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Chronic knee pain troubles a significant number of people worldwide. It is a common problem amongst the aging population, and can indeed be very painful and debilitating, sometime even confining individuals to the bed. The most common cause of knee pain in elderly is osteoarthritis (OA), a condition where the cartilages of the knee joint have worn out due to wear and tear.

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The acromioclavicular (ACJ) is a small joint between the collarbone (clavicle) and the tip of the shoulder blade (acromion). It is located at the tip of the shoulder forming the highest point of the shoulder. Like many other joints in the body, it has cartilage covering the ends of the bone, is surrounded by a capsule and stabilised by strong ligaments. This joint has minimal mobility. It is involved in overhead arm movement and when the arm is moved across the body.

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In India, there is a huge variability in the services offered by the existing pain clinics. Lack of recognized comprehensive training curriculum in pain medicine with government approved minimal training standards may be one of the contributing factors. The focus of most specialists is on interventions rather than holistic management.

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The increasing number of pain management centres in Delhi is a proof of changing times and increasing awareness about pain management options. Neuropathic or nerve pain is one of the common reasons for pain clinic consultation.

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Joint pain can be a source of prolonged discomfort which one may have to endure in life. This can affect your daily activities and make you feel depressed. Joint pain specialists in Delhi NCR are daily visited by numerous patients complaining of severe pain and in search of treatments which can provide quick relief.

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Myths About Slipped Disc

Bouts of back pain are common with up to 80% of people worldwide experiencing back pain at some point in their life. Most episodes are a result of minor problems such as a strained muscle, ligament and usually resolve soon. Less than 1 in 20 cases of sudden onset back pain are due to a slip disc and are often inappropriately managed. Here are some myths about slipped disc.

Myth #1: Discs slip out of place

The name slipped disc is a misnomer as the disc does not slip out of place. It is firmly supported in its place surrounded by strong ligaments on both sides. The discs have a tough outer layer that surrounds a jelly-like material in the centre. Slipped disc is used to refer to a condition where the disc looses its shape and/or consistency and either the central jelly-like material of the disc leaks or bulges out. In medical terminology other terms such as degeneration, bulging, protrusion, extrusion and sequestration are used to refer to varying magnitudes of the problem.

Myth #2: Slipped discs are always caused by injury

Slipped disc results from a magnitude of factors causing weakening of the disc such as genetic factors, age related wear and tear, lifestyle including physical activity, body weight, smoking etc. They may however come to light after a sudden movement/ injury but the predisposition is already present and sometimes even trivial activities can trigger the symptoms.

Myth #3: Slipped discs always cause excruciating pain

Whilst slipped discs can be quite painful, this is not the case always as the severity of pain can vary. It is possible for a person to have a slipped disc and feel no pain or show no symptoms. For most people, a slipped disc will cause some pain and discomfort, and this generally reduces with time.

The pain from a slipped disc may be felt in the back and/ or the arms/legs. This may be accompanied by other symptoms such as numbness, tingling and muscle weakness.

Myth #4: My x-ray is fine so I cannot have a slipped disc

X-rays of the spine are not good at looking at discs. Although they may show problems such as reduced disc height, they are not good for evaluating slipped discs. MRI scans are better at looking at the spine anatomy in detail. X-rays are used more for evaluation of bones.

Myth #5 : MRI imaging will show the cause of my back pain

Technological advancements have enabled us to identify minute changes in disc structure using investigations such as the MRI. A significant number of normal individuals with no symptoms, when scanned will show disc abnormalities on the MRI. This emphasises the point that not every slipped disc causes pain and the findings need to be interpreted in relation to your history and examination findings. Discs normally wear down as we age, so just because the MRI showed a disc problem doesn’t mean that it is the cause of your pain.

Myth #6: Slipped discs require Surgery Sooner Or Later

In an overwhelming majority of cases the problem will NOT require surgery and can be managed conservatively. Disc bulges are NOT forever. A recent study revealed that spontaneous regression of disc injury can occur with conservative care.

