Tuesday, 7 May 2013
Intraarticular injection of 1% Lidocaine
Intraarticular injection of 1% Lidocaine
It is recommended to obtain a standing AP, lateral, and 45° patellar sunrise (axial) radiographs of the knee to rule out other sources of pathology. While many patients who have an irritated medial synovial plica have normal radiographs, it is important to rule out that the patients do not have any underlying arthritis, areas of osteochondritis desiccans, osteophyte formation, fractures, or other bony pathology which could be contributing to the irritation of the medial synovial plica.
In addition, diagnosis of medial plica irritation on MRI scans is non-specific . The physical exam should be able to demonstrate any significant thickening and fibrosis of a medial synovial plica. MRI’s are more useful in determining if there are other pathologies contributing to medial synovial plica irritation rather than in directly diagnosing pathology in this portion of the knee.
Treatment of medial plica irritation
The main treatment regimen for medial plica irritation is non-operative. For patients who have medial plica irritation as their main diagnosis without any underlying knee pathology contributing to their plica irritation, there is a very good chance that their symptoms will improve with a guided rehabilitation program . The most successful rehabilitation programs focus on strengthening the quadriceps muscles, which are directly attached to the medial plica, and avoiding activities which cause medial plica irritation . These exercises can include quadriceps sets , straight leg raises , leg presses , and mini-squats, as well as, a walking program, the use of a recumbent or stationary bicycle , a swimming program, or possibly an elliptical machine. Patients should work on gradually increasing strength over time to overcome any strength deficit in their quadriceps mechanism. Concurrent with this, patients should also work on a frequent hamstring stretching program throughout the day . As mentioned previously, tight hamstrings can increase the force needed to extend the knee, which can be an important source of medial plica irritation. Thus, it is important to make sure that the hamstrings are stretched frequently to diminish this extra stress on the anterior part of the knee.
Most patients can utilize either a self-directed or a physical therapy guided exercise program for the first 6–8 weeks after they have been examined. In the majority of circumstances, this program will alleviate the patient’s symptoms and the patient can often follow-up with their physician on an as needed basis if symptoms persist after this rehabilitation program. In this therapy regimen, patients participate in quadriceps strengthening exercises including a walking program, the use of a recumbent or stationary bicycle, a swimming program, or utilizing an elliptical machine. It is especially important to make sure that patients avoid knee extension exercises , because open chain exercises can cause plica irritation and limit patient’s improvements with an exercise regimen.
Concurrent with a good quadriceps strengthening program, it is also important to make sure that patients work on a frequent hamstring stretching program . They should work on stretching their hamstrings several times a day and not just once daily. As mentioned previously, tight hamstrings place extra stress on the anterior aspect of the knee when the patient tries to extend their knee and this is a frequent cause of medial plica irritation. Thus, it is important to make sure that patients do stretch their hamstrings concurrently with strengthening their quadriceps to maximize the benefit from an exercise program.
Hamstring stretching
In cases where patients are not getting better with a physical therapy program, or in those patients who have such an irritated plica that a therapy program may not be beneficial directly, consideration for an intraarticular corticosteroid injection is necessary. In candidates for an intraarticular steroid injection, we perform the injection to attempt to quiet down their knee symptoms such that they can participate in an exercise program to address their medial plica irritation. It is not sufficient solely to rely on the injection to quiet down ones knee because the underlying problem of a weak quadriceps mechanism and tight hamstring muscles may persist after the injection and result in a recurrence of the medial plica irritation after the beneficial effects of the injection wear off. Thus, it is very important to make sure that the patients do participate in an exercise program, even if they have complete relief of their symptoms, after an intraarticular steroid injection to treat medial plica irritation. It is usually necessary to have the patients refrain from exercising or placing any significant stress to their knee for the first 24–48 h after their steroid injection because the knee may have more post-injection soreness. In addition, it is important to document with the patients whether or not they had good pain relief while the local anesthetic portion of the injection was working to verify that they do have an intraarticular knee cause of their knee pain.
