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Dr. Andrew Rynne
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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Yes. I have suffered from chronic pain for years. Currently

Answered by
Dr.
Dr. Dariush Saghafi

Neurologist

Practicing since :1988

Answered : 2429 Questions

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Posted on Sun, 17 Mar 2019 in Bones, Muscles and Joints
Question: Yes. I have suffered from chronic pain for years. Currently I am experiencing debilitating pain from my neck{ Arthritic/herniated), left shoulder (had a scope done 2 years ago), left arm(when I feel around the muscle I detect what appears to me to be small nodules?), the back of my leg pain{when I rub where the pain radiates from, pain comes from the tendons above and from the calf, and finally pain from peripheral artery disease in my foot?
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Answered by Dr. Dariush Saghafi 59 minutes later
Brief Answer:
Chronic pain with likely multiple causes

Detailed Answer:
Many thanks for submitting your concern here on the network and I'm sorry you are suffering from the all too familiar and oft times just as stubborn chronic pains in the joints and articulations that sound to be OSTEOARTHRITIC in nature.

Of course, without a good physical examination I can't be certain about the "nodules" you are feeling in the left shoulder area. Depending upon the size, firmness, and number you may be feeling anything from calcifications that occurred following the arthroscope you had performed in that region to simple bony calcifications which could be more easily felt now if you've lost any muscle mass or fat tissue in that area, or you could have something that many of US get as we age which are LIPOMAS or small fatty tumors which develop and are entirely benign as well as felt as small "nodules."

Therefore, a physician's HANDS would be very helpful to tell you more about those nodules, however, in terms of the chronic debilitating pain you mention in the shoulder this certainly could be due to a cervical (neck) spine problem of OSTEOARTHRITIS impinging upon a nerve root or peripheral "twiglets" of nerve that run into the shoulder. Unfortunately, the treatment to a herniated disk is really surgery vs. watchful waiting and conservative treatments. It is said that in the case of COMPRESSIVE RADICULOPATHIES (i.e. hernias that pinch nerves) that 50% will resolve on their own over time without the need for surgery. However, the other 50% that do not recede and simply get worse are approached surgically. I always try and advise my patients to go the conservative approach for as long as possible and only take steps to surgery if nothing else has given satisfactory relief or things progress such as loss of muscle mass in a specific area subserved by the nerve, weakness in the shoulder itself to the point of not being able to move it well...not because of pain but because lack of power/strength, etc. In those cases I'm more inclined to recommend surgery.

Having said that about surgery I can also tell you that nowadays, surgery for herniated disks on the neck and even the back are enjoying more successful outcomes than ever before due to a newer technique that more and more surgeons are learning called MINIMALLY INVASIVE surgery. I have sent several of my patients to a colleague who is a minimally invasive neurosurgeon with very good results. Surgeries are often done as an outpatient and the amount of rehabilitation, scarring, and after surgery pain is minimal. HOWEVER, and this is important the selection process for these patients (as I said earlier) really should be those folks who really respond to nothing else.

Of course, you've heard of the mainstay for all forms of arthritic disease of this type in terms of shoulder exercises, stretching, and practicing large muscle movements which tend to give you large excursions of the joints involved....even though all of things also HURT, right? The way to BEAT arthritic pain is often by doing things that actually result in MORE pain. The good news is though, that if you are able to discipline and teach yourself ways to put up with just some of that pain for short periods of time and if you perform the supervised and regimented tasks designed for you by a good physical and/or occupational therapist then, with time you will be able to tolerate longer and longer durations of discomfort while engaging the joint more and more resulting in MORE functionality and less overall debility.

The alternative to that scenario is that the patient avoids anything that requires the use of the shoulder to any great extent and this usually leads to sedentary periods of time to become more and more prolonged where the joint falls into disuse which only BEGETS more stiffness, more development of arthritic spurs, and overall less mobility. When it is essential to move the joint it is very painful and if not tolerated over time may result in the person simply refusing to perform that task anymore (e.g. putting in or taking off certain types of clothing, reaching overhead to get things from cupboards, closets, driving a car with the affected arm/shoulder, etc.). You do not want to go into that category.

Therefore, my recommendation is that you align yourself with someone who can FIRST and foremost do a good joint and other physical examination to see about the effects of the herniated disk in the neck. Is it truly impinging upon nerves or is it just causing what we call MECHANICAL PAIN due to deterioration of the disk and irritation of the surrounding soft and hard tissues from chemical elements released by the herniation itself. Then, you should get a person who is going to be able to help you choose an exercise regimen targeting that shoulder movement along with neck movements so that you maintain fluidity and continue to accomplish your normal routine tasks.

I HIGHLY RECOMMEND any type of AQUATHERAPY compared to land therapy so that you are not working against gravity so much.

Medications can be helpful but I'm sure you'll agree that they are not the panacea some would try and make you believe (i.e. DRUG REPRESENTATIVES calling on doctors' offices). No matter how many different versions of ibuprofen someone releases....it's still not great for the stomach when taken for long periods of time and it still reaches a point where it likely will not work as effectively anymore. The same can be said for injections and steroid shots which can cause chemical erosion of soft tissues necessary to maintain integrity of the musculoskeletal so again, I recommend caution and judicious choices when someone offers such shots. I counsel my patients to the point where if their shots must be done more frequently than once every 3-4 months then, it is likely going to get to a point where the risks will outweigh the benefits.

Tendons and soft tissues above the calf that you mention may actually be referred pain from the patella or the patellar ligaments themselves could also be involved in some processes of calcifications and increasing stiffness due to disuse. A little biking/cycling on a stationary bike could be very helpful...though also testy when it comes to generating more pain at first but this is likely going to get better with time.

As far as the pain in the foot. If you have neuropathic pains in your foot from a previous neuroma resection then, in my experience there may be medication that is suited for your needs, however, your neurologist is the best to gauge which ones are best to try based on other medications or conditions you may have as well as whether you are driving a car, still working, or how sensitive you may be to medications of this type. The mainstays of this type of painful residual of a neuroma resection are things such as gabapentin (Neurontin), pregabalin (Lyrica), and topiramate (Trokenda/Topamax). Other possible things that I've had success in my patients are NORTRIPTYLINE (I avoid amitriptyline due to its somewhat harsher side effects), IMIPRAMINE, and DESIPRAMINE but use these with caution in the setting of prostate trouble. And there are a plethora of other medications that can be tried. I always try to encourage patients to be aware that using medications for neuropathic conditions can be a long arduous process. Most of these drugs will take up to 30 days to be properly titrated to high enough doses so just taking a couple of doses without effect is not a fair test of the drug. It also could take as much as 2-3 weeks for these drugs to wash out of the system before a new one can be started so again, TIME and PATIENCE.

I have used BOTOX injections successfully in terms of local FOOT PAIN for things such as residual neuropathy after surgical resection of neuromas, arch procedures, and diabetes but this an OFF LABEL use and one that many neurologists would likely not know about unless they are familiar with how to inject BOTOX.

One final but perhaps MOST IMPORTANT tidbit of advice for you would be to check out the following website:

www.arthritis.org

This is the Arthritis Foundation's website which has a monstrous amount of GOOD and SOLID information regarding OSTEOARTHRITIS and other forms of arthridites. They talk about the exercises I mentioned, aquatherapy, alternative forms of therapies I didn't mention such as BIOFEEDBACK, TENS units, ACUPUNCTURE, (gotta tell you that I've not really seen great results in my patients who go for DRY NEEDLING...everyone seems to be doing it...but honestly, I don't think they really know how to best apply it....stick to ACUPUNCTURE), and here's something you may not have guessed, DIET.....There's an actual recommended diet by the Arthritis Foundation for OSTEOARTHRITIS which is relatively new information that came out several years ago and seems to be gaining traction. Hey, at least there's no downside to eating healthily....even if it can't CURE the disease, right? HA!

And there you have it...some of what I hope are good suggestions for you to investigate and work with your doctors on implementing if they haven't been done already. Take a look at the arthritis foundation's website and Tally Ho....I hope you get some amazing relief in the coming weeks and months based on what we've discussed.

And so kind sir, if I've provided useful or helpful information to your questions could you do me the favor of CLOSING THE QUERY along with some POSITIVE words of feedback and maybe even a 5 STAR rating?

This query has utilized a total of 45 minutes of professional time in research, review, and synthesis for the purpose of formulating a response.



Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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