Suite 13-14, Mt. Elizabeth Medical Center 3 Mt. Elizabeth, Singapore 228510
Tel: 65-6887 3044 Fax: 65-6887 3312 Email:
Practice & Services
Location & Staff
Patient Education
Braces & Cryotherapy

Patient Education

Knee Injuries and Cartilage Problems

  • The Knee Joint

  • Anatomy of The Knee
  • Arthritis

  • Chondromalacia Patella

  • Chondral or Cartilage injury of the knee joint

  • Injuries to the Meniscus

  • Anterior (ACL) and Posterior (PCL) Ligament Injuries

  • Medial (MCL) and Lateral Collateral Ligament (LCL) Injuries

  • Tendon Injuries and Other Knee Disorders
  • Tendinitis and Ruptured Tendons

  • Osgood-Schlatter Disease

  • Iliotibial Band Syndrome

  • Osteochondritis Dissecans (OCD)

  • Plica Syndrome
  • Shoulder Injuries
  • The Shoulder
  • Anatomy of the Shoulder
  • Acromioclavicular(AC)Joint Injury
  • Shoulder Dislocation and Injury of the Labrum
  • Tendinitis
  • Bursitis, Impingement Syndrome and Rotator Cuff Tears
  • Frozen Shoulder
  • Cortisone Injection
  • Investigations in Shoulder Pathology
  • Common Shoulder ProblemS
  • Arthroscopic Shoulder Surgery
  • Rehabilitation of the Shoulder

  • Other Common Injuries
  • Achilles tendon injury and tendinitis

  • Bunions
  • Carpal tunnel syndrome
  • Prolapsed intervertebral disc

  • The Knee Joint

    The knee is a synovial joint, which provides a stable support for the body and enables a person to ambulate. Both flexibility and stability are needed for standing, walking, running, crouching, jumping, and turning.

    Fixed and moving parts, including bones, cartilage, muscles, ligaments, and tendons, enable the knee to function normally. Any disruption to these structures results in dysfunction and pain and swelling are the most common symptoms.

    In all joints, the bones are kept from grinding against each other by a padding called cartilage. Bones are joined to bones by strong, elastic bands of tissue called ligaments. Tendons are tough cords of tissue that connect muscle to bone. Muscles work in opposing pairs to bend and straighten joints. While muscles are not technically part of a joint, they are important because strong muscles help support and protect joints.

    Some knee problems result from injury, such as a direct blow or sudden movements that strain the knee beyond its normal range of movement. These injuries are common following sporting accidents in all age groups. Other problems, such as osteoarthritis in the knee, result from wear and tear on its parts.

    Anatomy of The Knee

    Like any joint, the knee is composed of bones and cartilage, ligaments, tendons, and muscles (see diagram).

    The knee joint is the junction of three bones: the femur (thigh bone or upper leg bone), the tibia (shin bone or larger bone of the lower leg), and the patella (knee cap). The patella is 2 to 3 inches wide and 3 to 4 inches long. It sits over the other bones at the front of the knee joint and slides when the leg moves. It protects the knee and gives leverage to muscles.

    The ends of the three bones in the knee joint are covered with articular cartilage, a tough, elastic material that helps absorb shock and allows the knee joint to move smoothly. Separating the bones of the knee are pads of connective tissue cushions called the meniscus. The meniscus is crescent-shaped and positioned between the tibia and femur on the outer and inner sides of each knee. The two menisci in each knee act as shock absorbers, cushioning the lower part of the leg from the weight of the rest of the body as well as enhancing stability.

    There are two groups of muscles at the knee. The quadriceps muscle comprises of four muscles on the front of the thigh that work to straighten the leg from a bent position. The hamstring muscles, which bend the leg at the knee, run along the back of the thigh from the hip to just below the knee. Keeping these muscles in good condition will help prevent knee injuries as the muscle can absorb a significant amount of load.

    Tendons and Ligaments
    The quadriceps tendon connects the quadriceps muscle to the patella and provides the power to extend the leg. Four ligaments connect the femur and tibia and give the joint strength and stability:
    • The medial collateral ligament (MCL) provides stability to the inner (medial) part of the knee.
    • The lateral collateral ligament (LCL) provides stability to the outer (lateral) part of the knee.
    • The anterior cruciate ligament (ACL), in the center of the knee, limits rotation and the forward movement of the tibia.
    • The posterior cruciate ligament (PCL), also in the center of the knee, limits backward movement of the tibia.
    • Other ligaments are part of the knee capsule, which is a protective, fiber-like structure that wraps around the knee joint. Inside the capsule, the joint is lined with a thin, soft tissue called synovium.
    [ Knee Injuries and Cartilage Problems ]


    What Is Arthritis of the Knee?
    Arthritis of the knee is most often osteoarthritis. In this disease, the cartilage in the joint gradually wears away. In rheumatoid arthritis, which can also affect the knees, the joint becomes inflamed and cartilage may be destroyed. Arthritis not only affects joints; it can also affect supporting structures such as muscles, tendons, and ligaments.

    Osteoarthritis may be caused by excess stress on the joint from deformity, repeated injury, or excess weight. It most often affects middle-aged and older people. A young person who develops osteoarthritis may have an inherited form of the disease or may have experienced continuous irritation from an unrepaired torn meniscus or ligament injury. Rheumatoid arthritis often affects people at an earlier age than osteoarthritis.

