PMC physicians are problem solvers by nature.
What is a physiatrist?
A physiatrist specializes in restoring quality of life to people with muscle, bone, or nervous system injuries. Physiatrists are board-certified medical doctors who are skilled at diagnosing and treating pain. A physiatrist treats the whole person – not just the problem area – spending the time needed to accurately pinpoint the source of an ailment. Oftentimes the physiatrist works with a team of medical professionals such as neurologists, orthopedic surgeons, or occupational and physical therapists to provide a non-surgical treatment plan that focuses on decreasing pain, enhancing performance, restoring maximum function lost through injury, illness, or disabling conditions, and prevention of future pain.
My doctor ordered an EMG. What is it and what can I expect?
Electromyography, or EMG, is a diagnostic test completed by doctors trained to perform and interpret the procedure. An EMG will diagnose nerve and muscle injuries and disease. The test helps your doctor make an accurate diagnosis to treat your symptoms. Most patients will experience minimal discomfort during the test.
There are two parts to an EMG. The first part involves stimulating the nerve with a small electrical shock and recording the response. The second part involves placing a thin needle into a specific muscle to analyze the electrical activity in the muscle.
An EMG is a beneficial test used to pinpoint the problem so your doctor can help restore you to optimal health.
What is Spinal Stenosis?
Spinal stenosis is a narrowing of the spinal canal caused by either degenerating discs which lose height and bulge into the canal or the formation of bone spurs which crowd the canal.
Central stenosis occurs when the canal through which the spinal cord and multiple nerve roots run is narrowed. Foraminal stenosis occurs when the hole through which a nerve exits the spine is narrowed.
Stenosis causes the experience of pain in the distribution of the nerves being pinched. Nerves pinched in the neck will result in arm pain. Nerves pinched in the lower back will result in leg pain.
My doctor says I’m suffering from lumbar radiculopathy or sciatica. What does that mean?
pinal nerves exit from the lower spine and travel down your legs to your feet. Some of these spinal nerves form the sciatic nerve. The sciatic nerve is one of the main nerves in your leg.
When the spinal nerves become injured or inflamed, you may feel pain, tingling or numbness down your leg. This is called “sciatica” or lumbar radiculopathy. Damage to the spinal nerves is often caused by a disc bulge. Sciatica can also be caused by bone spurs that pinch the nerves.
X-rays or MRIs are sometimes ordered to help find the cause of the lumbar radiculopathy. Conservative treatment ranges from anti-inflammatory medications and exercise to physical therapy and steroid injections which will reduce the pain caused by the nerve irritation.
My doctor says that I have a pinched nerve in my back and he is recommending an injection. How does this help my condition?
Your doctor is most likely recommending an epidural steroid injection or a selective nerve root block. These blocks are performed with a special type of x-ray. The purpose is to deposit a corticosteroid and numbing medication around the nerve root to help in diagnosing and treating your pain condition. The anesthetic will numb the nerve; if the pain you are experiencing is relieved, then this provides confirmation that this nerve is the source of your pain. The steroid is a potent anti-inflammatory agent that reduces swelling and inflammation of the nerve with the goal of restoring the nerve to its previous, non-painful state.
What is neuropathic pain?
Neuropathic pain is a complex pain state and is caused by damage to or dysfunction of the nervous system. Damaged nerve fibers send incorrect signals of pain to the body. Common symptoms include burning, coldness, pins and needle sensation, numbness, and itching.
Common causes of neuropathic pain include alcoholism, amputation, chemotherapy, diabetes, thyroid dysfunction, facial nerve problems, HIV infection, shingles, and spine abnormalities.
In chronic form, symptoms often begin subtly and progress slowly. Treatment by a pain specialist may include electrical stimulation, topical medications like capsaicin, oral medications that may include certain anticonvulsant medicines, and certain antidepressant medications. Cortisone injections can also be used in certain cases. Better control of diabetes and thyroid problems can also help in improving symptoms.
What is a Spinal Cord Stimulator? How does it work?
A spinal cord stimulator is an implantable device much like a pacemaker. This implant has one or two leads that are positioned over an area of the spine with the other ends tunneled through the skin to a battery that is just under the skin in the soft tissues. An electrical stimulus is delivered over the back of the spinal cord to help in diminishing the intensity of the pain.
