At NMPM we specialize in Interventional Pain Management. An intervention is a strategy to step in (intervene), usually with injections, when other more routine methods are not working. PRP Stem Cell Joint Repair is the interventional pain management procedure that we emphasize as having the greatest effect of permanently resolving musculoskeletal pain by repairing damaged tissue by literally regrowing it in specific focused areas. Yet, there are other interventional pain management procedures, and some are listed below.
This is an older method that predates PRP Stem Cell therapy. PRP Stem Cell therapy is widely accepted to be stronger and more effective. But in the right situation, prolotherapy can still be useful or perhaps more convenient. Instead of concentrated super cells from blood, the older prolotherapy method most commonly involves injection of dextrose, a simple sugar, which is approved by the FDA for use in prolotherapy to grow and repair tissue. Click here for an entire page about prolotherapy. It will be up to your doctor to judge if prolotherapy is worth considering in your case.
Research studies in the past decade have shown that growth and repair can occur in tendons and ligaments by simply numbing them and poking many holes in them with a hypodermic needle. The concept is that the human body responds to an injury with repair. Injections can serve as a planned small injury just significant enough to kick start growth and repair of the structure that is repeatedly poked. While it is possible to use just such tenotomy (for a tendon) or fasciotomy (for fascia tissue), instead we usually use some tenotomy, and we add strong resources, such as stem cells, platelets, and white blood cells, for that calculated little injury to heal itself most thoroughly. Nevertheless, it should at least be educational to understand that part of the reason for the success of all of our regeneration procedures is that they involve some small, planned injury, exactly at the tiny places where the new growth and repair needs to happen.
We may “numb” some nerves with local anesthetic so that other injections after that will be more comfortable. While some of the time the subsequent injections may not be felt at all, it is more common for our regional anesthesia to just make the subsequent injections more comfortable. It is common for there to be variability in how effective the regional anesthesia is, from area to area, from time to time, from person to person. In many areas of the body, no effective regional anesthesia is possible, while in some other areas we choose not to be as heavy handed as anesthesiologists have to be with regional anesthesia for open surgical procedures. Plus, regional anesthesia adds time to the procedure, and you may need to stay in the office longer after the procedure before driving home. Even when regional anesthesia is possible, numerous patients try it and eventually elect not to bother with the extra hassle and time regional anesthesia involves, as they find that our injections are quite tame and manageable without regional anesthesia. Depending on the areas being treated, your doctor will make practical recommendations about how effective or worthwhile some regional anesthesia might be in your situation. In summary, we use regional anesthesia selectively, but we caution patients ahead of time not to expect complete “numbing” of the anesthetized part.
By the way, we do not use corticosteroids in our regional anesthesia injections
Over and above the use of nerve blocks for regional anesthesia, there is a separate reason to perform nerve blocks. The nerve blocks turn off or partly turn off the injected nerve for an hour. When it comes back on, we commonly see it behave a bit better. When you have a computer that is misbehaving, you may reboot it – turn it off and then turn it on – and this may resolve some computer problems. When a child in pre-school is misbehaving, they may be given a “time out”. When they come back from the time out, they may behave better with the other children. When a nerve has been painful and irritated for some time, this bad behavior may possibly be ameliorated by a nerve block, which turns it off, only to have it turn back on in about an hour, with the complex nerve function returning in a bit more orderly manner. Sure, there are physical, mechanical reasons for the bad nerve behavior; however, some of the bad nerve behavior reflects a habituated irritated state, and that can be reset, rebooted, refreshed, and thus regulated, hopefully making it feel somewhat better for weeks, a month, or longer. Results are partial and variable, and they work better with 1.) repetitions of the nerve block, and, of course 2.) repair of the cause of the nerve irritation. Still, nerve blocks are a great tool for making your pain lessen somewhat sooner than later. Many PRP Stem Cell procedures incorporate pain management nerve blocks. A few of these pain management nerve blocks can be used alone, without PRP or other procedures.