Understandably the idea of being under the knife can be terrifying for most people and this option is required only for severe/ non resolving cases. Experienced, knowledgeable medical professionals always try less invasive treatments first. Non surgical interventions, such as medications, physical therapy and injections, can help in reducing the symptoms. Spinal injections such as nerve root block can sometimes play a key role in controlling symptoms and speeding up recovery. Such injections are administered under x -ray guidance to ensure accuracy.

Myth #7: Movement will make my disc problem worse

Whilst extreme pain episodes may require rest, continued activity is generally advised. Simple activities (such as walking, mild stretches) as recommended by your specialist, can reduce the loss of muscle strength and endurance. It can reduce deconditioning of muscles which in itself can be a source of pain. It may be sensible to avoid certain types of activities such as heavy lifting, impact sports etc whilst the body attempts to repair itself. Movement can plan an essential role in the healing process.

Myth #8: Slipped disc is a permanently disabling condition

Many believe that once they get a slipped disc it’s a lifetime problem and they will never be able to return to normal activity. I have seen patients with normal spine who have not bent forwards for years as they were advised not to do that during a back pain episode. Such strongly embedded negative beliefs are disabling and dealing with them can be challenging. With patience, correct knowledge and timely treatment most individuals can return to 100% prior level of function without pain.

TAG : Best Pain Specialist in South Delhi, Pain Management in Delhi, Pain specialist doctor in Delhi, Body pain treatment in Delhi, Pain Treatment in Delhi

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Sports Injuries Prevention

Overuse and trauma are two common factors responsible for sports injuries. Both intrinsic (such as age, fitness level, muscle strength etc) and extrinsic factors (such as equipment, environment, type of activity etc) play a role in injuries.

Prevention of injuries may involve changing of training schedule, gear, training, practicing environment and style and many other factors. Primary prevention deals with prevention of an injury whereas secondary prevention is about prevention of re occurrence of injury. As "Prevention is better than cure," here are some tips that can help you prevent sports injuries. Whilst most of these may seem like common knowledge, you would be surprised by how many injuries can be avoided by following these tips.

Tip 1: Understand the importance of physical conditioning and know your limits

This factor is often overlooked by amateurs who easily succumb to temptation and overindulge.  It is easy to get carried away when you return to sports after a long time. Knowing ones limits, gradually increasing the intensity and duration of training can help in injury prevention. Regular exercise is an effective way to energize your body and keep fit.  On the other hand aggressive training beyond ones capabilities and the resulting overuse, fatigue, poor judgment makes injuries more likely.

Be mindful of old injuries and listen to your body. Warning signs such as joint pain, tenderness, and swelling are reasons to re-evaluate your technique and routine.

Tip 2: Invest in the right sporting gear

This includes every essential bit of equipment required for playing a particular sport, starting from the right shoes to the protective equipment such as helmets, gloves, protective pads etc. Right gear not only protects you from injuries but can also enhance your performance.

Tip 3: Warm and stretch your muscles

Warmed up muscles are less prone to injuries and overlooking warm-up sessions can cost one dearly. Warm up raises the core body temperature and gears up the body for the intended exercise.  It helps by increasing the blood flow to muscles improving the muscle efficiency, range of motion and stretching the muscles being used in particular sports. Stretching to the point of tension (not pain) helps to reduce stiffness and improve flexibility, thereby reducing the chances of injury.

Warm up may be general or specific to the intended sport.  The right exercises would vary depending on the sports. Starting the sport at a slow pace can be helpful. If you closely observe your sporting idols, you will always see them warm up prior to any game.

Tip 4: Use the right technique and follow the rules of the game

Correct techniques to play a sport are defined to minimize the chances of injuries and maximize your performance. The same can be said about the rules of the game. Incorrect overzealous manoeuvre can predispose one to injuries and hence the importance of concentrating on the precise technique. One example which I can quote as I commonly see this in my clinic is back injuries due to incorrect dead lift technique. Often that temptation to add the extra 5kgs compromises the technique predisposing one to injuries.

