Back Clinic Mobility & Flexibility: The human body retains a natural level to ensure all its structures are functioning properly. The bones, muscles, ligaments, tendons, and other tissues work together to allow a range of movement and maintaining proper fitness and balanced nutrition can help keep the body functioning properly. Great mobility means executing functional movements with no restrictions in the range of motion (ROM).
Remember that flexibility is a mobility component, but extreme flexibility really is not required to perform functional movements. A flexible person can have core strength, balance, or coordination but cannot perform the same functional movements as a person with great mobility. According to Dr. Alex Jimenez’s compilation of articles on mobility and flexibility, individuals who don’t stretch their body often can experience shortened or stiffened muscles, decreasing their ability to move effectively.
The discs that cushion the vertebrae are made up of a tough outer layer and a softer inner layer. When the outer layer is damaged and the inner layer comes out into the spine, it is referred to as�disc herniation.
Often the symptoms of a herniated disc include back pain, as the inner layer of the disc puts pressure on nerves in the spine. A herniated disc can impact the sciatic nerve, leading to sciatica.
If you know that your sciatica was caused by a herniated disc then try these exercises and stretches to help reduce back and leg pain.
Exercises that help relieve sciatica from a herniated disc
If your spine specialist or chiropractor informed you that a herniated disc is what caused the pain also known as lumbar radiculopathy they may recommend� three sciatica exercises:
Prone on elbows into Press-up
Upper back extension
Opposite arm and leg extension
These stretches can help provide relief when the root cause of sciatica from herniated or bulging disc.
Prone Elbows/Press-Up
This exercise is to ease sciatica from herniated disc pain and pressure in the lumbar spine/low back.
How to:
Lay on stomach
Slowly push up until rested on forearms
Beginners hold for 30 seconds
Once strength is gained and you feel comfortable then hold for 3 to 5 minutes
Gently lower to the floor
Repeat 10 times
Once comfortable holding for 5 minutes then perform an extended arms version, which is like push-ups raising your arms to the point where your elbows lock
Upper Back Extension
This exercise is to strengthen and stabilize the low back muscles.
How to:
Lay on your stomach with a small pillow or rolled towel under your hips
Rest your arms at your sides
Slowly lift your upper body up off the floor, contracting your low back muscles as you rise
Hold the lifted position for 3 seconds
Slowly lower your body to the ground
Repeat 10 times
Throughout this exercise, keep movements fluid and controlled.
Opposite Arm and Leg Extension
This exercise is to stabilize your spine and strengthen your low back, hamstring and gluteus muscles.
How to:
Lay on your stomach with a small pillow or rolled towel under your abdomen
Extend both arms in front of you
Contract your abdominal muscles as you slowly lift both your right arm and left leg
Hold for 3 seconds. Lower your leg and arm down
Repeat with your left arm and right leg
Hold for 3 seconds
Repeat the exercise 5 to 10 times on each side
As you alternate the lifts, make sure to keep abdominal muscles contracted to get the full benefit.
How do these exercises relieve sciatica from herniated disc
These exercises and stretches are designed to move the pain from the leg and into the low back.
This is centralization/localization.
This is a good thing, as the goal is to get the pain centralized and back at the source.
When the leg pain goes away, it means the pressure on the sciatic nerve and related nerves has been removed.
If sciatic pain stretches down to the foot, you will feel these exercises, meaning that the pain and electrical sensations will move through the ankle and knee. Which means you’re doing it correctly.
This does not mean that the pain is immediately going to centralize to the low back, it does take time because you are trying to stretch and straighten out this long nerve.
But you will notice sciatica pain does not go as far down the leg.
Therefore�these exercises need to be done consistently and be made a part of your routine.
What to know before exercising
Before starting these stretches, consider three recommendations:
Get a doctor�s approval
A spine specialist should clear you to perform these stretches and exercises before you start.
While these exercises are safe, get a doctor�s permission before starting physical activity.
Know the cause so your exercise program helps and not makes the condition worse
Sciatica from herniated disc means a different type of exercise than sciatica caused by piriformis syndrome.
Knowing this information will help you choose an exercise plan that provides maximum relief.
Don�t push too hard
Don’t aggravate sciatica, listen to your body and go slow.
Experience any pain or symptoms:
Weakness
Tingling
Numbness
Contact a spine specialist immediately!
Sciatic nerve pain caused by a herniated or bulging disc is a common problem.
But incorporating these exercises and stretches can provide sustained relief.
The sciatic nerve is a large nerve that travels from the lower back down both of the legs and into the feet. When pressure is placed on the nerve, such as from a herniated disc, it can lead to the symptoms commonly referred to as sciatica.
The sciatic nerve can be impacted by a number of different things, including injury and degenerative diseases.
Difference Foot Orthotics Make to *REDUCE FOOT PAIN* & Correct Posture | El Paso, TX (2019)
Custom made foot orthotics can help control foot motion and posture. Healthcare professionals prescribe custom foot orthotics to help patients focus on their foot posture and mobility control. Research studies have ascertained that using custom foot orthotics for posture and mobility control can help fix excessive foot pronation and supination to prevent a variety of foot health problems. The subsequent video describes how custom foot orthotics will help control foot posture and mobility to improve health and wellness.
NCBI Resources
Sciatica is a common back ailment that affects approximately 1 in 10 adults in the United States. It is most prevalent in people between the ages of 25 and 45. Sciatica is characterized by a shooting pain that originates in the lower back and travels down through the hip, buttock, and back of the leg.
The pain can be so severe that it inhibits mobility and can prevent people from working, taking care of their homes, or just enjoying their life. Traditionally, doctors have treated the condition with medications and some invasive therapies, but chiropractic treatments have been found to be extremely effective in alleviating the pain and curing the condition.
As people grow into adults, maintaining normal flexibility gets to be much more challenging and losing flexibility can result in a lot of pain to the musculoskeletal system.
Unfortunately, many of us do not retain flexibility throughout the day, even when attempting to be active. Many jobs are largely sedentary, and even leisure activities keep us stuck in one place. In order to remain functional, joints and muscles need to be used, which means they need to be properly stretched without being overworked. The balance is often very delicate, fortunately, chiropractic adjustments increase flexibility.
Chiropractic’s Role in Flexibility
Most adults are not concerned with being able to twist like a pretzel, however, they do want to be able to maneuver through daily life without a lot of pain. One of the main things accomplished in most chiropractic visits is that the chiropractor will look for misalignments in the spine and seek to correct them with a combination of chiropractic adjustments and exercises.
Adjustments
When the spine is misaligned it can affect many different areas of the body including flexibility. Someone who is not flexible will have a limited range of motion (ROM) and treatments are designed to improve this and restore natural posture.
But being flexible is about more than moving better. When the body is stiff, even simple movement results in pain because it is blocked by the misalignment. When this is adjusted/corrected, blood flow improves and the process of improving flexibility becomes less taxing.
Nutrition
There is more to a chiropractor’s day than correcting misalignments in the spine. Chiropractic is holistic in nature and in order to be truly successful, it relies on the patient to be a cooperative participant in treatment. Giving nutritional advice is a big part of this.
While advice can vary from patient to patient, generally, when a person struggling with flexibility adds protein and fatty acids into their diet it can help joints and muscles to be properly nourished. People should also monitor their intake of processed and pre-packaged foods as these can contribute to inflammation.
Training Exercises
Because of many factors in our lives, as well as the effects of aging, people’s range of motion inevitably decreases as time goes by, especially if nothing is purposefully done to maintain it. Flexibility exercises are commonly strongly suggested by chiropractors as they strive to help their patients with range of motion (ROM) and flexibility issues.
In many cases, such as those where someone is suffering from tendinitis or bursitis, the truly therapeutic exercises are resistive exercises. These, however, are limited, unless a higher level of flexibility is achieved.
Flexibility programs are implemented in order to make a given joint have a wider level of extensibility, which may be achieved by either traditional static stretching or Proprioceptive Neuromuscular Facilitation (PNF) techniques, which incorporates a slow reversal hold.
Working with a chiropractor on a regular basis for help in gaining flexibility can help assure that a patient moves forward at an appropriate pace that is in line with their age and fitness level. This will help them achieve a higher level of success in their chosen sport or similar activity, and/or become more productive in their daily lives while experiencing less pain.
*FIX BAD POSTURE* with Custom Orthotics | El Paso, TX (2019)
Proper Posture
Your spine does more than keep your body upright: it�s the brain that communicates to the rest of the body. Posture even affects your emotional well-being, including self-confidence!
Poor posture takes a serious toll on health. Here are a few of the negative results:
Muscle soreness
Subluxations
Blood vessel constriction
Nerve constriction
As the years go by the problems worsen, which results
Maintaining proper posture involves sitting, standing, and lying down properly. Here is an excerpt from the American Chiropractic Association website on how to:
Sit the right way
Keep your feet on the floor or on a footrest, if they can’t reach the floor
Don’t cross your legs. Your ankles should be in front of your knees
Keep a small gap between the back of your knees and the front of your seat.
Your knees should be at or below the level of your hips.
Bear your weight primarily on the balls of your feet.
Keep your knees slightly bent.
Keep your feet about shoulder-width apart.
Let your arms hang naturally down the sides of the body.
Lie down the right way
Find the mattress that is right for you. While a firm mattress is generally recommended, some people find that softer mattresses reduce their back pain. Go with your comfort
Sleep with a pillow. Special pillows can help with postural problems resulting from a poor sleeping position
Avoid sleeping on your stomach
Healthy Feet Equals A Healthy Spine
The feet are complex structures which function�to provide protection and support to the body in relation to the spine and head posture. The feet are essential towards balancing the body�s entire weight, allowing it to walk, run, stand, and, jump. Consequently, foot complications may cause severe issues throughout the spine, hips, knees, and ankles if left untreated.
Gait & Chronic Postural Pain
Chiropractic care can be effective for treating injuries or conditions such as plantar fasciitis, Achilles tendonitis, and ankle sprains, among others. Foot health is essential towards establishing the body�s proper support and balance, together with a proper spinal posture. In the presence of foot complications, chiropractic treatment can be used to achieve long-lasting health.
NCBI Resources
Flexibility is a critical component of keeping your body fit and healthy. Research shows that people who are more flexible are better able to reach their�optimum fitness level. It can also help to prevent injury and reduce your risk of conditions like arthritis and other�chronic diseases.�They also have a better range of motion and mobility as they age.
According to the American Chiropractic Association (ACA), approximately 31 million Americans deal with some form of low back pain. Fortunately, there are steps you can take to lessen the pain you are experiencing. Taking care of yourself � including maintaining a healthy weight and regular exercise � can help prevent back pain. And when you do experience back pain, chiropractic treatment and stretching can often ease your symptoms.
Prepare for Stretching
Before we get to the stretching, we recommend preparing for your stretching session so you can stretch comfortably and safely. Tips for stretching include:
Ease into it. Stretching should be done gently and smoothly, traveling from stationary to a position slowly and carefully. Avoid bouncing, which can tear muscles.
Stretching should not hurt. You should not feel significant pain when you stretch. As you move into your stretch, listen to your body and stop before you start to feel pain. Stretching should feel good, not painful.
Wear comfortable clothing. Wear loose clothing that will allow you the full range of motion.
Choose an area to stretch that is flat and clean. Choose an area that will be comfortable and well-suited for your activity.
Use padding when necessary. If you are going to be stretching on a hard surface, a little padding can make things much more comfortable.
Hold each stretch 15-30 seconds, and repeat at least 2 times. Holding a stretch lets the muscles elongate, and repeating the stretch improves your results. Repeat the stretch four times for maximum benefit.
Modify to fit your needs. Everyone must work within their limitations. When you try a stretch and you find it is not working for you, try to modify it to suit your needs. You can find modifications to most popular stretches online.
Three Stretches that Are Great For Back Pain
1. Children’s Pose
The name Child�s Pose comes from yoga, where this stretch is often used to begin each session of stretching. Child�s Pose is so popular because it is gentle and effective, and just about anyone can do it.
To do Child�s Pose, get down on your hands and knees. To begin with, place your knees slightly wider than hip-width. Flatten the tops of your feet to the floor, toes pointing behind you. Slowly move your hips back over your feet. Once you have rested your buttocks on your ankles, stretch your arms out in front of you. Feel your lower back stretch out as you hold the pose.
2. Knees/Chest
Lying on your back, use your hands to pull your knees up to your chest, rounding out your back in the process. You can interlace your fingers to hold your knees in position. If you like, hug your knees more tightly to your chest and rock left to right. To enhance the stretch, slowly bring your chin towards your chest.
3. Spine Twist
Lying on your back, stick each hand out to the side of your body to create a T shape. Bring the right knee up to your chest while keeping the left leg straight on the floor. Use your left hand to gently pull your knee higher, then pull the knee across your body to the left. Try to keep your right shoulder on the floor. Repeat on the left side.
