Category Archives for "Blogs"

August 13, 2020

Droitwich Knee Clinic Functional Restoration Program

Mr. Kirti Moholkar, Consultant Knee and Shoulder Surgeon

DKC Functional rehabilitation program (BPC-FRP) is a community-based pathway to help patients who are riddled with chronic pain (Knee, Back, or other musculoskeletal issues), reduced function, poor quality of life and weight management issues. It is a patient-centered and multidisciplinary program based on patient-reported outcome measures which has been put together by a team of health personnel comprising of a Surgeon (s), Senior Physiotherapist (s), Dietician, Personal trainer, Pain management consultant and a psychologist. The DKC believes that their FRP has a Bio-Ortho-Socio-Psychological approach to help patients caught in a complex issue in their One-Stop Clinic.

Knee pain after injury

DKC-FRP Helps patients to achieve the following

  • Complex problem addressed by a multidisciplinary team
  • Reduce chronic pain
  • Improve mobility
  • Reduce stress
  • Minimise work related absence
  • Reduce weight

Reason for DKC-FRP

  • Individual patient needs
  • Differing patient pain threshold
  • Varying activities of daily living

The DKC-FRP has been put together to treat patients on a private basis in the clinic and the pathway starts with a consultation at the clinic. DKC-FRP was started by Mr. Moholkar for knee pain sufferers but has now been expanded to include most of the other commonly seen MSK conditions including back pain patients. The program lasts for 6-10 weeks and is mainly based on a 1:1 consultation and the clinic is devising some group sessions for NHS patients. Currently we cannot provide this service to NHS patients.

Who is the FRP suitable for

  • Chronic knee pain
  • Chronic back pain
  • Fibromyalgia
  • Chronic pain

How is referral arranged?

Ideally, a referral to the DKC from your GP or a physiotherapist will be suitable on a private/insured or a self-pay. If patients like to refer themselves, the clinic will have the responsibility to write to your GP to involve their help in treating you.

Why does it take 6-10 weeks?

Anterior Knee Pain in a young women

FRP is a complex and multidisciplinary pathway that needs partnership from the care providers and the patients. Understanding of the individual patient’s problems and multidisciplinary team basis is time-consuming and following an initial consultation, usually with a physiotherapist kick starts the process. The Patient is then placed on a DKC-FRP pathway and the second consultation in the second week is held to discuss the protocol and modalities of options. It is the patient’s responsibility to participate in the recommended routine as dropouts in the middle of the treatment will not result in successful results

Patient Reported Outcome Measures

The DKC Ethos is “Keen on Evidence and Passionate about outcomes”. The DKC-FRP will be gauged by the following outcome measures

-EQ5D

-VAS Scores

-BMI

– Return to work statistics including absence from work days since start of the program

Modalities involved in DKC-FRP

Consultations: This occurs at the Droitwich Knee Clinic

Physiotherapy: The clinic has its own physiotherapy and gym facility. The clinic also has relationship with local physiotherapists and gymnasiums to provide this facility

Dietician: The clinic has access to a private dietician who will contribute towards planning a bespoke pathway.

Surgeons: We mostly get patients assessed by a physiotherapist but the surgeons are available on a standby basis and consultation can be arranged to seek expert help as and when required

Pain Management Consultant: The Droitwich Knee Clinic has access to a pain management consultant who is available for consultation

Clinical psychologist: Psychological help is available as and when required

Specialist Personal Trainer: The Droitwich Knee Clinic works with a local specialist personal trainer to provide help in a gymnasium setting when required.

August 13, 2020

Conditions Causing Shoulder Pain

Mr. Kirti Moholkar, Knee and Shoulder Surgeon

One of the common and painful shoulder condition seen in primary care is subacromial impingement (and related conditions).  Impingement refers to a condition where the head of the humerus with the surrounding bursa and tendon is pinched under the acromion. This condition results due to curved or hooked acromion which reduces the free space for the tendon/bursa to glide. Impingement ranges from mild pain on overhead activities to pain that can affect daily activities and work.  Degenerative tendon/rotator cuff tears are commonly seen beyond 45 years of age and in patients with long-standing impingement. Impingement can sometimes cause extreme pain pushing the shoulder into a frozen shoulder mode which results in a stiff and painful shoulder forcing patients towards surgery.

