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CHIROPRACTIC HELP #30: Arthritis pain in knee
June 17, 2012

Dear

Welcome again to the monthly newsletter from Chiropractic Help. Firstly, a big thank you to all of you who responded to my question last month. The longer monthly version of your newsletter is obviously the favourite. Apologies for not having responded to each and every one of you, but I want you all to know how much I appreciate the time you took to write. This one too is rather long, so make a big pot of tea, get comfortable and view this on your computer not the laptop. Why not?

Make sure you have set "view the graphics" if you're on a PC and, on an AppleMac, I fear you may have to look at the online back issues. The graphics may not appear.

Chiropractic Help backissues ...

Arthritis pain in knee

The knee obviously is a vital joint in locomotion and, with all the research coming out concerning speed of walking and longevity, arthritis pain in knee doesn't just make you miserable. It cuts your life short too. Literally.

So, what are the symptoms of arthritis in knee ?

Stiffness

First and foremost stiffness. We'll see later the reasons for it, but the chief sign of degenerative knee arthritis is loss of range of motion. What may be confusing is that sometimes there is loss of flexion - you can't bend your knee - and sometimes loss of extension - you can't straighten your knee.

Either way, it inhibits your walking, you develop a limp and there's a knock on effect. Invariably this limp leads to sacroiliac joint pain ...

Worse it may lead to slipped disc symptoms ...

In short, point out someone to me with knee arthritis, and I'll confidently tell you that they also have low back pain.

Crepitus

In the early stages one of the first knee arthritis symptoms is a grinding or clicking sound. Careful analysis is required: is this sound coming from under the kneecap, from within the knee proper, or even referred from the hip joint? One of South Africa's leading orthopaedic surgeons once told me that many a knee is operated on, when in actual fact the problem is in the hip not the knee.

I can appreciate that, the click from a hip condition reverberates right into the knee, misleading the hasty examiner.

Crepitus under the patella, causing Patello Femoral Pain syndrome is readily treatable with conservative chiropractic means, but that from within the knee is far more difficult.

Another cause of crepitus is a damaged meniscus which may even cause a locking knee. This may need to be surgically treated, though not necessarily so.

Yet another cause are "joint mice" - pieces of cartilage that have broken off - floating in the synovial fluid within the knee - and may become entrapped between the femor and the tibia causing...

Pain

The pain in the arthritic knee is often a dull ache initially but as the condition develops the pain becomes exquisite causing ultimately severe disablement. Stairs become an enormous challenge.

Causes of knee arthritis

Probably the most common cause of the knee arthritis symptoms is an old sporting injury. In football crazy Holland, and rugby crazy South Africa the wrenched knee causing injury to the ligaments or meniscus is common place. I am sure it is no different in basketball and American football.
Competing for first place is obesity. Simply put, the extra weight results in the cartilage of the femur pressing directly down on the cartilage of the tibia, something it was not designed by the Almighty to cope with. The result, knee arthritis symptoms. There are few obese people who escape the pain and disablement of knee arthritis.
More complex are dietary deficiencies. For example it is now fully accepted that a magnesium deficiency in the diet causes the deposition of calcium in the cartilage causing "ChondroCalcinosis", a disabling arthritic condition often affecting the knee. More serious, a magnesium deficiency also causes inflammation of the arteries.
Surgery. In the past, damaged menisci were completely removed resulting in bone on bone in the knee with inevitable onset of knee arthritis symptoms. Even conservative arthroscopies can set up inflammatory reactions within the knee. Arthroscopy knee surgery ...
The final cause that comes to mind is infection. Less common today with the antibiotics available, but bacteria in the synovial fluid in the knee may attack the cartilage causing severe arthritis ultimately.

Case File

Case History

Mrs X, middle aged, consulted us with severe left knee pain. The pain had begun some ten years previously, but grew progressively worse, especially the last three years.

At 5'1" and 207 pounds she had a body mass index BMI of 39.1 (above 30 is obese, above 35 life-threatening).

She had played a lot of sport, especially hockey, but having stopped her sport, she took on a sedentary lifestyle.

She described the pain as a deep ache, with very sharp stabs when walking. Kneeling was also very painful and she couldn't straighten her knee. She walked with a profound limp. This had provoked lower back pain.

