Tag Archives: Pain

Osteoarthritis: Increased Walking Lowers Knee Pain

People with knee osteoarthritis may reduce their risk of knee pain by walking more, according to a study published online June 8, 2022, by Arthritis & Rheumatology.

photo of three mature adults walking for fitness

Researchers looked at the walking habits of more than 1,200 people with knee osteoarthritis (average age 63, 45% men). They were asked how often they walked for exercise since age 50 and whether they had frequent knee pain. X-rays were done to assess structural knee damage.

The investigators first looked at participants who did not report regular knee pain. They found that among this group, those who walked for exercise were less likely to later develop knee pain (26%) at the follow-up eight years later compared with those who did not walk for exercise (37%).

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Tendinopathy: Diagnosis, Treatment & Prevention

Tendinopathy is the broad term for any tendon condition that causes pain and swelling. Your tendons are rope-like tissues in your body that attach muscle to bone. When your muscles tighten and relax, your tendons and bones move. One example of a tendon is your Achilles tendon, which attaches your calf muscle to your heel bone and causes ankle movement. If you have pain and/or swelling in that area, you might have Achilles tendinopathy.

The pain from tendinopathy can interfere with your daily life. For example, it can keep you from playing sports and from doing housework. So, if you have pain or swelling, make sure to contact your healthcare provider for help.

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Low Back Pain: Top New Approaches To Treatment

How big is this problem, and what did this study find?

Worldwide, low back pain is a leading cause of disability and affects more than 560 million people. In the US, four in 10 people surveyed in 2019 had experienced low back pain within the past three months, according to the Centers for Disease Control and Prevention.

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Back Pain: The Causes & Symptoms Of Sciatica

Sciatica refers to pain caused by the sciatic nerve that carries messages from the brain down the spinal cord to the legs. The pain of sciatica typically radiates down one side from the lower back into the leg, often below the knee. The most common cause is a bulging (“herniated”) disc in the lower back. Discs are tire-like structures that sit between the bones of the spine. If the outer rim of the disc tears, usually due to routine pressure on the lower back, the jelly-like inner material can come out and pinch or inflame the nearby nerve. Sciatica is most common in people 30 to 50.

How do you know if it is sciatica?

The key to diagnosing sciatica is a thorough history and a focused exam. Sciatica symptoms are often worse with sitting or coughing and may be accompanied by numbness or tingling in the leg. A physical exam can confirm that the sciatic nerve is involved. If there is muscle weakness or diminished reflexes in the involved leg, an imaging test such as a back MRI can be useful and help guide a decision for early surgery.  

Back Pain: The Symptoms And Causes Of Sciatica

Most sciatica is caused by problems that affect the L4L5, or S1 nerve roots. The nerve may be compressed or irritated, usually because it’s being rubbed by a disc, bone, joint, or ligament. The resulting inflammation makes the tis­sues and the nerves more sensitive and the pain feel worse.

Damage to or pinching of the sciatic nerve, or the nerves that feed into it, can have several causes.

Herniated disc

One of the most common causes of sciatica is a herniated disc in the lower part of the spine. It’s also called a slipped disc, though there’s no slipping going on.

Spinal discs are tucked between the vertebrae, where they act as cushions to keep the bones from touching one another. The discs absorb all the forces placed on the spine from walking, running, sitting, twisting, lifting, and every other activ­ity we do. They also absorb forces from falls, collisions, and other accidents.

Spinal stenosis

The spinal canal protects the spinal cord and the nerves that run up and down the spine. Spinal stenosis is the narrowing of the spinal canal. When this occurs, nerves can be compressed, causing pain. Because the lumbar verte­brae undergo the most consistent stress and support the most weight, lumbar stenosis is the most common type of spinal stenosis.

Spondylolisthesis

The bones of the spine are stacked on top of one another, separated by discs. Spondylolisthesis occurs when one spinal bone slips forward in relation to the bone below it. When the L4 vertebra moves over the L5 vertebra, it can cause a kink in the spinal canal leading to pressure on a nerve root and sciatica.

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Dr. C’s Journal: Pain Without Treatable Cause

Pain is useful to survival, and therefore is evolutionarily conserved. There is a very rare syndrome with the congenital inability to experience pain that Is caused by mutations in the SCN9A gene, which codes for a sodium channel (Nav 1.7). Research on this channel has apparently produced some advances in pain medication, but not as much as expected.

Individuals with insensitivity to pain have many accidental injuries which can cause blindness, mutilations of the extremities, and other severe problems. Lack of ability to feel pain is serious handicap.

Pain is generally a useful red flag that warns us to stop the painful activity, or guides us into the doctors office; about half of all medical visits involve pain of some sort.

Considered as a symptom, pain helps guide the physician into the proper diagnosis and treatment. Normally the pain stops when the condition that produced it is corrected. Pain sometimes outlives it’s usefulness, however, and becomes a major problem on his own. The most obvious condition is “phantom limb pain”. Most people who have had an amputation will continue to experience pain in the extremity that is no longer present.

Back pain that has no valid surgical treatment will sometimes drive individuals to surgeons who will operate on them unsuccessfully. A second opinion, preferably by a medical doctor like a neurologist, is always a good idea with back pain without sciatica, numbness, or other localizing symptom to tell the doctor where to operate.

Neuropathic pain is another conundrum. I know of an individual who was bitten on the foot by a dog, and continued to have severe foot pain for many years after the original injury healed.

All pain is interpreted in the brain, and continuing circles of central nerve activation is the leading theory of phantom limb and neuropathic pain. Pain is not objectively measurable; there is no meter that you can attach to the patient and find how much pain they are actually having. The doctor must assume that the patient has the pain they are describing, and ask the patient to rate it on a 0 to 10 scale, describe its severity, time course, quality, and any factors that will make it better or worse. Most often this produces an avenue to treatment, but sometimes not.

