Hip pain is typically felt in the groin, and often spreads down towards the knee. Pain felt around the buttock area is usually referred from the back. The commonest cause of hip pain in adults is osteoarthritis. In this condition the cartilage covering the joint surfaces wears away causing pain and stiffness of the joint. This typically occurs in older age groups, but can manifest itself much earlier in some patients. If symptoms are severe enough to warrant surgery then a total hip replacement is usually the procedure of choice.
Other disorders of the hip can occur in childhood, and these can lead to problems in younger adults. This is a fairly specialised area of orthopaedics.
Knee problems can present with pain or instability, or both. Swelling is often noticed, as is stiffness, clicking, locking or giving way of the joint. The best way to diagnose knee problems is by the pattern of symptoms and a physical examination. X-rays are usually taken, but MRI scans can often be misleading and I personally rarely request them.
Depending on the diagnosis, treatment may consist of physiotherapy, arthroscopy (often referred to as “keyhole surgery”) or even total joint replacement.
Cartilage tears usually present with so-called “mechanical symptoms” such as painful clicking, locking of the joint or giving way of the joint. Ligament damage may present as a feeling of an unstable knee. Knee arthritis presents with pain and stiffness of the joint.
Foot and Ankle disorders
Foot pain is a very common complaint and has multiple possible causes. The first port of call for treatment is often an orthotist, also known as a “surgical fitter”, as many instances of foot pain can be well treated by appropriate “off the shelf” or sometimes specially made footwear.
Bunions and other deformities of the toes are often caused by wearing inappropriate footwear (perhaps over many years) and can sometimes be corrected surgically, but the symptoms of deformity are again often best dealt with by properly fitting shoes.
Ankle problems are not very common. Ankle arthritis does occur, sometimes after fractures around the ankle many years previously, and rarely one will see ankle instability caused by ligament damage.
The commonest shoulder problems are instability, impingement, frozen shoulder and arthritis. The commonest symptoms are pain and stiffness. As for most conditions, the correct diagnosis is usually made by a thorough clinical assessment. Most shoulder problems can be definitively treated with a steroid injection (carried out in the clinic) and physiotherapy.
Impingement is caused when one or more of the tendons deep inside the shoulder gets pinched when raising the arm above head height. First line treatment is injection and physiotherapy, with surgery (usually “keyhole”) to open up the space for the tendon being a last resort.
Frozen shoulder is where the joint capsule becomes tight resulting in extreme stiffness of the joint. It can be improved by a manipulation under anaesthetic to get the shoulder moving again, followed by physiotherapy.
Shoulder arthritis is less common than that of the hip or knee (because we walk on our legs, not our arms!) but can occur. Injections can help, but usually temporarily. Shoulder replacement can be done if symptoms are very severe.
These are not very common in a general orthopaedic practice. Tennis and golfer’s elbow are painful conditions caused by inflammation of the tendons attaching to the bony bumps on the outside (inside in the case of golfer’s) of the elbow. They are usually treated with physiotherapy, splinting, anti-inflammatory medication or injection. Surgery is rarely required and is a last resort.
Olecranon bursitis, a painful swelling over the point of the elbow, is sometimes seen. Surgery in this condition is best avoided.
As with the shoulder, elbow arthritis is not common, and surgery in the form of joint replacement is very specialised work.
Hand and Wrist conditions
Arthritis in the small joints of the hand and wrist, and at the base of the thumb, is fairly common. The usual arthritic symptoms of pain and stiffness give the diagnosis, and treatment is often with physiotherapy or injections. Surgery, in the form of either fusion or sometimes joint replacement can be done if symptoms are severe enough.
Dupuytren’s disease is fairly common on the Isle of Man. This is a condition where the fingers (usually the ring and little) are pulled into the palm by a contracture of the fibrous fascial tissue under the skin. When the contracture is bad enough to interfere with everyday living the treatment is surgery, and the results are generally very good.
The ulnar nerve at the elbow and the median nerve at the wrist (carpal tunnel syndrome) are common sites of nerve compression. Symptoms are usually unpleasant tingling and pain in the hand, often worse at night and causing disturbed sleep. Diagnosis can be confirmed with nerve conduction tests, and surgical release is usually very successful.