Collection of orthopedic conditions

This article covers various orthopedic conditions including myositis ossificans, joint contractures, ganglion cysts, trochanteric bursitis, pes anserine bursitis, meniscal cysts, and heel pad syndrome.

Myositis ossificans (heterotopic ossification) is a benign, heterotopic ossification of soft tissue and/or skeletal muscle that either occurs congenitally or, more commonly, following soft tissue or muscle injury

Localized course (myositis ossificans localisata)

• Etiology
  • Posttraumatic; : especially after implantation of an artificial hip joint or after blunt muscle trauma
  • Neurogenic: after nerve injuries, meningitis, and spinal cord injuries
  • Chronic degenerative disease (e.g., in ankylosing spondylitis)
  • Muscle overuse (e.g., in athletes)
• Clinical features: localized symptoms in the affected muscle/tissue (e.g., quadriceps femoris muscle, brachialis muscle)
  • Restriction of movement
  • Muscle stiffness
  • Pain, swelling
  • Palpable soft tissue mass
• Diagnostics
  • Soft tissue ossification is detectable on conventional x-ray.
  • Radiological findings: periosteal reaction with periarticular soft tissue calcifications (eggshell calcification)
  • Laboratory findings: ↑ alkaline phosphatase and ESR levels
  • Positive scintigraphy
  • Histology: zonal distribution of immature, proliferating fibroblasts that are surrounded by metaplastic trabecular bone
• Differential diagnosis: malignant bone tumors (e.g., sarcoma)
• Treatment: radiotherapy, possibly surgery
• Prophylactic measures against recurrence
  • Single dose radiotherapy recommended (possibly postoperative or preoperative)
  • Alternative: postoperative administration of NSAID (indomethacin)

Progressive generalized disease (myositis ossificans progressiva/fibrodysplasia ossificans progressiva)

• Etiology: extremely rare, autosomal dominant hereditary disease
• Pathophysiology: Fibrocytes produce bone tissue instead of scar tissue in all types of trauma.
• Clinical features
  • Generalized ossification mainly from cranial to caudal (life-threatening if the respiratory muscles are affected)
  • Malformation of toes is frequently observed at birth.
  • During the course of the disease, large, painful, well-vascularized swellings appear at various sites, which develop into bone tissue after regression.
• Treatment
  • No causal treatment
  • Symptomatic: NSAIDs, radiotherapy, possible surgical removal of individual lesions

References:^[1][2]

• Definition: a restriction in joint movement resulting from connective tissue fibrosis in the skin, fascia, muscles, and/or joint capsule adjacent to the affected joint
• Etiology
  • Prolonged immobilization, especially bed care patients
    • Hospitalization > 2 weeks (especially in the ICU)
    • Bed care in the domestic or nursing home setting
  • Chronic disease (e.g., rheumatoid arthritis, severe burn, stroke, multiple sclerosis)
  • Trauma (e.g., fractures, connective tissue injury)
  • Congenital disease (e.g., cerebral palsy)
• Clinical features
  • Decreased range of motion (ROM) of the affected joint
  • Pain when attempting to move or extend the joint
  • See also “Dupuytren contracture.”
• Diagnostics
  • Assessment of the ROM of the affected joint
  • Imaging (to detect connective tissue fibrosis)
• Treatment
  • Conservative therapy (e.g., physiotherapy)
  • Surgery

References:^[3]

• Definition: benign mucin-filled cyst that develops along tendons or joints and has no true epithelial lining
• Epidemiology: most common type of hand mass
• Location: : wrist and fingers (most common at the dorsal wrist)
• Pathophysiology: herniation of connective tissue; associated with repetitive trauma and mucoid degeneration of periarticular structures → sac that is lined with synovial cells and contains paucicellular connective tissue (typically mucin)
• Clinical features
  • Usually asymptomatic but can occasionally cause joint pain
  • Fluctuant, transilluminant swelling
  • Can lead to nerve compression, which may cause numbness, weakness, or tingling (e.g., Guyon tunnel syndrome)
• Differential diagnoses: epidermoid cysts, lipoma, rheumatoid nodules, infectious tenosynovitis, soft tissue tophus
• Treatment
  • Asymptomatic: observation (ganglion cysts often regress spontaneously)
  • Symptomatic: aspiration or surgical resection

References:^[4]

• The sections below cover the following orthopedic conditions involving the lower extremities:
  • Greater trochanteric pain syndrome
  • Pes anserinus pain syndrome
  • Meniscal cyst
  • Heel pad syndrome
• For additional orthopedic conditions affecting the lower extremities see the following articles:
  • Leg length discrepancy
  • Tarsal tunnel syndrome
  • Angular deformities of the lower extremities

