Muscle - Ask Dr. P - The Pain Doc

Muscle Atrophy from Kenalog (Cortisone) Injection

by Pain Doc | Aug 10, 2013 | Uncategorized

If you are considering getting a cortisone shot for pain or allergies, I highly recommend that you do your due diligence in researching the safety of cortisone injections before you do it.

What exactly is cortisone? It is a type of corticosteroid. Corticosteroids are a class of chemicals naturally produced in the adrenal cortex (adrenal glands above the kidneys) that are used to regulate multiple body functions. The cortisone in cortisone shots are analogues (molecularly identical) of these hormones that are synthesized in laboratories.

According to Medicinenet,

Corticosteroids can be taken by mouth, inhaled, applied to the skin, given intravenously (into a vein), or injected into the tissues of the body. Examples of corticosteroids include prednisone and prednisolone (given by mouth), methylprednisolone sodium succinate injection (Solu-Medrol) (given intravenously), as well as triamcinolone, Kenalog, Celestone, methylprednisolone (Depo-Medrol), and others (given by injection into body tissues).

Corticosteroids affect a number of physiological responses including inflammation modulation, immune response, carbohydrate metabolism, protein catabolism (breakdown), stress response, immune response, and behavior/mood.

Cortisone shots for pain reduction have powerful anti-inflammatory capabilities, which is why they are a popular with orthopedic doctors in the treatment of injuries and joint pain. Cortisone shots, when they work, act almost instantaneously. They reduce pain by reducing the inflammatory response around the localized injection. Cortisone shots also usually include an anesthetic drug such as lidocaine.

Side effects can include redness and temporary increase in pain, and dermatological effects like skin discoloration (especially in dark-pigmented patients).

Severe side effects from prolonged steroid use or large doses can include hyperglycemia, insulin resistance, diabetes mellitus, osteoporosis, cataract, anxiety depression, colitis, hypertension, seizures, fainting, peptic ulcers, erectile dysfunction, hypogonadism, hypothyroidism, increased menses, and retinal damage.

Kenalog (Triamcinolone) is a type of corticosteroid that is used to treat inflammation; particularly inflammatory skin diseases like lupus; allergies, rhinitis, and bronchospasm. It is known to cause plenty of undesirable side effects especially dimpling/pitting at the injection site. Women especially are known to get terrible side effects from Kenalog injections, notably prolonged/ painful menstrual cycles.

Previously I related a personal experience where, due to the urgency of the situation, I decided to get a cortisone shot for severe neck pain and spasm (which I found out later was hyperkalemic muscle paralysis and did not involve inflammation). I had three Kenalog injections along my left upper trapezius muscle, about a 5 mL dose. Normally I avoid taking medications and injections for pain as much as possible, but I was scheduled to drive a 400 mile trip the next day and needed immediate relief.

Well, it turned out to be a very bad experience. The shot atrophied the muscle, and now I am unable to raise it above shoulder level from the side. The doctors I consulted with were uncertain of the long term prognosis. I was advised to get physical therapy (which I have been doing myself) to encourage the muscle to regain its functionality. However, it doesn’t appear to be changing. An ominous fact I learned during my research of corticosteroids is that protein catabolism (breakdown of protein into its amino acids components) is one of the functions of natural corticosteroids. Could it be that the Kenalog shot “dissolved” some muscle tissue? I certainly hope that is not the case. If it were, it is not possible to rebuild that muscle tissue through weight lifting, as muscle hypertrophy from weight lifting works for existing muscle tissue only.

The experience was so bothersome that I decided to make a case study out of it for readers of this blog, and hopefully save someone from going through this awful experience. Before you get a Kenalog injection, make sure you know what you are getting into. My advice, skip it— the problems it causes appear to outweigh the benefits (see this internet message board on muscle atrophy from Kenalog injection). Instead, try less invasive procedures appropriate for your condition such as massage, chiropractic, acupuncture/cupping, botanicals/herbs, laser treatment, ultrasound, traditional Chinese medicine, gluten-free diet, ketogenic diet, fasting, juicing, and detox/cleanses.

Hamstring muscle strain from running

by Pain Doc | Jun 29, 2012 | Uncategorized

I have a patient who complains of acute pain right under the right butt cheek, and inner part of the thigh. It is a persistent pain that has been bothering him for weeks and also feels stiff. He is in his mid 50s, professional, and in good health other than “high” cholesterol, for which he takes Lipitor.

The pertinent history for this patient is that he is an avid runner, and has been running regularly since his 20s. He is one of those folks who enjoys the feeling of running, during and after. It is a form of stress relief for him. He also does Pilates using the reformer, and enjoys 3-4 glasses of wine on most nights.