    Signs and Symptoms
    Someone who has arthritis of the knee may experience pain, swelling, and a decrease in knee motion. A common symptom is morning stiffness that lessens as the person moves around. Sometimes the joint locks or clicks when the knee is bent and straightened, but these signs may occur in other knee disorders as well. The doctor may confirm the diagnosis by performing a physical examination and examining X-rays, which typically show a loss of joint space. Blood tests may be helpful for diagnosing rheumatoid arthritis, but other tests may be needed too. Analyzing fluid from the knee joint may be helpful in diagnosing some kinds of arthritis.

    Most often osteoarthritis of the knee is treated with pain-reducing medicines such as nonsteroidal anti-inflammatory drugs (NSAIDs) and exercises to restore joint movement and strengthen the knee. Losing excess weight can also help people with osteoarthritis.

    Rheumatoid arthritis of the knee may require physical therapy and more powerful medications. In people with arthritis of the knee, a seriously damaged joint may need to be replaced with an artificial one.

    Newer Treatment Modalities

    A new procedure designed to stimulate the growth of cartilage by using a patient's own cartilage cells is being used to repair cartilage injuries in the knee. Unfortunately this is not suitable for all patients.

    The use of growth factors injections is an option for patient with early cartilage injuries and it is also applicable for repair of soft tissue damage such as hamstring injuries.

    Chondromalacia Patella

    Chondromalacia Patella (CMP) refers to softening of the articular cartilage of the kneecap. This disorder occurs most often in young adults and can be caused by injury, overuse, parts out of alignment, or muscle weakness. Instead of gliding smoothly across the lower end of the thigh bone, the knee cap rubs against it, thereby roughening the cartilage underneath the knee cap. The damage may range from a slightly abnormal surface of the cartilage to a surface that has been worn away to the bone. Chondromalacia related to injury occurs when a blow to the knee cap tears off either a small piece of cartilage or a large fragment containing a piece of bone (osteochondral fracture).

    Symptoms and Diagnosis
    The most frequent symptom is a dull pain around or under the kneecap that worsens when walking down stairs or an incline. A person may also feel pain when climbing stairs or when the knee bears weight as it straightens. The disorder is common in runners and is also seen in skiers, cyclists, and soccer players. A patient's description of symptoms and an MRI scan usually help the doctor make a diagnosis. Although arthroscopy can confirm the diagnosis, it is not performed unless the condition requires extensive treatment.

    Many doctors recommend that patients with chondromalacia perform low-impact exercises that strengthen muscles, particularly the inner part of the quadriceps, without injuring joints. Swimming, riding a stationary bicycle, and using a cross-country ski machine are acceptable as long as the knee does not bend more than 90 degrees. Brace may be indicated in some patients. Electrical stimulation may also be used to strengthen the muscles. If these treatments do not improve the condition, the doctor may perform arthroscopic surgery to smooth the surface of the cartilage and remove the cartilage fragments that cause the joint to catch during bending and straightening. In more severe cases, surgery may be necessary to correct the angle of the kneecap and relieve friction with the cartilage or to reposition parts that are out of alignment.

    Chondral or Cartilage injury of the knee joint

    Injury to the lining of the femur and tibia are common in sporting injuries. It is also associated with severe ACL injuries and knee dislocations. Often it can occur as an isolated condition. As the weight bearing surfaces are usually affected it affects the function of the knee joint, thereby restriction activity.

    Symptoms and Diagnosis
    Pain is usually the most common presenting symptom and often swelling accompanies soon afterwards. Continued participation in sporting activities may become difficult. Clinical examination of the knee reveals a swollen tender joint. The area affected is usually on the inner or the medial aspect of the femoral condyle or the thighbone. X-rays and more importantly an MRI scan are useful in establishing the diagnosis and pinpointing the exact size and location of the cartilage defect.

    For minor cartilage defects modification of activity, weight reduction and physiotherapy will help overcome the problem. However, once cartilage degeneration sets in the process is difficult to reverse though the extent of progress varies from patient to patient. It may take many years for the defect to become severe.

    For large or symptomatic cartilage defects various surgical options such as cartilage debridement, radio frequency smoothening, microfracture treatment, local cartilage transplants (mosaicplasty), autologous cartilage implantation (ACI) and osteotomy are available. These procedures, in general, do not provide total cure and may only partially alleviate symptoms.

    Newer Cartilage Regeneration Techniques (ACI & MACI)

    We have been performing cartilage transplant operation in our clinic for a selected group of patients with siaolted cartilage lesions with a reasonably good success rate using ACI techniques and MACI (Membrane autologous chondrocyte implantation) techniques.

    These surgeries involve two procedures - first to harvest the patient's own cartilage cells which are then sent to the laboratory for culture. Through a second operation the cultured cells, which take up to 6 weeks to grow in the laboratory, are then transplanted into the defect in the knee joint. This is followed by a 6 month rehabilitation program.

