When you come into Spine West for an injection in a location other than your spine, we will greet you with an ultrasound machine. Office-based diagnostic ultrasonography and ultrasound-guided injections are becoming increasingly common. It is an efficient and safe way to visualize what is going on in the joints and soft tissue. Why do we prefer to use ultrasound to guide our injections at Spine West? Because the most recent medical literature shows that ultrasound-guided injections are, for the most part, more accurate than “blind” or “landmark guided” injections. Visualizing the needle in real-time going into the target increases accuracy and reduces the risk of the needle damaging nearby structures. Additionally, using ultrasound allows us to quickly “take a look around” the area of interest, confirming the diagnosis or perhaps finding another injured structure that may be contributing to your pain.

Let us take a quick look at the current research, using the shoulder as an example. Most studies comparing ultrasound-guided injections versus blind injections are cadaveric studies, meaning they perform them on cadavers. In the glenohumeral, or shoulder joint, steroid injections are often used for osteoarthritis or adhesive capsulitis (also known as frozen shoulder). One sizeable cadaveric study compared ultrasound-guided injections with blind injections; The ultrasound-guided injections were accurate 92% of the time, and the blind injections were accurate 72.5%. Another study compared ultrasound-guided injections with blind injections in living patients with Frozen Shoulder. There were more significant improvements in pain, range of motion, and shoulder function in the group that had received ultrasound-guided injections. A similar study looking at another joint in the shoulder called the acromioclavicular (AC) joint found that 100% of the ultrasound-guided injections were placed successfully in the AC joint. By comparison, only 40% of the blind injections were accurate. Another common injection we do for pain in the front of the shoulder is a biceps tendon sheath injection. One study showed that when using ultrasound, the injection goes directly into the tendon sheath 86.7% of the time, whereas, without ultrasound, the injections were accurate only 26.7% of the time.

At Spine West, we inject everything from the shoulders to ankles and everything in between. For the most part, we will use ultrasound guidance. However, the research shows that using ultrasound is less critical for certain injections, such as subacromial injections in the shoulder, knee injections, and elbow injections. So, do not be alarmed if you get an injection without an ultrasound from time to time. However, we may also use ultrasound regardless because it is either how we were trained or we want to “take a look around.”

Written by Cassy Cooper, M.D.

There are two main causes of heel pain—plantar fasciitis and heel fat pad syndrome. Today we will discuss both of those conditions and an additional less common but more serious cause of foot pain. Here at Spine West, we diagnose and treat several causes of foot and ankle pain.

The plantar fascia is a wide band of tissue that arises from the heel bone (the calcaneus) and inserts on the toes, traveling along the foot’s arch. Plantar fasciitis is a condition where there is inflammation of the plantar fascia, usually where it attaches to the heel. People with plantar fasciitis normally report a gradual onset of pain on the inside of their heel. The pain is worse first thing in the morning (the first steps out of bed) and improves with exercise. However, it can be aggravated by prolonged standing. It is usually caused by overuse. Activities that involve pointing your feet, such as dancing or running, are the most common culprits. People with flat feet or high arches are especially at risk for developing plantar fasciitis. Additionally, tight calf, hamstring, or gluteal muscles can contribute to developing this condition.

If you suspect that you have plantar fasciitis, the best way to diagnose it is with ultrasound or MRI. Treatment includes rest, ice, NSAIDs, and self-massage with a frozen water bottle. We also recommend working with a physical therapist on eccentric strengthening exercises. Additionally, some people find shoe inserts, taping, and nighttime splints helpful. Finally, corticosteroid injections, extracorporeal shock wave therapy, or surgery are available for cases that do not improve with more conservative treatment.

The next common cause of heel pain is call fad pad syndrome or fat pad contusion. We have a fat pad over our heels that acts as a shock absorber. This fat pad can become damaged from a single traumatic episode or repeated trauma to the heels. People with fat pad syndrome report more sudden onset of pain on the outside or back of their heel. This is worse with weight-bearing activities. Fat pad syndrome is best diagnosed with MRI. Treatments include rest, ice, NSAIDs, silicone heel pads with good footwear, and taping.

