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Do you have Disc pain? Learn more about slipped disc/disc prolapse

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Do you have Disc pain? Learn more about slipped disc/disc prolapse

ANATOMY OF DISC

The true jelly throughout is termed nucleus pulposus and it is encompassed by the annulus. It has high proteoglycan content and plays a role in retaining water within the disc

The annulus fibrosus is the lamellar layer that surrounds the nucleus pulposus and is rich in collagen fibers.

STAGES OF PROGRESSION — DISC PROLAPSE/ HERNIATION

Bulging disc

  • Bulging—Extension of disc tissue beyond the edge of the ring apophyses, circumferentially.
  • Small tears in the annulus fibrosis cause diffuse bulging.
  • A 25% or greater part of the disc adapting to the adjacent deformity produces underlying asymmetric bulging.
  • Disc herniation differs from disc bulge due to the presence of intact annular covering in case of bulge.

Disc Herniation

Disc herniation is defined as focal displacement of disc material < 25% Of the disc circumference, outside the boundaries of the intervertebral disc space.

Uncontained herniated discs do not have the annulus covering, whilst contained herniated discs do. Learn more about the differences between Contained and Uncontained herniated discs, the protrusions have a smooth margin in the case of contained herniations.

Disc Protrusion and Extrusion

Disc Migration

  • Protrusion if the distance between the edges of the disc herniation is smaller (narrower) than the distance between the edges of its base.
  • This is known as disc extrusion where the apparent distance between the edges of the disc material post-surgery is greater than that at its base.
  • Extrusion is nearly always peracute with a lesion in the annulus fibrosus and is non-contained.

The term migration denotes disc material that has moved away from the site of extrusion, regardless of whether it is fragmented.

Disc Sequestration

The term sequestration means that the lost disc material is no longer continuous with the parent disc.

Inside vertebra Disk protrusion

  • Intravertebral herniation (Schmorl node) — Herniation of disc material in the vertical direction through a gap in the vertebral end plate.
  • CONSERVATIVE MANAGEMENT is usually the first line of treatment that is undertaken in most of the cases
  • Hands-on treatment, movement, and low-impact stretches to help take pressure off the nerve root
  • Using ice and heat for pain relief
  • Manipulation (chiropractic manipulation)
  • Pain relief with non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen or COX-2 inhibitors
  • Pain relief narcotic pain medications
  • Choose oral steroids for reducing inflammation for pain relief
  • Spinal traction and spinal decompression machines have been tried, with the recent literature suggesting otherwise.
  • IMAGE-GUIDED INTERVENTIONS are reserved for cases that do not respond well to conservative treatment. Image-guided interventions should be trialed in cases of disc bulge, protrusion, and relatively smaller herniations.

TRANSFORAMINAL INJECTIONS

  • Examples of Interlaminar Epidural Injections
  • CAUDAL EPIDURAL INJECTION
  • OZONE NUCLEOLYTIC
  • PLATELET-RICH PLASMA
  • STEM CELLS
  • Our 2-step multidisciplinary approach consists of – Comprehensive Platelet Rich Plasma with Prolotherapy to the lower back after Image-guided Anti-Inflammatory injections for pain and symptom control.
  • In conjunction with a back rehabilitation program, lifestyle changes and inputs from Clinical Nutrition and Clinical Psychology.
  • Of course, one thing like Microdiscectomy and Endoscopic Discectomy are surgeries that are
  • typically reserved for those not responding to non-operative means.
  • Motor weakness in patients
  • Discs that migrate, extrude, and sequester material that is causing signs/symptoms characteristically require surgical intervention.

Use of Botox in Musculoskeletal Pain Management

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Use of Botox in Musculoskeletal Pain Management

SEROTYPES AND MECHANISM OF ACTION Botulinum Toxin is one of the most powerful neurotoxins. It consists of a 50 kDa light chain and a 100 kDa heavy chain that is connected with a disulfide bond. Seven serotypes (A–G) have been detected. There are seven serotypes of Botulinum Toxins described to date, namely A through G. The Botulinum Toxin is observed to interfere with expression of many neuropeptides, including Subset ST and calcitonin gene-related protein (CGRP), which are main contributors to neurogenic inflammation from 16 Botulinum toxin A(BoNT/A) injection into rat cadavers had been shown to decrease paw edema in formalin treated rats, decrease tissue glutamate release and obtund spinal cord excitability. Overall, it is reported that Botulinum is a cytokine, neuropeptide, and other inflammatory mediators and its inhibitors. The proposed anti-nociceptive mechanism of action of Botulinum Toxin is further supported by, a lot of clinical studies.

APPLICATIONS

The neuromuscular blockade induced by BOTOX has demonstrated effective relief of pain and restoration of function in patients with painful, chronic musculoskeletal conditions.

OSTEOARTHRITIS

BOTOX is used more and more in the non-invasive treatment of arthritis of the knee, hip, shoulder, and other joints. Many patients demonstrated a marked response to treatment with improvement in pain scores and in quality of life. Patients of knee arthritis who were injected with BOTOX reported significant improvements, noted Moore and colleagues.

PLANTAR FASCIITIS

One of the most prevalent foot and ankle diseases seen among the population with BoNT being beneficial for refractory cases seen with failure of physical therapy and steroid injections. Year after year, the evidence of significant improvement in pain and the near lack of side effects is making it more popular among Musculoskeletal practitioners today.

MASSETER PAIN

Pain over the mastication muscles (MASSETER) – secondary over activity of the masticatory muscles responds well to intramuscular BOTOX injections. It is administered in the form of injections, usually through the oral route. The traditional recommended doses are 50 units into the masseter and 25 units injected into the temporalis. Experiments have described up to 80% of patients having everlasting ache alleviation for up to 10-12 months.

TENNIS ELBOW/ LATERAL EPICONDYLITIS

Likely the most common indication for tennis elbow, a recent publication found that BoNT-A injection was associated with decreased pain and improved functional ability. BoNT-A has temporary block features, however reduces finger movement and grip strength due to the motor effects, it is crucial to monitor the dosage and take care of the procedure.

