theodorides_knee_surgeon_review

De Quervain’s Tenosynovitis

info@theodorideskneesurgeon.com (Anthony Theodorides) — Sat, 03 Apr 2021 15:12:12 GMT

Introduction

De Quervain’s tenosynovitis (also called De Quervain’s tendinosis) is a painful condition of two tendons at the level of the wrist on the side of the thumb
It’s a repetitive strain injury due to overuse of two tendons used to move the thumb away from the other fingers

Anatomy

Tendons are strong fibres of collagen that attach muscles to bones and therefore enable muscles to produce movement
Tendons slide within a tissue that forms a tunnel called a sheath
The sheath helps keep the tendons close to the bones
Extensor tendons run on the back side of the wrist:
Their function is to straighten the fingers and extend the wrist
The extensor tendons are organised into 6 compartments at the level of the wrist
The 1 ^st compartment is on the side of the thumb and the 6 ^th on the side of the little finger
De Quervain’s tenosynovitis affects the 1 ^st compartment which contains two tendons:
Abductors pollicis longus:
Its function is to tilt the wrist towards the thumb and abduct the thumb (moving the thumb vertically away from the palm)
Extensor pollicis brevis:
Its function is to tilt the wrist towards the thumb and extend the thumb (moving the thumb sideways away from the palm)

Pathophysiology

It occurs due to thickening and/or swelling of the tendon or its covering sheath
This causes friction and pain as the tendon struggles to slide through the sheath

How often does it occur?

It is seen more commonly in patient who have tennis elbow or golfer’s elbow
Often seen on both wrists in new mothers or those who look after children and resolves on its own once lifting the child is less frequent

Symptoms

Pain occurs on the side of the wrist at the base of the thumb
Pain is made worse when gripping
The symptoms come on gradually
Pain on moving the thumb especially when gripping objects
Swelling at the base of the thumb has also been noted

Risk factors

It is more common in women than men:
Especially mothers of newborns who repeatedly lift the newborn with the thumbs away from the rest of the fingers
Typically affects 30-50 year olds
Most commonly affects the dominant wrist
It is an overuse injury of the thumb particularly from repetitive grasping
Can also be caused by a direct blow to the thumb or arthritis
Provocative movement in particular is the sideways wrist motion whilst gripping such as:
Lifting young children
Gardening
Racquet sports
Skiing
Using a hammer
Long hours pressing playing computer games that involve pressing a button repeatedly with the thumb

Diagnosis

The classic test for De Quervain’s tenosynovitis is the Finkelstein test
The patient is asked to make a fist by wrapping their fingers over the thumb (as opposed to the more conventional thumb over fingers)
Whilst keeping their fist in this position the doctor then moves the wrist sideways away from the thumb
If this causes pain then it is a positive test for De Quervain’s tenosynovitis as the irritated tendons are forced down the narrowed overlying sheath

Treatment

Most cases will settle with conservative management
High rate of recurrence i.e. can come back once the symptoms settle
First line treatment should be:
Rest
Avoiding repetitive thumb movements as much as possible
Anti-inflammatory medications
Thumb immobilisation splint
Ice
Physiotherapy to strengthen muscles used to move the thumb
Steroid injection into the affected tendon compartment of the wrist to help reduce
Studies have shown that 20% of patients using thumb immobilisation splint alone for 6 weeks had improvement in symptoms and this increased to 60% when combined with anti-inflammatory medications
The splint should allow some movement of the thumb as opposed to completely immobilising it
Surgical treatment is considered for cases when conservative management has failed:
It has a high success rate
A small cut is made on the wrist over the painful side and the sheath is released over the irritated tendons
This removes the pressure on the tendons and allows them to heal
The operation can be performed under local or regional anaesthesia
There is a nerve (superficial radial nerve) around the surgical incision site which provides sensation to the area so it is important to avoid this potential complication

Prevention

Avoiding provocative movements that cause pain
Taking breaks when having to carry out a repeated wrist motion
Keeping your hand and forearm muscles strong

Further helpful information can be found here on:

Cubital Tunnel Syndrome

info@theodorideskneesurgeon.com (Anthony Theodorides) — Sat, 03 Apr 2021 15:12:04 GMT

Introduction

Cubital Tunnel Syndrome occurs when the ulnar nerve is compressed within a tunnel on the inner (medial) side of the elbow just behind the bony prominence of the inner aspect of the elbow called the medial epicondyle
Cubital Tunnel Syndrome is the second most common cause of peripheral nerve compression:
The most common one being carpal tunnel syndrome (compression of the median nerve at the wrist)
The ulnar nerve is one of the three main nerves of the upper limb:
The other two nerves of the upper limb are the median nerve and the radial nerve
The ulnar nerve travels from the neck past the elbow and wrist and into the hand:
Along the way it travels past some narrow areas where it can be constricted and cause symptoms for the patient
The most common site of ulnar nerve compression is in the cubital tunnel at the elbow
The second most common site is in Guyon’s canal in the hand
When someone accidentally hits the inner side of the elbow (often termed hitting the funny bone) they get a sharp tingling sensation on the inner side of the elbow and forearm:
This occurs because the ulnar nerve was hit at the site of the cubital tunnel where the nerve is close to the skin surface and therefore easily injured from outside forces

What is the cubital tunnel?

The cubital tunnel is a space on the inner (medial) side of the elbow
It lies between the medial epicondyle (bony prominence on the inner sider of the elbow) and the olecranon (the large bony prominence at the back of the elbow)
The cubital tunnel is covered by the elbow joint capsule and the inner ligament called medial collateral ligament

Pathophysiology

The cubital tunnel is a small space with not much room to allow for expansion in volume
Any swelling in that vicinity will put pressure on the nerve and cause symptoms
The ulnar nerve is close to the skin at the cubital tunnel and so prolonged direct pressure such as leaning on elbows or sudden trauma will injure the nerve
The ulnar nerve is stretched when the elbow is bent and is less taught as the elbow straightens:
Therefore, keeping the elbow bent for prolonged periods stretches the nerve and irritates it
As a result of the ulnar nerve being stretched over inner bony prominence (medial epicondyle) it is irritated and injured causing initially changes in sensation and later the muscles that the nerve supplies are affected and atrophy

What is the function of the ulnar nerve?

The function of the ulnar nerve is:
Supplies sensation to the little and ring fingers
Controls most of the muscles in the hand that provide fine movements
Controls some of the muscles in the forearm that provide a strong grip
These functions are therefore affected pending on the severity of the cubital tunnel syndrome

Symptoms

Numbness and tingling of the little and ring fingers:
This sensation can be intermittent such as when the elbow is bent for prolonged period in the middle of the night which is then relieved by straightening the elbow
When more severe can lead to weak grip strength and poor finger coordination
Muscle wasting in the hand occurs in even more severe cases and this is irreversible so it is important to seek medical attention if symptoms persist for more than 6 weeks
Whilst most of the symptoms occur in the hand there can also be pain and tingling on the inner side of the elbow and forearm

Risk factors

In many cases the cause is unknown
Prolonged periods of elbow flexion (holding it bent) as occurs when sleeping or holding a mobile phone
Sustained leaning on your elbows on hard surfaces such as desks or arm chairs when working or studying
Previous fracture or dislocation of the elbow
Swelling or cysts on the inner side of the elbow
Bony spurs arising from arthritis in the elbow
Sports or occupations that involve repetitive elbow motion such as throwing

Diagnosis

History and examination are very suggestive of cubital tunnel syndrome
Altered sensation in the ulnar nerve distribution which covers the palm and the palmar aspect of the little and ring fingers
It is important to assess for sliding of the ulnar nerve during elbow flexion:
For some people when they flex their elbows the ulnar nerve slides over and in front of the medial epicondyle and this repetitive movement can irritate the nerve
Tinnel’s test:
Tapping on the ulnar nerve over the inner elbow sends electric shocks down the fingers innervated by the ulnar nerve
Elbow flexion test:
Keeping the elbow bent for a minute reproduces numbness and tingling in the little and ring fingers
It is important to rule out other causes of ulnar nerve entrapment such as:
Spinal disc protrusion in the neck that is pressing on a nerve
Thoracic outlet syndrome causing pressure on the brachial plexus
Xrays:
They can help rule out bony trauma or arthritis in the elbow
Nerve conduction studies (NCS):
It involves placing small electrodes on the skin and sending small electrical impulses that are then transmitted by the nerve being examined
Provides a detailed analysis of how well a nerve is functioning by measuring how fast the electrical signal travels down the nerve
The slower the speed the more damaged the nerve is
They detect whether and to what degree the nerve has been damaged as well as helping to locate the site of nerve damage
This will then help guide treatment
Electromyography (EMG):
This is similar to the nerve conduction studies but analyses the electrical activity produced by skeletal muscles
Muscles contract in response to nerve stimuli from the brain
EMGs measures how well the muscles respond to these nerve stimuli
If muscle damage has occurred then the nerve compression is more severe

Treatment

For most cases conservative treatment is effective
This involves:
Rest
Avoiding provocative actions such as:
Leaning elbows on hard surfaces
Keeping the elbow bent for prolonged periods especially at night
Wearing an elbow splint which minimizes elbow flexion:
Wrapping a towel around the elbow at night is particularly effective at avoiding elbow flexion whilst sleeping
Elbow splints that hold the elbow in 45 degrees of flexion have been shown to help
Anti-inflammatory medication can help
There is little evidence that physiotherapy or massage in the area improve symptoms
Surgical intervention is recommended if:
Conservative measures have not been effective over a period of time
There is severe compression of the ulnar nerve
Muscle weakness in the hand has occurred as a result of the nerve compression
There are numerous types of surgical options available pending on the severity and cause for cubital tunnel including:
Cubital tunnel release which releases the tissues that constrict the space around the nerve in the cubital tunnel and so reduces the pressure on the ulnar nerve
This is very effective for mild and moderate cases
Anterior transposition of the ulnar nerve involves moving the ulnar nerve in front of the inner bony prominence (medial epicondyle) and so it prevents it from rubbing against the bony part of the elbow and it is stretched less when the elbow bends
Medial epicondylectomy involves removal of part of the inner bony prominence which reduces the pressure on the ulnar nerve when the elbow is bent
These procedures are generally carried out as a day case with the patient able to go home the same day
The outcomes of surgery are generally good for most cases but the outcomes are less good for severe cases especially when muscle wasting has occurred:
It is therefore important to seek medical help soon if symptoms have persisted

Prevention

Avoid activities that keep the elbow bent for prolonged periods
If you work or study on a desk avoid:
A low chair
Resting the elbows on the armrest of a chair
Do not lean the elbows on hard surfaces such as a desk, arm chair or arm rest of a car door
When going to sleep wrap a towel gently around the elbow so as not to put pressure on the elbow which will help limit how far the elbow bends

Further helpful information can be found here on:

Carpal Tunnel Syndrome

info@theodorideskneesurgeon.com (Anthony Theodorides) — Fri, 02 Apr 2021 04:00:49 GMT

Introduction

Carpal tunnel syndrome is a common condition that causes numbness, tingling and weakness in the hand specifically affecting the thumb, index and middle fingers:
The little and ring fingers are not affected as they are supplied by another nerve called the ulnar nerve
It is the commonest cause of peripheral nerve entrapment
It is caused by compression of the median nerve as it passes from the forearm into the hand through a passage called carpal (i.e. wrist) tunnel
The median nerve is one of three main nerves that supply the upper limb:
The other two nerves are the ulnar nerve and the radial nerve

What is the carpal tunnel?

The carpal tunnel is a narrow canal in the wrist
It is formed by the carpal (wrist bones) and the transverse carpal ligament which is a tight strong structure that keeps the tunnel together
Through the tunnel pass:
9 tendons that flex the thumb, fingers and hand
Median nerve

What is the function of the median nerve?

The function of the median nerve in the hand is:
Supplies sensation to the thumb, index, middle and half the ring finger
Controls the muscles of the thumb
These functions are therefore affected pending on severity of the carpal tunnel syndrome

Pathophysiology

The carpal tunnel is a small space which doesn’t have the ability to expand in volume
Therefore, anything that occupies more space in the tunnel increases the pressure on the nerve

How often does it occur?

It is the most common cause of compression neuropathy (accounts for about 90% of them) and one of the commonest causes of pain in the hand and wrist
It affects around 3-5% of the adult population
Most commonly occurs between 35-60 years of age
Women are three times more likely to get it than men

Symptoms

In most cases the symptoms come on gradually without a specific event to set them off such as trauma
At the beginning the symptoms are intermittent but then become more frequent, lasting longer and eventually may become constant
Altered sensation (numbness, tingling, burning) in the distribution of the median nerve which is the thumb, index, middle and half of the ring finger which is closest to the middle finger
The little finger is characteristically not affected as this is supplied by the ulnar nerve
Many patients notice that their symptoms come on mostly at night waking them up when they feel the need to shake their hand which relieves their symptoms
Weakness in the hand comes on at a later stage and can present itself by dropping objects unexpectedly and having difficulty performing fine movements such as buttoning the clothes
Patients can find it difficult to write, type on a keyboard, handle small objects, holding a book to read, gripping the steering wheel whilst driving
In more severe and chronic conditions the muscles around the thumb on the palmar side can waste away (atrophy)
~60% of people have symptoms of carpal tunnel syndrome in both wrists

Risk factors

Repetitive strain injury is a common cause of carpal tunnel syndrome:
Repetitive wrist motions in occupations like typists, manufacturing, construction work
Regular use of vibrating tools or those that require forceful movements
Older age (rarely seen in under 20s)
Women are three times more likely than men
Pregnancy (the symptoms tend to go away following delivery of the baby)
Obesity
Diabetes
Low thyroid levels (hypothyroidism)
Rheumatoid arthritis
Previous wrist fracture

Diagnosis

History and examination are very suggestive of carpal tunnel syndrome
Altered sensation in the median nerve distribution which covers the palm and the palmar aspect of the thumb, index and middle fingers
Xrays:
They can help rule out bony trauma or arthritis in the wrist
Tinnel’s test:
Tapping on the median nerve over the wrist joint sends electric shocks down the fingers innervated by the median nerve
Phalen’s test:
Patient is asked to put their forearms out in front of them in a horizontal position and press the back of their hands together to cause maximal flexion (bend) of their wrists for 30-60 seconds
The test is positive for carpal tunnel syndrome if this reproduces their symptoms of numbness and tingling in the thumb, index and middle fingers
Durkan’s test:
Direct thumb pressure over the carpal tunnel for 30 seconds causes numbness and tingling in the median nerve distribution
Is the most sensitive test for carpal tunnel syndrome
Nerve conduction studies (NCS):
It involves placing small electrodes on the skin and sending small electrical impulses that are then transmitted by the nerve being examined
Provides a detailed analysis of how well a nerve is functioning by measuring how fast the electrical signal travels down the nerve
The slower the speed the more damaged the nerve is
They detect whether and to what degree the nerve has been damaged as well as helping to locate the site of nerve damage
This will then help guide treatment
Electromyography (EMG):
This is similar to the nerve conduction studies but analyses the electrical activity produced by skeletal muscles
Muscles contract in response to nerve stimuli from the brain
EMGs measures how well the muscles respond to these nerve stimuli
If muscle damage has occurred then the nerve compression is more severe

Treatment

Conservative management is usually the first approach except in the more severe cases and includes:
Wearing a wrist splint especially at night
Antiinflammatory medication as such ibuprofen
Steroid injections to the tunnel to help reduce the inflammation
Improving any correctable factors such as diabetes and low thyroid levels
Physiotherapy to help improve range of motion and strength in the hand, wrist and fingers
Use of heat and cold compresses to relieve pain
Optimising working environment to minimise repetitive strain injuries such as:
Sitting correctly on a chair at the right height and distance from the desk
Wrists should be in straight line with the forearms which should not be resting on any prominence such as the edge of the desk
Forearms should be horizontal
Carpal tunnel syndrome tends to deteriorate slowly but if treated appropriately and promptly it can help cure it
Surgery involves releasing the tight transverse carpal ligament which is termed carpal tunnel decompression:
This is a very common and highly successful operation (>90%) that is done as a day case procedure
It can be performed under local/regional anaesthesia and so the patient remains awake
Acts to release the pressure on the nerve
The more chronic and advanced the carpal tunnel syndrome prior to the operation the longer it takes for the symptoms to recover

Prevention

Take frequent breaks when carrying out repeated activities
Stretch regularly
Avoid poor posture as outlined previously
Keep neutral wrist position and avoid extreme positions of wrist extension and flexion
Avoid unnecessary and excessive force when carrying out a task:
It is frequently noted that patients put unnecessary extra force than what is required to carry out a task
Reducing the frequency and the force of gripping items in a flexed position

Further helpful information can be found here on:

Tennis Elbow

info@theodorideskneesurgeon.com (Anthony Theodorides) — Tue, 30 Mar 2021 17:27:32 GMT

Introduction

Tennis elbow (also known as lateral epicondylitis) is an overuse injury of the forearm tendons that originate over the lateral epicondyle of the humerus (bony prominence on the outside of the elbow) and act to bring the wrist backward away from the palm
Whilst tennis players are particular prone to this condition it does not occur exclusively to them

What causes tennis elbow?

