Acoustic Neuroma

Definition

Although it's frightening to learn that you have a tumor growing inside your head, it may be somewhat comforting to know that an acoustic neuroma is noncancerous (benign) and usually slow growing. These tumors develop adjacent to your brain on a portion of the eighth cranial nerve, which runs from your brain to your inner ear. Also known as vestibular schwannoma, acoustic neuroma is one of the most common types of brain tumors.

Symptoms of acoustic neuroma, including hearing loss, develop from the tumor pressing on the nerve. But, acoustic neuromas don't invade brain tissue like cancer does.

For some people, an acoustic neuroma remains so small it never causes problems. Treatment options include regular monitoring, radiation and surgical removal.

Symptoms

The signs and symptoms of acoustic neuroma develop from a tumor pressing on cranial nerves.

As the tumor grows, it may be more likely to cause signs and symptoms, although tumor size doesn't always determine effects. It's possible for a small tumor to cause significant signs and symptoms. In many cases, however, a small tumor of less than about six-tenths of an inch — about 1.5 centimeters (cm) — may cause no signs or symptoms. Some tumors grow as large as about 2.5 inches (more than 6 cm).

Signs and symptoms may include:

• Hearing loss, usually gradual — although in some cases sudden — and occurring on only one side or more pronounced on one side
• Ringing (tinnitus) in the affected ear
• Dizziness (vertigo)
• Loss of balance
• Facial numbness and weakness

The tumor also may press on the brainstem. In rare cases, an acoustic neuroma may grow large enough to compress the brainstem and be life-threatening.

When to see your doctor
See your doctor if you notice hearing loss, particularly in one ear, or develop ringing in your ear, dizziness or have trouble with balance. Early diagnosis of an acoustic neuroma may help keep the tumor from growing large enough to cause serious consequences, such as total hearing loss or a life-threatening buildup of fluid within your skull.

Causes

Your eighth cranial (vestibulocochlear) nerve has three branches, which transmit information from your inner ear to your brain. The cochlear branch carries sound. The superior vestibular branch and the inferior vestibular branch carry information regarding balance. Most acoustic neuromas develop on a vestibular branch.

The cause of acoustic neuromas is unknown. However, the tumors, in rare cases, are an indication of neurofibromatosis 2, a genetic disorder that involves the growth of tumors on the vestibulocochlear nerve. Tumors associated with neurofibromatosis often affect the nerve on both sides (bilateral).

Risk factors

The only known risk factor for acoustic neuroma is having the rare genetic disorder neurofibromatosis 2, which involves the development of benign tumors on the vestibulocochlear nerves on both sides of your head, as well as on other nerves.

Neurofibromatosis 2 is known as an autosomal dominant disorder, meaning the mutation occurs on a nonsex chromosome (autosome) and can be passed on from only one parent (dominant gene). If either parent has this disorder, their children have a 50-50 chance of inheriting it.

Acoustic neuromas are most common in people between the ages of 30 and 60 years old.

Some evidence has suggested that persistent exposure to very loud noise or heavy cell phone use may play a role in the development of acoustic neuroma, but findings from studies looking into these associations have been inconclusive.

Complications

An acoustic neuroma may cause a variety of complications, including:

• Permanent hearing loss
• Facial numbness and weakness
• Difficulties with balance and clumsy gait

Large tumors may press on your brainstem, preventing the normal flow of fluid between your brain and spinal cord (cerebrospinal fluid). In this case, fluid can build up in your head (hydrocephalus), increasing the pressure inside your skull.

Preparing for your appointment

You're likely to start by first seeing your family doctor or a general practitioner. However, in some cases when you call to set up an appointment, you may be referred immediately to an ear, nose and throat specialist (otolaryngologist), a neurologist, a neurosurgeon or an otolaryngologist that specializes in neurological surgeries (neurotologist).

Because there's often a lot of ground to cover during your appointment, it's a good idea to be well prepared. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, as well as any vitamins or supplements, that you're taking.
• Ask a family member or friend to join you, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Preparing a list of questions will help you make the most of your time with your doctor. For acoustic neuroma, some basic questions to ask your doctor include:

• What is likely causing my symptoms?
• Are there any other possible causes for my symptoms?
• What kinds of tests do I need?
• What treatment options are available?
• Which one do you recommend for me?
• What is the likelihood of side effects from each treatment option?
• What happens if I do nothing?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous, or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?

Tests and diagnosis

Because signs and symptoms of acoustic neuroma are likely to develop gradually and because hearing loss, tinnitus and dizziness can be indicators of other middle and inner ear problems, it may be difficult for your doctor to detect the tumor in its early stages. Acoustic neuromas often are found during screening for other conditions.