Contact For Customized Stretches
If you are suffering from back pain, please schedule an appointment to meet with our chiropractic team. We can help design a custom stretching plan to help you ease your back pain.
El Paso Back Clinic Chiropractor Personal Injury Attorney Recommended
Flexibility is something that many people would like more of, but few know how to achieve it. You might find that improving your flexibility is easier than you think.
This is because flexibility training is often seen as difficult, painful, and time-consuming. It is also significantly underestimated. Why bother getting flexible if you aren�t an athlete or dancer? Why do regular people need to improve their flexibility? The answers to these questions may surprise you.
Why is flexibility important?
Flexibility is a critical component of keeping your body fit and healthy. Research shows that people who are more flexible are better able to reach their optimum fitness level.
It can also help to prevent injury and reduce your risk of conditions like arthritis and other chronic diseases. They also have a better range of motion and mobility as they age.
Muscles that are flexible have the potential to become stronger. This can help increase metabolism and improve fitness level.
A more flexible body can also carry out day to day activities easier and have less chance of injury. Blood flow is increased and circulation is improved which also helps to prevent chronic conditions like kidney disease and diabetes as well as heart disease.
Stretch for upper body flexibility
This upper body stretch also helps improve your posture. It is also great if you are primarily sedentary throughout the day, such as sitting at a desk for extended periods.
Stand or sit in a chair, back straight, chin level, feel slightly apart and knees soft.
Put your hands behind your head, elbows out, chin tucked.
Gently press your head forward to feel the stretch through your neck, shoulders, and upper back; hold for five seconds.
Tilt your head back so that your chin is pointing toward the ceiling.
Place the heels of your hands on your forehead and gently press to get a stretch through the front of the neck and the arms; hold for five seconds.
Bring your head to the start position, chin parallel to the floor, neck straight.
Put your right hand on the top of your head and gently press as if you are trying to touch your right ear to your right shoulder and feel the stretch along the left side of the neck and shoulder; hold for five seconds.
Put your left hand on the top of your head and gently press as if you are trying to touch your left ear to your left shoulder and feel the stretch along the right side of the neck and shoulder; hold for five seconds.
Raise your hands over your head and clasp your hands.
Stretch and lift your body, lengthening your spine.
Release your hands and bend to the right, using your right hand to grasp your left elbow and gently pull it to the right. Hold for five seconds.
Raise your hands over your head and clasp your hands. Stretch and lift your body, lengthening your spine.
Release your hands and bend to the left, using your left hand to grasp your right elbow and gently pull it to the left. Hold for five seconds.
Stretch for lower body flexibility
This is a great stretch for women who wear high heels or for cyclists and people who walk, run, or use an elliptical machine.
Sit on the floor with your legs straight in front of you, feet together, knees soft, and back straight.
Slowly bend your right knee and lean back if necessary, using your right arm as support behind you. Place your left hand under your left knee and flex your toes toward the ceiling, feeling the stretch through your calf. Hold for five seconds.
Stretch both legs out straight in front of you.
Slowly bend your left knee and lean back if necessary, using your left arm as support behind you. Place your right hand under your right knee and flex your toes toward the ceiling, feeling the stretch through your calf. Hold for five seconds.
Roll onto your back with your knees bent toward the ceiling and feet flat on the floor.
Gently bring your right knee to your chest, holding it with your hands to get a nice stretch. Hold for five minutes.
Return to the start position, on your back with your knees bent and feet flat on the floor.
Gently bring your left knee to your chest, holding it with your hands to get a nice stretch. Hold for five minutes.
Return to the start position, on your back with your knees bent and feet flat on the floor.
Stretch for flexibility in the back
This stretch is very good for low back pain.
Lie on your stomach keeping your legs straight, knees soft, and feet shoulder-width apart.
Place your hands under your shoulders, palms down on the floor and push your upper body up so that your back is curved with your lower body still on the floor. Tilt your head back for more stretch. Hold for 10 seconds.
Lower your upper body back to the mat and slowly roll over to your hands and knees.
Keep your knees shoulder width apart and your back straight.
While on your hands and knees, tuck your chin and round out your back, pushing it towards the ceiling, feel the stretch through your entire back. Hold for 10 seconds.
Return to the start position with your knees shoulder width apart and your back straight.
While on your hands and knees, lift your chin, stretching it upwards and drop your back so that your spine curves toward the floor. Hold for 10 seconds.
