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Acute Pain Management

Management Team

Acute Pain Management

Overview

Acute pain is a sudden onset of pain that serves as a warning signal to the body regarding injury, illness, or another problem requiring attention. It typically lasts less than six months and resolves once the underlying cause is treated. Acute pain management is crucial for promoting comfort, enhancing recovery, and preventing complications for patients suffering from acute pain. While it offers numerous benefits, it is essential to tailor techniques to the individual’s condition and carefully manage associated risks. Multimodal approaches, combining pharmacological and non-pharmacological strategies, are often the most effective and safest for managing acute pain. Multimodal approaches, combining pharmacological and non-pharmacological strategies, are often the most effective and safest for managing acute pain.

  • Improved patient comfort:
    • Reduces physical distress and enhances overall well-being.
    • Allows patients to engage more comfortably in daily activities or rehabilitation.
  • Enhanced healing and recovery:
    • Alleviates pain that might otherwise impair mobility or cause muscle tension.
    • Promotes faster recovery by reducing stress on the body.
  • Prevention of chronic pain: Properly managed acute pain reduces the risk of developing chronic pain syndromes, such as post-surgical pain or nerve sensitisation.
  • Reduced physiological stress: Mitigates the body’s stress response (e.g., high blood pressure, increased heart rate), minimising complications like cardiac strain or respiratory issues.
  • Improved mobility: Effective pain control supports early mobilisation, especially after surgeries or injuries, preventing complications like deep vein thrombosis or muscle atrophy.
  • Better outcomes in surgery and recovery: Patients with well-managed pain post-surgery are more likely to adhere to physiotherapy and achieve optimal recovery.

  • Pharmacological methods:
    • Analgesics (pain killers): Over-the-counter pain relief medications (e.g., paracetamol) and non-steroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen, aspirin) for general pain, and prescription drugs (stronger opioids; e.g., morphine, fentanyl) for severe pain.
    • Local anaesthetics: Lidocaine or bupivacaine, delivered as injections or as topical creams (to be applied on the skin) to block pain signals.
    • Adjunctive medications: Steroids, anticonvulsants, or antidepressants to enhance pain relief in specific cases.
    • Regional anaesthesia:
      1. Nerve blocks: Targeted injections near specific nerves (e.g., intercostal or sciatic blocks) to block pain sensation.
      2. Epidural/spinal anaesthesia: Used in surgeries or childbirth to block pain in larger regions of the body.
  • Non-pharmacological methods:
    • Physical therapy: Techniques like massage, stretching, or exercise to relieve pain and improve mobility.
    • Cold or heat therapy: For inflammation or muscle spasms.
    • Acupuncture: Stimulating pressure points to reduce pain perception.
    • Cognitive-behavioural therapy (CBT): Psychological techniques to manage pain perception.
  • Advanced interventions:
    • Patient-controlled analgesia (PCA): A pump allows patients to self-administer a controlled amount of pain medication.
    • Intravenous (IV) therapy: For immediate and sustained pain relief, often in a hospital setting.
    • Multimodal analgesia: Combines different drug classes and techniques to target multiple pain pathways, enhancing efficacy while minimising side effects.

  • Medication-related risks:
    • Opioids: Risks of dependency, respiratory depression, and constipation.
    • NSAIDs: Prolonged use can cause gastrointestinal irritation, ulcers, or kidney damage.
  • Allergic reactions: Hypersensitivity to medications, such as anaphylaxis.
  • Regional anaesthesia risks:
    • Nerve Injury: Rare but possible during nerve block procedures.
    • Infection(s) or hematoma: Complications associated with needle insertion in spinal or epidural anaesthesia.
    • Cardiovascular effects: Hypotension (low blood pressure) can be caused due to sympathetic blockade.
  • Psychological and behavioural risks:
    • Inadequate pain relief: Failure to address the pain adequately may lead to frustration or mistrust in medical providers.
    • Fear of dependence: Anxiety about becoming reliant on pain medications.
  • Procedural risks:
    • Misplacement of injection: Misguided injections can lead to nerve damage, paralysis (rare), or ineffective pain control.
    • Overmedication: Excessive doses may result in toxicity or systemic complications.
  • Non-pharmacological risks:
    • Cold or heat therapy: Improper application may cause skin burns or frostbite.
    • Physical therapy: Overzealous exercise can aggravate pain or delay healing.
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Allergy

Management Team

Allergy

Do you often experience sneezing, itchy eyes, rashes or digestive issues like diarrhoea? These could be signs of an allergy. Allergies are one of the most widespread chronic conditions worldwide, affecting approximately 1 in 4 people. Symptoms can range from mild discomfort to severe, potentially life-threatening reactions, such as anaphylaxis. Unfortunately, many people endure these symptoms without seeking help, but it doesn’t have to be that way. Simple tests can identify if you’re allergic to specific substances, enabling effective management of your condition.

Our immune system plays a vital role in defending the body against harmful organisms. However, sometimes our immune system misidentifies harmless substances, such as certain foods, pollens, dust, or medications and triggers an allergic reaction. During this process, the body produces antibodies, leading to various symptoms. These symptoms can differ depending on the allergen involved, and your age. For instance, infants and toddlers are more likely to develop allergic reactions to foods like milk and eggs, while older children and adults might develop allergies to airborne substances, such as pollen or dust.

BODY PARTSYMPTOMSCOMMON TRIGGERS OR ALLERGENS
NOSESneezing, Itchy, Runny, Stuffy Mouth breathingPollen, house dust mites, cockroaches, pets and other animals
EYESItchiness, redness, watery or swollen eyesPollen, house dust mites, cockroaches, pets and other animals
MOUTHTingling and itching in the throat, mouth, and/or lips, swellingFruits, vegetables, nuts and legumes
SKINEczema (dry, itchy), rashes, hives, swellingNuts, shellfish, eggs, milk
LUNGSCoughing, wheezing, chest tightness, shortness of breath, asthmaPollen, house dust mites, cockroaches, pets and other animals, food
GASTROINTESTINALDiarrhoea, pain, nausea, vomiting, weight lossInfants and toddlers: Eggs, milk, wheat, soya bean
Children and adults: Eggs, milk, shellfish, wheat, peanuts, hazelnuts and other tree nuts, fruits and vegetables
VARIOUS ANAPHYLACTIC REACTIONSEARLY: Hives, tingling and itching around the mouth, swelling around mouth and eyes
SEVERE: Itching, tingling and swelling of the mouth and throat, abnormally low blood pressure, abdominal pain, nausea and vomiting, shortness of breath, asthma		Peanuts, tree nuts, fish, soybean, seafood, milk, eggs, seeds, fruits, drugs, bee and wasp venoms

Diagnosing allergies involves reviewing your family and medical history, conducting a physical examination, and performing tests to confirm the presence of an allergy.  Skin prick test is the most common and effective methods used for diagnosis. It is the gold standard diagnostic test worldwide for diagnosing IgE-mediated allergies.

Blood test can also be done for allergen-specific antibodies in patients where skin prick test is not possible.

The right allergy test depends on your specific symptoms, medical history, and individual needs. Blood testing is often recommended for individuals who cannot discontinue medications, have sensitive skin, or are at risk of severe allergic reactions during testing. Blood tests provide a comprehensive overview of your allergic profile, offering precise results that help identify triggers effectively. Allergy testing is a convenient and less invasive method for diagnosing allergies, offering several advantages:

  • Accuracy for certain foods: Blood tests for certain food allergies are more reliable than skin tests.
  • Medication-safe: Results are unaffected by medications you may be taking.
  • No risk of anaphylaxis: Blood testing eliminates the risk of triggering a severe anaphylactic reaction.
  • Skin condition independent: The test does not rely on the condition of your skin, making it suitable for various situations.
  • Infant-friendly: It is safe for infants as young as six weeks old.
  • Comprehensive and efficient: A single blood sample can be used to test for multiple allergens and allergen components. It can be easily ordered by your physician at allergy clinic

Treatments for allergies focus on managing symptoms and reducing exposure to allergens. Depending on the type and severity of your allergy, options include avoiding triggers, taking medications, or undergoing therapies like allergy shots to build long-term tolerance. Your doctor will help determine the most appropriate treatment for your specific condition. The common methods for the management of allergies are listed below:

Avoidance

For some allergies, particularly food-related ones, avoiding the allergen may be the only necessary treatment. This can prevent symptoms and eliminate the need for medications or additional interventions.

Medications

When avoiding allergens isn’t sufficient, medications can help manage allergy symptoms effectively. Fast-acting medicines such as epinephrine injections are also available to counter severe allergic reactions, such as anaphylaxis.

Allergy shots

Immunotherapy, commonly referred to as allergy shots, helps increase your tolerance to allergens over time. These are often recommended for severe allergies or persistent symptoms lasting more than three months annually. While allergy shots do not cure allergies, they significantly reduce your immune system’s sensitivity to allergens.

If you or your child experience symptoms of an allergy, consult a doctor about undergoing a blood test. If an allergy is confirmed through testing, you may be referred to a specialist, such as an allergist, for further evaluation and long-term management.

Allergies can evolve over time. For instance, infants may outgrow allergies to milk and eggs as they age, while other allergies might become more severe. Periodic testing is essential to accurately monitor and manage your allergy, ensuring better health and quality of life.

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Arthritis

Management Team

Arthritis

Overview

Arthritis is a broad term for joint inflammation, covering various conditions that affect the joints. It can cause pain, swelling, and stiffness, with severity ranging from mild to debilitating. Arthritis can significantly impact the quality of life.

Arthritis is categorised into the following types:

  • Osteoarthritis (OA): This is a degenerative joint condition associated with cartilage degeneration, which causes joint stiffness and pain; OA is the most common type of arthritis.
  • Inflammatory arthritis: This represents an autoimmune condition; the immune system mistakenly recognises the joint's synovial lining as ‘foreign’ and attacks it, leading to inflammation and pain. Common examples include rheumatoid arthritis (RA), ankylosing spondylitis (often affecting the spine), and psoriatic arthritis (linked with skin lesions).
  • Gout: This condition arises from the build-up of uric acid crystals in the joints, causing sudden, intense pain, typically in the big toe.
  • Juvenile arthritis: This type of arthritis typically occurs in children under the age of 16.

  • Ageing is the most common cause of arthritis, with the exception of juvenile arthritis.
  • According to gender differences, Some types of arthritis like RA and lupus are more common in women than men.
  • A family history of arthritis can increase the risk of developing specific types of arthritis, such as OA and RA.
  • Obesity has also been reported to serve as a risk factor for arthritis, given that excess weight puts pressure on the joints, particularly those associated with carrying weight, such as the knee joints.
  • Previous joint injuries or repetitive strain can lead to a higher likelihood of developing secondary osteoarthritis (OA).
  • People with autoimmune disorders may have an increased susceptibility to arthritis.

  • Persistent or occasional joint pain, particularly in weight-bearing joints, such as the knee and ankle joints
  • Swelling caused by inflammation in the affected joints
  • Stiffness, especially noticeable in the morning or after prolonged inactivity
  • Limited range of motion, causing difficulties in joint movement
  • Warmth and redness, commonly seen in inflammatory types of arthritis like rheumatoid arthritis (RA)

  • Physical Examination: The physician evaluates joint swelling, tenderness, range of motion, and overall joint function.
  • Medical History: This involves the discussion of the severity and duration of symptoms and any family history of arthritis.
  • Blood Tests: These help assess the levels of inflammation-specific markers, such as the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), autoimmune antibodies (e.g., rheumatoid factor for RA), and uric acid levels (for gout).
  • Imaging Studies: X-ray or magnetic resonance imaging (MRI) helps to assess structural changes in the joint and ascertain the severity of joint damage and inflammation.

Non-surgical treatment

Non-surgical treatment methods vary depending on the type and severity of arthritis; one or more of the following methods may be used:

  • Medications:
    • Analgesics: Mainly non-steroidal anti-inflammatory drugs (NSAIDs).
    • Disease-modifying antirheumatic Drugs (DMARDs): Used for rheumatoid arthritis (RA) and other inflammatory types of arthritis.
    • Urate-lowering medications: For managing gout.
  • Physical Therapy: Exercises for enhancing muscle strength and flexibility.
  • Lifestyle Modifications: Weight management, joint protection strategies, and regular exercise.

Surgical treatment

For patients with severe arthritis, surgical procedures, such as joint replacement or arthroscopy, may be necessary. Overall, a multidisciplinary approach is often required to effectively treat specific types of arthritis based on the severity of the condition.

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Anterior Knee Pain

Management Team

Anterior Knee Pain

Overview

Anterior knee pain refers to discomfort behind or around the kneecap (patella). It arises from various joint abnormalities and varies widely in severity.

  • Structural or anatomical abnormalities.
  • Patellar malalignment or instability.
  • Muscle weakness, tightness, or imbalance.
  • Overuse or repetitive use of knee muscles, especially in sports.
  • Patellar fractures.
  • Certain medical conditions like obesity.
  • Conditions causing anterior knee pain include:
    • Patellofemoral pain syndrome (Runner’s knee)
    • Patellar tendonitis (Jumper’s knee)
    • Chondromalacia patella
    • Patellar arthritis
    • Osgood Schlatter disease
    • Iliotibial band syndrome

The primary symptom is pain behind or around the kneecap, which may worsen during activities such as:

  • Descending the stairs
  • Wearing high heels
  • Sitting for prolonged durations
  • Squatting
  • Using a car clutch
  • Knee instability
  • Crepitus (grating feeling or noise)
  • Quadriceps muscle weakness if pain persists

  • Common in women, teenagers, adolescents (affects 30% of adolescents), and young adults.
  • Repetitive physical activity.
  • Engagement in running, cycling, and athletics.
  • History of knee injury.

  • Medical history
  • Physical examination
  • Imaging techniques, such as ultrasonography, radiography, or magnetic resonance imaging MRI for joint pain
  • Assessment of core stability, muscle imbalances, and functional limitations

Non-surgical treatment

  • Rest and pain management
  • Strengthening and stretching the thigh and buttock muscles
  • Maintaining a healthy weight
  • Using shoe inserts for flat feet
  • Taping to realign the kneecap
  • Proper footwear
  • Heat and ice application
  • Physical therapy helps address malalignment and provides strengthening programmes

Surgical treatment

Surgery is considered only for patients who do not benefit from non-surgical interventions and need fast recovery.

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Adhesive Capsulitis (Frozen Shoulder)

Management Team

Adhesive Capsulitis (Frozen Shoulder)

Overview

Adhesive capsulitis, or frozen shoulder, is a condition in which the glenohumeral (shoulder) joint loses motion due to thickening of the joint capsule. It is characterised by pain along with a decreased range of motion during active (own movement) or passive movement (supported movement).

  • Based on severity, adhesive capsulitis is classified into three stages: freezing, frozen, and thawing. Each stage lasts for 6–9 months
  • The primary symptoms are pain and stiffness, especially during external rotation and forward elevation

  • Age 40–60 years
  • Female gender
  • Diabetes mellitus, hypothyroidism, heart diseases, kidney diseases, or autoimmune diseases

  • Assessment of the range of shoulder motion (active and passive).
  • Assessment of specific shoulder muscles.
  • Radiography (X-ray) to rule out other conditions, such as calcification (excess calcium deposition) and arthritis.
  • Magnetic resonance imaging (MRI) for confirming other associated conditions, such as a rotator cuff tear.

Non-surgical treatment

Non-surgical treatment methods aim to provide osteoarthritis care, alleviate pain, and increase the range of motion. They include:

  • Oral anti-inflammatory medications
  • Steroids (oral or local injections)
  • Ultrasound-guided nerve block (suprascapular nerve)
  • Hydrodilatation
  • Physical therapy

Surgical treatment

Surgery is rarely indicated but may be required in the frozen stage. Surgical approaches include:

  • Manipulation under anaesthesia
  • Capsular release using the arthroscopy procedure
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Anterior Cruciate Ligament Injury

Management Team

Anterior Cruciate Ligament Injury

Overview

The anterior cruciate ligament (ACL) is a thread-like structure that connects the thigh bone (femur) and the leg bone (tibia) in the front part of the knee and maintains knee stability. ACL injuries can develop into partial or total sprains or tears.

ACL injuries are often caused by sudden changes in movement or direction while playing sports, pivoting (twisting) with a planted foot, landing awkwardly from a jump and twisting the knee, or direct blows. ACL tears may develop into knee osteoarthritis despite surgical intervention.

  • Knee popping  
  • Severe knee pain
  • Movement difficulties
  • Swelling in knee
  • Decrease in range of knee motion
  • Knee instability or collapsing with weight-bearing

  • Anatomical and hormonal characteristics of females.
  • Playing sports, such as soccer, football, basketball, gymnastics, and skiing.
  • Inadequate muscle strength and conditioning.
  • Wearing ill-fitting shoes or using poorly maintained sports equipment.
  • Playing on artificial turf.

  • Clinical tests: Physicians perform certain tests to assess the ACL (Drawer/Lachman/Pivot shift) and meniscus (McMurrays).
  • Magnetic resonance imaging (MRI): Recommended gold standard in diagnosis and can identify other pathologies or collateral injuries.

  • Strengthening core and leg muscles with a focus on the hips, lower abdomen, and hamstrings.
  • Ensuring proper techniques and correct knee position during jumps and landings.
  • Improving movement patterns and establishing safe techniques for pivoting.

Non-surgical treatment

  • Rest and limb elevation for early stages when the swelling is prominent.
  • Ice pack application to reduce inflammation.
  • Immobiliser to help reduce inflammation and pain associated with motion.
  • Rehabilitation is recommended for low-demanding patients and those who have partial ACL tears to strengthen the front (quadriceps) and back (hamstrings) thigh muscles.

Surgical treatment

Arthroscopic ACL reconstruction is the gold standard ligament construction method for surgical treatment. It is not a complex joint repair surgery and is recommended based on:

  • Patient’s age and requirements: Younger patients would benefit more because of their high demands.
  • Associated injuries: Patients with associated meniscus (knee shock absorber) injuries would benefit more from surgery.

Procedure:

  • Autograft (patient’s tendon): The physician harvests a graft (thread-like tendon) from just below the knee (hamstring), thigh (quadriceps), or ankle (peroneus).
  • Surgery: 2–3 small holes are drilled in the knee through which the camera and instruments are inserted, and the surgery is performed by observing a TV monitor.

After surgery:

  • The patient is asked to bear full weight and walk using a walker with a knee brace.
  • A physiotherapy programme is initiated to help the patient achieve a full range of motion at the end of the 6-week follow-up through a muscle strengthening programme.
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Achilles Tendinitis

Management Team

Achilles Tendinitis

Overview

The Achilles tendon, which is the largest and strongest tendon in the body, connects the calf muscles to the heel bone. It is essential for activities like walking, running, and dancing. Achilles tendinitis is the inflammation of the Achilles tendon, which occurs when it swells because of stress or improper training.

  • Pain in the heel with early morning stiffness and can radiate to the calf area.
  • Pain worsens with activities, such as walking or exercising.
  • Swelling around the back of the ankle.

  • Age above 30 years in males.
  • Diseases, such as diabetes, rheumatoid, and thyroid disorders.
  • Obesity, very tight or weak calf muscles, poor core stability, or joint stiffness.
  • Calcification (calcium deposition) or bony spur formation (bony growth).

  • Radiographs (X-rays): Recommended to assess bony spurs or calcification.
  • Ultrasonography: Affordable, can be performed in the clinic, and helps detect calcification or spurs.
  • Magnetic resonance imaging (MRI): Recommended for patients with long-standing heel pain to rule out tendinosis (degeneration of the tendon).

Non-surgical treatment

Non-surgical treatment is effective during the initial stages of the disease. It includes:

  • Rest and lifestyle modifications for avoiding strenuous activities and injury prevention.
  • Ice pack application.
  • Non-steroidal anti-inflammatory drugs (NSAIDs) to decrease the initial inflammation.
  • Physical therapy, including calf muscle stretches and isometric strengthening (unilateral and bilateral heel drops).
  • Use of night splints and orthotics with the foot pointing upwards (similar to calf stretches).
  • Extracorporeal shock wave therapy whereby high-energy and low-energy shock waves are induced around the heel area to decrease inflammation and swelling.

Surgical treatment

Surgical treatment is recommended when all non-surgical options fail. It includes:

  • Removing the degenerated (damaged) tissue around the tendon (debridement) and addressing other pathologies like bony spurs or calcification.
  • Gastrocnemius resection in patients with tight calf muscles in whom no improvement is observed with conservative management.
  • Minimally invasive surgery using an endoscope. It is highly recommended because it brings minimally invasive pain relief and causes less tissue damage.
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