Pain Doc - Ask Dr. P - The Pain Doc

Stenosing Tenosynovitis

by Pain Doc | Sep 22, 2010 | Hand and Wrist Pain

Stenosing tenosynovitis translates to “tendon inflammation due to narrowing passageways.” It is entrapment and inflammation of the extensor pollicus longus tendon, the muscle that moves the thumb up in a “hitchhiker sign.” It is also known as DeQuervain’s Syndrome.

The passageway in question is a tunnel formed by ligaments that hold the extensor pollicus longus tendon to the distal radius (lateral wrist), one of the two bones of the forearm.

The onset is gradual over a few days. There is a very sharp, unrelenting pain at the radial styloid, the bony prominence at the lateral wrist right below the wrist crease. There is no loss of muscle strength in the thumb. Bending the affected thumb inward towards the palm while bending the wrist sideways towards the ulna (in direction away from the pain) makes the pain much worse.

Causation is believed to be related to overusing the thumbs, such as BlackBerry use, or frequent bending of the wrist while carrying weight, such as in cradling a baby several times a day. However, there are documented cases of stenosing tenosynovitis occurring with no apparent trigger (idiopathic causation).

What is known is that the synovial sheath that covers the portion of the tendon in the tunnel gets inflamed and undergoes degenerative changes. It triggers a chronic, localized inflammatory response. Pain comes from tiny nerve endings in the synovial sheath that are irritated by rubbing against the ligament holding it to the distal radius, and perhaps also by exposure to the products of inflammation.

The condition is known to be self limiting, running its course for a few months and then resolving as the body regenerates the synovial sheath. However, during its acute stage it is quite unpleasant, despite the fact that only about an inch of tendon is involved.

TREATMENT:

Wrist immobilization (wrist brace with thumb splint) to limit movement of the adductor pollicus longus is recommended for 1-3 weeks. Wear most of the day and night; remove every hour or so to do ice therapy.

Ice massage is helpful in temporarily reducing the pain by numbing the area and constricting blood vessels, which tends to suppress production of inflammatory chemicals. A wrist ice wrap can also be effective. Apply ice for 10-20 minutes directly onto the painful area.

Topical ointments may be helpful in reducing the severity of the pain. Narayan oil and products containing capsaicin (don’t use together) are worth trying. Rub into inflamed tendon gently.

Chinese herbal patches may be helpful in temporarily relieving the pain as well.

Cortisone injection into the tunnel can be effective in neutralizing the pain; however it still may take a few weeks to months for the pain to go entirely away.

Whey Protein – Great Supplement for Healthy Tissue Healing

by Pain Doc | Sep 16, 2010 | Uncategorized

Image via Wikipedia

Whenever you suffer an injury to the musculoskeletal system, there is some degree of tissue damage. In minor sprains and strains, it is microscopic tears to the fascia, muscle fibers, tendons and ligaments; in major sprains and strains it is complete rupture or tearing of large groups of muscle, ligament and/or tendon fibers.

The first thing the body does at the onset of the injury is initiate the inflammatory response. Various biochemicals constitute inflammation; each having an important role. Inflammation confines the injury to the injury site and is actually the first step in tissue repair. It is only when it is overproduced that it becomes a problem in itself (which is why you should use ice therapy to mediate swelling the first few days after an injury).

At some point, the body sends special cells called fibroblasts to the injury site. These cells synthesize connective tissue comprised of collagen to close the tears of the injury.

Collagen is the main protein of connective tissue in animals, making up 25%-35% of the total protein content . It forms as elongated fibrils (long chain of amino acids in a strand formation) and is mostly found in fibrous tissues such as tendon, ligament and skin, as well as other places in the body.

Therefore, after sustaining an injury, the body needs a ready supply of protein in order to properly heal itself. If you recently sustained a soft tissue injury such as a sports injury to a joint, whiplash car accident, or sprained your lower back from heavy lifting, make sure you are eating enough protein. I recommend whey protein due to its ability to be digested very rapidly, making it available for use shortly after consumption. Whey is a protein-rich byproduct that is formed during cheese formation, usually from cow’s milk.

Body builders and athletes drink whey protein shakes after workouts to help increase amino acid levels in the blood, which are taken up by the muscles to ultimately increase mass. During exercise, whey helps improve blood flow by inhibiting an enzyme that constricts blood vessels; this allows better flow of nutrients to needed areas to help repair and rebuild muscle tissues.

Leucine is an amino acid found in whey protein shakes. When leucine is ingested in high amounts it stimulates protein synthesis, which may speed recovery and adaptation to the stress that occurs from heavy exercise and injuries.

Another good source of protein is eggs. Eggs are a complete source of protein, especially the yolk. Cook them at low heat; and if you have the stomach for it, eat them raw.

Exercises for stiff and achey shoulder joints

by Pain Doc | Sep 15, 2010 | Shoulder Pain

Dansk: Skulderled. Français : A. B. Acromion C. D. E. Tendon du biceps F. G. H. Processus coracoïde I. J. Clavicule K. Humérus. A = , B = Acromion, C , D , E = Tendon du biceps , F = , G = , H = Processus coracoïde , I = , J = Clavicule, K = Humérus (Photo credit: Wikipedia)

The shoulder is a complex body system tasked with moving the arms. It is comprised of the shoulder blade (scapula), collar bone (clavicle), humeral head (nearest end of the upper arm bone) and the breast bone (sternum), and associated muscles, ligaments and tendons that hold it together and move it.

When a patient complains of shoulder pain, it could mean pain in any of these areas. The doctor has to ask the patient to point to the precise area of pain, and ask the patient to move the arm and shoulder to get a better idea of what is causing the pain.

Today we’ll talk about general ache in the glenohumeral joint, comprised of the humeral head and glenoid fossa of the scapula (the shallow cup-shaped surface of the scapula).

First of all, realize that the glenohumeral joint has the widest range of motion of all the joints in the body. You can do all sorts of movements with your shoulder joint– raise your arm from the side, the front, the back; transcribe small and large circles, hug yourself, spread your arms far apart; throw a football, and throw an underhand pitch– that’s a lot of movement, compared to, say, the knee. In order to accomplish such a wide range of motion, there has to be a lot of moving parts (ligament and tendon attachments). When you have a lot of moving parts, there is a greater chance of something breaking down. And this is why shoulder problems are quite common in people.

A general ache in the glenohumeral joint can be the result of sleeping on your shoulder; an old injury, or simply over-using it. Tendons that slide over bony surfaces to move the shoulder joint in its many directions may be pinched in the narrow confines of the glenohumeral joint. It makes the shoulder feel stiff and achey.

NOTE: feeling a very deep and sharp, focal pain in the glenohumeral joint that is worse with a particular angle of arm movement is a different presentation and is not what we’re addressing here.

This is about general achiness and stiffness that does not cause any weakness or disability of the shoulder. If you have more of a sharp pain that doesn’t go away with rest or medications, refrain from doing the following exercise until you see a doctor who can properly diagnose your problem.

TREATMENT:

You will be doing gentle stretches to get the shoulder joint moving, eventually without the achey and stiff feeling.

First, let’s assume it’s your right shoulder that has the problem. Stand with your left foot about a foot forward of your right foot. Bend at the waist but keep your lower back straight, and rest your left hand on your left knee.

Let your right arm hang limp straight down. Sway your body in circles to get your limp right arm to transcribe a clockwise circle shape. Try not to use your right shoulder muscles themselves, let the rocking movement move the shoulder. Do ten circles, then reverse directions. Do 5-6 times a day. If you do it correctly, the mere weight of your right arm will traction the glenohumeral joint (slightly pull apart the surfaces) and the rotation movement will stretch the ligaments in all directions.

Try adding a small weight, in increments throughout the week (do not exceed ten pounds max) to increase the amount of traction. You should feel a gradual loosening of the shoulder joint, and less pain. Avoid sleeping on the affected shoulder for a few weeks.

The other exercise is more challenging, so only do it if the pain has gone down considerably. Take a bath towel and roll it length wise. Grab one end with your right hand, and raise that hand (90 degree elbow bend, upper arm at level of shoulder). Reach behind you with your left arm and grab the other end of the towel with your left hand. Now, extend your right elbow back and forth as though you are drying your back with the towel. Do for about a minute, and then switch hands. Repeat.

As always, if any of these exercises cause an increase in pain, stop immediately.

What to Do if You Have a Bulging Disk

by Pain Doc | Sep 13, 2010 | Low Back Pain

Image via Wikipedia

Lower back pain presents in a range of severity depending on the structures generating the pain.

A simple sprain/strain can still cause extreme pain, swelling, and immobilization for a couple of days but should completely resolve after a few weeks with proper care and rest. Lumbar sprain/strains are associated with lifting something heavy, or even simply bending or twisting at the waist; weight lifting, sports injuries and trauma like a car accident. By definition, they are limited to injury to the muscles, fascia, tendons and ligaments. The pain is limited to the area of injury.

Image via Wikipedia

A lumbar disc bulge occurs when a disc “bulges” outwards due to weakness or injury. A disc is a tough, fibrous ligament that holds the lumbar vertebrae together at the vertebral body. The disc’s outer periphery, called the annulus, resembles a slice of an onion, with multiple rings of fibrous tissue encasing a jelly-like material called the nucleus pulposus. While tough and strong, it allows movement of the individual vertebrae.