The forearm muscles that act to extend the wrist (lift up away from the palm) and fingers originate from the bony prominence on the outer aspect of the elbow called lateral epicondyle
Muscles attach to a bone via a strong fibrous tissue called a tendon
Tennis elbow arises due to injury of a specific extensor forearm muscle called extensor carpi radialis brevis (ECRB)
ECRB is particularly active when having to extend the wrist and fingers with the elbow straight which is the most provocative position to get tennis elbow
Tennis elbow is a type of repetitive strain injury and repeated extension of the wrist causes tiny tears of the ECRB tendon weakening it and altering its structure
Generally it is due to:
Overuse of the wrist extensor muscles such as excessive gripping, wringing of clothes, painting, hammering, typing
Intensifying forearm muscle activity rapidly that body is not accustomed
Weak forearm muscles
Poor technique such as how a backhand tennis shot is executed

Who is at risk of getting tennis elbow?

Tennis elbow affects 1-3% of the population
~50% of tennis players will get suffer from tennis elbow during their careers
<5% of cases are related to playing tennis
Most commonly occurs between 30 and 50 years
Males and females are equally affected
Those who play racket sports especially tennis are at risk
Occupations that require repetitive forearm movements are at risk such as butchers, carpenters, plumbers, musicians, painters, those who frequently use a computer or a screwdriver and hammer

Symptoms

Presents with pain, burning or an ache on the outside of the elbow and upper forearm which is made worse by extending the wrist
Sometimes the pain can go lower down the outer forearm
Weak grip
Pain when:
Shaking hands
Squeezing an object
Lifting something
Using tools such as a screwdriver or hammer
Opening a jar
Turning a door handle
Gardening

Diagnosis

History and examination are often enough to make a diagnosis
A simple test to confirm tennis elbow is asking the patient to go behind a chair, grip the top of it with palms facing downwards and with straight elbows to lift it up:
If this causes pain then it is positive for tennis elbow

Is Tennis elbow a tendonitis or tendinopathy

Numerous studies have shown that there is lack of acute inflammation in tennis elbow and therefore it is not a tendinitis but a tendinopathy
Tendinopathy is the degeneration of the normal collagen makeup of a tendon and not an inflammatory reaction like tendonitis
Tendinopathy is caused by numerous microtears of the tendon altering its structure
Healthy normal tendon is composed primarily of type I collagen
Collagen is the most abundant protein of the human body:
Collagen is found in high proportions in connective tissues, bone and skin
It provides strength to the tissue
In tendinopathy as a result of the body trying to heal the microtears, there is a greater proportion of the weaker type III collagen

Treatment

Conservative treatment is very successful (~90%) if followed correctly
Rest:
Resting by avoiding exertional painful activities for several weeks
Brace:
Tennis elbow brace can be helpful
Ice:
In the acute phase, ice can help relieve pain
Anti-inflammatory medication may be effective for pain relief:
Aspirin, ibuprofen, diclofenac
Use sparingly due to side effects when taken long term
Steroid injection:
Steroid injections are currently not recommended
Research shows that even though pain may reduce after 3-6 weeks it comes back to levels worse when compared by physiotherapy alone and healing is also delayed
Physiotherapy:
Exercises to help strengthen the extensor forearm muscles and promote healing of the damaged tendon
The most effective way to combat tennis elbow is through physiotherapy exercises in particular the research proven Tyler twist (described below)
Grip strength:
Squeeze a rolled up towel or tennis ball for 10 seconds and release for 5 seconds
Repeat 10 times or as many times as you can and repeat on the other arm
Supination strength:
Whilst sitting rest your forearm on your knee so that your shoulder and elbow are lying still
Hold a weight from one end of it e.g. a 1.5L bottle of water end on (the amount of water can be changed pending the strength and symptoms of the patient)
Turn your palm upwards rapidly whilst holding the weight end on
Let the weight turn your hand facing downwards slowly
Repeat 10 times on each side
Wrist extension:
Whilst sitting rest your forearm on your knee so that your shoulder and elbow are lying still
Hold a weight with your palm facing downwards
Whilst your palm is facing down extend your wrist by bringing your wrist upwards towards your body
Bring the weight up fast and lower it down slowly
Repeat 10 times on each side
Wrist flexion:
Whilst sitting rest your forearm on your knee so that your shoulder and elbow are lying still
Hold a weight with your palm facing upwards towards the ceiling
Whilst your palm is facing up flex your wrist by bringing your wrist upwards towards your body
Bring the weight up fast and lower it down slowly
Repeat 10 times on each side
Towel twist:
Hold a rolled-up towel in both hands out in front of you
Twist both wrists in opposite directions (one wrist extends whilst the other flexes) as if you are wringing out water
Repeat 10 times in each direction
Tyler twist:
To do this you will need a flexible bar that you can rotate and carry out the following movements in the sequence stated
Hold the flexible bar vertically on the painful side with the wrist in maximum extension
Whilst keeping the flexible bar vertically, reach across and grab the opposite end of the bar with the other hand, palm facing outward
Continue gripping the bar firmly with the wrist on the injured side in position of maximum extension and twist the bar clockwise by flexing the uninjured wrist
Maintain the twist whilst extending both arms out in front of you and holding the bar horizontally at the level of the shoulders with the involved wrist in full extension and the uninvolved wrist in full flexion
Using the injured arm slowly untwist the flexible bar by flexing the extended injured wrist
Do 3 sets of 15 repetitions a day
Surgery:
Considered following failure of conservative treatment in 6-12 months
Has good results long term

Further helpful information can be found here on:

Repetitive Strain Injury

info@theodorideskneesurgeon.com (Anthony Theodorides) — Sun, 14 Mar 2021 16:21:15 GMT

Introduction

This term is also known as repetitive motion or stress injury and occurs as a result of carrying out the same motion repeatedly over time causing injury to muscles and tendons
It is associated with repetitive tasks, sustained or awkward position, forceful exertion, vibration or compressive forces
It can affect almost any joint in the body
Most commonly affected areas are hands, wrists, shoulders and neck
It is thought to affect 5-10% of the general population but can be as high as 20-40% in specific working populations

Symptoms

Pain over a joint or muscle
Throbbing sensation in the affected area
Reduced or altered sensation such as tingling
Reduced strength
Sensitivity to heat or cold

Causes

Overuse of a muscle or muscle group
Poor posture whilst carrying out a repeated motion
Maintaining the same posture for prolonged periods of time
Use of vibrating equipment
Working in cold conditions
Vigorous activities
Lifting heavy loads
Fatigue
Sustained pressure over a certain area
Increased psychological stress worsens the symptoms of RSI

Diagnosis

Diagnosis is made through history in particular:
What triggers the pain
Details of the repetitive action
Examination of the patient

Treatment

Medication:
Anti-inflammatory painkillers such as ibuprofen and diclofenac
Muscle relaxants such as diazepam
Antidepressants
Sleeping tablets to alleviate sleep disturbance if present
Heat and cold:
Applying either one can help pending on patient’s symptoms
Brace or splint:
Immobilisation of the joint can help some patients but need to avoid prolonged use to prevent stiffness
Physiotherapy:
Exercises to help improve strength and range of motion around the painful joint
Improve posture
Steroid injections:
They can help to alleviate pain if inflammation is present
Surgery:
Can help alleviate pressure on nerves and tendons

Prevention

The best cure is always prevention
This can be difficult to do if due to work the same action is repeated over many years
The most effective way is to reduce the frequency (ideally stop) and intensity of the provoking activity
If the activity cannot be stopped then ways to reduce the risk of injury are:
Take regular breaks
Exercise regularly and keep in shape
Improve posture
Improve technique when carrying out the task
In case of a desk job, stand up and stretch frequently
Resting the eye by looking in the distance
Carrying out exercises to strengthen the eye muscles such as focusing both eyes on a pen tip and bringing it closer to your face as far as the eyes can maintain focus on it without it becoming blurred

Examples of common types of Repetitive Strain Injuries

Bursitis:
Inflammation of fluid filled sacs located at points where muscles or tendons slide over bony prominences commonly around the knee, elbow or shoulder causing pain and swelling
There are over 150 bursae in the human body
Commonly seen in patients who are on their knees (e.g. plumbers) or rest their elbows on solid arm rests (office jobs)
Avoid resting on hard surfaces and use cushions/pads to reduce the pressure and friction
Tendonitis:
A tendon is a strong fibrous connective tissue that connects muscle to bone and so when a muscle contracts causes movement on the bone it attaches to
Tendonitis is inflammation of the tendon and can occur anywhere in the body
Tendinopathy:
This is weakening of the tendon through multiple tears in its structure that fail to heal properly and there is a build up of collagen type III instead of the normal type I collagen
It can affect any tendon but is more common in tendons around the knee (patella tendon, quadriceps tendon), Achilles tendon
Tennis elbow:
Overuse injury of the wrist extensor tendons that originate over the lateral epicondyle of the humerus (bony prominence on the outside of the elbow) and act to bring the wrist backward away from the palm
The extensor tendon most commonly involved is the extensor carpi radialis brevis
Most commonly occurs between 30 and 50 years of age
Those who play racket sports especially tennis are at risk as well as butchers, carpenters, musicians, painters
Presents with pain, burning or an ache on the outside of the elbow and forearm which is made worse by extending the wrist
Treated with activity modification and avoiding provocative movements, anti-inflammatory medications, physiotherapy, injections and surgery
Golfer’s elbow:
Similar in nature to tennis elbow (although much less frequent) and it affects the wrist flexor muscles that originate over the medial epicondyle (bony prominence on the inside part of the elbow)
Pain is located on the inside part of the elbow and made worse when the wrist is flexed (bending the palm downwards)
Most commonly seen in people playing golf but is not limited to them
Racket sports, weight training, throwing sports and physically demanding occupations such as plumbers and carpenters are also at risk
Physiotherapy exercises are the most effective mode of treatment

Carpal Tunnel Syndrome:
Compression of the median nerve as it passes from the forearm into the hand through a passage called carpal (i.e. wrist) tunnel
Commonly seen in patients who type a lot or work in assembly lines
Presents with numbness, tingling and weakness in the hand (the thumb, index and middle fingers)
Treated with splints, steroid injections or more effectively with an operation called carpal tunnel decompression to release the tight transverse carpal ligament which forms the roof of the tunnel
Cubital Tunnel Syndrome:
The ulnar nerve is injured as it passes on the inner side of the elbow through the cubital tunnel becoming inflamed, swollen and irritated
Is the second commonest nerve entrapment after carpal tunnel syndrome of the median nerve
Common causes are sleeping with the elbows bent, resting the elbows on the arms of a chair or armrest of a car
Presents with pain and tingling and of the little and ring fingers and if more severe with weakness in grip strength
Treatment includes avoiding provocative activities that require holding the elbow bent for a prolonged period, not leaning the inner side of the elbow on hard surfaces, wrapping a towel around the elbow when going to sleep to keep it straight
Surgical decompression of the ulnar nerve at the elbow called cubital tunnel release can be performed and is reserved for more severe cases and those that fail to resolve with conservative measures
De Quervain’s tenosynovitis:
Pain and tenderness near the base of the thumb when turning the wrist, gripping something or making a fist
Sports that can cause this include tennis, golf and rowing
More common in women, during pregnancy, those over 40, sports or occupation involving repetitive wrist movements
Treated with rest, avoiding provocative movements, splints, anti-inflammatories, steroid injections, physiotherapy, surgery to release the pressure on the tendons

Dupuytren’s contracture:
One or more fingers (most commonly the little and ring fingers) bend and curl towards the palm permanently
It starts and progresses gradually
Usually starts with small hard nodules under the skin of the palm and over months or years gradually worsens with thickening and shortening of connective tissue in the palm (palmar aponeurosis)
The thickened palmar aponeurosis takes the form of cords which give a false impression that they are thickened tendons
Risk factors for Dupuytren’s contracture are:
Age:
More commonly found in over 50 year olds
Gender:
Men are more likely to be affected, to have a more severe and aggressive form and the finger contractures to occur more quickly
Hereditary:
Commonly found within families which also happens to be a more severe and aggressive form compared to those without a family history of Dupuytren’s
Ancestry:
More common in those who descend from Northern European countries
Consumption:
Excessive alcohol and tobacco consumption as well as chronic intake or anti-epileptic medications increase the risk
Endocrine:
Diabetes mellitus increases the risk of Dupuytren’s
Patients are unable to put their hand flat on a table and the bent finger frequently gets caught in simple activities like putting the hand in a pocket
Numerous treatment options are available including splinting, steroid injection, and surgery
Raynaud’s disease:
Raynaud’s disease occurs due to constriction (spasm) of the small blood vessels to the skin of the extremities when the patient is cold or emotionally stressed
The fingers are affected in particular as well as the toes and sometimes the nose and ears
There are two forms of Raynaud’s
Raunaud’s disease:
This is idiopathic without a specific cause
It is the more common type
Symptoms are milder but affect patients at a younger ager (15-25 years)
Raynaud’s phenomenon:
This is secondary to conditions such as connective tissue diseases (scleroderma, Sjögren syndrome, rheumatoid arthritis), carpal tunnel syndrome, traumatic secondary to chronic use of vibrating tools
It is less common but more severe form of Raynaud’s
Symptoms:
Cold fingers that change colour to blue, purple or white and when they are warmed up the become red and numb
Raynaud’s is more common in women, those living in colder climates and those using vibrating tools
Managed by keeping the extremities warm, wearing gloves, avoiding the cold, and taking medications that help open up the small arteries

Further helpful information can be found here on:

Sailing Injuries

info@theodorideskneesurgeon.com (Anthony Theodorides) — Mon, 21 Dec 2020 20:19:15 GMT

Introduction

For thousands of years sailing has been a mode of transportation and a recreational and competitive sport for hundreds of years
Sailing covers a wide spectrum of boats and activities from recreational sailing on a lake to around the world ocean racing
Injuries are dependent on the physical demands placed on the sailor, which in turn depend on the type of boat, crew position, and environmental conditions
The size and crew on a boat varies from a single person in a 2.4m dinghy to the 23m America’s Cup boats which carry a crew of 11
Broadly speaking sailboats can be categorised into dinghies and keelboats
In a dinghy, a sailor spends significant energy and time levering their body over the side of the boat (called hiking) to prevent it from capsizing whilst harnessing the wind to make it go faster
Keelboats are larger boats than dinghies and the sailor harnesses the wind by physically turning winches (called grinding) to pull in lines under tension

Parts of a sailing boat

Hiking position with knees extended

Hiking position with knees flexed

Injuries in small boats

Studies have reported that the most common areas of injury whilst sailing small boats are in the back (45%), knees (30%), shoulders (20%)
Injuries can be due to:
Inadequate physical fitness
Acute trauma
Overuse injuries
The sailor is predisposed to injuries because many movements in sailing are sudden short powerful bursts with inadequate warm up
Hiking (which is when the sailor of a dinghy levers themselves over the side of the boat) exerts large stresses to the knee and lumbar spine putting them at risk of injury
In Laser sailing, the hiking position is with a mainly extended (straight) knee which puts greater moment loads on the knee and lumbar spine but reduces the shear forces on the knee
However, in Finn sailing the knee is more flexed (bent) thus reducing the moment loads on the knee and spine but increasing the shear forces on the knee
The foot position whilst hiking alters the forces around the knee
The foot is often internally rotated and this results in hypertrophy of the outer portion of the quadriceps muscle (vastus lateralis):
This leads to excessive forces on the patella pulling it outwards, which manifests in anterior (front) knee pain and increased wear and tear of the cartilage behind the patella (knee cap)
The overtraining of the quadriceps (front thigh muscles) relative to the hamstrings (back thigh muscles) leads to an imbalance of forces around the knee increasing the risk of patella and quadriceps tendinopathies (tendons at the font of the knee) and shear forces on the cartilage

Injuries in large boats

Mainsheet handling requires powerful rapid movements which puts the shoulder and arms at risk of injury
Keeping proper form and posture whilst carrying out a task is difficult when speed is of the essence and this predisposes sailors to injury
Balancing on a constantly tilting floor and having to cope with the ever changing wind forces makes the situation for the sailor to have an injury
Handling of the sailing sheet needs to be done with care in order to avoid common hand injuries such as friction burns, fractures, and lacerations
Head injuries are common from the swinging boom either due to unexpected change in wind direction, or poor communication between the crew
Therefore, awareness and improved communication among the crew helps prevent head injuries

Windsurfing

The majority of injuries whilst windsurfing (~75%) are acute, caused by impact with equipment
Chronic lower back pain occurs more commonly during low wind speeds due to a prolonged lordotic posture
~20% of male competitive windsurfers suffer severe injuries such as:
Knee ligament sprains and ruptures
Shoulder dislocations
Disc herniations in the spine
Spine fractures

Windsurfing

Yacht racing

Turning a winch in a yacht

Yacht racing

The most physically demanding position in yacht racing is the grinder who is tasked with manually raising the sails by rapidly turning the winches
This is done in short powerful bursts placing great physical demands on the shoulders, neck, elbow, forearms and lumbar spine which are commonly injured
The most frequent type of injuries are ligament sprains and tendinopathies