The perception is a low-level tingling or “buzzing” sensation that replaces the pain. For people that are believed to be good candidates for this type of device, a trial lead is placed that is connected to an external battery that the patient wears for 3-7 days. If the patient finds the device beneficial, a permanent implant is placed. This involves placing similar leads as the trial and connecting them to either a rechargeable battery that lasts up to 10 years or a non-rechargeable battery that lasts 1-4 years. This can be used for many different types of painful conditions including: radiculopathy, neuropathy and complex regional pain syndrome.
I have arthritis in my knee and have tried medications, exercises and cortisone injections. I do not want surgery. Are there any other options available for me?
Yes. We are able to inject a substance called hyaluronate into the knee. Arthritis in the knee causes this molecule to decrease in the joint fluid. Hyaluronate acts as a lubricant and cushion for the knee joint. There are several different manufacturers of this substance. Your doctor can decide which brand is best for you. It’s not indicated for everyone, so you will need to be evaluated by a physician to see if it is right for you.
Typically the knee is injected once a week for 3 weeks. It can take several weeks after the last injection to get the full effect. Results usually last for 6 months. The series can be repeated if needed.
This type of injection may help prevent or prolong the need for knee surgery.
Botox has been recommended for my child, who has cerebral palsy. How does Botox work and what can I expect?
Botox (botulinum toxin) is a bacterium that secretes toxins which decrease muscle contractions. Doctors have discovered a way to use a small amount of the toxin in a safe, therapeutic way. It acts without destroying nerves. It is directly injected into muscles, affecting only the area in which it has contact. The Botox relaxes the muscles that are spasming (spasticity).
The toxin itself is painless and is not known to leave any painful sensation after it is given. Spasticity (muscle spasm) can be found in children with cerebral palsy or children or adults who have sustained a traumatic brain injury, spinal cord injury, or stroke.
The spastic muscles have too much tone and are “tight”. When left untreated, this can lead to joints being frozen in one position, bony deformities, and a host of other problems. Other ways to relax tight muscles include stretching, splinting, and medications, as well as certain surgical procedures.
I have been diagnosed with arthritis of the neck and my doctor is recommending a radiofrequency ablation of the medial branch nerves in my neck. What is this procedure?
The cervical facet joints serve as the bony connection between the vertebrae and are a common location for the development of osteoarthritis of the neck. The pain is usually aggravated with rotation and upward tilting of the head.
When the arthritis has worn the cartilaginous surface of the joint and conservation measures such as manipulation, physical therapy and anti-inflammatory medications no longer provide relief, the next option is to ablate the joint. This is a process by which the nerve that carries the pain signal from the arthritic joint, in this case the medical branch, is destroyed so that the pain signal cannot be communicated to the brain.
Radiofrequency ablation is accomplished by positioning a special insulated needle next to the targeted nerve and then inserting a probe in that needle that emits a radiofrequency wavelength that heats the surrounding tissues, thus destroying the nerve. Since this is a peripheral nerve, it will attempt to regenerate and if it finds its way back to the joint, the patient’s pain may return. This typically takes between 6 months and 4 years to occur, at which point the procedure can be repeated.
What is Complex Regional Pain Syndrome and how is it treated?
Complex regional pain syndrome (CRPS) is a condition that presents as an intense pain that can occur spontaneously or after mild trauma. This regional syndrome presents with continuous intense pain out of proportion to the tissue trauma.
Presenting symptoms include burning pain, swelling and stiffness of the affected region, motor disability, changes in hair and nail growth patterns and skin changes. The extremity can feel warmer or cooler than the opposite limb and present with a blotchy appearance. The condition is diagnosed based on the clinical findings, as a definitive test does not exist.
Treatment includes psychotherapy, physical therapy, medication management with topical analgesics, narcotics, corticosteroids, antidepressants and anti-seizure drugs. Advanced treatments include: sympathetic nerve blocks, surgical sympathectomy, intrathecal drug pumps, and spinal cord stimulation.
I am 35 years old and my doctor has diagnosed me with rheumatoid arthritis. I thought arthritis was a condition that affected older people?
There are two types of arthritis that affect joints, rheumatoid arthritis and osteoarthritis. A joint is the point where two bones come together and where motion occurs. The ends of the bones are covered by articular cartilage which provides a smooth surface for the two bones to articulate. The joint is surrounded by a capsule made of connective tissue. The synovial membrane is within the joint capsule and produces a fluid that lubricates the joint. In rheumatoid arthritis, the joint’s connective tissues such as the synovial membrane and the capsule become inflamed, causing the joint to become stiff and painful. The body’s immune system plays a role in attacking the connective tissues leading to the destruction of the articular cartilage. Medications that inhibit the immune system and manage pain are typically used to limit the damage and discomfort caused by this condition.
