Other Common Musculoskeletal Conditions

Tennis/Golfer’s Elbow (Lateral/Medial Epicondylitis)
These are common problems involving staining/overuse of forearm tendons which attach to the bony prominences on the upper arm bone close to the elbow joint. Tennis elbow involves the tendons attaching to the outer side of elbow and repetitive activities involving gripping or twisting of forearm makes this pain worse. It may affect one or more tendons and it’s not uncommon for the pain to radiate down further into the forearm. Golfers elbow involves the tendons on the inner side of elbow.

Treatment involves activity modification, physiotherapy and painkillers. In clinic diagnostic ultrasound scan followed by PRP or steroid injection and physiotherapy can help effectively deal with the condition.

Achilles Tendinopathy
Achilles tendon attaches the calf muscles to the heel bone and is the biggest tendon in the body. It is located behind and above the heel. Overuse or underuse of the tendon can predispose to tendinopathy hence it may be seen in very active people or in those with a sedentary life style. Other predisposing factors include incorrect footwear, poor flexibility, being overweight and sudden increase in physical activities.

Most common symptom is pain behind or just above the ankle with associated stiffness and swelling. Diagnosis can be made with the help of an ultrasound scan. Conservative management involves rest, activity and footwear modification, weight management, medications and physical therapy. Tendon sheath PRP or steroids injections under ultrasound guidance, extracorporeal shockwave therapy are reserved for those not responding to conservative management.

Plantar Fasciitis
Plantar Fascia is a tissue band in the sole of foot which stretches from the front part of heel to the toes. It works like a shock absorber playing an important role in pushing the foot off from the ground during walking. Repeated stress/ injury to the fascia can lead to a condition called plantar fasciitis, which present as pain on the underside of heel worse on taking first few steps after a period of rest. Risk factors include using footwear with poor cushioning, being overweight, sudden change in activity levels, and calf muscle tightness.

The diagnosis is made by history, clinical examination and is aided by an ultrasound scan. Ultrasound can help in identifying any partial tears, fascia rupture and any foci of calcification or calcaneal spurs. An x-ray may be requested to rule out any bony spurs.

Conservative management involves

Using correct footwear with shock absorbing sole and arch support
Rest/ activity modification
Physiotherapy involving stretching of plantar fascia and achilles tendon
Night splints
Painkillers
Weight management and
Ultrasound guided injections - Platelet Rich Plasma (PRP) or steroid
are reserved for patients with a poor response to conservative management.
De Quervain’s tenosynovitis
This condition results from irritation of two tendons as they travel in close proximity to each other in their course from the wrist towards the thumb. Irritation results in inflammation, swelling and thickening of the tendons or their covering sheath impacting their ability to glide freely during wrist and thumb movements. It is seen more commonly in women and presents as pain, swelling at the base of thumb, wrist.

Treatment involves rest, splints, medications, physiotherapy and if not responding to conservative measures then steroid injection. Ultrasound scans can help in verifying the diagnosis and precise injection of steroid to reduce the pain.

Injections for proximal hamstring tendinopathy & ischial bursitis
Hamstrings are a group of muscles present at the back of thigh. They extend from the pelvis (ischial tuberosity) to the knee and play an important role is everyday activities such as bending or running. Muscles attach to the bones with the help of a special type of tissue called tendons. With overuse, misuse or injury, these tendons can get inflamed, torn leading to development of a condition called tendinopathy. Involvement of proximal part of hamstrings presents as buttock pain radiating down the back of knee. Pain may be worse on sitting on a firm seat. Sciatic nerve is present close by and its irritation can cause pain to radiate further down the leg.

Condition such as unequal leg length, core and pelvic muscle weakness, being overweight and repeated overloading with insufficient warm up predispose to development of hamstring tendinopathy. Higher incidence is seen in runners, football players, dancers and older adults who do a lot of walking.

Treatment options include rest, activity modification, physical therapy and medications. If these fail to produce desired results then injections with Platelet Rich Plasma (PRP), autologous blood (ABI) or steroids are considered. Percutaneous tenotomy is another option. Injections are performed under ultrasound guidance in the peritendinous region. Direct injection into the tendons is avoided. These are performed under local anaesthesia as an outpatient procedure or a day case.

Platelet Rich Plasma (PRP)
Platelets are one of the blood components. They help in clotting and contain growth factors which promote the healing process. PRP is a blood plasma with concentrated platelets. PRP therapy is an attempt to utilise body’s natural ability to heal itself. It is utilised for tendon or ligament injuries which have not responded to conservative measures such as tennis elbow, golfer’s elbow, plantar fasciitis, achilles tendinosis.

The procedure involves collecting a blood sample from the patient which is then placed in a spinning machine to separate different blood components. The component containing high platelets is separated and then injected at the intended site under ultrasound guidance. Most people require 1-3 injections at 4 weekly intervals depending on the response. Growth factors are released from the platelets influence the process and accelerate the repair of tendon or ligaments.

Trigger Point Injections
Muscles ability to contract and relax plays an important role in body functioning. When muscles fail to relax, they form knots or tight bands known as trigger points. In simple words trigger points are irritable areas/ bands of tightness in a muscle. Pressure over a trigger point produces local soreness and may refer pain to other body parts. Common causes include inflammation, injury of the muscle or the neighbouring structures. Poor posture and repetitive strain are other predisposing factors. Trigger points can limit the range of movement; affect posture predisposing other areas to unaccustomed strain. They are more commonly observed in head, neck, and shoulder muscles.

Trigger point injections are performed in an outpatient/ day-care setting and the procedure involves injecting local anaesthetic with or without a small dose of steroid into the painful muscle. The local anaesthetic blocks the pain sensations and the steroids help in reducing the inflammation, swelling. I prefer to perform these injections under ultrasound guidance as it improves the accuracy and reduces the chances of complications. Post injection physiotherapy is essential to prevent recurrence and maximise the benefits.