Return to the start position with your knees shoulder width apart and your back straight.
You hear many people talk about the benefits of walking but may not know how it applies to you. Walking regularly can be exceptionally helpful if you have back pain by providing the spine with added support and increased blood flow. These three spinal health benefits of walking should be enough to convince you.
Walking Aids in Rehydrating Your Spinal Discs
Gravity is not your friend. Well, not when it comes to your back. From the time you get out of bed until you lay down again at the end of the day, the pressure of gravity compresses your spine. When your spine is compressed, that means your spinal discs are too. These fluid-filled discs provide a cushion for your vertebrae, but the constant compression that occurs throughout the day due to regular activity squeezes the fluid out of them.
Dehydrated discs can cause back pain and structural problems. That is why restful sleep and staying hydrated are essential for spinal health.
Walk because it increases circulation throughout your body, including your spine. This increased blood flow helps to rehydrate your discs that improve your spinal health. It also helps keep your spine younger, staving off the effects of the aging process.
Walking Relieves Back Pain and Reduces Stress to the Spine
Walking provides an excellent low impact aerobic workout, and it increases blood flow which helps improve mobility, flexibility, and range of motion. When you incorporate stretching, you can reap even more of the benefits of a healthy spine.
The human body is made to move. When you don’t move or are sedentary, your muscles become stiff and inflexible. Moving prevents that, but even if you are experiencing some stiffness, walking, stretching, and movement can help you regain that flexibility.
You will also find that walking regularly also helps with stress relief. Lower back pain is a prevalent stress symptom, but walking combats its effects by encouraging dopamine release.
When you are stressed, your pain sensitivity increases, you feel pain more acutely, and it is more challenging to manage. By reducing your stress level, you also make your pain more manageable but, at the same time, minimize lower back pain.
Walking Improves Posture
When you don’t use your muscles, they become weak and inflexible and cannot do their intended job. The back forces are designed to provide support to the spine, and when they are not used, they can atrophy and weaken, resulting in stooped or other improper posture.
Poor posture causes back pain by putting more pressure on the spine, leading to pain, soreness, tension, and headaches. Without the necessary support, it can also lead to misalignment of the spine, which can cause problems.
Walking strengthens the supporting muscle groups so that your back muscles get more robust, and your spine gets the structural support needed. As your back muscles get stronger, your body will naturally begin to adopt a correct posture. The benefits of good posture include improved organ function, reduced pain, less fatigue, and easier breathing.
Walking is good for your whole body as well as your mind. When you walk to reduce back pain, you are also doing great things for your body. If you have any questions about proper form or achieving a better, healthier posture, your chiropractor can help you. The spine is such an essential part of the body; it does so much. Please do your best to protect it and keep it in good health. In return, it will save you from moving for a long, long time.
If you are like most people, at some point in your life, you will experience back pain � if you haven�t already. The American Chiropractic Association estimates that around 80% of the population suffers from back pain, has suffered from back pain, or at some point in the future will suffer from back pain. That puts you in good company.
It also means that you have a better than average chance of falling into that 80%, so the smart thing to do is take steps not to prevent it. One powerful preventative measure against back pain is stretching. Try these four stretches to help your back pain.
Forward Bend
Stand with your feet shoulder width apart and your knees soft (not locked). Take a deep breath and as you exhale, bend forward at the waist, hands out as if you are reaching for the floor. When you feel a little stretching in your hamstrings (the backs of your legs), stop and hold that position for two or three breaths. If you can�t reach the floor, that is OK, don�t force it. If you need extra stability, you can use a chair to hold on to for balance. Repeat this movement seven to ten times.
Cat and Camel
This stretch is typically done on the floor, but if you don�t think you can safely get back up, you can stand and hold on to a chair. On the floor, get on your hands and knees with your back straight. If using a chair, stand with your feet shoulder width apart and your knees soft. Bend slowly and place your palms in the seat of the chair so that your back is parallel to the floor. Keep it straight.
Begin by arching your back up as high as you can. Hold for two or three breaths. Return to the starting position, then let it sway down toward the floor and hold for two or three breaths. Return to the starting position. Do this five to seven times.
Back Extension
Lie on your stomach on the floor or bed with your hand’s palm down near your face. Slowly push up with your arms, keeping your head level with your shoulders, until you are on your elbows. Hold for three or four breaths.
If you can push all the way up so that you are on your hands, that will give you a deeper stretch. You can also hold it for a little longer. Just remember to keep the movements slow and gentle to avoid injury.
If you are not able to safely get on the floor, you can stand with your feet several inches from a wall. Place both of your hands on the wall and bring your upper body toward them, letting your pelvis naturally follow. Gently push against the wall with your hands, pushing your upper body away from the wall. You can also do this with a chair if you need extra support. Repeat five to seven times.
Hip Flex and Stretch
Get on your hands and knees on the floor or bed. Slowly move your body back so that your bottom is over your heels. Keep your hips straight as you extend your arms in front of you. Drop your head between your arms and hold the stretch for three to five breaths.
If you can�t get on your hands and knees, sit in a chair with your feet flat on the floor in front of you, hip-width apart. Extend your arms in front of you and reach forward. Lean forward slightly until you feel the stretch.
You can also place your hands on your knees for support while you sit in a chair and bend at the waist, slowly rounding out your back over your thighs. Hold the stretch for three to five breaths then return to your upright position. Do this seven to ten times.
Before you begin any new exercise or stretching regimen, talk to your doctor or chiropractor to make sure you aren�t doing something that could exacerbate your problem. For the most part, stretching is very therapeutic and beneficial, but some injuries and conditions can be made worse.
It is well worth taking the extra time to talk with your doctor and perhaps even show him or her the movements. This will also allow them to correct any form problems you may have or recommend any modifications that will help you get the most out of your stretches.
Bone neoplasms and tumor-like conditions affecting the knee can be benign or malignant. Age at Dx is crucial for DDx
In patients <40: Benign bone neoplasms: Osteochondroma, Enchondroma are relatively frequent
Fibrous cortical defect (FCD) & Non-ossifying fibroma (NOF) are particularly frequent in children
Giant cell tumor (GCT) is the m/c benign neoplasm of the knee in patients between 20-40 years of age
Malignant bone neoplasms in <40: m/c Osteosarcoma and 2nd m/c Ewing sarcoma
In patients >40: malignant neoplasms: m/c are secondaries d/t bone metastasis. Primary bone malignancy:�the m/c
Multiple Myeloma (MM). Less frequently:�a 2nd�peak of Osteosarcoma (post-radiation or Paget�s), Fibrosarcoma or Malignant�Fibrous�Histiocytoma�(MFH) of bone.
Clinically: knee pain, pathological fracture
Some tumor-like conditions like FCD/Non-ossifying fibroma are asymptomatic and may regress spontaneously. Occasionally NOF may present with pathologic fracture. N.B. any knee/bone pain in a child/adolescents should be�treated with clinical suspicion and adequately investigated.
Imaging: 1st step: radiography
MRI with T1+C is crucial for lesion characterization/regional extent, staging and pre-operative planning. CT may�help with pathologic Fxs detection. If malignant bone neoplasms considered, CXR/CT, PET-CT to investigate�metastatic spread and staging are important
Imaging Approach Bone Neoplasms
Approach to imaging Dx of bone neoplasms includes age, bone location (epiphysis vs. metaphysis vs. diaphysis), zone of transition surrounding the lesion, periosteal response, type of matrix, permeating or moth-eaten destruction vs. sclerotic, ground-glass, osteoid, cartilaginous matrix, soft tissue invasion, etc.
Key x-radiography features to DDx benign vs. malignant bone neoplasm:
Zone of transition: lesion is geographic with a narrow zone of transition vs. ill-defined wide zone of transition suggesting aggressive bone resorption
What type of bone destruction occurred: soap-bubbly appearance vs. osteolytic vs. osteosclerotic changes
Is there a round-glass matrix? Is there a well-defined rim of the sclerotic border with septations potentially suggesting slow growth and encapsulation like most benign processes.
Periosteal proliferation: solid vs. aggressive spiculated/sunburst/hair-on-end with local soft tissue invasion and Codman triangle (study next slide)
FCD & NOF
FCD & NOF or more appropriately Fibroxanthoma of the bone are benign bone processes that m/c seen in children. DDx based on the size with FCD presenting as <3-cm and NOF >3cm lesion composed of a fibrous heterogeneous matrix. FCD are asymptomatic and may regress in many cases. Some may progress to NOF. Location: identified in the knee region as an eccentric cortical based lesion.
