Fractures Of The Distal Radius

A fracture of the distal radius occurs when the area of the radius (the largest forearm bone) near the wrist breaks. Sometimes, the position of the bone is so far out of place that it cannot be corrected using a cast. This has the potential to restrict effective movement in the arm. In this case, surgery may be required.

It may be possible to re-align the fracture without surgery. In some cases, it will be necessary to operate in order to access the broken bones to improve the alignment outcome.

Depending on the nature of the injury, there are several options for setting the bone in the correct position. These include casts, metal pins, a plate and screws, an external fixing or a combination of these techniques.

Scaphoid Fractures And Non-union

The scaphoid bone is located on the thumb side of the wrist, in the area where the wrist bends. It can be easily identified if the thumb is held in a "hitch-hiking" position. The scaphoid is at the base of the hollow made by the thumb tendons. Pain / tenderness in this region can be a sign that the scaphoid is damaged.

If your scaphoid is broken surgery may be required. During surgery, metal implants can be used to hold the scaphoid bone in place until it is fully healed. The incision may be made on the front or the back of the wrist.

Sometimes, the screw or wire can be sited with a small incision. In other cases, a larger incision is required. In cases where the fracture results in more than two pieces, a bone graft may be needed to assist healing. In this procedure, new bone is placed around the broken bone to stimulate healing. It promotes bone growth and aids healing.

Wrist Arthritis

A large number of people suffer from arthritis in their wrists, which makes it difficult to perform simple everyday activities.

Most wrist cases are caused by two variants: Osteoarthritis - a progressive condition that destroys the smooth articular cartilage covering the ends of bones. Unprotected bones then rub against each other, resulting in friction and ultimately pain, stiffness, and weakness.

Osteoarthritis can develop due to normal 'wear-and-tear' on the wrist - or as a side effect of any traumatic injury to the forearm, wrist, or ligaments.

Rheumatoid arthritis is an inflammatory disease that affects the joint linings and destroys bones, tissues, and joints. Rheumatoid arthritis often starts in smaller joints such as the wrist. It often affects the same joint on both sides of the body.

When initial treatments are ineffective, or if hand function is compromised, surgery is an option. The goal of surgery is to relieve pain. Depending on the type of surgery, joint function may also be impeded.

Surgical options include:

• Removal of the arthritic bones
• Joint fusion (making the joint solid and preventing movement of the wrist)
• Joint replacement

You and your GP can discuss these options and select the one that is most appropriate.

Wrist Ligament Injuries (Sprains)

Ligaments are strong bands of connective tissue that connect bones together. Wrist sprains are very common. There are many ligaments in the wrist that can be stretched or torn, resulting in a sprain. This occurs when the wrist is bent forcefully, such as in a fall onto an outstretched hand. These can be very prevalent in winter as a result of slipping on snow or ice.

A severe sprain occurs when the ligament is completely detached from the bone. These can often require surgical treatment. If the ligament tears from the bone, it may also take a small chip of bone with it – this is known as an avulsion fracture.

Severe sprains may require surgery to reconnect the ligament to the bone. Surgery is followed by a period of rehabilitation and physiotherapy. The ligament can be expected to heal in around 2 months. Full recovery of motion and strength can take several months, dependent on the nature of the initial injury.

Wrist Arthroscopy

Arthroscopy is a surgical procedure which helps diagnose and treat problems inside a joint. The wrist is a complex area with eight tiny bones and many more connecting ligaments.

Arthroscopy enables the surgeon to examine the wrist and its movements without major surgery.

An arthroscope is used for two reasons: to make accurate diagnoses and potentially to correct any problems with the wrist.

Arthroscopic surgery is an invaluable diagnostic and treatment tool. Because it needs fewer and smaller incisions patients generally enjoy a more rapid recovery than is seen with regular surgery. Because it is usually an outpatient procedure, most patients return home several hours after the procedure.

Hip Dislocation

When the head of the thighbone slips out of the socket in the hip bone. In most cases, the thighbone is pushed out of its socket in a backwards direction (posterior dislocation). This leaves the hip in a fixed position, bent and twisted in toward the middle of the body. The thighbone can also slip out of its socket in a forward direction (anterior dislocation). If this occurs, the hip will be bent only slightly, and the leg will twist out and away from the middle of the body.

