Bones & Muscles

Guillain-Barré syndrome (GBS) is a rare medical condition that affects the nerves outside the brain and spinal cord.

Guillain-Barré (GHEE-yan bah-RAY) syndrome often causes people to have weakness or even paralysis in parts of the body. Most people who get Guillain-Barré syndrome recover and return to their normal lives and activities.

What Is Guillain-Barré Syndrome?

Experts believe that GBS is an autoimmune disorder. The immune system usually protects us by attacking invading organisms that can harm the body. In autoimmune disorders, the immune system mistakenly thinks that the body’s own cells are invaders and begins to attack them. Guillain-Barré can affect people of any age, but it becomes more common with increasing age.

The nerves outside the brain and spinal cord are called the peripheral nerves. They transmit signals from our brain to our muscles and tell them to move. They also send sensory signals (such as touch, pressure, temperature, and pain) to the brain. When GBS causes these nerves to be temporarily damaged, the signals are interrupted. As a result, someone with GBS may have weakness or problems moving, or may feel numbness and tingling in the arms or legs.

GBS is rare, but can get serious: If the muscles in the chest are affected, for example, it may interfere with breathing and require the person to use a ventilator for a while. The good news is that the paralysis that goes with GBS is usually temporary.

What Causes It?

No one knows yet what causes GBS or why it affects some people and not others.

Although no one knows what causes GBS, scientists do have some theories about the syndrome and why it surfaces in the body. For example, doctors report that more than half of all GBS cases seem to happen after a viral or bacterial infection, such as those that cause sore throats or diarrhea. Occasionally, minor surgery or something else might trigger GBS symptoms.

There’s no reason to worry that a typical sore throat or a minor surgery is going to trigger an autoimmune response and lead to GBS, though. Colds, sore throats, and the occasional bout of diarrhea are fairly normal parts of everyone’s lives; getting GBS, thankfully, is not.

Signs and Symptoms

When GBS does strike, it can progress quickly, with the most severe symptoms taking place as soon as 2 weeks after the first signs appear. The first symptoms, such as weakness or tingling in the legs, can show up within a day. These sensations can then spread to the arms and upper body, and the person may feel increasingly tired. Sometimes, someone with GBS also begins to lose his or her reflexes (for example, the person may not have the knee-jerk reflex that happens when a doctor tests reflexes).

In the most severe cases of Guillain-Barré syndrome, the symptoms continue to get worse until certain muscles become completely paralyzed. At this stage, the paralysis can interfere with breathing or swallowing, so a person usually has to go to the hospital. It can be frightening, but even at this stage doctors expect most people to recover completely.

How Is GBS Diagnosed?

Doctors rely on a person’s medical history and a physical exam to diagnose GBS. If a doctor suspects GBS, he or she will ask some detailed questions, such as whether the symptoms affect both sides of the body (which is typical with GBS), how quickly the symptoms started, and how whether symptoms are getting worse. In GBS, it’s typical for symptoms to start with tingling in the toes and fingertips. Weakness usually starts in the feet and legs and spreads to arms, and occasionally involves the torso and breathing muscles.

Doctors also may do a few tests to confirm that a patient has GBS, including a lumbar puncture (spinal tap). Two other tests — an electromyogram (EMG) and a nerve conduction velocity (NCV) test — can show how well nerves are sending signals down to the arms and legs.

How Is It Treated?

People with GBS are usually hospitalized so doctors and nurses can monitor their body functions. Because the way GBS progresses can be unpredictable, some patients are cared for in an intensive care unit (ICU). This lets doctors and nurses keep an eye on vital signs, such as blood pressure or heart rate, and to step in and keep the body functioning until the nervous system can take over again.

In the hospital, somebody with GBS might also receive treatment to help speed recovery. One treatment for GBS is immunoglobulin therapy, which involves using healthy antibodies (immunoglobulins) from blood donors to help block the harmful antibodies in the body of the person with GBS.

Another treatment for GBS is plasmapheresis (plaz-muh-fuh-REE-sus) or plasma exchange, where blood is drawn from the body and then processed so that the red and white blood cells are separated from the plasma, the liquid portion of the blood. Then these cells are returned to the body without the plasma. Scientists think that this helps remove some of the harmful antibodies and seems to reduce the severity and length of GBS symptoms.

Another treatment for GBS is immunoglobulin therapy, which involves using healthy antibodies (immunoglobulins) from blood donors to help block the harmful antibodies in the body of the person with GBS.

How long someone with GBS has to stay in the hospital depends on how serious the condition is. Some patients are in the hospital for only a few days; others are hospitalized for several weeks.

Recovering From GBS

Even after coming home from the hospital, it may take a while before a person feels as good as new. Some people with GBS might need to be in a wheelchair or use a walker until they regain their strength. Many will need physical therapy to get their bodies moving well again.

Recovering from GBS takes patience: People may feel some weakness as long as 3 years after having the condition. But the good news is most people do eventually recover from even the most severe cases of GBS.

Because GBS strikes so suddenly and without warning, it can be difficult to deal with and to adjust to the recovery period. Doctors may recommend that a person see a counselor or therapist or join a support group as a way to talk through the many confusing feelings that can go with having the syndrome. People recovering from GBS usually have tons of questions, such as “Why me?” and “Will it come back?”

GBS can really affect a person’s lifestyle, and it might be a while before people can participate fully in their favorite sports or activities. This can feel particularly hard for someone who is usually very active.

For people who go through the ordeal of a slow recovery, it’s natural to worry that GBS might come back. Often, this is because some people notice symptoms during recovery that are similar to those they had during the GBS episode, such as tingling in the hands or feet. In most cases, though, these symptoms are not a sign that they have GBS again. More likely, these are due to lingering nerve trouble after the initial bout of GBS. Luckily, only a very small number of people who’ve had GBS get it again.

As with any medical condition, if you’ve had GBS and you notice some of the same symptoms coming back, talk to your doctor.

It may take a while before a person who has had GBS is ready to get back to sports and other physical activity, but there’s a lot that health care professionals can do to help make the road to recovery smoother and faster.

Whether your baby rises from a crawl with a shaky first step or a full-on sprint across the living room, chances are you’ll be on the edge of your seat. But remember — a child’s first steps usually aren’t picture perfect.

Learning to walk takes time and practice, and it’s common for kids to start walking with their toes and feet turned at an angle. When feet turn inward — a tendency referred to as walking “pigeon-toed” — doctors call it in-toeing. When feet point outward, it’s called out-toeing.

It can be upsetting to see your child develop an abnormal gait, but for most toddlers with in-toeing or out-toeing, it’s usually nothing to worry about. The conditions do not cause pain and usually improve as kids grow older.

Almost all healthy kids who toe-in or -out as toddlers learn to run, jump, and play sports as they grow up, just the same as kids without gait problems.

In-toeing and Out-toeing

Most toddlers toe-in or -out because of a slight rotation, or twist, of the upper or lower leg bones.

Tibial torsion, the most common cause of in-toeing, occurs when the lower leg bone (tibia) tilts inward. If the tibia tilts outward, a child will toe-out. When the thighbone, or femur, is tilted, the tibia will also turn and give the appearance of in-toeing or out-toeing. The medical term for this is femoral anteversion. In-toeing can also be caused by metatarsus adductus, a curvature of the foot that causes toes to point inward.

Why some kids develop gait abnormalities and others don’t is unclear, but many experts think that a family history of in-toeing or out-toeing plays a role. So, if you toed-in or -out as a child, there’s a chance that your child could develop the same tendency.

