Date: Tue, 03 Jun 1997 20:51:17 -0800 From: family Subject: Knee crepitus Content-Length: 1107 I have a 38 year old female patient who has come in with lowgrade spinal complaints and a primary concern of increasing Right knee crepitus. She smokes, and weighs 180lbs. She has had some chronic low grade back pain with an Industrial low back strain 3 years ago at which time she was off work two weeks. She has some pelvic rotation and bilateral pronation of her feet. The right patella tracks somewhat laterally and on side lying abduction of the right leg - her leg will internally rotate. She has no significant pain even with stressing the knee or direct patellar pressure or derangement. Xrays appear WNL other than some lateral positioning of the patella. Other than adjusting the pelvis and addressing the pronation with orthotics, does anyone have any ideas? I have thought of using short foot and proprioceptive exercises using a wobble board. Any ideas of ms to stretch or strengthen? I assume that the crepitus is from the compressive forces on the articular cartilage from the lateral tracking patella. Any ideas or comments are appreciated. Dr. Bill Pfeifer -------------------- Date: Wed, 4 Jun 1997 19:11:03 -0400 (EDT) From: "Mark Wells, DC" Subject: knee Bill, I forgot to also mention isometric exercises for vastus medialis oblique, which strengthens and stabilizes patellar tracking. Have the patient sit on an adjusting table, affected leg extended on the table, non-affected on the floor. Put a cervical roll under her knee, have her dorsiflex her big toe towards her head, and put her index finger on her VMO. Then have her extend her leg and contract and hold her quads, feeling for a contraction of VMO. It is very difficult to contract the VMO, expecially if under developed. Hold 15-20 secs, relax 5 secs, repeat 10x. Do 1 set daily the first week, 2 the 2nd, and 3 the 3rd. Usually by the 3rd week, her symptomology will reduce, but strengthening continues for 3 more weeks. Like everything, compliance is key! Mark Wells, DC drhondo@erols.com Beltsville, MD ------------------------ Subject: Re: knee From: grsooleydc@juno.com (George R Sooley) Date: Thu, 05 Jun 1997 12:52:14 EDT On Wed, 4 Jun 1997 19:11:03 -0400 (EDT) "Mark Wells, DC" writes: >Bill, >I forgot to also mention isometric exercises for vastus medialis >oblique, which strengthens and stabilizes patellar tracking. > ..... To add, make sure that the pressure exerted on the cervical roll remains constant to prevent hip involvement (patients tend to exert more downward pressure when attempting to extend the knee. Pumping up a BP cuff a little and then monitoring the pressure helps the patient or you monitor this aspect. George R. Sooley Chiropractic Intern grsooleydc@juno.com --------------------- From: Cates & Jensen Subject: RE: knee Date: Thu, 5 Jun 1997 12:30:54 -0500 I use the same knee exercise and use a full paper towel roll to space the leg away from the table... if the patient is "squishing" the roll they need to hold the thigh up. The nice thing is that they can use the= same technique at home. Jeffrey R. Cates, DC, DABCO -------------------------- Date: Wed, 04 Jun 1997 19:18:37 -0800 Subject: Knee Crepitus Reply-To: family Thanks to all for help regarding knee crepitus. Has anyone used the Chondroitin Sulphate and Glucosamine Sulphate with any success? Bill Pfeifer DC -------------- Date: Thu, 5 Jun 1997 23:22:23 -0400 (EDT) Subject: Re: Knee Crepitus Reply-To: Berrins@aol.com In a message dated 6/5/97 11:11:49 AM, you wrote: <> Yes, Bill, I used it myself after a partial menisectomy a year and a half ago. The ortho told me I had Grade 3 cartilage degeneration in the patellar groove (saw it myself on the video during the operation). He "smoothed" it out, and after that I had some deep pain in that area. I began taking the glucosamine soon after, and it helped very quickly. I have had a few patients use it, and it's been succesful in decreasing pain in most cases. As for the knee crepitus problem, be sure to also check for two separate foot problems: Morton toe structure, and "flexor hallicus limitus". Both can lead to gait problems. Check out Travell and Simons 2nd trigger point book for a good explanation of the Morton toe structure problem (I believe in the gluteus medius chapter); the illustrations are illuminating. Flexor hallicus limitus is a theory developed by a podiatrist in New Hampshire. It's a bit complicated, and I haven't had a lot of experience working with it, but it's an interesting concept. Basically, his theory is that the