Trigeminal neuralgia (TN)

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Trigeminal neuralgia (TN)

It is characterized by recurrent unilateral short (seconds) electric shock-like facial pain triggered by light stimuli in the trigeminal nerve distribution and is abrupt in onset and termination. Pain is limited to one or more of the trigeminal divisions, and innocuous sensory stimuli evoke it. TN is classified into classical TN (CTN) or secondary TN (STN) due to multiple sclerosis or a space-occupying lesion (e.g. tumor, cerebral aneurism, or megadolicho basilar artery).

Epidemiology

TN is frequently both misdiagnosed and underdiagnosed: Trigeminal neuralgia (TN) is often misdiagnosed, and an equally high percentage of patients are underdiagnosed. The prevalence of TN varies between studies, ranging from 4.3 to 27 new cases per 100,000 persons/year. It is more common in women, and higher with increasing age. In population-based studies, the lifetime prevalence was estimated at 0.16 – 0.3%. The age at onset of Classical TN and Secondary TN are commonly 53 years and 43 years respectively, but can occur from early to old ages. In studies done in the tertiary care setup, STN has been estimated to constitute 14–20% of TN patients.

Etiology and Pathogenesis

As early as 1930, Dandy suggested conservatively that 30% of patients with trigeminal neuralgia had vascular compression of the trigeminal nerve as a cause. Complicated Trigeminal Neuralgia which includes multiple sclerosis and such related conditions may occasionally develop classical-type pain due to a similar mechanism. The current understanding of the mechanism of Classical Trigeminal Neuralgia is that it is either due to compression or morphological changes in the trigeminal nerve due to mainly an artery in the cerebellopontine cistern. This is called a NEUROVASCULAR CONFLICT with compression. However, this also allowed many anatomical specimens to be identified which showed a transition from Schwann cell myelination to oligodendroglia myelination.

TRIGEMINAL NEURALGA (SYNDROME)

This term originated as Tic Doloureux, mindful of the characteristic grimace of TN patients occurring at the time of a painful paroxysm.

Patients described the pain as sharp shooting and stabbing and electric shock-like sensations. Trigeminal Neuralgia: The pain paroxysm of Trigeminal Neuralgia is one of the more painfully debilitating experiences that the system can go through. This type of highly unpleasant pain is terrifying for patients because the onset is sudden and unexpected.

The duration of a Pain Paroxysm varies, from a few seconds to occurring several times per day and these paroxysms are also can be initiated into repeated succession again and again following a refractory period. It can be experienced as a still series of attacks interspersed with many fits, punctuated with close runs. This paroxysmal pain may be associated with background dull achy continuous pain which tends to be milder as compared to paroxysmal pain. This background headache has been attributed more frequently to women.

Refractory period and precipitating factors

A common finding among patients after the paroxysmal attack is that they will not experience another attack during a refractory period (the time after an attack). This phenomenon has been attributed to the hyperpolarisation of the sensory neuron. Several patients go through a refractory period after paroxysmal attack in which no new attacks can be induced. The mechanism behind this phenomenon remains unknown. It was suggested that it is due to hyperpolarisation of the sensory neuron.

Astonishingly, the pain of Trigeminal Neuralgia can be provoked by innocuous sensory stimuli to the affected side of the face. The stimuli can be intraoral or extraoral. Well-known triggers are ordinary daily living such as light touch, speaking, chewing, brushing teeth, and cold wind blowing against the face.

Site of lesion

Affected most often are the second and third divisions of the trigeminal nerve. The right side is affected more often. Bilateral TN is uncommon in the classical form and should signal Secondary TN.

Natural Progression

It was previously assumed that TN becomes chronic and that pain gets worse over time. It has been suggested to worsen with time and TN in its chronic form is defined by more persistent, medically refractory pain, sensory abnormalities, and progressive neuroanatomical changes of the trigeminal root. More recently, studies have contested this notion, demonstrating that in most patients the pain did not increase in frequency or duration and did not become resistant to treatment, as well as, the dose limit has remained stable. A further common finding is months and even years of total remission. This is due to a decrease in irritable properties of nerve and partial demyelination.

Facial pain with autonomic symptoms

Tearing and rhinorrhea have long characterized TN. A large percentage of TN patients also consist of autonomic symptoms as a part of the symptom complex. The trigger seems to be the trigemino vascular reflex that is provoked by strong facial pain. Other causes of unilateral primary headache that may present similarly include short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing, and short-lasting unilateral neuralgiform headache attacks with autonomic symptoms.

The diagnosis of TN is essentially historical. Important to the history taking is the onset of the pain. A must be the history of any prior Herpes Zoster rash in that area, any invasive dental treatment, or any significant trauma to the ipsilateral side of the face. In the case of the history of a dental procedure or trauma, the possibility of Post Traumatic Trigeminal Neuropathy (PPTN) PPTN might be similar to TN but is characterized by discrete sensory deficits.

This must be confirmed with a detailed dental checkup to exclude the possibility of a cracked tooth (probably secondary to chewing hard foods) which can mimic the pain of TN. Even when the pain was bilateral constant in the jaw area, the potential for tension-type headache, temporomandibular joint disorder, and persistent idiopathic facial pain might increase.

Other differential diagnoses are Occipital neuralgia, paroxysmal hemicrania, glossopharyngeal neuralgia, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing, and short-lasting unilateral neuralgiform headache attacks with autonomic symptoms

Magnetic resonance imaging (MRI) imaging is useful for imaging changes in trigeminal root, any neuromuscular compression (e.g., tumors, vascular loops), and secondary pathology, but it is primarily a clinical diagnosis. The nerve can be diagnosed as the entire course of the nerve, root atrophy, and CPA cistern.

Treatment

Trigeminal Neuralgia has failed abortive treatments but still pharmacological management is the mainstay. Only when medical management cannot control the symptoms, ablative and non-ablative interventional procedures are reserved for patients.

