Milk and osteoarthritis

A glass of milk a day may delay knee osteoarthritis in women

KNEE OSTEOARTHRITIS CURRENTLY has no cure but new research shows that drinking milk every day has been linked to reduced progression of the disease.

Publishing their results in the American College of Rheumatology journal Arthritis Care & Research, researchers say while their findings show that women that regularly drank fat free or low fat milk experienced delayed progression of knee osteoarthritis (OA), those who ate cheese regularly actually experienced an increase in progression of the disease.

They also note that their findings are not applicable to men and that yoghurt did not affect OA progression.

The Centres for Disease Control and Prevention (CDC) say that OA, which is characterized by degeneration of the cartilage and its underlying bone in a joint, is believed to result from “mechanical and molecular events in the affected joint.”

The study authors say milk consumption has been acknowledged as playing an important role in bone health, but until now, its role in the progression of knee OA as been unknown.

Dr. Bing Lu from Brigham & Women's Hospital in Boston, Massachusetts and colleagues conducted the largest study to date to investigate the effect of dairy consumption on progression of knee OA.

A total of 2,148 individuals with knee OA were used as part of the osteoarthritis initiative. After collecting dietary information at the start of the study, investigators measured joint space between the medial femur and tibia of the knee with X-ray, to assess progression of OA.

Subjects for the study included 888 men and 1260 women, all of whom were followed up at 12, 24, 36, and 48 months, and the team notes that milk consumption was evaluated with a Block Brief Food Frequency Questionnaire

The researchers found that, in women as milk intake was increased (from none to less than 3, 4-6 and more than 7 glasses per week), the joint space width decreased (by 0.38 mm, 0.29 mm and 0.26 mm respectively).

Though obesity has been cited as a risk factor for knee OA the researchers say their results remained, even after adjusting the body mass index.

Additionally, they say there was no association between milk consumption and joint space width decrease in men.

The study showed that women who consumed cheese showed increase progression of OA, Dr. Li said that the high saturated fat acid in cheese could be to blame as recent study reported that increased consumption of saturated fatty acids was associated with an increased incidence of bone marrow lesions which may predict knee OA progression.

(source: Osteopathy Today May 2014)

White finger syndrome

Do you ever suffer from a white finger, fingers or toes?
It could be something called Raynauds syndrome. 

Raynauds syndrome is a condition where the blood vessels temporarily spasm, resticting the blood flow to the area supplied. This results in a white change in the tissues.  It is normally somthing that is very short lived and can be linked with cold temperatures or sometimes stress.  If there is no underlying reason for this phenomenun to occur it is known as 'primary' Raynauds.

The other type of Raynauds is known as 'secondary' and this is when the changes in the blood vessels occur in conjunction with another health condition.  Most of these cases are linked with immune conditions where the body attacks healthy tissue, however occaisonlly when a pateint has a trapped nerve you can get a similar change in the tissues.

There is a condition called thoracic outlet syndrome (TOS) where arteries, veins and nerves can become compressed in an area located around the collar bone and 1st rib.  Tight muscles, a problem with the ribs and certain habital postures adopted by people can compress this space and lead to symtptoms.

Because the nerves are compromised with the TOS this can be a trigger for the spasm which in turn leads to Raynauds.  Twice this week in clinic we have seen this phenomenon due to TOS. 

A clicky knee?

A common query and worry from patients is the occurrance of clicking in the knee.

There can be three explantions for this:

The first is when tendons and ligaments flick over a bony prominence they sometimes produce a clicking sensation.  This is completely normal and should cause no discomfort.

The second is due to the location of the patella (knee cap).  The patella is held in place by a shallow groove on the femur (thigh bone) and also the muscles of the thigh (the quadriceps).  If the muscle contraction on one side is stronger then the other the patella can articulate in a different part of the femur bone creating a click. This can cause pain and overtime creates wearing of the wrong part of the patella. 

The third reason is the more serious which is because of breakdown of cartilage.  There are two main areas of cartilage in the knee.  There is cartilage around all articulating surfaces of the knee, which is shown in blue on the picture below and the menisci of the knee, also shown on the picture below.

The menisci have several functions in the knee.  They act as shock absorbers and aid in health of the joint by helping with the nutrition and lubrication of the joint.

Menisci have no nerves so when they are damaged strictly speaking there is no pain.  In reality there is likely to be pain as other structures such as muscles, ligaments or the capsule may well be involved.  Unfortunately they also have poor blood supply so when the menisci are damaged and torn the healing rate is poor. 

When you come to the clinic with knee pain we often ask if there is any swelling, locking, clicking or giving way. Yes to more then one of these questions can strongly suggest to us you may have developed a tear in part of your menisci.

Tears can occur normally through an injury involving some flexion and rotation of the knee.  It maybe gradual or traumatic.

There are two types of tear depending on how they develop: a bucket handle tear and a radial tear.

Some meniscal tears settle with conservative treatment and are helped with strengthening the knee afterwards.  Depending on the severity, others however do not settle and need to be assessed by a surgeon. 

Painful shoulder?

A problem in the shoulder

Many patients will attend the clinic with shoulder pain as their main presentation. A number of problems can occur in the shoulder as it is a complex joint that we can put a lot of stress on.

Having ruled out the pain the patient has as definitely coming from the shoulder, and not referred from anywhere else such as the neck, we start to examine the different tissues and discover the source of the pain. 

 

 

As you can see from the picture there is a lot going on in the shoulder joint!

 

A very common problem is damage to part of your rotator cuff mechanism and that's what we will concentrate on in this blog.

 

Because the shoulder is such a mobile joint we have the normal supporting structures such as the ligaments and bony structure but there is a special set of muscles called the rotator cuff.  This cuff is made from four muscles that form a cuff around the shoulder joint therefore increasing its stability. 

 

Damage to these muscles can occur suddenly through an injury such as forcing your arm out to the side for example slipping on the stairs whilst holding onto the banisters. More often through these muscles become damaged slowly over time as part of the natural degenerative process.  Because the muscle on the top of the shoulder blade, the supraspinatus, has quite a poor blood supply this process tends to affect this muscle more so.  See the below image.

 

 

 

 

Treatment can help depending on the severity of the damage.  Often night pain is common and patients describe a throbbing pain that keeps them awake.

 

A lot of the rehabilitation with shoulder problems comes down to the same word again...posture!

 

If these muscles are under stress because of something you do then the damage will not get better.  Often sleeping position can be the culprit where people place their hands under the pillow or over the head.  

 

Rehabilitation often consists of graded exercises to strengthen the muscle to allow return to function once again.



Degenerative Disc Disease

Having attended the NSpine 2013 conference last week we came away with a mass of updated information regarding low back pain, surgical techniques, new research and procedures available to our patients.  It was fantastic to be listening to the same speakers as some of the most highly regarded surgeons in the world.

A lot of the talks focussed on degenerative disc disease (DDD) which is what this blog will be about.

Discs can degenerate for a number of reasons but unfortunately there is a strong genetic link. You are at higher risk of low back pain if you have a family history of DDD.

In DDD, it is thought that the discs dehydrate leading to a reduction in pressure in the discs.  This allows the disc to be more vulnerable to stress, therefore creating tears in the annulus. As a result rotation is very poorly controlled in the damaged segment. In turn this means the facet and capsule, that is attached to the facet hypertrophies, (becomes larger).  The next stage is then osteophyte formation which is the bodies attempt to re-stabilise the area. 

As part of this process if there is enough material in the centre of the disc and it 'leaks' out through theses tears this material can press on a nerve root leading to nerve compression.

All in all this can present clinically as low back pain with or without leg symptoms. It can be a chronic problem where people have pain for many years. 

One option to help DDD maybe surgery where the spinal consultants perform a fusion. (see image below).  Here they remove the interverbral disc and take a piece of bone, normally from your iliac crest/'hip' bone to use instead.  They place this part of bone where the disc was and use a system of screws and metalwork to hold it in place.  The end result is a 'fused' segment or segments depending on how many discs are affected.  The range of movement is lost at that segment but nearly normal mobility remains due to the movement in the rest of the spine and hips.

 

 

This unfortunately has only a 60% success rate with one in four patients having some remaining pain and/or disability after.  Often and particularly depending on the patients general health, the surgeons would prefer not to operate as the function, indicated by daily activities the person performs, one year after surgery is equal to the group of patients who had only conservative management ie./ manual therapy. 

Stress-the cause of pain?

We are often asked if the source of a patient's problem could be stress related?

The word 'stress' is open to interpretation and is often assumed to be negative whereas in actual fact some stress is essential to daily life or we would have no urgency to complete any tasks. 

In this context assuming the word 'stress' means 'excessive pressure or worry' then how do you get physical problems as a result?

All emotional states are reflected in the position and posture we adopt.  Think of the classic Charlie Chaplin surprised face. 

When an individual is stressed the typical posture they adopt is elevation of the shoulders.  The jaw can get tighter overloading the muscles around the jaw joint and those that run along the side of the neck.
Because a lot of the muscles that move the shoulders come from the neck, the tension in the shoulders transfers into the neck. Muscles then become fatigued causing pain themselves.  The picture is further aggravated by compressing the vertebrae potentially irritating the facet joints.  Headaches can then develop.

As part of the stress picture, breathing patterns alter leading to upper rib breathing taking over from diaphragmatic breathing.  This overworks the muscles at the front and side of the neck.

If this pattern is maintained for a while the muscles can change and symptoms can continue even after the stressor has eased. 

Try taking deep breaths to help stretch the diaphragm and relax the muscles.

 

Joints of the spine

Joints of the spine: Facet joints


Having discussed what a disc it seems obvious to talk about the joints that lay either side of the disc; the facet joints.

These are essentially designed the same from the neck to the bottom of the back but vary on the angle they sit to allow different ranges of movement to occur.  When all are working as they should, they allow the spine to move in every way imaginable. 

Facet joints can cause problems when they stop moving.  This could be due to a number of reasons.

Because they move continuously in day to day life they can wear out like any other joint.  The cartilage that lines the joints can break down becoming thinner and that is when pain and inflammation can occur.

Even though it doesn't necessarily press on a nerve the pain can refer into the legs or arms via a method called referred pain. In response to this wearing process the joints actually enlarge as the body places extra bone around the area to help. This can in turn cause pressure on the nerves leading to pins and needles and numbness. 

This degeneration process is termed arthritis or spondylosis when it is specific to the spine. 

Sometimes these facet joints can be perfectly healthy but just get 'stuck'. This can occur especially in the neck and lead to a sudden loss of mobility and a lot of pain.  Luckily with treatment these settle quickly and you can go back to normal life a few days later.