It is rare that patients need arthroscopic surgery to treat isolated medial plica pathology, because the medial plica is a part of the joint lining and resection of it will result in the joint lining growing back. Since the body heals back this type of resection with scar, the tissue may heal back with painful scar and the patient may have more symptoms. Since the treatment of a painful plica after an arthroscopic resection can often cause patients to have more pain than they did prior to the arthroscopic resection, it is important to make sure that a patient has pathology of this area which is not responsive to an exercise program, and possibly injections, prior to consideration of resection of this tissue . It is important to recognize that surgery for an irritated plica is uncommon, and historically it comprised only 2–5% of all arthroscopic surgery at a time when magnetic resonance imaging scans were not commonly used and more surgeries were performed for diagnostic reasons . We have found that arthroscopic resections of irritated plicas are rarely performed today. The usual instances where one may have some benefit from resection of a medial synovial plica may be where the plica is acting as a shelf which is catching over the medial femoral condyle and causing some erosion of the articular cartilage in this area. In these circumstances, patients may have good pain relief and decreased catching sensations in their knee after an arthroscopic resection of their medial plica. In this instance, it is usually not recommended to divide the pathologic plica and resect it totally because the pathologic plica may grow back and the patient may have recurrence of their symptoms . It has also been noted that the results of arthroscopic plica excision are more successful in adolescents than in older patients
Indirect treatment of the medial plica irritation may also be very beneficial to patients. In these instances, the pathology is deep within the knee. Treatment of localized areas of arthritis, meniscal tears, or other knee pathologies, may decrease the pain and swelling of the knee which resulted in secondary irritation of the medial plica. In these instances, it may be beneficial for the patient to undergo surgery to treat the secondary cause of plica irritation. In these circumstances, it is not recommended to resect the medial synovial plica, because there is a very good chance that it will get better with an exercise program after surgery and patients may not have pain relief of their plica irritation if it is resected arthroscopically.
Medial plica irritation: diagnosis and treatment
Abstract
Medial plica irritation of the knee is a very common source of anterior knee pain. Patients can complain of pain over the anteromedial aspect of their knees and describe episodes of crepitation, catching, and pseudo-locking events with activities. Patients commonly have pain on physical examination upon rolling the plica fold of tissue over the anteromedial aspect of their knees and often have tight hamstrings. The majority of the patients will respond well to a non-operative treatment program consisting of quadriceps strengthening along with concurrent hamstring stretching. In cases which do not respond initially to an exercise program, an intraarticular steroid injection may be indicated. In those few patients who do not respond to a non-operative treatment program, an arthroscopic resection of their medial plica may be indicated, especially in those cases where a shelf-like plica has been found to be causing damage to the articular cartilage of the medial femoral condyle.
Keywords: Plica irritation
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Anatomy
The medial plica of the knee is a thin, well-vascularized intraarticular fold of the joint lining, or synovial tissue, over the medial aspect of the knee (Fig. 1). It is present in everyone, but is more prominent in some people. It has been noted to be present as a shelf of tissue over the medial aspect of the knee at the time of arthroscopic surgery in up to 95% of patients [6]. Proximally, it is attached to the genu articularis muscle, while distally it courses over the far medial aspect of the medial femoral condyle to attach to the distomedial aspect of the intraarticular synovial lining of the knee. At this location, it basically blends into the medial patellotibial ligament on the medial aspect of the retropatellar fat pad [9]. The medial plica is composed of relatively elastic tissues which asymptomatically conform to the changes in shape and lengths of the plica folds as the knee flexes and extends [7]. In some patients, particularly those who may have had injuries or multiple surgeries over the medial aspect of the knee, the medial synovial plica may become very thick and fibrotic and may catch over the medial aspect of the medial femoral condyle [7, 10].
Fig. 1
Intraoperative visualization of medial synovial plica
In all patients, the medial synovial plica will glide over the anteromedial aspect of the medial femoral condyle with flexion and extension of the knee. In most patients, this gliding motion of the plica will occur without any symptoms, because of the high viscosity of the native synovial fluid of the knee. However, in patients with effusions, which decreases the viscosity of their synovial fluid, patients may either have crepitation or a catching of their medial synovial plica with flexion and extension of the knee. This crepitation or catching can occur with patients while going up or down stairs, squatting and bending, and other types of activities.