By the way, we do not use corticosteroids in our pain management nerve blocks.
It is a common strategy in interventional pain management to destroy some nerves that are causing pain. The nerves do grow back over part of a year. We believe such strategies have a place, yet we approach the process of such neurolysis or neuroablation with caution. We use milder, safer versions of these techniques, and in just a few clinical situations. For example, a Morton’s neuroma is a painful enlargement of nerve tissue in the foot near the toes. We find neurolysis to be a reasonable strategy for this disfigured nerve tumor. While other interventional pain management specialists commonly aim to destroy the neuroma all at once using stronger medicines, such aggressive approaches risk surrounding tissue damage and side-effects. We use a mild 4% alcohol injection, repeated comfortably over a series of monthly procedures, to accomplish the same goal more safely. We simultaneously use tissue regeneration procedures to stabilize the bones of the foot so they irritate that nerve less into the future, reducing cause for the return of a neuroma.
Injury, trauma, or repetitive overuse may in some people cause certain tissues to pinch on or adhere to a nerve. Pain, tingling, numbness or weakness may result. With ultrasound imaging, we may be able to see changes in the width of the nerve near where it might be pinched. Using ultrasound to guide injection, we are able, in a few areas of the body, to separate the tissue binding to and pulling the nerve, to soften the tissue pressing on a nerve, or, over time, to stimulate repair and eventual compacting of an enlarged structure pressing on a nerve. The injected substance could be PRP, 5% dextrose, local anesthetic, or some combination. In some cases, 1-2 procedures suffice. In cases where a structure needs to be gradually repaired and compacted back to normal size, it could take more repetition, much like any PRP Stem Cell procedure. The medical term for the short-term release process is sonographically guided percutaneous needle neuroplasty. What you need to know is that it may at times be an option for relieving some pain that you have.
A trigger finger is a finger that may occasionally lock in a bent position. Some cases are mild and painless. If such a finger locks often, and painfully, and possibly requires you to use your other hand to straighten it, you may need some intervention to fix that trigger finger tendency. The cause of the locking is wear and enlargement of tendons along the palm side of your trigger finger that pull your hand into a fist. Those tendons, at any one finger, need to go through some fabric tunnels, called pulleys, that hold the tendon close to the palm side of the finger bones, particularly to the palm side of the big knuckles of your hand. When the tendons in question are enlarged, like a worn, frayed rope, the get pulled through the fabric tunnels by the force of your grip muscles in the soft side of your forearm, but then they don’t easily come back out from those tunnels when your grip lets go.
We do not perform corticosteroid injections in general, as there are some negative side effects. However, we also try to rational and balanced. In some cases, corticosteroid injection of the trigger finger may be a reasonable option.
Optionally, we have two injection approaches to offer, often in combination:
The most important longer term strategy should always ideally be to renew and compact the enlarged frayed rope-like tendons, so that in time they compact and move through the fabric tunnels more easily. This is suitable for any of the fingers, or for the thumb.
The surgical approach is to open up the hand and fully cut one key fabric tunnel. We can cut or just shave/loosen that one key fabric tunnel safely, but without open surgery. This strategy is advisable for the most common trigger fingers at the 3rd and 4th digits (long and/or ring fingers). It is not suitable for use at the thumb. Even if we agree to use this method, we prefer to apply it incrementally, and to always emphasize the need to also regrow and compact the tendons that go through that fabric tunnel.
Trigger points are muscle knots that most adults have experienced in places such as the upper back. Such knots in any area of the body are overactive and thus contracted muscle tissue. And, such knots are always part of a taut band that extends from one end of the muscle to the other. Such trigger points may be a problem for at least the following reasons:
- local pain at the trigger point
- referred pain from the trigger point, even far from the trigger point
- muscle shortening
- muscle weakening because the muscle can’t be used and strengthened through its full range of motion
- simple or complicated dysfunction of other muscles and joints in the region effected by the dysfunctional, shortened muscle
There are some advantages for us to refer patients with problematic trigger points to physical therapists or other therapists who are trained in, and ideally who specialize in, using their hands in massage and stretching type hands-on therapy to manually release the effected muscle, and, ideally, the many related surrounding muscles. Many muscles may be involved in the region, or away from that region, in what we sometimes call a complex “soap opera” of muscle interactions. A few hour-long sessions thoroughly covering such regions using manual (hand) methods are thus often recommended.