CBZ and OXC

Carbamazepine and oxcarbazepine are the first-line management offered to patients suffering from TN. These are considered effective in providing initial pain control in 90% of the patients [35] although these effects may unfortunately fade with chronicity. Due to their severe side effect profile, these drugs are withdrawn in up to 40% of the patients. Women have a lower threshold for these drugs. [36] Carbamazepine is difficult to use in patients with other important comorbidities because it tends to interact with many medications. Despite having fewer side effects, oxcarbazepine can induce central nervous system depression or dose-related hyponatremia. (decreased sodium)

Patients vary widely in clinical response to either drug. The other can be moved to one to acquire a clearer answer. Warrier: ‘200mg of carbamazepine is as potent as 300mg of oxcarbazepine’ The impact of these drugs is notable on the control of paroxysmal pain

Lamotrigine

Lamotrigine is given as an adjunct for patients who show an adverse reaction to carbamazepine and oxcarbazepine. It tends to have less side effects than carbamazepine and oxcarbazepine

Gabapentin and pregabalin

In clinical application, gabapentin and pregabalin are shown to be less efficacious but lower in adverse effects than carbamazepine and oxcarbazepine. So, they may be used as an alternative to or in conjunction with carbamazepine or oxcarbazepine Although they are highly addictive.

Baclofen

Baclofen is especially useful in patients with a history of Multiple Sclerosis who may be treated with Baclofen for spasticity.

Botulinum toxin type A

Subcutaneous injection and injection of Botulin Toxin Type A over the gingival mucosa were found to significantly improve symptoms compared with placebo in a recent trial. Some of the mild adverse effects include transient facial edema and transient facial weakness.

Treatment of acute severe exacerbation

That is because in the case of severe exacerbations – these are the painful attacks that begin to occur more frequently, are more painful and the patient cannot even drink and eat. For short-course rehydration, maintenance of nutrition, and pain control, while optimizing long-term preventive treatment the patient would require hospital admission. However, opioids are used during such an episode but their effectiveness is debated. For immediate reduction of pain from these trigger zones, local anesthetic injections or topical lidocaine can be effective. Intravenous infusions of graded dosages of fosphenytoin (15mgs/kg over 30 minutes) and lidocaine (5mgs/kg over 60 minutes) while under cardiac monitoring are very efficacious.

Interventional treatments without Surgery

They are reserved for intractable pain resistant to medications. They can be divided into

  1. Needle-based Controlled Radiofrequency lesioning of the trigeminal ganglion.
  2. Trigeminoplasty: Cannonical Mechanical ballon compression of the trigeminal ganglion.
  3. Glycerol-based chemical rhizolysis
  4. Internal neurolysis – trigeminal nerve fascicle separation in the posterior fossa.
  5. Stereotactic Radiosurgery targeting the trigeminal root entry zone

Surgery for trigeminal neuralgia

Those patients who fail all of the above treatment methods are offered Microvascular decompression and we shall further discuss its surgical approach. The operating field is near the neurovascular structures, surgeon has to be careful. However, microvascular decompression has relatively superior outcomes in the elderly without co-morbidities compared to the younger population.

CAUSES OF ELBOW PAIN

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CAUSES OF ELBOW PAIN

The elbow joint is a hinge-joint that connects the humerus in the upper-arm (with two forearm bones, radius and ulna) at its distal end. Articular cartilage lines the ends of the bones, and ligaments support both sides of the elbow joint. This is because the elbow rests near nerves and vessels serving both the upper arm, problems with those that can mimic an “elbow issue” mentioned earlier.

TRAUMATIC

Fracture: Any fall, motor vehicle accident, or direct blow Whether dog bite or Human biting injury can be some of the mechanisms for sustaining fracture at the elbow. Commonly seen fractures include the Supra condylar fracture (common in the pediatric age group), Distal Humerus, Intercondylar, and Fracture Dislocations.

Dislocations: Dislocations commonly occur with a fall or the patient tries to avoid falling by using his hand for support. One of the most common is what happens in children called infantile subluxation or pulled elbow. This can occur when a child is swung by their arms or suddenly picked up jerkily catching the arm.

DEGENERATIVE

Tendonitis/ Tendinopathy: Lateral Epicondylitis or tennis elbow will have a pain on the lateral aspect of the elbow. The common extensor tendon is the one involved in this condition. Medial Epicondylitis/ Golfer’s elbow– Pain at the inner side of the elbow joint because here common flexor tendons are attached which leads to medial epicondylitis.

Elbow arthritis can occur as a result of mechanical wear and tear to the joint articulating surfaces or secondary to trauma. Auto immune conditions e.g. Rheumatoid arthritis Gout-which can lead to the Degeneration of the joint

Bursitis: Bursae are sac-like structures and may get packed with fluid leading to inflammation and pain. The most commonly-seen around the elbow was olecranon bursitis

INTRAARTICULAR

  • The wrong massage and improper manipulation of supracondylar fractures humerus cases is one more incidence of Myositis Ossificans/Heterotropic Ossification (this deformity mostly seen in Indian Sub-continent).
  • Intraarticular extension of loose bodies and osteophytes
  • Adhesive capsulitis

NERVE ENTRAPMENTS

  • C6 or C7 radiculopathy
  • Ulnar tunnel syndrome (ulnar nerve at the wrist) Cubital tunnel syndrome (entrapment of ulnar nerve at the elbow)
  • Ulnar or median neuropathy. Ulnar neuritis, anterior interosseous nerve entrapment there is tard Palsy of ulnar nerves

DEVELOPMENTAL

Osteochondritis dissecans: Often seen in adolescents, this condition results when a small piece of bone becomes avascular (as the cartilage and the underlying bone fragments). This causes pain on physical exertion. Most of these cases are treated conservatively.

