Elbow (Olecranon) Bursitis

Elbow bursitis occurs in the olecranon bursa, a thin, fluid-filled sac that is located at the boney tip of the elbow (the olecranon). There are many bursae located throughout the body that act as cushions between bones and soft tissues, such as skin. They contain a small amount of lubricating fluid that allows the soft tissues to move freely over the underlying bone. Normally, the olecranon bursa is flat. If it becomes irritated or inflamed, more fluid will accumulate in the bursa and bursitis will develop.

Cause

Elbow bursitis can occur for a number of reasons.

Trauma. A hard blow to the tip of the elbow can cause the bursa to produce excess fluid and swell.

Prolonged pressure. Leaning on the tip of the elbow for long periods of time on hard surfaces, such as a tabletop, may cause the bursa to swell. Typically, this type of bursitis develops over several months.

People in certain occupations are especially vulnerable, particularly plumbers or heating and air conditioning technicians who have to crawl on their knees in tight spaces and lean on their elbows. Certain athletic activities may also prompt the development of olecranon bursitis, such as long holds of the plank position.

Infection. If an injury at the tip of the elbow breaks the skin, such as an insect bite, scrape, or puncture wound, bacteria may get inside the bursa sac and cause an infection. The infected bursa produces fluid, redness, swelling, and pain. If the infection goes untreated, the fluid may turn to pus.

Occasionally, the bursa sac may become infected without an obvious injury to the skin.

Medical conditions. Certain conditions, such as rheumatoid arthritis and gout, are associated with elbow bursitis.

Symptoms

Swelling.  The first symptom of elbow bursitis is often swelling. The skin on the back of the elbow is loose, which means that a small amount of swelling may not be noticed right away.

Pain. As the swelling continues, the bursa begins to stretch, which causes pain. The pain often worsens with direct pressure on the elbow or with bending the elbow. The swelling may grow large enough to restrict elbow motion.

Redness and warm to the touch. If the bursa is infected, the skin becomes red and warm. If the infection is not treated right away, it may spread to other parts of the arm or move into the bloodstream. This can cause serious illness. Occasionally, an infected bursa will open spontaneously and drain pus.

Hip Bursitis

Bursae, are small, jelly-like sacs that are located throughout the body, including around the shoulder, elbow, hip, knee, and heel. They contain a small amount of fluid, and are positioned between bones and soft tissues, acting as cushions to help reduce friction.

Bursitis is inflammation of the bursa. There are two major bursae in the hip that typically become irritated and inflamed. One bursa covers the bony point of the hip bone called the greater trochanter. Inflammation of this bursa is called trochanteric bursitis.

Another bursa — the iliopsoas bursa — is located on the inside (groin side) of the hip. When this bursa becomes inflamed, the condition is also sometimes referred to as hip bursitis, but the pain is located in the groin area. This condition is not as common as trochanteric bursitis, but is treated in a similar manner.

Symptoms

The main symptom of trochanteric bursitis is pain at the point of the hip. The pain usually extends to the outside of the thigh area. In the early stages, the pain is usually described as sharp and intense. Later, the pain may become more of an ache and spread across a larger area of the hip.

Typically, the pain is worse at night, when lying on the affected hip, and when getting up from a chair after being seated for a while. It also may get worse with prolonged walking, stair climbing, or squatting.

Risk Factors

Hip bursitis can affect anyone, but is more common in women and middle-aged or elderly people. It is less common in younger people and in men.

The following risk factors have been associated with the development of hip bursitis.
 

• Repetitive stress (overuse) injury. This can occur when running, stair climbing, bicycling, or standing for long periods of time.
• Hip injury. An injury to the point of your hip can occur when you fall onto your hip, bump your hip, or lie on one side of your body for an extended period of time.
• Spine disease. This includes scoliosis, arthritis of the lumbar (lower) spine, and other spine problems.
• Leg-length inequality. When one leg is significantly shorter than the other, it affects the way you walk, and can lead to irritation of a hip bursa.
• Rheumatoid arthritis. This makes the bursa more likely to become inflamed.
• Previous surgery. Surgery around the hip or prosthetic implants in the hip can irritate the bursa and cause bursitis.
• Bone spurs or calcium deposits. These can develop within the tendons that attach muscles to the trochanter. They can irritate the bursa and cause inflammation.

Description

Simply defined, tendinitis is inflammation of a tendon. Inflammation is the body's natural response to injury or disease, and often causes swelling, pain, or irritation. Some types of tendinitus include:

Biceps Tendinitis

Biceps tendinitis is an inflammation or irritation of the upper biceps tendon. Also called the long head of the biceps tendon, this strong, cord-like structure connects the biceps muscle to the bone in the shoulder socket.

Pain in the front of the shoulder and weakness are common symptoms of biceps tendinitis. They can often be relieved with rest and medication. In severe cases, you may  need surgery to repair the tendon.

Cause

In most cases, damage to the biceps tendon is due to a lifetime of normal activities. As we age, everyday wear and tear causes our tendons to slowly weaken. This degeneration can be worsened by overuse — repeating the same shoulder motions again and again.

Many jobs and routine chores can cause overuse damage. Sports — particularly those that require repetitive overhead motion, such as swimming, tennis, and baseball — can also put people at risk for biceps tendinitis.

Repetitive overhead motion may play a part in other shoulder problems that occur with biceps tendinitis. Rotator cuff tears, osteoarthritis, and chronic shoulder instability are often caused by overuse.

Symptoms

• Pain or tenderness in the front of the shoulder, which worsens with overhead lifting or activity
• Pain or achiness that moves down the upper arm bone
• An occasional snapping sound or sensation in the shoulder

Achilles Tendinitis

Achilles tendinitis is a common condition that occurs when the large tendon that runs down the back of your lower leg becomes irritated and inflamed. 

The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, climb stairs, jump, and stand on your tip toes. Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration. 

Noninsertional Achilles Tendinitis

In noninsertional Achilles tendinitis, fibers in the middle portion of the tendon have begun to break down with tiny tears (degenerate), swell, and thicken. Tendinitis of the middle portion of the tendon more commonly affects younger, active people.

Insertional Achilles Tendinitis

Insertional Achilles tendinitis involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone.

In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify (harden). Bone spurs (extra bone growth) often form with insertional Achilles tendinitis.

Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active. More often than not, however, it comes from years of overuse (long distance runners, sprinters).

Cause

Achilles tendinitis is typically not related to a specific injury. The problem results from repetitive stress to the tendon. This often happens when we push our bodies to do too much, too soon, but other factors can make it more likely to develop tendinitis, including:

• Sudden increase in the amount or intensity of exercise activity—for example, increasing the distance you run every day by a few miles without giving your body a chance to adjust to the new distance
• Tight calf muscles—Having tight calf muscles and suddenly starting an aggressive exercise program can put extra stress on the
• Achilles tendon
• Bone spur—Extra bone growth where the Achilles tendon attaches to the heel bone can rub against the tendon and cause pain

Symptoms

Common symptoms of Achilles tendinitis include:

• Pain and stiffness along the Achilles tendon in the morning
• Pain along the tendon or back of the heel that worsens with activity
• Severe pain the day after exercising
• Thickening of the tendon
• Bone spur (insertional tendinitis)
• Swelling that is present all the time and gets worse throughout the day with activity
• If you have experienced a sudden "pop" in the back of your calf or heel, you may have ruptured (torn) your Achilles tendon. See your doctor immediately if you think you may have torn your tendon.

Sprains, Strains and Other Soft-Tissue Injuries

The most common soft tissues injured are muscles, tendons, and ligaments. These injuries often occur during sports and exercise activities, but sometimes simple everyday activities can cause an injury.

Sprains, strains, and contusions, as well as tendinitis and bursitis, are common soft-tissue injuries. Even with appropriate treatment, these injuries may require a prolonged amount of time to heal.

Cause

Soft-tissue injuries fall into two basic categories: acute injuries and overuse injuries.

Acute injuries are caused by a sudden trauma, such as a fall, twist, or blow to the body. Examples include sprains, strains, and contusions.

Overuse injuries occur gradually over time when an athletic or other activity is repeated so often that areas of the body do not have enough time to heal between occurrences. Tendinitis and bursitis are common soft-tissue overuse injuries.

Common Acute Soft-Tissue Injuries

Acute soft-tissue injuries vary in type and severity. When an acute injury occurs, initial treatment with the RICE protocol is usually very effective. RICE stands for Rest, Ice, Compression, and Elevation.

• Rest. Take a break from the activity that caused the injury. If the injury is to your leg, your doctor may also recommend that you use crutches to avoid bearing weight.
• Ice. Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly to the skin.
• Compression. To prevent additional swelling and blood loss, wear an elastic compression bandage.
• Elevation. To reduce swelling, elevate the injury higher than your heart while resting.

