Category Archives: Musculoskeletal

Plantar Fasciitis

What causes heel pain? 

— One of the most common causes of heel pain is a problem called “plantar fasciitis.”

Plantar fasciitis is the term doctors use when a part of the foot called the plantar fascia gets irritated or swollen. The plantar fascia is a tough band of tissue that connects the heel bone to the toes.

Heel pain caused by plantar fasciitis is very common. It often affects people who run, jump, or stand for long periods. Most people who get this type of heel pain get better within a year even if they do not get treated.

What are the symptoms of plantar fasciitis? 

— The most common symptom is pain under the heel and sole (bottom) of the foot. It commonly causes stabbing pain that usually occurs with your first steps in the morning. As you get up and move more, the pain normally decreases, but it might return after long periods of standing or after rising from sitting.

Plantar fasciitis pain can also be bad when you get up after being seated for some time.

What causes Plantar Fasciitis?

Under normal circumstances, your plantar fascia acts like a shock-absorbing bowstring, supporting the arch in your foot. If tension and stress on that bowstring become too great, small tears can arise in the fascia. Repetitive stretching and tearing can cause the fascia to become irritated or inflamed, though in many cases of plantar fasciitis, the cause isn’t clear.

What are the risk factors for the development of plantar fasciitis?

Though plantar fasciitis can arise without an obvious cause, factors that can increase your risk of developing plantar fasciitis include:

  • Age. Plantar fasciitis is most common between the ages of 40 and 60.
  • Certain types of exercise. Activities that place a lot of stress on your heel and attached tissue — such as long-distance running, ballistic jumping activities, ballet dancing and aerobic dance — can contribute to an earlier onset of plantar fasciitis.
  • Foot mechanics. Being flat-footed, having a high arch or even having an abnormal pattern of walking can affect the way weight is distributed when you’re standing and put added stress on the plantar fascia.
  • Obesity. Excess pounds put extra stress on your plantar fascia.
  • Occupations that keep you on your feet. Factory workers, teachers and others who spend most of their work hours walking or standing on hard surfaces can damage their plantar fascia.

Is there anything I can do on my own to feel better?

 — Yes, you can:

If you are overweight, loosing weight will help.

Rest – Give your foot a chance to heal by resting. But don’t completely stop being active. Doing that can lead to more pain and stiffness in the long run.

Ice your foot – Putting ice on your heel for 20 minutes up to 4 times a day might relieve pain. Icing and massaging your foot before exercise might also help.

Do special foot exercises – Certain exercises can help with heel pain. Do these exercises every day.

Take pain medicines – If your pain is severe, you can try taking pain medicines that you can get without a prescription. Examples include ibuprofen and naproxen . But if you have other medical conditions or already take other medicines, ask your doctor or nurse before taking new pain medicines.

Wear sturdy shoes – Sneakers with a lot of cushion and good arch and heel support are best. Shoes with rigid soles can also help. Adding padded or gel heel inserts to your shoes might help, too.

Wear splints at night – Some people feel better if they wear a splint while they sleep that keeps their foot straight. These splints are sold in drugstores and medical supply stores.

Is there a test for plantar fasciitis? 

— No, there is no test. But your doctor or nurse should be able to tell if you have it by learning about your symptoms and doing an exam. He or she might suggest an X-ray, or other tests to check whether your symptoms might be caused by something else.

Sometimes an X-ray shows a spur of bone projecting forward from the heel bone. In the past, these bone spurs were often blamed for heel pain and removed surgically. But many people who have bone spurs on their heels have no heel pain.

How is plantar fasciitis treated?

— The first step is to try the things you can do on your own. But if you do not get better, or your symptoms are severe, your doctor or nurse might suggest:

Athletic Tape – taping your foot in a special way that helps the support the foot

●Special shoe inserts, made to fit your foot

Shots (that go into your foot) of a medicine called a steroid, which can help with the pain. Multiple injections aren’t recommended because they can weaken your plantar fascia and possibly cause it to rupture. More recently, platelet-rich plasma has been used, under ultrasound guidance, to provide pain relief with less risk of tissue rupture.

Extracorporeal shock wave therapy. In this procedure, sound waves are directed at the area of heel pain to stimulate healing. It’s usually used for chronic plantar fasciitis that hasn’t responded to more-conservative treatments. This procedure might cause bruising, swelling, pain, numbness or tingling. Some studies show promising results, but it hasn’t been shown to be consistently effective.

Tenex procedure. This minimally invasive procedure removes the scar tissue of plantar fasciitis without surgery. This procedure allows you to get back to your regular routine in as little as 10 days.

●Putting a splint over your foot and ankle in a way that stretches your calf and the arch of your foot while you sleep. This holds the plantar fascia and Achilles tendon in a lengthened position overnight and facilitates stretching.

●Surgery (this is an option only in some cases that do not get better with other treatments)

Some doctors also suggest a treatment called “shock wave therapy.” This treatment is painful and has not been proven to work.

Is there anything I can do to keep from getting heel pain again? 

— Yes. To reduce the chances that your pain will come back:

●Wear shoes that fit well, have a lot of cushion, and support the heel and ankle

●Avoid wearing slippers, flip-flops, slip-ons, or poorly fitted shoes

●Avoid going barefoot

●Do not wear worn-out shoes

This content was written by

Dr. Carlo Oller

Board Certified Emergency Physician

Boxer’s Fracture

What is a boxer’s fracture?

 — A “fracture” is another word for a broken bone.