Selecting the appropriate surface for sports is equally important especially for repetitive activities such as running, jumping where the impact force on the body is magnified by 3- 12 times. Impact force on hard surfaces is much higher increasing the injury chances.

Tip 5: Cool down

Cooling down is another injury prevention technique that helps to return the heart rate, breathing, and blood pressure to the pre-training levels. It can also help to limit the post exercise muscle soreness and flush out toxins produced during the training.

Tip 6: Adequate recovery

Adequate recovery is essential no only for avoiding injuries but also for the full training effect. Inadequate recovery can lead to tiredness, lethargy, mental fatigue and impaired performance. Adequate recovery includes warm down sessions, re stand sleep, psychological and nutritional advices.

TAG : Best Pain Specialist in South Delhi, Pain Management in Delhi, Pain specialist doctor in Delhi, Body pain treatment in Delhi, Pain Treatment in Delhi

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Hamstring Sprain / Tendinopathy

Hamstrings are a group of muscles present at the back of thigh. They extend from the sit bones in pelvis to just below the knee joint and play an important an important role is daily activities such as walking & running. The names of the individual three muscles included in hamstrings are semimembranosus, biceps femoris and the semitendinosus. These, work in opposition to the muscles in the front of the thigh (quadriceps) and the two group of muscles together stabilize movements of the knee and pelvis.

INCIDENCE

Hamstring injuries account for approximately 12–16% of all injuries in athletes. They are seen more commonly in sports that involve sprinting, acceleration, deceleration, rapid change in direction and jumping such as football, basketball, rugby and baseball. Runners, ballet dancers and older adults who do a lot of walking are also at increased risk. Reinjury rates are high and generally require more time away from the field. Although any injury for a sportsperson is painful, this one can be quite frustrating for both the sufferer and the treating physician.

SYMPTOMS

Symptoms vary depending on the severity of the problem. When the upper part of hamstrings is involved the most common symptom is deep buttock pain or irritation at the back of thigh (minor sprains) associated with tightness or cramping sensation. Pain can radiate down the back of thigh and is generally aggravated by physical activity such as walking, running uphill, high speed or long distance running, leaning forwards, squats and sitting on a firm surface for long duration. Morning increase in severity of pain is not uncommon in this condition. In the early stages pain may reduce after warm up and then recur after activity. This changes with time with the pain persisting throughout the day.

Partial or complete tear of hamstrings may present with severe stabbing pain, bruising with inability to weight bear or walk. Sciatic nerve is present close by and its irritation can cause pain to radiate further down the leg. In severe cases the tendon may completely tear away, often taking a piece of bone with it and this is addressed as avulsion injury.

RISK FACTORS & BIOMECHANICS

Muscle attaches to the bone with the help of a special type of tissue called tendon. To simplify, you can look at these as ropes tying the muscles to the bones. Injuries can involve the muscles or the area where the muscle transforms into the tendon (myotendinous junction) or the tendon itself. Generally the closer the injury is to the pelvis / sit bones the longer it takes to heal. Of the three muscles, biceps femoris is the most commonly injured one.

The hamstrings cross two joints and help to bend the knee and move the hip backwards (extension). They play an important role in propelling the body forwards as we move. Hamstring injury may occur by high speed mechanisms such as running or low speed mechanisms such as stretching. Sudden loading of muscle while it is stretched as while kicking a football is also a common injury mechanism.

The risk factors most consistently associated with hamstring muscle strain-type injuries are age, previous hamstring injury and quadriceps peak torque. As mentioned previously hamstrings and quadriceps oppose each another and it is not uncommon to see imbalance between the two groups of muscles with the latter being stronger. This is expressed as low hamstring to quad ratio which essentially means weaker hamstrings. Weak hamstrings can quickly turn into tight hamstrings and require hamstring to work harder which tires them easily. Tight, tired and weak muscles are predisposed to injuries. When the hamstring are injured, other nearby body muscles are called into action such as those in lower back and hip predisposing them also to injuries/ pain.

