A tendon may rupture when the muscle to which it is attached contracts suddenly and powerfully, usually during vigorous physical activity such as playing sports or lifting a heavy object. Athletes tend to carry out these activities more often and are therefore more likely to sustain injury. A ruptured tendon may also result from a severe blow, deep cut, or fracture. In some cases, a ruptured tendon can occur spontaneously as a complication of long-term joint disease such as rheumatoid arthritis. The tendons in the limbs, particularly the Achilles tendon (which runs from the calf muscle to the heel bone) and those in the hands, are most susceptible to rupture.

You may feel a snapping sensation in the injured area at the time that the tendon ruptures. Other symptoms include pain, impaired movement, and swelling of the affected area.

What might be done?

Diagnosis is usually obvious from the symptoms and physical examination of the affected area. Your doctor may prescribe nonsteroidal anti-inflammatory dugs. In some cases of Achilles tendon rupture, surgery will be needed to join the torn ends of the tendon. Whether or not you have surgery for an Achilles tendon injury, the injured area will be immobilized by the successive application of different casts. The first cast holds the heel up and the toe down, to avoid stretching the tendon. Subsequent casts are used to flatten the foot gradually and return it to its normal position. You may also be advised to have physiotherapy to help to strengthen the muscles in the injured area around the tendon.

The time taken for recovery varies, but motion is usually fully restored in 4-12 months. If an Achilles tendon was involved, you may be vulnerable to further injury on the opposite side.

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Muscle strain occurs when a muscle is overstretched, damaging some of its fibres. A tear occurs when the damage is severe and affects many muscle fibres. Both conditions are usually caused by sudden, strenuous movements and occur most often in people who play sports. Abdominal and back muscles may be injured by lifting heavy objects. Athletes are particularly susceptible to these injuries. Symptoms may include pain, swelling, and bruising.

Muscle strains and tears may be prevented by preparing adequately before sports activities. If you do strain or tear a muscles, follow first-aid procedures. When the pain and swelling subside, usually within 2 days, you can exercise the muscle gently. However, if the pain remains, consult your doctor. Your doctor may suggest that you take a nonsteroidal anti-inflammatory drug. He or she may also advise you to rest the affected muscle and receive physiotherapy. If the injury is severe, you may have an X-ray to rule out a fracture. Rarely, surgery may be needed to repair a muscle that has been badly torn.

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Damage to cartilage commonly occurs in the knee joint, where two cartilage discs, known as menisci, act as shock absorbers between the femur (thigh bone) and tibia (shin bone). These discs help to distribute body weight in the joint. A torn cartilage often occurs in football players and is therefore more common in men. The injury is usually caused by a sudden twisting of the leg, often with the knee bent and the foot on the ground. A cartilage can tear without sudden injury, and people whose occupation involves squatting down and placing strain on the knees are at risk.

If you do tear a cartilage abruptly, you will feel a sharp pain and may hear a noise at the time of the injury. Pain usually becomes worse on moving the joint, and swelling may develop immediately or several hours later. You will probably be unable to straighten the joint. A torn cartilage may prevent the leg from supporting your body weight.

What might be done?

Your doctor will examine your knee and probably arrange for an X-ray to check for bone damage. The diagnosis may be confirmed by examining the knee using MRI or arthroscopy. Sometimes, damaged knee cartilage is repaired surgically under a general anaesthetic, and most people are able to use the injured joint 2-3 weeks after wards. Physiotherapy may be needed to help to mobilize the affected joint. There is a risk that torn knee cartilage may lead to early development of osteoarthritis, a degenerative disorder of the joints.

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Ligaments attach bones to each other within joints and help to keep joints stable. Ligaments are only slightly elastic and are easily damaged if they are overstretched. Possible injuries range from minor tears, also called sprains, to complete rupture. The most common cause of a ligament injury is a sudden twisting or wrenching due to a fall, playing sports, or exercising excessively. Such injuries occur more commonly in men because they exercise more vigorously. Failure to warm up properly before starting exercise is another cause of ligament injury. The ankle and knee are injured most often.

What are the symptoms?

Symptoms usually develop suddenly in the affected joint and may include:

- Pain, particularly on movement.
- Swelling and bruising.
- An abnormal range of movement at the joint.

If you are unable to use a joint after injuring it, you should consult your doctor promptly because tearing a ligament may lead to a dislocation of the bones within the affected joint.

What might be done?

Most ligament injuries heal well within 8 weeks without treatment, but you can help speed up recovery of a mild sprain using first-aid measures. To relieve pain, you may be given nonsteroidal anti-inflammatory drugs. If the pain is severe, you may take an X-ray to rule out a fracture. Physiotherapy is often needed after severe injuries, and surgery may also be necessary. Sometimes, the ruptured ligament is beyond repair. In such cases, the ligament may be replaced with a nearby tendon or a donor graft.

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A dislocated joint occurs when a bone has been displaced from its normal position. As a result of pain and the dislocation itself, movement of the joint is severe restricted. The ligaments that holds the bone in place are often torn during the process of dislocation, and the capsule that surrounds the joint may be damaged. Sometimes the bones within the joint also fracture. Shoulder and finger joints are particularly susceptible to dislocation.

Dislocation of shoulder.

What are the causes?

Any powerful force acting against may cause a dislocation. Contact sports, such as rugby, and heavy falls are common causes in men. Abnormally loose joints that are susceptible to dislocation may be an inherited condition. Dislocation may also be associated with a joint disorder, such as rheumatioid arthritis. Dislocation of the hip may be present from birth.

What are the symptoms?

If you dislocate a joint, the symptoms will appear suddenly and may include:

- Severe pain in the affected area.
- Deformity of the joint.
- Swelling around the joint.
- Brushing of the skin around the joint.

Displaced bones may cause damage to nearby nerves, tendons, and blood vessels, resulting in reduced circulation in tissues beyond the affected area.

If you think that you may have dislocated a joint, you should consult a doctor promptly. If a back injury causes dislocation of the vertebrae (bones of the spine), there may be damage to the spinal cord and consequent paralysis.

What might be done?

Diagnosis of a dislocated joint is usually obvious from the symptoms and a physical examination. However, you may have a X-ray to confirm the dislocation and to check for a fracture. Dislocated joints can usually be manipulated back into position by a doctor. You may be given a painkiller to relieve discomfort or, in some cases, a sedative to relieve muscle spasm while the joint is being manipulated. If manipulation is unsuccessful, you may need surgery to reposition the joint.

After treatment, the affected joint may be immobilized for 3-6 weeks and you may need physiotherapy to help you start to use the joint again. There may be an increased risk that the joint will dislocate again. Joints that dislocate repeatedly may require surgical treatment to stabilize them.

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Any bone in the body can be fractured. Most fractures are caused by an injury such as a direct impact or a twisting movement, which may occur during an athletic activity or a fall.

Susceptibility to fractures increases with the bone disorder osteoporosis, which mainly affects women after the menopause and results in brittle bones. Fractures that occur in bones affected by tumours are called pathological fractures and may occur after minor injury or even spontaneously.

The most common sites of fracture in elderly people are the neck of the femur (thighbone) and the lower end of the radius bone of the forearm near the wrist. A fracture at the end of the radius, known as a Colles’ fracture, may occur if a person trips and breaks his or her fall with an outstretched arm.


What are the types?

There are two main types of fracture: closed (simple), in which the broken bone does not break through the over-lying skin; and open (compound), in which the bone pierces the skin and is exposed. Open fractures are more serious because of the risk of infection and an increased risk of damage to nerves and blood vessels. Open and closed fractures may be further subdivided according to their shape and pattern.

