I had a young patient recently came to us because of inability to move her shoulder. Her new physician, diagnosed her with frozen shoulder and propose to inject her “right there“ in the office. The patient correctly asked for a diagnostic test to make sure nothing else was wrong. The doctor did not agree with this request and insisted on blindly injecting her frozen shoulder. She did not consent for two good reasons: 1) never treat pain without a diagnosis, and 2) try to avoid blind injections as much as possible. She came to us. We performed an ultrasound of the shoulder demonstrating that nothing was wrong with her shoulder, for example, no tear or calcium or bursitis, therefore, establishing the diagnosis of frozen shoulder given her severe restricted motion. Most of the time frozen shoulder is a diagnosis of exclusion, which means other causes of shoulder pain and immobility need to be investigated and excluded before blaming the symptoms on a frozen shoulder. Having established a diagnosis, we proceeded with an ultrasound-guided distension of her shoulder joint capsule with cortisone and anesthetic injection. She immediately experienced relief of pain and significant increased range of motion. With a little tear in her eyes, she exaggerated: you saved my life“. Of course, we did not save her life, we only manage her pain properly. Her shoulder immobility did not completely go away, but now she was able to perform some of her basic activities of daily life, such as applying deodorant, buckling to seatbelt, low, drying her hair.
The last but not least principle of pain management is the complex nature of pain. First of all, different patients feel pain differently. Even the same patient would feel her pain differently in different times. Second, some pains can arise from simple processes, such as bursitis. In these situations, it is easy to predict the outcome of a pain management procedure. In some cases, however, pain arises from structures with complex anatomy such as spine, larger joints such as shoulder and hip or deeper structures. For example, a patient with shoulder pain can have bursitis, calcium deposits, partial tendon tears and early osteoarthritis of the joint all at the same time. While the pattern of pain and clinical history, combined with imaging findings, can definitely help narrow down the source of the pain, this may not always be possible. In these cases, pain management’s needs to proceed with careful and complete patient education to adjust her expectation of the results of pain management procedure, as well as the importance of step by step, slowly progressive pain management.
I recently treated a middle-age man who came to us with severe knee pain. Ultrasound demonstrated some chronic changes in the tendons and ligaments around the knee, and more importantly, a large amount of fluid in the joint, as well as signs of degenerative joint disease or osteoarthritis. While the other structures surrounding the knee could contribute to some of this patient’s pain, the large fluid in the joint was the most likely cause of his severe pain. We drained his effusion and injected his knee joint with cortisone. This gave him immediate pain relief that lasted approximately three months. When his pain came back, he visited another doctor who did not attempt to drain any fluid from the knee, and only injected the knee blindly. The patient felt no relief at all and came to visit us three days after. As expected, ultrasound demonstrated the reaccumulation of the fluid. We drained this joint effusion, which led to immediate relief of his pain even without the cortisone. We decided not to inject cortisone since his pain completely disappeared, and since his preference was to receive as little medication as possible. We decided that if his pain comes back, we will proceed with the cortisone injection. He still has not called us back, and is looking forward to starting his golf season.
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: