OCD

Kindly drawn by my older son

In case you're wondering about the title, it's not obsessive compulsive disorder, I definitely can't write a post on that. But I do know about osteochondritis dissecans (OCD). In fact when I kept having recurrent knee pain back in 2002 (which subsequently led to 3 knee operations), I initially thought I had OCD myself, before MRI scans suggested otherwise.

OCD occurs when part of a bone within a joint dies due to lack of blood flow and partially or fully separates from the joint. This separated bone piece can cause pain and subsequently restrict movement in that joint. Meaning you cannot fully straighten or bend that joint.

The cause of OCD is unknown. It is suggested that reduced blood flow to the bone may occur from repetitive trauma like excessive running and jumping. Or small, multiple episodes of minor unknown injury that damage the bone over time. Some studies suggest that there may be a genetic component involved too.

OCD occurs most frequently in children and adolescents, most commonly in the knee, but can also occur in the elbow and ankle. 

Doctors stage OCD according to how big the bone fragment is, whether the bone fragment is totally or partially separated or whether it stays in place. If that loosened piece of bone is not detached, then there may be few or no symptoms. For younger children whose bones are still growing and developing, there is a chance that it can heal.

So it was a total surprise to me when my adult patient was diagnosed with OCD 2 days ago. 

She was in the process of sitting down on her sofa and slightly twisted her knee. She could not extend or bend her knee fully nor put weight on her foot after that. She went to the hospital and was told it might be a meniscus tear and may need surgery. The surgeon suggested an MRI to confirm his hypothesis.

Hence, when the MRI results came out it was a big surprise that there was a bone fragment dislodged. That's the reason why she could not straighten or bend her knee fully.

The only incident my patient could think of was during gymnastics, when she was 12, that her knee started to hurt (possibly from the impact of repeated running and landing). Her knee would 'lock' occasionally for a few days at a time. It gradually resolved and she would occasionally have some knee pain on that same left knee while she competed in triathlons. Otherwise, there was no other clue that she would have OCD.

Now my patient has to decide how she would like to proceed to get the bone fragment out after discussion with her surgeon.

Reference

Kocher MS, Tucker R, Ganley TJ et al (2006). Management Of Osteochondritis Dissecans Of The Knee: Current Concepts Review. AJSM. 34(7): 1181-1191. DOI: 10.177/0363546506290127.

Picture from RadioGraphics 

No Need To Treat Your Child's Flat Feet

My young patient (only 6 years young then) was told he had flat feet, pronated 'too much' and needed orthotics. He was prescribed the pair of ankle foot orthoses pictured below. His parents ended up a few thousand dollars poorer and they were told to bring him back for more appointments. 

I could not begin to imagine the trauma this child had to go through mentally and physically, having had to wear those *orthotics (picture below) whenever he went out.

Parents with children who have flat feet please take note. This latest Cochrane Review (just published on 14/1/22) states that "in the absence of pain, the use of high cost customised foot orthoses (CFO) for healthy children (from 11 months to 19 years old) with flexible flat feet has NO supporting evidence, and draws very limited conclusions about foot orthoses for treating paediatric flat feet". 

Review articles from the Cochrane Database of Systematic Reviews are highly respected and trusted. Google it if you like.

Not just costly CFO's, less expensive prefabricated (off the shelf) foot orthoses are not needed as well.

This Cochrane review also suggests that there is no further need to research asymptomatic flat feet in healthy children. It is better to focus on other paediatric conditions instead. 

Parents, now you know, do not waste your time and hard earned money on orthotics for your children. Don't worry too much about their shoes too. Email me if you want a copy of the article.

Reference

Evans AM, Rome K, Carroll M et al (2022). Foot Orthoses For Treating Paediatric Flat Feet. Cochrane Database of Systematic Reviews. Issue 1. Art No: CD006311. DOI: 10.1002/14651858.CD006311.pub3. Accessed 18 January 2022

*in my opinion, the orthotics look like they will do a better job limiting ankle movement with the stiff upright medial (inner) and lateral (outer) sections

The Escape Room

Our clinics took time off work this morning and had a Team Building session together. It was nice to spend some time together albeit in our groups of 5 outside the clinic.

Byron looking at the wrong camera

Both teams did 'escape' from their respective rooms even though the team above posed with the 'almost escaped' banner. It wasn't that easy, we needed to ask for clues and everyone had to work together.

So when's the next session, some of our staff are already asking. We're definitely already planning the next session.

How To Improve Your Shoulder Range (If You Have Frozen Shoulder)

Last week, we wrote about how Covid-19 may cause frozen shoulder (also known as adhesive capsulitis), so I thought I'd follow up with a post on how we can increase or at least maintain shoulder flexion range during the first and second stage of frozen shoulder. 

Table slide

Research (Rabin et al, 2021) suggest that doing the 'table slide' and 'forward bow' rather than self assisted flexion will give better results for shoulder flexion and less pain. Byron demonstrates the table slide above. Seat slightly forward comfortably on a standard chair (ususally 45 cm high) with your forearms resting on a higher table (80cm). Interlock your hands together and lean forward by sliding your forearms until you reach your tolerable stretch.

Forward bow

For the forward bow, in a standing position, you need to place both palms with elbows straight on a table. Next you need to step back slightly, lower your chest towards the floor until you reach maximum tolerable range.

Assissted flexion

Of course you can still do the self assissted flexion. But it may elicit more pain and the range you attain is usually less. This can be done in standing or even lying down. Thiviyan (above) is holding a stick with both elbows straight while using the unaffected arm to lift the stick into maximum tolerable shoulder flexion. 

Some physiotherapists may suggest using a rope and pulley anchored over the top of a door using the unaffected arm to pull the affected side up. Research also suggests the rope and pulley method is less effective and more painful.

How do we, at Physio Solutions and Sports Solutions, treat frozen shoulder? 

I already revealed this in a previous post. We get best results treating the hip and the arm lines. Remember I wrote previously that our arms and shoulders are connected to our hips?

Have a look at the connections again above and below.

Don't put up with pain and limited range. we are here to help you.

Reference

Rabin A, Maman E, Dolkart O et al (2021). Regaining Shoulder Motion Among Patients With Shoulder Pathology - Are All Exercises Equal? Shoulder and Elbow. 0(0): 1-8. DOI: 10.1177/17585732211067161

Cycling Champion Rides Again 2 Weeks After Breaking Collarbone

The champ Donaben Goh Choon Huat

While we're on shoulders, guess what? My patient fell while cycling on Boxing day (26/12/21) and fractured his left collarbone. He was operated on 27/12/21. Today he's back cycling again, not on an indoor trainer but outside.

Giving him some grief

We worked really hard getting his range and strength back so he could get back on the bike quickly.

Donaben won 2 bronze medals at the last Sea Games in 2019 in the time trial and road race event (Singapore last won a medal in the road race more than 30 years ago).

Please do not try this if you have a broken collarbone, not 14 days after your operation anyway. As a professional cyclist he needs to ride again as soon as possible.

Please ride safely Donaben! All the best as you train for the SEA Games and Asian Games later this year.

Can Frozen Shoulder Be Caused By Covid-19?

Aized was looking at her FB feed (pictured above) earlier this week when someone asked what else could be done for her frozen shoulder (or adhesive capsulitis). This lady was told by her doctor at Tan Tock Seng hospital that her frozen shoulder was possibly caused by her vaccination injections.

Then I recall reading a paper published last July 2021 that it may be Covid-19 that can cause frozen shoulder (rather than the vaccination injections). 

In that published paper (Ascani et al, 2021), 1120 patients were evaluated at the shoulder surgery unit. Of these, 146 were found to have frozen shoulder or adhesive capsulitis (AC). Of these 146 subjects, 12 had AC after contracting Covid-19, 8 female and 4 male. The patients were between 42-73 years. Frozen shoulder in the patients started 1.5 to 3 months after the Covid-19 diagnosis (mean onset was 2 months after Covid-19). 

Covid-19 symptoms were mild in 5 of the patients, were the other 7 were asymptomatic. None of the patients were severely or critically ill. 2 of the patients had diabetes that were well controlled. You can read more about that study and how the authors suggested AC can be caused by Covid-19 here.  

Can't do L hand on hip

With AC, there is pain and later lots of stiffness in the affected shoulder. First clue if you have AC, you cannot put your hands on your hips (the affected side of course, pictured above). That hand behind your back is definitely out of the question. You have difficulty bringing your arms overhead from the front and side (when your elbows are straight). The pain seems to worsen at night, disrupting sleep. Quality of life is definitely affected.

We really do not know what causes AC. Even doctors and research scientists are not sure either. However, we do know that AC afflicts women more commonly than men. Especially women above 50, more so if they are diabetic, had a prior stroke or thyroid disorders. Sometimes, it occurs after a recent shoulder surgery as well.

There seems to be some recent evidence that AC is a metabolic condition. Meaning if you're hypertensive, overweight, you drink, smoke, you have a poor diet and do little or no exercise, then you have a higher chance of getting AC.

