strong metal or ceramic material) and the socket component (a durable cup of plastic, ceramic or metal, which may have an outer metal shell).

The prosthetic components may be “press fit” into the bone to allow your bone to grow onto the components or they may be cemented into place. The decision to press fit or to cement the components is based on a number of factors, such as the quality and strength of your bone. A combination of a cemented stem and a non-cemented socket may also be used.

Your orthopaedic surgeon will choose the type of prosthesis that best meets your needs.

 

OLYMPUS DIGITAL CAMERA

(Left) A standard non-cemented femoral component. (Center) A close-up of this component showing the porous surface for bone ingrowth. (Right) The femoral component and the acetabular component working together.

 

OLYMPUS DIGITAL CAMERA

(Left) The acetabular component shows the plastic (polyethylene) liner inside the metal shell. (Right) The porous surface of this acetabular component allows for bone ingrowth. The holes around the cup are used if screws are needed to hold the cup in place.

 

Procedure

The surgical procedure takes a few hours. Your orthopaedic surgeon will remove the damaged cartilage and bone and then position new metal, plastic, or ceramic implants to restore the alignment and function of your hip.

thr-img9
X-rays before and after total hip replacement. In this case, non-cemented components were used.

 

After surgery, you will be moved to the recovery room where you will remain for several hours while your recovery from anesthesia is monitored. After you wake up, you will be taken to your hospital room.

Your Stay in the Hospital

You will most likely stay in the hospital for a few days. To protect your hip during early recovery, a positioning splint, such as a foam pillow placed between your legs, may be used.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Physical Therapy

Home Health - Respiratory Therapy

A spirometer measures the amount of air you breathe in and out.
Thinkstock © 2011

 

Walking and light activity are important to your recovery. Most patients who undergo total hip replacement begin standing and walking with the help of a walking support and a physical therapist the day after surgery. In some cases, patients begin standing and walking on the actual day of surgery. The physical therapist will teach you specific exercises to strengthen your hip and restore movement for walking and other normal daily activities.

Preventing Pneumonia

It is common for patients to have shallow breathing in the early postoperative period. This is usually due to the effects of anesthesia, pain medications, and increased time spent in bed. This shallow breathing can lead to a partial collapse of the lungs (termed “atelectasis”) which can make patients susceptible to pneumonia. To help prevent this, it is important to take frequent deep breaths. Your nurse may provide a simple breathing apparatus called a spirometer to encourage you to take deep breaths.

Recovery

The success of your surgery will depend in large measure on how well you follow your orthopaedic surgeon’s instructions regarding home care during the first few weeks after surgery.

Wound Care

You may have stitches or staples running along your wound or a suture beneath your skin. The stitches or staples will be removed approximately 2 weeks after surgery.

Avoid getting the wound wet until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.

Diet

Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength. Be sure to drink plenty of fluids.

Activity

Mature woman in physical therapy

Thinkstock © 2011

 

Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal light activities of daily living within 3 to 6 weeks following surgery. Some discomfort with activity and at night is common for several weeks.

Your activity program should include:

  • A graduated walking program to slowly increase your mobility, initially in your home and later outside
  • Resuming other normal household activities, such as sitting, standing, and climbing stairs
  • Specific exercises several times a day to restore movement and strengthen your hip. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy center the first few weeks after surgery

Possible Complications of Surgery

The complication rate following hip replacement surgery is low. Serious complications, such as joint infection, occur in less than 2% of patients. Major medical complications, such as heart attack or stroke, occur even less frequently. However, chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur they can prolong or limit full recovery.

Infection

Infection may occur superficially in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later.

Minor infections of the wound are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.

Blood Clots
thr-img12
Blood clots may form in the leg veins or pelvis.

 

Blood clots in the leg veins or pelvis are one of the most common complications of hip replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program which may include blood thinning medications, support hose, inflatable leg coverings, ankle pump exercises, and early mobilization.

Leg-length Inequality

Sometimes after a hip replacement, one leg may feel longer or shorter than the other. Your orthopaedic surgeon will make every effort to make your leg lengths even, but may lengthen or shorten your leg slightly in order to maximize the stability and biomechanics of the hip. Some patients may feel more comfortable with a shoe lift after surgery.

Dislocation

This occurs when the ball comes out of the socket. The risk for dislocation is greatest in the first few months after surgery while the tissues are healing. Dislocation is uncommon. If the ball does come out of the socket, a closed reduction usually can put it back into place without the need for more surgery. In situations in which the hip continues to dislocate, further surgery may be necessary.

 

thr-img13
Hip implant dislocation.

 

Loosening and Implant Wear

Over years, the hip prosthesis may wear out or loosen. This is most often due to everyday activity. It can also result from a biologic thinning of the bone called osteolysis. If loosening is painful, a second surgery called a revision may be necessary.

Other Complications

Nerve and blood vessel injury, bleeding, fracture, and stiffness can occur. In a small number of patients, some pain can continue or new pain can occur after surgery.

Avoiding Problems After Surgery

Recognizing the Signs of a Blood Clot

Follow your orthopaedic surgeon’s instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.

Warning signs of blood clots. The warning signs of possible blood clot in your leg include:

  • Pain in your calf and leg that is unrelated to your incision
  • Tenderness or redness of your calf
  • New or increasing swelling of your thigh, calf, ankle, or foot

Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:

  • Sudden shortness of breath
  • Sudden onset of chest pain
  • Localized chest pain with coughing
Preventing Infection

A common cause of infection following hip replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections.

Following surgery, patients with certain risk factors may need to take antibiotics prior to dental work, including dental cleanings, or before any surgical procedure that could allow bacteria to enter your bloodstream. Your orthopaedic surgeon will discuss with you whether taking preventive antibiotics before dental procedures is needed in your situation.

Warning signs of infection. Notify your doctor immediately if you develop any of the following signs of a possible hip replacement infection:

  • Persistent fever (higher than 100°F orally)
  • Shaking chills
  • Increasing redness, tenderness, or swelling of the hip wound
  • Drainage from the hip wound
  • Increasing hip pain with both activity and rest
Avoiding Falls

A fall during the first few weeks after surgery can damage your new hip and may result in a need for more surgery. Stairs are a particular hazard until your hip is strong and mobile. You should use a cane, crutches, a walker, or handrails or have someone help you until you improve your balance, flexibility, and strength.

Your orthopaedic surgeon and physical therapist will help you decide which assistive aides will be required following surgery, and when those aides can safely be discontinued.

Other Precautions

To assure proper recovery and prevent dislocation of the prosthesis, you may be asked to take special precautions when sitting, bending, or sleeping — usually for the first 6 weeks after surgery. These precautions will vary from patient to patient, depending on the surgical approach your surgeon used to perform your hip replacement.

Prior to discharge from the hospital, your surgeon and physical therapist will provide you with any specific precautions you should follow.

Outcomes

How Your New Hip Is Different

You may feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending. These differences often diminish with time, and most patients find these are minor compared with the pain and limited function they experienced prior to surgery.

Your new hip may activate metal detectors required for security in airports and some buildings. Tell the security agent about your hip replacement if the alarm is activated. You may ask your orthopaedic surgeon for a card confirming that you have an artificial hip.

Protecting Your Hip Replacement

There are many things you can do to protect your hip replacement and extend the life of your hip implant.

  • Participate in a regular light exercise program to maintain proper strength and mobility of your new hip.
  • Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery.
  • Make sure your dentist knows that you have a hip replacement. Talk with your orthopaedic surgeon about whether you need to take antibiotics prior to dental procedures.
  • See your orthopaedic surgeon periodically for routine follow-up examinations and x-rays, even if your hip replacement seems to be doing fine.
Last reviewed: August 2015
Contributed and/or Updated by: Jared R. H. Foran, MD
Peer-Reviewed by: Stuart J. Fischer, MD

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Your thighbone (femur) is the longest and strongest bone in your body. Because the femur is so strong, it usually takes a lot of force to break it. Car crashes, for example, are the number one cause of femur fractures.

The long, straight part of the femur is called the femoral shaft. When there is a break anywhere along this length of bone, it is called a femoral shaft fracture.

 

fsf-img1
The femoral shaft runs from below the hip to where the bone begins to widen at the knee.

 

Types of Femoral Shaft Fractures

Femur fractures vary greatly, depending on the force that causes the break. The pieces of bone may line up correctly or be out of alignment (displaced), and the fracture may be closed (skin intact) or open (the bone has punctured the skin).

Doctors describe fractures to each other using classification systems. Femur fractures are classified depending on:

The most common types of femoral shaft fractures include:

Transverse fracture. In this type of fracture, the break is a straight horizontal line going across the femoral shaft.

Oblique fracture. This type of fracture has an angled line across the shaft.

Spiral fracture. The fracture line encircles the shaft like the stripes on a candy cane. A twisting force to the thigh causes this type of fracture.

Comminuted fracture. In this type of fracture, the bone has broken into three or more pieces. In most cases, the number of bone fragments corresponds with the amount of force required to break the bone.

Open fracture. If a bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone, the fracture is called an open or compound fracture. Open fractures often involve much more damage to the surrounding muscles, tendons, and ligaments. They have a higher risk for complications — especially infections— and take a longer time to heal.

 

fsf-img2

Cause

Femoral shaft fractures in young people are frequently due to some type of high-energy collision. The most common cause of femoral shaft fracture is a motor vehicle or motorcycle crash. Being hit by a car as a pedestrian is another common cause, as are falls from heights and gunshot wounds.

A lower-force incident, such as a fall from standing, may cause a femoral shaft fracture in an older person who has weaker bones.

Symptoms

A femoral shaft fracture usually causes immediate, severe pain. You will not be able to put weight on the injured leg, and it may look deformed — shorter than the other leg and no longer straight.

Doctor Examination

Medical History and Physical Examination

It is important that your doctor know the specifics of how you hurt your leg. For example, if you were in a car accident, it would help your doctor to know how fast you were going, whether you were the driver or a passenger, whether you were wearing your seat belt, and if the airbags went off. This information will help your doctor determine how you were hurt and whether you may be hurt somewhere else.

It is also important for your doctor to know whether you have other health conditions like high blood pressure, diabetes, asthma, or allergies. Your doctor will also ask you about any medications you take.

After discussing your injury and medical history, your doctor will do a careful examination. He or she will assess your overall condition, and then focus on your leg. Your doctor will look for:

  • An obvious deformity of the thigh/leg (an unusual angle, twisting, or shortening of the leg)
  • Breaks in the skin
  • Bruises
  • Bony pieces that may be pushing on the skin

After the visual inspection, your doctor will then feel along your thigh, leg, and foot looking for abnormalities and checking the tightness of the skin and muscles around your thigh. He or she will also feel for pulses. If you are awake, your doctor will test for sensation and movement in your leg and foot.

Imaging Tests

Other tests that will provide your doctor with more information about your injury include:

  • X-rays. The most common way to evaluate a fracture is with x-rays, which provide clear images of bone. X-rays can show whether a bone is intact or broken. They can also show the type of fracture and where it is located within the femur.
  • Computed tomography (CT) scan. If your doctor still needs more information after reviewing your x-rays, he or she may order a CT scan. A CT scan shows a cross-sectional image of your limb. It can provide your doctor with valuable information about the severity of the fracture. For example, sometimes the fracture lines can be very thin and hard to see on an x-ray. A CT scan can help your doctor see the lines more clearly.

Treatment

Nonsurgical Treatment

Most femoral shaft fractures require surgery to heal. It is unusual for femoral shaft fractures to be treated without surgery. Very young children are sometimes treated with a cast. For more information on that, see Pediatric Thighbone (Femur) Fracture.

Surgical Treatment

Timing of surgery. If the skin around your fracture has not been broken, your doctor will wait until you are stable before doing surgery. Open fractures, however, expose the fracture site to the environment. They urgently need to be cleansed and require immediate surgery to prevent infection.

For the time between initial emergency care and your surgery, your doctor will place your leg either in a long-leg splint or in skeletal traction. This is to keep your broken bones as aligned as possible and to maintain the length of your leg.

Skeletal traction is a pulley system of weights and counterweights that holds the broken pieces of bone together. It keeps your leg straight and often helps to relieve pain.

External fixation. In this type of operation, metal pins or screws are placed into the bone above and below the fracture site. The pins and screws are attached to a bar outside the skin. This device is a stabilizing frame that holds the bones in the proper position so they can heal.

External fixation is usually a temporary treatment for femur fractures. Because they are easily applied, external fixators are often put on when a patient has multiple injuries and is not yet ready for a longer surgery to fix the fracture. An external fixator provides good, temporary stability until the patient is healthy enough for the final surgery. In some cases, an external fixator is left on until the femur is fully healed, but this is not common.

 

Leg with femur fracture Referenced from: Basic anatomical knowledge from WWW: http://www.anatomyatlases.org/firstaid/images/spiralfracture2.jpg

External fixation is often used to hold the bones together temporarily when the skin and muscles have been injured.

 

Intramedullary nailing. Currently, the method most surgeons use for treating femoral shaft fractures is intramedullary nailing. During this procedure, a specially designed metal rod is inserted into the marrow canal of the femur. The rod passes across the fracture to keep it in position.

An intramedullary nail can be inserted into the canal either at the hip or the knee through a small incision. It is screwed to the bone at both ends. This keeps the nail and the bone in proper position during healing.

Intramedullary nails are usually made of titanium. They come in various lengths and diameters to fit most femur bones.

 

Leg with femur fracture Referenced from: Basic anatomical knowledge from WWW: http://www.anatomyatlases.org/firstaid/images/spiralfracture2.jpg

Intramedullary nailing provides strong, stable, full-length fixation.

 

Plates and screws. During this operation, the bone fragments are first repositioned (reduced) into their normal alignment. They are held together with special screws and metal plates attached to the outer surface of the bone.

Plates and screws are often used when intramedullary nailing may not be possible, such as for fractures that extend into either the hip or knee joints.

 

fsf-img5

 

(Left) This x-ray shows a healed femur fracture treated with intramedullary nailing. (Right) In this x-ray, the femur fracture has been treated with plates and screws.

Recovery

Most femoral shaft fractures take 4 to 6 months to completely heal. Some take even longer, especially if the fracture was open or broken into several pieces.

Pain Management

Pain after an injury or surgery is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover faster.

Medications are often prescribed for short-term pain relief after surgery or an injury. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery or an injury, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your treatment.

Weightbearing

Many doctors encourage leg motion early in the recovery period. It is very important to follow your doctor’s instructions for putting weight on your injured leg to avoid problems.

In some cases, doctors will allow patients to put as much weight as possible on the leg right after surgery. However, you may not be able to put full weight on your leg until the fracture has started to heal. It is very important to follow your doctor’s instructions carefully.

When you begin walking, you will most likely need to use crutches or a walker for support.

Physical Therapy

Because you will most likely lose muscle strength in the injured area, exercises during the healing process are important. Physical therapy will help to restore normal muscle strength, joint motion, and flexibility.

A physical therapist will most likely begin teaching you specific exercises while you are still in the hospital. The therapist will also help you learn how to use crutches or a walker.

Complications

Complications from Femoral Shaft Fractures

Femoral shaft fractures can cause further injury and complications.

  • The ends of broken bones are often sharp and can cut or tear surrounding blood vessels or nerves.
  • Acute compartment syndrome may develop. This is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells. Unless the pressure is relieved quickly, permanent disability may result. This is a surgical emergency. During the procedure, your surgeon makes incisions in your skin and the muscle coverings to relieve the pressure.
  • Open fractures expose the bone to the outside environment. Even with good surgical cleaning of the bone and muscle, the bone can become infected. Bone infection is difficult to treat and often requires multiple surgeries and long-term antibiotics.
Complications from Surgery

In addition to the risks of surgery in general, such as blood loss or problems related to anesthesia, complications of surgery may include:

  • Infection
  • Injury to nerves and blood vessels
  • Blood clots
  • Fat embolism (bone marrow enters the blood stream and can travel to the lungs; this can also happen from the fracture itself without surgery)
  • Malalignment or the inability to correctly position the broken bone fragments
  • Delayed union or nonunion (when the fracture heals slower than usual or not at all)
  • Hardware irritation (sometimes the end of the nail or the screw can irritate the overlying muscles and tendons)

If you found this article helpful, you may also be interested in Open Fractures.

