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Ankle Joint Pain: 7 Medical Conditions That Can Cause Pain In The Ankle

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Ankle Joint Pain: 7 Medical Conditions That Can Cause Pain In The Ankle

Ankle Joint consists of many bones, tendons, ligaments, cartilages and muscles. Injury, infection or inflammation of any of them can cause ankle joint pain. This article explains about the medical conditions that can cause pain in the ankle joints.

Ankle Joint Pain

7 Major Medical Conditions That Can Cause Ankle Pain:

  1. Soft Tissue Inflammation– A Cause Of Ankle Joint Pain
  2. Arthritis of Ankle Joint Resulting In Ankle Joint Pain
    • Ankle Joint Rheumatoid Arthritis
    • Ankle Joint Osteoarthritis
    • Ankle Joint Psoriatic Arthritis
    • Ankle Joint Pseudo-Gout
    • Ankle Joint Gout
  3. Ankle Joint Septic Arthritis Causing Pain in the Ankle
  4. Tarsal-Tunnel Syndrome Resulting in Ankle Joint Pain
  5. Bone Spurs Causing Ankle Joint Pain
  6. Ankle Joint Trauma
  7. Ankle Fracture
    • Hairline Fracture
    • Stress Fracture
    • Avulsion Fracture

Let’s go over all of the above listed medical conditions that can cause ankle joint pain in detail.

Ankle Pain Caused By Ankle Joint Tendinitis

Inflammation of ankle joint tendon is known as tendinitis, which causes severe ankle joint pain. Inflamed tendon is often enlarged and swollen; inflamed tendon is extremely painful on examination.

Causes of Ankle Joint Tendinitis

  • Overuse of Calf and Foot Muscle and Tendon-
    • Athletes and jobs requiring long distance walk.
  • Anatomical Abnormalities-
    • Flat foot or high arch foot
  • Arthritis-
    • Rheumatoid Arthritis and Osteoarthritis.
  • Trauma-
    • Blunt Trauma
    • Penetrating Wound
    • Surgery
  • Infection-
    • Cellulitis of surrounding tissue may spread to tendon.
    • Infection of tendon following injury of the tendon.

Inflammation or Injury of Following Tendons Can Cause Ankle Joint Pain:

Pain Around Ankle Can Be Due To:

  • Peroneal Tendinitis
    • Recurring ankle sprain.
  • Achilles Tendinitis –
    • Most common sports injury.
  • Posterior Tibial Tendinitis –
    • Associated with flat foot.
  • Flexor Tendonitis
    • Pain mostly at the back of the foot.
  • Extensor tendonitis
    • Mostly occurs secondary to tight shoe.

Ankle Pain Caused By Ankle Bursitis

Inflammation of bursa is known as bursitis. Ankle bursitis causes extremely painful ankle joint pain. Bursas are placed between bone and tendon or ligament. Movements or transmission of weight along ankle joints results in extruciating ankle joint pain. Bursitis is often seen following injury and infection of soft tissue.

Ankle Pain Caused By Rheumatoid Arthritis Of Ankle

Rheumatoid Arthritis (RA) is an autoimmune form of arthritis in which the antibodies and the immune cells attacks joint tissue, causing inflammation, pain, and swelling. Any joint may be affected by rheumatoid arthritis, including the ankle joint resulting in ankle joint pain. Rheumatoid arthritis causes inflammation and thickening of synovial membrane and ligaments causing severe ankle joint pain.

Ankle Pain Caused By Degenerative Ankle Joint Arthritis?

Osteoarthritis is a degenerative arthritis. Untreated or long lasting osteoarthritis causes thinning of bones and ligaments resulting in degenerative arthritis. Ankle joint pain caused by osteoarthritis of ankle joint is associated with degeneration of the bones and joints.1

Is Osteoarthritis Self-Limiting Disease?

Osteoarthritis (OA) is not a self-limiting disease. Joint osteoarthritis if not treated may result in joint dislocation and tendon atrophy. Initial ankle joint pain is secondary to inflammation of synovial membrane and ligaments. During advanced stage of disease ankle joint pain is caused by dislocation or subluxation of the ankle joint.

Ankle Pain Due To Psoriatic Arthritis

Psoriatic ankle joint arthritis causes swelling and pain of the ankle joint resulting in severe sudden ankle joint pain. The ankle joint pain is associated with the psoriatic skin lesions. Many joints including the ankle joint is affected by psoriasis. Joint inflammation is periodic and ankle joint pain is seen during the joint inflammation. Ankle joint pain may be absent if the inflammation is diminished.

Gout- A Cause For Pain Around Ankle

Gout is a form of arthritis in which uric acid or monosodium urate crystals periodically deposit in ankle joints, causing severe ankle joint pain and swelling. Uric acid crystals induce inflammation of synovial membrane and ligament. The ankle may sometimes be affected by gout. Gout is most often seen over the big toe.

Pseudogout- Causing Ankle Joint Pain

Pseudogout means false gout. Pseudogout is caused by calcium pyrophosphate deposition over the cartilage or ligaments of the ankle joint. The term Pseudogout is used to indicate the similarities of the disease like gout. Both the diseases are caused by deposition of inorganic compound followed by inflammation of synovial membrane and ligaments. The ankle joint pain caused by pseudogout depends on crystal deposits inducing inflammation of synovial membrane and ligaments.

Ankle Pain Caused By Septic Ankle Arthritis

Septic ankle joint arthritis is an infection of the ankle joint resulting in ankle joint pain. Most common infection of the ankle joint is caused by bacterial infection. Septic arthritis develops quickly causing severe ankle joint pain, ankle joint swelling and fever. Joint movement and bearing weight on ankle joint causes severe ankle joint pain.

Causes of Septic Ankle Arthritis Are As Follows

  • Blunt Trauma To The Ankle
  • Penetrating Injury In The Ankle
  • Impaired immune system- AIDS
  • Diabetes

Ankle Pain Caused By Tarsal Tunnel Syndrome

Tarsal tunnel syndrome (TTS) is a very painful disease resulting in severe ankle joint pain spread over ankle joint and bottom of the foot. Tarsal tunnel is covered by tibiocalcaneal ligament. Ligament is known as tarsal ligament and spread in oblique direction on the medial side of ankle joint. Tarsal ligament is attached to medial malleolus of tibia and calcaneus bone. Posterior tibial nerve along with artery, vein, and tendons passes through the tunnel under the tarsal ligament. The ankle joint pain is caused by irritation or pinch of the posterior tibial nerve within tarsal tunnel. Initial symptoms are pain and tingling. Later if disease is not treated symptoms could be permanent numbness and weakness.

Ankle Pain Due To Bone Spurs

Bone spurs are abnormal spiking outgrowth of the bone around the edge or border of the bone. Spurs may be observed over shaft or end of the bone involved in joint formation. Spur causes ankle joint pain when located within ankle joint or causes friction with tendon. Spurs may discharge bone fragments in the ankle joint and may cause ankle joint pain with joint movements.

Ankle Joint Sprain

Several bones forming the joint are held together by ligaments. Ankle joint sprain is caused by turn and twist of the ankle joint resulting in tear or injury of the joint ligaments. Damage to any one of the ligaments in the ankle can cause severe ankle joint pain with joint movement or weight bearing in standing position. Pain is less severe when foot is elevated in lying position. Restriction of joint movement also reduces pain.

High Ankle Joint Sprain Causing Ankle Joint Pain

High ankle joint is ligamental binding between tibia and fibula above talus bone. The ligament, which binds tibia and fibula is known as syndesmotic ligament. High ankle sprain resulting in ankle joint pain is caused by injury, tear or scratch of the syndesmotic ligament. A high ankle sprain causes less ankle joint pain than ankle sprain. Swelling and tenderness is often not noticeable. The ankle joint pain lasts for long time and healing is often prolonged.

Pain Around Ankle Due To Tendon Tear or Tendon Rupture

Rupture or tear of tendons supporting ankle joint is a common injury among average individuals, which results in ankle joint pain. Twisting or tripping of lower leg or foot often occurs while ambulating on uneven or icy surface. Such injury results in rupture of one of the tendon of ankle joint. Tendon is non-elastic tight band attached to hard surface of bone and muscle fibers. During fall or twist, tendon is stretched to maximum length. In addition to being stretched, tendon is pulled by vigorously contracting muscles. Muscle contraction is a protective reflex during any painful events. Stretched tendon may result in tear when pulled by contracting muscles while opposite end is anchored to bone.

Pain In The Ankle Due To Dislocation

Ankle dislocation is a separation of joint link resulting from forceful sliding of one of the bone. True ankle joint dislocation involves dislocation between tibia and talus, or fibula and talus. Ankle joint dislocation is often associated with fracture of medial malleolus bone. Ankle dislocation without fracture is very rare. Subtalar dislocation occurs between talus and calcaneus bone. Ankle joint dislocation causes severe and continuous ankle joint pain.

Causes of Ankle Joint Dislocations Are As Follows:

  • Fall on uneven surface, ice or slope.
  • Automobile or Work accident.
  • Disabling Joint Disease- Advanced osteoarthritis.

Risk Factors for Ankle Joint Dislocation

  • Old age
  • Musculoskeletal Disorder- Muscle weakness and polio.
  • Neurological Diseases- Peripheral neuropathy, numbness, and paresthesia.
  • Frequent Fall- Epilepsy, dizziness, vertigo.
  • Pre-Existing Advanced Arthritis- Osteoarthritis and Rheumatoid Arthritis.
  • Slip and Fall- On slippery surface.
  • Direct Impact
  • Contact Sports- Like Wrestling, Football or Ice Hockey.

Ankle Joint Fracture

Ankle joint fracture involves break in any of the four bones in the ankle. Fracture of ankle joint mostly involves tibia and fibula. Most common fracture is medial malleolus and lateral malleolus bone, followed by lower end of tibia above medial malleolus. Fracture of talus and calcaneus is rare. Ankle joint fracture results in severe and continuous ankle joint pain.

Ankle Joint Fracture

Classification of Ankle Fracture

Types of Ankle Fracture-

  • Hairline Fracture of Ankle– Bone pieces or segments are not displaced.
  • Partial Separating Fracture of Ankle– Partial separation or shift is detected.
  • Complete Separation Fracture of Ankle-Divided in several groups as follows-
    1. Comminuted Fracture of Ankle- Broken into several pieces
    2. Impacted Fracture of Ankle- Bone fragments are impacted into adjacent fragments of fracture bone.
    3. Avulsion Fractures of Ankle- Fragments of the bone are displaced at adjacent position.

Causes of Ankle Fracture

  • Injury– Fall, direct impact caused by auto or work accident.
  • Degenerative Joint Disease– Osteoarthritis.
  • Sport Injury– Fall, stress on impact over outstretched upper extremity.

Watch Video Of Causes of Ankle Joint Pain

References:

  1. Ankle osteoarthritis: etiology, diagnostics, and classification.
    Barg A, Pagenstert GI, Hugle T, Gloyer M, Wiewiorski M, Henninger HB, Valderrabano V.FootAnkle Clin.2013 Sep;18(3):411-26. doi: 10.1016/j.fcl.2013.06.001.Orthopaedic Department, Osteoarthritis Research Center Basel, University Hospital of Basel, University of Basel, Spitalstrasse 21, Basel CH-4031, Switzerland; Harold K. Dunn Orthopaedic Research Laboratory, University Orthopaedic Center, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA. Electronic address: [email protected]
  2. Ankle dislocation without fracture.
    Wroble RR, Nepola JV, Malvitz TA.
    Foot Ankle.1988 Oct;9(2):64-74.
    University of Iowa Hospitals and Clinics, Department of Orthopaedic Surgery, Iowa City.

Understanding Ankle Joint: Know About the Supporting Ligaments, Tendons, Muscles

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Understanding Ankle Joint: Know About the Supporting Ligaments, Tendons, Muscles

What Is Ankle Joint?

Ankle Joint is hinged synovial joint supported by several ligament, tendon, cartilage and muscle. Ankle joint is made up of two joints, which functions together to achieve flexion (upward), extension (downward) and lateral (side to side) movement of the feet.

What Is Ankle Joint?

Ankle Joint–

  • True Ankle Joint.
  • Subtalar Joint.

What is True Ankle Joint?

The true ankle joint is composed of tibia, fibula and talus bone. Tibia lies on medial (inner) side and fibula lies on lateral (outer) side above the upper surface of talus. Ankle joint allows limited flexion and extension of the feet.

What is Subtalar Joint?

Subtalar joint is between talus and calcaneus bone. Talus sits on top of calcaneus bone. The subtalar joint allows side to side movements of the foot.

Which Ligaments Support Ankle Joint?

Ligaments are thick and tough band of fibrous tissue. The major ligaments of the ankle joints are as follows-

Anterior Ligament

This is divided in following sub-groups

  • Anterior tibio-fibular ligament- connects the tibia to fibula.
  • Anterior tibio-talar ligament.
  • Anterior talo-fibular ligament.

Posterior ligament

This is divided in following sub-groups

  • Posterior tibio-talar ligament.
  • Posterior fibula-talar ligament.

Lateral Collateral Ligaments

  • Calcaneo-fibular ligament, attach the fibula to the calcaneus bone.

Deltoid Ligaments

These lie on medial or inner side of the joint and connects tibia to the talus. Deltoid ligaments are divided in following subgroups-

  • Tibionavicular.
  • Tibiocalcaneal.
  • Tibiotalar anterior.
  • Tibiotalar posterior.

Capsular Ligaments

Capsular ligaments are thin and mostly support the anterior section of the joint.

  • Anterior (front) capsular ligament
  • Posterior (back of the joint) capsular ligaments

Which Are The Tendons That Support Ankle Joint?

Tendons are like ligaments a tough band of fibrous tissue connects end of muscles to bones. Tendon facilitates anchoring of the muscles to the bone around the joint. Tendon helps to stabilize the joint.

Ankle Joint

List of tendons supporting ankle joint are as follows-

  • Achilles Tendon– attaches calf muscles to back of calcaneus bone.
  • Flexor Hallucis Longus– lies along the inside of the ankle and attaches to the big toe.
  • Flexor Digitorum Longus– lies on medial or inside of the ankle joint and attaches to remaining 4 toes but big toe.
  • Peroneus Tendon– divided as peroneus brevis and peroneus longus lies on outside of the ankle joint and attaches to shaft of 5th metatarsal bone and spreads to bottom of the foot.
  • Posterior Tibial Tendon– attaches the midfoot and function is to maintain normal arch of the foot.
  • Anterior Tibialis Tendon– attaches anterior tibialis muscles to the bones of the midfoot.

Which Muscle Supports Ankle Joint?

Muscles are not directly in contact with ankle joint. Tendons are distal end of muscles and lies in contact with the ankle joint.

What Is Medial Malleolus?

The medial malleolus is the most prominent part of the lower end of the tibia, lies just under the skin on inner side of ankle joint.

What Is Lateral Malleolus?

Lateral malleolus is the bony prominence on outside of the ankle joint. Lateral malleolus is the lower end of the fibula bone and prone for fracture.

Watch 3D Video of Ankle Joint Anatomy

References:

  1. Ankle osteoarthritis: etiology, diagnostics, and classification.

    Barg A, Pagenstert GI, Hügle T, Gloyer M, Wiewiorski M, Henninger HB, Valderrabano V.FootAnkle Clin.2013 Sep;18(3):411-26. doi: 10.1016/j.fcl.2013.06.001.Orthopaedic Department, Osteoarthritis Research Center Basel, University Hospital of Basel, University of Basel, Spitalstrasse 21, Basel CH-4031, Switzerland; Harold K. Dunn Orthopaedic Research Laboratory, University Orthopaedic Center, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA. Electronic address: [email protected]

  2. Ankle dislocation without fracture.

    Wroble RR, Nepola JV, Malvitz TA.

    Foot Ankle.1988 Oct;9(2):64-74.

    University of Iowa Hospitals and Clinics, Department of Orthopaedic Surgery, Iowa City.

What Can Cause Lower Right Abdominal Pain?

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What Can Cause Lower Right Abdominal Pain?

Lower Right Abdominal Pain

Lower right abdominal pain is pain in the region where an imaginary horizontal line is drawn below the lower right ribs till the right side of another imaginary longitudinal line along the umbilicus. Pain occurring in the lower right abdominal region is often acute. Lower right abdominal pain can occur abruptly or can be chronic in nature. The pain can be of any nature, i.e. sharp or dull, diffuse or localized. Other symptoms accompanying lower right abdominal pain include: Nausea, vomiting, constipation, tenderness, diarrhea, gas, bloating, loss of appetite and fever.

Organs or Structures in the Lower Right Abdominal Region

Structures located in the lower right abdominal region, which can be a source of pain due to some problem in them:

  • Some regions of large intestine (cecum).
  • Appendix.
  • Ascending colon.
  • Some parts of small intestine.
  • Right ovary.
  • Right fallopian tube.
  • Right ureter.
  • Lower pole of the right kidney.
  • A part of the uterus.
  • Lymph nodes, blood vessels, bones, muscles and skin in that area.

Any problem, infection, injury, inflammation, twisting, wind retention, cancer or tumors in the above mentioned structures causes lower right abdominal pain. We will look at some of the common causes with symptoms, investigations and treatment for pain in the lower right abdomen.

Lower Right Abdominal Pain

What Can Cause Lower Right Abdominal Pain?

6 Most Common Causes of Lower Right Abdominal Pain are:

  1. Lower Right Abdominal Pain Caused Due to Appendicitis

    Appendicitis is a condition where the appendix gets inflamed and this is the most common cause for right lower abdominal pain.

    Symptoms: Pain which is achy in nature and starts around the umbilicus and then moves to the lower right abdominal region. The pain worsens and becomes more acute after some hours with tenderness to touch. Other symptoms include: Nausea, vomiting, low-grade fever, loss of appetite, and constipation or diarrhea.

    Investigations: Blood tests, urine tests, abdominal x-ray and CT scan.

    Treatment for Lower Right Abdominal Pain Caused Due to Appendicitis: Appendectomy is done to remove the inflamed appendix surgically.

  2. Lower Right Abdominal Pain Caused Due to Stones in The Right Kidney

    Stones in the right kidney causes pain in the lower right abdominal region.

    Symptoms: Extremely severe pain occurring beneath the right ribs, back and the right side. Pain caused due to right kidney stone may radiate towards the lower right abdominal region and groin. The pain can be spasmodic in nature and can vary in intensity. Other symptoms are: Pain when voiding, frequent urination, brownish/pinkish/reddish colored urine, cloudy/ foul-smelling urine, nausea, vomiting and fever with chills.

    Investigations: Urine tests, blood tests, x-rays, CT scan and intravenous pyelography.

    Treatment for Lower Right Abdominal Pain Caused Due to Right Kidney Stone: Treatment comprises of drinking lots of water. Pain killers help in relieving pain. For large stones, treatment comprises of extracorporeal shock wave lithotripsy (SWL), which breaks the stones into tiny pieces, so it can pass via urine. Surgical procedures such as percutaneous nephrolithotomy can be done to remove larger stones.

  3. Lower Right Abdominal Pain Caused Due to Infection in the Right Kidney

    Infection in the bladder or any part of the urinary tract can extend to kidneys resulting in kidney infection causing pain and inflammation.

    Symptoms: Pain is present in the lower abdomen, back, flank, or groin. Patient feels a constant need to urinate. Other symptoms are: Painful urination, blood or pus in the urine and fever.

    Investigations: Urine test is done and culture and sensitivity (C and S) test.

    Treatment for Lower Right Abdominal Pain Caused Due to Kidney Infection: Antibiotics are given to treat the infection. Painkillers are given for relief from pain.

  4. Lower Right Abdominal Pain Caused Due to Cysts in the Right Ovary

    Cysts are the fluid filled sacs on the ovary’s surface which can grow larger and cause pain and discomfort, especially if they get twisted.

    Symptoms: Pain in the lower right abdomen, which can be dull and achy in nature, pain in the pelvis which radiates towards the thigh and lower back. Other symptoms are: Feeling of fullness or heaviness in the abdomen, nausea, vomiting and pressure sensation on the rectum or bladder.

    Investigations: Pregnancy test, laparoscopy, pelvic ultrasound, and CA-125 blood test.

    Treatment for Lower Right Abdominal Pain Caused Due to Ovarian Cyst: OCPs are given. Surgery is done if the cyst is large.

  5. Lower Right Abdominal Pain Caused Due to Ectopic Pregnancy

    Ectopic pregnancy is a condition where the fertilized egg gets implanted outside the uterus, e.g. fallopian tube, ovary or in the abdominal cavity. If it gets implanted in right ovary or tube, then it causes severe lower right abdominal pain.

    Symptoms: Severe pain on the lower right abdomen (can be misdiagnosed as appendicitis), missed period, vaginal bleeding and other symptoms of pregnancy.

    Investigations: Pelvic exam, blood tests and ultrasound.

    Treatment for Lower Right Abdominal Pain Caused Due to Ectopic Pregnancy: If the ectopic pregnancy is detected in early stages, then methotrexate injection is given to halt the growth of the cells and disintegrate the remaining cells. Otherwise surgery is needed for later stages of ectopic pregnancy.

  6. Lower Right Abdominal Pain Caused Due to Constipation

    This is again a common cause of right (and even left) abdominal pain.

    Symptoms: Patient is not able to pass stools easily and often passes hard stools a couple of times a week. Symptoms other than abdominal pain are: Bloating, straining, rectal pressure and pain when defecating.

    Investigations: Barium enema x-ray, defecography, sigmoidoscopy, colonoscopy, anorectal manometry, colorectal transit study or marker study.

    Treatment for Constipation Causing Lower Right Abdominal Pain: Pain gets relieved after a bowel movement. Increasing dietary fiber benefits a lot in constipation. Other than this, you can try taking laxatives or stool softeners.

    So, there are many causes for lower right abdominal pain. Patients should consult their doctor immediately for severe and persistent pain in the lower right abdominal region. After testing and evaluation, treatment can be started after cause of the pain is identified.

Also Read:

Abdominal Pain or Stomach Ache in Children: Causes, Signs, Treatment

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Abdominal Pain or Stomach Ache in Children: Causes, Signs, Treatment

Abdominal Pain or Stomach Ache in children is the most common complaint and one of the most common reasons for parents to take their children to pediatricians. There are many causes for abdominal pain in children. Some of them are quite minor, whereas some can be quite serious in nature. However, with correct diagnosis and right treatment, the problem of abdominal pain or stomach ache in children can improve quite quickly. The tricky part for parents is to decide whether their children’s complaint warrants immediate medical attention or not. Treatment depends on the cause of abdominal pain and can range from rest and liquid diet to hospitalization and even surgery.

Abdominal Pain or Stomach Ache in Children

Causes of Abdominal Pain or Stomach Ache in Children

Given below are 6 common causes for the abdominal pain or stomach ache in children

Infections

Infections such as bacterial or viral can cause abdominal pain, e.g. stomach flu (gastroenteritis). Abdominal pain or stomach ache in children caused due to viral infections have a tendency to abate quickly, whereas bacterial infections need antibiotics for treatment.

Food Intake

If children have been exposed to eating contaminated food then it can lead to food poisoning, which has symptoms similar to that of gut/stomach flu. Other food related causes for abdomen pain or stomach ache in children include overeating, food allergies, gases resulting in bloating and discomfort. If the cause of abdominal pain or stomach ache in children was due to contaminated food intake then its symptoms often occur immediately after eating.

Medications

Over dosage of medications like acetaminophen (acetaminophen poisoning) also causes stomach ache in children.

Accidental Swallowing

Kids, especially infants, tend to put everything in their mouth, such as medicine tablets, eating soap, swallowing coins etc.. all these things result in abdominal pain or stomach ache in children. One has to be very careful about this aspect because accidental swallowing can also block the airway and that can be a medical emergency.

Surgery Related

Causes or problems related to surgery such as obstruction of the bowels or appendicitis also causes stomach ache in children.

Other Medical Issues:

Children can have abdominal pain, as a result of complications from diabetes. Other causes such as getting bitten by a black widow spider also causes pain in the abdomen.

Signs and Symptoms of Abdominal Pain or Stomach Ache in Children

When children, especially infants, have abdominal pain or stomach ache, they will cry a lot or curl up; this is the first indication that something is not right. Older children can easily tell their parents how they feel, where it hurts, etc. It’s very important for a parent to elicit correct information from their children so that their doctor can arrive at the correct diagnosis and treatment.

Parents should look into the following signs and symptoms of abdominal pain or stomach ache in children:

Duration of Discomfort

Length of the time for which the child has had symptoms of stomach ache is important. Abdominal pain in children subsides in a short time if the cause is minor. Other causes such as stomach flu, can cause persistent abdominal pain in children for more than a day and needs medical attention.

Site of the Pain

Usually pain symptoms from simple reasons is situated in the abdomen’s center. In such cases, children tend to rub around their belly button. If the abdominal pain is felt in other regions, then it is a cause for concern, especially if it is in the lower abdomen or in the right abdominal region, as then the symptoms of abdominal pain or stomach ache in children could be due to appendicitis.

General Appearance

If the child appears very sick, i.e. if one has pallor, is sweating, is not able to eat or hold down any food, then immediate medical attention should be sought to address these symptoms that accompany stomach ache in child.

Vomiting

Symptoms of abdominal pain in children is often accompanied by vomiting and it does not necessarily mean a serious problem. However, if the vomiting persists for a long time, i.e. for more than a day; and if the vomit is of yellow or green color; or if it contains blood, then it is a cause for concern and parents should take their child immediately to the ER.

Diarrhea

Like vomiting, diarrhea also often accompanies abdominal pain and indicates viral cause. In most cases diarrhea doesn’t last for more than 3 days, but if it persists beyond that and contains blood, then parents should seek immediate medical care.

Fever

If the cause of abdominal pain or stomach ache in children is infection, then fever is present and it may not necessarily be a serious problem; likewise, for some serious causes of abdominal pain, the child may have a high temperature.

Pain in The Groin

Abdominal pain or stomach ache in children can be radiated from other sources, such as in testicular torsion in boys. So, if your child indicates any groin pain, immediate medical attention should be sought and if ignored, then it can result in a serious situation.

Problems With The Urinary System

If abdominal pain is accompanied with signs or symptoms of difficulty in urinating, pain with urination, frequent urination, then it may indicate an infection in children and needs medical attention.

Appearance of Rash:

Abdominal pain in children when accompanied with a rash is a serious concern and requires immediate medical attention.

Abdominal Pain or Stomach Ache in Children

Investigations To Diagnose Abdominal Pain or Stomach Ache in Children

  • Blood tests including CBC, LFTs, blood cultures, lead level and/or amylase/lipase levels.
  • Complete urine examination (CUE) may be required to diagnose the cause of stomach ache in children.
  • Stool test to check for parasites, bacteria or blood.
  • X-ray of the abdomen.
  • Ultrasound of the abdomen (and testicles if needed).
  • CT scan of the abdomen.
  • Barium enema/swallow.
  • Pelvic exam.
  • Anal manometry.

Treatment of Abdominal Pain or Stomach Ache in Children

Treatment for abdominal pain in children depends on the cause of the pain. Minor causes only require rest, lots of fluids and a bland diet. If the cause of abdominal pain is some serious medical condition, then hospital stay and surgery may be needed.

Given below are some simple treatment measures which can help get rid of abdominal pain or stomach pain in children:

  • Rest: Rest is important for any illness. For abdominal pain in children, lying face down helps in alleviating pain from gases.
  • Diet: Liquid diet is very important; however, you should never force your child, especially if he/she is vomiting, as they won’t be able to hold too much liquid. The best way is to give your child small sips of fluids (around 1 to 2 ounces), periodically (every 10 to 15 minutes), till the child is able to keep down more. Drinks which are sugary, tinted, caffeinated, carbonated, salty or fatty should be strictly avoided.
  • Fluids to Give: Milk, tea, coffee, dark colas, fruit juices and sports drinks should not be given to children suffering from abdominal pain or stomach pain. Water and boiled milk should be avoided in infants, as they can cause disturbances with the salt content in their bodies, plus milk is difficult to digest for a sick stomach. Over-the-counter oral electrolytes are easily available and are recommended by the doctors as best to be given in such cases. However, the parents should try to get back their child on normal feedings as soon as the child feels better.
  • Start Solid foods slowly such as with toast and crackers then you can move on to regular foods depending on the tolerance level of your child.
  • Fruits, such as apple sauce and banana, and other foods like cooked rice are also recommended after a liquid diet.

References:

  1. “Abdominal Pain in Children: What Should Parents Do?” by Dr. Alan Greene, Verywell Family. Available at: https://www.verywellfamily.com/abdominal-pain-in-children-2633811
  2. “Abdominal Pain in Children” by Christopher Gambacorta, MD, MSD, MSDx. Available at: https://www.msdmanuals.com/professional/pediatrics/symptoms-in-infants-and-children/abdominal-pain-in-children
  3. “Abdominal Pain in Children” by Dr. Janice Joneja, HealthLink BC. Available at: https://www.healthlinkbc.ca/health-topics/abdominal
  4. “Abdominal Pain in Children” by Rachel Reiff Ellis, Healthline. Available at: https://www.healthline.com/health/childrens-health/abdominal-pain-in-children
  5. “Stomachache or Abdominal Pain in Children” by Nemours KidsHealth. Available at: https://kidshealth.org/en/parents/abdominal-pain.html

Cataract Surgery Video: Watch How Phacoemulsification Cataract Surgery is Performed

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Cataract Surgery Video: Watch How Phacoemulsification Cataract Surgery is Performed

Watch 3D Video of Cataract Surgery: How Phacoemulsification Cataract Surgery is Performed

Cataracts: A Brief Note

The cataract is the clouded area in the lens of the eye which causes poor vision. The lens of eye is situated behind the cornea, iris, and pupil. A normal human eye has clear lens. Human eye lens is just like a camera, it adjusts itself to focus the vision. Human eye lens contains water and protein.

Types of Cataracts

  • Nuclear Cataracts
  • Cortical cataracts
  • Posterior Subcapsular Cataracts
  • Congenital Cataracts

Risk Factors for Cataracts Development

  • Ageing
  • Alcoholism.
  • Diabetes mellitus
  • Excessive sunlight exposure
  • Hereditary
  • Recent eye injury and/or surgery.
  • Smoking

Diagnostic Tests for Cataracts

  • Slit-Lamp Examination
  • Visual Acuity Test
  • Retinal Examination

Cataract Surgery: Phacoemulsification Cataract Surgery Procedure

The protein content in the eye lens changes with age and some of the protein may clump together obstructing the vision. This condition can be treated by Phacoemulsification Cataract Surgery. Anesthesia is given around the eye. A small incision is made in the cornea of the eye and through it fluids are injected to support the surrounding structures. Top of the lens capsule is removed and the cloudy area, the cataract portion of the lens is accessed. The surgeon uses the ultrasonic waves to break up and remove the cataract. Once the cataract is removed, an intraocular lens is positioned properly into the empty lens capsule. The artificial lens (IOL) restores the patient vision after few days. All surgeries entail some or other risk. Fortunately, cataract surgery is highly successful with favorable outcomes at approximately 98%.

Q and A On Causes of Shoulder Pain: 13 Major Medical Conditions Causing Shoulder Pain

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Q and A On Causes of Shoulder Pain: 13 Major Medical Conditions Causing Shoulder Pain
What Causes Shoulder Pain

What Causes Shoulder Pain?

The following 13 Major Medical Conditions Can Cause Shoulder Pain or Shoulder Joint Pain

  • Inflammation– Tendinitis (rotator cuff tendinitis), bursitis and arthritis.
  • Rotator Cuff Tear
  • Frozen Shoulder
  • Shoulder Joint Instability
  • Calcified Tendinitis
  • Shoulder Joint Tear
  • Impingement Syndrome
  • Injury– Tear of soft tissue, dislocation and fracture.
  • Sprain– Overextension, falling on outstretched arm.
  • Pinched Nerve
  • Referred Pain– Gallbladder disease, heart disease.
  • Radicular Pain– Cervical (neck) disk herniation or bulge disk, cervical spinal stenosis.
  • Primary or Metastatic Tumor of shoulder joint.

What is Shoulder Joint Tendinitis?

Several tendons support shoulder joint. Inflammation of tendon is known as tendinitis. Most common tendinitis is rotator cuff tendinitis.

What Is Shoulder Joint Bursitis?

Bursa is the synovial sac filed with lubricant fluid and lies between tendon, muscles, and bones. There are four bursas around the shoulder joint. Bursa protects tendon, ligaments and muscles from friction with bones resulting in soft tissue damage. Bursitis is the inflammation of the membrane of the bursa.

Causes of Bursitis Are As Follows-

  • Excessive strenuous use of the shoulder joint
  • Excessive non-strenuous activity of shoulder joint like frequent combing of the hair
  • Associated with Rotator Cuff Tendinitis
  • Complications of Arthritis
  • Trauma

Watch 3D Video on 5 Major Types of Arthritis of the Shoulder Joint

What Is Shoulder Joint Arthritis?

Shoulder joint can be affected by rheumatoid or osteoarthritis. Osteoarthritis causes wear and tear of the joint structures causing tear of soft tissue or dislocation. Pain is secondary to inflammation of the joint soft tissue and capsule. Joint is swollen and stiff resulting in severe intractable pain.

What Is Rotator Cuff Tear or Injury?

Rotator cuff tear or injury occurs when the tendons of the rotator cuff separate from the capsule of the joint and bone. Surgery is sometimes necessary for this condition.

What Is Frozen Shoulder Pain?

Frozen shoulder is also known as adhesive capsulitis. Frozen shoulder results following injury and inflammation of the fibrous tissue of the capsule. Inflamed capsule and ligaments cause severe pain and restriction of the shoulder joint movements, thus known as frozen shoulder.

Causes of inflammation of the capsule are as follows-

  • Injuries
  • Autoimmune Disease
  • Diabetes
  • Stroke
  • Lung Diseases
  • Connective Tissue Disorders
  • Thyroid Disease
  • Heart Disease

What Is Shoulder Joint Instability?

The tensile strength of joint capsular ligament prevents subluxation and dislocation of the joint. Capsule is supported and reinforced by tendons and muscles of the shoulder joint. Instability of shoulder joint occurs secondary to loose capsule or weakness in tendon and muscles. Weak capsule or tendon causes on and often displacement of head of the humerus because of loose intact capsule, rim, and rotator cuff.

Complication of instable shoulder joint is as follows-

  • Dislocations– Partial or Complete.
  • Subluxation– Partial dislocation of shoulder joint.
  • Tear of ligament, tendon and muscles.

What is Calcific Tendinitis?

Calcific tendonitis is a painful condition seen in patient following calcium deposits within a tendon or ligaments. Several ligaments and tendons are involved in maintaining normal function of the shoulder joint. Calcium tendinitis is more often seen with calcium deposits of rotator cuff.

Causes of Calcium Tendinitis Are As Follows-

Acute Calcific Tendinitis (ACT)– ACT is cause by excessive use of shoulder joint and often seen in following individuals-

  • Tennis Player.
  • Baseball Pitcher.

Chronic Calcific Tendinitis (CCT)– CCT causes long-term chronic tendinitis and pain. CCT is observed in-

  • Degenerative Diseases- Like osteoarthritis
  • Old Age- Wear and tear of tendon

What Is Shoulder Joint Tear?

Shoulder joint tear could be partial or complete. Tear may involve one of the following soft tissues.

  • Ligaments
  • Tendons
  • Muscles
  • Cartilages
  • Glenoid Labrum Tear

What is Glenoid Labrum Tear?

X-Ray, CAT scan or MRIs are often used for diagnosis of fracture of bone. Fracture of cartilage and soft tissue is difficult to diagnose with radiological studies. Soft tissue and cartilage fracture is diagnosed using telescope as in arthroscopy. Glenoid labrum tear is a fracture of the rim of the capsule or the cartilage of shoulder joint. Diagnosis is often difficult unless arthroscopy is performed.

What Is Shoulder Joint Impingement Syndrome?

Shoulder impingement syndrome occurs as a result of thickening of coraco-acromial ligament. Rotation or movements of the shoulder joint causes pinch and pressure over the underlying soft tissue resulting in severe pain. Impingement can cause following complication resulting in severe pain.

  • Bursitis.
  • Tendinitis.
  • Rotator Cuff Tear.

What Is Shoulder Joint Dislocation?

Dislocation is a separation of head of the humerus from the socket or glenoid cavity of the scapula bone. Shoulder joint is susceptible for dislocation because of wide range of movements within the capsule. Shoulder joint dislocation results in 50% of the ER cases of joint dislocation. Shoulder joint dislocation causes shift of head of femur in anterior, posterior or inferior position of the joint.

What Is Shoulder Joint Fracture?

Fracture is a partial break or complete separation of the bone.

Classification of Fracture– Fracture is classified according to direction of the break or separation of the bones.

  • Direction
    • Transverse
    • Oblique
    • Spiral
  • Separation-
    • Hairline Fracture– bone pieces or segments are not dislodged.
    • Partial Separating Fracture– partial separation or shift is detected.
    • Complete Separation Fracture– divided in several groups as follows-
      • Comminuted– Broken into several pieces
      • Impacted Fracture– Bone fragments are impacted into adjacent fragments of fracture bone
      • Avulsion Fracture- Fragments of the bone are displaced at adjacent position.

Cause of Fracture–

  • Injury– fall, direct impact caused by auto or work accident.
  • Degenerative Joint Disease– Osteoarthritis.
  • Sports Injury– Fall, stress on impact over outstretched upper extremity.

Fracture Involves Following Shoulder Joint Bones–

  • Head of humerus
  • Shaft of the humerus
  • Glenoid cavity or socket of scapula

What Is Referred Shoulder Joint Pain?

Referred pain is the pain felt at different location while cause of the pain is at different site and unrelated to the region where pain is felt.

Following Diseases Causes Referred Pain at Shoulder Joint-

  • Gallbladder Disease
  • Liver Disease
  • Heart Disease
  • Diseases of Cervical (neck) spine– Disk Herniation, Bulge Disk, Spinal Stenosis, Cervical Radiculopathy, Cervical Facet Joint Pain

What Is The Risk Of Shoulder Joint Injury?

Risk of shoulder joint injury results from repeated use of optimum range of movements.

Following are the risk dynamics of shoulder joint injury-

  • Pre-Existing Arthritis– Osteoarthritis and Rheumatoid Arthritis.
  • Frequent Fall– Frequent spell of dizziness, history of Epilepsy.
  • Vertigo– Resulting in dizziness and frequent fall.
  • Slip and Fall– On slippery surface with arm outstretched.
  • Direct impact– Over the shoulder.
  • Contact Sports– Like Wrestling, Football or Ice Hockey.

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Shoulder Joint or Glenohumeral Joint: Structure, Function, Movements, Muscles

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Shoulder Joint or Glenohumeral Joint: Structure, Function, Movements, Muscles

What is Shoulder Joint?

Shoulder joint is a ball and socket joint also known as ‘Glenohumeral Joint”. The joint is formed by three skeletal bones and supported by several ligament and muscles. Synovial membrane covers the inner surface of the joint. Acromio-clavicular joint between lateral (outer) end of clavicle and acromion bone of scapula is also considered as a subsection of shoulder joint.

Shoulder Joint

What Is The Skeletal Structure of Shoulder Joint?

The proximal end (near shoulder joint) of the humerus is identified as head of the humerus, which is shaped like a ball known as head of humerus. Head of the humerus is larger in size than socket of the shoulder joint. The head rests over the socket known as glenoid. The contact between the bones is stabilized by a capsular rim consisting of thick band of fibrous tissue known as labrum. Rim enlarges the area of socket to accommodate the head of humerus. Rim also allows the strong band of outer surface for the ligaments to anchor to form a rotator cuff.

How Many Bones Are Included In Shoulder Joint?

Shoulder joint is formed by following three bones:

What Is The Function Of The Shoulder Joint?

Shoulder joint allows the most efficient use of upper extremities in almost all direction.

Shoulder Joint allows following movements of upper extremity-

  • Flexion
  • Extension
  • Lateral Rotation- Upper arm is turned outward at shoulder joint.
  • Medial Rotation- Upper arm is turned inward at shoulder joint.
  • Abduction- Arm is stretched away from the body and placed against the head.
  • Adduction- Arm is at rest position against side of the body
  • Circular rotation of upper extremity
  • Scapular elevation
  • Scapular depression

What Is Ball And Socket Joint?

The proximal end of the humerus near shoulder joint is shaped like a bony round ball attached to the shaft of the humerus. Ball like structure of the humerus fits in the socket of the scapula. Hollow socket is also known as “Glenoid”. Socket is the outermost part of the scapula. The shoulder joint is supported by a rotator cuff.

How Effectual Is Shoulder Joint Movements?

Movement of shoulder joint is extremely proficient. The upper extremity has a wide range of movements anchored around shoulder joint. An efficient movement of upper arm in various directions allows athletes to participate in various sports. Outstretched arm can protect body from injury during accidental fall or emergency situation. Joint efficiency is depended on least resistant rotating movements of head of humerus within stationary smooth least resistance sockets of scapula. Arm movement is further facilitated by the ability of the scapula itself to slide along the rib cage.

Which Are the Soft Tissue Supporting the Shoulder Joint?

Shoulder joint is supported by joint capsule made up of ligaments, tendon, bursa and muscles.

Describe the Ligaments Supporting Shoulder Joint?

Ligaments are band of tough fibrous tissue that links and anchors ends or sides of the bones to maintain the link and stability of the joint.

Following are the ligaments associated with shoulder joint-

Coracoacromion Ligaments– links coracoid bone to acromion bone.

Glenohumeral Ligaments (GHL)– forms the joint capsule, surrounds the joint from all sides. GHL is composed of group of ligaments that anchors the humerus to glenoid. GHL is the main capsule that encloses head of humerus in socket of scapula. GHL is made up of three ligaments called superior GHL, Middle GHL and Inferior GHL.

Coraco-Clavicular Ligament– Ligament is small and strong, and helps to anchor scapula to lateral (outer) end of clavicle.

Transverse Humeral Ligament- Ligament holds the tendons of the long head of biceps to the humerus.

List the Tendon Supporting Shoulder Joint?

Tendons are the thick bundle of tough fibrous tissue like ligaments. Tendons are located between end of muscle mass and bone. Tendon is continuation of muscle fibers as fibrous bundle, which anchors muscle to the bone

List of tendons associated with shoulder joint are as follows-

  • Supraspinatus Tendon
  • Subscapulais Tendon
  • Infraspinous Tendon
  • Teres Minor tendon
  • Long Head of Biceps

List of Muscles Supporting Shoulder Joint

Serratus anterior, subclavius, pectoralis minor, sternocleidomastoid, rhomboid major, rhomboid minor, trapezius and deltoid muscles are the muscles that support shoulder joint.

What Is Rotator Cuff?

Head of humerus and socket of scapula (Glenoid) held together by thick fibrous joint capsule. The capsule is reinforced and supported by muscles and tendons spread around the rim of the joint. The group of muscles and tendon supporting the shoulder joint is known as rotator cuff.

List The Cartilages Involved In Shoulder Joint?

Shoulder joint has two cartilages covering head of humerus and glenoid cavity (socket) of scapula. Surface of cartilage is smooth and allows glide and movements in all the directions.

References:

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Understanding Knee Joint, Its Structure, 6 Causes of Knee Joint Pain

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Understanding Knee Joint, Its Structure, 6 Causes of Knee Joint Pain

Understanding Knee Joint and its Structure

Knee joint Comprises Of:-

  • Bones- Femur, Tibia and Patella.1
  • Cartilages- Medial and Lateral Menisci.
  • Ligaments- Medial and Lateral Cruciate Ligaments, Medial and lateral Collateral Ligaments, Patellar Ligaments, and Oblique Popliteal Ligament.

Understanding Knee Joint

How Are The Three Bones Positioned In Knee Joint?

Femur lies on the top of tibia forming a main compartment of the knee joint, and patella lies in front of the knee joint.

Where Is Patella Located In Knee Joint?

The patella is a flat bone. Back (posterior) surface of patella articulate with femur and forms an anterior compartment of the knee joint. The tendon of the quadriceps femoris muscle adheres and covers anterior surface of the patella.

Where Are The Cartilaginous Menisci Situated In Knee Joint?

Two cartilaginous menisci are shaped like “C” lies on inner and outer side of upper flat surface of tibia. Fibrocartilaginous menisci are crescentic in shape. Outer border is convex and thick, while inner border is concave and thin.

What Is The Function Of Cartilaginous Menisci?

The cartilaginous menisci are fastened to superior or upper surface of tibia and lies between tibia and femur. The surface of the cartilaginous menisci is smooth and allows effortless movements of knee joint between tibia and femur. The outer thick portion of the menisci are well vascularized and heal completely following tear. Inner portion of the menisci are poorly vascularized and do not heal well, may at time ends in necrosis. Menisci assist in smooth flexion and extension movement of knee joint. Menisci also acts as a shock absorber when acute pressure changes occur within knee joint.

Which Are The Knee Joint Ligaments?

Ligaments are divided as extra-capsular ligaments and intraarticular ligaments.

Extra-Capsular (external) Ligaments–

  • Patellar Ligament.
  • Medial Collateral Ligament (MCL).
  • Lateral Collateral Ligament (LCL).
  • Oblique Popliteal Ligament.
  • Arcuate Ligament.

Intra-Articulate Ligaments–

  • Anterior Cruciate Ligament (ACL).
  • Posterior Cruciate Ligament (PCL).
  • Posterior Menisci-Femoral Ligament. 

What Are The Causes Of Knee Joint Pain?

6 Causes of knee joint pain are-

  1. Inflammation of Soft Tissues-
    • Bursitis
    • Synovitis
    • Tendinitis
  2. Injuries-
    • Bones- Fracture of tibia, femur, patella or fibula and Dislocation of knee joint and patella.
    • Tear-
      • Ligament
      • Muscles
      • Cartilages-menisci
  3. Knee Joint Disease-
    • Arthritis
    • Infection
    • Cancer Tumor
  4. Loose Body In The Joint-Fragments of:
    • Bones
    • Cartilages
    • Soft tissue
  5. Muscle Disease-
    • Spasm
    • Myalgia
  6. Pinch Nerve
    • Obturator Nerve
    • Femoral Nerve

What is Bursitis?

Bursa is a sac of natural lubricant fluid enclosed in a cyst that lies between bone and tendon or bone and muscles.2 Bursa prevents injuries of the tendon or muscles resulting from persistent friction of tendon or muscles over hard surface of bone. There are several bursas around knee joint protecting several tendons from friction injuries. Inflammation of bursa is known as bursitis. Bursitis is observed following knee joint surgery or injuries. Bursitis is very painful condition. Most common bursitis resulting in severe knee joint pain is ”housemaid’s knee” and ”preacher’s knee.” A ”Baker’s cyst” is a bursitis observed as a tender swelling over the back of the knee.

What is Tendinitis?

Inflammation of tendons is known as Tendinitis. Tendinitis is seen following trauma or injury to the tendon.3 Tendons and ligaments are occasionally damaged following sports injury, accidental injury, fall or surgical trauma. Tendinitis is very painful condition, mostly observed during joint movement, muscle contraction or direct pressure on tendon. Tendinitis is caused by irritation and inflammation of one or more tendons. Injured tendon may heal with scar tissue and become tight band of fibrous tissue. In few cases non-inflamed tendon could be painful as in Illiotibial band syndrome.

What Is Iliotibial Band Syndrome?

Iliotibial ligament is attached to pelvic bone and outside of knee joint over tibia. Sports injury of runners and contact sports participants often causes soft trauma of the Iliotibial tendon. Tendon injury heals with minor scarring of muscles and tendons. Tendon becomes very tight with scar tissue causing shortening of the tendon. The disease is very painful and known as an iliotibial band syndrome. Pain is on the outside of knee joint unlike patellar tendinitis and Osgood Schlatter disease.

What Is Patellar Tendinitis?

Patellar tendinitis causes pain in front of the knee joint.4 Patellar tendon is the distal end of quadriceps muscles. Patellar tendon is attached to anterior surface patella and tibia. Runners, skiers, cyclists and participants of contact sports often suffer with inflammation of the patellar tendon. Inflammation is caused by continuous contraction and friction between patella bone and patellar tendon. Pain often is mistaken for the patellar dislocation.

What is Osgood Schlatter Disease?

Tendon of the quadriceps muscles spreads over patella and attaches to anterior surface of patella and tibial bone below patella. Overuse of quadriceps muscles causes irritation of the tendon below patella. Continuous vigorous use of irritated tendon and quadriceps muscles causes pain over the tibial attachment and eventually results in inflammation of tendon. Symptoms are more common in young patients and examination indicates lump below knee joint. Disease is known as Osgood Schlatter disease. Patellar tendinitis and Osgood Schlatter disease may be misdiagnosed as Patella-Femoral Pain Syndrome.

What is Patella-Femoral Pain Syndrome?

Patella-femoral pain syndrome is also known as Patellar Chondromalacia. Pain is more predominant over the top of the patella near femur bone. Pain is caused by friction between patella and femur bone because of minor misalignment. Disease is seen in older patients secondary to degenerative patellar disease. Similar pain is also observed in patellar dislocation.

What is Patellar Dislocation?

Patellar dislocation is either partial or complete. Partial dislocation is also known as patellar subluxation. Area over Knee Cap (patella) is extremely painful and swollen. Examination may or may not indicate displaced patella. Patellar displacement is seen in complete dislocation of patella. Displacement of patella is not seen when patella is partially subluxated. Dislocated patella or kneecap in most cases lies on outside of knee. Patellar dislocation often follows tear of knee joint ligaments. Symptoms of Patellar Dislocation are often same as symptoms of Anterior Cruciate Ligament (ACL) or Posterior cruciate Ligament (PCL) injury.

What is Anterior Cruciate Ligament (ACL) injury?

Femur and tibia are fastened to each other by anterior and posterior cruciate ligament. Ligaments prevent subluxation and dislocation as well as hyperextension of knee joint. Anterior Cruciate Ligament (ACL) injury is often seen in athletes involved in contact sports. Ligaments may be partially or completely torn following overstretched knee joint in hyperextension. Ligament also tears following direct high-speed impact of the leg above the knee joint. Condition is extremely painful. Complete tear may be associated with partial dislocated knee joint.

What is Posterior Cruciate Ligament (PCL) Injury?

The posterior cruciate ligament (PCL) is one of the four major ligaments that lies within the knee joint. PCL is a tough ligament. PCL functions to prevent posterior subluxation of tibia over femur bone. PCL also prevents lateral shift of patella. PCL injury is observed in younger patients during contact sports resulting in partial or complete tear of ligaments. PCL tear is also observed in older patients suffering with degenerative knee diseases. Degenerative diseases cause degeneration of meniscus, ligaments and bones resulting in laxity of knee joint space. Slack knee joint of older patients occasionally hyper-extends while walking on rough uneven surface, and results in tear of PCL. PCL may follow subluxation of knee joint and patella. PCL and ACL tear may be associated with Meniscus tear.

What is Meniscus Tear?

Meniscus is a “C” shaped cartilage that adheres to tibia and participates in knee joint activities all the time. Meniscus tear is observed in all ages. Tear is common among younger patient involved in vigorous training for jogging, cycling, skiing and contact sports. Professional sports and vigorous training results in rapid wear and tear of knee joint structures and cartilages of meniscus. Forceful knee joint activities creates rapid changes in shearing forces within knee joint, which may result in meniscus tear. Meniscus tear is also common among elderly population secondary to degeneration of the cartilage. Meniscus tear causes severe pain with joint movements. Symptoms of meniscus tear are often same as loose body syndrome.

What Is Loose Body Syndrome?

Loose body syndrome is very painful condition. Pain is observed following any movements of knee joint. Loose body may be a fragment of bone, cartilage or soft tissue. This is common in older patients suffering with degenerative knee disease. Very rarely a loose body could be a foreign body such as fragments of bullets or metal accidentally introduced into knee joint. Loose body syndrome may be associated with degenerative knee joint arthritis.

What is Knee Joint Arthritis?

Arthritis is an inflammatory disease of knee joint. Most common arthritis causing knee joint pain is rheumatoid arthritis, osteoarthritis, psoriatic arthritis, gout and pseudogout.

  • Osteoarthritis– Osteoarthritis is most common type of degenerative arthritis of knee joint. Wear-and-tear with aging affects bones, cartilages and tendon causing severe pain. Osteoarthritis may be precondition for dislocation, meniscus tear and ligamental tear in older population.
  • Rheumatoid Arthritis- Rheumatoid arthritis is second most common arthritis of knee joint caused by autoimmune disease. Pain is moderate to severe and responds to treatment.
  • Gout- Gout of knee joint is a rare disease. Gout is caused by increased concentration of uric acid in knee joint.
  • Pseudogout- Pseudogout of knee joint is more common than gout. Pseudogout is caused by deposition of crystals of calcium in joint fluid.
  • Psoriatic Arthritis- Psoriatic arthritis is observed in 30% of patients suffering with psoriasis. Pain is often moderate to severe.

Watch 3D Video of Knee Joint Rheumatoid Arthritis:

 

What is Septic Arthritis?

Septic arthritis is seen following knee joint infection. Knee joint is swollen, painful and red. Septic arthritis is often seen after trauma, surgery and septicemia. Patient often has fever.

How Severe Is Pain Caused By Cancer Tumor Of Knee Joint?

Cancer tumor spread in knee joint could be benign or malignant. Knee joint cancer or metastatic bone tumor is very rare. Knee joint contains bones, cartilages and tendons. Malignant cancer of bone (Osteosarcoma), cartilage (Chondrosarcoma) or tendon (Fibrosarcoma) may occur within knee joint even though it is very rare. Benign tumor like lipoma is common mostly localized over posterior compartment of knee joint. Pain caused by spread of malignant cancer is extremely severe than benign cancer like lipoma. Malignant cancer spreads rapidly and causes severe intractable pain.

How Can A Muscle Disease Cause Knee Joint Pain?

Spasm of muscles around knee can cause severe pain and is often misdiagnosed as knee joint pain. Fatigue muscles often induce pain with flexion and extension of knee joint. Diseases such as fibromyalgia, myofascial disease and muscle tear affecting muscles close to knee can imitate pain similar to knee joint pain.

What Are The Pinch Nerve Pains Of Knee Joint?

Structures of knee joint receive sensory nerve from obturator, femoral and tibial nerve. All or any one of the three nerves can be pinched along its course to knee from spinal cord. Nerves may be pinched secondary to disk herniation, bulge disk, spinal stenosis or foraminal stenosis within spinal canal. Nerve could be pinched outside spinal canal along its course to knee joint by hematoma, abscess or tumor. Pain may be wide spread along the course of the nerve or localized depending on where the nerve is pinched. Pain is excruciating and continuous.

References:  

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Art Therapy or Activity Therapy: Uses, Benefits

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Art Therapy or Activity Therapy: Uses, Benefits

What is Art Therapy or Activity Therapy?

Psychotherapy which uses “Art” or “Activity” as a chief mode of interaction is known as “Art Therapy” or “Activity Therapy.” The overall goal of the practitioners of Art Therapy is to allow individuals have a change and grow at a personal level with the use of art materials in a conducive environment. The relation between the practitioner and the person receiving therapy is of utmost importance. Art therapy or Activity is different from other psychological therapies, in that it is a group process between the client, the therapist, and the medium of art which may include sculpting, drawing, painting, music, and other different art modalities. Thus, it gives the opportunity for putting across thoughts and interact, and it can be particularly helpful to people who find it difficult to put across their thoughts and feelings verbally.

Uses of Art Therapy or Activity Therapy

Art Therapy or Activity Therapy is generally used to treat anxiety, depression, family issues, relationship issues, domestic violence, substance abuse, emotional difficulties due to disability or illness, trauma, cognitive, and neurological problems.

Art therapy or Activity therapy is one of the various modalities competent of helping guide someone to good health and happiness. The quest of art can be accomplished through various mediums including sculpting, drawing, painting, music, and other different art modalities. Art therapy is very useful in assessing and treating a variety of the psychological disorders.

Art therapy or Activity therapy is applied on children, teenagers, adults, elderly, families, veterans, and people with chronic health issues. Art therapy is also used to treat anxiety, depression, family issues, relationship issues, domestic violence, substance abuse, emotional difficulties due to disability or illness, trauma, cognitive, and neurological problems.

Art therapy is not a mechanism capable of suddenly curing, healing, correcting, restoring, or resolving a person’s mental health needs. Rather, it is similar to a variety of psychotherapeutic modalities. It is an instrument that helps guide and promote psychological health and well being.

This therapy is useful for promoting self-expression, feelings, and emotions.

Understanding Art Therapy or Activity Therapy

Art therapists or Activity therapists have significant understanding of the processes involved, which is further strengthened by vast knowledge of remedial practice and they work with both individuals and groups in an array of residential and community based settings like learning disabilities, family centers, palliative care, etc. The specialty of this area of work is displayed in the number of “special interest organizations” that have developed in association with “British Association of Art Therapists.” More thorough information about this can be acquired from the Association.

Art Therapy or Activity Therapy

Art therapy or Activity therapy is a varied profession and thus it is necessary to make certain that the practitioners are maintaining standards that should be upheld by a professional body. Art Therapists are required to register with the “Health Professions Council.”

Benefits of Art Therapy or Activity Therapy

  • Art therapy has the ability to assist in positive viewpoint on one’s life.
  • It is beneficial in promoting a sense of personal independence, self-reliance, and self-sufficiency.
  • It can also benefit the child to work through difficult experiences.
  • One of the benefits of Art Therapy or Activity therapy is that it allows a child to communicate his/her emotions that otherwise may be abandoned from others in the community.
  • Art therapy encourages constructive techniques to self-manage.
  • It increases one’s awareness and orientation.
  • It helps facilitate and develop strategies for fine and gross motor skills, finger dexterity, etc.
  • It encourages development of healthy coping strategies.
  • Art Therapy or Activity therapy is beneficial in facilitating insight, understanding, and acceptance of other people’s life challenges.
  • Activity therapy is also helpful in promoting problem-solving skills.
  • It is capable of discovering, managing, and providing perception into traumatic experiences.
  • It is useful in developing interpersonal skills.
  • It allows and lends a voice to those receiving therapy.
  • Activity therapy or Art Therapy is capable of helping children increase their attention span and decreases any frustration in them.

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Lower Abdominal Pain: 9 Most Common Causes, Symptoms, Investigations, Treatment

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Lower Abdominal Pain: 9 Most Common Causes, Symptoms, Investigations, Treatment

Pain or discomfort in the abdomen, below the level of umbilicus (belly button) is known as lower abdominal pain. Lower abdominal pain is spread below the umbilicus in midline as well as on right and left side. The midline lower abdominal pain is spread between belly button and pubic symphysis. Pubic symphysis is a prominent pelvic bone that lies in lower abdomen close to midline. The pain felt above the pubic symphysis is known as suprapubic pain.

Lower abdominal pain is quite common, particularly in the women. The female reproductive organ lies in lower abdomen and pelvis. The reproductive organs are uterus, vagina, ovaries and fallopian tubes. The pain caused by diseases of these organs are referred to lower abdomen. Thus lower abdominal pain is observed more often in female than male.

9 Most Common Causes of Lower Abdominal Pain

9 Most Common Causes, Symptoms, Investigations and Treatment for Lower Abdominal Pain

  1. Appendicitis
  2. Cystitis (Bladder Infection)
  3. Pelvic Inflammatory Disease
  4. Dysmenorrhea (Menstrual Pain/Cramps)
  5. Miscarriage
  6. Endometriosis
  7. Urinary Tract Infection (UTI)
  8. Fibroids
  9. Polycystic Ovarian Syndrome

9 Most Common Causes, Symptoms, Investigations and Treatment of Lower Abdominal Pain

Appendicitis. Inflammation of appendix is a painful condition. If initial symptoms are ignored then infected appendix may rupture and spread infection in peritoneal tissue. Appendicitis pain occurs in the lower right abdomen and can radiate to other regions of the abdomen. The abdominal pain can worsen within a span of a few hours.

Symptoms of Appendicitis-

Pain-Pain is localized over lower right abdominal quadrant. Pain is also referred to area of umbilicus. Pain is burning in character and moderate to severe, when appendix is inflamed and not ruptured. Abdominal pain becomes severe and excruciating with character of burning, throbbing and piercing pain when appendix is ruptured. The area of abdominal pain become wider when appendix is.

Nausea and Vomiting- The symptoms of nausea and vomiting is observed when appendix is ruptured.

Abdominal Wall Guarding- The lower right abdominal muscle contracts when appendix is ruptured. The inflammation and infection spreads from lumen of infected appendix to surrounding peritoneal tissue. Any touch or palpation during examination increases pain and triggers muscle contraction. Such a severe muscle contraction causes contraction of overlying muscle and the condition is known as guarding. Guarding is often wide spread muscle contraction resulting in tight generalized abdominal wall.

Abdominal Wall Rigidity- The contraction of muscle causes tight or rigid right lower abdomen. Abdominal wall guarding is observed when inflamed swollen or ruptured appendix is irritating the overlying peritoneum and abdominal wall. The muscle contraction is often observed when abdominal organ is inflamed and such contraction protect the organs from spreading the infection and also prevents sudden increased pain by guarding the inflamed organ such as appendix. Abdominal wall rigidity is more local and observed over right lower abdomen.

Fever-The infection of appendix causes fever.

Investigations to Diagnose Appendicitis.

Full Blood Count-

White Blood Cell Count (WBC)-Increased WBC count indicates presence of infection.

Erythrocyte Sedimentation Rate (ESR)- The ESR is increased. The blood is collected in a special test tube. The ESR is a time taken by cells in blood to settle at the bottom of the tube. The faster ESR suggest presence of infection and tissue inflammation.

Electrolyte and Urea-In most cases electrolytes and blood urea nitrogen level are normal. Occasionally patient may suffer with severe dehydration and electrolyte abnormalities because of severe nausea and vomiting. In such cases abnormal level of sodium, potassium and blood urea nitrogen is found in blood examination.

C Reactive Protein (CRP)- CRP is increased in patient suffering with most infection such as appendicitis.

Ultrasound Scan- Ultrasound scan images show soft tissue abnormalities. Infected appendix is seen as a swollen finger like organ close to cecum and terminal part of small intestine. Ultrasound image can differentiate ruptured appendix and surrounding issue inflammation.

CT-scan and MRI-Computerized tomography scan (CT-Scan) images and Magnetic resonance images (MRI) show the swelling and abnormalities of appendix.

Laparoscopy- Laparoscopy study involves skin incision and then insertion of tubular camera known as laparoscope in to abdominal cavity. Surgeon then can see the color image of appendix on television. The study is performed in outpatient or hospital surgery room.

Treatment of Appendicitis.

Pain Medications-

  • NSAIDs- Motrin, Naproxen or Celebrex
  • Opioids-Severe lower abdominal pain due to appendicitis may not respond to NSAIDs. Severe lower abdominal pain is treated with opioids for 7 to 10 days.
  • Antibiotics-Bacterial infection resulting in appendicitis is treated with antibiotics.
  • Intravenous Fluid-Dehydration and electrolyte abnormalities are treated with saline (sodium chloride) intravenous fluid.
  • Surgery-Surgery is performed to remove the inflamed appendix.1

Cystitis (Bladder Infection)

Bacterial infection of urinary bladder is known as cystitis which can cause lower abdominal pain. Cystitis is a non-infectious or infectious condition. Non-infectious cystitis is caused by bladder mucosal trauma and irritation. Bladder mucosal trauma is caused by endoscope during cystoscopy procedure or prostate surgery. Cystitis causes mild to severe suprapubic lower abdominal pain.2

Symptoms of Cystitis.

  • Pain and feeling of pressure like symptom in lower abdomen above pubic symphysis.
  • Fever
  • Burning sensation while passing urine is felt in lower abdomen.
  • Increased urinary frequency
  • Small amount of urine is passed each time one feels urge of urination
  • Blood in urine
  • Cloudy urine

Investigations to Diagnose Cystitis-

  • Urine examination
  • Blood examination
  • Cystoscopy
  • CT scan and MRI.

Treatment of Cystitis.

  • Pain Medication
  • NSAIDs
  • Tylenol
  • Opioids
  • Antibiotics are given to treat the infection
  • Intravenous fluid
  • Heating pad

Pelvic Inflammatory Disease Causing Lower Abdominal Pain

Pelvic inflammatory disease involves infection of female reproductive organs. The pelvic organ infection causes lower abdominal pain. Pelvic inflammation is observed in uterus, fallopian tube and ovaries. Pelvic inflammatory disease in male is caused by inflammation or infection of prostate. Moderate to severe lower abdominal pain is felt above and below pubic symphysis when pain is caused by diseases of uterus and prostate. Lower abdominal pain on left or right side is caused by diseases of ovary and fallopian tube.

Lower abdominal pain caused by diseases of female reproductive is often referred to lower back. Pain intensity is increased during intercourse. Pain is felt during act of urination. Intensity of lower abdominal pain caused by diseases of pelvic organ increases when urinary bladder muscle is contracting to urinate.

Symptoms.

  • Pain- Mild to severe lower abdominal pain is felt in midline on the right and left side.
  • Fever
  • Increased vaginal discharge
  • Feeling weakness
  • Nausea

Investigations of Pelvic Inflammatory Disease.

  • Blood examination
  • CT scan or MRI examination
  • Pelvic ultrasound 3
  • Endometrial biopsy and
  • Laparoscopy

Treatment of Pelvic Inflammatory Disease.

  • Pain medications
  • NSAIDs– Motrin, Naproxen or Celebrex
  • Tylenol
  • Opioids for severe pain

Antibiotics- Antibiotics are the main line of treatment for lower abdominal pain caused due to pelvic inflammatory disease.

  • Surgery
  • Excision of pelvic abscess
  • Removal of fallopian tube
  • Excision of uterus
  • Removal of ovaries
  • Removal of prostate

Dysmenorrhea (Menstrual Pain/Cramps)

Dysmenorrhea is a cramping pain in the lower abdomen during and before a woman’s monthly period. Dysmenorrhea is caused by increased level of prostaglandin. Prostaglandin increases frequency and force of uterus muscle contraction. Dull and throbbing pain is felt in lower abdomen during menstrual period. Pain often radiates to the lower back and thigh. Fibroid disease of uterus also causes dysmenorrhea during menstruation. Symptoms of dysmenorrhea are often tolerable in individual who are involved in daily exercise and take daily hot water tub bath during menstrual period.

Symptoms of Dysmenorrhea.

  • Pain- Pain is mostly spread over lower abdomen and referred to back.
  • Abdominal Cramping- Cramping pain is felt in lower abdomen during menstrual periodic.4 Pain is frequently felt as squeezing and stabbing pain.
  • Nausea and vomiting
  • Feeling tired and fatigue

Investigations to Diagnose Dysmenorrhea.

  • Ultrasound
  • CT scan
  • Magnetic Resonance Imaging (MRI)
  • Hysteroscopy and
  • Laparoscopy.

Treatment of Dysmenorrhea.

  • Analgesics (pain medications)
  • NSAIDs such as ibuprofen and naproxen
  • Tylenol
  • Oral Contraceptive Pills
  • Pills are given to prevent ovulation.
  • Heating pad

Surgery-

  • Excision of uterus fibroid
  • Excision of uterus
  • Preventive Therapy-
  • Regular exercise
  • Rest
  • Hot tub bath during menstruation
  • Miscarriage

Spontaneous pregnancy loss before the 20th week is known as miscarriage and it causes pain in the lower abdomen. Uterus contracts during miscarriage that results in lower abdominal pain.

Symptoms to Diagnose Miscarriage.

  • Lower abdominal cramping pain.
  • Vaginal spotting or bleeding.
  • Amniotic fluid discharge from vagina.
  • Investigations to Diagnose Miscarriage.
  • Pelvic Exam- Check bleeding from uterus and remove any specimen of miscarriage.
  • Ultrasound Examination- Check the presence or absence of any tissue in uterus.
  • Hemoglobin- Check level of hemoglobin to evaluate loss of blood.
  • Human Chorionic Gonadotropin Hormone (HCGH)- Check the level and pattern of HCGH to confirm diagnosis of pregnancy.
  • Biopsy or lab study of discharged tissue.

Treatment of Miscarriage.

  • Rest is recommended for threatened miscarriage.
  • Pain medications if needed
  • Surgery- Patient is considered for dilatation and curettage procedure to remove any remains of incomplete miscarriage.

Endometriosis

Uterus is the major female sex organ. Fetus grows within uterus. The inner mucosal lining of uterus is known as endometrium. Occasionally endometrial mucosa starts growing within uterus and also outside uterus. The spots of endometrium travels through fallopian tube and spills outside fallopian tube over ovaries and pelvic floor.

Endometrial mucosa also lodges over the mucosal layer of fallopian tube. The deposited endometrial mucosa starts growing in size during menstrual cycle. Such condition is then known as endometriosis. Endometriosis involves ovary, fallopian tube and floor of pelvis. Endometrial tissue causing endometriosis is found over appendix and colon.5

Symptoms of Endometriosis.

  • Pain- Severe lower abdominal pain is felt during menstrual period.
  • Dysmenorrhea– Dysmenorrhea is a cramping pain in the pelvis that may refer to lower back and abdomen.
  • Dyspareunia– Intolerable pain is felt during intercourse.
  • Lower Abdominal Pain- Increased lower abdominal pain is felt during urination and defecation,
  • Heavy menstrual periods
  • Infertility.

Investigations to Diagnose Endometriosis-

  • Pelvic exam
  • Ultrasound
  • Laparoscopy.

Treatment of Endometriosis Causing Lower Abdominal Pain.

Analgesics- Analgesic are used to treat lower abdominal pain caused due to endometriosis.

  • NSAIDS
  • Tylenol
  • Opioid
  • Hormone therapy also helps in relieving endometriosis pain.
  • Surgery
  • Excision of Uterus when endometriosis is not responding to medication and not spread to other area.
  • Removal of fallopian tube and ovaries
  • Urinary Tract Infection (UTI)

Urinary tract infection involves infection of kidney, bladder, ureter and urethra. Urinary Tract Infection causes lower abdominal pain.

Symptoms of Urinary Tract Infection.

  • Pain in the lower abdomen and pelvis
  • Persistent urge to urinate
  • Burning micturition
  • Cloudy urine
  • Hematuria
  • Rectal pain.

Investigations to Diagnose Urinary Tract Infection.

  • Complete urine examination (CUE)
  • Culture and sensitivity test (C and S)
  • CT scan
  • Intravenous pyelogram (IVP)
  • Cystoscopy.

Treatment of Urinary Tract Infection.

  • Pain medication
  • Antibiotics- Antibiotics are the first line of treatment. Antibiotics are given as pills and I.V. antibiotics.
  • Fibroids

These are the noncancerous growths occurring in the uterus commonly seen during childbearing age in women. Fibroid causes severe lower abdominal pain during menstruation and severe bleeding.

Symptoms Caused By Fibroid.

  • Pain or pressure in the pelvis
  • Severe menstrual bleeding
  • Frequent urination
  • Constipation
  • Referred pain in the back and legs.

Investigations to Diagnose Uterine Fibroid.

  • CBC
  • Ultrasound
  • Magnetic Resonance Imaging (MRI)
  • Hysterosonography
  • Hysterosalpingography
  • Hysteroscopy.

Treatment to Diagnose Uterine Fibroid.

  • Pain
  • Hormone Therapy- Treatment comprises of hormonal therapy,
  • Uterine artery embolization,
  • Surgery-
  • Myolysis- removal of fibroid,
  • Laparoscopic or robotic myomectomy,6
  • Removal of uterus
  • Hysteroscopic Myomectomy
  • Endometrial ablation of fibroid
  • Resection of submucosal fibroids
  • Abdominal myomectomy
  • Hysterectomy.

Polycystic Ovarian Syndrome

Polycystic Ovarian Syndrome (PCOD) is a hormonal disorder commonly seen in women of childbearing age an can cause sever lower abdominal pain. The disease is associated with prolonged menstrual cycle. One of the reason for prolonged menstrual cycle is physiological increased secretion of male hormone known as androgen. The hormonal imbalance causes increased number of follicles in ovaries and also causes irregular release of eggs from ovaries.

Symptoms of Polycystic Ovarian Syndrome.

  • Pelvic pain
  • Irregular menses
  • Heavy periods
  • Excessive facial, male pattern baldness and body hair caused by increased secretion of male hormone (androgen).

Investigations to Diagnose Polycystic Ovarian Syndrome.

  • Blood tests
  • Pelvic exam
  • Pelvic endoscopy
  • Pelvic ultrasound.

Treatment of Polycystic Ovarian Syndrome.

Birth Control Pills- Low dose birth control pills are given in order to regulate the cycle.

Hormone Therapy-

  • Progestin is prescribed for 2 weeks every 2 months for 6 months. The treatment often helps to regulate the hormonal cycle.
  • Antiestrogen therapy- Patient is prescribed pills of clomiphene (cloid). Clomiphene acts as anti-estrogen and helps to decrease symptoms.
  • Letrozole (Femara) treatment often helps to relieve the symptoms. Letrozole stimulates ovaries to secrete normal estrogen and progesterone hormone.
  • Gonadotropine- Intravenous gonadotropin helps to correct the hormone irregularities.
  • Spironolactone (Aldactone)
  • Intravenous Fluid- IV fluid is given to correct electrolyte imbalance.
  • Surgery
  • Excision of ovaries
  • Excision of uterus

As you can see, lower abdominal pain is a symptom which indicates other underlying medical conditions. Treatment of lower abdominal pain depends on the cause and condition. We have given some of the common causes for lower abdominal pain with symptoms and treatment. For correct diagnosis and treatment, you have to undergo various investigations and exams by your doctor before arriving at the right diagnosis so that appropriate treatment can be provided.

References:

  1. Disease burden of appendectomy for appendicitis. a population-based cohort study. de Wijkerslooth EML1, van den Boom AL2, Wijnhoven BPL2., Surg Endosc. 2019 Mar 27.
  2. Interstitial cystitis. epidemiology, pathophysiology, and clinical presentation. McLennan MT1., Obstet Gynecol Clin North Am. 2014 Sep;41(3).385-95.
  3. Ultrasound of Pelvic Pain in the Nonpregnant Woman. Patel MD1, Young SW2, Dahiya N2., Radiol Clin North Am. 2019 May;57(3).601-616.
  4. Menstrual characteristics and prevalence of dysmenorrhea in college going girls. Kural M1, Noor NN1, Pandit D2, Joshi T1, Patil A1., J Family Med Prim Care. 2015 Jul-Sep;4(3).426-31.
  5. Appendiceal endometriosis invading the sigmoid colon. a rare entity. Lainas P1,2, Dammaro C3,4, Rodda GA3, Morcelet M5, Prevot S4,5, Dagher I3,4., Int J Colorectal Dis. 2019 Jan 21. doi. 10.1007/s00384-019-03242-0. [Epub ahead of print] Massive prolapsed submucous fibroid treated with laparoscopic surgery. A case report.
  6. Yabumoto K1, Ito F1, Matsushima H1, Mori T1, Kusuki I1, Kitawaki J1., J Obstet Gynaecol Res. 2019 Apr;45(4).942-946.

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What is Naturopathic Medicine or Naturopathy, Know its Uses, Ideology, Benefits, Practice

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What is Naturopathic Medicine or Naturopathy, Know its Uses, Ideology, Benefits, Practice

What is Naturopathic Medicine or Naturopathy?

Naturopathic Medicine is a diverse form of primary health care. It is a practice of diagnosing, treating, and preventing illnesses. Naturopathic Medicine or Naturopathy is characterized by the ideologies, which inspires and determines its practice. The ideologies of Naturopathic Medicine or Naturopathy are based upon the factual observation of the description of health and disease and are continuously examined in the face of scientific development. Methods that are implemented are based on these ideologies and are selected based on the person individuality.

Naturopathic Medicine or Naturopathy

Understanding Naturopathic Medicine or Naturopathy & Its Ideologies

Naturopathic practitioners or Naturopaths are trained as physicians with various methods of diagnosis and treatment comprising of contemporary and conventional as well as scientific and practical methods.

The following 6 Ideologies form the basis of Naturopathic Medicine or Naturopathy:

Nature’s Ability to Heal

Naturopathic Medicine or Naturopathy believes in the ability of nature to heal is the intrinsic healing process of living things which creates, maintains, and reconditions health. The role of a naturopath is to support, assist, and enhance the healing process by recognizing and eliminating barriers for good health and recovery and create a healthy inner and outer atmosphere.

Recognizing and Treating the Root Causes

It goes without saying that no illness occurs without a cause. The causes may come from many areas. According to Naturopathic Medicine or Naturopathy, the underlying root of the disease needs to be recognized and eliminated to facilitate a full recovery. The body’s attempt to guard and recover itself is prompted in the form of symptoms. The Naturopathic Medicine or Naturopathy aims to cure the root cause of a disease than just the symptoms.

First Priority is Not to Harm

Naturopathic practitioners or Naturopaths follow the following rules to make sure a patient is not harmed:

  • They utilize techniques which have minimal risk of harming an individual. The use of intervention in Naturopathic Medicine or Naturopathy is as less as possible for diagnosis and treatment.
  • As much as possible the naturopathic doctor avoids containment of symptoms, as it may interfere with healing.
  • Naturopathic doctors work using the healing power of nature and mind for diagnosis and treatment.

Doctor’s Aim Is To Educate

The main objective of Naturopathic Medicine or Naturopathy is educating a patient and stresses the importance of taking responsibility for one’s own health. Naturopathic practitioners also identify and utilize the beneficial capability of the relationship between the doctor and the patient.

Treating a Person

The process of fitness of a person and a disease arise from a mixture of physical, genetic, and environmental among other aspects. Since it also includes spiritual health, physicians support people to follow their spiritual development. Naturopathic medicine realizes the balanced functioning of all the features of an individual as of utmost importance for good health. The multifaceted nature of health and illness needs a thorough approach to diagnosis and treatment. Naturopathic physicians treat a person keeping all these factors in the mind.

Disease Prevention

The main objective of Naturopathic Medicine or Naturopathy is to prevent a disease and obtain total health in patients. These objectives are achieved through patient education and promoting healthy living. The physicians analyze a person’s risk factors, genetic history, and vulnerability to diseases and then make necessary interventions together with the patients to prevent diseases. Naturopathic medicine emphasizes that a person cannot be healthy in an unhealthy environment.

Uses of Naturopathic Medicine or Naturopathy

Naturopathic Medicine or Naturopathy is used for pain relief, stress reduction, maintaining weight, for higher energy levels, and increasing fitness levels etc.

How Is Naturopathic Medicine or Naturopathy Practiced?

Naturopathic Medicine or Naturopathy gets its definition primarily by its basic principles. The methods and techniques that are used are based on these principles in conjunction with the requirement of the patient. The methods are selected from different sources.

The Naturopathic Medicine or Naturopathy practice includes the following modalities: It utilizes all the tools of diagnostic testing to include clinical and laboratory testing. Naturopathic Medicine or Naturopathy also uses different imaging techniques. It uses nutritional medicine, medicines obtained from plants and animals. It also uses hygiene and measures used for public health. Also used are naturopathic manipulative therapy; electromagnetic and mechanical devices, ultrasound, therapeutic exercise; homeopathy; psychotherapy; acupuncture, intravenous therapy; prescription medicines.

Benefits of Naturopathic Medicine or Naturopathy

  • Naturopathic Medicine or Naturopathy is very beneficial in providing pain relief.
  • Yet another important benefit of Naturopathic Medicine or Naturopathy is that it helps avoid getting frequent colds, flu, etc.
  • Long-term solution to chronic discomforts can be provided by an experienced naturopathic doctor.
  • Naturopathic Medicine or Naturopathy is also beneficial in slowing down the progression of a degenerative disease process.
  • Weight maintenance.
  • Increasing fitness levels.
  • Increased energy.
  • To maintain emotional balance.
  • Stress reduction is also another benefit of Naturopathic Medicine or Naturopathy.

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Native American Herbal Remedies or Native American Healing: Study, Examples

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Native American Herbal Remedies or Native American Healing: Study, Examples

Many medications of the modern era have their roots in natural remedies. Some researchers state that many important clues of modern pharmacology are held by the traditional herbal remedies.

Study of American Herbal Remedies

The following is what a pharmacology professor, James Adams, teacher of pharmacology at the University of Southern California studying “Native American Healing” shared.

The Native Americans used local flora for healing such as plants like “Yerba Santa.” This plant had been used by ancient Spanish colonizers for lung disorders.

According to him Pharmacology originally was the science of moving out, talking to conventional healers to find out which plants they used for healing and then taking the plants back to the laboratory to investigate what did they have to make them work.

He gives an example of aspirin which is a medication used for pain relief and fever for a long time that it came into existence in the 19th century from salicylic acid that is found in plants like “willow” and “meadowsweet.”

He says every society has its own medicine based on plants like Ayurveda in India. Chinese people use traditional Chinese medicine. In the Middle East, traditional Arabic healing is used etc.

Herbal Medicines Found In the United States

Some of the Native American Herbs & Their Uses

In the United States, in California, the “Chumash” learned from their own knowledge as to which plant was useful for which disease.

  • The “Sagebrush” is a very powerful pain reliever. It is said to be much safer than NSAIDs and opioids. Apart from relieving pain, the pleasant smell of the “California Sagebrush” makes people relax.
  • “Spanish Bayonet” plant has leaves and roots which give out some sort of soap. The fiber from its stems may be used in wounds.
  • A plant called “Chamise” is used for skin problems.
  • The “California Bay” is used for toothaches due to its anesthetic qualities.
  • Skunk Cabbage was used by the “Winnebago” and “Dakota Tribes” to accelerate removal of phlegm in asthma.
  • Horsemint: The “Catawba Tribe” crushed and soaked fresh horsemint leaves in cold water and drank it to get rid of back pain.
  • Creosote Bush: Its leaves were made into a tea and used for bronchial and other respiratory disorders.
  • Devil’s Club: Used by the Indians of British Columbia. They made tea out of the root bark to compensate for the effects of diabetes.
  • Blackcherry: Used extensively by the Indians of North California, tea made of its roots is extremely useful for treatment of diarrhea.
  • Pennyroyal: The “Onondagas” soaked its leaves and drank the tea to treat the headaches.

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Holistic Medicine: Understand the Principles, Types of Treatments, Differences, Benefits

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Holistic Medicine: Understand the Principles, Types of Treatments, Differences, Benefits

Holistic medicine is a kind of healing that considers body, mind, spirit, and emotions in pursuit of optimal health. According to its theory, a person can obtain best possible health by having appropriate balance in life. This is the primary aim of Holistic Medicine.

Holistic Medicine

Understanding Holistic Medicine

People practicing Holistic medicine are of the belief that a system of parts that are dependent on each other constitutes a person and even of one part if not functioning appropriately it affects the functioning the other parts as well. Therefore, if a person has any physical, emotional, or spiritual imbalance, it adversely affects the health of that person.

A holistic physician uses all forms of healthcare right from standard medicine to alternative form of therapies for treatment. If we take an example of a person suffering from migraines, if one goes to a holistic physician, physician will consider all the potential factors that may be causing pain such as other health problems, stress etc. The treatment may not only involve medications for relief of symptoms but also other lifestyle modifications for migraine prevention.

Principles of Holistic Medicine

Holistic medicine is based on the principle a person holds the whole and sole responsibility of one’s own health. Other principles of holistic medicine are:

  • Everyone has natural healing powers.
  • The patient is an individual and not a disease.
  • Healing involves a patient-doctor relationship as a team with an aim to address all features of an individual’s life using different forms of healthcare techniques.
  • Treatment involves treating the root cause and not just putting a lid on the symptoms.

Types of Treatments in Holistic Medicine

Holistic physicians use different treatment techniques so that their patients start taking responsibility for their own health. Some of them are as follows:

  • Educating people on lifestyle changes and self-care to promote well being. This may include exercise, diet, and psychotherapy among other things.
  • Alternative therapies such as chiropractic methods, acupuncture, homeopathy, massage therapy, naturopathy etc.

How is Holistic Medicine Different from Alternative Medicine?

Holistic medicine involves the connection between the mind, body and spirit for healing. Lifestyle, social, cultural and environmental background as well as the patient-physician relationship is considered to be vital for healing of illness. For relief of symptoms imbalances in any of these areas need to be rectified.
Alternative medicine includes healing techniques like herbal medicine, biofeedback, acupuncture and other forms of treatment.

Benefits of Holistic Medicine

Holistic medicine identifies an individual having an illness more important than the illness itself. Holistic medicine uses treatment which has the least potential to harm an individual. It is more cost-friendly than the conventional drugs or surgery. Holistic medicine tries to achieve societal change through respect for individuals. It believes in the fact that healing should take place at all levels i.e., individual, social, and cultural.

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Herbal Medicine or Herbalism: It Uses Medicinal Abilities of Plants; History, Philosophy, Benefits

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Herbal Medicine or Herbalism: It Uses Medicinal Abilities of Plants; History, Philosophy, Benefits

Herbal medicine, also called as Herbalism, is a research and use of the medicinal abilities of plants. Herbal Medicine or Herbalism ranges from fungal substances to minerals, animal parts etc. The study that involves all medicines obtained from natural resources is called Pharmacognosy. Herbalism has many other synonyms such as botanical medicine, medical herbalism, herbology, or phytotherapy, which is the use of plants to cure human ailments.

Herbal Medicine or Herbalism

History of Herbal Medicine or Herbalism

The use of plants as medications started much before written human history. Many of the herbs and spices used by us for food also have the ability to give out useful medicinal compounds. Studies reflect that spices are highly used in tropical climate as pathogens in those conditions are abundant and the spices selected have the most effective antimicrobial activity. Many of the common weeds such as “nettle”, “chickweed”, etc. have medicinal properties.

There is a huge amount of archaeological evidence indicating that human beings were using plants as medicines during the Paleolithic Age.

Understanding Herbal Medicine or Herbalism

Herbs have the capability to amalgamate broad range of chemical substances that perform important biological activities. They also defend against attacks from insects, fungus, herbivorous animals etc. Many of these chemicals are beneficial for health when taken by humans and have the ability to be effective in treating a variety of diseases. Chemical ingredients in plants affect the human body through chemical processes that are similar to those chemical compounds that are used in normal medications. Thus, it can be said that herbal medicines are not too different from conventional drugs when one talks about their functioning. This makes herbal medicines as effective as normal standard medications.

Modern Herbal Medicine or Herbalism

The use of herbal medicine or herbalism for treatment of diseases is widespread among nonindustrialized communities.

Many of the medications currently used by practitioners have a history of being used as herbal medications. Some of the medications are opium, aspirin, quinine etc.

According to an estimation done by WHO, around 80% of the people in some of the countries in Asia and Africa use herbal medicine or herbalism for primary healthcare. Also modern medications used are extremely expensive for almost everyone whereas herbal medicines can be grown from seed or obtained from natural resources at little or no cost.

The use of drugs and dietary supplements obtained from plants has skyrocketed recently. According to another estimation done by the WHO, 25% of modern drugs used in the USA are obtained from plants.