Risk factors foe hamstring injury can be classifies into modifiable and non-modifiable ones.

Modifiable risk factors

Volume of training and rapid variations

Muscle fatigue

Weak hamstrings

Repeated overloading with insufficient warm-up

Over striding during running or abruptly changing direction

Lower back, core and pelvis weakness or trunk instability

Prolonged sitting (work, cycling etc)

Biomechanical issues such as unequal leg length

Non-Modifiable risk factors

Previous hamstring injuries – most consistent risk factor with two to six times increased risk of recurrence. Most repeat injuries occur within two months of return to the sport but the risk remains elevated up to three times for an year after initial injury.

Age – teens and young adults are more likely to experience hamstring injuries as muscles do not tend to grow at the same speed as bones. Aging adults are also at a higher risk possibly due to reduced muscle cross-sectional area.

Genetics (collagen types)

HAMSTRING INJURY GRADES

Most hamstring injuries occur in the thick, central part of the muscle or where the muscle fibres join tendon. Muscle strains are graded from 1 to 3 depending on their severity

Grade 1 – or hamstring pull is most minor form and usually heals readily. Most patients with this are able to walk easily although may notice pain at the back of the leg after prolonged or quick walking.

Grade 2 – this is associated with more pain (often shooting type) and patients may struggle to walk / limp.

Grade 3 – represents more marked muscle tears including complete tears which present with more severe pain, swelling and difficulty weight bearing. These may require several months of rehabilitation.

INVESTIGATIONS

MRI scans can help confirm the diagnosis, assess severity of the problem and estimate recovery time. Proximal injuries close to pelvis and those involving increased length and cross-sectional area require longer rehabilitation.

Ultrasound scans are an alternative although are not as reliable in assessing deep portions of the muscles and are unable to identify bone oedema.

TREATMENT

Most hamstring injuries can be managed conservatively. This includes using a combination of rest, activity modification, physical therapy and medications such as anti-inflammatory drugs. Activity modification will depend on the severity of problem and does not imply complete inactivity. Approximately 20% of people with proximal hamstring tendinopathy have residual pain despite conservative management and may require further treatment such as injections.

Injection options include

Percutaneous tenotomy

Platelet Rich Plasma (PRP)

Steroids

Ultrasound-Guided Percutaneous Needle Tenotomy

This is used for patients with refractory symptoms and is often in combination with the PRP treatment. It is an OPD procedure performed under local anaesthesia and ultrasound guidance. The aim of the procedure is to create an injury in the tendon by repeated punctures. As a result blood and platelets flow to the area increases, thereby promoting release of growth factors and promoting healing.

Ultrasound-Guided Platelet Rich Plasma (PRP) Injection

PRP injections are commonly used for treatment of hamstring tendinopathy and the evidence supporting their use is slowly accumulating. The procedure involves drawing out patient’s blood and placing it into a spinning machine which separates the platelets from the other blood components. This concentrated platelet layer containing growth factors is then injected into the problem area to induce tissue healing and regeneration. These injections take time to work with benefits becoming apparent 6 to 12 weeks after treatment. My practice is to perform PRP injections under ultrasound guidance and combine these with the needle tenotomy procedure mentioned previously. These injections are used in in combination with lifestyle modification and physical therapy.

Ultrasound-Guided Steroid Injection

These injections can be beneficial for some patients with chronic hamstring tendinopathy and are best avoided in treatment of acute hamstring injuries. Ultrasound guidance helps to improve the safety and accuracy of injections. The aim of thee injection is to deposit steroids in close proximity to the problem area- targeting the area around the tendon (peritendinous) and the overlying bursa. Steroids by their anti-inflammatory effects help to reduce pain, inflammation and improve sitting tolerance, provide a window of opportunity for rehabilitation.

PHYSICAL THERAPY

This is an important component of treatment irrespective of whether injections are performed or not. Continuous exercise program focusing on progressive eccentric hamstring strengthening and core stabilization is commonly used with expected recovery times from 1-3 months in majority. Other treatment goals include correcting postural imbalances and improving tissue mobility. Working on the gluteal muscles is equally important, as these are the strongest hip extensors and can assist in reducing/ sharing the hamstring load. Different phases of rehabilitation have been described for grade I and II hamstring strain injuries.