Osteoarthritis on the other hand is a deterioration of the articular cartilage due to “wear and tear”, and leads to bone overgrowth and the formation of spurs. Osteoarthritis is more common in the elderly whereas rheumatoid arthritis can affect an individual at any age. Treatment of osteoarthritis typically starts with the use of anti-inflammatory drugs such as NSAIDS or steroids and physical therapy to improve strength and range of motion. As the condition progresses, intra-articular injections of steroids or viscosuplementation can be performed in larger joints prior to proceeding to total joint replacement.
My muscles are tight and sore. I was told I have trigger points. What is a trigger point and can it be treated?
Trigger points are localized spasms in a muscle. These spasms cause the muscle to be painful and tight. Trigger points typically feel like tight bands in the muscle. Muscles around the neck and shoulders are common places for trigger points.
There are several different treatments for trigger points. Physicians may order a muscle relaxant, physical therapy treatments, or massage therapy. Physicians can also perform a trigger point injection to reduce the pain. This involves inserting a very thin needle into the muscle and then injecting numbing medicine. This forces the muscle to relax and lessens the pain.
Most people notice significant improvement with these treatments.
I am a 20 year old male that plays collegiate football. I recently suffered a back injury while blocking an opponent. My physician has diagnosed me with a spondylolysis of the 5th lumbar vertebra. What is this and how do I treat it?
here are three diagnostic terms in the lumbar spine that are often confused: spondylosis, spondylolysis and spondylolisthesis. Spondylosis, more commonly known as osteoarthritis, is an erosion of the cartilaginous surface of the facet joints that causes local back and buttock pain. Treatment consists of physical therapy to strengthen the supporting muscles, anti-inflammatory medications or intervention injection procedures. Spondylolysis is a stable fracture of a portion of the vertebra called the pars interarticularis.
This typically occurs due to a hyperextension of the lumbar spine and is commonly seen in gymnasts, football lineman and wrestlers. Occasionally, these fractures will cause pain and are typically treated with physical therapy, bracing and anti-inflammatory medications. Both degenerative spondylosis and spondylolysis can lead to the last condition: spondylolisthesis. This is a forward slip of one vertebral body in relation to another.
This can lead to back pain and, if a nerve is pinched, leg pain. Treatment of this condition includes medication to manage the pain, bracing and physical therapy to stabilize the spine. If these fail, surgery can be performed to fuse the vertebrae together and decompress the nerve impingement.
During the night I wake up with numbness and tingling in my hands. Could this be Carpal Tunnel Syndrome? What is Carpal Tunnel Syndrome, and how is it treated?
Carpal Tunnel Syndrome (CTS) is caused when the nerve in the carpal tunnel is pinched or inflamed. The carpal tunnel consists of the carpal bones and the transverse ligament. There are nine tendons and one nerve within the tunnel. The nerve is called the median nerve. When the median nerve is pinched, symptoms can develop and cause CTS. Symptoms typically involve the palm side of the thumb, index finger, middle finger, and half of the ring finger.
Treatment depends on the severity of the damage, which is usually determined by electrodiagnostic testing. If the damage is mild, treatment may consist of splints at night, anti-inflammatory medicines, and hand therapy. If the damage is more severe, injections and surgery may be helpful.
If you think you have CTS, it is important to see a physician who will properly diagnose and treat your symptoms.
My doctor has diagnosed me with tennis elbow, but I don’t play tennis. What is it and how is it treated?
Tennis elbow is a common term to describe lateral epicondylitis. This condition is one that produces pain and tenderness on the outside (lateral) aspect of the elbow. The typical patient with lateral epicondylitis or tennis elbow is between 35 and 50 years of age. Patients typically report the gradual onset of pain in the lateral aspect, i.e., outside aspect, of the elbow and forearm during activities involving wrist extension, such as lifting, turning a screwdriver, or hitting a backhand in tennis.
As a matter of fact, most people diagnosed with “tennis elbow” do not play tennis, and it typically can occur in the workplace with repetitive-type activity. With time, occasionally the pain can become fairly severe and even occur at rest. Individuals with lateral epicondylitis typically have pain when lifting with their palm down. Treatment can include modifying or eliminating any activities that caused the symptoms. Nonsteroidal anti-inflammatory medications can also be used for acute exacerbations.