Since the medial synovial plica does have an attachment to the genu articularis muscle, and also an indirect attachment to the quadriceps musculature due to its attachment to the joint lining, it is dynamically controlled by the quadriceps muscles [3]. Thus, medial plica irritation is more common in patients who have poor quadriceps tone or other problems with joint muscle balance around the knee.
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Diagnosis of medial plica pathology
One of the most important points in diagnosing medial synovial plica pathology is obtaining an appropriate history from the patient. Patients usually describe pain which is dull, achy, and increases with activity. When asked to point to the area of their pain, they will commonly point to the proximomedial aspect of the knee, proximal to the medial joint line. While some patients may note a history of trauma to this area of the knee, most patients do not have any specific history of trauma to their medial plica. Over half of patients have a history of participating in some type of strenuous activity which requires repetitive flexion and extension motion of the knee, which then irritates their patellofemoral joint.
Most patients will complain of an achy type pain over the medial aspect of their knee, which is aggravated by activity and can be particularly bothersome at night. Their complaints of night pain over this area of the knee are due to the effects of inflammation, which can be particularly bothersome with activities. Patients most commonly complain of pain with activities which stress their patellofemoral joints, such as ascending and descending stairs, squatting and bending, and arising from a chair after sitting for an extended period of time [11]. In addition, they may note difficulty with sitting still for long periods of time without having to move and stretch their knees. They also may complain of a catch over the anteromedial aspect of their knee upon arising from a chair following prolonged periods of sitting. In some patients, plica catching may present as a pseudo-locking event to their knee when they have been sitting down for an extended period of time and they first arise. Some patients may describe these pseudo-locking events as instability or catching of their patella. Clicking, giving way, and pseudo-locking have been reported in approximately 50% of all patients who present with medial plica irritation [8]. Patients who might have problems with activity-related effusions may also complain of pain over the anterior aspect of their knee. While these activity-related effusions may not be directly caused by medial plica pathology, and are more commonly due to underlying quadriceps mechanism weakness, meniscal tears, and/or osteoarthritis, but they can cause secondary medial plica irritation. In addition, patients who have had postoperative or post-injury weakness of their affected extremity may develop pain over the anteromedial aspect of their knee in the region of the medial synovial plica.
A definitive diagnosis of medial plica irritation is usually obtained by physical exam. A normal examination of the patellofemoral joint should always include an examination of the patient’s medial synovial plica fold to determine if they have any irritation of this structure.
In examining the medial synovial plica, it is important to make sure that the patient is relaxed, which is usually accomplished by having the patient lie supine on the examining table with both legs relaxed. The examiner then palpates for the medial synovial plica by rolling ones fingers over the plica fold which is located between the medial border of the patella and the adductor tubercle region of the medial femoral condyle (Fig. 2). The medial synovial plica will present as a ribbon-like fold of tissue under ones finger which can be rolled directly against the underlying medial femoral condyle [12]. While some patients may have a sensation of mild pain when palpating the medial synovial plica, it is important to ascertain while performing this test if this reproduces their symptoms. It is also very important to compare the sensation to the contralateral normal knee to see if there is a difference in the amount of pain produced. It has been well demonstrated that this portion of the medial joint line and synovium is well innervated and irritation of the medial plica can be quite painful in some patients [4].
