Non-Surgical Treatment Options for Common Orthopedic Conditions

by John Watson, MD

What is it you do again? As a physiatrist, this is a question that I get quite often. My specialty is called Physical Medicine and Rehabilitation (PM&R) and we are specialized in restoring function and motion and improving pain without surgery. It is my goal to maximize performance no matter what the age or circumstance. Physiatrists are experts in diagnosing and treating conditions affecting the joints, nerves and muscles in which the symptoms are either pain, numbness or weakness. PM&R is a blend of orthopedics, neurology, and general medicine and the field has been growing very quickly over the past several years. My specific area of focus is called non-surgical spine and sports medicine. By focusing on function and non-surgical care, a physiatrist is in strong demand for the treatment of athletes, injured workers, baby boomers and the elderly. I personally have sought out extra training to utilize the latest technology for both diagnosing and treating a wide variety of conditions such as arthritis, spinal stenosis, sciatica, tendonitis, bursitis and carpal tunnel syndrome just to name a few. This technology includes electromyography (EMG/NCV), MRI interpretation, Diagnostic Ultrasound, and both X-ray guided and Ultrasound guided injections.

Joint injections
Joint conditions are a common problem with the patients that present to OCI and of course most patients would rather avoid surgery if at all possible. Most people with arthritis are able to utilize non-surgical treatments until a total joint replacement becomes necessary. Steroid injections have been used for a long time and are excellent in giving short term relief. The steroids (also known as cortisone) are a very strong anti-inflammatory and are combined with lidocaine which is a quick acting numbing medication. This injection is excellent for immediate pain relief and the goal is to obtain several weeks or several months of longer term therapeutic relief. I personally perform all of my joint injections with ultrasound guidance which allows for a 100% accurate placement each time. It also allows for the injection to be less painful and more diagnostically valuable. The intra-articular hip injection is a very important injection since physicians are unable to inject this “blind”. The joint is quite deep and therefore we are unable to perform this without either X-ray or ultrasound guidance. With X-ray guidance, I am able to accurately place the injection into the joint using a fluoroscope and contrast dye (see figure 1). This is a very accurate procedure, but does included the extra risk and added inconvenience to the

 patient. Ultrasound guidance allows the procedure to be performed right in the office while avoiding both radiation and contrast dye. Some longer term options for joint injections exist including viscosupplementation. This is what some of my patients have referred to as “rooster shots” and “chicken fat”. The main medication that is injected is a hyaluronic acid derivative which can be from rooster combs or grown naturally in a controlled environment. Hyaluronic acid is natural substance in joint fluid and therefore we are able to inject this every six months to help people improve their pain and function. One of the newest medications in this category is called Gelsyn-3 and this is deposited into the knee joint once a week for three weeks in order to replenish the arthritic and inflamed joint. New options are becoming available including PRP (platelet rich plasma) and stem cells, which are currently not covered by most insurance plans. In the next several years I suspect there will be new regenerative techniques that may be more effective than our current options and OCI will continue to be on the forefront of this movement.

Spinal procedures

As a non-surgical spine specialist, it is my job to accurately find what we refer to as the “pain generator”. I have been known to say, “There is no such thing as back pain”, which might sound confusing to someone that has suffered from back pain, but hear me out. In my specialty, we locate the area of the back that is causing the pain in order to guide the proper treatment more effectively. The three most common causes of back related pain are the nerve root (L5, S1, etc.), the disc and the facet joint. Physical therapy is an excellent first step in treating all of these things and Midwest Rehabilitation does a great job in focusing on the pain generator and tailoring a program to the individual needs of our patients. Aquatic therapy is also the perfect companion to any rehabilitation program which allows for increased motion, increased blood blow, improved strengthening and conditioning, all which allowing the water to decreased the pressure on all these painful structures. Most people that have back pain, hip pain or “sciatica” are dealing with an inflamed nerve root in the lumbar spine. In order to both diagnose this and treat the pain, I am able to employ a procedure known as the Transforaminal Epidural Steroid injection (TFESI). This procedure allows me to precisely place medication directly on the source of pain, rather than into a general area of the spine.