At the same time, there are some advantages of injection of worse trigger points, and if we are in the midst of some greater interventional process, we may just add in some injection of just a few of your worst muscle trigger points.
More importantly, if it turns out that some of your pain is from muscle trigger points, it is worth our time to evaluate whether the trigger points are caused by, or perpetuated by, damaged tendons on the ends of the same muscle, or some other joint problem putting too much imbalanced stress on that muscle. The solution may be injections to regenerate those tendons or the underlying joint.
Some scar tissue, like that from deep spinal surgery, is far inside the body, hard to visualize, and difficult for anyone to treat. Some scar tissue closer to the surface may be softened by injection of local anesthetic and water, or possibly some natural enzymes that partially dissolve scar tissue. IF such scar tissue appears to be causing pain, limitation of motion, or altering joint mechanics, then it may be worth treating. Our injection methods may be suitable.
A new type of surface injection for pain has been developed in the past decade of so, and it is gaining popularity. It is a disarmingly simple injection of a very weak sugar solution, barely under the skin, in the area of pain. The amount of sugar is just 5%, much less than for prolotherapy. Many little bubbles of weak sugar solution are raised in the region of pain. The scientific theory is that this immediately calms inflammation of surface nerves. Pain relief can be immediate. Repetitions may be necessary, like perhaps weekly, but some pains will just go away, while others will require treatments of different sorts. Still, it is a non-toxic and wildly simple and easy procedure, and at times we may add it to some other injection process. See the reference section below for more info.
Click here for a book chapter on the scientific evidence for prolotherapy.
Dean Reeves, MD is Clinical Associate Professor at the University of Kansas. Click here for his summary slides on the topic “Prolotherapy is Not Experimental”, and those slides make reference to studies detailed on his website at this link.
Click here for a longer technical slide show by Dr. Reeves about the scientific evidence for dextrose prolotherapy as well as PRP and stem cell therapies.
Finnoff JT, Fowler SP, Lai JK, Santrach PJ, Willis EA, Sayeed YA, Smith J. Treatment of chronic tendinopathy with ultrasound-guided needle tenotomy and platelet-rich plasma injection. PM R. 2011 Oct;3(10):900-11. doi: 10.1016/j.pmrj.2011.05.015. Epub 2011 Aug 26.
Chiavaras MM, Jacobson JA. Ultrasound-guided tendon fenestration. Semin Musculoskelet Radiol. 2013 Feb;17(1):85-90. doi: 10.1055/s-0033-1333942. Epub 2013 Mar 13.
Housner JA, Jacobson JA, Misko R. Sonographically guided percutaneous needle tenotomy for the treatment of chronic tendinosis. J Ultrasound Med. 2009 Sep;28(9):1187-92.
McShane JM, Shah VN, Nazarian LN. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow: is a corticosteroid necessary? J Ultrasound Med. 2008 Aug;27(8):1137-44.
James SL, Ali K, Pocock C, Robertson C, Walter J, Bell J, Connell D. Ultrasound guided dry needling and autologous blood injection for patellar tendinosis. Br J Sports Med. 2007 Aug;41(8):518-21; discussion 522. Epub 2007 Mar 26.
Zhu J, Hu B, Xing C, Li J. Ultrasound-guided, minimally invasive, percutaneous needle puncture treatment for tennis elbow. Adv Ther. 2008 Oct;25(10):1031-6. doi: 10.1007/s12325-008-0099-6.