Transverse fracture: in a transverse fracture, there is a straight break across a bone. Transverse fractures, often in a long bone in the arm or leg, are usually due to a powerful blow, such as that sustained in a collision during a traffic accident.

Spiral facture: this type of fracture is also known as an oblique fracture. Spiral fractures are usually caused by sudden, violent, rotating movements, such as twisting the leg during a fall. Spiral factures usually occur in arm and leg bones.

Greenstick fracture: if a long bone in the arm or leg bends, it may crack on one side only, producing a break called a “greenstick” fracture. This type of fracture occurs only in children, whose bones are still growing and flexible.

Comminuted fracture: in a comminuted fracture, the bone is broken into small fragments, which increases the likelihood of damage to soft tissue surrounding the broken bone. These fractures are usually caused by severe, direct forces.

Avulsion fracture: in this type of fracture, a piece of bone is pulled away from the main bone by a tendon, a fibrous band that attached muscle to a bone. It usually results from a sudden violent twisting injury.

Compression fracture: a compression fracture occurs if spongy bone, like that in the vertebrae of the spine, is crushed. This type of fracture is often due to osteoporosis.

Fractures caused by repeated jarring of a bone are called stress fractures. They may occur in the feet or shinbones of long-distance runners. In the elderly, fractures may result from minor stress such as a cough, which can break a rib.

What are the symptoms?

The symptoms of a fracture depend on its type and may include:
- Pain and tenderness, which may limit movement of the affected area.
- Swelling and bruising.
- Deformity in the affected area.
- Crackling noise (crepitus) caused by grating of the ends of the bones on movement or pressure.
- In an open fracture, damage to skin, bleeding, and visible bone.

All fractures cause a certain amount of internal bleeding because of damage to blood vessels in the bone. The broken bone ends may cause further bleeding by damaging tissue and blood vessels in the injured area. In some fractures, blood loss may be severe and can occasionally lead to shock.

Various complications may be associated with a fracture. For example, if you fracture a rib, there is a risk that the broken rib may puncture a lung. An open fracture may become infected.

Delay in treating a fracture properly may result in failure of the bone to heal and permanent deformity or disability. Consult a doctor immediately if you think that you have a fracture.

How is diagnosed?

Your doctor will arrange for you to have X-rays of the affected area to reveal the type and extent of the fracture. CT scanning or MRI may be needed to investigate complex fractures. If a fracture was not due to injury, your doctor may check for a possible underlying disorder that may have weakened your bones.

What is the treatment?

If the broken ends of the bone have been displaced, they will need to be returned to their original position to restore normal shape. This process is known as reduction. Depending on the location and severity of the fracture, a broken bone may be manipulated back into its correct position under local or general anaesthetic, either 1 without an incision (closed reduction) or through an incision in the skin (open reduction). The fractured bone may be held in place until it has healed fully by using one of several methods.

In some cases, it may not be appropriate to immobilize a broken bone. For example, a broken rib is generally not immobilized because the chest needs to expand normally during breathing. This is important to reduce the risk of pneumonia, which can develop as a result of shallow breathing and an impaired ability to cough. As a preventive measure, you may be asked to take deep breaths regularly.

Occasionally, healing is slowed down because not enough blood can reach the fracture site or because the broken bone has not been immobilized effectively. In such cases, surgery may be needed; the splintered bone is removed and bone taken from a different part of the body is grafted in its place. A broken bone, such as a fracture in the femur close to the hip joint, may be replaced with an artificial substitute, in this case comprising either part of the femur or the entire hip joint.

You may need to have physiotherapy after the fracture has healed to restore mobility to a nearly joint and strengthen the surrounding muscles.

What is the prognosis?

In adults, most fractures take 6-8 weeks to heal. Fractures in children generally heal much more quickly. Fractures in babies may heal in a couple of weeks.

FRACTURES TREATMENS

Although some broken bones do not need immobilization, most have to be returned to their correct position (reduction) and held in place so that the fractured ends are able to heal and joint together properly. The method of immobilization chosen for a particular fracture depends on the type, location, and severity of the fracture.

Immobilization in a cast: the simplest form of immobilization is a cast, a rigid casing that is applied to a limb and left in position for several weeks to hold the fractured bone ends together and prevent movement. Casts are usually made from plaster, plastic, or resin. They are removed using an electric saw, which cuts through the cast.

Internal fixation: bones that are severely fractured may need metal plates, screws, nails, wires, or rods to be inserted surgically to hold the broken bone ends together. A cast may not be required. Internal fixation is often used for fractures at the ends of bones.

External fixation: a specialized technique known as external fixation is often required to repair bones that are fractured in several places. In this technique, pins are inserted through the skin into the bone fragments. The pins are help in place by an external metal frame, which allows the affected limb to be used normally within a few days. The frame and pins are removed when the bone has healed.

Traction: traction is used for the temporary immobilization of a fracture until further treatment of the injury can be carried out. The technique is often used for fractures in the shaft of the femur (thighbone). Weights are used to maintain alignment because the powerful muscles in the thigh would normally pull on the ends of the broken bone, forcing them out of alignment.

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A bunion is a thickened lump at the base of the big toe. It often becomes inflamed and painful, making walking difficult. The underlying cause is usually a minor bone deformity, called hallux valgus, in which the joint at the base of the big toe develops an abnormal projection, which forces the tip of the toe to turn towards the other toes. The cause of hallux valgus itself is not known, but the condition runs in some families. As a result of pressure on the deformity, the surrounding tissues thicken. The term Bunion refers to the thickened lump that is due to the combination of the bony deformity and thickening of the soft tissue around it. The condition is particularly common in young women who wear tight, pointed shoes with high heels.

In rare cases, the constant rubbing of tight shoes on the skin over a bunion may cause an abrasion, which then leads to a bacterial infection. People with diabetes mellitus are particularly susceptible to infected bunions because the sensation in their feet may be reduced. In such people, damage to the skin tends to heal more slowly.

Without attention, a bunion may gradually worsen. Pain may be alleviated by wearing comfortable shoes and a special toe pad or corrective sock that straightens the big toe. However, if a bunion causes severe discomfort, your doctor may suggest that you have surgery to correct the underlying deformity by realigning the bone. If the bunion becomes infected, your doctor will prescribe antibiotics. A bunion increases the chance of developing osteoarthritis of the toe joint in later life.

BUNION SURGERY

Surgery to treat a bunion is aimed at correcting the underlying bone deformity, known as hallux valgus. One common type of surgical procedure used to treat a bunion involves reshaping and realigning the deformed bone at the base of the big toe. The operation is performed under general anaesthesia and may require a brief stay in hospital. Normal activity can usually be resumed about 6 weeks after surgery.

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Athletes and other people who exercise vigorously risk injury. Sports injuries often occur in people who are new to a sport, begin to exercise after prolonged inactivity, or do not warm up properly before exercise. Men are at greater risk because they play more contact sports.

What are the types?

Any part of the musculoskeletal system may be injured while playing sports. In some sports, there is an increased risk of injury to a specific part of the body.

Bone injuries: many sports activities can cause damage to the bones, either through repetitive actions or as a result of an impact with another person, the ground, or equipment, such as a bat or a ball. Bones may be broken or cracked during contact sports such as rugby. The repetitive jarring of bones of the lower limbs of runners may cause stress fractures.

Joint injuries: the bones that form a joint may partially or completely pull apart during sports that put them under great strain, such as javelin throwing. Dislocation is also a risk in all contact sports. A common injury among foot-ball players is damage to the cartilage pads in the knee joint.