A boxer’s fracture is when a person breaks a specific part of one of the hand bones. The hand bones are also called the “metacarpals”. The hand bone involved in a boxer’s fracture is the bone between the little finger (pinky) and the wrist.

Even though this fracture is called a boxer’s fracture, it does not usually happen in boxers. Instead, it usually happens when people punch a wall or other hard object.

What are the symptoms of a boxer’s fracture? 

— Symptoms of a boxer’s fracture can include:

●Pain in the area of the fracture

●Swelling, usually on the back of the hand

●Bruising, usually on the palm of the hand

●The little finger or side of the hand looking like it’s bent in an abnormal position

Is there a test for a boxer’s fracture? 

— Yes. Your doctor or nurse will ask about your symptoms, do an exam, and order an X-ray of your hand.

How is a boxer’s fracture treated? 

— Treatment depends on how severe the fracture is.

If you have an open cut with your fracture, your doctor will wash the cut out well. He or she will also give you a tetanus shot if it’s been too many years since your last one.

For the first few days after your injury, your doctor will probably recommend one or more of the following:

●Resting your hand

●Keeping your hand up above the level of your heart (as much as possible) – This is helpful only for the first few days after an injury.

●Putting ice on your hand – You can put a cold gel pack, bag of ice, or bag of frozen vegetables on the area every 1 to 2 hours, for 15 minutes each time. Put a thin towel between the ice (or other cold object) and your skin. Use the ice (or other cold object) for at least 6 hours after the injury. Some people find it helpful to ice up to 2 days after the injury.

●Taking pain medicine – If you have a lot of pain or a severe fracture, your doctor will prescribe a strong pain medicine. If your fracture is mild, your doctor might recommend that you take an over-the-counter pain medicine. Over-the-counter pain medicines include acetaminophen (sample brand name: Tylenol), ibuprofen (sample brand names: Advil, Motrin), and naproxen (sample brand name: Aleve).

●Wearing a splint – Wearing a splint keeps your hand bones in one position so that the fracture can heal. But before your doctor puts the splint on your hand, he or she will make sure your hand bones are in the correct position. If your bones are not in the correct position, he or she might need to do a procedure to put your bones back in the correct position.

Later on, you might need surgery to fix your hand bones. Whether you need surgery depends on your fracture.

You might also need to work with a physical therapist (exercise expert) after your fracture heals. The physical therapist will show you exercises and stretches to strengthen your hand and finger muscles and keep them from getting stiff.

How long does a boxer’s fracture take to heal? 

— A boxer’s fracture usually takes 4 to 6 weeks to heal, depending on the type of fracture.

Healing time also depends on the person. Healthy children usually heal much more quickly than older adults or adults with other medical problems.

Can I do anything to improve the healing process? 

— Yes. It’s important to follow all of your doctor’s instructions while your fracture is healing.

Plus, doctors usually recommend that people with a fracture:

●Eat a healthy diet that includes getting enough calcium, vitamin D, and protein

●Not damage their splint or get it wet

●Stop smoking – Fractures can take longer to heal if people smoke.

When should I call my doctor or nurse? 

— After treatment, your doctor or nurse will tell you when to call him or her. In general, you should call him or her if:

●You have severe pain, or your pain or swelling gets worse.

●You have numbness or tingling in your fingers, or your fingers look blue or purple.

●You damage your splint.

  • Dr. Carlo Oller (emergency physician with has put together more than 1800 FREE patient education videos which can be found at
  • Please contact Dr. Carlo Oller at if you would like to use his videos in your own website, or educational materials. Or if you would like some more information or education on a title NOT available at this time.


What is fibromyalgia? 

Fibromyalgia is one of a group of chronic pain disorders that affect connective tissues, including the muscles, ligaments (the tough bands of tissue that bind together the ends of bones), and tendons (which attach muscles to bones).

It is a chronic condition that causes widespread muscle pain (known as “myalgia”) and extreme tenderness in many areas of the body. Many patients also experience fatigue, sleep disturbances, headaches, and mood disturbances such as depression and anxiety. Despite ongoing research, the cause, diagnosis, and optimal treatment of fibromyalgia are not clear.

In the United States, fibromyalgia affects about 2 % of people by age 20, which increases to approximately 8% of people by age 70; it is the most common cause of generalized musculoskeletal pain in women between 20 and 55 years. It is more common in women than men.


— The cause of fibromyalgia is unknown. Various physical or emotional factors (such as infection, injury, or stress) may play a role in triggering symptoms, although many patients report a lifelong history of chronic pain.

In people with fibromyalgia, the muscles and tendons are excessively irritated by various painful stimuli. This is thought to be due to a heightened perception of pain, a phenomenon called “central sensitization.” Other conditions may also develop as a result of central sensitization, including irritable bowel syndrome (IBS); chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS); chronic headaches; chronic pelvic and bladder pain; and chronic jaw and facial pain.

There is no generally agreed-upon explanation for how or why central sensitization develops in some people. The most likely theory suggests that there is a genetic component, meaning that some people are predisposed to having a heightened perception of pain.

People with a parent or sibling with fibromyalgia have a higher chance of developing it themselves. In some cases, various stressors, including infection (eg, Lyme disease or viral illness), diseases that involve joint inflammation (eg, rheumatoid arthritis or systemic lupus erythematosus), physical or emotional trauma, or sleep disturbances appear to trigger the development of fibromyalgia.

Brain imaging studies in people with fibromyalgia and related chronic pain disorders shave shown changes in brain function and connections between different parts of the brain. As research continues, the factors that lead to chronic pain in fibromyalgia will be better understood, hopefully allowing for the development of better treatments.

Can fibromyalgia be cured? — Some people seem to get over fibromyalgia. But in most people it cannot be cured. Even so, people can learn to deal with the condition and lead fairly normal lives. Fibromyalgia does not get worse over time, and it is not life-threatening.

Does fibromyalgia cause symptoms besides muscle pain? 

The primary symptom of fibromyalgia is widespread (or “diffuse”), chronic, and persistent pain. Although the pain is felt in muscles and soft tissues, there are no visible abnormalities in these areas. The pain may be described as a deep muscular aching, soreness, stiffness, burning, or throbbing. Patients may also feel numbness, tingling, or unusual “crawling” sensations in the arms and legs. Although some degree of muscle pain is always present, it varies in intensity and is aggravated by certain conditions, such as anxiety or stress, poor sleep, exertion, or exposure to cold or damp conditions. People often describe their muscle symptoms as feeling like they always have the flu.

The pain may be confined to specific areas, often the neck or shoulders, early in the course of the disease. Multiple regions are eventually involved, with most patients experiencing pain in the neck, middle and lower back, arms and legs, and chest wall. Areas called “tender points” can feel painful with even mild to moderate pressure. Many patients with fibromyalgia feel that their joints are swollen, although there is no visible inflammation of the joints (as would be found in forms of arthritis).

Other pain symptoms — Patients with fibromyalgia are often affected by other pain-related symptoms, including:

●Repeated headaches, including migraines

●Symptoms of irritable bowel syndrome (IBS), including frequent abdominal pain and episodes of diarrhea, constipation, or both

●Interstitial cystitis/painful bladder syndrome, in which bladder pain, urinary urgency, and frequency are typically present without an infection

●Temporomandibular joint (TMJ) syndrome, which can involve limited jaw movement; clicking, snapping, or popping sounds while opening or closing the mouth; pain within facial or jaw muscles in or around the ear; or headaches

Fatigue and sleep disturbances — Persistent fatigue occurs in more than 90 percent of people with fibromyalgia. Most people complain of unusually light, unrefreshing, or nonrestorative sleep. Difficulties falling asleep, awakening repeatedly during the night, and feeling exhausted upon awakening are also common problems.

People with fibromyalgia may also have sleep apnea (when the person stops breathing for a few moments while sleeping) or restless legs syndrome (when there is an uncontrollable urge to move the legs). Like some painful conditions, these sleep problems might also be triggers of fibromyalgia. If you have one or both of these problems, your doctor will likely recommend a formal sleep evaluation to confirm the diagnosis.

There appears to be a close relationship between fibromyalgia and chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), which is primarily characterized by chronic, debilitating fatigue. Most patients with CFS meet the “tender point” criteria for fibromyalgia (meaning that they have pain in many of the areas commonly affected in people with fibromyalgia), and up to 70 % of those with fibromyalgia meet the criteria for CFS. A better understanding of both conditions is needed to clarify how they may be related.

Depression and anxiety — Many people with fibromyalgia also have depression and/or anxiety at the time of diagnosis, or develop one or both later in life. However, this is true of most chronic pain conditions, and fibromyalgia is not simply a physical manifestation of depression.


— There are no specific laboratory or imaging tests used to diagnose fibromyalgia. Thus, the diagnosis is typically based upon a thorough patient history, a complete physical examination, and a limited number of blood tests, which are used to exclude conditions with similar symptoms.

Different diagnostic guidelines have been used, and different health care providers may vary in their process, but all approaches involve evaluating your pain, fatigue, and other symptoms that may be related.

●The American College of Rheumatology (ACR) developed classification criteria for fibromyalgia in 1990 that have often been used to help make the diagnosis. According to these criteria, a person can be diagnosed with fibromyalgia if he or she has widespread musculoskeletal pain and excess tenderness in at least 11 of 18 specific “tender points” (based on clinician examination).

●The ACR released updated diagnostic criteria in 2010. These criteria do not require a tender point examination but use a numerical scoring system based on how widespread and severe a person describes their pain to be. They also consider other symptoms such as fatigue, cognitive problems (eg, trouble thinking clearly), and other pain-related issues such as headache or digestive problems.

●Diagnostic criteria proposed by the Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAAPT) include multisite pain (defined as at least six out of nine possible sites) and moderate to severe sleep problems or fatigue, present for at least three months.

If you have symptoms of fibromyalgia, your doctor should obtain a medical history and do a physical exam to rule out arthritis, other connective tissue problems, neurologic conditions, and other disorders that may be causing your symptoms. Routine laboratory tests may be recommended to help exclude certain conditions, such as inflammatory arthritis, thyroid disease, and disorders of the muscles. Results of these tests are normal in most people with fibromyalgia.

Because people with fibromyalgia frequently have symptoms besides muscle pain, including persistent fatigue, headache, additional pain symptoms, and sleep and mood disturbances, your doctor may also suggest the following:

●Informal or formal evaluation of mood problems such as depression or anxiety – If you have symptoms of depression or anxiety, you may be referred to a mental health specialist for further evaluation or treatment.

●A thorough sleep history – If your sleep history suggests a sleep disturbance such as restless legs syndrome or sleep apnea, you will be referred to a sleep specialist for additional evaluation and treatment.

