American Association of Neuromuscular & Electrodiagnostic Medicine (formally called AAEE). A national association of board certified doctors who have specialty training in the performance and interpretation of electromyographic and nerve conduction procedures. Dr. Portner has been a member of this organization since 1982. See EMG
American Academy of Physical Medicine and Rehabilitation. This is a national organization of board certified physiatrists who have completed residencies in the specialty of PM & R. Dr. Portner has been a member of this Academy since 1982.
Brand name Tylenol, acetaminophen is a synthesized substantive for aspirin that has the benefits of relieving pain and lowering fever, but without the side effects of preventing clotting or causing gastrointestinal side effects. Available over-the-counter in many types of medications including cold remedies, headache medications and fever medications, Tylenol can be dangerous, sometimes causing liver damage, when taken in high doses for prolonged periods of time. Patients should generally avoid taking more than 2 or 3 grams total of Tylenol per day. Tylenol, useful for what is termed minor pain, has been shown effective for more serious conditions such as the pain associated with osteoarthritis of the hip or knee. Many narcotic pain medications are manufactured in combination with Tylenol, such as Tylenol with Codeine, Vicodin, Percocet, Norco and others.
This is an inflammatory condition of the large tendon at the very back of the heel and ankle.
This is a large tendon found in the back of the heel that attaches the large group of gastroc soleus muscles of the calf to the heel bone, or calcaneus. The achilles tendon is named after Achilles, the Greek mythological hero. Legend has it that his mother Thetis dipped her son into the river Styx holding onto her baby’s heel, rendering him invulnerable everywhere except at the back of the ankles, the body part that she held out of the river.
The ACL is 1 of 2 crossing ligaments inside the knee joint that prevents a forward gliding of the tibia relative to the femur. This ligament connects the femur to the tibia and is commonly injured in traumatic sports collisions. Injuries to this ligament can be repaired surgically, however, under some circumstances a patient may choose not to have it repaired and live their life with a deficient ACL.
Acupuncture is a tool of the ancient Chinese art of medicine based on a totally different understanding of the human body and human pathophysiology compared to western medicine. Acupuncture relies on an old concept of meridians and the flow of energy through the body. Recently, western medicine has adapted and incorporated acupuncture into its arsenal of treatments. Scientific studies have shown that acupuncture can be effective in relieving pain, although this is poorly understood. At the Portner clinic we have a wonderful, highly-trained acupuncturist, Dr. Yana, who helps our patients with pain, headache, muscle tension, sleeplessness and various other disorders. We use her services in conjunction with our more conventional western approach.
In medicine, acute refers not to the severity of symptoms, as it does in the common English language usage, but rather to the length of time a condition has been present. “Acute” implies a condition that has begun recently and come on suddenly. It is the opposite of “chronic,” which implies a condition that has been going on for a long time.
This is a common condition, especially in the shoulder, where the covering surrounding the joint becomes inflamed and shrinks in size, limiting the range of motion and causing pain. In the shoulder, this often interferes with simple activities of daily living (ADLs) such as dressing, brushing hair and reaching above your head. The pain often interferes with sleep. Fortunately, adhesive capsulitis can be effectively treated with physical therapeutics including joint mobilization and therapeutic exercises, along with a home exercise program. Oftentimes, anti-inflammatories, pain medication and occasionally sleeping medications are prescribed. In more difficult cases, intra-articular corticosteroid injection, usually guided fluoroscopically or by ultrasound, is safe and predictably effective.
This term describes those activities we do every day in order to care for ourselves. This includes dressing, bathing, using the restroom, etc. We do these activities when healthy without even thinking about them. Like so many other things, we appreciate the ability to do these things independently and pain-free only when we lose this ability. These functions are among the most important of those assessed by the physiatrist. An orthopedic condition that causes difficulty or inability to perform any of these functions is considered to have important functional deficit implications. Monitoring the patient’s progress and assessment of the success of our treatments is best assessed by looking to see if these ADLs can now be performed normally. If yes, then the treatment has been successful. If no, then further treatment will be required.
Advil is an over-the-counter nonsteroidal anti-inflammatory (NSAID) whose generic name is Ibuprofen and is also available by other name brands such as Motrin. Over-the-counter, these pills contain 200 mg of Ibuprofen. By prescription, Ibuprofen can be obtained in doses of 400, 600 and 800 mg. Like all other nonsteroidal anti-inflammatories, side effects mostly involve gastric and esophageal pain.
Aleve is an an over-the-counter nonsteroidal anti-inflammatory (NSAID) whose generic name is Naproxen. It is also available in higher doses by prescription under the name of Naprosyn and others.
Allodynia describes the physical symptom of hypersensitivity to even light touch of the skin. This is seen in conditions such as gouty arthritis and regional pain syndrome (reflex sympathetic dystrophy).
This is a term applied to any medication that relieves pain. Analgesics are usually divided into two major groups, opiates and non-opiates. The opiates are derived from the opium plant and are termed narcotics. All other medications used to relieve pain that are not derived from the opium family are included in the non-opiates. This group contains the nonsteroidal anti-inflammatories (NSAIDs) and other medications.
Analgesic balms are various creams and salves that can be rubbed into the skin over a painful area to give relief in many cases. Mentholated sports creams and ointments are available over the counter, such as Deep Heat or Tiger balm. Some local anesthetic creams are available by prescription only. These may contain local anesthetics such as lidocaine or ingredients derived from red hot chili peppers, as is the case with capsaicin cream.
Androgenic steroids are a group of hormones produced by the body, and now produced pharmacologically for therapeutic purposes, that cause a buildup of muscle and an expression of male traits, including beard growth. These hormones are often used illegally as performance enhancers for competitive athletes. The dangers of testosterone use for athletic enhancement are well-known and serious. These medications should only be used by prescription under very specific and serious medical conditions.
This is a term applied to a type of evidence used to support a claim that a treatment is effective. Anecdotal simply means “story.” Typically, anecdotal evidence will state that a patient was given conservative treatment and that seemed to help their condition, therefore that treatment is helpful. Of course, the anecdotes do not represent scientific evidence and are only sometimes proven true. Treatments based on anecdotal evidence alone should be scrutinized quite skeptically.
Anesthesia literally means “without feeling.” Anesthesia is applied to an area of the body that no longer has sensation. This can come about if the nerve to that area is diseased or injured. Doctors can produce this phenomenon using local anesthetics which block the electrical signal of nerves that carry the pain message up to the brain. Local anesthesia is produced by blockage of these peripheral nerves and often used in certain surgical procedures so the patient cannot feel the pain of the scalpel. Local anesthetics are often combined with cortisone and various orthopedic medical injections. General anesthesia is a term applied to rendering the patient unconscious and unable to feel pain anywhere in the body. This anesthetic unconscious state is induced by an anesthesiologist during major surgery.
This is the specialty of medicine that deals with relieving pain, mostly applied to the anesthesia induced during operations. Anesthesiologists who practice the specialty are also often trained in the management of chronic pain. They use many injection procedures, not unlike Dr. Portner’s clinic. Additionally, they are experts at managing chronic pain using various medication combinations and other pain relieving devices. More sophisticated pain relieving measures, such as spinal cord stimulators and morphine pumps, are also used and monitored by anesthesiologists specializing in chronic pain management.
This is an uncommon genetic disease that causes low back pain. It is characterized by a stiffening of the spine due to a calcification of the ligaments that are responsible for movement between the bones of the neck and back. Ankylosing spondylitis can cause pain elsewhere in the body including the heel and the sacroiliac joint. There are also other organ systems that can be affected by the disease, such as the intestines. While ankylosing spondylitis is not curable, many secondary complications that result from this condition can be prevented if detected soon enough.
This is a group of medications that are used as minor tranquilizers to help calm patients who have fears and nervousness that interfere with the their enjoyment of life. Benzodiazepines, a large group of anti-anxiety agents of which Valium, Ativan, Tranxene, and Xanax are just a few, represent most commonly used anti-anxiety agents. These medications can also aid insomnia. They can pose a risk of habituation and dependency and have other side effects such as depression. Like all drugs, the benefits of the medication must be weighed against their possible complications. When used short-term they can be most helpful. For example, people with claustrophobia cannot bear to lie still in confined spaces during an MRI examination. To combat this, severe anti-anxiety agents are given an hour before the MRI, and this usually allows the patient to tolerate the test. Similarly, patients with needle phobia often cannot tolerate undergoing an epidural injection or other spinal procedure without first being pre-medicated with an anti-anxiety agent. These agents can also be useful in the treatment of muscle spasms.
Anti-inflammatory describes any agent, usually pharmacological, that interrupts or minimizes the inflammatory response (see inflammation). Inflammation is our body’s natural response to insult, injury and infection and how we repair our injured tissues. You may question why would we ever want to stop this apparently healing process? That is a good question and can be discussed in the future. Medications that are classified as anti-inflammatories are divided into two basic groups. The first is the group of cortisone-type medicines. This is a naturally occurring hormone in the body that is the strongest of all the anti-inflammatory medications. This group that includes the cortisone family of medications: Cortisone, hydrocortisone, prednisone, medrol, methylprednisolone, dexamethasone, betamethasone, etc. are all anti-inflammatories use to treat various conditions that are characterized by inflammation. The second group of anti-inflammatories are the nonsteroidal anti-inflammatories. This large group of popular medications, available both over-the-counter and by prescription, are headed by the grandfather of them all, aspirin. Aspirin, a derivative of the willow tree, holds a distinguished place in the history of medicine and pharmacology. It was the very first medication synthesized in the chemical laboratory, rather than simply extracted from naturally-occurring plants. Aspirin is a very effective anti-inflammatory and has additional pharmacological effects as well (see aspirin). This group of anti-inflammatories are simply termed a nonsteroidal anti-inflammatories, or by their acronym NSAIDs, and include numerous medications that have become household terms such as Ibuprofen, Aleve, Advil, Motrin, etc. These medications are often available over-the-counter; however, this is not to be considered evidence that they are safe and harmless, as their are risks involved with all medications. In addition to their anti-inflammatory properties, aspirin and some of its relatives have anticlotting properties, side-pain properties and anti-fever benefits. Major side effects include serious gastric ulceration, irritation and bleeding. Therefore, these medications should always be taken with food and stopped at the first sign of stomach upset. They should certainly be avoided in anybody who already has a history of gastritis, gastric ulcer, GERD or other GI problems. Reye’s Syndrome is another condition associated with aspirin use.
Several types of medications have the effect of slowing down blood clotting. As a group, these are called anticoagulants. Warfarin, also known as Coumadin, is a very powerful anticoagulant also found and rat poison. Heparin is another very strong anticoagulant. Aspirin and other nonsteroidal anti-inflammatories also have a different anti-coagulation affect. Plavix is another anticoagulant often used in patients at risk for developing dangerous blood clots. These medications can be very dangerous and, as usual, their benefits must be carefully weighed against their possible and occasionally terrible side effects, which include stroke, excessive internal bleeding and even death. Prior to performing any spinal procedures, patients must be off of their anti-coagulation medications completely for the amount of time that it takes to restore their normal coagulation. Only then can their spinal procedure be performed without the risk of excessive bleeding into and around the spine. Patients should be sure that their physician is aware of any anticoagulants and all their other medications they are taking.
This is a group of medications used to treat depression. Depression is a debilitating mental disorder that can cause patients to have no desire or energy to do anything at all. Severe cases often end in suicide. Depression is one of the bipolar conditions grouped as manic depressive disorders. Antidepressants are sometimes used in the treatment of chronic pain conditions as well the “questionable” syndrome called fibromyalgia.
See anti-inflammatories. Few houses are without aspirin in their medicine cabinet. This medication, which is the oldest of all synthetically produced medications, can be used in the home for simple headaches, aches and pains, muscle, tendon and ligamentous injuries, etc. Baby aspirin is often prescribed to be taken once-a-day to help prevent stroke and heart attack. Aspirin is one of the medications that must be stopped for about five days prior to any orthopedic spinal injection for seizure.
“Benign” means good (its opposite is malignant). “Tumor” simply means swelling or mass of any kind. A benign tumor is a mass of tissue cells that have grown inappropriately but are not the type of tumor that will erode into adjacent tissues or breakoff and flow into the bloodstream and glands in other places in the body and continue to grow there. Benign tumors often affect the musculoskeletal system and are found in muscle, bone and nerves to name a few. Rarely do these tumors require surgical removal. Occasionally, biopsies will be performed to look at the tissue under the microscope to ascertain for certain that these tumors are benign and not malignant, or cancerous.
This is a group of medications called minor tranquilizers that are used to treat anxiety, muscle spasm, insomnia, and in some cases pain. The most common and familiar names in this classification include Valium, Xanax, Tranxene, Ativan, and many others. These are potent medications and can be used very effectively in the appropriate setting, however, like all medications they are not without certain inherent risks and side effects. They can cause drowsiness and are known to cause depression or make existing depression worse. They are habit-forming, if not addicting, and therefore need to be used with caution. When used as a sleeping aid, it is said that the quality of sleep induced is not as restful as the sleep obtained without these medications. Long-term usage is to be avoided as much as possible.
Fracture is synonymous with break. Several types of bony fractures exists. The most common and well-known type is equivalent to breaking a pencil. This usually occurs with a traumatic event and is easily diagnosed by X-ray. Compression fractures of the vertebral body are also common in orthopedics as a sudden cause of low back pain, usually present in an elderly patient who has fallen. In the presence of osteoporosis, or other bony pathology, rendering the bone weaker than usual compression fractures of the vertebral body become quite common (see compression fracture). Hairline fractures are fractures that are less easily seen on X-ray and do not cause any displacement of the two bony fragments. Sometimes the trauma of the fracture also breaks the skin and, in many cases, more than one fragment of bone is involved. A stress fracture is often seen in sports medicine where there is no one single event that suddenly breaks the bone. Rather, a stress fracture occurs when multiple repetitive microfractures to the bone are caused repeatedly over time when an athlete overdoes it. This is also sometimes seen in soldiers in boot camp and other training protocol, or workers starting a new job that requires a lot of walking or other repetitive activities.
This is a sophisticated imaging study that uses radioactivematerial (exposing the patient to small amounts of radiation) that is injected intravenously and subsequently attaches itself to actively metabolizing bone. In this way, various lesions of the bone, including fractures, infection, tumor, etc., can be detected. This test is used only infrequently now, preferable when the diagnosis is elusive and further imaging is required. In recent years, MRI testing has supplanted bone scan testing in many cases.
Also called osteophytes, bone spurs are seen on X-rays, particularly at the heel bone and in the spine. They are an indication of a degenerative process but are looked upon by some as normal findings, especially with advancing years. Osteophytes by themselves rarely cause pain. However, they are often confused with the actual diagnosis by some practitioners. A typical story is that a patient will go to the doctor with heel pain, an X-ray will reveal a bony spur, and both the doctor and the patient will conclude together that the bony spur is causing the pain. This is rarely true. Bony spurs are most often incidental and unharmful, and rarely need to be treated
This is a Yiddish expression meaning “old wives tale.” This is one of many terms used in describing commonly held misconceptions, dogma, superstition, and beliefs that are unusual but widely believed to be true. “Don’t go swimming for a half hour after you eat,” “don’t cross your eyes or they’ll get stuck in that position,” ”don’t wear someone else’s glasses or it’ll ruin your eyes…” the list is endless. Many of these widely held falsehoods are found in orthopedic medicine and this is a fun term to describe them.
This is a common condition affecting the area from the big toe at the joint of its attachment to the rest of the foot, aka the first metatarsophalangeal joint. The joint becomes deformed and the toe gradually migrates towards the outside of the foot. The joint enlarges and becomes arthritic and painful. Treating bunions can be challenging through the use of physical therapy, bracing and sometimes injections and medications when painful. In severe cases, surgery is performed where the bunion portion of the bone is actually removed.
One of many local anesthetics in the -caine family of medications that almost instantly block electrical signals from being conducted along the nerves. Bupivacaine is used often in conjunction with cortisone injections to make the injection itself more comfortable and to provide instantaneous relief to the patient for several hours. Some people are allergic to these drugs. Other drugs in the family include Novocain, Xylocaine, lidocaine, Marcaine, and cocaine (which also has highly addictive effects on the brain, unlike these other drugs).
“Bursa” is taken from the same Greek word that gives us our word for “purse,” which means “sac.” The body has numerous bursa, which can be thought of as flattened water balloons, positioned between two structures that move and would otherwise create friction and irritation between them. These bursa act as cushions and lubricants to allow free movement between adjacent structures. Normally, the amount of fluid in these bursa is minimal providing just a thin film. However, with irritation due to trauma or infection or other systemic illnesses (see gout, rheumatoid arthritis), the fluid volume will increase and painful inflammation can occur.
Bursitis refers to inflammation of a bursa. The -itis suffix always indicates that the structure name in front of it is inflamed. Common areas of bursitis include the shoulder, elbow, knee and hip. Oftentimes the diagnosis of bursitis is made without careful evaluation and is erroneous. The word “bursitis” is often used as a general term to mean pain in that particular area. The patient must be wary of this diagnosis if made casually and without careful evaluation.
This describes a tearing — either microscopic, partial or complete — of the muscles and/or tendons of the calf. These include the gastrocnemius and soleus muscles as well as the lesser muscles that control the ankle and toes. Strains, like most sports injuries, usually result either from one traumatic event or more gradually as a overuse injury. The term “calf strain” is general, but a more specific term naming the precise muscle or tendons involved is preferable. Like all strains, calf strains, once more precisely diagnosed, can often be treated successfully with rest, anti-inflammatory medications, ice, friction massage by a physical therapist trained in this technique, and therapeutic exercises when appropriate, but not too soon. Sometimes injections are required. The diagnosis cannot be confirmed by X-ray evaluation, but ultrasound diagnostic imaging can clearly demonstrate the lesion in most cases.
Often known as CTS, carpal tunnel syndrome is an injury to the median nerve as it crosses through the tunnel connecting the end of the forearm to the palm side of the wrist and hand. The median nerve carries sensation from the palm, thumb, index finger, middle finger and half the ring finger through the wrist canal (carpus means wrist), up the arm into the spinal cord and up to the brain. It also carries motor nerve signals from the brain down the arm through the wrist and into the hand controlling the muscles of the thumb predominantly. Symptoms of carpal tunnel syndrome include a painful numbness, most prevalent at night. Patients often wake up in the middle of the night and have to shake their hand because it “falls asleep.” In more severe cases, weakness and even atrophy of the thumb muscles become apparent. Certain occupations are more prone to carpal tunnel syndrome including dental hygienist, musicians, roofers and typists to name a few. Certain general medical conditions also predispose one to carpal tunnel syndrome, such as diabetes, rheumatoid arthritis, thyroid and parathyroid gland disorders, and pregnancy. Diagnosis of carpal tunnel syndrome is based on the history and physical exam. Confirmation of the diagnosis can and should be made with electrodiagnostic testing and nerve conduction studies. These are performed at Dr. Portner’s office by trained electromyographers. Treatment of carpal tunnel syndrome varies, depending on the underlying cause. If the carpal tunnel syndrome is a secondary complication of an underlying disease process, this must be addressed first. If the cause is due to repetitive overuse injuries then this activity must be modified. Wearing a splint at night is often effective. Certain medications, such as gabapentin, can be useful. An injection, usually done under the guidance of fluoroscopic or ultrasonic equipment, is usually very effective. In rare cases, surgical release of the carpal tunnel ligament will give the median nerve more room and cure the syndrome. Not all numbness in the hand is carpal tunnel syndrome, but all numbness in the hand should be investigated without unnecessary delay as this can otherwise result in permanent nerve injury and weakness.
Computerized axial tomography (CAT) is a sophisticated and expensive X-ray examination that shows us great detail of bones and, in some cases, adjacent soft tissue that cannot be seen on plain X-ray films alone. While very useful in certain situations to help diagnose particularly otherwise obscure bony pathology, CAT scans have their downside. They are not great at assessing most soft tissue injuries, they generally expose the patient to much more radiation than simple X-rays, and the patient has to be able to tolerate being enclosed in a confined space for a period of time (a challenge for claustrophobic patients). Despite these difficulties, CAT scans have their place and can be very helpful to the diagnostician.
This is a type of spinal injection used since the 1930s and developed by Dr. Portner’s mentor, Dr. James Cyriax, in the treatment of certain types of acute and severe low back pain. The term “caudal” means “tail or posterior.” This type of shot has similarities with the injection used during labor and delivery to anesthetize the mother’s saddle area and make the delivery less painful. While the medications are different and no saddle anesthesia is produced, the caudal epidural injection is a reliable way to treat low back pain in many cases. More recently, this injection has been used less often and in its stead, transforaminal epidural injections have become more commonplace. These epidural injections are generally quite safe and effective. Your doctor will discuss the possible benefits and risks of the various injection types.
This phrase describes the belief that Dr. Portner shares with most all physicians and scientists that all phenomena in nature have a cause. This seems simplistic but is central to the scientific process upon which modern medicine is based. Apparent cause and effect relationships are sometimes confusing. That is to say that not all observations of correlation can be considered causation. Just because a beneficial effect occurs in the patient after a certain treatment, the observer cannot correctly conclude that the beneficial effect came about because of the treatment. In other words, we cannot jump to conclusions when someone says something like, “Well, I tried this treatment (fill-in anything you like, such as magnets, acupuncture, aspirin, etc.), and the next morning I felt great. This really works!” This statement always sounds foolish.
“Let the buyer beware!” This is the best advice to give any customer walking to a health food store, drugstore, vitamin shop, chiropractors office, etc., with a pain or complaint looking for a remedy. People in pain are often desperate and easily fooled. Words like “charlatan” and “snake oil” come to mind.
This is an ancient and still useful physical therapy treatment that applies a pulling force to the bones of the neck in an effort relieve and resolve certain painful neck syndromes. Traction is best done in a steady static pulling mode, rather than a commonly used interrupted, intermittent mode. Traction should never hurt and can be done for 30 minutes or more at a time as long as it is comfortable. Cervical disc injuries can often be effectively treated with traction. In some cases, traction treatments must be carried on for long periods of time. In these cases a home traction unit is sometimes preferable.
A popular treatment approach to not only spinal pain but human pathology generally, this discipline emphasizes the central role of the spine as a causative factor in all human disease states. This blatantly false concept is only now being gradually dismissed even by some chiropractors. The chiropractic philosophy states that all diseases that afflict the human body, including such diverse and unrelated conditions as asthma, acne, liver disorders, diabetes and other ailments, are directly linked to misalignments in the spine. Chiropractic claims that adjustments, or manipulations, of the spine cure these diseases. This is blatantly false. However, certain painful conditions of the spine are manipulatable. Therefore, if the patient suffering with neck or back pain sees a chiropractor, and happens to have a manipulatable lesion, they might be served well with the experience of a chiropractic adjustment. The problem is that all chiropractic patients are subject to manipulation. Some get better, many don’t, and some are injured and made worse. Historically, medical doctors have had little regard for the chiropractic field, based mostly on their claims and understanding of human disease. However, more and more doctors, including Dr. Portner and staff, recognize the value of spinal manipulation in the treatment and management of certain spinal conditions. Chiropractic care, if attempted, should be done sparingly and not on a maintenance basis. Long-term, prepaid treatment packages should the avoided. Decide for yourself if chiropractic, or any other treatment, is useful, based on your diminishing painful symptoms and your improving functional abilities. This advice holds true for all treatment types, not just chiropractic.
A chiropractor is a healthcare provider who practices chiropractic services. See chiropractic.
This term is applied to those conditions that have been present for a long time, usually more than 6 months.
Cigarette smoking is well-known for its many damaging effects on human health: emphysema, chronic bronchitis, COPD, lung cancer, stomach cancer, throat, tongue, and esophageal cancer, peripheral vascular disease and numerous other conditions. What is not as well appreciated is the fact that smoking cigarettes delays recovery of disc pathology causing neck or back pain. People who smoke and suffer with back pain have an added incentive to quit smoking altogether. Smoking also prevents proper bone fusion in patients who have undergone surgery for severe back pain. For this reason, oftentimes surgeons will refuse to perform the surgery in patients who have not yet quit smoking.
This is an anxiety/neurosis disorder resulting in the irrational fear of confined spaces. This is relevant to those patients who suffer with spine or limb pathology and require either a CAT scan or MRI, imaging tests that require that the patient be placed in a small space. Milder cases can be sedated with oral anti-anxiety agents, like Valium, an hour before the test. In more severe cases, the patient might have to be rendered unconscious or simply forego the test altogether.
A common and relatively milder derivative of the opiate family, this narcotic is often combined with codeine or other pain relievers and taken by mouth. Codeine is available by prescription only and is found in common cold and cough remedies as narcotics, in addition to blocking pain, are very effective cough suppressants. Other forms of codeine are also available for injection or by suppository. The usual precautions apply, as with any narcotic, and there is a potential for addiction. Constipation can also be a problem, so laxatives are often prescribed along with codeine in order to prevent constipation. Sedation is also an issue and patients should not drive or operate machinery while under the influence of codeine or other narcotics. Certain people are allergic to codeine and may develop itchiness and rashes. In these cases, codeine should be avoided as more serious allergic reactions, even life-threatening anaphylaxis, may occur with further usage.
This condition causes pain in the leg brought on by running and is relieved by rest. This phenomenon occurs when an exercising muscle cannot receive the necessary increased blood flow because it is confined to an abnormally tight space. The results and increased pressure in the compartment collapses the blood vessels and prevents the blood from arriving to the exercising muscle. This results in a lack of oxygen, called ischemia, which is painful. The patient is forced to then stop exercising because of the pain, but demand for increased blood flow subsides. Blood flow then returns to the compartment as the pressure lessons and the ischemia is resolved, thereby causing the pain to subside. The diagnosis of this condition is a clinical one and can be confirmed by measuring the pressure in the compartment. Often surgery is required to release the tight tissues confining the muscle. This procedure is curative. In some cases, compartment syndrome can be a rare cause of “shin splints.”
The vertebral body is the block of bones that is stacked one on top of the other to form the spine in the back and neck. With trauma, this bone can be crushed, like stepping on an empty aluminum coke can, causing acute pain. This condition is often seen in elderly persons who suffer from osteoporosis and are more susceptible to injury. Other conditions (like cancer or infection) that render the bone weak can also predispose people to these compression fractures. In the past, patients would have to struggle with the pain for several weeks or months as the bone healed. Now, a procedure called a kyphoplasty is available to some patients with this condition that can, when successful, not only restore the vertebral body to its original height but also resolve the pain immediately. This involves placing a large needle through the skin and into the vertebral body, whereby a balloon is then inserted through the needle and inflated to jack up the height of the vertebral body. Cement is then instilled into the balloon and the needle is withdrawn. The results sometimes appear miraculous.
A sleep-like state induced usually with IV medication, such as Versed, which is related to the valium family of benzodiazepines. Conscious sedation is used for certain procedures that are uncomfortable to spare the patient the anxiety and pain of the procedure. Having a procedure under conscious sedation, while perhaps more comfortable, does add a little bit to the potential risks and side effects of the procedure (termed the morbidity). Like all treatments, the risks (which are minimal with conscious sedation) must be weighed against the benefits.