• Definition: lateral hip pain caused by tendinopathy of the gluteus medius or minimus
• Etiology: : gluteus medius or gluteus minimus muscle tendinopathy
  • Involvement of the trochanteric bursa is possible, although rare.
  • May also be associated with snapping hip (coxa saltans) or trauma
• Clinical features
  • Common cause of lateral hip pain
  • Pain is usually localized to the greater trochanter at the proximal end of the femur.
  • Tenderness to palpation over the greater trochanter
  • Pain is triggered by resisting active abduction or standing only on the affected leg.
• Diagnostics
  • Usually, clinical diagnosis is sufficient.
  • Imaging may be indicated if the diagnosis is unclear, if underlying pathology is suspected, or in cases that do not respond to initial treatment. ^[5]
    • X-ray: used to rule out other causes of hip pain (e.g., osteoarthritis, femoral neck fracture)
    • Ultrasound: may show thickening of the iliotibial band, tendinosis of the gluteal muscles, and/or trochanteric bursitis ^[6]
    • MRI: to evaluate for an underlying pathology or prior to surgery
• Treatment ^[5]
  • Mainly conservative
    • Physical therapy and relative rest
    • Oral NSAIDs or glucocorticoid injections for pain/discomfort
    • Management of comorbidities, including back pain, obesity, and leg length discrepancy
  • In refractory cases; (without improvement after > 12 months of conservative management), surgery is indicated (e.g., bursectomy). ^[7]

• Definition: a condition characterized by pain and tenderness at the anteromedial aspect of the knee
• Components: each of these can be present to varying degrees depending on the patient
  • Tendinopathy of the pes anserinus
  • Pes anserine bursitis
• Risk factors
  • Female sex
  • Type 2 diabetes mellitus
  • Obesity
  • Osteoarthritis of the knee
  • Knee arthritis, knee deformities (e.g., knee valgus; , knee varus)
• Clinical features
  • Pain on the medial aspect of the knee when rising from a seated position, ascending or descending stairs, and/or sitting with legs crossed
  • Worsening of pain at night
  • Tenderness over the upper medial tibia ^[8]
• Diagnostics
  • Clinical diagnosis
  • Physical examination: assessment of knee alignment, pes anserinus insertion site, pain or tenderness during knee flexion and extension
    • No pain on passive external rotation or valgus stress
    • Usually no joint instability or swelling
  • Imaging
    • AP x-ray of the knee: rule out underlying osteoarthritis and stress fractures
    • Knee ultrasound or MRI: indicated in patients with local inflammation and/or induration to rule out other diagnoses (e.g., tumors, meniscal tears, osteonecrosis) that cannot be diagnosed on x-ray
• Differential diagnosis
  • Tibial stress fracture
  • Medial meniscus injury
• Treatment
  • Rest (e.g., avoidance of high or heavy-impact activities), application of ice to the knee
  • NSAIDs
  • Physical therapy: quadriceps-strengthening exercises
  • Weight loss in patients with obesity
  • Soft knee brace
  • Steroid injections: indicated in patients with refractory symptoms, severe pain, or nocturnal pain

• Definition: a collection of synovial fluid in or around the meniscus
• Etiology: secondary to a meniscal tear → synovial fluid becomes encysted
• Clinical features
  • Pain and swelling
  • Decreased range of motion of the knee
  • Chronic meniscal tears → locking (decreased extension of the knee) and popping (knee joint laxity)
• Diagnostics
  • Clinical diagnosis
  • MRI can aid in management if surgical intervention is indicated.
• Treatment ^[9]
  • Conservative management with rest, pain control, and crutches
  • Surgical intervention is indicated in refractory cases that do not respond to conservative management, or if there are mechanical symptoms (locking, popping) or tears in an avascular zone.

• Definition: a condition characterized by damage to the fatty and fibrous tissue in the heel
• Etiology: typically caused by inflammation but can also be due to damage or atrophy of the heel pad
  • Acute trauma
  • Repetitive overload (e.g., running, prolonged standing or walking)
• Risk factors
  • Age (usually > 40 years old)
  • Corticosteroid injections
  • Improper footwear
  • Cavus feet
  • BMI > 30
• Clinical features
  • Deep, mid-heel pain that increases with activity and when walking on hard surfaces
  • Tenderness in the mid-portion of the heel
• Diagnostics
  • Clinical diagnosis
  • Imaging (x-ray, ultrasound) may be indicated if the diagnosis is unclear.
• Differential diagnosis
  • Plantar fasciitis
  • Calcaneal stress fracture
• Treatment: mainly conservative
  • Rest (decrease/avoid pressure to the affected area)
  • Ice packs
  • Oral NSAIDs for pain
  • Heel taping
  • Heel pads or cups
  • Use of proper footwear