Finally, Cherkin et al. evaluated worldwide surgical attitudes. [ 219 ]  There were twice the number of surgeons per capita in the  United States  compared to the  United Kingdom . Numbers were similar to  Sweden . Despite having very few spinal surgeons, the  Netherlands  proved to be quite aggressive in surgery. Sweden, despite having a large number of surgeons was conservative and produced relatively few surgeries. The most surgeries were done in the United States. In the UK, more than a third of non-urgent patients waited over a year to see a spinal surgeon. In  Wales , more than half waited over three months for consult. Lower rates of referrals in the United Kingdom was found to discourage surgery in general. Fee for service and easy access to care was thought to encourage spinal surgery in the United States, whereas salaried position and a conservative philosophy led to less surgery in the United Kingdom. There were more spinal surgeons in Sweden than in the United States.  However, it was speculated that the Swedish surgeons being limited to compensation of 40–48 hours a week might lead to a  conservative  philosophy. There have been calls for a more aggressive approach to lumbar surgery in both the United Kingdom and Sweden in recent years. [ 71 ] [ 220 ] [ 221 ]


Flat feet , also called  pes planus  or  fallen arches , is a  postural  deformity in which the  arches of the foot  collapse, with the entire  sole  of the foot coming into complete or near-complete contact with the ground. Sometimes children are born with flat feet (congenital). There is a functional relationship between the structure of the arch of the foot and the  biomechanics  of the lower  leg . The arch provides an elastic, springy connection between the  forefoot  and the hind foot so that a majority of the forces incurred during weight bearing on the foot can be dissipated before the force reaches the long bones of the leg and  thigh . [ 1 ]


In pes planus, the head of the  talus bone  is displaced medially and distal from the  navicular bone . As a result, the  plantar calcaneonavicular ligament  (spring ligament) and the tendon of the tibialis posterior muscle are stretched to the extent that the individual with pes planus loses the medial longitudinal arch (MLA). If the MLA is absent or nonfunctional in both the seated and standing positions, the individual has "sigma" flatfoot. If the MLA is present and functional while the individual is sitting or standing up on their toes, but this arch disappears when assuming a foot-flat stance, the individual has "supple" flatfoot. This latter condition is often treated with arch supports. [ 1 ]


Studies have shown flat feet are a common occurrence in  children  and adolescents. The human arch develops in infancy and early childhood as part of normal  muscle ,  tendon ,  ligament  and  bone  growth. [ 2 ]   Flat arches in children usually become high arches as the child progresses through adolescence and into adulthood. Children with flat feet are at a higher risk of developing knee, hip, and back pain. A 2007  randomized controlled trial  found no evidence for the efficacy of treatment of flat feet in children either from expensive prescribed  orthotics  (i.e. shoe inserts) or less expensive over-the-counter orthotics. [ 3 ]  As a symptom itself, flat feet usually accompany genetic musculoskeletal conditions such as  dyspraxia , [ 4 ]   ligamentous laxity  or  hypermobility .


Since children are unlikely to suspect or identify flat feet on their own, it is important for adult caregivers to check on this themselves. Besides visual inspection of feet and of the treadwear pattern on shoe soles, caregivers should notice when a child's gait is abnormal, or the child seems to be in pain from walking. Children who complain about calf muscle pains, arch pain, or any other pains around the foot area may be developing or have developed flat feet. A systematic review and meta-analysis study by Xu, et.al., found that urban sedentary boys, aged 6–9, were frequently diagnosed with flatfeet. The researchers also explored and listed additional risk factors that played a role in diagnosing flatfeet. [ 5 ]


Training of the feet, utilizing  foot gymnastics  and going  barefoot  on varying terrain, can facilitate the formation of arches during childhood, with a developed arch occurring for most by the age of four to six years. Ligament laxity is also among the factors known to be associated with flat feet. One medical study in India with a large sample size of children who had grown up wearing shoes and others going barefoot found that the longitudinal arches of the bare-footers were generally strongest and highest as a group, and that flat feet were less common in children who had grown up wearing  sandals  or  slippers  than among those who had worn closed-toe  shoes . Focusing on the influence of footwear on the prevalence of pes planus, the cross-sectional study performed on children noted that wearing shoes throughout early childhood can be detrimental to the development of a normal or a high medial longitudinal arch. The vulnerability for flat foot among shoe-wearing children increases if the child has an associated ligament laxity condition. The results of the study suggest that children be encouraged to play barefooted on various surfaces of terrain and that slippers and sandals are less harmful compared to closed-toe shoes. It appeared that closed-toe shoes greatly inhibited the development of the arch of the foot more so than slippers or sandals. This conclusion may be a result of the notion that intrinsic muscle activity of the arch is required to prevent slippers and sandals from falling off the child's foot. [ 7 ]  In children with few symptoms orthotics is not recommended. [ 8 ]


Flat feet can also develop as an adult ("adult acquired flatfoot") due to injury, illness, unusual or prolonged stress to the foot, faulty  biomechanics , [ 9 ]  or as part of the normal aging process.  This is most common in women over 40 years of age. Known risk factors include obesity,  hypertension  and  diabetes . [ 10 ]  Flat feet can also occur in pregnant women as a result of temporary changes due to increased  elastin  (elasticity) during pregnancy; if developed by adulthood, flat feet generally remain flat permanently.


If a youth or adult appears flatfooted while standing in a full  weight bearing  position, but an arch appears when the person  plantarflexes , or pulls the toes back with the rest of the foot flat on the floor, this condition is called flexible flatfoot.  This is not a true collapsed arch, as the  medial longitudinal arch  is still present and the windlass mechanism still operates; this presentation is actually due to  excessive pronation of the foot  (rolling inwards), although the term 'flat foot' is still applicable as it is a somewhat generic term.  Muscular training of the feet is helpful and will often result in increased arch height regardless of age. [ citation needed ]


Research has shown that tendon specimens from people who have adult-acquired flat feet show evidence of increased activity of  proteolytic   enzymes . These enzymes can break down the constituents of the involved tendons and cause the foot arch to fall. In the future, these enzymes may become targets for new drug therapies. [ 10 ]


Many medical professionals can diagnose a flat foot by examining the patient standing or just looking at them. On going up onto tip toe the deformity will correct when this is a flexible flat foot in a child with lax joints. Such correction is not seen in adults with a rigid flat foot. [ citation needed ]


An easy and traditional home diagnosis is the "wet footprint" test, performed by wetting the feet in water and then standing on a smooth, level surface such as smooth concrete or thin cardboard or heavy paper. Usually, the more the sole of the foot that makes contact (leaves a footprint), the flatter the foot.  In more extreme cases, known as a kinked flatfoot, the entire inner edge of the footprint may actually bulge outward, where in a normal to high arch this part of the sole of the foot does not make contact with the ground at all. [ citation needed ]


On  plain radiography , flat feet can be diagnosed and graded by several measures, the most important in adults being the talonavicular coverage angle, the calcaneal pitch, and the talar-1st metatarsal angle (Meary's angle). [ 11 ]  The talonavicular coverage angle is abnormally laterally rotated in flat feet. [ 11 ]  It is normally up to 7 degrees laterally rotated, so a greater rotation indicates flat feet. [ 11 ]  Radiographies generally need to be taken on weightbearing feet in order to detect misalignment. [ 12 ]


Most flexible flat feet are asymptomatic and do not cause pain. In these cases there is usually no cause for concern. Flat feet were formerly a physical-health reason for service rejection in many militaries. However three military studies on asymptomatic adults (see section below) suggest that persons with asymptomatic flat feet are at least as tolerant of foot stress as the population with various grades of arch. [ citation needed ]


In a study performed to analyze the activation of the tibialis posterior muscle in adults with pes planus, it was noted that the tendon of this muscle may be dysfunctional and lead to disabling weightbearing symptoms associated with acquired flat foot deformity. The results of the study indicated that, while barefoot, subjects activated additional lower-leg muscles to complete an exercise that resisted foot adduction. However, when the same subjects performed the exercise while wearing arch supporting orthotics and shoes, the tibialis posterior was selectively activated. Such discoveries suggest that the use of shoes with properly fitting arch-supporting orthotics will enhance selective activation of the tibialis posterior muscle, thus acting as an adequate treatment for the undesirable symptoms of pes planus. [ 14 ]


Rigid flatfoot, a condition where the sole of the foot is rigidly flat even when a person is not standing, often indicates a significant problem in the bones of the affected feet and can cause pain in about a quarter of those affected. [ 15 ] [ 16 ]   Other flatfoot-related conditions, such as various forms of  tarsal  coalition (two or more bones in the midfoot or hindfoot abnormally joined) or an accessory  navicular  (extra bone on the inner side of the foot), should be treated promptly, usually by the very early teen years, before a child's bone structure firms up permanently as a young adult.  Both  tarsal coalition  and an  accessory navicular  can be confirmed by  X-ray .  Rheumatoid arthritis can destroy tendons in the foot (or both feet), which can cause this condition, and untreated can result in deformity and early onset of osteoarthritis of the joint. Such a condition can cause severe pain and considerably reduced ability to walk, even with orthoses.  Ankle fusion is usually recommended. [ 17 ]


Treatment of flat feet may also be appropriate if there is associated foot or lower-leg pain, or if the condition affects the knees or the lower back. Treatment may include  foot gymnastics  or other exercises as recommended by a  podiatrist  or physical therapist. In cases of severe flat feet, orthoses should be used through a gradual process to lessen discomfort.  Over several weeks, slightly more material is added to the orthosis to raise the arch.  These small changes allow the foot structure to adjust gradually, as well as giving the patient time to acclimatize to the sensation of wearing orthoses.  In some cases, surgery can provide lasting relief and even create an arch where none existed before; it should be considered a last resort, as it is usually very time-consuming and costly. [ 18 ]  A minimally invasive surgical intervention involving a small implant is also available. The implant is inserted into the sinus tarsi and prevents the calcaneus and talus from sliding relative to each other. This prevents the sinus tarsi from collapsing and thus prevents the external symptom of the fallen arch from occurring. [ 19 ]


The effects of flat feet fall under two categories, which are asymptomatic and symptomatic. Individuals with rigid flat feet tend to exhibit symptoms such as foot and knee tendonitis and are recommended to consider surgical options when managing symptoms. Individuals with flexible flat generally exhibit asymptomatic effects in response to their flat feet. [ 2 ]


According to AAP news and journal gateway, being flexibly flat-footed does not impede athletic performance in children 11-15. [ 20 ]


It is generally assumed by running professionals (primarily including some physical trainers, podiatrists, and shoe manufacturers) that a person with flat feet tends to  overpronate  in the running form. [ 21 ]  However, some also assert that persons with flat feet may have an  underpronating  if they are not in a neutral gait. With standard running shoes, these professionals claim, a person who overpronates in his or her running form may be more susceptible to  shin splints , back problems, and  tendonitis  in the knee. [ 22 ]  Running in shoes with extra medial support or using special shoe inserts, orthoses, may help correct one's running form by reducing pronation and may reduce risk of injury. [ 23 ]


Studies analyzing the correlation between flat feet and physical injuries in soldiers have been inconclusive, but none suggests that flat feet are an impediment, at least in soldiers who reached the age of military recruitment without prior foot problems.