Phase 1: Focusses on protection, ice, anti-inflammatory drugs , improving soft tissue mobility via manual therapies and therapeutic exercises. In this phase one can initiate non-provocative core strengthening and gluteal and hamstring isometric exercises under guidance of a specialist. Isometric exercises contract muscles without moving them as while squeezing the buttcheeks. Progression to phase 2 occurs when able walk a normal stride without pain and when very low speed jogging is tolerated.

Phase 2: Different exercises called concentrics with shortening of muscles (such as hamstring curls) are added in this phase. End range movements are avoided.Anaerobic training and sports skills can be initiated with care, in the phase. Progression to next phase is considered when forward and backward jogging at 50% maximum speed is possible without pain.

Phase 3: In this phase the range of exercises in increased and eccentric exercises are added. Eccentric exercises are those in which a muscle is contracting while lengthening. An example would be when one is lowering the weights down in a controlled fashion during a hamstring curl. These exercises help in strengthening and remodelling of tendons. Modalities such as soft tissue mobilization and Extracorporeal Shockwave Therapy (ESWT) may be utilised along with exercises. Shockwave therapy delivers a small amount of controlled micro-trauma to the affected tendon. In order to reinitiate the natural healing process. Generally 3-5 sessions are required toreduce pain.

Surgery may be required to deal with severe cases such as avulsion injuries orcomplete/extensive partial tears not responding to other treatment options.

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Iliotibialband Syndrome

What is Iliotibial band syndrome?

Iliotibial band (ITB) is a thickened band of tissue that runs along the outer side of thigh from the pelvis to the shinbone (just below the knee joint). It helps to transmit forces from the hip to the knee and acts a stabiliser of the outer side of knee, playing an important role in postural control.

With bending and straightening of the knee this band moves over the lower outer end of thigh bone and sometimes repeated motion can cause the ITB to irritate the surrounding tissues. This is addressed as iliotibial band syndrome (ITBS) or IT syndrome. It manifests as pain along the outer side of knee after repetitive motion. Although anyone can develop this condition, it occurs more frequently in athletes and those participating in activities involving frequent knee bending and straightening.

Key points about iliotibial band syndrome

Iliotibial band syndrome causes pain on the outer side of the knee

This condition can affect anyone, although is more common in athletes especially runners

Most people recover with rest, simple painkillers and physical therapy

Early ultrasound guided injections can be helpful in reliving symptoms and promoting early return to routine activities

Identifying of the underlying cause is important for preventing reoccurrences

What are the symptoms of ITBS?

Common presenting features include:

Sharp, stinging, aching or needle-like pain on the outer side of the knee

This occurs at the same distance, late in or sometimes even after completing a sporting activity. As the condition progresses pain begins earlier in the course of the activity or can even affect the ability to walk or sit with knees bent.

Pain tends to be worse every time the heel strikes the ground. Activities such as running downhill, cycling or stairs can make it worse

Snapping or popping sound from the knee, sometimes associated with swelling

Pain may radiate upward towards the outer side of the thigh /hip or downwards towards the leg

ITBS is uncommon in the inactive population. It is seen more frequently in

Long distance runners- incidence ranges from 1.6% – 12%

Cyclists – accounting for 15–24% of overuse injuries in cyclists

Athletes participating in hiking, hockey, basketball, tennis, weightlifting, soccer, jumping activities, rowing and skiing

Military recruits – incidence between 1% to 5.3%

Those who squat repeatedly

What causes ITBS?

The exact cause of iliotibial band syndrome is not clear and there may be multiple factors contributing to its development. Most popular belief is that this is an overuse injury resulting from friction from the movement of the iliotibial band over the lower outer edge of the thigh bone, as during repeated bending and straightening of the leg. Most contact between the ITB and lower end of thigh bone occurs when the knee is bent (flexed) at 30 degrees, which is the angle at which the foot strikes the ground and hence the maximal pain at this time. Other theories attribute the condition to the abnormal compression of the tissues beneath ITB or to the inflammation in the small fluid-filled sac (bursa) bone and tendons in the area.