There are usually 3 stages with AC. The first stage is the 'freezing' stage where pain is increasing with most shoulder movements. End range of motion in the shoulder starts to be limited. This stage can last from 3 to 6 months. 

The next stage is the 'frozen' stage. There usually isn't as much pain as the first stage but shoulder range is definitely more limited. Patients often complain of increasing 'stiffness' in this stage.

The last stage is known as the 'thawing' state where shoulder range starts to improve. There is usually much less pain during this stage.

AC can last between 9 to 18 months. I've seen some patients get a whole better after 6 months although it can drag for up to 24 months in other patients. 

I will write how we can help with AC in my next post. Stay tuned.

Reference 

Ascani C, Passaretti D, Scacchi M et al (2021). Can Adhesive Capsulitis Of The Shoulder Be A Consequence Of Covid-19? Case Series Of 12 Patients. 30(7): E409-413. DOI: 10.1016/j.jse.2021.04.024

Pain Does Not Mean You're Injured

I had niggles most of the time when I was training seriously. Especially after a good block of training. If I tried running hard for consecutive days, my left knee usually would start to hurt a little.

Most elite athletes I treat are similar, always dealing with pain and niggles. Some pain would disappear while other pain tend to persist and linger.

A recent article (Hoegh et al, 2021) suggests that in the context of sports medicine, pain and injuries are 2 different distinct entities and should not be lumped together.

That article (Hoegh et al, 2021) suggests that when pain is inappropriately labeled as an injury, it creates fear and anxiety. It may even change how we move the affected body part, creating further problems.

From Hoegh et al, 2021

An example given in the article is patellofemoral joint pain, an extremely common diagnosis assigned to runners by sports doctors, physiotherapists etc. This just means that there is pain around/ inside the knee joint but they cannot figure out exactly why it's hurting. Compare this to patella tendinopathy where there is a clinically identifiable cause for pain (wear and tear in the tendon).

Reading words like stabbing pain or burning sensations can affect how you feel. When we complain of pain, it may feel like something is damaged. However, as I often tell my patients, pain is subjective. To my patient it may feel like a 3 out of 10 kind of pain, but to me it may be an 8 out of 10 pain. Or vice versa. Pain can occur and exist even without an injury.

Pain can be influenced by beliefs, the process of cognition (knowing and perceiving), expectations and circumstances. Injuries are not. The onset of pain can be unpredictable, and how severe the pain is does not usually depend on the stage of healing.

Injuries can be identified by sight, orthopaedic tests and scans. The prognosis for an injury will depend on where the injury is. A muscle tear will usually heal faster than a bone fracture. 

After a sports injury, in order for the athlete to return to sport, we gradually increase their training load on their damaged tissue during rehabilitation until healing is complete and able to handle the demands of more strenuous training and competition.

With sports related pain, one cannot gradually increase training load and hope that the pain will go away. However, we can improve the patient's ability to manage the pain especially since pain is subjective.

If you have a bone stress fracture, you will have to take time off running until it heals and gradually increase load. Once healed, pain usually is no longer an issue. The injury and the associated pain are tightly connected. 

Other cases may not be as straight forward. An example would be patients who have chronic pain in their Achilles tendon with no damage on their MRI scans. There is no clear link between the physical state of their tendon and how it feels (or hurts). In such cases, surely we can manage and reduce their pain to allow them to run rather than waiting for their tendon to 'heal'. 

Another recent publication by Friedman et al (2021) warn of the dangers of diagnostic labels. Calling a patient's knee injury a meniscal tear rather than a meniscal strain may nudge the patient to opt for arthroscopic surgery even though that may not be considered the best approach.

According to the authors (Friedman et al, 2021), words chosen by medical professionals to describe injuries may present a situation as considerably worse than it actually is. This will increase anxiety and cause fear of movement.

Judging what pain to ignore and which ones to take seriously can be a delicate art rather than science and how we choose to label it can affect the outcome.

Sometimes pain is just pain.

References

Friedman DJ, Tulloch D, and Khan KM (2021). peeling Off Musculoskeletal Labels: Sticka and Stones May Break My Bones, But Diagnostic Labels Can Hamstring Me Forever. BJSM. 55: 1184-1185. DOI: 10.1136/bjsports-2021-103998.

Hoegh M, Stanton T, George S et al (2021). Pain Or Injury? Why Differentiation Matters In Exercise And Sports Medicine. BJSM. DOI: 10.1136/bjsports-2021-104633.