Of the many aphorisms, and sayings that were part of my medical education, the earliest and one of  the truest was: “If you hear hoofbeats–don’t think of zebras.”  The meaning is pretty clear. When faced with a sign or symptom, its commonest cause is the 
most likely.
 
I think the first time I heard this I was in my clinical rotation in Metropolitan Hospital, while still in Medical School. If you ever saw the movie with George C. Scott called “The Hospital,” you’ve seen my old training site. They were filming the movie while I was there, and in fact, one of my senior residents in Cardiology was actually in the film, running a “code” (ie., cardiopulmonary resuscitation) on a guy who had a heart attack.
 
Anyway, whenever we’d make rounds with the attending physicians, we’d all go around and review the cases (patients) on the ward, one by
one (that’s why we call them “rounds”). That’s how Medicine is taught, if you didn’t know. 

Everybody would gather around the patient, while the Attending would present the patient’s history, symptoms and signs. Then, they’d ask us what the possible diagnoses were (differential diagnoses).  Naturally, we would all try to come up with as complete a list as we could remember from our reading, including all the most arcane and obscure diseases we could think of. And of course, 99 times out of 100, it’s the commonest cause, the “horse,”  not the “zebra.”
 
Now this seems like only common sense, but you’d be surprised how often the student gets lost in minutia and fails to see the obvious. That has to be learned. And this is how we learn that–from repetitive seeing and doing, and of course, periodic humiliation by the Attending, the Chief  Resident, Resident, and Intern. When you’re the student, YOU are the bottom rung and it ALL rolls downhill, on you.
 
After many, many episodes of this, you do begin to learn. You get tired of feeling like an idiot.  It gets old fast, believe me. And, of course, it’s
enhanced by physical and mental exhaustion (though this PALES in comparison to the internship, but that’s another story).
 
Then, one day, almost by accident, when you’re asked a question by the Attending or the Resident, you answer and–you’re RIGHT! Amazing!  Oh, what a feeling.  Well, I can tell you it feels a whole lot better than being withered with scorn, which had been my usual portion, prior to this. In psychological circles, they call this selective reinforcement: you repeat behavior that results in pleasure.
 
But just as in producing the best steel blades, the more they are bent over and folded, forged and tempered, the better their final quality, 
so too, with the young medical student: over time,  countless repetitions of this theme eventually result in what we call “clinical experience.”  And it only comes with time. There is no other way. 

And it all begins with a recognition of what is the most common cause of a disease, or medical condition. What are its key signs and symptoms? And what are the best methods to successfully relieve those signs and symptoms?
 
Bearing that in mind, I made one of the strongest features of my LITTLE GREEN BOOK an organization that recognizes the most common causes of knee pain, first. See what I mean at  http://drbillsclinic.com/eliminate_knee_pain.html
 
In the same way, the most effective exercises in my PAIN-FREE PROGRAM are listed first. See them at
http://drbillsclinic.com/exercise_eliminate.html
 
Just like my mother always said: “First things, first.”  That’s it for today, my friend. Have a great weekend.  Til next time, be well.
 
Yours for a pain-free tomorrow,

Dr. Bill
P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

Yesterday, we discussed the report of the Osteoarthritis Research Society International, regarding their recommendations for the treatment of ostearthritis.  I mentioned that this study was really significant, because it provides, for the first time, truly international guidelines for the rational treatment of arthritis, based on available evidence.
 
The group was headed by Dr. Zhang, of the University of Edinburgh, was drawn from six countries, including 11 rheumatologists, two primary care physicians,  one orthopaedist, and two experts in evidence based medicine. They reviewed the available evidence in the
literature to come up with their recommendations.  As I’ve mentioned before, each item was assigned a number, a percentage; the higher the number and the closer to 100, the more reliable that item and the more likely it is to be successful.
 
So, yesterday, we looked at the top non-drug methods, which mirrored my own recommendations. Today, let’s look briefly at their recommended drugs. As you might expect, NSAID’s (nonsteroidal anti-inflammatory drugs, like Advil or Aleve) at 93% and acetaminophen (ie., Tylenol) at 92% led the pack for relief of the pain of arthritis. A bit further down was topical NSAID’s and capsaicin (skin creams) at 85%.  Injections of intra-articular corticosteroids (ie., injection of cortisone, or similar drugs, into the
knee and other joints) ranked next, at 78%, followed by joint injections of hyaluronans (forms of hyaluronic acid, like Syn-Visc or Hyalgan) at 64%. We should bear in mind that these latter joint injections, steroids or hyaluronic acid, are used in the most serious and advanced forms of arthritis. So we need to interpret their effectiveness “numbers” based on that. Hyaluronic acid injections are used
as a non-surgical alternative for END STAGE arthritis. They can “buy time” before joint replacement is needed, but are only used in joints at that advanced state of disease, where total joints are the only other option.
 
