Our aim is to eliminate pain, reduce “sick” time and speed up your return to sports, work and your normal activities.
We are a Specialist Clinic in Singapore catered to the treatment of Sports and Orthopaedic problems. Our medical facility attends to all Orthopaedic needs and we specialize in complex musculoskeletal conditions and Orthopaedic trauma surgery (fractures, broken bones), leg lengthening, limb reconstruction, deformity correction, and non-union and bone infection surgery using the latest in orthopaedic techniques. We also focus on elective Orthopaedic surgery like knee arthroscopy, anterior cruciate ligament surgery, meniscus repair, bunion correction, carpal tunnel release and ingrown toenail correction amongst others.
Our clinic carries out diagnostic and therapeutic arthroscopy to operate on joints, reconstruction and recovery of ligaments and manages all sports related conditions of the shoulder, back, elbow, knee, foot and ankle. Our foot and ankle service provides treatment for bunions, heel pain, and deformity correction and arthritic conditions.
Our website contains educational resources for patients who you may like to read up on topics related to sports injuries, Orthopaedic problems and musculoskeletal pain and the treatments for conditions prior to consulting with us.
At our clinic we believe in a healthy holistic approach to Orthopaedic problems with integrity, honesty and openness as core values. We also believe that not all patients need operations and that every patient needs a proper management plan structured according to his/her needs and circumstances.
We are able to do same day X-rays and MRI Scans.
Our Clinic also provides local and overseas insurance liaison services to ensure that your treatment is adequately covered.
Please do not hesitate to contact us for further information you may require or to book an appointment at
Osteoarthritis (OA) of the Knee is one the most common knee joint disorder, which is due to aging and wear and tear on the knee joint.
Causes, incidence, and risk factors
Osteoarthritis of the knee is a normal result of aging. It is also caused by constant ‘wear and tear’ on the knee joint.
Cartilage is the firm, rubbery tissue that cushions your bones at the joints, and allows bones to glide over one another.
If the cartilage breaks down and wears away, the bones rub together. This causes pain, swelling, and stiffness around your knee.
Bony spurs or extra bone may form around the knee joint. The ligaments and muscles around the knee joint become weaker and stiffer which cause discomfort.
Often, the cause of Osteoarthritis of the knee is unknown. It is mainly related to aging.
The symptoms of Osteoarthritis of the knee usually appear in middle age. Almost everyone has some symptoms by age 70. However, these symptoms may be minor.
Before age 55, Osteoarthritis of the knee occurs equally in men and women. After age 55, it is more common in women.
Other factors can also lead to Osteoarthritis of the knee
Osteoarthritis of the knee tends to run in families.
Being overweight increases the risk of Osteoarthritis of the knee joints because extra weight causes more wear and tear.
Fractures or other joint injuries can lead to OA later in life. This includes injuries to the cartilage and cruciate ligaments in your knee joints.
Jobs that involve kneeling or squatting for more than an hour a day put you at the highest risk. Jobs that involve lifting, climbing stairs, or walking also put you at risk.
Playing sports that involve direct impact on the joint (such as football), twisting (such as basketball or soccer), or throwing also increase the risk of arthritis.
Medical conditions that can lead to Osteoarthritis of the knee include:
Bleeding disorders that cause bleeding in the joint, such as hemophilia
Disorders that block the blood supply near a joint and lead to avascular necrosis
Other types of arthritis, such as chronic gout, pseudogout, or rheumatoid arthritis
Pain and stiffness in the knee joints are the most common symptoms. The pain is often worse after exercise and when you put weight or pressure on the joint.
If you have Osteoarthritis of the knee, your knee joints probably become stiffer and harder to move over time. You may notice a rubbing, grating, or crackling sound when you move the knee joint.
The phrase “morning stiffness” refers to the pain and stiffness you may feel when you first wake up in the morning. Stiffness usually lasts for 30 minutes or less. It is improved by mild activity that “warms up” the joint.
During the day, the pain may get worse when you’re active and feel better when you are resting. After a while, the pain may be present when you are resting. It may even wake you up at night.
Some people might not have symptoms, even though x-rays show the changes of Osteoarthritis of the knee.
Signs and tests
A physical exam can show:
Joint movement may cause a cracking (grating) sound, called crepitation
Joint swelling (bones around the joints may feel larger than normal)
Limited range of motion
Tenderness when the joint is pressed
Normal movement is often painful
No blood tests are helpful in diagnosing Osteoarthritis of the knee.
An x-ray of affected joints will show a loss of the joint space. In advanced cases, there will be a wearing down of the ends of the bone and bone spurs.
Osteoarthritis of the knee will most likely get worse over time. However, your Osteoarthritis of the knee symptoms can be controlled.
You can have surgery, but other treatments can improve your pain and make your life much better. Although these treatments cannot make the arthritis go away, they can often delay surgery.
Over-the-counter pain relievers, which you can buy without a prescription, can help with Osteoarthritis of the knee symptoms. Most doctors recommend acetaminophen (Tylenol) first, because it has fewer side effects than other drugs. If your pain continues, your doctor may recommend nonsteroidal anti-inflammatory drugs (NSAIDs). Types of NSAIDs include aspirin, ibuprofen, and naproxen.
Other medications or supplements that you may use include:
Corticosteroids injected right into the joint to reduce swelling and pain
Over-the-counter remedies such as glucosamine and chondroitin sulfate
Capsaicin (Zostrix) skin cream to relieve pain
Artificial joint fluid (Synvisc, Hyalgan) can be injected into the knee to relieve pain for 3 – 6 months
Staying active and getting exercise helps maintain joint and overall movement. Ask your health care provider to recommend an appropriate home exercise routine. Water exercises, such as swimming, are especially helpful.