UNCOMMON CAUSES

  • Lyme’s disease
  • Lupus
  • Herpes Zoster
  • Several pathologies may mimic medial epicondylitis, including neuropathy (eg C6 or C7 radiculopathy, cubital tunnel syndrome, ulnar/median nerve entrapment, and neuritis among others) as well ligamentous injury to the elbow joint (eg. Ulnar/Medial collateral elongation or sprain);. This also encompasses intra-articular issues (adhesive capsulitis, arthrofibrosis, loose bodies); osseous concerns (medial epicondyle avulsion fracture; osteophytes), myofascial problems like flexor or pronator strain; tendinopathy ([including lateral] epicondylitis, triceps tendonitis) synovitis valgus extension overload dermatologic considerations (eg shingles) ways things can go wrong.
  • Note: Your elbow is a joint where three bones meet — the upper arm bone (humerus), and the ulna and radius, two bones of your forearm.
  • The cartilage on the end of each bone allows bones to slide against one another without damage and also absorbs shocks. They are held in place by strong tissues known as ligaments. From there, your bones are held together by ligaments (what holds your femur up to the rest of you) and then connective tissue like fascia helps compartmentalize muscles into groups for specific functions — say palming a basketball.
  • If anything goes wrong with any of those bits, let alone all the nerves and blood vessels around that can make you hurt.

Here are some of the different ways your elbow can hurt:

One-time Injuries

  • Many injuries— and let’s hope all of them are one-off events, as in the case when you fall hard or get hit playing hockey.
  • Dislocated elbow (the bones that make up the elbow are forced out of alignment)—Caused by a sharp blow to the joint an all-too-common reason is sticking your hand out when you fall. Toddlers can also do it when you swing them by their forearms — that’s nursemaid’s elbow. Call your doctor if you think that either you or someone else, such as a child in your family, has dislocated an elbow.
  • If you break (fracture) one of the bones in your forearm just above the elbow, it is called broken bone-fractured elbow. Typically, this occurs with a sudden impact such as you would receive while playing contact sports or during an auto collision. Then again, you could move your elbow, but do not be deceived. If you are hurting, and it’s not proper it may be broken. You will require healthcare
  • Strains and sprains: These fall into the category, “Oof, I might have overdone it a bit.” Strain: when muscles are stretched or torn. A sprain refers to ligaments.
  • If you put a lot of stress on your elbow muscles, such as lifting heavy items or oversporting yourself, the result can be activated by getting a strain.
  • Injuries that cause elbow sprains are often experienced by athletes who throw, use racquets, or play contact sports.
  • In general, both are managed with RICE (Rest-Ice-Compression-Elevation) initially followed by gentle range of motion exercises and strengthening around the hip after symptoms have settled.

Wear-and-Tear Injuries

Some injuries take time to develop as you repeat certain motions causing your elbow wear and tear. This could be playing a sport or on workplace accidents in any number of situations, from factories to officers.

  • Bursitis – Often the result of repeating the same motion, you may gain bursitis from trauma or infection as well. Bursa Bursae are small sacs filled with fluid. You have them inside of your joints to provide padding for your bones, tendons, and muscles. They also permit skin to slide over bone. But they can become inflamed and hurt. Most of the time, bursitis is treated with pain medicine and improves over a period of weeks.
  • Tennis elbow and golfer’s elbow: Both are forms of tendinopathy or tendinosis, in which the person has damage in his or her extensor/receiver tendon (what attaches that muscle to your bone) due to overuse. Although the name does imply a golfer or tennis player injury. You simply might as well be more likely to come down with them based on the armed actions necessary in those sports. The difference is that tennis elbow happens on the outside of your elbow, and golfers occur in view of within.
  • The most common is carpal tunnel syndrome, and that involves a nerve in your wrist being squeezed so it can cause some difficulty with your wrists and arm. Your elbow can have the same issues.
  • Cubital tunnel syndrome is when one of the major nerves in your arm (the ulnar nerve) becomes trapped as it passes through a tissue called the cubital tunnel, which runs along the inside part of your elbow. You might feel a burning sensation on your hand, arm, and fingers.
  • Radial Tunnel Syndrome: If you have radial tunnel syndrome, this means that the nerves associated with your arm are pinched as they cross through a small opening near the lateral part of your elbow called The Radial Tunnel. A sensation of your outside forearm and elbow burning or going numb.
  • Stress fractures: A small crack in one of your arm bones due to overuse is known as a stress fracture. So, thing occur many more frequently than in the elbow, often seen as “shinsplints” into lower extensions but a thrower (like a baseball pitcher) may have had one around an elbow. Pain is common, especially in throwing.

Diseases

  • Arthritis: Two main forms can affect your elbow, Rheumatoid arthritis and Osteoarthritis.
  • The most common type of arthritis in the elbow is rheumatoid. A condition in which your immune system attacks the body, which leads to swelling of joints is called Arthritis. Your elbow cartilage breaks down over the years and that’s how you end up with osteoarthritis- where your bones rub together, making it painful to move.
  • Osteochondritis dissecans: Occurs most often in children and adolescents, when a piece of bone along with its overlying cartilage gradually separates away from the end of the distal humerus within the elbow. A bone fragment and a bit of cartilage come off, triggering pain with exercise. The knee is most often affected, but the elbow may be involved as well.
  • Gout: Gout is a form of arthritis. What happens is that uric acid, which under normal circumstances should be excreted out of your body as a waste product, accumulates in the form of crystals inside tissues. If the buildup occurs in your elbow, it can be extremely painful.
  • Lupus: Another disease in which your immune system targets healthy parts of the body — especially your joints and organs. It most frequently involves the hands and feet, but it may affect your elbow.
  • Lyme disease: Transmitted by ticks, Lyme disease can have significant issues if left untreated. You may be diagnosed with a neurological problem such as pain in your joints or lower extremity (knee).

CAUSES OF CHRONIC NECK PAIN

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CAUSES OF CHRONIC NECK PAIN

Chronic neck Pain: Neck pain over 3 months. It can present with an endless variety of clinical manifestations from annoying occasional neck pain to devastating chronic and often disabling symptoms deleteriously affecting one’s quality of life. Cervical spondylosis is a broader term that describes conditions related to degenerative changes in the spine. It might include

Cervical osteoarthritis: Over time, the protective cartilage covering the surfaces of facet joints begins to break down and deteriorate due to wear and tear on these joint structures leading to Osteoarthritis (sometimes called degenerative arthritis) which just means “arthritis” in general terms.

Cervical herniated disc: Due to the tears, the jelly-like nucleus pulposus leaks out from the interior of the disc which suffers a lot as it is that tough outer layer known as annulus fibrosis. Inflammation proteins may trigger inflammation of the nerve root or the herniated segment can compress a nearby spinal nerve causing symptoms.

Cervical foraminal stenosis: Degenerative narrowing of the intervertebral foramen from disc involvement, ligamentous hypertrophy, and osteophytes can cause compression to a nerve root with sequelae in cervical radiculopathy.

Cervical central stenosis: The cause of myelopathy is that the spinal canal in the neck has narrowed and your cord got pinched.

Spondylosis is usually worn and torn with age but an injury could speed up this process.

  • Constitutional aspects like exposure to infection and conditions affecting the immune system that also play a significant role in causing back problems.
  • Traumatic injury due to a fall or collision can lead to an injury of the muscles, ligaments, joints, discs, or even vertebrae.
  • Frontal crash with seat belt restraints may cause whiplash — neck damage. Jetstar does any future Cervical degeneration and Instability. Force injury and falls in collisions, contact sports, or athletic events.

Slip-on wet floor

Falls (downsteps, off ladders)

Though neck pain often resolves with healing from an acute injury, in some cases the pain can be ongoing and persist as a chronic condition. Bad posture is the king of all bad habits that lead to neck pain. This neutral position for the cervical spine ideally should be an open chest, shoulders back, and ears aligned above your shoulders, which can become difficult to maintain because you stay slouched with your head drifting forward while sitting in front of a screen for long hours daily. This can speed up the degenerative process and may lead to neck pain.

Fibromyalgia: Fibromyalgia (fi-bro-my-al-juh) is suspected when widespread pain and tenderness are accompanied by fatigue, but fibromyalgia can be difficult to diagnose. The neck and upper back are a typical example of trigger points that manifest in patients with Fibromyalgia. The most common tender points are located in the neck and upper back.

Spondylolisthesis: This is indicated by one vertebra slipping over the top of the base vertebra. Such mechanisms may involve vertebral fracture, ligament laxity, and/or advanced disc degeneration -all causing spondylolisthesis.

Most neck pain is caused by Tumors and Infections,these are the rare causes of neck Pain.

There are also many other, less common causes of chronic neck pain like spinal tumors or infections

GOLFER’S ELBOW/MEDIAL EPICONDYLITIS

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GOLFER’S ELBOW/MEDIAL EPICONDYLITIS

Introduction

Medial epicondylitis, or more commonly known as golfer’s elbow is a tendonitis/tendinopathy of the common flexor tendon which sits on the inside part (medial) of your elbow. This is often caused by repetitive stress activities that overload the common flexor tendon Golfers account for a significant portion of sports-related cases among these, with the usual suspects being those involving an overhead throwing activity. The medial epicondyle is where the bony humeral ulnar-sided attachment for muscles of the common flexor tendon occurs.

COMMON TERMINOLOGIES

  • Medial Epicondylitis
  • Medial Epicondylalgia
  • Golfer’s elbow
  • Pitcher’s Elbow
  • Common Flexor Tendon of Elbow tendinosis/tendinopathy

ETIOPATHOGENESIS

Symptoms could be triggered by hand and arm movements (including the wrist), such as grasping, lifting, twisting, or bending. Golfer’s elbow tends to happen within people who engage in an activity where the flexor muscles are overworked which they are generally not used to or if you use your demands daily repetitive strain of the flexor muscle. The term golfer’s elbow is a bit of a misnomer as medial epicondylitis much more often occurs with other overuse activities.

The most accepted theory is that repetitive loading of the common flexor muscles causes micro-tears at the tendinous origin, triggering an inflammatory response. In chronic Tendinosis, the remodeling of the collagen fibers results in a thickening tendon as it progresses. Calcification may also occur with it.

The likely causes may be

  • Occupations demanding manual labour such as wood chopping, repairing automobiles, painting and hammering can produce repetitive load on the flexor muscles.
  • Sporting activities such as golf, weightlifting or sports involving overhead throwing actions like javelin and short put can lead to medial epicondylitis.
  • Working at a computer for long hours.
  • Cooking involving regular chopping and peeling.

PREVALENCE

Golfer’s Elbow occurs in not more than 1% of the population. Being predominantly noted in patients of 40–60 years. Its counterpart Tennis Elbow (lateral epicondylitis) is known to be very common in the community. Preponderance is equally balanced in men and women.

SYMPTOMS

The usual complaint from patients is dull aching pain on the medial/inner side of the elbow. Epicondylitis pain radiates down to the forearm and wrist from a bony prominence (medial epicondyle).

Such activities like writing and lifting which require the wrist to be bent may worsen pain. The symptoms are likely to be aggravated while making sudden jerky movements as can occur in golf or overhead throwing games, etc.

Some patients may have difficulties grabbing objects and others with more severe symptoms could even report a slight decrease in their grip strength. Rest often settles the symptoms but there may be residual achiness that does not allow for sleep either, and concerns patients with potential ulnar nerve involvement

Ulnar nerve involvement may be additional in up to 20% of patients. Symptoms often include numbness and tingling over the ulnar nerve distribution down to 5th followed by a hand condition shown secondary in weakness/stiff elbow accessed.

CLINICAL EXAMINATION

A patient may appear unwell with acute swelling, redness, and warmth; in chronic cases, this symptom complex is less often encountered. Pain is commonly elicited by palpation just anterior and distal to the medial epicondyle.

There are two parts to the clinical testing for golfer’s elbow / medial epicondylitis; an active and a passive component.