    Growth Factors and Stem Cell Treatment

    These are very new exciting and promising techniques that are currently available to treat a select group of patients with cartilage and joint injuries. Early results are promising and the practice is currently in the process of offering these procedures for a select group of patients where the potential for regeneration of damaged muscle, tendon and cartilage exists.

    Injuries to the Meniscus

    The meniscus is most commonly injured when the knee suddenly twist as in a sporting accident. A partial or total tear may occur when a person quickly twists or rotates the upper leg while the foot stays still (for example, when dribbling a basketball around an opponent or turning to hit a tennis ball). If the tear is tiny, the meniscus stays connected to the front and back of the knee; if the tear is large, the meniscus may be interposed between the bone of the knee joint thus causing a “locking” or “catching”. The seriousness of a tear depends on its location and extent.

    Symptoms and Signs
    Generally, when people injure a meniscus, they feel some pain, particularly when the knee is straightened. If the pain is mild, the person may be able to continue with physical activity. Severe pain may occur if a fragment of the meniscus catches between the femur and the tibia. Swelling may occur soon after injury if blood vessels are disrupted, or swelling may occur several hours later if the joint fills with fluid produced by the joint lining (synovium) as a result of inflammation. If the synovium is injured, it may become inflamed and produce fluid to protect itself. This makes the knee swell. Sometimes, an injury that occurred in the past but was not treated becomes painful months or years later, particularly if the knee is injured a second time. After any injury, the knee may click, lock, or feel weak. Although symptoms of meniscal injury may disappear on their own, they frequently persist or return and require treatment.

    In addition to listening to the patient's description of the onset of pain and swelling, the doctor may perform a physical examination and perform X-rays of the knee. The examination may include a test in which the doctor bends the leg, and then rotates the leg outward and inward while extending it. Pain or an audible click suggests a meniscal tear. An MRI may be recommended to confirm the diagnosis. Occasionally, the doctor may use arthroscopy to help diagnose and treat a meniscal tear.

    If the tear is minor and the pain and other symptoms go away, the doctor may recommend a muscle-strengthening program supplemented by ultrasound or short wave therapy supervised by a physiotherapist. Exercises for meniscal problems are best started with guidance from a doctor and physical therapist or exercise therapist. The therapist will make sure that the patient does the exercises properly and without risking new or repeat injury. The following exercises after injury to the meniscus are designed to build up the quadriceps and hamstring muscles and increase flexibility and strength.
    • Warming up the joint by riding a stationary bicycle, then straightening and raising the leg (but not straightening it too much).
    • Extending the leg while sitting (a weight may be worn on the ankle for this exercise).
    • Raising the leg while lying on the stomach.
    • Exercising in a pool (walking as fast as possible in chest-deep water, performing small flutter kicks while holding onto the side of the pool, and raising each leg to 90 degrees in chest-deep water while pressing the back against the side of the pool).
    If the tear is more extensive, the doctor may have to perform arthroscopic surgery to see the extent of injury and to repair the tear. The doctor can sew the meniscus back (meniscal repair) in place if the patient is relatively young, if the injury is in an area with a good blood supply, and if the ligaments are intact. Most young athletes are able to return to active sports after meniscus repair, though it may take a few months for it to heal and there is small possibility that the repair may not heal.

    If the patient is elderly or the tear is in an area with a poor blood supply, the doctor may cut off a small portion of the meniscus to even the surface. However, osteoarthritis is more likely to develop in the knee, after 10-20 years following meniscal resection.

    Recovery after meniscal repair takes several weeks, and postoperative activity is slightly more restricted than when the meniscus is removed. Nevertheless, putting weight on the joint actually fosters recovery. Regardless of the form of surgery, rehabilitation usually includes walking, bending the legs, and doing exercises that stretch and build up leg muscles. The best results of treatment for meniscal injury are obtained in people who do not show articular cartilage changes and who have an intact ACL.

    Knee ligament injuries


    The knee is the largest joint in the body and is vital to movement. Two sets of ligaments in the knee give it stability: the cruciate and the collateral ligaments.

    Cruciate ligaments

    The cruciate ligaments are located inside the knee joint and connect the thighbone (femur) to the shinbone (tibia). They are made of many strands and function like short ropes that hold the knee joint tightly in place when the leg is bent or straight. This stability is needed for proper knee joint movement.

    The name, cruciate, derives from the word crux, meaning cross, and crucial. The cruciate ligaments not only lie inside the knee joint, they crisscross each other to form an "x". The cruciate ligament located toward the front of the knee is the anterior cruciate ligament (ACL), and the one located toward the rear of the knee is called the posterior cruciate ligament (PCL).

    ACL injuries

    The ACL prevents the shinbone from sliding forwards beneath the thighbone. The ACL can be injured in several ways:

    • Changing direction rapidly
    • Slowing down when running
    • Landing from a jump
    • Direct contact, such as in a football tackle

    Recognizing an ACL injury

    If you injure your ACL, you may not feel any pain immediately. However, you might hear a popping noise and feel your knee give out from under you. Within 2 to 12 hours, the knee will swell, and you will feel pain when you try to stand. Apply ice to control swelling and elevate your knee until you can see an orthopaedic surgeon.

    If you walk or run on an injured ACL, you can damage the cushioning cartilage in the knee. For example, you may plant the foot and turn the body to pivot, only to have the shinbone stay in place as the thighbone above it moves with the body.