Last reviewed: August 2011
Contributed and/or Updated by: James F. Barwick, MD; Peter J. Nowotarski, MD
Peer-Reviewed by: Brett Crist, MD; Stuart J. Fischer, MD; Stephen Kottmeier, MD

 

orthopaedic-trauma-logo
Reviewed by members of the Orthopaedic Trauma Association

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Snapping hip is a condition in which you feel a snapping sensation or hear a popping sound in your hip when you walk, get up from a chair, or swing your leg around.

The snapping sensation occurs when a muscle or tendon (the strong tissue that connects muscle to bone) moves over a bony protrusion in your hip.

Although snapping hip is usually painless and harmless, the sensation can be annoying. In some cases, snapping hip leads to bursitis, a painful swelling of the fluid-filled sacs that cushion the hip joint.

Anatomy

The hip is a ball-and-socket joint formed where the rounded end of the thighbone (femur) fits into a cup-shaped socket (acetabulum) in the pelvis. The acetabulum is ringed by strong fibrocartilage called the labrum that creates a tight seal and helps to provide stability to the joint.

Encasing the hip are ligaments that surround the joint and hold it together. Over the ligaments are tendons that attach muscles in the buttocks, thighs, and pelvis to the bones. These muscles control hip movement.

Fluid-filled sacs called bursae are located in strategic spots around the hip to provide cushioning and help the muscles move smoothly over the bone.

snapping-img1
(Left) The bones of the hip. (Right) Ligaments, tendons, and bursae surround and protect the hip joint.
Reproduced with permission from The Body Almanac. © American Academy of Orthopaedic Surgeons, 2003.

Description

Snapping hip can occur in different areas of the hip where tendons and muscles slide over knobs in the hip bones.

When the hip is straight, the iliotibial band is behind the trochanter. When the hip bends, the band moves over the trochanter so that it is in front of it. The iliotibial band is always tight, like a stretched rubber band. Because the trochanter juts out slightly, the movement of the band across it creates the snap you hear.

Eventually, snapping hip may lead to hip bursitis. Bursitis is thickening and inflammation of the bursa, a fluid-filled sac that allows the muscle to move smoothly over bone.

snapping-img2
(Left) This front-view of the hip and thigh shows musculature most often associated with snapping hip: the iliotibial band, rectus femoris tendon, and iliopsoas muscle. (Right) The biceps femoris hamstring muscle travels under the gluteus maximus and can snap as it moves over the ischial tuberosity.
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

In addition to the rectus femoris tendon at the front of the hip, the iliopsoas tendon can catch on bony prominences at the front of the pelvis bone.

snapping-img3
Snapping or catching in the hip can also be caused by tears in the labrum or damage to the cartilage that covers the bones of the joint.

Cause

Snapping hip is most often the result of tightness in the muscles and tendons surrounding the hip. People who are involved in sports and activities that require repeated bending at the hip are more likely to experience snapping hip. Dancers are especially vulnerable.

Young athletes are also more likely to have snapping hip. This is because tightness in the muscle structures of the hip is common during adolescent growth spurts.

Home Remedies

Most people do not see a doctor for snapping hip unless they experience some pain. If the snapping hip bothers you — but not to the point of seeing a doctor — try the following conservative home treatment options:

If you are still experiencing discomfort after trying these conservative methods, consult your doctor for professional treatment.

Doctor Examination

Medical History and Physical Examination

Your doctor will first determine the exact cause of the snapping by discussing you medical history and symptoms, and conducting a physical examination. He or she may ask you where it hurts, what kinds of activities bring on the snapping, whether you can demonstrate the snapping, or whether you have experienced any injury to the hip area.

You may also be asked to stand and move your hip in various directions to reproduce the snapping. Your doctor may even be able to feel the tendon moving as you bend or extend your hip.

Imaging Tests

X-rays create clear pictures of dense structures, like bone. Although x-rays of people with snapping hip do not typically show anything abnormal, your doctor may order x-rays along with other tests to rule out any problems with the bones or joint.

Treatment

Initial treatment typically involves a period of rest and modification of activities. Depending upon the cause of your snapping hip, your doctor may also recommend other conservative treatment options.

Physical Therapy

Your doctor may prescribe exercises to stretch and strengthen the musculature surrounding the hip. Guidance from a physical therapist may also be recommended.

snapping-img4
Iliotibial band stretch

 

  • Iliotibial band stretch
    • Stand next to a wall for support
    • Cross the leg that is closest to the wall behind your other leg.
    • Lean your hip toward the wall until you feel a stretch at the outside of your hip. Hold the stretch for 30 seconds.
    • Repeat on the opposite side.
    • Perform 2 to 3 sets of 4 repetitions each side.
snapping-img5

 

Piriformis stretch
Exercise illustrations reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.
  • Piriformis stretch
    • Lie on your back with bent knees and feet flat on the floor.
    • Cross the foot of the affected hip over the opposite knee and clasp your hands behind your thigh.
    • Pull your thigh toward you until you feel the stretch in your hip and buttocks. Hold the stretch for 30 seconds.
    • Repeat on the opposite side.
    • Perform 2 to 3 sets of 4 repetitions each side.
Corticosteroid Injection

If you have hip bursitis, your doctor may recommend an injection of a corticosteroid into the bursa to reduce painful inflammation.

Surgical Treatment

In the rare instances that snapping hip does not respond to conservative treatment, your doctor may recommend surgery. The type of surgery will depend on the cause of the snapping hip.

    • Hip arthroscopy. During hip arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your hip joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments.

Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.

Hip arthroscopy is most often used to remove or repair fragments of a torn labrum.

  • Open procedure. A traditional open surgical incision (several centimeters long) may be required to address the cause of the snapping hip. An open incision can help your surgeon to better see and gain access to the problem in the hip.

Your orthopaedic surgeon will discuss with you the best procedure to meet your individual health needs.

Last reviewed: April 2013
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Post-Traumatic Stress Disorder After Orthopaedic Trauma

Post-traumatic stress disorder (PTSD) is a mental illness that can occur after injury. It was first described among soldiers who had been in combat and experienced severe emotional or physical trauma. It is part of the body’s response to a horrible situation.

 

What is Post-Traumatic Stress?

If you are confronted with death or serious injury, your body responds in several ways. For example, you may feel a rush of emotions or energy. If the threat is sudden and overwhelming, you may feel fear, helplessness, or horror. Later, you may be unable to forget the sights, sounds, and feelings of the event. These memories may make it difficult for you to function in social or work settings.

People who develop PTSD respond in similar ways. These responses, or symptoms, are used by doctors to help diagnose the condition.

A person must have all three types of symptoms to be diagnosed with PTSD.

 

PTSD in Orthopaedic Trauma

A study found that many patients who experienced an orthopaedic trauma, such as a gunshot wound or a fracture from a motor vehicle accident, developed symptoms of PTSD. In some cases, even though the injury healed properly, the patient continued to experience emotional problems.

Of the nearly 600 patients in the study, more than half had symptoms of PTSD. Among patients injured in vehicle crashes, 57 percent developed symptoms of PTSD. A person who was walking and struck by a car had an even higher risk of developing symptoms of PTSD. Two out of three people involved in vehicle-pedestrian collisions had symptoms of PTSD.

Post-traumatic stress disorder may not be evident right after the accident, but symptoms may develop over time. In this study, patients with more recent injuries were less likely to have symptoms of PTSD than those who had been injured some time ago.

 

Talk to Your Doctor

A serious injury can have a negative impact on your quality of life. For example, if your leg is broken in an automobile accident, you will experience pain and may need surgery to repair the leg. The orthopaedic surgeon may have to put a rod, pin, or plate in your leg to assist healing. For a while, you will probably have to use a walking aid such as crutches. It may be some time before you can resume sports and other activities.

In most cases, these physical effects gradually diminish. However, you and your doctor should be aware of, and address, other conditions that could affect your recovery. Your mental attitude is just as important to the final outcome as your physical response.

If you are having difficulty coping with the emotional effects of your injury, talk to your orthopaedic surgeon. In some cases, you may need a referral to a mental health professional. Other times, you may find it comforting just to know that there’s someone you can talk to about your feelings and response to the accident.

Last reviewed: March 2003
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Pelvic Fractures

The pelvis is the sturdy ring of bones located at the base of the spine. Fractures of the pelvis are uncommon—accounting for only about 3% of all adult fractures.

Most pelvic fractures are caused by some type of traumatic, high-energy event, such as a car collision. Because the pelvis is in proximity to major blood vessels and organs, pelvic fractures may cause extensive bleeding and other injuries that require urgent treatment.

In some cases, a lower-impact event—such as a minor fall—may be enough to cause a pelvic fracture in an older person who has weaker bones.

Treatment for a pelvic fracture varies depending on the severity of the injury. While lower-energy fractures can often be managed with conservative care, treatment for high-energy pelvic fractures usually involves surgery to reconstruct the pelvis and restore stability so that patients can resume their daily activities.

Anatomy

The pelvis is a ring of bones located at the lower end of the trunk—between the spine and the legs. The pelvic bones include the:

Each hip bone contains three bones—the ilium, ischium, and pubis—that are separate during childhood but fuse together as we grow older. These three bones meet to form the acetabulum—the hollow cup that serves as the socket for the ball-and-socket hip joint.

Bands of strong connective tissues called ligaments join the pelvis to the sacrum, creating a bowl-like cavity below the rib cage.

Major nerves, blood vessels, and portions of the bowel, bladder, and reproductive organs all pass through the pelvic ring. The pelvis protects these important structures from injury. It also serves as an anchor for the muscles of the hip, thigh, and abdomen.

pf-img1
The pelvis helps anchor the muscles and protect the organs in the lower abdomen.

Description

Because the pelvis is a ring-like structure, a fracture in one part of the structure is often accompanied by a fracture or damage to ligaments at another point in the structure. Doctors have identified several common pelvic fracture patterns. The specific pattern of the fracture depends upon the direction in which it was broken and the amount of force that caused the injury.

In addition to being described by the specific fracture pattern, pelvic fractures are often described as “stable” or “unstable,” based on how much damage has occurred to the structural integrity of the pelvic ring.

Stable fracture. In this type of fracture, there is often only one break in the pelvic ring and the broken ends of the bones line up adequately. Low-energy fractures are often stable fractures. Stable pelvic fracture patterns include:

pf-img2
Iliac wing fracture

 

pf-img3
Sacrum fracture

 

pf-img4
Superior and inferior pubic ramus fracture

 

Unstable fracture. In this type of fracture, there are usually two or more breaks in the pelvic ring and the ends of the broken bones do not line up correctly (displacement). This type of fracture is more likely to occur due to a high-energy event. Unstable pelvic fracture patterns include:

 

pf-img4
Anterior-posterior compression fracture

 

pf-img6
Lateral compression fracture. In this fracture, the pelvis is pushed inward.

 

pf-img7
Vertical shear fracture. In this fracture, one half of the pelvis shifts upward.

 

Both stable and unstable pelvic fractures can also be divided into “open” fractures, in which the bone fragments stick out through the skin, or “closed” fractures, in which the skin is not broken. Open fractures are particularly serious because, once the skin is broken, infection in both the wound and the bone can occur. Immediate treatment is required to prevent infection.

Cause

High-Energy Trauma

A pelvic fracture may result from a high-energy force, such as that generated during a:

  • Car or motorcycle collision
  • Crush accident
  • Fall from a significant height (such as a ladder)

Depending on the direction and magnitude of the force, these injuries can be life-threatening and require surgical treatment.

Bone Insufficiency

A pelvic fracture may also occur due to weak or insufficient bone. This is most common in older people whose bones have become weakened by osteoporosis. In these patients, a fracture may occur even during a fall from standing or a routine activity such as getting out of the bathtub or descending stairs. These injuries are typically stable fractures that do not damage the structural integrity of the pelvic ring, but may fracture an individual bone.

Other Causes

Less commonly, a fracture may occur when a piece of the ischium bone tears away from the site where the hamstring muscles attach to the bone. This type of fracture is called an avulsion fracture and it is most common in young athletes who are still growing. An avulsion fracture does not usually make the pelvis unstable or injure internal organs.

Symptoms

A fractured pelvis is almost always painful. This pain is aggravated by moving the hip or attempting to walk. Often, the patient will try to keep his or her hip or knee bent in a specific position to avoid aggravating the pain. Some patients may experience swelling or bruising in the hip area.

Doctor Examination

Emergency Stabilization

Patients with high-energy fractures will almost always go or be brought to an urgent care center or emergency room for initial treatment due to the severity of their symptoms.

These patients may also have additional injuries to the head, chest, abdomen, or legs. If their injuries cause significant blood loss, it could lead to shock—a life-threatening condition that can result in organ failure.

The care of patients with high-energy pelvic fractures requires a multidisciplinary approach with input from a number of medical specialists. In some cases, doctors must address airway, breathing, and circulatory problems before treating the fracture and other injuries.

Physical Examination

Your doctor will carefully examine your pelvis, hips, and legs. He or she will also check for nerve injury by assessing whether you can move your ankles and toes and feel sensation on the bottom of your feet.

Your doctor will also carefully examine the rest of your body to determine if you have sustained any other injuries.

Imaging Studies

X-rays. These studies provide images of dense structures, such as bones. All pelvic fractures require x-rays—usually from a number of different angles—to help the doctor determine how displaced place the bones are.

 

pf-img8

 

X-ray shows an unstable pelvic fracture with disruption of the pubis (arrow) and sacroiliac joint (arrowhead).
Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2016.

Computed tomography (CT) scans. Because of the complexity of this type of injury, a CT scan is commonly ordered for pelvic fractures. A CT scan will provide a more detailed, cross-sectional image of the pelvis. Your doctor will use this information to better determine the specific pattern and extent of your injury, look for associated injuries, and aid in preoperative planning.

Magnetic resonance imaging (MRI) scans: In rare cases, your doctor may order an MRI scan to discover a fracture that cannot be seen on x-ray or CT scan.

Treatment

Treatment is based on a number of factors, including:

Nonsurgical Treatment

Your doctor may recommend nonsurgical treatment for stable fractures in which the bones are nondisplaced or minimally displaced.

Nonsurgical treatments may include:

Walking aids. To avoid bearing weight on your leg, your doctor may recommend that you use crutches or a walker for up to three months—or until your bones are fully healed. If you have injuries above both legs, you may need to use a wheelchair for a period of time so that you can avoid bearing weight on either leg.

Medications. Your doctor may prescribe medication to relieve pain, as well as an anti-coagulant, or blood thinner, to reduce the risk of blood clots forming in the veins of your legs and pelvis.

Surgical Treatment

Patients with unstable pelvic fractures may require one or more surgical procedures.

External fixation. Your doctor may use external fixation to stabilize your pelvic area. In this operation, metal pins or screws are inserted into the bones through small incisions into the skin and muscle. The pins and screws project out of the skin on both sides of the pelvis where they are attached to carbon fiber bars outside the skin. The external fixator acts as a stabilizing frame to hold the broken bones in proper position.

In some cases, an external fixator is used to stabilize the bones until healing is complete. In patients who are unable to tolerate a lengthy, more complicated procedure, an external fixator may be used as a temporary treatment until another procedure can be performed.

pf-img9

 

In this x-ray, an external fixator has been used to stabilize the pelvis.
Reproduced from Kurylo JC, Tornetta P: Initial management and classification of pelvic fractures. Instructional Course Lecture 61. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2012, pp. 3-18.

Skeletal traction. Skeletal traction is a pulley system of weights and counterweights that helps realign the pieces of bone. Skeletal traction is often used immediately after an injury and removed after surgery. Occasionally, acetabular fractures can be treated with skeletal traction alone. This is rare, however, and will be a decision made jointly with input from your doctor.