Also, being cramped in the womb during pregnancy can contribute to a child in-toeing or out-toeing. As a fetus grows, some of the bones have to rotate slightly to fit into the small space of the uterus. In many cases, these bones are still rotated to some degree for the first few years of life. Often this is most noticeable when a child learns to walk because if the tibia or femur tilt at an angle, the feet will too.

Does Walking Improve?

As most kids get older, their bones very gradually rotate to a normal angle. Walking, like other skills, improves with experience, so kids will become better able to control their muscles and foot position.

In-toeing and out-toeing gets better over time, but this happens very gradually and is hard to notice. So doctors often recommend using video clips to help parents track improvement. Parents can record their child walking, and then wait about a year to take another video. This usually makes it easy to see if the gait abnormality has improved over time. In most cases, it has. If not, parents should speak with their child’s doctor to discuss whether treatment is necessary.

In the past, special shoes and braces were used to treat gait abnormalities. But doctors found that these didn’t make in-toeing or out-toeing disappear any faster, so they’re rarely used now.

If Walking Does Not Improve

Speak with your doctor if you’re concerned about the way your child walks. For a small number of kids, gait abnormalities can be associated with other problems. For example, out-toeing could signal a neuromuscular condition in rare cases.

Have your child evaluated by a doctor if you notice:

• in-toeing or out-toeing that doesn’t improve by age 3
• limping or complaints of pain
• one foot that turns out more than the other
• developmental delays, such as not learning to talk as expected
• gait abnormalities that worsen instead of improve

The doctor can then decide if more specialized exams or testing should be done to make sure that your child gets the proper care.

Torticollis, or wryneck, literally means “twisted neck” in Latin. You may have woken up with torticollis after an uncomfortable night of sleep. In newborns, torticollis can happen due to positioning in the womb or after a difficult childbirth. This is called infant torticollis or congenital muscular torticollis.

It can be upsetting to see that your baby has a tilted head or difficulty turning his or her neck. But most babies don’t feel any pain as a result of their torticollis. And, fortunately, the problem usually gets better with simple position changes or stretching exercises that can be done at home.

About Infant Torticollis

Torticollis is relatively common in newborns. Boys and girls are equally likely to develop the head tilt. It can be present at birth or take up to 3 months to develop.

No one knows why some babies get torticollis and others don’t. Most doctors believe it could be related to the cramping of a fetus inside the uterus or abnormal positioning (such as being in the breech position, where the baby’s buttocks face the birth canal). The use of forceps or vacuum devices to deliver a baby during childbirth also makes a baby more likely to develop torticollis.

These factors put pressure on a baby’s sternocleidomastoid (stir-noe-kly-doe-MAS-toyd) muscle (SCM). This large, rope-like muscle runs on both sides of the neck from the back of the ears to the collarbone. Extra pressure on one side of the SCM can cause it to tighten, making it hard for a baby to turn his or her neck.

Some babies with torticollis also have developmental dysplasia of the hip, another condition caused by abnormal positioning in the womb or a difficult childbirth.

Signs & Symptoms

Babies with torticollis will act like most other babies except when it comes to activities that involve turning. A baby with torticollis might:

• tilt the head in one direction (this can be difficult to notice in very young infants)
• prefer looking at you over one shoulder instead of turning to follow you with his or her eyes
• if breastfed, have difficulty breastfeeding on one side (or prefers one breast only)
• work hard to turn toward you and get frustrated when unable turn his or her head completely

Some babies with torticollis also will develop a flat head (positional plagiocephaly) on one or both sides from lying in one direction all the time. Or they might develop a small neck lump or bump, which is similar to a “knot” in a tense muscle. Both of these conditions tend to go away as the torticollis gets better.

Diagnosis

If you think your baby might have torticollis, ask your doctor to perform a physical examination on your baby, which involves seeing how far your baby can turn his or her head.

If a diagnosis is made, the doctor might teach you neck stretching exercises to practice with your baby at home. These exercises help loosen the tight SCM and strengthen the weaker one on the opposite side (which has weakened due to underuse). This will help to straighten out your baby’s neck.

In certain cases, the doctor may suggest taking a baby to a physical therapist for more intensive treatment. After treatment has started, the doctor may examine your baby every 2 to 4 weeks to see how treatment is going.

If your baby is 6 weeks of age or younger and also has signs of an unstable hip, the doctor might order an ultrasound to see if your baby also has developmental dysplasia of the hip.

Although most torticollis cases are not related to other medical problems, congenital muscular torticollis can happen in children who have infections, fractures, reactions to certain medicines, or genetic conditions like Down Syndrome or Klippel-Feil Syndrome. If your child has torticollis and you are concerned that other medical problems may be present, talk to your doctor.

Treatment at Home

The best way to treat torticollis is to encourage your baby to turn his or her head in both directions. This helps loosen tense neck muscles and tighten the loose ones. Rest assured that babies cannot hurt themselves by turning their heads on their own.

Here are some exercises to try:

• When your baby wants to eat, offer the bottle or your breast in a way that encourages your baby to turn away from the favored side. (Use your child’s desire to eat to encourage him or her along!)
• When putting your baby down to sleep, position him or her to face the wall. Since babies prefer to look out onto the room, your baby will actively turn away from the wall and this will stretch the tightened muscles of the neck. Remember to always put your baby to sleep on his or her back, as this helps reduce the risk of SIDS.
• During play, draw your baby’s attention with toys and sounds to make him or her turn in both directions.

Don’t Forget “Tummy Time”

Laying your baby on the stomach for brief periods while awake (known as “tummy time”) is an important exercise because it helps strengthen neck and shoulder muscles and prepares your baby for crawling.

This exercise is especially useful for a baby with torticollis and a flat head — and can actually help treat both problems at once. Here’s how to do it:

• Lay your baby on your lap for tummy time. Position your baby so that his or her head is turned away from you. Then, talk or sing to your baby and encourage him or her to turn and face you. Practice this exercise for 10 to 15 minutes.

Outlook

Most babies with torticollis get better on their own through position changes and stretching exercises. It might take up to 6 months to go away completely, and in some cases can take a year or longer.

Stretching exercises to treat torticollis are most likely to work well if started when a baby is between 3 to 6 months of age. If you find that your baby’s torticollis is not improving with stretching, talk to your doctor. Your baby may be a candidate for muscle-release surgery, a procedure that cures most cases of torticollis that don’t improve with physical therapy alone.

Jumper’s knee — also known as patellar tendonitis or patellar tendinopathy — is an inflammation or injury of the patellar tendon, the cord-like tissue that joins the patella (kneecap) to the tibia (shin bone). Jumper’s knee is an overuse injury (when repeated movements cause tissue damage or irritation to a particular area of the body).

Constant jumping, landing, and changing direction can cause strains, tears, and damage to the patellar tendon. So kids who regularly play sports that involve a lot of repetitive jumping — like track and field (particularly high-jumping), basketball, volleyball, gymnastics, running, and soccer — can put a lot of strain on their knees.

Jumper’s knee can seem like a minor injury that isn’t really that serious. Because of this, many athletes keep training and competing and tend to ignore the injury or attempt to treat it themselves. But it’s important to know that jumper’s knee is a serious condition that can get worse over time and ultimately require surgery. Early medical attention and treatment can help prevent continued damage to the knee.