A combination of issues may contribute to its development including

Poor training factors like running on uneven of hilly terrain, abrupt changes in training intensity, running with worn out shoes

Poor strength and flexibility of muscles such as having weak hip muscles, tight IT band. The hip muscles play an important role in the gait and their weakness places increased strain on ITB

Other mechanical imbalances such as unequal leg length, arthritis of the inner side of knee or bowed legs. Imbalances may also involve low back and pelvis (abnormal pelvis tilt). These situations can cause the iliotibial band to become excessively tight thus enhancing friction.

ITBS occurs more commonly in association with certain other conditions such as outer hip pain (greater trochanteric pain syndrome/ trochanteric bursitis) and pain along the kneecap (patellofemoral syndrome).

How is this condition diagnosed?

Iliotibial band syndrome can be diagnosed on the basis of history and examination findings. There is often history of recent change in level of activities with the typical symptoms as explained previously. Tenderness on the outer side of knee just above the joint and other special clinical tests can help in the diagnosis. Investigations such as the MRI or ultrasound scans can help confirm the diagnosis and rule out other conditions with similar presentation.

Ultrasound scan has the advantage of being a rapid, low cost, widely available, in clinic investigation which can demonstrate swelling, fluid collection, bursitis and thickening of the ITB. It has the advantage of being able to compare with the other side and carrying out a dynamic assessment (assessment with leg movement). MRI may show thickening, tearing of ITB or swelling above / below the ITB.

What are the treatment options for ITBS?

Optimal management of these patients requires a multidisciplinary team approach with the pain specialists and physiotherapists playing the key role.

Acute phase treatment

During this phase the aim is to relieve pain and limit the inflammatory response. This requires activity limitation or modification and refraining from provoking activities such as running. General principles of management during this phase are

Refrain from the inciting activity for up to 6 weeks or until the pain has resolved. Activities such as yoga, swimming, walking which do not provoke pain can be continued.

Rest, ice, compression and elevation (RICE)

Simple painkillers and anti-inflammatory medications

Ultrasound guided Injections

Physiotherapy

Ultrasound guided steroid Injections

Local injections are considered in severe cases where physical therapy and oral medications fail to provide adequate relief. Local injection can help in confirming the diagnosis, providing prolonged pain relief and facilitating early return to routine physical activities, especially when used early in the disease. Ultrasound guidance throughout the procedure is valuable in improving accuracy and reducing complications. Any fluid collection, if present, can be removed at the same time. Post injection activities can be increased in a graded fashion once the patient has been pain free for two weeks.

Subacute phase- Gradual Stretching

Once inflammation is under control exercises focussing on stretching and improving flexibility can be started. This lays the foundation for subsequent strength training. Any contributory factors such as footwear, posture, sports specific technique training etc should be addressed.

Restarting activities

Most patients are able to return to activity within 6 to 8 weeks. ITBS however can have a fluctuating course and may relapse during the treatment or return to activity phase. Stretching of the iliotibial band, gluteus muscles and strengthening of the low back, hips, knees, and leg muscles is frequently recommended as part of the treatment plan to prevent reoccurrences. Improving strength around the hip helps to reduce the forces on the IT band.

Identifying and addressing the underlying causes of the problem is important. It may involve analysis of gait, leg length, pelvic tilt, and that of muscle strength, balance and flexibility.

Surgical intervention is reserved for refractory cases not responding to the above-mentioned measures for more than 6 months. Options include ITB release, ITB lengthening, removal of bursa (ITB bursectomy), and arthroscopic ITB debridement.

TAG : Pain Clinic in Gurgaon, Knee Pain Treatment in India,  Sport Injury Treatment in Delhi, Pain specialist in Gurgaon, Best Pain Specialist in South Delhi