During skeletal traction, metal pins are implanted in the thighbone or shinbone to help position the leg. Weights attached to the pins gently pull on the leg, keeping the broken bone fragments in as normal a position as possible. For many patients, skeletal traction also provides some pain relief.

Open reduction and internal fixation. During this operation, the displaced bone fragments are first repositioned (reduced) into their normal alignment. They are then held together with screws or metal plates attached to the outer surface of the bone.

 

pf-img10

 

In this x-ray, plates and screws have been used to repair a fractured pelvis.
Reproduced from Mullis BH: Techniques of anterior pelvic fixation. Instructional Course Lecture 61. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2012, pp. 19-25.
Complications

There are risks associated with any surgical procedure. Before your surgery, your doctor will discuss each of these risks with you and will take specific measures to help avoid potential complications.

Possible complications include:

  • Wound healing problems, including infection
  • Damage to nerves or blood vessels
  • Blood clots
  • Pulmonary embolism—a blood clot in the lungs

Recovery

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Early Movement

In most cases, your doctor will encourage early movement. Most patients begin walking—with weight-bearing restrictions—and performing foot and leg exercises as soon as possible after surgery.

Physical Therapy

Specific exercises will help you regain flexibility and restore range of motion in your hip. Other exercises will help you build strength and endurance so that you are better able to perform your daily activities.

Blood Clot Prevention

Although early movement is encouraged, your mobility after surgery will still be somewhat limited. For this reason, your doctor may prescribe an anticoagulant, or blood thinner, to help prevent blood clots from forming in the deep veins of your pelvis and legs.

Weight Bearing

Your doctor may recommend that you use crutches or a walker for a period of time. Full weight bearing is usually allowed by 3 months—or when your bones are fully healed. You may require the use of a cane or walking aid for a longer period of time.

Outcomes

Stable pelvic fractures tend to heal well. Unstable pelvic fractures sustained during high-energy incidents, such as car accidents, may result in significant complications, including severe bleeding, internal organ damage, and infection. If these injuries are addressed successfully, the fracture usually heals well.

You may walk with a limp for several months if damage has occurred to the muscles around your pelvis. These muscles may take up to one year to become strong again.

Subsequent problems, such as pain, impaired mobility, and sexual dysfunction, may result from damage to nerves and organs that is associated with the pelvic fracture.

If you found this article helpful, you may also be interested in Deep Vein Thrombosis.

Last reviewed: February 2016
Contributed and/or Updated by: Robert P. Dunbar, MD; Jason A. Lowe, MD
Peer-Reviewed by: Stuart J. Fischer, MD

 

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Fractures (Broken Bones)

A fracture is a broken bone. A bone may be completely fractured or partially fractured in any number of ways (crosswise, lengthwise, in multiple pieces).

Types of Fractures

Bones are rigid, but they do bend or “give” somewhat when an outside force is applied. However, if the force is too great, the bones will break, just as a plastic ruler breaks when it is bent too far.

The severity of a fracture usually depends on the force that caused the break. If the bone’s breaking point has been exceeded only slightly, then the bone may crack rather than break all the way through. If the force is extreme, such as in an automobile crash or a gunshot, the bone may shatter.

If the bone breaks in such a way that bone fragments stick out through the skin, or a wound penetrates down to the broken bone, the fracture is called an “open” fracture. This type of fracture is particularly serious because once the skin is broken, infection in both the wound and the bone can occur.

Common types of fractures include:

fractures-broken-bones-img1

Types of fractures.

 Cause

The most common causes of fractures are:

Symptoms

Many fractures are very painful and may prevent you from moving the injured area. Other common symptoms include:

Doctor Examination

Your doctor will do a careful examination to assess your overall condition, as well as the extent of the injury. He or she will talk with you about how the injury occurred, your symptoms, and medical history.

The most common way to evaluate a fracture is with x-rays, which provide clear images of bone. Your doctor will likely use an x-ray to verify the diagnosis. X-rays can show whether a bone is intact or broken. They can also show the type of fracture and exactly where it is located within the bone.

Treatment

All forms of treatment of broken bones follow one basic rule: the broken pieces must be put back into position and prevented from moving out of place until they are healed. In many cases, the doctor will restore parts of a broken bone back to the original position. The technical term for this process is “reduction.”

Broken bone ends heal by “knitting” back together with new bone being formed around the edge of the broken parts.

Surgery is sometimes required to treat a fracture. The type of treatment required depends on the severity of the break, whether it is “open” or “closed,” and the specific bone involved. For example, a broken bone in the spine (vertebra) is treated differently from a broken leg bone or a broken hip.

Doctors use a variety of treatments to treat fractures:

Cast Immobilization

A plaster or fiberglass cast is the most common type of fracture treatment, because most broken bones can heal successfully once they have been repositioned and a cast has been applied to keep the broken ends in proper position while they heal.

Functional Cast or Brace

The cast or brace allows limited or “controlled” movement of nearby joints. This treatment is desirable for some, but not all, fractures.

Traction

Traction is usually used to align a bone or bones by a gentle, steady pulling action.

External Fixation

In this type of operation, metal pins or screws are placed into the broken bone above and below the fracture site. The pins or screws are connected to a metal bar outside the skin. This device is a stabilizing frame that holds the bones in the proper position while they heal.

In cases where the skin and other soft tissues around the fracture are badly damaged, an external fixator may be applied until surgery can be tolerated.

Leg with femur fracture Referenced from: Basic anatomical knowledge from WWW: http://www.anatomyatlases.org/firstaid/images/spiralfracture2.jpg

Leg with femur fracture
Referenced from:
Basic anatomical knowledge
from WWW:
http://www.anatomyatlases.org/firstaid/images/spiralfracture2.jpg

An external fixator applied to a broken thighbone.

Open Reduction and Internal Fixation

During this operation, the bone fragments are first repositioned (reduced) in their normal alignment, and then held together with special screws or by attaching metal plates to the outer surface of the bone. The fragments may also be held together by inserting rods down through the marrow space in the center of the bone.

Leg with femur fracture Referenced from: Basic anatomical knowledge from WWW: http://www.anatomyatlases.org/firstaid/images/spiralfracture2.jpg

Leg with femur fracture
Referenced from:
Basic anatomical knowledge
from WWW:
http://www.anatomyatlases.org/firstaid/images/spiralfracture2.jpg

A specially designed metal rod, called an intramedullary nail, provides strong fixation for this thighbone fracture.
fractures-broken-bones-img4
The broken bones of the forearm are held in position by plates and screws while they heal.

Recovery

Fractures take several weeks to several months to heal, depending on the extent of the injury and how well you follow your doctor’s advice. Pain usually stops long before the fracture is solid enough to handle the stresses of normal activity.

Even after your cast or brace is removed, you may need to continue limiting your movement until the bone is solid enough for normal activity.

During your recovery you will likely lose muscle strength in the injured area. Specific exercises will help you restore normal muscle strength, joint motion, and flexibility.

Prevention

Proper diet and exercise may help in preventing some fractures. A diet rich in calcium and Vitamin D will promote bone strength. Weightbearing exercise also helps keep bones strong.

Last reviewed: October 2012
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Un Gran Paso en el Reemplazo de Articulaciones

UnGranPaso-img1

 

Si está leyendo este folleto, probablemente usted (o algún ser querido) está considerando o preparándose para una cirugía de reemplazo de articulaciones. Probablemente ha seguido varias terapias no quirúrgicas, las que incluyen medicamentos antiinflamatorios, inyecciones en la articulación y fisioterapia. Aun así, el dolor y el movimiento limitado pueden reprimirlo de realizar las actividades que solía hacer sin preocuparse.

Y ahora tenemos aún mejores noticias. Se han hecho enormes avances en lo que se refiere al reemplazo de articulaciones, lo que hace esta opción viable para una mayor cantidad de personas como nunca antes. Durante las últimas cuatro décadas, se ha demostrado que el reemplazo de articulaciones alivia el dolor articular agudo y restaura la función articular en más del 90% de los pacientes que se someten al procedimiento.*

Mientras lee, tome nota de todo lo que no comprenda. Su médico responderá con gusto sus preguntas para que se sienta cómodo y seguro con respecto al plan de tratamiento que ha elegido.

Tecnología de Vanguardia
Durante el procedimiento de reemplazo de articulaciones, su cirujano se esforzará para garantizar que todo esté alineado correctamente. El alineamiento preciso de los componentes de la cadera o de la rodilla es de suma importancia para el funcionamiento general de su nueva articulación1,2 y también ayuda a que sienta la articulación saludable nuevamente y a que, en lo posible, el reemplazo de ésta dure más tiempo.

La tecnología asistida por computadora ha hecho posible que su especialista ortopédico realice procedimientos de reemplazo de articulaciones con un nivel de exactitud tan preciso que puede mejorar los resultados de su cirugía.1

¿Cuáles son algunas de las razones por las que los cirujanos ortopédicos eligen la tecnología asistida por computadora?

Playground Safety Guide

A00313F01Playgrounds are exciting, fun places for children. They can help to build dexterity, and they are a great place to make friends. Kids are marvelously inventive and use playground equipment in many different ways not intended by the manufacturers.

Each year in the United States, more than 156,000 children under age 14 are treated in hospital emergency rooms for injuries occuring on public playgrounds, according to the Centers for Disease and Prevention (CDC).

There are many ways to prevent these injuries and to lessen the severity of the injuries that do occur.

 

 

 

 

 

 

 

Types of Playground Injuries

Playground injuries range from bumps, bruises, and cuts to life-threatening injuries like strangulation.

According to the CDC, approximately 45% of playground injuries are severe. These injuries include:

The vast majority of injuries on the playground are connected with climbing equipment and swings.

 

Causes of Playground Injuries

Falls

Approximately 79% of equipment-related injuries are caused by falls. Most of these injuries are falls to the ground under equipment, rather than falling onto another piece of equipment.

Children fall because they slip, lose their grip, or lose their balance while playing on monkey bars, swings, slides, merry-go-rounds, and seesaws. Often, they’ll fall on their outstretched hand trying to protect themselves, and sustain a fracture involving the elbow. This type of elbow fracture (supracondylar fracture of the humerus) is the most common injury that requires a trip to the operating room for treatment.

Often children are hurt not only by the fall, but by being struck by the equipment as they fall. Something as simple as drawstrings from a hooded sweatshirt can catch on a piece of playground equipment and can lead to a fall.

Other injuries include falls that result from being struck by the same equipment the child was playing with, or as a result of being struck with moving equipment.

 

Parents and Injury Prevention

Supervision

Close supervision by a responsible adult may be the most important factor in preventing playground injuries.

Age appropriate equipment and carefully designed playground layouts, by themselves, won’t be enough to prevent all injuries that may occur. Adults must provide focused supervision. They must instruct children in proper use of the equipment, and monitor and enforce playground rules.

Playground Checkup

Parents, relatives, teachers, babysitters, or anyone who sends or brings children to the playground should periodically inspect the facility for hazards. Report any problems to the proper officials. Don’t let your children use that playground until the authorities have completed repairs.

 

Playground Considerations and Injury Prevention

Whether playground injuries are caused by falls or other types of contact, attention to three major factors can help to reduce the incidence of injury: playground surface, playground design, and equipment installation and maintenance.

Playground Surface

The type of surface on the playground is the most important factor in the number and severity of injuries due to falls.

The number and severity of injuries can be reduced by using softer surfaces, such as wood mulch or chips, shredded tires, or sand.

Hard surfaces, such as asphalt and concrete, would result in the most severe injuries and are unsuitable under any playground equipment.

Soil, packed dirt, grass, and turf are not recommended for surfacing, because their ability to absorb shock can be affected greatly by weather conditions and wear.

Playground Design

A well-planned playground should offer activities to encourage the development of perception and physical skills, including running, walking, climbing, dodging, swinging, sliding, throwing, catching, pulling, and pushing.

General guidelines for a well-planned playground include:

  • Separate areas for active play, such as swinging, and quiet play, such as digging in sandboxes.
  • Spaces for preschoolers should be located away from areas where older, more active children play.
  • A “use zone” should be established around equipment, with adequate space for entering and exiting. Open fields should be located so that children can run freely without colliding with other children or equipment.
  • Zones for popular activities should be separate to avoid overcrowding.
  • Pathways that link activity areas should provide for easy travel between areas, and unobstructed vision for a child’s height.
  • Sight lines in all playground areas should be clear to allow proper adult supervision.
Equipment Installation and Maintenance

Schools and cities should keep playgrounds in good condition by inspecting and maintaining the equipment throughout the year. Heavy rainfall, snow, temperature extremes and high winds can damage playground equipment. So can heavy use. The most popular equipment might wear out quickly.

Manufacturers’ instructions for proper installation and spacing should be followed carefully, including recommendations for maintenance.

Equipment should be inspected regularly to identify any loosening, rust or corrosion, or deterioration from use, rot, insects, or weathering.

No child should use equipment that does not meet U.S. Consumer Product Safety Commission guidelines. A copy of the guidelines is available, free of charge, by writing to U.S. Consumer Product Safety Commission, Washington, D.C. 20207.

For more in-depth information regarding safe playground equipment and playground guidelines, refer to the article Playground Safety Tips for Kids

 

Guidelines for Safe Playground Use

  • Avoid playgrounds that have concrete, asphalt, hard-packed soil, or grass. The surface should be made of wood chips, mulch, or shredded rubber for play equipment up to seven feet high.
  • Steer children to age-appropriate playground equipment.
  • Check to see that there is enough space for kids to easily get off the slide or merry-go-round. Don’t let kids crowd around the exit areas.
  • Try the handgrips to verify they are shaped and sized for easy grasp.
  • Swing seats should be made of plastic or rubber. Avoid metal or wood.
  • Avoid any equipment that has openings that could entrap a child’s head.
  • Be sure you can clearly see your children on the playground. The kids should have clear, unobstructed views from their height.
  • Remove tripping hazards such as exposed concrete footings, tree stumps, or rocks.

 

Additional Resources on Playground Safety

Try one of these Websites. You’ll find information on playground equipment and safety, links to other Websites, and injury prevention information.

Arthritis of the Hand

The hand and wrist have multiple small joints that work together to produce motion, including the fine motion needed to thread a needle or tie a shoelace. When the joints are affected by arthritis, activities of daily living can be difficult. Arthritis can occur in many areas of the hand and wrist and can have more than one cause.

Over time, if the arthritis is not treated, the bones that make up the joint can lose their normal shape. This causes more pain and further limits motion.

Description

Simply defined, arthritis is inflammation of one or more of your joints. The most common types of arthritis are osteoarthritis and rheumatoid arthritis, but there are more than 100 different forms.

Healthy joints move easily because of a smooth, slippery tissue called articular cartilage. Cartilage covers the ends of bones and provides a smooth gliding surface for the joint. This smooth surface is lubricated by a fluid that looks and feels like oil. It is produced by the joint lining called synovium.

Disease

When arthritis occurs due to disease, the onset of symptoms is gradual and the cartilage decreases slowly. The two most common forms of arthritis from disease are osteoarthritis and rheumatoid arthritis.

Osteoarthritis is much more common and generally affects older people. Also known as “wear and tear” arthritis, osteoarthritis causes cartilage to wear away. It appears in a predictable pattern in certain joints.

Rheumatoid arthritis is a chronic disease that can affect many parts of your body. It causes the joint lining (synovium) to swell, which causes pain and stiffness in the joint. Rheumatoid arthritis most often starts in the small joints of the hands and feet. It usually affects the same joints on both sides of the body.

Trauma

Fractures, particularly those that damage the joint surface, and dislocations are among the most common injuries that lead to arthritis. Even when properly treated, an injured joint is more likely to become arthritic over time.

arthris-hand-img1
Fractures within the finger joints.

Symptoms

Pain

Early symptoms of arthritis of the hand include joint pain that may feel “dull,” or a “burning” sensation. The pain often occurs after periods of increased joint use, such as heavy gripping or grasping. The pain may not be present immediately, but may show up hours later or even the following day. Morning pain and stiffness are typical.

As the cartilage wears away and there is less material to provide shock absorption, the symptoms occur more frequently. In advanced disease, the joint pain may wake you up at night.