Kaleli T, Ozturk C, Temiz A, Tirelioglu O. Surgical treatment of tennis elbow: percutaneous release of the common extensor origin. Acta Orthop Belg. 2004 Apr;70(2):131-3.
McNally EG, Shetty S. Plantar fascia: imaging diagnosis and guided treatment. Semin Musculoskelet Radiol. 2010 Sep;14(3):334-43. Epub 2010 Jun 10.
Lakhey S, Mansfield M, Pradhan RL, Rijal KP, Paney BP, Manandhar RR. Percutaneous extensor tenotomy for chronic tennis elbow using an 18G needle. Kathmandu Univ Med J (KUMJ). 2007 Oct-Dec;5(4):446-8.
There is a massive body of scientific literature on regional anesthesia and, secondarily, for the use of nerve blocks for longer pain management. We list below just a few interesting sample studies for how local anesthetic alone can have value in partially lessening pain for surprising durations of time.
Manchikanti L, Damron K, Cash K, Manchukonda R, Pampati V. Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial NCT0033272. Pain Physician. 2006 Oct;9(4):333-46. Click here for full text.
Boswell MV. Therapeutic cervical medial branch blocks: a changing paradigm in interventional pain management. Pain Physician. 2006 Oct;9(4):279-81. Click here for full text.
Manchikanti L, Singh V, Falco FJ, Cash KA, Fellows B. Comparative outcomes of a 2-year follow-up of cervical medial branch blocks in management of chronic neck pain: a randomized, double-blind controlled trial. Pain Physician. 2010 Sep-Oct;13(5):437-50. Click here for full text.
Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V, Fellows B. Comparative effectiveness of a one-year follow-up of thoracic medial branch blocks in management of chronic thoracic pain: a randomized, double-blind active controlled trial. Pain Physician. 2010 Nov-Dec;13(6):535-48. Click here for full text.
Palamar D, Uluduz D, Saip S, Erden G, Unalan H, Akarirmak U.
Ultrasound-guided greater occipital nerve block: an efficient technique in chronic refractory migraine without aura? Pain Physician. 2015 Mar-Apr;18(2):153-62. Click here for full text.
Herring AA, Stone MB, Frenkel O, Chipman A, Nagdev AD. The ultrasound-guided superficial cervical plexus block for anesthesia and analgesia in emergency care settings. Am J Emerg Med. 2012 Sep;30(7):1263-7. doi: 10.1016/j.ajem.2011.06.023. Epub 2011 Oct 24.
Gorthi V, Moon YL, Kang JH. The effectiveness of ultrasonography-guided suprascapular nerve block for perishoulder pain. Orthopedics. 2010 Apr;33(4). doi: 10.3928/01477447-20100225-11. Epub 2010 Apr 16.
Windsor RE, Jahnke S. Sphenopalatine ganglion blockade: a review and proposed modification of the transnasal technique. Pain Physician. 2004 Apr;7(2):283-6.
Cady R, Saper J, Dexter K, Manley HR. A double-blind, placebo-controlled study of repetitive transnasal sphenopalatine ganglion blockade with tx360(®) as acute treatment for chronic migraine. Headache. 2015 Jan;55(1):101-16. doi: 10.1111/head.12458. Epub 2014 Oct 23.
Dockery, GL. Dilute Alcohol Injections for Nerve Conditions and Keratotic Lesions of the Foot. Podiatry Management, Jan 2004.
Dockery, GL. Alcohol Injection Targets Intermetatarsal Pain. Biomechanics, April 2002.
Dockery GL. The treatment of intermetatarsal neuromas with 4% alcohol sclerosing injections. J Foot Ankle Surg. 1999 Nov-Dec;38(6):403-8.
Mozena JD, Clifford JT. Efficacy of chemical neurolysis for the treatment of interdigital nerve compression of the foot: a retrospective study. J Am Podiatr Med Assoc. 2007 May-Jun;97(3):203-6.
Hyer CF, Mehl LR, Block AJ, Vancourt RB. Treatment of recalcitrant intermetatarsal neuroma with 4% sclerosing alcohol injection: a pilot study. J Foot Ankle Surg. 2005 Jul-Aug;44(4):287-91.
Franson J, Baravarian B. Intermetatarsal compression neuritis. Clin Podiatr Med Surg. 2006 Jul;23(3):569-78.
Hughes RJ, Ali K, Jones H, Kendall S, Connell DA. Treatment of Morton’s neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases. AJR Am J Roentgenol. 2007 Jun;188(6):1535-9.
Masala S, Fanucci E, Ronconi P, Sodani G, Taormina P, Romagnoli A, Simonetti G. Treatment of intermetatarsal neuromas with alcohol injection under US guide. Radiol Med. 2001 Nov-Dec;102(5-6):370-3.
Musson RE, Sawhney JS, Lamb L, Wilkinson A, Obaid H. Ultrasound guided alcohol ablation of Morton’s neuroma. Foot Ankle Int. 2012 Mar;33(3):196-201.
Morgan P, Monaghan W, Richards S. A Systematic Review of Ultrasound-Guided and Non-Ultrasound-Guided Therapeutic Injections to Treat Morton’s Neuroma. J Am Podiatr Med Assoc. 2014 Jul;104(4):337-48. doi: 10.7547/0003-0538-104.4.337.
Gurdezi S, White T, Ramesh P. Alcohol injection for Morton’s neuroma: a five-year follow-up. Foot Ankle Int. 2013 Aug;34(8):1064-7. doi: 10.1177/1071100713489555. Epub 2013 May 13.
Mulvaney SW. Ultrasound-guided percutaneous neuroplasty of the lateral femoral cutaneous nerve for the treatment of meralgia paresthetica: a case report and description of a new ultrasound-guided technique. Curr Sports Med Rep. 2011 Mar-Apr;10(2):99-104.
McShane JM, Slaff S, Gold JE, Nazarian LN. Sonographically guided percutaneous needle release of the carpal tunnel for treatment of carpal tunnel syndrome: preliminary report. J Ultrasound Med. 2012 Sep;31(9):1341-9. Click here for full text.
Schreiber AL, Sucher BM2, Nazarian LN3. Two novel nonsurgical treatments of carpal tunnel syndrome. Phys Med Rehabil Clin N Am. 2014 May;25(2):249-64. doi: 10.1016/j.pmr.2014.01.008.
Malone DG, Clark TB, Wei N. Ultrasound-Guided Percutaneous Injection, Hydrodissection, and Fenestration for Carpal Tunnel Syndrome: Description of a New Technique. The Journal of Applied Research, Vol.10, No.3, 2010. Click here for full text.
Lam SKH, Reeves KD, Cheng AL. Transition from Deep Regional Blocks toward Deep Nerve Hydrodissection in the Upper Body and Torso: Method Description and Results from a Retrospective Chart Review of the Analgesic Effect of 5% Dextrose Water as the Primary Hydrodissection Injectate to Enhance Safety. Biomed Res Int. 2017;2017:7920438. doi: 10.1155/2017/7920438. Epub 2017 Oct 1.
Wu YT, Ho TY, Chou YC, Ke MJ, Li TY, Tsai CK, Chen LC. Six-month Efficacy of Perineural Dextrose for Carpal Tunnel Syndrome: A Prospective, Randomized, Double-Blind, Controlled Trial. Mayo Clin Proc. 2017 Aug;92(8):1179-1189. doi: 10.1016/j.mayocp.2017.05.025.
Chen SR, Shen YP, Ho TY, Chen LC, Wu YT. Ultrasound-guided perineural injection with dextrose for treatment of radial nerve palsy: A case report. Medicine (Baltimore). 2018 Jun;97(23):e10978. doi: 10.1097/MD.0000000000010978.
Wu YT, Chen SR, Li TY, Ho TY, Shen YP, Tsai CK, Chen LC. Nerve hydrodissection for carpal tunnel syndrome: A prospective, randomized, double-blind, controlled trial. Muscle Nerve. 2019 Feb;59(2):174-180. doi: 10.1002/mus.26358. Epub 2018 Dec 4.
Wu YT, Ke MJ, Ho TY, Li TY, Shen YP, Chen LC. Randomized double-blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Ann Neurol. 2018 Oct;84(4):601-610. doi: 10.1002/ana.25332. Epub 2018 Oct 4.
Wu YT, Ho TY, Chou YC, Ke MJ, Li TY, Huang GS, Chen LC. Six-month efficacy of platelet-rich plasma for carpal tunnel syndrome: A prospective randomized, single-blind controlled trial. Sci Rep. 2017 Dec;7(1):94. doi: 10.1038/s41598-017-00224-6. Epub 2017 Mar 7.
Senna MK, Shaat RM, Ali AAA. Platelet-rich plasma in treatment of patients with idiopathic carpal tunnel syndrome. Clin Rheumatol. 2019 Aug 16. doi: 10.1007/s10067-019-04719-7. [Epub ahead of print]
Shen YP, Li TY, Chou YC, Ho TY, Ke MJ, Chen LC, Wu YT. Comparison of perineural platelet-rich plasma and dextrose injections for moderate carpal tunnel syndrome: A prospective randomized, single-blind, head-to-head comparative trial. J Tissue Eng Regen Med. 2019 Jul 31. doi: 10.1002/term.2950. [Epub ahead of print]
Bahrami MH, Raeissadat SA, Nezamabadi M, Hojjati F, Rahimi-Dehgolan S. Interesting effectiveness of ozone injection for carpal tunnel syndrome treatment: a randomized controlled trial. Orthop Res Rev. 2019 May 6;11:61-67. doi: 10.2147/ORR.S202780. eCollection 2019.
Smith J, Rizzo M, Lai JK. Sonographically guided percutaneous first annular pulley release: cadaveric safety study of needle and knife techniques. J Ultrasound Med. 2010 Nov;29(11):1531-42. Click here for full text.
The below references do not describe a technique for treatment, but they provide scientific evidence that trigger fingers are at least in part due to tendinosis, the wearing and enlarging of rope-like tendons that go through fabric sleeves that hold the tendons close to bone. Reversing the degenerative enlargement of those tendons, and even the fabric tunnels (pulleys) that the tunnels go through, is a reasonable strategy for treatment of trigger fingers. Tissue regeneration procedures such as PRP stem cell treatment stimulate these broken down enlarged tendons and fabric tunnels to repair, grow back into a tighter weave and compact.
Lundin AC, Aspenberg P, Eliasson P. Trigger finger, tendinosis, and intratendinous gene expression. Scand J Med Sci Sports. 2014 Apr;24(2):363-8. doi: 10.1111/j.1600-0838.2012.01514.x. Epub 2012 Aug 12. Click here for abstract.
Lundin AC, Eliasson P, Aspenberg P. Trigger finger and tendinosis. J Hand Surg Eur Vol. 2012 Mar;37(3):233-6. Epub 2011 Oct 10. Click here for abstract.
Kim HR, Lee SH. Ultrasonographic assessment of clinically diagnosed trigger fingers. Rheumatol Int. 2010 Sep;30(11):1455-8. doi: 10.1007/s00296-009-1165-3. Epub 2009 Oct 23. Click here for abstract.
Sato J, Ishii Y, Noguchi H, Takeda M. Sonographic analyses of pulley and flexor tendon in idiopathic trigger finger with interphalangeal joint contracture. Ultrasound Med Biol. 2014 Jun;40(6):1146-53. doi: 10.1016/j.ultrasmedbio.2014.01.009. Epub 2014 Mar 6.
Simons D, Travell J, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1. Upper Half of Body, Second Edition, Baltimore:Williams & Wilkins, 1999.
Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2, The Lower Extremities, Philadelphia:Lippincott Williams & Wilkins, 1992.
