What Is Cluster Headache?

Cluster headache is NOT a “bad migraine.” It is a distinct headache disorder marked by:

• Sudden, severe, unilateral pain — usually around the eye or the temple
• Short attacks — lasting 15 to 180 minutes
• Frequent daily occurrence — often 1–8 attacks per day
• Associated autonomic symptoms — tearing, redness, nasal symptoms, eyelid edema, facial sweating on the side of pain, drooping of eyelid (ptosis)
• Restlessness and agitation during pain — patients often pace around

It affects roughly 0.1–0.3% of adults, and men are affected about 3–4 times more often than women.

Recognizing the Attack Pattern (Why “Clock-Like” Matters)

With more than 150 types of headaches, recognizing the pattern is important for the correct treatment. Cluster headaches often have predictable timing:

• ⁠⁠Attacks may occur at the same time each day, often 1–2 hours after sleep onset.
• ⁠⁠They may happen in seasonal clusters lasting weeks or months.
• ⁠⁠After a cluster period, patients may be pain-free for months or years.

Many sufferers are misdiagnosed with migraine or sinus headache, which delays effective care. As per one study the delay is as long as 6 years in many.

Common Triggers (What to Avoid)

While triggers don’t cause cluster headache, they can precipitate attacks during an active cluster period. Most common triggers:

• ⁠⁠Alcohol (especially during active periods)
• ⁠⁠Sleep disruption or irregular sleep patterns
• ⁠⁠Change in sleep schedule
• ⁠⁠Nitrate-containing medications (e.g., some heart meds)
• ⁠⁠Unusual strong smells or overheating

Keeping a headache diary of timing, food, sleep, alcohol, and environment can help identify patterns.

Treatment:

1.⁠⁠ Acute (Abortive) Treatment — to stop the pain ASAP during an attack

The goal in an acute attack is to stop the pain quickly.

• ⁠⁠High-Flow Oxygen

Giving 100% oxygen at 12–15 L/min for 15–20 minutes via a non-rebreather mask is a first-line treatment and often stops attacks rapidly.

• ⁠⁠Triptans: These act by narrowing blood vessels and inhibiting pain pathways.
• ⁠⁠Subcutaneous sumatriptan— fast and effective
• ⁠⁠Intranasal zolmitriptan or sumatriptan spray — alternative when injections aren’t feasible

Triptans should be avoided if you have cardiovascular conditions (e.g., heart disease, uncontrolled high blood pressure), as they can constrict blood vessels.

• ⁠⁠Lidocaine: Nasal instillation of 1 mL 4%–10% lidocaine into the same side nostril with the patient in reclining 45° position and 30–40° rotation toward the symptomatic side can be used for the control of acute symptoms [84]. This works by blocking the sphenopalatine ganglion by diffusing through the nose.

2.⁠⁠ Bridging or Transitional Treatment — Stop Frequent Attacks While Preventives Work

Preventive medications can take days to weeks to become effective. During this time, “bridging” therapies help suppress attacks:

• ⁠⁠Corticosteroids

Short courses of oral steroids like prednisone can dramatically reduce attacks while preventives ramp up.

• ⁠⁠Greater Occipital Nerve Block (GON Block) under ultrasound guidance

This is a safe, targeted injection near the occipital nerve at the back of the head. It can provide quick relief reducing attack frequency and intensity for weeks to months.

How it works:

• ⁠⁠A small amount of local anesthetic ± steroid is injected near the nerve
• ⁠⁠Interrupts pain signals from the head and neck
• ⁠⁠Often used alongside preventive medicines, not as a replacement

3.⁠⁠ Preventive Treatment — these are measures which reduce future attack frequency and/ or severity

• ⁠⁠Verapamil: This blood-pressure medicine is the most evidence-based preventive for cluster headache. It’s usually started at a low dose and slowly increased over weeks to minimize side effects like constipation or heart conduction changes. ECG monitoring is advised during titration.
• ⁠⁠Lithium: Particularly useful in chronic cluster headache but requires regular blood level checks due to its narrow therapeutic range and potential kidney/thyroid effects.
• ⁠⁠Topiramate: An anti-seizure medication that can be helpful in some patients but may cause cognitive slowing or paresthesias in others.
• ⁠⁠Melatonin:A safe, well-tolerated option that can be added to other preventives.
• ⁠⁠Galcanezumab (CGRP Monoclonal Antibody): A newer preventive medicine shown to reduce attack frequency in episodic cluster headache (not proven for chronic type). Availability may be limited and cost can be a factor, especially in India.

Side effects of preventive medications vary but can include:

• ⁠⁠Heart conduction changes (verapamil)
• ⁠⁠Tremor/weight changes (lithium/topiramate)
• ⁠⁠Injection site reactions (galcanezumab)

4.⁠⁠ Other Interventional & Neuromodulation Treatments

• ⁠⁠Non-Invasive Vagus Nerve Stimulation (nVNS): This involves a portable stimulator applied to the neck skin. It has shown benefit in episodic cluster headache, helping decrease attacks in some patients, though availability may be limited in India.
• ⁠⁠Sphenopalatine Ganglion (SPG) Stimulation: This technique targets a key nerve cluster involved in autonomic symptoms. Evidence shows pain relief in a substantial number of patients in specialized centers, especially in refractory chronic cluster headache.

Practical Tips for Everyday Life

• Avoid alcohol during active cluster periods
• Keep a headache diary
• Maintain regular sleep patterns
• Discuss trigger patterns with your doctor to personalize lifestyle changes
• Keep emergency abortive treatments accessible for quick use

Final Takeaway

Cluster headache is intensely painful but treatable with modern approaches. Early recognition and structured care — acute, bridging, and preventive — can dramatically improve quality of life. Discuss all options with your specialist to tailor the best approach for you.

References

• ⁠⁠May, A., Evers, S., Goadsby, P. J., Leone, M., Manzoni, G. C., Pascual, J., Carvalho, V., Romoli, M., Aleksovska, K., Pozo‐Rosich, P., & Jensen, R. H. (2023d). European Academy of Neurology guidelines on the treatment of cluster headache. European Journal of Neurology, 30(10), 2955–2979. https://doi.org/10.1111/ene.15956
• ⁠⁠Diener HC, May A. Drug Treatment of Cluster Headache. Drugs. 2022;82(1):33-42. doi:10.1007/s40265-021-01658-z
• ⁠⁠Robbins MS, Starling AJ, Pringsheim TM, Becker WJ, Schwedt TJ. Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache. 2016;56(7):1093-1106. doi:10.1111/head.12866
• ⁠⁠Lund NLT, Petersen AS, Fronczek R, et al. Current treatment options for cluster headache: limitations and the unmet need for better and specific treatments-a consensus article. J Headache Pain. 2023;24(1):121. Published 2023 Sep 4. doi:10.1186/s10194-023-01660-8
• ⁠⁠Castillo-Álvarez F, Hernando de la Bárcena I, Marzo-Sola ME. Greater occipital nerve block in the treatment of headaches. Review of evidence. Bloqueoanestésico del nervio occipital mayor eneltratamiento de las cefaleas. Revisión de la evidencia. Med Clin (Barc). 2023;161(3):113-118. doi:10.1016/j.medcli.2023.04.001
• Krymchantowski A, Jevoux C, Piovesan ÉJ, et al. Cluster headache and galcanezumab: the first real-world Brazilian study and an expert consensus on its use among other treatments. J Headache Pain. 2024;25(1):211. Published 2024 Dec 3. doi:10.1186/s10194-024-01909-w
• ⁠⁠Wei, D. Y., Khalil, M., &Goadsby, P. J. (2019). Managing cluster headache. Practical Neurology, 19(6), 521–528. https://doi.org/10.1136/practneurol-2018-002124

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Modern medical literature consistently shows three key realities:

• Muscle cramps and strains are the most frequent causes, affecting a large proportion of adults during life.
• Neuropathic causes such as lumbar radiculopathy, peripheral neuropathy, and restless legs syndrome are very common in clinics.
• Deep vein thrombosis (DVT) is less common overall but medically critical to exclude when suspected.

Because of this, doctors approach calf pain using a simple three-system model:

Muscle → Nerve → Blood vessel

Understanding which system is involved is the first step toward correct treatment.

1. Nocturnal calf cramps and muscle overactivity

This is one of the most common causes of calf pain.

What it feels like: sudden, painful tightening of thecalf (often at night), lasting seconds–minutes, sometimes leaving soreness.

Why it matters: very common and usually benign, but frequent nocturnal cramps degrade sleep and quality of life.Population studies report high lifetime prevalence (roughly one-third to over half of adults), with increasing frequency in older age.