Other lifestyle recommendations include:
Applying heat and cold
Eating a healthy, balanced diet
Losing weight if you are overweight
Protecting the joints
As the pain from your Osteoarthritis of the knee becomes worse, keeping up with everyday activities may become more difficult or painful.
Sometimes making changes around the home will take some stress off your joints, and relieve some of the pain.
If your work is causing stress in certain joints, you may need to adjust your work area or change work tasks.
Severe cases of Osteoarthritis of the knee might need surgery to replace or repair damaged joints. Surgical options include:
Arthroscopic surgery to trim torn and damaged cartilage
Changing the alignment of a bone to relieve stress on the bone or joint (osteotomy)
Surgical fusion of bones, usually in the spine (arthrodesis)
Total or partial replacement of the damaged joint with an artificial joint (knee replacement, hip replacement, shoulder replacement, ankle replacement, elbow replacement)
Every person with Osteoarthritis of the knee is different. Pain and stiffness may prevent one person from performing simple daily activities, while others are able to maintain an active lifestyle that includes sports and other activities.
Your movement may become very limited over time. Doing everyday activities, such as personal hygiene, household chores, or cooking may become a challenge. Treatment usually improves function.
Ankle sprain is a common injury in Singapore athletes as well as the active adult. Most of the time, the ankle heals with a little care (rest, taping, ice). But one rare complication of lateral ankle sprains is a condition called peroneal tendon instability.
A lateral ankle sprain means the side of the ankle away from the other leg is sprained. The two peroneal tendons go down the leg and around the back of the ankle bone. The tendons set down inside a tunnel formed by bone and connective tissue called the retromalleolar groove. A fibrous band (the superior peroneal retinaculum) goes across the tendon to hold them in the groove.
When this fibrous retinaculum is ruptured, the tendons can dislocate or pop out of the groove. The result is persistent pain along the outside aspect of the ankle bones. There may be a painful popping or snapping sensation.
Swelling may mask the symptoms of tendon displacement at first. It’s only weeks to months later when the painful symptoms don’t go away that the additional tendon damage is recognized. Early MRIs may not show peroneal tendon instability, especially if the tendon pops in and out of the groove spontaneously.
A relaxed tendon is more likely to remain in the groove. Any active movement of the ankle will force the tendon out of its protective tunnel. If the ankle is relaxed and the tendon is repositioned correctly at the time of the imaging study, then diagnosis can be delayed. Dynamic ultrasound tests are the best diagnostic tests because they will reveal the movement of the unstable tendon.
Since this problem is rare, not much is known about the best way to treat it. Conservative (nonoperative) care is only possible when the unstable tendons can reposition inside the retromalleolar groove. A cast or boot placed on the lower leg will give the tendon a chance to heal.
If conservative care is unable to achieve a stable gliding tendon or if the tendon displacement is unstable from the start, then surgery is necessary. There are several different surgical options to consider. The fibrous protective sheath (retinaculum) can be reinforced or reconstructed. The groove can be reshaped (deepened) and rebuilt. The surgeon must be careful not to destroy or disrupt the smooth gliding surface of the bone that helps form the retromalleolar groove.
The retinaculum is repaired or reconstructed depending on the severity of the damage. Incision shape, drill holes, suture type and placement, and method for protecting the groove surface are discussed. Photos of each step in the surgical procedure are provided.
In summary, traumatic displacement of the peroneal tendons is a rare but painful complication of some lateral ankle sprains. Pain and swelling may mask the presence of this problem at the time of the injury with a delayed diagnosis. A careful examination with tenderness palpated over the torn retinaculum is the best way to accurately identify the injury. Treatment is usually surgical with the surgeon’s own preferred treatment presented.
Greater trochanteric pain syndrome is also often called trochanteric bursitis in Singapore. The main symptom is pain over the outside of your upper thigh. Most cases are due to minor injury or inflammation to tissues in your upper, outer thigh area. Anti-inflammatory painkillers, physiotherapy and steroid injections can all sometimes help.
What is trochanteric bursitis?
Trochanteric Bursitis pain syndrome is a condition that causes pain over the outside of your upper thigh (or thighs). The cause is usually due to inflammation or injury to some of the tissues that lie over the bony prominence (the greater trochanter) at the top of the thigh bone (femur). Tissues that lie over the greater trochanter include muscles, tendons, fascia (strong fibrous tissue), and bursae.
Greater trochanteric pain syndrome is also commonly called trochanteric bursitis in Singapore. This was because the pain was thought to be coming from an inflamed bursa that lies over the greater trochanter. A bursa is a small sac filled with fluid which helps to allow smooth movement between two uneven surfaces. There are various bursae in the body and they can become inflamed due to various reasons.
However, research suggests that most cases of greater trochanteric pain syndrome are due to minor tears or damage to the nearby muscles, tendons or fascia and an inflamed bursa is an uncommon cause.
Greater Trochanteric Pain Syndrome
How common is greater trochanteric bursitis?
It is a common condition. It is more common in women than in men. It most often occurs in people who are aged over fifty. However, it can also occur in younger people, especially runners. It is not clear exactly how many people develop this condition. However, one US study of 3026 people from 50-79 years of age found that greater trochanteric pain syndrome was present in nearly 1 in 4 women and nearly 1 in 10 men.
What causes greater trochanteric bursitis?
Causes of greater trochanteric bursitis include:
An injury such as a fall onto the side of your hip area.