Sprains

A sprain is a stretch and/or tear of a ligament, a strong band of connective tissue that connects the end of one bone with another. Ligaments stabilize and support the body's joints. For example, ligaments in the knee connect your thighbone (femur) with your shinbone (tibia), enabling you to walk.

The areas of the body that are most vulnerable to sprains are the ankles, knees, and wrists. A sprained ankle can occur when your foot turns inward, placing extreme tension on the ligaments of your outer ankle. A sprained knee can result from a sudden twist, and a wrist sprain can occur if you fall onto an outstretched hand.

Sprains are classified by severity:

• Grade 1 sprain (mild):  Slight stretching and some damage to the fibers of the ligament.
• Grade 2 sprain (moderate):  Partial tearing of the ligament. There is abnormal looseness (laxity) in the joint when it is moved in certain ways.
• Grade 3 sprain (severe):  Complete tear of the ligament. This may cause significant instability.

While the intensity varies, pain, bruising, swelling, and inflammation are common to all three categories of sprains. Treatment for sprains begins with the RICE protocol and physical therapy. Moderate sprains often require a period of bracing (for example, a CAM walking boot can be worn to help support and immobilize a sprained ankle). The most severe sprains may require surgery to repair torn ligaments.

Strains

A strain is an injury to a muscle and/or tendon. Tendons are fibrous cords of tissue that attach muscles to bone. Strains often occur in the back or leg (typically, the hamstring).

Similar to a sprain, a strain may be a simple stretch of your muscle or tendon, or it may involve a partial or complete tear of the muscle and tendon.  Symptoms of a strain may include pain, muscle spasm, muscle weakness, swelling, inflammation, and cramping.

Soccer, football, hockey, boxing, wrestling and other contact sports put athletes at risk for hamstring strains, as do sports that feature quick starts, such as hurdling, long jumping, and running races. Gymnastics, tennis, rowing, golf and other sports that require extensive gripping have a high incidence of hand sprains. Elbow strains frequently occur in racquet, throwing, and contact sports.

The recommended treatment for a strain is the same as for a sprain: rest, ice, compression and elevation. This should be followed by simple exercises to relieve pain and restore mobility. Surgery may be required for a more severe tear.

Contusions (Bruises)

Contusions occur when a direct blow (or repeated blows) by a blunt object strikes part of the body, crushing underlying muscle fibers and connective tissue without breaking the skin.  A contusion can result from falling or jamming the body against a hard surface. Discoloration of the skin is caused by blood pooling around the injury.

Most contusions are mild and respond well to the RICE protocol. If symptoms persist, medical care should be sought to prevent permanent damage to the soft tissues.

Common Overuse Soft-Tissue Injuries

Tendinitis

Tendinitis is an inflammation or irritation of a tendon or the covering of a tendon (called a sheath). It is caused by a series of small stresses that repeatedly aggravate the tendon. Symptoms typically include swelling and pain that worsens with activity.

Tiny tears in the Achilles tendon cause it to swell and thicken.

Professional baseball players, swimmers, tennis players, and golfers are susceptible to tendinitis in their shoulders and elbows. Soccer and basketball players, runners, and aerobic dancers are prone to tendon inflammation in their knees and ankles.

Tendinitis may be treated by rest to eliminate stress, anti-inflammatory medication, steroid injections, splinting, and exercises to correct muscle imbalance and improve flexibility. Persistent inflammation may cause significant damage to the tendon, which may require surgery.

Bursitis

Bursae, are small, jelly-like sacs that are located throughout the body, including around the shoulder, elbow, hip, knee, and heel. They contain a small amount of fluid, and are positioned between bones and soft tissues, acting as cushions to help reduce friction.

Bursitis is inflammation of a bursa. Repeated small stresses and overuse can cause the bursa to swell. Many people experience bursitis in association with tendinitis.

Bursitis can usually be relieved with changes in activity and anti-inflammatory medications, such as ibuprofen. If swelling and pain do not respond to these measures, your doctor may recommend removing fluid from the bursa and injecting a corticosteroid medication. The steroid medication is an anti-inflammatory drug that is stronger than the medication that can be taken by mouth. Corticosteroid injections usually help relieve pain and swelling.

Although surgery is rarely necessary for bursitis, if the bursa becomes infected, an operation to drain the fluid from the bursa may be necessary. In addition, if the bursa remains infected or the bursitis returns after all nonsurgical treatments have been tried, your doctor may recommend removal of the bursa.

Removal (excision) of the bursa can be done using a standard incision (open procedure), or as an arthroscopic procedure with small incisions and miniature surgical instruments. Your doctor will talk with you about which procedure is appropriate for your situation.

Prevention

Injuries often occur when people suddenly increase the duration, intensity, or frequency of their activities. Many soft-tissue injuries can be prevented through proper conditioning and training. Other prevention tips include:

• Use proper equipment.  Replace your athletic shoes as they wear out. Wear comfortable, loose-fitting clothes that let you move freely and are light enough to release body heat.
• Aim for balanced fitness.  Develop a balanced fitness program that incorporates cardiovascular exercise, strength training, and flexibility. Add activities and new exercises cautiously. Whether you have been sedentary or are in good physical shape, do not try to take on too many activities at one time. It is best to add no more than one or two new activities per workout.
• Warm up.  Warm up to prepare for exercise, even before stretching. Run in place for a few minutes, breathe slowly and deeply, or gently rehearse the motions of the exercise to follow. Warming up increases your heart and blood flow rates and loosens up muscles, tendons, ligaments, and joints.
• Drink water.  Drink enough water to prevent dehydration, heat exhaustion, and heat stroke. Drink 1 pint of water 15 minutes before you start exercising and another pint after you cool down. Have a drink of water every 20 minutes or so while you exercise.
• Cool down.  Make cooling down the final phase of your exercise routine. It should take twice as long as your warm-up. Slow your motions and lessen the intensity of your movements for at least 10 minutes before you stop completely. This phase of a safe exercise program should conclude when your skin is dry and you have cooled down.
• Stretch.  Begin stretches slowly and carefully until reaching a point of muscle tension. Hold each stretch for 10 to 20 seconds, then slowly and carefully release it. Inhale before each stretch and exhale as you release. Do each stretch only once. Never stretch to the point of pain, always maintain control, and never bounce on a muscle that is fully stretched.
• Rest.  Schedule regular days off from vigorous exercise and rest when tired. Fatigue and pain are good reasons not to exercise.
• Avoid the "weekend warrior" syndrome.  Try to get at least 30 minutes of moderate physical activity every day. If you are truly pressed for time, you can break it up into 10-minute chunks.

Fractures (Broken Bones)

A fracture is a broken bone, the same as a crack or a break. A bone may be completely fractured or partially fractured in any number of ways (crosswise, lengthwise, in multiple pieces).

Types of Fractures

Althouh bones are rigid,  they do bend, or give, somewhat when an outside force is applied. However, if the force is too great, bones will break, just as a plastic ruler breaks when it is bent too far.

The severity of a fracture usually depends on the force that caused the break. If the bone's breaking point has been exceeded only slightly, the bone may crack rather than break all the way through. If the force is extreme, such as that caused by an automobile crash or gunshot, the bone may shatter.

If the bone breaks in such a way that bone fragments stick out through the skin, or a wound penetrates down to the broken bone, the fracture is called an open fracture. This type of fracture is particularly serious because once the skin is broken, infection in both the wound and the bone can occur.

Common types of fractures include:

• Stable fracture. The broken ends of the bone line up and are barely out of place.
• Open (compound) fracture. The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound.
• Transverse fracture. This type of fracture has a horizontal fracture line.
• Oblique fracture. This type of fracture has an angled pattern.
• Comminuted fracture. In this type of fracture, the bone shatters into three or more pieces.

Cause

The most common causes of fractures are:

• Trauma. A fall, motor vehicle accident, or tackle during a football game can all result in fractures.
• Osteoporosis. This disorder weakens bones and makes them more likely to break.
• Overuse. Repetitive motion can tire muscles and place more force on bone. This can result in stress fractures. Stress fractures are more common in athletes.

Symptoms

Many fractures are very painful and may prevent you from moving the injured area. Other common symptoms include:

• Swelling and tenderness around the injury
• Bruising
• Deformity — a limb may look out of place, or a part of the bone may puncture through the skin

Fibromyalgia

Fibromyalgia is a chronic, long-term illness. It causes all-over muscle pain, joint pain and fatigue. The pain may come and go. There’s no known cause, although certain factors such as stress and genetics may predispose someone toward the disease. Although there isn’t a cure, medications, lifestyle changes and other therapies offer relief.

Anyone can get fibromyalgia, including children. Women are twice as likely as men to have fibromyalgia. Symptoms often appear during middle age. Up to 20% of patients who suffer from other chronic disorders such as rheumatoid arthritis, lupus and sarcoidosis can also have fibromyalgia.

Causes

What causes fibromyalgia? Medical experts don’t know why some people develop fibromyalgia. It sometimes runs in families. Certain conditions or events may bring on symptoms, such as:

• Stressors such as: being born premature, traumatic life events such as abuse, accidents.
• Medical conditions such as viral infections or other illnesses.
• Anxiety, depression, other mood disorders, PTSD.
• Poor sleep.
• Lack of exercise.

Symptoms

Widespread muscle pain and joint pain along with fatigue and poor sleep are the defining symptoms of fibromyalgia. The disease affects people differently. You may also experience:

• Anxiety or depression.
• Digestive problems, including diarrhea or constipation.
• Face or jaw pain (temporomandibular disorders).
• Headaches or migraines.
• Memory problems.
• Tingling or numbness in hands or feet.

Triggers of a fibromyalgia attack

Certain things can bring on fibromyalgia symptoms (a flare-up) especially those that increase the level of stress. These include:

• Changes in daily routines.
• Dietary changes or a poor diet.
• Hormone fluctuations.
• Lack of sleep.
• Stressors such as work-related, illness, emotional stress.
• Treatment changes.
• Change in sleep patterns (for example, shift work).
• Weather or temperature changes.

Cervical Radiculopathy (Pinched Nerve)

Cervical radiculopathy, commonly called a "pinched nerve," occurs when a nerve in the neck is compressed or irritated where it branches away from the spinal cord. This may cause pain that radiates into the shoulder and/or arm, as well as muscle weakness and numbness.

Cervical radiculopathy is often caused by "wear and tear" changes that occur in the spine as we age, such as arthritis. In younger people, it is most often caused by a sudden injury that results in a herniated disk. In some cases, however, there is no traumatic episode associated with the onset of symptoms.

In most cases, cervical radiculopathy responds well to conservative treatment that includes medication and physical therapy.

Cause

Cervical radiculopathy most often arises from degenerative changes that occur in the spine as we age or from an injury that causes a herniated, or bulging, intervertebral disk.

Degenerative changes. As the disks in the spine age, they lose height and begin to bulge. They also lose water content, begin to dry out, and become stiffer. This problem causes settling, or collapse, of the disk spaces and loss of disk space height.

As the disks lose height, the vertebrae move closer together. The body responds to the collapsed disk by forming more bone—called bone spurs—around the disk to strengthen it. These bone spurs contribute to the stiffening of the spine. They may also narrow the foramen—the small openings on each side of the spinal column where the nerve roots exit—and pinch the nerve root.

Degenerative changes in the disks are often called arthritis or spondylosis. These changes are normal and they occur in everyone. In fact, nearly half of all people middle-aged and older have worn disks and pinched nerves that do not cause painful symptoms. It is not known why some patients develop symptoms and others do not.

Herniated disk. A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive nerve root, causing pain and weakness in the area the nerve supplies.

A herniated disk often occurs with lifting, pulling, bending, or twisting movements.

Symptoms

In most cases, the pain of cervical radiculopathy starts at the neck and travels down the arm in the area served by the damaged nerve. This pain is usually described as burning or sharp. Certain neck movements—like extending or straining the neck or turning the head—may increase the pain. Other symptoms include:

• Tingling or the feeling of "pins and needles" in the fingers or hand
• Weakness in the muscles of the arm, shoulder, or hand
• Loss of sensation
• Some patients report that pain decreases when they place their hands on top of their head. This movement may temporarily relieve pressure on the nerve root.

Alternative Methods to Help Manage Pain After Orthopaedic Surgery

After orthopaedic surgery, your doctors and nurses will make every effort to control your pain. While you should expect to feel some discomfort, advancements in pain control now make it easier for your doctor to manage and relieve pain.

Surgeons and their patients are increasingly using alternative methods, such as relaxation techniques and acupuncture, to supplement conventional medicine. A combined approach to pain management is often the best option because it allows the surgeon to tailor pain control methods to each individual patient.

Transcutaneous Electrical Nerve Stimulation (TENS)

In transcutaneous electrical nerve stimulation (TENS) a special device transmits low-level electrical charges into the area of the body that is in pain.

A TENS system consists of a small, battery-powered machine connected by wires to a pair of electrodes. The two electrodes are connected to your skin near the source of pain or at a pressure point. A mild electrical current travels through your skin and along your nerve fibers which may cause a warm, tingling sensation. A typical TENS session lasts anywhere from 5 to 15 minutes.

Many studies have found that TENS is useful in easing pain after surgery, as well as pain related to injuries, such as fractures and sprains. TENS may also be helpful for some chronic pain conditions, particularly low back pain. TENS is generally considered safe. However, its routine use is not recommended.

There is also an acupuncture version of TENS in which the electrical impulses are sent through acupuncture needles instead of electrode pads. This form of TENS is called "electro-acupuncture" or percutaneous electrical nerve stimulation (PENS).

How TENS Works

There are several ways TENS is thought to relieve pain:

Gate Control Theory. In order for you to feel pain, the sensation must travel through a "gate" to get to the brain. Normally, the pain is allowed to flow freely through the gate because it (pain) is the only sensation trying to get through. However, if the gate becomes flooded with another type of sensation (in this case, an electric current), the gate will reach capacity and no longer have room for the underlying pain sensation to get through.

Release of Endogenous Opiates. Some scientists believe that TENS works by forcing certain nerve cells to release more of the body's natural pain killers called "endorphins." This causes you to feel less pain.

Central Inhibitory Effect. TENS may also work by changing the way your brain perceives pain.

When to Avoid TENS

TENS might not work as well if your pain is caused by mental or emotional problems. It also does not work as well if you suffer from drug addiction.

TENS should not be used if you have any of the following conditions:

• Implanted medical device (defibrillator or pacemaker)
• Pregnancy
• Epilepsy
• Mental retardation
• Undiagnosed pain

Continuous Passive Motion

Continuous passive motion (CPM) is a technique in which your joint is moved constantly in a mechanical splint to prevent stiffness and increase range of motion. A CPM machine moves your joint for you without requiring you to exert any effort.

Medical evidence indicates that in many cases immobilization increases pain after surgery. As a result, early motion has been applied to many orthopaedic problems. CPM is thought to be most effective in the rehabilitation treatment of:

• Cartilage damage
• A bacterial infection inside a joint
• A fracture around a joint after it has been fixed with internal devices
• CPM is believed to enhance the nutrition of your joint, discourage the formation of scar tissue, and prevent the abnormal shortening of the muscles surrounding your joints.
• This CPM machine cradles the lower leg and gently moves it.

If you can already move — either actively or passively — without CPM, then using the device will not be beneficial. CPM is not a substitute for working with an experienced physical therapist who is trained to provide both active and passive motion exercises. If your doctor recommends CPM, you will also be monitored by a physical therapist.

The most important time to use a CPM device seems to be in the first 2 to 7 days after surgery, for about 4 to 6 hours every day.

Initially, CPM was only used in hospitals or outpatient physical therapy clinics, but today, CPM units can be purchased for use at home.

Acupuncture

When acupuncture is combined with traditional pain relief methods, it may be helpful for some types of chronic pain:

• Low back pain
• Osteoarthritis
• Fibromyalgia
• Aching muscle pain (knots)
• Tennis elbow
• Carpal tunnel syndrome
• Stroke rehabilitation

Acupuncture points tend to be areas of your skin that contain relatively large amounts of intersecting nerve endings that feed into your muscles or bones. Some scientists believe that these "acupoints" possess special electrical characteristics that can be manipulated using painless hair-thin needles.

A typical acupuncture procedure lasts for about 30 minutes. Treatments are used to relieve local pain and swelling, as well as to provide a more general feeling of relaxation due to the release of your body's natural painkillers, called endorphins.

Because each acupoint is responsible for producing effects in different areas of the body, it is important to be clear with your provider about the specific area and intensity of your pain. The acupuncturist can then target the correct acupoint.

Psychological Methods

Psychological methods can be effective as an additional treatment for pain control. These methods can reduce or eliminate the need for medication. Some of oldest and best documented psychological methods include:

• Relaxation techniques
• Guided imagery
• Medical hypnosis

In 18 medical research studies, medical hypnosis, guided imagery, or relaxation techniques were used to improve recovery after surgery. In 16 of the studies (4 were orthopaedic surgeries), researchers documented improvements in both the physical and emotional recoveries of the patients.

These results demonstrated that psychological methods are effective as an additional treatment for pain management, postsurgical recovery (physical and emotional), and orthopaedic rehabilitation.

These methods appear to have potential in orthopaedic surgery that could reduce pain, enhance treatment outcomes, and contain or even reduce medical costs.