A tennis elbow strap can be beneficial during any heavy lifting-type activities, as well as any application of ice or heat, whichever works best, to relieve the pain. Once the pain has decreased, then gentle stretching and strengthening exercises can occur through therapy, as well as a home program. If the pain continues, cortisone injections can occur. If pain is not relieved after one or two injections, other options include Sonorex, i.e., high energy wave treatment (similar to lithotripsy), as well as surgical intervention; however, most cases resolve with conservative care.
I recently injured my back and my doctor is recommending a steroid injection. What is this and how does it work?
An injection into the spine typically is done to obtain both diagnostic and therapeutic benefit. The solution used is typically a mixture of an anesthetic agent mixed with a corticosteroid. By using a special type of x-ray called fluoroscopy, the needle can be positioned to deliver the therapeutic solution to a specific target, such as a nerve or joint. A contrast agent is first injected to confirm the location of the needle tip by evaluating the flow pattern of the contrast. Once the correct pattern is confirmed, care is taken to make sure the needle tip does not move as the physician injects the therapeutic solution.
If the patient initially presenting with pain reports that the pain is substantially reduced or gone within 10-15 minutes following the injection, then the target of the injection is confirmed as the pain generator. This diagnostic response establishes the patient’s diagnosis and can assist the physician with future management decisions if the corticosteroid is not effective in relieving the pain long-term.
The therapeutic portion of the injection is derived from the corticosteroid which is a potent anti-inflammatory agent that reduces swelling and irritation of the nerve or joint. The therapeutic response typically occurs 3-5 days after the injection is delivered. Corticosteroids are different than the anabolic steroids that are commonly used by athletes as performance-enhancing agents.
My hip hurts and is very tender when I sleep on my side. Do I have arthritis in my hip?
There is a good chance it’s not arthritis. Bursitis is a more likely diagnosis. The trochanteric bursa is located on the lateral or outer part of the hip. It normally functions to keep the soft tissues around the hip moving smoothly. Sometimes the bursa gets inflamed and can cause pain. An inflamed bursa is tender to the touch. The pain is worse with activities such as side lying, climbing stairs or walking for long distances.
There are many causes for bursitis. Some of these causes include trauma to the hip from falling, a shorter leg on one side, and overuse. It can also develop spontaneously.
Treatment involves anti-inflammatory medications, proper stretching and strengthening exercises, cold application and a local cortisone injection. Persistent cases may require surgery to remove the bursa.
Six months ago I fell and landed on my buttock. Since that time, I have had pain in my low back and buttock and find it difficult to sit for longer than fifteen minutes. My doctor has diagnosed my condition as SI joint dysfunction. What is this and what can be done?
The sacroiliac joint, more commonly known as the SI joint, is the largest joint in the spine and is the point where the spine and pelvis come together. The SI joint is lined with cartilage and is supported by strong ligaments which limit the motion of this joint to 2-3 degrees of rotation.
Pain can originate from the joint as a result of direct trauma as in your situation, repetitive trauma as in the case of performing an activity repeatedly in the same direction, or as a result of weakening of the ligamentous support as commonly occurs in the third trimester of pregnancy when a hormone is released that allows the pelvis to expand in preparation for child birth. Treatment of SI joint dysfunction begins with a course of physical therapy to stabilize the joint and educate the patient to avoid activities that increase the instability of the joint.
An injection can be performed with a steroid/anesthetic mixture to reduce the inflammation of the joint as well as confirm the diagnosis by numbing the joint to see if the pain dissipates. If conservative measures fail, a radiofrequency ablation can be performed to denervate the joint and block the patient’s ability to perceive pain coming from the SI joint.
What is a frozen shoulder and how is it treated?
A frozen shoulder, or adhesive capsulitis, is the unexplained loss of both active and passive range of motion of a shoulder. Typically this affects patients between the ages of 40 and 60. Diabetes is a risk factor, as well as hypothyroidism, cervical disc herniation, Parkinson’s disease, strokes and rarely tumors. Typically on physical exam, there is substantial decreased range of motion of the shoulder and tenderness can occur. Typically x-rays are obtained to rule out any other causes, i.e. bone spurs, loose bodies, calcium deposits or tumors.