    Diagnosing an ACL injury

    A diagnosis of ACL injury is based on the clinical history and a thorough physical examination of the knee. The examination may include several tests to see if the knee stays in the proper position when pressure is applied from different directions. X-rays and MRI scans are useful in assessing the extent of the problem and the associated injuries.

    A partial tear of the ACL may or may not require surgical treatment. A complete tear is more serious. Complete tears, especially in younger athletes, may require reconstruction.

    Treating ACL tears

    Generally most ACL tears will require reconstructive surgery except for the very young patients.

    Operative treatment (Arthroscopic ACL Reconstruction)

    Uses a strip of tendon, usually taken from the patient’s knee, patellar tendon or hamstring tendon, that is passed through the inside of the joint and secured to the thighbone and shinbone.

    • Is followed by an exercise and rehabilitation program to strengthen the muscles and restore full joint mobility.



    ACL Reconstruction


    When you twist your knee or fall on it, you can tear a stabilizing ligament that connects your thighbone to the shinbone. An anterior cruciate ligament (ACL) unravels like a braided rope when it’s torn and does not heal on its own.


    Fortunately, reconstruction surgery can help many people recover their full function after an ACL tear.


    Successful ACL reconstruction surgery tightens your knee and restores its stability. It also helps you avoid further injury and get back to playing sports. It is particularly useful in preventing further deterioration of the articular cart ila ge and meniscus. The surgeries are successful about 85-92 percent of the time.

    After ACL reconstruction, you’ll need to do rehabilitation exercises to gradually return your knee to full flexibility and stability. Building strength in your thigh and calf muscles helps support the reconstructed structure. You may need to use a knee brace for awhile and will probably have to stay out of sports for about 4 to 6 months.

    Amongst the complications that may arise following this surgery you need to be aware of the following – infection, numbness, muscle wasting, loss of range of motion, stiffness, mechanical problems with the graft and implants used, chronic swelling, crepitus, clicking sensation and tendinitis.

      PCL Injuries

    The PCL is most often injured by a direct impact, such as in an automobile accident or football tackle.

    Associated injuries include lateral collateral liagment and posterolateral capsule. Instabilities vary from patient to patient and results of reconstruction are highly variable.

    Patients often complain of giving way or pain due to cartilage wear and tear from abnormal loads.


    For an incomplete tear, the doctor may recommend that the patient begin an exercise program to strengthen surrounding muscles. The doctor may also prescribe a brace to protect the knee during activity. For a completely torn PCL in an active athlete and motivated person, the doctor is likely to recommend surgery. The surgeon may reattach the torn ends of the ligament or reconstruct the torn ligament by using a piece (graft) of healthy ligament from the patient (autograft). Although synthetic ligaments have been tried in experiments, the results have not been as good as with human tissue. One of the most important elements in a patient's successful recovery after cruciate ligament surgery is a 4- to 6-month exercise and rehabilitation program that may involve using special exercise equipment at a rehabilitation or sports center. Successful surgery and rehabilitation will allow the patient to return to a near normal lifestyle.

    Medial (MCL) and Lateral Collateral Ligament (LCL) Injuries

    The MCL is more easily injured than the LCL. The cause is most often a blow to the outer side of the knee that stretches and tears the ligament on the inner side of the knee. Such blows frequently occur in contact sports like football or hockey.

    Symptoms and Diagnosis
    When injury to the MCL occurs, a person may feel a “pop” and the knee may buckle sideways. Pain and swelling are common. Sometimes in a complete tear of the MCL the swelling can be very minimal because of disruption of the joint capsule. A thorough examination is needed to determine the kind and extent of the injury. To diagnose a collateral ligament injury, the doctor exerts pressure on the side of the knee to determine the degree of pain and the looseness of the joint. An MRI is helpful in diagnosing injuries to these ligaments.

    Most sprains of the collateral ligaments will heal if the patient follows a prescribed exercise program. In addition to exercise, the doctor may recommend ice packs to reduce pain and swelling and a hinged knee brace to protect and stabilize the knee. A sprain may take 2 to 6 weeks to heal. A severely sprained or torn collateral ligament may be accompanied by a torn ACL, which usually requires surgical repair.
    [ Tendon Injuries and Disorders ]

    Tendinitis and Ruptured Tendons

    Knee tendon injuries range from tendinitis (inflammation of a tendon) to a ruptured (torn) tendon. If a person overuses a tendon during certain activities such as dancing, cycling, or running, the tendon stretches like a worn-out rubber band and becomes inflamed. Also, trying to break a fall may cause the quadriceps muscles to contract and tear the quadriceps tendon above the patella or the patellar tendon below the patella. This type of injury is most likely to happen in older people whose tendons tend to be weaker.

    Tendinitis of the patellar tendon is sometimes called jumper's knee because in sports that require jumping, such as basketball, the muscle contraction and force of hitting the ground after a jump strain the tendon. After repeated stress, the tendon may become inflamed or tear.