Fig. 2
Medial synovial plica palpation (Plica snap test)
As with any other physical diagnosis, it is important to concurrently ascertain if there are other areas of pathology for structures that are located close to the medial synovial plica to confirm one’s diagnosis. In acute injuries, one should make sure that there is no injury to the meniscofemoral portion of the superficial medial collateral ligament. In this instance, one would apply a valgus stress to the knee and palpate at the joint line for both any potential joint line opening to application of the valgus stress and also to see if there is any well localized pain or edema in the region of the meniscofemoral portion of the superficial medial collateral ligament (Fig. 3). In addition, in acute injuries, one should make sure that there has not been a lateral patellar subluxation episode with injury to the medial patellofemoral ligament. The lateral patellar apprehension test, performed with the knee flexed to approximately 45° of knee flexion, can help to determine if there has been injury to the medial patellofemoral ligament by applying a lateral translation force to the patella when it is flexed to approximately 45° of knee flexion and assessing if this translation causes pain or an apprehensive feeling like the patella will dislocate (Fig. 4). This pain should be different from pain produced when the plica is rolled under ones fingers. Further, one should make sure that the pain over the medial aspect of the knee is not directly due to localized or diffuse areas of chondromalacia of the patellofemoral joint. In this instance, one would roll the superior and inferior poles of the patella both proximally and distally, as well as medially and laterally, in the trochlear groove, to determine if there is any true retropatellar crepitation with translation of the patella in the trochlear groove (Fig. 5a, b). This evaluation is different from assessing for crepitation of the patellofemoral joint with active flexion and extension of the knee (Fig. 6a, b) as many of these patients may have catching of their medial plica causing the crepitation with active flexion and extension of the knee rather than true patellofemoral chondromalacia causing this auditory occurrence. In addition, one should assess for hamstring tightness, which can cause stress to the anterior aspect of the knee, by assessing the hamstring-popliteal angle (Fig. 7) and by palpation of the main hamstring attachment sites of the knee (pes anserine bursa (Fig. 8), semimembranosus bursa (Fig. 9), and biceps bursa (Fig. 10)).
Friday, 12 April 2013
Health Plans
As the Obama administration continues its top secret effort to build federal insurance exchanges in about 34 states while 16 states are doing it on their own, that continues to be the big question.
HHS is using IT consulting firm CGI for much of the work on the exchanges and the federal data hub. CGI has their plate full since they are not only working on the federal exchange but also doing work for the state exchanges in at least Colorado, Vermont, and Hawaii.
Earlier this month, the Senate Finance Committee held an oversight hearing. The Obama guy in charge of exchange development testified before them. I thought it was notable that it was the Democrats who expressed the greatest concern, and frustration, over senators not getting a clear idea for just where the administration is toward the goal of launching the new health insurance exchanges on October 1.
So far California has received $910 million in federal grants to launch its new health insurance exchange under the Affordable Care Act (“Obamacare”).
The California exchange, “Covered California,” has so far awarded a $183 million contract to Accenture to build the website, enrollment, and eligibility system and another $174 million to operate the exchange for four years.
The state will also spend $250 million on a two-year marketing campaign. By comparison California Senator Barbara Boxer spent $28 million on her 2010 statewide reelection campaign while her challenger spent another $22 million.
The most recent installment of the $910 million in federal money was a $674 million grant. The exchange’s executive director noted that was less than the $706 million he had asked for. “The feds reduced the 2014 potential payment for outreach and enrollment by about $30 million,” he said. “But we think we have enough resources on hand to do the biggest outreach that I have ever seen.”
Healthy living
Healthy living
"I'm confident in her," she said "She seems excited about the moment that she gets to hit the gym and get her body back, and she obviously trusts that I know how to do it, and I do. And as long as she shows up, she will do it."
SoulCycle, an intense, indoor cycling studio with locations in New York City and Los Angeles, where riders can burn hundreds of calories in a single class, has become a favorite workout for many new moms.
Ali Carlin is a stay-at-home mom with two kids, 2-year-old Adrianna and 1-year-old Brooks, living in New York. She had her kids back-to-back and said she wanted to get back in shape and finally focus on herself.
SoulCycle instructor Nick Oram said moms trying to lose baby weight are among his biggest clients.
And they aren't just doing one class a week. They are working out even before their babies are big enough to crawl. In fact, an entire industry has sprung up around mothers who want to look hot pushing a stroller, and even while they are still pregnant. There is maternity athletic gear, pregnancy workout DVDs and apps, all to keep Mom in shape before she even has the baby.
Celebrity trainer Tracy Anderson has built her brand around transforming women's bodies after childbirth. She has trained some of the biggest A-list celebrities around, from Jennifer Lopez to Victoria Beckham, and she went into business with her client and friend Gwyneth Paltrow.