Philosophy of Herbal Medicine or Herbalism

The philosophy of herbal medicine has four approaches to the use of plants as a medication. The following are the approaches:

  1. The Magical: In this approach, the practitioner is regarded as a person who has god gifted powers that allows one to use herbs in such a way, which is unknown to a person, that it affects the soul of the person.
  2. The Energetic: This approach includes Traditional Chinese Medicine, Ayurveda, etc. Herbs are looked upon as having actions which affect the energy of the body. The practitioner usually has extensive training in it.
  3. The Functional Dynamic: This approach was used by early Physio-Medical practitioners. In this approach, it is believed that herbs perform a function, which may not be connected to a compound, but may be linked to a physiological action.
  4. The Chemical: In this approach, the practitioners called Phytotherapist, try to explain actions of herbs related to their chemical ingredients. It is generally believed that a specific combination of metabolites in the herb is responsible for its action. This phenomenon is called “synergy”.

Benefits of Herbal Medicine or Herbalism

  • Herbal medicines very rarely cause side effects. In fact, a lot of the herbal medications are used to treat those people who have had allergic reactions or suffer from allergies.
  • People using herbal medications do not get dependent on it. Herbal medications do not have any constituents that are habit forming.
  • These medications are much safer than conventional medications. They are found in nature and do not have the ingredients that causes an individual to become habituated to it.
  • They are more affordable than conventional medications because they are obtained from natural resources and are abundant in nature.

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What Causes Hip Joint Pain or Acetabulofemoral Joint Pain?

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What Causes Hip Joint Pain or Acetabulofemoral Joint Pain?

Pain in the hip joint or acetabulofemoral joint is very common among both men and women across the world. Women tend to suffer more from hip pain than the men.(1) There can be various causes for the pain in the hip joint but before we cover the medical conditions that can cause hip joint pain, let us first try understanding the anatomy and the function of the hip joint or acetabulofemoral joint.

What Is Hip Joint or Acetabulo-Femoral Joint?

Anatomy of Hip Joint or Acetabulofemoral Joint and Its Function

Hip joint is also known as Acetabulofemoral joint. Hip joint is a synovial joint. Hip joint comprises of articulation of head of the femur and an acetabulum socket of pelvic bone. Inner surface of acetabulum and head of femur are covered with cartilage to allow smooth rotation of head of femur within the socket of pelvic bone known as acetabulum.

What Is An Acetabulum?

Acetabulum is a lateral part of pelvis and shapes as a hollow cup, which holds head of the femur bone. Acetabulum is a cup shape socket, which is a part of the pelvic bone.(2)

What Is Head of Femur?

Femur is a long bone that lies between pelvis and knee. Head of femur is a proximal (cephalic end) part of femur bone that rests within acetabulum.(3) Head of femur is round bony structure attached to acetabulum socket by a strong ligament.

What Is The Function of Hip Joint or Acetabulofemoral Joint?

Functions of The Hip Joint or Acetabulofemoral Joint are:

  • Hip Joint or Acetabulofemoral Joint supports the weight of the body in both static (e. g. standing) and dynamic (e. g. walking or running) postures
  • Maintains balance in standing position
  • Hip Joint or Acetabulofemoral Joint assists ambulation or mobility
  • Moves leg forward (flexion) and backward (extension)
  • Hip Joint or Acetabulofemoral Joint rotates leg outward (external rotation) and inward (internal rotation)

What Can Cause Hip Joint Pain or Acetabulofemoral Joint Pain?

Hip joint pain is caused by hip joint disease and referred pain to the hip.

Inflammatory Joint Disease That Can Cause Hip Joint Pain or Acetabulofemoral Joint Pain

  • Osteoarthritis of Hip
  • Rheumatoid Arthritis of Hip
  • Psoriatic Arthritis of Hip
  • Juvenile Rheumatoid Arthritis of Hip

Why Does Inflammatory Joint Disease Cause Hip Joint Pain or Acetabulofemoral Joint?

Inflammatory joint disease causes inflammation of synovial membrane and cartilage, which are covering the bones of head of femur and acetabulum. Inflammation releases certain irritants that stimulates pain receptors and induces pain1. Chronic pain caused by inflammatory joint disease is a nociceptive pain and responds to anti-inflammatory medications such as Motrin and Naproxen.

Infection of The Hip Joint that Can Cause Hip Joint Pain or Acetabulofemoral Joint Pain

  • Septic Arthritis of Hip

What Is Hip Joint Infection or Acetabulofemoral Joint Infection?

Infection is caused by colonization of bacteria, viruses, parasites and fungus within different organs including joints. Hip joint or Acetabulofemoral joint is mostly affected by bacterial infection. Infected hip joint or Acetabulofemoral joint is known as septic hip joint arthritis.

Why Is Hip Joint or Acetabulofemoral Joint Infection Painful?

Infected hip joint or Acetabulofemoral joint is extremely painful. Pain in the hips in initial stage is caused by continuous irritation of pain receptors and nerve fibers by nerve irritants, dead cells, and metabolites. Infection of the hip joint or Acetabulofemoral joint causes abscess or pus. Pus contains chemical irritants, dead cells and toxic metabolites. In the later stage, the hip joint becomes necrotic and joint is often filled with pus and blood. Hip necrosis occurs because of lack of blood supply to bones, cartilages, and synovial membrane1. Hip joint necrosis causes joint dislocation and fracture of hip joint resulting in severe pain. Fluid such as abscess or blood in joint causes pain by producing severe pressure over pain receptors.

Injuries That Can Cause Hip Joint Pain or Acetabulofemoral Joint Pain

  • Hip Fracture
  • Hip Joint Dislocation or Acetabulofemoral Joint Dislocation

Why Hip Joint Fracture or Acetabulofemoral Joint Fracture or Dislocation Results in Severe Intractable Pain in Hips?

Hip joint fracture involves fracture of pelvis, acetabulum, head of femur, or neck of femur. Dislocation often results following tear of ligaments and cartilages supporting hip joint. Immediately following fracture and dislocation of hip joint, pain is extremely severe. Pain following hip joint fracture or dislocations are divided as initial pain and delayed pain.

What Causes Initial Hip Joint Pain or Acetabulofemoral Joint Pain After Fracture or Dislocation?

Following Abnormalities Causes Initial Hip Joint Pain After Fracture or Dislocation:

  • Soft tissues tear such as muscles, ligaments and synovial membrane can cause hip pain.
  • Inflammation of the soft tissue like muscles, ligaments, and synovial membrane surrounding hip joint can also cause hip joint pain or Acetabulofemoral joint pain.
  • Fracture of cartilages resulting in release of irritants resulting in pain following stimulation of pain receptors.
  • Blood clots within the joint and around the joint stretching the joint and soft tissue.
  • Irritations of the pain receptors located over periosteum (covering of the bones), ligaments, synovial membrane, and cartilages.

Following Abnormalities Causes Delayed Hip Joint Pain or Delayed Acetabulofemoral Joint Pain:

  • Inflammation of the soft tissue and cartilages supporting joint.
  • Infection within joint or surrounding tissue.
  • Inability to stand or sustain the weight.
  • Ligament and muscles stiffness.

Diseases That Can Cause Hip Joint Pain or Acetabulofemoral Joint Pain

  • Osteoporosis
  • Avascular Necrosis
  • Bone Cancer and Metastasis

Why Does Osteoporosis Cause Severe Hip Joint Pain or Acetabulofemoral Joint Pain?

Osteoporosis causes bones to be brittle and weak. Osteoporosis itself often is not painful but osteoporosis causes fracture of neck of femur, which results in severe intractable hip joint pain.

How Does Avascular Necrosis Cause Hip Joint Pain or Acetabulofemoral Joint Pain?

Avascular necrosis is a bone disease that results from lack of blood supply. Lack of blood supply is often secondary to vasoconstriction, dehydration, and interruption of blood vessels following fracture. Long-term use of corticosteroids and alcohol consumption also causes avascular necrosis. Avascular necrosis is mostly observed (69 % cases or more) involving hip joint2.
Initial pain is mild to moderate and pain is observed during ambulation or following pressure on the affected bone. Initial pain is caused by lack of blood supply resulting in irritation of the pain receptors located over covering of bones known as periosteum. Later avascular necrose bone fractures and pain becomes extremely severe. Avascular necrosis of hip joint causes joint collapse resulting in severe pain with any movement of leg2.

Why Does Hip Joint Cancer or Metastasis Cause Severe Hip Joint Pain or Acetabulofemoral Joint Pain?

Hip joint cancer is rare but cancer metastasis of hip joint is often seen in colon or lung cancer. Initial pain is secondary to irritation of pain receptors during initial phase of growth and normal tissue encroachment by cancer tissue3.Later, as cancer tissue expands the pain is secondary to pressure over the nerves or secondary fracture of hip joint.

Inflammation of Soft Tissue Surrounding The Hip Joint That Can Cause Hip Joint Pain or Acetabulofemoral Joint Pain

  • Hip Bursitis
  • Hip Tendinitis
  • Hip Muscle Strain

Which Soft Tissues Surround The Hip Joint or Acetabulofemoral Joint?

Hip joint is surrounded by tendon, ligament and muscle. Tendons are the tough bands of fibrous tissue. Tendons are continuation of the tapering muscle tissue on both end muscles. Tendon holds to the bones with firm grips, so muscles can contract and relax without shifting its position around the bones and joint.

What Are The Functions of Hip Joint Ligament or Acetabulofemoral Joint Ligament?

Ligaments around hip joint are tough band of fibrous tissue with several anatomical functions as follows-

  • Muscle Ligaments- Ligaments of skeletal muscles are band of fibrous tissue like tendon situated between muscle and bones. A ligament anchor several muscles around the hip joint and stabilizes the hip joint.
  • Joint Ligaments- Two bones forming the joints are firmly held together by ligaments attached to proximal and distal bones of the joint. Strong and short length of ligament prevents joint dislocation.
  • Capsular ligaments – Synovial joint capsules are supported by capsular ligaments and provides joint stability.

Why Does Soft Tissue Inflammation Cause Hip Joint Pain?

Inflammation of soft tissue produces several chemicals such as prostaglandin, bradykinin and thrombin, which irritate pain receptors and nerve fibers resulting in nociceptive pain. In later stage continuous inflammation induces hypersensitivity of nerve receptors and nerve fibers. Hypersensitive receptors and nerve fibers when stimulated produce neuropathic pain.

What are the Causes of Referred Pain to the Hip Joint or Acetabulofemoral Joint?

Referred pain is the pain felt at distant or different location than the site where pain is induced. Referred hip joint pain or acetabulofemoral joint pain is often associated with normal hip joint. Radiological studies and other investigations is mostly normal in-patient suffering with referred hip joint pain.

Causes of Referred Hip Joint Pain or Referred Acetabulofemoral Joint Pain Are As Follows-

  • Lumbar disk herniation may pinch nerve in spinal canal or nerve foramina resulting in severe radicular pain, which may be felt as referred pain over hip joint.
  • Facet joint hypertrophy or arthritis may cause referred pain in hip joint
  • Sciatica pain is often felt in lower leg and may be associated with referred hip joint pain.
  • Cauda equina pain is caused by spinal stenosis and in most of the cases causes hip joint pain with urinary and fecal incontinence.
  • Spinal stenosis causes severe pressure on lumbar and sciatic nerves in spinal canal resulting in gluteal and hip referred pain.

References:  

Reference:

  1. Inflammatory diseases of the bones and joints.

    DiCarlo EF, Kahn LB.

    Semin Diagn Pathol. 2011 Feb;28(1):53-64.

    Department of Pathology, Hospital for Special Surgery, Weill College of Medicine of Cornell University, New York, NY 10021, USA.

  2. Avascular necrosis of bone after allogeneic bone marrow transplantation: clinical findings, incidence and risk factors.

    Socié G, Sélimi F, Sedel L, Frija J, Devergie A, Esperou Bourdeau H, Ribaud P, Gluckman E.

    Br J Haematol. 1994 Mar;86(3):624-8.

    Service de Greffe de Moëlle, Hôpital Saint Louis, Paris, France.

  3. Intraarticular osteoblastoma with subluxation of the hip joint.

    Okada K, Nagasawa H, Chida S, Nanjo H.

    Am J Case Rep. 2013 Jul 17;14:258-62. doi: 10.12659/AJCR.889243. Print 2013

    Department of Physical Therapy,Akita University Graduate School of Health Science, Hondo, Akita, Japan.

    J Bone Joint Surg Br. 2012 Nov;94(11 Suppl A):22-5. doi: 10.1302/0301-620X.94B10.30509.

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