The sacroiliac (SI) joint connects the sacrum at the base of the spine to the ilium of the pelvis. SI joint dysfunction is a frequently overlooked but significant cause of low back, buttock, and leg pain. It is estimated to account for up to 25% of chronic low back pain cases.

At Palm Beach Regenerative, image-guided SI joint treatment is an integral part of the lumbar spine care approach, with precise injection targeting the joint and surrounding ligaments. Reach out to our practice to schedule an appointment today.

The SI joint is heavily reinforced by ligaments and normally has very limited movement. Dysfunction arises from either too little movement (from arthritis or fusion) or too much movement (from ligament laxity), both of which can produce pain in the buttock, low back, and into the hip or thigh.

SI joint dysfunction is particularly common in women following pregnancy and delivery, in athletes with pelvic asymmetry, and in patients following lumbar fusion surgery.

• Pain in the low back, buttock, and sacral region, typically one-sided
• Pain that worsens with prolonged standing, walking, or transitions such as getting up from a chair
• Radiating pain into the hip, groin, or back of the thigh
• Pain with single-leg weight-bearing or stair climbing
• Tenderness directly over the SI joint
• Worse with prolonged sitting

• Ligament laxity from pregnancy or hormonal changes
• Trauma or fall directly onto the sacrum
• Arthritis or inflammatory conditions affecting the SI joint
• Altered gait mechanics from hip or lumbar pathology
• Post-lumbar fusion syndrome where forces transfer to the SI joint

Clinical examination with specific SI joint provocative tests (FABER, thigh thrust, Gaenslen’s test) is the starting point. A fluoroscopic or ultrasound-guided diagnostic injection into the SI joint that relieves pain is the most reliable confirmation of the SI joint as the pain source.

Dr. Ghattas incorporates diagnostic injection as part of his evaluation when SI joint involvement is suspected.

• Physical therapy for pelvic stabilization and SI joint muscle support
• SI joint belts for temporary stabilization
• SI joint steroid injections for inflammatory cases
• Prolotherapy for ligament laxity
• Radiofrequency ablation of SI joint nerves
• Surgical SI joint fusion for severe refractory cases

Dr. Ghattas offers image-guided orthobiologic injection into the SI joint using fluoroscopic guidance to confirm accurate placement. For patients with SI joint ligament laxity, prolotherapy or platelet injection targeting the posterior SI ligaments provides a stabilizing biological stimulus to support ligament tightening.

The choice between intra-articular joint treatment and peri-ligamentous treatment is guided by the specific findings of your clinical and diagnostic evaluation, reflecting the individualized approach at Palm Beach Regenerative.

Superior cluneal neuralgia is a frequently misdiagnosed cause of low back and buttock pain, caused by entrapment or irritation of the superior cluneal nerves as they cross the iliac crest from the lumbar region into the buttock. It is often confused with lumbar disc disease, facet pain, or SI joint dysfunction.

Accurate diagnosis of superior cluneal neuralgia is an important competency at Palm Beach Regenerative, where Dr. Ghattas’s comprehensive approach to back pain evaluation ensures this condition is not missed. Give us a call to Request a Consultation.

The superior cluneal nerves are sensory nerves that originate from the lateral branches of the posterior rami at L1-L3 and travel over the iliac crest to supply sensation to the upper buttock and lower back. They can become entrapped as they pass through the osseofibrous tunnel at the iliac crest, producing a distinct pattern of localized low back and buttock pain.

• Localized pain at the posterior iliac crest and upper buttock
• A tender, often reproducible trigger point just below or at the posterior iliac crest
• Pain that radiates into the buttock and may extend into the upper thigh
• Symptoms that can mimic lumbar radiculopathy but without true leg radiation below the knee
• Pain worsened by prolonged standing, walking, or lumbar extension

• Entrapment of the nerve at the iliac crest fascia
• Prior lumbar or pelvic surgery
• Weight gain or iliac crest prominence
• Trauma to the posterior iliac region

The diagnosis is confirmed by a positive response to a diagnostic nerve block at the point of nerve entrapment at the iliac crest, administered under ultrasound guidance.

A careful clinical examination identifies the characteristic tender point and differentiates this condition from lumbar disc, facet, and SI joint pathology.

• Diagnostic and therapeutic nerve block at the iliac crest entrapment point
• Physical therapy for lumbar and hip flexor stretching
• Nerve hydrodissection to release entrapment
• Surgical nerve decompression in refractory cases

Dr. Ghattas uses real-time ultrasound guidance to identify the entrapment point of the superior cluneal nerves at the iliac crest and deliver targeted nerve hydrodissection with platelet preparations to reduce perineural inflammation and free the nerve from its constriction.

Accurately identifying and treating this condition when it is the true pain source avoids unnecessary lumbar procedures and provides targeted relief.

Calcific tendinitis of the shoulder occurs when calcium deposits form within the rotator cuff tendons, most commonly in the supraspinatus. These deposits can cause episodes of intense shoulder pain, particularly during the resorptive phase when the body attempts to break down and absorb the calcium.

At Palm Beach Regenerative, Dr. Ghattas uses ultrasound-guided needle barbotage combined with orthobiologic injection to directly address calcium deposits and support the tendon’s recovery. To learn more, reach out to us today.

Calcium deposits in the rotator cuff go through distinct phases: a formative phase with minimal symptoms, a resting phase, and a resorptive phase that can cause sudden, severe shoulder pain. Ultrasound imaging allows precise characterization of the deposit size, consistency, and phase, which guides treatment decisions.

• Acute episodes of severe shoulder pain, sometimes debilitating
• Pain that worsens with arm elevation or reaching overhead
• Night pain disturbing sleep
• Chronic, lower-grade aching between acute episodes
• Limited shoulder range of motion during painful episodes

• Not fully understood, but likely involves local tendon hypoxia and abnormal tissue repair responses
• More common in women and individuals aged 30 to 60
• Associated with repetitive overhead activities
• Metabolic conditions including diabetes and thyroid dysfunction

Shoulder X-ray clearly shows calcific deposits. Diagnostic ultrasound provides additional detail about deposit consistency (hard, soft, or paste-like) and exact location within the tendon. MRI may be used to assess the surrounding tendon health.

Ultrasound is particularly valuable because it guides treatment in real time.

• NSAIDs and pain medications during acute episodes
• Steroid injections into the subacromial space for pain relief
• Extracorporeal shock wave therapy (ESWT) to break down calcium deposits
• Ultrasound-guided needle barbotage: Needle disruption and aspiration of the calcium deposit
• Arthroscopic calcium removal for refractory cases

Dr. Ghattas performs ultrasound-guided needle barbotage to mechanically disrupt and aspirate calcium deposits, followed by injection of platelet preparation into the tendon to support the body’s healing response and promote healthy tendon remodeling.

This combined approach addresses both the calcium deposit and the underlying tendon health simultaneously, which is an important distinction from barbotage alone. The real-time ultrasound guidance confirms accurate needle placement within the deposit for every procedure.

Most back pain is not a single-structure problem, and treating it like one is why so many patients cycle through injections, therapy, and even surgery without lasting relief. At Palm Beach Regenerative, every back pain patient is evaluated through the lens of the Functional Spinal Unit (FSU), the complete biomechanical system responsible for your spine’s stability, movement, and pain signals. We identify every contributing structure, then treat precisely what needs treating, guided in real time by imaging.

Results vary. Not all patients are candidates. Dr. Ghattas will discuss realistic expectations for your specific condition.

The Functional Spinal Unit is the smallest segment of the spine that replicates the mechanical behavior of the entire spinal column. Each FSU consists of two adjacent vertebrae and all the structures that connect them: the intervertebral disc, paired facet joints, anterior and posterior ligaments, nerve roots, and the deep stabilizing muscles, particularly the multifidus. These structures do not work in isolation. When one fails, the others compensate and often become painful themselves.

This is why treating “the disc” alone, or blocking “the nerve” alone, rarely resolves chronic back pain. The disc may be the visible finding on MRI, but the facet joints, ligaments, and destabilized multifidus are equally involved in generating and perpetuating the pain. The FSU approach means we look at all of them.

Standard pain management targets the most visible finding on MRI, usually the disc. Epidural steroid injections dampen inflammation around the nerve, and discectomy removes the offending disc fragment. These approaches can help, and Dr. Ghattas will tell you honestly when they are the right choice. But for patients with chronic, recurrent, or multi-level back pain, single-structure treatment often provides temporary relief because it leaves the rest of the FSU, the facets, ligaments, and multifidus, untreated and unstable.

Each condition below has its own dedicated page. All are evaluated and treated within the FSU framework — meaning no condition is viewed in isolation. Click any condition to learn more.

Lumbar facet disease is one of the most common causes of chronic low back pain. The facet joints are small paired joints at the back of each lumbar vertebra that guide movement and bear a portion of spinal load. When they degenerate from arthritis or injury, they become a persistent and often underappreciated source of low back pain and stiffness.

At Palm Beach Regenerative, Dr. Ghattas addresses lumbar facet disease with image-guided orthobiologic injection as part of a comprehensive spine care approach that treats the entire lumbar spinal unit. Request a Consultation today by filling out our online form.

Each lumbar spinal level has two facet joints. Degeneration of these joints produces local low back pain that typically worsens with lumbar extension, prolonged standing, and twisting. The pain pattern from lumbar facet disease is distinct from disc-related pain and can be reliably identified through diagnostic medial branch blocks.

• Localized low back pain, often on one or both sides of the spine
• Pain that worsens with standing, arching backward, or twisting
• Morning stiffness that improves with movement
• Referred aching into the buttocks or upper thighs (not typically below the knee)
• Relief when sitting or bending slightly forward

• Age-related facet joint cartilage degeneration
• Prior lumbar injury or surgery creating accelerated facet wear
• Disc degeneration transferring more load to the facet joints
• Repetitive lumbar extension activities
• Obesity increasing lumbar mechanical load

Lumbar MRI or CT shows facet joint arthritis. Diagnostic medial branch nerve blocks, which temporarily numb the nerves supplying the facet joints, remain the most accurate method for confirming that the facets are the primary pain generator.

Dr. Ghattas uses this diagnostic approach to ensure orthobiologic treatment is directed at the correct pain source.

• Physical therapy for lumbar stabilization and load management
• NSAIDs for pain control
• Lumbar facet steroid injections for temporary relief
• Medial branch radiofrequency ablation for longer-term nerve denervation

Image-guided orthobiologic injection directly into the lumbar facet joints delivers platelet preparations to address the underlying arthritis driving the pain, rather than simply interrupting the pain signal.

This approach is part of a broader lumbar treatment plan that also addresses the associated disc degeneration, paraspinal ligament health, and muscle stabilizer function. Treating the whole lumbar unit is the Palm Beach Regenerative standard.

Pronator syndrome is a form of median nerve compression that occurs in the forearm, where the nerve passes through or beneath the pronator teres muscle. It is often confused with carpal tunnel syndrome because it produces similar hand symptoms, but the nerve compression occurs much higher up in the forearm rather than at the wrist.

Accurate diagnosis of pronator syndrome is an area where Dr. Ghattas’s neurological expertise directly benefits patients who have received prior misdiagnosis or inadequate treatment. Request an appointment with Dr. Ghattas via our online form.

The median nerve can become compressed at multiple sites in the forearm, including between the heads of the pronator teres muscle, beneath the flexor digitorum superficialis arch, or at the ligament of Struthers. The resulting symptoms include forearm pain with a median nerve distribution in the hand.

• Aching forearm pain, particularly with repetitive pronation activities
• Numbness and tingling in the thumb, index, and middle fingers similar to carpal tunnel syndrome
• Forearm fatigue with sustained grip or pronation
• No worsening of symptoms at night (distinguishes it from carpal tunnel syndrome)
• Tenderness over the pronator teres muscle in the proximal forearm
• Weakness of thumb opposition in more severe cases

• Hypertrophied or tight pronator teres muscle from repetitive forearm activities
• Throwing athletes, rowers, and manual workers
• Fibrous bands or anomalous muscle anatomy at the compression site
• Direct forearm trauma

Clinical examination, including direct pressure over the pronator teres with resisted pronation reproducing symptoms, is the primary diagnostic tool. Electrodiagnostic studies can localize median nerve compromise to the forearm level rather than the wrist. Ultrasound allows direct visualization of the nerve at the compression site.

• Activity modification and ergonomic adjustment
• Physical therapy for pronator teres stretching and strengthening
• Ultrasound-guided injection to the pronator teres for diagnostic and therapeutic purposes
• Surgical decompression in refractory cases

Dr. Ghattas uses ultrasound-guided nerve hydrodissection at the pronator teres, precisely separating the median nerve from surrounding tissue and delivering platelet preparations to reduce perineural inflammation.

Accurate diagnosis of the compression level is critical to this approach, and Dr. Ghattas’s combined neurological and interventional expertise ensures the correct site is targeted.

Frozen shoulder, or adhesive capsulitis, is a condition in which the shoulder joint capsule becomes inflamed, thickened, and scarred, causing progressive loss of shoulder movement and significant pain. It typically develops in three stages: a painful inflammatory stage, a freezing stage with progressive stiffness, and a thawing stage where motion gradually returns.

At Palm Beach Regenerative, Dr. Ghattas offers targeted orthobiologic treatment of the shoulder joint capsule to address the underlying inflammatory process, combined with BioMod protocols to support the recovery of shoulder mobility. If you’re suffering from frozen shoulder, contact our office right away.

The shoulder joint is surrounded by a flexible capsule that normally allows a wide range of motion. In adhesive capsulitis, this capsule becomes inflamed and contracts, restricting movement in all directions. The condition is more common in women, individuals over 40, and those with diabetes or thyroid conditions.

Without treatment, frozen shoulder can persist for two to four years. Targeted intervention can shorten this course significantly.

• Gradual onset of shoulder pain and stiffness
• Progressive loss of shoulder movement in all directions, particularly external rotation
• Pain that worsens at night
• Difficulty reaching overhead, behind the back, or across the body
• Aching that is present both at rest and with movement

• Idiopathic (no clear cause) in many cases
• Diabetes and thyroid disorders significantly increase risk
• Prolonged shoulder immobilization following injury or surgery
• Prior rotator cuff injury or shoulder surgery
• Cardiovascular disease and Parkinson’s disease have associations

Diagnosis is clinical: characteristic loss of both active and passive shoulder movement in all planes is the hallmark finding. MRI can rule out other pathology and assess the degree of capsular thickening and joint volume reduction.

• Physical therapy focused on capsular stretching and joint mobilization
• Intra-articular steroid injections for the inflammatory stage
• Hydrodilatation: Injection of fluid to distend and stretch the capsule
• Manipulation under anesthesia: Forcible release of the capsule under general anesthetic
• Arthroscopic capsular release for severe, refractory cases

Dr. Ghattas uses ultrasound-guided intra-articular orthobiologic injection to address the capsular inflammation driving frozen shoulder, combined with targeted needle fenestration of the contracted capsule to support its release and promote the body’s own remodeling response.

This is combined with a structured home stretching protocol and close follow-up to monitor the progression through the stages and adjust treatment accordingly. The goal is to significantly shorten the natural history of frozen shoulder and restore functional shoulder mobility.

Thumb osteoarthritis, also known as CMC (carpometacarpal) joint arthritis, affects the joint at the base of the thumb where it meets the wrist. It is a very common condition, particularly in women over 50, and can significantly interfere with gripping, pinching, and everyday hand activities.

For appropriately selected candidates, image-guided orthobiologic injection may help manage CMC joint pain and improve hand function without surgery. Give us a call to learn more.

The CMC joint is a saddle joint that allows the thumb its wide range of motion, including the ability to grasp, pinch, and oppose the other fingers. When the cartilage in this joint degenerates, the bones rub against each other, causing pain at the base of the thumb that worsens with use.

• Pain at the base of the thumb, especially with pinching or gripping
• Swelling and tenderness at the thumb-wrist junction
• Reduced grip and pinch strength
• A visible ‘bump’ or prominence at the base of the thumb
• Difficulty with activities like opening jars, turning keys, or writing

• Age-related joint degeneration (most common cause)
• Ligament laxity at the CMC joint
• Prior thumb injuries
• Repetitive hand use, including crafts, writing, and musical instruments
• Female sex hormone changes affecting joint ligament stability

X-ray imaging of the thumb clearly shows CMC joint space narrowing and the stage of arthritis. Clinical examination includes provocative grind and traction tests specific to the CMC joint.

Dr. Ghattas will review your imaging and functional limitations to determine whether orthobiologic treatment is appropriate.

• Thumb splinting to rest the CMC joint
• Hand therapy and joint protection strategies
• NSAIDs for pain control
• Steroid injections into the CMC joint for temporary relief
• Surgery (trapeziectomy or CMC joint replacement): For severe, refractory thumb arthritis

For patients with mild to moderate CMC joint arthritis, image-guided platelet injection delivered precisely into the CMC joint under ultrasound visualization may help reduce inflammation and support the joint environment.

These treatments do not regenerate cartilage but may help manage pain and improve hand function in appropriately selected patients. Results vary based on the stage of arthritis.

Myofascial pain syndrome is a chronic pain condition characterized by trigger points, which are hypersensitive knots within muscle tissue that cause local pain and referred pain patterns. It is one of the most common yet underdiagnosed sources of musculoskeletal pain, often overlooked in patients who have received negative imaging results.

At Palm Beach Regenerative, Dr. Ghattas addresses myofascial pain as part of a comprehensive treatment philosophy. Trigger point injections are a core component of the practice’s treatment toolkit, delivered with the same precision and follow-through that defines every aspect of care here. Schedule your appointment today.

A trigger point is a localized area of muscle contraction and hypersensitivity that produces predictable referred pain patterns when compressed. For example, trigger points in the upper trapezius muscle commonly refer pain into the neck, head, and behind the eye. These patterns are well-documented and allow an experienced clinician to identify the source of seemingly diffuse pain.

Myofascial pain commonly coexists with other conditions, including cervical disc disease, facet arthritis, and rotator cuff pathology, making a comprehensive evaluation essential.

• Localized muscle pain that is reproducible with pressure at the trigger point
• Referred pain in predictable patterns away from the trigger point itself
• Muscle stiffness, tightness, or limited range of motion
• Pain that worsens with sustained postures, stress, or poor sleep
• Headaches, jaw pain, or arm pain arising from cervical and shoulder trigger points
• Fatigue and disrupted sleep from chronic pain

• Repetitive muscle overuse or strain
• Poor posture, particularly from prolonged sitting or screen use
• Physical or emotional stress
• Prior muscle injury or trauma
• Underlying joint pathology creating compensatory muscle overload
• Nutritional deficiencies, including magnesium and vitamin D

Myofascial pain is diagnosed clinically through physical examination. Dr. Ghattas performs a systematic assessment of muscle groups to identify active trigger points and their referred pain patterns, correlating findings with your symptom history.

Imaging is used to rule out underlying structural pathology contributing to the muscle dysfunction.

• Physical therapy with manual release techniques and dry needling
• Stretching and postural correction programs
• Trigger point injections with local anesthetic
• Oral medications including muscle relaxants and anti-inflammatories

Trigger point injections at Palm Beach Regenerative go beyond a standard anesthetic injection. Dr. Ghattas uses precise needle placement into the active trigger point, with the option to incorporate platelet preparations to support the muscle’s healing response alongside the mechanical disruption of the trigger point.

These injections are part of a broader treatment plan. Unlike clinics that perform trigger point injections as a standalone procedure, Dr. Ghattas integrates them with a structured approach to the underlying postural, nutritional, and joint factors that perpetuate myofascial pain.

De Quervain’s tenosynovitis is a painful condition affecting the tendons on the thumb side of the wrist, where the abductor pollicis longus and extensor pollicis brevis tendons pass through a tight fibrous sheath. It causes pain and swelling at the base of the thumb and wrist, and is particularly common in new parents from repetitive lifting and in athletes involved in racket sports and golf.

Precise ultrasound-guided injection into the tendon sheath at Palm Beach Regenerative offers an effective, targeted approach for this common wrist condition. For more information, feel free to contact our practice.

The first dorsal compartment of the wrist contains two thumb tendons that pass through a fibrous tunnel. When this tunnel becomes thickened and inflamed, or when the tendons swell within it, movement of the thumb causes pain and crepitus at the radial wrist.

• Pain and swelling on the thumb side of the wrist
• Pain worsening with thumb and wrist movement
• A positive Finkelstein’s test: pain with the thumb tucked into the fist and the wrist bent toward the small finger
• Tenderness directly over the first dorsal compartment
• Crepitus with thumb movement in some cases

• Repetitive thumb and wrist pinching or gripping
• New parent lifting of infants (often called ‘mommy wrist’)
• Racket sports and golf
• Pregnancy and postpartum hormonal changes affecting tendon inflammation

The Finkelstein’s test and clinical examination are usually sufficient for diagnosis. Diagnostic ultrasound confirms tendon sheath thickening and allows precise sheath injection targeting.

Dr. Ghattas uses real-time ultrasound to confirm the needle is within the tendon sheath before injection, which is critical for treatment accuracy.

• Thumb spica splinting to rest the tendons
• Anti-inflammatory medications
• Corticosteroid injection into the first dorsal compartment: Highly effective when accurately placed in the sheath
• Surgical sheath release for refractory cases

Dr. Ghattas uses real-time ultrasound guidance to deliver targeted injection precisely within the first dorsal compartment tendon sheath. Rather than or in addition to steroid, concentrated platelet preparation addresses the underlying tendon and sheath inflammation, supporting the body’s natural recovery.

Accurate sheath placement under ultrasound guidance produces significantly better outcomes than blind injection, which has a high rate of peritendinous misplacement.