Irwin Abraham, M.D. & 

Chronic Injury Medicine

Articles

Below is a link to a recent news article about Dr. Abraham and prolotherapy:

Nonsurgical Option Explored: Can 'sugar water' shots help ease chronic back pain?

Newsletters

Dr. Abraham periodically writes newsletters on the topics of diagnosis and pain management in orthopaedic medicine.

When I see some one for a first visit to treat years of chronic low back pain, certain structures typically stand out as causes of the various pains. Most often, a patient will have more than one structure injured.

But the lumbar disc is rarely the cause.

So when your friends and relatives complain about their backs to their doctors, these are the typical culprits:

Sacroiliac joints: located between the hipbones and the bottom of the spine: the sacrum

Ilio-lumbar ligaments: horizontal straps crossing from spine to hips, involved with trunk twisting

Buttock tendons: 6 or more on each side. it is the tendons not the muscles that get injured.

Two irritated nerves - the cluneal and Thoracic-10 (level) - which start in the mid-back (on either side) and travel diagonally down to the buttocks where they connect with other nerves.

The “core” muscles: around the trunk (not the abs) - 3 important muscles.

Hip: usually 4 sets of muscles are important.

Now. depending on the person and problems, they may have more structural issues.

What is rarely the case: A chronic disc problem.

So, if your friends and relatives go to a different doctor or therapist for chronic back pain, they ought to look at the list, see if the doctor examined for them, and so forth.

Many of you have seen me for chronic low back pain.
I would like to discuss some of the myths and facts about chronic low back pain:

Actual disc herniation and squeezing of the nerve root next to it (known as an impingement) is uncommon. Only 5- 11% of persons with acute low back pain will have a disc herniation.

Since a true disc herniation is so uncommon, it is usually the wrong diagnosis for 70 % of the 80% of people that will have back pain at some point during their lifetime.

Most people have a problem with the sacro-iliac joints. These are two large joints on the inside of the hipbones attaching them to the spine. The hip bone rotates forward a few degrees normally when the leg moves. If the hipbone has moved a few degrees too far, pain occurs.

My experience is that sacroiliac joint problems are the single most common causes of low back pain.

The sacroiliac joint was said to be a common cause of low back pain until 1934 ( when the laminectomy operation for disc herniations was invented).

Training for strength is very useful. It complements endurance or running exercise.

Stronger muscles are more efficient and require less blood from the heart and lungs.

One can increase ones strength greatly at any age as much as when young, but like most things, it takes time.

The heart and lungs lose efficiency very, very slowly over the years. However, strengthening exercise helps along with endurance (aerobic) exercise.

Remember, never exercise so much that it causes pain the same day or the next.

Remember, do not increase your work out greatly from one workout to another.

Use the 10% Rule, never increase time or difficulty more than 10% in a week.

Vitamin C has been used in the past for treatment of chronic pain.

It can add to the pain relief effects of opiods such as oxycodone. Vitamin C can help overall feeling of well-being and energy and to cut down daily use of opiods like oxycodone.

Vitamin C will cost only a few pennies for each tablet; this can be a considerable savings when it cuts down on daily opiod use. Also, Vitamin C cannot give you any severe side effects. Vitamin C is never habit forming. You cannot get addicted to it. You cannot get ill from an overdose like you could easily with oxycodone.

INSTRUCTIONS FOR VITAMIN C USE for PAIN:

Start with 1000 mg. tablets. Take 2 and then repeat every 2 hours by increasing gradually by 1000 mg. every 2 hours., until you get up to several thousand more (usually 4000 - 8000 mg.). You can do this all in one day.

If you get any nausea, cramps, or a loose stool, after a dose of Vitamin C, that is your signal to cut down on the next dose by 1000 mg. and stay at that dose. Depending on how much better you fell, you will want to continue taking it every 2 or 4 hours.

The vitamin is designed to help to decrease your pain. It will not interfere with any other pain medicine; it is not dangerous; it is impossible to overdose on Vitamin C at any amount. Vitamin C is also very useful if you have a viral or bacterial infections. Use the same formula for starting and continuing dosage. Stay on the same dose until symptoms resolve.

Knee osteoarthritis is an extremely common problem for 1/3 of middle aged and elderly adults. Osteoarthritis is the medical term for degenerative arthritis. These terms refer to a number of problems at the different knee joint structures.

The normal knee consists of one bone, the femur, sitting on top of the leg bone, the tibia.
There is some space between these 2 bones because of the cartilage the menisci; joint fluid.

There is a layer of cartilage (much like the layer of cartilage in one's ear) that covers the ends of each bone. The cartilage of the knee has some resilience like a sponge, and as pressure is placed on the knee the cartilage on both sides compresses. The cartilage bounces back to full height when the pressure is removed. This actually is the mechanism to move the fluid in the knee around and to the sides.

The knee fluid, the synovial fluid, contains a lot of proteins and is much thicker than plain water. This synovial fluid retrieves the waste products of cellular growth processes from the cartilage and ligaments inside the knee joint. The fluid also washes in nutrients from the local blood vessels to these same tissues.

Between these cartilage layers are two flat semi-circles of ligaments called the menisci. Each meniscus covers half of the area of the joint. Some of the joint fluid is above and some below the menisci. It forms a thin fluid coating that always remains in between the normal cartilage and the normal menisci. One can say that the femur and tibia each glide near each other on a layer of joint fluid. Similarly the tibia sits with a layer of fluid under the meniscus.

The process of degeneration usually occurs very slowly over many years. One large study looked at x-rays of persons with arthritis. The authors found that 11 years later, only 11% had any change indicating more damage.

If an osteoarthritic knee is very painful, the orthopedic surgeon may suggest surgery.
The MRI or x-ray will suggest loss of cartilage, damage to the menisci, extra bits of bone around the ends of the knee bones: the femur and tibia. The surgeon may say that there is "bone on bone". This term implies that no cartilage, and/or no mensici are there in between the two bones.

However, the important part is how the knee works and what is the easiest way to fix it.
Most people have a very long recuperation after a total knee replacement operation, so this is an operation not to be taken lightly.
Additionally the failure rate on average is 5% of all knee replacements. In some hospitals where many surgeries are done, the failure rate may be less.

What is often not considered when looking at an osteoarthritic knee is the number of tendons and ligaments outside the knee joint and the meniscus inside that may cause some, most, or all of the knee pain. These structures; tendons; ligaments; menisci, can definitely improve non-surgically by using prolotherapy.

Prolotherapy is the safe injections of the body's own sugar, dextrose, into these painful structures to jump start healing and reduce the pain burden. If you have not read about prolotherapy before, please go to my website: www.irwinabraham.com

In a chronic state of loss of the cartilage thickness that covers the ends of the bone, sometimes damage can also happen to the tissues inside the joint, and a long-standing and gradually progressive addition of extra bone at the edges of the normal bones. When there is a lot of damage to the knee and so much extra bone formation, this can be called "bone on bone". This term "bone on bone" suggests strongly that the extra bone, as mentioned above, interferes with proper straightening (known as extension) and bending (known as flexion) of the knee at the joint. The interference of the extra bone is understandably painful.

Getting out to exercise and playing sports in spring and summer may have given you new aches and pains or aggravated the old ones. Regardless of how and when these started, maybe it is time for tune-up for your chassis.

My practice is devoted to first finding the specific problems, setting out a plan, and helping you to get through your rehabilitation.
Sometimes physical therapy is needed. Sometimes some injections are helpful or the only curative options.
Often, use of therapy and injections makes a more efficient combination.

It always depends on the injuries, how badly they effect you, your personal resources of time, effort and finances. Rarely, very rarely, do I need to send someone to the orthopedic surgeon.

Tennis elbow; best treated with prolotherapy.
Rotator cuff injuries at the shoulder are very individual, as the specific sites and severity of damage differ greatly from one person to the next.

Low back pain is also very individual because most often after a structure is injured, other structures that try to help carry the load get secondary injuries. This can be one extra site or numerous tendons, ligaments, and/or joints.

Any initial visit to me requires a lot of time for a proper history and a careful exam. It always amazes me how fast the time goes.

For example, tennis elbow most often has a simple story if it only started this summer. It is usually easy to identify. However, other sites can create pain messages very nearby. A shoulder problem can send pain down to the thumb, right through the elbow. Wrist pain can be present from a different strain and also is part of the tennis elbow because of pain in this muscle unit at the other end of the elbow.

Patients tell me about other docs with faster visits. When my patients leave the office, I have to be satisfied that I found all the answers I can to best alleviate their pain.

For an acute problem, good physical therapy is the fastest way to get better.
However, if this acute problem has held on for a month or more then prolotherapy should be seriously considered. Tendons, ligaments and joints tend to heal slowly and hardly at all if not improved greatly in a month's time.

In an urgent case, when you have an acute problem, but are traveling in a few days or a week and will be gone for several weeks, then prolotherapy is a good answer. While you are away the prolotherapy will have started to slowly help that injury.

If your injury is chronic (a month or more) then prolotherapy is a good bet.

If your problem has lasted years, then you need to see this doc to sort out which are the major problems, which are best handled by physical therapy, and which are best handled by prolotherapy.
At this point of long chronic pain, prolotherapy is usually the best answer.

Physical therapy is almost always a good adjunct to prolotherapy for any problems, because even a few days after an injury will create weakness and muscle imbalance. Therapists are the experts to find and work with these problems.

I now have a new tool for helping shoulders in my medical tool box: neural prolotherapy.
(If you are unfamiliar with neural prolotherapy, read below). Neural prolotherapy is now my treatment of choice for shoulder pain.

Immediately after a set of neural prolotherapy injections, a patient with severe restriction at the shoulder can wave the arm painlessly through the air.

The only downsides are some very mild bruises, possibly a little discomfort for 24 hours, and the need to repeat the treatment at 1 to 2 week intervals until the therapy is complete and the shoulder is unfrozen.

I have treated the shoulders of many people over 30 years by doing regular dextrose prolotherapy. My success rate grew to about 95% as the years went on. However, it took a long time: A minimum of 8 weeks between sets of injections, with often up to 3 sets needed.

Treating a frozen shoulder with physical therapy is a very slow process with uncertain results.

Next time read about my relaxation therapies that improve the comfort of having prolotherapy therapy.

Neural prolotherapy is a very new type of prolotherapy. The rationale is that that chronic pain will switch on the activities of certain nerves. These specific nerves are in every bundle of nerves traveling under the skin throughout the body. These switched-on nerves, known technically as "C" fibers, will then transmit messages of pain for months to years. We can turn off the pain message by injecting a small amount of a dilute sugar (glucose) solution into the nerves in the skin over an injury. I have utilized this therapy for 3 years now and neural prolotherapy has gained quite a prominent place in my practice.

We find the relevant nerves for treatment by gently patting on the skin. Neural prolotherapy uses 5% concentration of glucose injected to the near vicinity of the nerves. The glucose literally turns off the pain message of the C fiber, and this can work very quickly. Most often the patient notices that she or he feels better as soon as the injections are completed.

Let’s talk about shoulder pain.

Shoulder problems generally fit into four different categories:

1) rotator cuff syndrome
2) labral tears
3) capsulitis, or “frozen shoulder”
4) dislocation of the shoulder joint

And separately….
5) upper back and neck pain, or shoulder pain originating from elsewhere, not the shoulder itself

Here’s a brief anatomy lesson.

Rotator cuff syndrome refers to a full or partial tear of the three major tendons that attach the muscles from the rounded top of the arm bone (called the head of the humerus) to the shoulder blade in the upper back. These three tendons are connected together side by side like three lengths of rope. At the edge at the humeral head they are a single piece like a mat. This “mat” is called the rotator cuff.

The labrum is a narrow circle of cartilage that is at the edge of the shoulder blade on the inner side of the shoulder joint. This structure is triangular and centuries ago looked like a lip to the ancient anatomist. The ligaments holding the bones together of the humeral head and the shoulder blade attach at the labrum. A sudden strain at the shoulder can tear the labrum which loosen the joint.

Capsulitis is a name for an inflammation of the ligaments of the shoulder (see above).

Imagine these ligaments like a hollow tennis ball, with bone sticking into it on either side. This capsule has some fluid in it and in general is very bendable.

A sudden jerk of the arm, however minimal, can irritate the capsule, resulting in a gradual onset of pain and inflammation. Then the capsule becomes very stiff, very painful within a few days and the shoulder joint moves very poorly.

The first big toe joint is known as the first metatarsal joint (1st MPT for short).

In 1999, I attended a workshop on this phenomena given by Dr. Dananberg. Since then, I have observed the connections between stiff big toe joints and walking pattern. Beyond that, I have noticed additional connections between the big toe and other parts of the body.

The big toe can get very stiff in many people. It can then interfere with the movement of the foot in walking, ultimately it can affect the rest of the body.

These are the common (but not well known) results of a stiff big toe joint (or 1st MTP).

1. Stiffness of the 1st MTP can cause the other side of the foot bear more of the force from the leg above. This can irritate various tendons and ligaments.

2. Stiffness of the 1st MTP often causes plantar fasciitis, the very painful problem in the bottom of the foot. People experience it most often when they first step out of bed in the a.m. and sometimes throughout the day.

3. Stiffness of the 1st MTP can cause one to walk improperly, very stiffly and the back tends to bend forward to compensate. This can result in chronic low back pain.

4. Stiffness of the 1st MTP can affect the knees and cause pain at the knee cap.

5. Stiffness of the 1st MTP, as we mentioned above, interferes with walking. It produces an abnormal back and forward motion that can affect the neck and be a cause of chronic neck pain.

How do we fix this? A simple manipulation by the doctor frees up a tendon that is the original cause of the stiff 1st MTP. Often we need to separately fix the the parts that have been damaged:; neck, back, knees, ankle tendons and ligaments.

This icy and slippery day in New York may cause a few unfortunate accidents. I remember having a severe ankle sprain when I was 20. It involved a sudden twist and a sudden pain, which subsided. I limped just a little and after about six months the problem resolved itself. I “knew,” like everyone “knows,” that the sprain would resolve itself “soon.” I just waited and waited and waited. Thinking back, this injury helped draw me into the discipline of sports medicine.

In order to diagnose and treat an ankle sprain depends, of course, on a good exam.

X-rays are usually not needed.

In 1992, a team of doctors in the emergency department of the Ottawa Civic Hospital published a list of rules governing ankle sprains. These rules state just how often an acutely sprained ankle requires an x-ray.

They established a set of criteria that would catch 99% of all possible fractures, missing no more than 1% of them.

The Ottawa Rules for Ankle Sprains:

An x-ray is required when:

There is any pain in the malleolar zone (either of the two rounded protuberances on each side of the ankle) and any one of the following:

Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR
Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR
An inability to bear weight on the ankle both immediately and in the emergency department for four steps.
Additionally, the Ottawa foot rules indicate whether a foot X-ray series is required. It states that it is indicated if there is any pain in the midfoot zone and any one of the following:
Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR
Bone tenderness at the navicular bone (for foot injuries), OR
An inability to bear weight both immediately and in the emergency department for four steps.

The current rules for treatment of an ankle sprain:

Using an ice pack every twenty minutes, alternating icing twenty minutes on and twenty off will make the ankle feel better within two weeks, but makes no long term difference in healing.
Keeping the foot up at a level above the waist is helpful only for significant swelling. Generally there is no more bed rest with the foot in the air.
Ace bandages are not helpful since they fail to provide enough pressure.
Many pharmacies provide a terrific ankle support, a brand known as AirCast. Alternatively, some high topped shoes can provide good support.
Move the ankle around. At least once every one hour lift the ankle up in the air and draw an air alphabet, A to Z using your big toe.
I find that very prompt physical therapy is essential. I arrange a quick appointment with me as soon as I find out about my patient having a sprained ankle, either that day or the next. We arrange for physical therapy as soon as possible.

A deep massage technique is very useful. Most therapists know about deep friction massage. Undergoing it as soon as possible is essential. Should a patient visit with an ankle sprain late in the week there’s a concern that the weekend will delay treatment too much. In these situations, I sometimes perform the ankle massage myself to initiate the healing process.

Should an ankle sprain persists for more than three or four weeks, then I strongly suggest dextrose prolotherapy to jump start healing. A steroid shot would NEVER be optimal therapy.

A dancer saw me after his MRI showed a loss of a small section of cartilage in his ankle joint. The area of loss looked to me like a divot on a golf course. A surgeon had suggested a surgical procedure to heal this hole. My exam showed some tendons near that joint that were weak and painful, as well as ligaments that had significant discomfort during stretching. Instead of recommending surgery, I gave him one session of injections with prolotherapy (the sugar water injections that jumpstart healing).

He recovered and returned to his brilliant ballet dancing.

Often enough a new patient will bring in a CD of their MRI exam, or ask to get one.

Here are some fun facts about MRI’s:

An MRI shows us pictures of the anatomy of the part imaged. It may show some damage, but except in a few circumstances it be unable to tell us if the injury is new or old.

An MRI does not always tell us where the pain is. Sure, identifying a fracture of a bone will clearly show where the problem lies. Tendons or ligaments, on the other hand, could have been torn months or years ago. By identifying damage on an MRI of a tendon, a ligament, or even a joint can be extremely misleading.

Disc herniations are visible only on an MRI or a CT scan, true, but only 5-11% of new low back pain is cause by a disc herniation, and 85% of such herniations will heal by themselves within 14 months.

A new patient who comes in presenting with chronic low back pain that has lasted for two to three years and tells me that the pain hasn’t changed recently is not going to make me immediately think of disc herniation first. The odds of a disc herniation causing pain currently is about 15% (the possibility that a disc herniation didn’t heal itself) out of a maximum of 11% (the chance that back pain is being caused by a disc herniation in the first place). More succinctly, there is a 1.6 % chance of a lumbar disc herniation causing the pain in a patient with several years of back pain.

The likelihood of a disc herniation causing chronic low back pain or still causing pain from two to three years ago is very low. Not never, but a very low chance.

So, I would rarely choose to get an MRI without a specific reason, such that:

The pattern of pain has changed significantly, or;

I have a specific question that the MRI will answer so that I can change my plan of treatment.

When I lived and practiced in upstate NY, patients often would say that their neck pain was from a “cold in the neck.” In fact, the most common cause is a neck sprain from sudden twisting, usually from a fall or a car accident.

Most often, one of two problems are present.

1) A mechanical problem of the little joints on the sides of the neck bones: namely, the cervical spine.
2) Damage to some of the tendons and ligaments around the joints.

Alternatively, damage to the bones or the discs is uncommon.

Most likely the sprain is minimal. In that case, the first treatment in my office is some gentlemanipulation. These manipulations will not hurt the spine. What they do is ease the stress on the affected joints, and relax the soft tissues.

Last week a patient came in with whiplash from a car accident. Gentle manipulation relieved some of his pain. Having learned manipulation a few ages ago (1978), I have followed up with many patients in the days and weeks afterwards. The manipulations have a lasting and increasing effect following treatment.

If two sessions of manipulation does not fix most of the pain, we have two options to resolve the problem.

1) Send the patient to physical therapy. I have a network of physical therapists that I work with and only send my patients to the very best.
2) Perform Neural Prolotherapy. If this is a chronic pain problem certain nerves underneath the skin can become “turned on” and carry some of the pain “message” to the brain.
By injecting just a tiny bit below the skin and reaching these nerves with glucose (the same sugar as in your blood) we can switch off these nerves. This will change the signals being sent to the deep irritated tissues and get them to start healing.

The terrific news is that most often one gets up right after these injections and feels less pain immediately.

I have seen many patients who have been declared by the orthopedic surgeon to have a knee that is “bone on bone” and who require knee replacements. Often, it just isn’t so.

This week I saw yet another patient with chronic knee degenerative arthritis. She came to the office for her initial dextrose prolotherapy treatment. She had previously seen an orthopedist before coming to me. At the time of her visit to the surgeon, her x-rays showed a narrowing between the bones of the knee joint (the femur or thigh bone, and the tibia, the larger of the two leg bones). The orthopedist declared that she was “bone on bone” and scheduled her for surgery for a total knee replacement.

I imagine that “bone on bone” means that the bones are scraping together. When this occurs it causes a great deal of pain and prevents proper movement. However, when I examined her I could not find any clinical evidence of this scraping.

She walked and stood with some pain, but also without any limp. Her knee straightened out fully, with only a little discomfort, and was able to bend nearly fully. She was capable of moving her heel very close to her buttock before she experienced some mild pain. The testing of her ligaments and her tendons around her knee joints produced only some mild pain.

While these structures were all tender to touch, my medical opinion was that her knee worked pretty well. The damage seen on the x-ray did not reflect how well her knee actually functioned. She was NOT a candidate for a knee replacement operation.

I treated her with dextrose prolotherapy.

Two to four sets of prolotherapy injections, spaced about six weeks apart, will most often fix the damaged tissues around the knee. After these injections the patient is normal or near normal again with the pain usually disappearing. I expect similar results for the woman who came in this week.

I have seen many patients who have been declared by the orthopedic surgeon to have a knee that is “bone on bone” and who require knee replacements. Often, it just isn’t so.

Videos

Below are some videos to get you started, from general descriptors to instructional guides on back exercises.