A hip dislocation is very painful. Patients are unable to move the leg and, if there is nerve damage, may not have any feeling in the foot or ankle area. Motor vehicle accidents are the most common cause of hip dislocations and wearing a seatbelt can greatly reduce the risk. Falls from a height or industrial accidents can also generate the required force to dislocate a hip.

Often other injuries will be present, fractures to the pelvis and legs, back injuries even head trauma. A hip dislocation is an orthopaedic emergency. Call for help immediately. Do not try to move the injured person, but keep him or her warm with blankets.

Hip dislocation can be diagnosed simply by looking at the position of the leg. X-rays will reveal any additional fractures in the hip or thighbone. If the patient has no other complications, the physician will administer an anaesthetic or a sedative and reposition the displaced bones. Surgery may be required to do this.

A hip dislocation can have long-term consequences, particularly if there are associated fractures. As the thighbone is pushed out of its socket, it can disrupt blood vessels and nerves. When blood supply to the bone is lost, the bone may die. The protective cartilage covering the bone may also be damaged, which increases the risk of developing arthritis.

Hip Fractures

The extent of the break depends on the forces that are involved. The type of surgery used to treat a hip fracture is based on the bones and soft tissues affected or on the severity of the fracture.

Hip fractures most commonly occur from a fall or from a direct blow. Some medical conditions such as osteoporosis, cancer, or stress injuries can weaken the bone and make the hip more susceptible to breaking. In severe cases, it is possible for the hip to break with the patient merely standing on the leg and twisting.

Patients with a hip fracture will experience profound pain over the outer upper thigh or in the groin. There will be significant discomfort with any attempt to flex or rotate the hip.

If the bone has been weakened by disease, the patient may notice aching in the groin or thigh area for a period of time before the break.

If the bone is completely broken, the leg may appear to be shorter than the non-injured leg. The patient will often hold the injured leg in a still position with the foot and knee turned outward.

Diagnosis is generally made by x-ray. In some cases an MRI scan will reveal a hidden fracture. In general, there are three different types of hip fractures.

Intracapsular Fracture

These fractures occur at the level of the neck and the head of the femur, and are generally within the capsule. The capsule is the soft-tissue envelope that contains the lubricating and nourishing fluid of the hip joint itself.

Intertrochanteric Fracture

This fracture occurs between the neck of the femur and a lower bony prominence called the lesser trochanter. This is an attachment point for one of the major muscles of the hip.

Subtrochanteric Fracture

This fracture occurs below the lesser trochanter, in a region that is between the lesser trochanter and an area approximately 2 1/2 inches below. In more complicated cases, the amount of breakage of the bone can involve more than one of these zones. This is taken into consideration when surgical repair is considered.

When a hip fracture has been diagnosed, the patient's overall medical condition will be reviewed.

Stable Impacted Fracture

Certain fractures that have not moved ("displaced") may not require surgery.

Because there is some risk that these "stable" fractures may instead prove unstable and displace (change position), periodic X-rays of the area are required.

The surgeon's decision as to how to best fix a fracture will be based on the area of the hip that is affected.

Hip replacement

Using metal alloys, high-grade plastics, and polymeric materials, orthopaedic surgeons can replace a painful, dysfunctional joint with a highly functional, long-lasting prosthesis. Over recent years, there have been many advances in the design, construction, and implantation of artificial hip joints, resulting in a high percentage of successful long-term outcomes.

Cemented Total Hip Replacement

A patient with a cemented total hip replacement can put full weight on the limb and walk without support almost immediately after surgery, resulting in a faster rehabilitation. Although cemented implants have a long and distinguished track record of success, they are not suitable in all instances.

Cemented fixation relies on a stable interface between the prosthesis and the cement and a solid mechanical bond between the cement and the bone. The bond between cement and bone is generally very durable and reliable. Cemented total hip replacement is more commonly recommended for older patients, for patients with conditions such as rheumatoid arthritis, and for younger patients with compromised health or poor bone quality and density. These patients are less likely to put stresses on the cement that could lead to fatigue fractures.

Cementless Total Hip Replacement

In the 1980s, new implant designs were introduced, which attach directly to bone without the use of cement. Most are textured or have a surface coating around much of the implant to promote 'natural bonding' with the bone. Cementless implants require a longer healing time than cemented replacements.