This is a type of scientific study that is a cornerstone to proper medical research. Whenever a treatment is to be assessed in a group of patients as to its effectiveness, a similar group of patients must be given no treatment in order to compare the treated group with the control group. Without a control group, no conclusions can really be reached because we do not know how many people in a group of patients will get well spontaneously, for example. There is also the placebo effect of giving a patient a pill, even if it only contains sugar, who subsequently states that they feel better. Controlled studies are made more reliable and more scientific if both the patients and the examiners do not know which group is getting the actual medication and which group is getting the sugar pill. This is referred to as a double-blind controlled study.
This is a group of exercises that emphasizes strengthening and re-educating the muscles of the trunk that support the pelvis and spine. These exercises are of the utmost importance for the proper rehabilitation of patients with back pain. Pilates exercises, originally designed for dancers, are very excellent tools to improve core strengthening. Other activities that are naturally good for core strengthening include martial arts and standup paddle surfing.
See cause and effect. Just because a patient gets better while taking a certain treatment, it does not necessarily indicate that they got better because of the treatment. Oftentimes conditions, even in orthopedic medicine, get better with time naturally. If one is taking a treatment during this natural healing process, it may appear as if the treatment itself caused the patient to improve. However, this is a dangerous conclusion as the patient may have gotten better independent of any treatments rendered. Avoid jumping to this often erroneous conclusion.
A large family of hormones, both occurring naturally and produced synthetically, that have profound and far-reaching effects on the tissue and metabolism of the body. In orthopedic medicine, corticosteroids, also called “cortisone” or “steroids,” are often used in injection form, and sometimes by mouth, to treat specific musculoskeletal injuries. When used appropriately, these medications have proven safe and effective. However, when abused, they can have devastating and dangerous side effects. Therefore, cortisone must be used by those physicians expertly trained on when and when not to use them. Usually, if you use sparingly on an otherwise healthy person, no problems are anticipated. However, patients with diabetes, heart failure, compromised immune systems, infections, or other medical conditions must use cortisone sparingly and with extra precaution. The reputation of cortisone as a bad drug is overplayed.
When the doctor takes a reflex hammer and taps a tendon eliciting a quick jerk of the leg, this is an example of a deep tendon reflex. Orthopedic physicians routinely tests the reflexes in order to assess the nerves that go from the tendon to the spinal cord and immediately back to the adjacent muscles to cause a contraction. When a nerve is pinched as it exits the spine, called the radiculopathy, this reflex is diminished or lost all together.
This describes an abnormal clot in a vein deep inside the calf or thigh. These are particularly dangerous as the clot can potentially break off, travel up the venous system to the heart and cause sudden onset of chest pain, shortness of breath and even death. There is an increased incidence of deep vein thrombosis in people who sit still for a long time, such as a long plane ride, and also post-operatively. One baby aspirin per day is often effective in preventing deep vein thrombosis. Patients with a deep vein thrombosis may present with a painful, swollen leg that is tender to the touch with redness and hardness that can sometimes be felt through the skin and muscle. A diagnostic ultrasound or venography can be used to diagnose this potentially life-threatening condition.
Degenerative disc disease, or DDD, is a common radiologic finding seen on X-ray reports of the neck and back. These X-rays demonstrate loss of disc space height, increased density of the adjacent bone above and below the shrunken disc, air in the disc and bony spurs. The condition is almost ubiquitous after the age of 40 or 50. Unfortunately, oftentimes the patient complaining of back pain due to a unrelated condition will also demonstrate DDD on X-ray causing confusion and misdiagnosis. Patients are warned that if the doctor tells them that their diagnosis is degenerative disc disease, they should know that it may be an incidental X-ray diagnosis and may not accurately reflect the actual cause of back pain. A herniated disc can occur with a perfectly normal X-ray. Patients with severe degenerative disc disease findings on an X-ray can live normal, active lives without pain at all.
One of many narcotic medications, all derived from the poppy plant, called opiates. This medication is available in oral form and injection form. It is very strong, very effective at relieving pain, highly addictive, sleep inducing and can cause constipation.
Depression describes clinical sadness not necessarily related to life stresses, believed to be chemically induced in the brain. Depressed patients often have difficulty performing even the simplest of tasks and only want to lie in bed. Chronic pain is often accompanied by depression. Sometimes depressed patients will go through cycles of unusual energy spurts. These are called manic phases. When a patient has both manic and depressive phases, this is called bipolar illness. Depression in a patient with chronic pain makes the treatment program far more difficult. Antidepressant agents are sometimes used to help treat patients with chronic pain and depression.
This is the name of the condition that is causing the patient’s pain or other complaints. In orthopedic medicine the diagnosis should include the exact anatomical structure (that is the tendon, muscle, ligament, joint, disc, meniscus, fascia, or other anatomical structure), that is actually injured or diseased. In this way, knowing the anatomy of the injury, treatment can be directed, whether it is physical therapeutics or injection, directly at the site of the lesion. (See lesion). Any diagnosis that does not include the anatomy and file is less useful and imprecise. The diagnosis and orthopedic medicine can often be achieved by performing a careful history and thorough physical examination. Ancillary tests, such as x-rays, EMGs, ultrasound, MRI, et cetera, are sometimes required to either confirm the clinical diagnosis or help establish a diagnosis when it remains puzzling after the initial clinical visit. Physical diagnosis, when the physician uses their hands to examine the patient and test each individual structure separately in order to discover the anatomical structure that is involved, is unfortunately a dying art. Dr. Portner continues to practice and teach the art of physical diagnosis.
Ultrasound technology, like that used to detect the gender of a developing fetus when a woman visits her obstetrician for an ultrasound examination, has improved with each passing year. It is now becoming more available to patients with orthopedic implants in order to help diagnose the anatomical structure that is injured and produce images of the injury without the need for X-radiation. Dr. Portner is one of the first orthopedic clinics in the state of Hawaii to use ultrasound in the office for diagnostic purposes, affording patients more accurate diagnoses and less exposure to X-rays.
A diagnostician is a physician who possesses expert skills at figuring out the exact anatomical cause of each patient’s complaints. The diagnostician will use their experience and knowledge to carefully ask specific questions that will be invaluable in determining a diagnosis. The physical exam will carefully assess each and every individual anatomical structure in the area of interest to better determine which of these structures are causing the trouble. Diagnostic tests, including X-ray, EMG, MRI, ultrasound and other studies will be implemented sparingly and only when necessary to help arrive at the precise diagnosis. Only when this diagnosis is determined can proper treatment be prescribed. Dr. Portner and his staff pride themselves on the reputation they’ve earned in the Honolulu medical community as excellent diagnosticians. The team is regularly sent the most difficult and puzzling cases to help the referring physician sort out the cause, or causes, of enigmatic orthopedic pains.
This is a short list of possible diagnoses that would explain a patient’s presenting complaints and initial physical exam results. After the first visit, if the precise diagnosis is not be clearly worked out, the doctor will instead make this list of possible conditions and diseases that might fit this particular case. The job then would be, through further testing and other investigations, to eliminate the less likely causes and finally to arrive at the precise and accurate diagnosis. For example, a patient presenting with low back pain radiating into the buttock might have a differential diagnosis of a disc problem, facet joint arthritis and spinal stenosis. These causes can then be considered through a process of elimination until the accurate diagnosis is clear.
International Musculoskeletal Medicine is an international medical journal based in London that publishes scientific articles in the field of orthopedic medicine. Dr. Portner is a long-time member of the editorial board of this prestigious journal.
This is a recognized board-certified specialty of doctors with M.D. or DOT degrees who, after medical school and internship, spend another 3-4 years of their residency studying the diseases of the internal organs. General interns are experts in the healthcare of adult diagnoses and disease management, including diseases of the heart, lungs, stomach, liver, kidneys, intestines, etc.
There is a space inside every joint that has a thin film of fluid which provides lubrication and nutrition. When this space becomes inflamed, it is called “arthritis.” Intra-articular joint injections are often useful to treat inflamed joints.
Sometimes the fluid that accumulates within the joint needs to be removed by the orthopedic specialist. This is done using a sterile technique called joint aspiration. The skin is washed off with iodine solution and locally anesthetized with the Xylocaine. A needle is then inserted into the intra-articular space, that is within the joint itself, and the fluid is carefully removed. Oftentimes at the end of this procedure a small amount of cortisone is instilled when appropriate.
This is a treatment provided by skilled physical therapists, osteopathic physicians, medical orthopedists and some chiropractors. First the affected joint is positioned at its maximum range of motion, and then a powerful but short maneuver is executed to push the joint beyond that range. The performance of this treatment must be performed by a professional who is skilled and practiced in its use.
This is the method upon which all of our science is based. Questions about our universe (including our bodies) are considered honestly, and observations are made carefully and accurately and without pre-prejudice. Conclusions are developed using logical reasoning. Experimentation is performed with proper controls. Final conclusions are reached only when these experiments can be duplicated independently. Even with the scientific method oftentimes medical knowledge is led astray, but it is the best method we have at present.
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