Platelet rich plasma (PRP) has been used medically since the late 1990′s. Dentists were the first to use this natural healing mechanism to improve outcomes of dental procedures. PRP has been used since 2000 for intraoperative (in the course of surgery) therapy following orthopedic, thoracic and cardiac surgical procedures. PRP has found wide use in non-surgical orthopedic treatment of knee pain and other joint injuries.

Platelet rich plasma also can heal injured tendons, ligaments, muscle, cartilage and bone. Major league sports has discovered the incredible natural healing effects of PRP. Many national and international sports leagues have adopted PRP therapy as one of the first line treatments of their injured athletes. Professional sports has recognized the economic value of PRP in that one PRP treatment costs $1500-2000 as compared to the typical orthopedic surgery which can range from $20,000 – 40,000. Additionally PRP has virtually no down time and does not require months of physical rehabilitation.  Platelet rich plasma has become an early treatment option in the treatment of professional athletes that have suffered muscle, joint, tendon and ligament injures.

NFL Players Who Have Received PRP

Hines Ward: Multiple PRP Treatments & 2 Super Bowl Wins!

Hines Ward, the Pittsburgh Steelers wide receiver, has use platelet rich plasma therapy on at least two occasions  for a torn medial collateral ligament — a knee injury. The use of PRP allowed him to go on and win two Super Bowls. Mr. Ward has attributed his ability to play to receiving PRP.

Other NFL players have successfully been treated with PRP for various injuries. Troy Polamalu, a Steeler’s defensive safety, has had his share of traumatic injuries. As one of the top defensive players, Polamalu has had repeated trauma to his knees. He had one significant MCL injury for which he had PRP therapy.

Donald Jones of the Buffalo Bills and Andre Dixon of the Hartford Colonials have also had PRP therapy for their injuries -all with excellent success.  Houston Texans wide receiver Andre Johnson suffered a high ankle sprain. To expedite the recovery process, Johnson underwent platelet rich plasma therapy.

These professional athletes were able to get back to playing football in only a few short weeks, instead of the normal 2-4 months of healing and rehabilitation time it take for more conventional therapies. Surgical treatment would sideline these highly trained athletes for a whole season. NFL physicians have discovered that PRP is the answer to getting these players healed quickly, with needing to resort to surgery. Platelet rich plasma regenerates new, stronger tissue in these injured players.

Major League Baseball and PRP

Alex Rodriguez: 5-time PRP Recipient

Alex Rodriguez, one of Major League Baseball’s most famous players used five PRP treatments to accelerate healing and recovery following hip surgery that left him in pain. His trainers were amazed to see how much faster A-Rod was able to get back into playing baseball.

Takashi Saito suffered an elbow injury in his pitching arm while playing as a Pitcher for the LA. At 38, surgery was not a good option, as recovery could have taken as much as 9 months. He had PRP therapy and was able to resume pitching in only a few weeks. Saito credited his unlikely recovery from a partially torn ulnar collateral ligament to PRP therapy.

Takashi Saito in his 2009 Season with the Boston Red Sox

In one year, Major League Baseball’s 30 teams had 519 players who spent 28,602 days on the disabled list for injuries sustained while playing baseball. This represented $455 million in total salary sitting idle, as these athletes were sidelined. PRP therapy can and does have a major effect in reducing recovery and down time.

National Basketball Association and PGA

One of the most famous basketball players, Kobe Bryant, has had several arthroscopic knee surgeries for right knee pain. He went to Germany to receive platelet rich plasma therapy. Being in his 30′s, he did not see more surgery as a good alternative. The promise of non-surgical, more rapid improvement with PRP therapy for his knee pain convinced this basketball legend to undergo therapy. Similarly professional golf star, Tiger Woods has undergone platelet rich plasma therapy more than once following ACL reconstructive surgery. His knee pain continued after surgery and he went with PRP with beneficial results.

National Tennis and World Soccer

Rafael Nadal: PRP Recipient

Other major national and international sports have recognized PRP therapy as an outstanding alternative to “standard” conservative therapy and certainly its benefits over surgical intervention. World tennis star, Rafael Nadal underwent PRP therapy after injuring his knee. His physician, Dr. Mikel Sanchez, described platelet rich plasma as a miraculous regenerative treatment. Indeed, that is what PRP does, regenerates new tissue. Major League Soccer players have also discovered the potential for better, rapid healing with PRP therapy.

Jonathan Bornstein, one of the top new young stars in soccer, twisted his knee resulting in a torn ligament. Facing the prospect of being out of playing soccer for 10 weeks, Bornstein elected to have PRP for his knee injury. He was back to running in 3 weeks and was ready to resume playing soccer only 2 weeks later. The list of professional athletes in a broad range of Major League sports, who have undergone platelet rich plasma therapy is growing every week. This list is beyond the scope of this article. The conclusion though is that PRP therapy is here to stay in the treatment of these injured, highly trained athletes.

PRP therapy is considered to be acceptable medical therapy by the International Olympic Committee, World Anti-Doping Agency and most professional sports association. Platelet rich plasma therapy is distinctly not blood doping and has been ruled on by the IOC and WADA as well as professional athletic associations.

Platelet rich plasma is a novel, non-surgical therapy to heal injured tissue. The platelets contain growth factors, cytokines and other agents that trigger the healing cascade. The difference is, is that with PRP therapy, a massively concentrated amount of platelets and supporting proteins are injected directly into the damage tissue. The body uses the same natural healing process for injuries but not in this high concentration. With this high concentration of healing platelets and growth factors, injured tissues can be regenerated and healed in only a few weeks. Many patients can have pain relief in 3 weeks. Many other painful conditions can be treated with PRP. If you suffer from joint, muscle, tendon or back pain – contact Sarasota Neurology for PRP therapy in Sarasota.

Photo Credits: tomcoolinmiami (Hines Ward) Keith Allison (Alex Rodriguez) Keith Allison (Takashi Saito) Francisco Diez (Rafael Nadal)

Lower back pain is a common complaint seen by almost every primary care doctor in the United States. So common in fact that 80% of the population will experience at least one episode of significant low back pain in their life. Many will experience recurrent episodes of lower back pains. Of those patients, one third will have some degree of leg pain in one or both legs. Back pain and most cases of associated leg pain do not originate from lumbar (lower back) spinal disc problems. There are many pain fiber bearing structures in the lower back including muscle, tendons, ligaments, vertebral joints and bone itself. The good news is that over 97% of all low back pain problems can be treated without surgery. Low back surgery is the most commonly overly performed surgical procedure in the United States and all too frequently the results are poor and even worse, makes the patient’s condition (back pain) more severe.

In the vast majority of patients, a careful history and detailed physical exam is the basis for developing a comprehensive, conservative treatment plan. Most patients show significant back muscle spasm with tenderness. Some will have exquisite tenderness in the sacroiliac joint where the tail bone meets the hip bone – a condition known as sacroiliitis. Piriformis Syndrome can cause low back pain and leg pain, but there is no spine involvement in this condition. The patient’s neurological exam is usually normal – it is uncommon to find clinical evidence of lumbar spinal nerve root compression (“pinched nerve”). In any clinical setting however, non-surgical treatment is indicated. Even in individuals who have evidence of a disc herniated, on exam, need conservative therapy – physical therapy, massage and anti-inflammatory medication. The natural history of disc herniation is to heal without the need for surgery or other invasive procedures such as epidural spine injections. A specifically designed course of hands on physical therapy combined with neuromuscular therapy in combination with self administered back stretching exercises will result in favorable outcomes the majority of the time While not clinically needed, many patients undergo CT or MRI scanning to look for the cause of their low back pain. This is where the road splits on the proper decision to use appropriate conservative therapy or improper decision to go to with an invasive route such as spinal injections or worse, surgery. Studies have shown that epidural steroid injections are no better than placebo. Other studies have shown that the outcome of back pain patients treated surgically is no better than those treated with best medical therapy. Narcotics should be avoided as they are habit-forming and do nothing to clear up the pain.

For patients that do get MRI studies, it is not uncommon to find spine MRI abnormalities. The important fact is that these abnormal MRI findings do not necessarily explain the pain that that individual is experiencing. To account for an individual’s back pain or sciatica (leg pain), the MRI findings must correlate exactly with the patient’s symptoms and neurological exam to have clinical significance. MRI studies of normal individuals without back pain or sciatica have been done. The results have shown that approximately 55% had bulging discs at one or more levels, 28% had disc herniation on the MRI scans. More than 70% of the MRI scans showed abnormalities and yet the patients had no symptoms! These MRI scans were done on patients who never had any back or leg pain – 70% of the MRIs were “abnormal.” The conclusion that just because the MRI scan shows “something”, does not mean that the findings are the cause of any given patient’s back or leg pain.

With conservative treatment and patient cooperation to do the back exercises, most patients have significant relief with clearing of their pain within 4-6 weeks. It is then important that patients continue to do their back exercises on a regular basis, as part of their daily exercise routine. Physical body reconditioning and core strengthening will also help a great deal. Back surgery (or neck surgery) can almost always be avoided. If you have back or neck pain that is troubling you, contact Dr. Kassicieh now for treatment.

What do you think of when you think of neck or back massage therapy? Most people think of the type of massage you would receive if you went to the spa for the day.  That type of massage therapy is known as a Swedish Massage. Swedish Massage is only one of over 40 types of massage that a person can receive. When you say you went to see your doctor today, what do you think of?  If I went to see my family doctor, my image would be different than if I said I went to see my Cardiovascular surgeon.  They are both doctors, but the exams and procedures that they perform are vastly different.

The field of massage is similar in its sub-specialization within the scope of massage therapy. Swedish Massage is great for relaxation and stress reduction, but if your back just went into spasm and is  locked up, you would be much better served going to a Massage Therapist that specializes in Rehabilitation and back pain relief.   Neuromuscular Therapy, Myofascial Release, Positional Release and Muscle Energy are just a few of the specialized massage techniques that were developed to treat muscle pain and skeletal dysfunction.  These techniques are focused on looking at the role of the soft tissues in causing pain. Soft tissues include muscle, tendon, ligament and fascia. Fascia is the covering over muscles and internal organs that provide stability and strength. Neuromuscular therapy treats fascia and muscle pain. Myofascial Release treats connective tissue disorders, particularly tight fascia which is a painful syndrome that frequently accompanies muscle pain and spasm. Positional Release treats muscle spasms, muscle energy treats joint restrictions.

These techniques are taught to Massage Therapists as advanced, highly specialized postgraduate courses. Just as a doctor can practice medicine after four years in medical school, he/she must first participate in a postgraduate internship and residency program to specialize in his/her specific field of medicine.  A Massage Therapist who is treating patient for acute and chronic muscle and joint pain should have more than just basic, Swedish Massage training. What patient’s want most is pain relief.

In summary, specialized massage therapy for medical conditions, requires advanced training on the part of the massage therapist. Many hours of postgraduate massage therapy education and training is necessary for successful outcomes in the treatment of patients suffering from pain in the neck, back, head or extremities. For more information visit Soar Point Massage or contact Jack Ryan, LMT a 941–993-3339 for an appointment.

Patients are being treated currently at Sarasota Neurology with PRP (platelet rich plasma) for a wide variety of joint pain and other pain issues. Among the more common uses for PRP are knee pain, shoulder pain and other painful conditions such as plantar fasciitis, tennis elbow, some types of low back pain. PRP can also be used in patients that have residual joint pain from having had orthopedic arthroscopic knee or shoulder surgery.

PRP works to heal painful joints by using the patients’ own natural biological healing mechanism. The injured or damaged tissue in the joints, ligament and tendons or muscle send out chemical signals that there is injury or incomplete healing. PRP has receptors on the active platelets that seek out these damaged tissues. The PRP graft then biologically and molecularly attach to the damage tissue and trigger the natural healing process of making new collagen. This process takes six weeks to have a full effect although actual healing can continue for up to three months.

PRP may be used in some patients as an alternative to having surgery on their knees, rotator cuffs or in cases of plantar fasciitis (foot pain). Beginning in early 2011, Sarasota Neurology will be offering a new and innovative uses for PRP. This highly effective treatment is ideal for patients who would prefer to avoid the cost, pain and time involved in having surgery for the same problem. Check back with us in February to get more details of this exciting treatment with PRP in Sarasota.