Ligament and tendon injuries: the fibrous bands of tissue that hold the structures of the musculoskeletal system together are often injured during sports activities. Ligaments, which hold the bones together, may become damaged by a sudden twisting movement or during a fall. Tendons, which attach muscle to bone, may become torn during athletic activities, such as jumping, that involve a sudden muscle contraction.

Muscle injuries: most sports rely on strength and suppleness of the muscles, and damage to muscles is common in athletes. For example, calf strain, overstretching of the muscles in the calf region, is a common injury in basket-ball players. Muscle injury is frequently caused by sudden, strenuous movements and lifting heavy objects.

Can they be prevented?

Many sports injuries could be prevented by warming up correctly before starting exercise. Adequate preparation can increase flexibility and reduce stiffness in the muscles and joints. In sports such as running, you should start gently, gradually increasing your pace to prevent placing too much strain on your body.

Wear clothes and footwear designed for your type of sport and use recommended safety equipment.

What might be done?

Many minor injuries to ligaments, tendons, and muscles can be treated using basic first-aid procedures and nonsteroidal anti-inflammatory drugs. If a sports injury is causing intense or persistent pain, you should consult a doctor. He or she will examine you and may arrange for you to have an X-ray to check whether you have sustained a fracture.

If you have a fracture, it may be necessary to immobilize the injured area by using a cast. Surgery may be required for some injuries, such as a ruptured tendon. You may also need physiotherapy from a sports therapist. You should not participate in any sports until you are free of pain.

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Bursae act as friction-reducing cushions around joints. Inflammation of a bursa, called bursitis, may occur if it is put under prolonged or repeated stress. The bursa becomes tender and swollen, and movement of the joint is restricted.

The knee is most commonly affected, especially as a result of frequent kneeling, but the elbow or other joints may also be affected. Bursitis may also follow injury or unaccustomed exercise. Certain joint diseases, such as rheumatoid arthritis and gout, increase the risk of bursitis. Rarely, the condition is due to a bacterial infection. Your doctor will probably diagnose bursitis from a physical examination. Treatment includes resting the affected joint.

Your doctor may also recommend a non-steroidal anti-inflammatory drug and application of ice packs. However, if symptoms persist, he or she may drain the bursa and inject it with a corticosteroid drug to reduce inflammation. If a bacterial infection is present, antibiotics will be prescribed, in which case the symptoms usually subside within a few days. If bursitis is persistent or recurrent, surgical removal of the bursa may be necessary.

ARTHROSCOPY

In arthroscopy, the inside of a joint is inspected with a viewing instrument called an arthroscope. The procedure is most commonly used to inspect the inside of the knee joint and to treat disorders such as a damaged cartilage. It may be performed under general or local anaesthesia. The arthroscope is inserted into the joint through a small incision in the skin. Surgical instruments can then be passed down through the arthroscope or through other incisions. During the examination, the surgeon can remove or repair tissue, such as damaged cartilage, or shave the surface of the patella (kneecap).

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Chondromalacia, also referred to as patellofemoral pain syndrome, occurs when the cartilage surface of the back of the patella (kneecap) is damaged. The underlying cause of the condition is not known, but it can be triggered by strenuous exercise or repeated knee injuries. In teenagers, chondromalacia may be caused by increased weight-bearing on the knee joint during a growth spurt. The condition may also be associated with a misaligned or a recurrently dislocated patella or with muscle weakness in the upper leg.

What are the symptoms?

Symptoms vary in severity from person to person but may include:

- Pin in the knee when the leg is bent and straightened (such as when going up or down stairs).
- Stiffness after prolonged sitting.
- Crepitus (a crackling noise) during knee movement.

Chondromalacia usually occurs in only one knee, although the condition does sometimes develop in both knees.

What might be done?

Your doctor will examine your knee and press down on the patella to see if your symptoms worsen. He or she arrange for X-rays of the knee and back of the patella. In severe cases, arthroscopy (below) may be performed to examine the interior of the knee joint and remove damaged cartilage.

Your doctor may advise you to take a painkiller or a nonsteroidal anti-inflammatory drug and to apply ice packs for pain relief. He or she may also advise exercise to strengthen thigh and knee muscles and reduce stress on the knee joint. You may be advised to wear a knee support as a temporary measure. In rare cases, surgery is necessary to realign the patella.

What is the prognosis?

Chondromalacia often improves over time and most people are not disabled, although they may have mild recurrences of pain in the knee. Regular exercise to strengthen the muscles of the thigh and the ligaments around the knee will reduce the risk of developing osteoarthritis in later life.

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Pain and stiffness in a shoulder joint, severely restricting its movement, is known as frozen shoulder. The condition may be due to inflammation resulting from an injury to the shoulder region. Frozen shoulder can also sometimes occur if the shoulder is kept immobilized for a log period of time, such as following a stroke. However, in many cases, frozen shoulder develops for no apparent reason. The condition occurs most frequently in people over the age of 40 and is more common in women. People who have diabetes mellitus are more susceptible to the condition.

What are the symptoms?

The symptoms of frozen shoulder often begin gradually over a period of weeks or months. They may include:

- Pain in the shoulder, which is severe in the early stages of the condition and is often worse at night.
- With time, gradually decreasing pain but increasing stiffness and restricted joint movement.
- In severe cases, pain traveling down the arm to the elbow.

If you have pain in the shoulder that lasts for more than a few days, you should consult your doctor.

What may be done?

Your doctor will probably diagnoses frozen shoulder from the symptoms and an examination of your shoulder. A painkiller or nonsteroidal anti-imflammatory drug may be prescribed to relieve the discomfort and reduce in flammation.

If the pain persists or is severe, you may be given a corticosteroid drug by means of a direct injection into the shoulder joint. You may also be referred for physiotherapy. Despite these measures, your shoulder may remain stiff for up to 2 years.

Even when the stiffness has disappeared, recovery is usually slow and may take up to a further 6 months.

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In spondylolisthesis, a vertebra (bone of the spine) slides forwards to project over the vertebra below, distorting the spinal canal. Spondylolisthesis usually affects the vertebrae in the lower part of the back. The disorder may be caused by a deformity of the spine present from birth or a tress fracture due to overstretching, especially in people who take part in sports, such as cricketers and rowers. In elderly people, particularly women, spondylolisthesis may be the result of a joint disorder such as osteoarthritis. In rare cases, the condition is caused by a severe injury.

Many people with spondylolisthesis have no symptoms. However, sometimes pain an stiffness may be felt in the affected area of the spine. Pressure on the spinal roots of the sciatic nerve may lead to sciatica, a condition in which pain is felt in the lower back and travels down the leg.

A diagnosis of spondylolisthesis will need to be confirmed by X-ray. Procedures such as mri or CT scanning may also be needed to exclude other possible causes of back pain such as a prolapsed or herniated disc. Treatment may include wearing a support, such as a brace, and a course of physiotherapy, which helps to strengthen the muscles supporting the affected vertebrae. Rarely, surgery may be needed to fuse the affected vertebrae together.

Normal activity can often be resumed about 6 months after treatment.

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The shock-absorbing discs between the vertebrae (bones of the spine) consist of a strong, fibrous outer coat and soft, gelatinous core. A prolapsed disc occurs when the core pushes outwards, distorting the shape of the disc. If the outer coat ruptures, the condition is termed a herniated disc. When a disc prolapses or herniates, the surrounding tissues become inflamed and swollen. Then together with the disc, the tissues may press on a spinal nerve or the spinal cord, causing pain.