The pelvis is prepared using a process similar to that used in a cemented total hip replacement procedure. The intimate contact between the component and bone is crucial to permit bonding.

Patients with large cementless stems may also experience mild thigh pain.

Cementless total hip replacement is most often recommended for younger, more active patients and patients with good bone quality where bone ingrowth into the components can be predictably achieved. Individuals with juvenile inflammatory arthritis may also be candidates, even though the disease may restrict their activities.

Partial Hip Replacements

If only one part of the joint is damaged or diseased, a partial hip replacement may be recommended. In most instances, only the head of the femur is replaced, using components similar to those used in a total hip replacement. The most common form of partial hip replacement is called a bipolar prosthesis.

Osteotomies Around The Knee

The word describes the cutting of bone. This simple procedure is a tried and tested technique in orthopaedics. It is used to straighten deformed bones and to alter the line of weight bearing through an arthritic joint to provide pain relief.

Osteotomy is used only on patients who are too young for knee replacement surgery.

In young children and adolescents, there are conditions which give rise to quite severe knock knees or bow legs. In such cases, osteotomy is employed to straighten the legs.

Osteotomies around the knee are done either on the femur or thigh bone above the knee or in the tibia or shin bone below the knee. The required amount of correction can be determined prior to surgery.

A small incision is made over the part of the bone to be treated. The bone is exposed and using a very fine saw the bone is cut across. Once cut and repositioned the bone is 'set' in place using a plate and tiny screws.

Alternatively a slice of bone is removed and then the two edges are brought together. Again this is set with a plate and screws or sometimes a small staple. Full recovery generally takes 6 weeks to 3 months.

A plaster cast may be applied to the limb following the operation. Often a plaster is not used. This also allows the knee to start moving as soon as possible to prevent arthritic symptoms.

Anterior Cruciate Ligament Replacement

The knee joint is supported by four ligaments - two outside the knee joint and two inside. The inside the knee joint are called the anterior and the posterior cruciate ligaments.

These ligaments provide stability to the knee joint. Specifically, the main function of the anterior cruciate ligament (ACL) is to prevent the knee from 'giving way'.

The ligament is often damaged during sporting activities which involve the foot being fixed onto the ground and the body twisting - causing the ligament to rupture. Typical scenarios involve skiing, football or rugby. When the ligament ruptures, a crack or a pop is heard and the knee gives way and swells quickly.

It is difficult to bear weight at the knee joint. After the trauma it is best to allow the knee to rest completely, apply an elasticated stocking and to take pain relief medication.

An x-ray is taken to ensure that there are no other bone injuries or fractures. Once this acute phase has passed the knee can be thoroughly examined. An MRI scan is often employed to assess the status of the cartilage, ligaments and soft tissues.

Occasionally arthroscopy (keyhole surgery) may be required to give a clearer picture of the damage sustained. Once the diagnosis has been confirmed physiotherapy is recommended. If the knee continues to present problems it is appropriate to consider surgery.

The operation involves three stages. A graft which will be used as the new ACL. The second stage is preparation of the knee for insertion of the graft. This procedure is carried out arthroscopically (keyhole surgery). The final stage consists of inserting the graft using screws or special pins. The operation usually takes about 40-60 minutes and assessment of the other structures in the knee is also made at the same time.

Finally the wound is dressed and an ice pack is applied. Physiotherapy will usually commence within 24 hours of surgery. CPM (continuous passive motion) is also commenced within 24 hours of surgery. This consists of placing the leg into a machine which assists in extending and flexing the knee. The hospital stay is usually between 1 to 3 days but ultimately depends upon the patient's circumstances and the surgeon's advice.

A great deal of success of the reconstruction depends upon the subsequent post-op physiotherapy. This can last 6-9 months and only at the end of this period is one able to participate in sports such as football, rugby or skiing.

Meniscectomy

The menisci act as 'shock absorbers' between the long bones making up the knee. They are made fibrous material. The majority of the meniscus does not have a blood supply and it is for this reason that healing of these tissues once damaged is practically impossible.

Damage to the meniscus is an extremely common condition that can occur during practically any form of activity. Symptoms are pain felt along the inside or outside aspect of the knee depending on which cartilage has been torn. Often pain may appear to subside, only to return later. Twinges upon movement of the knee, a sense of 'giving way' within the knee and inability to fully straighten the leg are other indications.