It's never too late to change your habits, and by establishing a healthy lifestyle now, you'll continue to reap the rewards in the future. Discover the facts behind nutrition so you can make informed choices, understand how BMI, or body mass index, affects you, or take part in our six-week diet and exercise programme."Everybody's life is unique," Anderson said. "As soon as your doctor releases you to work out, you have to start reconnecting to your body. What's hard is that you know what it's like to start working out again after being pregnant, it's the worst thing ever. "
PHOTOS: Celebrity Baby Bumps
Most medical experts agree it is healthy to work out during pregnancy. But being obsessed with your weight while pregnant and immediately after giving birth is another story.
In fact, a recent study by the University College London of 700 pregnant women found that 1 in 14 had an eating disorder during the first part of their pregnancy, roughly the same as the general population.
"Comparing a normal post pregnancy body to a celeb's is like expecting one's face to look like an airbrushed and photoshopped magazine ad," said Vivian Diller, a psychologist in New York. "It's just not realistic and leaves many moms falling short of expectations. Bodies change for real women throughout real life."
Unlike most people, celebrities have armies of people to help them get their post-baby body back, from personal trainers at the gym to plastic surgeons who can perform tummy tucks and liposuction.
"The average new mom needs to keep in mind that most celebs view working out as a part of their job," Diller said. "Prior to pregnancy, they are often in very good shape. Getting back to it as soon as possible is, in part, what they are paid to do."
Some famous moms can't even live up to the perfect image that's demanded of them. Kim Kardashian has been skewered in the tabloids for gaining weight during her pregnancy.
"It's like adult bullying," Anderson said. "It's the most ridiculous thing I've ever heard."
Even though Kardashian is working out with Anderson, every pound she has gained during her pregnancy has been plastered across magazine covers.
"I feel badly for her because anybody who has to do that under the pressure of being photographed all the time ... sometimes when you're pregnant, it's like the last thing you want to do," Anderson said. "You want to be in sweats."
But Anderson is confident that like all of her celebrity mom clients, Kardashian too will be back and better than ever.
"I'm confident in her," she said "She seems excited about the moment that she gets to hit the gym and get her body back, and she obviously trusts that I know how to do it, and I do. And as long as she shows up, she will do it."
But for real moms, just feeling good and looking good, for themselves and their kids is what really matters.
Healthy Families
Healthy Families
Today I would like to introduce a guest writer. Carolyn is a 20-something year old with a passion for life, fitness and overall well-being. She is an avid cycler, golfer and has been known to bust some serious moves on the dance floor.
Carolyn wrote to me (not too long ago) about her passion for getting healthy- starting at home. As a mother, I am constantly trying to better my own health- and that of my family. I honestly believe that mothers are the most influential factors in raising healthy children. After all, we do the majority of the grocery shopping and activity planning. So, I thought Carolyn would be a wonderful addition to Diapers & Daisies today and help to expand our knowledge on leading healthy lives.
Thanks Carolyn.
With no further ado...
When the calendar flips to the new year, people around the world get to work on their New Year’s resolutions. For my family, changes in habits had to be addressed in November of last year, which was when my young cousin was diagnosed with Type 2 Diabetes. I couldn’t believe that someone who is only 13 years old could develop this disease…but after talking with her doctors and doing my own research, I found that it has become quite common among young children to develop Type 2.
What was even scarier to me than the sheer number of kids affected by this disease, are all of the possible consequences that can come from it. Information provided by St. Joseph’s Hospital Cardiac Center describes how, if left untreated, Diabetes can lead to things such as eye problems and blindness, heart disease, and even neurological problems. Seeing as how this disease can frequently be treated and prevented with adjustments to diet and exercise, I took it upon myself to work with my family to make healthy adjustments to diet and exercise so that none of my other cousins will run the risk of developing this disease. Seeing that we are in the New Year, it’s a perfect time for other families to make this their resolution for 2013 as well!