Although discs in the lower back are most often affected, herniation of the discs in the neck and rarely the upper back can occur. People between the age of 25 and 45 are most vulnerable to disc prolapse or herniation. The disorder is slightly more common in men.

What are the causes?

With age, the discs begin to dry out. They also become more vulnerable to prolapse or herniation as a result of the normal stresses of daily life and minor injuries. Sometimes, a disc is damaged by bending forwards or a sharp twisting movement, or by lifting a heavy object incorrectly.

What are the symptoms?

Symptoms of a prolapsed or herniated disc may develop gradually over a period of weeks or may appear suddenly. They may include:

- Dull pain in the affected area.
- Muscle spasm and stiffness around the affected area that makes movement difficult.

If the disc presses on a spinal nerve, you may also have the following symptoms:

- severe pain, tingling or numbness in a leg or if the neck is affected, in an arm.
- Weakness or restricted movement in the leg or arm.

The pain is frequently relieved by rest but may be made worse by sitting, coughing, sneezing, bending, or bowel movement.

What might be done?

Diagnosis is usually made from your symptoms and a physical examination. Your doctor may also arrange for you to have an X-ray, to rule out other causes of back pain, and MRI or CT scanning, which can locate the position of the prolapsed or herniated disc accurately.

Although the disc is permanently damaged, the pain usually improves over 6-8 weeks as the swelling subsides. Your doctor will probably suggest ways in which you can modify physical activities to avoid further stress on your back. He or she may also recommend painkillers and refer you for physiotherapy, which can reduce muscle spasms and speed recovery.

Rarely, pain may be relieved with traction, in which the spine is gently stretched with weights to create more space around a nerve and reduce pressure on it. Some people benefit from an epidural injection or a selective nerve root block, in which a local anesthetic, sometimes used in combination with a corticosteroid drug, is injected around the compressed nerve to decrease swelling. If the damaged disc is in the neck, a supportive collar may be helpful.

In a few cases, if bladder or bowel function is impaired due to pressure on a nerve or the spinal cord or if there is severe pain or muscle weakness, urgent surgery on the disc may be required.

MICRODISCECTOMY

Microdiscectomy is a surgical procedure used to treat a prolapsed or herniated disc pressing on a spinal nerve or the spinal cord. The protruding part of the disc is removed through an incision in the fibrous outer coat of the disc. The operation is performed under general anaesthesia and requires a brief stay in hospital.

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Lower back pain affects about 6 in 10 adults during the course of a year. More working days are lost due to back pain than to any other medical condition. In most cases, the pain lasts for only a week or so, but many people find that their problem recurs. In a minority of people, persistent lower back pain causes long-term disability.

Lower back pain is usually caused by minor damage to the ligaments and muscles in the back. The lower back is vulnerable to these problems because it supports most of the body’s weight and is under continual stress from movements such as bending and twisting. Less commonly, lower back pain may be a result of an underlying disorder such as a prolapsed or herniated disc in the spine.

What are the causes?

Lower back pain may come on suddenly (acute) or develop gradually over a period of weeks (chronic).

Acute back pain is often caused by a physical injury due to lifting heavy objects or to activities such as digging in the garden. The pain is commonly caused by a strained muscle or tendon. The injury may be aggravated by subsequent activity. In most cases, symptoms subside within 2-14 days.

Back pain that is more persistent may be improved by changing your posture, for example while sitting at a desk or driving a car. Pain may be aggravated by emotional stress and excessive muscle tension. Lower back pain may also occur during pregnancy, due both to changes in posture because of the extra weight of the baby and to softening of ligaments supporting the spine caused by hormonal changes.

Another cause of lower back pain is a prolapsed or herniated disc exerting pressure on a spinal nerve or the spinal cord. Back pain of this type may have a gradual or sudden onset and is accompanied by sciatica, in which severe shooting pain extends down the back of one or both legs.

Persistent lower back pain may be caused by joint disorders. In people over the age of 45, the most common joint problem is osteoarthritis, while in younger people the problem may be ankylosing spondilitis, which affects the joints of the spine. Less often, back pain results from bone disorders, such as Paget’s disease of the bone, or cancer that has spread to bone from a tumour elsewhere in the body.

In some cases, disorders affecting internal organs can lead to pain in the lower back. Examples include certain disorders of the female reproductive system, such as pelvic inflammatory disease, and of the urinary system, such as prostatitis.

What are the symptoms?

Pain in the lower back can take various forms. You may experience:

- Sharp pain localized to a small area of the back.
- More general, aching pain in the back and buttocks, which is made worse by sitting and relieved by standing.
- Back stiffness and pain on bending.
- Pain in the back that radiates to the buttock and leg, sometimes accompanied by numbness or tingling.

Back pain that is associated with weight loss or difficulty in controlling your bowel or bladder may be due to a serious underlying disorder.

What can I do?

In most cases, you should be able to treat lower back pain yourself by taking an over-the-counter painkiller. If the pain persist, additional relief may be provided by a heat pad or wrapped hot-water bottle and sometimes by ice placed against your back.

If the pain is severe, you may be more comfortable resting in bed, but you should not stay in bed for more than 2 days. Start moving around as soon s possible and gradually return to normal activities. If the pain worsens or is still too severe to allow you to move around after a few days, you should consult your doctor.

Once the pain has subsided, you can help to prevent recurrence if you pay attention to your posture, learn to lift correctly, and do regular exercises to strengthen the muscles of your back and make your spine more flexible.

What might be doctor do?

If you need to consult your doctor because of severe or persistent lower back pain, he or she will probably carry out a full physical examination to assess your posture, the range of movement in your spine, and any areas of local tenderness. Your reflexes, the strength of different leg muscles, and the sensation in your legs may also be tested to look for evidence of pressure on spinal nerves or the spine cord. A pelvic or rectal examination may be necessary if you have symptoms that are associated with the female reproductive organs or with the bowels.

You may have various blood tests and X-rays to look for underlying causes of the pain, such as joint inflammation or bone cancer. If there is evidence of pressure on the spinal cord or spinal nerves, MRI or CT scanning may be carried out to detect abnormalities that require additional treatment, such as a prolapsed or herniated disc.

Unless there is a serious underlying cause for your back pain, your doctor will probably advise you to continue taking a painkilling drug. You may be given physiotherapy to mobilize stiff and painful joints between the vertebrae. In some cases, an injection combining a local anaesthetic with a corticosteroid is given directly into areas of tenderness.

What is the prognosis?

Most episodes of lower back pain clear up without treatment, but the problem may recur. Improving posture and lifting techniques reduces the risk.

In a small number of people, lower back pain may be a long-standing condition, severely disrupting their work and social life and sometimes leading to depression. Effective pain control is essential in these cases, and maintaining physical activity, despite some pain, reduces disability. People who become depressed because of their condition will benefit from treatment with anti-depressants.

PREVENTING BACK PAIN

Most people have experienced back pain at some time in their lives, but in many cases the problem could have been avoided. Back pain may be due to poor posture, weak abdominal or back muscles, or sudden muscle strain. You can improve your posture by wearing comfortable shoes, by standing or sitting with your spine properly aligned, and by choosing an appropriate mattress for your bed. Regular exercises strengthen abdominal and back muscles, and losing excess weight will relieve stress on joints and muscles. Learning how to perform physical tasks safety, including how to lift and carry objects, can help to prevent back strain. Ask your doctor or physiotherapist to give you advice on posture, exercises, and diet.

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Septic arthritis is an infection in the synovial fluid or tissues of a joint, such as a hip or a knee. The condition is usually caused by bacteria that have entered the joint through a nearby open wound or have traveled through the bloodstream from an infection elsewhere in the body. For example, the bacteria that cause gonorrhoea may spread from the genital track through the bloodstream. The risk of developing septic arthritis is increased in people who have fitted with an artificial joint or who use intra-venous recreational drugs.