A 2005 study of  Royal Australian Air Force  recruits that tracked the recruits over the course of their basic training found that neither flat feet nor high-arched feet had any impact on physical capability, injury rates or bipedal aptitude, although there have been results of military trials that have shown those with flat feet to have fewer injuries. [ 24 ]


No current studies have been successful in fully ascertaining the long-term detriments to health caused by the overexertion (necessary for athletes/soldiers performing with flat feet) and other compensating measures commonly enacted by the body during bipedal movement.


Another divergent study of 295  Israel Defense Forces  recruits found that those with high arches had almost four times as many stress fractures as those with the lowest arches. [ 25 ]


A later study of 449  U.S. Navy special warfare  trainees found no significant difference in the incidence of stress fractures among sailors and Marines with different arch heights. [ 26 ]


A  flexion teardrop fracture  is a  fracture  of the anteroinferior aspect of a  cervical vertebral  body due to flexion of the spine along with vertical axial compression. [ 1 ]  The fracture continues sagittally through the vertebral body, and is associated with deformity of the body and subluxation or dislocation of the  facet joints  at the injured level. [ 2 ]  A flexion teardrop fracture is usually associated with a  spinal cord injury , often a result of displacement of the posterior portion of the vertebral body into the  spinal canal . [ 3 ]


The flexion teardrop fracture should not be confused with a similar-looking vertebral fracture called "extension teardrop fracture". Both usually occur in the cervical spine, but as their names suggest, they result from different mechanisms (flexion-compression vs. hyperextension). Both are associated with a small fragment being broken apart from the anteroinferior corner of the affected vertebra. Flexion teardrop fractures usually involve instability in all elements of the spine at the injured level, commonly occur at the C4-C7 vertebra, and have a high association with spinal cord injury (in particular  anterior cord syndrome ). In comparison, the extension-type fracture occurs more commonly at C2 or C3, causes less if any disruption to the middle and posterior elements, and does not usually result in spinal cord injury (however, it may co-occur with more serious spine injuries). [ 2 ]


This article about an injury is a  stub . You can help Wikipedia by  expanding it .


Genu recurvatum  is a deformity in the  knee joint , so that the knee bends backwards. In this deformity, excessive extension occurs in the  tibiofemoral joint . Genu recurvatum is also called  knee hyperextension  and  back knee . This deformity is more common in women [ citation needed ]  and people with familial  ligamentous laxity . [ 2 ]  Hyperextension of the knee may be mild, moderate or severe.


The normal range of motion (ROM) of the knee joint is from 0 to 135 degrees in an adult. Full knee extension should be no more than 10 degrees. In genu recurvatum, normal extension is increased. The development of genu recurvatum may lead to  knee pain  and  knee osteoarthritis .


The following factors may be involved in causing this deformity: [ citation needed ]


The most important factors of knee stability include: [ citation needed ]


Treatment generally includes the following: [ citation needed ]


This condition is considered to be rare, with about 1 in 100,000 births being affected by the congenital form of genu recurvatum, [ 3 ]  although it's a common feature in some disorders, such as in joint hypermobility, which affects 1 in 30 people. [ 4 ]


A  Hill–Sachs lesion , or  Hill–Sachs fracture , is a cortical depression in the posterolateral  head  of the  humerus . It results from forceful impaction of the humeral head against the anteroinferior  glenoid  rim when the  shoulder is dislocated  anteriorly.


Pain while rotating joint bones sounds of rotating bone joints


Recurrent dislocation of shoulder
Apprehension sign


The lesion is associated with anterior  shoulder dislocation . [ 1 ]  When the humerus is driven from the  glenoid cavity , its relatively soft head impacts against the anterior edge of the  glenoid . The result is a divot or flattening in the  posterolateral  aspect of the  humeral head , usually opposite the  coracoid process . The mechanism which leads to shoulder dislocation is usually traumatic but can vary, especially if there is history of previous dislocations.  Sports , falls,  seizures , assaults, throwing, reaching, pulling on the arm, or turning over in bed can all be causes of anterior dislocation. [ citation needed ]


Diagnosis can be suspected by  history  and  physical examination  which is usually followed by imaging. Because of the mechanism of injury, apprehension of anterior dislocation is common with provocative maneuvers. Hill–Sachs lesions have been classified as "engaging" or "non-engaging", with engaging lesions defined by the ability of the glenoid to  sublux  into the humeral head defect during  abduction  and external rotation. Engaging dislocations have a higher risk of recurrent anterior dislocation, and their presence can help guide surgical management. [ 2 ]  Imaging diagnosis conventionally begins with  plain film   radiography . Generally, anteroposterior (AP) radiographs of the shoulder with the arm in internal rotation offer the best yield while axillary views and AP radiographs with external rotation tend to obscure the defect. However, pain and tenderness in the injured joint make appropriate positioning difficult and in a recent study of plain film x-ray for Hill–Sachs lesions, the sensitivity was only about 20%. i.e. the finding was not visible on plain film x-ray about 80% of the time. [ 3 ]


By contrast, studies have shown the value of  ultrasonography  in diagnosing Hill–Sachs lesions. In a population with recurrent dislocation using findings at surgery as the gold standard, a sensitivity of 96% was demonstrated. [ 4 ]  In a second study of patients with continuing shoulder instability after trauma, and using double contrast  CT  as a gold standard, a sensitivity of over 95% was demonstrated for ultrasound. [ 5 ]  It should be borne in mind that in both those studies, patients were having continuing problems after initial injury, and therefore the presence of a Hill–Sachs lesion was more likely. Nevertheless, ultrasonography, which is noninvasive and free from  radiation , offers important advantages. [ citation needed ]


MRI  has also been shown to be highly reliable for the diagnosis of Hill-Sachs (and  Bankart ) lesions. One study used challenging methodology. First of all, it applied to those patients with a single, or first time, dislocation. Such lesions were likely to be smaller and therefore more difficult to detect. Second, two radiologists, who were blinded to the surgical outcome, reviewed the MRI findings, while two orthopedic surgeons, who were blinded to the MRI findings, reviewed videotapes of the arthroscopic procedures. Coefficiency of agreement was then calculated for the MRI and arthroscopic findings and there was total agreement (  kappa  = 1.0) for Hill-Sachs and Bankart lesions. [ 6 ]


The decision to repair of the Hill–Sachs lesion is based on its association with continuing symptoms and instability. This is particularly important in patients below 25 year of age and in throwing athletes. The role of the Hill-Sachs in continuing symptoms, in turn, may be related to its width and depth, particularly if involving greater than 20% of the articular surface. Associated bony lesions or fractures may coexist in the glenoid such as the bony Bankart lesion. In such scenarios, surgical repair may include bony augmentation, a common example of which is the  Latarjet procedure . Additional lesions such as a Bankart,  SLAP tear , or biceps injury may also be present. [ 7 ]


The  incidence  of Hill–Sachs lesion is not known with certainty. It has been reported to be present in 40% to 90% of patients presenting with anterior shoulder instability, that is subluxation or dislocation. [ 8 ] [ 9 ]  In those who have recurrent events, it may be as high as 100%. [ 10 ]  Its presence is a specific sign of dislocation and can thus be used as an indicator that dislocation has occurred even if the joint has regained its normal alignment. Large, engaging Hill-Sachs fractures can contribute to shoulder instability and will often cause painful clicking, catching, or popping. [ citation needed ]  The average depth of Hill–Sachs lesion has been reported as 4.1 mm. [ 11 ]


The lesion is named after Harold Arthur Hill (1901–1973) and Maurice David Sachs (1909–1987), two radiologists from San Francisco, USA. In 1940, they published a report of 119 cases of shoulder dislocation and showed that the defect resulted from direct compression of the humeral head. Before their paper, although the fracture was already known to be a sign of shoulder dislocation, the precise mechanism was uncertain. [ 12 ]


Knee pain  is  pain  in or around the  knee .


The  knee  joint consists of an articulation between four bones: the  femur ,  tibia ,  fibula  and  patella . There are four compartments to the knee. These are the medial and lateral tibiofemoral compartments, the patellofemoral compartment and the superior tibiofibular joint. The components of each of these compartments can experience repetitive strain, injury or disease. [ 1 ]


Running long distance can cause pain to the knee joint, as it is a high-impact exercise. [ 2 ]


The location and severity of knee pain may vary, depending on the cause of the problem. Signs and symptoms that sometimes accompany knee pain include: [ 1 ]


Some common injuries based on the location include: [ 3 ]


Some of the diseases of cause of knee pain include the following:


Common deformities of the knee include:


Knee pain is more common among people working in the cold than in those in normal temperature. [ 21 ]  Cold-induced knee pain may also be due to  tenosynovitis  of the  tendons  around the knee, in which cold exposure has a specific role, either as a causative or a contributing factor. [ 21 ]  Frank  arthritis  has been reported in children due to  frostbite  from extreme cold causing direct  chondrocyte  injury. [ 22 ]


There is also a  hereditary disease ,  familial cold autoinflammatory syndrome  (FCAS), which often features knee pain, in addition to hives, fever and pain in other joints, following general exposure to cold. [ 23 ]


A lower level of physical activity and a work environment where one is required to sit in a chair during the work day is one reason for developing knee joint pain, as the lower degree of physical movement tends to weaken the knee muscles. Blood vessels also can be affected, leading to development of painful conditions. Working on building strength through a full range of motion is crucial for rebuilding strength and getting rid of knee pain.  [ citation needed ]


As age progresses the movement of the knee joint involves higher friction with adjacent tissue and cartilages. [ citation needed ]


Referred pain  is that pain perceived at a site different from its point of origin but innervated by the same spinal segment. [ 24 ]  Sometimes knee pain may be related to another area from body. For example, knee pain can come from ankle, foot, hip joints or  lumbar spine .