Pain might be made worse with use and relieved by rest. Many people with arthritis complain of increased joint pain with rainy weather. Activities that once were easy, such as opening a jar or starting the car, become difficult due to pain. To prevent pain at the arthritic joint, you might change the way you use your hand.

Swelling
arthris-hand-img2

 

Thumb extension deformity. This patient has lost mobility at the base of the thumb due to arthritis. The next joint closer to the tip of the thumb has become more mobile than normal to make up for the arthritic joint. Normally, the thumb does not come to a right angle with the rest of the hand.

When the affected joint is subject to greater stress than it can bear, it may swell in an attempt to prevent further joint use.

Changes in Surrounding Joints

In patients with advanced thumb base arthritis, the neighboring joints may become more mobile than normal.

Warmth

The arthritic joint may feel warm to touch. This is due to the body’s inflammatory response.

Crepitation and Looseness

There may be a sensation of grating or grinding in the affected joint (crepitation). This is caused by damaged cartilage surfaces rubbing against one another. If arthritis is due to damaged ligaments, the support structures of the joint may be unstable or “loose.” In advanced cases, the joint may appear larger than normal (hypertrophic). This is usually due to a combination of bone changes, loss of cartilage, and joint swelling.

Cysts
arthris-hand-img3

 

Mucous cyst of the index finger.

When arthritis affects the end joints of the fingers (DIP joints), small cysts (mucous cysts) may develop. The cysts may then cause ridging or dents in the nail plate of the affected finger.

Doctor Examination

arthris-hand-img4

 

Bone scans of the hands. The darker color is indication of arthritis.

A doctor can diagnose arthritis of the hand by examining the hand and by taking x-rays. Specialized studies, such as magnetic resonance imaging (MRI), are usually not needed except in cases where Keinbock’s disease (a condition where the blood supply to one of the small bones in the wrist, the lunate, is interrupted) is suspected. Sometimes a bone scan is helpful. A bone scan may help the doctor diagnose arthritis when it is in an early stage, even if x-rays look normal.

Treatment

Arthritis does not have to result in a painful or sedentary life. It is important to seek help early so that treatment can begin and you can return to doing what matters most to you.

Nonsurgical Treatment

Treatment options for arthritis of the hand and wrist include medication, splinting, injections, and surgery, and are determined based on:

  • How far the arthritis has progressed
  • How many joints are involved
  • Your age, activity level and other medical conditions
  • If the dominant or non-dominant hand is affected
  • Your personal goals, home support structure, and ability to understand the treatment and comply with a therapy program

Medications
Medications treat symptoms but cannot restore joint cartilage or reverse joint damage. The most common medications for arthritis are anti-inflammatories, which stop the body from producing chemicals that cause joint swelling and pain. Examples of anti-inflammatory drugs include medications such as acetaminophen and ibuprofen.

Glucosamine and chondroitin are widely advertised dietary supplements or “neutraceuticals.” Neutraceuticals are not drugs. Rather, they are compounds that are the “building blocks” of cartilage. They were originally used by veterinarians to treat arthritic hips in dogs. However, neutraceuticals have not yet been studied as a treatment of hand and wrist arthritis. (Note: The U.S. Food and Drug Administration does not test dietary supplements. These compounds may cause negative interactions with other medications. Always consult your doctor before taking dietary supplements.)

Injections
When first-line treatment with anti-inflammatory medication is not appropriate, injections may be used. These typically contain a long-lasting anesthetic and a steroid that can provide pain relief for weeks to months. The injections can be repeated, but only a limited number of times, due to possible side effects, such as lightening of the skin, weakening of the tendons and ligaments and infection.

Splinting
Injections are usually combined with splinting of the affected joint. The splint helps support the affected joint to ease the stress placed on it from frequent use and activities. Splints are typically worn during periods when the joints hurt. They should be small enough to allow functional use of the hand when they are worn. Wearing the splint for too long can lead to muscle deterioration (atrophy). Muscles can assist in stabilizing injured joints, so atrophy should be prevented.

Surgical Treatment

If nonsurgical treatment fails to give relief, surgery is usually discussed. There are many surgical options. The chosen course of surgical treatment should be one that has a reasonable chance of providing long-term pain relief and return to function. It should be tailored to your individual needs.

arthris-hand-img5

 

A joint fusion using a plate and screws at the base of the thumb.

If there is any way the joint can be preserved or reconstructed, this option is usually chosen.When the damage has progressed to a point that the surfaces will no longer work, a joint replacement or a fusion (arthrodesis) is performed.

arthris-hand-img6

 

An example of a finger joint prosthesis used in joint replacement surgery.

Joint fusions provide pain relief but stop joint motion. The fused joint no longer moves; the damaged joint surfaces are gone, so they cannot cause pain and other symptoms.The goal of joint replacement is to provide pain relief and restore function. As with hip and knee replacements, there have been significant improvements in joint replacements in the hand and wrist. The replacement joints are made of materials similar to those used in weightbearing joints, such as ceramics or long-wearing metal and plastic parts. The goal is to improve the function and longevity of the replaced joint.

Most of the major joints of hand and wrist can be replaced. A surgeon often needs additional training to perform the surgery. As with any evolving technology, the long-term results of the hand or wrist joint replacements are not yet known. Early results have been promising. Talk with your doctor to find out if these implants are right for you.

After Surgery

After any type of joint reconstruction surgery, there is a period of recovery. Often, you will be referred to a trained hand therapist, who can help you maximize your recovery. You may need to use a postoperative splint or cast for awhile after surgery. This helps protect the hand while it heals.

During this postoperative period, you may need to modify activities to allow the joint reconstruction to heal properly. Typically, pain medication you take by mouth is also used to reduce discomfort. It is important to discuss your pain with your doctor so it can be adequately treated.

Length of recovery time varies widely and depends on the extent of the surgery performed and multiple individual factors. However, people usually can return to most if not all of their desired activities in about three months after most major joint reconstructions.

New Developments

Increasingly, doctors are focusing on how to preserve the damaged joint. This includes getting an earlier diagnosis and repairing joint components before the entire surface becomes damaged.

Arthroscopy of the small joints of the hand and wrist is now possible because the equipment has been made much smaller.

There have been encouraging results in cartilage repair and replacement in the larger joints such as the knee, and some of these techniques have been applied to the smaller joints of the hand and arm.

In addition, stem cell research may be an option to regenerate damaged joint surfaces.

If you found this article helpful, you may also be interested in Managing Arthritis Pain with Exercise.

Last reviewed: December 2013
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

The Achilles Tendon

Achilles Tendon Injuries

The Achilles tendon is the largest tendon in your body. It connects the muscles in the back of your lower leg to your heel bone (the calcaneus) and must withstand large forces during sporting exercises and pivoting. There are two main types of injuries that affect the Achilles tendon: 1) overuse and inflammation, called Achilles Tendonitis, and 2) a tear of the tendon.

Achilles Tendonitis

Achilles tendonitis often occurs when you rapidly increase the intensity of training or start new types of training when your body is not fully conditioned, e.g., adding uphill running to your training schedule or restarting training after a period of inactivity. You may experience mild pain after exercise that gradually worsens. Mild swelling, morning tenderness, and stiffness may also occur, but may improve with use. Severe episodes of pain along the length of the tendon several hours after exercise may also be experienced.

Because other symptoms may be present, it is best to see your doctor for full evaluation of an Achilles injury. Treatment depends on severity and typically involves rest and nonsteroidal anti-inflammatory medications (NSAIDs) to relieve pain and inflammation. An orthosis (a brace) may be needed to relieve the stress on your tendon and support your ankle, or bandages may be applied to restrict joint movement.

Surgery is sometimes an option to repair any tears and remove any inflamed or fibrous (toughened) tissues. Recovery in general includes rehabilitation to avoid future weakness in your ankle.

Achilles Tear

Your Achilles tendon may tear if it is overstretched, usually while playing sports. The tear may be partial or complete and most commonly occurs just above the calcaneus (your heel bone). A snap or crack sound may be heard at the time of injury. Pain and swelling near your heel and an inability to bend your foot downward or walk normally are signs that you may have ruptured your Achilles tendon.

Surgery is typically needed for a complete rupture. After surgery, your ankle will be kept stable in a cast or walking boot for up to 12 weeks. A torn ligament may also be managed nonsurgically with a below-knee cast, which would allow the ends of the torn tendon to heal on their own. This nonsurgical approach may take longer to heal, and there is a higher chance that the tendon could re-rupture. Surgery offers a better chance of full recovery and is often the treatment of choice for active people who wish to resume sports.

If you suspect that you have signs or symptoms of an Achilles tendon injury, please see your doctor for further evaluation and discussion of treatment options.

The Aging Spine

As the spine ages, a number of conditions can result in chronic pain in various parts of your body, not just your neck or back.

Some of the more common disorders in the spine include:

To a large extent, these spinal disorders are not problems in themselves. The trouble starts when they put pressure on the nearby nerve roots or spinal cord, causing pain, numbness, or even paralysis in the limbs. Pinched nerves can be treated with anti-inflammatory medications, steroid injections, physical therapy, or surgery, with the aim being to relieve pressure on the nerve by increasing the space around it.

Deciding the right way to treat your neck or back pain begins with an accurate diagnosis, which involves a thorough orthopaedic evaluation and the use of tools such as MRI and electrodiagnostics.

Back Pain

Back pain often occurs when one or more nerves in the spinal column become impinged, or pinched. This is commonly caused by a disc or bone spur pushing into the canal that houses the spinal cord and the nerve roots. Often back pain can be treated nonsurgically, but in some cases, surgery is necessary.

Neck Pain

The part of the spine that supports your neck is called the cervical spine. The neck must allow for a significant amount of movement, in addition to supporting the weight of the head. Unlike the rest of the spine, which is relatively protected from injury, the cervical spine has a relatively small number of muscles and ligaments that surround and protect it from injury.

Neck pain may result from abnormalities in the soft tissues (muscles, ligaments, or nerves) or in the vertebrae or joints of the cervical spine. The most common causes of neck pain are degenerative diseases (such as arthritis) or soft tissue abnormalities following injury. In some individuals, neck problems may cause pain felt in the upper back, shoulders, or arms.

Foot and Ankle Pain

footThe foot and ankle are two of the most versatile and complex areas of your body. One foot alone contains 26 bones supported by a network of muscles, tendons, and ligaments. When everything is working well, you hardly give them a thought. But when a problem arises, it’s often impossible to ignore.

More than 11 million visits were made to physicians’ offices in 2003 because of foot and ankle problems, including more than 2 million visits for ankle sprains and strains and more than 800,000 visits for ankle fractures.* Some conditions that may affect your foot and/or ankle could be:

 

 

 

Your Treatment Options for Foot and Ankle Pain

Fortunately, most cases of foot and ankle pain respond well to treatments like rest, ice, orthotics (shoe inserts), prescribed exercises, and anti-inflammatory medications. Local cortisone injections can also provide pain relief.

However, when these medical treatments fail to provide adequate pain relief, surgery may be an option. Often foot and ankle surgery is performed on an outpatient basis using minimally invasive techniques. These techniques may mean less pain and less risk, as well as a faster recovery time.

Care of Casts and Splints

Information on casts and splints is also available in Spanish: Cuidado de yesos y férula.

Casts and splints support and protect injured bones and soft tissue. When you break a bone, your doctor will put the pieces back together in the right position. Casts and splints hold the bones in place while they heal. They also reduce pain, swelling, and muscle spasm.

In some cases, splints and casts are applied following surgery.

Splints or “half-casts” provide less support than casts. However, splints can be adjusted to accommodate swelling from injuries easier than enclosed casts. Your doctor will decide which type of support is best for you.

Types of Splints and Casts

Casts are custom-made. They must fit the shape of your injured limb correctly to provide the best support. Casts can be made of plaster or fiberglass — a plastic that can be shaped.

Splints or half-casts can also be custom-made, especially if an exact fit is necessary. Other times, a ready-made splint will be used. These off-the-shelf splints are made in a variety of shapes and sizes, and are much easier and faster to use. They have Velcro straps which make the splints easy to put on, take off, and adjust.

Materials

Fiberglass or plaster materials form the hard supportive layer in splints and casts.

Fiberglass is lighter in weight and stronger than plaster. In addition, x-rays can “see through” fiberglass better than through plaster. This is important because your doctor will probably schedule additional x-rays after your splint or cast has been applied. X-rays can show whether the bones are healing well or have moved out of place.

Plaster is less expensive than fiberglass and shapes better than fiberglass for some uses.

Application

Both fiberglass and plaster splints and casts use padding, usually cotton, as a protective layer next to the skin. Both materials come in strips or rolls which are dipped in water and applied over the padding covering the injured area.

The splint or cast must fit the shape of the injured arm or leg correctly to provide the best possible support. Generally, the splint or cast also covers the joint above and below the broken bone.

In many cases, a splint is applied to a fresh injury first. As swelling subsides, a full cast may replace the splint.

Sometimes, it may be necessary to replace a cast as swelling goes down and the cast gets “too big.” As a fracture heals, the cast may be replaced by a splint to make it easier to perform physical therapy exercises.

Getting Used to a Splint or Cast

Swelling due to your injury may cause pressure in your splint or cast for the first 48 to 72 hours. This may cause your injured arm or leg to feel snug or tight in the splint or cast. If you have a splint, your doctor will show you how to adjust it to accommodate the swelling.

It is very important to keep the swelling down. This will lessen pain and help your injury heal. To help reduce swelling:

cc-img1
Apply ice to the splint or cast and elevate your leg to reduce swelling.

Warning Signs

Swelling can create a lot of pressure under your cast. This can lead to problems. If you experience any of the following symptoms, contact your doctor’s office immediately for advice.

Taking Care of Your Splint or Cast

Your doctor will explain any restrictions on using your injured arm or leg while it is healing. You must follow your doctor’s instructions carefully to make sure your bone heals properly. The following information provides general guidelines only, and is not a substitute for your doctor’s advice.

After you have adjusted to your splint or cast for a few days, it is important to keep it in good condition. This will help your recovery.

Use common sense. You have a serious injury and you must protect your cast from damage so it can protect your injury while it heals.

After the initial swelling has subsided, proper splint or cast support will usually allow you to continue your daily activities with a minimum of inconvenience.

Cast Removal

Never remove the cast yourself. You may cut your skin or prevent proper healing of your injury.

Your doctor will use a cast saw to remove your cast. The saw vibrates, but does not rotate. If the blade of the saw touches the padding inside the hard shell of the cast, the padding will vibrate with the blade and will protect your skin. Cast saws make noise and may feel “hot” from friction, but will not harm you — “their bark is worse than their bite.”

If you do feel pain while the cast is being removed, let your doctor or an assistant know and they will be able to make adjustments.

cc-img2
The saw vibrates but does not rotate. Cast saws make noise but will not harm you.

Rehabilitation

Broken bones take several weeks to several months to heal. Pain usually stops long before the bone is solid enough to handle the stresses of everyday activities. You will need to wear your cast or splint until your bone is fully healed and can support itself.

While you are wearing your cast or splint, you will likely lose muscle strength in the injured area. Exercises during the healing process and after your cast is removed are important. They will help you restore normal muscle strength, joint motion, and flexibility.

Last reviewed: August 2015
posna-logo
Reviewed by members of POSNA (Pediatric Orthopaedic Society of North America)

The Pediatric Orthopaedic Society of North America (POSNA) is a group of board eligible/board certified orthopaedic surgeons who have specialized training in the care of children’s musculoskeletal health. One of our goals is to continue to be the authoritative source for patients and families on children’s orthopaedic conditions. Our Public Education and Media Relations Committee works with the AAOS to develop, review, and update the pediatric topics within OrthoInfo, so we ensure that patients, families and other healthcare professionals have the latest information and practice guidelines at the click of a link.
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

    Your Treatment Options

Hip and Knee Pain

      Topics

 

tjr1

tjr2

 

 

 

 

 

 

Did you know?

