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Understanding Low Back Pain
Anatomy | Mechanical Low Back Pain | Treating Low Back Pain

It is estimated that 80%of the human race experiences low back pain at least once throughout their lifetime. Fifty percent of the working population admit to experiencing low back pain each year. Each year 15-20% of the people in the United States see a have complaints of low back pain. Two percent of the U.S. population is either temporarily or chronically disabled by low back pain. 14 Millions of workers suffer on the job injuries annually which costs 100 billion dollars in lost wages, time, and productivity and medical costs.

It is important to understand that there is an outstanding chance that you will recover from your low back pain in the near future. Research studies have shown that 74 % of those that suffer from back pain return to work within 4 weeks and > 90 % in 3 months or less. Some health care providers feel low back pain is like catching a cold- you experience it and in time it goes away.

To sum it up, there is a good chance you will have low back pain, there is a good chance that you will recover but there is also a good chance that you will experience the pain again. Medical research suggests that an active exercise program will reduce disability and may prevent future episodes of pain.

Anatomy of the Low Back

The low back or lumbar spine is an extraordinary engineering marvel. It is composed of bones, discs, joints, tendons, muscles, ligaments and nerves. The spine has 3 main functions. 1.) It connects the pelvis to the trunk and head. 2.) It protects and houses the spinal cord which is made up of billions of nerves that connect the brain to most of the body’s major organs. 3.) The spine provides stability, balance, flexibility, and mobility in order for us to perform our daily activities. It allows you to swing a golf club and at the same time withstands and transfers tremendous forces. For example, let’s assume you weigh 150 pounds, and you bend over about 65 degrees. Your back muscles generate 375 pounds of force to keep you from falling over and if you carry a 50 pound object at the same time, your muscles generate about 700 pounds of force.

Closer inspection reveals five vertebra (bones) stacked on top of each other with a fluid - filled disc in between each vertebrae. The Lumbar spine is like a hollow, C-shaped curve (called the lumbar lordosis) which is arranged to balance tremendous forces. The curve or lumbar lordosis allows the spine to be 15 times stronger than if it were straight. Within the "hollow" of the spine is the spinal cord.
The spinal cord is made up of nerves that, very simply put, wire your brain to your muscles and tell them when to contract. These nerves also are responsible for the sensation of touch and pain among other things. They exit out of holes called intervertebral (meaning in between the vertabra) foramen and are called nerve roots. The vertebral bodies bear most of the weight and have cartilage end plates which attach to the discs. Spinous processes emerge from the back of a vertebrae and two other bones point to the sides and are called transverse processes. These processes serve as attachments for muscles and ligaments.

Between each vertebral body is a fluid filled disc similar to a jelly donut. The outer fibrous portion is called the annulus fibrosus and the inner jelly is called the nucleus pulposus. Healthy discs provide necessary height to the spine, absorb shock, and distribute forces in all directions.

Ligaments are tough non-elastic (they stretch very little) structures that attach a bone or bones together. There are many ligaments associated with the lumbar spine. The anterior longitudinal ligament holds the front of the vertebral bodies together. The posterior longitudinal ligament holds the back of the vertebral bodies together. The interspinous and intertransverse ligaments pass in between the spinous processes and transverse processes respectively. The ligamentum flavum holds the rear portion of the vertebra together and helps to protect the spinal cord. The thoracolumbar fascia is a large piece of ligamentous tissue that helps hold all of the lumbar vertabra together and works with muscles to stabilize the spine.

There are over 140 muscles that work together to move and stabilize the spine. Many of these muscles are located around the lumbar spine. There are the abdominal muscles, the erector muscles, the hip muscles, and lateral stabilizing muscles. The abdominal muscles consist of the rectus abdominus, the internal and external obliques, and the transverse abdominus. They provide frontal support, help maintain good posture, hold the abdominal organs in the correct location, and act together as your body’s own natural "back belt." The erector spinae muscles run up and down your back to help you maintain erect posture and they assist in recovering from the forward bent position. Even deeper is a layer of muscles that assist in rotational movements and side bending. The hip muscles, most notably the gluteus maximus, hamstrings, and psoas (pronounced soas) move the pelvis and thighs. The gluteus maximus and hamstrings are your major lifting muscles. In fact, when you bend down to touch your toes, about 67% of the bending comes from your hips which is in turn control by the gluteus maximus and hamstrings muscles. The psoas muscles help lift your thigh and stabilizes the spine. The lateral stabilizers - the quadratus lumborum and the latissamus dorsi both insert into the spinous and transverse processes via the thoracolumbar fascia. They also stabilize and move the spine. Any one or combination of structures can affect the curve or lumbar lordosis.

