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By: N. Cole, M.B. B.A.O., M.B.B.Ch., Ph.D.
Associate Professor, East Tennessee State University James H. Quillen College of Medicine
Knee soreness pain after anterior cruciate ligament recon- after surgery is more commonly the complaint structive surgery diabetes mellitus type 2 as complication of obesity generic metformin 850mg without a prescription. This pain is often vague and can- discussions will include incidence and possible not be specifically localized with one finger diabetes type 1 and alcohol cheap metformin 850 mg overnight delivery. Prevention of anterior knee pain will patient blood sugar keeps dropping low purchase metformin 850 mg without a prescription, when asked to point to where it hurts, be addressed, including preoperative, intraop- will often sweep his fingers along both sides of erative, and postoperative concerns. Finally, the patellar tendon, from the sides of the patella treatment options will be offered. Often, the patient will think practice in our clinic to evaluate patients care- of this as “kneecap” symptoms. A review of the literature offers many possible fac- Through the course of the chapter, we will inter- tors leading to anterior knee pain in patients who ject our findings where appropriate in an effort have not had surgery. These include malalign- to shed light on this complicated subject. A knee that functions well until a of anterior knee pain. It is defined as the angle created believe that this is a completely different entity by drawing lines from the anterior superior iliac from the anterior knee pain that we are discussing spine to the middle of the patella to the tibia in this chapter, it should be included in the differ- tubercle. The average Q-angle is 10 to 15 degrees ential diagnosis when an ipsilateral bone-patellar with knee extended. An increased Q-angle theo- tendon-bone autograft technique is utilized. Some retically places more stress on the lateral portion of our patients who have undergone the contralat- of the patella as the knee is flexed as the contact eral graft procedure have complained of soreness area decreases. This may result in tilting, sublux- in the graft-donor knee after completing a few ation, or even frank dislocation. The soreness in is most common especially in women and may this setting is simply overuse-related patella ten- cause poor patella tracking and excess wear. We reached this conclusion by realizing Some surgeons will perform a lateral retinacular that the graft-donor knee does not share many of release in conjunction with anterior cruciate lig- the same concerns as the injured knee, which ament reconstruction if tilting of the patella is therefore excludes many possible sources of pain. Because patella tilt is usually asympto- Assuming the graft-donor leg is normal (no previ- matic in these patients before injury, it has been ous injuries or congenital abnormalities), there our experience that a lateral release is usually not are no other associated pathologies such as carti- necessary and we no longer perform it unless lage damage or meniscus tears that could cause properly indicated. Harvesting the graft is an Muscle imbalance has also been proposed as a extra-articular procedure; therefore, iatrogenic cause of tilt and subluxation. Given that knee range of motion and taught to be a key component of muscle imbal- strength are normal preoperatively, and are easily ance, and physical therapy protocols have been regained postoperatively, the contributions by designed to selectively strengthen this muscle. Furthermore, However, it has recently been shown by EMG the athletes do not complain of pain during the analysis that it is difficult if not impossible to iso- first few days of the new practice week, but only late the vastus medialis using the proposed exer- after many successive practices, and rest usually cises, and in reality the entire quadriceps is being alleviates their symptoms. For the same causes a temporary shutdown of the quadriceps reason that weightlifters alternate which body muscles, causing it to be weak. While many pre- region they concentrate on each day, the patella operative protocols stress regaining quadriceps tendon and quadriceps muscle need a day to rest strength before surgery, we mainly emphasize between heavy strengthening workouts. We have the return of full range of motion and leg control therefore recently changed our contralateral in the injured knee. What this clearly shows is that the har- preoperative and postoperative rehabilitation on vesting of the tendon itself is probably not the regaining range of motion and leg control with- cause of the anterior knee pain syndrome. Separating the postoperative rehabilitation the pain not be found. Sustaining an anterior between knees allows for an earlier return of cruciate ligament injury, while certainly not as range of motion in the ACL reconstructed knee career threatening and ominous as it may have and a quicker return of strength in graft-donor been only a few short years ago, can have a very knee. Ultimately, patients are able to return to strong effect on an athlete’s mental state.
Syndromes
Sinclair (1996) and Hill (1998) consider how to involve children in decision-making diabetes diet orange juice metformin 500mg amex, stressing the need to listen to what they say about services blood sugar 60 buy metformin american express. Although they are writing about children in general gestational diabetes test preparation purchase metformin online from canada, their work has clear relevance for disabled children. Bond (1999) reviews a pack specifically designed for children with learning difficulties to help them communicate their wishes and participate in service design. She stresses the necessity for creative and child-friendly tools and environ- ments. Agencies like the National Childrens Bureau, SCOPE and Mencap may act as representatives of young disabled people. However, the possible exploitation of disabled people by professionals, researchers and non-disabled people needs to be fully considered; non-disabled profes- sionals should review the approach to their work that they adopt and be aware that the dissemination of information which concerns disabled people will affect those people’s lives (Connors and Stalker 2003, p. Nevertheless, it would be difficult to argue that siblings of children with disabilities do not need concerned adults to help them make their needs and wishes known (Ward 1998; Ward and Simons, 1998). It is part of parental and professional responsibility to speak up for children, but to do so at the cost of excluding the child’s viewpoint would essentially isolate the child further. SUPPORT SERVICES AND BEING EMPOWERED / 113 In the following case example, the experience of Rachel is compounded following a medical intervention which directs attention from her disabled sister, Susan, to herself. The sequence of events raises issues about possible causation which ultimately reflect on the difficulties which Rachel has to learn to handle. The case of Rachel and Susan (high negative association) Rachel, aged 14, has a younger sister Susan, aged 12, who has profound physical and intellectual disabilities. Susan attends a special school,requires one-to-one attention at all times and spends most of her time during the day in a purpose-built wheelchair. Susan is unable to feed herself and is fed via a tube directly into her stomach and, to add to her difficulties,she suffers from frequent epileptic fits. Rachel, a bright girl with a lively personality, attends a secondary school and helps with the care of Susan when at home. Rachel spoke only of caring for Susan; there was no expression equivalent to ‘playtime with Susan’, an indication that Rachel was more conscious of ‘a sense of duty to care’ (my expression) than simply enjoying the company of her sister. At the time of interview, Rachel had recovered from minor surgery to remove a lump from her neck, but some days after the operation she had experienced an ‘epileptic fit’ (as explained to her) which lasted about ten minutes. Rachel was taken to hospital and stayed for a period including overnight observation. She returned home only to find, some weeks later, that a similar thing happened again. The doctor indicated on the second occasion that the attack was likely to be of ‘psychological origins’ and not a true fit. Rachel was sent home and has had subsequent fits and experienced going to hospital on a regular basis as a consequence. Rachel has been prescribed medication to help control the fits,although an optimum balance appears yet to be determined and the fits continue on a regular basis. Comment The medical view appears to favour ‘psychological’ rather than a ‘physio- logical’ explanation for Rachel’s fits. Rachel indicates that she feels she is being blamed for something she cannot control.
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