Following that, glucosamine, with or without chondroitin sulfate, ranks at 63%, when used strictly for relief of symptoms. But this falls to only 41% when used for possible structural modifying effects of the joint (ie., “regrowing” cartilage).  This, too is expected. There is little scientific evidence for cartilage regeneration, at present (maybe someday, with stem cells…). 

While it’s known that glucosamine is often effective for pain relief, as I point out in my LITTLE GREEN BOOK (see how I put this into proper perspective at http://drbillsclinic.com/eliminate_knee_pain.html),  there is little hard proof for any structural effects 
on the joint from its use. That absence of evidence is reflected in the lower number.
 
Glucosamine is the closest this study comes to touching on the Alternative Medicine options. This, too, makes sense. Alternatives, by their nature, have few if any accepted scientific studies as their basis. They are usually based instead on anecdotal histories, folk lore or an Alternative traditon. So long as no one is going to make a buck on them, don’t look for large, double blinded, randomized and controlled studies, anytime in the near future.

The last category studied was the Surgeries. No surprises here. Total joint replacement was the most effective treatment, backed by hard evidence at 96%.  That TJR is one of the most successful treatments in the history of Medicine is well known. But its less complete cousin, the unicompartmental replacement, was less so, at 76%. Its success requires accurate diagnosis, disease limited to one compartment, very
accurate placement and angulation, and more rigorous technique, but fewer surgeons are experienced in this technique. These limitations result in less succesful studies and therefore, the lower number.
 
Osteotomies and other joint preserving procedures are nearly the same, at 75%. But joint lavage (washing out the arthritic joint with water) and arthroscopic debridement were less effective, at only 60%. My own clinical experience, and the recommendation of our
Academy also argue that these procedures are less effective treatments for arthritis.
 
This study is very useful for selecting arthritis treatment options, based on the evidence. I congratulate the authors. It’s not just the actual ranking of the options that’s useful, but that the principles the study invokes can be applied to all other areas. Instead of guessing, basing your decisions on hard, rigorous, scientific evidence is as close to KNOWING as you can come.
 
For example, when I selected the knee exercises for my PAIN-FREE PROGRAM, I chose them based on the reported evidence of effectiveness in the literature, my own observations of patients, for whom I prescribed them, and my own personal experiences, as a knee patient myself. In other words, my choices were based on all available evidence. See what I mean, by visiting
http://drbillsclinic.com/exercise_eliminate.html
 
So whatever advice you decide to follow, in whatever field you find yourself, you can’t go far wrong if you base your choices on the strongest available evidence. EVIDENCE BASED TREATMENTS are your best bet for successful results. And that’s the tip ‘o’ the day. Til next time, my friend,  be well.
 
Yours for a pain-free tomorrow,
 
Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

While reviewing a number of news items and health related blogs, in preparation for my own blog, I came across an interesting study. This was done by Dr. Zhang and his coworkers at the University of Edinburgh, under the auspices of the Ostearthritis Research Society International. What Dr. Zhang and his collaborators did was to identify 25 different treatments used for the symptoms of osteoarthritis.
They divided them into non-pharamacologic, pharmacologic and surgery categories. So far, so good.
 
But what made this study uniquely useful was that they assigned each treatment a number, a percentage based on the available evidence for effectiveness in the literature. In other words, each method, drug, or surgery was an EVIDENCE BASED RECOMMENDATION. By referring to the number assigned, the reader can get a pretty good idea of how much evidence backs up each item, and can compare one 
against another.
 
In the past, most recommended treatments were based on individual experiences of the practitioner. Right or wrong, it was still anecdotal. But with this study, we can base recommendations on the collective experience and multiple sources of the medical literature. This adds a great degree of confidence in the expected results for a specific treatment. In other words, we’re not guessing what works–we now KNOW, based on evidence, not anecdote.
 