Treatment involves nonsteroidal anti-inflammatory medications and moist heat followed by a gentle stretching program. Intra-articular steroid injections can also help the situation. Ideally, the stretching should be performed at least three to four times per day and may take an extended period of time until range of motion is fully restored and pain completely relieved, i.e. one to two years. However, if there is lack of progress and substantially impaired range of motion, occasionally patients need to be taken to surgery to “break up” the adhesions.
While on a ladder hanging Christmas lights, I slipped and fell, landing on my knee and twisting my back. Should I use ice or heat to manage the pain and swelling?
An acute musculoskeletal injury initiates an inflammatory process that increases blood flow to the affected area and causes vascular membranes to become porous, thus resulting in swelling. The initial goal with these injuries is to control the swelling and inflammation. Conservative management can be remembered by the mnemonic RICE (Rest, Ice, Compression and Elevation). Ice cools the tissues and decreases blood flow to the area, thus reducing swelling. Ice also slows nerve transmission and numbs the area, providing partial pain relief. This is very beneficial in the first 48-72 hours after an injury or following any increased activity during the healing phase, such as following physical therapy when inflammation can reoccur. A towel should be placed between the skin and ice, which should be applied 20 minutes on and 20 minutes off to protect the skin from damage.
Heat increases blood flow to an area and relaxes soft tissues. It is often helpful after the inflammation has been controlled to soothe muscles and is frequently used prior to a physical therapy program that involves a stretching component. Heat can be applied from an external source such as a heating pad or with the use of devices such as ultrasound or diathermy. Tissues can also be heated by performing a light activity such as walking or riding an exercise bike prior to stretching or performing a more physically demanding activity. As with ice, care must be taken to protect the skin and soft tissues from injury when using heat.
My ring finger on my right hand catches in a bent position and will sometimes snap. It really hurts and is swollen. What is this problem and can it be treated?
This condition is called a trigger finger, or stenosing tenosynovitis. Narrowing of the lining (sheath) that surrounds the tendon causes the affected finger to snap when straightening. If the condition is severe, the finger may become locked in a bent position. Trigger fingers are more common in people whose work or hobbies require repetitive gripping actions. It’s also more common in women and in people with diabetes, gout, and rheumatoid arthritis.
Usually the finger pops or clicks as you move it. Sometimes the finger is tender at its base, where a nodule may be felt. It typically occurs in your dominant hand, and most often involves your thumb, middle, or ring finger.
After the diagnosis is made by your doctor, treatment may involve activity restrictions, rest and splinting the finger in extension. Hand therapy for exercises can help maintain mobility. Medications such as anti-inflammatory drugs may relieve the inflammation and pain. Cortisone injections can also reduce inflammation and pain. In more severe cases, surgical intervention may be necessary.
What is a bone spur and how is it treated?
A bone spur, or osteophyte, is a bony growth formed on normal bone in response to pressure, rubbing, or stress that continues over a long period of time. Some spurs form as part of the aging process such as in osteoarthritis of the hips and knees. In the spine, spurs form as discs degenerate and can lead to impingement of nerves as they exit the spine. A spur causes pain if it presses or rubs on other bones or soft tissues such as ligaments, tendons, or nerves. Common places for bone spurs include the spine, shoulders, hands, hips, knees, and feet. Bone spurs also form as a response to repetitive trauma such as in the feet in response to activities such as dancing and running, or due to increased pressure from being overweight.
While spurs can be seen on an x-ray and can support a diagnosis, the condition that leads to the development of the spur is the patient’s diagnosis. Most bone spurs do not cause problems. Treatment of the underlying condition that causes the bone spur to develop may include weight loss to take pressure off the joints and stretching the affected area to increase the flexibility of ligaments and tendons that pull on the attachment points to bone. Seeing a physical therapist for ultrasound or deep tissue massage may be helpful to assist in development and tolerance of these stretching programs. Inflammation at the spur site is treated with rest, ice, stretching, and nonsteroidal anti-inflammatory drugs (NSAIDs).
If the bone spur continues to cause symptoms, your doctor may suggest a corticosteroid injection into the painful area next to the bone spur. Sometimes surgery is required to remove a spur as part of the treatment to replace a joint when osteoarthritis has caused considerable damage. A spur can also be removed if it continues to irritate surrounding soft tissues, such as occurs in the shoulder with rotator cuff impingement or in the spine with stenosis.