Injury prevention

The most common method of injury whilst sailing is tripping and falling and so it is important to keep your eyes open and your wits about you to help minimise the risk of:
Falls (this could be over a step, a misplaced item, an open hatch or even falling overboard)
Head injuries
Bruises
Fractures
Hence the adage one hand for yourself and one for the boat:
This practically means always use one hand to steady yourself on the boat and the other hand to work with
It reminds sailors to never use two hands to work with especially when using steps or walking on a slippery surface as this puts them at risk of falling
Improving the ergonomics of the boat or using straps whilst hiking contribute to reducing the risk of injuries
Research on injury prevention whilst sailing show that incorporating exercises that focus on the following are helpful:
Strength
Power
Cardiovascular fitness
Core stability
Weightlifting
Balance
Agility
Improving endurance has shown to greatly reduce injuries especially towards the end of the race when physical and mental tiredness increase the risk in errors of judgement and injuries
Cardiovascular training and fitness lead to:
Improved reaction time to changing wind speeds and boat position
Improved decision making and concentration especially in the latter stages of a race where injuries are more commonly noted
Reduced physical and mental recovery times following a race
Aerobic workouts should be varied to maximise the benefits and include:
Running
Swimming
Cycling
Rowing
Performing functional movements (e.g. squats) rather than isolation exercises (e.g. knee extensions) aid in maintaining balance between agonists and antagonists which in turn helps minimise the risk of tendinopathies
Avoiding prolonged positions and taking frequent breaks whilst sailing helps avoid overuse and postural injuries
Ropes should not be left loose and always safely stored ideally within a case
Whilst there are numerous injury prevention programmes with great effect, there is limited evidence on how effective they are at preventing sailing injuries
This is because of the difficulty in carrying out such research when there are so many variables (e.g. different sail boat categories, different crew positions asked to carry out different tasks, wind speeds, wave size and speed)

Improved technique

Sailors involved in competitions should have regular assessments for:
Underlying pathologies
Technique
Performance
Provide advice on injury prevention
The risk of injury can be reduced by improving the technique used to carry out physically demanding activities such as:
Maintaining neutral foot position whilst hiking
High amplitude low frequency pumping in windsurfing
Utilising the lower limbs to provide power whilst grinding
Monitoring the volume and intensity of training and competitions helps prevent fatigue and better manage recovery
Hydration and nutrition before and during a competition should be carefully checked as they are important factors to minimise fatigue and dehydration thereby preventing injuries
Sailing should be avoided if fatigue sets in, as the risk of injuries is markedly raised:
Physical fatigue results in poor performance, diminished coordination and support across a joint
Mental fatigue increases the risk of poor judgement and awareness

Strength training

Part of injury prevention is to analyse and correct an imbalance of muscle strength across a joint:
Agonists – the muscles that cause movement about a joint
Antagonists – the muscles on the opposite side of the agonists that help control that movement
A functional movement requires activation of both the agonists and the antagonists
Hikers are prone to knee injuries because their quadriceps muscles are constantly contracting leading to a marked imbalance of strength with their relatively weaker hamstrings
Grinders are prone to shoulder injuries because their front shoulder muscles are considerably stronger compared to their shoulder muscles towards the back
Emphasis should be placed on strengthening joint stabilisation muscles such as the rotator cuff muscles of the shoulder, the core, as well as exercises to help improve balance around the knee and ankle
Depending on the type of sailing being carried out, certain muscle groups which are prone to injury should be strengthened for peak power as well as endurance
Strengthening specific muscle groups should be tailored to the physical sailing demands of the sailor:
Forearm strengthening is helpful for grinders and windsurfers
Posterior shoulder muscles for big boat sailors
Medial quadriceps and hamstrings for hiking sailors
Lower limb strengthening should not be ignored especially for windsurfers and grinders as power from there helps increase force generation for activities like pumping, grinding and steering
All sailors should strengthen their lower back, and improve their core stability

Protective Clothing

Sailors due to their exposure to UV light are at risk of skin cancer, cataracts, and macular degeneration so measures should be taken to protect against UV light such as waterproof sunscreen protection, protective clothing, hats, and sunglasses
Protective head gear can reduce the incidence of head injuries in slalom windsurfers
Non-slip shoe wear should be worn by all windsurfers and wetsuits to protect from being stung by jellyfish
Lumbar supports can be worn by windsurfers to help protect from lower back injuries
Hand injuries are among the most common severely injured parts of the body
Wearing high-performance enduring sailing gloves helps:
Protect against friction burns and lacerations
Keeping hands warm
Life jackets should be worn at all times whilst sailing:
Unfortunately, they are an essential item that is often overlooked
Death by drowning accounts for three quarters of all deaths by recreational sailors
~80% of the sailors who drown were not wearing a life jacket

Improving the ergonomics

Improving safety as well as equipment that simplify the activities whilst sailing are key factors in reducing injuries
Windsurfers would benefit from a smoother and faster foot strap release so as to minimise foot and ankle injuries
Increasing the friction of the steering wheel in large boat racing
Improving the height of the pedestal, handle position, width and grip shape can all help reduce back, shoulder and forearm injuries in grinders
Better antiskid deck surface helps reduce risk of sliding and falling

Summary

The risk of acute and chronic injuries can be greatly reduced by taking the necessary precautions such as improving levels of fitness, strength and endurance, incorporating proper technique, wearing sunscreen, life jackets, gloves and shoes

The Benefits and Risks of Exercise in Women

Tue, 12 May 2020 13:26:49 GMT

The Benefits and Risks of Exercise in Women

There is plenty or research to support and promote the benefits of life long exercise:

Improved overall physical and mental health
Reduced stress levels
Reduced risk of chronic diseases
Reduced overall health care costs
Building on social networks

Regular physical activity and competitive sports, help women aside from the physical health benefits, by:

Improved self-confidence
Improved self-esteem
Improved body image
Improved academic success
Socialising and development of friendships
Feeling appreciated as part of a group
Improved body confidence
Reducing depression
Reducing anxiety
Less emotional volatility

For women postnatally exercise improves satisfaction with:

Motherhood
Their partners

The benefits of physical activity far outweigh the risks
However, knowing the risks, and how to mitigate them will help further enhance the benefits and quality of life
Sedentary lifestyle increases the risk of:

Obesity
Diabetes mellitus
Cardiovascular disease
Hypertension
Reduced metabolic rate so easier to gain weight with the same calorie consumption
Osteoporosis
Cancer
Depression

There is still more to be done to improve participation of women in sport and exercise

Studies show that women of all ages are less likely to exercise recreationally and even less likely to participate in team sports compared to men
Women with young children are the least likely to exercise compared to single women or those with older children due to having increased child caring duties
Given the benefits of exercise for women there should be ongoing education and promotion

Female athletes are at higher risk of certain injuries

Due to various anatomical and physiological differences between the genders, females are more prone to certain injuries
By knowing what these are, the necessary precautions can be taken and appropriate exercises implemented in training to help minimise the risks
Women have greater soft tissue laxity:

That means soft tissues are more stretchy
Their joints have a greater range of motion and hyperextension:
Knee hyperextension is seen when upon standing the knee goes too far backwards in relation to the foot
Up to 5-20 degrees of hyperextension is acceptable

In comparison to males, females have:

Lower participation in team sports
Higher participation in aerobics, yoga and dancing

Concussion

Concussion is a traumatic injury to the brain that affects its function:

Usually caused by a direct blow to the head or violent shaking of the head
Rarely there may be loss of consciousness
Falls and contact sports are most commonly responsible
Headache, nausea, vomiting, ringing in the ears, dizziness, blurred vision
Most people make a full recovery
However, it is essential to never return to play until all symptoms and signs of a concussion have completely resolved in order to avoid developing a more long-term debilitating condition called post-concussion syndrome

Female athletes appear to be at greater risk of a concussion than males playing the same sport:

Whilst it is not clear why that is, some attribute this to the difference in neck musculature

This is particularly prevalent in women’s football
Females also experience more severe symptoms for similar traumatic brain injuries and concussions

ACL Injury

Females are 2-10 times more likely than men playing the same sport to sustain an ACL injury
More details on why females are more prone to ACL injuries can be found here

Anterior knee pain

Anterior knee pain is more common in females as is patellofemoral instability
More information can be found in the patellofemoral pathology section

Stress fracture

Stress fracture is a bone fracture that is caused by overuse
Occurs when the amount or intensity of an activity is increased too rapidly or suddenly or playing on a harder surface
This was typically found in military recruits
Muscles become fatigued and are less able to absorb the shocks of high impact passing more stress to the bones
Most stress fractures occur in the foot
Females are more prone to stress fractures and can be one of the first signs of the Female Athlete Triad (see below)
Males have greater muscle mass and bone density than females
It is therefore imperative to maintain good nutrition and calorie intake when active, to wear appropriate shoe wear and progress activities gradually

Medial Tibial Stress Syndrome (MTSS)

This is commonly known as shin splints
It is an overuse injury of the shin area causing pain in the middle to lower end of the medial tibia (inner part of the shin bone)
It tends to be due to training errors:

Training too hard too soon
Running on hard or uneven surfaces
Exercise that involves high impact activities are especially prone such as running, basketball, football, and dancing

Biomechanical factors that predispose to MTSS:

Malalignment with either genu varus or genu valgum (bow legged or knock kneed), femoral or tibia rotational abnormalities, low or high arched feet, and leg length discrepancy
Muscle imbalance in strength and flexibility:

Tight Achilles tendon
Weak gastrocnemius and soleus muscles which are responsible for plantar flexion (pushing the foot downwards)
Muscle imbalance and tightness of hamstrings and/or quadriceps
Weak core muscles
Weak hip muscles

Women are more prone to them and are three times as likely as men to develop into stress fractures

Ankle Sprains

Ankle sprains are most common single injury in high school sports
Girls are more likely to sustain ankle sprains than boys across a number of sports
Girls’ ankle tendons are laxer than boys making them more prone to sprains

Rotator cuff injury

Rotator cuff is a group of four muscles and tendons around the shoulder joint which are key to providing stability and is composed of:

Supraspinatus
Infraspinatus
Teres minor
Subscapularis

The shoulder joint is a ball and socket joint which has the greatest range of motion out of any joint in the body
However, stability is compromised in order to allow for this range of motion:

The socket of the shoulder (called glenoid) is quite shallow and so it allows the top of the arm bone called the humerus which is shaped like a ball to move freely
The hip is the other large ball and socket joint of the body but it is more stable as the socket (called acetabulum) is deeper and covers a much larger area of the ball

This lesser bony coverage of the shoulder joint means that stability is reliant more on the surrounding soft tissues
Most people focus on strengthening the powerful muscles around the shoulder and upper arm and neglect the rotator cuff
Whilst the rotator cuff muscles are in comparison weak muscles they are key to providing shoulder stability and preventing shoulder injuries
Exercises to strengthen the rotator cuff muscles focus on form and technique in all planes and not just strength
Of critical importance in shoulder stability is the control and coordinated movement of the shoulder blade (called scapula) together with the arm:

This helps place the shallow socket (glenoid) in an optimal position in relation to the humeral head as failure to do so risks the humeral head slipping off from the glenoid:

This is called shoulder subluxation if there is partial loss of contact between the two joint surfaces or dislocation if there is complete loss of contact

This becomes even more apparent in sports that rely on a lot of arm movement such as basketball, volleyball, tennis, swimming, and overhead lifting

Further helpful information can be found here on:

Influence of Gender on Risk of Sports Injuries

Wed, 06 May 2020 13:47:18 GMT

Running

Women have 50% greater risk of some common pathologies sustained whilst running:

Anterior knee pain
Plantar fasciitis
Iliotibial Band Syndrome

During the stance phase of running (i.e. when the foot is in contact with the ground) women place the knee at a position of risk:

Adduction of the hip (knee comes towards the midline)
Internal rotation of the hip (knee points inwards)
Ankle eversion (more pressure going on the inside arch of the foot)

This is due to weaker muscles:

Hip abductors
Hip external rotators
Hamstrings

In this position excessive stresses are placed on:

Ligaments especially of the knee and ankle making them prone to injury
Patellofemoral joint (where the knee cap articulates in the knee) producing instability and anterior knee pain

Women run more upright:

During stance phase of running:

Less flexion at the hip
Less flexion at the knee

Landing after jumping

Landing from a jump requires strong muscles to absorb the forces
Women tend to land flat footed
Men tend to land on the ball of their foot:

This is the area around the metatarsal heads at the front of the foot

Landing on the ball of the foot means more energy is absorbed by the calf muscles and Achilles tendon and so passing less stresses to the knee:

To do this requires stronger calf muscles

Women bend less at the knee and hips when they land
Consequently, women pass more of the landing forces to their knees subjecting them to greater risk of injury
These factors occur due to weaker muscles but with proper training and education they can be improved
Injury prevention programmes are particularly good for this

Plyometrics

With activities that involve quick turns and change of direction, strong balanced musculature together with proprioception are critical in order to avoid injuries
Women tend to be more quadriceps dominant due to weaker hamstrings than men which puts them at increased risk

Neuromuscular control

Neuromuscular control requires various components working in synergy so as to perform a movement in a controlled manner
It involves coordinating movement of multiple joints at the same time and sequentially
Timing of the muscle contraction and in the correct sequence is key
It is not unheard of to cause severe injury to a joint simply by untimely contraction of a muscle whilst carrying out a rapid movement
This coordination of movement around multiple joints is so that less stress is placed on the joints and ligaments and it involves:

Perception
Detection
Processing of incoming sensory information

One of the key causes for the increased risk of injury in females is the lack of neuromuscular control
Neuromuscular fatigue occurs when as the exercise continues over time the muscles start to fatigue and this is more prominent in women:

This leads to excessive stresses on joints and ligaments which are therefore put at risk of injury and pain

Neuromuscular control can however by improved with correct training:

Female football players have been noted to improve their risk of ACL injury by almost 90% and of frank tears by 75% simply by incorporating neuromuscular training
More details on this can be found on lower limb injury prevention programme and specific ACL injury prevention programmes

Metabolic differences

Men have higher testosterone levels and women have higher oestrogen levels
This results in differences in the way blood sugars and lipids are metabolised, utilised and stored all of which impact sport performance as well as overall health
Testosterone helps build more muscle mass so it is easier for men to get stronger:

However, its levels are known to reduce in male endurance runners

Oestrogen increases the laxity of tendons and ligaments:

This is useful for when giving birth but not when participating in sport

The impact of oestrogen on musculoskeletal tissues

The exact impact of oestrogen on musculoskeletal tissues in young active women is still unclear
Oestrogen receptors are present in all musculoskeletal tissues:

Muscles
Tendons
Ligaments
Bones

Various studies have shown that:

Menstruating women are at higher risk of ACL injuries
As oestrogen level rises during the menstrual cycle so does the risk of ACL injury during this period:

The average menstrual cycle is 28 days long but it can vary and between 21 and 35 days is considered normal
Day zero is taken to be the first day of menstruation, day 14 time of ovulation which is when the egg is released from one of the ovaries
Oestrogen levels start to rise on days 8-11 of the cycle reaching their highest level in days 12-13 and return to original levels by day 16
Some studies have measured the ACL to increase in laxity by 1-5mm
For every 1.3mm increase in ACL laxity the risk of ACL injury increased by 4 times thus helping to explain the 2-10 fold increase of ACL injury in women

Menopause accelerates bone and muscle mass wastage, and increases risk of musculoskeletal injury
Hormone Replacement Therapy (HRT) given to postmenopausal women reduces rate of muscle and bone loss
Postmenopausal women have reduced sensitivity to anabolic stimuli that help build muscle

Muscle fibre differences

Women tend to have a higher proportion of type I muscle fibres and men more type II fibres (further information on muscle and fibres can be found here )

This difference is one of the reasons why male athletes tend to be faster and stronger than females

Tendon injuries

Women have reduced risk of muscle injuries than men
In professional football female players have 50% less muscle strains than males:

Females professional football players also have 80% less groin injuries and 35% less hamstring injuries

Women compared to men, have reduced risk of Achilles tendon injury than males until menopause, after which the risk equalises
Whilst these differences have been found, it is not clear why that is

Further helpful information can be found here on:

Female Athlete Triad - Symptoms and Treatment

Fri, 01 May 2020 12:27:19 GMT

Female Athlete Triad

This is a condition found in active females
It is composed of three components:

Low energy availability with or without an eating disorder
Menstrual dysfunction
Decreased bone mineral density (BMD)

For each component there is a spectrum of severity from normal to most severe
Women may be affected by one or all of the components of the triad simultaneously
It is therefore important that any female athlete presenting with any one feature of the three components to be screened for all three
The prevalence of having all three parts of the triad at the same time is not common ~1%
Prevalence of any two is ~20%
Prevalence of just one is ~40%
Women who are involved primarily in sports that focus on weight or aesthetics e.g. running or ballet are more at risk
The approach to treatment is challenging due to the complex nature and interconnection of the three factors
Treatment is optimised through a multidisciplinary approach:

Physician
Psychologist or psychiatrist
Dietician
Physiotherapist
Coach:

They focus on a team success through team skills and strategies

Athletic trainer:

They focus on optimising fitness and injury prevention for an individual athlete

Family members:

They are key to providing continued support and encouragement

Patient:

Patient education is key to helping them understand their condition, the potential consequences and the benefits of receiving treatment

Patient should have a thorough and holistic examination and laboratory tests to assess:

Which organs have been affected
Bone mineral density though DEXA scan as they are at risk of earlier osteoporosis
Nutrition
Menstrual dysfunction
Psychological and behavioural health

The aim of treatment is to:

Consume sufficient calories to provide a positive energy balance:

This is the first and most important step

Resumption of menses:

Nonpharmacological options are usually first choice
Medication tends to be reserved for those with oestrogen deficiency or infertility

Improve bone mineral density:

Improve intake of calcium and vitamin D guided by initial blood level for both

It is essential for health care professionals, coaches, personal trainers and nutritionists dealing with female athletes to be aware of the Female Athlete Triad as the consequences can be severe
The best approach is education and prevention of this condition with regular screening of athletes for concerning behaviours and signs and symptoms of the triad
Early detection and appropriate prompt intervention is required once diagnosed
Bone is highly responsive to loading activities such as impact and resistance training:

However, they need to be tailored to the patient and the severity of loss of bone mass and should be progressed gradually
Doing high impact activities from the outset in the presence of grossly weakened bones can lead to stress fractures

Low energy availability

Energy availability is simply:

Energy intake in the form of calories consumed minus
Energy that is used up through:

Exercise
Activities of daily living:

These are activities of self-care e.g. feeding, cleaning, dressing

Normal bodily functions:

Cellular maintenance:

Body has 37 trillion cells!!!
Takes a bit of energy looking after all of them
Cells replicate and divide to replace dead or damaged cells
Most cells in the body can do this
Heart muscle cells and nerve cells are not able to and so what you are born with is all that you have and once they die off there is no replacement

Thermoregulation:

Maintaining body core internal temperature within a small range of 37 degrees Celsius

Reproduction:

Energy spent through the menstrual cycle

Low energy availability can be due to a host of factors:

It can occur without an eating disorder
Unintentional:

Athlete is unaware how many calories are required to offset what has been consumed

Intentional:

Conscious decision to reduce calorie consumption:

This can be part of an eating disorder involving:

Restricted eating
Elimination of specific food groups
Fasting
Skipping meals
Diet pills
Laxatives
Diuretics
Binge eating followed by intentional vomiting

Excessive exercise:

The single most important factor associated with suicidal behaviour in females with an eating disorder is exercising excessively

When there is negative energy balance i.e. caloric intake is less than the body’s energy expenditure, then the body will reduce the amount of energy directed to maintain bodily functions such as cellular maintenance, thermoregulation and reproduction
Irrespective of when the eating disorder presents itself, the poor eating habits and behaviours are formed during adolescence
The prevalence of eating disorders in adolescent and young female athletes is ~30%
High school athletes with eating disorders are twice as likely to sustain a musculoskeletal injury

Consequences of someone with an eating disorder

Effect of poor diet:

Significant and rapid weight loss not explained by another illness
Lack of expected weight gain during puberty
Feeling full after only a small amount of food
Fatigue

Gastrointestinal irregularity:

Constipation
Diarrhoea

Mental health issues:

Chest pain with or without palpitations
Low self-esteem
Depression
Anxiety
Compulsive behaviour
Sleep disturbance

Gynaecological impact:

Delayed onset of menstruation
Cessation of menstruation
Infertility

Impact on renal function:

Poor hydration leads to electrolyte imbalance
Increased risk of cramps
Acute kidney failure
Chronic kidney failure

Musculoskeletal problems:

Stress fracture
Delayed healing following an injury

Socioeconomic impact:

Lower academic achievement
Lower socioeconomic achievement during early adulthood and later on

Menstrual Dysfunction

This like the other two components can be at any part of a spectrum of severity ranging from:

Eumenorrhoea (normal menses)
Primary amenorrhoea:

Delayed onset of menses beyond 15 years of age

Secondary amenorrhoea:

Cessation of menstruation for 3 consecutive months in a female who has already started menstruating

Oligomenorrhoea:

Regular menstrual cycles but wider apart (>35 days)

Menstrual irregularity is:

Very common (~90%) within the first two years of menarche (onset of menstruation) and so caution should be used before diagnosing menstrual dysfunction in this age group

Menstrual dysfunction is highest among lean and aesthetic athletes:

Gymnastics, diving, dancers, cheerleaders

Can lead to infertility:

Women with amenorrhoea are infertile as they do not produce ovarian follicles or ovulate

Low bone mineral density (BMD)

BMD in the female triad is along the complete spectrum from normal bone density to osteopaenia and osteoporosis
The prevalence of osteopenia is ~35% in female athletes and osteoporosis ~7%
In comparison the prevalence of both is 12% and 2% in the general population thus showing a 3 times higher risk for female athletes
A DEXA scan is required to assess BMD (further information can be found here )
The T-scores which are typically used for osteoporosis in post-menopausal women are not suitable for young people and so the Z-scores are preferred as these compare individuals to people of the same age, sex and ethnicity (unlike T-scores which compare the value to a healthy 30 year old individual)
A Z-score in adolescent or premenopausal females that is below -2.0 e.g. -2.1 or -3.0 (which is worse than -2.1) is termed low BMD for chronological age
Further information for causes of low BMD and how to optimise bone density throughout life can be found in the article How to Best Invest in your Bones
Athletes whose sport involves mainly weightbearing activities are known to have higher BMD and because of this the American College of Sports Medicine defines:

Osteopaenia in an athlete to be a Z-score between -1 and -2 together with risk factors for fracture such as amenorrhoea, reduced energy availability, and history of a stress fracture
Osteoporosis in an athlete to be a Z-score less than -2.0 (e.g. -2.1) with risk factors for fracture

The greatest amount of bone accrual occurs during puberty and in girls between 11-14 years

25% of the gain in bone mass occurs within 2 years of menarche
92% of the gain occurs by 18 years
99% of the gain occurs by 26 years

Exercise can help improve gain in bone mass by 5% in children
Amenorrhoeic athletes who play the same sport as eumenorrhoeic athletes, will have lower BMD:

Studies have shown as much as 10-20% reduced lumbar spine BMD in amenorrhoeic athletes compared to eumenorrhoeic
This shows that the beneficial effect of exercise on BMD is much less than the detrimental effect of amenorrhoea which should raise alarm bells in adolescent female

If amenorrhoea continues and goes untreated 2-3% of bone mass will be lost each year

Complications of Female Athlete Triad

Infertility
Raised bad form of cholesterol (Low Density Lipoprotein)
Increased risk of cardiovascular disease
Reduced immunity
Stress fractures:

2-4 times more likely than eumenorrhoeic females
Most frequent site is tibia (~50% of stress fractures)

Lower peak bone mass achievement than eumenorrhoeic females:

This puts them at higher risk of developing osteoporosis
Depending on the duration of the triad, measures taken to improve BMD and time to recovery, BMD may not catch up to the expected BMD for someone of the same age as the patient

Nutritional deficit can include:

Deficiency in essential amino and fatty acids can lead to reduced ability to repair damaged tissue, build muscle mass and recover from injury

Low energy availability can lead to:

Depression
Low self-esteem
Anxiety disorders
Increased risk of suicide and earlier death associated with the more severe eating disorders such as anorexia nervosa and bulimia

Low energy supply can adversely affect numerous systems:

Gastrointestinal
Metabolic
Endocrine
Immunological

Further helpful information can be found here on:

Vitamin D – The Unappreciated Vitamin

Mon, 27 Apr 2020 20:47:29 GMT

Vitamin D deficiency continues to be a global pandemic

Vitamin D Deficiency is a recognised pandemic:

It not only affects countries with low amounts of sunshine but also those that have lots of it

Vitamin D deficiency is thought to affect over 1 billion people worldwide
Over 77% of people in USA are considered to have vitamin D deficiency and this has become worse over the last 30 years
Vitamin D has the unique property than unlike any other vitamin it can be produced by the body (from sunlight) and is not entirely reliant on diet consumption:

Hence it’s often called the sunshine vitamin

It is a fat soluble vitamin that is found naturally in very few foods
The biggest and easiest contribution of vitamin D in body is through ultraviolet rays (UVR) from sunlight exposure which stimulates the body to produce its own vitamin D
Other sources of Vitamin D are through:

Medications
Food fortified with vitamin D

What is the function of Vitamin D?

Vitamin D increases calcium and phosphate absorption from the intestines
Vitamin D inhibits the effect of parathyroid hormone on bones:

Parathyroid hormone stimulates cells in the bone called osteoclasts to remove bone in a process called resorption
Vitamin D insufficiency (and to a greater extent deficiency) is unable to inhibit this process so with more bone resorption come reduced bone density and osteoporosis

Vitamin D receptors have been found in almost every tissue in the body meaning that it has an effect throughout the body
>80% of the body’s vitamin D is involved in essential body functions such as:

Synthesis of proteins and hormones
Immune and inflammatory responses
Cell turnover and synthesis
Regulation of gene expression:

Gene expression is the process by which a gene produces the functional product that it codes for

This essentially means that without vitamin D the cell is unable to adequately respond to normal physiological signals as well as pathological ones

How is vitamin D synthesised from sunlight?

During sun exposure UVB rays penetrate the skin and is absorbed by a cholesterol (7-dehydrocholesterol)
Vitamin D exists in two forms:

Vitamin D3 is produced in the skin from sun exposure
Vitamin D2 is produced by plants
Both types are found in supplements
But D3 is more beneficial than D2 which is only 20-40% as effective as D3

Both vitamin D3 and D2 are prehormones and need to be hydroxylated in two steps to become active:

First in the liver to form 25-hydroxyvitamin D (also called calcidiol)
It then travels in the blood stream to the kidneys where the second round occurs forming 1,25-hydroxyvitamin D (also called calcitriol) which is the only active form of the vitamin
This last step is regulated by blood levels of calcium, phosphorus, and parathyroid hormone

Vitamin D deficiency vs insufficiency

Numerous authorities have different levels on what constitutes deficiency and insufficiency
The level of 25-hydroxyvitamin D in the blood stream is the best assessment of vitamin D in the body
The American Endocrine Society defines them as:

Deficiency: 50nmol/l (<20ng/ml)
Insufficiency: 50-75nmol/l (20-30ng/ml)

As per the American Endocrine Society, for marked beneficial effects of Vitamin D the blood level of 25-hydroxyvitamin D should be >75nmol/l (30ng/ml):

However, for optimal benefit the target should be 100nmol/l (40ng/ml)

How much vitamin D should I take?

The body requires 3000-5000IU of vitamin D daily for normal healthy function
The daily requirement of Vitamin D remains controversial because:

The daily requirements and recommendations were designed more to prevent deficiency than to achieve a level that recent studies suggest are needed to achieve maximal benefits from vitamin D
Vitamin D is also synthesised from sunlight so dietary requirement and supplementation will also depend on effective exposure to UVB rays and degree of skin pigmentation
People absorb dietary vitamin D quite variably
Over time research has shown that we should be taking greater amounts than what we previously thought

Oral vitamin D supplementation therefore should be guided by the level of 25-hydroxyvitamin D in the bloodstream:

The ideal target concentration is 75-100nmol/l
As per the American Endocrine Society, for marked beneficial effects of Vitamin D the blood level of 25-hydroxyvitamin D should be >75nmol/l (30ng/ml):

However, for optimal benefit the target should be 100nmol/l (40ng/ml)

Initial vitamin D dosage will depend on how severe the deficiency is
Dosage up to 10,000IU per day have been found to be safe when the deficiency is severe or there is resistance to improving the vitamin D levels

If there is inadequate sun exposure 800-1000IU of vitamin D3 is recommended and the level titrated pending on the patient’s response:

Some people absorb vitamin D better than others so they may need even higher concentration of vitamin D3 in their medication in order to achieve the recommended level in the blood stream

IU: International Units

Which foods are high in vitamin D?

Very few foods naturally contain vitamin D
Foods that have significant amount of vitamin D are:

Oily fish like tuna, mackerel, salmon, herring, sardines
Egg yolk
Mushrooms

Foods that are fortified with vitamin D (cereals, milk, juices) are often inadequate to meet daily requirements of vitamin D
The body can only absorb ~50% of the vitamin D that is naturally occurring in food
Without enough vitamin D only ~10% of dietary calcium is absorbed and this only rises to 30-40% when vitamin D is in its normal limits

Vitamin D from food

Who is most at risk of vitamin D deficiency?

People with reduced exposure of skin to sunlight
>65 years of age:

Concentration of the cholesterol precursor of vitamin D (7-dehydrocholesterol) declines with age
A 70-year-old has ~25% of the ability of a young healthy person to produce vitamin D from sunlight
Despite this elderly are still capable of producing adequate amounts of vitamin D from sun exposure but just need longer time to achieve this

Infants and children younger than 5 years
Pregnant and breast feeding women
Malnutrition and those not consuming adequate amounts of vitamin D containing foods
Dark skin:

Dark skinned people can require 5-10 times longer sun exposure than fair skinned people to produce the same amount of vitamin D

Obesity:

Vitamin D is fat soluble and is stored in body fat
In obese people this vitamin D is stored more deeply and is less available to the body
Blood level of 25-hydroxyvitamin D is ~20% less in obese people than normal weight
For every 1 point rise on BMI (Body Mass Index) there is a 1.15% drop in 25-hydroxyvitamin D blood level
Obese people with similar sunlight exposure to normal weight people produce the same amount of vitamin D but it is diluted into a greater volume of fat so the amount in the blood stream is less
As a result of this dilution obese people need greater vitamin D supplementation to reach the desired blood levels

Sedentary lifestyle
People who work many hours indoors
Conditions that reduce absorption of vitamin D in the gastrointestinal tract:

Inflammatory bowel disease (Crohn’s, Ulcerative colitis)
Pancreatitis
Short bowel syndrome (either part of the small intestine has been removed, or born with short sections of it)
Bariatric surgery
Liver failure
Kidney failure
Medications that affect vitamin D metabolism e.g. antiepileptics, long term steroids

What are the benefits of vitamin D?

Vitamin D has been shown to have a protective effect against the following conditions which have been noted to be at higher risk of getting them when there is vitamin D deficiency:

Numerous musculoskeletal benefits (see below)
inflammatory and autoimmune diseases such as:

Diabetes mellitus (both type 1 and 2)
Multiple sclerosis
Rheumatoid arthritis
Sjogren syndrome
Colds and flu
Periodontal disease: a leading cause of tooth loss in older people

Cardiovascular disease:

Heart attack
Hypertension
Heart failure
Peripheral vascular disease

Cancers:

Colorectal
Breast
Ovarian
Prostate
Oesophageal

Mental health problems:

Depression
Seasonal Affective Disorder (SAD)
Dementia
Schizophrenia

Pregnancy:

Increased risk of pre-eclampsia and diabetes during pregnancy

The role of vitamin D on musculoskeletal health

Low vitamin D results in reduced absorption of calcium and phosphorus which are essential minerals for bone strength
Low bone mineralisation leads to softening and weakening of bones:

This is termed rickets when it occurs in children
This is termed osteomalacia when it occurs in adults

Vitamin D has been shown to help reduce bone fracture risk in two different ways:

Reduces risk of fall
Increasing bone density

Vitamin D reduces risk of:

Falls by 19%
Hip fracture by 18%
Non-vertebral fracture by 20%
Hip by 19%

The benefits of vitamin D are dose dependent:

Reduced risk of falls was seen with doses greater than 700IU per day
Reduced risk of fractures was seen with doses greater than 400IU per day
No improvement in risk of fracture has been found for doses lower than 400IU

The level of 25-hydroxyvitamin D in the blood stream was shown to have an impact on the extent of the benefit from vitamin D:

Reduction of risk of falls was seen with levels at least 60nmol/litre (24ng/ml)
Reduction of fracture risk was seen with levels at least 75nmol/litre (30ng/ml)
The magnitude of the benefit for both increased with higher 25-hydroxyvitamin D levels in the bloodstream

Muscle weakness is closely associated with falling and risk of fracture
Vitamin D supplementation in the elderly has been shown to:

Increase muscle strength
Improve balance
Reduce risk of falling
Improvement in walking distance

30% of people who have sustained a fracture secondary to a fall develop a fear of falling that results in:

Self-restriction of activities
Decreased quality of life

400IU of vitamin daily has been shown to reduce risk of:

Rheumatoid arthritis by 40%
Multiple sclerosis by 40%

Vitamin D deficiency leads to a myopathy characterised by:

Proximal muscle weakness
Widespread muscle pain
Gait impairment (difficulty walking)
Muscle impairment starts even before the occurrence of adverse effect on bone

Proximal muscle weakness:

Weakness of the muscles in the shoulders and hips
30% of patients with vitamin D deficiency present with proximal muscle weakness before changes are seen in the bloodstream
Therefore, patients who present with proximal muscle weakness should consider vitamin D and calcium supplementation

Vitamin D status of athletes

Whilst the effect of vitamin D on sports performance in athletes is still an area requiring more research, so far there have been some positive indications of its impact
The level of 25-hydoxyvitamin D was found to be linked to jump height, jump velocity and power in adolescent females
Positive correlation has been found between 25-hydroxyvitamin D with maximal oxygen uptake (VO2max) which is in indictor of aerobic fitness
Greater gains on sport performance are made if the athlete has a lower 25-hydroxyvitamin D level prior to treatment and the gains are maximised when this level reaches >100nmol/l (40ng/ml)
Vitamin D deficiency can result in reduction in the number and size of Type II (fast twitch) muscle fibres in the elderly population which is reversed with correction of vitamin D levels
25-hydroxyvitamin D level below 30ng/mL significantly increases the risk of stress fracture:

10-30% of track and field athletes are reported to have stress fractures
More common in women
Common cause of military recruits failing to complete training

Even outdoor athletes have been found to be vitamin D insufficient
Many outdoor athletes train early in the morning or late at night as they avoid peak sunlight hours
Various studies have shown that athletes in sunnier countries have unacceptably high rates of vitamin D deficiency and insufficiency

Vitamin D levels in various athletes

The role of sunlight

There are three types of ultraviolet radiation (UVR) coming from the sun and they are classified according to their wavelength:

UVA:

Long wavelength
95% of UV radiation reaching the Earth
The most penetrable type of UVR and causing the most damage to the skin
Sunscreens are less effective at blocking it

UVB:

Medium wavelength
Most UVB is filtered by the atmosphere
Biologically active and is the one responsible for Vitamin D synthesis
Sunscreens can block it (higher the SPF the better the block)

UVC:

Short wavelength
The most damaging type of UVR
Filtered by the Earth’s atmosphere so doesn’t reach Earth’s surface

A light skinned individual can produce 10,000 to 20,000IU in 15 minutes of unprotected sun exposure
Interestingly the highest levels of vitamin D are found in farmers and lifeguards both of which involve many hours outdoors

Factors that affect UVR reaching Earth

Time of day:

At noon the sun is directly above and takes the shortest path to reach the Earth’s surface so this is the maximum time for UVR and therefore vitamin D synthesis
There is a 4 hour window around noon during which time the UV rays are strong
During early morning and late afternoon the sun’s rays reach Earth at a greater angle so more of the rays are absorbed by the atmosphere and less reach the Earth

Time of the year:

The angle the sunrays take to reach the Earth changes with the seasons
This affects the distance they need to travel and the shorter it is, the greater the amount of UVR that reaches Earth
Summer therefore provides the greatest exposure to UVR and winter the least

Latitude:

UV levels are highest closest to the equator as the sun’s rays travel the least distance through the atmosphere
Evidence shows that latitudes greater than 37 degrees from the equator are an increased risk for lower vitamin D synthesis from sunlight
Below are a list of cities and their latitudes for ease of reference:

Abu Dhabi: 24
Miami: 25
Cairo: 30
Los Angeles, Sydney: 34
Las Vegas, Rhodes, Santorini: 35
Athens: 37.98 degrees
Beijing, Valencia: 39
Thessaloniki, New York, Madrid: 40
Montreal, Milan, Belgrade: 45
Paris, Munich: 48
London: 51
Edinburgh, Moscow: 55

Altitude:

The greater the vertical height from sea level the less atmosphere exists to absorb the sunlight
For every 1km height, the UV levels under clear skies increase by ~7%

Atmospheric conditions:

Clouds:

Cloud cover can affect UVR penetration but this depends on the type of cloud and how deep it is in the atmosphere
A fully cloudy day can reduce the UV rays by 70-90%
A thin or partly cloudy day can actually increase UVR exposure by 20% by having a mirror effect

The thinner the ozone the less UVR is absorbed
The greater the air pollution the more UVR are absorbed

Ground reflection:

Various surfaces can add to the UV exposure through reflection

Grass, soil, water provide <10% reflection
Sand 15% reflection
Snow can through reflection can nearly double UV exposure

Factors that affect ability to make vitamin D from sunlight

Skin pigmentation:

There are 6 different types of skin based on their ability to tan (Fitzpatrick skin pigmentation scale)
As the skin gets darker the ability to synthesise vitamin D reduces but there is greater protection against skin cancer

Amount of skin exposed:

The more skin that is exposed the greater the potential for vitamin D synthesis

Posture of the body under the sun:

Greatest exposure is when the skin is 90 degrees to the sunrays i.e. lying horizontally at noon
Standing up reduces the amount of skin exposed to the sunlight

Surroundings:

Presence of objects providing shade e.g. umbrellas
Urban areas have buildings that reduce sunrays reaching ground level compared to open rural areas

Sun exposure:

There is a lot of misconception regarding how to best produce vitamin D from sunlight
Many people avoid exposure to sunlight around noon and instead spend long time sunbathing outside of these hours
Literature shows that the best time to absorb UVB are for a few minutes at lunchtime
Outside of this time, UVB rays reduce in intensity whilst UVA rays continue to reach Earth and so lengthy sun exposure in late afternoon and early morning actually increases risk to skin cancer whilst offering less vitamin D benefits compared to 5-10 minutes at lunchtime (lighter skin need less, darker skin needs a lot longer)
An easy indication of when sunbathing does not produce vitamin D is when the shadow of someone who is standing is longer than what they are in height

Fitzpatrick skin pigmentation scale

Vitamin D levels and skin pigmentation

Vitamin D insufficiency is more common in African Americans than Caucasians
Dense skin pigmentation can reduce vitamin D production by >90%
The darker pigmentation is due to the higher concentration of melanin in the skin which absorbs ultraviolet light and reduces the amount that reaches the deeper layers of skin thus protecting it from UVR damage
Unfortunately the deeper layers is where vitamin D is synthesised from UV light
African Americans are also noted to have lower dietary intake of vitamin D perhaps due to higher rate of lactose intolerance leading to reduced intake of milk products and cereals fortified with vitamin D
Darker skinned people whilst they are more protected more from skin cancers than fair skinned people, they would need to expose themselves for longer duration to sunlight to synthesise the same amount of vitamin D
However African Americans have lower rates of osteoporotic fractures:

A 65 year old Caucasian woman has an 11% chance of a hip fracture by the time she is 80 compared to only 4% of an African American woman
It isn’t entirely clear why this difference is noticed despite the lower vitamin D levels in African Americans but it is thought to be due to higher bone mineral density early in life

The Mediterranean paradox

Despite countries in Southern Europe having more abundant UVB sunlight, they have been shown to have higher prevalence of vitamin D deficiency compared to countries in central Europe – the so called Mediterranean paradox
This has been shown to be the case in Greece as well and reasons for the lower than expected vitamin D are:

Higher melanin concentration in the skin
Avoidance of sunlight exposure and use of sunscreen
Reduced outdoor activity especially in cities compared to rural regions
Reduced consumption of food rich in vitamin D
Absence of vitamin D fortified foods (except for children’s and infants’ milk)

Many countries like Greece do show seasonal variation whereby there are lower vitamin D levels occur post-winter and the highest post-summer
Vitamin D produced from sunlight is stored in the body 2-3 times longer than from oral supplements
There are no reports of vitamin D toxicity due to excessive sun exposure and the reason being that the previtamin D compounds that are produced have very little effect on calcium levels

The Middle East is plagued with low vitamin D

Countries in the Middle East with an abundancy of UV light have some of the lowest levels of vitamin D worldwide:

Limited sun exposure in these countries can be due to cultural practices
Very hot climate makes it difficult to sunbathe under the sun
Dark skin colour
10-60% of mothers and 40-80% of neonates are found to have negligible levels (0-10 ng/ml)
Adults are similarly affected with rates of 30-80%
Interestingly immigrants from the middle East to Western countries continue to have some of the lowest levels of vitamin D in that country

Does sunscreen reduce ability to make vitamin D?

Skin cancer is the most commonly occurring cancer in the white population
Sunscreen helps protect skin from the harmful effects of UVR and helps reduce risk of:

Squamous cell carcinoma by 40%
Melanoma by 50%
Premature skin ageing by 24%

Whilst there have been some reports raising concerns over the negative impact of use of sunscreen on vitamin D production, evidence is lacking to support this
Areas of skin that have less cholesterol under them produce less vitamin D i.e. face, hands, and feet:

It is particularly important to put sunscreen to face and wear a hat to protect it from sun exposure

What would be the optimal way to produce vitamin D from sunshine?

The latest guidelines suggest 5-15 min/day of sun exposure at midday would produce enough daily vitamin D and this can be followed by application of a broad spectrum sunscreen with an SPF of at least 15:

Darker skinned individuals are likely to need longer

This approach helps to maximise the benefits from UVB rays in the shortest possible time whilst minimising the damaging effect from UVA rays
Sunbathing for longer periods especially without sunscreen increases risk of skin cancer whilst being less beneficial for vitamin D production

Vitamin D insufficiency in schoolchildren

Studies have shown the prevalence of vitamin D insufficiency in schoolchildren living in Europe to be 25-63%
In large study in Greece this was found to be 53% and is higher than most other European nations:

Girls are significantly at higher risk
More prevalent in areas in and around cities rather than rural areas:

This has been noted in studies of other countries as well and thought to be due to more open spaces, more outdoor activities, less tall buildings and clearer skies in rural areas

Children who have taken 2000IU of vitamin D daily since 1st year of age and were followed up for 25 years had 80% reduced risk of developing type 1 diabetes:

In the same study children who were vitamin D deficient, had 4 times risk of developing type 1 diabetes later in life

In Greece the prevalence of vitamin D insufficiency is 60% for obese and 50% for overweight children:

This is the critical time period to build strong bones and failure to maximise this opportunity due to vitamin D deficiency poses a significant risk of osteoporosis and fractures later in life

Whilst the prevalence of vitamin D insufficiency among children and adolescents in Greece is better than some other countries (96% in Germany, 78% in USA) it is still of great concern and there should be a nationwide campaign to improve on this easily modifiable health risk

Vitamin D toxicity

Vitamin D toxicity is extremely rare
The resulting increased calcium concentration is the main worry
When hypercalcaemia is mild it can be asymptomatic but more severe levels can present with:

Nausea
Dehydration, excessive thirst and frequent urination
Abdominal pain
Constipation
Kidney stones
Bone pain and muscle weakness
Hypertension
Anxiety and depression
Confusion, lethargy and fatigue

Once again there isn’t widespread agreement on what toxicity levels are, simply because people have different sensitivities to vitamin D
Most report this to be 250nmol/l (100ng/ml) but there are rare cases happening below this level
That is why it is important to analyse the calcium and vitamin D levels as well as patient’s symptoms
Whilst the upper daily safe limit for adults has been set at 10,000IU/day it would take months or even years for this to become toxic
One report showed no cases of toxicity with daily intake of 30,000IU/day for an extended period of time

Seasonal Affective Disorder (SAD)

A type of depression caused by the changes in the seasons
It usually starts around the same time each year, most commonly during autumn and goes into the winter months and goes away when the sunnier days arrive in spring and summer
Symptoms:

Feeling depressed
Low energy and tiredness
Oversleeping
Weight gain and craving for foods high in carbohydrates
Difficulty concentrating
Low self esteem
If severe can lead to thoughts of suicide

Risk of SAD is increased if:

There is family history of SAD or other form of depression
Personal history of depression
Reduced sunlight exposure which is more common in people living far from the equator

Rickets

Rickets is softening and weakening of the bones in children due to poor mineralisation of the bones
It is caused by deficiency in vitamin D, calcium or phosphorus
It can lead to deformation of a child’s bones and making them prone to fractures
Due to the increased calcium requirements of children, insufficient intake can lead to rickets:

Rickets is most commonly seen between 6 and 36 months of age
During this period there is a rapid growth spurt

Whilst rickets is largely eradicated in Western countries it is still found in dark skinned communities that have migrated to latitudes far away from the equator
Some of the highest rates of rickets is found in the Middle East despite the abundance of sunlight
This is largely due to:

Limited sun exposure
Cultural practices
Darker skin colour
Low calcium intake

Presentation

Pain:

The child may be reluctant to walk due to bone pain
When they walk it may look different (called waddling gait)
Pain in legs, pelvis and spine

Musculoskeletal problems:

Thickening of various joints:

Ankle, wrists, knees

Characteristic bowing of the legs (varus deformity)
Softening of the skull bones
Muscle weakness

Poor growth and development:

Child will end up being shorter than average

Dental problems:

Defective or weak tooth enamel
Increased risk of tooth cavities

Causes

Low vitamin D:

Inadequate oral intake
Inability to absorb vitamin D despite adequate intake:

This is hereditary and runs in families

Mother’s vitamin D deficiency during breastfeeding
Exclusive breast feeding: as this doesn’t have any vitamin D
Northern latitudes
Premature birth

Osteomalacia

Osteomalacia is softening and weakening of bones like rickets but for adults
Most often caused by severe vitamin D deficiency
Increases the risk of fractures in adults

What is the difference between osteomalacia and osteoporosis?

In osteomalacia there is normal bone density but inadequate bone mineralisation:

Bone mineralisation is the process of addition of calcium and phosphorus containing complexes (called hydroxyapatite) to the bone structure and gives it additional strength

On the other hand, osteoporosis has normal bone mineralisation but low bone density:

This reduced bone density in osteoporosis makes the bones weaker and susceptible to fractures

Causes

Osteomalacia is caused by any process that reduces bone mineralisation
Bone mineralisation requires adequate intake of calcium, phosphorus and vitamin D
Vitamin D deficiency is the most common cause
The Middle East and north Africa has one of the highest rates of rickets and osteomalacia in the world

Symptoms

In the early stages there are often no symptoms
As it gets more severe it can present with:

Dull achy bone pain especially in lower back, pelvis, hips, legs and ribs
Pain is typically not completely relieved by rest
Pain can be worse at night and on pressure upon the bones

Further relevant information can be found on:

Osteoporosis - Diagnosis and Treatment

Tue, 21 Apr 2020 18:49:38 GMT

Overview

Osteoporosis is significantly weakened bones that puts them at greater risk of fracture (breaking) from low energy trauma
Osteopaenia is a milder version of osteoporosis
Both are caused due to reduced bone density
Osteoporosis is one of the commonest chronic diseases worldwide
Throughout life, new bone is formed (by cells in bone called osteoblasts) and old bone is removed through a process called resorption (by cells in bone called osteoclasts )
The balance of this process is predominantly bone formation until peak bone mass is achieved after which it remains relatively stable until after menopause when the rate of bone loss predominates
For more information on how to invest in your bones and minimise risk of osteoporosis later in life click here
When this rate of bone loss is too great and depletes a critical level of bone material, it is termed osteoporosis
Osteoporosis mainly affects women as their rate of bone resorption is greater than that of men especially in the early years following menopause
Men can also get osteoporosis but are 4 times less likely
Just 10% loss of bone mass in vertebrae will double the risk of fracture
10% loss of bone mass in hip will increase the risk of fracture by 2.5 times
A prior osteoporotic fracture increases the risk of further fracture by 86%
This means that more needs to be done to screen, diagnose and manage appropriately people over 50 years who have sustained a low energy fracture

How common is osteoporosis?

Worldwide osteoporosis causes 9 million fractures every year:

That’s one osteoporotic fracture every 3 seconds

It is estimated to affect 200 million women worldwide:

10% of women in their 60s
20% of women in their 70s
40% of women in their 80s
66% of women in their 90s

1 in 3 women and 1 in 5 men over 50 years will experience an osteoporotic fracture
About 15% of Caucasians in their 50s and 70% of those over 80 have osteoporosis
In the EU in 2010 ~22 million women and 5.5 million men had osteoporosis
It affects ~80 million people in Europe, USA and Japan
Due to the ageing population this will only increase:

By 2050 incidence of hip fracture in men will increase by 310% and 240% in women compared to those in 1990

Osteoporosis in men

Whilst women are 4 times as likely to get osteoporosis than men, men do still get it
By ~70 years men and women lose bone mass at a similar rate
Whilst men have lower risk than women of developing osteoporosis they have twice the mortality risk of women a year following their hip fracture
There needs to be greater awareness in the public domain that men are not exempt from osteoporosis

Impact on disability

Following an osteoporotic hip fracture:

40% cannot walk independently
80% cannot do basic activities of daily living independently such as shopping
10-20% of hip fractures require permanent care in a nursing home
Osteoporosis in women over 45 years accounts for more days in hospital than heart attacks, breast cancer or diabetes

The financial burden of osteoporosis

The financial impact of osteoporosis in the EU is €37 billion and in the USA $19 billion per year and is likely to double by 2050:

66% went to treatment of fractures
29% for long term care of fractures
5% for medications
Therefore by improving osteoporosis prevention through nutrition, medication and exercise are very cost effective

In 2010 in the EU the cost of long-term disability following osteoporotic fractures alone was almost €11billion
Globally 40% of osteoporotic fractures occur in the working population:

The annual cost of treating these fractures in Europe, USA and Canada is $48billion excluding the indirect cost of disability and loss of productivity

The cost of osteoporosis treatment in Greece is estimated to be ~€900million

What is a fragility fracture?