    Symptoms and Diagnosis
    People with tendinitis often have tenderness at the point where the patellar tendon meets the bone. In addition, they may feel pain during running, fast walking, or jumping. A complete rupture of the quadriceps or patellar tendon is not only painful, but also makes it difficult for a person to bend, extend, or lift the leg against gravity. If there is not much swelling, the doctor will be able to feel a defect in the tendon near the tear during a physical examination. An X-ray will show that the patella is lower than normal in a quadriceps tendon tear and higher than normal in a patellar tendon tear. The doctor may use an MRI to confirm a partial or total tear.

    Initially, the doctor may ask a patient with tendinitis to rest, elevate, and apply ice to the knee and to take anti-inflammatory medicines to relieve pain and decrease inflammation and swelling. A special brace may also be necessary. If the quadriceps or patellar tendon is completely ruptured, a surgeon will reattach the ends. After surgery, the patient will wear a cast for 3 to 6 weeks and use crutches. For a partial tear, the doctor might apply a cast or a brace without performing surgery.

    Rehabilitating a partial or complete tear of a tendon requires an exercise program that is similar to but less vigorous than that prescribed for ligament injuries. The goals of exercise are to restore the ability to bend and straighten the knee and to strengthen the leg to prevent repeat injury. A rehabilitation program may last 6 months, although the patient can return to many activities before then.

    Osgood-Schlatter Disease

    Osgood-Schlatter disease, seen in young athletes, is caused by repetitive stress or tension on part of the growth area of the upper tibia (the apophysis). It is characterized by inflammation of the patellar tendon and surrounding soft tissues at the point where the tendon attaches to the tibia. The disease may also be associated with an injury in which the tendon is stretched so much that it tears away from the tibia and takes a fragment of bone with it. The disease most commonly affects active young people, particularly boys between the ages of 10 and 15, who play games or sports that include frequent running and jumping.

    Symptoms and Diagnosis
    People with this disease experience pain just below the knee joint that usually worsens with activity and is relieved by rest. A bony bump that is particularly painful when pressed may appear on the upper edge of the tibia (below the knee cap). Usually, the motion of the knee is not affected. Pain may last a few months and may recur until the child's growth is completed.

    Osgood-Schlatter disease is most often diagnosed by the symptoms. An X-ray may be normal, or show an injury, or, more typically, show that the growth area is in fragments.

    Usually, the disease resolves without treatment. Applying ice to the knee when pain begins helps relieve inflammation and is sometimes used along with stretching and strengthening exercises. The doctor may advise the patient to limit participation in vigorous sports. Children who wish to continue moderate or less stressful sports activities may need to wear knee brace for protection and apply ice to the knee after activity. If there is a great deal of pain, sports activities may be limited until discomfort becomes tolerable.

    Iliotibial Band Syndrome

    This is an overuse condition in which inflammation results when a band of a tendon rubs over the outer bone (lateral condyle) of the knee. Although iliotibial band syndrome may be caused by direct injury to the knee, it is most often caused by the stress of long-term overuse, such as sometimes occurs in running and sports training.

    Symptoms and Diagnosis
    A person with this syndrome feels an ache or burning sensation at the side of the knee during activity. Pain may be localized at the side of the knee or radiate up the side of the thigh. A person may also feel a snap when the knee is bent and then straightened. Swelling is usually absent and knee motion is normal. The diagnosis of this disorder is typically based on the symptoms, such as pain at the outer bone, and exclusion of other conditions with similar symptoms.

    Usually, iliotibial band syndrome disappears if the person reduces activity and performs stretching exercises followed by muscle-strengthening exercises. In rare cases when the syndrome does not disappear, surgery may be necessary to split the tendon so it isn't stretched too tightly over the bone.

    Osteochondritis Dissecans (OCD)

    Osteochondritis dissecans results from a loss of the blood supply to an area of bone underneath a joint surface and usually involves the knee. The affected bone and its covering of cartilage gradually loosen and cause pain. This problem usually arises spontaneously in an active adolescent or young adult. It may be due to a slight blockage of a small artery or to an unrecognized injury or tiny fracture that damages the overlying cartilage. A person with this condition may eventually develop osteoarthritis.

    Lack of a blood supply can cause bone to break down (avascular necrosis). The involvement of several joints or the appearance of osteochondritis dissecans in several family members may indicate that the disorder is inherited.

    Symptoms and Diagnosis
    If normal healing does not occur, cartilage separates from the diseased bone and a fragment breaks loose into the knee joint, causing weakness, sharp pain, and locking of the joint. An X-ray, MRI, or arthroscopy can determine the condition of the cartilage and can be used to diagnose osteochondritis dissecans.

    If cartilage fragments have not broken loose, a surgeon may fix them in place with pins or screws that are sunk into the cartilage to stimulate a new blood supply.

    If fragments are loose, the surgeon may scrape down the cavity to reach fresh bone and add a bone graft and fix the fragments in position. Fragments that cannot be mended are removed, and the cavity is drilled or scraped to stimulate new cartilage growth. Research is being done to assess the use of cartilage cell and other tissue transplants to treat this disorder.

    Plica Syndrome

    Plica syndrome occurs when plicae (bands of synovial tissue) are irritated by overuse or injury. Synovial plicae are the remains of tissue pouches found in the early stages of fetal development.