Knee MRIs should be avoided for knee pain without symptoms or  effusion , unless there are non-successful results from a functional rehabilitation program. [ 25 ]


In some diagnosis, such as in knee osteoarthritis, magnetic resonance imaging does not prove to be clear for its determination. [ 26 ]


Although surgery has a role in repairing traumatic injuries and broken bones,  arthroscopic surgeries  do not provide significant or lasting improvements to either pain or function to people with  knee pain, and therefore should almost never be performed. [ 27 ]  Knee pain is pain caused by wear and tear, such as  osteoarthritis  or a  meniscal tear .  Effective treatments for knee pain include  physical therapy  exercises, [ 28 ]  pain-reducing drugs such as  ibuprofen , joint stretching, [ 29 ] [ 30 ]   knee replacement  surgery, and weight loss in people who are overweight. [ 27 ]


Overall, a combination of interventions seems to be the best choice when treating knee pain. Interventions such as exercises that target both the knee and the hip, foot bracing, and patellar taping are all recommended for use with patients who have knee pain. [ 31 ]


Current evidence suggests that psychological factors are elevated in individuals with patellofemoral pain. [ 32 ]  Non-physical factors such as anxiety, depression, fear of movement, and catastrophizing are thought to have a linear correlation with increased pain experience and decreased physical function. [ 32 ]  Catastrophizing is defined as imagining the worst possible outcome of an action or event. [ 33 ]  The psychosocial factors may have either a positive or negative impact on adherence to rehabilitation programs for managing knee pain. [ 32 ]  Furthermore, studies have found knee pain to be negatively associated with health-related quality of life, and an increase in knee pain to be associated with a reduction in patient-reported quality of life, as compared to those with no or stable knee pain, even in the relatively younger middle-aged population. [ 34 ]


About 25% of people over the age of 50 experience knee pain from degenerative knee diseases. [ 27 ]


In the United States, more than US$3 billion is spent each year on arthroscopic knee surgeries that are known to be ineffective in people with degenerative knee pain. [ 27 ]


Larsen syndrome  ( LS ) is a  congenital disorder  discovered in 1950 by Larsen and associates when they observed  dislocation  of the large joints and face anomalies in six of their patients. [ 1 ]  Patients with Larsen syndrome normally present with a variety of symptoms, including  congenital  anterior  dislocation  of the knees,  dislocation  of the hips and elbows, flattened facial appearance, prominent foreheads, and depressed nasal bridges. [ 2 ]  Larsen syndrome can also cause a variety of  cardiovascular [ 3 ]  and  orthopedic  abnormalities. [ 4 ]  This rare disorder is caused by a genetic defect in the gene encoding  filamin  B, a cytoplasmic protein that is important in regulating the structure and activity of the  cytoskeleton . [ 5 ]  The gene that influences the emergence of Larsen syndrome is found in chromosome region, 3p21.1-14.1, a region containing human type VII  collagen  gene. [ 6 ]  Larsen syndrome has recently been described as a  mesenchyme  disorder that affects the  connective tissue  of an individual. [ 2 ]   Autosomal dominant  and  recessive  forms of the disorder have been reported, although most cases are autosomal dominant. [ 1 ]  Reports have found that in Western societies, Larsen syndrome can be found in one in every 100,000 births, but this is most likely an underestimate because the disorder is frequently unrecognized or misdiagnosed. [ 6 ]


Symptoms are related to defects in connective tissue.


Cardiac defects are similar to those associated with  Marfan's syndrome , a disorder of the connective tissue.


These symptoms were found in rare cases of Larsen syndrome. [ citation needed ]


Filamins are cytoplasmic proteins that regulate the structure and activity of the  cytoskeleton . These proteins serve as scaffolds on which intracellular signaling and protein trafficking are organized.  Filamin B  has been found to be expressed in human growth plate  chondrocytes , which are especially important in vertebrae segmentation and skeleton  morphogenesis . Genetic analysis of patients with Larsen syndrome has found the syndrome is caused by  missense mutations  in the gene that codes for filamin B. These mutations cause an accelerated rate of  apoptosis  in the  epiphyseal growth plates  of individuals with the mutation. The defects can cause short stature and other symptoms associated with Larsen syndrome. [ 5 ]


Genetic analysis has found that a gene linked to Larsen syndrome,  LAR1 , is strongly linked to chromosome 3p markers. The locus of this gene is found in a region defined distally by D3S1581 and proximally by D3S1600. This location can be mapped to chromosome region 3p21.1-14.1. Human type VII collagen gene is found within this region in chromosome region 3p21.1. It is reasonable to believe that the joint abnormalities and cardiac anomalies associated with Larsen syndrome are related to the fact that the human type VII collagen gene is found within the same chromosome region as the  LAR1  gene. [ 6 ]


Both  autosomal dominant  and  recessive  forms of Larsen syndrome have been reported. The former is significantly more common than the latter. Symptoms such as  syndactyly ,  cleft palate , short stature, and cardiac defects are seen more commonly in individuals with the autosomal recessive form of the disorder. A lethal form of the disorder has been reported. It is described as being a combination of the Larsen  phenotype  and  pulmonary hypoplasia . [ 1 ]


Ultrasound  remains as one of the only effective ways of prenatally diagnosing Larsen syndrome.  Prenatal  diagnosis is extremely important, as it can help families prepare for the arrival of an infant with specifics necessities. Ultrasound can capture prenatal images of multiple joint dislocations, abnormal positioning of legs and knees, depressed nasal bridge, prominent forehead, and  club feet . These symptoms are all associated with Larsen syndrome, so they can be used to confirm that a  fetus  has the disorder. [ 7 ]


Treatment for Larsen syndrome varies according to the symptoms of the individual. [ 1 ]  Orthopedic surgery can be performed to correct the serious joint defects associated with Larsen syndrome. Reconstructive surgery can be used to treat the facial abnormalities. Cervical kyphosis can be very dangerous to an individual because it can cause the vertebrae to disturb the  spinal cord . Posterior cervical  arthrodesis  has been performed on patients with cervical kyphosis, and the results have been successful [ 4 ]   Propranolol  has been used to treat some of the cardiac defects associated with Marfan's syndrome, so the drug also has been suggested to treat cardiac defects associated with Larsen syndrome. [ 3 ]


While Larsen syndrome can be lethal if untreated, the prognosis is relatively good if individuals are treated with orthopedic surgery, physical therapy, and other procedures used to treat the symptoms linked with Larsen syndrome. [ 7 ]


Ankyrin :  Long QT syndrome 4


Myelopathy  describes any neurologic deficit related to the  spinal cord . [ 1 ]  The most common form of myelopathy in humans,  cervical spondylotic myelopathy (CSM) , [ 2 ] [ 3 ]  also called  degenerative cervical myelopathy , [ 4 ]  results from narrowing of the spinal canal ( spinal stenosis ) ultimately causing compression of the spinal cord. [ 5 ]
When due to  trauma , myelopathy is known as (acute)  spinal cord injury . When inflammatory, it is known as  myelitis . Disease that is vascular in nature is known as  vascular myelopathy .


In Asian populations, spinal cord compression often occurs due to a different, inflammatory process affecting the  posterior longitudinal ligament . [ citation needed ]


Clinical signs and symptoms depend on which spinal cord level (cervical, [ 6 ]  thoracic, or lumbar) is affected and the extent (anterior, posterior, or lateral) of the pathology, and may include: [ citation needed ]


Myelopathy is primarily diagnosed by clinical exam findings. Because the term  myelopathy  describes a clinical syndrome that can be caused by many pathologies the differential diagnosis of myelopathy is extensive. [ 7 ]  In some cases the onset of myelopathy is rapid, in others, such as CSM, the course may be insidious with symptoms developing slowly over a period of months. As a consequence, the diagnosis of CSM is often delayed. [ 8 ]  As the disease is thought to be progressive, this may impact negatively on outcome. [ citation needed ]


Once the clinical diagnosis  myelopathy  is established, the underlying cause must be investigated. Most commonly this involves medical imaging. The best way to visualize the spinal cord is  magnetic resonance imaging  (MRI). Apart from T1 and T2 MRI images, which are commonly used for routine diagnosis, more recently researchers are exploring quantitative MRI signals. [ 9 ]  Further imaging modalities used for evaluating myelopathy include plain  X-rays  for detecting arthritic changes of the bones, and  Computer Tomography , which is often used for pre-operative planning of surgical interventions for cervical spondylotic myelopathy.  Angiography  is used to examine blood vessels in suspected cases of vascular myelopathy. [ citation needed ]


The presence and severity of myelopathy can also be evaluated by means of  transcranial magnetic stimulation  (TMS), a neurophysiological method that allows the measurement of the time required for a neural impulse to cross the pyramidal tracts, starting from the cerebral cortex and ending at the anterior horn cells of the cervical, thoracic or lumbar spinal cord. This measurement is called  Central Conduction Time  ( CCT ). TMS can aid physicians to: [ 10 ]


TMS can also help in the differential diagnosis of different causes of pyramidal tract damage. [ 12 ]


The treatment and prognosis of myelopathy depends on the underlying cause: myelopathy caused by infection requires medical treatment with pathogen specific antibiotics. Similarly, specific treatments exist for  multiple sclerosis , which may also present with myelopathy. As outlined above, the most common form of myelopathy is secondary to degeneration of the cervical spine. Newer findings have challenged the existing controversy with respect to surgery [ 13 ]  for cervical spondylotic myelopathy by demonstrating that patients benefit from surgery. [ 14 ]


Creutzfeldt–Jakob disease


Olecranon fracture  is a  fracture  of the  bony portion  of the  elbow . The injury is fairly common and often occurs following a fall or direct trauma to the elbow. The olecranon is the proximal extremity of the  ulna  which is articulated with the  humerus  bone and constitutes a part of the elbow articulation. Its location makes it vulnerable to direct trauma.


People with olecranon fractures present with intense elbow pain after a direct blow or fall. [ 1 ]  Swelling over the bone site is seen and an inability to straighten the elbow is common. Due to the proximity of the olecranon to the ulnar nerve, the injury and swelling may cause numbness and tingling at the fourth and fifth fingers. [ 1 ]  Examination can bring out a palpable defect at the site of the fracture. [ 2 ]


Olecranon fractures are common. Typically they are caused by direct blows to the elbow (e.g. motor vehicle accidents), and due to falls when the triceps are contracted. [ 1 ] [ 3 ]   "Side-swipe" injury when driving a motor vehicle with an elbow projecting outside the vehicle resting on an open window's edge is an example. [ 4 ]


Direct trauma:  This can happen in a fall with landing on the elbow or by being hit by a solid object. Trauma to the elbow often results in  comminuted fractures  of the olecranon.


Indirect trauma : by falling and landing with an outstretched arm.


Powerful pull of the  triceps muscle  can also cause  avulsion fractures .


To assess an olecranon fracture, a careful skin exam is performed to ensure there is no open fracture. Then a complete neurological exam of the upper limb should be documented. [ 5 ] [ 2 ]  Frontal and lateral  X-ray  views of the elbow are typically done to investigate the possibility of an olecranon fracture. [ 1 ]  A true lateral x-ray is essential to determine the fracture pattern, degree of displacement, comminution, and the degree of articular involvement. [ citation needed ]


There are several classifications that describe different forms of olecranon fractures, yet none of them have gained widespread acceptance: [ 5 ]


Based on the stability, the displacement and the  comminution of the fracture . It is composed of three types, and each type is divided in two subtypes: subtype A (non-comminuted) and subtype B (comminuted).


This classification incorporates all fractures of the proximal ulna and radius into one group, subdivided into three patterns:


In fractures with little or no displacement, immobilization with a posterior splint may be sufficient. [ 1 ]  Elbows may be immobilized at 45°–90° of flexion for 3 weeks, followed by limited (90°) flexion exercises. [ citation needed ]


Most olecranon fractures are displaced and are best treated surgically: [ 1 ]


Tension band fixation is the most common form of internal fixation used for non-comminuted olecranon fractures. [ 5 ]  It is typically reserved for noncomminuted fractures that are proximal to the coronoid. [ 2 ]  This procedure is performed using  Kirschner wire  (K-wires) which converts tensile forces into compressive force. [ 2 ]


Single intramedullary screws can be used to treat simple transverse or oblique fractures. [ 5 ]  Plates can be used for all proximal ulna fracture types including Monteggia fractures, and comminuted fractures. [ 2 ]


This method is indicated for cases when open reduction and internal fixation is unlikely to be successful. For example: extensive comminutions, elderly patients with osteoporotic bone, and small or non-union fractures. [ 5 ] [ 2 ]


Olecranon fractures are rare in children, constituting only 5 to 7% of all elbow fractures. This is because in early life, olecranon is thick, short and much stronger than the lower extremity of the humerus. [ 5 ]


However, olecranon fractures are a common injury in adults. This is partly due to its exposed position on the point of the elbow. [ citation needed ]


Patellar subluxation syndrome  is an injury involving the  kneecap . Patellar subluxation is more common than patellar dislocation and is just as disabling. [ 1 ]


In this condition, the  patella  repetitively subluxates and places  strain  on the  medial restraints  and excessive  stress / tension  on the  patellofemoral joint . Patellar subluxation can be caused by osseous abnormalities, such as incorrect articulation of the femoral groove with the patella, trochlear dysplasia, or patella alta, which is a distance of greater than 20 mm between the tibial tubercle and the trochlear groove. It can also result from soft-tissue abnormalities, such as a torn medial patellofemoral ligament, or a weakened vastus medialis obliquus. [ 2 ]  Symptoms are regulated by the amount of activity. Such  pain  is commonly caused by running and jumping  sports  and activities that place large forces on the patellofemoral joint. [ 1 ]


Symptoms usually include: [ 3 ]


Patellar subluxation was once thought to occur mainly in women, [ 1 ]  due to the frequency of  genu valgum  and lax  ligaments . However, now the frequency of this condition in any athletic person, man or woman, is apparent. [ citation needed ]


Conservative treatment in primary acute LPD (lateral patellar dislocation) is the therapy of choice. It includes a multimodal approach with behavioural education of the patient, physical therapy, braces, weight reduction and pain medication. [ 4 ]


Physical therapy especially focuses on muscle strengthening and proprioceptive exercises. The vastus medialis oblique muscle is described to have an important role in functional stabilization of the patella against lateral vector force. [ 5 ]  Proprioceptive exercises and strengthening of the hip abductors and positioning of the foot are crucial, especially indicated in patient with miserable malalignment syndrome or medial collapse. [ 6 ]


Several patellar braces or taping methods exist to improve return to sport. They may however not alter medial or lateral displacement, but can be helpful as a diagnostic tool for occult patellofemoral instability. [ 7 ]


Increasing age is associated with decreased physical activity after surgical stabilization, and therefore in growing and very active athletes early surgical treatment intervention needs to be considered. Reconstruction of the MPFL (medial patellofemoral ligament) in patients with minor trochlear dysplasia is technically possible without interfering with distal growth plate of the femur, [ 8 ]  however, large studies are missing. Osseous articular correction before epiphyseal closure is contraindicated. [ 9 ]


In adult patients with recurrent LPD and without trochlear dysplasia or type A or C according to Dejour classification, MPFL reconstruction alone might be beneficial, in which unchanged osseous or dynamic instability will be compensated. [ 10 ]  Patients with an important supra-trochlear spur as in type B and D trochlear dysplasia and chronic instability are more reluctant to conservative and soft-tissue surgical treatment options. [ 11 ]  In such cases sulcus-deepening trochleoplasty should be performed. [ 10 ]  Typically, post-surgical results are more favourable when instability was the main symptom. Hence, in such patients low-pivoting physical activity may be re-achieved. [ citation needed ]


Perthes lesion  is a variant of  Bankart lesion , presenting as an  anterior   glenohumeral  injury that occurs when the  scapular   periosteum  remains intact but is stripped medially and the anterior  labrum  is  avulsed  from the  glenoid  but remains partially attached to the scapula by intact periosteum.


The lesion is associated with any damage to the antero-inferior labrum. Most commonly due to anterior  shoulder dislocation . The lesion often occurs after the initial dislocation. In chronic cases, there may be  fibrosis  and resynovialization of the labrum and periosteum. [ citation needed ]


The lesion is best identified on MR  arthrography . Additional views in  ABER  ( AB duction and  E xternal  R otation) of the shoulder aid in this diagnosis.


Differential diagnoses include:


Treatment is surgical re-attachment of the labrum preferably via  arthroscopy . [ citation needed ]


It is named after  Georg C. Perthes  (1869-1927), a German Surgeon and X-Ray diagnostic pioneer who first described the lesion in 1905. [ citation needed ]


1. Perthes Lesion (A Variant of the Bankart Lesion): MR Imaging and MR Arthrographic Findings with Surgical Correlation
Thorsten K. Wischer, Miriam A. Bredella, Harry K. Genant, David W. Stoller, Frederic W. Bost, and Phillip F. J. Tirman
AJR January 2002 178:233-237


2. MRI of the shoulder By Michael B. Zlatkin, Lippincott, Williams and Wilkins 2003


Pigeon toe , also known as  in-toeing , is a condition which causes the toes to point inward when walking. It is most common in infants and children under two years of age [ 1 ]  and, when not the result of simple muscle weakness, [ 2 ]  normally arises from underlying conditions, such as a twisted  shin bone  or an excessive anteversion (femoral head is more than 15° from the angle of torsion) resulting in the twisting of the  thigh bone  when the front part of a person's foot is turned in.


The cause of in-toeing can be differentiated based on the location of the misalignment. The variants are: [ 3 ] [ 4 ]


This is the most common form of being pigeon toed, when the feet bend inward from the middle part of the foot to the toes. This is the most common congenital foot abnormality, occurring every 1 in 5,000 births. [ 5 ] [ 6 ]  The rate of metatarsus adductus is higher in twin pregnancies and preterm deliveries. [ 5 ]   Most often self-resolves by one year of age and 90% of cases will resolve spontaneously (without treatment) by age 4. [ 7 ]


Signs and Symptoms [ 5 ]


The tibia or lower leg slightly or severely twists inward when walking or standing.  Usually seen in 1-3 year olds, internal tibial torsion is the most common cause of intoeing in toddlers. [ 5 ]   It is usually bilateral (both legs) condition that typically self-resolves by 4 to 5 years of age. [ 6 ] [ 5 ]


The neck of the femur is angled forward compared to the rest of the bone, causing a compensatory internal rotation of the leg. [ 8 ]  As a result, all structures downstream of the hip including the thigh, knee, and foot will turn in toward mid-line. [ 8 ]  Femoral anteversion is the most common cause of in toeing in children older than 3 years of age. [ 5 ] [ 6 ]  It is most commonly bilateral, affects females twice as much as males, and in some families can show a hereditary pattern. [ 5 ]  This condition may progressively worsen from years 4 to 7, yet the majority of cases still spontaneously resolve by 8 years of age. [ 6 ]


Signs and Symptoms [ 5 ] [ 6 ]


Pigeon toe can be diagnosed by  physical examination  alone. [ 10 ]  This can classify the deformity into "flexible", when the foot can be straightened by hand, or otherwise "nonflexible". [ 10 ]  Still,  X-rays  are often done in the case of nonflexible pigeon toe. [ 10 ]  On X-ray, the severity of the condition can be measured with a "metatarsus adductus angle", which is the angle between the directions of the  metatarsal bones , as compared to the lesser  tarsus  (the  cuneiforms , the  cuboid  and the  navicular bone ). [ 11 ]  Many variants of this measurement exist, but  Sgarlato's angle  has been found to at least have favorable correlation with other measurements. [ 12 ]   Sgarlato's angle  is defined as the angle between: [ 9 ] [ 13 ]


This angle is normally up to 15°, and an increased angle indicates pigeon toe. [ 9 ]  Yet, it becomes more difficult to infer the locations of the joints in younger children due to incomplete ossification of the bones, especially when younger than 3–4 years. [ citation needed ]


Internal Tibial Torsion


Internal tibial torsion is diagnosed by physical exam. [ 6 ]  The principle clinical exam is an assessment of the thigh-foot angle. [ 6 ]   The affected individual is placed in prone position with the knees flexed to 90 degrees. [ 6 ]   An imaginary line is drawn along the longitudinal axis of the thigh, and of the sole of the foot from a birds-eye view and the angle at the intersection of these two lines is measured. [ 6 ]   A value greater than 10 degrees of internal rotation is considered internal tibial torsion. [ 6 ]   A thigh-foot angle less than 10 degrees internal, and up to 30 degrees of external rotation is considered normal. [ 6 ]


Femoral Anteversion


Femoral anteversion is diagnosed by physical exam. [ 6 ]   The principle physical exam maneuver is an assessment of hip mobility. [ 6 ]  The child is evaluated in the prone position with knees flexed to 90 degrees. [ 6 ]  Using the tibia as a lever arm the femur is rotated both internally and externally. [ 6 ]   A positive exam demonstrates internal rotation of greater than 70 degrees and external rotation reduced to less than 20 degrees. [ 6 ]  Normal values for internal rotation are between 20 and 60 degrees and normal values for external rotation are between 30 and 60 degrees. [ 6 ]


In those less than eight years old with simple in-toeing and minor symptoms, no specific treatment is needed. [ 14 ]


Metatarsus Adductus


Nonoperative management:   Non operative treatment of metatarsus adductus is dictated by the flexibility of the forefoot. [ 6 ]   If the child can actively correct the forefoot to midline no treatment is indicated. [ 6 ]   If the adduction cannot be corrected actively but is flexible in passive correction by an examiner, at-home stretching that mimics this maneuver can be performed by parents. [ 6 ]  In the case of a rigid deformity serial casting can straighten the foot. [ 6 ]


Surgical Management:   Most cases of metatarsus adductus that does not resolve is asymptomatic in adulthood and does not require surgery. [ 6 ]   Occasionally, persistent rigid metatarsus adductus can produce difficulty and significant pain associated with inability to find accommodating footwear. [ 5 ]   Surgical options include tasometatarsal capsulotomy with tendontransfers or tarsal osteotomies. [ 5 ]   Due to the high failure rate of capsulotomy and tendon transfer it is generally avoided. [ 6 ] [ 5 ]   Osteotomy (cutting of bone) and realignment of the medial cuneiform, cuboid, or second through fourth metatarsal the safer and most effective surgery in patients over the age of 3 years old with residual rigid metatarsus adductus. [ 5 ]


Nonoperative management:   There are no bracing, casting, or orthotic techniques that have been shown to impact resolution of tibial torsion. [ 5 ] [ 6 ]   This rotational limb variant does not increase risk for functional disability or higher rates of arthritis if unresolved. [ 6 ]  Management involves parental education and observational visits to monitor for failure to resolve. [ 15 ]


Surgical management:   Indications for surgical correction are a thigh foot angle greater than 15 degrees in a child greater than 8 years of age that is experiencing functional limitations because of their condition. [ 6 ]   Surgical correction is achieved most commonly through a tibial derotational osteotomy.  This procedure involves the cutting (osteotomy) and straightening (derotation) of the tibia, followed by internal fixation to allow the bone to heal in place. [ 15 ]


Nonoperative management:   Nonoperative treatment includes observation and parental education. Treatment modalities such as bracing, physical therapy, and sitting restrictions have not demonstrated any significant impact on the natural history of femoral anteversion. [ 6 ]


Surgical management:   Operative treatment is reserved for children with significant functional or cosmetic difficulties due to residual femoral anteversion greater than 50 degrees or internal hip rotation greater than 80 degrees after age 8. [ 5 ] [ 6 ]   Surgical correction is achieved  though a femoral derotation osteotomy. [ 8 ]  This procedure involves the cutting (osteotomy) and straightening (derotation) of the femur, followed by internal fixation and to allow the bone to heal in place. [ citation needed ]


Planovalgus deformity  is a postural deformity,  flat foot  typology,  very frequent in people with  cerebral palsy  and often due to muscle imbalance resulting in a predominance of the pronotory versus the supinatory forces.