Man Suffering With Frozen Shoulder

It is very important to diagnose and treat these conditions in their infancy. Examination of the shoulder, range of motion and impingement tests are diagnostic of this condition. Physiotherapy and steroid injection in early stages are of diagnostic and therapeutic value. Mild impingement related conditions may not be curable following steroid injection and physiotherapy however if the pain completely subsides and comes back again, it vital to assess the state of the tendons. Ultrasound scan/MRI scans are recommended. The old practice of multiple steroid injections on a six weekly interval is a thing of the past.  In the author’s opinion one or maximum 2 injections to establish the diagnosis and provide some help with reference to physiotherapy is recommended. Steroid injection as a time buying tactic is not practised in modern shoulder surgery practice.

Man suffering from neck or shoulder pain

If conservative line of management fails to relieve the symptoms, timely referral is recommended. With advanced arthroscopic techniques, impingement related surgery or sub acromial decompression is an operation which is carried out as a day case procedure. Pain usually subsides within 1-2 weeks and 95% of patients are doing most of the daily activities by 4-6 weeks. If tendons are torn, the recovery takes a few weeks longer but with enhanced recovery and double row repair techniques, 85 to 90% patients are back to their daily activities within two months. Physiotherapy in the postoperative phase is immensely important (first 3-6 weeks) which decides the outcome of the operation.

Young man suffering from pain in shoulder and AC joint

Tendon tear in elderly patients is a challenging and interesting area to treat.  Tendon tears in asymptomatic shoulders are treated conservatively. Painful shoulders with tendon damage detected early (before infiltration of the muscles with fat) can be treated quite successfully with surgery. Tendon repairs and superior capsular reconstruction provide good results in elderly patients without arthritis

Doctor Examining Patient With Shoulder stiffness

Arthroscopic shoulder surgery- Kirti Moholkar, Knee and Shoulder Surgeon

Modern arthroscopic shoulder techniques have massively changed the results of shoulder conditions. Most of the shoulder problems are now dealt with arthroscopic modalities thereby reducing the morbidity and improving outcomes.  Shoulder surgeons finish their training by arthroscopic fellowships and bring their skill set to their patients and local communities.

Diagnostic shoulder operations are not indicated any more due to modern investigations when required by means of x-ray, ultrasound and MRI scans. Intra-articular shoulder conditions may need contrast injection followed by MRI scans referred as MRI Arthrogram.

Sub-acromial decompression is a simple operation which usually takes 20 minutes and requires assessment of the sub-acromial space to shave the hooked or curved part of the acromion which causes impingement of the tendons.

Open Rotator cuff tendons repair is quite rarely seen these days in modern shoulder practice.  Morbidity as well as a recovery time and outcomes are significantly improved by minimally invasive techniques. The author uses arthroscopic enhanced recovery techniques by means of double row repair of tendons which allows shoulder rehabilitation to start as early as one week after operation. Arm sling is retained for 1-3 weeks and physiotherapy is initiated soon based upon the state of the tendons at the time of surgery.

Acromioclavicular joint arthritis is commonly seen in patients who do regular overhead activities like window cleaners. Injection is diagnostic and operation is required in resistant cases. Arthroscopic procedure (excision of lateral end of clavicle) is done to excise about 1 -1.5 cm of the lateral end of the clavicle which reduces pain.

Shoulder stabilisation is an operation to reconstruct the soft tissue structures in the anterior capsular region of the Gleno-humeral joint. Bankarts tear or meniscal tear of the shoulder results due to significant trauma. Traumatic instability is successfully treated by arthroscopic stabilisation operation. Failure rate of arthroscopic shoulder stabilisation has reduced significantly in modern arthroscopic techniques. Multidirectional instability is treated by physiotherapy.

