January 21, 2010

The other day, I got another email from one of my subscribers, who had an interesting, but not uncommon story. Seems he had knee pain located right on his inner (medial joint line). He saw his doctor, and was sent for an MRI.
 
Sure enough, he had a torn medial meniscus. He also had some degenerative changes (read that as “early arthritis”), not uncommon in a middle aged guy. His question for me was, do I REALLY need to have an arthroscopic surgery? 
 
He was understandably reluctant to go “under the knife,” and was hoping that I could give him some less aggressive treatments that would relieve his pain, but help him avoid surgery. He also didn’t understand why these structures simply didn’t heal.
 
So, I tried to explain. I used to have to do this a dozen times a week, in my practice–meniscal injuries were the second most common cause of knee pain that I saw, after kneecap problems. So here’s the short story.
 
In each knee, there are two crescent shaped fibrocartilage structures that guide and cushion the knee in motion. They help to spread out the stresses of weightbearing over a larger surface area, kind of the way snowshoes work to keep you from sinking into a snow bank.
 
I have a great illustration of this principle in my LITTLE GREEN BOOK FOR ELIMINATING KNEE PAIN http://www.drbillsclinic.com/eliminate_knee_pain.html  which I drew myself. (I used to work for the comics as an artist, back in the 70′s.) 
 
Here’s the thing he didn’t understand, though, that makes all the difference: These structures are mostly avascular. That means that they mostly lack a blood supply. There is virtually no circulation within these cartilage cushions, at least in the inner 2/3 to 3/4. There IS a marginal circulation at the periphery, where the medial (but NOT the lateral) meniscus attaches to the fibrous capsule of the knee joint.
 
If a tear occurs within this so-called “red zone,” it does have the potential to heal. But only 10% of tears occur there. The remainder occur in the avascular part, and therefore CANNOT heal (at least not without fairly sophisticated surgical help), because nothing heals without blood. 
 
This anatomical fact governs the behavior of meniscal tears AND determines what constitutes effective treatment.
 
Given that he has a positive MRI, he probably SHOULD have an arthroscopic examination. If pathology is confirmed at surgery, it can be fixed on the spot. This is a prime example of what I like to call a NECESSARY surgery. And, it’s a simple, outpatient procedure, with a fairly rapid recovery. I know. I’ve not only done thousands of them, but I’ve had the surgery myself, too.
 
Had he presented with the same pain pattern, but NOT had an MRI, I probably would have urged him to try the non-surgical treatments I teach in my healing program, HOW TO AVOID KNEE SURGERY, which you can get here:
 http://www.drbillsclinic.com/avoid_knee_surgery.html
 
With methods from across the entire medical spectrum, including many effective alternative treatments, it can provide relief of pain and help you avoid surgery, in many cases. 
 
In this way, if pain is relieved, you’ve avoided an UNNECESSARY surgery. If not, you’ve “burned no bridges” and can still get an MRI and if that is positive, arthroscopy, if needed. But it gives your knee a chance to heal itself.
 
Except in case of a completely locked knee, which is a surgical emergency, it can buy you time, perhaps heal you, and you lose nothing. 
 
For other causes of knee pain, like chondromalacia patellae, or arthritis of the knee, it may be definitive treatment. I teach you how to relieve pain fast, but also how to stay pain-free for the long term, with special, modified exercises and the anti-inflammatory properties of my pharmaceutical grade fish oil, DR. BILL’S POWERHOUSE OMEGA FORMULA:   http://www.favoriteformulas.com 
an ultra pure, highly concentrated omega 3 formulation, with a special enteric coating that prevents virtually all the fishy aftertaste and fish burps that plague other, lesser brands. 
 
But in this man’s case, he already had a demonstrated, through and through tear in the avascular zone. The probablity of healing was poor to none. And further delay would accomplish nothing good, but might result in degenerative damage to the articular cartilage, which is permanent damage. This must be avoided. 
 
THAT’S why I recommended that he proceed with surgery. And now, you can understand the thought processes that led me to that conclusion, too.
 
In the end, judgment has to be based on the anatomical and pathological facts. And that’s another good reason to get your doctor involved early in the course of your knee problem. Til next time, my friend, be well.
 
Yours for a pain-free tomorrow and optimal health,
 
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

January 19, 2010

Last week, while I was perusing my emails for Dr. Bill’s Clinic, I came across a request from one of my older subscribers. By older, I mean (quite naturally) older than ME. Ever notice how when anyone talk about “old guys,” they always mean older than THEM. Right?
 
Anyway, this man is, shall we say, in late middle age, has stayed in good shape and has been a runner for years. Problem is that he recently had a sudden onset of severe knee pain, after running to catch a bus, or something.
 
He was seen by an orthopaedist, who after examining him, decided that he may well have a torn meniscus. 
 
As you may know, there are two crescent shaped fibrocartilages, called menisci, which lie between the end of the femur (thigh bone) and the upper tibia (shin bone), inside the knee. 
 
They act as cushions and guides for motion of the joint, especially in twisting, or cutting movements. For more about these and other causes of painful knee pathology, please refer to my LITTLE GREEN BOOK:  http://www.drbillsclinic.com/eliminate_knee_pain.html
 
Because these cartilage structures are invisible on standard x-rays, the doctor ordered an MRI scan of the offending knee. This scan is terrific, because it can show the structures and can predict if they are torn, with an accuracy of about 90-95%, on the medial (inside) compartment of the knee.
 
Sure enough, he had a torn medial meniscus. But he also had a surprise–he had almost completely bare bone exposed on the end of his femur, in the medial compartment. The guy was understandably shocked. How could he have such bad arthritis and not have felt it before this injury?
 
The answer is, this is not an uncommon picture. Sometimes, the articular cartilage becomes degenerative and gradually erodes away, exposing the bone. Though most people will feel this as significant pain, as it happens, a few will compensate (high pain threshhold, endorphins, etc.) and will feel nothing, at all. Until something happens, as did here, to DE-compensate his defenses against pain. THEN, he felt it.
 
Naturally, as a believer in natural healing, he was leery of knee surgery. And studies have demonstrated that arthroscopic surgery added nothing to just medicine, physical therapy and exercises, like those I teach in my newly updated and expanded PAIN-FREE PROGRAM & DVD:  http://www.drbillsclinic.com/exercise_eliminate.html 
 
HOWEVER…in this case, I DID recommend that he go ahead with surgery. Here’s why.
 
This man is very active and wants to remain so. He has exposed bare bone and therefore, will need at least a partial knee replacement, perhaps a total knee replacement, when his symptoms warrant it. But then, he will NOT be able to run or do any exercises involving impact, which could damage, or loosen the artificial implants.
 
He also has a significant tear, easily fixed, in addition to his arthritis. It seems reasonable to conclude that if the tear were “fixed,” he might well “buy time” and return to his asymptomatic state, at least for a while.
 
The studies that recommended against knee surgery for arthritis were talking about a general “clean out,” or debridement, NOT addressing a specific torn meniscus, with very specific mechanical symptoms, directly attributed to that damaged structure. When dealing with arthritis and knee pain, it IS best to be conservative, in most cases, where there is diffuse disease and no specific mechanical symptoms, as seen here.
 
That’s why I wrote my newest healing program, HOW TO AVOID KNEE SURGERY, which you can get here: http://www.drbillsclinic.com/avoid_knee_surgery.html 
 
The many treatments from both conventional and alternative medicine are designed to help you avoid the UNNECESSARY procedure. but if the surgery IS necssary, as it was here, then it should be done.
 
Well, he DID have the arthroscopy, he did, in fact have the tear that the MRI predicted, and he DID do very well. He’s now glad he did it, as he has returned to his preoperative state of virtually no pain. And the procedure has bought him time, which he can continue to enjoy, until further progress of his disease makes a total knee unavoidable.
 
I love being right. 
 
And the only other recommendation I gave him that I would give you, too, is to get on my Powerhouse Omega Formula, an ultra pure, highly concentrated, pharmaceutical grade fish oil, with a special enteric coating that prevents any fishy aftertaste and the dreaded “fish burps.”
 
http://www.favoriteformulas.com  
 
Omega 3′s have potent, long term anti-inflammatory properties that help to control the pain of arthritis, a as well as many heart and brain healthy effects, as well.
 
I also advised him to consider giving up the running, in favor of power walking, or hill sprints, which avoid the damaging shocks to the weight bearing joints, seen with running. If he listens to me, these measures may buy him even more time….
 
Til next time, my friend, be well.
 
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

One of the girls at my local comics shop (well, actually she’s a woman, with a couple of kids) had arthroscopic knee surgery lately. I had occasion to see her today,  as I picked up my weekly comics. Yup, I still read them regularly and I have a collection of various titles that goes way back to the sixties. Some of you know that I was a professional comic book artist for a brief period in the early seventies. I was pretty good, and might have been very, very good, maybe even great, if I had stayed with that as a profession. But Fate had other plans for me…
 
While I wanted to be a surgeon since around the age of seven, drawing and art were freak abilities that I could always do, from the cradle (literally–my mother has a documented drawing that I did at age 18 months). So I got interested in comic books in the late fifties and very early sixties (God! I’m getting to be older than dirt!). 

Initially, like everyone else, I read Superman and Batman, which had been around since the late thirties.  Looking back, the stories were formulaic and pretty banal, but at least some of the art work holds up pretty well, even today. But it was Stan Lee and Jack Kirby’s (writer and artist, respectively) creation of  The Fantastic Four, followed by The Amazing Spider-Man, The Hulk, Iron Man, The Mighty Thor, and The X-Men, that really hooked me on Marvel Comics. 

These names are probably familiar to you, even if you’re not into comics, since all of them have found new life in current films (except Thor, and that film’s been greenlighted for production for a year or two down the road). These blockbuster movies all had their origin, like Hellboy, The Hulk, 300,  Wanted, and of course, the venerable Superman and Batman franchises, in graphic novels and the comics. 

A despised medium in the early years, except in France and the rest of the Continent, where graphic arts are highly respected (a whole separate wing in the Louvre, for example), comics have since grown into a major creative source for the movies. I always loved their spontaneity, their draftsmanship, storytelling ability and graphic design.
 
My flirtation with the medium gave my mother palpitations, when she though I might abandon my plans for medical school (“If you’re a doctor, you can lie down in the street like a bum, but when you decide to get up out of the gutter, you’ll still be a DOCTOR.” Yeah, I know. It doesn’t make sense to me either, but she thought it was persuasive. Go figure.) 

My wife was always mortified that someone (like my patients or my peers) might discover my guilty pleasure.  “Suppose your patients saw you reading COMICS.  What would they think?” I replied (with characteristic humility),  “Honey, when you’re as smart as I am, you really don’t give a damn WHAT they think!” So, my harmless wierdness persists far beyond the period in my life when most serious people have put aside such things. 

Old Ojibway proverb: “For every responsibility of manhood a young man gains, he loses a greater pleasure of youth.” Screw that! I still read them and I like them. So that’s what brought me to the local comic shop (ACME SUPERSTORE, in Longwood, FL) and meeting with the lady with the knee surgery, who works there, today.
 
She’s doing OK now, but she’d had a significant amount of pain right after the surgery, and spent a few days on crutches, until the swelling from postoperative bleeding resolved. She had a few Polaroid spot photos of her intraoperative pathology (taken through the arthroscope) that she had asked me to look at and interpret for her.
 
Sure enough, the photos showed that she had a torn medial (inner side) meniscus cartilage and some articular cartilage shredding, which would be expected, since the torn meniscus is likely to have caused the degenerative shredding. But what was so striking to me was that her kneecap was tilted way off to one side.  This picture is typical of a condition called “maltracking,” or “lateral tracking” of the patella.
 
And, since she didn’t have a terrifically sore lower, outer thigh, I’m betting that this wasn’t addressed by her surgeon. Given this condition, he probably should have done what’s called a lateral release,” at a minimum. In this procedure, the surgeon uses a knife or scissors to split the tough outer fibrous capsule. This releases the kneecap and allows it to return to its normal position, riding in its straight and narrow pathway, in the center of the knee. Since she was in surgery anyway, she already bought the risks and complications, so you might as well do everything you can to correct pathology and save the patient from yet another procedure.
 
BUT, if she had read my newest book, HOW TO AVOID KNEE SURGERY (http://drbillsclinic.com/avoid_knee_surgery.html),
she might have learned stretches and strengthening exercises, and other non-operative methods, conventional and alternative, to fix her problem, WITHOUT SURGERY.
Not all meniscal tears need surgery and many patella problems respond to the various measures I teach at
http://drbillsclinic.com/avoid_knee_surgery.html 

Well, hopefully, she’ll know better next time. And until 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

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