For the active component, the patient should resist wrist flexion with the arm in extension and supination. For Passive Component Wrist Extension with Elbow in Extension. If these provocative maneuvers produce pain, the golfer’s elbow should feature highly in the clinical differential diagnosis. Clinical assessment must incorporate ruling out ulnar neuropathy

There may be erythema, swelling, or warmth on the exam in acute cases; chronic events have less chance of revealing any abnormalities. Localization tenderness will be at the site or 5-10 mm distal and anterior from it in an area close to the conjoined tendon if not combining both groups

The golfer elbow test / medial epicondylitis test has a passive and an active component. The patient actively resists wrist flexion while the arm is in extension and supination. The passive element involves being in wrist extension with the elbow extended. A positive test is one in which the patient describes pain with this maneuver.

However, the difference is that Tinel‘s test should be used to evaluate for ulnar neuropathy and stress particularly applied to the ulnar collateral ligament in a throwing athlete.

INVESTIGATION

A diligent history and physical exam are typically highly suggestive of the diagnosis, but imaging studies such as musculoskeletal ultrasound or MRI of the elbow may be performed to confirm the findings.

TREATMENT

For most cases of golfer’s elbow, conservative management is recommended. It means: to enforce that constraint as far as possible, particularly within the constraints of an individual’s vocation. Medical management consists of anti-inflammatory medications. Use ice or cold packs when inflammation is at its worst. Modalities like Ultrasound, shock waves, and electrical stimulation have been tried. When it comes to physical therapy, eccentric exercises are key. Right Stretching and strengthening certainly is an integral part of the rehabilitation process. Other patients will be recommended with night splints.

Anti-Inflammatory injection: If a patient is in pain, Corticosteroids can be injected blindly or under image guidance at the inflamed site to take inflammation down so that they may start with their rehabilitation. To avoid such setbacks repeat steroid injections in the same area should be prevented.

Quadriceps Tendonitis

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Quadriceps Tendonitis

Introduction

Our body generally loads over the knee which is a major weight-bearing joint so it takes lots of stress as we age. Decades of stress on the joint can induce overutilization. This then causes stress, friction, and swelling of the quadriceps tendon and sometimes results in a torn tendon. This can present as an aching sensation over the knee and possibly includes swelling and reduced function of your quadriceps muscles. Causes For Quadriceps Tendonitis This overuse injury is commonly associated with sports that require constant bending and straightening of the knee such as running.

Relevant Anatomy

The quadriceps mechanism is the tendon from where the big muscle of the thigh, called as quadriceps converges. The patella is smack bang in the middle of that, it has within this a tendon that extends inferiorly from the patella and goes further down until inserts into the tibia on something known as a tubercle. The tendon is the remainder of the quadriceps mechanism in addition to the patella. Anatomically the tendon is referred to functionally as one but it consists of two different structures with an upper half, which corresponds to quadriceps tendon insertion on the patella, and a lower portion –the remaining part attaching to tibial tubercle–which corresponds to the real patellar attachment (patellar ligament), also known in first cell line anterior knee pain.

The quadriceps contracts, causing the knee to straighten. Both the leg bone(tibia) and thigh femur of the figure can act as levers with one articulating end (the transverse axis or pivot point). During the walking there are forces of up to 2-3 times body weight (foot and ankle joint reaction) with p a marathon runner which may climb up to around>5X’s this while completing running.

Causes

  • A cause for Quadriceps tendonitis, an overuse injury can be intrinsic or extrinsic.
  • Extrinsic- These are factors like using the wrong footwear, Following appropriate training protocols, and most importantly constant playing in training on hard unforgiving surfaces such as cement. Quadriceps tendonitis also can be affected by overtraining (either too long or too hard) and sudden changes in the level of training.
  • Predisposing factors are classified into Intrinsic are host specific factors like age, flexibility, and joint laxity. Some specific host characteristics predispose an individual area following:
  • Foot, ankle, and leg malalignment.
  • Flat foot (pes plants),
  • Patellar maltracking
  • Rotation of tibia
  • Leg length discrepancy
  • Obesity

Symptoms

Where patients usually feel the pain at the lowest part of their thigh a few cm above their kneecap. Pain at and around the tendon attachment, aggravated further by movements of the knee joint.

Sometimes the presentation may have swelling in the lower end of the thigh, Swelling is very tender to touch in some cases. Morning stiffness or symptoms on waking up from rest and prolonged immobility, as well after exercise.

Diagnosis

It is a clinical examination done after the thorough history taking. Usually, tenderness is elicited with palpation of quadriceps tendon insertion. An assessment of the knee is made with a view to a range of movements, detecting for laxity and integrity in their axial (AP/PA), coronal or sagittal planes. Intrinsic and extrinsic factors (i.e., sudden changes in training habits) affecting the knee should be ruled out by the clinician [9]. Proper alignment with the knee, foot, and ankle is also reviewed. In the case of quadriceps tendon rupture with gap can be felt at the insertion site. Weakness in the extensor mechanism is often synonymous with a dysfunction of the quadriceps.

An X-ray of the knee can demonstrate fractures or calcific deposits in the quadriceps muscle but this will not pick up soft tissue injuries. Tears, tendonitis, and tendinosis are diagnosed with high-definition Ultrasound and MRI. The utility of ultrasound even extends to the guidance for Regenerative treatments such as Platelet Rich Plasma and Prolotherapy.

Treatment

CONSERVATIVE TREATMENT

The first Effective Treatment employed would involve Rest, Ice, Elevation and anti-inflammatory Drugs.

The answer to that is relative rest… followed by some very gradual increase of activities which will enforce the physiology behind recovery. However, immobilization is the first thing to be done for a patient who has pain at rest with a splint or brace. Relative rest → a detail of the resting-to-recovery process varying in intensity according to symptoms. If the pain is at rest, then full immobilization is strict. brace or splint will be for a short duration of time. Progressive activity as such is permitted only when it will not cause a return of the resting pain.

