The conditions treated at PM&R Associates can be divided into spinal and non-spinal conditions. The spinal conditions are painful spinal discs or spinal joints. All treatments are treated by either Ultrasound or X-ray guidance

Disc Pain:

Disc pain can be caused when the discs degenerate or sometimes herniate

Painful spinal discs are usually first treated by injecting a synthetic cortisone (steroid) preparation around the outside of the discs. This space is the epidural space and the procedure is called an epidural steroid injection. It works best if there is radiation of the pain into the legs or arms, but can work if there is only pain in the spine. If there is a steroid intolerance, this step can be skipped.

The next step is to place medication inside the center of the disc. The first medication used is Platelet Rich Plasma (PRP). Platelets initiate healing, and are taken from the patient’s own blood. A more advanced treatment that can be placed into the disc are stem cells. Stem cells are taken from the patients’ own body, usually fat.

Spinal Arthritis Pain:

The first step in treating painful spinal joints is to inject medication into the joint. Either steroid or non-steroid medication can be used. If the joint injection does not last long enough or if the joints are too narrowed to accept medication, a Medial Branch Block (MBB) is done as a test for arthritis pain. A MBB is where local anesthetic is placed on the small nerves going to the facet joint. This causes the joint to be numb, much as a dentist numbs your teeth. If good relief is obtained for 4-6 hours, a radio-frequency neurotomy is done. A radio-frequency neurotomy is a procedure where the small nerves to the joint are cauterized.

The sacroiliac joints are in the pelvis. One of these joints can become “stuck”, which is very painful. This condition can be treated by an injection, physical therapy, or manipulation.

Non-Spinal Conditions:

Non-spinal conditions treated at PM&R Associates include the joints of the arms and legs such as the shoulders, hips or knees, tendons (tendonitis or tendinopathy, bursitis, ligaments (sprains), or muscles (strains). Treatment consists of the injection of medications into these structures. The medications used include steroids (cortisone), dextrose, platelet rich plasma (PRP), or stem cells. Nerve conditions such as carpal tunnel syndrome can also be injected.

All of these procedures are discussed in greater detail below.

ESI: Epidural injection of medication (ESI) places a steroid anti-inflammatory medication into the epidural space (the space outside the disc) to calm down the chemical or allergic irritation caused by the leaking of chemicals. If there is no leaking, the epidural will not work. There can be pain down the leg without leaking, same as a heart attack can cause arm pain. This is called referred pain. An epidural injection works best in cases of disc herniation. See Herniated Disc.

Disc injection: In order to treat degenerative disc disease, medication must be injected inside the disc, not around the outside of the disc such as is done with an epidural injection. Medications that can be injected include newer, cutting-edge procedures such as the injection of stem cells or platelet rich plasma (PRP). By injecting stem cells from your own body into the disc, the disc cells that repair the disc wall can be augmented or replaced. Disc cells diminish in number or even disappear as the disc degenerates. The injected stem cells are suspended in platelet rich plasma, which by itself is a potent treatment for degenerative disc pain. This adds fibrin and growth factors to the mixture. This approach is a three-pronged treatment: stem cells, PRP, and fibrin. All three have been used separately for disc pain treatment, but very few clinics are using all three together. Stem cells are harvested on the day of the procedure from the patient’s own adipose tissue (fat) and re-injected the same day, so there is no chance of rejection or disease transmission.

Facet joint injections:

Injecting medication into the facet joints is a way of treating pain due to spinal arthritis. Medication is injected into the painful joint under x-ray guidance. Medications available for injection include steroids (cortisone), or our no-steroid option.

Medial Branch Blocks: With a MBB, local anesthetic is placed on the small nerve going to the facet joint. This numbs the joint much like a dentist numbs your teeth. This is purely a test block and it wears off in about four or five hours. You will be asked to measure your pain every hour for 6 hours. It is best if you are active enough before either procedure, so there will be enough pain present that we can see the effect of the local anesthetic.

