Articular cartilage is the smooth, white tissue that covers the ends of bones where they come together to form joints. Healthy cartilage in our joints makes it easier to move. It allows the bones to glide over each other with very little friction.
Articular cartilage can be damaged by injury or normal wear and tear. Because cartilage does not heal itself well, doctors have developed surgical techniques to stimulate the growth of new cartilage. Restoring articular cartilage can relieve pain and allow better function. Most importantly, it can delay or prevent the onset of arthritis.
Surgical techniques to repair damaged cartilage are still evolving. It is hoped that as more is learned about cartilage and the healing response, surgeons will be better able to restore an injured joint.
The main component of the joint surface is a special tissue called hyaline cartilage.When it is damaged, the joint surface may no longer be smooth. Moving bones along a tough, damaged joint surface is difficult and causes pain. Damaged cartilage can also lead to arthritis in the joint.
The goal of cartilage restoration procedures is to stimulate new hyaline cartilage growth.
Identifying Cartilage Damage
In many cases, patients who have joint injuries, such as meniscal or ligament tears, will also have cartilage damage. This damage may be hard to diagnose because hyaline cartilage does not contain calcium and cannot be seen on an X-ray.
If other injuries exist with cartilage damage, doctors will address all problems during surgery.
Articular cartilage in the knee damaged in a single, or focal, location.
Most candidates for articular cartilage restoration are young adults with a single injury, or lesion. Older patients, or those with many lesions in one joint, are less likely to benefit from the surgery.
The knee is the most common area for cartilage restoration. Ankle and shoulder problems may also be treated.
Many procedures to restore articular cartilage are done arthroscopically. During arthroscopy, your surgeon makes three small, puncture incisions around your joint using an arthroscope.
Some procedures require the surgeon to have more direct access to the affected area. Longer, open incisions are required. Sometimes it is necessary to address other problems in the joint, such as meniscal or ligament tears, when cartilage surgery is done.
In general, recovery from an arthroscopic procedure is quicker and less painful than a traditional, open surgery. Your doctor will discuss the options with you to determine what kind of procedure is right for you.
The most common procedures for cartilage restoration are:
- Abrasion Arthroplasty
- Autologous Chondrocyte Implantation
- Osteochondral Autograft Transplantation
- Osteochondral Allograft Transplantation
The goal of microfracture is to stimulate the growth of new articular cartilage by creating a new blood supply. A sharp tool called an awl is used to make multiple holes in the joint surface. The holes are made in the bone beneath the cartilage, called subchondral bone. This action creates a healing response. New blood supply can reach the joint surface, bringing with it new cells that will form the new cartilage.
The goal of microfracture is to stimulate the growth of new cartilage by creating a new blood supply.
A sharp tool called an awl is used to make multiple holes in the joint surface. The holes are made in the bone beneath the cartilage, called subchondral bone. This creates a healing response. New blood supply can reach the joint surface. This will bring new cells that will form cartilage.
Microfracture can be done with an arthroscope. The best candidates are young patients with single lesions and healthy subchondral bone.
Normal healthy articular cartilage in the knee (left). A large cartilage defect in the knee joint surface (center). During microfracture, an awl is used to penetrate the defect (right).
Drilling, like microfracture, stimulates the production of healthy cartilage. Multiple holes are made through the injured area in the subchondral bone with a surgical drill or wire. The subchondral bone is penetrated to create a healing response.
Drilling can be done with an arthroscope. It is less precise than microfracture and the heat of the drill may cause injury to some of the tissues.
Abrasion arthroplasty is similar to drilling. Instead of drills or wires, high speed burrs are used to remove the damaged cartilage and reach the subchondral bone.
Abrasion arthroplasty can be done with an arthroscope.
Autologous Chondrocyte Implantation (ACI)
ACI is a two-step procedure. New cartilage cells are grown and then implanted in the cartilage defect.