Meniscectomy is the surgical removal of all or part of a damaged meniscus. This is one of the most common procedures performed in the UK using a technique referred to as arthroscopy (keyhole surgery). A small camera is inserted into a small incision at the front of the knee. This allows the whole of the knee to be fully inspected.

MRI scans will show whether a meniscus is torn and on that basis a decision can be taken about the need for surgery. There is never an absolute need for surgery, however in over 90% of cases surgery will be effective.

A small incision is made into the knee, and a fibre optic telescope instrument is used to view the internal cavity. The surgeon will only remove the damaged portion of the cartilage retaining the cushion function of the cartilage.

Recovery time varies between 2 and 6 weeks. Post surgery, the patient should be returning to normal activity. Sporting activity can be resumed after approximately one month.

Total Knee Replacement

One of the most common procedures used in joints that have become stiff and painful and significantly damaged by arthritis and where loss of mobility and loss of function are present.

The objective is to re-line the damaged surface of the joint using a plate placed into the shinbone and a metal sleeve which is placed over the lower end of the thighbone. High density polyethylene decreases friction between the two metal plates.

The main reason for surgery is pain relief and enhanced mobility. The procedure takes up to two hours under a full general anaesthetic or with a spinal anaesthetic in which numbs the lower part of the body.

Following surgery the patient is rested for 24 hours after which the knee can be bent. The patient is usually able to walk with a frame or crutches. Over the following week the patient slowly increases the amount of knee movement exercises and by 7 to 10 days afterwards, the patient is able to walk reasonable distances and is able to walk up and down stairs.

Physiotherapy as an outpatient should normally continue for around 3 months.

Chondral Damage

The articular cartilage covers the bony surfaces within the knee joint. Assessment of articular cartilage is made x-rays and / or an MRI scan. If the condition of the knee remains unclear, arthroscopic (keyhole surgery) assessment is a good way of assessing the condition of the articular cartilage.

Surgery may be required in cases of severe pain, locking or swelling and to prevent later osteoarthritic progression in the knee.

Surgical options are:

• Arthroscopy and debridement
• Microfracture
• Autologous chondrocyte implantation
• Chondral grafting
• Allograft
• Osteotomy
• Knee Replacement

Multi-ligament Injury To The Knee

Major multiple ligament injuries to the knee are relatively rare. It is however not uncommon to have a minor injury to another ligament, particularly to the medial collateral ligament. This is common amongst ski injuries. The majority of these sprains will heal without surgery. If there is an excessive laxity in the ligaments, bracing is beneficial.

When two or more ligaments have a serious injury then the knee joint has usually dislocated at the time of injury. Often it immediately springs back into place.

These type of injuries can be limb threatening if the artery adjacent to the knee is torn and emergency surgery is required to re-establish blood supply to the leg below the knee. It is not uncommon for the major nerves that cross the knee to be damaged.

Early surgery is beneficial in that it offers the opportunity for repairing ligaments rather than having to reconstruct them with tendon grafts later.

Many of these injuries, if treated early can result in a good level of mobility. Our advice is that patients should avoid running and or sports to help protect the knee in the long term. The risk of minor complications such as stiffness is high and many patients will require either a manipulation under anaesthetic for stiffness or an arthroscopy.

It takes approximately 18 months to 2 years to achieve final recovery. The most arduous period is in the first 3 to 6 months. The knee will require bracing for 6 to 12 weeks and an intensive physiotherapy work.

Achilles Tendon

An Achilles tendon problem needs to be diagnosed and treated as soon as possible. The Achilles tendon is located just behind and above the heel and connects the calf muscle in the leg to the heel itself.

Two major problems are ruptures and tendonitis. The Achilles is a very strong tendon, but it can rupture when there is a sudden force or stress – particularly during sports and activities.

Tendonitis (inflammation of the Achilles) can lead to weakness and other medical conditions. Rheumatoid arthritis, gout and lupus can all leave the Achilles prone to a rupture injury.

In the case of an Achilles tendon rupture, the tear is often described as 'partial' or 'complete'. In a partial tear, there is still some degree of connection to the calf muscle. If there is a complete tear, all connection has been severed. Urgent treatment is vital.

