Musculoskeletal medicine involves the diagnosis and treatment of disorders of the musculoskeletal system (bones, muscles, cartilage, ligaments, tendons).

Musculoskeletal pain may occur secondary to injury or degeneration which the latter usually being of gradual onset process such as osteoarthritis. Treatment can involve multiple modalities and approaches such as patient education, analgesic medications, manipulative techniques, exercise rehabilitation, injection therapies and minimally invasive procedures.

Osteoarthritis also known as degenerative arthritis occurs when there is a breakdown of the cartilage (chondral) leaving the bones exposed. This often involves a complex enzymatic pathway with genetic, mechanical, and environmental factors having a role in it.

However, in simple terms it is ‘wear and tear’ of the joint which can occur at any joint in the body subjected to movement and stress. This usually affects people as they get older.  You can get it at any age and are more likely to if you have previously injured a joint, have significant muscle wasting or are overweight.

Symptoms can range from mild to severe daily pain, i.e., pain at rest, with light activity, joint stiffness (gelling), and nocturnal pain. The diagnosis is made based on the clinical history, examination and sometimes x-ray imaging.

Treatment includes guided exercises, weight loss if needed, analgesic medication, injection therapy (corticosteroid, platelet rich plasma etc.) and sometimes surgery.

Cervicogenic headaches are headaches that is experienced in the head, but the source of pain emanates from the cervical spine. There are precision diagnostic procedures for this with subsequent injection therapy or minimally invasive treatment.

Chronic pain syndromes such as fibromyalgia and complex regional pain syndrome (CRPS). These conditions are often overlooked and diagnosed after many years of failed treatment. Seeing a specialist who is familiar with this allows early and adequate treatment for pain management. This often involves a myriad of treatment modalities with long term care.

Shoulder conditions such as frozen shoulder (adhesive capsulitis), subacromial impingement syndrome, supraspinatus tendinopathy, and long head of biceps tendonitis.

Adhesive capsulitis (AC) of the shoulder is a pathological process where excessive fibrous tissue is formed across the glenohumeral joint causing restriction of the shoulder range of motion (ROM) which then leads to subsequent pain and dysfunction.

AC is a common musculoskeletal malady in primary care. AC affects up to 5% of the population with the propensity for women and age of onset usually around 40 to 60 years old. Most commonly AC causes are divided into idiopathic if the aetiology is unknown, or secondary if attributed to rotator-cuff pathology, diabetes, or trauma. It is important that a differential diagnosis is postulated in the early stages.

Emphasis is placed on the clinical acumen of the clinician to best manage AC since there are multiple treatment modalities. The chronicity of the condition which can take up to a few years can often be frustrating. The three widely accepted sequential phases of AC are pain, freezing and thawing/recovery stages. As for all the facets of treatment, treatment targets anti-inflammation and anti-adhesion.

Hip and knee pain are common presentations which can be secondary to a variety of pathologies. Treatment of this can be done with the right injection therapy such as corticosteroid, platelet rich plasma, prolotherapy or autologous blood injection.

Greater trochanteric pain syndrome (GTPS) or lateral hip pain constitute many musculoskeletal related presentations at the doctor’s office. GTPS is an umbrella term encompassing different clinical entities that may contribute to chronic intermittent lateral hip pain. Multiple labels such as “trochanteric bursitis” and “tronchanteritis” have been used in the past which is now regarded as a misnomer.

Invariably, the inflamed or enlarged bursa due to friction (sub-gluteal minimus/medius) is secondary or co-exist with an underlying pathology. Gluteal tendinopathy is identified as one of the major culprits of GTPS along with iliotibial band (ITB) and tensor fascia lata (TFT) as potential causes. Gluteal tendinopathy has a propensity for middle-aged women, between 40 and 60 years.

Large number of patients fail non-operative treatment with significant levels of dysfunction making important to find novel treatment strategies. Pain tends to be localized to the bony greater trochanter with aggravating activities such as walking, stair climbing and lying on the affected side.

Ultrasound guided injections are more accurate in depositing the medicinal liquid on the area of interest. This involves injecting corticosteroid, platelet rich plasma, dextrose liquid or autologous blood.

Again, this is discussed with the patient in terms of the pros and cons of each injection based on the current evidence-based medicine.

Nerve entrapment conditions such as carpal tunnel syndrome, lateral femoral cutaneous nerve (LFCN), ulnar nerve etc.

Hydro-dissection of tendon sheaths and/or entrapped nerves with ultrasound guidance can help with pain relief. Nerve pain also known as neuropathic pain can often be uncomfortable. Having correct and prompt treatment invariably leads to better outcomes.

Sports related injuries can involve from acute, sub-acute to chronic conditions. Having a wide range of medical training exposure allows good, directed therapy. This involves from conservative to minimally invasive therapy to aid recovery.

Acute and Chronic spinal pain involving the cervical, thoracic, lumbar and sacroiliac joints. Ultrasound and fluoroscopic guided (more often used in spinal procedures) injections are done to help diagnose and treat spinal related pain.

These are diagnostic injections done under fluoroscopy (X-ray guidance) to help diagnose the source of pain. The practitioners in New Zealand follow a strict criterion of having complete or >80% pain relief with two positive concordant local anaesthetic diagnostic blocks.

This gives a lower false positive rate with higher success rates with the definitive radiofrequency thermal ablation treatment. These blocks are diagnosing pain arising from the culprit facet joint and NOT other structures in the neck or back such as the discs.

Cervical facet joint pain is often missed in whiplash injuries. Studies have shown that these injuries are too subtle to be picked up on modern imaging especially when the injury has healed. Nevertheless, damaged structures such as the joint cartilage, capsule and/or ligaments can give rise to chronic pain.

Radiofrequency (RF) thermal nerve ablation is done following two positive diagnostic medial branch blocks. RF is a minimally invasive surgical procedure often done under local anaesthesia.

A needle is introduced through the muscles of the neck under X-ray (fluoroscopy) guidance. The procedure is done under strict sterile technique. The idea is to place the electrode tip parallel to the small nerves which carry pain messages from the facet joints to the brain. 

The electrode is then heated to 80-85 ºC for 90 seconds. The outer part of the culprit nerve coagulates which then blocks pain signal from travelling.

However, the nerve regrows gradually over 1-2 years. RF has been shown to provide complete pain relief for 12-24 months. Some people may get longer relief.

The use of PRP has been controversial, especially in tendinopathies given its slower onset of action to see its efficacy. Some tendons respond differently to PRP. Technician skills, type on condition being treated and type of PRP used are all variables that can affect its effectiveness.

The aetiology of tendinopathy has been proposed to be “failed healing” response. Ergo, lately ortho-biologics such as PRP has become popular in the musculoskeletal/orthopaedic community.

PRP is postulated to promote natural healing and provide a cocktail of high concentration cellular growth factors that mediate the regeneration tenocyte population in tendons. Theoretically, the higher the concentration of platelets, the more growth factors will be present to promote healing at the desired area of injection.

PRP may often shorten rehab time and is an avenue to consider prior to considering surgery. High levels of platelets can be derived by centrifugation process of whole blood sample. FDA approved specific platelet harvesting centrifuge devices can increase the local concentration of platelets which is then injected into the target site.

Usually about 22 mL of whole blood is extracted from the patient (from a vein in the elbow region) and mixed with anti-coagulant liquid in the centrifuge tube. This is then spun at high RPMs for 10-12 mins depending on the centrifugation kit (and protocol) and desired PRP required by the clinician.

This process separates the blood components to discard elements not suitable (red blood cells which are heavy sink to the base), and to gather elements with therapeutic effects such as platelets, white cells, growth factors and fibrin.

Common conditions treated with PRP – Lateral epicondylitis/epicondylalgia (Tennis elbow), Medial epicondylitis/epicondylalgia (Golfer’s elbow), Patellar tendinosis, Achilles tendinosis, Plantar fasciitis, Rotator cuff tendinosis, Gluteal tendinosis/Bursitis, Hip Labral tear, and Knee osteoarthritis.

Prolotherapy involves injecting irritant liquid for instance concentrated Dextrose in the joint, tendon or around the tendon.

The logic behind this is to stimulate natural healing. The advantage is cheaper cost and less side effects as compared to steroid injections. This usually involves two to three injections at two weeks interval.

First and only approved* combination hyaluronic acid (HA) plus steroid treatment for the pain of osteoarthritis.

This product is known as Cingal. The product contains 22 mg/mL high molecular weight cross-linked hyaluronic acid produced from bacterial fermentation, 4.5 mg/mL triamcinolone hexacetonide.

Retrospective studies have shown it delays knee replacement surgery by 1.4 years with better pain results following the injection. The other advantage is minimal steroid exposure to the body.