A few decades ago, busy doctors would label the pain that they could not diagnose as “psychological”, and dismiss the patient to suffer in silence. Much of the pain, however, was very real to the patients, who joined in patient advocacy groups and produced a political backlash which induced doctors to overtreat the pain, often with opioids.

The over-prescribing  doctors, and unscrupulous drug companies led to the flooding of the market with opioid medication, leading to the opioid crisis that is now being addressed. There is difficulty in making scientific progress on an adversary that cannot be measured properly.

Some doctors, usually anesthesiologists, specialize in treating the chronic, severe pain that standard medical practice has been unable to diagnose or alleviate.

They may use nerve blocks, antidepressants and combinations of different pain medication. Judicious propofol has been used also not only for chronic undiagnosed pain, but also depression.

My wife had a pain problem which responded to a combination of two simple medications, motrin and acetaminophen. The suggested overall approach is to get the best medical care available to diagnose the cause of the pain, and ask for a pain management referral if a solution is not found.

More information can be found in the appended Wikipedia article.

—Dr. C.

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DR. C’S JOURNAL: SIGNS AND SYMPTOMS OF APPENDICITIS

The appendix is a finger like projections at the origin of the colon in the right lower part of your abdomen. It may become inflamed, especially if there is a blockage. Appendicitis is best considered a medical emergency, since it may rupture and infect the entire abdominal cavity.

When I was a practicing pediatrician, appendicitis was one of the two conditions I refused to allow myself to overlook; the other one was meningitis, which is now mostly prevented by immunization.

Pain in the abdomen is almost invariably present as the main symptom of appendicitis. This pain often begins around the belly button and then migrates to the right lower part of the abdomen. The patient should try to notice whether jarring the abdomen by walking makes the pain worse; if so, this finding would favor an inflammatory condition like appendicitis.

A similar condition, diverticulitis, may cause similar symptoms in the left lower part of the abdomen, and other conditions may cause confusion. The doctor checks to see if it is more painful in the right lower belly area, and she may pull her hand away suddenly. If the pain intensifies, there may be inflammation around the appendix. Sometimes a vaginal examination or rectal examination will be needed to help with the diagnosis; the appendix is close to these areas.

Other symptoms and signs may be a low-grade fever, vomiting, add an elevated white blood cell count. In the modern medical era, ultrasound, CT scans, and MRIs are sometimes used to visualize the appendix to evaluate its size and possible inflammation.

Treatment used to consist only of surgery, but with imaging techniques available to prevent disaster, the condition can be treated with antibiotics. 30 to 50% of those so treated will still eventually require surgery. Removal of the appendix is now sometimes performed through a fiberoptic scope, leading to more rapid recovery.

A dilemma is present for individuals who go to the south pole to live for several months, and where weather may prevent them from getting proper medical help. Such  people may have their appendix removed as a preventative. Of course they also can take antibiotics if appendicitis develops, but it’s really scary to use medical treatment only, without the aid of modern imaging techniques.

Please consult the following Mayo clinic article for more information.

—Dr. C.

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DR. C’S JOURNAL: PAIN FOLLOWING TOTAL KNEE REPLACEMENT SURGERY


Total knee replacement(arthroplasty) is one of the most successful orthopedic operations. Satisfaction rate varies between 75 and 90%. Even so, almost 10% of operated individuals will have anterior knee pain, the most common complication, 1 year after TKR.

I had an even greater appreciation of the knee after reading the following article, which explain the causes of knee pain more adequately than I can, and would be good to read.

With knee replacement surgery, a great deal depends on the technical expertise and precision of the operating surgeon. A rotational error more than a degree or two can be critical, so important is proper tracking of the kneecap in the trochlea, or groove in the leg bone(femur). An imbalance in the pull  of muscles, or a knock knee, (Valgus) angulation of the knee, hip rotation, spinal problems, all can be important in generating pain as you get older.

There are psychological factors too. The knee pain after TKR average is only 1/3 of that suffered before the operation, on average. However if you expect that discomfort will disappear completely, or if your pain threshold is low, or if you have anxiety or depression, you may have more postoperative pain, and  be disappointed with the surgery.

My immediate reason to write this article was the anterior knee pain developing in a friend of mine, 15 years after surgery, at the age of 89. She had polio in childhood, and her right leg was severely affected. This caused her to overuse her left leg, resulting in a TKR 15 years ago. Just recently, she started developing anterior knee pain in the left knee. A thallium scan showed a lot of signal on the inside of the kneecap, most likely indicative of inflammation. She is not enthused about having another operation because of her age., and wondered about other things she might do.

An orthopedic friend of mine suggested that injections of a viscous lubricant might help, if the initial operation did not include resurfacing of the kneecap (patella). I would imagine that eventually the resurfacing of the patella with advanced materials, or perhaps stem cells might help.
I also thought of a special brace with a motor assist for her right leg, but the orthopedist said that this did not work very well in polio patients, who have a weak nerve signal.

Although my friends polio made her TKR almost inevitable, there are things that you can do, or avoid doing, that could help avoid TKR. Activities to reduce include squatting, deep lunging, running (particularly in deep sand), high impact sports, repetitive jumping, and running up stairs. Basketball, football, and volleyball come to mind as regular sports that are risky. Maintaining a healthy weight, controlling blood sugar, stoppage of smoking, avoidance of injury, and regular exercise, particularly walking and swimming ,are things that might help.

Remember that your knees are your wheels and are jewels to protect as you get older.

–Dr. C

Intensive Care Views: ‘Pain & Airway Management’

Pain Management in the Intensive Care Unit.

Institution: Department of Anesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin & Massachusetts General Hospital, Harvard Medical School, Boston