I was sitting in my study this afternoon, fielding calls, writing emails and other correspondance and perusing the Google Alerts I have in place for interesting topics. I came across an interesting article from The New York Times Health Section, dated 12/09/08 (you see, there are some uses for the NYT other than lining bird cages and wrapping fish) that reminded me of the many times I faced similar diagnostic dilemmas in my years of practice. 
 
The gist of the article was that, in the quest for better and ever more sensitive noninvasive methods of diagnosis, like MRI Scans, more and more pathology is being revealed. But, the pathology observed may have nothing to do with the patient’s symptoms. 
 
This leads to a number of unnecessary surgical procedures, as doctors try to treat the pathology revealed by the scan, even if that was not the actual cause of the patient’s pain. This is the paradox of the nonsurgical study–it may result in MORE surgery, not less.
 
A good example is the common finding of a torn meniscus, inside the knee, revealed by an MRI Scan. It’s now well known that many middle aged and elderly people are walking around with torn menisci, without any resulting pain or other symptoms. So they really don’t need surgery, just because they have a torn meniscus, UNLESS they also have very specific mechanical findings or very specific pain, localized to the area where there is an identified torn meniscus. And yet, that is exactly what was happening, until recently.
 
I always got an MRI if my patient had persistent pain that failed to respond to conservative treatments, like those I describe in my newest healing program, HOW TO AVOID KNEE SURGERY, which you can see at  http://drbillsclinic.com/avoid_knee_surgery.html
But they only came to arthroscopic surgery if they had identified pathology AND specific symptoms and signs, consistent with the observed pathology.
 
I remember once, when I was much younger, I had a young man who had very specific joint line pain. He failed to get better with all the conservative treatments I prescribed–medications, local heat, physical therapy, the works. So, we got an MRI Scan. WOW! He apparently had an enormous tear of the posterior horn of his medial meniscus. Lit up like a Christmas tree! So obvious, even a lay person could see it from across the room.

Now, in a young person, job #1 is to preserve the articular cartilage at all costs: in other words, prevent arthritis, which is what happens if an untreated, unstable torn meniscus is allowed to remain, without treatment. So, with this as our goal, the patient, his parents and I were all of one mind: this kid needed surgery, pronto!
 
With all best intentions, I scoped the kid, expecting to see and repair or remove this enormous tear. Only…there WASN’T ANY TEAR. I looked and probed everywhere.  Nope.  Nada.  Well, I wasn’t about to fix what wasn’t broken, so I shaved away some inflamed synovium at the medial (inner) joint line, and got out.
 
He had what we call a “false positive” MRI Scan, a diagnostic image that appears for all the world to be a bona fide meniscus tear, only the tear doesn’t really exist. Imagine my embarrassment when I had to tell the family that I didn’t find the expected pathology, other than the inflamed synovitis (swollen, reddened lining membrane of the joint, which can get caught between the moving bones, just like a torn meniscus).  

The family was very grateful that he didn’t have a tear and all turned out well, because the patient’s preop pain was relieved, probably because I cut away that inflamed membranous tissue. But you could very easily argue that this was a completely unnecessary surgery–I was chasing the chimera of a false finding on a scan. It taught me a lesson, that’s for sure.
 
The fact is, MRI Scans are, at best, only 90-95% accurate on the medial (inner) compartment of the knee joint. This drops to only 60-70% accuracy on the outer or lateral compartment of the knee, because of the more complex anatomy of the lateral meniscus. Bottom line: MRI Scans and other diagnostic tests are NOT 100% accurate. They are just one part of the puzzle and have to be interpreted, based on the physical findings and a patient’s response to treatment. 
 
There are lots of reasons for knee pain. You can learn more about them, in layman’s English, in my best selling LITTLE GREEN BOOK FOR ELIMINATING KNEE PAIN (see here at http://drbillsclinic.com/eliminate_knee_pain.html )
 
Many, if not most of them, can be treated with effective nonsurgical treatments, including alternative and complementary methods. The trick is knowing when surgery is really warranted–and when it’s NOT. That’s why I wrote HOW TO AVOID KNEE SURGERY, which you can see here http://drbillsclinic.com/avoid_knee_surgery.html
 
Remember, the very best surgery is the one you avoid. 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

Later this morning, I have to break down and clear out all the furniture and other crap that has accumulated around and in front of my bookcases. These are the same bookcases I had in my medical office when I was in practice. They’ve “seen” a lot. I got them originally back in the mid- eighties, when I first set up my “satellite” office, with the rheumatologists.