Radio-frequency Neurotomy: Radio-frequency Neurotomy is another method of treating spinal joint pain. In this procedure, the nerve to the spinal joint is destroyed by placing a needle next to the nerve and putting radio waves through the needle electrode, which cauterizes the nerve. This procedure usually lasts much longer than facet joint injection, usually between six months and two years. A radio-frequency neurotomy is indicated where the joints are very narrow and degenerated, when a facet joint injection doesn’t last long enough, or for anyone who simply wants longer lasting relief. Typically, a test block is required before the neurotomy.

Sacroiliac joint injections: The sacroiliac joints are paired joints on each side of the pelvis. Pain originating in the sacroiliac joints can be due to arthritis, but usually is do to a somatic dysfunction. This is where one of the two joints is not moving as it should. By injecting medication into the two sacroiliac joints, the joints again become mobile, restoring motion causing the pain to be relieved. Medication used is either steroid or the non-steroid option. If the condition has been present too long, the ligaments may be stretched out and the joints frequently “get out of alignment”. In that case, ligament-strengthening injections are necessary. See SIJ Dysfunction

Joint disorders: Joint pain such as the shoulder, hip or knee can be treated by injecting medications into the joint. There are several options as to what medication to use.

Steroid (cortisone) injections: The injection of steroid medications will reduce inflammation, if inflammation is present, and will reduce pain, swelling, and fluid in the joint. Steroid medications are of limited use with osteoarthritis (OA) or degenerative joint disease, which is usually not associated with inflammation.
Low or non-steroid injections: These injections work best in degenerative joint disease or osteoarthritis (OA). It is a biologic treatment, which means the effect gets better with time and lasts longer than pharmaceutical treatments. Since there is no cortisone, these injections can be repeated as often as needed and they typically are covered by insurance.

Viscosupplementation: (Supartz, Synvisc, others). Viscosupplementation is Hyaluronic acid from rooster combs which works like an artificial joint fluid given by injection. This procedure works well in some patients. It is expensive, but is usually covered for some joints by most insurances.
PRP (Platelet Rich Plasma): This is a biologic treatment which means the patient gets better with time and the effect lasts longer than pharmaceutical treatments. PRP is taken from the patient’s own blood and is given back the same day. This is done all over the country and can last 6 months to a year or longer. Patients with PRP injections have decreased pain scores and increase in function scores at 6 months following the injection. Sometimes more than one injection is required. Although there is no improvement of the x-rays, the progression of the arthritis is usually halted. Sometimes the injection lasts longer, but not everyone benefits.

Stem Cells: The injection of stem cells is a biologic treatment, which means the patient gets better with time and the effect lasts longer than pharmaceutical treatments. Stem cells are taken from the patient’s own adipose tissue (fat) and given back the same day. This procedure is done all over the country. Patients that have had the injection of stem cells into the knee show decreased pain scores of 75-78% at 6 months. There is also an increase in lifestye scores by 75% at 6 months. The injection of stem cells is able to treat avascular necrosis, which is where some of the bone has died. Stem cell injections are the only treatment, surgical or non-surgical, that show an increase in both cartilage and menisci by MRI. The injection of stem cells from adipose tissue (fat) is less painful and works better than stem cells from bone marrow because there is 500 times the number of the stem cell type that makes cartilage than in bone marrow. Stem cells are suspended in PRP, so the patient gets the benefits of both at the one price: The patient gets stem cells, platelets, fibrin, and growth factors. This is also done all over the country.

Tendon pain: When tendons degenerate they become painful. In early stages there is inflammation and anti-inflammatory medication by mouth or injection may work. In late stages the pain is almost always due to degeneration and anti-inflammatory medication has a limited role. The two most commonly involved areas are the shoulder (rotator cuff) and the elbow (tennis or golfers’ elbow). See ultrasound-guided injections

Sprains: Ligament injuries are called sprains and can occur anywhere in the body but especially the knee and ankle. First and second-degree sprains are incomplete and respond to non-surgical treatment. Third degree sprains are complete tears and usually require surgery. Non-surgical treatment involves the use of physical therapy, bracing or the injection of medication into the sprained ligament.

Bursitis of the hip, shoulder and knee: A bursa is a sac between a bony prominence and a ligament or tendon. There is a small amount of fluid in the sac and the sac acts like a pulley which prevents the ligament or tendon from wearing out. If this sac becomes inflamed due to trauma or calcium deposits, the amount of fluid increases and the sac becomes very painful. Treatment usually involves the injection of cortisone, non-steroid medication, or PRP.

Nerve conditions: Nerve conditions, such as carpal tunnel and other entrapments, such as at the wrist and elbow, produce pain, and if severe, will produce weakness, numbness and tingling:

Carpal tunnel symptoms often occur at night or early morning and interfere with sleep. Nerve entrapments often require surgery to release the entrapment, but the injection of cortisone or PRP can be helpful.

Neuropathy is a condition, usually related to another illness such as diabetes that produces painful numbness and tingling. The use of oral medications can be helpful, but Spinal Cord Stimulation is usually very helpful.

Muscle injuries: Muscle injuries (strains) can occur in any muscle, but are common in the upper back, shoulder blades, or arms and legs. They are related to injury or posture and often occur because of abnormal body mechanics due to another painful condition. Treatment can involve physical therapy, medications, home exercise and occasionally injection of medication.

Selective nerve root injection with Platelet Rich Plasma (PRP): In cases with persistent nerve pain, injecting platelet rich plasma that has had the blood cells removed can significantly reduce the pain from the affected nerve. Removing all the blood cells is necessary as the white and red blood cells can be a cause of pain.

Spinal Cord Stimulation: Spinal Cord Stimulation is a treatment long used for low back pain due to any cause. It is excellent for nerve pain or neuropathy. It is usually covered by insurance and is a good alternative for patients that are not good candidates or cannot afford stem cell therapy. Once approved for the treatment, a “trial” electrode or lead is placed in the back in a non-surgical procedure and left for one week. During that time the patient can tell how much pain relief and increase in function they get from the spinal cord stimulator. Only if enough benefit occurs, will a permanent stimulator and lead be implanted as an outpatient.

Platelet Rich Plasma (PRP) injections: Platelet Rich Plasma, or PRP, is whole blood that has been centrifuged to concentrate the platelets. Platelets are in large part responsible for the initiation of healing. The concentrated platelets found in PRP contain huge reservoirs of bioactive proteins, including growth factors that are vital to initiate and accelerate tissue repair and regeneration. These bioactive proteins initiate connective tissue healing, cartilage regeneration and repair, promote development of new blood vessels, and stimulate the wound healing process. There is also fibrin in the solution, which has been found to be effective in treating disc pain. It is important to separate out all of the white and red blood cells as these cells make the procedure painful. PRP can be used to treat arthritis, painful tendons and ligaments, or anywhere healing is important. It is useful to tighten lax ligaments as well. Most insurance programs do not cover PRP.

Prolotherapy: The most basic form of regenerative medicine is the injection of dextrose-based medicines into ligaments or tendons. Dextrose has been proven to stimulate connective tissue and cause repair. This is useful in treating lax ligaments and degenerated tendons. Prolotherapy is not covered by any insurance program. See Tendon Pain, Sprains, Strains

Ultrasound-guided injections: To be effective, medications have to be injected into the joint cavity, ligament, or tendon sheath . This can be done “blind” where no guidance is used, under x-ray guidance where the patient is exposed to x-rays, and with ultrasound guidance. Done blindly, up to 25% of all limb joint injections are “missed” and the medication is not introduced into the target.

Sympathetic block

Pulsed Radio-frequency procedure