January 25, 2010

Over the weekend, I got an email from a subscriber who complained of a very common problem. So, I thought I’d pass it along, as you may well have, or have had, this same problem yourself.
 
He wrote that he had developed a pop or snapping sensation inside his knee, which had cause him to start having pain, when bending or straightening the joint. He didn’t recall any specific injury to the knee.
 
That’s not at all uncommon, you know. Many is the time that patients came to see me in the office with an obvious injury, yet they couldn’t remember any such trauma in the recent past. In these cases, what I surmised is that they had a minor injury, perhaps a bump into the corner of a piece of furniture, not bad enough to remember, so it didn’t register. 
 
But over a few days, the incident now forgotten, the body set up a “delayed” inflammation, mediated by a cellular response. From the standpoint of the patient, this pain seemed to come out of the blue. But there really WAS an injury–just not one they could recall.
 
I’ve had this happen, myself. It was only when I really made the effort to remember and retrace my steps that I finally recalled the minor bump, several days before, that was the cause of the pain. That’s more likely to happen, now that I’m back on my POWERHOUSE OMEGA FORMULA  http://www.favoriteformulas.com
 
The pharmaceutical grade fish oil has real anti-coagulant properties, among others, like preventing heart attacks and strokes, anti-inflammatory properties, and many others. While that’s usually a good thing, preventing abnormal clots and deep vein thrombosis, the price you pay is a greater tendency to bruise, which is simply bleeding under the skin.
 
Blood in the tissues is a common cause for delayed inflammation and resultant pain. In this case, this person likely had a bruise, which he no longer recalls, which then set up the inflammation, which then resulted in inflammation of the synovial membrane, that lines the knee. 
 
The synovium normally has a few small folds from birth. When these folds are swollen from inflammation, they enlarge into plicae(meaning “folds” in Latin). These plicae can then snap, or pop, as they are rubbed against the bony contours of the end of the femur, within the knee. In effect, they are plucked, like the strings of a guitar, when bending or extending the knee.
 
If the inflammation is chronic, lasting for an extended period of time, the synovial membrane may be replaced by thick, fibrous tissue, thereby becoming a stiff cord of scar. Once that happens, that plica is there for good. It can only be removed by surgery. 
 
Prior to that, however, the irritated and swollen fold in the membrane can be shrunk, by using one, or several, of the many            non-surgical treatments in my newest healing program, HOW TO AVOID KNEE SURGERY http://www.drbillsclinic.com/avoid_knee_surgery.html 
 
In the short term, ice applications, for the first 24-48 hours helps, because the cold constricts the blood vessels, thereby limiting the amount of bleeding and swelling in the injured tissues. After that, intermittent heat is more beneficial. 
 
How do you know when to switch?
 
See how it feels. If heat makes the knee hurt more, then it still needs ice. If, on the other hand it feels good, then heat is what’s needed. Like we used to say in the 60′s and 70′s: “If it feels good, do it.”
 
And, though this may seem like just common sense, you should NOT continue to snap the knee. Continually “plucking the string” will only prolong the ongoing inflammation, maintaining the swelling of the tissues and preventing resolution. To keep the knee still, you may need to place it in a knee immobilizer, which will hold it straight, while still allowing weight bearing.
 
If you follow these few tips and use the methods I outline in HOW TO AVOID KNEE SURGERY, http://www.drbillsclinic.com/avoid_knee_surgery.html  and you will get fast relief, shrink the plica and get rid of that irksome, snapping knee pain. Til next time, my friend, be well. Talk to you again, soon.
 
Yours for a pain-free tomorrow,
 
Dr. Bill
 
“The Wellness warrior”       TM
 
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 conventional and alternative treatments and exercises to relieve knee pain without surgery click on http://drbillsclinic.com/avoid_knee_surgery.html 
 
P.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, 2010 by William Thomas Stillwell, MD, FACS
All rights reserved

A few days ago, one of the members of an exclusive fitness group, for whom I serve as a medical advisor, emailed me with a knee injury. He had been participating in his jiujitsu class and was close to the end of his class, when he experienced a “pop” within the inner aspect of his left knee. He didn’t feel pain when it happened, but he was smart enough to stop what he was doing and not finish the class. He was also able to
bear weight without difficulty.
 
But by the next day, the knee was aching and swelling.  He iced his knee through the night, took just a couple of Aleve caplets and wondered whether he should visit a doctor. Then, he asked for my advice.

Since I had no way of seeing him or examining his knee, I had to base my differential diagnoses (ie., educated guesses of the likely source of his pain) on his history alone. Now, even in a clinical setting, history is THE most important factor in determining a diagnosis. But the physical examination adds important mechanical information that leads the examiner toward one possible diagnosis and away from another.
 
In this instance, the leading contenders were a snapping synovial plica (a thickened band of lining membrane of the joint, that is plucked like a banjo string over the end of the femur), or a torn medial meniscus (the inner cartilage cushion, between the femoral condyle and the tibial plateau). Both of these can cause popping and be initially painless. And both can result in a delayed inflammation, manifested by stiffness, pain and swelling.
 
This man was smart–he stopped doing the class immediately after his incident, suspicious that he had sustained some injury. He iced his knee a number of times over the next couple of days, took it easy and took just two Aleve caplets. Then, he decided to ask for my advice.
 
I advised him to follow the usual conservative measures, as I have described in detail in my LITTLE GREEN  BOOK  (http://drbillsclinic.com/eliminate_knee_pain.html)   These included switching to local heat, increasing his use of Aleve to 2 caplets twice a day (with FOOD or MILK, to protect your stomach from the side effects of NSAID’s), and selected exercises to preserve his quad strength, while avoiding motion, like those at   http://drbillsclinic.com/exercise_eliminate.html
I also advised him to consider going to see an orthopaedist, if his symptoms don’t improve pretty soon.

Then, he asked a very good question: “What about bracing?” 

As it happens, bracing is a very good idea. But you  don’t need an expensive, custom brace. No, just an elastic or neoprene sleeve, to provide some extra support and a gentle, generalized compression of the knee joint. Compression is important as a counter-pressure to the swelling and fluid generation of the inflamed knee. The external squeeze tends to minimize the production of excess joint fluid. 

Unless you have a specific ligament problem (which, based on his presentation, he does not), you don’t need hinges on the sides of the brace, either. A central hole, a patella cutout, is warranted if you have pain in the kneecap, but is otherwise not necessary. But this simple and inexpensive addition to the usual anti-inflammatory regimen is a great help in relieving pain and restoring function after a knee injury. And
I heard today that, sure enough, he’s getting better already.  Hopefully, he’ll be back in action again, real soon.

Well, that’s it for today, my friend. Have a great weekend and, 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 sent my bride’s new RAV4 to Southampton by an auto transport service, so she’ll have access to an all wheel drive vehicle up there. Then, she had the bright idea of packing some boxes of books, pictures and other stuff in the car, so we wouldn’t waste the trip. This had to be done the night before, so the car would be ready for transport. Guess who was tagged for this packing detail.
 
Right, the first time! “C’est Moi.”
 
You know, it always amazes me just how heavy a bunch of books really is, when you’re carrying them. Now, as a physician and an orthopaedist, I certainly know better. But when I’m not wearing my “Doctor’s Hat,” I’m just as stupid as anyone else. When faced with
the petty little problems of daily life, I tend to  just do what I need to do to accomplish my purpose, without thinking much about it.

While I appreciated the fact that the books were heavy, I was very careful, moved slowly, with good body mechanics and I didn’t feel any pain or spasm at the time. I was very pleased with myself and I thought I’d gotten away with it….
 
Nope.
 
Here it is, two days after the fact, and I’m standing in my local comic shop, looking over the latest arrivals to indulge my hobby. Out of the blue, WHAM!  I got a sudden, painful spasm in my mid-back, right over the site of my old spinal fracture, like someone stuck a knife in my spine, that took my breath away.  I was just standing there. But thanks to a phenomenon called “delayed inflammation,” I was now paying the price for my recent indiscretion. Any slight twist to the spine, any attempt to bend, even slightly,  resulted in a sharp, burning spasm, right in the center of my back. You play, you pay. Terrific.
 
To make matters worse, thinking it would be a nice outing for her, I had brought my dog, Kelly, to the shop with me (For long time readers, she is doing fine, much better than before, though her hindquarters are still not normal, and she still needs my help to get in and out of the car) and I had to help her out of the back seat. WHAM!  Another spasm hit.  Just great.
 
What I hate most about the situation is that I have to move around slowly and gingerly, like I’m walking on eggshells, anticipating a new spasm with every move. Now, in my case,  my pain and spasm are due to discogenic disease, compression and shearing forces on spinal discs, crushed in my fall.  But, more commonly, this type of presentation is due to an acute sprain, or strain of the ligaments and muscles, respectively. Or, it may result from an acute herniated disc, where the central gel (nucleus) in the center of the disc is squirted out, like toothpaste out of a tube, putting pressure on the nerve roots and causing pain and sometimes, weakness. If you have any doubt, get yourself checked by a physician, or other health care provider.
 
Besides bed rest, lie with a couple of pillows under your knees, to flex your hips and knees and flex the pelvis, flatten the spine and reduce forces across the back. To function in a sitting position, I use a NADA CHAIR–a back pad, attached to two slings that wrap around the knees, providing substantial support for the back. You can get one on the web site of the same name.
 
The usual measures to reduce the accompanying inflammation should be used (these are reviewed,  albeit in the context of knee pain, in my LITTLE GREEN BOOK, which you can order here at    http://drbillsclinic.com/eliminate_knee_pain.html),  including local heat, either heating pad, or local application of magnetic therapy (which increases blood flow) to relax muscles, and anti-inflammatories. These can be Natural, like fish oil, DHA, Lyprinol, ginger, or willow bark tea, though all except for  the last, require time to work. Or, you can use OTC  NSAID’s, like Advil or Aleve, for more rapid relief (you should take two or three times the normal dose, with FOOD or MILK, to protect the stomach from side effects, like pain, bleeding, or ulcers).
 
But when it comes to relief of muscle spasms, nothing, and I mean NOTHING, works better than VALIUM. This is an older muscle relaxant (a benzodiazepam) that was often abused as a tranquilizer. But it was designed as a muscle relaxant and works by blocking impulses
at the neuromuscular junction (that site that is where the nerve “plugs in” to the muscle). It’s the only drug that does this. All the later relaxants work in the central nervous system (ie., the brain), by  “unknown mechanisms of action,” and in my opinion, are not nearly as effective.
 
The downside is that you need a prescription from a doctor, but if you’re in severe pain and spasm, that’s a good idea, anyway. Fortunately, I AM one, so I had an emergency supply on hand. Five milligrams and the spasms settled down. Thank God. Viva Valium!  Hopefully, with all these measures, I’ll be back in action, minus the back spasms, in a day or so.  So, til next time, my friend, I wish you 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