Joint and Muscle Pain

Prolonged use of NSAID’s can increase blood pressure, cause gastrointestinal bleeding, increase the risk of heart attack and stroke, and cause kidney damage. They also increase the propensity to bleed so patients on blood thinners or who have problems with bleeding disorders should avoid these medications. They are not a good choice for patients who have had bariatric (weight loss) surgery.

Steroids are potent medications that reduce inflammation. They are useful for a multitude of conditions associated with inflammation, including arthritis and soft tissue/musculoskeletal pain. While they have more potent anti-inflammatory effects than NSAID’s, they have no pain-relieving properties.

Marketers selling a variety of “natural products” often exaggerate the side effects of steroids while downplaying the benefits. Steroids can have many side effects when taken for a long time (greater than 3 months). For a short course of 5-10 days of steroids, which is what we typically use, side effects are usually limited to:

• gastrointestinal upset (which is why we advise taking it with food and usually add something to protect the stomach)
• insomnia (which is why we recommend taking it in the morning)
• potentially increase blood sugar transiently

A short course of 5-10 days of steroids is very unlikely to cause significant weight gain if the person taking the steroid does not overeat.

Muscle relaxants are medications used to reduce muscle spasms or tightness. Because of this, they also cause sedation or sleepiness. In fact, muscle relaxants that do not cause some sedation typically don’t have much of an effect at all.

This is why they are usually prescribed for use at bedtime. They typically do not cause any gastrointestinal problems but they have to be taken with caution to avoid becoming over-sedated. Be sure to follow all instructions regarding the use of these medications.

Opioids are potent pain medications but have very limited anti-inflammatory effects. Like other medications, they can be addicting if used improperly. They can also cause constipation, sedation, and dysphoria (make you feel bad).

When used for a long time, opioids begin to lose their pain-relieving effects, but the side effects do not diminish. That is why it is best to minimize the use of opioids or avoid them altogether. In order to decrease the risks associated with opioids, the amount prescribed is limited or reduced. This helps preserve the patient’s ability to continue to benefit from these medications.

Patients usually receive an initial evaluation by the therapist, who develops a treatment plan tailored to the patient’s specific conditions. This is followed by several weeks of therapy sessions. Depending on the condition, therapy can include modalities such as heat or cold, therapeutic ultrasound, massage, stretching and range of motion exercises, as well as strengthening or resistance exercises. Usually, patients are also given a home exercise program to supplement the work done in physical therapy and prevent future injuries.

There are many types of therapy in addition to physical therapy and occupational therapy. Some specialized therapy programs include gait rehabilitation to improve balance and walking, vestibular rehabilitation to control vertigo, pelvic floor rehabilitation for pelvic pain and incontinence, and aquatic therapy which is done in a pool. Depending on the patient’s condition we may order more specialized therapy.

Some patients may need mobility aids in addition to therapy. Ideally, part of the therapy program will include instruction on how to find and use the appropriate device. Below is some information regarding canes, walkers, and braces that are commonly used by pain patients.

Viscosupplementation: For chronic knee pain due to arthritis, we may recommend viscosupplementation, which involves injecting hyaluronate into the knee. This is a good alternative to repeated steroid shots and works best when there is still some cartilage remaining in the knee. If the joint has already become “bone-on-bone,” this treatment is less effective.

Viscosupplementation doesn’t work as well for other joints like the hips or shoulders. In those cases, we may use prolotherapy as an alternative.

Choosing the Right Cane

• Select a cane that reaches the crease of your wrist when standing upright with your arms relaxed at your sides.
• You should not have to stretch your arms out fully to use the cane properly. Your elbow should bend slightly (about 15-20 degrees) when holding the cane.
• The handle should be at about the height of your pants pockets. Adjustable canes make this easier.
• Ensure it has a comfortable grip and a sturdy base for stability.
• Some patients may require a quad cane (a cane with 4 feet) for extra stability.

How to Hold the Cane

• Hold the cane in the hand opposite the injured or weaker leg. This helps distribute weight more effectively.
• Keep your elbow slightly bent (about 15-20 degrees) for better control.

Walking with a Cane

• Move the cane forward at the same time as your weaker leg.
• Step forward with your stronger leg while keeping the cane steady.
• Repeat the pattern, ensuring smooth and controlled movements.

Using a Cane on Stairs

• Going Up – Step up with your stronger leg first, then bring the cane and weaker leg up together.
• Going Down – Place the cane on the lower step first, then step down with your weaker leg, followed by your stronger leg.

Choosing the Right Walker

• Select a walker that fits your height—when standing upright, the handles should align with the crease of your wrist.
• Choose between a standard walker (without wheels) for maximum stability or a rolling walker (with two or four wheels) for easier movement.

How to Use a Walker

• Standing Position: Stand upright between the back legs of the walker, keeping your hips aligned with the frame.
• Moving Forward: Lift or slide the walker one step ahead of you.
• Step with the Weaker Leg First: Move your weaker leg forward while placing weight on the walker.
• Step with the Stronger Leg: Bring your stronger leg forward to meet the weaker leg.
• Maintain Good Posture: Keep your shoulders back and avoid hunching over the walker.

Using a Walker on Stairs

• Going Up: Step up with your stronger leg first, then bring the walker and weaker leg up together.
• Going Down: Place the walker on the lower step first, then step down with your weaker leg, followed by your stronger leg.