Understanding Your Body’s Mechanics

Your musculoskeletal system — which is comprised of 206 bones connected by joints, muscles, ligaments, tendons, and nerves — protects your internal organs, supports your weight, and allows you to move. It’s a complex, interdependent system where even a minor disruption can result in discomfort and physical limitation.

Your orthopaedic surgeon is trained to diagnose and treat any injury, deformity, or disease that interrupts this system. General orthopaedics covers all kinds of common and complex conditions like:

Shoulder Anatomy and Function

How a Healthy Shoulder Works

Your shoulder is the most moveable joint in the body. It is made up of three bones:

There are also two important joints that allow for movement:

replaced_shoulder_wAlthough the shoulder is the most moveable joint in the body, it is unstable because the ball (the humerus) is larger than the socket (the glenoid) that holds it. To maintain stability, the bones of the shoulder are held in place by muscles, tendons, and ligaments. Tendons are tough cords of tissue that attach muscles to bone, and ligaments attach bones to each other for stability.

The rotator cuff is made up of four muscles and their tendons, which act to hold the upper arm (humerus) to the socket of the shoulder (glenoid fossa). The rotator cuff also provides mobility and strength to the shoulder joint. Two sac-like structures, called bursae, allow smooth gliding between the bone, muscle, and tendon. They also cushion and protect the rotator-cuff structures from the upper part of the scapula (the acromion).

What causes shoulder pain?

normal_shoulder_wAccording to the AAOS about 23,000 people have shoulder replacement surgery each year. This compares to more that 700,000 Americans a year who have knee and hip replacement surgery*. Shoulder problems may arise because of injury to the soft tissues of the shoulder, overuse or underuse of the shoulder, or even because of damage to the tissues.

Shoulder problems result in pain, which may be localized to the joint or travel to areas around the shoulder or down the arm. Damage to the shoulder joint may result in instability of the joint, and pain is often felt when raising the arm or when soft tissues are trapped between the bones (impingement). Impingement is particularly common in sports activities that involve repetitive overhead arm motions, such as pitching baseballs.

You may have a shoulder injury if:

Another common cause of shoulder pain is arthritis. The most common type of arthritis is osteoarthritis (OA) — sometimes called degenerative arthritis because it is a “wearing out” condition involving the breakdown of cartilage in the joints. OA can occur without a shoulder injury, but this seldom happens since the shoulder is not a weight-bearing joint like the knee or hip. Instead, shoulder OA commonly occurs many years following a shoulder injury, such as a dislocation, that has led to joint instability and damage, allowing OA to develop.

Your Treatment Options for Shoulder Pain

arthritic_shoulder_wFollowing an orthopaedic evaluation of your shoulder, your doctor will review and discuss the results with you. Based on his or her diagnosis, your treatment options may include:

When joint pain and stiffness become severe enough to affect your daily life and comfort, and when that pain is not relieved by other treatment options, shoulder replacement may be recommended.

*AAOS.org — January 2006.

About Shoulder Replacement

Replacement of an arthritic or injured shoulder is less common than knee or hip replacement. However, shoulder replacement typically offers all the same benefits as those procedures — including joint pain relief and the restoration of more normal joint movement.

Restoring your movement is particularly important in the shoulder, because it’s the mechanism that allows your arm to rotate in every direction. If you’re experiencing severe shoulder pain and reduced shoulder movement, there are probably many daily activities you can no longer do — or do as comfortably — as before your shoulder problems began. This may mean you’re ready to consider shoulder replacement surgery.

In shoulder replacement surgery, the artificial shoulder joint can have either two or three parts, depending on the type of surgery required.

There are two types of shoulder replacement procedures:

  1. Partial shoulder replacement is performed when the glenoid socket is intact and does not need to be replaced. In this procedure, the humeral component is implanted, and the humeral head is replaced.
  2. Total shoulder replacement is performed when the glenoid socket is damaged and needs to be replaced. All three shoulder joint components are used in this procedure.
What’s involved in shoulder surgery?

Certain parts of your shoulder joint are removed and replaced with a plastic or metal device called a prosthesis, or artificial joint. The artificial shoulder joint can have either two or three parts, depending on the type of surgery required.

Slipped capital femoral epiphysis (SCFE) is a hip condition that occurs in teens and pre-teens who are still growing. For reasons that are not well understood, the ball at the head of the femur (thighbone) slips off the neck of the bone in a backwards direction. This causes pain, stiffness, and instability in the affected hip. The condition usually develops gradually over time and is more common in boys than girls.

Treatment for SCFE involves surgery to stop the head of the femur from slipping any further. To achieve the best outcome, it is important to be diagnosed as quickly as possible. Without early detection and proper treatment, SCFE can lead to potentially serious complications, including painful arthritis in the hip joint.

Anatomy

The hip is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

Like the other long bones in the body, the femur does not grow from the center outward. Instead, growth occurs at each end of the bone around an area of developing cartilage called the growth plate (physis).

Growth plates are located between the widened part of the shaft of the bone (metaphysis) and the end of the bone (epiphysis). The epiphysis at the upper end of the femur is the growth center that eventually becomes the femoral head.

slipped-capital-img1

 

(Left) Normal anatomy of the hip. (Right) The location of the growth plates and epiphyses at the ends of the femur (thighbone). The epiphysis at the upper end of the bone eventually becomes the femoral head.

Description

SCFE is the most common hip disorder in adolescents. In SCFE, the epiphysis, or head of the femur (thighbone), slips down and backwards off the neck of the bone at the growth plate, the weaker area of bone that has not yet developed.

slipped-capital-img2

 

An illustration of SCFE. The femoral head has shifted slightly downward off the neck of the bone through the growth plate (arrow).
Courtesy of John Killian, MD, Birmingham, AL

SCFE usually develops during periods of rapid growth, shortly after the onset of puberty. In boys, this most commonly occurs between the ages of 12 and 16; in girls, between the ages of 10 and 14.

Sometimes SCFE occurs suddenly after a minor fall or trauma. More often, however, the condition develops gradually over several weeks or months, with no previous injury.

SCFE is often described based on whether the patient is able to bear weight on the affected hip. Knowing the type of SCFE will help your doctor determine treatment.

Types of SCFE include:

SCFE usually occurs on only one side; however, in up to 40 percent of patients (particularly those younger than age 10) SCFE will occur on the opposite side, as well—usually within 18 months.

Cause

The cause of SCFE is not known. The condition is more likely to occur during a growth spurt and is more common in boys than girls.

Risk factors that make someone more likely to develop the condition include:

Symptoms

slipped-capital-img3

 

An 11-year-old boy with unstable SCFE. His affected leg is turned outward and is shorter than the other leg.
Reproduced from Weber MD, Naujoks R, Smith BG: Slipped capital femoral epiphysis. Orthopaedic Knowledge Online Journal 2008; 6(2). Accessed June 2016.

Symptoms of SCFE vary, depending upon the severity of the condition.

A patient with mild or stable SCFE will usually have intermittent pain in the groin, hip, knee and/or thigh for several weeks or months. This pain usually worsens with activity. The patient may walk or run with a limp after a period of activity.

In more severe or unstable SCFE, symptoms may include:

Doctor Examination

Physical Examination
slipped-capital-img4

 

Your doctor will check range of motion in the affected hip.
Reproduced from Weber MD, Naujoks R, Smith BG: Slipped capital femoral epiphysis. Orthopaedic Knowledge Online Journal 2008; 6(2). Accessed June 2016.

During the examination, your doctor will ask about your child’s general health and medical history. He or she will then talk with you about your child’s symptoms and ask when the symptoms began.

While your child is lying down, the doctor will perform a careful examination of the affected hip and leg, looking for:

  • Pain with extremes of motion
  • Limited range of motion in the hip–especially limited internal rotation
  • Involuntary muscle guarding and muscle spasms

Your doctor will also observe your child’s gait (the way he or she walks). A child with SCFE may limp or have an abnormal gait.

X-rays

This type of study provides images of dense structures, such as bone. Your doctor will order x-rays of the pelvis, hip, and thigh from several different angles to help confirm the diagnosis.

In a patient with SCFE, an x-ray will show that the head of the thighbone appears to be slipping off the neck of the bone.

slipped-capital-img5

 

X-ray of a 12-year-old boy with stable SCFE in his left hip (arrow).
Reproduced from Weber MD, Naujoks R, Smith BG: Slipped capital femoral epiphysis. Orthopaedic Knowledge Online Journal 2008; 6(2). Accessed June 2016.

Treatment

The goal of treatment is to prevent the mildly displaced femoral head from slipping any further. This is always accomplished through surgery.

Early diagnosis of SCFE provides the best chance of stabilizing the hip and avoiding complications. When treated early and appropriately, long-term hip function can be expected to be very good.

Once SCFE is confirmed, your child will not be allowed to bear weight on his or her hip and will probably be admitted to the hospital. In most cases, surgery is performed within 24 to 48 hours.

Procedures

The surgical procedure your doctor recommends will depend upon the severity of the slip. Procedures used to treat SCFE include:

In situ fixation. This is the procedure used most often for patients with stable or mild SCFE. The doctor makes a small incision near the hip, then inserts a metal screw across the growth plate to maintain the position of the femoral head and prevent any further slippage.

Over time, the growth plate will close, or fuse. Once the growth plate is closed, no further slippage can occur.

slipped-capital-img6

 

Illustration and x-ray of in situ fixation. A single screw is inserted to prevent any further slip of the femoral head through the growth plate.
(Left) Courtesy of John Killian, MD, Birmingham, AL. (Right) Reproduced from Weber MD, Naujoks R, Smith BG: Slipped capital femoral epiphysis. Orthopaedic Knowledge Online Journal 2008; 6(2). Accessed June 2016.

Open reduction. In patients with unstable SCFE, the doctor may first make an open incision in the hip, then gently manipulate (reduce) the head of the femur back into its normal anatomic position.

The doctor will then insert one or two metal screws to hold the bone in place until the growth plate closes. This is a more extensive procedure and requires a longer recovery time.

slipped-capital-img7

 

(Left) X-ray of a 12-year-old boy with unstable SCFE (arrow). (Right) The femoral head has been manipulated (reduced) back into place and two screws have been inserted to hold it in place.
Reproduced from Weber MD, Naujoks R, Smith B: Slipped capital femoral epiphysis. Orthopaedic Knowledge Online Journal 2008; 6(2). Accessed June 2016.

In situ fixation in the opposite hip. Some patients are at higher risk for SCFE occurring on the opposite side. If this is the case with your child, your doctor may recommend inserting a screw into his or her unaffected hip at the same time to reduce the risk of SCFE. Your doctor will talk with you about whether this is appropriate for your child.

slipped-capital-img8

 

In this x-ray, two screws have been inserted in the patient’s right hip to stop progression of a slip. A single screw has been inserted in the left hip to prevent SCFE from developing.
Reproduced from Woiczik MR, Pizzutillo PD, Gross RH, Carroll KL: Musculoskeletal effects of Down Syndrome. Orthopaedic Knowledge Online Journal 2012; 10(10). Accessed June 2016.

Complications

Although early detection and proper treatment of SCFE will help decrease the chance of complications, some patients will still experience problems.

The most common complications following SCFE are avascular necrosis and chondrolysis.

Avascular Necrosis

If severe cases, SCFE causes the blood supply to the femoral head to become limited. This can lead to a gradual and very painful collapse of the bone—a condition called avascular necrosis (AVN) or osteonecrosis.

When the bone collapses, the articular cartilage covering the bone also collapses. Without this smooth cartilage, bone rubs against bone, leading to painful arthritis in the joint. For some patients with AVN, further surgery may be needed to reconstruct the hip.

AVN is more likely to occur in patients with unstable SCFE. Because evidence of AVN may not be seen on x-ray for up to 12 months following surgery, the patient will be monitored with x-rays during this period of time.

Chondrolysis

Chondrolysis is a rare but serious complication of SCFE. In chondrolysis, the articular cartilage on the surface of the hip joint degenerates very rapidly, leading to pain, deformity, and permanent loss of motion in the affected hip.

Although the cause of the condition is not yet fully understood by doctors, it is believed that it may result from inflammation in the hip joint.

Aggressive physical therapy and anti-inflammatory medications may be prescribed for patients who develop chondrolysis. Over time, there may be some gradual return of motion in the hip.

Recovery

Weight Bearing

After surgery, your child will be on crutches for several weeks. The doctor will give you specific instructions about when full weight bearing can begin. To prevent further injury, it is important to closely follow your doctor’s instructions.

Physical Therapy

A physical therapist will provide specific exercises to help strengthen the hip and leg muscles and improve range of motion.

Sports and Other Activities

For a period of time after surgery, your child will be restricted from participating in vigorous sports and activities. This will help minimize the chance of complications and enable healing to take place. Your doctor will tell you when your child can safely resume his or her normal activities.

Follow-Up Care

Your child will return to the doctor for follow-up visits for 18 to 24 months after surgery. These visits may include x-rays every 3 to 4 months to ensure that the growth plate has closed and that no complications have developed.

Depending upon the patient’s age and other factors, a team approach that includes a general pediatrician, endocrinologist, and/or dietician may be necessary for comprehensive care in the long run.

For More Information

If you found this article helpful, you may also be interested in The Impact of Childhood Obesity on Bone, Joint, and Muscle Health.

Last reviewed: June 2016
posna-logo
Reviewed by members of the Pediatric Orthopaedic Society of North America

The Pediatric Orthopaedic Society of North America (POSNA) is a group of board eligible/board certified orthopaedic surgeons who have specialized training in the care of children’s musculoskeletal health. One of our goals is to continue to be the authoritative source for patients and families on children’s orthopaedic conditions. Our Public Education and Media Relations Committee works with the AAOS to develop, review, and update the pediatric topics within OrthoInfo, so we ensure that patients, families and other healthcare professionals have the latest information and practice guidelines at the click of a link.
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Knee Anatomy and Function

Understanding How the Knee Works

normal_knee_w

A joint is formed by two or more bones that are connected by thick bands of tissue called ligaments. The knee is the largest joint in the body and is made up of three main parts:

The thigh bone (femur) turns on the upper end of the shin bone (tibia), and the kneecap (patella) slides in a groove on the end of the thigh bone. Ligaments, which are bands of tissue, connect the thigh bone and the shin bone to help keep the knee joint steady. The quadriceps, the long muscles on the front of the thigh, help strengthen the knee.

 

 

total_knee_arthritic_w

A smooth substance called articular cartilagecovers the surface of the bones where they touch each other within the joint. This articular cartilage acts as a cushion between the bones. The rest of the surfaces of the knee joint are covered by a thin, smooth tissue liner called synovial membrane, which makes a small amount of fluid that acts as a lubricant so that the joint bones will not rub against each other.

 

 

 

 

What Causes Knee Pain?

normal_knee_wOne of the most common causes of knee pain and loss of mobility is the wearing away of the joint’s cartilage lining. When this happens, the bones rub against each other, causing significant pain and swelling. The most common cause is a condition known as osteoarthritis. Trauma or direct injury to the knee can also cause osteoarthritis. Without cartilage there is no shock absorption between the bones in the joint, which allows stress to build up in the bones and contributes to pain.

 

 

 

 

Your Treatment Options for Knee Pain

You may be able to get pain relief from treatments like steroidal and nonsteroidal anti-inflammatory drugs, physical therapy, bracing, and cortisone injections. But, if you’ve tried these methods and haven’t experienced adequate relief, you don’t have to live with severe knee pain and the limitations it puts on your activities.

Knee replacement surgery may provide the pain relief you long for and enable you to return to the things you enjoy doing. Remember, even if your doctor recommends knee replacement for you, it is still up to you to make the final decision. The ultimate goal is for you to be as comfortable as possible with your choice — and that always means making the best decision based on your own individual needs.

If you do choose surgery, you’ll be in good company: More than a quarter-million Americans have knee replacement surgery every year.1 First performed in 1968, the procedure typically relieves pain and restores joint function.

Hip fractures are breaks in the thighbone (femur) just below the hip joint. They are serious injuries that most often occur in people aged 65 and older.

Women are especially vulnerable to hip fractures. According to 2010 data from the National Hospital Discharge Survey, approximately 70% of hip fractures occur in women.

Hip fractures can limit mobility and independence. Most hip fractures require surgery, hospitalization, and extended rehabilitation.

Most people who previously lived independently before hip fracture require assistance afterward. This can range from help from family members and home health professionals, to admittance to a nursing home or other long-term health facility.

preventing-hip-fracture-img
Hip fractures occur in the upper section of the femur (thighbone). The x-ray image on the right shows a hip fracture.

Cause

Most hip fractures are caused by factors that weaken bone, combined with the impact from a fall.

Bone Strength

Bone strength decreases as we age. Bones can become very weak and fragile — a condition called osteoporosis. Osteoporosis often develops in women after menopause, and in men in older age. This bone-thinning disorder puts people at greater risk for broken bones, particularly fractures of the hip, wrist, and spine.

Risk Factors

Many of the factors that put you at greater risk for a hip fracture are those that cause bone loss.

  • Age. The risk for hip fractures increases as we age. In 2010, more than 80% of the people hospitalized for hip fractures were age 65 and older, according to the National Hospital Discharge Survey (NHDS).
  • Gender. In 2010, 72% of hip fractures in people aged 65 and older occurred in women (NHDS).
  • Heredity. A family history of osteoporosis or broken bones in later life puts you at greater risk for a hip fracture. People with small, thin builds are also at risk.
  • Nutrition. Low body weight and poor nutrition, including a diet low in calcium and Vitamin D, can make you more prone to bone loss and hip fracture.
  • Lifestyle. Smoking, excessive alcohol use, and lack of exercise can weaken bones.

In addition to factors that affect bone strength, things that put you at greater risk for falling can increase the possibility of hip fracture.

  • Physical and mental impairments. Physical frailty, arthritis, unsteady balance, poor eyesight, senility, dementia and/or Alzheimer’s disease can increase the likelihood of falling.
  • Medications. Many medicines can affect balance and strength. Side effects of some medications can also include drowsiness and dizziness.

Preventing Hip Fractures

Home Safety

Most hip fractures occur as a result of a fall, and most falls occur in the home. Many falls can be prevented by simple home safety improvements, such as removing clutter, providing enough lighting, and installing grab bars in bathrooms.

For more comprehensive information on preventing falls: Guidelines for Preventing Falls

Exercise

Moderate exercise can slow bone loss and maintain muscle strength. It can also improve balance and coordination. Good exercise options include climbing stairs, jogging, hiking, swimming, dancing, and weight training.

Balance training and tai chi have been shown to decrease falls and reduce the risk of hip fracture. Tai chi is a program of exercises, breathing, and movements based on ancient Chinese practices. These classes can also increase self-confidence and improve body balance.

Be sure to talk to your doctor if you are just beginning an exercise program.

Understand Your Health and Medications

Each year, be sure to have an eye examination, as well as a physical that includes an evaluation for cardiac and blood pressure problems. Talk with your doctor about the side effects of any medications and over-the-counter drugs you take. It is helpful to keep an up-to-date list of all medications you take so that you can provide it to any other doctors with whom you consult.

Maintain Your Bone Health As You Age

As we age, our bones are affected by genetics, nutrition, exercise, and hormonal loss. We cannot change our genes, but we can control our nutrition and activity level, and if necessary, take osteoporosis medications.

There are things you can do to maintain and even improve your bone strength.

  • Understand your individual risk for fracture. This is based on any risk factors you have for fracture and your bone density. Ask your doctor if you need a bone density test.
  • Understand your individual risk for bone loss. Genetics plays a role in bone health, and some people have genetically determined high rates of bone turnover after menopause or with aging. Talk to your doctor about bone metabolism testing. Bone metabolism testing can provide additional information about your risk for fracture.
  • Make healthy lifestyle choices. Maintain a healthy weight and eat a diet rich in calcium and Vitamin D. Do not smoke and limit your alcohol intake.
  • Consider bone-boosting medications. In addition to calcium and Vitamin D supplements, there are many drug options that slow bone loss and increase bone strength. Talk to your doctor about these methods for protecting your bones.

For More Information

Learn more about bone health and osteoporosis prevention: Bone Health Basics.

In order to assist doctors in the management of hip fractures in the elderly, the American Academy of Orthopaedic Surgeons has done research to provide some useful guidelines. These are recommendations only and may not apply to each and every individual case. For more information: AAOS Clinical Practice Guideline: Management of Hip Fractures in the Elderly.

Source: National Hospital Discharge Survey, National Center for Health Statistics. As reported by the Centers for Disease Control and Prevention, http://www.cdc.gov/homeandrecreationalsafety/falls/adulthipfx.html. Accessed December 2012.

Last reviewed: January 2013
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood supply to the rounded head of the femur (thighbone) is temporarily disrupted. Without an adequate blood supply, the bone cells die, a process called avascular necrosis.

Although the term “disease” is still used, Perthes is really a complex process of stages that can last several years. As the condition progresses, the weakened bone of the head of the femur (the “ball” of the “ball-and-socket” joint of the hip) gradually begins to break apart. Over time, the blood supply to the head of the femur returns and the bone begins to grow back.

Treatment for Perthes focuses on helping the bone grow back into a more rounded shape that still fits into the socket of the hip joint. This will help the hip joint move normally and prevent hip problems in adulthood.

The long-term prognosis for children with Perthes is good in most cases. After 18 months to 2 years of treatment, most children return to daily activities without major limitations.

perthes-img1
The hip is a “ball-and-socket” joint. The rounded head of the femur easily fits into the cup-shaped acetabulum to allow for a wide range of motion.

Description

Perthes disease — also known as Legg-Calve-Perthes, named for the three individual doctors who first described the condition — typically occurs in children who are between 4 and 10 years old. It is five times more common in boys than in girls, however, it is more likely to cause extensive damage to the bone in girls. In 10% to 15% of all cases, both hips are affected.

perthes-img2
In the first stage of Perthes disease, the bone in the head of the femur slowly dies.

There are four stages in Perthes disease:

Cause

The cause of Perthes disease is not known. Some recent studies indicate that there may be a genetic link to the development of Perthes, but more research needs to be conducted.

Symptoms

One of the earliest signs of Perthes is a change in the way your child walks and runs. This is often most apparent during sports activities. Your child may limp, have limited motion, or develop a peculiar running style. Other common symptoms include:

Depending upon your child’s activity level, symptoms may come and go over a period of weeks or even months before a doctor visit is considered.

Doctor Examination

After discussing your child’s symptoms and medical history, your doctor will conduct a thorough physical examination.

perthes-img3
In this x-ray, Perthes disease has progressed to a collapse of the femoral head (arrow). The other side is normal.
Courtesy of Texas Scottish Rite Hospital for Children

A child with Perthes can expect to have several x-rays taken over the course of treatment, which may be 2 years or longer. As the condition progresses, x-rays often look worse before gradual improvement is seen.

Treatment

The goal of treatment is to relieve painful symptoms, protect the shape of the femoral head, and restore normal hip movement. If left untreated, the femoral head can deform and not fit well within the acetabulum, which can lead to further hip problems in adulthood, such as early onset of arthritis.

There are many treatment options for Perthes disease. Your doctor will consider several factors when developing a treatment plan for your child, including:

Nonsurgical Treatment

Observation. For very young children (those 2 to 6 years old) who show few changes in the femoral head on their initial x-rays, the recommended treatment is usually simple observation. Your doctor will regularly monitor your child using x-rays to make sure the regrowth of the femoral head is on track as the disease runs its course.

Anti-inflammatory medications. Painful symptoms are caused by inflammation of the hip joint. Anti-inflammatory medicines, such as ibuprofen, are used to reduce inflammation, and your doctor may recommend them for several months. As your child progresses through the disease stages, your doctor will adjust or discontinue dosages.

Limiting activity. Avoiding high impact activities, such as running and jumping, will help relieve pain and protect the femoral head. Your doctor may also recommend crutches or a walker to prevent your child from putting too much weight on the joint.

Physical therapy exercises. Hip stiffness is common in children with Perthes disease and physical therapy exercises are recommended to help restore hip joint range of motion. These exercises often focus on hip abduction and internal rotation. Parents or other caregivers are often needed to help the child complete the exercises.

  • Hip abduction. The child lies on his or her back, keeping knees bent and feet flat. He or she will push the knees out and then squeeze the knees together. Parents should place their hands on the child’s knees to assist with reaching a greater range of motion.
  • Hip rotation. With the child on his or her back and legs extended out straight, parents should roll the entire leg inward and outward.
perthes-img4
Petrie casts keep the legs spread far apart in an effort to maintain the hips in the best position for healing.
Courtesy of Texas Scottish Rite Hospital for Children

Casting and bracing. If range of motion becomes limited or if x-rays or other image scans indicate that a deformity is developing, a cast or brace may be used to keep the head of the femur in its normal position within the acetabulum.

Petrie casts are two long-leg casts with a bar that hold the legs spread apart in a position similar to the letter “A.” Your doctor will most likely apply the initial Petrie cast in an operating room in order to have access to specific equipment.

  • Arthrogram. During the procedure, your doctor will take a series of special x-ray images called arthrograms to see the degree of deformity of the femoral head and to make sure he or she positions the head accurately. In an arthrogram, a small amount of dye is injected into the hip joint to make the anatomy even easier to see.
  • Tenotomy. In some cases, the adductor longus muscle in the groin is very tight and prevents the hip from rotating into the proper position. Your doctor will perform a minor procedure to release this tightness — called a tenotomy — before applying the Petrie casts. During this quick procedure, your doctor uses a thin instrument to make a small incision in the muscle.

After the cast is removed, usually after 4 to 6 weeks, physical therapy exercises are resumed. Your doctor may recommend continued intermittent casting until the hip enters the final stage of the healing process.

Surgical Treatment

Your doctor may recommend surgery to re-establish the proper alignment of the bones of the hip and to keep the head of the femur deep within the acetabulum until healing is complete. Surgery is most often recommended when:

  • Your child is older than age 8 at the time of diagnosis. Because the potential for deformity during the reossification stage is greater in older children, preventing damage to femoral head is even more critical.
  • More than 50% of the femoral head is damaged. Keeping the femoral head within the rounded acetabulum may help the bone grow into a functional shape.
  • Nonsurgical treatment has not kept the hip in correct position for healing.

The most common surgical procedure for treating Perthes disease is an osteotomy. In this type of procedure, the bone is cut and repositioned to keep the femoral head snug within the acetabulum. This alignment is kept in place with screws and plates, which will be removed after the healed stage of the disease.

perthes-img5
An osteotomy of the femur places the femoral head in a better position to heal.
Courtesy of Texas Scottish Rite Hospital for Children

In many cases, the femur bone is cut to realign the joint. Sometimes, the socket must also be made deeper because the head of the femur has actually enlarged during the healing process and no longer fits snugly within it. After either procedure, the child is usually placed in a cast for 6 to 8 weeks to protect the alignment.

After the cast is removed, physical therapy will be needed to restore muscle strength and range of motion. Crutches or a walker will be necessary to reduce weightbearing on the affected hip. Your doctor will continue to monitor the hip with x-rays through the final stages of healing.

Outcomes

In most cases, the long-term prognosis for children with Perthes is good and they grow into adulthood without further hip problems.

If there is deformity in the shape of the femoral head, there is more potential for future problems; however, if the deformed head still fits into the acetabulum, problems may be avoided. In cases where the deformed head does not fit well into the acetabulum, hip pain or early onset of arthritis is likely in adulthood.

Last reviewed: May 2015

posna-logo

 

Reviewed by members of the Pediatric Orthopaedic Society of North America

The Pediatric Orthopaedic Society of North America (POSNA) is a group of board eligible/board certified orthopaedic surgeons who have specialized training in the care of children’s musculoskeletal health. One of our goals is to continue to be the authoritative source for patients and families on children’s orthopaedic conditions. Our Public Education and Media Relations Committee works with the AAOS to develop, review, and update the pediatric topics within OrthoInfo, so we ensure that patients, families and other healthcare professionals have the latest information and practice guidelines at the click of a link.
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Arthritis of the Knee

Information on arthritis of the knee is also available in Spanish: Osteoartritis de rodilla.

Arthritis is inflammation of one or more of your joints. Pain, swelling, and stiffness are the primary symptoms of arthritis. Any joint in the body may be affected by the disease, but it is particularly common in the knee.

Knee arthritis can make it hard to do many everyday activities, such as walking or climbing stairs. It is a major cause of lost work time and a serious disability for many people.

The most common types of arthritis are osteoarthritis and rheumatoid arthritis, but there are more than 100 different forms. In 2012, more than 51 million people reported that they had been diagnosed with some form of arthritis, according to the National Health Interview Survey. While arthritis is mainly an adult disease, some forms affect children.

Although there is no cure for arthritis, there are many treatment options available to help manage pain and keep people staying active.

 

Anatomy

A00212F01The knee is the largest and strongest joint in your body. It is made up of the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap). The ends of the three bones where they touch are covered with articular cartilage, a smooth, slippery substance that protects and cushions the bones as you bend and straighten your knee.

Two wedge-shaped pieces of cartilage called meniscus act as “shock absorbers” between your thighbone and shinbone. They are tough and rubbery to help cushion the joint and keep it stable.

The knee joint is surrounded by a thin lining called the synovial membrane. This membrane releases a fluid that lubricates the cartilage and reduces friction.

Description

The major types of arthritis that affect the knee are osteoarthritis, rheumatoid arthritis, and posttraumatic arthritis.

Osteoarthritis

A00389F02TOsteoarthritis is the most common form of arthritis in the knee. It is a degenerative,”wear-and-tear” type of arthritis that occurs most often in people 50 years of age and older, but may occur in younger people, too.

In osteoarthritis, the cartilage in the knee joint gradually wears away. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone, and produce painful bone spurs.

Osteoarthritis develops slowly and the pain it causes worsens over time.

 

 

Rheumatoid Arthritis

Rheumatoid arthritis is a chronic disease that attacks multiple joints throughout the body, including the knee joint. It is symmetrical, meaning that it usually affects the same joint on both sides of the body.

In rheumatoid arthritis the synovial membrane that covers the knee joint begins to swell, This results in knee pain and stiffness.

Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. The immune system damages normal tissue (such as cartilage and ligaments) and softens the bone.

Posttraumatic Arthritis

Posttraumatic arthritis is form of arthritis that develops after an injury to the knee. For example, a broken bone may damage the joint surface and lead to arthritis years after the injury. Meniscal tears and ligament injuries can cause instability and additional wear on the knee joint, which over time can result in arthritis.

 

Doctor Examination

During your appointment, your doctor will talk with you about your symptoms and medical history, conduct a physical examination, and possibly order diagnostic tests, such as x-rays or blood tests.

Physical Examination

During the physical examination, your doctor will look for:

  • Joint swelling, warmth, or redness
  • Tenderness about the knee
  • Range of passive (assisted) and active (self-directed) motion
  • Instability of the joint
  • Crepitus (a grating sensation inside the joint) with movement
  • Pain when weight is placed on the knee
  • Problems with your gait (the way you walk)
  • Any signs of injury to the muscles, tendons, and ligaments surrounding the knee
  • Involvement of other joints (an indication of rheumatoid arthritis)
Imaging Tests
  • X-rays. These imaging tests create detailed pictures of dense structures, like bone. They can help distinguish among various forms of arthritis. X-rays of an arthritic knee may show a narrowing of the joint space, changes in the bone and the formation of bone spurs (osteophytes).
  • Other tests. Occasionally, a magnetic resonance imaging (MRI) scan, a computed tomography (CT) scan, or a bone scan may be needed to determine the condition of the bone and soft tissues of your knee.

A00212F02

Laboratory Tests

Your doctor may also recommend blood tests to determine which type of arthritis you have. With some types of arthritis, including rheumatoid arthritis, blood tests will help with a proper diagnosis.

 

Treatment

There is no cure for arthritis but there are a number of treatments that may help relieve the pain and disability it can cause.

Nonsurgical Treatment

As with other arthritic conditions, initial treatment of arthritis of the knee is nonsurgical. Your doctor may recommend a range of treatment options.