How the Knee Works

To understand how jumper’s knee happens, it helps to understand how the knee works. The knee, which is the largest joint in the body, provides stability to the leg and allows it to bend, swivel, and straighten. Several parts of the body interact to allow the knee to function properly:

• Bones like the femur (thighbone), the tibia (shinbone), and the patella (kneecap) give the knee the strength needed to support the weight of the body. The bones that meet at the knee allow it to bend smoothly.
• Muscles provide the tug on the bones needed to bend, straighten, and support joints. The muscles around the knee include the quadriceps (at the front of the thigh) and the hamstring (on the back of the thigh). The quadriceps muscle helps straighten and extend the leg, and the hamstring helps bend the knee.
• Tendons are strong bands of tissue that connect muscles to bones. The tendons in the front of the knee are the quadriceps tendon and the patellar tendon. The quadriceps tendon connects to the top of the patella and allows the leg to extend. The patellar tendon connects to the bottom of the kneecap and attaches to the top of the tibia.
• Similar to tendons, ligaments are strong bands of tissue that connect bones to other bones.

By working together, bones, muscles, tendons, and ligaments enable the knee to move, bend, straighten, provide strength to jump, and stabilize the leg for landing.

About Jumper’s Knee

When the knee is extended, the quadriceps muscle pulls on the quadriceps tendon, which in turn pulls on the patella. Then, the patella pulls on the patellar tendon and the tibia and allows the knee to straighten. In contrast, when bending the knee, the hamstring muscle pulls on the tibia, which causes the knee to flex.

In jumper’s knee, the patellar tendon is damaged. Since this tendon is crucial to straightening the knee, damage to it causes the patella to lose any support or anchoring. This causes pain and weakness in the knee, and leads to difficulty in straightening the leg.

Symptoms

Common symptoms of jumper’s knee include:

• pain directly over the patellar tendon (or more specifically, below the kneecap)
• stiffness of the knee, particularly while jumping, kneeling, squatting, sitting, or climbing stairs
• pain when bending the knee
• pain in the quadriceps muscle
• leg or calf weakness

Less common symptoms include:

• balance problems
• warmth, tenderness, or swelling around the lower knee

Treatment

Jumper’s knee is first evaluated by a grading system that measures the extent of the injury (grades range from 1 to 5, with grade 1 being pain only after intense activity and grade 5 being daily constant pain and the inability to participate in any sporting activities).

While examining the knee, a doctor or medical professional will ask the patient to run, jump, kneel, or squat to determine the level of pain. In addition, an X-ray or MRI might be recommended. Depending on the grade of the injury, treatment can range from rest and icepacks to surgery.

For mild to moderate jumper’s knee, treatment includes:

• resting from activity or adapting a training regimen that greatly reduces any jumping or impact
• icing the knee to reduce pain and inflammation
• wearing a knee support or strap (called an intrapatellar strap or a Chopat strap) to help support the knee and patella. The strap is worn over the patellar tendon, just beneath the kneecap. A knee support or strap can help minimize pain and relieve strain on the patellar tendon.
• elevating the knee when it hurts (for example, placing a pillow under the leg)
• anti-inflammatory medications, like ibuprofen, to minimize pain and swelling
• massage therapy
• minimum-impact exercises to help strengthen the knee
• rehabilitation programs that include muscle strengthening, concentrating on weight-bearing muscle groups like the quadriceps and calf muscles
• specialized injections to desensitize nerve endings and reduce inflammation

On rare occasions, such as when there’s persistent pain or the patellar tendon is seriously damaged, jumper’s knee requires surgery. Surgery includes removing the damaged portion of the patellar tendon, removing inflammatory tissue from the lower area (or bottom pole) of the patella, or making small cuts on the sides of the patellar tendon to relieve pressure from the middle area.

After surgery, a rehabilitation program involving strengthening exercises and massage is followed for several months to a year.

Recovery

Recovering from jumper’s knee can take a few weeks to several months. It’s best to stay away from any sport or activity that can aggravate the knee and make conditions worse.

However, recovering from jumper’s knee doesn’t mean that someone can’t participate in any sports or activities. Depending on the extent of the injury, low-impact sports or activities can be substituted (for instance, substituting swimming for running). Your doctor will let you know what sports and activities are off-limits during the healing process.

Preventing Jumper’s Knee

The most important factor in preventing jumper’s knee is stretching. A good warm-up regimen that involves stretching the quadriceps, hamstring, and calf muscles can help prevent jumper’s knee. It’s always a good idea to stretch after exercising, too.

No parent wants to see their sports-loving child sitting on the sidelines, but knee injuries put thousands of young athletes on the bench every year. It’s not unusual for kids to fracture, sprain, strain, or dislocate the knee joint while playing on the field or just goofing around with friends.

Most kids just need a few days or weeks of rest to recover from a knee injury. Severe cases can require surgery and a longer recovery before kids are walking again and back on the playing field.

How the Knee Works

To understand how injuries happen, it helps to know how the knee works. The knee is the largest joint in the body; it provides stability and allows the legs to bend, swivel, and straighten.

The knee joint is at the ends of the femur (thighbone) and the tibia (shinbone); it is protected by the patella (kneecap). The ends of the femur and tibia and the back of the patella are covered in articular cartilage, which acts as a cushion to keep the femur, patella, and tibia from grinding against each other. On the top of the tibia, extra pads of cartilage called menisci help absorb the body’s weight. Each knee has two menisci — the inside (medial) meniscus and the outside (lateral) meniscus.

The muscles around the knee include the quadriceps, a large muscle at the front of the thigh, and the hamstrings, located at the back of the thigh. The quadriceps help straighten the leg and the hamstrings help bend the knee.

Several tendons — cables of strong tissue that connect muscles to bones — work together to help move the knee. The tendons in the knee are the quadriceps tendon, the patellar tendon, and the hamstring tendons. All work together to allow the leg to extend.

Ligaments are cables of strong tissue that connect bones to bones. The four main ligaments in the knee that help connect the femur to the tibia and keep the knees stable are:

1. medial collateral ligament (MCL): connects the femur to the tibia along the inside of the knee. It keeps the inner part of the knee stable and helps control the sideways motion of the knee, keeping it from bending inward.
2. lateral collateral ligament (LCL): connects the femur to the tibia along the outside of the knee. It keeps the outer part of the knee stable and helps control the sideways motion of the knee, keeping it from bending outward.
3. anterior cruciate ligament (ACL): connects the femur to the tibia at the center of the knee. It helps control the knee’s rotation and forward motion.
4. posterior cruciate ligament (PCL): connects the femur to the tibia at the back of the knee. It helps control the knee’s backward motion.

Types of Knee Injuries

Because the knee is such a complex joint with many moving parts, knee injuries are quite common. Frequent causes of injuries are overuse (from repetitive motions, as in many sports), sudden stops or twists, or direct blows to the knee.

Common injuries among kids include:

Sprains

Knee sprains usually involve damage to the ACL and/or MCL. The most serious sprains involve complete tears of one or more of the knee ligaments. Symptoms of knee sprains include:

• a popping or snapping sound in the knee at the time of injury
• pain that seems to come from within the knee, especially with movement
• not being able to bear weight on that leg
• swelling
• the knee feels loose or unstable

Strains

A strain happens when a child partially or completely tears a muscle or tendon. With knee strains, kids may have bruising around the knee in addition to the symptoms mentioned above for sprains.

Tendonitis

Tendonitis happens when a tendon gets irritated or inflamed. It is often caused by overuse or poor training (such as lack of strength exercises or stretching). A child with tendonitis might have pain or tenderness when walking or at rest, or when bending, extending, or lifting a leg.