First, healthy cartilage tissue is removed from a non-weightbearing area of the bone. This step is done as an arthroscopic procedure. The tissue which contains healthy cartilage cells, or chondrocytes, is then sent to the laboratory. The cells are cultured and increase in number over a 3- to 5-week period.
An open surgical procedure, or arthrotomy, is then done to implant the newly grown cells. The cartilage defect is prepared. A layer of bone-lining tissue, called periosteum, is sewn over the area. This cover is sealed with fibrin glue. The newly grown cells are then injected into the defect under the periosteal cover.
ACI is most useful for younger patients who have single defects larger than 2 cm in diameter. ACI has the advantage of using the patient’s own cells, so there is no danger of a patient rejecting the tissue. It does have the disadvantage of being a two-stage procedure that requires an open incision. It also takes several weeks to complete.
Osteochondral Autograft Transplantation
In osteochondral autograft transplantation, cartilage is transferred from one part of the joint to another. Healthy cartilage tissue – a graft — is taken from an area of the bone that does not carry weight (non-weightbearing). The graft is taken as a cylindrical plug of cartilage and subchondral bone. It is then matched to the surface area of the defect and impacted into place. This leaves a smooth cartilage surface in the joint.
Mosaicplasty type osteochondral autograft transplantation procedure.
A single plug of cartilage may be taken or a procedure using multiple plugs, called mosaicplasty, may be performed.
A single plug of cartilage may be transferred or a procedure with multiple plugs, called mosaicplasty, may be done.
Osteochondral autograft is used for smaller cartilage defects. This is because the healthy graft tissue can only be taken from a limited area of the same joint. It can be done with an arthroscope.
Osteochondral Allograft Transplantation
If a cartilage defect is too large for an autograft, an allograft may be considered. An allograft is a tissue graft taken from a cadaver donor. Like an autograft, it is a block of cartilage and bone. In the laboratory it is sterilized and prepared. It is tested for any possible disease transmission.
An allograft is typically larger than an autograft. It can be shaped to fit the exact contour of the defect and then press fit into place.
Allografts are typically done through an open incision.
Stem Cells and Tissue Engineering
Current research focuses on new ways to make the body grow healthy cartilage tissue. This is called tissue engineering. Growth factors that stimulate new tissue may be isolated and used to induce new cartilage formation.
The use of mesenchymal stem cells is also being investigated. Mesenchymal stem cells are basic human cells obtained from living human tissue, such as bone marrow. When stem cells are placed in a specific environment, they can give rise to cells that are similar to the host tissue.
The hope is that stem cells placed near a damaged joint surface will stimulate hyaline cartilage growth.
Tissue engineering procedures are still at an experimental stage. Most tissue engineering is performed at research centers as part of clinical trials.
After surgery, the joint surface must be protected while the cartilage heals. If the procedure was done on your knee or ankle, you may not be able to put weight on the affected leg. You will need to use crutches to move around for the first few weeks after surgery.
Your doctor may prescribe physical therapy. This will help restore mobility to the affected joint. During the first weeks after surgery, you may begin continuous passive motion therapy. A continuous passive motion machine constantly moves the joint through a controlled range of motion.
As healing progresses, your therapy will focus on strengthening the joint and the muscles that support it. It may be several months before you can safely return to sports activity.
Carpal tunnel syndrome is a common source of hand numbness and pain. It is more common in women than men.
The carpal tunnel is a narrow, tunnel-like structure in the wrist. The bottom and sides of this tunnel are formed by wrist (carpal) bones. The top of the tunnel is covered by a strong band of connective tissue called the transverse carpal ligament.
The median nerve travels from the forearm into the hand through this tunnel in the wrist. The median nerve controls feeling in the palm side of the thumb, index finger, and long fingers. The nerve also controls the muscles around the base of the thumb. The tendons that bend the fingers and thumb also travel through the carpal tunnel. These tendons are called flexor tendons.
The carpal tunnel protects the median nerve and flexor tendons that bend the fingers and thumb.