A recent report in the Journal of the AMA (De Vos, et al JAMA 2009) reported that platelet rich plasma therapy was no more effective for chronic Achilles tendinopathy than standard, conservative therapy. This study was inherently flawed in its design resulting in incorrect conclusions. Platelet rich plasma is the healing component of blood. It is derived and concentrated from a patient’s own blood and then injected into the affected area. Not all PRP is the same. Blood processing is the key, levels of growth factors are of utmost importance and successful outcomes will vary with the technique, protocol and level of expertise the clinician possesses. Different PRP extraction equipment and how the blood product is handled during this process is also critical.

De Vos et al commented “A limitation of the study was that the amount of platelets and quantity of activated growth factors that were present in the PRP injections were unknown.” This introduces several variables that would invalidate the data and the study’s conclusion:

1. What PRP processing system was used?

2. Were the levels of Growth Factors therapeutic? Therapeutic level ranges  are usually 4-5  times the baseline.

3. No levels or PRP concentrations were taken or reported.

All of these are significant study design flaws that will result in invalid study conclusions. Additionally the study stated “Platelets are slow to activate by exposure to tendon collagen, but it might be that therapeutic pressure within the tendon, a large amount of PRP diffused rapidly out of the tendon thereby reducing its effect.” Additionally thrombin – a critical component in PRP therapy – was not used to activate the platelets. PRP and growth factors will not activate or be as effective if thrombin is not used in this procedure.

Perhaps most significant study design error was that only one PRP injection was given. The study patients, by design criteria, were required to have chronic Achilles tendinopathy that had responded poorly to prior therapies. Chronic tendon injuries, particularly those in the Achilles tendon, heal poorly due to inherently poor blood circulation. The standard PRP technique in this type of injury would be a series of three injections over a period of 3-4 months. A study that specifies treating a patient with a chronic tendinopathy with a single PRP injection is setting up the patient unnecessarily for failure. Lastly, the study had a low number of subjects in it to make any clinically significant conclusions. Only 27 subjects were treated, each with a single PRP injection and there were 27 control subjects.

Regenerative medicine – Platelet rich plasma – has been FDA approved for medical use for 20 years. It has been used widely in dental, cardiac, orthopedic medicine to assist in and improve medical outcomes. The professional horse racing associations widely use PRP therapy to heal leg injuries in their million dollar race horses. Major league sports such as the NFL and MLB consider platelet rich plasma therapy an important treatment option to get their elite athletes “back into the game” in as short of time as possible. PRP healing typically takes six weeks, particularly when combined with rehabilitation. In conclusion, PRP is a highly effective medical treatment for ligament, tendon, muscle and other knee/shoulder injuries as well as lower back pain. Even patients with post-operative knee pain or shoulder pain can benefit from PRP therapy.  Outcomes are entirely dependent on the preparation and handling of the blood, equipment used and experience as well as skill of the treating physician. Additional information on PRP can be found at PRP Stops Pain. Excellent clinical study references can be found by clicking here.

As a neurologist who sees many patients with neck, back and various joint pains, I practice an area of medicine known as neuro-orthopedics. As such, I treat patients for their pain without surgical intervention. Many patients with neck, back and joint pain (knee pain, shoulder pain, elbow pain, etc.) can be successfully treated without invasive surgery and the many risk that go along with this. With surgery there is also a prolonged recovery time and need for extensive rehabilitation. The area of medicine that applies to successfully treating patients without surgery or use of narcotic medications is known as regenerative medicine. In this field, platelet rich plasma is injected into the affected joint, tendon, ligament or soft tissue area that has pain and is failing to heal completely. Tendons attach muscle to bone and ligaments attach bones to bones. Platelet rich plasma (PRP) is the concentrated healing components of the blood. Only one percent of the blood contains the bioactive proteins and platelets that are involved in healing. Through a specialized process, we can take the patient’s own blood and concentrate the platelets and bioactive proteins up to 500%. This small amount of concentrated PRP is then injected into the joint or other body area, that needs regeneration, after local anesthetic is administered. The PRP graft is then activated with thrombin and the healing process begins. Using the patient’s own blood eliminates the risk of transmitting disease and prevents graft rejection. PRP also has the benefit of being antimicrobial, killing off bacteria thereby limiting the risk of infection. David Crane, MD published an excellent overview of platelet rich plasma.

Platelet rich plasma works by first being injected into the affected area and activated. The activated platelets attach themselves to the damaged tissue, whether that be tendons, ligaments, muscle or bone. The platelets release alpha granules and dense particles. The small packets contain powerful bioactive proteins that begin the healing process. The alpha granules contain clotting factors, growth factors, cytokines and adhesion molecules. These substances allow the PRP graft to attach to the damaged tissue and start recruiting other healing cells to migrate into the area. The dense particles contain proteins that allow the platelets to clump together, forming the structural matrix of the PRP graft.

Bioactive proteins recruit fibrinocytes that move into the area, attaching to the matrix. Fibrinocytes begin laying done new collagen. Collagen is the basic building block for soft tissue, tendons, ligaments and cartilage structures in the joint area. Initially after platelet rich plasma is injected there is an inflammatory response where the new cells, including fibrinocytes, white blood cells and stem cells move into the graft. This phase usually lasts about a week and may be associated with slight swelling and mild pain.  As new collagen is being laid down, the proliferation phase begins. During this phase, the collagen is laid down in sufficient quantities to regenerate the damaged tissue. A stem cell is an immature cell that can transform into whatever tissue is needed for repair. This phase can take about 4 weeks. After this the remodeling phase occurs, where the new collagen contracts and becomes much stronger, building stronger tendons and ligaments. The entire process takes about 6 weeks but remodeling can go on for as long as six months.

Regenerative medicine offers patient with hip, knee, shoulder, elbow, neck and back pains the opportunity to have the damaged tissues repaired non-surgically. Injection of PRP results in regenerating the damaged tissue and thus restoring normal function. It also offers patients hope for pain relief, who have failed surgery and do not want to take (or continue to take) narcotics. PRP is also excellent for some patients who have joint problems that would prefer to avoid surgery or are not good surgical candidates. This may be especially true for patients with severe knee arthritis. PRP is safe and effective. It has been FDA approved for 20 years. Platelet rich plasma has the advantage that it can be done as an outpatient procedure and there is virtually no “recovery time.”

Platelet rich plasma has been used many times in professional athletics. Hines Ward, the Pittsburgh Steeler’s wide receiver, sprained his medial collateral knee ligament. It was thought that he would not be able to play in the Super Bowl due to his knee pain. He was given a PRP treatment and went on to play in the Super Bowl. He actually caught the 38 yard pass that won the game! During his knee surgery, Tiger Woods had the additional benefit of having a PRP graft put on the surgical site of his knee surgery. Both the NFL and MLB consider platelet rich plasma a viable medical treatment in the management of their elite athletes. For athletes with intractable tennis elbow, PRP is an excellent treatment modality to avoid surgery. Similar benefits can be found in the treatment of professional baseball pitchers who suffer from pitcher’s shoulder.
Platelet rich plasma therapy can be used in other chronic painful conditions such as plantar fasciitis – a condition characterized by persistent foot pain that is difficult to treat. A PRP graft can be administered to the heel area and frequently provides patients with healing of the plantar fasciitis.  Sacroiliitis, an inflammation of the tailbone where it attaches to the hip bones is a very common cause of persistent lower back pain. It can mimic sciatica (leg pain) and yet has nothing to do with the low back spinal nerves. In patients who fail to respond to standard therapies such as anti-inflammatory agents, physical therapy or a cortisone injection, PRP is a excellent treatment alternative to heal and regenerate the sacroiliac joint ligaments. Patients with persistent hip pain frequently have a condition known as trochanteric bursitis. This is a hip bursitis that is sometimes difficult to treat. PRP repairs the tendon damage, thereby relieving the pain.

In summary, platelet rich plasma and regenerative medicine offer patients an exciting and innovative treatment that has a proven track record of healing patients and regenerating damaged tissues. With an experienced treating physician, success rates of up to 85% can be seen. Depending on the severity of the injury anywhere from 1-3 treatments with PRP may be needed, at 4 week intervals. PRP is an ideal treatment modality as it can be given to patients who would prefer to avoid surgery or it can be given after surgery, in patients who have persistent pain, despite adequate rehabilitation. If you have chronic joint, neck or back pain, you may want to consider getting PRP therapy. PRP therapy clearly can improve a patient’s quality of life. Call today for a consultation and evaluation to see if platelet rich plasma therapy may be right for you. For more information, see Sarasota Neurolgy PRP blog site at PRP Stops Pain.

The FDA has approved two additional medications specifically for the treatment of fibromyalgia symptoms. The first drug to ever be approved for fibromyalgia treatment was Lyrica. Lyrica was developed as an anti-seizure medication and has FDA approval for this and treatment of painful diabetic neuropathy. Since its initial release, the FDA approved its use for symptomatic treatment of fibromyalgia.

Cymbalta was the second drug to be FDA approved for the treatment of fibromyalgia. This has been a tremendous addition to treatment of this disabling condition. The most recent medication approved for FM treatment is Savella. Prior to the FDA approval of these three medications, there were no proven effective treatments for fibromyalgia. What is fibromyalgia?

Fibromyalgia (FM) is a syndrome of diffuse muscle pains, fatigue, subjective weakness and multiple points of tenderness in spinal muscles (neck pain, back pain) as well as extremities. Other symptoms can be seen with FM. Mental clouding known as fibromyalgia fog is seen in some patients. These patients have a poorly understood clouding of their ability to think clearly. They are able to function but just feel slower in their ability to think and some have memory difficulties as well. It should be made clear that these patients do not have dementia. Fatigue is quite prominent and patients do not seem to be able to be able to get enough rest or restorative sleep. Sleep hygiene is frequently disturbed. Affected individuals have difficulty falling asleep or staying asleep, primarily due to their pain. There is a higher incidence of restless legs syndrome and sleep apnea in FM patients. Other common neurological conditions seen include headache, which is often a mixed headache disorder. Patients complain of a dull low grade daily headache combined with intermittent migraine-type headaches. Due to the chronic refractory nature of their pain and associated symptoms, there is a high incidence of depression in FM patients. It is absolutely necessary to recognize this depression and treat it aggressively to improve the quality of life for FM patients.

The precise cause of FM is not clearly understood. Frequently there is a history of preceding physical trauma. This can be seen after motor vehicle accidents with significant physical trauma or after other physically traumatic events. Some patients may develop FM after particularly severe infections or prolonged acute illnesses. There is a genetic component to FM as it tends to run in families. Put another way, if you have a first degree relative who suffers from FM, you have a higher chance of developing this condition than the general population. There is a clear female predominance of this condition. The exact mechanism of the muscle pain is also not well understood. Extensive study of the muscles has failed to reveal any muscle abnormality. EMG studies in affected patients are normal. More recent theories include the concept of central sensitization. In central sensitization, the FM patient’s brain has a different perception of pain signals. These patients seem to have marked hypersensitivity to lower degrees of pain impulses. These impulses are magnified to a much greater degree in FM patient as compared to the general population.

Treatment of FM can be difficult. Over-the-counter analgesics such as aspirin, ibuprofen, naproxen or Tylenol-like products may provide some temporary relief. Some patients may get benefit from a non-narcotic analgesic tramadol. Narcotics should be avoided due to the risk of abuse and addiction. Currently the state-of-the-art treatment in FM is using one of the three agents: Lyrica, Cymbalta or Savella. Lyrica is an antiseizure drug that also has proven effects in certain painful conditions, including FM. Cymbalta and Savella are both antidepressants that elevate the levels of norepinephrine in the brain. Norepinephrine is a major brain neurotransmitter. Higher levels of this transmitter somehow suppress the pain signals in the brain. These are nonnarcotic, nonaddictive medications. They also have added benefit in that they are antidepressants and can treat the depression that so often accompanies the pain of FM. Certainly some type of regular exercise can benefit patients. Each patient needs to find the particular exercise program that they can do without triggering worsening of their fibro pain. Water based or other nontraumatic exercises are the best in this regard.

Fibromyalgia can also be managed by appropriate, well balanced diet. Eat regularly with adequate daily intake of fruits and vegetables. In some patients, a dietary consultation can be helpful in designing a more appropriate diet. Adequate, restorative sleep is critical in controlling and improving the quality of life in fibro patients. If necessary, a mild sleeping agent can be employed. Despite these measures, FM patients will still have good and bad days. On the bad days, one must recognize this and have a more restful, less stressed day.

The first step in getting better, is to see a physician that specializes in treating fibromyalgia. Adequate laboratory testing should be performed to rule out more serious conditions such as thyroid disease, other muscle diseases, rheumatoid arthritis or other connective tissue disorders.

How many people do you know who tell of back pain that has no cure? Or sciatica or leg pain than doctors cannot find the cause for. They tell you that the MRI scan was normal, back injections of steroids do not help and no medication has relieved their pain. There are tens of thousands of people with back pain and sciatica who never get the right diagnosis despite having several MRI scans and seeing numerous physicians. There is a high probability that these individuals suffer from a condition called piriformis syndrome. Unfortunately piriformis syndrome is frequently misdiagnosed as sciatica.

The piriformis muscle is a triangular shaped muscle that is in the middle of the buttocks. The base of the triangle attaches to the side of the sacrum (tailbone) and the tip attaches to the top of the femur (the major bone in the hip and leg.) An excellent piriformis diagram is found on the Institute for Nerve Medicine website. Injury or sprain to the piriformis muscle causes spasm, which in and of itself is painful. This can cause back pain and buttocks pain. Prolonged sitting will make the pain worse. Walking, climbing stairs or bending can be difficult and painful. The sciatic nerve comes out of the spine, exiting just below the piriformis muscle. In approximately 15% of individuals, the sciatic nerve pierces through the lower border of the piriformis muscle. It is these individuals who are predisposed to developing sciatica with injury to the piriformis muscle. Even without this, a strained, inflamed piriformis muscle will cause irritation to the sciatic nerve thereby causing sciatica.

There is no specific test, MRI or EMG findings in piriformis syndrome. It is a diagnosis made on the basis of getting the patient’s history, unique set of symptoms and detailed physical exam. Ordering an MRI of the back and getting an EMG will only help to exclude other causes of back pain and sciatica. Remember, just because you may have a “bulging disc” or “herniated disc” does not mean that this is causing your back pain or sciatica. Thirty percent of the general population have disc herniation on their MRI scans that are causing no symptoms. Therefore disc herniation does not equal back pain or sciatica Once the diagnosis is made, treatment should be started as soon as possible. The first is to educate the patient about the condition and identify activities that they are doing that irritate the piriformis muscle. Avoiding these activities and holding off on sports activities will help to stop straining the hip muscles. A set of stretching exercises for the back and hip muscles should be done twice daily to relieve the spasm, which will reduce the pain. Muscle Ventures has an excellent diagram and explanation of the piriformis stretch, even with a video.  With this stretching, an anti-inflammatory medication, such as ibuprofen or naproxen, can be taken to lessen the pain and treat the inflammation in the muscle, tendon and sciatic nerve. Physical therapy can have a part in treating piriformis syndrome. It takes a therapist familiar with the condition to effectively provide relief. This in combination with deep neuromuscular therapy in the buttocks region will also help. Injections into the piriformis muscle are rarely performed due to its close relationship to the sciatic nerve and risk of injury to the nerve. Surgery has been tried but it is a major procedure and the effectiveness of this remains in question.

In summary, piriformis syndrome is a condition of strain and injury to the muscle. The sciatic nerve runs immediately below or just exits through the lower piriformis muscle. When injury occurs to the piriformis muscle, the sciatic nerve becomes irritated. This causes lower back and buttocks pain with sciatica. Diagnostic tests can only help in excluding other causes of back and leg pain. Therapy for piriformis syndrome consists of daily stretching, antiinflammatory medication and physical therapy. Affected individuals should avoid activities that aggravate their back pain and sciatica. Healing time can be weeks to months.

Fibromyalgia is a chronic muscle pain disorder that has no underlying identifiable cause. Sufferers have muscle pain, multiple areas of tenderness and fatigue. It is a poorly understood disorder, with many physicians not even acknowledging that it is a real illness. There is , however ample evidence that fibromyalgia is a real condition as it has been estimated that as many as 6 million Americans suffer from this affliction annually. Patients typically see several physicians and become frustrated when all their testing comes back normal. Other accompanying symptoms may include poor sleep hygiene, headache, mental clouding (fibromyalgia fog) and depression. Although this conditions rarely clears, suffers can be treated successfully with a combination of medications and regular exercise.

The FDA has recently approved Lyrica as the first drug specifically for fibromyalgia treatment. Lyrica (pregabalin) was originally approved for treatment of seizures and painful diabetic neuropathy. Based on two large, double-blind studies with 1,800 patients enrolled, the FDA approved labeling for Lyrica to be used in the non-narcotic control of fibromyalgia pain. The exact mechanism by which Lyrica controls the pain of fibromyalgia is not well understood. I have used this drug extensively in my practice to help individuals with fibromyalgia, who have failed other therapies. With FDA approval, more insurance companies will be compelled to cover this otherwise costly medication.

Other medications have been used to help patients with fibromyalgia. Medications in the tricyclic antidepressant family such as amitriptyline, nortriptyline and trazodone have been used with varying degrees of success. Some anti-inflammatory medication may be helpful as well. In combination with medications, it is important for patients with fibromyalgia to get some type of regular exercise that involves muscle resistance. The combination of medications and exercise provide the best hope for controlling the symptoms of fibromyalgia as there is no definitive cure. Mayo Clinic published an excellent summary of fibromyalgia. If you feel that you have this condition, find a neurologist or rheumatologist in your area that has knowledge in treating this condition.

Neck and back pain are some of the most common conditions for which patients seek out medical care. It is estimated that 8 out of 10 Americans will have at least one significant episode of back or neck pain in their life. For many, this can be a recurrent or persistent problem. Fortunately over 90% of the cases can be treated without surgery or other invasive procedures. The most common underlying cause for back pain is poor body conditioning. With our sedentary life styles, it is no wonder that we become deconditioned. Even persons who exercise regularly are prone to developing back or neck pain problems. Without doing specific back and neck stretching and strengthening exercises, we are setting ourselves up to have back pain. Something as simple as bending over to tie a shoe, reaching up in the cupboard or even sneezing can trigger an acute back pain episode. Neck pain is frequently caused by “sleeping wrong at night”, sleeping on a plane or just straining the neck when lifting or playing sports. All of these variations of neck and back pain have as a cause, muscle, tendon and ligament strain. Particularly in the back, individuals will have gradual tightening of the back and hip muscles and not even feel it. Then, when a “minor event” such as coughing occurs, these already tight muscles go into sudden spasm which then is felt as pain. With the acute spasm, patients can have trouble turning their head, bending over, walking and sleeping. Fortunately most of these conditions can be treated without surgery, invasive procedures or even MRI scanning.

In the vast majority of patients, a careful history and detailed physical exam is the basis for developing a treatment plan. Most patients show significant back and/or neck muscle spasm with tenderness. Some patients can have exquisite tenderness in the sacroiliac joint – where the tail bone meets the hip bone. The rest of their neurological exam is usually normal. In these individuals having a CT or MRI scan of the neck or back is not a necessary part of the initial treatment plan. A specifically designed course of hands on physical therapy combined with neuromuscular therapy in combination with self administered neck and back stretching and strengthening exercises will result in favorable outcomes the majority of the time. Sometimes anti-inflammatory medications or muscle relaxants can be of benefit. Narcotics should be avoided as they are habit-forming and do nothing to clear up the pain. In very specific cases, limited use of nerve blocks in the sacroiliac area or lower neck may be helpful. Epidural steroids, for the most part, are not particularly helpful and carry significant complication risks with them; particularly in the neck. For patients that do go on to have MRI studies, it is not uncommon to finding xray abnormalities but these do not necessarily explain the pain that that individual is experiencing. The important message is that the MRI findings must correlate exactly with the patient’s symptoms and neurological exam to have clinical significance. MRI studies of normal individuals without back pain have been done. The results have shown that approximately 38% of these MRI scans showed abnormalities and yet the patients had no symptoms. The conclusion is that just because the MRI scan shows “something”, it does not necessarily mean that that is the cause of your pain.
With careful management and patient cooperation to do the exercises most patients have significant relief with subsequent clearing of their pain within 4-6 weeks. It is then important that patients continue to do their neck and back exercises on a regular basis, as part of their daily exercise routine. With doing this back surgery or neck surgery can almost always be avoided. The most important step in getting better is to seek out care from a knowledgeable, medical physician such as a neurologist or physiatrist who specializes in the non-surgical treatment of neck and back conditions. More information on back disorders can be found at my website or at Spine Universe.