Conditions that can be similar to fibromyalgia 

— The process of determining whether a person’s signs and symptoms are related to fibromyalgia or to another condition can be lengthy and complex in some cases. Many illnesses can cause generalized muscle aches, fatigue, and other common symptoms of fibromyalgia.

It is important to note that fibromyalgia can occur in people with rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, and other conditions. If this is the case, it may be difficult to determine whether your symptoms of chronic pain and fatigue are caused by fibromyalgia or your other condition. Often this will require consultation with a rheumatologist.

The following is a sample of disorders that your doctor may consider during the diagnostic process:

●Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) – RA is a chronic disease that causes inflammation of joints, resulting in pain, swelling, and potential deformity of the affected joints. SLE is also a chronic, inflammatory disorder of connective tissue that can affect multiple organs.

Although both RA and SLE share many symptoms with fibromyalgia, they have other features that are not usually seen in people with fibromyalgia, including inflammation of the synovial membranes (connective tissue that lines the spaces between bones and joints).

●Osteoarthritis (OA) – OA causes stiffness, tenderness, pain, and potential deformity of affected joints, and it most commonly occurs in older individuals. Doctors can differentiate OA from fibromyalgia based upon a person’s medical history, physical examination, and x-ray results (in OA, x-rays can show degenerative joint changes that are not present in fibromyalgia).

●Ankylosing spondylitis (AS) – AS is a chronic, progressive, inflammatory disease involving joints of the spine. This condition leads to stiffness, pain, and decreased movement of the spine. AS also causes characteristic findings that can be seen on x-ray, which are absent in people with fibromyalgia. By contrast, spinal motion and x-rays are usually normal in people with fibromyalgia.

●Polymyalgia rheumatica (PMR) – PMR is an episodic, chronic, inflammatory condition that causes stiffness and pain in the shoulders, hips, or other areas of the body. The disorder, which primarily affects people older than 50, is frequently associated with inflammation of certain large arteries. PMR is differentiated from fibromyalgia based upon a person’s medical history, physical examination, and blood tests.

●Hypothyroidism and other endocrine disorders – Decreased activity of the thyroid gland, known as hypothyroidism, can cause fatigue, sleep disturbances, and generalized aches, similar to those in fibromyalgia. Blood tests to measure thyroid function are routinely conducted to help exclude hypothyroidism. Other endocrine disorders, including increased activity of the parathyroid glands (hyperparathyroidism), can also cause symptoms similar to fibromyalgia.

●Muscle inflammation (myositis) or muscle disease due to metabolic abnormalities (metabolic myopathy) – These conditions cause muscle fatigue and weakness, compared with the widespread pain seen in fibromyalgia. In addition, patients with myositis typically have abnormal levels of muscle enzymes.

●Neurologic disorders – These may include disorders of the brain and spinal cord (central nervous system or CNS) or of nerves outside the CNS (peripheral nervous system). A thorough neurologic examination can assist in differentiating fibromyalgia from neurologic disease.

How is fibromyalgia treated? 

Ideally, the treatment of fibromyalgia should involve you and your doctor, as well as (in many cases) a physical therapist, mental health expert, and other health care professionals.

It may help to keep the following in mind:

●Fibromyalgia is a real illness, and your pain is not “all in your head.”

●Fibromyalgia is not a degenerative or deforming condition, nor does it result in life-threatening complications. However, treatment of chronic pain and fatigue is challenging, and there are no “quick cures.”

●Treatments are available. Medications may be helpful in relieving pain, improving your quality of sleep, and improving your mood. Exercise, stretching programs, and other activities are also important in helping to manage symptoms. An approach that involves combining multiple different types of intervention into an organized treatment program is usually best. Being physically active will not cause harm or long-term muscle damage, and it can help improve pain and function.

●Understanding fibromyalgia, and accepting that its cause is not well understood, may help to improve your response to treatment. As an example, some people believe that their illness is due to an undiagnosed or persistent infection; however, there is no evidence that this is true. Learning about fibromyalgia as well as some of the common myths may help you to cope better with your symptoms.

●It is important to try to have realistic expectations about your fibromyalgia and how much it can be managed. Symptoms often increase and decrease over time, but some degree of muscle pain and fatigue generally persist. Nevertheless, most people with fibromyalgia improve, and most people lead full, active lives.

Medications — In addition to exercise and coping techniques to help manage symptoms, some people with fibromyalgia benefit from medication. The medications that have been most effective in relieving symptoms of fibromyalgia in clinical trials are drugs that target chemicals in the brain and spinal cord that are important in processing pain. These include some of the medications usually used to treat depression (antidepressants) and epilepsy (anticonvulsants). By contrast, medications and techniques that work to decrease symptoms of pain locally, such as antiinflammatory drugs and analgesics, are less effective.

The best medication for you will depend on your symptoms, preferences, and cost concerns, as well as which drugs are available in your area. Your doctor can talk to you about options and how to begin medication therapy. In general, medication is usually started at a low dose and then increased slowly as needed.

Antidepressants — There are several different classes of drugs used to treat depression. Some of these can be effective in treating fibromyalgia symptoms as well.

●Tricyclic antidepressants (TCAs) – These drugs are often used first in treating fibromyalgia. Examples include amitriptyline and nortriptyline. Cyclobenzaprine, a closely related medication, may help in treating fibromyalgia but is not effective for depression. Taking TCAs before bedtime may promote deeper sleep and may alleviate muscle pain. Lower doses are usually used in fibromyalgia than the doses needed to treat depression, but even when taken at low doses, side effects are common; they may include dry mouth, fluid retention, weight gain, constipation, or difficulty concentrating.

●Dual-reuptake inhibitors – These drugs, also called serotonin-norepinephrine reuptake inhibitors (SNRIs), can help with symptoms of fibromyalgia as well. They include duloxetine and milnacipran. The most common side effects are nausea and dizziness, but these are generally more tolerable if the dose is started at a low level and is increased very slowly.

●Selective serotonin-reuptake inhibitors – Selective serotonin-reuptake inhibitors (SSRIs) such as fluoxetine and paroxetine may also be effective in fibromyalgia. SSRIs are not typically used as initial treatment of fibromyalgia, but doctors might try them in some situations. These are a group of antidepressant drugs that work to increase the concentration of serotonin in the brain. Serotonin is a naturally produced chemical that regulates the delivery of messages between nerve cells.

Anticonvulsants — Certain anticonvulsants (drugs used primarily for treating epilepsy) may help to relieve pain and improve sleep. They include pregabalin and gabapentin and are thought to relieve pain by blocking certain chemicals that increase pain transmission. The most common side effects of these drugs include feeling sedated or dizzy, gaining weight, or developing swelling in the lower legs; however, most people tolerate these medications well.

Other drugs — You may wonder about other medications for treating your symptoms. However, evidence is limited, and it’s important to talk with your doctor about your situation and what approach is most likely to help.

Fibromyalgia does not cause tissue inflammation; thus, neither nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (sample brand names: Advil, Motrin) or naproxen (sample brand name: Aleve) nor glucocorticoids (steroids) are effective in relieving fibromyalgia symptoms.

Analgesics (pain-relieving medications) are sometimes added to fibromyalgia medications for people who need additional short-term pain relief. They include acetaminophen (sample brand name: Tylenol) and the prescription medication tramadol (sample brand name: Ultram), which may be used alone or in combination. Tramadol is an opioid, although it is weaker than other opioid drugs and less likely to result in addiction. It may cause dizziness, diarrhea, or sleep disturbances in some people.

There is no evidence that long-term opioids are effective in treating fibromyalgia symptoms, and these drugs come with potentially serious side effects as well as a risk of addiction.

Non-medication treatments

Exercise — Regular exercise, such as walking, swimming, or biking, is helpful in reducing muscle pain and improving muscle strength and fitness in fibromyalgia. If you are beginning an exercise program for the first time, it’s best to start slowly and gradually increase your level of activity. Over time, exercise typically improves fibromyalgia symptoms. Muscle strengthening programs also appear to improve pain, decrease the number of tender points, and improve muscle strength.

It can also help to work with a physical therapist to develop an appropriate, individualized exercise program that will be of most benefit to you. Eventually, a good goal is to exercise for at least 30 minutes three times weekly. A separate topic review discusses exercise and arthritis; some of these approaches may also help people with fibromyalgia.

Relaxation therapies — In some cases, participating in stress-reduction programs, learning relaxation techniques, or participating in hypnotherapy (hypnosis), biofeedback, or cognitive behavioral therapy (CBT) may help to relieve certain symptoms. Of these approaches, the most is known about CBT.

●CBT is based on the concept that people’s perceptions of themselves and of their surroundings affect their emotions and behavior. The goal of CBT is to change the way you think about pain and to deal with illness more positively. CBT has been especially effective when combined with patient education and information, ie, learning about your disease and how to manage it.

●Hypnosis induces a trance-like state (similar to daydreaming) of altered awareness and perception, during which there may be heightened responsiveness to suggestions.

●During biofeedback, patients use information about typically unconscious bodily functions, such as muscle tension or blood pressure, to help gain conscious control over such functions.

Tai chi and yoga — Some people with fibromyalgia benefit from a traditional Chinese exercise called tai chi (which combines mind-body practice with gentle, flowing movement exercises) or yoga.

Acupuncture — Acupuncture involves inserting hair-thin, metal needles into the skin at specific points on the body. It causes little to no pain. In some cases, a mild electric current is applied to the needle. Evidence on the effectiveness of acupuncture in relieving fibromyalgia symptoms is mixed; while some people seem to find if helpful, it is not typically recommended.


— While fibromyalgia is not a life-threatening disorder, many people worry that their symptoms represent the “early stages” of a more serious condition, such as systemic lupus erythematosus. However, long-term studies do not indicate that people with fibromyalgia have an increased risk of developing other rheumatic diseases or neurologic conditions.

Most people with fibromyalgia continue to have chronic pain and fatigue throughout their lives. However, most people are able to work and do normal activities. The degree to which fibromyalgia impacts a person’s day-to-day life varies, and everyone’s situation is unique. Working with your doctors (and other health care providers) to understand your condition and manage your symptoms, learning effective coping techniques, and having strong family and social support can really help improve and maintain your quality of life.

What can I do on my own? — It is really important that you stay active. Walking, swimming, or biking can all help ease muscle pain. If you have not been active, it might hurt a little more when you start. But being active can help improve your symptoms.

It is also really important that you try not to be too negative about your life. Your outlook has a big effect on how you feel pain. I know it will be hard, but do your best to stay positive.

  • Dr. Carlo Oller (emergency physician with has put together more than 1800 FREE patient education videos which can be found at
  • Please contact Dr. Carlo Oller at if you would like to use his videos in your own website, or educational materials. Or if you would like some more information or education on a title NOT available at this time.


Basic Patient education

What is bursitis? — Bursitis is a condition that can cause pain or swelling next to a joint. Most of the time, bursitis happens around the shoulder, elbow, hip, or knee. It can also happen around other joints in the body.

A “bursa” is a small fluid-filled sac that sits near a bone. It cushions and protects nearby tissues when they rub on or slide over bones. These sacs, called “bursae,” are found in many places throughout the body. Bursitis happens when a bursa gets irritated and swollen. This can happen when a person:

Moves a joint over and over again in the same way, over a short period of time

Sits on a hard surface or stays in a position that presses on the bursa for a long time

Has certain kinds of arthritis, such as gout or rheumatoid arthritis, that can affect their joints and bursae

Gets hurt near a bursa

Has an infection that spreads to a bursa

What are the symptoms of bursitis? — Symptoms of bursitis can include:

Pain or tenderness


Trouble moving the joint

A bursa can get infected if a person gets a cut on the skin nearby. An infected bursa can cause a fever and the area around the bursa to be:





If you have any of the symptoms of an infected bursa, let your doctor or nurse know as soon as possible.

Is there a test for bursitis? — Yes. Your doctor or nurse will ask about your symptoms and do an exam.

If you have symptoms of an infected bursa, your doctor might use a needle to remove some fluid from the bursa. Then he or she can do lab tests on the fluid to find out what is causing the bursitis, and if you need antibiotics. He or she might also order imaging tests, such as an MRI scan or ultrasound. Imaging tests can create pictures of the inside of the body.

What can I do to treat my bursitis? 

— To treat your bursitis, you can:

Rest, cushion, and protect the area – Try not to irritate the area that hurts. For example, people with very painful shoulder bursitis might need to avoid lifting or carrying heavy things for a while. They might also need to wear an arm sling. People with bursitis behind the heel might need to use a thick heel pad. This can raise the heel so that it does not rub against the back of the shoe.

Avoid positions that put pressure on the area – For example, people with bursitis in the front of the knee should avoid kneeling.

Put ice on the area to reduce pain – Use a frozen bag of peas or a cold gel pack a few times a day for 20 minutes each time.

Put heat on the area to reduce pain and stiffness – Do not use heat for more than 20 minutes at a time. Also, do not use anything too hot that could burn your skin.

What other treatments might I have? — Your doctor or nurse might use other treatments, depending on your symptoms and where your bursitis is. Treatments can include:

Pain-relieving medicines called “nonsteroidal antiinflammatory drugs” or “NSAIDs” – NSAIDs include ibuprofen (sample brand names: Advil, Motrin), and naproxen (sample brand name: Aleve). These medicines can reduce pain and prevent the bursae from getting swollen and painful.

Steroid injections – Steroid medicines help reduce inflammation. These medicines are different from the steroids athletes use to build muscle. Doctors can inject steroids into the area of the bursitis to help reduce symptoms.

Exercises and stretches – Your doctor or nurse might recommend that you work with a physical therapist. A physical therapist can teach you stretches and exercises to help reduce your symptoms.

Surgery – A doctor can do surgery if other treatments do not work and you have had symptoms for a long time.

People with an infected bursa might also have treatment that includes:


Having the fluid in the bursa drained – A doctor can drain the fluid using a needle and syringe, or by doing surgery.

Can bursitis be prevented? — Yes. To help reduce the chance that you get bursitis, you can:

Use cushions or pads to avoid putting too much pressure on joints – For example, people who garden can kneel on a kneeling pad. People who sit for a long time can sit on a cushioned chair.

Take breaks, if you are using a certain joint too much

Stop an activity or change the way you are doing it, if you feel pain


Lose weight, if you are overweight

Use good posture

BURSITIS OVERVIEW — Advanced Patient Education 

— Bursitis is an inflammation or irritation of the bursae (plural of “bursa”). The bursae are fluid-filled sacs in the joints that decrease friction and provide a cushion between bones, muscles, and skin.

Bursitis can be acute (often as a result of an injury or infection) or chronic (for example, following a long period of repetitive use or motion). It can affect almost any joint in the body, although some are more commonly affected than others.


— Causes of bursitis include:

Injury, such as from a fall or hit

Prolonged pressure, which can result from kneeling, sitting, or leaning on a particular joint for a long period

Strain or overuse from repeating the same motion many times

Joint stress from an abnormal gait; for example, walking unevenly because one leg is shorter than the other

Gout or other crystal diseases

Certain types of arthritis, like rheumatoid arthritis or psoriatic arthritis

Infection resulting from bacteria entering the body through a cut or scrape in the skin


— Common symptoms of bursitis include pain and swelling in the affected joint. Visible swelling is more common in bursae that are closer to the surface of the skin (such as those around the elbows, kneecaps, and heels), and less common in deeper areas (such as the shoulders, hips, and inner knees).

In acute bursitis, there is often pain directly over the affected bursa; active motion (when the patient moves or bends the joint) also causes pain. People with chronic bursitis are more likely to have swelling, often with minimal pain. They may have limited range of motion due to avoiding moving the joint and surrounding muscles. Bursitis caused by an infection is called “septic bursitis.” Symptoms may include pain, swelling, warmth, and redness around the affected joint. Fever may also be present. This is a potentially serious condition, since infection can spread to nearby joints or the blood. Specific symptoms vary depending on the area that is affected. (See ‘Types of bursitis’ below.)


— Diagnosing bursitis involves a physical examination, a review of your symptoms, and sometimes tests.