FCD must be DDx from an avulsive irregularity d/t repeated stress along Linea aspera by extensors muscles
Dx: radiography
Management: leave-me-alone lesion. Occasionally NOF may progress and lead to pathologic fracture requiring orthopedic consult
Osteochondroma
Osteochondroma: m/c benign bone neoplasm. Knee is the m/c location. Contains all bone elements with a cartilaginous cap. Presented as pedunculated or sessile bone exostosis pointing away from the joint.
1% malignant degeneration to chondrosarcoma if solitary lesion and 10-15% in cases of HME
Other complications: fracture (top left image) pseudoaneurysm of the Popliteal artery, adventitious bursa formation
Hereditary Multiple Exostosis (HME)– autosomal dominant process. Presents with multiple osteochondromas (sessile-type dominates). May lead to limb deformities (Madelung deformity, coxa valga) reactive ST pressure, malignant degeneration
Dx: radiography, MRI helps to Dx malignant degeneration to chondrosarcoma by changes in size and activity of cartilaginous cap (>2-cm in adults may manifest malignant degeneration). MRI will also help with Dx of regional complications
HME & Knee Pain
37-y.o male with HME and knee pain. Axial T1, T2 and STIR MRI slices at the popliteal region. Large cartilaginous cap and possible compression of the popliteal artery by osteochondroma. MRA was performed to evaluate popliteal A. pseudoaneurysm (large arrow). Pathology specimen obtained from the cartilaginous cap showed increased cellularity suggestive of malignant degeneration. Operative care was planned
Giant Cell Tumor (GCT) aka Osteoclastoma
GCT- is a relatively common primary benign bone neoplasm. Age 25-40. M>F slightly.
GCT is the M/C benign sacral tumor. In 50% of cases, GCT occurs about the knee.
GCT is histologically benign, but lung Mets may develop esp. if in distal radius and hands, often termed Malignant GCT
<1% unresponsive/recurring GCTs may undergo malignant transformation to high-grade bone sarcoma
Pathology: histologically composed of osteoclasts-multinucleated giant cells with stromal cells derived from precursors monocyte-macrophage type. Produces cytokines and osteolytic enzymes. GCT may contain blood and associated with secondary Aneurysmal Bone Cyst (ABC)
Clinically: knee pain unresponsive to conservative care. Pathologic Fx may occur
Imaging: always begins with radiography followed by MRI and surgical biopsy that are crucial to Dx.
Rx: operative with curettage and cementing, a surgical appliance may be used if pathological fx present and cortical breach. In more severe cases other options available
Radiologic-Pathologic Dx
Radiologic-pathologic Dx: osteolytic and soap-bubbly lesion typically involving metaphysis and into epiphysis (classic key feature) with subarticular extension. Zone of transition is generally narrow but occasionally in aggressive lesions wide zone of transition may be seen.
MRI: low T1, highT2/STIR, characteristic fluid-fluid levels noted that are present in GCT and ABC. Histology is crucial to Dx.
DDx: ABC, Brown cell tumor of HPT (osteoclastoma), Telangiectatic Osteosarcoma
Radiological rule: if the physeal growth plate is present Dx of GCT is taken off the list in favor of chondroblastoma and vice versa.
Primarily Soap-Bubbly Appearance of GCT
Coronal, Fat-Sat Sagittal & Axial MRI Slices of GCT
T1 coronal, T2 fat-sat sagittal and T2 axial MRI slices of GCT. Typically: low T1, highT2/STIR and fluid-fluid levels
Characteristic MRI Appearance of GCT
Fluid-fluid levels d/t different composition of blood degradation products
Important DDx: ABC
Malignant Neoplasms About the Knee
In children and very young adults, m/c primary malignant neoplasm is central aka intramedullary (osteogenic) osteosarcoma (OSA). Second peak of OS: >70 y.o d/t Paget�s (1%) and/or post radiation OSA.
The knee is the m/c location of OSA (distal femur, prox. Tibia)
A 2nd m/c malignant pediatric primary is Ewing sarcoma.
In adults >40 y.o. the m/c primary is Multiple Myeloma (MM) or Solitary Plasmacytoma
Overall m/c bone neoplasms in adults d/t bone Mets from lung, breast, prostate, renal cell, thyroid (discussed)
Dx: clinical and radiological with surgical biopsy
Imaging is crucial to Dx. 1st step x-radiography. MRI+ gad C is vital
CT scanning occasionally helps to evaluate pathological fracture
Central (Intramedullary) Osteosarcoma (OSA)
m/c age: 10-20. m/c location: knee, males>females. Increased risk in some
congenital syndromes and mutation of the retinoblastoma gene: Rothmund-Thompson AR syndrome.