Repetitive movements involving your hip area such as excessive running or walking.
Prolonged or excessive pressure to your hip area (for example, sitting in bucket car seats may aggravate the problem).
Some infections (for example, TB) and some diseases (for example, gout and arthritis) can be associated with an inflamed bursa.
The presence of surgical wire, implants or scar tissue in the hip area (for example, after hip surgery).
Having a difference in your leg length.
What are the symptoms of greater trochanteric bursitis?
The most common symptom is pain in your outer thigh and hip area. Many people find this pain to be a deep pain which may be aching or burning. The pain may become worse over time.
The pain may be more intense when you are lying on your side, especially at night. The pain may also be made worse by doing exercise. You may find that you walk with a limp.
How is greater trochanteric bursitis diagnosed?
The diagnosis is usually made based on your symptoms and an examination by a doctor. Dr Kevin Yip (Tel: +65 9724 1219) will usually examine your hip and legs. You may find it be to be very tender when Dr Kevin Yip presses over the trochanter area. Investigations are not normally needed unless your doctor suspects that infection of the bursa is the cause (rare), or if the diagnosis is not clear. For example, an X-ray of your hip or an MRI scan may be advised if the diagnosis is unclear.
What is the treatment of greater trochanteric bursitis?
Greater trochanteric bursitis is usually self-limiting. That is, it usually goes away on its own in time. However, it commonly takes several weeks for the pain to ease. Symptoms can persist for months, and sometimes longer in a small proportion of cases. However, persistence does not mean that there is a serious underlying condition or that the hip joint is being damaged.
Decreasing activity such as running or excessive walking for a while may help to speed recovery. In addition, the following may be useful:
Applying an ice pack (wrapped in a towel) for 10-20 minutes several times a day may improve your symptoms.
Taking paracetamol or non-steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen may help to reduce the pain.
Losing weight. If you are overweight or obese then losing some weight is likely to improve your symptoms.
Injection of steroid and local anaesthetic. If the above measures do not help then an injection into the painful area may be beneficial.
Physiotherapy. If a steroid injection does not improve your symptoms then you may be referred to a physiotherapist. They will be able to give you advice on improving your flexibility and strengthening your muscles.
If the condition is severe or persistent then you may be referred to a specialist (Tel: +65 9724 1219) for advice regarding further treatment.
Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used in Singapore for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.
Platelets are part of the blood that circulate around the body ready to help with blood clotting should you have a cut, broken bone, injury that bleeds internally, or any other type of injury. Besides containing clotting factors, the platelets release growth factors that help start the healing sequence. With a concentrated amount of platelets, larger quantities of these growth factors are released to stimulate a natural healing response. Plasma is the clear portion of the blood in which all the other blood particles such as platelets, red blood cells, and white blood cells travel.
Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems in Singapore, but gaining popularity quickly.
In theory, blood injection therapy could be used in any area where a rapid healing response is desired such as the tendon-muscle junction, muscle injuries, torn ligaments, damaged joints, or inflamed tissue (e.g., plantar fasciitis).
Torn tendons and ligaments don’t always heal well because they have a poor blood supply. Connective tissues such as ligaments and tendons heal by filling in with scar tissue that doesn’t bear the brunt of large loads well. This increases the risk of re-injury. Other available treatments for chronic tendon problems do not necessarily improve the tendon’s ability to heal in the same way that PRP does. And injections of PRP don’t have the side effects that can occur with steroid injections or long-term use of non-steroidal anti-inflammatory drugs (NSAIDs).
The platelet-rich plasma therapy has been around long enough now to start studying it more carefully. Researchers have found that the platelet-rich plasma preparation varies significantly from sample to sample. That means patients aren’t always getting the same amount of platelets and growth factors. This has been shown to be true from one treatment to the next and even from one patient to the next. The question comes up: why the differences?
To find out, researchers sampled blood from eight people on three separate occasions (baseline or first blood draw, fourteen days later, one month later). Each sample was analyzed for each patient at each of those time periods.
They used three different lab techniques to harvest the platelets: 1) a single-spin technique (referred to as LP), 2) an alternative single-spin method (the HP method, and 3) a double-spin (DS) technique. Each technique is carefully described for the reader including the number of minutes spun and the revolutions per minute.
In all cases, the HP (alternative single-spin separation method) gave the best results with the highest percentage of white blood cells and platelets. The one-step LP method far outperformed the other two methods.
There were clear differences in outcomes not only with the differing techniques used but also for the different times the samples were taken for each individual. The question naturally arises: why would platelet levels and white blood cell levels vary over time for the same person? The authors suggest age could make a difference. Or there could be a physiologic reason why these variations exist that we just don’t know about yet.
What the study does show is that the method of separation when obtaining platelet-rich plasma makes a difference in the number of white blood cells and platelets collected. Physicians may want to take this fact into consideration when selecting the method used.
For example, it might be helpful to choose the method that matches the intended use of the plasma. One thing to keep in mind is the fact that too many white blood cells can actually cause an overreaction in the tissues. And too much inflammation at certain points in the healing process may not be a good idea.
Perhaps the double spin method (yields lower levels of platelets and white blood cells) would work best when a mild healing response is needed. Likewise, there may be times and situations where increased antibacterial and an increased immune response would be helpful. In those cases, the single-spin method might be the most useful.