The area in question is the biceps femoris tendon, which is part of the “hamstrings” of the leg. It functions as the major knee flexor of the leg (its agonist, opposing muscle is the quadriceps group). The biceps femoris muscle inserts into the ischial tuberosity, which is the bony part of the ischium (half of the pelvis) that we use to sit.

Without the benefit of an MRI or CT scan, and based mostly on the history and lack of other findings that would cause me to think otherwise, I diagnosed myofascial strain of the biceps femoris tendon, with possible tendinopathy (degradation of the tendon from overuse). Basically, something has happened to the muscle and tendon that is resulting in unrelenting pain.

Running is the repetitive, alternating contraction and relaxation of opposing muscles. The most stress occurs at the tendinous attachments to the anchor points on the bone. However, the spot where the tendon attaches to bone is stronger than the breaking point of the tendon itself, so when it is stressed, the body of the tendon will experience tearing (strain) first. It is rare for a tendon to separate from bone at the attachment site. This is the case for this patient, as his pain is described as about 2-3 inches from the attachment point on the ischial tuberosity.

I am treating his injury with a LiteCure deep tissue laser and have given him a nutritional prescription consisting of whey protein to provide the building blocks for repair; high potency fish oil and capsaicin to help reduce the inflammation, and bromelain supplements to serve as an enzyme to soften scar tissue formation. Today, I advised him to drink distilled water for 2-3 weeks. Distilled water may have a chelating-type of effect (binding) on dissolved, inorganic toxins or debris in tissues, which could help with the situation; it is often used for detox programs because of this quality. He was advised to rest, ice and compress the area for 3 days to help suppress the inflammatory reaction.

The case is a very interesting one that will hopefully have a good outcome. We should realize that a muscle is very much like an organ of the body, although it is rarely referred to as one. It has its own unique type of cells, blood supply, and plays an important function. As in all cases of disease of the body, a good strategy is to give it an edge in repairing itself. Diet modification, concentrated, high potency supplements, and non-pharmacological, manual therapy, when used in the right manner can oftentimes hasten recovery.

Prolotherapy: A Controversial Remedy for Muscle and Ligament Pain

by Pain Doc | May 28, 2011 | Uncategorized

Prolotherapy, short for proliferation therapy is a controversial technique that involves a series of injections of an inactive irritant substance into a painful joint, or area where ligaments or tendons insert into bone. The injected substance can be dextrose, phenol, saline solution, glycerol, lidocaine, or even cod liver oil extract. Prolotherapy injections are intended to artificially initiate the natural healing process by causing an influx of fibroblasts that synthesize collagen at the injection site, leading to the formation of new ligament and tendon tissue.

Some of the signs that might benefit from prolotherapy include:

Joint laxity, such as in the shoulder, that does not resolve with standard treatment
Distinct tender points at tendons or ligaments as they attach to the bones
Unresolved, intermittent swelling or fullness involving a joint or muscle
Popping, clicking, grinding, or catching sensations in joints
Temporary benefit from chiropractic manipulation or manual mobilization
Aching or burning pain that is referred into an upper or lower extremity
Recurrent headache, face pain, jaw pain, ear pain
Chest wall pain with tenderness along the rib attachments on the spine or along the sternum
Spine pain that does not respond to surgery, or where there is no definitive diagnosis despite X-rays, MRIs and other tests.

So why is prolotherapy considered “controversial?” Because, according to the federal government (Health Care Financing Administration) there is currently no strong, compelling study that proves prolotherapy can cure cases of soft tissue pain. A “strong” study is one that has at least several hundred test subjects; has a control group (who get a placebo, or fake treatment) and is done in a “double-blind” methodology where the test subject and the administering doctor do not know if the injection is a prolotherapy agent (only a third member of the research study knows). However, there are numerous studies in the literature using smaller test populations (less than a hundred) that support prolotherapy as an effective treatment for pain.

A 2005 study entitled A systematic review of prolotherapy for chronic musculoskeletal pain (Clin J Sport Med. 2005 Sep;15(5):376-80) analyzed major studies on prolotherapy and reached the following conclusion:

Two RCTs (randomized controlled trials) on osteoarthritis reported decreased pain, increased range of motion, and increased patellofemoral cartilage thickness after prolotherapy
Two RCTs on low back pain reported significant improvements in pain and disability compared with control subjects, whereas 2 did not. All studies had significant methodological limitations.

There is a research project at the University of Wisconsin involving prolotherapy to treat knee osteoarthritis that is due to publish its results soon.

So, if you have chronic musculoskeletal / joint pain, especially related to trauma, that has not resolved with cortisone injections, chiropractic, physical therapy, personal training, surgery, and time, prolotherapy may be worth investigating. The good thing about it is that it is generally safe.

Foot Pain Can Be Caused By This

by Pain Doc | Dec 20, 2010 | Foot and Ankle Pain

Image via Wikipedia

If you have pain in your feet, it could be that your feet’s intrinsic muscles are weak and are not supporting and moving your foot bones properly during gait (walking). As a result, certain bones can bear more weight pressure than others and develop pain; for example the first metatarsal-phalangeal joint (big toe joint).

Muscles can become weak when they are underused, or immobilized in some way over a long period of time. For example, if you fracture your lower leg and had to wear a cast for three months, that leg would be smaller than the non-injured leg after taking off the cast. This is because the calf muscle in the injured leg would experience some atrophy due to three months of decreased muscle activity. You would most likely feel the difference in leg strength as well, after removing the cast.

But what would cause the foot muscles to weaken? It’s a very simple action just about everyone does in the morning before going to work, and that is putting on shoes. Shoes, especially snug fitting ones like lace-up formal leather shoes with hard heels constrict the feet and don’t allow proper engagement of the foot joints when walking. Basically, shoes act like a cast or splint on your feet. Imagine wearing a shoe-equivalent on your hands, lacing them up tightly for nine hours a day. Your hands would weaken eventually, and probably experience pain.

So what’s the solution? Realize that the feet are designed to grip the ground with the toes/ forefoot, and elongate slightly at the arch to build up energy for toe-off during gait. The toes splay out when bearing weight to increase stability to the body above. Wearing shoes inhibits all these actions and can have an adverse effect on foot biomechanics.

Therefore, it is a good idea to exercise your feet by walking barefoot; preferably on a non-flat surface. Find a grassy park and try running barefoot. These activities will offer badly needed exercise (strengthening and stretching) for your feet. If you’re like most people who have been wearing shoes most of their lives, your feet will be highly sensitive to the pebbles and small objects on the ground; this is normal. Keep walking and running barefoot as much as you can, breaking them in but obviously avoiding sharp objects on the ground. This will strengthen your feet and make it more resistant to developing foot problems.

If you arent’ into going barefoot, the next best thing is to wear the Vibram Five Fingers KSO – Men’s walking “shoe.” It offers the protection of a shoe, while offering the most freedom of movement of your feet.

Whey Protein – Great Supplement for Healthy Tissue Healing

by Pain Doc | Sep 16, 2010 | Uncategorized

Image via Wikipedia

Whenever you suffer an injury to the musculoskeletal system, there is some degree of tissue damage. In minor sprains and strains, it is microscopic tears to the fascia, muscle fibers, tendons and ligaments; in major sprains and strains it is complete rupture or tearing of large groups of muscle, ligament and/or tendon fibers.

The first thing the body does at the onset of the injury is initiate the inflammatory response. Various biochemicals constitute inflammation; each having an important role. Inflammation confines the injury to the injury site and is actually the first step in tissue repair. It is only when it is overproduced that it becomes a problem in itself (which is why you should use ice therapy to mediate swelling the first few days after an injury).

At some point, the body sends special cells called fibroblasts to the injury site. These cells synthesize connective tissue comprised of collagen to close the tears of the injury.

Collagen is the main protein of connective tissue in animals, making up 25%-35% of the total protein content . It forms as elongated fibrils (long chain of amino acids in a strand formation) and is mostly found in fibrous tissues such as tendon, ligament and skin, as well as other places in the body.

Therefore, after sustaining an injury, the body needs a ready supply of protein in order to properly heal itself. If you recently sustained a soft tissue injury such as a sports injury to a joint, whiplash car accident, or sprained your lower back from heavy lifting, make sure you are eating enough protein. I recommend whey protein due to its ability to be digested very rapidly, making it available for use shortly after consumption. Whey is a protein-rich byproduct that is formed during cheese formation, usually from cow’s milk.

Body builders and athletes drink whey protein shakes after workouts to help increase amino acid levels in the blood, which are taken up by the muscles to ultimately increase mass. During exercise, whey helps improve blood flow by inhibiting an enzyme that constricts blood vessels; this allows better flow of nutrients to needed areas to help repair and rebuild muscle tissues.

Leucine is an amino acid found in whey protein shakes. When leucine is ingested in high amounts it stimulates protein synthesis, which may speed recovery and adaptation to the stress that occurs from heavy exercise and injuries.

Another good source of protein is eggs. Eggs are a complete source of protein, especially the yolk. Cook them at low heat; and if you have the stomach for it, eat them raw.