Among the non-pharmacological methods that enjoyed the highest levels of confidence were: EDUCATION & SELF MANAGEMENT (ie., what you’re doing right now): (97%), EXERCISE (96%), WEIGHT LOSS (96%), WALKING AIDS (like canes): (90%) and referral to
PHYSICAL THERAPY: (89%).
 
Imagine that! The very things that I’ve been telling you, the very things that I’ve always promoted, were the most beneficial to patients, based on all the available evidence. Am I surprised? No. But I am gratified to see the “occular proof,” as The Bard said. 

Some things are basic–not because they’re simple, but because they’re fundamental, the things on which everything else is based. These basics are available for you in my LITTLE GREEN BOOK FOR ELIMINATING KNEE PAIN, which you can get for yourself at http://drbillsclinic.com/eliminate_knee_pain.html
 
And the best exercises ever prescibed for the relief and prevention of knee pain are laid out for you at
http://drbillsclinic.com/exercise_eliminate
 
Everything I write has been based on evidence I’ve acquired through a lifetime of practice, the world orthopaedic literature, and my own personal experience, as a patient, myself. Don’t guess, when you can KNOW. Then, you can KNOW what it’s like to have your pain disappear!

That’s it for today, my friend. Til next time, be well.
 
Yours for a pain-free tomorrow,
 
Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
http://drbillsclinic.com/advanced_masters.html

FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

One advantage to living in a menagerie of seemingly endless cats is the virtual absence in the house of  vermin, of all kinds. Giant palmetto bugs? No chance. Spiders? Endangered species. Rats, field mice, moles? I haven’t seen one in fifteen years or more. Even flies aren’t immune. Hunter, one of our younger boys, who lives up to his name, snatches them right out of the air — and eats them!
 
When you’re living in the middle of what used to be a giant swamp, and on the border of a huge nature conservation area, it’s good to have that kind of  additional “border control” in addition to Terminix. If anything manages to get past the initial chemical barrier, it has the proverbial snowball in Hell’s chance. Like the old “Roach Motel” commercials: “they check in…but they DON’T check out.”
 
On occasion, I’ve even found baby lizards and newts, and once, what I thought was a baby rattlesnake — cold, stiff and dehydrated. But til now, that’s about the worst of it.
 
So imagine my surprise when I came in the other night and found what I thought was a coil of heavy black cable, next to a pair of my wife’s shoes,  just inside the entry door. Since we have some construction going on, I didn’t think much of it. Then, going into the attached garage, to get some food for the dog, I noticed a smear of bright red blood on the floor.
 
Uh-oh. That’s not good. First thing I thought of was that the cats had gotten a little too aggressive with each other. Then, on the way back in, I saw that “coil of cable,” lying on the floor, again. Turned the lights up a little. Not cable. Not rope.
 
Black snake. About an inch thick. Quite dead. Coiled, pretty as you please, and PLACED there as an offering by one of our little sentries. My money’s on Hunter.
 
Great. Now, I had to get rid of it before my wife saw it, or we’d be having funeral services for the snake. She’s never accepted the idea that in Nature, some critters kill others. It’s just how it is. Especially when you’ve chosen to live with a small army of little furry carnivores.
 
Besides, she’s always refused to dispose of “dead things.” That’s my job. Anything nasty or potentially disgusting–my job. That’s just how it is, too.
 
So, I got out my trusty old bottle forceps from the drawer (why I have bottle forceps, when we’ve never had kids, is another story), hoisted up the snake and took him out back to reunite him with the swamp that spawned him. During the entire procedure, the cats were supremely disinterested.
 
Never a dull moment around here.
 
Speaking of snakes, that reminds me a a trick you can do with a piece of rope when you have calf cramps. Just loop the rope around your foot,
while you’re sitting with your knee out straight, and gently but firmly pull the foot back toward your head, until you can feel the stretch. You
can also use this to stretch the calf muscles, to help fully extend the knee. For other useful stretches and exercises around the knee go see
http://drbillsclinic.com/exercise_eliminate.html
 
Well, that’s my report on today’s adventures. Hope all is well with you and yours. Til next time, my friend, be well.
 
Yours for a pain-free tomorrow,

Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

Well, this evening, at the risk of being completely banal, I watched the 80th Annual Oscars. I know, I know. It’s about as dull as dull can be, but as I get older, I find a kind of comfort in the little riuals that mark the milestones of the year. And The Oscars is one such milestone. And I was somewhat curious to see if the recent writers’ strike had impacted the show. Now that I’ve seen it, I’m still not sure.
 
