Pain Management Solutions

Regain Your Function with Confidence Book an appointment at ISMI for your pain management needs.

We offer a comprehensive approach to pain relief, including diagnostic injections, aspirations, visco-supplements, and ortho-biologics. Our specialists use ultrasound guidance to accurately target the source of pain, and we tailor treatments to each individual’s unique condition. Start your journey to- wards regaining function and managing pain effectively at ISMI today.

What is the most important rule of pain management?

The most important aspect of pain management is not our current advanced minimally invasive procedures, or new effective pain medications, but the phrase itself: pain management.

Pain management sometimes is able to completely take the pain away, and sometimes it can only control the pain so that the patient an manage her or his daily activities without significant limitation.

“Not every pain requires treatment, not every pain requires
extensive diagnostic work up, not every pain Can be completely treated.”

What is the second most important rule of pain management?

Pain is not a disease, it is the manifestation of a disease. Pain should never be treated without a diagnosis, or enough investigation to make sure serious, life or limb threatening diseases are not the cause of pain. To understand this better
Read this patient story

What is the third most important rule of pain management?

The third rule for pain management is to perform minimally invasive procedures not blindly, but using some kind of accurate guidance. Most pain management procedure can be done using ultrasound and fluoroscopy guidance. Some have to be done under CT scan and a minority can only be done under MRI.

Ultrasound is an ideal modality for pain management because

1) it allows interactive physical examination in real time of the different structures in the area of the pain.
2) it can diagnose the cause of the pain in many instances.
3) it does not involve radiation.
4) it does not required large equipment and can be portable.

What is step by step, progressive pain management?

When multiple potential sources of pain are identified, it is important to perform diagnostic or therapeutic pain procedures in a graded, step-by-step, and controlled manner.

These are the general categories of interventions for pain management:


a small amount of biological fluid is required for normal functioning of our joints and tendons. However, extra fluid in the joints by itself can be a cause of pain. The simplest method of reducing the pain in the joint that has extra fluid (effusion) is to remove this fluid by a small needle. This is called a joint aspiration. Aspiration of fluid can control acute pain where there is damage to the joints due to trauma. For example I recently removed 30 ml of blood a few hours after my wife had a ski accident, significantly reducing her pain. In chronic pain, especially in osteoarthritis or degeneration of the joint, removal of excess fluid is essential for successful pain management. This fluid is usually discarded but in the proper clinical context it can be sent to laboratory for analysis, for example, when there is suspicion of gout or joint infection.


The next category of pain management treatments involves injection of one or multiple substances in the joint. When this is done to prove that a specific structure is the source of the pain, it is called a diagnostic injection. In these cases, a short acting anesthetic is injected in or around the suspected source of pain. When pain disappears, the injected structure is confidently identified as the main source of pain. Afterwards other long-acting medications such as cortisone alone or in combination with long acting anaesthetic agents can be injected to provide longer term pain relief.

Viscous supplements:

The other category of injectables are substances that are not considered medication, but mechanical lubricating agents, collectively known as visco-supplements. These substances are synthetic material almost identical to the normal synovial compounds of healthy joints (hyaluronic acid). By promoting lubrication and providing mechanical support, these agents can result in longer lasting pain relief. Some examples of this supplements include:

These substances have traditionally been used as intra-articular lubricants to treat chronic pain due to degenerative joint disease or osteoarthritis. In addition, a new generation of these substances, called Sportvis, has been adapted and approved for use in soft tissues outside the joint. SportVis is now available for treatment of acute ankle sprain.

Another class of visco-supplements combines steroid/cortisone with hyaluronic acid. Available in Canada under the trade name Cingal, this combination adds the long-standing anti-inflammatory properties of steroids to the superior mechanical lubrication and supportive effects of visco-supplements.

Frequently Asked Questions

A common question is: how do I know which product is appropriate for me?

There is no definite answer to this question because it is very difficult, and probably impossible, to scientifically compare these compounds. This is due to the extreme variation and complexity of pain mechanisms, which does not allow proper comparison and matching of individuals in different treatment categories.

At ISMI, we recommend a stepwise approach to our patients: we start with the simpler, safer and cheaper treatments and move to the more complex and expensive treatments once the simpler treatments prove ineffective or lose their effectiveness over time.

Unless the patients ask for a specific medication or treatment, we recommended starting with steroids. We stay with steroids as long as there is adequate pain reief and functional recovery for approximately three months. Once the steroids lose their effectiveness, we move to Cingal. Finally, a trial of PRP can be attempted after other treatments have proven to be ineffective.