    As the fetus develops, these pouches normally combine to form one large synovial cavity. If this process is incomplete, plicae remain as four folds or bands of synovial tissue within the knee. Injury, chronic overuse, or inflammatory conditions are associated with this syndrome.

    Symptoms and Diagnosis
    People with this syndrome are likely to experience pain and swelling, a clicking sensation, and locking and weakness of the knee. Because the symptoms are similar to those of some other knee problems, plica syndrome is often misdiagnosed. Diagnosis usually depends on excluding other conditions that cause similar symptoms.

    The goal of treatment is to reduce inflammation of the synovium and thickening of the plicae. The doctor usually prescribes medicine such as ibuprofen to reduce inflammation. The patient is also advised to reduce activity, apply ice and an elastic bandage to the knee, and do strengthening exercises. A cortisone injection into the plica folds helps about half of those treated. If treatment fails to relieve symptoms within 3 months, the doctor may recommend arthroscopic or open surgery to remove the plicae.
    [ Shoulder Injuries ]

    The Shoulder

    The shoulder is a very mobile joint capable of complex movements to enable us to achieve specific tasks. The shoulder has three components: the glenohumeral joint, acromioclavicular joint and the scapulothoracic articulation. The bony elements include the upper end of the humerus [upper arm bone], the outer end of the clavicle [collarbone] and the entire scapula, with its shoulder blade, glenoid [shoulder socket] and acromion.  As the shoulder is comprised of many joints, muscles, tendons and ligaments, extreme mobility is possible. However, this large degree of mobility can result in problems such as instability or impingement when overused or excessively such as during sports.

    Most shoulder problems involve the soft tissue, ligaments and tendons, rather than the bones. The commonly seen conditions of the shoulder are listed below.

    Anatomy of the shoulder

    Acromioclavicular (AC) Joint Injury

    The AC joint connects the collarbone or the clavicle to the acromion, part of the scapula. A fall directly onto the shoulder may tear the ligaments that surround and stabilize the AC joint. Symptoms vary according to the severity of the tears, and may range from mild pain with little or no deformity to great pain with obvious deformity.

    Minor injuries can be treated with analgesics, rest, ice and a sling. Healing may take four to six weeks. Complete disruption usually requires surgery especially in active individuals. Sometimes this injury can be associated with a facture of the outer end of the clavicle, which usually needs surgery to stabilize the joint.


    Shoulder Dislocation and Injuries of the Labrum

    The shoulder joint is a shallow ball and socket joint, with the head of the humerus resting in the shallow socket. Because the head of the humerus is usually larger than the socket itself, a rim of cartilage called the labrum, surrounds the socket to increase its depth and stability.

    A shoulder dislocation, a very common injury, occurs when the head of the humerus slips out of the shoulder socket [glenoid].

    This problem is often seen following a sports injury or for example a tackle at rugby. It can also be caused by falls. This injury is particularly common in young or active individuals. Varying degrees of displacement occur between the humerus and glenoid. The milder forms are often termed subluxation and can be common in loose jointed individuals.

    A dislocation pulls the labrum off the glenoid making the humeral head more susceptible to slip forwards (anterior), backwards (posterior), downwards (inferior) or in multiple directions.

    A Bankart lesion, a peeling of the labrum from the glenoid, occurs when there is damage to the middle of the socket.  In young patients, dislocation can be a recurring problem and repeated dislocations can damage the surrounding soft tissues, aggravating the injury. This condition often requires keyhole surgery to repair the damaged labrum. Bio-absorbable suture anchors are used to reattach the labrum to the glenoid.  Despite surgery, the dislocation can recur.

    Physiotherapy and adequate rehabilitation of the shoulder muscles are an integral part of the management of shoulder dislocation and should take place before surgery is considered. Following surgery a sling is used for a month to allow the repaired labrum to heal. 

    A SLAP (Superior Labrum from Anterior to Posterior) lesion occurs when there is a tear of the rim above the middle of the socket, where the biceps tendon attaches. This lesion is often seen in sports such as tennis, baseball and other throwing sports.

    A SLAP lesion can cause pain when serving a tennis ball or releasing a ball while throwing. The symptoms can affect sports performance. Surgery to reattach the SLAP lesion is required in symptomatic patients if non-operative treatment such as rest and rehabilitation fail.


    Tendinitis refers to the inflammation of a tendon. A tendon is a collagenous structure that connects muscle to bone thereby enabling joint motion.  Acute tendinitis may occur from repetitive use especially that associated with sports. Chronic tendinitis may develop from acute tendinitis or results from degenerative disease or repetitive wear and tear due to age. Tendons may split and tear due to acute injury or degenerative changes in the tendons. Rotator cuff injuries are among the most common type of tendon injury in the shoulder.


    Bursitis, Impingement Syndrome and Rotator Cuff Tears

    Bursitis of the shoulder refers to pain, swelling and limitation of function of the shoulder joint secondary to inflammation of the shoulder.  This is the mildest type of condition affecting the rotator cuff.  One of the main muscle groups in the shoulder is the rotator cuff. The rotator cuff, comprised of three connected tendons, links the upper end of the humerus to the shoulder blade. These tendons cover the uppermost part of the shoulder joint and help to lift and rotate the shoulder.