Some tips for the upcoming Adidas Sundown Marathon are, when it comes to pacing, top runners aren’t just fast-they’re also very, very consistent. Like finely calibrated metronomes, they quickly dial into a target pace and then hold it steady mile after mile. If you race, this skill is essential: Let the pace lag, and you give up time that you can’t claw back; accelerate too much, and you’ll pay for your exuberance with a late-race fade. If you run simply for fitness, a reliable sense of pace is just as valuable: Channel your inner Goldilocks – not too fast, not too slow, but just right-and you will better achieve the purpose of each workout. Of course, that’s easier said than done. The ability to run by feel is a skill that has to be learned. For example, in a study in the European Journal of Applied Physiology, researchers found that experienced collegiate runners could nail their pace to within about lO seconds per mile, while less seasoned recreational runners were off by an average of more than 40 seconds a mile. But simply running more isn’t sufficient-and neither is relying on a GPS, as you’ll never learn how to monitor internal feedback. You also have to adjust your training to fine-tune your inner pacemaker.
Most beginners have very little pace sense when they first start running. To fix that, we suggest paying attention to how your pace relates to your sense of effort. Which paces feel easy, medium, and hard? By focusing on cues like your breathing, the rhythm of your legs, and the motion of your arms, you’ll ingrain the physical sensations that correspond to different speeds.
Twice a week, time a mile in the middle of an easy run. Don’t speed up or slow down-the goal is to just gather information to gradually calibrate your internal speedometer. In your log, note your time and an effort rating on a scale of 1 to 10, along with brief comments on how your breathing and legs felt. After a few weeks, do the same thing during tempo runs to fine-tune your faster pace. Then try timing miles near the beginning and end of workouts to learn the difference between, say, tempo or goal race pace on tired legs and fresh legs. Spend at least a month in this awareness-building phase.
DITCH THE GADGETS
Some runners depend exclusively on their watches to tell them their speed. “Instead of relying on a sense of pace, they turn to the Garmin every 15 seconds and run like they’re in stop-and-go traffic.
Once you’re familiar with your split times during certain runs, start trying to guess your time for those sections-before you look at your watch. Initially, you may be a minute or more off per mile, but you’ll get better. It takes about six months of strict attention to feeling pace to consistently get within 10 seconds a mile of your goal pace.
To be able to call up any given pace on demand, the final step is to practice shifting back and forth between paces. “A lot of times people are great at hitting a certain pace, but only if they can lock into it and stay there. But in the real world, hills, sharp turns, or crowds can break your rhythm. Running work-outs that call for frequent pace changes will help you quickly resume your desired pace after a disruption.
The simplest exercise is to shift back and forth between two speeds. For example, alternate between 800 meters (or a half-mile) at tempo pace and 800 meters at one minute per mile slower than tempo pace for two to four miles. Initially, check your watch every 400 meters to ensure you’re hitting the proper speed. Then check every 800 meters. Use this exercise for all your training paces.
One of the most important and crucial pieces of advice we can give is to never go into a marathon head on with any existing pain or injuries. If you feel any discomfort around your knee cap region which could be a possible worn meniscus or any aches and pains around your anterior cruciate ligament, you should stop your practice and seek help immediately. If there is a prolong period of soreness and swelling after a run, stop rest and call your doctor. If you would like to schedule an assessment with us do call us at +65 9724 1219 or if you have any further queries you can call or email us at firstname.lastname@example.org
Some years ago I met a patient; Mr Chan Meng Hui. Having heard some of Mr Chan Meng Hui’s extraordinary stories, I have seen that there is more to this man than his passion about running. It is ultimately about overcoming the odds, and going through adversity while staying true to yourself. It is about hope and love for his fellow man, and letting one’s light shine and sharing it with the world. It is about an ordinary man who has achieved extraordinary things – all by the power of the will.
The fact that Mr Chan did not start running until he was 55 years old, and that to date he has completed 87 marathons not to mentions runs of various other distances including a 100 km trek through Mongolia (despite the risk of running in the dark, he managed to complete 66 km), made me feel extremely humbled. The fact that he is still running marathons at the age of 81 is just awesome.
Being part of a growing group of middle aged individuals who have taken up endurance sports at a relatively late stage in our lives, I can just about to appreciate what he has gone through to make it to where he is now with all those amazing achievements under his belt.
Someone once said that the longest distance in endurance races is the space between your two temples – the limiting factor in most people’s lives is the willpower (or lack of ) to get out of your comfort zone (and your comfortable chairs) and start putting one foot in front of the other.
Mr Chan feels strongly that if he can do it, anyone else can. As he is often asked how he has been able to achieve so much and how he got started, he tells everyone how he could barely run 100m when he first started. And his book is to inspire others to push themselves beyond their own perceived limits. In doing so, they will discover a whole new person underneath.
The below video is an interview with Mr Chan on how he started. If you have any queries to the questions in the video you can call us at +65 9724 1219
Most people’s feet point straight ahead or slightly outward. Some people’s feet, however, point inward a musculoskeletal condition referred to as in-toeing. In-toeing affects infants and children and is characterized by an inwardly rotated foot or feet, or, less often, an outwardly rotated foot or feet (sometimes called out-toeing ). Doctors may also refer to this as a rotational problem’ of the lower extremity, which can arise from abnormalities in the growth or alignment of the upper legs, lower legs, or feet. The vast majority of such problems, however, represent simply a physiological variation during a normal stage of development. As a result, a child may be pigeon-toed,’ or, alternatively, one or both feet appear splayed outwards. Depending on the specific cause of the condition, in-toeing may appear at different ages, from birth to adolescence.
There are three common causes of in-toeing: (1) medial femoral torsion (also called femoral anteversion ), in which the femur, or thighbone, is rotated inward; (2) medial tibial torsion (also called internal tibial torsion ), which is marked by an inwardly rotated tibia or shinbone in the lower leg; and (3) metatarsus adductus, in which the foot is bent inward like a kidney bean.
Out-toeing is much less common than in-toeing, but is caused by similar problems.
Some basic facts about in-toeing
Generally, children with in-toeing are otherwise completely healthy and do not suffer from other congenital abnormalities or diseases.
In-toeing does not cause arthritis or clumsiness.
In-toeing is significantly more common than out-toeing and occurs in about 2 out of every 1000 children.
Rotational problems are much more common in infants and young children than in adolescents.
The most common overall cause of in-toeing is tibial torsion, which usually becomes apparent when infants begin to walk. Tibial torsion :
Affects boys and girls to an equal degree
Is bilateral about two-thirds of the time, meaning that both legs are affected, but in most cases is asymmetrical (i.e. the legs are not affected equally, with one leg rotated more than the other)
Occurs more frequently in the left leg than the right leg when the condition is unilateral
Metatarsus adductus , another frequent cause of in-toeing, is the most common congenital foot deformity.
When the onset of in-toeing occurs in early childhood, it is most frequently due to medial femoral torsion. Femoral torsion :
Is usually diagnosed before 3 years of age, but the resulting in-toeing becomes most pronounced between 4 and 6 years of age
Is twice as common in girls than boys
Almost always presents symmetrically (i.e. affects both legs equally)
Is believed to be inherited, to some degree, because of the disproportionate number of cases that occur in siblings or offsprings of people who themselves had femoral torsion
Sometimes causes affected children to have an abnormal gait and difficulty running
Out-toeing is most often caused by lateral tibial torsion
Out-toeing caused by lateral tibial torsion is most often first seen during late childhood or adolescence. Lateral tibial torsion :
Unlike medial tibial torsion, is frequently unilateral and affects the right side more than the left side
When bilateral, is usually symmetrical
Can produce pain around the knee, called patellofemoral pain , which is not uncommon in adolescents (for a variety of reasons)
The normal leg and the normal foot
The upper portion of the leg consists of a single bone called the femur , or thighbone. The top of the femur inserts into the pelvis to form the hip joint, which is a ball-and-socket joint. The bottom of the femur connects to the lower portion of the leg at the knee joint, which is a hinge joint. The lower leg consists of two bones, the tibia and the fibula . The tibia is the shin bone, which is the larger of the two bones, bears most of the weight placed on the lower leg, and is located to the inside of the fibula. The other leg bone is the fibula , which is a thinner bone located to the outside of the tibia and runs parallel to it.
The foot has a complex musculoskeletal structure, consisting of 7 bones in the base of the foot, known as tarsal bones , 5 bones in the middle portion of the foot, called metatarsal bones , and a series of 14 small bones, or phalanges , which comprise the toes. The bones are attached to each other and to the lower leg bones by an integrated meshwork of thick, fibrous structures known as ligaments . The areas in which two bones make contact with each other are lined with smooth cartilage coated with a natural lubricating material known as synovial fluid , allowing them to slide past each other with minimal friction. These areas are the joints , and there are many joints in the foot, which collectively allow for movement in the foot and ankle.
When a fetus is developing in the womb, the lower limbs initially point outward, then begin rotating inward around the seventh week. However, this rotation causes the toes to point towards each other. During the rest of fetal development, the legs gradually rotate laterally again. This lateral rotational growth continues slightly during childhood, but by the time of birth, the feet are approximately pointed straight forward. A small amount of rotation in infant legs is considered within the range of normal growth variation and is referred to as version. An abnormal amount of rotation is termed torsion .
What causes in-toeing
In healthy children, in-toeing is caused by three conditions. They are metatarsus adductus, internal tibial torsion, and increased femoral anteversion:
Metatarsus Adductus : Metatarsus adductus is an inward curve of the forefoot. The hindfoot, or heel, is normal. It is usually caused before the baby is born due to the way the baby was packed inside the uterus or womb. Generally, the curve is very flexible and the foot can be straightened by gently pushing it in the opposite direction. In 90% of infants, this bend will resolve on its own. If, after 3-4 months, the curve persists, the foot may benefit from gentle stretching exercises in order to straighten it. If the foot is more rigid, casting is sometimes performed. The goal of treatment is to have a foot that will fit comfortably in a shoe. A little residual inward bending will not cause pain or functional problems. Surgery is very rarely necessary.
Internal Tibial Torsion : Internal tibial torsion is a twist in the tibia or the large bone in the lower leg. It is typically first noticed by parents when their child begins walking. It usually affects both legs equally. Most infants have some internal twist of the tibia that disappears by one year of age. If it persists, it is called internal tibial torsion. The cause is unknown but is believed to be related to the way the baby was positioned inside the uterus. In some cases, it may run in families. Typically, the child will stand or walk with the knees pointing forwards, but the feet turning in. In the past, tibial torsion was treated with boots connected by bars that held the feet turned outward. Many children have been treated this way and most of them have developed perfectly straight legs. The problem is that many children who were not treated with the boots and bars also developed straight legs. It turns out that most children correct their twist on their own without any treatment at all. In very rare instances, the child may still have internal tibial torsion as a young adolescent. If this becomes a cosmetic problem for the patient, the bone may be cut and rotated outward to improve the appearance. Internal tibial torsion does not lead to arthritis.
