What are Pain Injections?

August 18, 2014August 25, 2016 / Thomas Cohn, MD

Patients often have severe pain that has not responded well to conservative care. Rest, ice, physical therapy, and over the counter medications may not solve the pain problem. When the regular treatments are not working, sometimes it is appropriate to have a specific injection to treat pain. Most injections are used to decrease inflammation that is causing pain from a specific location, such as a joint, tendon, nerve or the spine. The most common medication injected is a corticosteroid, a type of steroid used to decrease inflammation.

The most common steroids used are:

Dexamethasone
Methylprednisolone
Betamethasone
Triamenacelone

How Pain Works

Pain is expressed as sensory signals from a structure that is generating unpleasant signals. The signals travel from a remote location in the periphery of the body, travel by the nerves to the spine, then travel up the cord to the brain to be deciphered. Unfortunately, the brain sometimes cannot identify the exact location that is generating the signals. Injections are recommended by many different physicians to control pain, but since pain is often very complex, determining what should be injected and where to inject it can prove problematic. A good patient history, physical exam, and sometimes, special studies including MRI scans are helpful to identify the possible sources of the pain signals. If the source is possibly acute inflammation and irritation of a structure, placing a steroid injection in the area may allow the structure to return to normal and alleviate pain.

The structures that receive injection include the space around the spine and spinal nerves – the epidural space – joints, areas around nerves, tendons, ligaments, bursa, and muscles. Any of these areas can become inflamed. If they are not healing with conservative care, then placing corticosteroid in the area can allow the inflammation to resolve. Once the inflammation is improved the structures need to be strengthened so that the problem does not return. Sometimes the procedure needs to be repeated to further decrease damage. At other times, multiple structures are inflamed and multiple structures need to be treated.

The key to successful injections includes having someone to determine what is wrong and the structures that need to be treated. Having a skilled clinician perform the injections is important. A physician who has been trained in interventions is also beneficial. The treating physician may be an expert in one of many specialties, but most commonly they are trained in Anesthesia, Physical Medicine or Radiology. An experienced specialist will be able to performed the injection comfortably and effectively. Consult a Physical Medicine pain specialist to develop a comprehensive treatment plan if your symptoms are not resolving.

Ailing Tiger Woods Hopes to be Ryder Cup Pick

August 12, 2014August 12, 2014 / Thomas Cohn, MD

Tiger Woods was able to play through some back discomfort during golf’s final major of the season last week, but he struggled to find a rhythm and missed the cut after posting a +7 through 36 holes.

Many in the golf community believe Woods will take some time off to give his surgically repaired back some rest, but the 14-time major winner hopes to play in next month’s Ryder Cup. Sources say Woods has spoken with USA Ryder Cup captain Tom Watson about a spot on the team, and Watson has been open about Tiger’s chances.

“Tiger said to me: I want you to pick me,” Watson said. “I will continue to speak with Tiger over the next three weeks to monitor his situation. He has not been playing well but I think it’s been a result, as you well know, of his injury and his coming back from back surgery.”

Aside from the nine golfers who automatically qualify for a spot on the Ryder Cup team based on last year’s earnings, each side’s captain is allowed to make three “wildcard” selections. The wildcard selections can be any player regardless of earnings or World Rank.

The nine American golfers who have earned a spot on the team are Phil Mickelson, Bubba Watson, Rickie Fowler, Jim Furyk, Jimmy Walker, Matt Kuchar, Jordan Spieth, Patrick Reed and Zach Johnson. Only Furyk, Kuchar, Watson and Mickelson are ranked ahead of Woods in the current World Golf Rankings. Watson’s wildcard selections are due by September 2.

Comes Down to Health

Watson said he would continue to talk to Tiger about his progression from back surgery, noting that in the end it will come down to Tiger’s health.

“The most important thing is his health. I’ve said it consistently all the way through the issue with Tiger. If he’s healthy and is playing well, I’ll pick him,” said Watson. “Right now, his health is not good. Whether that can change in the next three weeks, as I said, I’ll monitor the situation. I’ll be talking with him and as far as his playing in concerned, I’ll monitor that as well.”

Based on Watson’s words, Woods may be stuck between a rock and a hard place. He needs to prove that his game is up to par, but continuing to play with a less-than-100-percent back could worsen the injury. He certainly won’t want to withdraw from the Ryder Cup during the competition, so Woods will have to be sure he can make it through the grueling competition.

As someone who helps patients with back pain on a regular basis, I know how crippling back pain can be to everyday activities, let alone sport at the highest level. If I had to take a guess at how this situation would play out, I’d bet that Tiger tells Watson that he will remove his name for consideration for selection. It’s obvious that Tiger wants to play, but I think he realizes he needs the rest if he wants to have his best chance at chasing down Jack Nicholas’ record of 18 majors. Tiger won’t want to deal with the media frenzy that would occur if Watson decided not to select him to the team, so I believe he’ll withdraw his name from consideration to remove that decision from Watson’s metaphorical plate.

Pain-Free Tiger Woods Struggles at PGA Championship

August 7, 2014 / Thomas Cohn, MD

Tiger Woods felt fine physically during his opening round at the PGA Championship today, but his golf game wasn’t up to par with his body as he shot a first round 74 to finish Thursday at +3.

After his exit at the Bridgestone Invitational last week, many wondered if Tiger would attempt to play in golf’s final major. Woods arrived to the tournament Wednesday morning in time to get a practice round in, telling reporters after the round he felt “pain-free.”

“I felt pretty good about how I played and the shots I hit,” Woods said of Wednesday’s practice round. “I have to get used to how this golf course is playing.”

Woods looked a little flustered by the course on Thursday, shooting +1 on the back nine and +2 on the front. Currently he sits nine strokes behind Lee Westwood and Kevin Chappell, who both carded an opening round 65.

Back to His Back

Woods opened up about the back injury he suffered at Bridgestone during Wednesday’s press conference. He said he jarred his back when he stepped into a bunker and displaced his sacrum bone.

“Yeah, basically when I landed in the bunker, my sacrum went out,” Woods said. “So pinched the nerve, and hence the spasm. My physio put it back in, and we’ve just been treating it.”

Woods added that he still needs to build strength in his ailing back.

“My physio is here,” he said. “If it does go out, he’s able to fix it. One of those things, again, I still need to build strength, still continue to get stronger. Just going to take more time.”

Woods also noted that his sacrum issue was unrelated to the microdiscetomy operation he underwent on March 31 to address a pinched nerve.

“It was a different pain than what I had been experiencing, so I knew it wasn’t the site of the surgery,” Woods said. “It was different, and obviously it was just the sacrum.”

Woods said he took anti-inflammatory medication prior to his practice round, but he didn’t take any pain meds or receive a cortisone shot. He’ll try to end up on the right side of the cut line when he tees off Friday at 1:45 pm ET.

Related source: ESPN, USA Today

Tiger Woods Is Past His Prime

August 5, 2014February 17, 2016 / Thomas Cohn, MD

Tiger Woods is an excellent athlete who has strived to stay in the best of condition, but unfortunately he is no longer in his prime. To be a top-notch athlete, one needs to be able to perform without distraction and have a perfectly tuned body. Tiger is no longer 25 years old and in perfect health. Today, there are many professional golfers who are younger and in better health. A 25-year-old Woods may be better than a 25-year-old Rory McIlroy, but Woods doesn’t have the luxury of a time machine. The injuries that Tiger has had are not going to heal perfectly and his performance is clearly in decline.

Tiger Woods is now 38 years old and he is certainly past his prime. Woods has had significant knee surgeries and recently underwent a Microdiscectomy for a lumbar disc protrusion in his back. The body and all its parts age and show signs of wear in everybody. Typically by the age of 30, there are often subtle changes in the spine and joints as we stress them. The cartilage in the knee joints can show changes, and in the spine the discs bulge, tear, and show degeneration. By age 40, everyone has different signs of deterioration throughout the body. The design of the body is such that we can do most activities well until about age 40. 150 years ago, it was typical that people would die due to trauma, disease, infections, or even heart problems by age 40-50 years. Today, we are outliving the design of our body since we have better medical care.

The difference between amateur and professional athletes is the level of perfection they achieve in their sport. Physically, to achieve that level of perfection, everything in the body must be in perfect shape. A slight abnormality in the body sometimes can be compensated for, but often the level of ability is diminished. Today, the difference between the best athletes and an average athlete is the ability to do everything in a sport without compromise. Tiger’s back and knee injuries are forcing him to compromise. Tiger may be able to golf and occasionally win, but he will not be a future force and consistent top contender.

PGA Championship in Doubt

Woods was forced to withdraw from last week’s Bridgestone Invitational after suffering another setback with his surgically repaired back. The injury occurred as Woods took a step into a bunker on the 9th hole, and he withdrew from competition shortly thereafter. Some speculate that Tiger only withdrew because he was out of contention and didn’t want to jeopardize his chance to play in golf’s final major of the year this week at the PGA Championship, but his absence from the course Tuesday shows that something is clearly wrong with Woods.

Woods’ agent said the 38-year-old was at his home in Florida resting, but Tiger’s caddie went to the tournament to scout the course in case he decides to play, so there’s still a chance the 14-time major winner will chase another tour victory this week. We should know more about his status by the end of the day Wednesday. We’ll provide an update once more is known.

Painkillers Most Often Prescribed in the South

July 31, 2014 / Thomas Cohn, MD

Many people have heard the term “Minnesota Nice,” but the term “Minnesota Tough” may soon be a new moniker after it was revealed that Minnesota was among the lowest per capita states for pain pill prescriptions.

The report published earlier this month by the Centers for Disease Control and Prevention assessed painkiller prescriptions and analyzed how they varied state to state. The study analyzed prescription totals for common painkillers including Vicodin and OxyContin, and the findings uncovered an alarming trend about painkiller prescriptions, particularly in southeast.

Alabama had the highest rate of prescriptions, followed closely by Tennessee, West Virginia, Kentucky, Oklahoma, Mississippi and Louisiana. Doctors in the south also had higher prescription rates for antibiotics and stimulants for children.

The study wanted to pinpoint the problemed states after some concerning overdose death trends emerged over the last few years. In 2011, 41 percent of the 41,000 overdose deaths were from prescription pain meds.

“Prescriptions go up, deaths go up. Prescriptions go down, deaths go down,” said CDC Director Dr. Tom Frieden.

Frieden added that more drug monitoring programs at the state level and more laws aimed at shutting down “pill mills” are two main ways local and national governments could help curb prescription painkiller overdoses.

Minnesota’s Number Encouraging

Although the exact numbers aren’t known, USA Today published a color-coded map that determined whether a state’s total painkiller prescription per capita total was low, medium, high or very high. Minnesota was one of 13 states to earn the “low” distinction along with Alaska, California, Colorado, Hawaii, Illinois, Maine, Massachusetts, New Jersey, New York, South Dakota, Vermont and Wyoming.

Aside from being tough, it appears that Minnesotans are aware that pain care needs to be a multi-faceted approach. There is no magic pain pill. Prescriptions need to be combined with diet, exercise, physical therapy and help from a trained professional if you want to give yourself the best chance to live a pain free life.

Keep it up, Minnesota.

Related source: Lee County Courier