By definition, a disc bulge is still intact and has not ruptured (as opposed to a disc herniation or rupture). The bulge represents a weakened area in the annulus that allows the nucleus to gravitate towards a section of the periphery, usually the posterior (rear-facing) edge, facing the spinal canal (where nerve tissue is present). It can be a broad-based bulge, or a more focal bulge. If it is greater than 5mm (measured from the edge of the vertebral body to the tip of the bulge) it is clinically significant. Many people have disc bulges and have no back pain at all; in fact, it is normal for the discs to bulge slightly in the weight bearing position (standing).

The problem occurs when the bulge contacts nerve structures. If large enough, they can contact the thecal sac (contains the spinal cord and cauda equina) by bulging backwards into the canal, and they can press on spinal nerve roots by bulging to the sides. The spinal nerve roots branch out in pairs from either side and exit holes formed between adjacent vertebrae called vertebral foramen, or lateral canals. A disc bulging to the posterior and side can narrow this opening and pinch the nerve root causing pain to travel down the buttock or leg, depending on which nerve root.

TREATMENT:

If your lower back pain is felt deep, and you can make it hurt more by bending your lower back backwards and to the side, you may have a disc bulge. You may or may not have pain and/or numbness going down the buttock and leg (same side of the pain). If it happened while lifting something heavy, the diagnosis is more likely. If you have extreme, unchanging pain with more constant leg pain or paresthesias (numbness, tingling) that does not get better with ice and rest, you may have a disc rupture (also called prolapse) where the inner nucleus had broken through the annulus and is in the spinal canal or lateral canal. If you have changes in your gait (walk) such as foot drop, weakness in your legs, difficulty walking upstairs, then the diagnosis of disc prolapse is more probable.

Disc bulges can be managed with conservative treatment like home care, chiropractic, and physical therapy. Disc prolapses should be evaluated by an orthopedic surgeon or neurosurgeon. An MRI should be ordered to evaluate the extent of the injury.

If you suspect you have a disc bulge, take care not to aggravate it. No heavy lifting, no jumping activities (basketball, badminton– anything where your feet leave the floor and land hard).

Discs usually bulge backwards (posterior), so do movements that encourage the bulge to move back to center. Lie on your back and bring both knees to your chest (ok to use your arms to grab your knees while they are bent, and pull and hold to your chest). This will put your lumbar spine in flexion, or a nice convex curl. Your back contour should be like that of an egg, and you should be able to rock back and forth. Maintain the pull, stretching your lower back into this curve. Hold for 30 seconds, then slowly extend your legs on the floor and rest for 15 seconds (optional: put a frozen ice gel pack covered with a kitchen towlette under your lower back during this exercise). Repeat six times. This will have the effect of creating separation between the posterior ends of the lumbar vertebrae, helping to reduce the bulge.

Next, stand and place your hands on your hips, and slowly arch your back backwards, putting your lumbar spine into extension— the opposite curvature as the previous exercise. Bend back until you can’t anymore, but don’t over do it. Hold this position for six seconds, then return to neutral. Repeat eight times. This will have the effect of bringing the posterior ends of the lumbar vertebrae closer together and pushing the nucleus back towards the center.

Do the above series of exercises three-four times a day for a week until the discomfort is gone. At this point, you should focus on doing things to strengthen the disc. Eating a wholesome, healthy diet with enough protein, fat and plant material will help; avoiding destructive activities like smoking, alcohol, and staying up late will enable optimum conditions for tissue healing. Gradually start doing exercises that improve lower back muscle conditioning and coordination.

Getting a series of 6-8 chiropractic adjustments to the lumbar spine may also be helpful in reducing your bulging disc.

How to Relieve Pain from Hot Peppers

by Pain Doc | Sep 13, 2010 | Uncategorized

Habanero pepper (Photo credit: Wikipedia)

Peppers contain a substance called capsaicin that gives them that hot sensation when exposed to thin membranes such as in the mouth, eyes, nose, and open wounds on the body. The amount of capsaicin determines the “hotness” of the pepper. Bell peppers are on the low end, while habanero peppers are on the high end.

Research shows that capsaicin, despite its fiery reputation can reduce inflammation. There are now over the counter pain relief products that contain capsaicin, mostly topical applications. The capsaicin creates a mild burning sensation on the skin, resulting in a counter-irritant effect that may temporarily relieve muscle pain.

Some people may apply too much of the product on their skin and suffer from a very uncomfortable burning area on their body that doesn’t go away with soap and water. If you find yourself in this situation, here are some suggestions:

1. Rub coconut oil over the area. You can buy virgin coconut oil in most health food stores. It is even better if it is in a solidified state (below melting temperature).

2. If it is a case where you ate a pepper, don’t try to wash it out with icewater; instead, gargle whole milk for 30 seconds; spit out. Repeat three times.

You can experiment with other types of fats such as olive oil, lard, and butter.

Before handling very hot peppers in preparation for cooking (especially if you are going to slice them and expose the capsaicin) coat your hands in olive oil.

By all means, do not touch the eyes and nose during the handling, and even several minutes after you’ve handled very hot peppers and washed your hands, just in case.