Increased Femoral Anterversion : Increased femoral anteversion is an inward twisting of the thigh bone or femur. Many children are born with a small twist of their femur, however this generally improves within the first few years of life. If it persists, the condition is called increased femoral anteversion. Typically, a 3-8 year old child is brought to the physician because the parents have noted in-toeing. The child will stand with the kneecaps and toes pointing inward. It is diagnosed by measuring and comparing the degree of inward and outward rotation of the child’s hips. Recent studies examining many children over time have confirmed that femoral anterversion corrects on its own. Special braces, shoes, and exercises are not needed. Even when it does not resolve completely, it does not cause any functional problems. Very rarely, an adolescent will be unhappy with the appearance of their legs. In this uncommon circumstance, an operation may be necessary to correct the rotation.
How is in-toeing diagnosed?
As described above, in-toeing or out-toeing may begin to manifest itself at different ages, depending on the underlying musculoskeletal cause of the condition. When a rotational problem of the lower extremities is suspected, a complete physical examination will be performed to evaluate the severity of the condition and its cause, and to ensure that no other deformities or orthopaedic conditions are present. An assessment known as the rotational profile (also called the torsional profile ) will also be performed, which involves taking six different measurements of the angles of the feet, legs, and hips when the child is in various positions and when walking or running. This allows for detection of isolated abnormal angles and facilitates identification of the cause of the rotational problem. X-rays of the legs and feet will also be taken to assist with definitive diagnosis and treatment planning. More sophisticated radiographic imaging techniques, such as a CT (computed tomography) scan and MRI (magnetic resonance imaging), are sometimes performed as well.
Coping with in-toeing or out-toeing
Rotational problems are common in infants and children. However, the majority of deformities are minor, will not cause functional deficiencies, and will resolve on their own. Operative treatment is rarely necessary. Children with in-toeing or out-toeing go on to have no limitations in their activities, from simple outdoor games to competitive sports. Therefore, although rotational problems may present some early challenges for children and parents alike, parents can expect their child to live a normal, active, and healthy life.
Naturally, you may have other questions about in-toeing or out-toeing that are not answered in the above summary. As your orthopaedic surgeon, we welcome any and all questions you may have, which we urge you to pose during your next office visit. Do give us a call at +65 9724 1219 or email us at email@example.com if you have any further queries.
Leg length discrepancy is an orthopaedic problem that usually appears in childhood, in which one’s two legs are of unequal lengths. Often abbreviated as ‘LLD,’ leg length discrepancy may be caused by or associated with a number of other orthopaedic or medical conditions, but is generally treated in a similar fashion, regardless of cause and depending on severity. Leg length discrepancy is sometimes divided up into ‘true LLD’ and ‘functional LLD.’ Functional LLD occurs when the legs are actually equal in length, but some other condition, such as pelvic obliquity (a tilt in the position of the pelvis), creates the appearance of legs of different lengths. True LLD will be the focus of this website and its causes are more fully described in the below section (?What causes leg length discrepancy?’).
As patients develop LLD, they will naturally and even unknowingly attempt to compensate for the difference between their two legs by either bending the longer leg excessively or standing on the toes of the short leg. When walking, they are forced to step down on one side and thrust upwards on the other side, which leads to a gait pattern with an abnormal up and down motion. For many patients, especially adolescents, the appearance of their gait may be more personally troublesome than any symptoms that arise or any true functional deficiency. Over time, standing on one’s toes can create a contracture at the ankle, in which the calf muscle becomes abnormally contracted, a condition that can help an LLD patient with walking, but may later require surgical repair.
If substantial enough, LLD left untreated can contribute to other serious orthopaedic problems, such as degenerative arthritis, scoliosis, or lower back pain. However, with proper treatment, children with leg length discrepancy generally do quite well, without lingering functional or cosmetic deficiencies.
Some basic facts about leg length discrepancy
The majority of people in the world actually have some degree of leg length discrepancy, up to 2cm. One study found that only around 1/4 of people have legs of equal lengths. LLD of greater than 2cm is relatively rare, however, and the greater the discrepancy, the greater the chances of having a clinical problem down the road.
A limp generally begins when LLD exceeds 2cm and becomes extremely noticeable above 3cm.
When patients with LLD develop an abnormal gait, one of the debilitating clinical features can be fatigue because of the relatively high amount of energy needed to walk in the new, inefficient way.
Poliomyelitis, or polio, as it is more commonly known, used to account for around 1/3 of all cases of LLD, but due to the effectiveness of polio vaccines, it now represents a negligible cause of the condition.
Functional LLD, described above, usually involves treatment focused on the hip, pelvis, and/or lower back, rather than the leg. If you have been diagnosed with functional LLD or pelvic obliquity, please ask your orthopaedic surgeon for more information about treatment of these conditions.
The normal leg
The upper portionof the leg consists of a single bone called the femur, or thighbone. The top of the femur inserts into the pelvis to form the hip joint, which is a ball-and-socket joint. The bottom of the femur connects to the lower portion of the leg at the knee joint, which is a hinge joint. The lower leg consists of two bones, the tibia and the fibular. The tibia is the shin bone, which is the larger of the two bones and bears most of the weight placed on the lower leg, and is located to the inside of the fibular, closer to the other leg. The other leg bone is the fibular, which is a thinner bone located to the outside of the tibia and runs parallel to it.
Like all long bones in the human body, the tibia does most of its growing not in the middle, but at the end of the bone during childhood, in a region known as the epiphysis . The epiphysis is responsible for the rapid production of bone and cartilage cells and the gradual lengthening of the leg.
What causes leg length discrepancy?
The causes of LLD may be divided into those that shorten a limb versus those that lengthen a limb, or they may be classified as affecting the length versus the rate of growth in a limb. For example, a fracture that heals poorly may shorten a leg slightly, but does not affect its growth rate. Radiation, on the other hand, can affect a leg’s long-term ability to expand, but does not acutely affect its length.