Surgical treatment in the presence of planovalgus deformity can be of two types:
 [ 1 ]


Both techniques provide for a thirty-day subsequent protection with a plastered knee-high without load. [ citation needed ]


This article about a disease of musculoskeletal and connective tissue is a  stub . You can help Wikipedia by  expanding it .


Radioulnar synostosis  is a rare condition where there is an abnormal connection ( synostosis ) between the  radius  and  ulna  bones of the  forearm . [ 1 ]  This can be present at birth ( congenital ), when it is a result of a failure of the bones to form separately, or following an injury (post-traumatic). [ 2 ]


It typically causes  restricted movement  of the forearm, in particular rotation ( pronation  and  supination ), though is usually not painful unless it causes  subluxation  of the  radial head . [ 1 ]  It can be associated with  dislocation  of the radial head which leads to limited elbow extension. [ 2 ]


Congenital radioulnar synostosis is rare, with approximately 350 cases reported in journals. It typically affects both sides (bilateral) and can be associated with other skeletal problems such as hip and knee abnormalities, finger abnormalities ( syndactyly  or  clinodactyly ), or  Madelung's deformity . [ 1 ]  It is sometimes part of known genetic syndromes such as  Klinefelter syndrome  (48,XXXY variant),  Apert ,  Williams ,  Cornelia de Lange , or  Holt–Oram . [ 1 ] [ 3 ]  It has been reported to run in families typically following an  autosomal dominant  inheritance pattern, which means that children of an affected parent have a 50% chance of having the condition. [ 3 ]  When associated with  amegakaryocytic thrombocytopenia , this inheritance has been found to be caused by mutations to the  HOXA11  gene. [ 4 ]  It is also one of the known manifestations of the  fetal alcohol spectrum disorder , which results from prenatal exposure to alcohol. [ 5 ] [ 6 ]


Post-traumatic cases are most likely to develop following surgery for a forearm  fracture ; this is more common with high-energy injuries where the bones are broken into many pieces ( comminuted ). [ 1 ]  It can also develop following soft tissue injury to the forearm where there is  haematoma  formation. [ citation needed ]


Diagnosis at birthday [ clarification needed ]  is best done using ultrasound technology. In younger children and adults, diagnosis is done with x-ray machine at the radioulnar bones. [ citation needed ]


It is sometimes possible to correct the problem with surgery, though this has high failure rates for treatment of post-traumatic radioulnar synostosis. [ 1 ]  Indication for the surgical treatment of congenital radioulnar synostosis include severe disability due to bilateral disorder or hyperpronation ≥ 90°. [ 7 ]


Rounded shoulder posture (RSP) , also known as “mom posture”, [ 1 ]  is a common postural problem in which the resting position of the shoulders leans forward from the body’s ideal alignment. [ 1 ]  Patients usually feel slouched and hunched, [ 2 ]  with the situation deteriorating if left untreated. A 1992 study concluded that 73% of workers aged 20 to 50 years have a right rounded shoulder, [ 3 ]  and 66% of them have a left rounded shoulder. [ 3 ]  It is commonly believed that digitalisation [ 4 ]  combined with the improper use of digital devices have resulted in the prevalence of sedentary lifestyles, which contribute to bad posture. Symptoms of RSP will lead to upper back stiffness, neck stiffness and shoulder stiffness. [ 1 ]  It can be diagnosed by several tests, including physical tests [ 5 ]  and imaging tests. [ 5 ]  To prevent RSP from worsening, maintaining a proper posture, [ citation needed ]  doing regular exercise, [ 6 ]  and undergoing therapeutic treatments [ 7 ]  could be effective. If the situation worsens, patients should seek help from medical practitioners [ 8 ]  for treatments. If RSP is left untreated, chronic pain, [ 9 ]  reduction in lung capacity [ 10 ]  and worsened psychosocial health [ 11 ]  are likely to result.


Poor posture can cause rounded shoulders because of the  muscle imbalance [ 12 ]  and uneven weight distribution in our upper body. [ 13 ]  Long periods of time spent in positions that put undue strain on the shoulders and neck may wear out some of the muscles while weakening others. For instance, if an individual spends a long period of time in sitting positions without stretching, the chest and front arm muscles shorten and tighten, whereas the upper back and neck muscles weaken and lengthen. [ 14 ]  Due to this asymmetry, the shoulders may roll forward and the upper back may be rounded.


The development of RSP is often influenced by genetics, as certain inherited traits could possibly have an impact on bone structure, muscular strength, and connective tissue elasticity. [ 15 ]  For instance, some people naturally have a rounded upper back because of the way their spinal vertebrae are arranged. [ 16 ]  Others may naturally have muscles in their upper back and neck that are weaker and more prone to stretching, as well as with chest and front shoulder muscles that are more resistant to stretching.  Connective tissue disorders , such as  Ehlers-Danlos syndrome , [ 17 ]  could also alter the strength and elasticity of ligaments and tendons. [ 18 ]  The risk of  joint hypermobility  and instability will be increased.


When the brain detects a threat, whether it is physical or psychological, the body will prepare itself to react against the threat (also known as the “ fight or flight response ” [ 19 ] ). Common responses include tensing one’s jaw, contracting the  abdominal muscles , holding one’s breath and hunching one’s shoulders. [ 20 ]  Persistent psychological stressors such as career dissatisfaction, financial difficulties, or family problems [ 21 ]  may cause physical changes in the body like rounded shoulders, tension headaches and muscle tension. [ 22 ]


RSP could be a symptom of some medical conditions, such as  kyphosis ,  scoliosis  or  ankylosing spondylitis . [ 23 ]   Kyphosis  is a spinal disorder that contributes to excessive curvature of the upper back, [ 24 ]  leading to a hunched posture and RSP.  Scoliosis  refers to a condition where there is a sideways curve in a person's  spine , [ 25 ]  causing our shoulders to become uneven and rounded.


Symptoms of RSP include forward head posture, [ 3 ]  chronic shoulder and neck pain, [ 11 ]  as well as reduced mobility and flexibility in the shoulder; [ 26 ]  hindering the ability to perform daily activities.


The diagnosis of rounded shoulders involves a physical examination. Healthcare professionals will assess the patient’s posture, range of motion and strength during the examination. The following tests may be carried out:


Patients are instructed to stand normally with their hands by their sides. Their  coracoid process  (CP),  sternal notch  (SN),  posterolateral angle of acromion  (PLA), and adjacent  thoracic vertebral spine  (TS) are found and marked. [ 27 ]  The distance between the CP and SN, and the distance between the PLA and TS are measured with tape to calculate  scapular index  using the formula (CP to SN)/(PLA to TS) *100. [ 28 ]


The ability of the patient to move their shoulders and upper back through their complete range of motion [ 29 ]  will be assessed by the medical professionals to check if there are any restrictions or limitations.


Muscle strength  testing are also utilised to evaluate RSP. The following tests can assess the strength of muscles:


With this test, the strength of external rotators of the shoulders are examined, including the  infraspinatus  and  teres minor muscles . [ 30 ]  Patients are instructed to keep their forearms bent at right angles while holding their arms at their sides. Resistance will be applied on patients while the patient rotates their shoulders.


The middle and lower  trapezius , which are responsible for retracting the  scapula , are evaluated in this test. Patients are instructed to pose with their arms at the sides. [ 31 ]  Resistance is applied as the patients try to pinch their shoulder blades together.


Deltoid muscle  strength is measured by this test. [ 32 ]  Patients are instructed to lift the arm away from the body. Resistance is applied when the patients attempt to raise the arm during the test.


The examiner will feel the patient’s upper back and neck muscles with their hands to check the tightness, tension or abnormalities of muscles. [ 33 ]


Imaging tests such as  X-rays ,  CT scans  and  MRI [ 7 ]  scans are used to determine the cause and extent of RSP.


The examiner will be able to identify areas of weakness, and provide patients with a targeted exercise regime for treatment to improve RSP.


Although the cause of RSP is multifactorial, two major contributors to RSP are the tightness of the  pectoralis minor muscle  and the weakening of lower  trapezius  muscle. [ 34 ]  As the only  scapulothoracic muscle  anteriorly originating and inserting to the  scapula , the  pectoralis minor ’s function in favoring the internal and downward rotation of the scapula has been clinically established. [ 35 ]  Muscle strength deficits in the lower  trapezius  muscles are also a common clinical finding in patients with rounded shoulders as it has been speculated to restrict  zygapophyseal  extension in the middle to lower  thoracic spine . [ 36 ]  Therefore, RSP treatment often targets the symptoms or root causes associated with these problem areas.


A randomized, blinded and controlled experimental study concluded that physical therapy treatment targeting the pectoralis minor soft tissue combined with self-stretching significantly improved rounded shoulder posture. [ 37 ]  Commonly applied regimens include the  McKenzie exercise – [ 38 ]  a self therapy exercise consisting of repetitive motions such as mobilization and manipulation to aid posture correction; and the  Kendall exercise  for strengthening the deep  cervical flexor  and  pectoral muscle  to correct neck alignment.


Chiropractic adjustments, decompression therapy as well as therapeutic massages have also been known to unlock tight shoulders by strengthening the chest muscles. [ 39 ] [ 40 ]  By applying controlled forces to spinal joints, creating space between vertebrae [ 41 ]  and kneading soft tissues of the body [ 42 ]  respectively; these therapeutic treatments address core sources of rounded shoulders and restore musculoskeletal imbalances by realigning the spine and shoulders.


