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.

What is an intervertebral disc?

What is an intervertebral disc?

A lot of our time is spent at the clinic talking about discs and different states they can be in, but what is a disc?

A disc is a fibro-cartilaginous structure that are situated between the vertebrae, the bones of the spine. They are located from the bottom of the skull right the way down to the tail bone. The purpose of the discs are to provide a shock absorbing system and to allow the spine to move.

The discs themselves have two parts to them; the outer part is called the annulus fibrous and the central part is the nucleus pulposus. Think of a jam do nut, the outer edge is the dough (the annulus), and the central part is the jam, (the nucleus).
 

Both parts of the disc contains water but more so the nucleus. This water content varies through the day. That is why you are slightly taller in the morning! The discs ability to hold water decreases with age as the discs become dehydrated. Amongst other things this contributes to the loss of height with age.

The disc is just part of a complicated system of the spine that allows us to do our daily activities.

We will discuss other parts of the spine and what happens when things go wrong in future blogs!

Why do we ask so many questions?

Sometimes when new patients enquire about an initial appointment they can be surprised that it takes an hour.  The reason for this is we need to assess the background to your injury and work out how best to help you.

Symptoms that appear to be a simple strain or muscle pull can occasionally be something much more serious.

Many of our patients are not seen by a GP before presentation.  Even if you have seen your doctor before coming to the clinic we do not have access to your medical records and are reliant on you telling us what the doctor or other specialist thinks, or has previously investigated. 

Some of our questioning may seem irrelevant but it all helps us build a picture of what your tissues, joints and muscles go through on a regular basis and guide us to help you in the best way we can.

If you have had any investigations such as an MRI scan, then bring in any reports or any other information you have.  Also a copy of any prescription medication you take.