Lifestyle modifications. Some changes in your daily life can protect your knee joint and slow the progress of arthritis.

  • Minimize activities that aggravate the condition, such as climbing stairs.
  • Switching from high impact activities (like jogging or tennis) to lower impact activities (like swimming or cycling) will put less stress on your knee.
  • Losing weight can reduce stress on the knee joint, resulting in less pain and increased function.

Physical therapy. Specific exercises can help increase range of motion and flexibility, as well as help strengthen the muscles in your leg. Your doctor or a physical therapist can help develop an individualized exercise program that meets your needs and lifestyle.

Assistive devices. Using devices such as a cane, wearing shock-absorbing shoes or inserts, or wearing a brace or knee sleeve can be helpful. A brace assists with stability and function, and may be especially helpful if the arthritis is centered on one side of the knee. There are two types of braces that are often used for knee arthritis: An “unloader” brace shifts weight away from the affected portion of the knee, while a “support” brace helps support the entire knee load.

Other remedies. Applying heat or ice, using pain-relieving ointments or creams, or wearing elastic bandages to provide support to the knee may provide some relief from pain.

Medications. Several types of drugs are useful in treating arthritis of the knee. Because people respond differently to medications, your doctor will work closely with you to determine the medications and dosages that are safe and effective for you.

    • Over-the-counter, non-narcotic pain relievers and anti-inflammatory medications are usually the first choice of therapy for arthritis of the knee. Acetaminophen is a simple, over-the-counter pain reliever that can be effective in reducing arthritis pain.

Like all medications, over-the-counter pain relievers can cause side effects and interact with other medications you are taking. Be sure to discuss potential side effects with your doctor.

    • Another type of pain reliever is a nonsteroidal anti-inflammatory drug, or NSAID (pronounced “en-said”). NSAIDs, such as ibuprofen and naproxen, are available both over-the-counter and by prescription.
    • A COX-2 inhibitor is a special type of NSAID that may cause fewer gastrointestinal side effects. Common brand names of COX-2 inhibitors include Celebrex (celecoxib) and Mobic (meloxicam, which is a partial COX-2 inhibitor). A COX-2 inhibitor reduces pain and inflammation so that you can function better. If you are taking a COX-2 inhibitor, you should not use a traditional NSAID (prescription or over-the-counter). Be sure to tell your doctor if you have had a heart attack, stroke, angina, blood clot, hypertension, or if you are sensitive to aspirin, sulfa drugs or other NSAIDs.
    • Corticosteroids (also known as cortisone) are powerful anti-inflammatory agents that can be injected into the joint These injections provide pain relief and reduce inflammation; however, the effects do not last indefinitely. Your doctor may recommend limiting the number of injections to three or four per year, per joint, due to possible side effects.

In some cases, pain and swelling may “flare” immediately after the injection, and the potential exists for long-term joint damage or infection. With frequent repeated injections, or injections over an extended period of time, joint damage can actually increase rather than decrease.

    • Disease-modifying anti-rheumatic drugs (DMARDs) are used to slow the progression of rheumatoid arthritis. Drugs like methotrexate, sulfasalazine, and hydroxychloroquine are commonly prescribed.

In addition, biologic DMARDs like etanercept (Embril) and adalimumab (Humira) may reduce the body’s overactive immune response. Because there are many different drugs today for rheumatoid arthritis, a rheumatology specialist is often required to effectively manage medications.

    • Viscosupplementation involves injecting substances into the joint to improve the quality of the joint fluid. For more information: Viscosupplementation Treatment for Arthritis
    • Glucosamine and chondroitin sulfate, substances found naturally in joint cartilage, can be taken as dietary supplements. Although patient reports indicate that these supplements may relieve pain, there is no evidence to support the use of glucosamine and chondroitin sulfate to decrease or reverse the progression of arthritis.

In addition, the U.S. Food and Drug Administration does not test dietary supplements before they are sold to consumers. These compounds may cause side effects, as well as negative interactions with other medications. Always consult your doctor before taking dietary supplements.

Alternative therapies. Many alternative forms of therapy are unproven, but may be helpful to try, provided you find a qualified practitioner and keep your doctor informed of your decision. Alternative therapies to treat pain include the use of acupuncture and magnetic pulse therapy.

Acupuncture uses fine needles to stimulate specific body areas to relieve pain or temporarily numb an area. Although it is used in many parts of the world and evidence suggests that it can help ease the pain of arthritis, there are few scientific studies of its effectiveness. Be sure your acupuncturist is certified, and do not hesitate to ask about his or her sterilization practices.

Magnetic pulse therapy is painless and works by applying a pulsed signal to the knee, which is placed in an electromagnetic field. Like many alternative therapies, magnetic pulse therapy has yet to be proven.

 

Surgical Treatment

Your doctor may recommend surgery if your pain from arthritis causes disability and is not relieved with nonsurgical treatment. As with all surgeries, there are some risks and possible complications with different knee procedures. Your doctor will discuss the possible complications with you before your operation.

Arthroscopy. During arthroscopy, doctors use small incisions and thin instruments to diagnose and treat joint problems.

Arthroscopic surgery is not often used to treat arthritis of the knee. In cases where osteoarthritis is accompanied by a degenerative meniscal tear, arthroscopic surgery may be recommended to treat the torn meniscus.

Cartilage grafting. Normal, healthy cartilage tissue may be taken from another part of the knee or from a tissue bank to fill a hole in the articular cartilage. This procedure is typically considered only for younger patients who have small areas of cartilage damage.

Synovectomy. The joint lining damaged by rheumatoid arthritis is removed to reduce pain and swelling.

A00212F03

Osteotomy. In a knee osteotomy, either the tibia (shinbone) or femur (thighbone) is cut and then reshaped to relieve pressure on the knee joint. Knee osteotomy is used when you have early-stage osteoarthritis that has damaged just one side of the knee joint. By shifting your weight off the damaged side of the joint, an osteotomy can relieve pain and significantly improve function in your arthritic knee.

Total or partial knee replacement (arthroplasty). Your doctor will remove the damaged cartilage and bone, and then position new metal or plastic joint surfaces to restore the function of your knee.

 

Recovery

After any type of surgery for arthritis of the knee, there is a period of recovery. Recovery time and rehabilitation depends on the type of surgery performed.

Your doctor may recommend physical therapy to help you regain strength in your knee and to restore range of motion. Depending upon your procedure, you may need to wear a knee brace, or use crutches or a cane for a time.

In most cases, surgery relieves pain and makes it possible to perform daily activities more easily.

Source: Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL: AAOS; April 2014. Based on data from the National Health Interview Survey, 2012; U.S. Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Health Statistics.

Thighbone (Femur) Fractures In Children

The thighbone (femur) is the largest and strongest bone in the body. It can break when a child experiences a sudden forceful impact.

Cause

Statistics

The most common cause of thighbone fractures in infants under 1 year old is child abuse. Child abuse is also a leading cause of thighbone fracture in children between the ages of 1 and 4 years, but the incidence is much less in this age group.

In adolescents, motor vehicle accidents (either in cars, bicycles, or as a pedestrian) are responsible for the vast majority of femoral shaft fractures.

Risk

Events with the highest risk for pediatric femur fractures include:

  • Falling hard on the playground
  • Taking a hit in contact sports
  • Being in a motor vehicle accident
  • Child abuse

Types of Femur Fractures (Classification)

Femur fractures vary greatly. The pieces of bone may be aligned correctly (straight) or out of alignment (displaced), and the fracture may be closed (skin intact) or open (bone piercing through the skin). An open fracture is rare.

thighbone-femur-img1
Types of femur fractures. (Left) An oblique, displaced fracture of the femur shaft. (Right) A comminuted fracture of the femur shaft.

Specifically, thighbone fractures are classified depending on:

Symptoms

A thighbone fracture is a serious injury. It may be obvious that the thighbone is fractured because:

Take your child to the emergency room right away if you think he or she has a broken thighbone.

Doctor Examination

It is important that the doctor know exactly how the injury occurred. Tell the doctor if your child had any disease or other trauma before it happened.

The doctor will give your child pain relief medication and carefully examine the leg, including the hip and knee. A child with a thighbone fracture should always be evaluated for other serious injuries.

Imaging Tests

Your orthopaedic doctor will need x-rays to see what the broken bone looks like (refer to “Classification”). Your child’s healthy leg may also be x-rayed for comparison.

The orthopaedic doctor will also check the x-ray for any damage to the growth area (growth plate) near the end of the femur. This is the part that enables the child’s bone to grow. If needed, surgery may help to restore the growth plate’s function, and regular x-rays may be taken for many months to track the bone’s growth.

Treatment

To treat a child’s thighbone fracture, the pieces of bone are realigned and held in place for healing. Treatment depends on many factors, such as your child’s age and weight, the type of fracture, how the injury happened, and whether the broken bone pierced the skin.

Nonsurgical Treatment
thighbone-femur-img2
A young child in a hip spica cast to immobilize a femoral shaft fracture.
Courtesy of Texas Scottish Rite Hospital

In some thighbone fractures, the doctor may be able to manipulate the broken bones back into place without an operation (closed reduction). In a baby under 6 months old, a brace (called a Pavlik Harness) may be able to hold the broken bone still enough for successful healing.

Spica casting. In children between 7 months and 5 years old, a spica cast is often applied to keep the fractured pieces in correct position until the bone is healed.

There are different types of spica casts, but, in general, a spica cast begins at the chest and extends all the way down the fractured leg. The cast may also extend down the uninjured leg, or stop at the knee or hip. Your doctor will decide which type of spica cast is most effective for treating your child’s fracture.

Your doctor will sedate your child for the closed reduction, and apply a spica cast immediately (or within 24 hours of hospitalization) to keep the fractured pieces in correct position until healing occurs.

Leg with femur fracture Referenced from: Basic anatomical knowledge from WWW: http://www.anatomyatlases.org/firstaid/images/spiralfracture2.jpg
A thighbone fracture before and immediately after treatment with a spica cast. The femur will remodel over time so that it appears normal.

When a bone breaks and is displaced, the pieces often overlap and shorten the normal length of the bone. Because children’s bones grow quickly, your doctor may not need to manipulate the pieces back into perfect alignment. While in the cast, the bones will grow and heal back into a more normal shape.

In general, for the best results, the broken pieces should not overlap more than 2 cm when in the cast. The growth of the thighbone may be temporarily increased by the trauma. The mild shortening from the overlap will resolve.

Traction. If the shortening of the bones is too much (more than 3 cm) or if the bone is too crooked in the cast, it may be helpful to put the leg in a weight and counterweight system (traction) to make sure the bones are properly realigned.

Surgical Treatment

Doctors generally agree that displaced femur fractures that have shortened more than 3 cm are not acceptable and require treatment to correct at least a portion of the shortening.

thighbone-femur-img4
Left, Preoperative X-ray of a child with a fracture through the midshaft of the left femur. Right, Postoperative X-ray of the same child shows that the fracture was treated with internal flexible nailing to restore stability and allow early mobilization.

In some more complicated injuries, the doctor may need to surgically realign the bone and use an implant to stabilize the fracture.

Doctors are treating pediatric thighbone fractures more often with surgery than in previous years due to the benefits that have been recognized. These include earlier mobilization, faster rehabilitation, and shorter time spent in the hospital.

In children between 6 and 10 years old, flexible intramedullary (inside the bone) nails are often used to stabilize the fracture. Over the past decade, this treatment method has gained great acceptance.

Occasionally, the broken bone has too many pieces and cannot be treated successfully with flexible nails. Other options that can lead to successful outcomes in this situation include:

  • A plate with screws that “bridges” the fractured segments
  • An external fixator — this is often used if there has been a large open injury to the skin and muscles
  • Prolonged traction with a pin temporarily placed into the thighbone
External fixation is often used to hold the bones together when the skin and muscles have been injured.

As the child nears the teenage years (11 years to skeletal maturity), the most common treatment choices include either flexible intramedullary nails or a rigid locked intramedullary nail. The rigid nail is particularly useful when the fracture is unstable. Both types of nails allow for the child to begin walking immediately.

A rigid, locked intramedullary nail is often used for femur fractures in adolescents who are nearly full grown.

Long-Term Outcomes

Generally, children who sustain a thighbone fracture will heal well, regain normal function, and have legs that are equal in length. The intramedullary nails may need to be removed following healing if they cause irritation of the skin and tissues underneath.

Occasionally, children will require further treatment, either early on or in subsequent years, if they have a significant difference in the length of the legs, unacceptable angulation of the healed bone, abnormal rotation of the healed bone, infection, or (rarely) if a thighbone fracture persists (nonunion).

These problems can nearly always be resolved with further treatment.

For More Information

If you found this article helpful, you may also be interested in Internal Fixation for Fractures.

In order to assist doctors in the treatment of thighbone fractures, the American Academy of Orthopaedic Surgeons has done research to provide some useful guidelines. These are recommendations only and may not apply to each and every individual case. For more information: AAOS Clinical Practice Guideline: Treatment of Pediatric Diaphyseal Femur Fractures

Last reviewed: February 2015
thighbone-posna-logo
Reviewed by members of POSNA (Pediatric Orthopaedic Society of North America)

The Pediatric Orthopaedic Society of North America (POSNA) is a group of board eligible/board certified orthopaedic surgeons who have specialized training in the care of children’s musculoskeletal health. One of our goals is to continue to be the authoritative source for patients and families on children’s orthopaedic conditions. Our Public Education and Media Relations Committee works with the AAOS to develop, review, and update the pediatric topics within OrthoInfo, so we ensure that patients, families and other healthcare professionals have the latest information and practice guidelines at the click of a link.
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

Arthritis of the Hand

The hand and wrist have multiple small joints that work together to produce motion, including the fine motion needed to thread a needle or tie a shoelace. When the joints are affected by arthritis, activities of daily living can be difficult. Arthritis can occur in many areas of the hand and wrist and can have more than one cause.

Over time, if the arthritis is not treated, the bones that make up the joint can lose their normal shape. This causes more pain and further limits motion.

 

Description

Simply defined, arthritis is inflammation of one or more of your joints. The most common types of arthritis are osteoarthritis and rheumatoid arthritis, but there are more than 100 different forms.

Healthy joints move easily because of a smooth, slippery tissue called articular cartilage. Cartilage covers the ends of bones and provides a smooth gliding surface for the joint. This smooth surface is lubricated by a fluid that looks and feels like oil. It is produced by the joint lining called synovium.

Disease

When arthritis occurs due to disease, the onset of symptoms is gradual and the cartilage decreases slowly. The two most common forms of arthritis from disease are osteoarthritis and rheumatoid arthritis.

Osteoarthritis is much more common and generally affects older people. Also known as “wear and tear” arthritis, osteoarthritis causes cartilage to wear away. It appears in a predictable pattern in certain joints.

Rheumatoid arthritis is a chronic disease that can affect many parts of your body. It causes the joint lining (synovium) to swell, which causes pain and stiffness in the joint. Rheumatoid arthritis most often starts in the small joints of the hands and feet. It usually affects the same joints on both sides of the body.

Trauma

Fractures, particularly those that damage the joint surface, and dislocations are among the most common injuries that lead to arthritis. Even when properly treated, an injured joint is more likely to become arthritic over time.

A00224F01

 

 

Symptoms

Pain

Early symptoms of arthritis of the hand include joint pain that may feel “dull,” or a “burning” sensation. The pain often occurs after periods of increased joint use, such as heavy gripping or grasping. The pain may not be present immediately, but may show up hours later or even the following day. Morning pain and stiffness are typical.

As the cartilage wears away and there is less material to provide shock absorption, the symptoms occur more frequently. In advanced disease, the joint pain may wake you up at night.

Pain might be made worse with use and relieved by rest. Many people with arthritis complain of increased joint pain with rainy weather. Activities that once were easy, such as opening a jar or starting the car, become difficult due to pain. To prevent pain at the arthritic joint, you might change the way you use your hand.

Swelling

When the affected joint is subject to greater stress than it can bear, it may swell in an attempt to prevent further joint use.