Causes that shorten the leg are more common than those that lengthen it and include congenital growth deficiencies (seen in hemiatrophy and skeletal dysplasias ), infections that infiltrate the epiphysis (e.g. osteomyelitis ), tumors, fractures that occur through the growth plate or have overriding ends, Legg-Calve-Perthes disease, slipped capital femoral epiphysis (SCFE), and radiation. Lengthening can result from unique conditions, such as hemihypertrophy , in which one or more structures on one side of the body become larger than the other side, vascular malformations or tumors (such as hemangioma ), which cause blood flow on one side to exceed that of the other, Wilm’s tumor (of the kidney), septic arthritis, healed fractures, or orthopaedic surgery.
Leg length discrepancy may arise from a problem in almost any portion of the femur or tibia. For example, fractures can occur at virtually all levels of the two bones. Fractures or other problems of the fibula do not lead to LLD, as long as the more central, weight-bearing tibia is unaffected. Because many cases of LLD are due to decreased rate of growth, the femoral or tibial epiphyses are commonly affected regions.
How is it diagnosed?
Leg length discrepancy may be diagnosed during infancy or later in childhood, depending on the cause. Conditions such as hemihypertrophy or hemiatrophy are often diagnosed following standard newborn or infant examinations by a pediatrician, or anatomical asymmetries may be noticed by a child’s parents. For young children with hemihypertophy as the cause of their LLD, it is important that they receive an abdominal ultrasound of the kidneys to insure that Wilm’s tumor, which can lead to hypertrophy in the leg on the same side, is not present.
In older children, LLD is frequently first suspected due to the emergence of a progressive limp, warranting a referral to a pediatric orthopaedic surgeon. The standard workup for LLD is a thorough physical examination, including a series of measurements of the different portions of the lower extremities with the child in various positions, such as sitting and standing. The orthopaedic surgeon will observe the child while walking and performing other simple movements or tasks, such as stepping onto a block. In addition, a number of x-rays of the legs will be taken, so as to make a definitive diagnosis and to assist with identification of the possible etiology (cause) of LLD. Orthopaedic surgeons will compare x-rays of the two legs to the child’s age, so as to assess his/her skeletal age and to obtain a baseline for the possibility of excessive growth rate as a cause. A growth chart, which compares leg length to skeletal age, is a simple but essential tool used over time to track the progress of the condition, both before and after treatment. Occasionally, a CT scan or MRI is required to further investigate suspected causes or to get more sophisticated radiological pictures of bone or soft tissue.
How is it treated?
The treatment of LLD depends primarily on the diagnosed cause, the age of the patient, and the severity of the discrepancy. Non-operative treatment is usually the first step in management and, in many cases, LLD is mild or is predicted to lessen in the future, based on growth rate estimates in the two legs. In such cases, no treatment may be necessary or can be delayed until a later stage of physical maturity that allows for clearer prognostic approximation. For LLD of 2cm to 2.5cm, treatment may be as simple as insertion of a heel lift or other shoe insert that evens out leg lengths, so to speak. For more severe cases, heel lifts can affect patient comfort when walking, decrease ankle stability, and greatly increase the risk of sprains. For infants with congenital shortening of the limb, a prosthetic ? often a custom-fit splint made of polypropylene ? may be successful in treating more severe LLD without surgery.
In many instances, however, a surgical operation is the best treatment for LLD. Surgeries for LLD are designed to do one of three general things ? shorten the long leg, stop or slow the growth of the longer or more rapidly growing leg, or lengthen the short leg.
Stopping the growth of the longer leg is the most commonly utilized of the three approaches and involves an operation known as an epiphysiodesis , in which the growth plate of either the lower femur or upper tibia is visualized in the operating room using fluoroscopy (a type of real-time radiographic imaging) and ablated , which involves drilling into the region several times, such that the tissue is no longer capable of bone growth. Because the epiphyseal growth capabilities cannot be restored following the surgery, proper timing is crucial. Usually the operation is planned for the last 2 to 3 years of growth and has excellent results, with children leaving the hospital within a few days with good mobility. However, it is only appropriate for LLD of under 5cm.
Leg shortening is employed when LLD is severe and when a patient has already reached skeletal maturity. The actual surgery is called an osteotomy , which entails the removal of a small section of bone in the tibia (shinbone) and sometimes the fibula as well, resulting in the loss of around an inch in total height.
Leg lengthening is a difficult third option that has traditionally had a high complication rate. Recently, results have improved somewhat with the emergence of a technique known as callotasis , in which only the outer portion of the bone (the cortex ) is cut, (i.e. a corticotomy ). This allows the bone to be more easily lengthened by an external fixation device that is attached to either side of the cut bone with pins through the skin. The ?ex-fix,’ as it is sometimes called, is gradually adjusted by an orthopaedic surgeon, and healing can occur at the same time that the leg is being distracted , or lengthened over time. Unlike epiphysiodesis, leg lengthening procedures can be performed at almost any skeletal or chronological age.
Coping with leg length discrepancy
For some cases of leg length discrepancy, real adjustments may be required for parents and their child with the condition. Frequent visits to the doctor or a surgical operation at a young age can represent an emotional and physical challenge for children and parents alike. However, almost all patients respond tremendously well to treatment and the condition does not present any lingering deformities. Moreover, the vast majority of children with LLD have no future restrictions on their activities and abilities following treatment, from everyday walking to demanding, competitive sports.
