Common types of headache include tension headache, migraine, cluster and sinus headache. Headache related to serious causes as bleeding in the brain or tumor which requires a team based approach along with other tests. Headache needs to be diagnosed, differentiated and treated accordingly.

Neck (Servical) Pain

Understanding Chronic Pain with Pain Management

Neck pain is described as an aching, burning, stabbing, shooting, or cramping pain and frequently spreads into the Head, upper back, the arm or the hand. It is frequently made worse by activities that require one to be static or perform repetitive tasks like typing and answering the phone. It might be post trauma or a degenerative problem. Common sources of neck pain include Facet joints, Herniated discs, Muscles etc. The causes are almost similar to that for back pain (see above)

Medical management and specialized targeted physiotherapy at TPM gives quick relief to the patients. Sometimes Injections therapies like cervical epidural steroid injections, facet joint or its nerve block, radiofrequency ablation, Prolotherapy, Provocative discography, Cervical Nucleoplasty and in the end if everything fails to achieve relief then disc removal Surgery for pain are the treatment options.

Our body constantly degenerates. Decades of bending, lifting, turning, and twisting can really take their toll on your neck. Considering all that repetitive stress, it's no surprise that about two-thirds of people will experience neck pain at some point in their lives.

A cervical degenerative process can cause neck pain, cervical pain, radiating pain, as well as numbness and weakness in your shoulders, arm, and hand. That discomfort and loss of mobility can have a major impact on your career, family, and quality of life.

Neck pain may also be caused by vehicular accidents causing whiplash neck injuries, some chronic diseases like Ankylosing spondylitis, Arthritis, Fractures and Dislocations, Herniated Disc, Myelopathy, Osteoporosis, Radiculopathy, Spinal Cord Injury, Spondylolysis, Stenosis etc.

Diagnosing Your Cervical Disc Disease

To diagnose your cervical disc disease, your doctor will first take a medical history to find out when your symptoms started, how severe they are, and what causes them to improve or worsen. You'll likely have a neurological exam to test your strength, reflexes, and the sensation in your arm and hand, if they are affected.

Imaging tests such as X-rays, magnetic resonance imaging (MRI), and computed tomography (CT) scans can help your doctor visualize your spinal cord to pinpoint the source of your neck pain.

What to Do About Cervical Disc Disease

Even if you have degenerative disc disease or a slipped disc, chances are good that you'll be able to treat it without surgery. The first line in treatment for cervical disc disease is pain medications, including Paracetamol, and nonsteroidal anti-inflammatory medications such as ibuprofen; acetaminophen and naproxen. These medications can help reduce pain and inflammation. Some muscle relaxant, antidepressant medicines may be added for chronic neck pain.

Physical therapy is another treatment option for cervical spine pain. The therapist at TPM can use Interferrential therapy (IFT), US (Ultrasound), cervical traction, or gently manipulate your muscles and joints to reduce your pain and stiffness. The physical therapist can also help you increase your range of motion and show you exercises and correct postures to help improve your neck pain.

Your neck pain should improve with these conservative treatments. If you also have continued pain & disability or significant numbness or weakness, contact us right way. You and your doctor will need to consider the next step in your treatment. The next step is Epidural cortisone injection under x-ray control.

Other non-surgical treatment options are transforaminal selective nerve root injection, pulsed RF, discography, >95% of moderate to severe neck pain do respond to these therapies.

The main surgery for degenerative disc disease is called a discectomy. During this procedure, the surgeon removes the deteriorating disc. Discectomy is often followed up by artificial disc replacement, in which a metal disc is inserted in place of the disc that was removed. Discectomy may also be followed by cervical fusion, in which a small piece of bone is implanted in the space between the vertebrae. As the bone heals, it fuses with the vertebrae above and below it.

Special Procedure at Trident pain management for disc pain

  • Cervical Nucleoplasty
  • Radiofrequency Rhizotomy for Facet joint Pain causing Neck Pain

After You Heal: Keeping Your Neck Healthy

Even though degenerative disc disease is most often due to age, it can also be influenced by lifestyle factors. To make sure you keep your spine as healthy as possible, eat a balanced diet and exercise regularly. Don't smoke, because, aside from its other affects on your health, smoking is a risk factor for cervical disc disease. Also watch your posture, always keeping your neck straight and your back well supported.

Although neck pain from cervical disc disease can return, you'll lower the chances if you take good care of your neck and the rest of your body. Most people don't have constant neck problems throughout their lives. Usually it comes and goes. "If you have a problem with your neck now, the odds are it won't last forever."

Shoulder Pain

The shoulder is the most movable joint in the body. However, it is an unstable joint because of the range of motion allowed. It is easily subject to injury because the ball of the upper arm is larger than the shoulder socket that holds it. To remain stable, the shoulder must be anchored by its muscles, tendons, and ligaments. Some shoulder problems arise from the disruption of these soft tissues as a result of injury or from overuse or underuse of the shoulder. Other problems arise from a degenerative process in which tissues break down and no longer function well.

Shoulder pain may be localized or may be referred to areas around the shoulder or down the arm. Disease within the body (such as gallbladder, liver, or heart disease, or disease of the cervical spine of the neck) also may generate pain that travels along nerves to the shoulder.

X-rays, MRI, arthrogram are usual tests to diagnose cause of shoulder pain.

Tendinitis, Bursitis & Impingement of soft tissues in & around shoulder are some of the common causes of shoulder pain.

Intra-articular, peri-articular, intrabursal injection of Hylan GF20, steroid or prolotherapy agents are some of the very effective.

Shoulder Pain/ frozen shoulder

Shoulder being the most mobile joints is also prone for most types of injuries and degeneration. It results in chronic pain and limitation of movement. Shoulder pain is when the shoulder is painful and loses motion because of inflammation. The joint capsule of the shoulder joint has ligaments that hold the shoulder bones to each other. When the capsule becomes inflamed, the shoulder bones are unable to move freely in the joint.

Most of the time there is no cause for shoulder pain. However, risk factors include:

  • Cervical disk disease of the neck
  • Diabetes
  • Shoulder injury
  • Shoulder surgery
  • Hyperthyroidism
  • Decreased motion of the shoulder
  • Pain
  • Stiffness


The shoulder is comprised of three bones: the humerus, scapula and calvicle. The shoulder is a very mobile joint and receives minimal stability from the bony structures. The soft tissue of the shoulder, including the rotator cuff muscles and joint capsule, function to help provide stability to the most mobile shoulder joint.

Shoulder being the most mobile joints is also prone for most types of injuries and degeneration. It results in chronic pain and limitation of movement.

Frozen shoulder is when the shoulder is painful and loses motion because of inflammation.

The joint capsule of the shoulder joint has ligaments that hold the shoulder bones to each other. When the capsule becomes inflamed, the shoulder bones are unable to move freely in the joint. Most of the time there is no cause for frozen shoulder.Degenerative disease and overuses is the common in shoulder pain along with some inflammatory diseases.

Risk Factors

  • Cervical disc disease of the neck.
  • Diabetes
  • Shoulder injury.
  • Shoulder surgery.
  • Hyperthyroidism.

Frozen shoulder without any known cause starts with pain. This pain prevents you from moving your arm. The lack of movement leads to stiffness and eventually less motion of the shoulder. Over time, you are unable to perform activities such as reaching over your head or behind you.

Diagnosis of Frozen shoulder

Based on patients symptoms and examination (movements restriction) of your shoulder, x-rays or MRI of the shoulder (as per requirement) diagnosis will be given.

Shoulder pain with limited range of movements

  • Osteoarthritis of joint
  • Capsulitis of joint
  • Rotator cuff syndrome
  • Osteoarthritis of Acromio-clavicular joint
  • Impingement syndrome
  • Subacromial bursitis

Shoulder pain without limited range of movement due to problem outside shoulder

  • Shoulder instability (Habitual dislocation)
  • Cervical Radicular syndrome
  • Brachial plexus syndrome
  • Intrathoracic tumor / cancer / Metastases

Treatment are in two forms as:

1. Conservative Frozen Shoulder Treatment :

  • Analgesics, Muscle relaxants, Local applications.
  • Exercise, Physiotherapy.
  • Local application of Hot & Cold fomentation

2. Interventional Management Frozen Shoulder Treatment:

When conservative management is not giving satisfactory outcome and there is no indication of surgical management, Interventional therapy is the best choice.

  • Intra-articular Steroid injection
  • Suprascapular nerve block
  • Intra-articular acromio-clavicular steroid injection
  • Cervical Epidural analgesia
  • Injection of Subacromial Bursitis
  • Trigger point injection
  • Intramuscular stimulation (IMS) markedly reduce pain.
  • Pulse Radio-frequency of Suprascapular nerve

Cancer Pain

Most cancer pain is caused by the tumour pressing on bones, nerves or other organs in the body.Cancer pain may also be caused due to your cancer treatment. For example, some chemotherapy drugs can cause numbness and tingling in your hands and feet. Or they might cause a burning sensation at the spot where you have the injection. Radiotherapy can cause skin redness and irritation.


  • Oral medicine.
  • Skin patch – a clear, sticky patch placed on the skin. It slowly – but constantly – releases medicine through the skin for 2 to 3 days.(e.g. Fentanyl patches, buperonorphine patches).
  • Rectal suppositories – medicine that dissolves in the rectum and is absorbed by the body.
  • Injections

    i. Intravenous (IV) injection – medicine goes right into a vein through a needle, port, or catheter.

    ii. Intrathecal and epidural injections – medicine is put into the fluid around the spinal cord (intrathecal) or into the space around the spinal cord (epidural).

    iii. Sympathetic blocks with local anaesthetics and steroids/ neurolytic agents.

Muscle Pain

Muscular pain is a major component of chronic pain. It can be associated with other painful conditions or can be present by itself. Myofascial Pain can lead to severe spasm and restrict day to day activities due to pain.


  • Muscular injury- sports, gym, weight lifting etc.
  • Bad posture- desk jobs,computer use, prolonged sitting, fine workers etc.
  • Nutrition, vitamin deficiency.
  • Other neurological diseases.
  • Associated with other causes of back pain, neck pain, joint pain etc.

Back Pain

Back pain is a common complaint. Four out of five people in the India will experience lower back pain. People loose work, become less productive and also have many social and psychological problem due to chronic back pain.

The good news is that, most back pain is preventable and treatable. Simple home treatment and proper body mechanics will often cure your back within a few weeks without any recurrence.

Surgery is rarely needed in back pain treatment. When back pain does not subside within 3 months, it becomes chronic back pain. It may be mild nagging pain or severe pain. Most common causes for your back pain may be facet joint pain or herniated intervertebral disc (slipped disc).

Back pain is a disease of modern times. Most people have low back pain at some point of time. Mostly people who experience lower back pain for first time get better in 2-6weeks. However chronic back pain or recurrent back pain requires special management.

Symptoms of Back Pain

Persistent aching or stiffness anywhere along your spine, from the base of the neck to the tail bone • Sharp, localized pain in the neck, upper back, or lower back — especially after lifting heavy objects or engaging in other strenuous activity • Chronic ache in the middle or lower back, especially after sitting or standing for extended periods • Back pain that radiates from the low back to the buttock, down the back of the thigh, and into the calf and toes • Inability to stand straight without having pain or muscle spasms in the lower back 

  • 1. Pain in low back.
  • 2. Pain in the buttocks.
  • 3. Pain in the hips.
  • 4. Pain going from back through the buttocks, thigh, and legs to the feet.
  • 5. Tingling numbness in legs.
  • 6. Weakness in the legs.
  • 7. Inability to walk, stand for long duration, sit or turn in bed.
  • 8. Cramps in the calf.
  • 9. Back pain persisting after surgery.

Symptoms of Back Pain

  • Wrong posture.
  • Wear & tear of spine called degeneration.
  • Prolonged sitting in one place without movement.
  • Injuries to spine.
  • Picking heavy objects causing a jerk to the spine.

Low Back Pain

Low back pain is one of the most common causes of patient disability and suffering. The cause of pain depends on the diagnosis of the structure causing the pain (pain generator).

Back Pain can be generated due to –

  • Vertebral bodies
  • Facet joints
  • Spinal Nerves
  • Ligaments
  • Intervetebral discs
  • Muscles
  • Fascia
  • Spinal cord
  • Connective tissue layers

Primary Causes of Back Pain

  • Acute and Chronic Disc protrusion or prolapse with Radiculopathy (disc slipping back onto the nerve & compressing it to cause pain shooting down the leg). It is also called Sciatica.
  • Facet joint pain (Facet joint arthritis).
  • Spondylolysis (sliding of one vertebra over another vertebra).
  • Lumbar canal stenosis (hard bones and firm ligaments of vertebral canal narrowing onto the soft spinal cord).
  • Sacroiliac joint pain.
  • Failed Back Surgery Syndrome.
  • Sports Injuries- Usually pains from the muscles tendons and ligaments.
  • Any muscular pain in back and lower limb – e.g. Pain from Pyriformis syndrome.

All these conditions produce a tremendous muscle spasm on either side of the spine. Most spine pains are a direct result of this spasm.

Incorrect posture is a major cause of back pain. It puts a lot of load on the spine. The areas particularly stressed are neck, the thoracolumbar junction and the lumbar region, where the load is maximum. Modern lifestyle adds to the problem. Lack of back exercise, prolonged sitting especially people with desk jobs, sitting on soft sofas in front of TV etc aggravates back pain further. Nature has designed our body well. Hence the body tolerates a lot of abuse before it expresses its distress by way of pain. By the time pain is felt considerable damage is done to the spine. This can be reversed in most cases with the help of well-planned exercises, Physical therapy and IMS.

But if there is presence of a disc prolapse (slipped disc) or a small tear in the disc then interventional pain procedures may be necessary to reverse the damage.

Diagnosis of Back Pain

  • 1. Diagnosis of the exact location of back pain is done with help of X rays, CT scans, MRI.
  • 2. Medical history of the patient is studied.
  • 3. Thorough clinical examination.

Lower Back Pain Treatment

We offer a complete rehabilitation package for low back pain. The treatment conpreventive pain management to comprehensive back pain treatment strategies that include correct diagnosis and comprehensive treatment as follows.

  • Medications.
  • Interventional procedures like: Transforaminal epidural injection of local anaesthetic (steroid methylprednisolone or triamcinolone). This injection reduces the irritation of the nerve root by the disc.
  • Facet joint injection- To reduce pain coming from facet joints due to arthritis.
  • Radiofrequency ablation of medial branch nerves supplying facet joints for pain coming from facet joints.
  • Sacroiliac joint injections- for Sacroilitis which can cause low back pain.
  • Caudal epidural injections.
  • Intramuscular stimulation (IMS). Whatever may be the pain generator (disc facet etc), muscle spasm is always associated with it. The muscles go into spasm with any insult which is initially painless and later becomes a painful spasm. These spasm can increase the nerve irritation.

    IMS of the muscles of back and legs has the potential to completely resolve this problem of paraspinal muscle spasm.

  • Physical therapy: Physiotherapy plays an important role in pain management. It is an essential adjunct to the nerve block and IMS. After pain is relieved, physiotherapy will help in strengthening back muscles to have a long term pain relief.
  • Trigger injections, Botox injections for muscles and targeted physical therapy. If the result of these is not satisfactory then advanced interventions like spinal cord stimulator or intrathecal pump are available.

Knee Pain

Common cause of knee pain is due to osteoarthritis of the knee, or after injuries or other unusual causes like gout rheumatoid arthritis etc Osteoarthritis of the knee results from age related degenerative changes in the joint and in the muscles responsible for movement of the joint. This is more commonly seen with women, the obese and the elderly.

Patients are advised to manage conservatively till surgery is indicated. Treatment for knee joint pain depends on the cause and severity.In most patients pain is from a combination of all these.

Knee Pain Symptoms

  • Difficulty in climbing down the stairs and later up the stairs.
  • Difficulty in standing
  • Difficulty in walking.
  • Difficulty in squatting.
  • Difficulty in performing prayers, sitting cross legged, etc.

After a while, many patients complain of pain in the other knee as well along with low back pain The reason for the pain and the common occurrence in population is lack of exercise. Traditional Indian life used to entail considerable exercise to the knee with the cross legged sitting, walking as a part of daily work, use of the Indian toilet etc.

Knee Pain Treatment

  • Nerve blocks of the nerves.
  • IMS of specific muscles involved in moving the knee.
  • Intraarticular injections (injection into the joint). Very selected cases, injection of hyaluron, a lubricant may be given.
  • Physical therapy
  • Weight loss
  • Posture correction, nutritional correction, lifestyle modification and patient education are other aspects of complete therapy

Ankle Pain

Ankle Pain Causes

  • Plantar fascitis.
  • Constantly being on your feet, especially on a hard surface like concrete and wearing hard-soled footwear.
  • Thinning or weakness of the fat pads of the heel.
  • Injury to the bones or padding of the heel.
  • Arthritis in the ankle or heel (subtalar) joint .
  • Irritation of the nerves on the inner or outer sides of the heel.
  • Fracture of the heel bone (calcaneum) .

The function of the heel in walking is to absorb the shock of your foot striking the ground as it is put down and to start springing you forward on the next step. It contains a strong bone (the calcaneum). Under the bone are a large number of small pockets of fat in strong elastic linings, which absorb much of the shock (fat pads). The heel is attached to the front of the foot by a number of strong ligaments which run between the front part of the calcaneum and various other parts of the foot. The strongest ligament is the plantar fascia, which attaches the heel to the toes and helps to balance the various parts of the foot as you walk. It therefore takes a lot of stress as you walk.

In some people the plantar fascia becomes painful and inflamed. This usually happens where it is attached to the heel bone, although sometimes it happens in the mid-part of the foot. This condition is called plantar fasciitis. There are a number of common causes:

    • It is due simply to constant stress, and is therefore commoner in people who spend all day on their feet or are overweight.
    • stiffness of the ankle or tightness of the Achilles tendon increase the stresses on the heel. Most people with plantar fascitis have a rather tight Achilles tendon.
    • people who have high-arched (“cavus”) feet or flat feet are less able to absorb the stress of walking and are at risk of plantar fascitis
    • sometimes it starts after an injury to the heel.
    • people who have a rheumatic condition such as rheumatoid arthritis or ankylosing spondylitis may get inflammation anywhere a ligament is attached to bone (enthesopathy), and plantar fascitis in these people is part of their general condition.
    • Usually plantar fascitis eventually gets better itself, but this can take months or even years. If you have it once you are more likely to get it again.

Ankle Pain Treatment

Intralesional injections in the ankle & heel have been found to provide significant pain relief in cases where medicines haven’t worked. Such interventional techniques should be followed by regular stretching and exercises for better results.