The prevalence of rounded shoulders is often linked to modern lifestyles, [ 43 ]  such as spending long hours sitting in front of a computer or hunching over a mobile device. [ 44 ]


One of the most direct preventive measure for rounded shoulders is consistently maintaining a good posture. [ 45 ]  Sitting up straight and engaging the core muscles to keep the shoulders back and down can help maintain proper alignment and prevent the shoulders from rounding forward. [ 46 ]  Additionally, stretching the chest muscles and strengthening the back muscles can also help improve posture. [ 47 ]  Exercises that strengthen the back muscles include rows, pull-ups, and shoulder blade squeezes. Exercises like doorway stretches for the chest can help stretch out tension that contributes to rounded shoulders. Synergistically implementing muscle strengthening and stretching can effectively prevent the development of rounded shoulders. [ 47 ] [ 48 ]


Rounded shoulders can also be prevented by taking frequent breaks from prolonged sitting to engage in regular physical activity. [ 6 ]  Activities that require arm and shoulder motion, such as swimming, walking, and other sports, can help to strengthen and stretch the associated muscles, improving posture and reducing the likelihood of developing rounded shoulders. [ 6 ]


However, if left undiagnosed, rounded shoulders can lead to several prolonged complications. The extent of postural abnormality may result in a significantly increased incidence of pain and discomfort in the neck, shoulders, and upper back, which then possibly affects overall health and well-being. [ 49 ]


Chronic pain  and discomfort brought on by the persistent tension in the muscles of the upper body may have a negative influence on everyday life. [ 9 ]  This discomfort leads to reduced  agility  and range of motion, making it harder to accomplish regular chores. A patient's quality of life may also be significantly impacted by unilateral cervicogenic headaches that originate in musculoskeletal tissue innervated by  cervical nerves  and progress to the  fronto-temporal  and  orbital areas . [ 50 ]


Lung capacity  reduction is another issue associated with rounded shoulders. The chest cavity might become constrained when the shoulders are positioned forward, making it more difficult to take deep breaths due to a lowered total lung capacity. Furthermore, secondary muscles of inspiration, such as the  serratus anterior ,  sternocleidomastoid , and  pectoralis minor , become weak as a result of the kyphotic posture and  posterior pelvic tilt  that flatten the  lumbar lordosis . [ 10 ]  Atypical breathing patterns then arise from the overactivation of secondary muscles of inspiration due to their weakness. [ 10 ] [ 51 ] [ 52 ]  This might lead to shortness of breath and exhaustion, making it increasingly difficult to participate in physical exercise. [ 10 ]


Rounded shoulders can also affect psychosocial and mental health [ 11 ]   Depression  and anxiety are two prevalent psychological side effects of chronic pain. Individuals with chronic pain may have anxiety about the future and their capacity to manage the pain, as well as depressive symptoms owing to the negative effects the pain has on their quality of life. If the pain is not being properly managed or if it is interfering with everyday tasks, these emotions can be particularly difficult to navigate. [ 53 ]  Social interactions could also be impacted by chronic pain. [ 54 ]  Patients with chronic pain could find that their discomfort makes it difficult for them to work, exercise, and socialize, which can lead to feelings of loneliness and frustration that might exacerbate the psychological issues outlined above.


Additional reported complications of rounded shoulders include poor balance, jaw pain,  migraines  and other issues.


RSP is an issue that should be addressed, as many serious complications, such as chronic pain, headaches, or breathing difficulties will result if left untreated. RSP may also lower one’s self-esteem and confidence because of its atypical appearance.


To prevent or correct RSP, individuals should maintain good posture when performing daily tasks, and take frequent breaks when necessary. Regular exercise is also useful in strengthening the upper back and neck muscles. Postural alignment, pain and discomfort will be reduced to improve our overall health and wellbeing.


Prolonged pain or discomfort as a result of rounded shoulders should be reported to medical practitioners. [ 33 ]  Seeking the counsel of a physician or physical therapist could help create a specific strategy for avoiding and treating the issue. Any underlying problems correlated to the patient’s lifestyle habits can be addressed by a healthcare expert, who can then suggest particular stretches and exercises to correct them. [ 8 ] [ 55 ]


Sciatica  is  pain  going down the leg from the  lower back . [ 1 ]  This pain may go down the back, outside, or front of the leg. [ 3 ]  Onset is often sudden following activities such as heavy lifting, though gradual onset may also occur. [ 5 ]  The pain is often described as shooting. [ 1 ]  Typically, symptoms are only on one side of the body. [ 3 ]  Certain causes, however, may result in pain on both sides. [ 3 ]   Lower back pain  is sometimes present. [ 3 ]  Weakness or numbness may occur in various parts of the affected leg and foot. [ 3 ]


About 90% of sciatica is due to a  spinal disc herniation  pressing on one of the  lumbar  or  sacral nerve  roots. [ 4 ]   Spondylolisthesis ,  spinal stenosis ,  piriformis syndrome ,  pelvic tumors , and  pregnancy  are other possible causes of sciatica. [ 3 ]  The  straight-leg-raising test  is often helpful in diagnosis. [ 3 ]  The test is positive if, when the leg is raised while a person is lying on their back, pain shoots below the knee. [ 3 ]  In most cases  medical imaging  is not needed. [ 2 ]  However, imaging may be obtained if bowel or bladder function is affected, there is significant loss of feeling or weakness, symptoms are long standing, or there is a concern for  tumor  or infection. [ 2 ]  Conditions that may present similarly are diseases of the hip and infections such as early  shingles  (prior to rash formation). [ 3 ]


Initial treatment typically involves  pain medications . [ 2 ]  However, evidence for effectiveness of the pain medication and  muscle relaxants  is lacking. [ 6 ]  It is generally recommended that people continue with normal activity to the best of their abilities. [ 3 ]  Often all that is required for sciatica resolution is time; in about 90% of people symptoms resolve in less than six weeks. [ 2 ]  If the pain is severe and lasts for more than six weeks, surgery may be an option. [ 2 ]  While surgery often speeds pain improvement, its long term benefits are unclear. [ 3 ]  Surgery may be required if complications occur, such as loss of normal bowel or bladder function. [ 2 ]  Many treatments, including  corticosteroids ,  gabapentin ,  pregabalin ,  acupuncture , heat or ice, and  spinal manipulation , have  limited or poor evidence  for their use. [ 3 ] [ 7 ] [ 8 ]


Depending on how it is defined, less than 1% to 40% of people have sciatica at some point in time. [ 4 ] [ 9 ]  Sciatica is most common between the ages of 40 and 59, and men are more frequently affected than women. [ 2 ] [ 3 ]  The condition has been known since ancient times. [ 3 ]  The first known modern use of the word  sciatica  dates from 1451, [ 10 ]  although  Dioscorides  (1st-century CE) mentions it in his  Materia Medica . [ 11 ]


The term "sciatica" usually describes a  symptom —pain along the  sciatic nerve  pathway—rather than a specific condition, illness, or disease. [ 4 ]  Some use it to mean any pain starting in the lower back and going down the leg. [ 4 ]  The pain is characteristically described as shooting or shock-like, quickly traveling along the course of the affected nerves. [ 12 ]  Others use the term as a  diagnosis  (i.e. an indication of cause and effect) for nerve dysfunction caused by compression of one or more lumbar or sacral nerve roots from a spinal disc herniation. [ 4 ]  Pain typically occurs in the distribution of a  dermatome  and goes below the knee to the foot. [ 4 ] [ 6 ]  It may be associated with neurological dysfunction, such as weakness and numbness. [ 4 ]


Modifiable risk factors for sciatica include  smoking ,  obesity , occupation, [ 9 ]  and physical sports where back muscles and heavy weights are involved. Non-modifiable risk factors include increasing age, being male, and having a personal history of  low back pain . [ 9 ]


Spinal disc herniation  pressing on one of the  lumbar  or  sacral nerve  roots is the most frequent cause of sciatica, being present in about 90% of cases. [ 4 ]  This is particularly true in those under age 50. [ 13 ]  Disc herniation most often occurs during heavy lifting. [ 14 ]  Pain typically increases when bending forward or sitting, and reduces when lying down or walking. [ 13 ]


Other compressive spinal causes include  lumbar spinal stenosis , a condition in which the  spinal canal , the space the spinal cord runs through, narrows and compresses the spinal cord,  cauda equina , or sciatic nerve roots. [ 15 ]  This narrowing can be caused by  bone spurs ,  spondylolisthesis ,  inflammation , or a  herniated disc , which decreases available space for the spinal cord, thus pinching and irritating nerves from the spinal cord that become the sciatic nerve. [ 15 ]  This is the most frequent cause after age 50. [ 13 ]  Sciatic pain due to spinal stenosis is most commonly brought on by standing, walking, or sitting for extended periods of time, and reduces when bending forward. [ 13 ] [ 15 ]  However, pain can arise with any position or activity in severe cases. [ 15 ]  The pain is most commonly relieved by rest. [ 15 ]


Piriformis syndrome is a condition that, depending on the analysis, varies from a "very rare" cause to contributing up to 8% of low back or buttock pain. [ 16 ]  In 17% of people, the sciatic nerve runs through the  piriformis muscle  rather than beneath it. [ 15 ]  When the piriformis shortens or spasms due to trauma or overuse, it is posited that this causes compression of the sciatic nerve. [ 16 ]  Piriformis syndrome has colloquially been referred to as "wallet sciatica" since a  wallet  carried in a rear hip pocket compresses the buttock muscles and sciatic nerve when the bearer sits down. Piriformis syndrome may be suspected as a cause of sciatica when the spinal nerve roots contributing to the sciatic nerve are normal and no herniation of a spinal disc is apparent. [ 17 ] [ 18 ]


Deep gluteal syndrome is non-discogenic, extrapelvic sciatic  nerve entrapment  in the deep gluteal space. [ 19 ]  Piriformis syndrome was once the traditional model of sciatic nerve entrapment in this anatomic region. The understanding of non-discogenic sciatic nerve entrapment has changed significantly with improved knowledge of posterior hip anatomy, nerve kinematics, and advances in  endoscopic  techniques to explore the sciatic nerve. [ 20 ] [ 21 ]  There are now many known causes of sciatic nerve entrapment, such as fibrous bands restricting nerve mobility, that are unrelated to the piriformis in the deep gluteal space. Deep gluteal syndrome was created as an improved classification for the many distinct causes of sciatic nerve entrapment in this anatomic region. [ 21 ]  Piriformis syndrome is now considered one of many causes of deep gluteal syndrome. [ 20 ]


Sciatic  endometriosis , also called catamenial or cyclical sciatica, is a sciatica whose cause is endometriosis. Its incidence is unknown. Diagnosis is usually made by an  MRI  or CT- myelography . [ 22 ]


Sciatica may also occur during pregnancy, especially during later stages, as a result of the weight of the  fetus  pressing on the sciatic nerve during sitting or during leg spasms. [ 15 ]  While most cases do not directly harm the woman or the fetus, indirect harm may come from the numbing effect on the legs, which can cause loss of balance and falls. There is no standard treatment for pregnancy-induced sciatica. [ 23 ]


