Enthesopathy in elderly patient

[GlowInTheDark]

Patient sent to me with for epidural due to radicular pain. Clearly no physical exam had been done, pain is recreatable pushing with a single finger over the insertion and then origin of LCL. Occurs with ambulation. Varus stress is negative though. This has been going on for years, so they swear. In fact, the pain allegedly was what prompted a knee replacement (I question this) and was not improved after surgery. There is some associated non-painful numbness in lateral lower leg, they’re unsure of timeline of that.

Another pain physician has done genicular blocks x 2, patient has no interest in that route again—said it was hell, which I believe. NSAIDs have been tried, not sure of topicals off top of my head.

I injected local under ultrasound, they claim to my secretary it didn’t help at all, but followup is next week. Was going to offer PRP if that had helped.

Any ideas of alternative dx/management.

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[lobelsteve]

No to chronic LCL pain. Yes to ITB.

 

[MitchLevi]

Patient sent to me with for epidural due to radicular pain. Clearly no physical exam had been done, pain is recreatable pushing with a single finger over the insertion and then origin of LCL. Occurs with ambulation. Varus stress is negative though. This has been going on for years, so they swear. In fact, the pain allegedly was what prompted a knee replacement (I question this) and was not improved after surgery. There is some associated non-painful numbness in lateral lower leg, they’re unsure of timeline of that.

Another pain physician has done genicular blocks x 2, patient has no interest in that route again—said it was hell, which I believe. NSAIDs have been tried, not sure of topicals off top of my head.

I injected local under ultrasound, they claim to my secretary it didn’t help at all, but followup is next week. Was going to offer PRP if that had helped.

Any ideas of alternative dx/management.

See this frequently.

Lateral thigh and knee pain, especially if Gerdy's tubercle hurts is ITB until proven otherwise.

PT is the most important thing you'll do, but this doesn't go away quickly. Many reasons the ITB hurts. Muscle imbalance and deconditioning are common.

CSI at the greater trochanter helps, but these pts will ask you to inject Q6W. Don't do that obviously.

Voltaren + Lido gel.

Geniculars won't treat this IMO, and the fact the pt called that procedure "hell" is a red flag. Talk about an easy shot that no one really ever complains about FFS...

Edit - I misread you...Did the pt get a TKA?

 

[GlowInTheDark]

See this frequently.

Lateral thigh and knee pain, especially if Gerdy's tubercle hurts is ITB until proven otherwise.

PT is the most important thing you'll do, but this doesn't go away quickly. Many reasons the ITB hurts. Muscle imbalance and deconditioning are common.

CSI at the greater trochanter helps, but these pts will ask you to inject Q6W. Don't do that obviously.

Voltaren + Lido gel.

Geniculars won't treat this IMO, and the fact the pt called that procedure "hell" is a red flag. Talk about an easy shot that no one really ever complains about FFS...

Edit - I misread you...Did the pt get a TKA?

Yep. States pain was present before and after, it’s only distal over femoral epicondyle and Gerdys/fibular head. Ortho probably heard “knee pain” and looked at an arthritic radiograph and sawed away.

I’ll examine again, may have no TTP over trochanter. Is there actually a role to inject there if no pain proximal?

Appreciate the input, I’m anesthesia background and so are my in office colleagues.

 

[deleted131481]

Geniculars won't treat this IMO, and the fact the pt called that procedure "hell" is a red flag. Talk about an easy shot that no one really ever complains about FFS...

If done in AP walking off bone, it can indeed be 'hell'. This is how I did it in fellowship and those in my group do. I did the same first few months out of training til I changed to lateral after following this board.

 

[MitchLevi]

Yep. States pain was present before and after, it’s only distal over femoral epicondyle and Gerdys/fibular head. Ortho probably heard “knee pain” and looked at an arthritic radiograph and sawed away.

I’ll examine again, may have no TTP over trochanter. Is there actually a role to inject there if no pain proximal?

Appreciate the input, I’m anesthesia background and so are my in office colleagues.

Had a TKA...Either ITB or simply persistent post surgical knee pain.

Genicular nerve ablation, PT, meds, trochanteric CSI.

If done in AP walking off bone, it can indeed be 'hell'. This is how I did it in fellowship and those in my group do. I did the same first few months out of training til I changed to lateral after following this board.

Definitely not "hell." I do them AP, then lateral to check depth, then final AP and inject. Definitely not "hell."

 

[deleted131481]

Definitely not "hell." I do them AP, then lateral to check depth, then final AP and inject. Definitely not "hell."

I was originally taught to bullseye in AP and slowly walk off and in my experience was the most stimulating simple fluoro procedure I did and observed.

I do AP for RFA and now I start just a bit lateral to target and the needle bend is enough to walk deeper if needed. Maybe it's just experience but much better tolerated now.

 

[MitchLevi]

I was originally taught to bullseye in AP and slowly walk off and in my experience was the most stimulating simple fluoro procedure I did and observed.

I do AP for RFA and now I start just a bit lateral to target and the needle bend is enough to walk deeper if needed. Maybe it's just experience but much better tolerated now.

I think you're just better at your job now man.

My first few out of fellowship I had a couple of ppl who grimaced and groaned. I'm not trying to sound like I'm the best pain doctor on Earth, but I really don't get complaints about GN RFA. I'd say a few ppl groan while I drop anesthetic in the skin, which I do immediately after prepping. I mix a little bicarb in my lido, and my lido is either 1% or a 1:1 mix of 1% and 2%.

I draw the rest of my meds and continue setting up the procedure while the local soaks in...

 

[SSdoc33]

its definitely ITB. LCL? what?

i suppose you could put some PRP in there. probably wont work -- or will work as well as steroid. this is one of the things PT helps with. unlike most LBP it seems

 

[GlowInTheDark]

If done in AP walking off bone, it can indeed be 'hell'. This is how I did it in fellowship and those in my group do. I did the same first few months out of training til I changed to lateral after following this board.

That’s how I was taught. Haven’t done any out of training, I’ll look into the lateral approach. Definitely sounds better for patient comfort.