Disorders of the musculoskeletal system
Joints are a major site of injury, and joint diseases are among the most frequent causes of chronic pain.
Osteoarthritis, which occurs when the cartilage that cushions the bone ends is damaged, is one of the most common joint diseases. Initially, pain in osteoarthritic joints is caused during movement and weight-bearing activities. However, it can progress to continuous pain, even while at rest.
Other causes of joint pain include inflammation, falls, fractures, ligament sprains, car accidents, dislocations, muscle trauma and direct blows to the muscle. In these instances, joint pain can be related to damage to the muscles, tendons, fascia, other joints and ligaments.
Intra-articular joint and bursa (fluid-filled sacs around joints that can become inflamed) injections treat pain in the joint and surrounding structures. These injections, a combination of steroids and a local anesthetic, are generally performed under fluoroscopic (X-ray) guidance. Steroids have significant anti-inflammatory effects that help to decrease swelling, and the local anesthetic provides pain relief during the needle insertion while also helping dilute and spread the steroid within the joint.
Viscosupplementation (Synvisc) refers to intra-articular injection of hyaluronic acid, which is FDA approved for knee osteoarthritis. The exact mechanism of action is unknown, but the goal of the treatment is to restore the natural properties of the synovial fluid that lubricates joints.
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Myofascial pain is one of the most common debilitating pain complaints. It is believed to result from repetitive injury to a weakened tissue, an autoimmune reaction (body attacks itself) or even from a decreased amount of blood flow to the area. The muscles most commonly involved are the trapezius, splenii, cervical and lumbar paraspinal, and quadratus lumborum.
Myofascial pain can present with regional body pain and stiffness, limited range of motion, a twitch response producing a taut band, or even as trigger points. Trigger points are painful knots that develop in muscles when muscles are unable to relax. They are tender with deep palpation (pressing down with a finger), and the pain usually travels throughout the affected muscle. This usually causes a “twitch” response, which can be felt as a band that limits normal motion of the affected muscle.
Trigger point injections are injections into the affected muscle area with local anesthetic with or without corticosteroid or Botox. Steroids help to decrease inflammation, and Botox can help the muscle relax. Dry needling (needle insertion without injecting medication) can also be performed to help break up the trigger points.
Patients who have localized muscle pain can achieve significant relief for days to months. Overall success regarding pain relief is dependent on patients stretching and strengthening the muscle region after receiving the injection.
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Persistent knee pain
Persistent knee pain is a common complaint and can occur for a number of reasons, with two of the most common being osteoarthritis and post-total knee replacement pain syndrome.
In knee osteoarthritis, the cartilage is initially damaged and affects the entire joint. When viewed during imaging, knee osteoarthritis may appear as a narrow joint space, bony outgrowths, swelling or even worn-away cartilage. In general, however, imaging is not needed to make a diagnosis if typical symptoms and signs are present.
Movement and loading of the joint can cause knee osteoarthritis pain, which can progress to continuous pain, even while at rest. Inflammation may also occur in the joints leading to swelling and feelings of stiffness.
If conservative treatment options, including oral medications, physical therapy and injections, do not help the patient find relief, total knee replacement/arthroplasty (TKA) surgery is typically the next step. While TKA usually resolves the issue, that’s not always the case. In some instances, postsurgery pain (known as post-TKA pain) persists. While the cause of this pain is complex and not entirely understood, various structures in the skin, muscle, nerves and bones are stressed, stimulated or injured, potentially leading to increased inflammation and pain.
Patients with persistent knee pain who have not found relief through conservative care may be candidates for a genicular nerve block and ablation, or even [“dorsal root ganglion (DRG) stimulation”: anchor to dorsal root ganglion stimulation in Treatment section]. Genicular nerve blocks are based on the theory that pain relief and possibly improved function can be achieved by anesthetizing (blocking) the genicular nerves.
The genicular nerves are a collection of nerve branches that surround and innervate the knee joint. During a genicular nerve block, these nerves are blocked with a local anesthetic under fluoroscopic (X-ray) guidance. This is a diagnostic procedure and will unlikely provide long-term pain relief. However, if these blocks provide adequate pain relief — which should be noticeable immediately after the procedure — then a radiofrequency ablation (burning) of the genicular nerves can be performed for longer-lasting pain relief.
During radiofrequency ablation, the genicular nerves are ablated by creating a heat lesion around them. This can result in several months or years of pain relief.
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