Pain, pain and more pain

woman-in-pain

Pain is a real pain

I often get asked by patients, 'why am I in pain?'
Its a natural question, but the real answer might not be what the person was expecting!
As with most things they are many personal opinions and lots of research which can be interpreted in different ways.

I like the first part of the answer to refresh a basic understanding that changes in mechanical forces, temperature and chemistry can all generate a pain response. In summation, you can hit yourself, burn yourself and become poisoned. All these things really do hurt.

With muscle and bone pain, temperature is not really an issue, so most people have pain due to abnormal mechanical stress and strain and chemical changes such as inflammation.
To be more specific, a persons posture or movement pattern can elicit a mechanical strain on any joint, which if repeated for a long time, or performed with force or at speed, will result in the body tissues initiating a warning. Pain.

Mechanical

The video shows the difference in lifting techniques whilst getting the same job done.
The top video will only ever result in back pain. Notice how the spine is flexed and there is no use of leg muscles to make the lift.
It might takes years before this movement generates a warning stimulus, but the pain will come because the movement is wrong.

Inflammation

Chemical changes such as inflammation will also initiate a pain response. The next picture shows an inflamed bursa within the shoulder. The inflammatory process  makes the tissue bigger, which can cause further problems as the tissue can then become mechanically squashed.
This situation is a 'chicken and egg' scenario. The mechanical compression causes the bursa to become irritated and inflamed, the inflamed bursa is bigger and therefore gets squashed.

ultrasound-showing-shoulder-bursitis

So what is the answer?

The answer exists in a tissue based diagnosis.

What tissues are mechanically strained and which tissues are chemically inflamed.

You may experience pain because your shoulder movement is wrong resulting in an inflamed bursa. Or you may have joint irritation due to long term postural dysfunction and/or factors of ageing.

Sometimes 'pain' is more chemical than mechanical, as is the case with Gout.

In any situation, pain is a warning and the diagnosis is the determination of what tissues are mechanically strained or damaged and what tissues are inflamed.

A description of pain is not a diagnosis!

A description of pain will not determine what is strained and what is inflamed.

To determine a true diagnosis it requires observation, examination and investigation.
At the Injection Clinic we perform all three in one appointment for a set fee of £75.

If significant chemical changes are identified we can also administered medication. Price for a guided cortico-steroid injection is £75.

One visit: job done. Don't let your pain take over. Find out what is wrong and address the mechanical and chemical factors.

Please note this post, like all brief explanations only covers the basics for pain arising from muscle, bone, tendon and ligament structures. There are many other factors that influence the experience of pain and much research has been done on the emotional components of pain and the sensitisation of the pain mechanism.  

The error of chasing pain!

All too common problem
The error of chasing pain !
For over two years this person visited their GP with knee pain. Injections and physiotherapy did not improve the symptoms or the persons mobility.
The x-ray below shows the painful knee joint. There are no major changes seen on the x-ray, but because the experience of the pain remained around the knee, so did this persons treatment.

By staying focused on examining how joints and tissues are performing and not chasing the pain, we observed the whole person and in particular examined the joints above and below the knee.

The examination of the hip revealed significant changes. A loss of movement was quickly apparent and further investigation with x-ray highlighted the severe degenerative changes (bottom picture).

severe-oa-hip-joint

Its not uncommon for an experience of pain to mislead both patient and practitioner and therefore it is important not to be lead by an experience of pain alone.

Remember that an experience of pain is your body’s alarm, it is an essential warning mechanism, but the detail of your pain experience is not a reliable indicator of what the true nature of the problem is.

If in doubt get the problem checked out!

Examination and ultrasound scan to assist diagnosis £75. When indicated x-rays and MRI scans can be arranged.

 
 

Treatment for Knee Osteoarthritis

Knee osteoarthritis is not just mechanical wear and tear, it also involves cellular and chemical changes. These changes affect all the tissues that make up a knee joint (cartilage, bone, joint capsule, ligaments and muscle).

In the event of trauma and/or age related changes, the body will attempt to repair damaged tissue. However this process does not replace like for like. Consequently tissue repair can result in changes that further affect the normal function of the joint.

It is therefore essential that both mechanical and chemical changes are minimised.

patient review on treatment of knee pain and osteoarthritis

Mechanical Factors

In order to decrease abnormal mechanical stress on the knee joint there are three keys factors that a person should identify. Their joint alignment, strength and functional movement.

OA knee

The photograph shows a typical valgus alignment of the left knee and the x-ray shows what lays beneath the skin. You can clearly see the erosion of the left side of the knee joint. In this situation mechanical correction by surgery and a joint replacement is likely to provide the best outcome.

severe-oa-knee

Most are not that bad!

Fortunately, most knees with osteoarthritis are not that bad and therefore mechanical improvements can be made via exercises. The video shows good technique for a wall squat. You don’t have go very deep into the squat but it is important to get your hips, knees and feet in good alignment. The squat will improve knee joint strength.

Chemical Changes

The chemical changes within a knee joint can also vary. Many arthritic joints have inflammatory flare ups and at times the fluid within the joint needs to be aspirated. Other chemical changes include Gout. The video shows the technique for joint aspiration.