Rehabilitation is not complete without physical therapy. Ice massage, local ultrasound application, and electrical stimulation are all modalities that help to keep the pain and inflammation under control. Stretching and strengthening are the means by which we correct those imbalances of muscle dominance. Eccentric Muscle strengthening is useful in cases where the primary cause of pain is excessive eccentric muscle loading during weight-bearing closed-chain kinetic activities. (Open Chain- foot is free from ground)

SURGICAL INTERVENTION

Rehabilitation is not complete without physical therapy. Ice massage, local ultrasound application, and electrical stimulation are all modalities that help to keep the pain and inflammation under control. Stretching and strengthening are the means by which we correct those imbalances of muscle dominance. Eccentric Muscle strengthening is useful in cases where the primary cause of pain is excessive eccentric muscle loading during weight-bearing closed-chain kinetic activities. (Open Chain- foot is free from ground)

Tennis Elbow/Lateral Epicondylitis Explained

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Tennis Elbow/Lateral Epicondylitis Explained

Tennis elbow, also known as lateral epicondylitis causes tenderness and pain in the outer side of the elbow. The common extensor origin is the part of the elbow where all the extensor muscles of the forearm originate on the humerus (bone) It involves the tendon of the Extensor Carpi Radialis Brevis most commonly. Degenerative changes are most widely identified where the tendon attaches to bone. The attachment is weakened, which as you can imagine results in more tension in the area since it breaks up the tendon from the bone. Tennis and many activities that require repeated gripping, grasping, or lifting movements are common offenders of tennis elbow progression. Most of the time in the age group 30-50, is commonly seen and there is no gender preponderance.

Why Does Tennis Elbow Occur?

Everything that might overload the extensor tendons of the forearm, notably when our palm gets into a position facing down, can promote micro tears and inflammation seen in Lateral epicondylitis/tennis elbow.

Such types of activities include

Repeated gripping or holding activities idiopathically driven two-wheeler riding, playing tennis, carrying and pushing heavy objects
Activities like typing words of tools on a daily basis cause the extensor muscle to a repetitive load. is a painful condition that occurs when the tendons in your elbow are overworked, usually by repetitive motions of the wrist and arm.
Direct trauma or blow to the elbow can bring about inflammation of a tendon resulting in degeneration as well.

Symptoms

Bothering outer elbow symptoms, most notably. The lateral epicondyle is the bony point of tenderness. Pain increases with activities such as gripping, pushing, and grasping Pain may be experienced localized to the lateral epicondyle, but some patients could have pain radiating down to the forearm.

Diagnosis

These types of injuries are usually very suggestive history and clinical examination but can be confirmed by imaging (Ultrasound or MRI elbow).

Treatment

Had I wanted to take the more conservative approach, I could have only stopped or substantially slowed doing simple tasks like typing or gripping. Anti-inflammatory medications may be prescribed for patients. Tennis Elbow Splints/Braces: These braces can help take some of the strain off the elbow extensors. Manual massage, ice massage, or modalities like Ultrasound in physical therapy have been used to provide symptomatic relief of lateral epicondylitis. Taping the painful elbow can be another approach used in addition to these.

Tennis Elbow Exercise Protocol

Stretching and strengthening the muscle groups involved are essential to any rehabilitation program. Exercises broadly include

  • Forearm extensor
  • stretch
  • The muscular eccentric Extensors of the Wrist
  • Wrist Extension Isometric Strengthening
  • Isotonic Wrist Extensor Strengthening

Anti-Inflammatory injection- Corticosteroids can be blindly injected over the inflammation or image-guided using an imaging modality (eg. Multidetector CT scanner/X-ray) to restain the inflammation so that the patient can take rehabilitation). Steroid injections should not be given in the same area back-to-back

PRP and Phototherapy

This is a very good treatment with Ultrasound-guided platelet-rich plasma with Prolotherapy) as it works to heal the damaged tendon. So, 2-3 sittings of PRP with prolotherapy along wed regular exercises have been quite effective in controlling the troublesome symptoms of tennis elbow.

Stem Cells: Stem Cell injection has been attempted in a few chronic cases into the damaged tendon.

Surgery- Arthroscopic: (or) open surgery for removal of the degenerated tendon in chronic, resistant cases not responding to non-operative means.

Forearm extensor stretch

Keep your arm straight and bend the elbow slightly.
Now just curl your fingers and the other hand over your knuckles. Pull the affected arm hand and wrist gently further inward until you can feel a small stretch along your arm. You want to make certain that there is some pressure from the pull in your arm, but you should not be pulling so hard that the pull hurts.

Eccentric Lean-to Fist with the Wrist Extensors

  • Gently place your affected arm on a table with the hand hanging free over the edge.
  • Use the other hand to raise the hand of the affected arm into elevation. Maintain this grip with your hand as you release the hand assisting.
  • Gently encourage the hand of your affected arm to return to neutral (hanging). They then lower the weight back down in a slow manner which is referred to as “controlled release” or an “eccentric muscle contraction”.
Isometric wrist extensor strengthening
  • Place your affected arm on a flat surface with your wrist extended beyond the edge of the table.
  • Apply downward pressure on the hand of the affected arm with one of your hands while keeping the wrist out straight.
Wrist Extensor Isotonic Strength

Place the arm of those affected face down on a table or in your lap, and let your hand hang over the edge.
Lift and lower your hand by bending the wrist.
These are the joints at which the muscle attaches to the bone via tendons. In this condition, the involved muscle, the Extensor Carpi Radialis Brevis, is an important wrist extensor for maintaining the stability of the wrist.

Cause

Tennis elbow, on the other hand, is when you damage some of the muscles in your forearms that aid you in extending your wrist and fingers. Excess or repeated stress to the tissue can cause small tears in the tendons that connect on the outside of the elbow.
Tennis elbow can develop if any activity is played on the upper limb in pronation performed by turning the arms face down. These activities include:

  • Similar jobs are performed several times:​ Typing, using tools, etc.
  • Activities that require prolonged gripping, such as riding a motorcycle or bicycle, working with vibrating tools, and pushing or carrying heavy loads.
  • Trauma: A direct blow to the elbow can cause the tendon to swell, which may trigger degeneration. A rapid force or activity also could harm the tendon.
Who gets it?

Most people with this condition are between ages 30 and 50, although it can occur in those younger and older, as well as in both men and women.