Ankle Instability

Ankle instability is characterised by a feeling that the ankle is about to 'give way' or a feeling that the ankle feels 'wobbly', particularly on uneven surfaces. Two main ligaments support the ankle. The outer ligaments are known as the lateral ligaments and have three components which stop the ankle from rolling and sliding forward. These ligaments are attached to the fibula (a small bone next to the shin), the talus (the ankle bone) and the calcaneus (heel bone). An ankle sprain can stretch or tear these ligaments and if the sprain doesn't heal well, ankle instability can develop.

'Giving way' often takes place on the outer side of the ankle and can occur during sports and walking. It can also occur whilst standing and may be accompanied by swelling, tenderness and significant pain.

Chronic instability often follows an undiagnosed ankle sprain that was not diagnosed and treated. An ankle sprain stretches and tears the connective tissues, known as the ligaments.

When this happens, nerve sensors in the ligament are often damaged. These nerve sensors give your brain information about the position of your joints, allowing you to protect them.

If these nerve endings are not working properly, your brain does not get reliable information and the muscles around your ankle may not operate in unison. This causes the ankle to 'give way'.

Ankle instability can lead to further sprains, which in turn weaken the ankle even more. With every additional sprain, ligaments are significantly weakened. If your ankle feels unreliable and gives way repeatedly, or you are prone to ankle sprain injury, a consultation would be beneficial.

First the foot will be examined for evidence of swelling. By stretching the ankle in different directions, it is possible to determine if the ankle ligaments are compromised. X-rays and an MRI scan may also be taken.

Treatment depends upon the severity of the condition and the patient's activity levels.

Physiotherapy is effective for many cases. Surgery may be considered if ankle instability fails to improve following non-surgical treatment. There are two main surgical procedures for ankle instability:

1. Damaged ligaments are tightened and re-attached to the bone. This type of operation is highly successful and is appropriate for people with active lifestyles.
2. A tenodesis procedure involves relocating hamstring tissue to recreate ligaments. This procedure should only be considered when the instability is profound and there is a great deal of stress on the ankle. This operation is very successful but can cause ongoing stiffness.

Ankle osteoarthritis

Cartilage allows smooth movement of joints. Ankle osteoarthritis results from damage to the cartilage. Loss of, or damage to the cartilage causes inflammation of the joint and can lead to deformity.

Ankle osteoarthritis can cause stiffness, pain, swelling, deformity and problems with mobility. Some patients suffer a bony protrusion known as an osteophyte or spur and this can lead to pinching of the lining of the joint. Osteoarthritis of the foot and ankle can reduce the ability to walk and stand for prolonged periods.

In the early stages, pain may only occur at the beginning and at the end of an activity but as the condition progresses the pain occurs more frequently to the extent that it can occur with each step and even at rest.

The most common incidence of ankle osteoarthritis is following a fracture of the ankle or repeated sprains. Other causes of are flat feet or high-arches of the feet.

The diagnosis of ankle osteoarthritis is made on the basis of the patient history, examination the surgeon and is confirmed with weight-bearing x-rays. MRI scans can also be helpful.

Non-surgical treatment of includes footwear modification, anti-inflammatory medication and physiotherapy in order to promote flexibility. Injections to lubricate the ankle joint or cortisone to damp down inflammation can help but their effect is only temporary.

Arthroscopy (keyhole surgery) for ankle osteoarthritis allows the surgeon to assess and treat the joint from the inside using very small incisions. Arthroscopy however, does not cure the condition or halt the progression of the condition.

After two or three small incisions, fine surgical instruments are employed to remove any fragments of bone, cartilage and inflamed tissue. The cartilage surfaces of the joint are also 'smoothed' during the procedure.

Bunions

Bunions are swellings on the side of the big toe joint, a condition which occurs when the big toe leans too much toward the second toe. As the swelling is prominent, this area is prone to rubbing from shoes, causing inflammation and pain.

Some people have large bunions without experiencing any serious pain or discomfort. However the deviating big toe can cause pressure on the second toe, resulting in the second toe becoming a hammer toe. In some cases, the first two toes will cross over, making walking difficult.

Tight footwear is likely to cause the big toe to deform. This is almost certainly the reason why the condition is much more common in females than males. High heeled, pointed toe shoes are not the primary cause of the problem, but such footwear can accelerate the condition.