You see, when I was first in practice, I had a “baby face.” I looked younger than my stated age, as we say in the trade. Now, considering that I was the only fellowship trained orthopaedic joint surgeon on Long Island at that time, I was trained and hot to do some major reconstructive surgery. But when little old ladies who needed their hips replaced came in, I could almost “hear” them thinking: “Right, kid! Where’s your father?” And who could blame them?
 
So I figured that I needed to reassure them, with visual cues, that I was competent and worthy of their trust. After all, they were being asked to put their lives in my hands. And that commitment requires a leap of faith. So I set about getting them to “believe.” I couldn’t do much about my face, so I had to find a way to instill confidence, without saying anything that could be interpreted as empty bluster or boasting. 

Nonverbal cues, as the shrinks call them, are very effective for this purpose. So I had real engraved stationery and business cards made–not cheap thermographed cards, that mimic engraving, but the real thing, on Crane’s Crest linen paper, no less. The difference is subtle, but those who recognize the difference KNOW and those who don’t still FEEL the weight of the paper stock. Either way, it goes right to their subconscious and screams QUALITY, albeit quietly, in an understated way.
 
Then, I got a real antique oak partner’s desk, circa 1865, large, long and supported by smooth turned columns on each corner. I bought real leather furniture, brown tufted wing chairs for the patients to sit on and an even larger cordovan leather wing chair for myself, all sitting on plush wine colored carpeting. 
 
There was mahogany chair rail all around the room, and there was a set of richly polished cherry bookcases, some open, some with windowed doors, backlit with subtle lighting. The very same bookcases I still have. 
 
The overall effect was more like a lawyer’s office than a physician’s. But it stated, without saying so, that this was an office of substance, of permanence, of quality and traditional values. In short, it projected an aura of gravitas and competence that compensated for my youthful appearance. And you know, it worked. And once I showed what I could do, the issue of my relatively tender years never came up again….
 
Well, time has had its way with my face, like everyone else. But I still love my bookcases and have them filled with leatherbound volumes, novels as well as medical texts, these days. They still make a nice backdrop for an office, or a video set. So, I’m going to use them as a backdrop for my next major production.
 
I have a video producer coming over and we’re about to shoot my very first video DVD. As you may know, I’ve written a number of books and produced a few audio CD’s to teach you about the various problems that can result in knee pain and the various options you have to relieve that pain, especially those options that allow you to stay out of the operating room and avoid knee surgery. These topics are well covered in my LITTLE GREEN BOOK FOR ELIMINATING KNEE PAIN   http://drbillsclinic.com/eliminate_knee_pain.html
 
But now, I’ll have the opportunity to SHOW you what I’m talking about. I can SHOW you the bones, show you where the ligaments attach, show you what torn menisci look like, and what actually happens in surgery, from videos taken during actual procedures. There isn’t anything like this for lay people on the market. So, I’m pretty excited about it. I hope when it’s released that you’ll like it and find it useful, as well.  I guess we’ll see….
 
Well, have a great weekend and I’ll talk to you next week, with some new tips and things you can do for yourself, to prevent or eliminate knee pain. 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

Last Friday about nine AM, I was sitting in the Grand Ballroom of a hotel, listening with rapt attention to the speakers at an internet marketing seminar, with a number of high profile entrepreneurs. To my surprise, a number of the particpants were martial artists, and pretty well-known champions, at that. One guy, from Canada, actually did two pushups ON TWO FINGERS, just to demonstrate that it could be done. That’s TWO FINGERS of just ONE HAND, by the way. And he did it not two feet from my seat, so I can tell you, it was no trick. Wow! I couldn’t do that on my best day…and I have very strong fingers, from years of crushing bones in the OR .  This young man and his father are among the most successful martial artists in their country.
 
Another one of the speakers was a champion karateka in Tae Kwon Do and is now the President of NAPMA, National Association of Professional Martial Artists and a successful informational marketer. Man, how things have changed from the old days, when I studied Goju-Ryu karate in New York.
 
I remember entering the rickety elevator in the five story commercial building on 17th Street, just North of Union Square, in the summer of1967. The dojo was a large loft, with a polished wooden floor, on the third floor. On the fifth floor were the offices of Al Goldstein’s Screw magazine (but, of course, I never went up there). The sensei was a medium tall, very broad shouldered Hispanic guy (though no one had thought up that term, at that time) named Joe Lopez, a fourth dan (4th degree black belt) in Goju. 
 