Previous treatment included six cortisone shots, an arthroscopy which included debridement and a "microfracture" procedure, 9 months before the first chiropractic consultation. After the arthroscopy she was unable to straighten her knee, and the pain became far worse.

She was taking anti-inflammatories nightly, or couldn't sleep. A glucosamine chondroitin product and Synvisc injections had brought minimal relief.

She was scheduled for a total knee replacement in two months time, but decided to consult us in the interim.

On examination

An obese woman, she walked with an extreme limp, unable to straighten her left knee. The pelvis was markedly low on the left, in part due to the bent knee, but also due to a leg length inequality with the expected right sacro-iliac joint fixation. Both lower legs, particularly the left were swollen.

Flexion of the knee was almost normal, but there was loss of 25 degrees of extension. Any attempt to straighten the knee caused extreme pain. The Bounce Home test was very positive.

The tests for meniscus damage were normal. The AP drawer test for the cruciate ligments was normal, but both collateral ligament tests were very lax, but non-painful.

Clarke's test for PFPS was negative.

Noble's test for a ITB syndrome was positive; active trigger points were found down the ITB and in the Tensor Fascia Latae muscle. IlioTibial band stretch ...

Examination of the lower back revealed a routine uncomplicated L5 lumbar facet syndrome ...

X-rays

X-rays show severe loss of the hyaline cartilage that lines the medial femoral and tibial condyles, with many fragmented pieces of cartilage (joint mice) floating in the synovial fluid. The tibial spines are severely sharpened.

There is almost certainly a hole in the cartilage as seen above in the stock arthroscopic photo (not hers, thus speculative just how serious it could be). On the left side fragments of cartilage are seen, about to break off and form joint mice.

AP Left knee

Lateral Left knee

Chiropractic treatment

Consult 1

The first consultation consists of a full history and examination of each patient, and she was no exception.

We gave her some gentle knee exercises do be done daily with each cup of tea; frequently during the day.

Consult 2

A report of findings was given to Mrs X, and a short tour of what is Chiropractic. There was no need to stress the seriousness of her case; she knew. Moreover, her dietician had spelled out that a BMI of 39 meant her whole life was at risk, not just a disabled knee. For three years she had limped from one doctor to another, unable to walk even the mall, unable to sleep without painkillers.

Nevertheless, I made it plain that I was not prepared to accept her case without a firm commitment to get the pounds off. At least 50. Because without that, she was wasting her time and money in our clinic.

Finally, she was ready to do what she knew had to be done. Make some vital dietary changes. More about that later.

The first chiropractic treatment consisted of a gentle mobilisation of the knee joint, with axial traction, and use of electro-stimulation.

I referred Mrs X to our free weight loss programs and recommended fatty fish several times a week, plus omega 3 supplementation. Fish oil health benefits ...

Consult 3

She felt a slight improvement in her knee pain. We introduced the first chiropractic treatment for her pelvis and lower back, and our lower back exercises programme.

We addressed for the first time the lateral thigh myofasciitis. Treatment was painful.

Consult 4

She felt a distinct improvement and for the first time in months was able to hobble around the mall, but suffered the next day. Her knee was still locked in flexion. Three pounds weight loss.

Her right foot was painful, which she had not mentioned earlier. We found fixations of the cuboid and medial cuneiform, and a general plantar myofascitis. Treatment for foot pain ...

Consult 5

Improving. She felt the sharp pain was 50% less, but was still unable to straighten her knee. She was off medication at night. Her lower back pain was much improved. She had lost 8 pounds. Some suboccipital headaches. Upper cervical adjustment.

Consult 6

Improving, same treatment. We are definitely getting increased movement in the knee, and extension is not so limited. She is walking better. 12 pounds weight loss

Consult 7

Setback. She stumbled on a step and came down hard on her left knee. McMurray's test was positive for the first time. 14 pounds.

Consult 8

Despite the setback, continued improvement. She was able to stand in church for a longer period, and she managed to do 16 lengths of backstroke at the pool. Her foot continued to burn when walking, but was much less swollen. No lower back pain. 18 pounds.

Consult 9

Two weeks later. Her knee had locked over the weekend. Extension reduced again. Discouraged. 22 pounds weight loss.