    The rotator cuff tendons are protected from abrading under the acromion during upward and forward movement, by a layer of tissue called the bursa. The bursa provides cushioning. When the tendon is inflamed, the bursa swells. Bursitis can result from trauma, injury, wear and tear, and ageing. Occasionally one has to distinguish this condition from other inflammatory conditions such as infection and gout and calcific tendonitis of the shoulder.

    Treatment of bursitis involves anti-inflammatory medication, rest and physiotherapy.    

    Another common shoulder condition is Impingement Syndrome. This occurs when the rotator cuff tendons are repeatedly pinched between the upper end of the humerus and the acromion. It is common in patients over the age of 40, and in young and athletically active individuals who are involved in overhead or throwing sports such as basketball, tennis and baseball.

    The acromion, sitting over and in front of the humeral head, rubs on the upper surface of the rotator cuff whenever the arm is elevated forward or sideways. When there is degeneration of the AC joint with bony prominence or acromial spur, the impingement symptoms are further aggravated. When there is inflammation in this area, this rubbing or impingement causes pain and limits movement. Reaching for objects above the level of the shoulder or across the body can be painful.

    Impingement also causes swelling and tenderness in the front of the shoulder. As the problem worsens, there may be pain at night and strength of the shoulder may be affected.

    Chronic impingement of the tendons may cause a partial tear of the rotator cuff. Complete or large tears of the rotator cuff are most often the result of severe impingement and progressive wear and tear. It is difficult to distinguish partial tears from complete tears of the cuff from patient presenting symptoms alone, unless the tear is of a very severe nature. MRI scans are essential to assess the extent of the tear and determine the need for surgery. Once a tear develops in the rotator cuff, most patients will require keyhole surgery at some stage if they wish to remain active. If left untreated, the function of the shoulder will be compromised.

    Surgery involves re-attaching the tendon to the upper end of the humerus. This is a complex surgical procedure.  It is often performed arthroscopically, depending on the type of tear and other associated problems in the shoulder.

    As in shoulder dislocation surgery, specially designed bio-absorbable suture anchors are used to re-attach the tendon to its original location. When repairing the torn rotator cuff during surgery, it is possible to address other pathologies identified. Following surgery, a sling is worn for between 4 to 6 weeks and active shoulder movements are restricted. Full rehabilitation following rotator cuff surgery can take up to 6 months or more. Results vary from patient to patient depending on the severity of the tear.



    Frozen Shoulder

    Frozen shoulder is a painful condition that results in thickening and contracture (tightening) of the capsule (the tissue that envelopes the joint) surrounding the shoulder joint.

    It can arise without an underlying cause and is often seen in diabetic patients. It can also occur as a secondary problem following any chronic shoulder condition such as injury, rotator cuff pathology, degenerative conditions and sometimes following shoulder surgery.

    Common symptoms include pain that is usually dull or aching, located over the outer shoulder area and sometimes in the upper arm, as well as loss of motion or stiffness in the shoulder.  Early physiotherapy and shoulder motion will avert permanent dysfunction. Treating the underlying cause will usually resolve the problem in secondary frozen shoulder.

    Cortisone Injections in shoulder problems

    One of the modalities of treating shoulder problems, in general, is the use of cortisone  or steroid injection. 

    In general, this is not the first line of treatment but it is often helpful when analgesics fo not work. A low dose of steroid combined with a local anesthetic are infiltrated into the area just above the rotator cuff tendons in case of rotator cuff tendinitis without a significant tear. It can also be helpful in early frozen shoulder, impingement syndrome and bursitis.

    Caution has to be exercised in the use of steroids as complications such as infection, progression of damage, discoloration of skin over the injected area and masking of serious conditions may occur. It is generally not advisable to give more than one or two injections into any area.

    Investigations in Shoulder Pathology

    Generally plain X-rays are the first line of investigation in shoulder pathology.

    An MRI scan is often required to make a definitive diagnosis of shoulder pathology.

    Blood tests and special investigations such as bone scans and CT scans are sometimes useful to establish a diagnosis.



    Common Shoulder Pathology

    Normal view of shoulder                          Partial tear of rotator cuff (joint side)

    SLAP lesion                                             Complete tear of rotator cuff

    Bankart lesion                                         Acromial spur

    Arthroscopic Shoulder surgery

    With the advent of newer equipment, surgical accessories and technology most common shoulder conditions that require surgery may be performed arthroscopically or by means of keyhole incisions. The advantage of this type of surgical procedure as opposed to traditional open surgery is that of minimal disruption or damage of normal tissue and quicker recovery. Most procedures can be performed as a day case or overnight stay in the hospital.


    Rehabilitation of the injured shoulder

    Analgesics, physiotherapy, rest and avoidance of precipitating activities are the main modalities of treating shoulder conditions. Surgery is only considered in patients where symptoms are troubling the patient despite the above conservative means of treatment. Physical therapy following surgery is important and one has to adhere to the advise of the therapist strictly to achieve optimal outcome. Some of the rehabilitative exercise modalities for the shoulder are described below and you need the advise of the surgeon and the therapist to decide which set of exercises are beneficial to treat your ailment. 