SLAP or Superior Lateral Anterior Posterior meniscal lesions result due to trauma and are detected by MRI Arthrograms rather than plain MRI. These conditions are usually seen in young patients and surgery is the treatment of choice in symptomatic conditions. Rehabilitation is usually slow but timely exercises are rewarding.

August 13, 2020

Anterior Cruciate Ligament Injury Prevention Program

‘You should be fit to play sport – not play sport to get fit’ Lesley Hall

No one wants to be out of their sport due to injury however, certain activities do carry an increased risk. Sports which involve contact, pivoting, jumping and cutting movements are often linked with serious lower limb injuries particularly around the knee and ankle ligaments. You may be aware that historically, cruciate ligament damage at the knee, was a career ending injury for many professional footballers; thankfully, with advances in knowledge and treatment this is no longer the case, but it is nevertheless, a serious injury which can mean a lengthy absence and failure to return to the same level.

In recent years there have been a significant number of studies showing that specific focus on certain aspects of training can directly reduce the incidence of these injuries. Most of the studies focused on reduction of ACL injuries, particularly in women, who inherently have an increased risk compared to men. Interestingly, studies found a decrease in all lower limb injuries, and programmes have now been tailored across various sports for both men and women, boys and girls.

The basic principle of any injury prevention scheme, is to ensure that adequate training encompasses the following key elements:

  1. Flexibility – optimise joint mobility and muscle length.
  2. Strength – It is imperative that the individual has the strength to participate in the relevant sport for the relevant time – lack of adequate strength leads to increased vulnerability to injury.
  3. Good technique during exercise and skills training will reduce vulnerability. Individuals need to have body awareness and work with coaches, teachers and trainers to develop this. The classic example of this is jump landing technique which is frequently a contributory issue in sports such as basketball, handball, football and netball.
  4. Incorporate rebound (plyometric) activities in the training programme.
  5. Increase speed and agility (proprioception) with appropriate training.

Example:                             Control of jump landing

DSC00992
Poor position
DSC00989
Ideal position

                     

Note: feet pointing forwards, hip distance apart (the outside of the thighs are parallel). Softly flexed knees bending directly over the 2nd toe.

   Depth of bend on landing

DSC00991
Poor
DSC00990
Good

                          

    Soft landing on flexed hips and knees.

Much of the original work in this area was carried out on female soccer players in L.A. – see the ‘PEP’ programme (prevent injury, enhance performance), developed by the Santa Monica Orthopaedic and Sports Medicine Group. FIFA have developed the 11+ programme for young footballers. Both of these suggest a warm up programme done a few times per week, prior to training, which incorporates all of the above elements.

In recent years many more studies have replicated these results across various sports and such programmes are becoming an integral part, particularly of youth, training.

With regards to non professional or individual sportsmen and women, there may not be this help readily available and therefore it is up to you to find relevant information.

Here are some tips and examples you might like to incorporate in a regular training programme:

  1. Always gently warm up to get your blood flowing to your muscles and joints, before training or playing.
  • Flexibility is important to enable you to move freely and reduce the risk of stresses and strains – or tears, of tight structures. Don’t forget calves, quads, hamstrings, hip flexors, adductors, glutes and trunk. Do not stretch cold – after warm up and/or at the end of the exercise.
  • Strength – Your muscles control and protect your joints. Maintain adequate strength for your sport and always concentrate on getting this back before competing after a   holiday or lay off (close season!!!!!) – pre-season training is for this preparation.

Squats, lunges, steps, walking lunges, etc are all appropriate but good technique is imperative.

                                                      

Squats
Split squats (step lunges)
  • Core strength – pay special attention to this. Bridging, plank etc, again with good technique.
  • Balance, speed and agility – Practice controlled movements/skills balancing on one leg, fast feet activities and change of direction activities – initially steady and controlled and gradually increasing speed and difficulty.
  • Plyometric – rebound and jump training – think about landing technique –  hips, knees and ankles in line and soft landing with flexed hips and knees.

As you can see, any training programme must contain multiple elements to give all round balanced fitness and this will minimise the risk of serious injury.