Inactivity and obesity are two contributing factors to the rise in Type 2 Diabetes in youngsters under the age of 20. The best tools against it, of course, are exercise and a healthy diet. It is always a good idea to check with a doctor concerning best dietary options and exercise regimes, but here are a few tips to get you and your children started on the right track for the New Year.
Get Active to Get Healthy!
First, take advantage of the weather to enjoy exercising outdoors with the kids. Those who live in cold climates will find winter sports a great way to stay fit. Take the kids tubing, sledding or skiing. Spend an afternoon building snow forts and having a snowball fight.
If snow doesn’t fall where you live, take the kids on a family bike ride or go rollerblading together. If weather is bad enough that going outside isn’t an option, turn on some music and have a family dance contest or pick up some exercise DVDs from the library and enjoy the workout together! The key is to get moving every day, and it makes it easier and way more fun if everyone does it together!
Eat Right to Get Healthy!
To improve your children’s diet, make some moderate changes to start (changing everything at once can be a major shock, and they are much more likely to resist each change). Replace sugary drinks with water. If the kids don’t like the taste, offer purified drinking water or add a squeeze of lemon, lime, or cucumber to the drink.
At snack time, offer fresh or dried fruit with no added sugar, almonds or crunchy vegetables. Hummus and guacamole are great, healthy sides that are both delicious, healthy, and great with veggies or whole grain pita chips!
At mealtime, use proper portion control and replace processed food and red meat with options such as fish, brown rice, poultry and legumes. For a balanced plate, ½ the plate should be filled with fruits and/or non-starchy vegetables, ¼ should be lean protein, and the last ¼ should be whole grains/healthy carbs.
As with any disease, it is easier to prevent Type 2 Diabetes that to treat it following onset. A few lifestyle changes will ensure better health for the entire family, and will build healthy habits for years to come!
Students whose parents are engaged in their school lives are more likely to practice healthy behaviors and succeed academically.
Chickenpox Can Be Serious: Protect Your Child
Most children with chickenpox completely recover. But it can be serious, even fatal, for babies, adolescents, and adults. Be proactive. Get vaccinated if you are not protected against chickenpox.
Most children with chickenpox completely recover. But it can be serious, even fatal, for babies, adolescents, and adults. Be proactive. Get vaccinated if you are not protected against chickenpox.
Antibiotics Aren't Always the Answer
Antibiotics do not fight infections caused by viruses like colds, most sore throats and bronchitis, and some ear infections. Unneeded antibiotics may lead to future antibiotic-resistant infections. Symptom relief might be the best treatment option.
Antibiotics do not fight infections caused by viruses like colds, most sore throats and bronchitis, and some ear infections. Unneeded antibiotics may lead to future antibiotic-resistant infections. Symptom relief might be the best treatment option.
Traveling Overseas? Consider Getting Insurance
If you are planning an international trip, there are 3 types of insurance you should consider: trip cancellation insurance, travel health insurance, and medical evacuation insurance. These will cover different situations and may give you financial peace of mind, as well as allowing for safe and healthy travel.
If you are planning an international trip, there are 3 types of insurance you should consider: trip cancellation insurance, travel health insurance, and medical evacuation insurance. These will cover different situations and may give you financial peace of mind, as well as allowing for safe and healthy travel.
Inspiration for a Healthy New Year
Make being healthy your resolution and find ways to get and stay healthy this year. Meet three people who changed their health habits—and their lives. Here are their stories and tips for making healthy living easier.
Make being healthy your resolution and find ways to get and stay healthy this year. Meet three people who changed their health habits—and their lives. Here are their stories and tips for making healthy living easier.
Inspiration for a Healthy New Year
Inspiration for a Healthy New Year
Make being healthy your resolution and find ways to get and stay healthy this year. Meet three people who changed their health habits—and their lives. Here are their stories and tips for making healthy living easier.
Traveling Overseas? Consider Getting Insurance.
Traveling Overseas? Consider Getting Insurance.
If you are planning an international trip, there are 3 types of insurance you should consider: trip cancellation insurance, travel health insurance, and medical evacuation insurance. These will cover different situations and may give you financial peace of mind, as well as allowing for safe and healthy travel.
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