If infection or crystal disease (for example, gout) is suspected, your doctor may use a syringe and needle to remove a sample of fluid from the affected bursa. This is called “aspiration.” The fluid can then be examined under a microscope for crystals, bacteria, and white blood cells. Imaging (such as radiograph, MRI, or ultrasound) is not usually needed to diagnose bursitis. However, it can help in some situations, such as when other problems (for example, a tear in the cartilage or ligament) need to be ruled out quickly. It can also be useful if your doctor needs to remove fluid from a bursa near other areas that could be injured, such as nerves or blood vessels. Imaging can allow the doctor to see where the needle is going.


— Bursitis can affect many different areas of the body. The exact symptoms and preferred treatments depend on the location as well as the cause.

Shoulder (subacromial bursitis) — Shoulder bursitis causes pain in the shoulder and outside of the upper arm (figure 1). Pain is often present at rest but increases with movement of the arm, especially with lifting the arms above the head; it also often interrupts sleep. It can be difficult to differentiate shoulder bursitis from other issues such as a rotator cuff tear or tendinitis.

Upper back (scapulothoracic bursitis) — Upper back bursitis affects the space between the scapula (shoulder blade) and ribs, and can cause pain or a popping sensation. Reaching the arms overhead or doing pushups can make pain worse.

Elbow (olecranon bursitis) — Elbow bursitis usually causes a visible swelling at the tip of the elbow, like a golf ball. It can result from injury, infection, crystals (gout), or rheumatoid arthritis. It usually causes pain when the elbow is flexed, but not extended. The elbow often extends fully without discomfort.

Pelvis (ischial bursitis) — Pelvic bursitis has also been referred to as “weaver’s bottom” or “tailor’s bottom,” since it is often caused by prolonged sitting on hard surfaces. It causes pain in the lower buttocks that is aggravated by sitting (figure 2); pain may disappear when the person stands.


Greater trochanteric pain syndrome (formerly called trochanteric bursitis) — The greater trochanteric bursa is located in the upper outer part of the femur (thigh bone) (figure 2). Bursitis in this area is usually associated with inflammation of nearby tendons and can cause pain while lying or sleeping on the affected side of the body. People with greater trochanteric pain syndrome also tend to have pain when extending the leg to walk, but not while standing still. Symptoms can be aggravated by an abnormal gait, due to uneven stress on the hips. There are many contributing factors, including chronic back pain, contralateral knee pain (knee pain on the opposite side of the body from the bursitis), different leg lengths, and being overweight.

Iliopsoas bursitis — The iliopsoas bursa is deep in the front of the hip. This type of bursitis causes pain in the groin area, particularly when the hip is flexed against resistance. It can result from arthritis in the area, overuse (for example, excessive running), or injury. Because symptoms are similar to those of other hip problems (for example, problems with the bone or cartilage), imaging tests are often required to confirm the diagnosis. Infection in the psoas muscle (psoas abscess) can have similar symptoms. (The psoas muscle runs from the spine to the femur, and is used to flex the hip.)


Prepatellar and infrapatellar bursitis — The prepatellar bursa is located at the front of the knee, on top of the patella (kneecap) (figure 3); the infrapatellar bursa is below this. Bursitis in these areas can result from recurrent injury to the knee, and is often seen in people who frequently kneel (prepatellar bursitis has been referred to as “housemaid’s knee” or “nun’s knee”). It can also happen as a result of infection, gout, or rheumatoid arthritis. Swelling occurs within the bursa, not in the knee joint itself. People with prepatellar and infrapatellar bursitis usually feel more comfortable lying down with the knee extended, while people with swelling within the true knee joint tend to feel better lying down with the knee bent.

MCL bursitis — The medial collateral ligament (MCL) is located on the inner side of the knee, and connects the femur (thigh bone) to the tibia (shin bone) (figure 4). Bursitis in this area can cause pain and tenderness, but doesn’t usually involve swelling. It must be differentiated from an injury or tear to the MCL or meniscus (the cartilage in the knee).

Pes anserinus pain syndrome — The anserine bursa is located about two inches below the top of the tibia (shin bone), on the inner side of the knee. Pes anserinus pain syndrome (formerly referred to as anserine bursitis) causes pain on the inner side of the knee, which tends to come on abruptly, often during the night. It is common in people with arthritis of the knee; it can also result from an uneven gait (for example, walking with a limp or while favoring one leg over time), or from flat feet.

Heel (retrocalcaneal bursitis) — The retrocalcaneal bursa is between the heel bone and the Achilles tendon, which connects the heel to the calf muscle. It normally serves as a cushion to absorb impact when walking. Retrocalcaneal bursitis can cause pain and swelling in the area. It can be easily confused with tendinitis (inflammation of the Achilles tendon).


— Bursitis treatment focuses on relieving inflammation and pain, treating infection (if present), and preventing complications and future recurrence.

Medication — In most cases, nonsteroidal antiinflammatory drugs (NSAIDs) can help relieve pain and inflammation. NSAIDs include ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand name: Aleve); other NSAIDs, as well as higher doses, are also available by prescription. (See “Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)”.)

A glucocorticoid (steroid) injection can also help with inflammation. This is more often used when the affected area is deep under the skin (see ‘Shoulder (subacromial bursitis)’ above and ‘Greater trochanteric pain syndrome (formerly called trochanteric bursitis)’ above and ‘MCL bursitis’ above and ‘Pes anserinus pain syndrome’ above). It is not usually helpful for more superficial types of bursitis, for example, in the olecranon bursa of the elbow, prepatellar bursa of the knee, or retrocalcaneal bursa of the heel. Septic bursitis requires drainage of the infected fluid and antibiotics to treat the underlying infection. (See ‘Treating infection’ below.)

Protecting the joints — It is important to protect the affected joints in order to help the bursae to heal, and to prevent the bursitis from getting worse or recurring. Examples of joint protection include:

Avoiding or modifying activities that cause pain

The use of pads or cushions for people who have to kneel or sit frequently

Modifying footwear to reduce pressure on the back of the heel (eg, cutting a “V”-shaped groove into the back of a shoe; using a pad inside the shoe to lift the heel)

Custom-fitted devices worn over the elbows to protect them and prevent fluid from building up again

Other measures 

— Ice can help relieve pain, particularly for bursitis affecting superficial areas like the elbow, kneecap, and heel. Heat (eg, a heating pad) may be more effective for deeper forms of bursitis, such as the hip, shoulder, or inner knee.

In many cases, physical therapy can help treat symptoms of bursitis and prevent future recurrence. The optimal exercises depend on the type and severity of bursitis, but may involve stretching, strengthening, or working to improve (and maintain) range of motion. Rarely, surgery is required to remove all or part of the affected bursa.

Treating infection — Septic bursitis is treated with antibiotics. The choice of which antibiotic to use, and for how long, is based on the type and severity of infection. For mild cases, a few weeks of oral antibiotics may be enough; for more severe infection, intravenous (IV) antibiotics (given in the hospital) may be required.

It is also often necessary to drain infected fluid using a needle. This is done in a doctor’s office, usually several times, until the infection has resolved.


— Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

Achilles Tendonitis

In this video Dr. Carlo Oller, emergency physician, discusses achilles tendonitis.

What is Achilles tendinopathy? — Achilles tendinopathy (sometimes called Achilles tendinitis) is a condition that causes pain in the back of the leg, just above the heel. It happens when people hurt their Achilles tendon. Tendons are strong bands of tissue that connect muscles to bones. The Achilles tendon connects the calf muscles to the heel bone.

You use your Achilles tendon when you walk, run, and jump.

What causes Achilles tendinopathy? — Achilles tendinopathy can happen when people:

Suddenly increase their exercise or activity (such as running)

Do the same exercises or activities (such as jumping) over and over

Don’t warm up their calf muscles before exercising

Exercise in shoes or sneakers that are worn-out or not made for exercise

Have arthritis or a bone growth on the back of their heel bone – This can rub against the tendon and hurt it.

What are the symptoms of Achilles tendinopathy? — The most common symptoms are:

Pain in the back of the leg, just above the heel – The pain usually gets worse with exercise and better with rest.

Stiffness or soreness in the back of the leg, especially in the morning

Swelling of the skin over the Achilles tendon

Trouble standing on tiptoe

Sometimes, an Achilles tendon tears. Doctors call this a “rupture.” Symptoms of an Achilles tendon rupture can include:

Sudden, severe pain in the back of the leg

Trouble putting weight on the foot or walking normally

Is there a test for Achilles tendinopathy? — No. But your doctor or nurse should be able to tell if you have it by learning about your symptoms and doing an exam. Your doctor or nurse might order an X-ray or other test to check if another condition is causing your symptoms.

If your doctor or nurse thinks that you tore your Achilles tendon, you might have an imaging test called an MRI. This test can create pictures of the tendon.

How is Achilles tendinopathy treated? — Achilles tendinopathy usually gets better on its own, but it can take months to heal completely. To help your symptoms get better, you can:

Rest your Achilles tendon and avoid activities that cause pain

Ice the area – If your pain gets worse after activity, put a cold gel pack, bag of ice, or bag of frozen vegetables on the injured area every 1 to 2 hours (for up to 6 hours), for 15 minutes each time. Put a thin towel between the ice (or other cold object) and your skin.

Wrap your ankle with an elastic bandage (or other wrap) – This can help keep your tendon from moving too much. Your doctor or nurse will show you how to wrap your ankle correctly.

Take medicine to reduce the pain – Your doctor might recommend that you take a medicine to relieve pain, such as acetaminophen (sample brand name: Tylenol), ibuprofen (sample brand names: Advil, Motrin), or naproxen (sample brand names: Aleve).

Do exercises to make your calf muscles stronger and more flexible – Your doctor or physical therapist (exercise expert) will show you which exercises to do.

What if my symptoms don’t get better? — If your symptoms don’t get better, your doctor might suggest other possible treatments. These can include:

A device to wear in your shoe or around your ankle to keep your foot in a position where it can heal properly


How is an Achilles tendon rupture treated? — A tendon rupture is usually treated with surgery.

Is there anything I can do to keep from getting tendinopathy again? — Yes. To lower the chance of getting Achilles tendinopathy again, you can:

Warm up your muscles before you exercise. For example, if you run, you can warm up your muscles by jogging slowly and then slowly increasing your pace.

Avoid sudden increases in your exercise or activity. When you begin a sport or activity, start off slowly. Over time, you can exercise harder and for longer periods of time.

Avoid running or exercising outside in cold weather. If you need to be outside, wear warm clothes.

Wear the correct sneakers or shoes for your sport or activity.

Replace worn-out sneakers or shoes.

Avoid running on hard surfaces.

Dr. Carlo Oller Board Certified Emergency Physician Please visit my website, make sure you subscribe, comment, and share! That is the best way to show your support.