A less common but more serious cause of heel pain is a calcaneal (heel bone) stress fracture. This is most commonly caused by repetitive trauma to the heel, especially in the military (from marching), runners, ballet dancers, and jumpers. In this case, the heel pain comes on slowly, is worse with weight-bearing activities, and notably improves with rest. Squeezing the back of the heel can reproduce the pain. X-ray and/or MRI can be used to diagnose a calcaneal stress fracture. Treatment includes a period of absolute rest and non-weight bearing followed by a progressive rehabilitation course.

Written by Cassy Cooper, M.D.

Movements of the forearm and hand are controlled by muscle tendons that attach at the medial (inside) and lateral (outside) elbow. Degenerative changes within these strong bands of the tissue connecting muscle to bone can cause significant pain. Two common issues are lateral epicondylitis, or “tennis elbow,” and medial epicondylitis, or “golf elbow.”

These conditions do not happen overnight; instead, they occur over time and with repetitive use. This is why they are referred to as “overuse injuries.”

Lateral epicondylitis, or tennis elbow, is much more common than golf elbow. It affects 1% to 3% of people and is most common in individuals aged 30 – 50. Pain is typically reproduced with extension of the wrist as if going to give a high five, and clockwise rotation of the forearm, similar to turning a key in the ignition. Common activities that aggravate the extensor muscle tendons include typing, handshaking, racquet sports, carrying groceries, painting, knitting, and raking. Chronic pain caused by degenerative changes of these tendons typically lasts 12-18 months before complete resolution.

Medial epicondylitis, or golf elbow, affects less than 1% of the population, usually in individuals aged 30 – 50. Pain is reproduced with flexion at the wrist, like when bouncing a basketball, and counterclockwise rotation of the forearm. Repetitive motions during golf, tennis, overhead throwing, and activities requiring forceful grip (e.g., machine working and automotive work) over time may lead to medial (inside) tendon wear at the elbow.

In most cases, diagnosing conditions of the elbow can be done with a simple exam in the office. Ultrasound and MRI are modalities used to identify tendinopathy or degenerative changes within tendons. X-rays also can be useful if joint pathology is suspected. The treatment goals are to treat pain and inflammation, return to normal function, and
prevent a recurrence. This is done by minimizing overuse of the tendons, using ice, bracing, and medication, as well as physical therapy. If conservative therapies are inadequate, local injection with steroid or platelet-rich plasma (PRP) is then given. Surgery is required in very few cases.

The physicians and physician assistants at Spine West will use a combination of the above diagnostic tools and therapies to treat disorders of the elbow.

Written by Laura Boucher, PA-C

Most pregnant women do well through the pregnancy with minor aches in pains as it relates to increased body weight and changes in the forces on the low back and pelvis. A woman with sudden onset of severe back pain needs to be evaluated by her Obstetrician to ensure the cause is not preterm labor, kidney stone, or other complications of the pregnancy. When those issues are ruled out, then we can address the common causes of low back pain in pregnancy.

Some pregnant women struggle with a generally achy low back pain with standing and position changes. Others may experience severe disabling back pain with sciatica type symptoms. We know that 80% of back pain in pregnancy is musculoskeletal and sacroiliac joint-related pain. A physical examination would include functional and musculoskeletal testing and neurologic examination to ensure that there is no neurologic deficit or worrisome findings.

The treatment for most pregnancy-related back pain involves conservative care, which often includes a focus of gentle manual therapy/physical therapy approaches along with mild core exercises to help stabilize the deep core and pelvic floor muscles. A sacroiliac joint belt can be useful for stability with increased standing and walking and pain in the sacroiliac joint.

Written by Sara Meadows, DO

Hip pain is a common concern among patients and surprisingly is not always due to arthritis of the joint. In fact, pain on the edge, or lateral aspect of the hip is often entirely unrelated for the ball-in-socket hip joint itself. Instead, the surrounding muscles of the joint are often affected, namely the gluteal muscles that form the buttocks.