Mechanical Low Back Pain

Mechanical low back pain has been reported to arise from trauma (either chronic or sudden) such as a fall, a motor vehicle accident, twisting, prolonged poor postures, mental stress, fatigue, disc extrusion (also known as a slipped disc, rupture, or disc herniation), sometimes painful degenerative disc disease(also called arthritis), aging, congenital defects, poor flexibility, etc. Causes such as infection, hormonal problems, broken bones, systemic disease, and tumors require serious medical intervention but are very rare and are beyond the realm of this discussion.

Acute low back pain is defined as activity intolerance due to lower back or back-related leg symptoms of less than 3 months' duration. Chronic low back pain, therefore, is defined as pain/problems lasting greater than 3 months. Regardless of the cause or duration of mechanical low back pain, the result is likely to be damaged soft tissue(s) which can stimulate nerves and produce pain.

It is important to understand that it is next to impossible to determine exactly which tissue(s) are the cause of the low back pain. Someone like yourself may be experiencing pain and quite frankly, the cause is unknown. It could be muscle(s), ligament(s), disc(s), tendon(s), joint(s), and/or other connective tissue. They all can produce similar symptoms which commonly present as pain on one side of the back or across the back. It may radiate into the buttock or into the thigh. Quite often it will be accompanied by painful cramping of the muscles called a muscle spasm. Furthermore, medical research has shown that x-rays are of little help in determining the cause of low back pain except in rare cases such as severe trauma. Magnetic resonance imaging (MRI) is also ineffective at determining the cause of low back pain. For example 2 out of 3 people have positive findings for disc abnormalities on an MRI but are painless. As many as 1 in 3 people have disc bulges and are completely painless. Health care professionals often call low back pain a "pain in search of a pathology." This means that a patient’s medical tests will be negative or a test will produce a false positive. The cause could be any number of structures.

Treating Low Back Pain

So how do we treat something if we don't know what exactly is wrong. We do know that mechanical low back pain is caused by damaged soft tissue. The damage stimulates pain nerves called nociceptors. The goal then is to promote healing of the damaged soft tissue which will eliminate the pain, not just treat the pain itself. This is done with a program that is customized to your individual needs.
Here are the steps:
1.) Protecting the damaged soft tissue to prevent further breakdown. The area of damaged soft tissue is protected with rest and positioning. Activities that cause the pain should be avoided while the low back heals. Pain management techniques should be used and are discussed in the pain control section. Bed rest is usually only necessary for 1-3 days (longer periods of bed rest have not been proven to be beneficial).
2.) Increasing the circulation and mobility. This will deliver the proper building blocks (proteins, repair cells called fibroblasts, oxygen, proteins, etc.), remove inflammatory and waste products that build up in painful tissue(s), and prevent tissue atrophy. Increasing circulation is accomplished by walking and performing painless range of motion, stretching, and strengthening exercises.
3.) Correcting the dysfunctions (weakness, poor posture, poor flexibility) that caused the problem in the first place. Progressive strengthening exercises, flexibility exercise, and postural/body mechanics education will help reduce the stress on your low back and promote proper repair.
The Key: Your physical therapist will give you the tools to treat your dysfunctions and create your own customized treatment program.
That's not all. Anyone who has suffered from low back pain must understand that the problem is not corrected when the pain ends. Muscles must be stronger than before the pain started (that takes 12+ weeks), many weeks are needed to improve flexibility, and repeated practice to is necessary to incorporate proper posture and body mechanics into your daily activities.

The Ankle

Ankle Sprains/Instability

Ankle sprains are a common injury. They usually occur when the foot is forcefully inverted or turned inward. Grade I (minor tear), Grade II (partial tear), or a Grade III (complete tear into two pieces) damage of the outer ligament complex (the anterior talofibular ligament and less often the calcaneofibular ligaments) is the result. Injuries to the inner aspect of the ankle are rare and often result in a fracture before ligamentous damage occurs.

Signs and symptoms of an ankle sprain include lateral ankle pain, swelling and a sense of instability. Stress X-rays may be helpful in ruling out fractures.

Treatment of an acute injury requires Rest Ice Compression Elevation and bracing of the injured ankle. Early rehabilitation assists in a rapid recovery. Surgery (reconstruction of the ligaments) is only necessary when the ankle is repeatedly sprained.

Fractures (Broken Bones)

Fractures may involve the outside or inside of the ankle joint.
The signs and symptoms of fractures are pain, swelling and bony deformities. X-rays are essential and rapid “reduction” (setting the bones close together for healing) is necessary. In extreme cases, open surgery is necessary to reduce the fracture. Often pins, plates and screws are used to maintain the reduction.

Achilles Tendonitis and Rupture

The Achilles tendon attaches the calf muscle (called the gastrocnemius and soleus muscles) to the heel. Excessive stress or a tight or fatigued calf muscle can result in microtrauma and inflammation of the tendon- a condition called Achilles Tendonitis. Prolonged walking, overtraining ( excessive running or jumping), or walking hills can cause this condition.

Treatment usually consists of rest, NSAID’s, ice, stretching, strengthening and progressive return to function or sport.

Forceful contraction of the calf muscle may rupture (completely tear) the Achilles tendon. It occurs when during jumping, running, and cutting and is often seen in basketball and baseball players.
The patient often reports the sensation of having been hit or violently kicked in the lower calf. There is pain and a “divot” in the tendon above the heel.

Treatment- non-surgical rehabilitation and surgical repair are viable treatment options. Active people may experience more benefit from surgical repair. Rehabilitation may require six to twelve months of progressive care.

Plantar Fasciitis

Inflammation of the fascia on the bottom of the foot is the most common cause of heel pain.

There are many documented causes of plantar fasciitis. Poor flexibility of the calf muscles, no arch support, a sudden increase in one's level of activity, poor foot ware, being overweight, excessive pronation, or repetitive stress conditions (long distance running). Common causes of a bruised heel bone are poor cushioning of the heel due to fat pad atrophy (shrinkage in the size of the fat pad) poor foot ware, excessive walking on hard surfaces, and being overweight.

Depending on which medical study you read, anywhere form 8-21% of the population suffers from plantar fasciitis. The pain is typically located at the front of the base of the calcaneus. Less often, the pain extends along the arch of the foot. The result is micro-tearing of the plantar fascia where it attaches to the base of the calcaneus. An ensuing inflammatory response occurs producing pain, swelling, warmth, loss of function (difficulty with any standing or walking), and less often, redness.

Plantar fasciitis is often worst in the morning when one takes his /her first steps out of bed. Theories propose that when we are sleeping, the inflamed fascia is shortening and perhaps attempting to heal. If the problem is chronic, a bone spur may be seen on
x-ray.

Currently, we believe that that bone spur is not the cause of the pain but the result of the body's attempt to heal the damaged plantar fascia.

Treatment Treatment consists of anti-inflammatory medications, a soft heel cup, (orthotics) and stretching. Very rarely is surgery indicated. Equivocal results with surgery have been reported.

Stress Fractures

These fractures result from repetitive submaximal loads applied to the foot, ankle, leg; they are usually the result of overuse (in athletes, overtraining). They are common in long distance runners and female athletes.

Common stress fracture sites include the lower leg (in runners), calcaneus, talus, metatarsals in distance runners, and the big toe.
There is pain and point tenderness, often relieved by rest, is typical. X-rays do not always show the fracture. Bone scans and MRI may be useful.

Most heal with rest, immobilization and cross training. Avoid high impact workouts and wear good shoes.

Tibialis Posterior Tendinitis

This often occurs in overweight, middle aged women >men as a result of degenerative changes in the tendon. The rupture may be partial or complete with pain below or behind the inside ankle bone (medial malleolus). A flattened arch is common. Anti-inflammatory treatment (physical therapy modalities), orthoses, and surgical debridement are common treatments.

The Elbow

Tennis Elbow (Lateral Epicondylitis)

Lateral (meaning away from the midline of the body) epicondylitis (meaning inflammation of the epicondyle) is a painful condition on the outer aspect of the elbow. The common name for lateral epicondylitis is tennis elbow but only 5% of the people afflicted with this condition play tennis. It often occurs with repetitive use of the arm especially with a clenched fist. Most cases are not due to tennis.

Local tenderness and pain with resisted and passive extension of the wrists is common.

Activity modification, anti-inflammatory medications, ice, and progressive stretching and strengthening will relieve most cases. Surgery is only an option in recalcitrant cases.

Golfers Elbow (Medial Epicondylitis)

People that suffer from golfer’s elbow are often involved with racquet sports or golf. As with tennis elbow, they may overuse the forearm, traumatize the elbow by hitting several “fat” golf shots, or have poor swing technique.

Pain at the inner aspect of the elbow and reproduction of symptoms with resisted wrist flexion are common.

Activity modification, anti-inflammatory medications, ice, and progressive stretching and strengthening will relieve most cases. Surgery is only an option in recalcitrant cases.

Fractures/Dislocation Elbow

Usually a fall onto the outstretched arm or experience a direct trauma to the elbow. With elbow dislocations there may be associated nerve and/or blood vessel injuries. X-rays may show the fracture or dislocation but small breaks may be difficult to see.

Fractures are an emergency and immediate reduction (or placing the bones together to allow healing) is necessary. Bone breaks within the joint need special attention to insure recovery of proper function of the joints.

Loose bodies

Loose bodies are usually the result of old injuries or osteoarthritis of elbow joint. Locking and pain are the predominant signs and symptoms. The symptoms are treated by surgical removal of the loose bodies.

Ulnar Nerve Injuries

This injury is usually the result of excessive valgus stress on the elbow during repeated throwing (especially during the cocking phase of a throw). Sometimes a direct injury to the nerve within the cubital tunnel (“hitting your funny bone”) will result in nerve damage. Symptoms include tingling and numbness in the ring and pinky fingers. This may occur during or after throwing or with prolonged bending of the elbow.

Changing throwing technique, bracing if necessary, and therapeutic exercise may be helpful. If the problem persists or there is prolonged weakness then surgery is indicated.

Biceps rupture at the Elbow

This injury usually the result of sudden forceful straightening of the elbow during concurrent contraction of the biceps muscle. Typically, there is sudden forearm pain and weakness. Surgical repair is necessary.

Distal Triceps Rupture

Sudden forced flexion while the elbow is being extended is a common mechanism. As with biceps rupture, surgical repair is necessary.

Hip and Thigh Injuries

Quadriceps Muscle Strains

This injury is commonly the result of quick sprints or quick stops while running. With a muscle strain, there is localized tenderness or a “bulge” in the tender area of the thigh. The pain is aggravated by lifting the thigh (a straight leg raise), ascending/descending stairs, or getting up from a seated position
.
Quadriceps Tendon Rupture

This injury is often the result of forceful kicking or a traumatic impact to the tendon, which may occur with a fall. Signs and symptoms include pain and bruising just above the kneecap, an inability to walk, and severe weakness of the quadriceps (making it impossible to ascend/descend stairs). Surgical repair is necessary.

Groin strain (Adductor Strain)

This injury usually occurs in sports where cutting, side-stepping, or pivoting are required. Often, there is forceful separation of the legs or twisting of the toe outward. Signs and symptoms include pain and tenderness in the inner thigh region.

Hip Pointer

Hip pointers are the result of a direct blow to the iliac crest in sports such as football, rugby, and soccer. Signs and symptoms include pain, bruising, and tenderness at the bony prominence at the side of the hip. Treatment usually involves rest, ice, and compression.

Trochanteric Bursitis

A bursa is a fluid-filled sack that decreases shear forces between tissues of the body. Trochanteric bursitis (inflammation of a bursa) is caused by excessive stress on the bursa between the IT Band and the greater trochanter. Signs and symptoms include pain over the outer aspect of the hipbone, which often is exacerbated when lying on the affected side,standing on the affected leg, or excessive walking. Treatment often includes rest, ice, and compression, physical therapy including stretching and progressive strengthening, and steroid injection may be helpful.

Hamstring Strains

A strain is a minor tear of a muscle. Quick acceleration while running or cutting is most often the cause of hamstrings strains. A minor pulling or a pop may be noted in the back of the thigh. Pain, swelling, and an inability run result. Treatment includes rest, ice, compression, elevation, and physical therapy.

Femoral Neck Fracture

A bad fall or blow to the hip can break (fracture) the thigh bone typically around the femoral neck region. If the broken bone does not heal properly, the joint may slowly wear down. Blood flow through the femoral head may be restricted or cut off leading to the necrosis of the joint.

Avascular Necrosis of the Hip

Avascular necrosis means bone death due to a lack of blood supply. A disrupted blood supply occurs when there is a fracture, dislocation, or repetitive trauma to the neck of the femur. Signs and symptoms include pain, limitation of movement and and pain with walking. X-rays, MRI, or a bone scan may be helpful in diagnosing this disorder. Surgical decompression or total hip replacement may be necessary.

The Knee

Meniscal Tears

The menisci (plural for meniscus) are cartilage pads, which function to cushion the compressive loads in the knee. One or both of these pads can be torn which often occurs when the lower leg is forcefully bent and twisted. Signs and symptoms include joint line pain, locking and swelling of the knee. The tear often has a bucket handle or parrot beak shape. Treatment should consist of rest, ice, compression and elevation. Arthroscopic surgery is indicated for a large tear.

Anterior Cruciate Ligament (ACL) Tear

The cruciate (or crossing) ligaments stabilize the knee. The anterior cruciate (ACL) may completely break (rupture) when the knee is bent beyond its normal range of motion or with excessive twisting. Signs and symptoms include a ‘pop’ sensation with significant swelling and pain. There is a sense of instability or the knee giving away. Initial treatment includes rest, ice, elevation, and compression. Physical therapy consisting of progressive strengthening and functional exercise may facilitate recovery. If knee instability persists, surgery is indicated. The middle third of the patellar tendon, hamstrings, or cadaver ligament may be used to reconstruct the lost ligament.

Posterior Cruciate Ligament (PCL) Tear

The posterior cruciate ligament (PCL) is stronger and less commonly injured. Motor vehicle accident, when the knee(s) forcefully impact the car dashboard, is a common mechanism of injury. Initial treatment includes rest, ice, elevation, and compression. Physical therapy consisting of progressive strengthening and functional exercise may facilitate recovery. Surgery is not typically required.

Medial Collateral Ligament (MCL) Tear

MCL tears are common injuries. A forceful stress on the outside of the knee can cause a stretching and injury of the MCL. Signs and symptoms include knee pain at the inner aspect and swelling. Medial meniscal tear and ACL injury may occur with severe trauma (commonly occurs during football and rugby). Initially, rest, ice, elevation and compression is necessary followed by bracing and rehabilitation. Severe tears may require surgery.

Lateral Collateral Ligament (LCL) Tears

Lateral collateral ligament tears (LCL) are less common. Initially, rest, ice, elevation and compression is necessary followed by bracing and rehabilitation. Surgery is uncommon.

Anterior Knee Pain

The patello-femoral joint (the joint between the kneecap and the thigh bone-called the femur) is a problematic area for many. Improper tracking of the kneecap (causing painful stress on the cartilage on the underside of the kneecap), quadriceps and patellar tendonitis are three common causes of pain in the front of the knee.

Patello-femoral Pain commonly called Chondromalacia Patella

Chondromalacia meaning softening of the patellar cartilage, is a common misdiagnosis. Softening of the cartilage can only be detected by directly visualizing the cartilage during surgery. The correct diagnosis for pain and swelling originating from under the kneecap is Patello-femoral Pain.

Treatment includes pain relief with rest, ice, compression, and elevation. Swelling must be controlled. Anti-inflammatory medications, bracing, and physical therapy are often helpful. Progressive strengthening of the quadriceps is essential. Occasionally, foot orthoses may be helpful. Rarely, surgery is required to assist in realigning the kneecap by releasing the tight structures on the outside of the kneecap and reefing the inner structures.

Patellar Tendinitis (Jumper’s Knee)

Jumping sports (such as basketball and volleyball) put a huge load on the kneecap and attached tendons. Signs and symptoms of patellar tendonitis include pain to touch directly on the patellar tendon and occasionally, swelling. Treatment includes activity modification, and physical therapy.

Sinding-Larsen-Johansson is a specific disorder of the patellar tendon where it attaches to the base of the kneecap. In contrast, Osgood-Schlatter disease is a disorder of the tendon where it attaches at the tibial tuberosity of the leg. Both are common disorders in maturing teens. Treatment includes activity modification, physical therapy, and rarely surgical excision of the associated necrotic debris.

Iliotibial Band Friction Syndrome

The iliotibial band originates from the tensor fascia latae and gluteus maximus muscles, crosses the knee joint (some of its fibers insert into the kneecap), and inserts into the outer aspect of the upper leg. Shear stress of the iliotibial band over the lateral femoral epicondyle can cause pain at the outer aspect of the knee. This is a common injury in runners and cyclists. Anti-inflammatory medications, physical therapy, activity/training modification may be helpful. Occasionally, foot orthoses may be helpful.

Plicas

Plicas are folds of the knee joint lining in the upper and inner aspect of the knee joint. They may become inflamed, thickened and scarred causing pain, swelling, and weakness. Physical therapy may be helpful. If conservative care fails, arthroscopic surgical removal is necessary.

The Neck

Neck Pain

Neck pain can be so mild that it is merely annoying and distracting. Or it can be so severe that it is unbearable and incapacitating.
Most instances of neck pain are minor and commonly caused by something you did. That is, if you keep your head in an awkward position for too long the joints in your neck can "lock" and the neck muscles can become painfully fatigued. Poor postures while working, watching TV, using a computer, reading a book, or talking on the phone with the receiver held against your shoulder and under your chin can be responsible for neck pain.
Neck pain that persists for many days or keeps coming back may be a sign that something is wrong. Disease, an injury (such as whiplash in an auto accident), a congenital malformation, or age-related changes may be responsible for more significant pain. A trained medical professional must determine the underlying causes of such neck pain. Examination and diagnosis by a medical doctor and treatment by a physical therapist may quickly relieve your pain or help you deal with it on a long-term basis.

Who suffers from neck pain?

Almost everyone experiences some sort of neck pain or stiffness at one time or another during their life. Because you walk upright and your head is "balanced" on top of your spine like a golf ball on a tee. The head weighs between 10 and 15 pounds. If the muscles that support your head and neck are not kept flexible and strong, poor and prolonged postures can put too much stress on the head and neck muscles and joints. This can lead to strains of the muscles and sprains of the ligaments that support your head and neck.
As we age, our joints wear out (this is called osteoarthritis) and the discs in the spine dry up and flatten (this loosely describes Degenerative Disc Disease). You may experience pain may radiates into the top of the shoulders or in between your shoulder blades. Occasionally, a pinched nerve (called a radiculopathy) occurs and you may feel tingling, pain, and/or numbness radiating into the arm, forearm, hand, and fingers. As always, with persistent pain you should be evaluated by a medical doctor and seek treatment from a trained physical therapist.

The Shoulder

Adhesive Capsulitis

Adhesive Capsulitis or a Frozen Shoulder poorly understood condition in which the deepest layers of soft tissue, called the joint capsule, become diseased. Shoulder range of motion becomes very limited and painful. The cause of a frozen shoulder is still not known but minor traumas, hyperthyroidism, diabetes, psychiatric patients, post-surgical patients, and prolonged immobilization of the shoulder may in some way cause this condition. The disease is characterized as having a freezing, frozen, and thawing stages, and is self-limiting (in time it goes away on its own). However, it can take two years or more to recover from this condition. Physical therapy consisting of patient education, stretching, joint mobilization, and a home exercise program can help speed recovery.

Shoulder Instability

Shoulder instability occurs when the shoulder moves completely out of it’s socket (dislocation) and requires a medical professional to “relocate it”, or to a lesser degree, when it of slips out of joint but spontaneously move back in place (subluxation). Usually, the shoulder dislocates or subluxes forward (this is call an anterior dislocation). Much less often, it dislocates backward (posterior dislocation), and sometimes, it can slip out forward, backward, or downward (this is call multidirectional instability). Remember, you may have an “unstable” shoulder that has not completely dislocated.

The shoulder is most at risk for anterior dislocation when the arm is placed in an abducted and external rotated position (such as a fall on the outstretched hand or tackling a player).

An anterior dislocation is obvious because it is immediately noticed by the person right after the trauma. However, minor instability may result in a sensation that the shoulder is slipping out of place with or without pain. One might also experience pain or a sense of “apprehension” when the arm is abducted and externally rotated (ask your physical therapist about this).

A sudden dislocation is an emergency. The patient should be taken to the emergency room immediately to make sure there is no damage to the blood vessels or nerve that go to the shoulder, arm, and hand. Usually, the emergency room physician can move the arm in such a way that the dislocated shoulder reduces back into its proper place. Rarely is surgery indicated. Pain and muscle relaxant medication is often prescribed. Ice can also help reduce the pain. Physical therapy is usually started 2-3 weeks after a dislocation to strengthen the muscles that support the shoulder joint.

Reoccurring Dislocations

For those patients with reoccurring dislocations or instability, treatment is to modify or avoid the known activities, rehabilitate the shoulder with a physical therapist, and if theses are not successful, consider stabilizing surgical procedures.

Posterior Dislocation

Dislocations in which the arm moves backward out of the socket (called a posterior dislocation) are uncommon (4%). Posterior subluxation is being recognized more frequently occurring in athletes involved in sports such as tennis and baseball.
As mentioned above, sudden dislocation is an emergency. The patient should be taken to the emergency room immediately to make sure there is no damage to the blood vessels or nerve that go to the shoulder, arm, and hand. Usually, the emergency room physician can move the arm in such a way that the dislocated shoulder reduces back into its proper place. Rarely is surgery indicated. Pain and muscle relaxant medication is often prescribed. Ice can also help reduce the pain. Physical therapy is usually started 2-3 weeks after a dislocation to strengthen the muscles that support the shoulder joint.

Multidirectional Instability Signs and Symptoms

Signs of ligamentous laxity are present. Pain and weakness are present in the shoulder that subluxes (partially moves out of joint) forward, backward, or downward. A positive “sulcus sign” is present on examination by a medical professional.

Most patients respond well with physical therapy. Rarely surgery is indicated because it is hard to stabilize the shoulder in all directions.

Shoulder Tendonitis and Impingement

Tendonitis is an inflammation of the shoulder tendons. The signs of inflammation are pain, warmth, redness, tenderness to touch, and loss of function. Shoulder tendonitis (often called Rotator Cuff Tendonitis) can occur when the rotator cuff overloaded, fatigued, traumatized, and with age-related degenerative changes. Pinching or impinging on the rotator cuff tendons occurs in a region under a bony structure called the acromion (the projection of the shoulder blade that forms the tip of the shoulder). Impingement happens when the arm is raised overhead repeatedly, raised overhead with a heavy load in your hand, or often when you sleep on your shoulder. X-rays may show a hook or spur that increases the odds that you will pinch the rotator cuff tendons.

Treatment for impingement or rotator cuff tendonitis usually involves rest, anti-inflammatory medications like ibuprofen, physical therapy to restore proper strength and movement, and less often, a cortisone injection.

Rotator Cuff Tears

Rotator cuff tears happen in younger people when they experience a trauma such as a fall. In middle-aged people and seniors, rotator cuff tears are usually the result of a gradual wearing out of the rotator cuff tendon(s). The signs and symptoms of rotator cuff tears are pain in the shoulder often radiating down to the middle of the arm especially when the arm is raised overhead, weakness, and in severe cases, a complete loss of the ability to lift the arm. Diagnostic tests often include an arthrogram (a radio-opaque dye is injected into the shoulder, and if it leaks out of the rotator cuff, it can be viewed on x-ray), ultrasound or an M.R.I.

Treatment in young and middle-aged patients is usually arthroscopic or open repair of the torn tendons. In the older patients, activity modification, anti-inflammatory medication, physical therapy and cortisone injections are typical. Surgery is a last resort because it is so hard on the body and many seniors may not survive the affects of anesthesia.

Separated Shoulder or Acromioclavicular Separation

An “AC Separation” is commonly the result of a fall on the end of the shoulder. It results in pain, swelling, and often deformity in which it appears that the collar bone is “sticking up.””
Treatment for a separated shoulder usually involves rest, ice, pain and anti-inflammatory medication, and physical therapy to restore motion. Rarely is surgery indicated. However, sometimes the ligaments that attach the collar bone to the shoulder blade are repaired.

Labral Tears

The labrum is a cartilage ring that surrounds the shoulder socket (called the glenoid) and makes it deeper. Since the socket is deepened by the labrum, the ball of the arm bone (called the head of the humerus) has a better fit into it. Labrum or labral tears are usually associated with trauma, instability of the shoulder, or repetitive throwing as with a baseball player.