With all the 7th, 8th, and 9th dans floating around today, 4th dan doesn’t sound like much, but I can tell you, Goju was a Japanese style, and pretty conservative about promoting people. Joe had come out of the old Peter Urban dojo in New york and he was widely respected by all the martial artists, of all schools, for his unbelievable strength and tremendous punching power. Even the Chinese respected him and actually taught him Gung Fu. Today, that’s no big deal, but in those days, they wouldn’t teach “white guys.” So he was the real deal. Solid and traditional–Nothing inflated, or puffed up about him.
 
Goju only had four belt ranks, too: white, green, brown and black. None of the multicolor constellation you often see with the Korean styles. Pretty conservative, all around. And our sensei absolutely idolized the Grand Master of the style, Gogan “The Cat” Yamaguchi.
 
“Cat” Yamaguchi was a really impressive guy, too: Short man, with long flowing black hair past his shoulders, who wore traditional black Japanese robes all the time. By the time I got involved in Goju, he had become a Shinto priest, with great emphasis on the “internal” or meditative aspects of the art. But when he was young, by all accounts, he was a real street fighter. He was one of the original students of Chojun Miyagi, the Okinawan founder of Goju, and he represented a direct lineage to the roots of modern karate. So everyone in the dojo, from the sensei on down, was greatly honored to follow in the footsteps of the “Cat.”
 
One of the things I admired most about the style was its Chinese influence and its emphasis on flowing, circular motions, very unlike the linear forms seen in Shotokan style, another Japanese form. But, some of these circular movements, especially round house kicks, if not done correctly, would result in knee pain, and occasionally, torn menisci, or injured ligaments, that could result in knee surgery–and they didn’t have arthroscopy in those days.
 
Of course at that time, I didn’t know what I know today. I knew barely enough anatomy to be dangerous. And as for exercises, I was into weights, like everyone else and the basic exercises taught at the dojo, some of which could actually cause knee injuries. But who knew? Had I known then what I know now, I could have helped a number of my fellow students avoid pain and disability, with the exercises I teach today in my new healing program, HOW TO AVOID KNEE SURGERY, which you can see at  http://drbillsclinic.com/avoid_knee_surgery.html
 
Whether you’re a fledgling karate student like I was in 1967, or a champion mixed martial arts fighter, an aging Boomer, or an aspiring young athlete, if you have knee pain, or would like to be sure you avoid it, try the measures I reveal in HOW TO AVOID KNEE SURGERY http://drbillsclinic.com/avoid_knee_surgery.html   I thnk you’ll be glad you did. 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 time, we discussed what’s really involved in arthroscopic knee surgery. My thesis is that you’re far less likley to be afraid of necessary, needed surgical procedures, if you understand what’s actually done. Otherwise, your imagination creates a lot of nightmares that are much more intimidating than the real thing–by far!
 
Although the procedure I described was for treating a painful, degenerative kneecap, the same basic techniques are utilized when dealing with torn menisci, loose bodies, inflamed synovium and even ACL ruptures and tibial plateau fractures. The specifics are different for each type of pathology, but the basic approach is the same.
 
Let’s look at torn menisci first, for today. As I point out in the section on menisci in my LITTLE GREEN BOOK FOR ELIMINATING KNEE PAIN    http://drbillsclinic.com/eliminate_knee_pain.html   these cushions have no blood supply, except for the peripheral 25-30%. So many tears on the inside of the knee simply won’t heal. Therefore, treatment is basically removing the loose, torn fragment. 

After inserting the arthroscope into the joint, as we discussed yesterday, and identifying the loose torn piece of the meniscus, the surgeon uses small nippers, called “basket forceps” to nibble away the offending fragment. The little pieces of the meniscus float around inside the joint, until they’re sucked out by a power shaver (basically a tube with a rotating blade, attached to suction).  This shaver is also used to cut away overgrown and/or inflamed synovium (joint lining membrane), or shredded, fragmented articular cartilage (a process called debridement, or “house cleaning”).
 
Loose bodies, usually fragments of bone coated with cartilage, which have “fallen out” of the articular surface by disease, have been grown inside the synovial membrane, or have been “knocked out” of the joint surfaces by trauma, are removed by long grasping forceps. These are basically “grabbers” that the surgeon uses to capture the loose body and extract it. If it’s too big to pass through the arthroscopic portal (the little incision used to introduce the scope into the knee), either the incision can be enlarged, or the loose body can be broken up into smaller pieces and remove them, one by one.
 
Anyway, as you can see, you can do lots of different things through the arthroscope, but since nearly all the stuff inside the knee is devoid of nerves (or blood), the minimal disability is about the same, no matter WHAT you do inside. And THAT’S what the arthroscopic revolution is all about. And that’s why the pain is so minimal and recovery so rapid after this type of surgery. Pain and disability are functions of the size of the incisions and the amount of internal bleeding.  Minimal incisons, minimal disability. Simple, no? Pretty cool, too. It’s really transformed surgery!
 
Now, you know the worst of it. Not so scarey, is it? But that doesn’t mean you want to have surgery if it isn’t really necessary. That’s the key: you don’t want to be irrationally afraid of surgery, because there ARE times it’s needed. But you DO want to AVOID the UNNECESSARY surgery. This is a common sense, rational approach and the same one I used for lo those many years in practice, which resulted in my treating over 90% of my patients, WITHOUT SURGERY.
 
If you want to give your body the chance to heal naturally, if you want to stay OUT of the operating room, if you want to improve the odds of conservative treatment working, or use alternative methods to relieve your pain, then you need my newest healing program, HOW TO AVOID KNEE SURGERY, which you can see at   http://drbillsclinic.com/avoid_knee_surgery.html
 
Now, I had planned to continue with a description of joint replacement — what it is and what it isn’t–with the same idea: you will be less afraid if you understand what it really is. But I have a special treat for you instead. My friend, Fred Nicklaus, a veteran of 30 years in the martial arts and a guy who has HAD a hip replacement himself, is going to have a special offer on his Combat Endurance course, a proven method to give you a core of steel. But more about that tomorrow…
 
Meanwhile, if you have knee pain and you’re keen to stay out of the O.R., try HOW TO AVOID KNEE SURGERY at
http://drbillsclinic.com/avoid_knee_surgery.html  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

Over the weekend, like many other people, I’m sure,  I periodically tuned in to the Olympics on NBC. The other night, I watched as Mariel Zagunis beat a much taller, larger woman, in the sabre fencing competition, with lightning quick stabs. Not quite like the flamboyant displays of Errol Flynn, or more recently, Antonio Bandaras as Zorro, but effective, nonetheless. 

She then went on to beat her own team mate, Sada Jacobsson (ranked world number one) 15-8 in the finals competition to win the gold medal, the first US gold in Beijing. In fact, the USA swept the women’s individual sabre competition.
 
Now, fencing isn’t usually a sport that holds my interest. It just happened to be on the TV when I tuned in. But I was captivated by the jittery, lightning quick moves displayed by the combatants. It certainly was different from what we’ve come to think of as fencing. And I was particularly struck by the role of the knees in executing these lunges.
 
I could easily imagine how strong their legs must be to hold that en guarde position and then rapidly uncoil to lunge forward in the thrust past the opponent’s sword. It all depends on their knees. 

Now imagine how different the results would have been if Mariel Zagunis, or any of the other competitors, had serious knee pain. No contest. They simply couldn’t do it.  Any attempt to lunge forward in that case would cause a quick, stabbing pain in the front of the knee and abort any attack. And of course, if it were real sabres in a real duel, that would result in death.
 
Well, the reason these world class competitors are able to execute these lunges is because the years of exercise have strengthened their knees and stabilized their kneecaps, so they don’t develop chondromalacia patellae, or degenerative disease, which cause the anterior compartment pain in the knee. You can learn more about the various disease that can cause you pain at
http://drbillsclinic.com/eliminate_knee_pain.html
 
Same thing in Women’s soccer, which I watched the next day. The continual conditioning of these athletes is what helps to protect them from injury. Now, soccer, which requires running, sudden changes of direction and rotational movements, like pivoting and twisting, often with all the body weight on one foot, is a sport that subjects it practitioners to a much higher risk of injury than fencing, which involves chiefly linear movements. Like professional American football, soccer players often get torn menisci and ruptured anterior cruciate ligaments(ACL) from these torsional forces.
 
While you can’t play these aggressive competitive sports and not expect that you might be injured, you can minimize the risk by strengthening all the muscles around the knee, especially the VMO. Quarter squats, terminal extensions with resistance, Hindu squats, all are excellent exercises for creating a margin of safety for the athlete. And the same exercises are fundamental in treating knee pain for the long term.
 
After an injury, the initial treatment is aimed at reducing the resultant tissue inflammation. But after the initial swelling, fluid build-up and redness of inflammation have receded, it’s important to rehabilitate the knee with a variety of exercises to enhance stability, ensure central patella tracking and increase strength.
 
These and other specially modified knee exercises, which are designed to prevent or eliminate knee pain, are the core of my popular PAIN-FREE PROGRAM. See it at http://drbillsclinic.com/exercise_eliminate.html
Choose your own selection from the recommended exercises. Do these exercises at least three times a week, and they will relieve your pain and literally transform your life. Try it and see for yourself.
 
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