big toe is a major pivot point for the body during gait. If the big toe is not dorsiflexing properly (and this may not be obvious by simply dorsiflexing the big toe during an exam), then the body compensates by flexing elsewhere; the mid foot (causing a dropped arch and possibly pronation), the knee, hip, or even the lower back, or any combination of the above. He has designed what he calls a "kinetic wedge" to be put under the metatarsal arch, usually in an orthotic. It's not the usual round lump found as a metatarsal support in most orthotics. If you are interested, as soon as I get some details, I'll let you know. In the meantime, K & E orthotics (I believe out of NY state) makes an orthotic with the kinetic wedge built in. I've been trying to find my information; during a recent back office reorg some of my information got misplaced. Drat!! Good luck with your patient-- -Roger B., D.C. ------------------------------- Date: Wed, 4 Jun 1997 15:59:28 -0400 (EDT) From: "Mark Wells, DC" Subject: Re: Knee crepitus Bill, I had that same scenario myself (minus the smoking), and aside from adjusting and orthotics, myofascial release and stretching of the quad muscles, really improved my condition rapidly. I live in an area of 3 level townhomes, and people are constantly complaining of pain and crepitus when using stairs. After improving their biomechanics, this protocol seems to be "the" key to improved function. Hopefully this helps! Good luck. Mark Wells, DC drhondo@erols.com Beltsville, MD --------------------- Date: Fri, 06 Jun 1997 05:20:57 -0500 From: "Noel A. Taylor" Subject: Re: Knee crepitus At 08:51 PM 6/3/97 -0800, you wrote: >I have a 38 year old female patient who has come in with .... Bill, my suspicion is that she has excess motion in one sacroiliac joint, best treated using SOT blocking and avoiding HVLA adjusting of the pelvis. Sounds like you're already on that track. Foot Leveler orthotics have shown some good results in stabilizing such problems, especially with indications in the feet such as you describe. Wobble board may be useful as well. So far so good. Beyond this, there _are_ some other things which can be done: 1) If you do not already incorporate checks for inequality of psoas/diaphragm and TFL/ITB tension, with soft tissue manipulation to correct these, you may wish to consider SOT protocol in this regard, as it is vital to stabilizing the Category II pelvic lesion. In addition, having the patient avoid hip flexion and external rotation on the side of the sacroiliac lesion, during daily activities, will assist in stabilizing that joint during the acute treatment phase. 2) Lateral tracking of the patella is often (especially with pelvic unleveling and obliquity) the result of unequal forces from the vastus musculature. If you find that the patient's right vastus medialis is weak, use of a rehab program with a Theraband or a bungee cord could be quite beneficial. This therapy involves repeated knee extension from the "neutral" position of 90 degrees of flexion to 45 degrees of flexion against the resistance of the band or cord, done while the leg and foot are held in external rotation. Once the vastus medialis "catches up" with the vastus lateralis, patellar tracking should be restored to normal. 3) A "trochanter belt" or sacroiliac stabilization belt may be required if there is hypermobility which proves refractory to the other care indicated above. The only belt I've seen which is firm enough to provide adequate stabilization during regular activity is vendored by Serola Biomechanics. 4) While smoking cessation would be ideal, with or without it this patient needs nutritional support during the acute phase (usually 6-8 weeks for the ligaments). I use Vitamin C at 3 grams/day; Vitamin E at 200 i.u./day of d-alpha tocopherol or up to 800 i.u./day if using the alpha, gamma, lambda, and other mixed natural tocopherols with the d-alpha; a good multi-vitamin/mineral daily; and glucosamine sulfate (500 mg b.i.d.). 5) Little known and contrary to normal instruction at chiropractic colleges ("there are no muscles that originate and insert directly across the sacroiliac joint") but clearly described in Gray's Anatomy is the presence of a small portion of the iliacus muscle inserting onto the posterior aspect of the sacral base. Leg lowering exercises (patient supine, hips at 90 degrees flexion with knees not bent, both legs slowly lowered to 45 degrees flexion and then returned to 90, three sets of 10 reps twice daily) not only firm up the lower abdominal musculature for a more stable lower lumbar spine but synergistically exercise this portion of the iliacus at about 30% force, providing further stabilization of the SI joint. 