They had no production numbers (a big plus), the nominated songs were all entirely forgettable and the usual Hollywood Leftist drivel was only barely perceptable. But it all struck me as bland, flat, and not all that interesting.
 
I admit I haven’t seen even one of the contenders for any of the awards. In fact, the best part of it for me was the frequent clips of old time movie stars, directors and films. Those were real personalities, archtypes, even. Many of today’s stars can’t hold a candle to them–but that’s just my opinion. And, also, I have to admit that I don’t find John Stuart, who was the Host, very funny. I just never have. Maybe it’s me.
 
One part that was quite interesting was the presentation of an honarary Oscar to an older gentleman, Robert Boyle, introduced by Nicole Kiddman, and his frail little body, in a tuxedo, complete with a snowy white opera scarf, was practically carried to the podium by two rather statuesque female escorts.  This guy was 98!  His voice was firm though, and he  pointed out that “this is one of the best parts of  being old. I don’t recommend the other part.”
 
My best guess is he’s referring to his physical infirmities, but hey, he IS 98. And there’s only two ways I know of to avoid infirmity at that age — one: don’t live that long, or two: EXERCISE, NOW.
 
It’s a fact. Regular exercise is the closest thing we have to a natural “fountain of youth,” with resulting increased muscle mass, growth hormone release, optimal digestion and increased metabolism.  If Mr. Boyle had been doing the exercises I teach at
http://drbillsclinic.com/exercise_eliminate.html   he wouldn’t have needed those Amazons to hold him up at the podium.
 
So, the big winners were: “No Country For Old Men,” Best Picture; Daniel Day-Lewis, Best Actor (for “There Will Be Blood”) and Marion Cotillard, Best Actress for her role as Edith Piaf in “La Vie En Rose.”  So it goes. The 80th Annual Oscar Awards are now history. I guess I’ll wait for the DVD’s.
 
But what was REALLY funny was the parody on Jimmy Kimmel, after the Oscars. Appeals to my perverse sense of humor. Anyway, that’s it for today.  Be well, my friend.
 
Yours for a pain-free tomorrow,
 
Dr. Bill
 
 
P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

My wife and I have recently decided to resurface our pool in Florida. The old Marcasite coating was worn away in over 20 spots, so it was long past due. It’s just one of those things that you tend not to think about, until it’s almost too late to fix.
 
So first, they have to empty the pool. Fortunately, they have a strong professional pump that sucks the water out fast! Then, they sent over one single tile guy, to remove all of the old tile just above the water line. He got most of it off yesterday, and the remainder, today. Then, he laid down a scratch coat over the bottom and sides, in preparation for
the finished DiamondBrite coating that we chose. 

While he was out there, laying a level line for the new tile, I went out to offer him a drink. I noticed that he was wearing knee pads. So, I casually asked him a question.
 
“Say, I notice that you’re wearing rubber kneepads. Do you have a problem, or are you trying to prevent one?”
 
“No. Nothing wrong with me, right now,” he said. “But I’ve seen a lotta older guys who have sore knees, or arthritis now, ’cause they didn’t use them, back when. I don’t wanna be like them.”
 
Hallelujah! I felt like Diogenes who had finally found an an honest man. Only I had found an intelligent young man–usually an oxymoronic phrase. In fact, in all the years of my orthopaedic practice I had never run across anyone who “got it,” the way this young man did. Usually, the very worst offenders were the ones who were the most at risk: bricklayers and masons, pavers, tilemen, flooring men, plumbers, electricans, and my personal favorite, carpet layers.
 
Did you ever see what these guys actually do when they lay a carpet? First, they kneel on a hard wooden subfloor and nail down wooden tack strips around the periphery of the room. These strips have angled sharp tack points to catch the carpet from below. Then, after attaching the carpet to one side of the room, they stretch the expanse of carpet to the other side,
by using a “kicker.” This device is a long, toothed metal “comb” of sorts, with a leather pad at the other end, into which the worker repeatedly BASHES his knee, to progressively tighten the carpet across the room. Not surprisingly, these guys often showed up with severe kneecap problems, but were highly resistant to suggestions that they use knee pads.
 
Now, direct trauma to the kneecap, that’s a part of all these listed jobs, is a great way to develop chondromalacia patellae and eventual arthritis. You can read more about these conditions, and how to avoid them, in my LITTLE GREEN BOOK FOR ELIMINATING KNEE PAIN. To get your own copy, Go to   http://drbillsclinic.com/eliminate_knee_pain.html
But the simple use of rubber kneepads is a great way to avoid these consequences. 
 
This young man intuitively understands that; most young men just don’t. They feel immortal and invincible. When they finally begin to develop pain, the damage is done. From that point onward, they can improve, but they can’t ever be normal again.
 
So this one simple thing will have a profound impact on this guy’s life. He won’t develop the pain and degenerative disease that other workers will. Just by the application of a little intelligence–that’s the BEST way to avoid surgery. Good for him.
 
Til next time, my friend, be well.

Yours for a pain-free tomorrow,
 
Dr. Bill
 
P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to   http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

The last few days, I’ve been sick–hacking cough, joint pain, muscle aches and the heavy head that comes from inflamed sinuses. Just miserable. So I’ve been spending a lot of time sleeping, in hopes of shaking this. But, sick or not, I had to get out of bed for a special event.
 
Last night, we had a spectacular view of the total lunar eclipse. The moon was tinged a rusty red from the shadow of the earth on the lunar landscape and whenever a wisp of cloud would cover the moon, the red was more pronounced. Now, these lunar eclipses aren’t as rare or as spectacular as total solar eclipses, but they’re still pretty impressive, and they have the advantage that you don’t risk blindness by looking at them.

More to the point, celestial events like these remind me that any problems of mine, or any accomplishments, as well, are hardly of any import in the vast scheme of things. I think they give us perspective.
 
I remember when the comet Hale-Bopp was so brightly shining in the night sky. Unlike Haley’s Comet, which required a telecsope to see, this was clearly visible to the naked eye, a brilliant blue-white, shining adornment to the northern heavens. I was endlessly fascinated by it and would go out every night to see it, until, it was no longer visible and had left us again for the depths of space. I think I was captured by the idea that it was here over 4,000 years ago, and would come again in something over 4,000 years, long after I and everything and everyone I ever knew, or cared about, was long turned to dust.
 
Of course, the press was all about the moonbats of Heaven’s Gate, the suicide cult that believed they were going to rendezvous with a UFO. Not me. That was just, more or less, psychopathology. No, I was enthralled by the comet itself and the implications of the scale of the universe.
 
So, too, with the eclipsed red moon. 

Then, the moment of totality was gone, and a crescent of brilliant moonlight, all the brighter for the absence of light during the eclipse, began to gleam from the lower right quadrant of the moon. Little by little,  it grew, until the moon was full again. 
 
Then, the clouds moved in. Lucky that they held off,  just long enough for the sky show. Again, it points out how often that what we get to experience in life is just plain luck.

I’ve read that the next total lunar eclipse will be in 2010. But who knows if I’ll be in a position to see it, or if the weather will permit it to be seen. Like all of life’s little milestones, I’m grateful I was here for this time, for tomorrow is promised to no one. 

Til next time, my friend, be well.
 
Yours for a pain-free tomorrow,
 
Dr. Bill
>
> P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
>
> P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
> http://drbillsclinic.com/exercise_eliminate.html
>
> P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
> http://drbillsclinic.com/advanced_masters.html
>
> FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
>
> Copyright, 2008 by William Thomas Stillwell, MD
> All rights reserved

 The other day, in response to my earlier request that all my subscribers send me their single most important question about orthopaedics and knee pain, or arthritis in particular, for a future teleseminar, I received a question about a “frozen kneecap.” Assuming that the woman hadn’t been buried in an avalanche, or fallen into a vat of liquid nitrogen, I was forced to ask what she was talking about.
 
Turns out that she was asking about her patella tending to track laterally, that is, on the outer side of her knee. From her point of view, the fact that her kneecap was stuck in a lateral track, she interpreted as being “frozen.” Now, I’m not picking on this lady, who I’m sure is very nice and who,  in any case, needed help. In retrospect, I can sort of see the reason she chose that word, but the point is, it makes no sense to anyone else, like me, and therefore, does not accomplish what words are supposed to–communication.
 
This episode reminded me of how many times I had to try to draw out of my patients what their real complaints were. Sometimes, it was like pulling teeth. I don’t mean or expect that a lay person will describe their symptoms or complaints in technical terms that I would use to another orthopod. No, I just mean plain, descriptive English that actually tells me what’s wrong.  Vocabulary is one of the main barriers between  physicians and their patients. It’s sometimes hard for the patients to make the doctor understand what they mean.
 
My father-in-law is another great example of this. If he’s asked whether he has any hip or leg pain, he replies that his leg is “numbish.” Now, you would think that this would imply some decrease in sensation, like when something is “numb.” But no, what he actually means is that he has a dull  ache in his hip. This took me quite a while to pull out of him, trying different definitions, or outright guessing what he was trying to express. The point is, it takes time and effort to figure out what the problem is. And today, a lot of  doctors either don’t have, or won’t take, the time to try to interpret what you’re trying to say.
 
“Uh-huh. Take two of these twice a day. See you in two weeks.” Bam! Out the door. Next patient.
 
Because you don’t share the same vocabulary with your doctors, it’s important that you be as clear as possible. DON’T try to be “creative.” Just name the part, state what you feel, describe what happens, in as simple and lucid a fashion as you can. If it hurts, say so. Then, try to describe what kind of pain it is: sharp, dull, deep, superficial; then, what brings it on, what makes it worse, or better.

It helps if you have some understanding of what the possibilities are. For example, if you’ve read my LITTLE GREEN BOOK, which you can get at   http://drbillsclinic.com/eliminate_knee_pain.html    you will know what the most likely diseases are, since they’re presented in the approximate order of frequency that they occur.

In the case of the woman who wrote to me about her “frozen kneecap,” her problem was really a lateral tracking syndrome. This is usually due to weakness of the VMO (vastus medialis obliquus) muscle, the only one of the quadriceps that attaches directly to the inner, upper margin of the kneecap. When that muscle is weak, the other muscles pull the kneecap outward, and over time, the soft tissues contract and become tight. 

To correct this, you need to stretch the outer soft tissues by massage, and sometimes by using a brace. You also want to build up the strength of the VMO, with the specially modified exercises I teach at   http://drbillsclinic.com/exercise_eliminate.html   None of this can occur if the problem isn’t first accurately defined.

So, what’s in a word? Everything.

That’s my word for today. Hope all is well with you. Til next time my friend.

Yours for a pain-free tomorrow,

Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

February 19, 2008

AARP sent me a membership card fully three years before I qualified for one, by age. I was outraged! “Hey, don’t rush it, guys! It’s going fast enough,” I thought. But then, I discovered the substantial discounts they offered, and I wasn’t so outraged anymore. In fact, these discounts are a fairly nice perk for aging. Not as good as getting younger, but since that’s not likely, this will have to do.
 
So last night, my wife decided to go to a local buffet for dinner. She just didn’t feel like cooking, and she had a yen for the buffet. Now, this is almost always a mistake. The fact that we affectionately call it “the pig-out” should give a clue as to the problem with it. Even though we both know better, once we’re there, the “buffet mentality” takes over–you feel like you just have to get your money’s worth. Even though I qualify for the senior discount.

I still keep hoping they’ll “card me” (oh, sir, you couldn’t POSSIBLY be that old), but to the kids who are the cashiers, we probably look pretty well qualified. The only good thing about this (in addition to the discount) is that there are a host of folks there who are not only considerably older than us, but in much worse shape, as well.
 
There are enough walkers and canes in this place to open a store. One old woman came in with a cane and, even through her pants, I could see a severe knock-knee deformity. Damn thing could barely hold her up. This is probably indicative of arthritis, and probably needs total knee replacement, at this stage. The sad thing is that she might have put off the day she needed surgery by the use of a few conservative measures.

First, she might have used a medial (inner side) heel and sole lift on her shoe, to counter the tendency to knock her knee. She might have also used an unloader brace, which, as the name implies, shifts the body weight to the other, less involved side of the knee. Both these measures might have bought her time. She and her family would have known about these options if they had read my LITTLE GREEN BOOK.   She might also have strengthened the muscles around her knee with the exercises in the PAIN-FREE PROGRAM, which I teach at
http://drbillsclinic.com/exercise_eliminate.html
 
But, that’s water under the bridge, as they say. At this point, the deformity is too pronounced and it indicates destruction and loss of the bone on the lateral (outer) compartment of the knee joint. Once you’ve got bone loss, nothing will do but replacement.

But even there, if there are medical or social issues that argue for a delay in surgery, you can buy time by viscosupplementation. That’s a fifty dollar word that means injecting the knee joint with a gel made of hyaluronic acid, a constituent of normal joint fluid.  Although it won’t restore the correct angle to the knee, or stability, it may relieve pain for months at a time, with virtually no side effects. This and
all the measures I noted above are discussed in detail in my handbook for lay people, DR. BILL’S LITTLE GREEN BOOK FOR ELIMINATING KNEE PAIN (please see   http://drbillsclinic.com/eliminate_knee_pain.html  )
 
And, oh yeah, cut back on your eating. Extra weight increases pain and disability in arthritis. The buffet is the last place she should be.       And me, too….

Til next time, my friend, be well.
 
Yours for a pain-free tomorrow,
 
Dr. Bill
 
P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

February 18, 2008

Last week, we discussed some of the problems caused by fixed flexion contractures, inability to fully straighten the knee. Among these are potential instability, with giving way, and early fatigue of the quadriceps muscles. When push comes to shove, you’re better off with a stiff, straight knee, than with a flexible knee that can’t fully extend. That’s because you can walk safely on a stiff straight knee, without giving way.
 
But there are also problems with the opposite problem–stiffness and limited flexion of the knee. Whether you’ve had an injury, gradual onset arthritis, or you’re post-surgery, if you fail to get a rapid return of flexion, you’re likely to have persistent swelling, warmth, inflammation, fluid and pain.

Over the years, I’ve seen this presentation again and again. The reverse is true, as well. If a patient had surgery but “bit the bullet” to get the knee to bend over 90 degrees within three days, they invariably went on to get full range of motion and full function, without pain or swelling. The faster they got full motion, the better they did. 

And here’s where personality traits come in–people who are open, trusting and rational tend to do very well. By contrast, those who are fearful, mistrustful, anticipate pain and magnify what pain there is, are far more likely to have a fair to poor result. 

I remember two patients in adjoining hospital rooms, who were great contrasting examples of this observation. One was a fairly elderly man, over 80; the other an elderly woman, about 76. 

The man, who had a terrific positive attitude, began doing his exercises in bed and cranking up his CPM (Continuous Passive Motion) machine as high as he could. Hell, he got up to 120 degrees of flexion on THE NIGHT OF SURGERY!
 
The nurses were all atwitter, fearing that he would ”ruin” his total knee, or rip open his incision. When I went to see him that night on rounds, I encouraged him. I knew his incision would be just fine and in fact would heal better, faster, and with less scar tissue because of his early flexion. Next day, he was walking. Day after that, he was home. Did great!
 
Next door, not so much. The lady was a classic “touch-me-not” personality. Despite ongoing anesthesia that had her knee completely numb, she tensed up with every flexion of the CPM machine at only 30 degrees. Now, she couldn’t feel pain; but she could feel the pull of the muscles, as the CPM cradle bent her knee, and she tensed up. She literally fought the machine, anticipating pain, though she couldn’t feel any. She needed higher doses of analgesics than her neighbor, had barely 80 degrees on discharge and less than that on her first followup visit, eight weeks later. 

We had a time getting her swelling down, increasing her flexion and reducing her pain. She was her own worst enemy. The other guy acted like he didn’t even have surgery. No pain. Improved motion from his preop state. A complete success, in every way.
 
So here you have two patients, both with exactly the same surgery, done by the same surgeon, following the same postop care plan — but vastly different results. The difference? Personality and Attitude.
 
But physiologically, what happens? If you have any bleeding in the joint, or any fluid, restricted motion allows the proteins in those fluids to congeal into threads, and with time, the threads become fibrous bands called adhesions. Likewise, the capsule that encloses the joint becomes swollen and thickened, with inflammation. These fibrous tissues act to further restrict motion. Fibrous tissues gradually contract, further tightening the adhesions and capsule.  The stronger they become, the tighter they get, the more they hurt. It’s a vicious cycle.
 
To avoid this scenario, it’s necessary to get early return of motion. Here are a few ways to do that:
 
1.) Sit at the side of the bed and let gravity gradually bend the knee to 90 degrees, passively.
2.) Sit on a few pillows in a rocking chair. By rocking back and forth, in gradually larger arcs, with feet firmly on the ground, the body’s weight acts like a pendulum to flex the knee.
3.) Kneeling on a pillow, on all fours, you can rock back and forth, each time trying to sit on your heels.
4.) When using a statioanry bike or ergometer, gradually drop the seat. That will allow your knee to bend more deeply.
 
The key is to bend it early. Bend it often. Rock on….
 
Til next time, my friend, be well.
 
Yours for a pain-free tomorrow,
 
Dr. Bill
 
P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to   http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved