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Ask Dr. Arun Phophalia Your Own Question
Dr. Arun Phophalia
Dr. Arun Phophalia, Doctor (MD)
Category: Health
Satisfied Customers: 35038
Experience:  MBBS, MS (General Surgery), Fellowship in Sports Medicine
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Dear Dr., I have had a recent MRI due to back and knee pain.

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Dear Dr. Mark, I have had a recent MRI due to back and knee pain. The following is a summary: Multilevel degenerative disc disease and facet arthrosis, most pronounced on the right at L4-L5 and on the left at L5-S1, with likely abutment of the exiting right L4 and left L5 nerve roots. I am an RN with a fairly good understanding of this report. What I don't know is how are these problems usually approached - is surgery the best(only) option?

I am Dr. Arun and will be helping you today.

Dr. Mark is offline. If you wish I can answer your question. Or do you want to wait for him?

What are your symptoms?

What are the treatment done?

Thank you.

Customer: replied 3 years ago.

You can answer my questions. I have severe right knee pain, sometimes right hip pain that affects my ability to walk. I have difficulty sitting for any length of time, because my back hurts, I get burning pain in my right buttock, and occasionally my right foot goes numb. The longer I am up on my feet during the day, the more my back hurts. Sometimes it feels as if someone has taken a sledgehammer to the top of my head and is bashing it to make me shorter.

I have had my hips and knees injected, which did not work. They are recommending physical therapy, which I have tried and failed before.

Thanks for the opportunity to help you.

The indications of the surgery are;

1) Failure of the conservative treatment.
2) Progressive or severe / excruciating pain.
3) Increasing neurological signs and symptoms
4) Involvement of bladder and bowel.

Following investigations also would be required, if not yet done;

1) Nerve conduction velocity (NCV) study

2) Electromyography (EMG)

Following measures usually are advised for the conservative treatment;

1) Back care in the activities of daily living, which is an integral component of the treatment of back problems. Back education is one of the most important thing which teaches the basic body mechanics, like correct posture for standing, standing at a desk or drawing board, sitting, brushing teeth, washing the face, pushing and pulling a weight, lifting a weight, getting in and out of bed, sleeping, getting into and sitting in a car. The training for these routine activity helps in preventing the spasm of the muscles. One needs to consult an occupational therapist or physical therapist which can educate about the proper and improper behaviors when back is painful in case they have to sit, bend forward, lie down, walk, cough, or sneeze. Following more need to be done:

a) Avoid activities which increase the pain.

b) Rest intermittently

c) Avoid bending at 90 degrees

d) Pushing and pulling should be avoided till pain subsides

f) Avoid prolonged sitting and standing

g) Avoid sitting or sleeping on floor

2) Anti-inflammatory analgesics like ibuprofen, other analgesics and muscle relaxants

3) Local analgesic gels or sprays / ointment

4) Hot fomentation

5) Electrotherapy like trans cutaneous electrical nerve stimulation: done by physical therapist. Other thing are ice packs, heating pads, electrical stimulation, phonophoresis, iontophoresis, relaxation, and biofeedback.

6) Good supervised physiotherapy: The exercises consist of abdominal bracing, modified sit-ups, double-knee-to-chest or low back stretches, seat lifts, mountain and sag exercises, knee-to-elbow exercises, hamstring stretches, extension exercises, and extension flexibility exercises. Swimming exercises (pool exercises) are best for back pain. Initial stretching and later strengthening exercises are taught.

7) Lumbosacral corset or support or brace

8) If obese or over weight, reduce weight for long term benefit.

9) Epidural steroid shots

10) Radio frequency ablation of the nerves in facet joints.

Surgery is usually last resort, when the above conservative measures fail or symptoms are progressively increasing. You may start the following exercises, meanwhile;

1) Straight leg raising: Lie on the bed with your back and remain in a relaxed position. Slowly raise one of your legs upward and keep it as straight as possible. Count up to ten, and slowly bring down the leg. Do the same with the other leg. Repeat this exercise ten times.

2) Curl ups; lie on the back with knees bent, fold arms across the chest, tilt the pelvis to flatten the back, and curl-up lifting the head and shoulders from the bed / couch. Hold for ten seconds, then slowly lower to starting position. As strength builds, aim to complete one sets of ten curls. The exercise should be done twice a day (both the sets).

This is a slide show for the exercises (you can pick up your own set, which suits you);

You can consult following specialists (apart from your GP);

a) Orthopedist

b) Neurologist

c) MD in Physical medicine and rehabilitation

Your knee and hip pain are due to concomitant conditions of osteoarthritis (degenerative / age related arthritis) and due to radiculopathy from the back. These may need hip and knee replacement if conservative measures as following have not helped;

1) Physical therapy; this is the mainstay of the management of the osteoarthritis. Stretching exercises, strengthening exercises, mild weight bearing exercises, swimming on the week-ends etc would be helpful. Going to pool on week-ends will further enhance the benefit. You need to incorporate the exercises in your routine as much as possible.

2) Deep electrotherapy; this entails going to physical therapy center and take care of specific issues which are more painful.

3) Glucosamine and chondroitin supplements

4) Diacerin too can be tried which suppose to regenerate the cartilage.

5) Local analgesic sprays

6) Acupuncture

7) Consideration of hyaluronic acid injection in the joints which are more painful. Some physician may inject steroid too for the pain relief.

8) Warm shower in morning would open up the joints.

9) Capsaicin (Zostrix, ArthriCare) is an irritant derived from chili peppers that provide relief by depleting a chemical that transmits pain from nerve endings. Various strengths are available without prescription. (It causes a burning sensation thus one has to be careful while applying and should wear a disposable plastic glove).

10) Acupuncture; most popular forms of alternative or complementary medicine, particularly for pain relief.

11) Analgesic patches too are available for the pain relief.

If overweight is an issue; long term is achieved by weight reduction. High impact exercises should be avoided; like kneeling and bending.

Please feel free for your follow up questions.

I would be happy to assist you further, if you need any more information.

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Dr. Arun Phophalia and 2 other Health Specialists are ready to help you
Customer: replied 3 years ago.

43 years of nursing, plus the increasing weight of our patient population has now made it impossible for me to work due to the pain. Over the past 6 months, the pain has gotten increasingly worse. I sent you separately the lengthy list of meds I am taking to deal with this, and many days it is not enough. It is better now that I am out on disability, as I can rest when I need to, and get off my feet.

The lidocaine patches did nothing for me. The TENS unit occasionally helps my knees, but that it inconsistent as well. It is better for the knee muscle spasms, or my restless leg syndrome (another blessing). What I really want to know is will all this physical therapy prevent or slow the disease process, or will I likely end up needing surgery in the future? I have been pursuing treatment for my knee pain for 18 years now, most of which I consider to have been wasted until my referral to the pain clinic. I don't want to stay on narcotics forever, and there are a limited number of physical therapy sessions I can afford to attend,as I have not yet received a disability check. Having been an OR nurse for 20+ years, I have to admit, I'd rather just "get better"

I think on the right track. Pacing the activity and relative rest with these ailments is definitely important part of the management. Once you learn the tailor made exercise regime made by an MD in physical medicine and rehabilitation; you can do the exercises at home, with not much dependence on the physical therapy center. This is a slow process of improvement so give some time. I appreciate your concern and it is better to gradually taper off the narcotic analgesics gradually.

Rest Leg Syndrome can develop as a result of certain conditions, particularly iron deficiency and peripheral neuropathy. Other causes of RLS are folate or magnesium deficiency, amyloidosis, diabetes mellitus, lumbosacral radiculopathy, or vitamin B-12 deficiency. Following investigations are advised;

1) A complete iron panel including iron levels, ferritin, transferrin saturation, and total iron binding capacity.
2) BUN,
3) creatinine,
4) magnesium,
5) thyroid-stimulating hormone (TSH),
6) vitamin B-12, and folate.

These investigation results will help to treat the primary problem so symptoms are benefited.

Following measures usually are helpful;

1) Avoidance of caffeine, alcohol, or nicotine (if one takes them).
2) Exercise before the bed time
3) Medications
a) Pramipexole (Mirapex)
b) Ropinirole hydrochloride (Requip).

In addition to above and the medicines which you are already taking, non pharmacologic therapy comprises of the following components:

1) Iron replacement therapy

2) Mental alerting activities such as video games or crossword puzzles, may reduce symptoms at times of boredom.

It is privilege assisting you.
Customer: replied 3 years ago.

Thank you! You have been extremely helpful! I appreciate your time and your patience.


You are most welcome, Marilyn.

Thanks for your kind words.

Wishing you all the very best