Managing Pain in Orthopedics

People tend to seek orthopedic care for one root reason: They’re experiencing pain. Whether from an acute sports injury or after enduring years of joint aches and stiffness, orthopedic specialists see people looking for relief. But when should you seek care? How do you figure out the cause of your pain? And what options do you have for treatment?

As innovators, orthopedic surgeons are constantly refining their approach to care before, during, and after surgery. Here, we asked three leading orthopedic surgeons about their views on and approaches to pain in orthopedics. Read on for answers from:

Q: How do you recommend people find the root cause of their pain?

Smith: When the source of the pain differs from where the pain is felt, we call this referred pain. Problems of the hip or spine can often present as pain lower in the limb, such as knee pain from a hip injury or arm pain due to problems in the neck. We can even see shoulder pain caused by abdominal issues. In children with spine curves that have increased due to rapid growth in puberty, there may be pain with breathing or standing for more than a few minutes. A musculoskeletal specialist like an orthopedist, physiatrist, or neurologist can usually recognize when pain is referred and recommend the appropriate diagnostic testing or treatment

Bedi: Referred pain is not uncommon and can be part of the diagnostic challenge for physicians. Providing a good history to your treating doctor about what elicits your pain, as well as its character and frequency, can help them hone in on the correct diagnosis. They may use diagnostic injections of different joints, combined with imaging, to help confirm the diagnosis and make a best plan.

Romeo: While imaging is important, the importance of a detailed history identifying the activities that cause the pain — as well as a comprehensive physical examination — cannot be overstated. I often uncover important clues by listening carefully to the explanation of how a pain began, followed by guiding the patients through specific range-of-motion exercises and strength testing. Often we’re able to find the root cause of their pain right away. Other times, a CT scan or MRI can confirm the answer.

Q: What are the three most common causes of joint pain?

Bedi: While there are myriad causes of joint pain, among the most common causes are arthritis, trauma, and overuse. Arthritis most commonly results from the lack of cartilage or “padding” that causes bone to rub against bone, which can be quite painful. Trauma is often responsible for meniscus and ligament tears in the knee, cartilage injuries, rotator cuff tears, as well as fractures. Overuse can cause tendinitis, stress fractures, fasciitis, and more.

Smith: In children, we often see pain in the joints from sports injuries, congenital problems, and juvenile arthritis. Unexplained lingering joint pain in children should be evaluated.

Q: How do new orthopedic technologies compare to pain medication for people experiencing chronic pain?

Bedi: As we improve our advanced imaging techniques like MRI, and develop new minimally invasive tools like cameras that are the size of a needle, our ability to build on our history and physical exam to find the pain generator for patients keeps improving. Continuing to make advances in treating patients in pain, however, with non-opioid options remains equally important.

Romeo: Chronic pain is challenging as it involves not only injury to our joints and other areas of our body, but also the person’s psychological response to pain. Some new technologies allow for improved management of the physical component of chronic pain, providing a better opportunity to successfully treat the psychological component. For example, surgical procedures performed with minimally invasive or arthroscopic techniques will minimize damage to the patient’s normal tissues, thus avoiding the risk of adding additional areas that can contribute to the overall symptoms of chronic pain.

Q: When is a good time to have your pain evaluated by an orthopedic specialist?

Smith: When pain does not resolve with simple measures of rest, ice, and compression, or if it interferes with the ability to participate in daily or desired activities, then it’s time to be evaluated by a physician. Sometimes a child may simply say, “My leg hurts,” repeatedly over time. That should be discussed with the child’s pediatrician.

Romeo: If you’ve been dealing with a gradual onset of pain and it’s now interfering with your quality of life, it’s time for an evaluation. Whether you’re losing sleep from shoulder pain or not able to keep up in your tennis game, it’s important to get to the root cause before it gets worse. Of course, if the pain starts suddenly after an injury, get help right away. Some injuries — such as a biceps tendon tear or an elbow dislocation — may require prompt intervention. Also, if you see a defect in your muscle or a change in bone shape, or can’t move your joint, see an orthopedic specialist right away.

Q: What’s the best way for people to manage pain before surgery and after surgery?

Smith: Before and after surgery, we use certified child life specialists to educate children, gain their trust, and help them through parts of the hospital stay that may make them nervous or hurt. This gives the child more a sense of control over their experience and understand what will happen before and after surgery. These specialists use play and the child’s interest to distract them during pre-surgical and post-surgical times. Our anesthesiologists can perform nerve blocks as part of a multimodal approach to pain management, inserting IVs after the patient is asleep in children younger than 8. In addition, the on-site bracing and therapy departments can provide equipment to support the painful limb to improve a patient’s mobility without increasing pain.

Romeo: Before surgery, patients should develop a strategy to get plenty of rest, minimize activities that directly worsen the pain, establish a good nutrition plan, and maintain their joint flexibility and strength as much as possible. On the day of surgery, before the operating room, patients can be provided with several non-narcotic medications and medications that minimize nausea, which may contribute to their post-operative pain. Prior to making an incision for surgery, I use a regional nerve block to numb the area being operated on. It’s very important that this is done before the procedure to pre-empt an excessive pain experience. As the nerve block gradually wears off after surgery, oral pain medications can manage discomfort for a short period of time. My multimodal analgesia approach relies on familiar medications such as Extra Strength Tylenol and nonsteroidal anti-inflammatory drugs. I often recommend cold therapy or ice to the surgical site as cryotherapy helps reduce swelling and hypersensitivity, which can reduce pain and the need for medications, especially narcotic medications.

Q: What new treatments or advances are you most excited about now?

Bedi: I’m very excited about the application of artificial intelligence and decision science in orthopedics patient care. Our ability to use evidence-based outcomes to guide the best plan for each patient, personalized to their condition, will be transformative for the field. I’m equally excited about the rapid growth in orthobiologics. I hope the next few years will allow us to advance the optimism and excitement around stem cells into meaningful and proven approaches to help healing with musculoskeletal injuries or delay the progression of osteoarthritis.

Romeo: As a specialist in shoulder and elbow surgery, the arthroscopic techniques for the treatment of all types of injuries and problems around these joints has been amazing and continue to evolve. We’re improving our ability to repair, restore, and even replace rotator cuff tendons using minimally invasive arthro- scopic techniques. When the problem is a joint that is arthritic or no longer functions properly, we now routinely restore an arthritic joint surface with a stemless implant that minimizes removal of the patient’s normal bone and facilitates a truly anatomic reconstruction of the joint surfaces. When the problem is more severe, the reverse shoulder replacement has revolutionized our treatment options and improved outcomes for patients with complex shoulder problems.

Smith: A recent publication from Shriners Children’s highlights pain as “the elephant in the room” for children with osteogenesis imperfecta and other bone and joint conditions. We’re making a commitment to measure pain and make multiple resources available to our patients to manage it.