Chemical changes are not simply achieved by taking excessive fluid out, improvements can also be made by injecting medication directly into the knee. A common injection is a Corticosteroid. This will directly decrease inflammation and can often decrease the persons experience of pain.

Other injections can also be considered. These include viscosupplementation, such as Ostenil and Platelet Rich Plasma (PRP). Please click the button for more information on the different types of joint injection.

Diagnosis is critical for best treatment

For any treatment to be effective it must be tailored to the specific requirements of the individual. There are many other factors that affect knee osteoathritis including problems with the hip joint, foot and ankle. The pain experience itself is not diagnostic, it simply informs the person that they have a problem.

New patient examination and ultrasound scan £75

Please remember that the Injection Clinic provides a high quality service for all your joint aches and pains. Please visit the website for full details.

Platelet Rich Plasma (PRP) injections

The search for best treatment of joint degeneration and OA changes continues.

A growing number of people are hearing about Platelet Rich Plasma (PRP) injections, but what are they and do they work?

All mammals, and that includes us, have cells within their blood. Different cells do different jobs. Most people have heard of red blood cells as these help carry oxygen and white blood cells that help fight infection.

There are however lots of other ‘bits’ within our blood and these are called ‘platelets’. Platelets are fragments of cells that originate in bone marrow cells. These fragments contain many different proteins and are most commonly associated with ‘plugging’ a hole in any damaged tissue. They form a blood clot and prevent excessive bleeding, but they also initiate the process of repairing tissue and some of the proteins within platelets are referred to as Growth Factors.

The idea behind PRP injections is that you take a persons blood and separate the red bloods cells away from the platelets. You then have a higher concentration of proteins and growth factors which you inject into the area of damaged or degenerate tissue. This is essential as you do not want red blood cells inside joints or ligaments as this can cause a further inflammatory response (red blood cells should not be in these places).

platelet-rich-plasma-prp

The aim is to stimulate new cellular growth and therefore boost the repair process. Sounds good, but does it work?

Like most things there is no clear answer. Research is a mixed affair with animal dissection after injections showing an improvement in the surface of joint cartilage. We don’t tend to be that cruel to humans, so most outcomes in people are based on pain and disability scores. Research tries to compare the benefit of PRP to exercise and/or other medication. The results are not conclusive but there is a trend and as the use of PRP has grown there has been more widespread acceptance of PRP as a valid treatment option. It is now acknowledged by the NHS and in some areas of the UK offered as a treatment.

One big advantage of PRP is that it is safe and there are no long term side effects. The physiological basis has merit, mainly because usually platelets have difficulty reaching ligament, tendon and cartilage tissue. Consequently, I tend to refer to PRP as a fertiliser to aid healing and ensure the best outcome. It is not however a miracle cure or a stand alone treatment. Its needs to be used in conjunction with corrections to strength, alignment and patterns of movement.

If you wish to discuss your problem further or arrange an appointment for PRP treatment please visit with main website and book an appointment.

Hip Pain

Hip Pain: a joint that often gets over looked.

The hip is a weight bearing joint and is affected by degenerative changes and inflammation. But despite these common and shared problems with the knee joint, treatment for hips is more limited.
Whilst there are some GP’s that will provide knee injections and day case surgery for knee arthroscopy’s is widespread practice; injections and surgical intervention for the hip joint is much more difficult to access.
This is mainly due to the depth of the joint and the costs involved with guided injections performed in Theatre .

However, with appropriate diagnosis and modern ultrasound scans the hip joint does not need to be a poor relation to the knee. For a new patient examination and ultrasound guided cortisone injection the cost is only £150.

ultrasound-guided-hip-injection
There are two key areas that can benefit from injections; the Trochanteric Bursa and the joint capsule. Both these areas can be visualised on ultrasound scans and allow for accurate guided needle placement. The worry of touching a nerve or deep vascular structure is gone, because they are clearly visible.
Secondly, hip injections are relatively painless. In the Journal of Arthroscopic Surgery 49 out of 50 patients preferred ultrasound guided injections over x-ray guided. Most people comment ‘is that it’. The worry of the injection is typically far worse than the injection itself!

Hip joints also have a large number of surrounding muscles and therefore with appropriate exercises the mechanical stability of the joint can be improved.

The key to all muscle and joint related problems remains the same: Improve the joint chemistry by decreasing inflammation or adding joint lubrication and then optimise the movement pattern and supporting muscle strength.
If you feel you may benefit from a clinical examination and ultrasound scan of your hip joint and surrounding tissues then please phone 0114 267 1901 to check on appointment availability.

Book an appointment

Frozen Shoulder

Frozen shoulder is a common shoulder problem; it typically starts without any trauma and last for around 18 months. Quite often it affects the persons non dominant arm and after a period of several weeks it can cause the shoulder joint to loose its range of movement. Washing hair, fastening bras, putting on jumpers etc all become problematic.

Diagnosis is established by the presenting loss of movement and ultrasound scans can further ensure there is no tissue damage. A frozen shoulder on both ultrasound scan and x-ray will look normal.