6) In cases of pelvic instability which are refractory to all of the above, Category II cranial sutural protocol is indicated, and often produces rapid resolution of instability in a sacroiliac joint. If you have any questions regarding details of or references for these protocols, I'll be happy to respond further. Best wishes to you and your patient! --Noel ------------------------------- Message-ID: <33982C00.3DBF@ptialaska.net> Date: Fri, 06 Jun 1997 07:25:52 -0800 From: family Subject: Re: Knee crepitus Noel A. Taylor wrote: > Bill, my suspicion is that she has excess motion in one sacroiliac joint, > best treated using SOT blocking and avoiding HVLA adjusting of the pelvis. How do you go about making this determination? > !) If you do not already incorporate checks for inequality of > psoas/diaphragm and TFL/ITB tension, with soft tissue manipulation to > correct these, you may wish to consider SOT protocol in this regard, >as it is vital to stabilizing the Category II pelvic lesion. More information on this would be helpful. > 2) Lateral tracking of the patella is often (especially with pelvic > unleveling and obliquity) the result of unequal forces from the vastus > musculature. If you find that the patient's right vastus medialis is weak, > use of a rehab program with a Theraband or a bungee cord could be quite > beneficial. This therapy involves repeated knee extension from the > "neutral" position of 90 degrees of flexion to 45 degrees of flexion against > the resistance of the band or cord, done while the leg and foot are held in > external rotation. Once the vastus medialis "catches up" with the vastus > lateralis, patellar tracking should be restored to normal. This sounds like a good idea. Is this done sitting? > 3) A "trochanter belt" or sacroiliac stabilization belt may be required if > there is hypermobility which proves refractory to the other care indicated > above. The only belt I've seen which is firm enough to provide adequate > stabilization during regular activity is vendored by Serola Biomechanics. Do you have a phone # or an address for these? Do you use them to supply other supports or are they a single item vendor? > 6) In cases of pelvic instability which are refractory to all of the above, > Category II cranial sutural protocol is indicated, and often produces rapid > resolution of instability in a sacroiliac joint. I have absolutely no knowledge of cranial work. could you give me some information? Also does this really seem to work for those who are using it? What is the mechanism? Is it just an extension of the occipital-sacral pumping mechanisms of CSF, and a stagnation theory? BILL Pfeifer DC ---------------------- Date: Fri, 06 Jun 1997 13:17:48 -0400 To: "Noel A. Taylor" From: vonder@netonecom.net (JERRY VONDERHARR) Subject: Re: Knee crepitus >3) A "trochanter belt" or sacroiliac stabilization belt may be required if >there is hypermobility which proves refractory to the other care indicated >above. The only belt I've seen which is firm enough to provide adequate >stabilization during regular activity is vendored by Serola Biomechanics. I've had excellent results with the belt by Leander. Jerry Vonderharr, DC ----------------------- Date: Fri, 6 Jun 1997 12:40:04 -0700 From: dcarpent@orednet.org (Nancy Carpentier) Subject: Re: Knee crepitus >> 2) Lateral tracking of the patella is often (especially with pelvic >> unleveling and obliquity) the result of unequal forces from the vastus >> musculature. If you find that the patient's right vastus medialis is weak, >> use of a rehab program with a Theraband or a bungee cord could be quite >> beneficial. This therapy involves repeated knee extension from the >> "neutral" position of 90 degrees of flexion to 45 degrees of flexion against >> the resistance of the band or cord, done while the leg and foot are held in >> external rotation. Once the vastus medialis "catches up" with the vastus >> lateralis, patellar tracking should be restored to normal. OK, I may be wrong, but it is my understanding that vastus medialis strengthening is best done in the last 10 degrees or so of extension. Let me quote from Kessler & Hertling MANAGEMENT OF COMMON MUSCULOSKELETAL DISORDERS, PT PRINCIPLES & METHODS (the management of patellar tracking dysfunction section) There are few patients with patellar tracking dysfunction who do not respond satisfactorily to a well-designed and appropriately