After asking questions about your symptoms, your doctor will conduct an ear exam and may request the following tests:

• Scans. Magnetic resonance imaging (MRI) or computerized tomography (CT) scans of your head can provide images that confirm the presence of an acoustic neuroma.
• Hearing test (audiometry). During this test conducted by a hearing specialist (audiologist), you wear earphones and hear sounds directed to one ear at a time. The audiologist presents a range of sounds of various tones and asks you to indicate each time you hear the sound. Each tone is repeated at faint levels to find out when you can barely hear. The audiologist will also present various words to determine your hearing ability.
• Electronystagmography (ENG). This test evaluates balance (vestibular) function by detecting abnormal rhythmic eye movement (nystagmus) often present with inner ear conditions. The test measures your involuntary eye movements while stressing your balance in various ways.
• Brainstem auditory evoked response (BAER). This test checks hearing and neurological functions. Electrodes on your scalp and earlobes capture your brain's responses to clicking noises you hear through earphones and record the responses on a graph.

Treatments and drugs

There are three options for managing an acoustic neuroma: observation to determine whether it's growing and how fast, radiation and surgical removal.

Monitoring
If you have a small acoustic neuroma that isn't growing or is growing slowly and causes few or no signs or symptoms, you and your doctor may decide to monitor it, especially if you're an older adult or otherwise not a good candidate for treatment.

Your doctor may recommend that you have regular imaging and hearing tests to determine whether the tumor is growing and how quickly. If the scans show the tumor is growing or if the tumor causes progressive hearing loss or other difficulties, you may need to undergo treatment.

Stereotactic radiosurgery
Stereotactic radiosurgery, such as gamma-knife radiosurgery, enables doctors to deliver radiation precisely to a tumor without making an incision. The doctor attaches a lightweight headframe to your numbed scalp. Using imaging scans, your doctor pinpoints the tumor and then plots where to apply the radiation beams. This procedure often is performed under local anesthesia.

The purpose of radiosurgery is to stop the growth of a tumor. It may also be used for residual tumors — portions of a tumor that traditional brain surgery can't remove without damaging brain tissue.

It may take weeks, months or years before the effects of radiosurgery become evident. Your doctor will monitor your progress with follow-up imaging studies and hearing tests.

Surgical removal
The goal of surgery is to remove the tumor and preserve the facial nerve to prevent facial paralysis and preserve hearing. Performed under general anesthesia, this type of surgery involves removing the tumor through an incision in your skull. You may need to stay in the hospital from four to six days after the surgery, and recovery may take six weeks or more.

Acne

Definition

Zits. Pimples. Blemishes. No matter what you call them, acne can be distressing and annoyingly persistent. Acne lesions heal slowly, and when one begins to resolve, others seem to crop up. This ongoing battle and long-lasting cycle is both wearisome and frustrating.

Hormones likely play a role in the development of acne, making the condition most common in teenagers. But people of all ages can get acne. Some adult women experience mild to moderate acne due to hormonal changes associated with pregnancy, their menstrual cycles, or starting or stopping birth control pills.

Teenage and adult acne can take months or years to treat successfully. Depending on its severity, acne can cause emotional distress and lead to scarring of the skin.

The good news is that effective treatments are available. Acne treatment for mild cases usually involves self-care measures, such as washing your skin daily with a gentle cleanser and using an over-the-counter acne cream. Acne treatment for severe cases usually includes one or more prescription medications. Once acne is under control, prevention strategies can help keep your skin clear of breakouts.

Symptoms

Acne typically appears on your face, neck, chest, back and shoulders, which are the areas of your skin with the largest number of functional oil glands. Acne can take the following forms:

• Comedones (whiteheads and blackheads). Comedones (kom-uh-DO-neze) are created when the openings of hair follicles become clogged and blocked with oil secretions, dead skin cells and sometimes bacteria. When comedones are open at the skin surface they're called blackheads because of the dark appearance of the plugs in the hair follicles. When comedones are closed, they're called whiteheads — slightly raised, skin-colored bumps.
• Papules. These are small raised bumps that signal inflammation or infection in the hair follicles. Papules may be red and tender.
• Pustules. Similar to papules, pustules are red, tender bumps with white pus at their tips.
• Nodules. These are large, solid, painful lumps beneath the surface of the skin. They're formed by the buildup of secretions deep within hair follicles.
• Cysts. These are painful, pus-filled lumps beneath the surface of the skin. These boil-like infections can cause scars.

Causes

Three factors contribute to the formation of acne:

• Overproduction of oil (sebum)
• Irregular shedding of dead skin cells resulting in irritation of the hair follicles of your skin
• Buildup of bacteria

Acne occurs when the hair follicles become plugged with oil and dead skin cells. Each follicle is connected to sebaceous glands. These glands secrete an oily substance known as sebum to lubricate your hair and skin. Sebum normally travels up along the hair shafts and then out through the opening of the hair follicle onto the surface of your skin. When your body produces an excess amount of sebum and dead skin cells, the two can build up in the hair follicle and form together as a soft plug.

This plug may cause the follicle wall to bulge and produce a whitehead. Or, the plug may be open to the surface and may darken, causing a blackhead. Pimples are raised red spots with a white center that develop when blocked hair follicles become inflamed or infected. Blockages and inflammation that develop deep inside hair follicles produce lumps beneath the surface of your skin called cysts. Other pores in your skin, which are the openings of the sweat glands onto your skin, aren't normally involved in acne.

It's not known what causes the increased production of sebum that leads to acne. But a number of factors — including hormones, bacteria, certain medications and heredity — play a role.

Contrary to what some people think, foods have little effect on acne. Acne also isn't caused by dirt. In fact, scrubbing the skin too hard or cleansing with harsh soaps or chemicals irritates the skin and can make acne worse.

Risk factors

Hormonal changes in your body can provoke or aggravate acne. Such changes are common in:

• Teenagers, both in boys and girls
• Women and girls, two to seven days before their periods
• Pregnant women
• People using certain medications, including cortisone

Other risk factors include:

• Direct skin exposure to greasy or oily substances, or to certain cosmetics
• A family history of acne — if your parents had acne, you're likely to develop it too
• Friction or pressure on your skin caused by items such as telephones or cell phones, helmets, tight collars and backpacks

When to seek medical advice

Acne treatments work by reducing oil production, speeding up skin cell turnover, fighting bacterial infection, reducing the inflammation or doing all four. With most prescription acne treatments, you may not see results for four to eight weeks, and your skin may get worse before it gets better.

Your doctor or dermatologist may recommend a prescription medication you apply to your skin (topical medication) or take by mouth (oral medication). Oral prescription medications for acne should not be used during pregnancy, especially during the first trimester.

Types of acne treatments include:

• Topical treatments. Acne lotions may dry up the oil, kill bacteria and promote sloughing of dead skin cells. Over-the-counter lotions are generally mild and contain benzoyl peroxide, sulfur, resorcinol, salicylic acid or lactic acid as their active ingredient. These products can be helpful for very mild acne. If your acne doesn't respond to these treatments, you may want to see a doctor or dermatologist to get a stronger prescription lotion. Tretinoin (Avita, Retin-A, Renova) and adapalene (Differin) are examples of topical prescription products derived from vitamin A. They work by promoting cell turnover and preventing plugging of the hair follicles. A number of topical antibiotics also are available. They work by killing excess skin bacteria. Often, a combination of such products is required to achieve optimal results.
• Antibiotics. For moderate to severe acne, prescription oral antibiotics may be needed to reduce bacteria and fight inflammation. You may need to take these antibiotics for months, and you may need to use them in combination with topical products.
• Isotretinoin. For deep cysts, antibiotics may not be enough. Isotretinoin (Accutane) is a powerful medication available for scarring cystic acne or acne that doesn't respond to other treatments. This medicine is reserved for the most severe forms of acne. It's very effective, but people who take it need close monitoring by a dermatologist because of the possibility of severe side effects. Isotretinoin is associated with severe birth defects, so it can't be taken by pregnant women or women who may become pregnant during the course of treatment or within several weeks of concluding treatment. In fact, the drug carries such serious potential side effects that women of reproductive age must participate in a Food and Drug Administration-approved monitoring program to receive a prescription for the drug. In addition, isotretinoin may increase the levels of triglycerides and cholesterol in the blood and may increase liver enzyme levels. Although cause and effect hasn't been proved, studies have reported the development of inflammatory bowel disease with isotretinoin use.
• Oral contraceptives. Oral contraceptives, including a combination of norgestimate and ethinyl estradiol (Ortho-Cyclen, Ortho Tri-Cyclen), have been shown to improve acne in women. However, oral contraceptives may cause other side effects that you'll want to discuss with your doctor.
• Laser and light therapy. Laser- and light-based therapies reach the deeper layers of skin without harming the skin's surface. Laser treatment is thought to damage the oil (sebaceous) glands, causing them to produce less oil. Light therapy targets the bacterium that causes acne inflammation. These therapies can also improve skin texture and lessen the appearance of scars, so they may be good treatment choices for people with both active acne and acne scars.
• Cosmetic procedures. Chemical peels and microdermabrasion may be helpful in controlling acne. These cosmetic procedures — which have traditionally been used to lessen the appearance of fine lines, sun damage and minor facial scars — are most effective when used in combination with other acne treatments.

