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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.

mild knee degeneration
missed diagnosis

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 hip OA
missed diagnosis

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

Osteoarthritis is a chemical process. It is not just mechanical wear and tear, but a process that involves cellular and chemical changes. These changes affect all joint tissues (cartilage, bone, joint capsule, ligaments and muscle).

In the event of any trauma and age related changes, the body will attempt to repair damaged tissue. With synovial joints, such as the knee, the repairs to cartilage and bone are not made with exactly the same tissue. Consequently tissue re-modelling can result in changes to the joint surface.

The pictures below show how these changes can progress over time and result in significant loss of function. Not to mention discomfort!

Knee One
mild osteoarthritis knee joint

On the right of the joint you can see a small bone spur. Also notice how the joint space on the right side (medial compartment) is less than the left side ( lateral compartment). This is a sign that the cartilage is breaking down faster than it can be re-built.

Knee Two
moderate OA knee

Further narrowing of the medial joint space and more irregularities along the surface of the joint line.

Knee Threesevere osteoarthritis knee Wide spread joint changes with the complete loss of medial compartment joint space. This knee is appropriate for joint replacement.

But what about knees one and two?

Is it possible to minimise the inappropriate / excessive chemical response and minimse any additional trauma?

Chris Creaghan at  Injection Clinic believes that by focusing treatment on the metabolic process (chemistry) and the mechanical forces (strength, alignment, range of movement)  then positive changes can be made.

To minimise mechanical trauma aspects such as footwear, movement patterns, joint strength and range of movement all need to be addressed.

But whilst many people follow this exercise advice, the correction of the joints chemistry is often overlooked. Osteoarthritis is an active metabolic process and therefore exercising a knee joint when the process is active can often cause more pain and further inflammation.

To detect these changes Ultrasound scans can highlight excessive blood flow through joint tissues and also detect excessive fluid / swelling. Once detected these areas can be directly injected with medication or excessive fluid can be aspirated. Guided injections of cortisone are an efficient and proven way to suppress inflammation and once the metabolic process has been calmed down, then exercises can commence.

For maintaining the health of the knee joint, along with exercises, medication such as Ostenil can be used. This helps restore normal levels of joint lubrication.

Platelet Rich Plasma (PRP) can also be used to ensure there is optimal nutrition to the joint. (For more information please have a look at the latest post on PRP Injections). Click here.

Remember that best chemistry and best mechanics will always pave the way for the best treatment of any arthritic joint. There isn’t a cure, but there is best management.

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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).

PRP preparation
PRP separation of red blood cells leaving the plasma (yellow bit) containing the platelets.

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.

Hip injection by ultrasound guidance
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.

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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.

frozen shoulder injection

Pain Scores: are they damaging us?

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

person in pain

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 measure?

With regard to muscle and joint pain we should investigate and measure mechanical strength, alignment and movement patterns. We should observe the true status of tissues and look for tears, ruptures, levels of degeneration and damage. We should measure chemistry to ensure our blood, hormone and endocrine systems are normal and check our temperature. 

The image (on the right) shows a partial tear to a patients rotator cuff tendon. The left image is normal. This person had several treatments and discussions about their pain before visiting InjectionClinic. Once we established a diagnosis treatment could then focus on the condition, not just the ‘pain’ experience.
rotator cuff tear ultrasound scanFollowing investigation we should also acknowledge ‘normal’ findings as a process of exclusion. We should understand that not all pain arises because of damaged tissue, pain can occur because of irritation without damage. Most back pain for example occurs because of poor posture and patterns of movement, not medical pathology. We should therefore measure our improvements in mechanical and chemical terms if we really want to improve our health. The ‘pain alarm’ will then turn itself off.

Is it really that simple?

Yes and no. Yes, because best mechanical function and best chemistry are key to making us healthy.

No, because nationally this would require a significant shift in financial resources and a change in the current model of healthcare. We would need frontline clinicians with appropriate diagnostic skills, the time to diagnose and access to investigations.

It is however simple on an individual level, because it is easier for one person to elicit change than a national organisation.

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

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..
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.
guided ultrasound injection into subacromial bursa shoulder
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 ultrasound scan
Acromio-clavicular joint inflammation
A common and often over looked problem is inflammation of the acromioclavicular joint (ACJ). The image below shows an inflamed ACJ which again 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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