    [ Other Common Injuries ]

    Achilles tendon injury and tendinitis

    The achilles tendon attaches the calf muscle (gastrocnemius) to the heel. The two main conditions affecting this tendon are rupture and tendonitis (inflammation). Rupture results in a sudden onset of pain, like that of being kicked or cut in the back of the leg. The patient usually feels he/she cannot walk. Swelling ensues and a bulge may be felt at the back of the leg. Athletes who forcefully push off the ground with their feet usually sustain this injury. Tendonitis occurs in runners, gymnasts, cyclists, and volleyball players and results in an aching pain at the back of the leg.

    Diagnosis is by physical examination, an X-ray of the heel and sometimes an MRI.

    Tendon rupture can be treated by surgical reattachment or medical therapy. The latter consists of rest, pain control and serial casting. Tendonitis is treated similarly. Rehabilitation is important for complete recovery in both conditions.


    Bunions, or Hallux Valgus, are one of the most common foot problems. A bunion is defined as a prominent bump on the inside of the foot around the big toe joint. This bump is formed by a bone protruding towards the inside of the foot. As the big toe moves towards the smaller toes, it is common to find the big toe resting under or over the second toe (which leads to overlapping of the toes). This condition causes inflammation, swelling, and soreness on the side surface of the big toe. The patient is unable to walk properly and old shoes tend not to fit very well.

    Tailor's Bunion, or bunionette, involves the little toe. As with the big toe, the little toe moves towards the other toes and forms a bump on the outer surface of the little toe. Similar symptoms occur as with as bunion.

    Bunions usually affect women. They can be caused by an abnormality in foot function, or arthritis, but is more commonly caused by wearing improper fitting footwear. Tight, narrow dress shoes with a small restrictive toe area can cause the foot to begin to take the shape of the shoe, which leads to the formation of a bunion. Women who have bunions normally wear dress shoes that are too small for their feet. Their toes are compressed together in their shoes causing the toe bone to protrude on the side of the foot.

    The continued practice of wearing these restrictive shoes will worsen the problem and increase the likelihood of corrective surgery being done.

    Here are some tips on preventing the progression of bunions.

    • Soaking feet in warm water can alleviate the problem
    • Properly fitted shoes should help reduce the pain and discomfort (i.e. shoes with a high, wide toe box and rocker soles)
    • Orthotics can help to provide extra comfort, support, and protection
    • Using forefoot products such as bunion shields, bunion night splints, and bunion bandages. These conservative treatments can limit the progression of the bunion formation, relieve pain and provide a healthy environment for the foot.

    If the problem persists or worsens, do not hesitate to consult your doctor

    Carpal tunnel syndrome

    Symptoms and Diagnosis
    This condition is defined by a number of symptoms arising from compression of an area on the palmar side of the wrist (called the carpal tunnel). The tunnel contains the median nerve and three tendons. It is the compression of the median nerve that gives rise to the symptoms.

    The causes include repetitive hand or wrist movements, pregnancy, birth control pill use, hypothyroidism (thyroid dysfunction), diabetes and Rheumatoid arthritis.

    Classical symptoms are pain (usually a burning sensation), numbness and tingling (especially in the fore and middle finger). These symptoms may be present in the forearm as well. They are worse at night and may be temporarily relieved by shaking of the hand. Home treatment measures such as anti-inflammatory drugs can relief the symptoms. Using a wrist splint at all times and avoiding activities that aggravate the problem are other simple steps that you can take. If symptoms persist, please consult your doctor.

    The diagnosis is easily confirmed after a physical examination. In a few cases, nerve conduction studies may be required to confirm the diagnosis. Treatment options are similar to those mentioned above. Some patients find relief with steroid injection, which reduce the swelling in the tunnel. However, this method is temporary. The last option is surgery (a small incision is made in the wrist and some ligaments are cut to release pressure in the tunnel). Surgery has a good outcome and can be performed on an outpatient basis.

    Prolapsed intervertebral disc

    Injury to the back is common from sports as well as degenerative problems. The disc most commonly affected is the L4/5 and L5/S1 levels. A sudden fall or a twist can precipitate a disc prolapse or a rupture. Common terms such as “slipped disc”, “ruptured disc” and “prolapsed disc’ all refer to similar conditions. In essence the disc impinges or presses on the nerve root and this causes pain to shoot down the leg – this is referred to as sciatica.

    MRI scans and CT Scans are useful to image the lumbar spine. Plain X-rays are also useful to plan the treatment procedure.

    Treatment and Surgery
    Treatment of this condition, either due to trauma or without trauma, involves rest with analgesics and back physiotherapy. Analgesics and anti-inflammatory medication is helpful in the initial stages. Various modalities such as ultrasound, short wave therapy, manipulation, acupuncture and TENS methods have been used in the past. It is best to consult your doctor regarding the best form of treatment.

    If symptoms do not improve one may consider a surgical removal of the offending disc. This can be done as a microdiscectomy through a small incision in the back. In degenerative disc prolapse a larger incision may be required. Single level disc removals require a day or two in hospital and the patient is usually ambulant or walking about in a day.

    It is best to avoid excessive walking or activity following this type of surgery. It is recommended that one does not carry or lift heavy objects following disc surgery. Rehabilitation following surgery is important.


    © 2017 Orthopaedic Sports Medicine. All Rights Reserved