Carpal tunnel syndrome occurs when the tissues surrounding the flexor tendons in the wrist swell and put pressure on the median nerve. These tissues are called the synovium. The synovium lubricates the tendons and makes it easier to move the fingers.
This swelling of the synovium narrows the confined space of the carpal tunnel, and over time, crowds the nerve.
Carpal tunnel syndrome is caused by pressure on the median nerve traveling through the carpal tunnel.
Many things contribute to the development of carpal tunnel syndrome:
- Heredity is the most important factor – carpal tunnels are smaller in some people, and this trait can run in families.
- Hand use over time can play a role.
- Hormonal changes related to pregnancy can play a role.
- Age — the disease occurs more frequently in older people.
- Medical conditions, including diabetes, rheumatoid arthritis, and thyroid gland imbalance can play a role.
In most cases of carpal tunnel syndrome, there is no single cause.
The most common symptoms of carpal tunnel syndrome include:
- Numbness, tingling, and pain in the hand
- An electric shock-like feeling mostly in the thumb, index, and long fingers
- Strange sensations and pain traveling up the arm toward the shoulder
Symptoms usually begin gradually, without a specific injury. In most people, symptoms are more severe on the thumb side of the hand.
Symptoms may occur at any time. Because many people sleep with their wrists curled, symptoms at night are common and may awaken you from sleep. During the day, symptoms frequently occur when holding something, like a phone, or when reading or driving. Moving or shaking the hands often helps decrease symptoms.
Symptoms initially come and go, but over time they may become constant. A feeling of clumsiness or weakness can make delicate motions, like buttoning your shirt, difficult. These feelings may cause you to drop things. If the condition is very severe, muscles at the base of the thumb may become visibly wasted.
To determine whether you have carpal tunnel syndrome, your doctor will discuss your symptoms and medical history. He or she will also examine your hand and perform a number of physical tests, such as:
- Checking for weakness in the muscles around the base of your thumb
- Bending and holding your wrists in positions to test for numbness or tingling in your hands
- Pressing down on the median nerve in the wrist to see if it causes any numbness or tingling
- Tapping along the median nerve in the wrist to see whether tingling is produced in any of the fingers
- Testing the feeling in your fingers by lightly touching them when your eyes are closed
Electrophysiological tests. Electrical testing of median nerve function is often done to help confirm the diagnosis and clarify the best treatment option in your case.
X-rays. If you have limited wrist motion, your doctor may order x-rays of your wrist.
For most people, carpal tunnel syndrome will progressively worsen without some form of treatment. It may, however, be modified or stopped in the early stages. For example, if symptoms are clearly related to an activity or occupation, the condition may not progress if the occupation or activity is stopped or modified.
If diagnosed and treated early, carpal tunnel syndrome can be relieved without surgery. In cases where the diagnosis is uncertain or the condition is mild to moderate, your doctor will always try simple treatment measures first.
Bracing or splinting. A brace or splint worn at night keeps the wrist in a neutral position. This prevents the nightly irritation to the median nerve that occurs when wrists are curled during sleep. Splints can also be worn during activities that aggravate symptoms.
Medications. Simple medications can help relieve pain. These medications include anti-inflammatory drugs (NSAIDs), such as ibuprofen.
Activity changes. Changing patterns of hand use to avoid positions and activities that aggravate the symptoms may be helpful. If work requirements cause symptoms, changing or modifying jobs may slow or stop progression of the disease.
Steroid injections. A corticosteroid injection will often provide relief, but symptoms may come back.
Surgery may be considered if you do not gain relief from nonsurgical treatments. The decision whether to have surgery is based mostly on the severity of your symptoms.
- In more severe cases, surgery is considered sooner because other nonsurgical treatment options are unlikely to help.
- In very severe, long-standing cases with constant numbness and wasting of your thumb muscles, surgery may be recommended to prevent irreversible damage.
The ligament is cut during surgery. When it heals, there is more room for the nerve and tendons.