It is extremely important to know that no single combination of these treatments would apply to all patients. Pain management is a complex medical practice, and all treatments need to be individualized on a case by case basis, considering patients understanding of the causes of pain, the desired level of functional recovery and patient’s individual values and beliefs, and finally patient doctor shared decision making process.

The goal of pain management is not to become pain free. It is to regain adequate function in presence of tolerable pain.

What if the pain management procedure is not effective?

Sometimes, after a procedure, pain comes back too quickly, which means before our expected few weeks or few months of relief. Most patients feel disappointed, and rightfully so. Some even think that they had even wasted their money for nothing.

We completely understand these feelings and disappointments. It would not be an exaggeration to say that the time I spend speaking to patients with suboptimal results is longer than the time I perform procedure during one week.

These are the steps to go through after a suboptimal result after a pain management procedure:

The first question is: was the diagnosis correct? This is a problem in practices where pain treatments are done empirically, without appropriate diagnostic tests. For example, some doctors treat every shoulder pain initially as bursitis. While bursitis is a common cause of shoulder pain, it is certainly not the only cause.

When the correct diagnosis has been made, the next possible cause for suboptimal result is technical failure of the procedure, i.e. missing the target. At ISMI, we minimize the probability of technical failure by using real-time guidance under ultrasound.

Despite an accurate diagnosis and a technically successful procedure, the pain may still come back. There are a few main reasons for this: 1) The problem has been unusually severe, resulting in only partial response to the usual dose of medication. In these cases, we always examine the patient, and if required repeat the diagnostic ultrasound. If there is a small amount of residual bursitis, a second treatment can be done. At ISMI these supplementary treatments are offered to our patients at no additional cost.

2) Pain may return due to a complication from the procedure, for example, a small amount of bleeding in the muscles surrounding the joint, which would make movements painful. This is not uncommon and is usually treated with over-the-counter non-steroidal, anti-inflammatory drugs, such as ibuprofen/Advil. Sometimes an ultrasound is performed to confirm such a diagnosis. This diagnosis is facilitated by help from the patient: the patient usually is able to tell her doctor that the nature of the pain, its location, and its characters are different from the original treated pain.

Some complications are more severe, for example, soft tissue or joint infections. These complications cause progressive and worsening pain usually with fever. These conditions require immediate repeat examination, and additional tests to prove or exclude the diagnosis for prompt and proper treatment.

Again, at ISMI, these follow-up examinations are always free of charge.

3) The new pain can be what is called breakthrough pain. In structures that are complex there can be one more than one source of pain. For example, shoulder pain can come from bursitis, tendon tears and osteoarthritis. When multiple abnormalities are present at the time of diagnosis, pain management is done in a stepwise fashion, targeting either the most severe problem or the most superficial structure requiring the least invasive procedure. For example in case of shoulder pain, bursitis is always treated first. However once bursitis is resolved, the co-existing tendon tears and joint disease have an opportunity to show themselves. This is especially common in the shoulder and hip: after successful treatment of the inflammatory pain of bursitis, the patient will gain more mobility and range of motion, using the diseased tendons and joint more frequently, leading to worsening of mechanical pain from these structures.

With breakthrough pain, patient’s help is essential in making the diagnosis. Patients usually describe that their original pain had subsided after the procedure, and after a short time a new pain in a different location and/or with a different character has appeared. In other words, treating the main cause of pain has now unmasked the presence of other painful problems in the area. In many instances, these can be diagnosed based on patient’s history and symptoms alone. In other cases, repeat examination or additional testing such as an MRI may be indicated.

A note on technical failure: not every intervention is successful. The only way not to fail in a procedure is never to do one. They can be multiple causes for technical failure of a procedure. When you have your procedure at ISMI, our specialists will immediately inform you of the technical success of the procedure. We will never pretend that a failed procedure was successful, even though in some cases there may be immediate relief of pain despite technical difficulties.

In these cases, once the cause of the technical difficulty is explained to and understood by the patient, the procedure is rescheduled at no further cost.

Finally, there are patients who have pain originating from distant anatomical structures. As for the case of shoulder pain, degenerative changes in the neck and cervical spine can contribute to shoulder pain. In these cases usually further testing is also required.

In 90–9–1 rule of thumb may be useful to adjust patient’s expectations from procedures: 90% of the time after a technically successful injection, the pain management goals will be achieved. In 9% of patients after a technically successful procedure, a second injection or a repeat examination to identify, alternative or new sources of pain may be required. In 1% of cases, resistant pain will become a problem that both patient and doctor need to deal with patiently and judiciously.

In the cases where pain comes back earlier than expected, our Specialists will patiently and judiciously work with you, according to the principles evolve to allow you to resume your function on daily activities.

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