A fragility fracture is when a fracture (broken bone) results from low energy trauma such as a fall from standing height or less:

Normally should be able to withstand such a fall without sustaining a fracture
Osteoporosis is the major cause for this

The most common location for fragility fractures are:

Vertebral body (bone segment of the spine):

They are the most common type of fragility fracture
They often occur without a fall

Hip:

>85% of hip fractures are due to falls
They carry the greatest mortality risk of the fragility fractures
Typically occur in less mobile patients than wrist fractures as they have slower reflexes and don’t manage to break their fall using their hands

Wrist:

Is often the first indicator of osteoporosis if sustained after 50 years of age following low energy trauma
The third commonest fragility fracture
Tends to occur in more mobile and fitter patients with osteoporosis as they put their hand out to break a fall

Half of all women and a quarter of all men will have a fragility fracture in their lifetime
80% of people who have had an osteoporotic fracture are neither identified nor treated

Hip fractures

~75% of all hip fractures occur in women and 25% in men
Hip fractures are associated with chronic pain, reduced mobility, disability and loss of independence:

10-20% of independent patients require long term nursing care following an osteoporotic hip fracture

The lifetime risk of hip fracture in white women is (1 in 6) more common than breast cancer is (1 in 9)
Hip fractures by 2050 are predicted to triple
Hip fractures have a mortality rate of ~10% at one month and 20-30% at 1 year post injury
The higher risk of mortality persists for at least 5 years post injury
There is marked loss of independence even a year later:

40% unable to walk independently
60% requiring assistance to walk

5-10% of patients with a hip fracture will experience another one within 3 years

Vertebral Fracture

Vertebral fractures are the most common type of fragility fractures:

One occurs every 20 seconds worldwide

There is an 8 fold increase in mortality rate following one
The lifetime risk of a vertebral fracture in a white 50 year old woman (16%) is three times greater than that of a 50 year old white man (5%)
30-45% of vertebral fractures go unnoticed i.e. patients don’t realise or don’t seek medical attention so many will be incidental findings at a routine check-up or visiting a doctor for something else
Following a vertebral fracture there is an increased risk of another fracture elsewhere in the body in the next 1-2 years
>55% of patients with a hip fracture show evidence of a previous vertebral fracture
Vertebral fractures can lead to:

Back pain
Loss of height
Spine deformity (bent forwards)
Reduced mobility
Reduced lung function leading to greater shortness of breath and more susceptible to chest infections
Reduced quality of life due to:
Reduced mobility
Reduced self-esteem
Reduced body image
Depression
Difficulty carrying out activities of daily living i.e. ability to self-care:

Feeding, cleaning, dressing, grooming

Risk factors for sustaining an osteoporotic fracture

Although osteoporosis is defined in terms of bone mineral density, it is only one component of fracture risk, so the other risks need to be considered when assessing and managing someone’s osteoporosis and fracture risk:

Genetic:

Presence of hip fracture in parents is an independent risk factor to bone mineral density

Lack of physical activity and living a sedentary lifestyle increase the risk of fragility fractures
Low weight in infancy increases the likelihood of reduced bone mass in adulthood thus increasing risk of developing osteoporosis
Smoking
Alcohol

Drinking >4 units a day doubles the risk of hip fracture

Long term use of corticosteroids is the commonest cause of secondary osteoporosis:

30-50% of patients on long term corticosteroids risk of getting fracture

Low body weight (BMI <20) is associated with increased risk of fracture
Female Athlete Triad :

Young females who train excessively, eat too little and have menstrual dysfunction are prone to low bone mineral density and increased risk of fractures

Men and women >50 years who lose >0.5cm of height per year are at increased risk of fracture
Long term intake (>2 years) of certain antacids called proton pump inhibitors (e.g. lansoprazole, omeprazole) reduce the absorption of calcium

Falls are a major contributor to fractures:

~33% of people >65 years fall annually
90% of hip fractures are caused by falls
10-15% of falls in elderly will result in a fracture
60% of those who fall will fall again
The risk of falls increases with age due to:

Poor eyesight
Poor balance
Poor coordination
Slower reflexes
Reduced strength
Increased risk of conditions that predispose to falls such as dementia, heart arrhythmias, fainting and seizures

Presentation

Osteoporosis itself does not cause pain:

There are no signs or symptoms until a fracture occurs
Hence it is often termed a silent disease

However, the broken bones that result cause pain and morbidity and can increase risk of mortality (especially hip fractures)
When more severe, even a cough or a sneeze can cause a broken rib or collapse of bones (vertebrae) in the spine
Elderly patients who have a stooped (bent forward) posture is often secondary to collapse of vertebrae in the spine
Back pain in the elderly can be a sign of osteoporotic fracture in the spine

Osteopaenia

Osteopaenia is a stage before osteoporosis:

It has a higher bone mineral density than osteoporosis but is less than normal

It does not always lead to osteoporosis but it is important to take measures to reduce risk of deteriorating to osteoporosis

How is osteoporosis and osteopaenia diagnosed?

Osteoporosis cannot be diagnosed on plain X-rays:

You can though get a feeling of reduced bone density without knowing the severity of it

The only way to diagnose osteoporosis and differentiate it from osteopaenia is through a DEXA scan:

DEXA = Dual Energy X-ray Absorptiometry
It is a non-invasive test
Uses X-rays
You lie on your back and it takes 10-20 minutes after which you can go home
No injection is involved and you won’t go into a tunnel like some other scans
Osteopaenia will show up on X-ray after 40% loss of bone density
DEXA scan can detect changes as small as 1%:

It is therefore more sensitive and accurate than plain X-rays

DEXA scan results are reported using T-scores
A T-score is a number that is relative to how much the measured bone mineral density differs from the mean mineral bone density of a healthy 30 year old person
It is measured in standard deviations away from the mean
Normal T-score as per the World Health Organisation (WHO) is within 1 standard deviation from the mean:

That means anything greater than -1 is normal e.g. +0.5 or -0.9 (which is worse than +0.5)

Osteopaenia is defined by a T-score that is between -1 to -2.5 i.e. between 1 and 2.5 standard deviations below the mean value e.g. -1.1 or -2.4 (which is worse than -1.1)
Osteoporosis is defined by a T-score that is below -2.5 i.e. more than 2.5 standard deviations below the mean e.g. -2.6 or -3.5 (which is worse than -2.6)
In the T-score graph below age is shown on the x-axis (horizontally), bone mineral density on the left y-axis (vertical axis) and T-score on the right y-axis:

The top green zone is normal bone mineral density and represents values greater than -1.0
The middle yellow area shows osteopaenia zone between -1.0 and -2.5
The lower red area shows the osteoporosis zone which is anything below -2.5

Z-score is another scale often used in relation to osteoporosis:

Whilst it is not used to diagnose osteoporosis it can provide useful information especially when it is secondary to a coexisting illness and is found in the less common groups of people e.g. children, young adults, pre-menopausal women and men under 50 years of age
It compares patient’s bone density to the mean bone density of someone of the same age, sex and ethnicity

There are numerous tools used to assess an individual’s fracture risk at 10 years and this helps guide their management

Screening

There are numerous screening tools that can help identify high risk patients that would benefit from formal screening of osteoporosis
Current guidelines on screening recommend all women over 65 years and men over 70 years should be screened with a DEXA scan
Anyone over 50 years who is high risk such as:

Previous bone fracture from low energy trauma e.g. hip fracture
Low body weight
Excessive smoking or alcohol

Patients who have an increased risk of osteoporosis should consider earlier screening
All post-menopausal women who have incurred a fracture
Any wrist fracture sustained following a minor fall in those over 50 years

Treatment

Treatment is guided not only by the DEXA scan T-score but also by the risk factors each patient has for osteoporosis
Recognition and treatment of a fragility fracture can help reduce the risk of future fractures by 50%:

With the added benefit of preventing exposure to the additional morbidity and mortality risks that occur following a fragility fracture

Effective medical treatment can reduce the risk of:

Vertebral fracture by 50%
Hip fracture by 40%
Other fractures by 20%

Poor compliance (patients not following doctor’s advice) is one of the most important issues at effectively combatting osteoporosis:

Only 40% of patients continue to take their treatment after a year
Only 20% of patients continue to take their treatment after two years

Exercise

Exercises that help people with osteoporosis should focus on strengthening bones, muscles and preventing falls through the following types of exercises:

Weight-bearing:

Exercises that are minimal or non- weight bearing offer little benefit to improving bone strength

Strengthening:

Helps put load on bones that over time will make them denser and stronger

Balance:

This is key and often forgotten exercise that will help prevent falls

Flexibility:

Helps improve overall physical function
Must avoid exercises that flex the spine such as sit ups in order to avoid fractures in the spine

Posture:

Focusing on strengthening spine extensor muscles
Helps prevent kyphosis and risks of falls

Exercise during childhood and adolescence is particularly important in order to gain bone mass
Regular exercise helps reduce risk of:

Osteoporosis
Fracture
Injuries due to falls

Strengthening back muscles helps reduce risk of vertebral fractures and kyphosis (excessive forward curve of the spine)
Activities that help improve balance and confidence in the elderly help prevent falls and subsequent injuries:

Tai chi has been shown in some studies to help reduce falls by 50% and hip fractures by 25%:

Tai chi is an ancient Chinee martial arts that focuses on slow movements and deep breaths
Helps to reduce stress, anxiety, depression
Improves muscle strength, balance, flexibility, stamina
Minimal impact on joints so safe to do in presence of arthritis

Yoga:

Can also be beneficial for the elderly with osteopaenia and osteoporosis
However, patients should avoid positions that involve:

Spinal flexion (forward bending of back)
Extreme twists and sidebends
They can increase the risk of an inadvertent fracture in the spine

Nutrition

Children during their growth should have adequate intake of calcium in order to maximise the beneficial effect of exercise in boosting bone mass which will be beneficial for them during their elderly years
Postmenopausal women who take calcium tablets improve their bone mineral density
One of the key risk factors in osteoporosis and route for prevention and treatment of osteoporosis is vitamin D

The elderly are particularly prone to low vitamin D levels as they are often indoors and receive suboptimal sun exposure

Fruit, vegetables and good protein intake have been shown to lower rate of bone loss with age
Good nutrition is essential for those who have sustained a hip fracture especially the more frail and elderly patients:

Failure to address this slows recovery and increases risk to further fracture

Those with lactose intolerance and those who drink less milk have increased risk of lower bone mass
Whilst mild to moderate alcohol intake is not harmful, chronic alcohol abuse (>4 units daily) greatly reduces bone mineral density
Anorexia nervosa is an eating disorder and mental health illness characterised by persistent restriction of calories consumed, abnormally low weight, intense fear of gaining weight, and disturbed self-perceived weight or shape:

Its onset is typically during puberty which is the period of gaining maximal bone mass and thus putting patients at high risk of reduced peak bone mass and subsequent early osteoporosis

Falls Prevention

Whilst treatment of osteoporosis and making the bones stronger is beneficial and helps prevent bone fractures, taking measures to minimise the risk of falls is even more important
Falls prevention can be simple to carry out and effective but not very well carried out and often forgotten
Try and let someone know where you are and keep regular contact with people
Carry a portable phone at all times in order to be able to call for an emergency
If living alone, consider using a monitoring company that can be accessed 24/7
Outdoors:

Wear rubber soled shoes to improve traction and avoid high heels
Taking care in the winter especially when there is rain, frost or snow:

If unsteady on feet and need to go out try holding on to someone with better balance

Leaves on the ground can be particularly slippery especially when wet
Keep the walkways and driveways around your house free of rubbish, and tidy so as to prevent tripping over things
Have good lighting outside your house when it goes dark
Use a walking aid that has good rubber grip to the ground
Taking care when walking on smooth polished surfaces e.g. marble especially if they are wet as they can be very slippery
Being observant of the ground surface when walking outside:

Uneven ground e.g. from pavement slabs, cobblestones
Pot holes
When stepping on and off from pavements and road curbs

Indoors:

Floors:

Ensure any carpets are secured down well especially the edges
Keep floors tidy free of clutter
Wires and cables should be secured around the edges of walls and not go across pathways

Bathroom:

Use a non-skid rubber mat in shower/bath as well as outside of it where you step off
If unsteady on feet, consider placing a plastic chair with back and rubber covered feet to minimise skidding
Consider walk-in and zero-entry showers that have no step and so helps prevents falls whilst transferring in and out of showers
Install rails around bath, shower and toilet
Try and keep the walkway between bedroom and bathroom tidy
If tend to go to toilet in middle of the night consider leaving light on in walkway

Bedroom:

Ensure there are light switches by the door and around bed and bathroom
Whenever getting out of bed, take your time, sit on edge of bed and wait until more alert before getting out of bed in order to prevent dizziness and fainting:

Common cause of hip fractures in the elderly is falling between bedroom and bathroom in middle of the night

Have a flashlight handy on bed side table

Stairs:

Sturdy hand rails on both sides
Keep the area well lit, with light switches top and bottom and free of any objects
If there are carpets ensure they are secured well and if hard surface that they are clean and dry

Kitchen:

Use non-skid mats around the sink and hob
Any spills should be cleaned up immediately

Reducing the impact of a fall

Try if possible to fall forward or on buttocks and to break the fall using your hands:
This helps reduce chance of a hip fracture which is a bigger health risk than a broken wrist
Walk carefully on hard surfaces
Do not run on hard surfaces:
If the phone rings do not rush to get it
Wear protecting clothing

Medication for osteoporosis

The purpose of the medication is to increase bone density
Over the first 3 years of treatment bone density in the hip can increase by 1-3% and in the spine by 4-8%
Medication can help reduce the risk of hip fracture by 30-50% and in the spine by 50-70%
However, these benefits are not instant and they start to be seen 6-12 months after commencement of medication
Generally speaking osteopaenia requires monitoring, improvement in nutrition and exercise, and consideration of calcium and vitamin D supplements
For confirmed osteoporosis or those with osteopaenia but a high 10 year fracture risk, additional medication should be considered
There are numerous types available which are often in addition to calcium and vitamin D medications
The first line are usually bisphosphonates and they are the most commonly used medication:

E.g. Alendronate (Fosamax), Risedronate (Actonel), Zolendronate (Reclast)
They work by inhibiting the actions of bones cells called osteoclasts that resorb bone
They can reduce the risk of fracture by 25-70%
They are not absorbed will in the stomach and can cause stomach upset and heartburn
Recommendation is to take them on an empty stomach with plenty of water and to remain sitting up for at least 30-60 minutes and then to have breakfast:

Bending over or lying down will aggravate the heartburn

They take 6-12 months to take effect on the bones
There is little evidence that they add benefit for most patients after 3-5 years of use after which time rare potential side effects arise:

Atypical femoral fractures as the bones get too strong and brittle
Osteonecrosis of the jaw - the jaw bone can start to die off

For high risk patients can consider taking them for 10 years

Other commonly used medications include:

Denosumab (Prolia):

Newer medication that is better tolerated than bisphosphonates
Is a monoclonal antibody and works by preventing development, function and survival of bone resorbing cells called osteoclasts
Taken as an injection twice a year
Should not be taken if blood calcium is low
Like bisphosphonates can rarely cause atypical femoral fractures and osteonecrosis of the jaw after prolonged use

Teriparatide (Forteo):

Is a form of parathyroid hormone and stimulates bone forming cells called osteoblasts to lay down new bone
Side effects include leg cramps, nausea and dizziness

Further helpful information can be found here on:

How to Best Invest in your Bones

Wed, 15 Apr 2020 16:36:58 GMT

The importance of peak bone mass

Healthy bones are essential throughout our lives
Bones are living tissues that continuously undergo regeneration with removal of old bone and replacement by new bone
During times of growth (children and teenagers), more new bone is laid down than what is removed and so bones get bigger, denser and stronger
This process continues until peak bone mass is achieved which is when the bones are at their strongest and most dense
Peak bone mass occurs typically in late 20s and after that the balance slowly changes and bone resorption outpaces new bone formation
Around 90% of peak bone mass is accumulated by 18 years for women and 20 years for men
Therefore, the first 20 years of life is the best time to invest and accumulate as much bone as possible which is achieved with optimal levels of vitamin D, calcium and exercise
Men overall achieve a larger peak bone mass than women
Between 30 years and menopause, women (like men) have minimal change in total bone mass
After menopause though, women experience a rapid bone loss which then slows down
If it drops low enough it can lead to osteoporosis
It is therefore prudent to invest as much as possible in the earlier years to maximise the peak bone mass and to continue to take measures to reduce the rate of bone loss later in life
A 10% increase in peak bone mass can postpone development of osteoporosis by 13 years

Factors that affect peak bone mass and risk of osteoporosis

Numerous factors affect peak bone mass

Genetic:

These are factors you are born with and cannot change e.g. age, gender, race, body size, and family history
Thought to have the biggest impact ~75%
Over 60 genes have already been identified in relation to bone mineral density

Environmental:

These are factors that surround you throughout life e.g. exercise, diet, hormonal, medication, lifestyle, smoking, and alcohol
Less of an impact but the only ones that can be modified ~25%

Age:

As one gets older the risk of osteoporosis increases and this is due to:
Reduced protective effect of sex hormones
Increased risk of vitamin D insufficiency
Reduced calcium absorption
Reduced stresses on bones from less exercise and muscle mass

Gender:

Males tend to have bigger peak bone mass than women
Before puberty boys and girls have similar rates of growth in their bone masses
After puberty, boys acquire bone at a great rate and this continues until ~30 years
Women lose bone at a greater pace after the menopause and because they have lower peak bone mass they have less bone to lose
Women as a result are 4 times as likely as men to develop osteoporosis

Race:

African American and Hispanic females manage to achieve greater peak bone mass than white and Asian females and as a result they are more protected against osteoporosis

Body size:

Small framed individuals (more common in women) are at greater risk as they have less bone stock in reserve to draw from as they age

Family history:

Positive family history of osteoporosis has been shown to greatly affect the patient’s risk of osteoporosis but also their peak bone mass

Hormonal:

Oestrogen has a protective effect on bones by inhibiting bone resorption:

This is the process by which bone is broken down by bone cells called osteoclasts
This means that the longer women are exposed to oestrogen the greater the benefit for their bones
Women who start their menstrual cycles younger and start their menopause later have had longer exposure to oestrogen and so reach a greater peak bone mass
Abnormal cessation of periods (amenorrhoea) such as due to extremely low body weight (anorexia) or from excessive exercise (e.g. Female Athlete Triad ) or low oestrogen levels in postmenopausal women and those on certain treatments for breast cancer all increase the risk of osteoporosis
Men with low testosterone levels (e.g. following chemotherapy for prostate cancer) have increased risk of osteoporosis:

Testosterone stimulates cells in bone called osteoblasts to lay down new bone
A small portion of testosterone is normally converted to oestrogen and this has been shown to be the bigger determinant of bone health in men

Other hormones that can increase risk of osteoporosis are overactive thyroid, parathyroid and adrenal glands

Nutrition:

Calcium is an essential mineral required for bone mineralisation and consequently bone strength (see below)
Calcium deficiency can have a significant impact on peak bone mass
Vitamin D deficiency is a well-known risk factor for development of osteoporosis and a key nutrient together with calcium in the initial treatment against osteoporosis
Surgery that has removed parts of stomach or intestine can reduce the amount of nutrients (e.g. calcium) that are absorbed
Diets low in protein have an adverse effect on bone strength
Consumption of soft drinks with inorganic phosphate additives such as Colas increases the risk of fragility fractures

Exercise:

Exercise is essential for bone health throughout life
Bones are living tissues and they get stronger when under stress
Hence people who live a sedentary lifestyle or patients who lie in bed for periods of time and astronauts exposed to low gravity for periods of time have weakened bones
Gentle aerobic exercise like walking is insufficient to improve bone strength
More brisk walking and hiking are more beneficial than normal walking
Exercises like cycling and swimming whilst being a great aerobic exercise they are considered low impact and do not make bones stronger and in fact if not combined with other strength and resistance training can weaken the bones
Strength and resistance training:

The heavier the weights one can lift the more beneficial for the bones
Therefore, for bone health lifting a heavier weight less times is more beneficial than a lighter weight more times

High impact activities such as jumping, sprinting and plyometrics are very beneficial for building bone strength because they subject the bones to multiple times the body weight over a fraction of a second that the foot is in contact with the ground
Exercise has the added benefit of helping to improve muscle strength, balance, coordination, reaction times all of which help prevent falls and fractures:

This is especially important for people with osteoporosis and the elderly

A medical consultation should be considered prior to commencing exercise for those over 40 years or have health conditions such as heart problems, high blood pressure, diabetes or obesity
In the presence of osteoporosis care should be taken when exercising in order to minimise risk of fracture:

Avoid movements that bend or twist the spine
Avoid high impact activities e.g. running, jumping

Lifestyle behaviours:

Smoking:

Smoking is thought to inhibit the action of cells that lay down new bone called osteoblasts
It increases the breakdown of oestrogen which is known to have a protective effect
Reduces body weight which has adverse effect on bone density
Induces an earlier menopause
Reduces calcium and vitamin D absorption
It increases production of cortisol in the body (a naturally occurring steroid)
The impact of smoking is more drastic when it starts at a younger age and in heavy smokers

Alcohol:

Consumption of >4units/day is detrimental to bone strength

Sedentary lifestyle:

Bones become weaker as they are subjected to lower stresses

Prevention

By maintaining a healthy lifestyle, exercise and nutrition throughout life, is the best investment in achieving as strong bones as possible early in life and therefore minimising the risk of developing osteoporosis later in life
The genetic factors which have the greatest influence on someone’s risk of osteoporosis cannot be modified, so the focus will need to be on optimising the aforementioned modifiable risk factors

The role of calcium

Calcium is a mineral:

>99% is found in bones and teeth
It adds strength to the bones and helps them withstand stresses

A mineral is a chemical element (inorganic substance) that is an essential nutrient required by the body in order to carry out functions necessary for life
Essential nutrient is one that is required by the body to carry out its normal functions:

They cannot be synthesised from other ingested nutrients

There are four groups of essential nutrients:

Minerals
Vitamins
Essential fatty acids
Essential amino acids

Calcium is the most abundant mineral in our bodies:

The other major minerals in the body are phosphorus, potassium, sodium and magnesium

Since calcium is a mineral it cannot be made in the body and so it must be absorbed from food that is consumed
If there is inadequate consumption of calcium, then bone is broken down as it has the largest reserves of calcium in the body (increased activity by bone cells called osteoclasts) and calcium is released into the bloodstream:

Over time this will reduce bone mineral density, and therefore weaken the bones and lead to osteoporosis

What is the daily recommended intake of Calcium?

The recommended daily intake varies for men and women and also varies with age:

Recommended Daily Allowance in milligrams (mg)

Which foods have high calcium?

Dairy products are the biggest sources of calcium:

Milk, yoghurt, cheese

Other sources are:

Broccoli, kale, green leafy vegetables
Salmon, sardines, other soft bone fish
Tofu
Bread, pasta, grains
Cereals fortifies with calcium

What are the symptoms of low calcium?

Low vitamin D causes reduced calcium absorption and this in turn causes:

Osteoporosis and osteopaenia
Fatigue:

Low energy and feeling tired
Dizziness
Sleepiness

Muscle problems:

Cramps
Muscle ache and spasms

Neurological:

Paraesthesia (pins and needles) or numbness to hands, feet and around mouth
Confusion
Memory loss
Hallucinations

Skin problems:

Dry and itchy skin
Eczema:

Inflammation of the skin leading to itchiness and skin to be cracked and rough

Psoriasis:

A chronic autoimmune disorder where skin cells multiply 10 time faster than normal
Leads to scaling of the skin typically over knees, elbows and scalp
Can also lead to arthritis of joints such as the knee

Alopecia:

Autoimmune disorder leading to hair loss

Weak and brittle nails

Painful Premenstrual Syndrome:

Daily supplementation with 500mg/day can significantly reduce premenstrual depression, fatigue, oedema and pain in women with Premenstrual Syndrome

Dental Problems:

Weak roots, brittle teeth, tooth decay
In infants this can lead to delay in tooth formation

Further helpful information can be found here on:

• Vitamin D – The Unappreciated Vitamin

• Osteoporosis

All About Muscles, Tendons and Ligaments

Tue, 07 Apr 2020 17:22:09 GMT

What are the different types of muscle?

Skeletal muscle:

This is voluntary muscle which means muscles contract on conscious demand
They are anchored to bones via tendons and when the muscle contracts on demand it causes movement of a joint
They are responsible for the human body to move in space and to maintain posture

Smooth muscle:

This is involuntary muscle and so it is not under conscious control
They line the walls of organs and help with vital bodily functions
Examples of where they are located: oesophagus, stomach, intestines, bladder, bronchi in the lungs and blood vessels

Cardiac muscle:

This is unique in that it is between skeletal muscle and smooth muscle
It is involuntary like smooth muscle but its structure resembles more closely that of skeletal muscle
It is only found in the heart

Skeletal muscle anatomy

Whilst the number of bones in the human body is consistent at 206 the number of different skeletal muscles vary:

There are over 650 named skeletal muscles

Skeletal muscle is a highly organised structure with its own nerve and blood supply and connective tissue
Skeletal muscle can vary in size and shape:

The gluteus maximus is the largest muscle in the body and forms the largest part of the buttocks
Has an average weight of 850g, is ~2cm thick and covers an area of ~66cm2
Stapedius is the smallest muscle in the body and helps stabilise the stapes in the middle ear which is the smallest bone in the body

Each muscle is enveloped in a connective tissue called epimysium
Within the epimysium are numerous muscle fascicles which are enveloped by perimysium within which are numerous muscle fibres lined by endomysium
Within the muscle fibre and numerous myofibrils and the individual functioning cell is called a sarcomere
Within a sarcomere are two filaments:

Thick myosin filaments
Thin actin filaments

Muscle contraction occurs when an electrical impulse sent by a nerve to the muscle causes the release of calcium (from the sarcoplasmic reticulum)
This release of calcium causes the actin filaments to attach to the myosin filaments and they pull on the myosin filament to cause shortening of the length of the sarcomere
Energy (ATP) is required to detach the actin from the myosin and for the sarcomere to go back to its original resting length:

That’s why when someone dies the muscles stay contracted as there is no new energy production to cause detachment of actin from myosin which is necessary for muscle relaxation
This state is called rigor mortis and it is temporary for about 3 days

Some uniquely strong muscles

Gluteus maximus is the largest muscle in the body:

Helps maintain posture, standing from a sitting position and going upstairs

The heart is the hardest working muscle in the body:

The heart is about the size of your fist
It beats about 115,000 times a day or 40 million times in a year and for an 80 year old that is 3.2 billion times!
It pumps 6,000-7,500 litres a day
Normal resting heart rate for an average adult male is 72 and for a female 80
Athletes can have a resting heart rate of 40:

They can achieve this by pumping more blood with each heart beat contraction (called stroke volume)

The masseter (part of the jaw muscles) is the strongest muscle in the body compared to its weight:

The strongest human bite strength produced 442kg for two seconds

The external eye muscles work constantly to position the eye to help keep eyesight focused on a point whilst the body and head moves:

In one hour, it can make 10,000 contractions

Soleus is a muscle in the calf that lies deep to the more superficial and visible gastrocnemius muscle:

It is thought to develop the greatest force of pull as it contracts against gravity to help us from falling over

Muscle fibre differences within skeletal muscle

Skeletal muscle is made of individual muscle fibres
They are broadly split into slow-twitch (type I) and fast twitch (type II) which can be further categorised into type IIa and IIb fibres
The different types split the fibres into how they contract, what type of fuels they use and how they respond to physical training
Type I (slow twitch):

They react less slowly, produce less force but can do so over a longer period of time, and are more efficient at using oxygen to generate the fuel (called adenosine triphosphate or ATP) needed for the muscle contraction
They are more fatigue resistant and are important for aerobic and endurance exercises e.g. marathon runners

Type II (fast twitch):

They are better at providing quick, short but more powerful bursts of strength or speed than slow twitch type I fibres
They use an anaerobic metabolism which produces ATP in the absence of oxygen and are therefore quicker to fatigue
Type IIa can be thought of as intermediate fast twitch fibres using both aerobic and anaerobic metabolism which explains their improved fatigue resistance compared to type IIb
Type IIb fibres produce the greatest force and most rapidly compared to the other muscle fibres but fatigues quickest as it relies solely on anaerobic metabolism

The impact of training on muscle fibre types

We all have all the types of muscle fibres
The amount of force generated by a muscle is most dependent on its cross-sectional area than on the type of muscle fibre it has
Duration and speed of contraction is most dependent on muscle fibre type
Muscle fibre size increases with strength training
Muscle fibre types are split equally in non-athletic individuals
As we age there is not only loss of lean muscle mass but the fast twitch (especially type IIb) reduce in number whilst the proportion of type I increases
With training the proportion of muscle fibres changes according to the exercises carried out
Power athletes such as sprinters have predominantly type II muscle fibres (70-80%)
Endurance athletes have predominantly type I muscle fibres (70-80%)
Whilst training can increase the proportion of a a muscle fibre depending on the exercise, the elite athletes seem to have a genetic advantage in being able to achieve a higher percentage:

However, without intense training to reach the maximum potential, genetics alone are not enough

Role of genetics on athletic performance

Training, motivation, nutrition are key components in maximising performance of an athlete
Genes are thought to contribute to 30-80% of the difference between individuals in factors that are key to athletic performance such as:

Strength
Muscle size
Muscle fibre composition
Lung capacity
Anaerobic threshold which is when lactate builds up and the athlete tires out
Cardiac output (ability of the heart to pump blood around the body in a given time)
Ability of muscle to utilise oxygen and the energy molecule called ATP:

The efficiency of this process is measured by VO2 max which shows the maximum amount of oxygen a person can use during intense exercise
VO2 max is one of the key tests for the cardiovascular fitness of an athlete

Types of muscle contraction

Isometric:

Muscle contracts with constant length e.g. holding a weight but not moving it or pushing against an immovable object

Isotonic:

Muscle contracts with constant tension e.g. lifting the same weight through a range of motion
There are two types:

Concentric:

Muscle shortens during contraction e.g. biceps curl and bringing a weight from an outstretched hand position up to the shoulder by bending at the elbow
This contraction is required to initiate a movement

Eccentric:

Muscle lengthens during contraction e.g. reverse biceps curl whereby the downward motion of the weight from the flexed elbow position to the arm straight, is performed slowly
Eccentric training compared to concentric has been shown to cause greater muscle hypertrophy, muscle strength and flexibility as well as to help treat tendinopathies and makes tendons stronger
Eccentric contractions occur to slow down and stop a movement

Isokinetic:

Muscles contract under constant speed
This requires special equipment

Plyometric:

Rapid lengthening of a muscle followed by contraction
Often involve the athlete to jump, hop or skip and exert maximum force over a short time interval e.g. box jumping
Shown to improve strength, speed, power, speed of changing direction, balance, jumping, and bone density
Have been shown to reduce risk of lower limb injuries in team sports
However, activity should be supervised and athlete to be in good condition as the high sudden forces can cause injuries if done incorrectly by someone with insufficient strength and poor proprioception

Muscle strain

Muscle strain (commonly known as pulled muscle) occurs when a muscle is torn or overstretched
They are most commonly due to fatigue or a heavy/rapid eccentric contraction
Strains can occur in any muscle but are most common in the lower back, neck, hamstrings and shoulder
Three muscle types are more prone to injuries:

Muscles that cross over two joints:

These are also called biarticular and as such influence the movement of two joints at the same time
Examples of biarticular muscles around the knee are:

Rectus femoris – primary action is to extend the knee, secondary is to flex the hip
Gastrocnemius – primary action is to plantarflex the ankle (downward motion), secondary action is to flex the knee
Hamstrings – composed of semitendinosus, semimembranosus, long head of biceps – primary action is to flex the knee and secondary is to extend the hip

However functionally the biarticular muscles are important in controlling complex movement of the whole limb and they act primarily in an eccentric manner by helping decelerate the limb when it is swung forward preparing it for ground contact such as when we run and walk
Movement of one joint will stretch the biarticular muscle which may then be required to contract forcefully at a very stretched position
It is this eccentric contraction during a rapid movement such as sprinting and jumping that predisposes these muscles to injuries

Muscles contracting eccentrically:

Eccentric contractions are essential when we walk and run because they control movement of a limb by decelerating its movement
The muscle is required to contract whilst at the same time lengthening (therefore placed under tension) at speed and if the muscle isn’t strong enough to overcome this tension then injury can occur

Muscles with a higher percentage of type II fibres:

Since type II fibres produce a large amount of force over a short period of time they are bound to be more susceptible to injuries
These fibres predominate in muscles involved in sprinting which involves mostly eccentric contractions
The most commonly injured muscles are those that have all three components such as: hamstrings, gastrocnemius, rectus femoris (the only part of the quadriceps muscle which is biarticular)

Symptoms of a muscle strain

Sudden pain
Bruising
Swelling
Stiffness with reduced range of movement
Weakness

Treatment

Rest:

First few days should try and limit movement of the affected muscle
After that movement needs to gradually start so as to prevent stiffness

Ice:

Ice should be applied immediately but should not be applied directly to skin
Wrap a bag of peas in a pillow case or towel
Apply for 20 minutes

Compression:

Applying pressure on the muscle with a suitably wrapped compression bandage will help reduce swelling and therefore pain
This should not be applied though too tight so as not to adversely affect blood flow to the area as well as the distal part of the limb

Elevation:

Elevating the injured limb above the level of the heart will help reduce the swelling to that area

Ways to minimise risk of muscle strains

Keeping muscles healthy, strong and flexible throughout life:

This will also help keep tendons, ligaments and bones strong as well

Warm up gradually before starting more strenuous activities:

Try and focus on dynamic stretching before an exercise and static stretching afterwards (further information to this can be found in the lower limb injury prevention programme section)

Build the intensity of your training programme gradually with rest periods in between and these rest periods need to be longer when the individual is less physically fit
For the middle aged and elderly, it would be worth seeking a medical consultation prior to commencement of physical training
Careful attention should be placed on correct technique at all times especially when lifting weights and carrying out high impact activities e.g. those involved in plyometrics and team sports
If overweight try and lose weight first through lower impact activities (cycling, rowing, crosstrainer) and dieting prior to starting higher impact activities (jogging) in order to minimise the stresses to your lower limb joints
Listen to your body:

If something doesn’t feel right, stop and seek help

Tendon

Tendons attach muscles to bone to enable the muscle to move the bone
Each muscle has two tendinous attachments to a bone:

The proximal tendon is called the origin
The distal tendon is called the insertion

Tendons have a very dense, organised and parallel array of collagen fibres
Tendons are stronger but less elastic than ligament

Tendon injuries

Tendon injuries most commonly occur at the musculotendinous junction:

This is the area where the muscle turns into a tendon
It is also the area of least blood supply which is why it is most commonly injured

Tendinopathy

This is a chronic injury in a tendon resulting in a failed healing response
The tendon is not ruptured but there is a breakdown in its collagen composition making it less strong but also very painful
Tendinopathy is different from tendonitis:

Tendonitis is inflammation of the tendon
In tendinopathy there is no inflammatory reaction
Unfortunately, all too commonly steroid injections are still used to treat tendinopathies despite research confirming that this is detrimental to its healing

Treatment of tendinopathies is primarily:

Activity modification by doing less of the activities that exacerbate the problem
Assessment by a suitably qualified person to evaluate cause of the tendinopathy e.g. muscle imbalance around a joint
Physiotherapy with exercises to address the muscle imbalance
Loading the muscle of the tendon involved in ways to make it stronger:

This will help change the collagen type III which is found in tendinopathies to collagen type I which is what it should have

Ligament

A ligament is a fibrous connective tissue that connects bones to bones
Whilst there are various types of ligaments, articular ones are the most common ones and they span across the joint surfaces connecting the bones above and below thus providing stability to the joint
Ligaments are not as tough as tendons but they are more elastic
Ligament injuries range from mild sprains with only a few fibres being torn to complete ruptures rendering the joint unstable

Ligament sprain

Ligaments sprains are split into 3 grades
Grade I sprain:

Some stretched fibres but joint is still stable
Mild to minimal swelling

Grade II sprain:

Moderate stretching of the ligament but overall is still in tact
Examination shows increased laxity of the ligament but there is an end point
Moderate swelling with perceived pain instability by patient on function

Grade III sprain:

Complete tear of the ligament
Marked swelling and tenderness
Gross instability with no firm end point when stressing the ligament on examination

Treatment

Same initial principles of rest, ice, elevation and compression
Grade I and II sprains are often treated with some type of splint or brace for 4-6 weeks
Grade III sprains are more likely to need an operation to either repair or reconstruct the injured ligament

M ore relevant information can be found on:

Joints and Movement

Mon, 30 Mar 2020 22:16:01 GMT

Types of joints

Joints form where two or more bones come together
There are three main types of joints:

Fibrous:

Held together by fibrous connective tissue
No joint cavity between the bones
Immovable
E.g. between the various bones of the skull

Cartilaginous:

Connected together by cartilage
Allow partial movement – a bit more movement than fibrous joints but much less than synovial joints
No joint cavity between the bones
Further subdivided into:

Synchondrosis (primary cartilaginous joint):

Bones are joined by hyaline cartilage
Most of them are the growth plates and are therefore only present in children until puberty

once growth stops the growth plates become calcified and so fuse to become solid bone

An example of synchondrosis that remains into adulthood is that between the first rib and the manubrium sternum

Symphysis (secondary cartilaginous joint):

Bones are joined by fibrocartilage
Located in the midline plane of the skeleton
E.g. pubic symphysis located at the front of the pelvis has fibrocartilage
E.g. intervertebral discs located between the vertebrae of the spine

Synovial:

They are the most abundant type of joint in the body
Characterised by three main structures:

Synovial cavity:

The enclosed space around the joint surfaces is filled with synovial fluid which is the lubricant of the joint

Articular capsule:

Composed of fibrous connective tissue and forms the wall of the joint
The inner surface of the articular capsule is lined by synovial membrane
The cells of the synovial membrane produce the synovial fluid

Articular cartilage:

The ends of the articulating bones are lined by articular cartilage which helps reduce friction to movement
Unlike cartilaginous joints, the cartilage on each bone is not continuous with each other and instead allow movement between each other

There are 6 different types of synovial joints:

Ball and socket joint:

They comprise of a spherical end of a bone articulating with a dished end of another bone
Due to their shape they allow the maximum range of movement: flexion, extension, abduction, adduction, rotation, circumduction
E.g. shoulder and hip joints

Hinge joint:

Like a hinge of a door, the majority of movement allowed in these joints is in one plane: flexion and extension
E.g. elbow; the knee is primarily a hinge joint but is more complex as it also allows some rotation and translation

Saddle joint:

Shaped like a saddle of a horse
Similar to hinge joint but oval shape of the saddle provides greater range of motion
Movements allowed: flexion, extension, adduction, abduction and circumduction
They do not allow axial rotation
E.g. at the base of the thumb (called first carpometacarpal joint)

Condyloid (ellipsoid) joint:

Shallow depression of one bone articulates with rounded end of the other bone
Movements allowed: flexion, extension, abduction, adduction, circumduction
They do not allow axial rotation
E.g. metacarpophalangeal joints of the hand and metatarsophalangeal joints of the foot

Pivot joint:

They only allow axial rotational movement
E.g. the top two vertebral bones in the neck (atlas and axis)

Gliding (plane) joint:

Allow only for sliding movement between small bones with flat surfaces in the plane of the articular surface
E.g. small bones in the wrist and foot

Functional classification of joints

Joints can also be classified according to the degree of movement they allow:

Synarthrosis:

These are the fibrous joints
Permit little to no movement

Amphiarthrosis:

These are the cartilaginous joints
Permit little mobility

Diarthrosis:

These are the synovial joints
Allow the greatest amount of mobility

Anatomical Terminology

Directional terms

Superior:

Towards the head end of the body
E.g. the head is superior to the hip

Inferior:

Towards the foot end of the body
E.g. the foot is inferior to the chest

Towards the front
E.g. the patella sits on the anterior aspect of the knee joint

Posterior:

Towards the back
E.g. the ears lie posterior to the nose

Medial:

Towards the midline of the body
E.g. the nose is medial to the ear

Lateral:

Away from the midline and towards the periphery of the body
E.g. the ear is lateral to the nose

Proximal:

Towards the point of origin or trunk of the body
E.g. the hip is proximal to the knee

Distal:

Away from the point of origin or trunk of the body
E.g. the ankle is distal to the knee

Superficial:

Towards the surface of the body
E.g. skin is superficial to a muscle

Deep:

Away from the surface of the body
E.g. muscle is deep to the skin

Ipsilateral:

Same side of the body
E.g. the right hand is ipsilateral to the right knee

Contralateral:

Opposite side of the body
E.g. the left knee is contralateral to the right knee

Unilateral:

One side of the body
E.g. Lifting a weight with just one hand is a unilateral exercise

Bilateral:

Both sides of the body
E.g. Lifting a weight with both hands is a bilateral exercise

Varus:

Distal part is closer to the midline than the proximal part
E.g. genu varum is when the foot is closer to the midline than the knee also known as bow legged as the lower limbs take on the shape of a bow

Valgus:

Distal part is further away from the midline than the proximal part
E.g. genu valgum is when the foot is further away from the midline than the knee also known as knock kneed as the knees are knocking (touching) against each other

Planes of the body

Coronal (frontal) plane:

A vertical plane that runs from side to side
E.g. looking at someone from the font

Sagittal (lateral) plane:

A vertical plane that runs from front to back
E.g. looking at someone from the side

Axial (transverse) plane:

A horizontal plane that is 90 degrees to the length of the body
E.g. looking at someone from above

Description of movement

Flexion and extension occur in the sagittal plane:

Flexion (bending):

Reduces the angle between the body parts
E.g. flexion of the elbow brings the hand towards the shoulder
E.g. flexion of the knee brings the foot towards the buttocks
Hyperflexion is excessive flexion of a joint

Extension (straightening):

Increased the angle between the body parts
E.g. extension of the elbow brings the hand away from the shoulder
E.g. extension of the knee brings the foot away from the buttocks
Hyperextension is excessive extension of a joint

Abduction and adduction occur in the coronal plane:

Abduction:

Moves the limb away from the body
E.g. abduction of the shoulder is movement of the arm laterally away from the body
E.g. spreading of the fingers or toes apart, away from each other

Adduction:

Moves the limb towards the body
E.g. adduction of the shoulder is movement of the arm medially towards the body
E.g. bringing the fingers or toes towards each other and closing the gap between each finger or toe

External and internal rotation:

External (lateral) rotation:

Rotation of the limb so that the anterior surface rotates away from the midline
E.g. external rotation of the hip moves the anterior thigh to face away from the midline whilst the sole of the foot faces towards the midline

Internal (medial) rotation:

Rotation of the limb so that the anterior surface of the limb rotates towards the midline
E.g. internal rotation of the hip moves the anterior thigh to face towards the midline whilst the sole of the foot faces away from the midline

Circumduction:

Movement in a circular manner
E.g. circumduction at the shoulder joint involves moving the arm in a circle

Supination and pronation:

Rotational movement at the forearm or foot
Supination brings the palm or sole of the foot facing forward
Pronation brings the palm or sole of the foot facing backwards

More relevant information can be found on:

Bone Anatomy and Function

Mon, 30 Mar 2020 21:38:52 GMT

Overview

Bone is a living tissue with its own blood vessels, living cells proteins and minerals
It is the hardest living tissue in the body
Largest bone in human body is the femur (tibia is second)
Smallest bone in human body is the stapes in the middle ear which is just 3mm long
>99% of the body’s calcium is within the bones and teeth
Is made up of two components:

Organic component:

40% of dry weight
Numerous proteins:

Collagen:

Makes up 90% of organic component
Primarily type I collagen
Provides tensile strength (resistance to tension)

Proteoglycans:

Provides strength to compression

Inorganic component:

60% of dry weight
Primary mineral is calcium hydroxyapatite:

Provides main strength to compression

What are the different types of bones?

Long bones:

Located in the limbs and are longer than they are wide:

Upper limb:

Composed of shoulder, arm, elbow, forearm, wrist, hand
Long bones are humerus of the arm, radius and ulna of the forearm, metacarpals and phalanges of the hand

Lower limb:

Composed of hip, thigh, knee, leg, ankle, foot
Long bones are: femur of the thigh, tibia and fibula of the leg, metatarsals and phalanges of the foot

Short bones:

Length and width are similar
Roughly cube shaped
Provide stability and movement
Located in wrist and ankle joints

Flat bones:

Flat and wide
Skull
Sternum
Ribs

Irregular bones

Vertebrae:

They are the bones of the spinal column

Pelvis:

Made up of the pubis, ilium and ischium

Sesamoid bones:

They are bones found within a tendon or muscle that glide over joints
They are named so because they resemble a sesame seed
Their function is to:

Reduce friction on the tendon as it glides over bony prominence
Provide mechanical advantage by increasing the lever arm of the pull of the tendon:

That means that they amplify the force created by the muscle
The patella for instance amplifies the pull of the quadriceps by 30-40%

Examples of sesamoid bones:

Patella:

The largest sesamoid bone in the human body

In the flexor tendons of the big toe and thumb

How many bones are there in the human skeleton?

We are born with around 300 soft bones
As we grow these soft bones are ossified with deposition of minerals (calcium and phosphorus) and many of them fuse together
There are 206 bones in the adult human skeleton which make up 15% of the body weight
This excludes teeth and sesamoid bones which are found in tendons going over bony prominences
The human skeleton can be subdivided into:

Axial skeleton:

80 axial bones
Located in the central axis of the body
Skull, vertebrae, ribs, sternum

Appendicular skeleton:

126 appendicular bones
Composed of the bones that form the limbs with their attachment points to the axial skeleton called girdles:

Limbs:

Upper limbs
Lower limbs

Girdles – they are the attachment points for the limbs:

Pelvic girdle:

Attachment point for the femur (thigh bone) of the lower limb
Consists of the ilium, ischium and pubis

Pectoral girdle:

Attachment point for the humerus (arm) of the upper limb
Consists of clavicle and scapula

How do bones form?

Bone formation (osteogenesis or ossification) begins in the 2nd month of foetal life and is completed in late adolescence
The clavicle (collar bone) is the first bone to ossify in the developing embryo (~5th week of gestation)
The clavicle is also the last to fully fuse – most happen by 20 years but can take as long as 25 years
It occurs via two processes:

Intramembranous ossification:

Connective tissue membrane that is initially laid out is replaced by bone tissue
Occurs in the formation of flat bones e.g. skull and clavicle
Unlike endochondral ossification cartilage is not present during intramembranous ossification

Endochondral ossification:

Cartilage that is initially laid out is replaced by bone tissue
Occurs in the formation of long bones (e.g. femur and tibia) and most other bones
Ossification occurs at two centres:

Primary ossification centre:

Is the first area of bone that starts ossifying
Usually appears before the baby is born
Located in the central part of each developing bone
In long bones this would be located in the centre of the diaphysis

Secondary ossification centre:

Appears after the primary ossification centre in the first years of life
Located on either end of long bones in the epiphyses
Longitudinal growth of a long bone occurs at the growth plate (physis):

This is where new cartilage is formed continuously which is subsequently ossified
The presence of cartilage means this is an area of weakness for the developing bone since cartilage is softer and weaker than bone
They are seen as black lines across the width of long bones on X-rays and so can be confused as fractures
When growth ceases at about 20 years the cartilage of growth plates is ossified and fuses with the rest of the bone

What are the different parts of a long bone?

A long bone can be split into three sections:

Diaphysis:

Long slender middle portion of the bone also called the shaft
The longest portion of the bone
The cortex is thick and strong

Metaphysis:

Area between the diaphysis and epiphysis
It contains the physis (growth plate):

Location where the bone grows during childhood
The physis is cartilaginous but is ossified once growth stops in early adulthood

The bone becomes increasingly wider towards the epiphysis
The cortex is thinner
Has a rich bloody supply so prone to spread of infection from blood stream to the metaphysis leading to osteomyelitis

Epiphysis:

Large rounded end of the bone that forms the articular surface
Section of bone from the joint surface to the physis
Separated from the metaphysis by the physis

Structural organisation

Cortical (compact) bone:

Located on the periphery of the bone:

If a bone is likened to a pipe, cortical bone is the wall of the pipe and cancellous bone is located inside the pipe

Makes up 80% of skeleton by weight despite a much smaller proportion by volume than cancellous bone
Strongest part of the bone but also more brittle
Provides strength and protection to bones
Slow turnover rate so remodels slowly
Structure is highly organised into osteons:

Cylindrical structures aligned along the lines of stress the bone is exposed to in order to maximise strength of the bone

A fracture is a broken bone and is defined by discontinuity in the cortex of the bone and so state of the cancellous bone is irrelevant when considering whether a bone is fractured

Cancellous (spongy) bone:

Located inside the canal of the bone
Less strong than cortical bone but more elastic and flexible
High turnover rate so remodels quickly
Less organised than cortical bone with a loose network of bone
30-90% of the cancellous bone is porous (has many holes) where bone marrow is located
Despite making up the larger portion of bone by volume it only makes up 20% by weight
During osteoporosis the porosity increases i.e. more and bigger holes so less bone per unit volume (density)

Types of bone cells

Osteoprogenitor cells:

Derived from mesenchymal stem cells
Located in the bone marrow
Produce osteoblasts

Osteoblast:

Forms new bone
Stimulated by Vitamin D
Regulates osteoclast activity

Osteoclast:

A large cell that reabsorbs existing bone and removes unwanted tissue
Derived from haematopoietic stem cells
Essential in bone remodelling such as due to stresses a bone is subjected to
A target of many osteoporotic medications:

By inhibiting their function less bone is eaten away thus increasing bone density

Osteocyte:

Mature bone cells
Former osteoblasts trapped within the bone matrix they produce
Commonest cell in bone ~90%
Important in regulating the calcium and phosphorus concentrations

What are the functions of bones?

Healthy bones are important throughout our lives
Bones are living tissues and play a vital role in numerous functions:

Support:

They provide a framework for attachment of muscles via their tendons
Ligaments connect bone to bone and so provide support across a joint

Movement:

As a result of this framework of muscles, tendons and ligaments, bones facilitate movement by acting as levers
Joints act as the fulcrum (pivot point) across which the lever acts

Protection:

Bones protect vital organs:

skull – brain
rib cage – heart and lungs
vertebrae – spinal cord
pelvis – internal reproductive organs, bladder, lower digestive tract

Mineral storage:

Bones act as the storage bank for vital minerals such as calcium and phosphorus
When they are in excess they can be stored in the bones
When the body needs more of these minerals they can be released from the bones but beyond a point this will cause reduced bone mineral density resulting in increased fragility and increased risk of fracture
Calcium is essential for muscle contraction and transmission of nerve impulses

Blood cell production:

Red marrow is located between the cavities of a bone and is where the blood cells are formed by the multipotential haematopoietic stem cell:

Red blood cells:

They carry oxygen from the lungs to the rest of the body and return carbon dioxide from the body to the lungs

White blood cells:

They fight off infection

Platelets:

They help form blood clots in order to stop bleeding

Energy storage:

Lipids (fats) are stored within the yellow marrow of a bone
Yellow marrow like red marrow, is also located within the cavities of a bone
This fat can be broken down and used for energy when required

More relevant information can be found on:

• Joints and Movement

• All About Muscles, Tendons & Ligaments

theodorides_knee_surgeon_review

De Quervain’s Tenosynovitis

Cubital Tunnel Syndrome

Carpal Tunnel Syndrome

Tennis Elbow

Repetitive Strain Injury

Introduction

﻿

Sailing Injuries

The Benefits and Risks of Exercise in Women

Influence of Gender on Risk of Sports Injuries

Female Athlete Triad - Symptoms and Treatment

Vitamin D – The Unappreciated Vitamin

Osteoporosis - Diagnosis and Treatment

How to Best Invest in your Bones

All About Muscles, Tendons and Ligaments

Joints and Movement

Bone Anatomy and Function