Acne scar treatment
Doctors may be able to use certain procedures to diminish scars left by acne. These include fillers, dermabrasion, intense light therapy and laser resurfacing.

• Soft tissue fillers. Collagen or fat can be injected under the skin and into scars to fill out or stretch the skin, making the scars less noticeable. Results from this acne scar treatment are temporary, so you'd need to repeat the injections periodically.
• Dermabrasion. Usually reserved for more severe scarring, dermabrasion involves removing the top layer of skin with a rapidly rotating wire brush. Surface scars may be completely removed and deeper acne scars may appear less noticeable. Dermabrasion may cause pigmentation changes for people with darker skin.
• Microdermabrasion. This newer acne scar treatment involves a hand-held device that blows crystals onto skin. These crystals gently abrade or "polish" the skin's surface. Then, a vacuum tube removes the crystals and skin cells. Because just the surface cells are removed, the skin isn't damaged. However, results are subtle and scars may still be noticeable, even after several sessions.
• Laser, light source and radiofrequency treatments. In laser resurfacing, a laser beam destroys the outer layer of skin (epidermis) and heats the underlying skin (dermis). As the wound heals, new skin forms. Less intense lasers (nonablative lasers), pulsed light sources and radiofrequency devices don't injure the epidermis. These treatments heat the dermis and cause new skin formation. After several treatments, acne scars may appear less noticeable. This means shorter recovery times, but treatment typically needs to be repeated more often and results are subtle.
• Skin surgery. A minor procedure (punch excision) cuts out individual acne scars. Stitches or a skin graft repairs the hole left at the scar site.

Prevention

Once your acne improves or clears, you may need to continue your acne medication or other treatment to prevent new acne breakouts. In some cases, you might need to use a topical medication on acne-prone areas, continue taking oral contraceptives or attend ongoing light therapy sessions to keep your skin clear. Talk to your doctor about how you can prevent new eruptions.

You can also prevent new acne breakouts with self-care measures, such as washing your skin with a gentle cleanser and avoiding touching or picking at the problem areas. Other acne prevention tips include:

• Wash acne-prone areas only twice a day. Washing removes excess oil and dead skin cells. But too much washing can irritate the skin. Wash areas daily with a gentle cleanser and use oil-free, water-based skin-care products.
• Use an over-the-counter acne cream or gel to help dry excess oil. Look for products containing benzoyl peroxide or salicylic acid as the active ingredient.
• Avoid heavy foundation makeup. Choose powder cosmetics over cream products because they're less irritating.
• Remove makeup before going to bed. Going to sleep with cosmetics on your skin can clog tiny openings of the hair follicles (pores). Also, be sure to throw out old makeup and clean your cosmetic brushes and applicators regularly with soapy water.
• Wear loosefitting clothing. Tightfitting clothing traps heat and moisture and can irritate your skin. Also, whenever possible, avoid tightfitting straps, backpacks, helmets or sports equipment to prevent friction against your skin.
• Shower after exercising or doing strenuous work. Oil and sweat on your skin can trap dirt and bacteria.

Lifestyle and home remedies

You can avoid or control most acne with good basic skin care and the following self-care techniques:

• Wash problem areas with a gentle cleanser. Products such as facial scrubs, astringents and masks generally aren't recommended because they tend to irritate skin, which can worsen acne. Excessive washing and scrubbing also can irritate skin. If you tend to develop acne around your hairline, shampoo your hair frequently.
• Try over-the-counter acne lotion to dry excess oil and promote peeling. Look for products containing benzoyl peroxide or salicylic acid as the active ingredient.
• Avoid irritants. You may want to avoid oily or greasy cosmetics, sunscreens, hair-styling products or acne concealers. Use products labeled "water-based" or "noncomedogenic." For some people, the sun worsens acne. Additionally, some acne medications can make you more susceptible to the sun's rays. Check with your doctor to see if your medication is one of these, and if so, stay out of the sun as much as possible and anytime you have to be in the sun, use sunscreen that doesn't clog your pores.
• Watch what touches your face. Keep your hair clean and off your face. Also avoid resting your hands or objects such as telephone receivers on your face. Tight clothing or hats also can pose a problem, especially if you'll be sweating. Sweat, dirt and oils can contribute to acne.
• Don't pick or squeeze blemishes. Picking or squeezing can cause infection or scarring. Most acne will clear up without this kind of intervention. If you need aggressive treatment, see your doctor or dermatologist.

Anterior Cruciate Ligament Injury

Definition

An ACL injury is the tearing of the anterior cruciate (KROO-she-ate) ligament in your knee. An ACL injury may make your knee feel unstable or loose, and your knee may "give way" if you return to your sport too quickly.

Although an active lifestyle benefits your overall health, exercise isn't always easy on your knees. The anterior cruciate ligament is especially susceptible to the demands of certain sports, such as volleyball, gymnastics, basketball, soccer and football.

Treatment of an ACL injury may include surgery to replace the torn ligament, along with an intense rehabilitation program. As for prevention, if your favorite sport involves pivoting or jumping, a proper training program can help you avoid an ACL injury.

Symptoms

At the time of an ACL injury, signs and symptoms may include:

• A loud "pop" sound
• Severe pain
• Knee swelling that usually worsens for hours after the injury occurs
• A feeling of instability or "giving way" with weight bearing

Once the swelling subsides, your knee may still feel unstable. It may feel as if it's going to "give way" during twisting or pivoting movements.

When to see a doctor
If you experience any of the signs and symptoms of ACL injury — a popping sound, severe knee pain, a swollen knee or a feeling that your knee is giving out — see a doctor. Also see your doctor if your knee feels loose or unable to support your weight. In general, the longer you wait to start treatment, the longer it will take to get better.

Causes

Ligaments are strong bands of tissue that attach one bone to another. The ACL, one of two ligaments that cross in the middle of the knee, connects your thighbone (femur) to your shinbone (tibia) and helps stabilize your knee joint.

Most ACL injuries happen during sports and fitness activities. The ligament may tear when you slow down suddenly to change direction or pivot with your foot firmly planted, twisting or overextending your knee.

Sports that involve running, turning sharply, pivoting and jumping — especially basketball, soccer and gymnastics — put your knee at risk. The ACL can also tear when the tibia is pushed forward below the femur, such as during a fall in downhill skiing. A football tackle or motor vehicle accident also can cause an ACL injury. However, most ACL injuries occur without such contact.

Risk factors

ACL injuries are most common among:

• Athletes. If you engage in certain sports, such as those that rely on cut-and-run techniques (basketball, soccer, football) you're more at risk of an ACL injury.
• Women. Women are significantly more likely to have an ACL tear than are men participating in the same sports. Women tend to have imbalanced thigh muscles, with stronger muscles at the front of the thigh (quadriceps), compared with those at the back of the thigh (hamstrings). The hamstrings help protect the shinbone from sliding too far forward. When landing from a jump, some women may land in a position that increases stress on the ACL.

Complications

In the short term, you'll have to stop doing the activities that cause pain until your injured ligament has healed. You may have to take time off work, school and sports.

Other complications may include:

• Torn meniscus. In many cases, an ACL injury also results in a tear of the meniscus — the cartilage in your knee between the thighbone and shinbone. A cartilage tear increases the risk of future joint problems.
• Arthritis. A common long-term complication is the early onset of knee osteoarthritis, in which joint cartilage deteriorates and its smooth surface roughens. About half the people with an ACL tear develop osteoarthritis in the involved joint 10 to 20 years later. Arthritis may occur even if you have surgery to reconstruct the ligament.

Preparing for your appointment

You're likely to start by first seeing your family doctor or a general practitioner. However, in some cases when you call to set up an appointment, you may be referred immediately to an orthopedist, an orthopaedic surgeon or a sports medicine specialist.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Write down any symptoms you're experiencing, including what you were doing when you first started experiencing the symptoms.
• Ask a family member or friend to join you, if possible. Sometimes it can be difficult to soak up all the information and treatment options provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your appointment. List your questions from most important to least important in case time runs out. For an ACL injury, some basic questions to ask your doctor include:

• What's the most likely cause of my symptoms?
• Are there other possible causes for my symptoms?
• What kinds of tests do I need? Will these tests definitively diagnose my condition?
• What treatment options are available?
• Which do you recommend for my situation?
• If I choose not to have surgery, how long might recovery take?
• If I don't have surgery, what signs and symptoms would indicate a need for surgery?
• If I have surgery, what's the average recovery time?
• What activity restrictions do I need to follow?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms?
• What were you doing at the time?
• Did you experience immediate swelling?
• Have your symptoms been continuous, or occasional?
• How severe are your symptoms?
• Does anything seem to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Does your knee ever "lock" or feel blocked when you're trying to move it?
• Do you ever feel that your knee is unstable or unable to support your weight?