instituted conservative treatment program. Common causes of failure include (1) inadequate restriction of activities in the early stages of treatment or (2) inadequate or inappropriat quadriceps strengthening. Typical faults include 1. Resisting through too geat an arc of movement. Only the terminal 5-10 degrees of extension should be resisted; resistance to kene extension applied at greater ranges of flexion causes excessive patellofemoral compression stress and may perpetuate the problem. **** Nancy K. Carpentier, DC, DABCO **** ****** AKA: dcarpent@orednet.org ******* ------------------ Date: Sat, 7 Jun 1997 07:36:33 -0400 (EDT) Subject: Re: Knee crepitus Reply-To: LHBWeitz@aol.com Noel, Knee extensions with the feet turned out do not recruit the medialis any more than the lateralis. Recent research has dispelled this misperception. See: Signorile JF, Kwiatkowski K, Caruso JF, Robertson B. Effect of foot position on the electromyographical activity of the superficial quadriceps muscles during the parallel squat and knee extension. J of Strength and Conditioning Research. 1995; 9(3): 182-187. Ben Weitz, D.C., C.C.S.P. LHBWeitz@aol.com -------------------------------- Date: Sat, 7 Jun 1997 07:48:04 -0400 (EDT) Subject: Re: Knee crepitus Reply-To: LHBWeitz@aol.com Noel, This is truly amazing--what imaginations chiropractors have! All this stuff just from the information that a patient has some clicking in her knee. Imagine if this patient were to explain to an orthopedist that whe went to a chiropractor because she had some clicking in her knee and he treated her with the following: 1. SOT blocking 2. Foot leveler orthotics 3. Wobble board training 4. Soft tissue manipulation 5. Avoid hip flexion and external rotation 6. Knee extension exercises 7. Trochanter belt 8. Stop smoking 9. Vit C, E, Carotenoids, Multivitamins, Glucosamine sulphate 10. Leg lowering exercises 11. Cranial work The orthopedist would think the DC was nuts. Wow! Imagine what the treatment would be if this patient came in with something wrong with them! Ben Weitz D.C., C.C.S.P. LHBWeitz@aol.com ------------------- From: Ed Merrifield To: LHBWeitz@aol.com Subject: Re: Knee crepitus Date: Sat, 07 Jun 1997 08:30:56 -0400 Ben, I also disagree with some of the ideas presented for "helping" crepitus, but I'm glad they were posted. This little round of posts showed a mailing list at its best. DCs were trying to help other DCs by giving advice that may or may not work for an individual patient. The important part is they were sharing in a positive, non threatening way. As for those who expect every post here to be approved by every guidelines committee in existence --- well, if they can't take a joke... ------------------------- Date: Sun, 08 Jun 1997 15:16:42 -0500 From: "Noel A. Taylor" Subject: Re: Knee crepitus At 07:48 AM 6/7/97 -0400, you wrote: >Noel, > >This is truly amazing--what imaginations chiropractors have! All this stuff >just from the information that a patient has some clicking in her knee. > Imagine if this patient were to explain to an orthopedist that whe went to a >chiropractor because she had some clicking in her knee and he treated her >with the following: > >1. SOT blocking >2. Foot leveler orthotics >3. Wobble board training >4. Soft tissue manipulation >5. Avoid hip flexion and external rotation >6. Knee extension exercises >7. Trochanter belt >8. Stop smoking >9. Vit C, E, Carotenoids, Multivitamins, Glucosamine sulphate >10. Leg lowering exercises >11. Cranial work > >The orthopedist would think the DC was nuts. Wow! Imagine what the >treatment would be if this patient came in with something wrong with them! Ben: If there were no objective findings and all these items were in the treatment plan, the DC would, as you say, "be nuts." However, you'll note that my recommendations are all (excepting the reported smoking habit) connected with proposed or stated objective findings much more specific than "clicking in the knee." A sequence of possible clinical findings connected with appropriate treatment protocols is hardly, as you suggest, imagination. It's simply a series of answers to the original question asked, given from the perspective of my own clinical experience. This is what the doctor requested, and what he received, not only from me but from many other members of this list. >Knee extensions with the feet turned out do not recruit the medialis >any more than the lateralis. Recent research has dispelled this >misperception. > >See: Signorile JF, Kwiatkowski K, Caruso JF, Robertson B. Effect of foot >position on the electromyographical activity of the superficial quadriceps >muscles during the parallel squat and knee extension. J of Strength and >Conditioning Research. 