It is necessary to take an x-ray in order to determine the extent of the bunion and any associated arthritis. Around half of bunion cases can be successfully treated without surgery, the remainder are minimally invasive – involving new techniques. Gone are the days of 'extremely painful' bunion surgery.

Stiff Big Toe

A form of osteoarthritis which occurs when cartilage in the joint wears out. With every step, a force equal to about twice your body weight passes through the big toe. The big toe is under constant pressure - even whilst we stand still.

Symptoms include:

1. Pain and stiffness whilst moving the toe joint
2. Difficulty with activities such as running
3. Swelling and inflammation
4. Increased symptoms during cold or damp weather

Symptoms of advanced cases include:

1. Constant pain and discomfort - even whilst resting
2. Bony bumps on the top of the toe which rubs against footwear
3. Walking on the outer side of the foot to avoid pain.

This in turn can produce pain in the ball or outside of the foot. The big toe can ultimately become 'frozen' - where all independent movement is lost.

It is recommended that you seek medical attention if the big toe feels stiff or it is painful when you walk, bend or stand. Once the condition becomes more advanced and bone spurs develop, it is more complicated to treat.

After an examination to determine the range of movement, x-rays are taken to evaluate the extent of the condition and to note any abnormalities, which may have developed.

If the condition is caught early, non-surgical treatment is more likely to be effective.

The toe joint is usually most painful when it is bent upwards whilst walking. It can help to stiffen the sole of the shoe so it does not bend. A small 'rocker bar' can be fitted so you can walk without bending the toe. Shoes with plenty of room for the big toe should be worn. High heels and shoes with pointed toes should not.

Anti-inflammatory drugs such as ibuprofen, and may be prescribed to help reduce pain and inflammation. Injections can also help in terms of reducing pain and inflammation.

Surgery may be considered if other approaches fail to eliminate or reduce pain. There are several different types of non-invasive surgery that can be undertaken to correct the condition.

Hammer Toe

A key symptom is pain in the ball of the foot, after which the toe rapidly deforms. This is due to rupture of a structure called the plantar plate. When the toe deforms, pain is much less noticeable, but this is usually a temporary event. Pain in the ball of the foot often reappears and when the toe begins to rub against footwear and this can be very painful indeed.

Mallet Toe

A mallet toe is caused by a tightening of flexor tendon and is the easiest condition affecting lesser toes to be treated.

Cross-over Toe

A mallet toe is caused by a tightening of flexor tendon and is the easiest condition affecting lesser toes to be treated.

Other Conditions

There are a number of rarer conditions where lesser toes can be excessively short, long, big or bent.

Treatment of all of these problems can be non-operative or surgical but it is important to make a correct diagnosis and to understand the underlying mechanism that has lead to the deformity. For example operating on a hammer toe that has occurred as a result of a bunion will not work unless the bunion is treated at the same time.

Once an examination has been completed, the condition can be effectively treated.

Surgery is performed under local or general anaesthetic and for minor problems, a temporary wire in the toe will be required for up to six weeks.

Even minor toe deformities generally get worse with time and action now can prevent more serious problems in future.

Forefoot Pain

Pain is often on the sole of the foot and described as 'sharp' or 'shooting pain', similar to having a stone in the shoe. Some people describe localised pain to one or two toes whilst others describe more generalised pain or burning pain.

Sometimes there is associated swelling in the foot although not always. Hard skin may build up in the painful area. This is called a callosity. People usually experience more pain when placing weight on the affected foot but this can also occur when at rest or in bed at night. Other symptoms include numbness in the toes.

Common causes include:

1. Obesity
2. Overuse caused by sporting activity
3. Bunions
4. Arthritis of the big toe
5. Arthritis of other areas of the foot
6. Gout
7. Fracture of a metatarsal
8. Stress reaction in a metatarsal (which can precede a fracture)
9. Problems with the nerves
10. Deformed toes rubbing in the shoe

Identifying the underlying diagnosis and cause is essential to being able to advise the correct treatment. Sometimes more than one condition will be present.

Using modern keyhole surgery, many of the problems encountered with older techniques are totally avoidable. The period of immobilisation after surgery for is about 2 months and it takes approximately 6 months to resume normal use.

Midfoot Arthritis

Patients with midfoot arthritis often experience pain and swelling particularly when walking or taking part in sport. A change in the shape of the foot can then occur later.

The pain is described by sufferers as 'sharp' or 'burning'. The condition makes it difficult to find suitable and comfortable footwear.

Midfoot arthritis is largely caused by specific injury, often minor. It can lead to joint damage and osteoarthritis. The process can develop over years if the middle part of the foot is under stress because of, for example, an existing serious bunion.

Rheumatoid arthritis may also affect the midfoot. A careful clinical assessment needs to be supplemented with x-ray and MRI scans may be neccessary.

Pain relief and anti-inflammatories can help to reduce symptoms. Limiting activities that aggravate the condition is advised. Shoes should be stiff, rather than soft. Walking boots and MBT trainers are effective.

In some instances, where arthritic spurs have developed, these can be removed with a minor surgical procedure.

If the condition is advanced, fusion of the joints may be considered. By fusing together the joints using screw plates and / or staples, pain is significantly reduced.

Heel Pain

Around one in ten people will suffer heel pain during their lives. There are two main types of heel pain, occurring in different places.

1. The 'grumbling' Achilles.
   A ruptured Achilles is well known condition, but it is more common to suffer from a grumbling Achilles. The pain is felt at the back of the heel above where the Achilles tendon joins the bone. Symptoms are stiffness and swelling, especially in the morning.
2. Policeman's heel.
   The fascia is a strong band of tissue stretching from your heel to your toe bones. It supports the arch of your foot and performs the role of a 'shock absorber' for the foot. Symptoms are pain at the bottom of the heel where it meets the ground with each step. This can see patients "limping" first thing in the morning. Pain can be acute, especially after standing for prolonged periods.

Causes of the conditions vary but include:

• Long distance running
• Obesity and a sedentary lifestyle which places the heel under excessive pressure
• Tight calf muscles. This can cause the patient to 'walk on tip toes', putting the Achilles and the arch of the foot under significant pressure.

The first treatment is calf stretching exercises – as demonstrated by a qualified physiotherapist. Heel cushions are very helpful. Most patients with this condition find the pain is managed by the use of stretching exercises.

For those experiencing significant heel pain, other options include

• Extracorporeal shockwave therapy
• A course of injections
• Surgical calf stretching

After a full examination of the foot and an ultrasound 'Doppler' scan, a same day assessment can be completed. If the calf is extremely tight, we recommend surgical calf stretching because injections or shockwave therapy will prove ineffective.

Surgical calf stretching is a simple procedure involving a very small incision behind the knee.

Flat Feet

This occurs when the main arch on the insole of the foot drops, and this can be mild to severe in its extent. Often people are completely unaware of the condition

Common causes of painful flat foot are:

Inflammation of the tendon which passes to the foot on the inside of the ankle. The symptoms are pain, swelling and progressivde flattening of the foot. Untreated this can result in major disability.

Arthritis of the joints. Joints affected are the ones in the middle of the foot and the one below the ankle. These occur a result of an inflammatory condition after an injury or due to 'wear and tear'. The symptoms are those of pain and progessive deformity over time.

Many patients with a structural deformity require surgery but often no treatment other than observation and special footwear modifications are required.

Physiotherapy can help manipulate tightened muscles but won't correct a deformity. Surgery is recommended for patients with a deformity.

Surgery involves tendon transfers, reshaping bones and fusing joints, thereby releasing contractures of the soft tissue.

After a limited period in plaster, physiotherapy can optimise the final recovery. This procedure is mostly very successful, allowing the patient to resume normal activities and wear normal footwear.

Tendon Problems

Tendons and ligaments perform differing roles. Tendons connect muscles to bones. When the muscle contracts, the tendon pulls on the bone and movement occurs at the joint. Ligaments stop a joint moving too far in the wrong direction.

Tendons can be thought of as ropes, and are not as dynamic as the muscle, they do have a degree of elasticity. Stress on the tendon results in thickening, splitting or even tearing. When this occurs the whole unit of muscle and tendon loses elasticity and cannot function properly.

Patients may notice pain, swelling, weakness or a reduced sense of balance.

Problems include:

Achilles tendinopathy

Pain and discomfort is noted just above the heel bone, often due to a compromised blood supply. Thickening and tenderness of the tendon causes pain and stiffness and is often worse first thing in the morning.

Insertional tendinopathy

This condition occurs when the back of the heel bone, where the tendon meets the bone, becomes painful and swollen. Normally with the right shoes and insoles and physiotherapy surgery is not required, however surgery may be needed for the most severe cases of inflammation.

Adult flat foot

Not all cases of flat foot are due to tendon problems. However a problem involving the posterior tibial tendon is the most common. This tendon runs around the inner ankle bone and attaches to the navicular bone in the instep. It functions like braces to hold up the arch of the foot and if the tendon fails to perform its role, adult flat foot often develops.

Peroneal Tendinopathy

This condition occurs when there is damage to the tendons which run around the outer ankle bone and turn upwards and outwards at the ankle. Pain, swelling and giving-way or ankle instability are the usual complaints from this type of tendon problem.

In certain instances surgery is required to correct these problems – please speak to your GP about a referral if you believe you may suffer from one of the above conditions.

Arthrocentesis

Arthrocentesis is the clinical procedure of using a syringe to collect synovial fluid from a joint capsule. It is also known as joint aspiration. Arthrocentesis is used in the diagnosis of gout, arthritis, and synovial infections.

Collateral ligament of elbow joint

AKA 'Tommy John' surgery – named after a famous American Baseball pitcher, is a surgical graft procedure in which a ligament in the medial elbow is replaced with a tendon from elsewhere in the body (often from the forearm, hamstring, hip, knee, or foot of the patient).

The procedure is common among collegiate and professional athletes in several sports.

Elbow dislocation

A simple elbow dislocation means there is no fracture of the bones around the elbow joint. Often surgery is not required.

A complex elbow dislocation occurs where there is a fracture, usually of the forearm, that has occurred along with the dislocation. In a complex elbow dislocation, surgery is often needed to fix the broken bone in order to restore the elbow joint to a normal position.

Lateral epicondylitis (tennis elbow)

The procedure involves removal of the diseased tissue. This procedure can been performed through open and arthroscopic approaches. While the classic open approach provides excellent reproducible results, the mentioned minimally invasive approaches are reported to allow earlier rehabilitation and speedier resumption of normal activity.

Olecranon bursitis

Olecranon bursitis (also informally known as "student's elbow", "baker's elbow", "swellbow", or "water on the elbow") is a condition characterised by pain, redness and swelling. The bursae contains only a very small amount of fluid in its normal state, and fulfills the function of facilitating the joint's movement.

If the fluid continues to return after draining or the bursae is constantly causing pain, surgery to remove the bursa is an option. The minor operation removes the bursa from the elbow and is left to re-grow but at a normal size over a period of ten to fourteen days. It is usually done under general anaesthetic and has minimal risks. The surgery does not disturb any muscle, ligament, or joint structures. To recover from surgical removal a splint will be applied to the arm to protect the skin. Exercises will be prescribed to improve range of motion.

Olecranon Fractures

Olcranon fractures are common. Although they usually occur in isolation (that is, there are no other injuries), they can be a part of a more complex elbow injury.

Olecranon fractures can occur as a result of a direct blow in a fall or by being struck by a hard object. Another possibility is an indirect fracture. This can happen by landing on an outstretched arm. The person lands on the wrist with the elbow locked out straight.

Surgery to treat an olecranon fracture is usually necessary when the fracture is out of place ("displaced"). Because the triceps muscles attach to the olecranon to help straighten the elbow, it is important for the pieces to be put together so you can straighten your elbow.

Medial epicondylitis

Medial epicondylitis is commonly known as golfer's elbow. This does not mean that only golfers suffer from it, but the golf swing is a common cause. Throwing, chopping wood, using power tools, many activities that stress the same forearm muscles can be a cause.

Sometimes non-surgical treatment fails to stop the pain or regain full use of the elbow. In these cases, surgery may be necessary.

Tendon Debridement
When problems are caused by tendonosis, surgeons may choose to remove the affected tissues within the tendon. In these cases, the surgeon cleans up the tendon, removing only the damaged tissue.

Tendon Release
This surgery takes tension off the tendon. The surgeon begins by making an incision along the arm over the medial epicondyle. Soft tissues are gently moved aside so the surgeon can see the point where the flexor tendon attaches to the medial epicondyle.

The flexor tendon is then cut where it connects to the medial epicondyle. The surgeon splits the tendon and takes out any extra scar tissue. Any bone spurs found on the medial epicondyle are removed.