What are the symptoms?

The symptoms of septic arthritis usually appear suddenly and may include:

- Fever.
- Swelling, tenderness, redness and warmth around the affected joint.
- Severe pain and restricted movement of the affected joint.

If pus builds up in an infected area, the joint may be damaged permanently. If you develop the above symptoms, consult your doctor immediately.

What may be done?

Your doctor may arrange for you to have a sample of fluid taken from the affected joint. The fluid is analysed to look for evidence of infection and to try to establish its cause.

Septic arthritis caused by bacteria is initially treated with intravenous antibiotics for at least 4 weeks. Your doctor may then prescribe oral antibiotics for several weeks or months.

To help to relieve pain and inflammation, pus may be drained from the infected joint several times. Your doctor may also prescribe a nonsteroidal anti-inflammatory drug. You should rest the joint until the inflammation has completely subsided.

Gentle movement is allowed and is important later on to prevent the joint becoming stiffened by shrinkage (sự co rút) of the surrounding tissues. If the infected joint is an artificial joint, it may need to be replaced surgically with a new artificial joint to allow the infection clear up.

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In pseudo-gout, crystals of calcium pyrophosphate or similar chemicals are deposited in joints, causing attacks of pain and stiffness. Usually, a single joint is affected. The most common sites are the knee and wrist, but crystals may be deposited in any joint. Although the process of formation and deposition of the crystals may start earlier, symptoms are less common before the age of 60.

In most people, the cause of pseudo-gout in unknown, although attacks may be triggered by surgery, infection or injury. Pseudo-gout is often associated with other joint disorders, particularly osteoarthritis. Pseudo-gout may also be linked hyperparathyroidism (tăng năng tuyến cận giáp), a hormonal condition that leads to high blood levels of calcium or haemochromatosis (nhiễm sắc tố sắt), a disorder in which the body is overloaded with iron. Pseudo-gout is more common in women and may run in families.

What are the symptoms?

Symptoms are similar to those of gout. Attacks may cause:

- Severe pain, stiffness, swelling, and redness of the affected joint.
- Mild fever.

Some people have no pain between attacks, while others experience persistent pain and stiffness.

What might be done?

If your doctor suspects pseudo-gout, he or she may arrange for X-rays of the affected joint. You may also need joint aspiration, in which fluid is removed from a joint for analysis and to relieve swelling.

The symptoms of pseudo-gout may relieved by simply removing fluid from the affected joint. In severe cases, a corticosteroid drug may be injected directly into the joint during the same procedure. You may also need nonsteroidal anti-inflammatory drugs. Once treatment starts, symptoms usually clear up within 48 hours.

There is no cure for pseudo-gout, but if the underlying cause is treated many people lead normal lives. Physiotherapy can help to increase joint mobility and muscle strength.

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Gout causes sudden pain and inflammation, usually in a single joint. The base of the big toe is the most common site, but any joint may be affected. The disorder affects many more men than women. In women, gout rarely appears before the menopause.

What are the cause?

An attack of gout is usually caused by raised blood levels of uric acid (a waste product of the breakdown of cells and proteins). An excess of uric acid may be caused by the overproduction and/or decreased excretion of uric acid and may lead to uric acid crystals being deposited in a joint. The underlying cause of gout is unknown, but the condition, is often inherited. A few people with gout also develop kidney stones formed from excess uric acid.

Gout may occur spontaneously or be triggered by surgery, being over-weight, drinking alcohol, treatment with diuretics, or excess cell destruction associated with chemotherapy.

What are the symptoms?

The symptoms if gout usually flare up suddenly. They may include:

- Redness, tenderness, swelling and warmth around the affected area.
- Pain, which may be severe, in the affected joint or joints.
- Mild fever.

In long-standing gout, deposits of uric acid crystals, may collect in the earlobes and the soft tissues of the hands or feet, forming small lumps called tophi.

What might be done?

Your doctor may suspect that you have gout from your symptoms and arrange for blood tests to measure your uric acid levels. To confirm the diagnosis, he or she may arrange for you to have a joint aspiration (below), in which fluid is withdrawn from the affected joint and examined for uric acid crystals.

Gout may subside by itself after a few days. To reduce severe pain and inflammation, you may be treated with a nonsteroidal anti-inflammatory drug, the antigout drug colchicine, or with oral corticosteroids. If gout persists, your doctor may give you a corticosteroid injection directly into the affected joint.

If you have recurring gout, you may need lifelong treatment with preventive drugs such as allopurinol to reduce the production of uric acid or probenecid to increase the excretion of uric acid.

Your doctor may recommend that you reduce alcohol consumption and avoid foods such as liver. You may be able to reduce the frequency and severity of attacks by losing excess weight.

What is the prognosis?

Gout is painful and can disrupt normal activities, but attacks can be controlled with drugs and changes in lifestyle. Repeated attacks may damage the joint.


JOINT ASPIRATION

During joint aspiration, fluid is withdrawn from a swollen joint with a needle and syringe, possibly under local anaesthesia. The fluid is then examined to find the cause of the swelling. Joint aspiration may also be carried out to relieve swelling due to excess fluid and to diagnose or treat disorders such as gout, pseudogout, and rheumatioid arthritis.

Knee joint aspiration

You will be asked to keep your knee relaxed so that the needle can be inserted easily. The patella is held still while the needle is passed into the space under the patella and fluid is withdrawn.

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Reactive arthritis is usually a short-term disorder that develops after a bacteria; infection of the genital tract, such as chlamidial infection or non-gonococcal urethritis, or the intestinal track. Any of these infections may stimulate an abnormal immune respone that causes tissues in the joints, usually the knee or ankle, to become inflamed. If inflammation also affects the eyes or the genital tract, the condition is known as Reiter’s syndrome.

About 8 in 10 people who develop Reiter’s syndrome have a particular antigen (a substance capable of stimulating an immune response in the body). Known as HLA-B27. Although Reiter’s syndrome is induced by infection, it usually develops in people who have a genetic predis-position to it. The disorder may therefore run in families.

What are the symptoms?

Depending on the infection that has triggered reactive arthritis or Reiter’s syndrome, you may experience symptoms of a genital infection, such as pain on passing urine, or symptoms of gastroenteritis, such as diarrhoea. However, some people have no initial symptoms.

Both conditions develop 3-30 days after the initial infection has appeared. Symptoms may include:

- Painful, red, tender joints.
- Swelling about the joints.

Although the knees or ankles are most commonly affected, other joints may also be involved. If you have Reiter’s syndrome, you may also notice:

- Sore, red eyes.
- Pain on passing urine and a discharge from the penis or vagina.
Less commonly, complications such as mouth ulcers, inflammation of the penis, lower back pain, and skin lesions on the hands and feet may develop.

What may be done?

Your doctor may diagnose reactive arthritis or Reiter’s syndrome from your medical history and symptoms. He or she will probably take swabs from your urethra or cervix or collect a stool sample to try to establish the source of infection. Further tests may include a blood test to detect signs of inflammation and an X-ray to look for evidence of joint damage.

If you are still affected by a genital or intestinal infection, your doctor may prescribe oral antibiotics. To relieve pain in your joints, he or she may recommend a nonsteroidal anti-inflammatory drugs. If the pain is very severe and there is no infection present in the joint itself, you may be given a corticosteroid drug, injected directly into the joint.

What is the prognosis?