A00224F04

Changes in Surrounding Joints

In patients with advanced thumb base arthritis, the neighboring joints may become more mobile than normal.

Warmth

The arthritic joint may feel warm to touch. This is due to the body’s inflammatory response.

Crepitation and Looseness

There may be a sensation of grating or grinding in the affected joint (crepitation). This is caused by damaged cartilage surfaces rubbing against one another. If arthritis is due to damaged ligaments, the support structures of the joint may be unstable or “loose.” In advanced cases, the joint may appear larger than normal (hypertrophic). This is usually due to a combination of bone changes, loss of cartilage, and joint swelling.

Cysts

A00224F05When arthritis affects the end joints of the fingers (DIP joints), small cysts (mucous cysts) may develop. The cysts may then cause ridging or dents in the nail plate of the affected finger.

 

 

Doctor Examination

A00224F02A doctor can diagnose arthritis of the hand by examining the hand and by taking x-rays. Specialized studies, such as magnetic resonance imaging (MRI), are usually not needed except in cases where Keinbock’s disease (a condition where the blood supply to one of the small bones in the wrist, the lunate, is interrupted) is suspected. Sometimes a bone scan is helpful. A bone scan may help the doctor diagnose arthritis when it is in an early stage, even if x-rays look normal.

 

 

 

Treatment

Arthritis does not have to result in a painful or sedentary life. It is important to seek help early so that treatment can begin and you can return to doing what matters most to you.

Nonsurgical Treatment

Treatment options for arthritis of the hand and wrist include medication, splinting, injections, and surgery, and are determined based on:

  • How far the arthritis has progressed
  • How many joints are involved
  • Your age, activity level and other medical conditions
  • If the dominant or non-dominant hand is affected
  • Your personal goals, home support structure, and ability to understand the treatment and comply with a therapy program
Medications

Medications treat symptoms but cannot restore joint cartilage or reverse joint damage. The most common medications for arthritis are anti-inflammatories, which stop the body from producing chemicals that cause joint swelling and pain. Examples of anti-inflammatory drugs include medications such as acetaminophen and ibuprofen.

Glucosamine and chondroitin are widely advertised dietary supplements or “neutraceuticals.” Neutraceuticals are not drugs. Rather, they are compounds that are the “building blocks” of cartilage. They were originally used by veterinarians to treat arthritic hips in dogs. However, neutraceuticals have not yet been studied as a treatment of hand and wrist arthritis. (Note: The U.S. Food and Drug Administration does not test dietary supplements. These compounds may cause negative interactions with other medications. Always consult your doctor before taking dietary supplements.)

Injections

When first-line treatment with anti-inflammatory medication is not appropriate, injections may be used. These typically contain a long-lasting anesthetic and a steroid that can provide pain relief for weeks to months. The injections can be repeated, but only a limited number of times, due to possible side effects, such as lightening of the skin, weakening of the tendons and ligaments and infection.

Splinting

Injections are usually combined with splinting of the affected joint. The splint helps support the affected joint to ease the stress placed on it from frequent use and activities. Splints are typically worn during periods when the joints hurt. They should be small enough to allow functional use of the hand when they are worn. Wearing the splint for too long can lead to muscle deterioration (atrophy). Muscles can assist in stabilizing injured joints, so atrophy should be prevented.

Surgical Treatment

If nonsurgical treatment fails to give relief, surgery is usually discussed. There are many surgical options. The chosen course of surgical treatment should be one that has a reasonable chance of providing long-term pain relief and return to function. It should be tailored to your individual needs.

If there is any way the joint can be preserved or reconstructed, this option is usually chosen.

When the damage has progressed to a point that the surfaces will no longer work, a joint replacement or a fusion (arthrodesis) is performed.

Joint fusions provide pain relief but stop joint motion. The fused joint no longer moves; the damaged joint surfaces are gone, so they cannot cause pain and other symptoms.

The goal of joint replacement is to provide pain relief and restore function. As with hip and knee replacements, there have been significant improvements in joint replacements in the hand and wrist. The replacement joints are made of materials similar to those used in weightbearing joints, such as ceramics or long-wearing metal and plastic parts. The goal is to improve the function and longevity of the replaced joint.

A00224F07 (1)Most of the major joints of hand and wrist can be replaced. A surgeon often needs additional training to perform the surgery. As with any evolving technology, the long-term results of the hand or wrist joint replacements are not yet known. Early results have been promising. Talk with your doctor to find out if these implants are right for you.

After Surgery

After any type of joint reconstruction surgery, there is a period of recovery. Often, you will be referred to a trained hand therapist, who can help you maximize your recovery. You may need to use a postoperative splint or cast for awhile after surgery. This helps protect the hand while it heals.

During this postoperative period, you may need to modify activities to allow the joint reconstruction to heal properly. Typically, pain medication you take by mouth is also used to reduce discomfort. It is important to discuss your pain with your doctor so it can be adequately treated.

Length of recovery time varies widely and depends on the extent of the surgery performed and multiple individual factors. However, people usually can return to most if not all of their desired activities in about three months after most major joint reconstructions.

New Developments

Increasingly, doctors are focusing on how to preserve the damaged joint. This includes getting an earlier diagnosis and repairing joint components before the entire surface becomes damaged.

Arthroscopy of the small joints of the hand and wrist is now possible because the equipment has been made much smaller.

There have been encouraging results in cartilage repair and replacement in the larger joints such as the knee, and some of these techniques have been applied to the smaller joints of the hand and arm.

In addition, stem cell research may be an option to regenerate damaged joint surfaces.

If you found this article helpful, you may also be interested in Managing Arthritis Pain with Exercise.

Information on hip osteoarthritis is also available in Spanish: Osteoartritis de cadera.

Sometimes called “wear-and-tear” arthritis, osteoarthritis is a common condition that many people develop during middle age or older. In 2011, more than 28 million people in the United States were estimated to have osteoarthritis. It can occur in any joint in the body, but most often develops in weight-bearing joints, such as the hip.

Osteoarthritis of the hip causes pain and stiffness. It can make it hard to do everyday activities like bending over to tie a shoe, rising from a chair, or taking a short walk.

Because osteoarthritis gradually worsens over time, the sooner you start treatment, the more likely it is that you can lessen its impact on your life. Although there is no cure for osteoarthritis, there are many treatment options to help you manage pain and stay active.

Anatomy

The hip is one of the body’s largest joints. It is a “ball-and-socket” joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

The bone surfaces of the ball and socket are covered with articular cartilage, a smooth, slippery substance that protects and cushions the bones and enables them to move easily.

The surface of the joint is covered by a thin lining called the synovium. In a healthy hip, the synovium produces a small amount of fluid that lubricates the cartilage and aids in movement.

osteoarthritis-hip-img1
The anatomy of the hip.

Description

Osteoarthritis is a degenerative type of arthritis that occurs most often in people 50 years of age and older, though it may occur in younger people, too.

In osteoarthritis, the cartilage in the hip joint gradually wears away over time. As the cartilage wears away, it becomes frayed and rough, and the protective joint space between the bones decreases. This can result in bone rubbing on bone. To make up for the lost cartilage, the damaged bones may start to grow outward and form bone spurs (osteophytes).

Osteoarthritis develops slowly and the pain it causes worsens over time.

osteoarthritis-hip-img2
A hip damaged by osteoarthritis.

Animation courtesy Visual Health Solutions, Inc.

Cause

Osteoarthritis has no single specific cause, but there are certain factors that may make you more likely to develop the disease, including:

Even if you do not have any of the risk factors listed above, you can still develop osteoarthritis.

Symptoms

The most common symptom of hip osteoarthritis is pain around the hip joint. Usually, the pain develops slowly and worsens over time, although sudden onset is also possible. Pain and stiffness may be worse in the morning, or after sitting or resting for a while. Over time, painful symptoms may occur more frequently, including during rest or at night. Additional symptoms may include:

Doctor Examination

During your appointment, your doctor will talk with you about your symptoms and medical history, conduct a physical examination, and possibly order diagnostic tests, such as x-rays.

Physical Examination

During the physical examination, your doctor will look for:

  • Tenderness about the hip
  • Range of passive (assisted) and active (self-directed) motion
  • Crepitus (a grating sensation inside the joint) with movement
  • Pain when pressure is placed on the hip
  • Problems with your gait (the way you walk)
  • Any signs of injury to the muscles, tendons, and ligaments surrounding the hip

Imaging Tests

X-rays. These imaging tests create detailed pictures of dense structures, like bones. X-rays of an arthritic hip may show a narrowing of the joint space, changes in the bone, and the formation of bone spurs (osteophytes).

osteoarthritis-hip-img3
(Left) In this x-ray of a normal hip, the space between the ball and socket indicates healthy cartilage. (Right) This x-ray of an arthritic hip shows severe loss of joint space and bone spurs.

Other imaging tests. Occasionally, a magnetic resonance imaging (MRI) scan, a computed tomography (CT) scan, or a bone scan may be needed to better determine the condition of the bone and soft tissues of your hip.

Treatment

Although there is no cure for osteoarthritis, there are a number of treatment options that will help relieve pain and improve mobility.

Nonsurgical Treatment

As with other arthritic conditions, early treatment of osteoarthritis of the hip is nonsurgical. Your doctor may recommend a range of treatment options.

Lifestyle modifications. Some changes in your daily life can protect your hip joint and slow the progress of osteoarthritis.

  • Minimizing activities that aggravate the condition, such as climbing stairs.
  • Switching from high-impact activities (like jogging or tennis) to lower impact activities (like swimming or cycling) will put less stress on your hip.
  • Losing weight can reduce stress on the hip joint, resulting in less pain and increased function.

Physical therapy. Specific exercises can help increase range of motion and flexibility, as well as strengthen the muscles in your hip and leg. Your doctor or physical therapist can help develop an individualized exercise program that meets your needs and lifestyle.

Assistive devices. Using walking supports like a cane, crutches, or a walker can improve mobility and independence. Using assistive aids like a long-handled reacher to pick up low-lying things will help you avoid movements that may cause pain.

Medications. If your pain affects your daily routine, or is not relieved by other nonsurgical methods, your doctor may add medication to your treatment plan.

  • Acetaminophen is an over-the-counter pain reliever that can be effective in reducing mild arthritis pain. Like all medications, however, over-the-counter pain relievers can cause side effects and interact with other medications you are taking. Be sure to discuss potential side effects with your doctor.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) may relieve pain and reduce inflammation. Over-the-counter NSAIDs include naproxen and ibuprofen. Other NSAIDs are available by prescription.
  • Corticosteroids (also known as cortisone) are powerful anti-inflammatory agents that can be taken by mouth or injected into the painful joint.
Surgical Treatment

Your doctor may recommend surgery if your pain from arthritis causes disability and is not relieved with nonsurgical treatment.

Osteotomy. Either the head of the thighbone or the socket is cut and realigned to take pressure off of the hip joint. This procedure is used only rarely to treat osteoarthritis of the hip.

Hip resurfacing. In this hip replacement procedure, the damaged bone and cartilage in the acetabulum (hip socket) is removed and replaced with a metal shell. The head of the femur, however, is not removed, but instead capped with a smooth metal covering.

Total hip replacement. Your doctor will remove both the damaged acetabulum and femoral head, and then position new metal, plastic or ceramic joint surfaces to restore the function of your hip.

osteoarthritis-hip-img4
In total hip replacement, both the head of the femur and the socket are replaced with an artificial device.

Animation courtesy Visual Health Solutions, Inc.

Complications. Although complications are possible with any surgery, your doctor will take steps to minimize the risks. The most common complications of surgery include:

  • Infection
  • Excessive bleeding
  • Blood clots
  • Hip dislocation
  • Limb length inequality
  • Damage to blood vessels or arteries

Your doctor will discuss possible complications with you before your surgery.

Recovery

After any type of surgery for osteoarthritis of the hip, there is a period of recovery. Recovery time and rehabilitation depends on the type of surgery performed.

Your doctor may recommend physical therapy to help you regain strength in your hip and to restore range of motion. After your procedure, you may need to use a cane, crutches, or a walker for a time.

In most cases, surgery relieves the pain of osteoarthritis and makes it possible to perform daily activities more easily.

Source: National Estimates: Osteoarthritis. Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL: AAOS; January 2013. Based on Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum 2008;58(1):26-35 and U.S. Census Bureau, Population Division, 2011.

Last reviewed: July 2014
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.

A muscle strain (muscle pull or tear) is a common injury, particularly among people who participate in sports.

The thigh has three sets of strong muscles: the hamstring muscles in the back of the thigh, the quadriceps muscles in the front, and the adductor muscles on the inside. The quadriceps muscles and hamstring muscles work together to straighten (extend) and bend (flex) the leg. The adductor muscles pull the legs together.

The hamstring and quadriceps muscle groups are particularly at risk for muscle strains because they cross both the hip and knee joints. They are also used for high-speed activities, such as track and field events (running, hurdles, long jump), football, basketball, and soccer.

muscle-strain-img1
Hamstring muscles at the back of the thigh.
muscle-strain-img2
Quadriceps muscles at the front of the thigh.

Muscle strains usually happen when a muscle is stretched beyond its limit, tearing the muscle fibers. They frequently occur near the point where the muscle joins the tough, fibrous connective tissue of the tendon. A similar injury occurs if there is a direct blow to the muscle. Muscle strains in the thigh can be quite painful.

Once a muscle strain occurs, the muscle is vulnerable to reinjury. It is important to let the muscle heal properly and to follow preventive guidelines from your doctor.

Symptoms

A person who experiences a muscle strain in the thigh will frequently describe a popping or snapping sensation as the muscle tears. Pain is sudden and may be severe. The area around the injury may be tender to the touch, with visible bruising if blood vessels are also broken.

Doctor Examination

Your physician will ask about the injury and examine your thigh for tenderness or bruising. You may be asked to bend or straighten your knee and/or hip so the doctor can confirm the diagnosis.

An x-ray may be needed if there is a possible fracture or other injury to the bone. Muscle strains are graded according to their severity. A grade 1 strain is mild and usually heals readily, whereas a grade 3 strain is a severe tear of the muscle that may take months to heal.

Treatment

Most muscle strains can be treated with the RICE protocol. RICE stands for Rest, Ice, Compression, and Elevation.

Your doctor may recommend a non-steroidal anti-inflammatory medication, such as ibuprofen for pain relief. As the pain and swelling subside, physical therapy will help improve range of motion and strength. The muscle should be at full strength and pain-free before you return to sports. This will help prevent additional injury.

Prevention

Risk Factors

Several factors can predispose you to muscle strains, including:

  • Muscle tightness. Tight muscles are vulnerable to strain. Athletes should follow a year-round program of daily stretching exercises.
  • Muscle imbalance. Because the quadriceps and hamstring muscles work together, if one is stronger than the other, the weaker muscle can become strained.
  • Poor conditioning. If your muscles are weak, they are less able to cope with the stress of exercise and are more likely to be injured.
  • Muscle fatigue. Fatigue reduces the energy-absorbing capabilities of muscle, making them more susceptible to injury.
Precautions

You can take the following precautions to help prevent muscle strain:

  • Condition your muscles with a regular program of exercises. You can ask your physician about exercise programs for people of your age and activity level.
  • Warm up before any exercise session or sports activity, including practice. A good warm up prepares your body for more intense activity. It gets your blood flowing, raises your muscle temperature, and increases your breathing rate. Warming up gives your body time to adjust to the demands of exercise. It increases range of motion and reduces stiffness.
  • Take time to cool down after exercise. Stretch slowly and gradually, holding each stretch to give the muscle time to respond and lengthen. You can find examples of stretching exercises on this website or ask your physician or coach for help in developing a routine.
  • If you are injured, take the time needed to let the muscle heal before you return to sports. Wait until your muscle strength and flexibility return to preinjury levels. This can take 10 days to 3 weeks for a mild strain, and up to 6 months for a severe strain, such as a hamstring strain.

If you found this article helpful, you may also be interested in Hamstring Muscle Injuries.

Last reviewed: March 2014
AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS “Find an Orthopaedist” program on this website.