Naturally, you may have other questions about leg length discrepancy that are not answered in the above summary. As your orthopaedic surgeons, we welcome any and all questions you may have, which we urge you to pose during your next office visit. Do call us at +65 9724 1219 if you have any queries.
In case of significant arthritic changes of the facet joints with hypertrophy of the capsule, hypertrophied facet osteophytes, incomplete spontaneous fusion of the facet joints, and air inclusion, the patients may profit from a facet joint infiltration. If a temporary pain release can be reached, a direct fusion or screw fixation of the arthritic joint may be quite helpful. The so-called “facet joint syndrome” which is radiologically difficult to identify, even with MRI, is a diagnosis which rarely goes along with long-lasting periods of pain relief after
surgical treatment. Even if the facet joint infiltration may be suggestive for a facet joint syndrome, the pain relief through fusion may only be temporarily. In a recent study it has been demonstrated that cases where there is fluid in the lumbar facet joints, detected on MRI, as well as instability in flexion lumbar radiographs, in patients with L4/5 degenerative disease,
pain correlates well with the morphological findings. Therefore, fluid on MRI in the facet joints should raise suspicion of lumbar instability and qualifies for fusion
The X-rays, respectively the MRI, of significant facet arthritis should be done supine as well as standing to demonstrate the fluid in the joint. When standing, the fluid is pressed out and the facet joints are almost locked. When the patient is supine, the joints may open and air inclusion can be demonstrated on the conventional X-rays as well as fluid in the joints. These
patients often indicate typical pain in the night when turning in bed which wakes them up and pain in the morning while getting up until the facet joints have “settled” under the axial load. True facet joint arthritis, as the relevant pain source, can usually be stabilized with simple translaminar or transfacetal screws. In case of a still significantly good disk, a combination with an
anterior interbody fusion through a TLIF or PLIF may be mandatory to get the patient pain-free.
Kyphotic curves refer to the outward curve of the thoracic spine (at the level of the ribs).
Lordotic curves refer to the inward curve of the lumbar spine (just above the buttocks).
Scoliotic curving is a sideways curvature of the spine and is always abnormal.
A small degree of both kyphotic and lordotic curvature is normal. Too much kyphotic curving causes round shoulders or hunched shoulders (Scheuermann’s disease).
Too much lordotic curving is called swayback (lordosis). Lordosis tends to make the buttocks appear more prominent. Children with significant lordosis will have a significant space beneath their lower back when lying on their back on a hard surface.
If the lordotic curve is flexible (when the child bends forward the curve reverses itself), it is generally not a concern. If the curve does not move, medical evaluation and treatment are needed.
Corns and calluses are annoying and sometimes painful thickenings that form in the skin in areas of pressure. The medical term for the thickened skin that forms corns and calluses is hyperkeratosis. A callus refers to a more diffuse, flattened area of thick skin, while a corn is a thick, localized area that usually has a conical or circular shape. Corns, also known as helomas, sometimes have a dry, waxy, or translucent appearance.
Corns and calluses occur on parts of the feet and sometimes the fingers. Corns can be painful to walk on, even when they are small. Common locations for corns are
on the sole, over the metatarsal arch (the “ball” of the foot);
on the outside of the fifth (small or “pinky”) toe, where it rubs against the shoe; and
between the fourth and fifth toes. Unlike other corns that are firm and flesh-colored, corns between the toes are often whitish and messy; they are sometimes called “soft corns” (heloma molles), in contrast to the more common “hard corns” (heloma durums) found in other locations.
Why do corns and calluses develop?
Hyperkeratosis simply means thickening of the skin; this thickening occurs as a natural defense mechanism that strengthens the skin in areas of friction or pressure. Abnormal anatomy of the feet, such as hammer toe or other toe deformities, can lead to corn or callus formation as can bony prominences in the feet. Footwear that is too tight or that exerts friction at specific points can also cause skin thickening that leads to corns and calluses. Abnormalities in gait or movement that result in increased pressure to specific areas can also be the cause.
It can be hard to know why finger corns develop since they often don’t appear at sites of obvious pressure. Finger calluses may develop in response to using tools, playing musical instruments, or using work equipment that exerts pressure at specific sites.
When should you seek professional treatment for corns or calluses?
If the corn bothers you and doesn’t respond to salicylic acid and trimming, you might consider seeing a physician or podiatrist who can physically pare corns with scalpels. Podiatrists also can measure and fit you with orthotic devices to redistribute your weight on your feet while you walk so that pressure from the foot bones doesn’t focus on your corns. (Off-the-shelf cushioned insoles are one size fits all and may not be effective.)
People with fragile skin or poor circulation in the feet (including many people with diabetes or peripheral arterial disease) should consult their health-care practitioner as soon as corns or calluses develop. Further, you should seek medical care immediately if corns or calluses show signs of infection (such as increasing pain, the presence of pus or other drainage, swelling, and redness).
Surgery for corns is rarely necessary. When a corn is surgically removed, the pressure that caused it to form in the first place will just make it come back if this pressure is not removed or reduced. When necessary, surgery for corns involves shaving the underlying bone or correcting any deformity that is causing undue pressure or friction on the skin.
Corns and Calluses At A Glance
Corns and calluses are annoying and sometimes painful thickenings that form in the skin in areas of pressure.
Corns and calluses can be prevented by reducing or eliminating the circumstances that lead to increased pressure at specific points on the hands and feet.
Corns and calluses can be treated with many types of medicated products to chemically pare down the thickened, dead skin.
People with fragile skin or poor circulation in the feet (including many people with diabetes or peripheral arterial disease) should consult their health-care practitioner as soon as corns or calluses develop.