The symptoms usually last for less than 6 months, and most people recover fully from reactive arthritis or Reiter’s syndrome. People who are susceptible to Reiter’s syndrome can reduce the risk of recurrence by taking care with personal hygiene and practicing safe sex.

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In ankylosing spondylitis, persistent joint inflammation affects the sacroiliac jonts at the back of the pelvis and the vertebrae in particular. If the spine is severly diseased, new bone grows between the vertebrae, which eventually fuse together.

This form of arthritis is four times more common in men than in women. A variant of ankylosing spondylitis is associtated, in some cases, with the persistent skin disorder psoriasis or with inflammatory bowel disease, such as Crohn’s disease.

What are the cause?

The cause of ankylosing spondylitis is unknown, but about 9 in 10 affected people have a particular antigen (a substance that is capable of stimulating an immune response in the body) called HLA-B27 on the surface of most cells. This antigen is inherited, which helps to explain why ankylosing spondylitis runs in some families. Most people with HLA-B27 do not develop the condition, and a bacterial infection is thought to trigger ankylosing spondylitis in those who are predisposed.

What are the symptoms?

The symptoms of ankylosing spondylitis usually appear in late adolescence or early adulthood and develop gradually over a period of months or even years. Men are usually more severely affected. The main symtpoms include:

- Lower back pain, which may spread down into the buttocks and thighs.
- Lower back stiffness that may be worse in the morning and improves with exercise.
- Pain in other joints, such as the hips, kness and shoulders.
- Pain and tenderness in the heels.
- Tiredness, weight loss, and mild fever.

If left untreated, ankylosing spondylitis can distort the spine, resulting in a stooped posture. If the joints between the spine and the ribs are affected, expansion of the chest becomes restricted. In some people, ankylosing spondylitis causes inflammation or damage to tissues in areas other than the joints, such as the eyes.

How is it diagnosed?

Your doctor may suspect that you have ankylosing spondylitis from the pattern of your symptoms. He or she will perform a physical examination and may arrange for an X-ray to look for evidence of fusion in the joints of the pelvis and the spine. Your doctor may also arrange for you to have blood tests to measure the level of inflammation and look for the HLA-B27 antigen.

What is the treatment?

Treatment if ankylosing pondylitis is aimed at relieving the symptoms and preventing the development of spinal deformity. Your doctor may prescribe a nonsteroidal antififlammatory drug to control pain and inflammation. He or she mau also refer you for physiotherapy, which may include breathing exercise and daily exercises to help to improve your posture, strengthen the back muscles, and prevent deformities of the spine. You may also benefit from regular physical activity, such as swimming, which may help to relieve pain an stiffness. If a joint such as a hip is affected, you may eventually need to have it replaced surgically.

If your mobility is severely reduced, you may need occupational therapy. The therapist may suggest that you use specially designed equipment and furniture to make your life easier.

What is the prognosis?

Although the condition is not curable, most people with ankylosing spondylitis are only mildly affected, causing minium disruption of their everyday lives. In many cases, early treatment and regular exercise help to relieve pain and stiffness of the back and prevent deformity of the spine. However, about 1 in 20 people who develop ankylosing spondylitis may eventually become disabled and have difficulty in carrying out many routine activities. If disability is due to an affected joint, a replacement may be carried out.

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In rheumatoid arthritis, the affected joints become stiff and swollen as a result of inflammation of the synovial membrance, which encloses each joint. If the inflammation persists, it may damage both the ends of the bones and the cartilage that cover them. Tendons and ligaments, which support the joints, may also become worn and slack, and deformity of the joints occurs.

In most cases, rheumatoid arthritis affects several joints. The disorder usually appears first in the small joints of the hands and feet but may develop in any joints. Rheumatoid arthritis usually tends to appear in similar areas on both sides of the body. Tissues in other parts of the body, such as the eyes, the lungs, the membranous sac around the heart, and blood vessels, may also be affected.

Rheumatoid arthritis is a long-term disease and usually recurs in episodes lasting for several weeks or months. Some people remain free of symptoms between episodes. The disorder affects about 1 in 100 people and is three times more common in women than in men. A similar but distinct arthritis disorder can develop in children.

Rheumatoid arthritis is an autoimmune disorder in which the body produces antibodies that attack the synovial membrane and, in some cases, other body tissues.

What are the symptoms?

Rheumatoid arthritis usually develops slowly, although sometimes the onset of the inflammation can be abrupt. General symptoms associated with the condition may include tiredness, poor appetite, and lost of weight. Specific symptoms may include:

- Painfull, swollen joints that are stiff on waking in the morning.
- Painless, small bumps (nodules) on areas of pressure, such as the elbows. Since the condition can be both painful and debilitating, depression is common in people with rheumatoid arthritis. In women, the symptoms of rheumatoid arthritis may be improve during pregnancy but may then flare up again after the baby is born.

Are there complications?

Over time, thinning of the bones and greater susceptibility to fractures may develop in people with rheumatoid arthritis. This results partly from the disease itself and partly from reduced mobility.

The general symptoms of rheumatoid arthritis are partly due to anaemia, cause by a failure of the bone marrow to manufacture enough new red blood cells.

Bursitis may develop, in which one or more of the fluid-filled sacs around a joint become inflamed. Swelling that compresses the median nerve in the wrist may lead to a tingling feeling and pain in the fingers. Spasm or narrowing of the walls of the arteries that supply the fingers and toes results in Raynaud’s phenomenon, in which the digits become pale and painful on exposure to cold.

A less common complication is when the spleen and the lymph nodes enlarge. Inflammation may affect the membranous sac that surrounds the heart and also the lungs. In some cases, there may be inflammation of the white of the eye, or the eyes may become very dry.

How is it diagnosed?

The diagnosis is usually based on your medical history and a physical examination. Your doctor may arrange for blood tests to check for the presence of an antibody known as rheumatoid factor, which is usually associated with rheumatoid arthritis. You may also have blood tests to measure the severity of the inflammation. X-rays of the affected joints may be taken to assess the degree of damage.

What is the treatment?

There is no cure for rheumatoid arthritis. The aim of treatment is to control symptoms and reduce further joint, damage by slowing the progression of the disease. Various types of drug are available, and your doctor’s recommendation will depend on the severity and progression of the disease, your age, and your general health.

If your symptoms are usually mild, your doctor may simply prescribe a nonsteroidal anti-inflammatiory drug. However, if your symptoms are severe, he or she may prescribe drugs that slow the progression of the disease, which should limit permanent joint damage. These drugs may have to be taken for several months before the full benefits are felt. An antirheumatic such as sulfasalazine or hydroxychloroquine may be given first. If your symptoms persist, the doctor may prescribe a drug such as gold, penicillamine, methotrexate, or ciclosporin. Since these drugs can sometimes cause serious side effects, which include kidney damage and blood disorders, the doctor will closely monitor your condition.

Your doctor may recommend that you use a splint or brace co support a particularly painful joint and to slow down the development of deformities. Taking gentle, regular exercise may help to keep your joints flexible and prevent supporting muscles from weakening. Physiotherapy may be given to improve your joint mobility and help to increase muscle strength. Hydro-therapy and heat or ice treatments may provide pain relief.

An intensely painful joint may be eased if your doctor injects it with a corticosteroid drug. If a joint is severely damaged, your doctor may suggest that you have surgery to replace the damaged joint with an artificial one.

What is the prognosis?

Many people with rheumaitoid arthritis are able to lead a normal life, but lifelong drug treatment may be needed to control the symptoms. About 1 in 10 people becomes severely disabled as repeated attacks destroy the joints. To monitor progression of the disease and your response to treatment, regular blood tests will be needed. Sometimes, the attacks gradually cease, and the disease is said to have burned itself out, but some permanent disability may remain.