Why cramps happen

• Dehydration or electrolyte imbalance
• Pregnancy
• Medication effects (for example diuretics)
• Underlying metabolic or neurological contributors in persistent cases

Usual management: stretching routines, hydration review, correction of abnormal electrolytes,and review of medications.When cramps are frequent, severe, or resistant, a pain physician evaluates for other causes such as nerve hyperexcitability, nerve compression in the spine (lumbar radiculopathy) , metabolic causes such as diabetes or vitamin deficiency

Targeted treatment may include:

• Nerve pain medications
• Muscle relaxant strategies when appropriate
• Treatment of the underlying trigger

2. Calf muscle strain, soleus overload, and partial tears

What it feels like: acute sharp pain on push-off or explosive movement (athletes), local tenderness, possible bruising or loss of power. Soleus strains can present more insidiously and with pain during knee-bent activity.

Sports-medicine literature describes this as a frequent athletic injury requiring structured rehabilitation rather than simple rest.Many patients keep stretching the superficial gastrocnemius, while the real problem is the deeper soleus muscle, producing persistent deep calf ache.

Pain-clinic treatment options

• Ultrasound confirmation of tear severity
• Guided rehabilitation planning
• Platelet-rich plasma (PRP) injections in selected non-healing tears- Evidence remains mixed, so careful case selection is essential.
• Biomechanical correction to prevent recurrence

This is an area where specialised intervention can significantly shorten recovery time.

3. Achilles tendinopathy / rupture

What it feels like: distal posterior calf/heel painespecially after activity. A complete rupture is often described as a “snap” with immediate weakness.

Pain-specialist role

• High-resolution ultrasound diagnosis
• Image-guided regenerative or anti-inflammatory injections when conservative therapy fails
• Coordination with advanced physiotherapy protocols

Modern physiotherapy research strongly supports structured loading programmes as first-line treatment for tendinopathy whereas a rupture requires urgent surgical referral, not pain treatment.

4. Deep vein thrombosis (DVT)

What it feels like: one sided (unilateral) calf swelling, warmth, tenderness, sometimes redness. Risk factors include recent surgery, prolonged immobilisation, active cancer, pregnancy and oral contraceptives.Modern diagnostic pathways show that only a minority (10-25%) of suspected cases are confirmed, but missing one can be dangerous.

Pain-clinic  can help with recognition and referral is important.Even though treatment is vascular. Avoid massage of the affected leg. .

5. Peripheral arterial disease (intermittent claudication)

What it feels like: reproducible calf pain brought on by walking and relieved by rest. Intermittent claudication is a vascular problem, not a problem of the calf muscle per se, and needs a vascular pathway.Associated cardiovascular risk factors (smoking, diabetes, hyperlipidaemia) increase probability

Pain-clinic can help by

• Early clinical suspicion
• Referral for ankle–brachial index testing and vascular care

Correct identification prevents serious cardiovascular complications.

6. Lumbar radiculopathy (sciatica presenting as calf pain)

What it feels like: radiating leg pain often with back pain, paresthesia, numbness or weakness; may be exacerbated by coughing/sneezing or straight-leg raise.Many patients are surprised to learn that

the calf may not be the real problem.Compression of spinal nerve roots can produce radiating calf pain, tingling, numbness, or weakness.

How pain specialists treat this

• Targeted epidural steroid injections
• Selective nerve-root blocks
• Advanced non-surgical pain management pathways

These treatments are supported by modern spine-care guidelines and can avoid unnecessary surgery in selected patients.

7. Peripheral neuropathy (diabetes, vitamin deficiency, metabolic causes)

What it feels like: burning, tingling or numbness, often in both legs (bilateral) and worse at night; pain may involve the calves as part of a stocking-glove distribution.Diabetic neuropathy remains the most common global neuropathic pain disorder.

Pain-clinic treatment advances

• Evidence-based neuropathic pain medications
• Intravenous infusion therapies for refractory neuropathic pain
• Peripheral nerve neuromodulation techniques in selected severe cases

These options are usually unavailable in routine primary care, making specialist input crucial.

8. Restless legs syndrome (often mistaken for cramps)

What it feels like: an irresistible urge to move the legs, usually in the evening/nighttemporarily relieved by movement. Global prevalence estimates are around 5–10% of adults.Distinguishing it from cramps or neuropathy is essential to avoid unnecessary interventions

Pain clinics evaluate for any iron/B12 deficiency, Medication-related of any other triggers

Treatment includes:

• Evidence-based neurological medications
• Sleep and metabolic optimisation

Correct diagnosis dramatically improves sleep and quality of life.

9. Focal nerve entrapments, Baker’s cyst and compartment syndrome

This final category includes several commonly missed causes:

Local nerve entrapments including Tibial nerve (soleal sling), Sural nerve irritation and Peroneal nerve compression can cause produce burning or deep focal calf pain and often respond to:

Ultrasound-guided diagnostic blocks, hydrodissection procedures and targeted rehabilitation

A Baker’s cyst behind the knee can leak fluid into the calf and mimic a clot. And in athletes, tight muscle compartments can trap pressure — pain builds with running and disappears with rest. but if pain is out of proportion with a tense calf, that’s needs urgent medical review.

10. Footwear & Load-Related Soleus Overload

Sudden change to low heel-drop or unstable shoes increases calf load.This leads to soleus overworks and deep calf tightness as a result. This Heal drop effect is increasingly common in runners.

Management:  requires load modification,footwear transition planning and targeted soleus rehab.
Biomechanical correction and rehab usually resolve symptoms.

When should you see a pain specialist for calf pain?

Seek specialist evaluation if you have:

• Persistent or recurrent calf pain
• Burning, tingling, or nerve-type symptoms
• Pain not improving with stretching or rest
• Repeated athletic injuries
• Unclear diagnosis despite treatment

Pain clinics focus on precise diagnosis and targeted treatment, not just temporary relief.

The key message

Most calf pain is treatable.Some calf pain is dangerous.The difference lies in correct diagnosis.A structured evaluation using the muscle–nerve–vessel framework allows safe, effective, and often non-surgical treatment.

Need help with calf pain? International Pain Centre +91-9993336525

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References

1. Blyton F, Chuter V, Burns J. Muscle cramps. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; updated 2023.

2. Grandner MA, Winkelman JW. Nocturnal leg cramps: prevalence and associations in a community population. Sleep Med. 2017;32:1-7.

3. Meek WM, Garvey KD. Calf strain in athletes. JBJS Rev. 2022;10(3):e21.00166.

4. Kearon C, de Wit K, Parpia S, et al. Diagnosis of venous thromboembolism with D-dimer–adjusted clinical probability. Ann Intern Med. 2019;171(11):766-774.

5. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases. Eur Heart J. 2018;39(9):763-816.

6. Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for low back pain and sciatica: systematic review. Lancet Rheumatol. 2020;2(7):e415-e429.

7. Pop-Busui R, Boulton AJM, Feldman EL, et al. Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes Care. 2017;40(1):136-154.

8. Wittens C, Davies AH, Bækgaard N, et al. Management of chronic venous disease: clinical practice guidelines of the European Society for Vascular Surgery. Eur J VascEndovasc Surg. 2015;49(6):678-737.

9. Tagliafico A, Perez MM, Martinoli C. Nerve entrapment syndromes of the lower limb: imaging features and clinical relevance. Br J Radiol. 2020;93(1115):20190857.

10. Hollander K, Heidt C, Van der Zwaard BC, et al. The effects of footwear heel-to-toe drop on running biomechanics and lower-limb loading. Appl Sci (Basel). 2021;11(24):12144.

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Rib fractures are common and painful injuries that can dramatically affect your ability to breathe, cough, and move. This guide explains rib anatomy, why ribs break, how injuries are diagnosed and treated, the risks involved — especially in high-risk groups — and modern pain-relief options, with a focus on pain relief and treatment approaches including intercostal nerve blocks and cryoneurolysis.

Rib Anatomy

The human rib cage has 12 pairs of ribs that protect the lungs, heart, and major vessels. All ribs attach to the spine at the back, but their connections in front differ:

• True ribs (1–7): Attach directly to the breastbone (sternum) via their own cartilage.
• False ribs (8–10): Connect indirectly to the sternum via cartilage of the rib above.
• Floating ribs (11–12): Do not attach to the sternum at all and are more mobile.
  These differences in ribs are important as theyaffect vulnerability and how fractures present.

Beneath each rib runs an intercostal nerve, artery, and vein, which is why rib injuries cause sharp pain and sometimes nerve-related symptoms.

What are Rib Fractures &Why do they Happen

Rib fractures are breaks in one or more of the ribs and usually occur following significant chest trauma. The common causes include:

Common Traumatic Causes

• Motor vehicle collisions
• Falls and blunt force impacts— particularly in older adults
• Direct blows during contact sports or accidents- Even seemingly low-impact mechanisms like a sudden force from a golf swing or vigorous twisting can cause a rib fracture, especially in people with underlying bone weakness.

Non-Traumatic Causes

• Cancer metastasis to ribs: Tumors weaken bone and can lead to fractures with minimal force.
• Severe osteoporosis: Bones become fragile and break more easily.

Children’s rib cages are more flexible, so fractures are less common in young patients. Those at high risk of having rib fractures include

• Elderly people: Age-related bone loss and falls raise risks.
• People with metabolic bone disease (osteoporosis).
• Patients with cancer or prior radiation.These groups not only fracture more easily but also face higher complications from rib injuries.

Types of Rib Fractures: Location, Stability, and Severity

Rib fractures can differ significantly based on where the rib breaks and how stable the fracture is, and these differences often explain why some patients experience more pain or complications than others.

Based on Location

• Anterior rib fractures (Front) theseoccur at the front of the chest are usually located close to the breastbone. They can be particularly painful during movement, coughing, or changing posture. In some cases, especially when the injury involves the rib cartilage, standard X-rays may not clearly show the injury, even though the pain can be severe.
• Lateral rib fractures (Side), which occur along the side of the chest, are the most common type of rib fracture. Because this area of the chest wall moves significantly during breathing, pain tends to worsen with deep breaths, twisting, or lying on the affected side. These fractures also sit directly over the lungs, which is why they are more commonly associated with lung-related complications and often respond well to targeted pain treatments such as intercostal nerve blocks.
• Posterior rib fractures (back), located near the back of the chest close to the spine, are often more serious. They may cause less visible bruising but are frequently associated with underlying lung bruising. They are also more likely to be missed on plain chest X-rays and are better identified on CT scans.

Based on Fracture Stability: Non-Displaced Vs Displaced

Rib fractures are also classified by whether the broken bone remains in place or shifts from its normal position. In non-displaced rib fractures, the bone cracks but stays aligned. Although these fractures usually heal without surgery, they can still cause significant pain and breathing difficulty. In contrast, displaced rib fractures occur when the broken ends of the rib move apart. These fractures are associated with higher pain levels, a greater risk of lung injury, and a higher chance of complications or prolonged recovery.

Complex Fracture Patterns: Flail Chest (Severe Injury Pattern)

A particularly severe pattern of injury is known as a flail chest. This occurs when three or more adjacent ribs are each fractured in two or more places, creating an unstable segment of the chest wall. Instead of moving normally with breathing, this segment moves paradoxically, making breathing inefficient and placing the patient at high risk of respiratory failure. Flail chest represents a serious injury that often requires intensive monitoring and advanced pain and respiratory support.

What Happens When Ribs Break

• Pain and Its Consequences

Broken ribs are very painful, especially during deep breathing, coughing, or movement. Pain leads to shallow breathing and reduced cough effectiveness, which increases the risk of complications like collapse of lung areas(atelectasis) and pneumonia. This can also increase the risk of respiratory failure and other related complications.

Pain → shallow breathing → collapse of lung areas (atelectasis) → pneumonia → respiratory failure

• Complications of Rib Fractures

When ribs break, the force can also injure underlying structures such as the lung lining (pleura) and lung tissue, leading to complications like pneumothorax (air leak around the lung), hemothorax (blood around the lung), or pulmonary contusion (lung bruise). Broken ribs can also injure nearby organs and tissues.

• Prolonged disability and chronic pain in some patients

How Rib Fractures Are Diagnosed

Clinical Examination -Doctors assess your history (cause of injury) and do a physical exam, noting pain location, swelling, bruising, and respiratory function.

Imaging

• Chest X-ray: Often the first test ordered but can miss up to ~50% of rib fractures — especially nondisplaced or subtle ones.
• Computed Tomography (CT): Good for detecting rib fractures and associated chest injuries, including lung or vascular damage. It can also provide detailed 3D reconstructions useful for planning treatment.
• Ultrasound: Can detect rib fractures and related issues like pneumothorax when used by trained clinicians but is not routinely used in all settings.
• MRI: Occasionally used when cartilage injuries (e.g., costal cartilage) are suspected but not visible on CT or X-ray.

Accurate diagnosis is crucial, because the number and location of fractures predict complications and guide treatment.

Treatment Approaches

Effective management has three goals:

• Reduce pain,
• Protect lung function, and
• Prevent and treat complications.

Multimodal Pain Management is the preferred approach. Options to be used are decided after a risk assessment which includes multiple parameters including number of ribs involved, displacement, patients age, pain severity, breathing impairment etc. Combining medications with physiotherapy and interventions such as injections or surgery as required

MEDICATIONS– Options include:

• Paracetamol, Anti- inflammatory medications, Muscle relaxants
• Opioids (Morphine like medications)- if the above medicines prove to be insufficient and pain is severe.

INCENTIVE SPIROMETRY & PHYSIOTHERAPYBreathing exercises and early mobilization help clear secretions and avoid complications like pneumonia.Devices and exercises promoting deep breathing are clinically shown to reduce respiratory complications and improve lung function in rib fracture patients.

INJECTIONS AND REGIONAL ANALGESIA TECHNIQUES- These are key for strong pain relief especially if there are multiple fractures. Multiple options are present, and choices are made based on individual circumstances. Options include:

• Erector Spinae Plane (ESP) Block – in this procedure the drug is injected between the muscle planes under ultrasound guidance fascial plane block) that spreads and covers pain over several ribs. This is associated with a lower complication rate and is technically easier to perform.

Studies show that ESP can provide analgesia comparable to epidural or paravertebral blocks with a lower complication rate, although sometimes the effect can be unpredictable.

• Paravertebral Block (PVB)- in this procedure the numbing medicine(Local anaesthetic) is injected beside the spine near the nerve roots as they come out of the spine. It requires technical expertise and can be effective for one-sided rib pain with a safety profile similar to or better than epidural in some patients.
• Thoracic Epidural Analgesia- epidurals provide excellent pain relief and improve lung function but require skilled placement and monitoring. The pain relief effect can be prolonged by leaving a small tube (catheter) in the spine through which repeated doses of medicines can be given for up to a few days.
• Intercostal Nerve Blocks – individual nerves carrying the pain form the fractures ribs can be targeted to provide pain relief, improve breathing, and reduce needs for other medicines including opioids.

The biggest limitation of all these techniques is the duration of pain relief, which is limited at best to a few days whereas the pain from rib fractures can persist for much longer. Generally, bone healing takes 6–8 weeks with peakpain in the first 1–2 weeks, however the residual pain or movement pain may last many weeks. The next-explained technique of cryoablation offers the advantage of prolonged relief in many situations.

CRYONEUROLYSIS (CRYOABLATION) OF THE INTERCOSTAL NERVES

This technique uses extreme cold up to minus 80 degrees to temporarily disrupt the pain signals travelling via the intercostal nerves, providing extended pain relief lasting weeks to months while allowing nerve regeneration later. Simply explained, it can be viewed as a nerve block lasting for weeks to months, providing effective relief whilst fracture healing occurs.

This minimally invasive technique performed under ultrasound guidance does not involve any cuts or incisions and can provide effective, lasting relief. Using a cryoprobe and a cryoablation machine, gases like nitrous oxide or carbon dioxide are delivered through the probe, creating extremely low temperatures at the probe tip. The probe is placed near the target nerve using ultrasound, X-ray, or CT guidance, and the freezing mode is activated. An ice ball forms at the probe tip, freezing the nearby nerves and reducing their ability to transmit pain. After the procedure, the cryoprobe is removed, and the site is covered with a small bandage.

Evidence suggests cryoneurolysis can improve breathing parameters and reduce pain killer requirements, making it a valuable adjunct in selected patients.

SURGERY: Surgical Stabilization of Rib Fractures (SSRF)

In patients with flail chest or multiple displaced fractures, particularly when associated with breathing compromise, rib fixation with plates can restore chest wall stability. Evidence shows SSRF is associated with reduced ventilator requirements, improved pain control, shorter ICU stay, and lower death ratesand better recovery in selected patients. Early fixation is preferred and has been associated with improved outcomes.

Why Early, Evidence-Based Care Matters

• Each additional rib fracture increases the risk of respiratory complications and longer hospital stays.
• Elderly adults have higher mortality rates from rib fractures —10–22% in hospitalized patients and even higher in flail chest or elderly subgroups.
• Multimodal analgesia and early physiotherapy reduce the incidence of pneumonia and respiratory failure.
• Prompt coordinated care that includes pain control, respiratory support, and appropriate surgical evaluation leads to faster recovery and fewer long-term problems.

Practical Tips for Patients & Families

At home and in hospital:

• Use prescribed pain medication and blocks as advised
• Perform deep breathing exercises several times a day
• Use an incentive spirometer if recommended
• Stay mobile within comfort limits
• Watch for worsening shortness of breath, fever, or chest wall instability — and seek help immediately

References & Further Reading

• Rib fractures: StatPearls review — anatomy, causes, diagnosis, management. (https://www.ncbi.nlm.nih.gov/books/NBK541020/)
• Chest trauma and rib fracture imaging/diagnosis evidence. (https://jtd.amegroups.org/article/view/88701/html)
• Anatomy of true, false, and floating ribs. (https://en.wikipedia.org/wiki/Rib_cage)
• Benefits of incentive spirometry in rib fractures. (https://pubmed.ncbi.nlm.nih.gov/31888765/)
• Epidemiology of rib fractures and mortality data. (https://pmc.ncbi.nlm.nih.gov/articles/PMC8825616/)
• Role of cryoneurolysis and nerve blocks. (https://ccts.amegroups.org/article/view/104585/html)
• Surgical stabilization evidence for rib fractures. (https://pmc.ncbi.nlm.nih.gov/articles/PMC11487890/)

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What are “true”, “false” and “floating” ribs — and why it matters

• True ribs (1–7) attach directly to the breastbone (sternum).
• False ribs (8–10) attach indirectly via cartilage that joins the cartilage above to form the costal margin.
• Floating ribs (11–12) do not attach anteriorly.

SRS involves the false ribs (8–10) because their cartilage and the associated joints (interchondral joints) may become loose. The 10th rib is most commonly affected.

What patients usually experience (Symptoms)

Generally, the patients experience

• Sharp, stabbing or aching pain at the lower chest or upper abdomen.
• A clicking, popping or slipping sensation near the rib margin — sometimes reproducible
• Pain worse with bending, twisting, coughing, deep breathing, or certain sports movements.
• Local tenderness on pressure at the rib tip.
• Pain may radiate to the back or flank.
• Sometimes associated with nausea and vomiting in some people.

Because the pain often mimics biliary (gallbladder), gastric or cardiac pain, many patients undergo multiple tests before the right diagnosis is made.

Who gets Slipped Rib Syndrome? (Causes & risk factors)

Slipped Rib Syndrome can occur in both young and older individuals. It is seen in children, adolescents, and adults with the mean age at diagnosis is 19 years with most patients less than 40 years old. There is a predilection for females with female athletes being more commonly affected, possibly related partly to hormonal influences on ligaments. SRS arises when the costal cartilage attachments weaken or break down such as with:

• Trauma — direct blows or indirect forces (e.g., a sudden twist or extreme respiratory effort). Even minor trauma can be responsible.
• Repetitive strain — sports involving twisting (swimming, gymnastics, throwing) or repetitive one-sided movement.
• Hypermobility or connective tissue weakness — conditions like Ehlers-Danlos or general ligament laxity.
• Degenerative changes or prior chest surgery.

Often the cause is multifactorial — a combination of minor trauma, repetitive strain, and ligament laxity.

Why SRS is commonly missed (diagnostic delay & consequences)

SRS frequently mirrors other problems. Patients commonly see several specialists and undergo many tests before diagnosis:

• In published series, 19% of patients with SRS had previously undergone laparoscopic cholecystectomy (gallbladder removal) for pain — without benefit.
• Median time from symptom onset to surgery has been reported as up to 18 months in adults and 2.5 years in children.
• Delayed diagnosis has serious effects on wellbeing: in one adult cohort one third had suicidal thoughts because of uncontrolled pain.

These figures show how important correct early diagnosis is — it prevents unnecessary operations, long waits, and mental health harm.

How SRS is diagnosed

SRS is primarily a clinical diagnosis — a careful history and physical exam are essential. Common diagnostic steps:

• History — ask specifically about clicking, movement-related pain, and prior trauma or sports activity.
• Physical exam — look for a tender point at the costal margin and try the hooking manoeuvre (Doctor hooks fingers under the lower rib margin and pulls upward). Reproduction of pain or a click supports SRS.

Studies show exam variations exist; gentle palpation to reproduce pain is often most helpful. One study suggested objective examination criteria for aiding diagnosis including  at least 1 cm separation at the anterior insertion of the 10th rib, unusual mobility of the 10th rib, and reproduction of the patient’s pain with local pressure.

• Dynamic ultrasound — increasingly used and useful as ultrasound can show one rib cartilage moving under or over the adjacent rib during maneuvers (e.g., crunch).
• Other imaging (CT/MRI/X-ray) — often normal for SRS but useful to exclude other causes and for surgical planning if needed.
• Diagnostic intercostal nerve block — injecting local anaesthetic under ultrasound can confirm the painful nerve and predict response to further nerve-targeted treatments.

Other research findings: Romano et al. showed thinning of rectus abdominis near the xiphoid in SRS patients, possibly from chronic nerve irritation; this may contribute to instability.

Treatment — stepwise and evidence-based

Treatment should be progressive: start simple and move to minimally invasive or surgical options only if needed.

Conservative measures (first line)

• Reassurance and activity modification — avoid triggers (twisting, heavy lifting, certain sports).
• Anti-inflammatory painkillers for short periods.
• Heat/cold packs, posture correction, physiotherapy — breathing mechanics and core strengthening help rib stability.
• Taping or compression may provide temporary support.

Most patients improve with 2-6 weeks of these measures, but many do not — and that’s where targeted interventions help.

Diagnostic and therapeutic intercostal nerve block

This is an important minimally invasive option for those not improving with conservative measures and for those not keen on surgical options.

• Ultrasound-guided intercostal nerve block is commonly used. Typical injectate includes local anaesthetic ± steroid. This can confirm the pain source (diagnostic) and provide meaningful short-term relief. A ≥50% reduction in pain predicts a good chance of success with neuroablative procedures discussed below.
• Repeated blocks are often used as a bridge or when patients prefer to avoid surgery.

Cryoablation / cryoneurolysis

• This involves freezing the intercostal nerve, causing interruption of the pain signals being transmitted through these nerves. It does not destroy the nerves completely and the sensation gradually returns with time without the risk of any neuroma ( nerve swelling) formation.

Case series and newer reports show good medium-term relief (months to years) with low complication rates. It is an attractive option for patients who want to avoid surgery.

Radiofrequency ablation (RFA) — alternative option

and commonly reported specifically for SRS but used in intercostal neuralgia. It is considered where cryoablation is not available or based on clinician experience. Evidence is weaker than for cryoablation for this condition.

Surgery — for persistent structural hypermobility

Surgery is reserved for patients with clear structural problems failing other measures.

• Cartilage resection (CRE) — excision of the slipping costal cartilage; commonly used and often relieves pain. However, because hypermobility may persist, recurrence rates can be significant.
• Costal margin reconstruction / suture repair — stabilises the rib without removing cartilage.
• Vertical rib plating (VRP) / rib fixation — newer approach to stabilize the rib; recent series show lower recurrence. Bioabsorbable plates are also used in some centres.
• Laparoscopic or minimally invasive approaches — allow smaller incisions and faster recovery in select patients.

When to see a specialist

See a pain specialist or thoracic surgeon if:

• Pain is severe, recurrent, or long-standing despite basic measures.
• You have a clear clicking/rib-tip sensation and localised tenderness.
• Prior tests (heart, stomach, gallbladder) are normal but pain persists.
• Pain affects sleep, work or mental health.

Early referral can avoid unnecessary tests and procedures.

Final note

Slipped Rib Syndrome can be disabling and is often missed, but it is treatable. Many people improve with a combination of conservative care and targeted procedures. For others, surgery yields excellent long-term relief. Honest discussion about realistic outcomes, stepwise care, and mental health support is important.

For help, diagnosis, or a second opinion, contact International Pain Centre:
+91-9993336525
internationalpaincentre.com

The post Slipping Rib Syndrome (SRS) appeared first on Dr Amod Blog.

What is Vitamin B12?

Vitamin B12 is a vital nutrient that plays an important role in our overall health. It is essential for:

• Producing red blood cells (important for carrying oxygen in the body)
• Maintaining healthy nerves and brain function
• DNA production
• Helping convert food into energy

The human body cannot make Vitamin B12 on its own. We must get it from food or supplements.

Why is Vitamin B12 Important for Pain?

Vitamin B12 supports the health of nerves, which means it can play a key role in pain conditions—especially nerve-related pain.

Research shows that Vitamin B12 can be helpful in treating:

• Diabetic neuropathy
• Postherpetic neuralgia
• Chronic low back pain
• Peripheral neuropathy
• Chemotherapy-related nerve pain
• Aphthous mouth ulcers
• Morton’s neuroma

How Does B12 Help with Pain?

• Nerve Healing: It helps repair damaged nerves and supports nerve regrowth.
• Reduces Inflammation: It reduces inflammation linked to chronic pain.
• Improves Nerve Signals: It boosts nerve conduction and the ability of nerves to send signals properly.
• Supports Brain Chemicals: It helps balance neurotransmitters like serotonin and noradrenaline, which can reduce pain.
• Works with Painkillers: It may reduce tolerance and dependence on opioids when used together.

Signs and Symptoms of Vitamin B12 Deficiency

Early symptoms:

• Weakness and fatigue
• Pale skin
• Headaches
• Mild mood changes

Intermediate symptoms:

• Tingling or numbness in hands and feet
• Breathlessness
• Heart palpitations
• Mouth ulcers or a red, swollen tongue (early to intermediate signs)

Advanced symptoms:

• Memory problems
• Depression, anxiety, mood swings
• Poor balance or coordination
• Weight loss, poor appetite
• Constipation or loose motions
• Visual disturbances

In some cases, long-term deficiency can cause permanent nerve damage, so early detection is key.

Who Is at Risk of Vitamin B12 Deficiency?

You may be at risk if you:

• Are in the elderly age group
• Follow a vegetarian or vegan diet
• Have had stomach or intestinal surgery
• Suffer from digestive issues like celiac disease or Crohn’s disease
• Take acid-lowering medications like PPIs or H2 blockers
• Take metformin for diabetes
• Are pregnant or breastfeeding

Sources of Vitamin B12

B12 is mainly found in animal-based foods:

• Meat, poultry, fish (especially liver)
• Eggs and dairy (milk, cheese, curd, paneer)
• Fortified cereals and plant-based milk (almond or soy milk)

Note: B12 is not naturally found in plant foods, so vegetarians need to ensure they get it from dairy or fortified foods.

How is Vitamin B12 Deficiency Diagnosed?

Doctors may recommend tests such as:

• Blood test for B12 levels (normal range: 200–950 pg/mL)
• Homocysteine or methylmalonic acid tests (for unclear cases)
• Blood count to check for anaemia

How is Vitamin B12 Treated?

Depending on severity, your doctor may suggest:

1. Oral Supplements/ nasal sprays- Ideal for mild deficiencies.

2. Injections

• Used in moderate to severe cases or if absorption is poor and in those with neurological signs. Injections are often needed—daily/ alternate days at first, then weekly or monthly.
• For those with chronic absorption problems, lifelong treatment may be necessary.

Most people feel better within days to weeks of starting treatment, especially with fatigue and mood symptoms. Nerve symptoms can take longer and neurological damage is difficult to reverse.”

Can B12 Cause Side Effects?

Vitamin B12 is usually very safe. Side effects are rare but may include:

• Mild allergic reactions
• Acne-like skin rash
• Nausea or upset stomach

Always consult your doctor before starting B12 supplements, especially if you are on other medications.

Important Tips

• Avoid alcohol, processed foods, excessive coffee, and sugary snacks, which can worsen B12 absorption.
• If you are vegetarian or elderly, consider regular B12 testing.
• Do not ignore symptoms like tingling or weakness—early treatment can prevent permanent nerve damage.

Final Word from Dr Amod Manocha

Vitamin B12 plays a powerful role in nerve health and pain management. Many people are unaware they may be deficient, and this deficiency can worsen or even cause chronic pain.

If you have nerve-related pain or any of the symptoms listed above, talk to your doctor about checking your Vitamin B12 levels.

Simple blood test can help
Early treatment is effective and safe
Don’t wait for serious symptoms to show up

The post Vitamin B12 and Pain – What You Need to Know appeared first on Dr Amod Blog.

Temporomandibular Joint (TMJ) pain is a common yet often misunderstood condition that can significantly affect one’s quality of life. It can cause jaw discomfort, headaches, facial pain, and difficulty eating or speaking. At International Pain Centre, we aim to raise awareness about TMJ pain and provide comprehensive solutions tailored to each individual’s needs.

In this blog, we’ll explore what TMJ pain is, what causes it, common symptoms, how it is diagnosed, and the range of treatment options available.

What Is TMJ Pain?

The temporomandibular joints (TMJs) are the two joints that connect your lower jaw (mandible) to your skull. These joints are located just in front of your ears and help you chew, speak, yawn, and perform various jaw movements.

When these joints or the surrounding muscles become dysfunctional, it can lead to a condition known as Temporomandibular Disorder (TMD) – commonly referred to as TMJ pain.

Common Symptoms of TMJ Disorders

Symptoms can vary from person to person and may affect one or both sides of the face. Common complaints include:

• Jaw pain or tenderness
• Clicking, popping, or grinding sounds in the jaw
• Difficulty opening or closing the mouth
• Locking of the jaw
• Headaches or migraines
• Ear pain or pain around the ears with ringing sounds or fullness sensation in ears
• Facial pain or pressure
• Neck and shoulder stiffness or discomfort
• Eye or dental pain

These symptoms may worsen with jaw movements such as chewing, talking, or stress.

What Causes TMJ Pain?

TMJ disorders are often multifactorial, meaning several contributing factors may be at play:

• Bruxism (Teeth Grinding or Clenching) –Unconscious clenching or grinding, especially during sleep, puts excessive pressure on the jaw muscles and joints.
• Jaw Injury or Trauma –Accidents, dental procedures, intubation during a general anaesthetic or even excessive yawning can strain or injure the TMJ.
• Arthritis- Both osteoarthritis and inflammatory arthritis (like rheumatoid arthritis) can affect the TMJ.
• Stress and Emotional Tension – Stress often leads to muscle tightening and jaw clenching, which can exacerbate TMJ issues.
• Poor Posture- Prolonged poor neck or jaw posture, while working or sleeping, can strain jaw muscles.
• Structural Abnormalitiessuch asmisalignment of the jaw or teeth, or displacement of the disc within the joint.
• Associated Conditions- People with fibromyalgia, irritable bowel syndrome (IBS), or chronic headaches often experience TMJ symptoms.

How Is TMJ Pain Diagnosed?

Diagnosis is primarily clinical, based on a thorough history and physical examination by a pain specialist. Key aspects include:

• Palpation of the jaw and facial muscles to identify tender points
• Assessment of jaw movement, joint sounds (clicking, popping) and tenderness
• Evaluation of posture and bite alignment

In some cases, imaging may be recommended including:

• MRI – to assess disc position and joint inflammation
• CBCT or CT scan – to evaluate bone structure and joint alignment
• Ultrasound – for dynamic assessment of joint and soft tissues
• Scintigraphy – in suspected inflammatory cases

Treatment Options for TMJ Pain

At International Pain Centre, we follow a stepwise, evidence-based approach tailored to each patient’s needs.

1. Self-Care and Lifestyle Changes

• Avoid hard or chewy foods
• Use warm or cold compresses
• Practice good posture
• Manage stress with relaxation techniques

2. Medications

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Muscle relaxants
• Low-dose antidepressants (especially for chronic pain)

3. Mouthguards / Occlusal Splints

Custom-fitted appliances that reduce teeth grinding and jaw pressure during sleep.

4. Physiotherapy

Jaw exercises, massage, and posture correction by a trained therapist can significantly improve symptoms.

5. Minimally Invasive Injections

These are offered when conservative treatments do not provide sufficient relief. These may not only provide relief but also help identify the precise pain source and may include:

Steroid Injections – reduce joint inflammation and in many cases are the fastest route to manage these persistent problems followed by supportive therapies inclusive of physical therapy.However, the effectiveness of these injections can vary from person to person. These injections can be helpful in

• Confirming diagnosis
• Reducing inflammation and Pain
• Quick recovery, and rapid relief from chronic jaw pain, headaches, and discomfort.

Botulinum Toxin (Botox) – relax overactive jaw muscles

Platelet-Rich Plasma (PRP) – promotes healing in chronic joint or muscle inflammation

Trigger point injections– Trigger points are painful “knots” in muscles that can be sensitive to touch / pressure. These can form after acute trauma or by repetitive micro-trauma, leading to muscle fibersstress and causing them to be stuck in a state of sustained contraction. Quite often these knots when you rub your muscles. A trigger point injection is used to relax the muscle tension.

Nerve Blocks e.g. auriculotemporal nerve. These blocks can be performed by trained specialists using ultrasound guidance.

All injections are best performed using image-guidance (ultrasound or fluoroscopy) to ensure accuracy and safety.

6. Surgery

Reserved only for very severe, resistant cases with structural damage. Most people do not require surgery.

Tips to Prevent and Manage TMJ Pain

• Avoid excessive jaw movements like chewing gum or wide yawns
• Use ergonomic pillows and avoid sleeping on your stomach
• Perform regular jaw relaxation and stretching exercises
• Identify and address stress triggers
• Seek specialist opinion

Final Thoughts

TMJ pain can be debilitating, but with a correct diagnosis and personalised treatment plan, relief is absolutely possible. At International Pain Centre, we specialise in managing TMJ disorders using a combination of modern diagnostics and minimally invasive techniques.

If you’re struggling with persistent jaw pain of any of the above symptoms, don’t ignore it. Reach out to us for a consultation and let us help you get back to a pain-free life.

Book an appointment at International Pain Centre today.
www.internationalpaincentre.com
Delhi, India

The post Understanding TMJ Pain – Causes and Solutions appeared first on Dr Amod Blog.

Introduction

Have you or a loved one experienced back pain that started or worsened after spinal anaesthesia—especially following childbirth or surgery? This condition, often referred to as Post-Dural Puncture Backache (PDPB) or Post-Spinal Anaesthesia Back Pain, is a common but frequently misunderstood problem.

In this blog, we explain why this happens, who is more at risk, how long it usually lasts, and what you can do to manage or prevent it.

Is Post-Spinal Back Pain Common?

Yes, back pain after spinal anaesthesia is common. In fact, up to 70–80% of adults will suffer from back pain at some point in their life, and 20–40% of patients undergoing spinal anaesthesia report back discomfort in the days or weeks following the procedure.

Among women undergoing C-section deliveries, up to 24% experience significant backache afterwards. While most cases are mild and resolve on their own, some people experience pain that lasts for several weeks or even months.

Why Does This Happen?

There are several possible causes of back pain after spinal anaesthesia:

• Needle trauma to tissues and ligaments in the back
• Multiple attempts during the spinal injection
• Muscle spasm or inflammation at the injection site
• Prolonged surgical positioning, especially in awkward or strained positions (e.g. lithotomy)
• Pregnancy-related changes like increased weight, posture changes, and ligament laxity

Sometimes, back pain may be coincidental and not directly caused by the spinal anaesthesia at all—especially if the patient had back pain before the procedure.

Who Is More At Risk?

Certain people are more likely to experience this kind of pain, such as:

• Those with pre-existing back pain
• Individuals with a high BMI (Body Mass Index)
• Patients who remained in one position for long surgeries
• Women who have undergone C-sections
• Those who needed multiple spinal puncture attempts

Interestingly, studies show that new cases of persistent back pain after spinal anaesthesia are rare—less than 1%.

How Long Does It Last?

In most cases, this type of back pain:

• Appears within a few days after the procedure
• Begins to improve within 1–2 weeks
• Resolves completely by 3 months

Only a very small number of patients experience pain beyond this period. When this happens, it’s often related to underlying issues that were already present before the spinal injection.

How Can You Prevent It?

While it may not always be preventable, the following steps can reduce the risk:

• Using smaller gauge spinal needles
• Choosing the paramedian approach instead of the midline technique (less tissue trauma)
• Minimising the number of puncture attempts
• Ensuring good positioning during and after surgery
• Staying active after surgery (as per medical advice)

Your anaesthetist can play a key role in adopting these techniques to make your spinal procedure safer and more comfortable.

What Can You Do to Manage the Pain?

Most cases of PDPB are self-limiting and respond well to conservative care. Here are some useful management tips:

• Rest: Allow your back to recover, especially in the early days.
• Heat therapy: Warm compresses or hot baths can relax tense muscles and reduce spasms.
• Gentle exercise: Light stretching, yoga, or walking can aid recovery and prevent stiffness.
• Maintain good posture: Use pillows for support while feeding your baby or sitting for long periods.
• Avoid heavy lifting: Learn to lift using your legs, not your back.
• Pain relief medications: Paracetamol or anti-inflammatory medicines can be helpful if prescribed by your doctor.
• Physiotherapy: Can be very effective in restoring strength and function.
• Massage therapy: Helps to relax the back muscles and improve blood circulation.

If your pain continues or worsens over time, consult a pain specialist to rule out other causes and discuss further treatment options.

Final Thoughts

Back pain after spinal anaesthesia can be a source of discomfort but is usually temporary and treatable. With the right care and guidance, most people make a full recovery within a few weeks.

If you’re experiencing persistent back pain after surgery or childbirth, don’t ignore it. At the International Pain Centre in Delhi, we offer expert evaluation and evidence-based treatments to help you live pain-free.

Need help with persistent back pain?

Contact our experienced Pain Specialists at International Pain Centre, Delhi.

Let’s work together to remove your pain.

For more information watch the video below

References

• Schwabe K, Hopf H-B. Persistent back pain after spinal anaesthesia in the non-obstetric setting: incidence and predisposing factors. British Journal of Anaesthesia. 2001;86(4):535–539. https://doi.org/10.1093/bja/86.4.535
• Aryasa T, Pradhana AP, Ryalino C, Hartawan IGAGU. Post-Spinal Backache after Cesarean Section: A Systematic Review. Bali Journal of Anesthesiology. 2021;5(4):234–238. https://doi.org/10.4103/bjoa.BJOA_72_21
• Rafique MK, Taqi A. The causes, prevention and management of post spinal backache: An overview. Anaesthesia, Pain & Intensive Care. 2011;15(1):65–69.
• Munnur U, de Boisblanc MR, Suresh MS. Backache, headache, and neurologic deficit after regional anesthesia. Anesthesiology Clinics of North America. 2003;21(1):71–86.
• Mishra NK, Singh R, Prakash R, et al. Post-Spinal Anesthesia Low Back Pain in Obese Female Patients: Comparison of the Median Versus Paramedian Approach. Cureus. 2024;16(3):e56784. https://doi.org/10.7759/cureus.56784
• Lee JH, Yoon DH, Heo BH. Incidence of newly developed postoperative low back pain with median versus paramedian approach for spinal anesthesia. Korean Journal of Anesthesiology. 2020;73(6):518–524. https://doi.org/10.4097/kja.19409
• Shanthi M, Gayathiri N, Paul EJ. Prevalence of back-pain following caesarean section under spinal anesthesia. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2023;12(9):2876–2880. https://doi.org/10.18203/2320-1770.ijrcog20232758
• Akdemir M, Kaydu A, Yanlı Y, et al. The Postdural Puncture Headache and Back Pain: The Comparison of 26-gauge Atraucan and 26-gauge Quincke Spinal Needles in Obstetric Patients. Anesthesia: Essays and Researches. 2017;11(2):458–462.

The post Post-Spinal Anaesthesia Back Pain: What You Need to Know appeared first on Dr Amod Blog.

Are you experiencing pain at the back of your heel, especially when walking, running, or rising onto your toes? If so, you might be dealing with a common but often misunderstood condition known as retrocalcaneal bursitis.

In this blog, I’ll explain what retrocalcaneal bursitis is, why it happens, its symptoms, and how it can be treated effectively.

What Is Retrocalcaneal Bursitis?

Let’s break it down:

• Retro = behind
• Calcaneal = related to the heel bone (calcaneus)
• Bursitis = inflammation of a bursa (a small fluid-filled sac that reduces friction)

Retrocalcaneal bursitis refers to inflammation of the bursa located between the heel bone and the tendon at the back of ankle called the Achilles tendon. This bursa acts as a cushion, helping smooth movement at the back of the ankle. When it becomes irritated or inflamed, it leads to pain and swelling.

This is the most common type of heel bursitis and is often confused with a problem in the Achilles tendon called the Achilles tendinopathy.

Causes of Retrocalcaneal Bursitis

Retrocalcaneal bursitis can affect both active individuals and those with sedentary lifestyles. Common causes include:

• Overuse or repetitive strain – such as frequent running, jumping, or walking uphill
• Wearing tight or poorly fitting shoes that rub the back of the heel
• Sudden increase in physical activity
• Lack of stretching before workouts or intense activity
• Switching from high heels to flat shoes, putting unexpected strain on the Achilles tendon
• Foot or ankle trauma, such as a fall or impact
• Medical conditions like rheumatoid arthritis, gout, or other inflammatory joint diseases
• Haglund’s deformity – a bony prominence at the back of the heel that can irritate the bursa

Who’s at Risk?

Athletes, dancers, runners, yoga lovers… and yes, even non-athletes who wear high heels or flat shoes suddenly! You may be more likely to develop retrocalcaneal bursitis if you:

• Are over 65 years of age
• Play high-impact sports (like running, tennis, or football)
• Have a job that involves repetitive ankle movements
• Don’t stretch or warm up properly before exercise
• Have tight calf muscles
• Wear shoes that compress the back of your heel
• Wear high heels for prolonged periods and switch to flats suddenly
• Have autoimmune conditions like rheumatoid arthritis, gout, or ankylosing spondylitis

Common Symptoms of Retrocalcaneal Bursitis

The hallmark sign of retrocalcaneal bursitis is pain at the back of the heel, especially when:

• Walking or running uphill
• Rising on your toes (e.g., standing tip-toe)
• Wearing shoes that press on the heel
• Flexing your foot

Other symptoms include:

• Swelling and tenderness at the back of the heel
• Redness or warmth over the affected area
• Pain in the calf or stiffness in the ankle
• A crackling or creaking sound when moving the ankle
• Stiffness or reduced range of motion in the ankle

Symptoms can worsen with increased physical activity or tight footwear and improve with rest.

How Is Retrocalcaneal Bursitis Diagnosed?

At the International Pain Centre, diagnosis begins with a detailed history and clinical examination. If required, the following tests may be used to confirm the diagnosis or rule out other conditions:

• X-ray: To detect bone spurs or deformities (like Haglund’s deformity)
• Ultrasound: To view bursa swelling and rule out Achilles tendon injuries
• MRI: if symptoms are persistent or diagnosis is unclear
• Fluid aspiration: Rarely done, but may be considered if infection is suspected

Treatment Options for Retrocalcaneal Bursitis

Most people recover well with non-surgical treatments. The goal is to reduce inflammation, protect the bursa, and prevent further irritation.

Conservative Treatment Options:

• Rest & Activity Modification- Avoid activities that aggravate your pain, such as running or jumping and switch to low-impact exercises such as swimming or cycling.
• Ice Therapy- Apply an ice pack to the back of the heel for 15–20 minutes, several times daily, especially during flare-ups.
• Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and swelling.
• Footwear Changes – Avoid tight shoes that rub against the heel. Choose shoes with a soft heel counter or open backs (like clogs) and use cushioned heel inserts or pads.
• Physical Therapy & Stretching- Gentle stretching and strengthening exercises for the calf and ankle improve flexibility and reduce pressure on the bursa. Avoid aggressive calf stretches during acute pain as this can worsen symptoms.
• Ultrasound-Guided Corticosteroid Injections – In severe or persistent cases, an ultrasound guided corticosteroid injection may be considered to reduce inflammation. This is generally helpful in reducing/ controlling symptoms.

When Is Surgery Considered?

Surgery is rarely needed. However, if conservative treatments fail and symptoms are disabling, a bursectomy (removal of the inflamed bursa) may be considered, sometimes combined with treatment for any bone abnormalities such as Haglund’s deformity.

Can Retrocalcaneal Bursitis Be Prevented?

While not all cases can be prevented! Here are simple steps to reduce your risk:

• Warm up and stretch properly before physical activities
• Avoid sudden increases in activity & training intensity
• Choose supportive, well-fitting footwear
• Maintain good posture and body mechanics during sports and daily activities
• Listen to your body—if your heels hurt, don’t ignore it

Final Thoughts

Retrocalcaneal bursitis is a painful but treatable condition. Early recognition, proper footwear, and conservative management can help you get back to your normal activities without long-term problems. If you’re struggling with persistent heel pain or suspect you may have bursitis, don’t delay and seek specialist help. At the International Pain Centre, we offer advanced diagnostic tools and personalised treatment plans to help you get lasting relief.

Written by Dr. Amod Manocha
Consultant in Pain Medicine
International Pain Centre – Excellence in Pain Management

The post Pain Behind The Heel: Retrocalcaneal Bursitis appeared first on Dr Amod Blog.

Imagine being able to freeze nerves to minus 80 degrees Celsius to manage pain. This isn’t science fiction; it’s a reality with cryoablation. The term "cryoablation" breaks down to "cryo" meaning cold and "ablation" meaning destruction. This innovative, minimally invasive technique uses extreme cold to temporarily disable nerve function and reduce pain. Cryoablation interrupts pain signals transmitted to the brain, providing an alternative to traditional nerve destruction methods like alcohol neurolysis or surgery, in certain situations.

Which type of pain conditions can be treated using this technology?

Cryoablation is effective for a variety of common pain conditions, including:

Acute and Post-Surgery Pain: Used for pain associated with surgeries such as hernia repair, rib fractures, thoracotomy (chest surgery), mastectomy (breast surgery), shoulder surgery, and knee replacement surgery.

Musculoskeletal pain such as shoulder or knee pain secondary to arthritis.

• Shoulder pain: arthritis, rotator cuff repair, adhesive capsulitis, bursitis.
• Knee pain: osteoarthritis, persistent post-surgical pain.
• Hip pain: osteoarthritis, avascular necrosis, trochanteric bursitis.
• Chest pain: Post-rib fracture and persisting costochondritis pain.

Chronic longstanding painconditions such as

• Chest wall pain: Including post thoracotomy, post herpetic (after herpes zoster infection) pain, and pain originating from chest nerves (intercostal Neuralgia).
• Chronic groin and pelvic pain: Including genital pain.
• Headache disorders: with favourable response to nerve blocks such as the Occipital, supraorbital or supratrochlear nerves.
• Phantom Limb Pain:common after amputation.

Nerve (Neuropathic) pain such as headaches from occipital Neuralgia or thigh pain form meralgia paresthetica, neuroma pain after amputation. Neuromas including Morton’s and Stump neuromas.

Spinal pain: such as from the arthritis of spinal joints (facet joint pain) in neck, middle of back, lower back, and pelvis joints (Sacroiliac Joints)

Chronic post-surgical pain (CPSP)- Post-surgical pain secondary to nerve injuries and entrapments in scar tissue or mesh can be treated with cryoablation. It is frequently used for treating persisting pain after chest wall, hernia, and amputation surgery.

Cancer pain: Localized to a nerve or region, particularly in cases of tumor infiltration of nerves. Has been used for pain related to abdominal, pelvic, and thoracic neoplasms.

How does it Work?

As explained earlier cryoablation involves applying extreme cold to targeted nerves, causing reversible nerve injury that stops the nerve from transmitting pain signals. The temperatures range from −20°C to −100°C, causing a temporary disruption of the nerve with the potential for regeneration. This interruption prevents pain signals from reaching the brain, offering immediate and prolonged relief.

How is cryoablation performed?

The procedure is simple, minimally invasive, and doesn’t require cuts, incisions, or suturing. Performed as a day-care procedure, it typically doesn’t require general anesthesia. Using a cryoprobe and a cryoablation machine, gases like nitrous oxide or carbon dioxide are delivered through the probe, creating extremely low temperatures at the probe tip. The probe is placed near the target nerve using ultrasound, X-ray, or CT guidance, and the freezing mode is activated. An ice ball forms at the probe tip, freezing the nearby nerves and reducing their ability to transmit pain. After the procedure, the cryoprobe is removed, and the site is covered with a small bandage.

What are the advantages of cryoablation?

Cryoablation offers several benefits over other pain relief methods:

• Immediate and prolonged relief: Unlike other treatments like steroid injections and radiofrequency, cryoablation provides rapid relief, with nerve recovery taking six to twelve months, and sometimes even longer.
• Minimally Invasive: No cuts or incisions are needed, and the procedure is performed using image guidance as an outpatient or day-care procedure.
• Safety: Minimal to no risk of worsening pain, as there’s no risk of neuroma formation. The use of ultrasound and nerve stimulators ensures correct nerve identification and precise treatment.The formation of ice ball can be monitored real-time.
• Repeatable: Treatments can be repeated as necessary without increased risks.
• Reduced Painkiller Requirements: Less reliance on pain medications reduces their side effects.
• Reduced Patient and Healthcare Burden: Early discharge and minimal monitoring requirements lower healthcare costs and improve patient convenience.

Cryoablation represents a significant advancement in pain management, providing a safe, effective, and minimally invasive alternative to traditional treatments.

This Treatment Option Is Available In India At The International Pain Center. Feel Free To Contact Us
On +91-9993336525

Further Reading

For those who are interested in knowing more, the article below can be helpful.

• Biel E, Aroke EN, Maye J, Zhang SJ. The applications of cryoneurolysis for acute and chronic pain management. Pain Pract. 2023 Feb;23(2):204-215. doi: 10.1111/papr.13182. Epub 2022 Dec 4. PMID: 36370129; PMCID: PMC10107282.
• Trescot AM. Cryoanalgesia in interventional pain management. Pain Physician. 2003 Jul;6(3):345-60. PMID: 16880882.
• Filippiadis D, Efthymiou E, Tsochatzis A, Kelekis A, Prologo JD. Percutaneous cryoanalgesia for pain palliation: Current status and future trends. DiagnInterv Imaging. 2021 May;102(5):273-278. doi: 10.1016/j.diii.2020.11.007. Epub 2020 Dec 3. PMID: 33281081. .
• Erinjeri JP, Clark TW. Cryoablation: mechanism of action and devices. J VascIntervRadiol. 2010 Aug;21(8 Suppl):S187-91. doi: 10.1016/j.jvir.2009.12.403. PMID: 20656228; PMCID: PMC6661161.
• Ilfeld BM, Finneran JJ. Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain. Anesthesiology. 2020 Nov 1;133(5):1127-1149. doi: 10.1097/ALN.0000000000003532. PMID: 32898231.

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Ankylosing spondylitis:

Ankylosing spondylitis is a chronic inflammatory disease that primarily affects the spine and sacroiliac joints, leading to pain, stiffness, and potential fusion of the spine. It falls under the category of spondyloarthritis, a group of inflammatory conditions that affect the joints and entheses (the sites where ligaments and tendons attach to the bones).

The symptoms of AS typically begin to manifest in young adults. Inflammationof the joints in the spine and pelvis is a feature of ankylosing spondylitis. Other joints in the body, including the hips, shoulders, and knees, may also be impacted. Back stiffness and pain, fatigue, and loss of flexibility are all signs of AS.

Theme for World Ankylosing Spondylitis Day 2024:

"Moving for axSpA" is the theme of this year’s World Ankylosing Spondylitis Day, which emphasizes the importance of exercise for people with this condition. Although the term "World AS Day" was originally used to refer to ankylosing spondylitis, its current focus is axial spondyloarthritis (axSpA), which includes ankylosing spondylitis and other closely related conditions.

The importance of World Ankylosing Spondylitis Day:

World Ankylosing Spondylitis Day is observed annually in an effort to increase public awareness of the condition and better understand the effects it has on those who are affected by it. This day offers an occasion for people to come together, show support for one another, and promote better healthcare and resources for those who have AS.

How to get involved:

There are numerous ways to participate in World Ankylosing Spondylitis Day in 2024, such as:

• You can spread knowledge about AS on social media platform
• Take part in events and activities planned by different organizations
• Create your own events
• You can donate to organizations that promote AS research and advocacy.

Dr. Amod Manocha’s message

A type of arthritis known as ankylosing spondylitis primarily impacts the spine. It’s a chronic illness in which exercise, medications, and lifestyle modifications can all help manage symptoms, allowing you to live a long and fulfilling life. The best pain management expert in Delhi and Gurgaon, Dr. Amod Manocha, can advise you on how to stay active while managing your symptoms.

The post Theme And Importance Of World Ankylosing Spondylitis Day, May 6, 2024 appeared first on Dr Amod Blog.

If you suffer from severe headaches, your lifestyle habits may be to contributing to it. Chronic headaches can be caused by poor sleeping routine, alcohol and tobacco use, excessive tea or coffee, stress and even your posture.

Different causes of headaches

There are different types of headaches, ranging in severity from a mild ache to severe pain. A variety of lifestyle factors and external triggers can cause each type of headache. When your headaches first appear, it can be difficult to determine what is causing them; however, this is an important step in determining how to prevent and treat your headaches.

Headaches can be caused by a variety of factors, including:

• Stress
• Lack of sleep
• Hunger
• Hormone changes
• Lack of caffeine
• Too much caffeine
• Change in weather
• Certain foods or food additives

Some causes can trigger more than one type of headache. These triggers aren’t always obvious, so you may have to suffer through several headaches before you figure out what’s causing them. Headaches aren’t always harmless, so if you get a sudden headache that’s worse than usual or if your symptoms are severe, seek specialist/ emergency care.

Which lifestyle changes can ease your pain?

Your headache might be difficult to deal with, but the small changes you make in your lifestyle can go a long way in managing it. It can be quite simple to keep your headaches at bay, once you’ve mastered the art of avoiding certain triggers and sticking to a routine.

You can take several steps to reduce the likelihood of headache attacks, including:

Getting adequate sleep daily

A common trigger for headaches is lack of sleep. Establish good sleep hygiene by going to bed at the same time every night (preferably not very late), not eating a heavy meal before sleeping, and taking a bath before bed.

Live a stress-free life

Stress is again a common trigger for your headache. As much as possible, you should avoid stress. Staying stress-free lowers, the chances of getting a headache. Meditation can be quite helpful in promoting relaxation and helping you control your mind especially if you have a problem of excessive thinking.

Avoid certain food items

For some individuals, certain foods can trigger headaches, like cheese, chocolate, alcohol, very heavy and oily meals, and sweets. Avoiding these triggers can go a long way. However, don’t skip meals. Skipping meals or eating excessively can both cause headaches. You must eat on a regular basis and in moderation.

Avoid going out in the bright sunlight

If bright sunlight gives you a headache, you may be suffering from a light-sensitive migraine or a heat headache. Heat headaches are common in hot weather or after prolonged sun exposure.

Drink plenty of water daily

Water is essential for overall health, but it is especially important if you suffer from dehydration headaches.

Do regular exercise

Regular exercise can reduce the frequency and intensity of headaches. When you exercise, your body produces endorphins, which are natural pain relievers and ‘feel-good’ hormones. Exercise relieves stress and improves sleep quality. Doing 30 minutes of moderate physical activity daily is recommended.

Takeaway

Many lifestyle-related headaches can be avoided by making these simple changes to your daily routine. If you have frequent headaches, seek a specialist opinion.

Dr. Amod Manocha, the best pain management specialist in Delhi and Gurgaon, has a goal: to help you get rid of your headaches as best as possible so you can live a pain-free life. He is an expert in treating all types of pain, including headaches.

CONNECT TO DISCONNECT WITH YOUR PAIN.

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Exercises and physiotherapy can help rehabilitate minor sports injuries, but severe sports injuries require a visit to the doctor.

Sports injury types:

Different sports injuries result in various symptoms and effects. The most common types of sports injuries consist of:

• Sprains: They are caused by overstretching or tearing of the ligaments. Ligaments are strands of connective tissue that hold two bones together at a joint.
• Strains: It occurs when muscles or tendons are overstretched or torn. Tendons, which connect bone to muscle, are substantial, fibrous strands of tissue. Sprains and strains are frequently confused.
• Muscle swelling: It is a typical response to an injury. Muscles that are swollen may also hurt and feel weaker.
• Fractures:
• Dislocations: Bones in your body might dislocate/ yanked out of its socket. Swelling and weakening may result from this, which can be uncomfortable.
• Knee injuries: Any injury that restricts the knee joint’s motion may qualify as a sports injury. It may be anything from an overstretch to a tear in the knee’s ligaments,menisci or muscles.
• Rotator cuff injury: The rotator cuff is made up of four separate muscles. Your shoulder may move in any direction thanks to the rotator cuff. The rotator cuff can become weak if one of these muscles’ tears.
• Achilles tendon rupture: At the rear of your ankle, the Achilles tendon is a strong, thin tendon. This tendon may rupture or break when playing sports. When it does, you could feel sharp, excruciating pain and have trouble walking.

It is advised that you speak with a qualified pain management specialist to go through your treatment choices if you have any of the above injuries or symptoms. To get timely treatment, it’s crucial to schedule a consultation with a pain management specialist for evaluation and diagnosis.

Sports-related injuries are common, and effective pain management and treatment are crucial for athletes to recover and get back to their activities.

Here’s a basic guide to sports pain management, injuries, and treatment:

• R.I.C.E. method: For acute injuries like sprains, strains, or contusions, the R.I.C.E. the method can help with pain management and initial treatment. R.I.C.E. stands for Rest, Ice, Compression, and Elevation. Rest the injured area, apply ice packs for 15-20 minutes at a time, use compression bandages to reduce swelling, and elevate the injured limb above heart level when possible.
• Over-the-counter pain relievers: can help manage pain, reduce inflammation, and relieve swelling. Follow the recommended dosage and consult a healthcare professional if you have any concerns or if you need stronger pain medications.
• Physical therapy: For more severe injuries or as part of the recovery process, physical therapy can be beneficial. A qualified physical therapist can guide you through exercises, stretches, and rehabilitation techniques to strengthen the injured area, improve mobility, and reduce pain.
• Injury-specific treatments:

• Sprains and strains: Depending on the severity, sprains and strains may require immobilization with braces, casts, or splints. Physical therapy can aid in restoring function and flexibility. Injections such as steroids or PRP may also be considered.
• Fractures: Broken bones may require casting, splinting, or even surgery in some cases. Follow your healthcare professional’s guidance for immobilization, weight-bearing restrictions, and rehabilitation.
• Tendinitis: Rest, ice, and avoiding activities that exacerbate the pain are the initial steps for managing tendinitis. Physical therapy, stretching, and strengthening exercises can help alleviate symptoms and prevent recurrence. Injections such as steroids or PRP may also be considered.

• Injury prevention: Proper warm-up and cool-down exercises, stretching routines, wearing appropriate protective gear, maintaining good technique, and gradually increasing training intensity can help reduce the risk of sports-related injuries.
• Professional medical advice: If you experience severe pain, persistent symptoms, or suspect a serious injury, it’s important to consult a healthcare professional, such as a pain specialist or sports medicine physician. They can provide an accurate diagnosis, recommend appropriate treatment, and create a tailored rehabilitation plan.

Final words from Dr. Amod Manocha

Sports and exercise are crucial for maintaining good health, yet they frequently result in accidents. Many minor sports injuries that are anticipated can be managed at home with rest and other techniques.

If swelling, discomfort, and bruising don’t go away or if there is a serious injury, you need to contact a doctor. Additionally, sports injuries happen frequently, despite your best efforts. Dr. Amod Manocha, the best pain management specialist in Delhi and Gurgaon, offers a one-stop solution with top-notch technology, ensuring the best care and a quick recovery.

CONNECT TO DISCONNECT FROM PAIN!

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