Early Dx is important d/t 10-20% present with Lung Mets at Dx. Prognosis depends on stages. Early stages with local bone invasion and no
mets 76% of survival.
Rx: limb salvage procedures preferred with 8-12 weeks of chemo, amputation if encased neurovascular tissue, path Fx, etc.
Imaging: radiography and MRI.
Clinically: bone pain, Inc. Alkaline Phosphatase
Chest CT if lung Mets considered
Classic Rad Features of OSA
Osteoid forming a sclerotic mass with aggressive hair-on-end/speculated/sun-burst periosteal reaction, Codman’s triangle and soft tissue invasion. Order MRI for staging and extent. Chest CT is crucial for Lung Mets dx.
MRI is Crucial for Dx/Staging
Note sagittal T1 (left) and STIR (right) MR slices: large mass extending from distal femoral metaphysis to remaining shaft. A low signal on T1 and high on STIR d/t marrow invasion with edema, hemorrhaging and tumor invasion. Local ST invasion seen (white arrows). Periosteal lifting and Codman�s triangle (green arrow) are additional signs of aggressive neoplasm.
Note an interesting feature that the epiphysis is spared d/t physeal plate serving temporarily as an additional barrier to the tumor spread.
Ewing Sarcoma
Ewing sarcoma: age: 2-20, uncommon in black patients. 2nd m/c highly malignant bone neoplasm in children that typically arises from medullary cavity (Round cell tumors). Key symptom: bone pain that may mimic infection (ESR/CRP/WBC) Considered PNET Key Rad Dx: aggressive moth-eaten/permeative lucent lesions in the shaft of long bones with sizeable soft tissue invasion/typical onion skin periostitis. May produce saucerisation May affect flat bones. May appear as sclerotic in 33%. Early lung Mets (25-30%) bone-to-bone Mets Poor prognosis if delayed Dx. Imaging steps: 1st step x-rad, MRI is v. important followed by a biopsy. CXR/CT PET-CT Rx: combined rad-chemo, operative.
Note aggressive expansile osteolytic lesion in the distal femur metaphysis into epiphysis. No periosteal reaction present. Following further work up with abdominal and chest CT scanning, Dx of Renal cell carcinoma was established
Distal Mets into lower extremity are more common with lung, renal cell, thyroid and breast CA.
Renal cell and Thyroid will typically present with aggressive osteolytic expansile mass aka �blowout Mets.�
In general, imaging approach should consist of Radiographic knee series, followed by MRI if x-rays are unrewarding
Tc99 Bone scintigraphy is the modality of choice to evaluate metastatic bone disease
Soft Tissue Neoplasms About the Knee
Malignant fibrous histiocytoma (MFH) reclassified as Pleomorphic Undifferentiated Sarcoma (PUS) is the m/c S.T. sarcoma. MFH is aggressive biologically with poor prognosis M>F (1.2:1) 30-80 with a peak in a 6th decade. 25-40% of all adults sarcomas m/c extremities. Retroperitoneum next (worst prognosis d/t late Dx and large growth w/o symptoms) Clinically: painful, hard mass typically about the knee or thigh. Histology: poorly differentiated/undifferentiated malignant fibroblasts, myofibroblasts, and other mesenchymal cells Imaging: MRI is the modality of choice with T1, T2, T1+C. Typically appears as an aggressive heterogeneous mass intermediate to low signal on T1 and high signal on T2 with areas of necrosis and enhancement on T1+C. May appear misleadingly encapsulated w/o true capsule Management: operative with radiation and chemotherapy. Tumor depth is crucial for prognosis. 80% 5-year survival if <5cm deep in ST and 50% if >5-cm deep in ST.
Synovial Sarcoma
Synovial sarcoma: common malignant ST neoplasm esp. in younger patients or older children/adolescents. M/C found in knee area Clinically: can present slowly as a palpable mass in the extremity often ignored d/t slow growth Imaging is the key: radiography may reveal ST. density/mass. Some synovial sarcomas may show calcification and mistaken for Myositis Ossificanse or heterotopic bone formation MRI with T1, T2 and T1+C are Dx modality of choice. Other modalities: US, CT are non-specific DDx: MFH Management: operative, chemo-radiation Prognosis: variable depending on size, invasion, metastasis
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