JOINT REPLACEMENT

Joints that have been severely damaged by a disorder such as arthritis or by an injury may be surgically replaced with artifical joints made of metal, ceramic, or plastic. The joints in the body that are most commonly replaced are the hips, knees, and shoulders. During the operation, the ends of damaged bones are removed and the artificial components are fixed in place. The operation usually relieves pain and increases the range of movement in the affected joint.

Hip replacement

The most commonly replaced joint in the body is the hip. During the operation, both the pelvic socket and the head of the femur (thighbone), which fits into the socket, are replaced. The operation is carried out under general anaesthesia and involves a short stay in hospital.

Other joints

Many different types of joint in the body can be replaced, from tiny finger joints to large joints such as the knees.

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Cervical spondylosis is osteoarthritis affecting the upper spine. In this disorder, the vertebrae (bone of the spine) and the discs of cartilage between them begin to show signs of disease. The bones thicken, and bony outgrowths called osteophytes develop on the vertebrae. Inflamed joints and osteophytes may press on spinal nerves or compress blood vessels in the neck.

The conditions is increasingly common over the age of 45 and affects more men than women. In rarely, it is triggered by injury and affects younger people.

What are the symptoms?

Many people do not have symptoms or may develop only very mild symptoms. When symptoms do become apparent, they may include:

- Restricted neck movement that may be painful.
- Pain at the back of the head.
- Aching or shooting pain that travels from the shoulders to the hands.
- Numbness, tingling, and muscle weakness in the hands and arms.

Sometimes, if the head is moved too quickly, the deformities in the upper spine may suddenly compress blood vessels that carry out blood to the brain, resulting in dizziness, unsteadiness, or double vision.

In rare cases, joints that have severely degenerated may put prolonged pressure on the spinal cord, causing tingling and muscle weakness or paralysis in the legs or, sometimes difficulty in controlling bladder or bowel function.

How is it diagnosed?

Some people do not have symptoms and cervical spondylosis may be recognized only when an X-ray is taken for another reason. However, if you experience neck pain or dizziness, consult your doctor, who may arrange for X-rays to look for signs of cervical spondylosis. If your doctor thinks that your symptoms may not be due solely to cervical spondylosis, he or she may arrange further tests to look for other causes, such as prolapsed or herniated disc. You may also undergo nerve conduction studies and EMG to assess nerve activity in your arms and hands. CT scanning or MRI may also be carried out to see whether there have been any changes affecting the bones of the spine, the discs of cartilage between them, or the tissues around them.

What is the treatment?

Changes in the spine are not inevitably progressive. There may be little deterioration for many years, and sometimes symptoms improve. To relieve symptoms in mild cases, your doctor may recommend painkillers or prescribe nonsteroidal anti-inflammation drugs. Once the initial pain has been relieved, the doctor may also suggest some simple exercises to maintain mobility and increase the strength of muscles in your neck.

If cervical spondylosis had damaged a nerve, surgery may be recommended to prevent the symptoms from getting worse. In this operation, the surgeon widens the natural opening between the vertebrae through which the nerve passes when it branches off the spinal cord. In a few rare cases, surgery may also be carried out to stabilize the spine by fusing together affected vertebrae.

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In a joint affected by osteoarthritis, the protective cartilage found at the ends of bones is worn away. As the condition develops, the bone around the affected joint thickens, and bony growths called osteophytes form. If the synovial tissue that lines the joint capsule becomes inflamed, fluid accumulate within the joint. These changes cause pain, swelling, and stiffness of the joints, reducing their mobility.

Osteoarthritis is most common in weight-bearing joints, such as the knees and hips. However, the hands, feet, and shoulders may also be affected, as may the bones of the neck. Nearly everyone has developed a degree of osteoarthritis by the age of 70, but only some people have symptoms. Women are more commonly affected by osteoarthritis than men and their symptoms are more severe. This form of arthritis sometimes develops in younger people, particularly in those who have had joint injuries.

What are the causes?

There is often no obvious cause for the onset of osteoarthritis, but there are known factors that may increase the risk of developing the disorder. Wear occurs most often in joints that have been damaged by repeated minor injuries. For example, the pressure that ballet dancers exert on their feet makes tem susceptible to developing osteoarthritis of the ankle. Osteoarthritis is also common in former athletes.

Damage to a joint early in life may lead to osteoarthritis later on. Excessive weight can also increase a person’s risk of developing the condition because of the extra stress it places on the joints. Another risk factor is damage to cartilage caused by another joint disorder, such as septic arthritis. Finally, if a close member of your family has osteoarthtitis you are more likely to develop the condition yourself.

What are the symptoms?

Initially, the symptoms are mild, but they may slowly get worse. Often only one or two joints are badly affected, but sometime osteoarthritis is more widespread. The symptoms may include:

- Pain and tenderness that worsen with activity and are relieved by rest.
- Swelling around the joint.
- Stiffness lasting a short time after a period of inactivity.
- Restricted joint movement.
- Enlarged, distorted finger joints if the hand are affected.
- Crackling noise (called crepitus) on moving the affected joint.

Referred pain, which is felt in areas remote from the site of damage but on the same nerve pathway as the affected joint, may develop. For example, an arthritic hip may cause referred pain in the knee. The pain may become worse towards the end of the day.

If movement is severely restricted, an affected person may be confined to the home. Lack of mobility may lead to weakness and wasting of muscles and sometimes to weight gain.

What might the doctor do?

Your doctor may suspect that you have osteoarthritis from you symptoms, a history of joint problems, and a physical examination. It is often possible to confirm a diagnosis of osteoarthritis, while at the same time ruling out other types of arthritis, by means of blood tests and X-rays.

Osteoarthritis cannot be cured, but with treatment most symptoms can be relieved. Your doctor may recommend that you take paracetamol or a nonsteroidal anti-inflammatory drug. If you experience a severe flare-up of pain and inflammation in a single joint, your doctor may inject a corticosteroid drug directly into the affected joint to reduce swelling and relive pain.

To improve muscle function around joints affected by osteoarthritis, your doctor may refer you for physiotherapy. If osteoarthritis is very severe, surgery may be necessary to repair or replace an affected joint.

What can in do?

If you have mild osteoarthritis, you may be able to participate in everyday activities by adapting our lifestyle. If you are overweight, ask your doctor for dietary advice to enable you to lose weight and reduce further wear on your joints. If possible, take gentle exercise to help to lose weight, maintain muscle tone, and delay the progression of the disease. Supportive shoes with rubber soles will absorb shock and reduce further wear. If you have a painful hip or knee, use a walking stick for support. Massage, warm baths, or a heat pad may ease joint pain and increase mobility.

Living with arthtitis

If you have long-term arthritis, you may be able to manage your symptoms so that you can maintain an active lifestyle. Consult your doctor about pain relief and keeping joints mobile. Organizations concerned with arthritis can also provide you with valuable information and support.

Mobility

Gentle, regular exercise helps to relieve stiffness and improve mobility. Physical activity also helps to strengthen the muscles that support joints. However, if exercise causes swelling or pain, stop the activity and consult your doctor.

Pain relief

To relieve severe joint pain, apply heat or cold to the affected area. Heat increases blood flow, and cold helps to reduce swelling. Both decrease sensitivity to pain.

Specialized equipment

Your doctor or a physiotherapist may be able to suggest specially adapted pieces of equipment to help you with household tasks. The equipment may have particular features, such as handless that are easy to grip or extending arms to help you reach objects without bending down.

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The term arthritis covers a group of inflammatory and degenerative conditions that cause stiffness, swelling, and pain in the joints. Arthritis may also be linked with disorders such as psorasis and Crohn’s disease.

What are the types?

There are several different types of arthritis, each having different characteristics. The most common form is osteoarthritis, which most often involves the knees, hips, and hands and usually affects middle-aged and older people. Cervical spondylosis is a form of osteoarthritis that affects the joints in the neck.

Rheumatoid arthritis is a damaging condition that cause inflammation in the joints and in other body tissues, such as the membranous heart covering, lungs, and eyes. The disorder has different effects in children.

Ankylosing spondylitis is an other persistent form of arthritis that initially affects the spine and the joints between the base of the spine and the pelvis. Other tissues, such as the eyes, may also be affected. The disorder may eventually cause the vertebrae (bones of the spine) to fuse together.

Reactive arthritis typically develops in susceptible people after they have had an infection, most commonly of the genital tract or intestines. Reactive arthritis most often causes inflammation in an ankle or a knee.

Both gout and pseudogout are types of arthritis in which crystals are deposited in a joint, resulting in swelling and pain.

Septic arthritis is a relatively rare condition that can develop when infection enters a joint either through a wound or from the bloodstream.

Treatment depends on the type of arthritis. Painkillers, such as paracetamol, and nonsteroidal anti-inflammatoty drugs may relieve symptoms. Physiotherapy may keep joints mobile. Severely damaged joints may be replaced surgically.

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Infection of the testis and epididymis (the coiled tube that stores and transports sperm away from the testis) can lead to inflammation called epididymo-orchitis. This condition usually causes painful swelling of one testis and may be accompanied by fever.

What are the causes?

Epididymo-orchitis is usually caused by bacteria that have traveled from the urinary tract along the spermatic duct (vas deferens) to the epididymis. In men under 35 years of age, a common cause of the condition is a sexually transmitted infection (STI), such as nongonococcal urethritis. In older men, a urinary tract infection, prostatitis, or recently having had a catheter inserted to drain urine are possible causes. In rare cases, an infection that is transmitted through the bloodstream, such as tuberculosis, leads to the development of epididymo-orchitis.

In boys and young men, the most common cause of the condition used to be inflammation due to mumps, but this has become less common since the introduction of immunization.

What are the symptoms?

The symptoms of epididymo-orchitis usually develop over a period of several hours and may include:
- Swelling, redness, and tenderness of the scrotum on the affected side.
- In severe cases, extreme pain in the scrotum, with fever and chills.

You may also have some symptoms of the underlying disorder, such as painful and frequent passage of urine in the case of a urinary tract infection.

The symptoms of epididymo-orchitis are similar to those of a more serious condition called torsion of the testis (right). For this reason, you should consult your doctor immediately if you have any of the symptoms listed above.

What may be done?

Your doctor will ask you to provide a urine sample to be tested for infection. If the doctor suspects an STI, he or she will take a swab from your urethra (the tube from the bladder to the outside of the body) to check for infection. If the diagnosis is unclear, you will need to go to hospital as an emergency for tests to rule out torsion of the testis. In some cases, exploratory surgery is necessary.

Your doctor will probably prescribe antibiotics unless the inflammation is caused by infection with the mumps virus, in which case antibiotics are ineffective. You may be advised to rest in bed and drink plenty of fluids. Taking painkillers may help to ease the discomfort, and using an ice pack may reduce the swelling and pain in the scrotum. An athletic support can be worn to support the scrotum.

Pain is usually relieved in 1-2 days, but the swelling of the scrotum may take several weeks to subside.

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Pelvic inflammatory disease (PID) is a common cause of pain in the pelvic region in women. In this condition, some of the female reproductive organs become inflamed, usually as a result of an infection. Young and sexually active women are most likely to be affected. PID may have no obvious symptoms, and some women are unaware that they have had the condition until, years later, they are investigated for infertility.

PID is usually caused by a sexually transmitted infection (STI), such as gonorrhoea or chlarmydial infection. PID may also be caused by an infection developing after a termination of pregnancy or after childbirth. In rare cases, tuberculosis can develop in the pelvis.

The infection spreads upwards from the vagina to the uterus and fallopian tube. The ovaries may also be affected. An intra-uterine contraceptive device (IUD)makes this spread of infection more likely. If you think you may have an infection, tests will usually be performed so that you can be treated before PID develops. When PID is discovered during investigations for infertility, the original cause may remain unknown.

What are the symptoms?

PID may have no obvious symptoms, especially when caused by Chlamydia. If there are symptoms, they may include:

- Pain in the pelvic region.
- Fever.
- An abnormal vaginal discharge.
- Heavy or prolonged periods.
- Pain during sexual intercourse.
- Tiredness.

If PID develops suddenly, you may have severe pain, nausea, and vomiting, and urgent hospital attention is required.

If the condition is not treated, the fallopian tubes may be damaged. The infection may also spread to other organs in the pelvis and the abdomen.

What might be done?

If your doctor suspects that you have PID, he or she will carry out a pelvic examination. Swabs may be taken from both the cervix and the vagina to identify the organisms causing the infection. Ultrasound scanning of the pelvis may also be performed. If you have severe symptoms, you will be admitted to hospital, and a laparoscopy may be performed to view the abdominal and pelvic cavities.

Your doctor will probably prescribe antibiotics, which will be given intravenously if you are in hospital. You may also be given painkillers.

You should not have sexual intercourse until your recovery is complete. Your sexual partner should have tests to look for sexually transmitted infections and should be treated (if necessary to prevent a reinfection). If you use an IUD, you may be advised to change to a different method of contraception.

If PID is detected and treated early, you should make a complete recovery. If PID is not treated, damage to the fallopian tubes can increase the risk of having an ectopic pregnancy or may lead to infertility.

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Normally, low levels of male sex hormones are present in females and are produced by the adrenal glands and the ovaries. However, if the production of these hormones increases significantly, various male characteristics begin to develop, a condition called virilization.

Virilization most commonly occurs in adulthood, causing symptoms such as deepening of the voice, excessive hair growth on the face and body known as hirsutism, and thinning of the hair on the temples and crown. These symptoms often cause psychological distress. Rarely, the condition is present at birth, virilization is usually due to a genetic disorder that causes abnormal hormones levels.

What are the causes?

When virilization develops later in life, the possible causes induce abnormalities of the ovaries, such as certain types of ovarian cysts, cancer of the ovary, and polycystic ovary syndrome. Hormone levels can also be increased by adrenal tumours and the use of certain male hormone supplements by athletes.

What are the symptoms?

Symptoms appear gradually as male sex hormone levels rise. They include:

- Excessive growth of hair on the face and body.
- Less regular or absent menstruation.
- Reduction in breast size or in rare cases failure of the breasts to develop.
- Enlargement of the clitoris.
- Irreversible enlargement of the larynx (Adam’s apple), causing the voice to become deeper.
- Thinning of the hair around the temples and crown.

The hormonal imbalance may lead to increased muscles development, producing a male body shape.

What may be done?

Your doctor will examine you and may arrange tests to determine the cause of your symptoms. These tests include blood tests to measure hormone levels, MRI or CT scanning to look for an adrenal tumour, and ultra-sound scanning to check the ovaries. Treatment of the cause, such as removal of a tumour, should reverse some of the changes. If no cause is found, oral contraceptives may be given to suppress hormone production by the ovaries and reduce male sex hormone levels. You may be given advice on how to manage excessive hair, perhaps by using electrolysis or waxing. Counseling is often helpful.

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