What you can do in the meantime
If you've injured your knee, don't move the joint. Use a splint to keep your knee protected in a comfortable position until a doctor examines it. Avoid returning to a sport or activity until you've had the injury evaluated.

Tests and diagnosis

To diagnose a torn ACL, your doctor first wants to know as much as possible about the injury, such as whether you heard or felt your knee pop, whether your knee swelled up afterward and if you were able to continue being physically active.

Swelling that occurs shortly after the injury usually means there's blood in the joint from torn blood vessels in the damaged ligament. Your doctor may decide to draw the blood out with a needle and syringe. This can reduce pain and make it easier to examine the knee joint.

Your doctor examines your knee in a variety of positions to assess whether or not your ACL is torn. Two common exams are:

• Lachman's test. In this test you lie on your back on the exam table with your injured leg bent at a 30-degree angle and your foot flat on the table. Your doctor then moves the lower portion of your injured leg forward from the knee. If your leg moves freely without reaching a firm endpoint, you have a tear in your ACL.
• Pivot shift test. For this test, your injured leg is extended, and your doctor rotates your foot at the same time he or she applies pressure to the outside of your knee and bends your knee. Signs of instability in your shinbone suggest an ACL tear.

Often the diagnosis can be made on the basis of the physical exam alone, but you may need X-rays to rule out a bone fracture. If your doctor has questions about the cause or extent of your injury, he or she may order a magnetic resonance imaging (MRI) scan, a painless procedure that uses magnetic fields to create an image of the soft tissues of your body. An MRI can show the extent of ACL injury and whether other knee ligaments or joint cartilage also are injured.

Treatments and drugs

Initial treatment for an ACL injury aims to reduce pain and swelling in your knee, regain normal joint movement and strengthen the muscles around your knee. You and your doctor will then decide if you need surgery plus rehabilitation or intense rehabilitation alone.

Which option is right for you depends on several factors, including the extent of damage to your knee and your willingness to modify your activities. When a young child whose bones are still growing injures his or her ACL, doctors may recommend postponing surgery until the child's bones have stopped growing.

Short term
To treat the acute injury:

• Use ice. When you're awake, try to ice your knee at least every two hours for 20 minutes at a time.
• Elevate your knee.
• Take pain relievers such as ibuprofen (Advil, Motrin, others) as needed.
• Wrap an elastic bandage around your knee.
• Use a splint or walk with crutches if needed.
• Work with a physical therapist on range-of-motion and muscle-strengthening exercises.

Surgery
A torn ACL can't be sewn back together. The ligament is reconstructed by taking a piece of tendon from another part of your leg and connecting it to the thighbone and shinbone (autograft). If your own tendons don't provide the best replacement for the injured ligament, your doctor may recommend using a tendon from a cadaver (allograft). The cadavers used for allografts have been carefully screened and tested for diseases.

You may consider surgery if:

• Your knee is unstable and gives way during daily activities or sports
• You're very active and want to resume heavy work, sports or other recreational activities
• Other parts of your knee, such as the meniscus or other ligaments, were also injured
• You want to prevent further injury to your knee

ACL reconstruction surgery is an outpatient procedure using arthroscopic techniques. The surgeon inserts a thin instrument (arthroscope) with a light and a small camera into one or two small incisions. This allows your surgeon to see the inside of your knee joint and make the repairs.

After surgery you'll go through a rehabilitation program. In addition to working with a physical therapist, you may wear a knee brace and you'll need to avoid activities that put undue stress on your knee. Most people can return to their sports about six months after surgery. About nine in 10 people who undergo ACL reconstruction report good to excellent results and satisfactory knee stability, according to the American Academy of Orthopaedic Surgeons.

Nonsurgical rehabilitation
A rehabilitation program without surgery involves physical therapy, modifying your activities and knee bracing. This approach can be effective as long as you're willing to give up the sports and other activities that place extra stress on your knee. You may want to consider rehabilitation alone if:

• You have a partial tear
• You don't participate in sports that involve cutting, pivoting or jumping
• Your knee isn't painful or unstable during normal activities
• You lead a fairly sedentary life
• Your knee cartilage hasn't been damaged
• You have advanced knee arthritis

Prevention

To reduce your chance of an ACL injury, follow these tips:

• Improve your conditioning. Training programs that have been shown to be effective in helping to prevent ACL injuries typically include stretching and strengthening exercises, aerobic conditioning, plyometric exercises, "jump training" and risk-awareness training. Exercises that improve balance also can help when done in conjunction with other training exercises.
• Strengthen your hamstrings (women). Women athletes should take care to strengthen and stretch their hamstring muscles as well as their quadriceps.
• Keep fit year-round. If you're on a seasonal sports team, stay conditioned all year. This will help with your balance, strength and coordination when the next season starts.
• Use proper techniques when playing sports or exercising. If your sport involves jumping, learn how to land safely. Learn to do cutting maneuvers in a crouched posture with a slight bend at the knee and hip.
• Check your gear. In downhill skiing, make sure your ski bindings are adjusted correctly by a trained professional so that your skis will release when you fall.

Using a knee brace during sports doesn't reduce your risk of injury - and may provide a false sense of security.

Achilles Tendinitis

Definition

Achilles tendinitis is present when your Achilles tendon becomes inflamed or irritated.

Often, Achilles tendinitis results from sports that place a lot of stress on your calf muscles and Achilles tendon, such as basketball. Achilles tendinitis also is often associated with a sudden increase in the intensity or frequency of exercise.

When treated promptly, Achilles tendinitis is often short-lived. Left untreated, Achilles tendinitis could cause persistent pain or cause your tendon to tear (rupture). If so, you may need surgery to correct the damage.

Fortunately, rest and over-the-counter medications to reduce your pain and inflammation may be all the treatment you need for Achilles tendinitis.

Symptoms

The signs and symptoms of Achilles tendinitis often develop gradually. They include:

• Dull ache or pain when pushing off your foot during walking or when rising on your toes
• Tenderness over your Achilles tendon
• Stiffness that lessens as your tendon warms up
• Mild swelling or a "bump" on your tendon
• A crackling or creaking sound when you touch or move your Achilles tendon

You may notice that the affected tendon is sore when you get up in the morning or after you've rested, improves slightly once you start moving around, and then worsens again when you increase your activity level.

If you have sudden pain and swelling near your heel and are unable to bend your foot downward or walk normally, you may have ruptured your Achilles tendon. If you've ruptured the tendon completely, you won't be able to rise on your toes on the injured leg. You may feel as if you've been kicked in the back of your ankle. See your doctor immediately if you suspect you have an Achilles tendon rupture.

Causes

Your Achilles tendon is the large band of tissues connecting the muscles in the back of your calf to your heel bone. Also called the heel cord, the Achilles tendon is used when you walk, run, jump, or push up on your toes.

When you place a large amount of stress on your Achilles tendon too quickly, it can become inflamed from tiny tears that occur during the activity. A sudden increase in a repetitive activity that involves the Achilles tendon can be to blame. A number of other factors can cause Achilles tendinitis, including:

• Improper conditioning. Achilles tendinitis is most common among athletes whose bodies aren't properly conditioned for their sport or activity. Inadequate flexibility and strength of the calf muscles can contribute to overload of the tendon. Frequent stops and starts during the activity, as well as activities that require repeated jumping — such as basketball or tennis — also can increase your risk of Achilles tendinitis.
• Too much, too soon. Achilles tendinitis resulting from overuse can occur when you begin a new exercise regimen. If you're just beginning a new exercise program, be sure to stretch before and after exercising, and start slowly, increasing your activity over time. Don't push yourself too quickly. If you're a runner, excessive hill running can contribute to Achilles tendinitis.
• Flattened arch. Flattening of the arch of your foot (excessive pronation) can place you at increased risk of developing Achilles tendinitis. This is because of the extra stress placed on you Achilles tendon when walking. If you have excessive pronation, be sure to wear shoes with appropriate support to avoid further aggravating your Achilles tendon.
• Trauma or infection. In some cases, inflammation of the Achilles tendon is due to trauma or infection near the tendon.

When to seek medical advice

If you experience pain around your Achilles tendon that worsens with activity, call your doctor for an evaluation and to discuss treatment options.

See your doctor if you experience persistent pain near the back of your heel in the area of your Achilles tendon, and especially if the pain doesn't markedly improve within one to two weeks despite self-care measures. See your doctor immediately if you experience signs or symptoms of an Achilles tendon rupture.

Tests and diagnosis

To diagnose Achilles tendinitis, your doctor will examine your foot and may have an X-ray taken of the area to rule out other causes of your pain. He or she will also ask questions about your physical activity.

If your doctor suspects that your Achilles tendon has torn, he or she may order an MRI scan, a painless procedure that uses magnetic fields to create a computer image of the soft tissues of your body.

Complications

Achilles tendinitis can progress to a degenerative condition called Achilles tendinosis, in which the tendon begins to lose its organized structure, making the tendon weaker and more fibrous. Continued stress to your Achilles tendon could cause it to tear (rupture), which may require surgery to correct the damage

Treatments and drugs

If you've tried self-care measures, such as rest, ice and over-the-counter pain relievers, and they aren't working for you, your doctor may suggest other Achilles tendinitis treatments:

• Orthotic devices. A temporary foot insert (orthotic device) that elevates your heel within your shoe may relieve strain on the stretched tendon. Your doctor also might prescribe special heel pads or cups to wear in your shoes to cushion and support your heel, or a splint to wear at night that will keep the Achilles tendon stretched while you sleep.
• Boot and crutches. In severe cases, your doctor may suggest a walking boot or have you use crutches to enable the tendon to heal.
• Surgery. Nonsurgical treatments, including physical therapy and perhaps a change in your exercise program, should allow the tendon to heal and repair itself over a period of weeks. If these treatments aren't effective, surgery to remove the inflamed tissue from around the tendon may be necessary; however, this is usually a last resort.

If left untreated and if the tendon continues to sustain small tears through exercise and repeated movement, the tendon can rupture under excessive stress.

Prevention

While it may not be possible to prevent Achilles tendinitis, you can take measures to reduce your risk:

• Increase your activity level gradually. If you're just beginning an exercise regimen, don't feel like you have to be marathon-ready in record time. Starting slowly will help you determine your limits and follow a sensible exercise program.
• Take it easy. Avoid activities that place excessive stress on your tendons, especially for prolonged periods. If you participate in a strenuous activity, warm up first by exercising at a slower pace. If you notice pain during a particular exercise, stop and rest.
• Choose your shoes carefully. The shoes you wear while exercising should provide adequate cushion for your heel and should have a firm arch support to help reduce the tension in the Achilles tendon. Replace shoes that show excessive wear. If your shoes are in good condition but don't support your feet, try arch supports in both shoes.
• Stretch daily. Take the time to stretch your calf muscles and Achilles tendon in the morning, before exercise and after exercise to maintain flexibility. This is especially important to avoid a recurrence of Achilles tendinitis.
• Strengthen your calf muscles. Performing exercises such as toe raises, especially with a slow return to the ground after each toe raise, trains the muscle-tendon unit to withstand more loading force.
• Cross-train. Alternate impact activities, such as running and jumping, with low-impact activities, such as cycling and swimming.

Lifestyle and home remedies

If you think you may have Achilles tendinitis, help speed your recovery and prevent further problems by trying these at-home care methods:

• Rest. Avoid activities that increase the pain or swelling. Don't try to work or play through the pain. Rest is essential to tissue healing. But this doesn't mean complete bed rest. You can do other activities and exercises that don't stress the injured tendon, especially low-impact activities, such as bicycling.
• Ice. To decrease pain, muscle spasm and swelling, apply ice to the injured area for up to 20 minutes, several times a day. Ice packs, ice massage or ice water slush baths all can help. For an ice massage, freeze a plastic foam cup full of water so that you can hold the cup while applying the ice directly to the skin.
• Compression. Because swelling can result in loss of motion in an injured joint, compress the area until the swelling has ceased. Wraps or compressive elastic bandages are best.
• Elevation. Raise the affected ankle above the level of your heart to reduce swelling. It's especially important to use this position at night.

Keep moving
Although rest is a key part of treating tendinitis, prolonged inactivity can cause stiffness in your joints. Move the injured ankle through its full range of motion and perform gentle Achilles tendon stretches to maintain joint flexibility.

Anti-inflammatory medications
You can also try nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen (Advil, Motrin, others) or products containing acetaminophen (Tylenol, others) to try to reduce the discomfort associated with tendinitis.

Be sure to talk to your doctor if you feel you need NSAIDs for an extended time because some of these drugs should be used for only short periods — around seven to 10 days — to avoid complications.

If you take NSAIDs frequently or take more than the recommended dose, these medications can cause stomach pain, stomach bleeding and ulcers. Rarely, prolonged use can disrupt normal kidney function. If you have liver problems, talk to your doctor before using products containing acetaminophen.

Diseases and Conditions

A

Absence seizure (petit mal seizure)

Acanthosis Nigricans

Achilles Tendinitis

Anterior Cruciate Ligament Injury

Acne