Surgical technique. In most cases, carpal tunnel surgery is done on an outpatient basis under local anesthesia.
During surgery, a cut is made in your palm. The roof (transverse carpal ligament) of the carpal tunnel is divided. This increases the size of the tunnel and decreases pressure on the nerve.
Once the skin is closed, the ligament begins to heal and grow across the division. The new growth heals the ligament, and allows more space for the nerve and flexor tendons.
Endoscopic method. Some surgeons make a smaller skin incision and use a small camera, called an endoscope, to cut the ligament from the inside of the carpal tunnel. This may speed up recovery.
The end results of traditional and endoscopic procedures are the same. Your doctor will discuss the surgical procedure that best meets your needs.
Recovery. Right after surgery, you will be instructed to frequently elevate your hand above your heart and move your fingers. This reduces swelling and prevents stiffness.
Some pain, swelling, and stiffness can be expected after surgery. You may be required to wear a wrist brace for up to 3 weeks. You may use your hand normally, taking care to avoid significant discomfort.
Minor soreness in the palm is common for several months after surgery. Weakness of pinch and grip may persist for up to 6 months.
Driving, self-care activities, and light lifting and gripping may be permitted soon after surgery. Your doctor will determine when you should return to work and whether there should be any restrictions on your work activities.
Complications. The most common risks from surgery for carpal tunnel syndrome include:
- Nerve injury
Long-term outcomes. Most patients’ symptoms improve after surgery, but recovery may be gradual. On average, grip and pinch strength return by about 2 months after surgery.
Complete recovery may take up to a year. If significant pain and weakness continue for more than 2 months, your physician may instruct you to work with a hand therapist.
In long-standing carpal tunnel syndrome, with severe loss of feeling and/or muscle wasting around the base of your thumb, recovery is slower and might not be complete.
Carpal tunnel syndrome can occasionally recur and may require additional surgery.
Tendons are tissues that connect muscles to bone. The muscles that move the fingers and thumb are located in the forearm. Long tendons extend from these muscles through the wrist and attach to the small bones of the fingers and thumb.
The extensor tendons on the top of the hand straighten the fingers. The flexor tendons on the palm side of the hand bend the fingers.
The extensor tendons straighten the fingers and thumb through a very complex arrangement.
In a mallet injury, when an object hits the tip of the finger or thumb, the force of the blow tears the extensor tendon. Occasionally, a minor force such as tucking in a bed sheet will cause a mallet finger.
The injury may rupture the tendon or pull the tendon away from the place where it attaches to the finger bone (distal phalanx). In some cases, a small piece of bone is pulled away along with the tendon. This is called an avulsion injury.
The long, ring, and small fingers of the dominant hand are most likely to be injured.
The finger is usually painful, swollen, and bruised. The fingertip will droop noticeably and will straighten only if you push it up with your other hand.
Risk for Infection
It is very important to seek immediate attention if there is blood beneath the nail or if the nail is detached. This may be a sign of a cut in the nail bed, or that the finger bone is broken and the wound penetrates down to the bone (open fracture). These types of injuries put you at risk for infection.
To relieve pain and reduce swelling, apply ice to your finger immediately and keep your hand elevated above your heart.
A mallet finger injury requires medical treatment to ensure the finger regains as much function as possible. Most doctors recommend seeking treatment within a week of injury. However, there have been cases in which treatment was delayed for as long as a month after injury and full healing was still achieved.
After discussing your medical history and symptoms, your doctor will examine your finger or thumb. During the examination, your doctor will hold the affected finger and ask you to straighten it on your own. This is called the mallet finger test.
During a mallet finger test, your doctor determines whether you can straighten your fingertip without assistance.
Your doctor will most likely order x-rays of the injury. If a fragment of the distal phalanx was pulled away when the tendon ruptured, or if there is a larger fracture of the bone, it will appear in an x-ray. An x-ray will also show whether the injury pulled the bones of the joint out of alignment.
Mallet finger injuries that are not treated typically result in stiffness and deformity of the injured fingertip. The majority of mallet finger injuries can be treated without surgery.
In children, mallet finger injuries may involve the cartilage that controls bone growth. The doctor must carefully evaluate and treat this injury in children, so that the finger does not become stunted or deformed.
Most mallet finger injuries are treated with splinting. A splint holds the fingertip straight (in extension) until it heals.
There are several types of splints used to treat mallet finger, many of them fabricated by hand therapists.
To restore function to the finger, the splint must be worn full time for 8 weeks. This means that it must be worn while bathing, then carefully changed after bathing. As the splint dries, you must keep your injured finger straight. If the fingertip droops at all, healing is disrupted and you will need to wear the splint for a longer period of time.
When removing the splint for cleaning and drying, the fingertip must stay in extension.
A temporary splint is applied with two pieces of tape.
Because wearing a splint for a long period of time can irritate the skin, your doctor may talk with you about how to carefully check your skin for problems. Your doctor may also schedule additional visits over the course of the 8 weeks to monitor your progress.
For 3 to 4 weeks after the initial splinting period, you will gradually wear the splint less frequently — perhaps only at night. Splinting treatment usually results in both acceptable function and appearance, however, many patients may not regain full fingertip extension.
For some patients, the splinting regimen is very difficult. In these cases, the doctor may decide to insert a temporary pin across the fingertip joint to hold it straight for 8 weeks.
Your doctor may consider surgical repair if there is a large fracture fragment or the joint is out of line (subluxed). In these cases, surgery is done to repair the fracture using pins to hold the pieces of bone together while the injury heals.
It is not common to treat a mallet finger surgically if bone fragments or fractures are not present. Surgical treatment of the damaged tendon usually requires a tendon graft — tendon tissue that is taken (harvested) from another part of your body — or even fusing the joint straight.
An orthopedic surgeon should be consulted in making the decision to treat this condition surgically.
The biceps muscle is in the front of your upper arm. It helps you bend your elbow and rotate your arm. It also helps keep your shoulder stable.
Tendons attach muscles to bones. Your biceps tendons attach the biceps muscle to bones in the shoulder and in the elbow. If you tear the biceps tendon at the shoulder, you may lose some strength in your arm and be unable to forcefully turn your arm from palm down to palm up.
Many people can still function with a biceps tendon tear, and only need simple treatments to relieve symptoms. Some people require surgery to repair the torn tendon.
There are two attachments of the biceps tendon at the shoulder joint.
Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).
The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket. These tissues are called the rotator cuff. They cover the head of your upper arm bone and attach it to your shoulder blade.
The upper end of the biceps muscle has two tendons that attach it to bones in the shoulder. The long head attaches to the top of the shoulder socket (glenoid). The short head attaches to a bump on the shoulder blade called the coracoid process.
Biceps tendon tears can be either partial or complete.
A complete tear of the long head at its attachment point in the glenoid.
Partial tears. Many tears do not completely sever the tendon.
Complete tears. A complete tear will split the tendon into two pieces.
In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.
The long head of the biceps tendon is more likely to be injured. This is because it is vulnerable as it travels through the shoulder joint to its attachment point in the socket. Fortunately, the biceps has two attachments at the shoulder. The short head of the biceps rarely tears. Because of this second attachment, many people can still use their biceps even after a complete tear of the long head.
When you tear your biceps tendon, you can also damage other parts of your shoulder, such as the rotator cuff tendons.
There are two main causes of biceps tendon tears: injury and overuse.
If you fall hard on an outstretched arm or lift something too heavy, you can tear your biceps tendon.
Many tears are the result of a wearing down and fraying of the tendon that occurs slowly over time. This naturally occurs as we age. It can be worsened by overuse – repeating the same shoulder motions again and again.
Overuse can cause a range of shoulder problems, including tendonitis, shoulder impingement, and rotator cuff injuries. Having any of these conditions puts more stress on the biceps tendon, making it more likely to weaken or tear.
Your risk for a tendon tear increases with:
Age. Older people have put more years of wear and tear on their tendons than younger people.
Heavy overhead activities. Too much load during weightlifting is a prime example of this risk, but many jobs require heavy overhead lifting and put excess wear and tear on the tendons.
Shoulder overuse. Repetitive overhead sports – such as swimming or tennis – can cause more tendon wear and tear.
Smoking. Nicotine use can affect nutrition in the tendon.
Corticosteroid medications. Using corticosteroids has been linked to increased muscle and tendon weakness.
- Sudden, sharp pain in the upper arm
- Sometimes an audible pop or snap
- Cramping of the biceps muscle with strenuous use of the arm
- Bruising from the middle of the upper arm down toward the elbow
- Pain or tenderness at the shoulder and the elbow
- Weakness in the shoulder and the elbow
- Difficulty turning the arm palm up or palm down
- Because a torn tendon can no longer keep the biceps muscle tight, a bulge in the upper arm above the elbow (“Popeye Muscle”) may appear, with a dent closer to the shoulder.
Medical History and Physical Examination
After discussing your symptoms and medical history, your doctor will examine your shoulder. The diagnosis is often obvious for complete ruptures because of the deformity of the arm muscle (“Popeye Muscle”).
A biceps tendon tear is made more obvious by contracting the muscle (“Popeye Muscle”).
Partial ruptures are less obvious. To diagnose a partial tear, your doctor may ask you to bend your arm and tighten the biceps muscle. Pain when you use your biceps muscle may mean there is a partial tear.
It is also very important that your doctor identify any other shoulder problems when planning your treatment. The biceps can also tear near the elbow, although this is less common. A tear near the elbow will cause a “gap” in the front of the elbow. Your doctor will check your arm for damage to this area.
In addition, rotator cuff injuries, impingement, and tendonitis are some conditions that may accompany a biceps tendon tear. Your doctor may order additional tests to help identify other problems in your shoulder.
X-rays. Although X-rays cannot show soft tissues like the biceps tendon, they can be useful in ruling out other problems that can cause shoulder and elbow pain.
Magnetic resonance imaging (MRI). These scans create better images of soft tissues. They can show both partial and complete tears.
For many people, pain from a long head of biceps tendon tear resolves over time. Mild arm weakness or arm deformity may not bother some patients, such as older and less active people.
In addition, if you have not damaged a more critical structure, such as the rotator cuff, nonsurgical treatment is a reasonable option. This can include:
Ice. Apply cold packs for 20 minutes at a time, several times a day to keep down swelling. Do not apply ice directly to the skin.
Nonsteroidal anti-inflammatory medications. Drugs like ibuprofen, aspirin, or naproxen reduce pain and swelling.
Rest. Avoid heavy lifting and overhead activities to relieve pain and limit swelling. Your doctor may recommend using a sling for a brief time.
Physical therapy. Flexibility and strengthening exercises will restore movement and strengthen your shoulder.
Surgical treatment for a long head of the biceps tendon tear is rarely needed. However, some patients who require complete recovery of strength, such as athletes or manual laborers, may require surgery. Surgery may also be the right option for those with partial tears whose symptoms are not relieved with nonsurgical treatment.
Procedure. Several new procedures have been developed that repair the tendon with minimal incisions. The goal of the surgery is to re-anchor the torn tendon back to the bone. Your doctor will discuss with you the options that are best for your specific case.
Complications. Complications with this surgery are rare. Re-rupture of the repaired tendon is uncommon.
Rehabilitation. After surgery, your shoulder may be immobilized temporarily with a sling.
Your doctor will soon start you on therapeutic exercises. Flexibility exercises will improve range of motion in your shoulder. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.
Be sure to follow your doctor’s treatment plan. Although it is a slow process, your commitment to physical therapy is the most important factor in returning to all the activities you enjoy.
Surgical Outcome. Successful surgery can correct muscle