The signs and symptoms of a labral tear are painful clicking, locking, or popping. Instability may be present because the labrum is not doing its job of holding the ball in the socket. Treatment for a labral tear is typically an MRI for diagnosis and arthroscopic repair but labral tears are often hard to diagnose. A special kind of labral tear, a SLAP tear, often involves the biceps tendon as well.

The Wrist/Hand

Skier’s Thumb (Gamekeeper’s thumb)

Skier’s Thumb is caused by a traumatic force on the thumb that forces it out (radial deviation is the anatomical direction). It often occurs with skiing and football.

Signs and symptoms include pain on the inside of the base of the thumb between the thumb and first finger, swelling, and an unstable joint. X-rays often show a small fragment of the metacarpal that has been pulled off by the ligament (called and avulsion fracture).
Treatment usually consists of bracing or splinting of partial tears and surgically repair if the tear is complete.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a compression of the median nerve within the carpal tunnel. There is pain, tingling, and in severe cases, numbness in the thumb, index middle and ½ of the ring finger. It is often caused by repetitive tasks involving the hand and wrist. Typing with the wrists resting on hard surfaces can result in this problem.
It is often worse at night and can lead to loss of grip strength and coordination. As the problem progresses, there is typically atrophy (muscle wasting) of the thumb muscles.
Treatment typically consists of splinting, anti-inflammatory medication, and most importantly, activity modification. Surgical release of the transverse carpal ligament is often performed before muscle wasting occurs. Physical therapy follows to help restore range of motion, strength, and to educate the patient of factors that can lead to a reoccurrence of the problem.

Guyon’s Canal Syndrome (Handlebar palsy)

Like Carpal Tunnel Syndrome, this condition is seen in cyclists when the ulnar nerve is compressed in its canal over the wrist. Resting the palms of the hands on bicycle handlebars is typically the cause.
Treatment is similar to that for Carpal Tunnel Syndrome- activity modification, rest, splinting, and less often, surgery.

De Quervain's Tenosynovitis

This is a condition in which the tendons of the thumb and their surrounding sheaths, (extensor pollicus brevis and abductor pollicus longus) become inflamed. Pain is located at the lateral side (outer aspect) of the end of the forearm, wrist, and often radiates into the thumb.

It is common with repetitive work activities, tennis players and golfers.
Treatment includes, rest, splinting, physical therapy, and rarely surgery.

Fractures of the Forearm/Wrist

Fractures of the wrist and hands are commonly named for their anatomical location, how they occurred, or a doctor that discovered or studied the given type of fracture. Below

Distal radius fracture Colles, Smith Fractures

These fractures often result from a fall onto the outstretched hand or a direct blow. Pain, tenderness, and deformity are common. X-ray are used to rule in/out a fracture.

Treatment for a fracture involves “closed reduction” in which the bones are moved back into alignment. If the bones cannot be moved back into the proper position manually, open reduction and often internal fixation is used. This means that surgery is used to expose the fractured bones, they are positioned next to each other and might be pinned, screwed or wired togther.

Scaphoid Fracture

This is the most common carpal bone (hand bone) fracture. Often wrongly diagnosed as a wrist sprain, there is tenderness or pain where the base of the thumb meets the wrist and/or with axial compression along the thumb.

Treatment for a scaphoid fracture can be difficult. If there is just a crack in the scaphoid bone, it requires a thumb splint for 6 weeks or until healed. If the bone is completely broken apart, it will require surgical fixation. Because of the unusual blood supply, the fracture may not heal completely (malunion) or avascular necrosis (death of the bone because of loss of the blood supply) may result.

Other fractures

Fracture of the Hook of Hamate

This is a fracture of a small region on the palm of the hand opposite the thumb. It typically occurs when the golf club impacts the ground. Signs and symptoms consist of point tenderness and pain in the palm of the hand. X-rays are used to rule this in/out.

Bennett's Fracture

This is a fracture of the base of the 1st metacarpal.

Mallet (baseball) finger

This fracture results from a trauma to tip of the finger forcing the into flexion (rapidly bending it down toward the palm) and avulsing the extensor tendon. Commonly occurs in baseball and basketball when attempting to catch a ball. Signs and symptoms include pain, swelling, and an inability to straighten out the last digit of the involved finger.

Treatment includes splinting of the finger in the straight position and if this is unsuccessful, surgical repair.


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