A properly fitted brace should support your spine or joint without causing discomfort or limiting circulation. Long term use of a brace simply for pain relief without a clear goal, however, can cause gradual atrophy of the muscles around the joint or spine and lead to dependence on using the brace to maintain proper alignment, good posture, and control pain. Braces should not be used without medical supervision.

Spinal Braces – (also known as spine orthotics) are supportive devices designed to help stabilize the spine, reduce pain, and improve posture. They can be used for conditions like scoliosis, back injuries, or post-surgery recovery.

There are times, such as when recovering from a vertebral fracture or after spine surgery, when a spinal brace can help improve provide pain relief and assist recovery. Braces can also be used for posture correction in patients with adolescent scoliosis. In some occupations, braces are used to prevent back injuries when doing heavy work.

Symptoms of SI joint pain include:

• Pain in the lower back, buttocks, or hips and can sometimes spread to the thighs or groin.
• It might feel worse after sitting or standing for a long time, climbing stairs, or taking large steps.
• Some people experience stiffness or a feeling of instability in the hips or lower back.

• Trauma or injury: A fall or sudden impact can damage the sacroiliac joints.
• Degenerative changes: Age-related wear and tear on the sacroiliac joints and surrounding ligaments.
• Autoimmune conditions: Ankylosing spondylitis (AS), rheumatoid arthritis (RA), and other autoimmune conditions commonly affect the sacroiliac joints.
• Repetitive stress: Activities like heavy lifting, jogging or running, or prolonged sitting with bad posture can strain the joints.
• Pregnancy: Hormonal changes and added weight can loosen the joints.
• Infections or tumors: Rarely, nearby infections or tumors can cause SI joint pain.

Lifestyle changes can play a significant role in managing sacroiliac joint pain. Here are some helpful adjustments:

• Use good posture: Sit with proper alignment, avoiding slouching.
• Modify physical activities: Avoid activities like jogging or running that can put extra strain on the sacroiliac joints. Always use good form when weight training.
• Maintain a healthy weight: This reduces stress on the sacroiliac joints.
• Maintain good bone health: Osteoporosis and even osteopenia can speed up wear-and-tear of the sacroiliac joints.

• Medications: Oral and topical.
• Physical therapy: Strengthening and stretching exercises for the lower back and hips.
• Sacroiliac joint injections: To reduce joint inflammation and pain.
• Surgery: Rarely needed, but an option for severe cases.

Coccydynia is a condition that causes pain around the tailbone, which is the small bone at the bottom of the spine. This area is medically referred to as the coccyx, but most people commonly refer to coccydynia as tailbone pain.

Symptoms include:

• Pain or tenderness at the base of the spine (the tailbone), especially when sitting.
• Discomfort that worsens with prolonged sitting, especially on hard surfaces, or leaning backward.
• Pain during activities that put pressure on the coccyx, such as cycling.
• Sharp pain during movements like standing up from a seated position.
• Pain during bowel movements due to pressure on the coccyx.
• Pain during sexual activity may occur in some cases.
• In severe cases, pain may spread to nearby areas like the lower back or hips.

• Trauma or injury: Falls or direct impact can bruise, dislocate, or fracture the coccyx (tailbone).
• Repetitive strain: Activities like cycling or rowing that involve prolonged pressure on the tailbone.
• Prolonged sitting: Sitting on hard or narrow surfaces for extended periods.
• Poor posture: Slouching or improper alignment while sitting can strain the tailbone.
• Obesity: Excess weight can increase stress on the tailbone.
• Degenerative changes: Age-related wear and tear on the coccyx or surrounding structures.
• Pregnancy and childbirth: Hormonal changes and pressure during delivery can strain or injure the coccyx.
• Infections or tumors: Rarely, nearby infections or tumors can cause tailbone pain.

Lifestyle changes can play a significant role in managing coccydynia (tailbone pain). Here are some helpful adjustments:

• Avoid prolonged sitting, especially on hard surfaces. Take frequent breaks to stand or walk during long sitting periods.
• Use a cushion with a cutout or sit on a soft surface to help reduce pressure on the affected area.
• Use good posture. Sit with proper alignment, avoiding slouching.
• Modify physical activities. Activities like cycling, squatting, or horseback riding can make symptoms worse. Consider adjusting or avoiding these activities to prevent flare-ups. Cyclists may need to use a custom seat to avoid putting too much pressure on the coccyx.
• Strengthen core muscles to support the spine and pelvis and focus on low-impact exercises like walking to avoid strain on the coccyx.
• Eat a high-fiber diet to prevent constipation and reduce strain during bowel movements.
• Maintain a healthy weight to reduce stress on the coccyx.
• Learn techniques to relax the pelvic floor muscles and reduce stress. Diaphragmatic breathing or gentle stretches can help ease tension and reduce pain.

Successful treatment usually consists of one or more of the following:

• Medications: Oral and topical (such as creams or suppositories).
• Pelvic floor therapy: A specialized type of physical therapy for treatment of pelvic conditions.
• Biofeedback and counseling: As an alternative or complement to medications.
• Acoustic wave therapy: Another alternative or complement to medication that can promote healing of the muscles, tendons, and ligaments around the coccyx.
• Injections along the sacrococcygeal ligaments and other soft tissue around the coccyx: To reduce inflammation and pain of the ligaments and tendons.
• Caudal epidural steroid injections: To reduce inflammation and pain at the coccyx.

Coccygectomy (removal of the coccyx), is considered only when all other treatments fail. This is a major surgery with a prolonged recovery time that is not always successful in controlling the pain.