Pain that does not improve when lying down suggests a nonmechanical cause, such as  cancer ,  inflammation , or  infection . [ 13 ]  Sciatica can be caused by tumors impinging on the spinal cord or the nerve roots. [ 4 ]  Severe back pain extending to the hips and feet, loss of bladder or bowel control, or muscle weakness may result from  spinal tumors  or  cauda equina syndrome . [ 15 ]  Trauma to the spine, such as from a car accident or hard fall onto the heel or buttocks, may also lead to sciatica. [ 15 ]  A relationship has been proposed with a latent  Cutibacterium acnes  infection in the intervertebral discs, but the role it plays is not yet clear. [ 24 ] [ 25 ]


The sciatic nerve comprises nerve roots L4, L5, S1, S2, and S3 in the spine. [ 26 ]  These nerve roots merge in the pelvic cavity to form the  sacral plexus  and the sciatic nerve branches from that. Sciatica symptoms can occur when there is pathology anywhere along the course of these nerves. [ 27 ]


Intraspinal, or discogenic sciatica refers to sciatica whose pathology involves the spine. In 90% of sciatica cases, this can occur as a result of a spinal disc bulge or  herniation . [ 14 ] [ 28 ]  Sciatica is generally caused by the compression of  lumbar nerves  L4 or L5 or  sacral nerve  S1. [ 29 ]  Less commonly,  sacral nerves  S2 or S3 may cause sciatica. [ 29 ]


Intervertebral spinal discs consist of an outer  anulus fibrosus  and an inner  nucleus pulposus . [ 14 ]  The  anulus fibrosus  forms a rigid ring around the  nucleus pulposus  early in human development, and the gelatinous contents of the nucleus pulposus are thus contained within the disc. [ 14 ]  Discs separate the spinal vertebrae, thereby increasing spinal stability and allowing nerve roots to properly exit through the spaces between the vertebrae from the spinal cord. [ 30 ]  As an individual ages, the  anulus fibrosus  weakens and becomes less rigid, making it at greater risk for tear. [ 14 ]  When there is a tear in the  anulus fibrosus , the  nucleus pulposus  may extrude through the tear and press against spinal nerves within the spinal cord,  cauda equina , or exiting  nerve roots , causing inflammation, numbness, or excruciating pain. [ 31 ]  Inflammation of spinal tissue can then spread to adjacent facet joints and cause  facet syndrome , which is characterized by lower back pain and referred pain in the  posterior thigh . [ 14 ]


Other causes of sciatica secondary to spinal nerve entrapment include the roughening, enlarging, or misalignment ( spondylolisthesis ) of  vertebrae , or  disc degeneration  that reduces the diameter of the lateral foramen through which nerve roots exit the spine. [ 14 ]   When sciatica is caused by compression of a  dorsal nerve root , it is considered a lumbar  radiculopathy  or  radiculitis  when accompanied by an inflammatory response. [ 15 ]


The sciatic nerve is highly mobile during hip and leg movements. [ 32 ] [ 33 ]  Any pathology which restricts normal movement of the sciatic nerve can put abnormal pressure, strain, or tension on the nerve in certain positions or during normal movements. For example, the presence of  scar tissue  around a nerve can cause traction neuropathy. [ 34 ]


A well known muscular cause of extraspinal sciatica is  piriformis syndrome . The  piriformis muscle  is directly adjacent to the course of the sciatic nerve as it traverses through the intrapelvic space. Pathologies of the piriformis muscle such as injury (e.g. swelling and scarring), inflammation (release of  cytokines  affecting the local cellular environment), or space occupying lesions (e.g. tumor, cyst, hypertrophy) can affect the sciatic nerve. [ 35 ]  Anatomic variations in nerve branching can also predispose the sciatic nerve to further compression by the piriformis muscle, such as if the sciatic nerve pierces the piriformis muscle. [ 36 ]


The sciatic nerve can also be entrapped outside of the pelvic space and this is called  deep gluteal syndrome . [ 19 ]  Surgical research has identified new causes of entrapment such as fibrovascular scar bands, vascular abnormalities,  heterotropic ossification ,  gluteal muscles ,  hamstring muscles , and the  gemelli - obturator internus  complex. [ 20 ]  In almost half of the endoscopic surgery cases, fibrovascular scar bands were found to be the cause of entrapment, impeding the movement of the sciatic nerve. [ 37 ] [ 38 ]


Sciatica is typically diagnosed by physical examination, and the history of the symptoms. [ 4 ]


Generally, if a person reports the typical radiating pain in one leg, as well as one or more neurological indications of nerve root tension or neurological deficit, sciatica can be diagnosed. [ 6 ]


The most frequently used diagnostic test is the  straight leg raise  to produce  Lasègue's sign , which is considered positive if pain in the distribution of the sciatic nerve is reproduced with passive flexion of the straight leg between 30 and 70 degrees. [ 39 ]  While this test is positive in about 90% of people with sciatica, approximately 75% of people with a positive test do not have sciatica. [ 4 ]  Straight leg raising of the leg unaffected by sciatica may produce sciatica in the leg on the affected side; this is known as the Fajersztajn sign. [ 15 ]  The presence of the Fajersztajn sign is a more specific finding for a herniated disc than Lasègue's sign. [ 15 ]  Maneuvers that increase intraspinal pressure, such as coughing, flexion of the neck, and bilateral compression of the  jugular veins , may transiently worsen sciatica pain. [ 15 ]


Imaging modalities such as  computerised tomography  or magnetic resonance imaging can help with the diagnosis of lumbar disc herniation. [ 40 ]  Both are equally effective at diagnosing lumbar disk herniation, but computerized tomography has a higher radiation dose. [ 6 ]   Radiography  is not recommended because disks cannot be visualized by  X-rays . [ 6 ]  The utility of  MR neurography  in the diagnosis of piriformis syndrome is controversial. [ 16 ]


Discography  could be considered to determine a specific disc's role in an individual's pain. [ 14 ]   Discography  involves the insertion of a needle into a disc to determine the pressure of disc space. [ 14 ]   Radiocontrast  is then injected into the disc space to assess for visual changes that may indicate an anatomic abnormality of the disc. [ 14 ]  The reproduction of an individual's pain during  discography  is also diagnostic. [ 14 ]


Cancer  should be suspected if there is previous history of it, unexplained weight loss, or unremitting pain. [ 13 ]  Spinal  epidural abscess  is more common among those who have  diabetes mellitus  or  immunodeficiency , or who have had  spinal   surgery ,  injection  or  catheter ; it typically causes  fever ,  leukocytosis  and increased  erythrocyte sedimentation rate . [ 13 ]  If cancer or spinal epidural abscess is suspected, urgent  magnetic resonance imaging  is recommended for confirmation. [ 13 ]   Proximal diabetic neuropathy  typically affects middle aged and older people with well-controlled type-2  diabetes mellitus ; onset is sudden, causing pain, usually in multiple  dermatomes , quickly followed by weakness. Diagnosis typically involves  electromyography  and  lumbar puncture . [ 13 ]   Shingles  is more common among the elderly and immunocompromised; typically, pain is followed by the appearance of a  rash  with small blisters along a single  dermatome . [ 13 ] [ 41 ]  Acute  Lyme radiculopathy  may follow a history of outdoor activities during warmer months in likely tick habitats in the previous 1–12 weeks. [ 42 ]  In the U.S., Lyme is most common in  New England  and  Mid-Atlantic  states and parts of  Wisconsin  and  Minnesota , but it is expanding to other areas. [ 43 ] [ 44 ]  The first manifestation is usually an  expanding rash  possibly accompanied by flu-like symptoms. [ 45 ]  Lyme can also cause a milder, chronic radiculopathy an average of 8 months after the acute illness. [ 13 ]


Sciatica can be managed with a number of different treatments [ 46 ]  with the goal of restoring a person's normal functional status and  quality of life . [ 14 ]  When the cause of sciatica is  lumbar disc herniation  (90% of cases), [ 4 ]  most cases resolve spontaneously over weeks to months. [ 47 ]  Initially treatment in the first 6–8 weeks should be conservative. [ 4 ]  More than 75% of sciatica cases are managed without surgery. [ 14 ]  Smokers with sciatica are strongly urged to  quit  in order to promote healing. [ 14 ]  Treatment of the underlying cause of nerve compression is needed in cases of  epidural abscess ,  epidural tumors , and  cauda equina syndrome . [ 14 ]


Physical activity is often recommended for the  conservative management  of sciatica for persons who are physically able. [ 3 ]  Bed rest is not recommended. [ 48 ]   Although structured exercises provide small, short-term benefit for leg pain, in the long term no difference is seen between exercise or simply staying active. [ 49 ]  The evidence for  physical therapy  in sciatica is unclear though such programs appear safe. [ 3 ]  Physical therapy is commonly used. [ 3 ]  Nerve mobilization techniques for sciatic nerve are supported by tentative evidence. [ 50 ]


There is no one medication regimen used to treat sciatica. [ 46 ]  Evidence supporting the use of  opioids  and  muscle relaxants  is poor. [ 51 ]  Low-quality evidence indicates that  NSAIDs  do not appear to improve immediate pain, and all NSAIDs appear to be nearly equivalent in their ability to relieve sciatica. [ 51 ] [ 52 ] [ 53 ]  Nevertheless, NSAIDs are commonly recommended as a first-line treatment for sciatica. [ 46 ]  In those with sciatica due to  piriformis syndrome ,  botulinum toxin  injections may improve pain and function. [ 54 ]  While there is little evidence supporting the use of epidural or systemic  steroids , [ 55 ] [ 56 ]  systemic steroids may be offered to individuals with confirmed disc herniation if there is a contraindication to NSAID use. [ 46 ]  Low-quality evidence supports the use of  gabapentin  for acute pain relief in those with chronic sciatica. [ 51 ]   Anticonvulsants  and  biologics  have not been shown to improve acute or chronic sciatica. [ 46 ]   Antidepressants  have demonstrated some efficacy in treating chronic sciatica, and may be offered to individuals who are not amenable to NSAIDs or who have failed NSAID therapy. [ 46 ]


If sciatica is caused by a herniated disc, the disc's partial or complete removal, known as a  discectomy , has tentative evidence of benefit in the short term. [ 57 ]  A modest reduction in pain is seen after 26 weeks, but not after one year (about 52 weeks). [ 48 ]   If the cause is spondylolisthesis or spinal stenosis, surgery appears to provide pain relief for up to two years. [ 57 ]


For non-discogenic sciatica, the surgical treatment is typically a  nerve decompression . A decompression seeks to remove tissue around the nerve that may be compressing it or restricting movement of the nerve. [ 58 ] [ 59 ] [ 60 ]


Low to moderate-quality evidence suggests that  spinal manipulation  is an effective treatment for acute sciatica. [ 3 ] [ 61 ]  For chronic sciatica, the evidence supporting spinal manipulation as treatment is poor. [ 61 ]  Spinal manipulation has been found generally safe for the treatment of disc-related pain; however, case reports have found an association with  cauda equina syndrome , [ 62 ]  and it is  contraindicated  when there are progressive neurological deficits. [ 63 ]


About 39% to 50% of people with sciatica still have symptoms after one to four years. [ 64 ]  In one study, around 20% were unable to work at their one-year followup, and 10% had surgery for the condition. [ 64 ]


Depending on how it is defined, less than 1% to 40% of people have sciatica at some point in time. [ 9 ] [ 4 ]  Sciatica is most common between the ages of 40 and 59, and men are more frequently affected than women. [ 2 ] [ 3 ]


Shoulder problems  including  pain , are  one of the more common reasons for physician visits for musculoskeletal symptoms. The shoulder is the most movable joint in the body.  However, it is an unstable joint because of the range of motion allowed. This instability increases the likelihood of joint injury, often leading to a degenerative process in which tissues break down and no longer function well.


Shoulder pain may be localized or may be referred to areas around the shoulder or down the arm. Other regions within the body (such as  gallbladder ,  liver , or  heart disease , or disease of the cervical spine of the neck) also may generate pain that the brain may interpret as arising from the shoulder. [ 1 ]


The  shoulder  joint is composed of three bones: the  clavicle  (collarbone), the  scapula  (shoulder blade), and the  humerus  (upper arm bone) (see diagram). Two joints facilitate shoulder movement. The  acromioclavicular (AC) joint  is located between the  acromion  (part of the scapula that forms the highest point of the shoulder) and the clavicle. The  glenohumeral joint , to which the term " shoulder joint " commonly refers, is a ball-and-socket joint that allows the arm to rotate in a circular fashion or to hinge out and up away from the body. The "ball" is the top, rounded portion of the upper arm bone or humerus; the "socket," or  glenoid , is a dish-shaped part of the outer edge of the scapula into which the ball fits.  Arm movement is further facilitated by the ability of the scapula itself to slide along the rib cage.  The capsule is a soft tissue envelope that encircles the glenohumeral joint. It is lined by a thin, smooth synovial membrane. [ citation needed ]


The bones of the shoulder are held in place by  muscles ,  tendons , and  ligaments . Tendons are tough cords of tissue that attach the shoulder muscles to bone and assist the muscles in moving the shoulder. Ligaments attach shoulder bones to each other, providing stability. For example, the front of the joint capsule is anchored by three glenohumeral ligaments. [ citation needed ]


The  rotator cuff  is a structure composed of tendons that, with associated muscles, holds the ball at the top of the humerus in the glenoid socket and provides mobility and strength to the shoulder joint. [ 2 ]


Four filmy sac-like structures called  bursa  permit smooth gliding between bone, muscle, and tendon. They cushion and protect the  rotator cuff  from the bony arch of the acromion. [ citation needed ]


Following are some of the ways doctors diagnose shoulder problems:


The shoulder joint is the most frequently dislocated major joint of the body. In a typical case of a dislocated shoulder, a strong force that pulls the shoulder outward (abduction) or extreme rotation of the joint pops the ball of the humerus out of the shoulder socket. Dislocation commonly occurs when there is a backward pull on the arm that either catches the muscles unprepared to resist or overwhelms the muscles. When a shoulder dislocates frequently, the condition is referred to as shoulder instability. A partial dislocation where the upper arm bone is partially in and partially out of the socket is called a subluxation. In the medical community, dislocation is commonly referred to as luxation. [ citation needed ]


Almost all shoulder dislocations are downwards (inferior) and of these, 95 percent are in a forward direction. Clinically this is referred to as an anterior dislocation of the glenohumeral joint. Not only does the arm appear out of position when the shoulder dislocates, but the dislocation also produces pain. Muscle spasms may increase the intensity of pain. Swelling and bruising normally develop, and in some cases there may be numbness and muscle weakness. Problems seen with a dislocated shoulder are tearing of the ligaments or tendons reinforcing the joint capsule and, less commonly, nerve damage. Doctors usually diagnose a dislocation by a physical examination, but X-rays are taken to confirm the diagnosis and to rule out a related fracture and other complications. X-rays are also taken after relocation to ensure it is in the correct place. [ citation needed ]


Doctors treat a dislocation by putting the head of the humerus back into the joint socket (glenoid fossa) of the scapula—a procedure called  manipulation and reduction . This is usually followed up with an X-ray to make sure the reduction did not fracture the surrounding bones. The arm is then immobilized in a sling or a device called a shoulder immobilizer for several days. Usually the doctor recommends resting the shoulder and applying ice three or four times a day. After pain and swelling have been controlled, the patient enters a rehabilitation program that includes exercises to restore the range of motion of the shoulder and strengthen the muscles to prevent future dislocations. These exercises may progress from simple motion to the use of weights. [ citation needed ]


After treatment and recovery, a previously dislocated shoulder may remain more susceptible to reinjury, especially in young, active individuals. Ligaments are stretched and may tear due to dislocation. Torn ligaments and other problems resulting from dislocation can increase the chance of repeated dislocation.  A shoulder that dislocates severely or often, injuring surrounding tissues or nerves, usually requires surgery to repair the damaged parts of the shoulder. [ citation needed ]


Sometimes the doctor performs surgery through a tiny incision into which a small scope (arthroscope) is inserted to observe the inside of the joint. After this procedure, called arthroscopic surgery, the shoulder is generally restrained by a sling for three to six weeks, while full recovery, including physical therapy, takes several months. Arthroscopic techniques involving the shoulder are relatively new and many surgeons prefer to repair a recurrent dislocating shoulder by the time-tested open surgery under direct vision. There are usually fewer repeat dislocations and improved movement following open surgery, but it may take a little longer to regain motion. [ citation needed ]


A shoulder separation occurs where the collarbone (clavicle) meets the shoulder blade (scapula). When ligaments that hold the AC (acromioclavicular) joint together are partially or completely torn, the outer end of the clavicle may slip out of place, preventing it from properly meeting the scapula. Most often the injury is caused by a blow to the shoulder or by falling on an outstretched hand. After injury it is hard to do a 180 degrees rotation. [ citation needed ]


Shoulder pain or tenderness and, occasionally, a bump in the middle of the top of the shoulder (over the AC joint) are signs that a separation may have occurred. Sometimes the severity of a separation can be detected by taking X-rays while the patient holds a light weight that pulls on the muscles, making a separation more pronounced. [ citation needed ]


A shoulder separation is usually treated conservatively by rest and wearing a sling. Soon after injury, an ice bag may be applied to relieve pain and swelling. After a period of rest, a therapist helps the patient perform exercises that put the shoulder through its range of motion. Most shoulder separations heal within two or three months without further intervention. However, if ligaments are severely torn, surgical repair may be required to hold the clavicle in place. A doctor may wait to see if conservative treatment works before deciding whether surgery is required. [ citation needed ]


While not directly a shoulder problem, this may affect shoulder functionality due to problems with sternoclavicular rotation.  A sternoclavicular separation occurs when the  sternum  separates from the clavicle at the  sternoclavicular joint .  Sternoclavicular separations (dislocation and subluxation) are rare [ 6 ]  and generally caused by accident.  If the clavicle is separated posteriorly (i.e. the clavicle separates and goes behind the sternum) the situation can be dangerous and the clavicle can cause damage to interior arteries, veins or organs. [ citation needed ]


An X-ray or CT Scan may be necessary to accurately diagnose a sternoclavicular separation. [ citation needed ]


Treatment consists of the standard use of plenty of rest, icing, NSAIDs and a sling.  The joint may need to be reduced (i.e. put back in place), especially after posterior separations.  In severe cases, surgery may be advised. [ citation needed ]


The "rotator cuff" is a group of four tendons that blend together as they attach to the upper end of the arm bone (humerus). These tendons transmit the force of muscles originating on the shoulder blade (scapula) to the arm providing rotational motion and centering or stability of the joint. [ citation needed ]


The rotator cuff tendons degenerate with age. [ 7 ] [ 8 ] [ 9 ] [ 10 ]  A group of respected scientists wrote in a review of existing evidence that, the theory that this degeneration is related to pinching (or impingement) between the head of the  humerus  and the  acromion  is now considered inaccurate. [ 11 ]  Rotator cuff pathology is similar in non-dominant compared to dominant and symptomatic compared to asymptomatic shoulder. [ 8 ] [ 9 ] [ 12 ] [ 13 ] [ 14 ] [ 15 ]  About two-thirds of all humans develop rotator cuff tendinopathy if they live to 70 years of age. [ 7 ]  The pathology is mucoid degeneration, not inflammation. [ 11 ]  The process can involve the intra-articular part of the long head of biceps in addition to the supraspinatus, infraspinatus, and subscapularis tendons. [ 16 ]


Tendinitis  is inflammation (redness, soreness, and swelling) of a tendon. In tendinitis of the shoulder, the rotator cuff and/or biceps tendon become inflamed, usually as a result of being pinched by surrounding structures. The injury may vary from mild inflammation to involvement of most of the rotator cuff. When the rotator cuff tendon becomes inflamed and thickened, it may get trapped under the acromion. Squeezing of the rotator cuff is called impingement syndrome. [ citation needed ]


An inflamed bursa is called  bursitis . Tendinitis and impingement syndrome are often accompanied by inflammation of the bursa sacs that protect the shoulder. Inflammation caused by a disease such as rheumatoid arthritis may cause rotator cuff tendinitis and bursitis. Sports involving overuse of the shoulder and occupations requiring frequent overhead reaching are other potential causes of irritation to the rotator cuff or bursa and may lead to inflammation and impingement. [ citation needed ]


The most commonly affected tendon is that of the supraspinatus muscle. Defects in the rotator cuff can come from an injury (cuff tear) or from degeneration (cuff wear). The degree to which a tendon is reparable depends on its quantity and quality. Degenerated tendons are often frail and retracted and may not be amenable to repair. Individuals that are elderly, smokers, or those having had cortisone injections often have weaker tendon tissue that fails without a significant injury. By contrast those whose tendon was torn by a substantial fall often have good quality tendon that can be repaired if surgery is performed promptly after the injury. The symptoms of rotator cuff disease include difficulty lifting the arm. Repair of a rotator cuff requires that the tendon be securely anchored to the bone at surgery and that the repair be protected for several months during healing. [ citation needed ]


Signs of these conditions include the slow onset of discomfort and pain in the upper shoulder or upper third of the arm and/or difficulty sleeping on the shoulder, similar condition can have sharp pain or discomfort when the upper shoulder is positioned at certain angles. Tendinitis and bursitis also cause pain when the arm is lifted away from the body or overhead. If tendinitis involves the biceps tendon (the tendon located in front of the shoulder that helps bend the elbow and turn the forearm), pain will occur in the front or side of the shoulder and may travel down to the elbow and forearm. Pain may also occur when the arm is forcefully pushed upward overhead. [ citation needed ]