This procedure has been shown to prevent surgery in certain patients and it has completely modernized the way we treat stenosis and sciatica. These injections are best for hip and leg pain and are best used for short term pain relief in conjunction with a rehabilitation program.

The most common cause of back pain in any patient over 65 is arthritis of the facet joints. These are small joints in the spine and there are two on each side of our back and degenerate over time, especially in the obese population and those that have overworked their spine through wear and tear. These are very similar joints to the hips and knees, just much smaller. Therefore, steroid injections into the joints must be done under x-ray guidance to ensure proper placement (see figure 2). The latest treatment technique for these joints is called Radiofrequency Neurotomy (RF) (see figure 2)and is referred to as “burning the nerves”. After confirming that the facet joints are causing pain, the RF procedure involves safely placing a probe next to a special nerve called the medial branch. An electrical impulse is used to the destroy these medial branch nerves which can diminish or eliminate facet joint pain for 1-2 years. Since surgery is not a good option for “back pain”, these procedures can be utilized to improve pain, while maintaining function.

 

Musculoskeletal ultrasound has been my passion
for many years now and the applications are only growing. My ultrasound machine is very mobile and is able to be taken from room to room in the clinic, to the training room, and even to an athletic field of play. It is revolutionizing sports medicine and non-surgical orthopedics due to the rapid diagnosis and the point of care treatments available. In the shoulder, I can quickly and painlessly evaluate the rotator cuff to see if someone is dealing with bursitis, tendonitis, or a surgical tear (see figure 3). It is especially convenient to those patients that are claustrophobic of MRI machines and those that can’t have an MRI for various reasons (pacemaker, metal clips, etc) Diagnostic Ultrasound is also significantly cheaper, quicker and is much more patient friendly than an MRI. My patients are able to watch the structures in real time as I evaluate the anatomy and are they are actively included in the entire process. I am able to diagnose the problem and guide an injection into the pain generator on the same visit which can be quite efficient for the patient. It also has fantastic diagnostic utility in conditions such as carpal tunnel syndrome and cubital tunnel syndrome (see figure 4). Some patients may want to delay a carpal tunnel surgery for various reasons and a safely placed ultrasound guided injection can allow for short term improvements.

Several procedures have started to emerge since ultrasound technology has blossomed. Ultrasound guided tenotomy is a new treatment that has been shown to prevent surgery or be a non-surgical alternative for patients with severe tennis elbow and tendonopathies affecting the knee, hip, and shoulder. We have utilized steroid injections into these areas for a generation and are now realizing that this may cause more harm in the long term. Some tendons that are painful are not inflamed, but instead are thickened and have restricted blood flow which diminishes their ability to heal. To help with this healing process, a needle is introduced into the abnormal tendon safely and easily under ultrasound guidance and several passes are used to fenestrate the thickened tendon. This allows the body to naturally start an inflammatory response which will introduce growth factors and healing cells into a tendon that has been chronically injured.

You can also inject PRP into the tendon which may also improve the chances of a positive outcome and improved function. Another procedure that has helped people avoid surgery is called a calcific aspiration and tenotomy. Rotator cuff tendons can form very painful calcifications which can be broken up and aspirated out the body using ultrasound guidance rather than surgical decompression. Some of the other orthopedic conditions where ultrasound guidance are helpful include the thumb joint, the bursa around the hip, and aspiration/injection of a Baker’s cyst. A Baker’s cyst is formed from joint fluid that escaped the knee and positioned itself behind the knee near the calf. This can cause significant pain and can be drained for pain relief and improve function.

The scope and depth of the care rendered by a physiatrist results in a thorough, comprehensive strategy to get patients of all ages back to an acceptable level of functioning through non-surgical treatments. It is always important to thoroughly understand the condition that you have in order to implement prevention strategies that may help avoid pain and dysfunction in the future. I have always been a firm believer that “exercise is medicine” and encourage everyone to increase their activity level. If pain is slowing you down, then hopefully one of these non-surgical treatment options will help decrease your pain, improve your function and increase your overall quality of life!