eatwellgetwell – a nutrition and medicine study blog

Joint Injuries

“Sprains” – joints have a ligamentous binding system, much tougher than muscles. Ligaments prevent the joints from moving outside their natural physiological ranges. However, sometimes, trauma can force a joint beyond this natural range, and a ligament/s might become stretched or torn. This then leads to a natural instability of the joint in a particular axis of movement. E.g: Anterior cruciate ligament – remember D. Beckham.

Dislocation/Subluxations
When a joint surface actually becomes partially or fully separated from its neighbour, we consider it subluxed or even dislocated.
3 grades of subluxation, then dislocation; e.g. S/C joint, Shoulder joint

Cartilage damage
A common example of this is a torn articular disc in the knee (aka meniscus). Damaged cartilage has a terrible blood supply, and often requires removal by surgery. i.e. arthroscopy (key-hole surgery).

Joint swelling
Immediate swelling can be due to rupture of local blood vessels around a joint (especially knee and ankle).
A gradual swelling, post-trauma, could be due to an irritated synovial capsule. Excessive production of synovial fluid is often referred to as “water on the knee”.

Bursitis
Inflammation of the cushioning fatty sac/s that occur in the joints. Might be due to sudden shock trauma, infection or wear and tear.

Spinal Curves and Deformities

The typical spine has 4 curves, considered in a sagittal plane (front to back). When put together, the spine can be thought of as a flexible spring-like mechanism, enabling effective shock absorption and force distribution.

Considering the spine from a coronal view (plane from side to side), one can very often observe another form of curve. This might look like a gentle, single curve (‘C’ shaped), or multiple curves (‘S’ shaped). A curve in this plane is called a Scoliosis. This occurs naturally due to the imbalance of our everyday lives – e.g. right handed / wearing rucksack on one shoulder / leg length difference. When these curves become extreme, they can lead to various complaints, including back ache and “trapped nerves”.

Cervical and Lumbar Disc Lesions

The spine contains 24 shock absorbing and separating discs.
These “Intervertebral Discs” bind the bodies of the vertebrae together, and provide cushioning for all spinal movement.
The discs have two elements:
Annulus fibrosus
Nucleus pulposus

Degrees of damage:

annular tear

disc prolapse (see above diagram)

disc herniation

When a disc bulges far enough out of its normal place, it may press on a nerve leading to pain and spasm,
This, if prolonged, can badly damage a nerve’s function ® neurological problems ensue e.g. sciatica.
With age, the toothpaste like fluid in the nucleus dries up. Hence, there is less danger of discal damage, as we get older.

Cauda Equina Syndrome

This very important and serious pathology occurs when a discal bulge or herniation becomes too large, below the level at which the spinal cord stops at L2/3, although there is the potential for similar problems to occur anywhere below T10. The nerves which spread out below this level supply much of the control for the abdominal and pelvic organs and lower extremeties.

Red flag symptoms include:

Severe bilateral leg pain
Weakness and paralysis of both legs
Saddle anaesthesia (numbness)
Urine retention

If any combination of these factors comes to light in a case history, it is important that the patient is referred immediately to hospital for an emergency MRI scan. They could be sitting on a paralysis timebomb!
Bone Pathologies

Osteoporosis – meaning “porous bone”

An animation about Osteoporosis can be seen here.

Thinning of bone from loss of mineral content, although bony architecture is retained.
After the age of 30, the body’s ability to retain calcium diminishes, while excretion rates remain the same. This reduction is because of the demand for minerals for bony remodeling
When bones reach critical thinness, fractures occur, either spontaneously or with minor trauma
The most important factor is ↓ oestrogen at the menopause (oestrogen suppresses bone resorption and improves calcium uptake in the gut).
Osteoporosis it the most common bone disease in older Caucasian women of northern European descent, who have inadequate dietary calcium and who lead sedentary lifestyles.

Risk factors include:
Smoking
High alcohol consumption
Poor diet
Sedentary lifestyle
Family history
Long term steroid use
Endocrine problems – e.g. inability to produce oestrogen

· Clues to Diagnosis:
Ø Pain is usually severe and localized to site of fracture
Ø Aggravated by increased sitting, standing or bending
Ø Relieved by lying on side with hips and knees flexed
Ø Rib or spinal deformities (e.g. scoliosis)
Ø Loss of height due to vertebral crumpling and fracture

Osteomalacia or “Rickets” in children

· This is a softening of bones due to failed mineralization in the bone matrix
· Caused by Vitamin D deficiency in adults
· This might be due to:
↓ ultraviolet rays
↓Vitamin D diet
Failure to absorb in gut
↓ receptor sites for the vitamin in the tissues

· Characterised by decalcification of bone, especially the spine, pelvis and Lower Extremities
· Bones bend, become flattened or otherwise deformed

· Signs and Symptoms include:
Severe back pain
Severe muscle weakness
Fracture

Paget’s Disease

A focal inflammatory condition of the skeleton, that produces disordered bone remodeling
New bone is larger, less compact, more vascular and more susceptible to fracture
M:W – 3:2
Most commonly seen in people under the age of 70
Cause is unknown, with possible genetic involvement
Signs and symptoms vary from person to person. Some have mild to no pain. Others have disabling pain and bones that are easily deformed and fracture.
Typically, the weight bearing bones and ribs are most affected
Pain is “aching, deep, boring, worse at night, and eases with activity”
Can potentially cause spinal stenosis, or a range of other neurological symptoms due to nerve compression
Predisposes sufferer to Fracture, Osteoarthritis and Osteosarcomas

Osteomyelitis

A bone infection, most often affecting first and second lumbar vertebrae, or growing regions of long bones of children.
Many causative factors:
diabetes
injection drug users
alcoholics
Immune–suppressed people.
· Bacterial infection (Staphylococcus aureus) can spread through any wound into the blood steam.
Symptoms:
Marked local tenderness over S.Ps., exquisitely sensitive to percussion.
Generalized, “non-specific backache”
Muscular guarding of paravertebral muscles and housings.
Severe night pain.

Tumours of bone

Benign tumours grow inside bones.
They cause pressure, deep pain, fracturing and the potential to change into malignant tumours
Malignant tumours of bone are usually “secondaries” from organs, especially breast, lungs, thyroid, kidneys and prostate.
“Primary” malignancies are called Osteosarcomas or Chondrosarcomas, depending on the type of tissue in which they develop.

Soft tissue Strains and Tears

A muscular strain is a common minor soft tissue injury.
A certain number of myofibrils are torn and broken, but the muscle as a whole is still in one piece.
Blood supply to muscle bellies is sufficient to provide good healing to the fibres. (this fibre damage and healing is the very same mechanism by which muscle bulk and strength is increased.)
A tear is more significant. If enough fibres are damaged that there is local separation of the tissue, then natural and complete healing cannot happen. In such cases, skeletal muscle tissues undergo fibrosis, and damaged tissue is replaced by fibrous connective tissue.

Muscular Pathologies

Duchenne Muscular Dystrophy (dystrophy = degeneration)

M.Ds are inherited muscle destroying diseases, which result in gradual, progressive atrophy (wasting) of skeletal muscles
Typically, it is the external mobiliser muscles that are most affected
Duchenne is almost exclusively found in boys (1:3500)
Common age of onset is 3-5 years old, and always <10
Mechanism of muscular breakdown is only hypothesised, but might be due to unwanted Calcium ions triggering an enzymal breakdown of muscle fibres

Signs and Symptoms
Walking development can be delayed, with clumsiness and a waddling gait
Proximal limb weakness
Most patients die before reaching 20 – often due to respiratory weakness and failure

The Muscular Dystrophy Campaign is the only UK charity focusing on all muscular dystrophies and allied disorders.

Myasthenia Gravis (myo = muscle; asthenia = weakness; gravis = serious)

”Autoimmune” disease, characterised by fluctuating fatigueable weakness caused by an abnormality at the neuromuscular junction, that partially blocks contraction.
Antibodies are directed at Ach receptors on the Motor End Plate in a synapse. They prevent Ach binding, and hence prevent the motor impulse being sent to fibres.
Muscle becomes increasingly weaker, until it ceases to function.
Most common in women, age 20-50
Muscles of face and neck are most commonly affected.
Initial symptoms include:
Difficulty swallowing
Weakness of eye muscles
Problems with chewing
Problems with talking
Death may result from failure of the respiratory muscles.
Steroidal drugs have been found to reduce the effects of the antibodies.

Fibromyalgia (algia = painful condition)

A group of non-articular disorders
M:W – 1:15
Typical age of onset between 25-50
A significant sign is pain that results from gentle pressure at specific “tender spots”.
Also, generalised tenderness and stiffness of muscles, tendons and ligaments
Caused or aggravated by:
Stress
Trauma
Exposure to damp or cold
Poor sleep

Definition: Pain on palpation must be present in at least 11 of the 18 points shown:-

Osteoarthritis (OA)

A degenerative wear and tear process in joints.
Weight bearing joints are typically the most affected
There are nearly always predisposing factors that accelerate the wearing process. E.g.
congenital ill-development
irregularity of jt. surfaces e.g. from fracture
internal derangements – e.g. torn meniscus
previous disease e.g. RA
Mal-alignment of a joint
Obesity and overweight.
Pathology of OA

Articular cartilage wears away, until the underlying bone is exposed.
| ↓
| Subchrondral bone becomes hard and glossy (eburnation)
| ↓
| Cysts and sclerosis occurs in bone surface.
|
→ Bone at margins hypertrophies, forming projecting spurs.

The spurs of bone are called Osteophytes.
Onset is gradual, with pain increasing imperceptibly over month to years. Movements become restricted.
Joints like the hip demonstrate deformity in later stages.
Not usually associated with inflammatory symptoms.
Diagnosis can be confirmed by X-Ray. Typical features looked for are:
Joint space narrowing
Subchondral Cysts in ends of bone
Osteophyte formation
Squaring of rounded joint surfaces

Rheumatic and Autoimmune Diseases 

Rheumatoid Arthritis (RA)

Affects 1% of people world wide, most of whom have a positive “Rheumatoid Factor” in their genetic make-up.
Peak occurrence is between 30–50
Unknown cause
It involves inflammation of synovium, potentially in all organs except the brain.

Onset of symptoms usually involves symmetrical arthritis of hands and feet, morning stiffness and swelling. Gradually spreads through more proximal structures.
Other symptoms include:
Ø Eye problems – pain in eyes or dry eyes
Ø Subcutaneous nodules
Ø General malaise symptoms
Ø Neurological complications, especially due to erosion of the odontoid peg of C2, or the cruciate ligaments that supports this part of the neck
Ø Atlatoaxial subluxation and compression of the spinal cord ® quadriparesis.
Ø Kidney problems

Ankylosis Spondylistis (AS)

95% of patients carry HLA–B27 gene
Age of onset 20–45.
1/3 have a family history
M:W – 8:1

A sufferer presents with low back pain, possibly radiating into posterior thighs.
Stiffness and pain is marked in the mornings, and improves with activity.
Early on in the progression, the lumber lordosis becomes flattened and mobility is lost. Gradually, the thoracic kyphosis becomes restricted, and as the rib joints become affected, chest expansion is diminished.
Hip and heel pain are common. 20% suffer acute iritis.
90% of suffers have mild disease, settling in the 4th decade.
10% have severe spinal restriction, often with hip disease.

Reiter’s Disease

M:F – 15:1 This is possibly inaccurate.
Triggering factors are bacterial
Predisposing factor: 90% have HLA–B27 gene

Reiter’s refers to a triad of symptoms:
Ø Arthritis
Ø Urethritis
Ø Conjunctivitis.
½ improve over several months. The rest have repeated episodes over many years.

Psoriatic Arthritis

Peak age of onset is 30 – 50
5% of people with psoriasis develop arthritis – 90% of these have nail changes.
Further symptoms and signs include:
Asymmetrical hand and feet pain and/or swelling – all joints are susceptible.
Sausage toes
Heel pain
Peripheral symmetrical arthritis, distinguished from RA by psoriasis and lack of rheumatoid factor.

Crystal Arthropathy

Gout
Problems occur when the level of uric acid in the blood stream becomes too concentrated. Uric acid is derived from the breakdown of purine from nucleic acids. A small contribution comes from diet (see later).
Obesity and high alcohol consumption accelerate Sodium Urate production.
Sodium Urate levels are higher in men than women until the menopause, when they balance out. Hence, men are more likely to suffer (M:F – 8:1).
Mean age of onset is 40 in men, 70 in woman.
Urate slowly crystallises on cartilage surfaces, in people suffering from “hyperuricaemia”.
May be precipitated by trauma, illness, dietary or alcohol excess.

Acute Gout
Monoarticular, especially in base of the big toe.
Joint becomes red, swollen, very painful and shiny.
Can resolve in days with use of Nonsteroidal Anti-inflammatories (NSAIDS), and 2 weeks if untreated.
90% of sufferers have recurrent attacks.

Tophaceous Gout
After recurrent attacks, solid deposits may form in fingers, big toes, pinna of ear and olecranon of the elbow. These nodules shine white through overlying skin, which may ulcerate or become infected.
Untreated these “tophi” eventually destroy joints.
Gout often points to more serious problems:
alcohol abuse
obesity
artherosclerosis
hypertension (­B.P.)
Developmental Abnormalities

Achondroplasia

Caused by a genetic mutation in sperm.
Abnormal growth of cartilage at the start of life, especially of the long bones. This leads to the classic characteristic of dwarfism.

Osteogenesis imperfecta – aka – “Brittle Bone Syndrome”.

A congenital defect of osteoblasts (bone forming cells) and hence failure of ossification. This leads to easy bone fracture.

Spina Bifida (Occulta)

This is when there is a failure of enfolding of nerve elements in the spinal canal during early development.
In mild cases this might be failure of fusion of one or more verbal arches, in the lumbosacral area. (It can lead to neurological problems).
The far more serious cases are called “Spina Bifida Aperta.”