Meniscal Cartilage Tears

Damage to the menisci is a very common sports injury, especially in sports where kids have sudden changes in speed or make side-to-side movements. Meniscal injuries can occur together with severe sprains, especially those involving the ACL. Meniscal injuries can cause tenderness, tightness, and swelling around the front of the knee. Sometimes fluid collects around the knee (known as effusion).

Fractures and Dislocations

A fracture is a cracked, broken, or shattered bone. Kids may have trouble moving the bone and are likely to have a lot of pain. Patellar dislocation happens when the patella is knocked off to the side of the knee joint, by twisting or some kind of impact. Sometimes it will go back to its normal position by itself, but usually needs to be put back in place by a doctor. Symptoms include swelling and pain in the front of the knee, an abnormal bulge on the side of the knee, and inability to walk on the leg with the affected knee.

Articular Cartilage Injuries

Sometimes a small piece of bone or articular cartilage softens and/or breaks off from the end of a bone, causing long-term knee pain. This is called osteochondritis dissecans (OCD). Symptoms include pain; swelling; an inability to move the joint; and stiffness, catching (“locked knee”), or popping sensations with knee movement.

Chondromalacia pattellae happens when the cartilage in the patella softens or wears away because of injury, muscle weakness, or overuse, and the patella and the thighbone may rub together. This causes pain and aching, especially when a person walks up stairs or hills.

Bursitis

A bursa is a sac filled with fluid located over a bony prominence to prevent friction. If a bursa in the knee becomes irritated and swollen from overuse or constant friction, it can develop into a condition called bursitis. Symptoms of bursitis in the knee include warmth, tenderness, swelling, and pain on the front of the kneecap.

Osgood-Schlatter Disease

Osgood-Schlatter disease is a painful disorder caused by repetitive stress on the front end of the tibia where the patellar tendon connects to the bone. Most common in athletes 10 to 15 years old, its symptoms include a bump below the knee joint that’s painful to the touch and painful with activity. Pain is relieved with rest.

Diagnosis

Most knee exams involve lying down flat on a table while the doctor manipulates the knee to see how stable it is and if any part of the joint hyperextends or dislocates.

Imaging tests (like an MRI, X-ray, or CAT scan) also might be done to confirm a knee injury and determine its severity.

Treatment

Any child with a knee injury should rest the knee as much as possible.

Immediately after the injury, apply ice to the area for 20-minute intervals to reduce swelling and use compression bandages for comfort. A child can usually bear weight as tolerated, and should elevate the leg (above the heart) on pillows or other soft objects to reduce pain and swelling.

Doctors call this method of treatment RICE:

• Rest
• Ice
• Compression
• Elevation

The doctor might prescribe painkillers or anti-inflammatory pills or liquid if your child has severe inflammation and pain.

After initial treatment, some kids may wear a knee immobilizer (a brace or a sleeve that’s wrapped around the knee to keep it from moving too much) for a few weeks while the knee heals, and might need to use crutches to get around.

More serious knee injuries can require surgery to reconstruct the knee if the child has torn ligaments or tendons or bone fractures.

During arthroscopy (a minimally invasive surgical technique) surgeons make a small opening in the knee and insert an arthroscope, a tiny tube-like tool, into the joint. The arthroscope has a lighted video camera on the end that is wired to a TV screen to give the surgeon a magnified view while operating.

Most of the time, the doctor is able to fix the problem during an arthroscopy. But if the injury is too complex, the surgeon will have to switch to “open” surgery, which requires a larger incision to see the area with the naked eye.

Regardless of whether a child has arthroscopy or a traditional open surgical procedure for a knee injury, the recovery period will be several weeks to a couple of months.

Rehab Therapy

Most kids who recover from a knee injury will need some sort of rehabilitation (“rehab”) therapy to help heal the knee and to:

• restore range of motion
• regain strength in the knee, thigh, and shin muscles to prevent atrophy (the breakdown of muscle tissue)
• reduce pain and swelling
• improve balance
• regain functional performance for activity

Most kids undergo rehab at a center three times a week, with daily exercises they practice at home. Accelerated rehab programs involve more frequent therapy, but will not necessarily speed up recovery.

While most sports are off limits — especially the one that caused the injury in the first place — kids can do some low-impact activities that may be fun and even therapeutic, like swimming, bike riding, or protected running. Talk to your doctor about which of these might benefit your child and when normal activities can be resumed.

Preventing Knee Injuries

Preventing knee injuries is a lot less painful and a lot less hassle than undergoing surgery.

If your kids play sports, be sure they always wear appropriate protective equipment during practices and competitions. Kneepads and shin guards when appropriate (as well as helmets and other protective gear) will help prevent injury. Also be sure that they wear supportive shoes that are in good condition and appropriate for the sport.

More tips for avoiding sports injuries:

• During workouts, always make sure kids warm up and cool down.
• Encourage kids to do regular strength training to support muscles, and stretching or yoga to improve flexibility.
• Practice your sport on the training surfaces that aren’t too hard. Running and jumping on asphalt can be tough on the knees.
• When jumping, make sure your child bends the knees while landing. This takes pressure off the ACL and prevents injury.
• If kids cut laterally or pivot frequently (as in soccer), encourage them to crouch and bend at the knees and hips to reduce the chance of an ACL injury.
• For kids who play just one sport, conditioning and training year-round — even if it’s at a lower intensity than during the competitive season — can help them stay in shape and reduce the chances of injury.

Everyone’s spine is slightly rounded as it runs up the back. The thoracic vertebrae, which are attached to the ribs, usually round forward at a gentle angle that everybody has, about 20-40 degrees. If this angle is too pronounced, more than 50 degrees or so, it’s called kyphosis (also known as roundback or hunchback).

In many cases with kyphosis, the spine may look normal and the condition will require no treatment. Some cases of kyphosis in kids can even be fixed by teaching them not to slouch, and strengthening their back with core exercises and physical therapy.

Severe and visible cases of kyphosis, however, can be painful, cause problems in the lungs and other organs, or lead to issues with self image or appearance.

Most of the time, kyphosis will become evident during adolescence, though adults can develop it as they age due to spine trauma and the onset of degenerative conditions such as arthritis and osteoporosis.

Treatment for adolescent kyphosis can include bracing and rarely will require surgery. Even after surgery, kids can usually resume an active lifestyle.

About Kyphosis

Kyphosis is an abnormal rounding of the spine that occurs in the upper and middle part of the back. Only the most serious cases will result in a hunchback or cause discomfort or breathing problems.

Different types of kyphosis can affect kids, each with its own cause:

• Postural kyphosis, the most common type of kyphosis, usually becomes noticeable during adolescence. It can cause mild discomfort, but rarely causes pain or problems later in life. Postural kyphosis occurs when bones and muscles develop abnormally, possibly due to slouching or poor posture. It’s more common among girls than boys.
• Scheuermann’s kyphosis, named for a Danish radiologist, also typically appears during adolescence, especially during a growth spurt. It can run in families, and causes the vertebrae to appear wedge-shaped, rather than rectangular, when viewed from the side on X-rays. It’s slightly more common among boys than girls.

• Congenital kyphosis occurs when the spinal column develops abnormally before a baby is born. Several vertebrae can be fused together or the bones can form improperly. Growth can cause the kyphosis to get worse. It’s important to check children with this condition for other orthopedic problems and heart or kidney defects.

Diagnosing Kyphosis

In the most severe cases of kyphosis, there can be a visible rounding of the upper back or a hump that is easy to see. In many cases, though, kyphosis won’t exhibit any obvious symptoms and can be hard to diagnose.

To check for kyphosis, a doctor will examine the spine and might ask a child to bend forward from the waist. Often, kyphosis becomes more apparent when the back is bent this way. A child might also be asked to lie down, which can help in diagnosing postural kyphosis.

If kyphosis is suspected, the doctor will order X-rays of the spine, which can help determine which type of kyphosis it is. To see if the kyphosis is affecting breathing, the doctor may ask the child to perform pulmonary function tests.

If a doctor thinks something else is causing the problem, such as an infection or tumor, an MRI (magnetic resonance imaging) scan of the back might be ordered.

Treating Kyphosis

If it appears the rounding of the back isn’t going to cause any problems, kyphosis may not need any treatment, just routine checkups to make sure the rounding doesn’t become worse. Most cases of kyphosis will stop progressing once kids are fully grown.

Some cases may be referred to an orthopedist, a doctor who specializes in treating medical conditions involving the bones. The orthopedist will examine the spine to determine the cause and extent of the kyphosis and then recommend treatment.

Treatment varies depending on the type of kyphosis and how severe it is:

• Postural kyphosis doesn’t progress and can improve on its own. All that may be required is physical therapy to decrease pain and improve posture, plus exercises to strengthen the back muscles to help them support the spine better. Some people also respond well to sleeping on a firm bed.
• Scheuermann’s kyphosis may require a brace. Surgery might be required in severe cases (rounding of 75 degrees or more), if there is pain or breathing difficulty, or if the back doesn’t respond to other treatments.
• Congenital kyphosis sometimes requires surgery at an early age to fix.

Back Braces and Surgery

Braces often need to be worn — some just at night, others for 18-20 hours a day — until a child stops growing and the kyphosis is unlikely to progress. The purpose of the brace is to try to keep the degree of rounding from getting worse while the bones develop.

The brace that the orthopedist recommends will depend on the location of the rounding and its severity. One common type of brace used in the treatment of kyphosis is a thoracolumbosacral orthosis, or TLSO, a brace that comes up under the arms and can be worn beneath the clothes.

If kyphosis requires surgery, the orthopedic surgeon will likely perform a spinal fusion. In this procedure, several of the affected vertebrae are fused (joined together) to reduce the rounding in the spine. The surgeon will attach new pieces of bone to the vertebrae with metal rods and screws, placed deep under the spine muscles.

After a few months to a year, the bones grow together, or “fuse,” but the metal pieces are typically allowed to stay in place, as they are not noticeable, can’t be felt, and don’t cause any discomfort. Doctors will often prescribe physical therapy after surgery to help the back recover more quickly.

Every situation is different, but most kids who’ve had surgery to correct their kyphosis are up and walking within a day or two, and can generally go home from the hospital within a week. Most will return to school within a month of the surgery and can resume some activities in 3 to 4 months. By 6 months to a year, most will be able to resume all routine activities; the bones should be fully fused by about 1 year. Most kids who’ve had this surgery and their parents report being very satisfied with the results.

With proper observation and the right treatment — be it exercise, a back brace, or surgery — almost every child with kyphosis can lead an active, normal life with no restrictions on activities.

About Marfan Syndrome

Marfan syndrome is a progressive genetic disorder that affects the body’s connective tissue. Connective tissue is everywhere in the body, providing structure and support for cells. Think of it as a sort of “glue” that helps support every organ, blood vessel, bone, joint, and muscle.

In people with Marfan syndrome, this “glue” is weaker than normal because of a defect in the body’s production of the protein fibrillin, a major component of connective tissue. Weakened connective tissue can lead to problems in many parts of the body, especially the heart, eyes, and bones.

Even though the disease has no cure, the good news is that doctors can successfully treat just about all of its symptoms. Just a few decades ago, most people with Marfan syndrome didn’t live past 40 years old. Now, thanks to new research and treatments, those who are diagnosed early and get good medical care have just about the same lifespan as everyone else.

Research on a group of medicines called ARBs (angiotensin receptor blockers) has been extremely promising and has improved the health of people with Marfan syndrome.

Causes

Marfan syndrome is pretty rare, affecting about 1 in every 5,000 people. Researchers have traced the disorder to a defect in a gene found on chromosome 15. It’s this mutation (change) that causes the abnormality in the production or the structure of fibrillin.

About 75% of the time, the gene for Marfan syndrome runs in families, getting passed down to kids from parents who have the disease. The gene change is inherited as autosomal dominant, which means every child born to a parent who has Marfan syndrome has a 50% chance of having it too.

In the remaining 25% of cases, though, neither parent has the disease; the genetic mutation responsible for Marfan syndrome happens spontaneously in either the egg or sperm cell at the time of conception. No one knows what causes this mutation, but those born with it have a 50% chance of passing it on to their kids.

Although people with Marfan syndrome often have similar physical features, the disease doesn’t affect everyone in the same way. Some have very mild symptoms, while others have severe ones — even within the same family. This is known as “variable expression,” and it makes it almost impossible to predict how the disease will progress in any affected individual.

Signs and Symptoms

People with Marfan syndrome are often (but not always) much taller than their family members and peers and have a lean, lanky build. Their fingers and toes are usually long and thin, and their joints are loose. Their arms and legs are often disproportionately long compared with their torso, and their arm span is often a lot greater than their height.

They may share some facial characteristics, too, including a long, thin face; deep-set eyes; a small jaw; a high, arched roof of the mouth; and crowded teeth.

Complications

People with Marfan syndrome are also at risk for complications in the following body systems:

Heart and Blood Vessels

The most serious complication of Marfan syndrome involves the heart. Over time, the disorder can cause the aorta — the large artery that carries blood away from the heart to the body — to stretch and dilate (widen).

If undetected or untreated, the wall of the aorta eventually can begin to tear and separate, allowing blood to leak through (this is known as an aortic dissection). A large, sudden rupture can be fatal.

Problems with the heart valves are common too. Instead of closing tightly, valves (usually the mitral and/or aortic valves) may become large and floppy, letting blood leak backward through the heart. A minor leak may cause few symptoms, but a large one can cause shortness of breath and an irregular heartbeat, as well as a heart murmur. Leaky heart valves cause the heart to work harder and become enlarged, so they must be carefully monitored.

Eyes

More than half of all people with Marfan syndrome have a condition known as ectopia lentis (lens dislocation). That means the lenses of the eye, which are usually centered behind the pupil and held in place with connective tissue, may shift out of the normal position, usually upward and outward. Vision problems can follow, depending on the position of the lens. Kids who develop vision problems may wear glasses at first, but might need surgery later.

People with Marfan syndrome also often have myopia (nearsightedness) and are at greater risk for developing other eye problems — like detached retinas (when the light-sensing tissue at the back of the eye comes loose), glaucoma (high pressure in the eye), or cataracts (cloudy lenses) — earlier in life than other people. Young children are especially prone to developing strabismus and possibly amblyopia.

Skeletal Problems

In addition to excessive height and unusually long limbs, Marfan syndrome may cause other skeletal problems, such as scoliosis (abnormal curvature of the spine) and chest wall abnormalities in which the chest bone may either curve in or stick out, giving the chest a sunken-in or a pigeon-breasted appearance. Overly loose joints and flat feet are common.

Other symptoms may affect the skin, nervous system, and lungs, but these tend to be less common and less serious, especially in kids and teens.

Diagnosing Marfan Syndrome

Diagnosing Marfan syndrome usually involves detailed exams by different doctors, including a geneticist (a doctor who specializes in inherited disorders), a cardiologist (heart specialist), ophthalmologist (eye doctor), and an orthopedist (bone specialist). Molecular testing for a mutation in the FBN1 gene is often part of the comprehensive evaluation.

First, a geneticist will ask about any family history of the disorder or whether any relatives died early from heart-related deaths. He or she may also take detailed skeletal measurements. The geneticist might do mutation testing on a small blood sample.

A cardiologist will listen for a heart murmur and perform tests such as:

• a chest X-ray
• an electrocardiogram (EKG), which measures electrical activity in the heart
• an echocardiogram, which uses sound waves to produce a picture of the heart to check the size of the aorta and the functioning of the valves

An ophthalmologist may perform a “slit lamp” test (a slit lamp allows the doctor to see the front of the eye under high magnification) while the eyes are dilated to check for lens dislocation and any other abnormalities.

An orthopedist will check for curvatures of the spine and chest bone, as well as joint problems and flat feet.

Diagnostic Criteria

The criteria for diagnosis of Marfan syndrome are complex, mainly because many features of the syndrome also appear in the general population (obviously, not every tall, thin person with long fingers has the disorder), and because other connective tissue diseases have similar features. In 2010, the criteria were revised to consider the presence of a mutation in the FBN1 gene in the evaluation.

If a family history is already known, a diagnosis of Marfan syndrome can be based upon problems in two of the body systems known to be affected.

If there’s no family history, diagnosis requires very specific findings in several different systems. This can be frustrating for parents because symptoms may not appear during childhood but emerge over time. Finding a mutation in the FBN1 gene can help confirm a diagnosis.

Fortunately, doctors can treat symptoms even before there’s a firm diagnosis.

Monitoring and Treatment

Kids and teens with Marfan syndrome must be followed closely by a team of doctors. Because their bodies grow and change so quickly, most will need echocardiograms at least once a year, plus frequent eye and bone exams. This helps doctors stay on top of any new problem.

Kids and teens with Marfan syndrome can do many things to help keep themselves healthy. The most important is to avoid putting extra stress on the heart. That means avoiding contact sports or any activity that involves a lot of running, muscle straining, or the risk of a blow to the chest — things like basketball, football, baseball, gymnastics, weightlifting, and track, to name a few.

Keeping Active

Kids with Marfan syndrome should not be couch potatoes. They can and should play, exercise, and generally be active — they just have to learn to be a little more careful. Although a doctor should always have the final say about what activities are safe, things like non-competitive bike riding, swimming, dancing, walking — anything that’s low-impact and can be done at a slower pace — usually get the green light.

Many of the complications of Marfan syndrome can be managed with medicines and, if necessary, surgery. Medications known as beta blockers and ARBs work to lower blood pressure and reduce wear and tear on the blood vessels, and often can delay the progression of aortic dilation. If the aorta does eventually widen to a potentially dangerous size, or if valve leakage becomes a problem, surgery may be recommended either to repair or replace the damaged parts of the heart.

Kids who are nearsighted or who have strabismus probably will have to wear glasses. Teens may be able to wear contact lenses. In some cases, if the lens of the eye becomes significantly dislocated or if there are other complications, surgery may be necessary.

Kids who develop scoliosis may have to wear a special back brace. Sometimes severe cases of scoliosis and chest wall abnormalities may require surgery. Some teens may want to have surgery for cosmetic reasons.

Anyone with heart problems associated with Marfan syndrome (especially anyone who’s had heart surgery) should always take antibiotics before going to the dentist to prevent bacterial endocarditis, an infection of the walls of the heart caused when bacteria enter the bloodstream.

It is recommended that kids and teens with Marfan syndrome wear a medical alert bracelet, in case there is an accident and the patient can’t explain his or her medical condition.

Teen girls with Marfan syndrome should also be made aware that pregnancy puts extra strain on the heart and may increase the risk of damage to the aorta.

Caring for Your Child

It’s not easy to learn your child has a genetic disorder. It’s normal to have a whole range of emotions, from fear and anger to sadness and guilt. But the genetic mutation that causes Marfan syndrome is nobody’s fault and could not have been prevented.

The first thing you can do to help your child is to educate yourself and seek doctors who are knowledgeable about the disease and its management. An experienced medical team is your child’s best chance to prevent or delay complications. Your family also may benefit from a visit with a genetic counselor.

Other tips for helping your child cope:

• Be honest when faced with questions about the disease, from your child or others. Your child will be reassured that you’re at ease discussing it.
• Promote healthy self-esteem and body image from an early age by acknowledging your child’s differences in a positive light. Also teach your child constructive ways to deal with teasing.
• Try to guide younger kids gently toward activities they won’t have to give up later — for example, encourage non-competitive swimming over basketball. If your child is older when diagnosed and is forced to give up some favorite sports, encourage the development of other talents and interests.
• Keep in touch with teachers and explain that even though Marfan syndrome doesn’t affect your child’s intelligence, some modifications may be needed in class (such as letting your child sit near the board if vision is a problem).

Finding Safe Activities

• Talk to the P.E. teacher about safe vs. unsafe activities, and ask that your child be included even when he or she cannot compete (for example, if your child can’t play in the soccer game, can he or she be the scorekeeper?).
• Encourage exercising. Staying active is important for everyone, including kids with Marfan syndrome, so ask your doctor for a list of appropriate activities.
• Above all, remember that kids need to be kids! Children with Marfan syndrome need to play and laugh and learn that there’s so much more they can do than they can’t.

If you or your child needs help adjusting to a diagnosis of Marfan syndrome, look for a support group near you or seek professional counseling.

When to Call the Doctor

Although aortic dissections are extremely rare in kids, call the doctor if your child has chest pain, shortness of breath (especially during exercise), an irregular pulse, sudden weakness or tingling in the legs and arms, or an unexplained fever. Also call the doctor if your child experiences any sudden vision changes.

About Knee Injuries

Knee injuries are common among active kids and teens, especially athletes. A torn medial collateral ligament (MCL) — a ligament that helps give the knee its stability — is one of the more serious injuries.

Kids who tear their MCL tend to play contact sports, like football and soccer. More severe injuries happen when the outside of the knee is struck, causing it to unnaturally bend inward (toward the other knee). MCL tears can also happen when the lower leg twists or bends out too far. This creates tension on the MCL, a rope-like band, and it stretches or breaks in half.

Children with a partially or completely torn MCL might have swelling and pain in the first 24 hours of injury. Fortunately, this injury can heal on its own from 1 to 6 weeks of resting the joint.

Most kids and teens will still need to undergo rehabilitation (“rehab”) therapy to help regain strength in the joint.

What an MCL Does

The MCL is one of the four main ligaments in the knee joint. It’s located on the side of the knee that’s closer to the other knee. One end of the ligament is attached to the femur, while the other end is attached to the tibia.

With the lateral collateral ligament (LCL), which is in the same location on the outside of the knee, the MCL helps prevent the knee joint from bending too far from side-to-side.

Signs and Symptoms

A child with a partially or completely torn MCL may or may not have symptoms, depending on the severity of the injury.

Pain and swelling can be intense initially, and some kids and teens with more severe injuries will have instability when walking, feeling “wobbly” or unable to bear weight on the affected leg.

Many kids and teens, especially those who are familiar with the injury or have torn a ligament before, report hearing a “pop” sound — the sound of the shinbone popping out of and back into the knee joint.

A child who has injured a knee — whether on the field or at home — should stop all activity, to prevent further injury, and seek immediate medical care. In the meantime, keep the area iced — place the ice in a plastic bag, wrap the bag in a cloth, and hold it to the knee for 20 minutes at a time. Also, keep the knee elevated as much as possible to reduce swelling. As long as walking isn’t painful, it’s OK to walk with an MCL tear. But if standing or walking causes any pain, don’t let your child put weight on the knee.

Diagnosis

At the doctor’s office or emergency room, doctors will perform physical exams and imaging tests to determine if there’s a knee injury and, if so, how severe it is.

To help diagnose an MCL injury, doctors do a Valgus test. The child lies down flat, and the affected leg is moved out to the side, and the knee is flexed about 30 degrees. The doctor places one hand on the back of the knee joint and the other on the top side of the ankle. The doctor then rotates the shin bone and pushes the foot outward, to see how far the MCL will extend. Too much flexibility can signal an injury.

To properly diagnose MCL injuries, doctors usually perform these tests in combination or in addition to other physical exams.

While X-rays might be taken to determine the extent of the injury, they only look at bone and can only confirm the presence of bone fractures in the knee. An MRI, which looks at soft tissue (like ligaments and muscles), can confirm a partial or complete MCL tear, so some doctors will order one to confirm a diagnosis.

Types of Injuries

Doctors categorize MCL injuries according to the following criteria:

• Grade I tear. This is a slight tear (or stretch) of the MCL. Both ends of the ligament are still attached to the bone, but part of the ligament may sag and be less tight. Recovery usually takes 1 to 2 weeks; therapy may not be needed.
• Grade II tear. This is a slightly more severe tear of the MCL, with part of the ligament sagging. Pain and swelling is usually more severe than with a grade I tear. Kids usually need 3 to 4 weeks of rest and sometimes therapy.
• Grade III tear. With this type of injury, the MCL breaks in half. Kids and teens often can’t bend the knee or put weight on it without pain. They might be unstable while walking, and the knee may sometimes “give out.” Doctors may recommend a temporary knee brace for this injury as well as rehab therapy for 6 weeks or longer.

Treatment

Treatment of MCL injuries requires initial rest of the joint, along with icing, elevation, and compression bandages to help ease discomfort. It’s OK for your child to put weight on the knee as long as it’s not painful. Depending on the severity of the injury, doctors may recommend crutches, limiting physical activity, and a temporary knee brace. Putting too much pressure on the knee can cause reinjury. Over-the-counter or prescription painkillers and anti-inflammatory medicine can help kids and teens deal with the pain and feel more comfortable.

Doctors usually recommend rehabilitation therapy to help heal the knee and to:

• restore range of motion
• regain strength in the knee, thigh, and shin muscles (and prevent atrophy, the breakdown of muscle tissue)
• reduce pain and swelling
• improve balance

Most kids undergo rehab at a center three times a week, with daily exercises they practice at home. Accelerated rehab programs involve more frequent therapy, but that won’t necessarily speed recovery.

While most sports are off limits — especially the activity that caused the injury — kids and teens can do low-impact activities that may be fun and even therapeutic, like swimming, bike riding, or protected running. Talk to your doctor about what activities might benefit your child.

Helping Your Child Cope

Being told that you can’t do the things you love — like running or playing football, field hockey, or softball — can be a devastating blow to any child. Kids and teens recovering from an MCL injury, especially a severe one, may feel angry, frustrated, and even depressed, especially if they’re no longer participating in team sports with their friends.

But in the meantime, there are ways to still feel like part of the team. Keeping score, being a coach’s assistant, or bringing water to the games may help. If your son or daughter doesn’t want to do these things, suggest starting a hobby, like playing the guitar, painting, drawing, or another activity that won’t put too much strain on the knee. Low-impact activities, like swimming, are another option.

In time, kids and teens can again do the things they love. But if your child continues to feel angry or depressed during recovery, encourage him or her to talk to a school psychologist or counselor, who can help your child cope and look ahead to better days.

About MD

Muscular dystrophy (MD) is a genetic disorder that gradually weakens the body’s muscles. It’s caused by incorrect or missing genetic information that prevents the body from making the proteins needed to build and maintain healthy muscles.

A child who is diagnosed with MD gradually loses the ability to do things like walk, sit upright, breathe easily, and move the arms and hands. This increasing weakness can lead to other health problems.

There are several major forms of muscular dystrophy, which can affect the muscles to varying degrees. In some cases, MD starts causing muscle problems in infancy; in others, symptoms don’t appear until adulthood.

There is no cure for MD, but researchers are quickly learning more about how to prevent and treat it. Doctors are also working on improving muscle and joint function and slowing muscle deterioration so that those with MD can live as actively and independently as possible.

First Symptoms

Many kids with muscular dystrophy follow a normal pattern of development during their first few years of life. But in time they develop problems with movement. A child who has MD may start to stumble, waddle, have difficulty going up stairs, and toe walk (walk on the toes without the heels hitting the floor). A child may start to struggle to get up from a sitting position or have a hard time pushing things, like a wagon or a tricycle.

Kids with MD often develop enlarged calf muscles (called calf pseudohypertrophy) as muscle tissue is destroyed and replaced by fat.

Diagnosis

When first suspecting that a child has muscular dystrophy, a doctor will do a physical exam, take a family history, and ask about any problems — particularly those affecting the muscles — that the child might be having.

In addition, the doctor may do tests to see what type of MD is involved and to rule out other diseases that could cause the problem. These might include a blood test to measure levels of serum creatine kinase, an enzyme that’s released into the bloodstream when muscle fibers are breaking down. High levels indicate that something is causing muscle damage.

The doctor also may do a blood test to check the DNA for gene defects or do a muscle biopsy. In a muscle biopsy, the doctor surgically removes a small sample of muscle and looks at it under the microscope. The muscle cells of a person with MD have changes in appearance and could have low levels of dystrophin, a protein that helps muscle cells keep their shape and length.

Types of Muscular Dystrophy

The different types of muscular dystrophy affect different sets of muscles and cause different degrees of muscle weakness.

Duchenne muscular dystrophy is the most common and the most severe form of MD. It affects about 1 out of every 3,500 boys. (Girls can carry the gene that causes the disease, but they usually have no symptoms.) This form occurs because of a problem with the gene that makes dystrophin. Without this protein, the muscles break down and a child becomes weaker.

Children with Duchenne MD usually begin to have problems around age 5, as the pelvic muscles begin to weaken. Most kids with this form need to use a wheelchair by age 12. Over time, their muscles weaken in the shoulders, back, arms, and legs.

Eventually, the respiratory (breathing) muscles and heart muscle also may weaken in the teenage years, requiring further treatments. Although most kids with Duchenne MD have average intelligence, about a third experience learning disabilities and a small number are intellectually disabled.

Advances in medical care are helping kids with Duchenne to live longer and healthier lives.

While the incidence of Duchenne is known, it’s unclear how common other forms of MD are because the symptoms can vary so widely between individuals. In fact, in some people the symptoms are so mild that the disease goes undiagnosed.

Becker muscular dystrophy is similar to Duchenne, but is less common and progresses more slowly. This form of MD, which affects about 1 in 30,000 boys, is caused by insufficient production of dystrophin, too.

Symptoms begin during the teen years, then follow a pattern similar to Duchenne MD. Muscle weakness first begins in the pelvic muscles, then moves into the shoulders and back. Many children with Becker MD have a normal life span and can lead long, active lives without the use of a wheelchair.

Myotonic dystrophy, also known as Steinert’s disease, is the most common adult form of MD, although half of all cases are diagnosed in people under 20 years old. It is caused by a portion of a particular gene that is larger than it should be. The symptoms can appear at any time during a child’s life.

The main symptoms include muscle weakness, myotonia (in which the muscles have trouble relaxing once they contract), and muscle wasting (when the muscles shrink over time). Kids with myotonic dystrophy also can have cataracts and heart problems.

Limb-girdle muscular dystrophy affects boys and girls equally. Symptoms usually start when kids are between 8 and 15 years old. This form progresses slowly, affecting the pelvic, shoulder, and back muscles. The severity of muscle weakness varies — some kids have only mild weakness while others develop severe disabilities and as adults need to use a wheelchair.

Facioscapulohumeral muscular dystrophy can affect both boys and girls, and the symptoms usually first appear during the teen years. It tends to progress slowly. Muscle weakness first develops in the face, making it difficult for a child to close the eyes, whistle, or puff out the cheeks. The shoulder and back muscles gradually become weak, and kids have trouble lifting objects or raising their hands overhead. Over time, the legs and pelvic muscles also may lose strength.

Other types of MD, which are rare, include distal, ocular, oculopharyngeal, and Emery-Dreifuss.

Caring for a Child With MD

There’s no cure for MD yet, but doctors are working to improve muscle and joint function, and slow muscle deterioration.

If your child is diagnosed with MD, a team of medical specialists will work with you and your family, including: a neurologist, orthopedist, pulmonologist, physical and occupational therapist, nurse practitioner, cardiologist, registered dietician, and a social worker.

Muscular dystrophy is often degenerative, meaning that it slowly affects more organs and can’t be reversed. So, kids may pass through different stages as it progresses and need different kinds of treatment. During the early stages, physical therapy, joint bracing, and medications are often used.

During the later stages, doctors may use assistive devices, such as:

• physical therapy and bracing to improve flexibility
• power wheelchairs and scooters to improve mobility
• a ventilator to support breathing
• robotics to help perform routine daily tasks

Physical Therapy and Bracing

Physical therapy can help a child maintain muscle tone and reduce the severity of joint contractures with exercises that keep the muscles strong and the joints flexible.

A physical therapist also uses bracing to help prevent joint contractures, a stiffening of the muscles near the joints that can make it harder to move and can lock the joints in painful positions. By providing extra support in just the right places, bracing can extend the time that a child with MD can walk independently.

Prednisone

If a child has Duchenne muscular dystrophy, the doctor may prescribe the steroid prednisone to help slow the rate of muscle deterioration. By doing so, the child may be able to walk longer and live a more active life.

There is some debate over the best time to begin prednisone treatment, but most doctors prescribe it when a child is 5 or 6 years old or when the child’s strength begins to significantly decline. Prednisone does have side effects, though. It can cause weight gain, which can put even greater strain on already weak muscles. It also can cause a loss of bone density and, possibly, lead to fractures. If prescribing prednisone, your doctor will closely monitor your child.

Spinal Fusion

Many children with the Duchenne and Becker forms of MD develop severe scoliosis — an S- or C-shaped curvature of the spine caused by back muscles that are too weak to hold the spine upright.

Some kids with severe cases undergo spinal fusion, a surgery that can reduce pain and lessen the curvature so a child can sit upright and comfortably in a chair. This surgery ensures that the spine curvature doesn’t have an effect on breathing. Usually, spinal fusion surgery only requires a short hospital stay.

Respiratory Care

Many kids with muscular dystrophy also have weakened heart and respiratory muscles. As a result, they can’t cough out phlegm and sometimes develop respiratory infections that can quickly become serious. Good general health care and regular vaccinations are especially important for children with muscular dystrophy to help prevent these infections.

Assistive Devices

A variety of new technologies can provide independence and mobility for kids with muscular dystrophy.

Some kids with Duchenne MD might use a manual wheelchair once it becomes difficult to walk. Others go directly to a motorized wheelchair, which can be equipped to meet their needs as muscle deterioration advances.

Robotic technologies also are under development to help kids move their arms and perform activities of daily living.

If your child would benefit from an assistive technological device, contact your local chapter of the Muscular Dystrophy Association to ask about financial assistance that might be available. In some cases, health insurers cover the cost of these devices.

The Search for a Cure

Researchers are quickly learning more about what causes the genetic disorder that leads to muscular dystrophy, and about possible treatments for the disease.

To learn more about the most current research on MD, contact the local chapter of the Muscular Dystrophy Association or talk to your doctor, who also can tell you about clinical trials on MD.

About Nursemaid’s Elbow

Toddlers and preschoolers are at risk for a common elbow injury called nursemaid’s elbow. This happens when a ligament slips out of place and gets caught between two bones of the elbow joint.

Sometimes it gets unstuck by itself. In most cases, a health care professional gets the ligament back in place by doing a quick, gentle move of the arm.

A child with nursemaid’s elbow has some arm pain when the injury happens, but it doesn’t cause long-term damage.

Causes

Nursemaid’s elbow (also called pulled elbow) usually happens in kids 1 to 4 years old. Their ligaments (the elastic-like bands that hold bones together) are a bit loose. So it can be easy for a ligament in the elbow to slip into the joint and get stuck.

Nursemaid’s elbow can happen with just a small amount of force. For example:

• Pulling a child up by the hands can put stress on the elbows. Never pick up a toddler or infant by the hands or wrists, but lift under the armpits.
• Swinging a toddler by holding the hands or wrists can put stress on the elbow joint and should be avoided.
• Jerking an arm when pulling a toddler along or quickly grabbing his or her hand can make the ligament slip. Always be gentle when taking a child by the hand.
• Breaking a fall by reaching an arm out for protection can overextend the elbow, causing the ligament to slip.
• Rolling over in an awkward way in a crib, bed, or on the floor can cause nursemaid’s elbow in infants and very young children.

As kids get older, the ligaments tighten. Most won’t get nursemaid’s elbow after they turn 5 years old, though it can happen up to age 6 or 7.

Signs and Symptoms

A child with nursemaid’s elbow will not want to use the injured arm because moving it is painful. He or she will keep the arm in a straight position or with a slight bend in the elbow. The injury won’t be obvious because nursemaid’s elbow doesn’t cause deformity or swelling.

An arm or elbow injury that causes severe pain might be a sign of an elbow fracture (broken bone) or a bad bruise. It can be hard for a parent to tell whether an injury is nursemaid’s elbow or a fracture, so it’s important to call your doctor if your child has injured an elbow.

Treatment

At a doctor’s office or an emergency room, a health care professional will examine the child’s arm and ask questions about how the injury happened. Usually, no special tests are needed to diagnose nursemaid’s elbow. X-rays are done only if a fracture is suspected.

If there’s no swelling or signs of another injury, the doctor will do a gentle maneuver called a reduction. This procedure takes only a few seconds. The child will sit on a parent’s lap while the doctor gently takes the arm from a straight position and bends it upwards or straightens the arm while turning the palm to the floor.

Kids might have a brief moment of pain during the reduction, but quickly feel much better. Most have full use of the arm within 5 to 10 minutes. Some cases may require more than one reduction to successfully fix the injury.

Occasionally, a child may not want to use the arm after a reduction, fearing it will be painful. If there is some discomfort, the doctor may put the arm in a sling and say it’s OK to give acetaminophen or ibuprofen for pain relief. In some cases, the doctor may place a splint (a partial cast) to protect the arm until a specialist can check it after a few days of rest.

Prevention

It’s important to know that kids who get nursemaid’s elbow might get it again. So be mindful of the risks and don’t pull, tug, or swing your child by the arms or hands, and be sure to tell all caregivers to do the same.

Still, some kids are just more prone to getting nursemaid’s elbow than others and might get it again even when parents try hard to prevent it.