Rib fractures can lead to chronic pain through several mechanisms and reasons.

The first is through inadequate healing during which either a nonunion, where the rib fracture fails to heal, or malunion where the bone ends reunite, but in a misaligned way leading to ongoing pain.

Immobilization of a fracture is a priority for orthopedists treating broken bones. The purpose of a splint, cast or surgery with rods, plates or screws is to provide fracture stability and immobilization during the healing process. But, with rib fractures there is no splint/cast available because the chest is constantly required to move during respiration. Fortunately, the vast majority of fractures heal and slight degrees of malalignment do not cause significant problems.

The intercostal nerve is a small nerve that travels from the back along the underneath side of each rib. Fractured ribs can damage or irritate the intercostal nerves, leading to persistent nerve pain or neuropathy.

Rib fractures near the costochondral junction (where the rib meets the cartilage) can be particularly painful and can lead to chronic pain due to the movement of the chest wall.

The intercostal muscles (the barbecue rib meat) may be strained or injured at the time of the fracture and can remain painful.

Scar tissue forming as part of the healing process may compress nerves or limit mobility, leading to ongoing discomfort.

Though not a true source of pain, the shallow breathing to the avoid pain from a rib fracture can lead to decreased lung function or pneumonia, compounding pain issues.

There are several reasons why the aforementioned issues may develop. The rib cage is in constant motion due to breathing, coughing, and physical activity, which can impede the healing process and exacerbate pain.  Ribs also have a relatively limited blood supply, and the slow healing process can contribute to prolonged pain.

Chronic pain after rib fractures can severely impact one’s quality of life.  In rare cases, if conservative care and injections do not provide adequate relief of the pain, surgery may become an option.

Diabetes mellitus can significantly impact musculoskeletal healing through several mechanisms.

Diabetes can cause vascular complications, reducing blood flow to affected areas and slowing the delivery of essential nutrients and oxygen needed for healing.

High blood glucose levels, the hallmark of diabetes, can impair the body's ability to repair tissues efficiently, leading to delayed wound healing.

Collagen is crucial for tissue repair, and diabetes can decrease collagen synthesis, leading to weaker scar tissue and slower healing processes.

Diabetic individuals are more susceptible to infections, which can complicate and prolong the healing of musculoskeletal injuries and surgical procedures.

Nerve damage associated with diabetes (diabetic neuropathy) can lead to decreased sensation, which might result in further injuries and complications during the healing process due to lack of protective pain sensations.  This is especially important for patients that require casting or splinting of an injured extremity.  Pressure sores may develop in diabetic patients beneath the cast/splint because of the lack of pressure recognition caused by their neuropathy.  In a worst case scenario, a tight cast may lead to vascular insufficiency causing gangrene and the need for an amputation.

Diabetes can alter the normal inflammatory response, either prolonging inflammation or impairing the transition to the healing phase, both of which can delay recovery.

Diabetes can impair bone metabolism, leading to delayed fracture healing and increased risk of complications such as nonunion or malunion.

These factors collectively compromise the body's ability to efficiently repair musculoskeletal injuries, leading to longer recovery times and an increased risk of complications in individuals with diabetes mellitus.

Serologic arthritis is a type of arthritis that is characterized by the presence of specific antibodies in the blood, which can be detected through serologic (blood serum) tests. These antibodies are typically markers of autoimmune disorders. Some of the more common types of serologic arthritis includes rheumatoid arthritis, lupus, sarcoidosis, Reiter’s syndrome, psoriatic arthritis and Lyme disease.

And yes, these joints are more easily injured by trauma for several reasons. The chronic inflammation associated with these diseases, can weaken the joint structures making it easier for them to be injured from even minor trauma.  Serologic arthritis is often associated with stiffness and reduced flexibility which makes a joint less capable of handling stress and the sudden movements that can occur during a traumatic event.

Many of these conditions lead to bone erosion, and joint deformities with malalignment. These structural changes may compromise the stability and integrity of the joint, making it more vulnerable to an injury.

Finally, chronic pain and inflammation can lead to decreased physical activity, resulting in muscle atrophy (weakening). Weaker muscles provide less support and protection to the joints, leading to an increased risk of injury.

The exact percentage of asymptomatic individuals with osteoarthritis can vary, but studies suggest that a significant portion of people with osteoarthritis may not experience noticeable symptoms.

Shoulder research indicates that up to 30% of people over the age of 60 may have shoulder osteoarthritis, but a substantial number of them might not exhibit symptoms.

Approximately 20% of people over the age of 65 may have radiographic evidence of hip osteoarthritis, yet many of them are asymptomatic.

Estimates suggest that around 40% of individuals over the age of 70 have knee osteoarthritis based on radiographic or MRI imaging, but about half of these individuals may not report symptoms.

These estimates highlight the prevalence of osteoarthritis that can remain asymptomatic and undetected without noticeable symptoms.

Degenerative rotator cuff tears, which occur due to the gradual wear and tear of the tendons rather than a sudden injury, are quite common, especially in older adults. However, not all degenerative tears result in symptoms.   Studies suggest that roughly 35% to 50% of degenerative rotator cuff tears are symptomatic, meaning they cause noticeable symptoms such as pain, weakness, and limited range of motion. The remaining 50% to 65% tend to be asymptomatic and may be discovered incidentally during imaging for other issues or routine check-ups.

Larger tears or ones that have recently progressed, especially in more active individuals are more likely to cause symptoms.  Overtime, large asymptomatic tears can lead to rotator cuff arthropathy (osteoarthritis of the shoulder joint secondary to a rotator cuff tear), which may then cause shoulder pain.

Not all torn anterior cruciate ligaments (ACL) require surgery. The decision depends on several factors including the individual's activity level, the severity of the injury, and personal goals.

Minor tears and partial tears are often treated with physical therapy to strengthen the muscles that support the knee.

Older or less active individuals that have a low demand lifestyle may be able to avoid the need for surgery by focusing on muscle strengthening and possibly using a knee brace.

On the other hand, athletes, those engaged in physical work or individuals with active lifestyles that have complete ACL ruptures with a desire to return to high demand activities typically require ligament reconstruction to regain functionality and stability. Patients that have failed non-operative treatment due to significant knee instability or pain should undergo and ligament reconstruction.

In general, younger, active individuals are more likely to benefit from ACL reconstruction surgery than non-operative treatment. If the knee remains unstable and causes issues like giving away, surgery should be considered. Finally, if the individual has plans to return to sports or high impact activities, the decision-making should lean toward surgical reconstruction.

Whether or not a repeat medial branch block (MBB) is needed after a radiofrequency ablation (RFA) procedure depends on the treating  physician and the insurer. Some insurers require a repeat set of MBBs.  However, I am of the opinion that the patient does not necessarily require a repeat set of diagnostic medial branch blocks if the pain occurs during the six month to two year time frame, and is of the same quality and character, and in the same location as the pain prior to initial procedure.

If the patient receives less than complete relief after the initial RFA procedure, and there is evidence of facet pathology at additional levels, then a repeat medial branch block incorporating those additional levels may be a value prior to a repeat RFA.