Signs and Symptoms

Patients historically seek medical attention for pain. Pain over the lateral (outside) aspect of the elbow, over an area of bone called the lateral epicondyle. And this area gets sore when you touch it. Any activity which overloads the tendon, such as gripping or lifting, will cause pain. Pain with activity usually starts at the elbow and may travel to the hand down the forearm. Sometimes, pain can occur with any elbow motion. Tennis elbow pain may develop gradually or can occur suddenly. Symptoms can include

Care at home Home care Management of tennis elbow
  • Adjusting activity and rest: In the short term, the FFWZ as a condition should be reduced – Rather, the recommendation is to limit that aggravating activity; not total rest.
  • Medicine: Anti-inflammatory medicine might help control the pain.
  • Brace: wearing a tennis elbow brace, which is worn around your forearm muscle and just below the elbow will decrease tension on the tendon making it easy to heal.
  • Taping: Tape your elbow to provide support to the soft tissues. You may want to consult a physical or occupational therapist on how to tape your elbow.
  • Apply ice-icing the knee multiple times per day helps reduce pain.
  • Ice pack application: Hold the ice pack up to your skin with a towel. Apply the ice pack to the painful area for 15–20 minutes. Every five minutes, check your skin to make sure you are not damaging it.
  • Ice massage: Apply an ice pack, and massage around the elbow area for about 5 mins as a loop process [14].
  • Manual massage:  A good massage is known to help improve blood circulation, reduce sensitivity, and relieve pain in the bladder. Learn how to massage from a physical or occupational therapist.
Exercises

This May Help Stretching and Strengthening for Tennis Elbow Exercising helps to keep the muscles strong so that they can support you as your body recovers. For many people, this relief from pain starts almost immediately after exercise.

Neck Muscle Sprain

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Neck Muscle Sprain

The neck, muscle, and sprain are so regular among individuals now. A neck muscle sprain can aggravate it or in the worst case worsen it. A neck sprain occurs when there is a stretch in the muscle or ligament of the neck. That would be the typical thing like a bump into something, or going that extra little bit when you should have stopped twisting for example; or some sort of accident. Therefore, there are many causes of neck muscle sprain. If a sprain is mild it will heal without treatment in days to weeks. This is a stark, real pain—hard or tougher or excruciating; it hurts. Getting medical intervention right away will prevent the condition from becoming severe.

Consulting with the best neck specialist doctor will help you get the best treatment process.

When should you see a doctor for treatment?

Usually, the strain triggered by a neck sprain will take days or weeks to heal. People often feel that during neck muscle sprain, they cannot even move side to side, it also occurs when it is extremely painful. Thus consulting the right doctor and getting proper treatment can make the recovery rate high.

Neck Muscle Sprain Diagnosis

Your condition will be accessed by an expert neck specialist doctor. A physical examination may be in order if your doctor wishes to observe how you move, stand, and sit. Neck Specialist Center has reputed advanced facilities, resources, and tests to identify a genuine solution for the ailment.

Cure for Neck Muscle Sprain

When you visit the neck pain clinic, they use some effective techniques to treat neck muscle sprain. Once a precise cause is identified for the neck muscle sprain, your neck pain doctor will employ the best method to treat your disorder in a risk-free manner.

  • Medications over the Counter: Medications that can be taken to help relieve pain and reduce swelling are prescribed.
  • DO NOT: USE HEAT AND COLD PADS On the advice of your surgeon, you should use heat or cold pads for the sore areas If there is any swelling keep it down.
  • Workouts: Doing light workouts will help in movement and increase flexibility.
    Physical Therapies: A physical therapist will be assigned for your chronic neck muscle strain which helps in reducing the inflammation and pain.

Picking the right clinic for your neck muscle sprains and spasm needs with best way to take. Many neck disorders have been treated at Alleviate Pain Clinic successfully by the seasoned and valued hands of their qualified neck pain specialist doctors. Anyone suffering from neck pain, experiencing numbness or stiffness of the neck should book an appointment with their doctor as soon as possible.

Frozen Shoulder treatment in Punjab

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Frozen Shoulder treatment in Punjab

Frozen shoulder is quite common now. Many people complain about pain & stiffness in their shoulder joints, which can even cut down on how well you can move. Folks also call it adhesive capsulitis. Your shoulder has three bones that form a ball-and-socket joint (yep, that’s what it’s called). This joint involves the upper arm (humerus), shoulder blade (scapula), and collarbone (clavicle). Together, they are known as the shoulder capsule. When someone deals with a frozen shoulder, this capsule gets thick and tight. That means less movement and more pain. Ignoring it can make things worse. It might last anywhere from 1 to 3 years or even longer.

Best treatment for Frozen Shoulder

Before starting any treatment, your specialist will ask for some tests. These tests will help figure out just how bad things are and the best way to treat it. Usually, surgery isn’t needed – which is good news! People often get back to their normal activities without going under the knife.

For Frozen Shoulder Treatment in Punjab—Book An Appointment!

Here’s how frozen shoulder can be treated

Over-the-counter Medication – Your pain specialist will prescribe meds like paracetamol or ibuprofen to ease pain and help you move your shoulder again.

Hydrodilatation – A fine needle goes into your shoulder joint with ultrasound or X-ray guidance. Then, an injection with corticosteroid, local anesthesia & sterile water is given.

Nerve Blocks – Here, the doctor gives you general anesthesia to block pain signals from your nerves through minor surgery using nerve stimulation or ultrasound.

Exercise and Physical Therapies – Easy exercises & physical therapy tailored by a therapist can strengthen your shoulder, reverse stiffness & improve motion range.

You might find relief with just one treatment or a mix of them

If you need top-notch frozen shoulder treatment in Punjab, understanding non-surgical success rates is key. A good center will have experienced pain specialists & standout physiotherapists who know how to boost movement and ease stiffness.

Amandeep Hospital is your go-to for frozen shoulder treatment in Punjab. It’s advanced & home to highly reputed doctors and physiotherapists who can help you get better fast!