1995; 9(3): 182-187. I'll be interested to see if Signorile et al provide a record of methods and data which truly "dispelled this misperception" regarding knee extension. The title sounds promising. However, having witnessed the vastus musculature changing from an unequal state to an equal one during knee extension therapy with external rotation of the foot and leg, in every patient with relative v. medialis weakness to which this had been applied, I am not likely to change my treatment protocol for the related condition until I find a better one, Signorile's electromyography not withstanding. The literature is replete with examples of therapy modalities which work quite well, are found to not work for exactly the reasons originally supposed, and then found to produce the results seen from the approach used, via some other mechanism. The specific chiropractic spinal adjustment is only one such example. Clinical science is nonetheless still science. I trust that no one on this list suggests that each of us give our clinical experience and observations less value than published research, as we all work to refine our own, and our profession's, understandings of neurophysiological processes. I also trust no one expects those of us involved the exchange of clinical observations to refrain from doing so on this list. Otherwise, I might be reminded of the infomercials on lubrication those products that allow people to race their vehicles after the oil is drained, and the opportunity to conclude from these displays that purchasing this product and then driving one's vehicle without oil is an appropriate protocol. --Noel ---------------------------------- Date: Sun, 8 Jun 1997 19:03:22 -0400 (EDT) To: nataylor@hsonline.net, chirosci-list@silcom.com Subject: Re: Knee crepitus Reply-To: LHBWeitz@aol.com Noel, I agree that clinical observations are often quite helpful, esp. where there is limited research. I am not suggesting that you stop offering your often interesting clinical insights and pearls on patient diagnosis and treatment. However, it is very easy to fool ourselves that what we do works since many of the conditions we treat have a tendency to resolve by themselves, such as back pain. Therefore, I feel that we should give more weight to published research, esp. if it is good solid research (RCTs) that has been repeated, than to our our clinical experience. We should constantly alter our protocals based on new research. Clinical experience may be all we have to go on in certain areas. But we should as much as possible based what we do on scientific studies. What really got my hair to stand up on this topic is that we shouldn't be treating someone for knee crepitus in the first place unless there is pain or some functional limitation. This is the equivalent of treating someone for scoliosis or DJD or spondylolisthesis in the absence of pain or functional deficits. Ben Weitz, D.C., C.C.S.P. LHBWeitz@aol.com ---------------------------- To: LHBWeitz@aol.com Date: Sun, 8 Jun 1997 23:39:16 -0400 Subject: Re: Knee crepitus From: docdaniel@juno.com (Daniel A. Shaye-Pickell) Ben: A comment on your comment: >What really got my hair to stand up on this topic is that we shouldn't be treating someone for knee crepitus in the >first place unless there is pain or some functional limitation. This is the equivalent of treating someone for >scoliosis or DJD or spondylolisthesis in the absence of pain or functional deficits. Hm, here I have to disagree strongly. Scott Banks, DC, FICC starts his scoliosis lecture with a question: "Is scoliosis painful?" I remember that question, because I stuck up my eager little hand and piped up, "Yes!" Wrong. It is rarely (except in the cases with serious associated pathology) painful- thus, the difficulty motivating youngsters to comply with treatment protocols. The problem with scoliosis is PROGRESSION RISK, i.e. the likelihood that the curve magnitude will increase. Adolescents who have high progression risk should be treated, REGARDLESS of lack of pain or functional limitations, because of the likelihood that in the future their function will be negatively impacted. So, I agree that we need to be cautious treating problems that we ourselves define; however, scoliosis might not have been the best example to choose. Dr. Daniel A. Shaye-Pickell, Chiropractic Physician Performance Chiropractic, LLC (R) -------------------------- To: LHBWeitz@aol.com Date: Sun, 8 Jun 1997 23:50:08 -0400 Subject: Re: Knee crepitus (and Scoliosis) From: docdaniel@juno.com (Daniel A. Shaye-Pickell) One addendum on treating high progression risk (scoliosis) adolescents: The next logical response to my previous post is, "There exists no good evidence that chiropractic interventions alters the course of scoliosis progression!" I, and Dr. Banks, might agree; however, our protocols may be less invasive, and less expensive, than traditional medical intervention. The responsible answer seems to be, that if a kid's at high risk for progression, that doing something that at worst will deplete a few dollars and have no effect is a worthwhile risk, so long as the patient is informed that there are no guarantees. If I remember correctly, the traditional medical interventions don't have good outcomes either! And yes, if we have no efficacy, then doing nothing at no charge is better than doing something with a financial impact. Which is where research begins... but, until that research is in, I find it justifiable that we offer hope, and our best efforts to do some good. Not just to turn a buck, but to try and help. If the research later says that we wasted our time, then so be it; and I won't continue ineffective interventions. But I won't wait on that research, provided that my interventions make logical sense and are unlikely to cause harm. Dr. Daniel A. Shaye-Pickell, Chiropractic Physician Performance Chiropractic, LLC (R) -------------------------- Date: Sun, 08 Jun 1997 21:46:45 -0500 From: "Noel A. Taylor" Subject: Re: Knee crepitus >What really got my hair to stand up on this topic is that we shouldn't be >treating someone for knee crepitus in the first place unless there is pain or >some functional limitation. This is the equivalent of treating someone for >scoliosis or DJD or spondylolisthesis in the absence of pain or functional >deficits. Ben: I'm glad you brought up this idea. Since an earlier post of yours postulated reaction from orthopedists, let me share the apparent orthopedic standard of care for scoliosis here in Indiana. Remember that 16 year old patient of mine who progressed from 20 to 37 degrees under orthopedic "care" with the doctor advising the parents that there was nothing to worry about and no need for any kind of treatment? The orthopedist never did bone age evaluations, yet he stated that the curve would not progress further. (It did progress.) When the parents sought my care for their daughter, the orthopedist suddenly referrred her to the number one pediatric orthopedic surgeon at Riley Childrens Hospital in Indianapolis, who upheld the referring orthopedist's opinion, again without determining bone age. This was a patient with a number of symptomatic complaints related to her condition, all of which responded quite nicely to chiropractic care. When I submitted a left hand film for comparison to Greulich & Pyle, the bone age came back as more than 14 years 6 months and less than 16 years, with the comment that there was still plenty of time for curve progression (this from the chiropractic profession.) Medical standards of care in any other state include left hand film, plus supine left- and right- bending films, to determine bone age and maximum potential for curve reduction. Yet these medical doctors, including the top man in the field in this state, ignored these well established standards. I suspect that this type of medical negligence is hardly what you intended to set as a standard for us to honor, in your original post; yet it and similar actions are repeatedly demonstrated everywhere I turn. Chiropractic has a good track record in the management of juvenile "ideopathic" scoliosis, with and without patient symptoms. I hope you are not suggesting in your comment above that such conditions should be untreated unless symptomatic. Perhaps you could explain your comment more thoroughly, including rationale for not rendering preventative care in DJD and degenerative spondylolisthesis as well. Also please comment upon the apparent possibility of recommendations to withhold nutritional adjunctive treatment in asymptomatic DJD, and correlate this with recent published research on glucosamine sulfate. --Noel --------------------------------- Date: Sun, 8 Jun 1997 23:24:51 -0400 (EDT) To: nataylor@hsonline.net, chirosci-list@silcom.com Subject: Re: Knee crepitus Reply-To: LHBWeitz@aol.com Noel, Show me one randomized clinical trial that shows that chiropractic care has any significant effect on the progression or regression of adolescent scoliosis. Show me one RCT that demonstrates that chiropractic care can affect degenerative spondylolisthesis or DJD. Yes, I know about the rabbit studies that show that immobilized cartilage degenerates and that chiro mobilization of joints will keep the necessary motion in otherwise hypomobile joints. It's an interesting speculation that chiro care may decrease the severity or likelihood of DJD of the spine. However, this is only an interesting speculation. Glucosamine sulfate has not yet sufficiently been demonstrated to result in joint regeneration--only in decreased pain in patients with osteoarthritis of the knee. No studies have ever shown that it will affect osteoarthritis of the spine. Probably worth a try for your patients, provided that they can afford it and know that they very well may be throwing their money away. But you certainly can't tell your patients with any certainty that glucosamine will have any effect. Ben Weitz, D.C., C.C.S.P. LHBWeitz@aol.com ---------------------- Date: Mon, 9 Jun 1997 10:52:56 -0400 (EDT) From: "Stephen Perle, DC" To: LHBWeitz@aol.com Subject: Re: Knee crepitus On Sun, 8 Jun 1997 LHBWeitz@aol.com wrote: > Show me one RCT that demonstrates that chiropractic care can > affect degenerative spondylolisthesis or DJD. Yes, I know about the rabbit > studies that show that immobilized cartilage degenerates and that chiro > mobilization of joints will keep the necessary motion in otherwise hypomobile > joints. Dr. Weitz is has extrapolated from rabbit studies a bit. I have an extensive collection of studies on the effects of immobilization on cartilage. The studies (not all done on rabbits, a lot on dogs) have shown that immobilization results in atrophy not degeneration of the cartilage and GAGs become soluble. Although this is often used in research as the animal model for DJD it is not DJD but atrophy. Second I am not aware of any studies that show that adjustments (manipulation) has any effect on hypomobile joints. I believe at this time we can say that manipulation may move a joint but I do not believe that we have the data to support the conclusion that we move hypomobile joints or that we have been able to find clinically significant hypomobile joints. If you know of any studies I would be appreciate the citation, for I do believe that is what we do but... Stephen M. Perle, D.C. Assistant Professor of Clinical Sciences University of Bridgeport College of Chiropractic Bridgeport, CT 06601 ______________________________ Date: Thu, 15 May 1997 16:04:08 -0400 Sender: AMSSMNET From: Ian Shrier Subject: knee pain in 22 yo female I have a 22 y.o. female patient who complains of a 5 year history of = knee pain. The history is suggestive of a meniscal tear because she had = a locked knee for over 12 hours the first time, and continues to have = similar episodes although they last only minutes. Her pain occurs = whenever she runs for over 25-30 minutes, and prevents her from = continuiingto run or play soccer. Full squats do not hurt, but she will = have pain getting up from the squat. The pain is usually located over = the lateral aspect of the knee, but can also be located over the medial = or anterior aspect. During my physical exam though, the only thing to = reproduce the pain was mobilization of the proximal fibular head. = McMurray and Appley tests were negative and there was no ligamentous = instability nor signs of current patello-femoral syndrome. The pain = persists despite physiotherapy and strengthening of the hamstrings, and = quadriceps, and stretching of ITB. Before she became my patient, she has = already had a normal x-ray, bone scan (to rule out stress #), and MRI = (for meniscal lesion). My impression is that she has a subluxing fibular = head with mild compensatory patello-femoral syndrome. My question is, do you think this is likely to be a subluxing fibular = head or a meniscal tear? Is it worth exploratory surgery? Even if = exploratory surgery is advisable, do you have any other suggestions for = conservative treatment for a patient who really doesn't want to have an = operation? Ian Shrier ---------------------------- Date: Sat, 17 May 1997 10:07:20 +1200 Sender: AMSSMNET From: I Bell Subject: Re: knee pain in 22 yo female I have a 22 y.o. female patient who complains of a 5 year history of knee pain. .. My impression is that she has a subluxing fibular head with mild compensatory patello-femoral syndrome. My question is, do you think this is likely to be a subluxing fibular head or a meniscal tear? Is it worth exploratory surgery? Have you tried taping strapping the fibular head either in an anterior or posterior direction according to your examination findings? Simple, cheap and may be diagnostic. Ragards, Iain Bell, MB ChB Timaru, New Zealand ------------------------- Date: Thu, 5 Jun 1997 13:15:49 -0400 (EDT) Subject: re: treating crepitus Reply-To: LHBWeitz@aol.com I don't feel that crepitus is a complaint that warrants any concern or treatment. When not associated with pain or loss of knee function, crepitus should be treated like a normal variant--leave it alone. It has not been shown to be associated with increased knee degeneration or loss of knee function, despite the untested common perception that it is caused by chondromalacia. Ben Weitz, D.C., C.C.S.P. LHBWeitz@aol.com ----------------------- Date: Fri, 06 Jun 1997 08:02:19 -0800 From: family Subject: Re: treating crepitus LHBWeitz@aol.com wrote: > I don't feel that crepitus is a complaint that warrants any concern or > treatment. .... I would like some clarification, has it been proven not to be associated with any knee dysfunction or precursor of DJD etc., or has there been no srudies done. If studies were done do you have some cites? If no studies have been done, why would you favor a "normal variant" position over one that would look to biomechanical changes and exercise deficiencies as a potential cause. Especially if others have made changes to similar patients that eliminated the crepitus. I would agree that some minor intermittent crepitus is nothing to worry about. But this is unilateral and is repetative, intense, "gravel truck unloading" type of crepitus. (I don't know if there is a scientific rating scale for crepitus?) There is also laterality to the patella. I am also reminded of the patient I recently had who was in her 60's. She came in with no pain but had a funny gate that friends had noticed and suggested she get checked. Her gait was odd because she had a, 10 degree plus, Valgus distortion to her lower leg caused by a completely degenerated knee. We sent her to an orthopedist who concurred that she needed a complete knee replacement but was hesitant to intervene since she had no pain. Could this woman had been helped if biomechanical stresses were altered early in her life? Obviously we don't know that answer, and all the exercises at this point are likely futile. I am not trying to be critical and raise flames, but, I am truly curious about your thought process on this one. While certain treatment for anything is not the answer, being to quick to jump on the "normal variant" bandwagon isn't always the answer. Many medical radiologists would classify everything we deal with as "normal variants". Thanks, Bill Pfeifer DC ---------------------- Date: Thu, 5 Jun 1997 17:04:50 -0500 (CDT) To: LHBWeitz@aol.com From: bbleck@escape.ca (Brian E. Lecker) Subject: re: treating crepitus Dear Ben: Well said. If there's no pain and no interference of function I'd leave it alone.I've got two real noisy knees, no symptoms and have run 5 full marathons(slowly but not knee related).Of interest, there are some D.C.'s that consider and treat spontaneous spine cracking (cavitation) as a condition.While these patients are asymptomatic to begin with, many eventually develop symptoms! I guess the bottom line is: no pain ;no impediment of function;no underlying pathology.......make note of it.....then leave it alone.A good example is the number of patients that I've seen with painless crepitus in their TM Joints who've had their bites altered; teeth ground; splints and what look like dog muzzles prescribed. In the end ,they still have the crepitus; some now are symptomatic; and all are a little lighter in the pocket books. Brian E. Lecker, D.C. Winnpeg,MB. --------------------------- Date: Sat, 7 Jun 1997 18:56:43 -0500 (CDT) To: grsooleydc@juno.com (George R Sooley) From: bbleck@escape.ca (Brian E. Lecker) Subject: Re: treating crepitus Dear George: If there is a dysfunction,an impairment of functionality, with or even without pain, then I'd concure that treatment should be considered. My advise however is do not fall into the trap of treating non-conditions such as painless crepitus that has not and is likely not to impede function.Many of us have learned the hard way that 'if it ain't broke, don't try to fix it'.As well and please take this with a grain of salt, I'm not sure there is a typical allopathic way of thinking.There are good allopaths... bad allopaths....good chiro's.....and..... have a nice SATURDAY NIGHT! Brian E. Lecker,D.C. bbleck@escape.ca