The strong tendons of the gluteus minimus, gluteus medius, and gluteus maximus muscles wrap around from the rear to the lateral hips and attach to a bony growth of the femur bone called the “greater trochanter.” Normally this attachment site on the hips is hard to feel, but it is easily localized by your fingertips if you suffer from “greater trochanteric pain syndrome,” or GTPS. A common complaint among people who have GTPS is the inability to sleep on the painful side due to the pressure placed on and around the greater trochanter.
GTPS can occur when there is a repetitive overload placed on the gluteus medius and gluteus minimus muscles. These muscles function to stabilize the pelvis when walking, climbing stairs, hiking, and running; they are the target muscles responsible for lifting the leg sideways and away from the body; and they engage when balancing on one leg. When these muscles are overworked and weak, the tendons can begin to fray or tear and become inflamed. This local “tendinopathy” is the source of greater trochanteric pain syndrome.

Factors that may contribute to the development of GTPS include female gender, age over 50, obesity, unequal leg length, scoliosis, low back pain, and pains such as arthritis of the knee, hip, and ankle that may cause limping and favoring of one side. Treatment for GTPS includes medication for pain and inflammation. The NSAID family is typically the first choice. Activity modification is a key component of treatment and includes reducing stair and hill-climbing, avoiding sitting with crossed legs, standing with equal weight bearing on both legs, and avoiding side-lying. A formal physical therapy program is the most essential treatment piece. A licensed physical therapist will focus on activating and strengthening the gluteus muscles to off-load the tendons and eventually improve symptoms. This may also include body alignment and posture training. If conservative treatment is not effective, injection with cortisone or biologic substances like platelet-rich plasma can provide relief. Finally, surgery is not typically needed for GTPS.

Written by Laura Boucher, PA-C

Peripheral neuropathy is a condition in which the most distal (peripheral nerves) are injured or damaged. This usually manifests in the feet first but can affect the hands if it progresses. Symptoms are often described as burning, stabbing, or tingling pain but also include numbness and weakness in a stocking and glove distribution. It can also affect sensory perception, including temperature, pain, and vibration. The onset of symptoms is typically gradual, often over months or years.

Many diseases or conditions can contribute to the development of peripheral neuropathy. The most common cause is diabetes, while other somewhat frequent contributors are vitamin B-12 deficiency, hypothyroidism, and alcohol use. There are several much less common causes, including autoimmune diseases, infections, inherited disorders, medications, chemotherapy, and heavy metal exposure. Age is also a contributing factor. About half of the cases in the United States are idiopathic (have no identifiable causative source).

There is recent research that about half of idiopathic cases may be due to a delayed return-to-normal fasting blood sugar after a meal even though such an individual may have normal fasting blood sugar and normal a hemoglobin A1C. The implication is that not only is having chronically high levels of blood sugar damaging to nerves but so can intermittently prolonged elevated blood sugars.

There is also new data showing there is a relationship with the fluoroquinolone family of antibiotics (Cipro, Levaquin, etc.) and the development of peripheral neuropathy. This has only been found with oral, IV, or injectable administration. It is not known if there is an association with eye or ear drops causing neuropathy. It is unknown if these side effects are permanent or temporary, but one British study found symptoms that developed after fluoroquinolone antibiotics lasted up to 180 days after exposure

If peripheral neuropathy is suspected by history or examination, it can sometimes be detected by nerve function tests (EMG). Other causes of nerve symptoms, such as being referred from the spine, need to be ruled out. Blood tests can be ordered to assess for identifiable causes such as hypothyroidism and Vitamin B12 deficiency. The primary treatment is focused on correcting any identifiable causative factors such as better management and control of hypothyroidism or diabetes. For patients where it is idiopathic, dietary changes could still help. Decreasing alcohol intake and low sugar diets could both prove to be beneficial. From a medication standpoint, anti-seizure medications such as gabapentin or Lyrica can be helpful. Some antidepressant-type drugs such as Cymbalta can also control the symptoms. Physical therapy can be helpful for the treatment of weakness and balance changes associated with neuropathy.

If you have additional questions or want to discuss the diagnosis or treatment options in further detail, please feel free to make an appointment with a provider at Spine West.

Written by Vaheed Sevvom, PA-C