Due to the high level of pain and limited movement, the condition has a significant impact on a persons life. Whilst treatments such as gentle exercises and soft tissue massage to the surrounding muscles can benefit, the main change in symptoms and movement is provided for by injection therapy.

Guided corticosteroid injections help reduce inflammation and in so doing decrease the pain experience. Hydro-dilitation or distention helps to stretch the shoulder joint capsule from the inside and can provide immediate improvement in joint range of movement.

It must be noted that all injections have to be administered under guidance. The joint space is relatively small and can be as deep as 6cm on some individuals. For Hydro-dilitation, the use of ultrasound scan enables a clear image of the expanding joint capsule.

ultrasound-guided-injection-for-shoulder-shoulder

Guided injections work well to suppress excessive inflammation. This can often improve night time rest, enabling better sleep.

To book an appointment with Injection Clinic and find out if you could benefit from a guided injection please ‘click here’.

Pain Scores: are they damaging us?

Are ‘Pain’ scores damaging the public’s health!

 

Ever been asked to score your pain out of 10?

Ever been asked to describe your pain and even draw a picture of where it is?

Ever wondered why?

We are taught to believe that a description of our pain and its intensity will help us to find out what’s wrong. This approach has grown in popularity, in part fuelled by a trend in cultural expectations that we should be pain free. In part driven by commercial practice that attempts to sell a ‘pain free’ lifestyle. It is both tempting and financially lucrative.

So does this approach work?

No. The number of people with long term pain is rising, mental ill health associated with pain is rising, the financial cost for the management of long-term pain is increasing and the health of the nation is decreasing. 

So why is it that a standard medical consultation spends time discussing a persons experience of pain and how it affects them?

There are several reasons, the key ones include:

  • All NHS contracts in orthopaedics stipulate that outcome measures based on pain scores are put in place as part of service contracts. Consequently, the clinicians have to ask and patients have to score high in order to gain access to care.
  • It is cheaper to talk about pain than it is to investigate.
  • Many clinicians are taught to ask about pain and there is trend in becoming more empathetic as opposed to diagnostic. ‘How do feel’ has gained priority over ‘this is what’s wrong’. 

Is this pain discussion really that bad?

At its current level, yes. As a consequence of our focus on ‘pain’, our time and financial resources are being spent on ‘pain’ driven pathways instead of appropriate investigation and medical intervention. The focus on ‘pain’ is like having focus on the noise a fire alarm makes. The alarm is not the real problem, the alarm is a warning. It is the resultant investigation that determines if there is a problem and if so, where it is and how big it is.

Side note: Veterinary practitioners have the luxury of avoiding the whole pain score and pain discussion because animals don’t speak. Veterinary clinics have ultrasound scans, x-rays, some even have MRI’s. Many have blood laboratories on site and as a result our pet animals have immediate focus on ‘what is wrong’. 

So, if we don’t measure ‘pain’ what should we do?

Firstly, we should make a tissue based diagnosis to determine the nature of the problem. Then we should deliver treatments that are backed by research.

Corrections to posture, alignment and strength, including surgery; all help improve body mechanics.
Corrections to chemistry within our bodies will always promote health.

If we stop chasing pain and start chasing after best health, then our healthcare resources will be used to improve the health of the nation. 

Book an appointment to find out what is causing your pain

If you are in pain but don’t know what tissues are damaged or irritated, then a physical examination enhanced by ultrasound is a great place to start. It costs £75.

Book your initial consultation including ultrasound scan 

www.injectionclinic.co.uk

Shoulder Pain

 
What does shoulder pain look like?
Shoulder pain and ‘pain’ in general cannot be seen. What can be seen are changes to the tissues that make up our shoulder joints.
Shoulder Bursitis
Common problems include shoulder bursitis, which is the inflammation of a fluid sac within your shoulder joint. This can be seen on the ultrasound image below (see the darkened band pointed to by the white arrow) . It is a common painful condition that responds very well to ultrasound guided cortisone injections.
 
ultrasound-showing-shoulder-bursitis
Next picture shows a needle directed into the bursa. Note the measurement ‘A ‘(3.6mm). This is the size of the bursa after injecting with cortisone. To ensure accurate needle placement when the tissues are so small requires ultrasound guidance.
 
shoulder-bursitis-guided-injection
 
Rotator cuff tendon tear
Another common shoulder problem is a tear within the rotator cuff tendon. The image below shows a comparison between a normal supraspinatus tendon (left image) and a torn supraspinatus tendon (right image). This problem is not for injection, but requires surgical consideration and appropriate rehabilitation.
 
rotator-cuff-tear-diagnosis-of-shoulder-problem
Acromio-clavicular joint inflammation
A common and often over looked problem is inflammation of the acromioclavicular joint (ACJ). When inflamed the joint responds really well to injection therapy.
 
If your shoulder is painful then first establish a diagnosis and then select the right treatment for your problem.
Call Active Healthcare Sheffield on 0114 2671901 and ask about an ultrasound scan and injection therapy.

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