Consult 10

Much improved for two weeks but then sharp stabs in the knee again. No lower back pain. Foot improving. Almost full extension for the first time. Bounce home test negative. 28 pounds loss.

Consult 11

Her knee pain is much reduced. She can straighten her knee for the first time since the arthroscopy surgery, now one year previously. She can walk much further, is taking virtually no medication. She has now lost 36 pounds, and is taking an extended overseas holiday with family. She feels up to it.

Some midthoracic and rib pain after much sewing. A thoracic spine exercise, and rib pain treatment ...

Review of this Knee arthritis symptoms casefile ...

"There is a tide in the affairs of men.

Which, taken at the flood, leads on to fortune;

Omitted, all the voyage of their life

Is bound in shallows and in miseries.

On such a full sea are we now afloat,

And we must take the current when it serves,

Or lose our ventures."

spoken by Brutus, from Shakespeare's epic Julius Caeser.

There come vital moments in the lives of all of us, a tide in our affairs. Such was the defining moment when Mrs X first consulted us. She was faced with "shallows and misery" for the rest of her life, and I didn't need to point it out. She knew she had to take the flood tide...

The Chiropractic knee arthritis treatment was, of course, important, but the vital decision was to lose weight, and a lot of it.

There is of course no certainly of the future. Research at the medical university at Utrecht, NL, has shown that cartilage can regrow if the knee is unloaded. Mrs X has done most of that hard work. Another 10-15 pounds and she has a good chance of escaping a total knee replacement, at least in the immediate future.

I have the utmost admiration for Mrs X. It's not been an easy, happy ride I can assure you. Both she and we have had doubts. Were we wasting precious time and money? Should she just go and have the operation? But no, she stuck with the programme, even when there were setbacks. Her determination to get well was overwhelmingly evident.

Anti inflammatory drugs

One of the good things about chiropractic help for knee arthritis symtoms is that it is TOTALLY safe. Provided used by a skilled and well trained chiropractor, the chances of making the condition worse are zero. And when the patient is on the verge of a total knee replacement, there is nothing to be lost.

I have no difficulty with taking anti inflammatory drugs (NSAIDs) for a short trial to see if they might help, but taking them long term as Mrs X had done, is highly dangerous. With NSAIDs there is much to be lost. Even in the treatment of neck pain, where there is some very small risk from chiropractic manipulation, a literature search by Dabbs and Lauretti concluded "The best evidence indicates that cervical manipulation for neck pain is much safer than the use of NSAIDs, by as much as a factor of several hundred times."

Further, "The likelihood of a serious gastrointestinal bleed from NSAIDs is 1 per 1000 and the death rate for NSAID associated GI problems is estimated at 0.04% (4 per 10,000) per year among patients with osteoarthritis who receive NSAIDs".

Absolutely avoid the taking of dual antiinflammatory drugs; consider rather alternating ice and heat treatment, exercise class benefits arthritis and of course Chiropractic Help and the vital weight loss. New research also proves that adipose tissue itself produces highly toxic inflammatory agents, further aggravating the problem. Arthritis and obesity ...

In the next week I'll be writing up a similar case of a woman who was also much worse after arthroscopy. She was unable to bend her knee... signed up for our Chiropractic Help blog? You'll find it, called RSS at the bottom of the navigation bar at the left at the Chiropractic Help homepage. Then you'll get all the new pages as they come off the press!

Think...

Successful health care depends on both the practitioner and patient applying their minds, particularly when things aren't going as planned.

Mrs Y's neck pain wasn't responding as expected. A cycle of improvement, followed by relapse. True, she had a very arthritic neck, I foolishly reasoned, but that was not the cause of her problems.

Finally, after one very serious attack of torticollis, I finally applied my mind. What is happening, Mrs Y? Sleeping on your tum again? Doing my neck exercises? Back on the laptop? Finally it came out. She was doing 100 crunches at the gym several times a week, and doing "lat pull downs", both absolute NO-NO's for patients with chronic neck pain. There are better ways to strengthen the core muscles.

Had I questioned, thought, applied my mind earlier, I could have saved her several months of neck pain. And quite a lot of money! So, too if she had applied her mind, not presuming that this or that was okay.

Things not going well with your chiropractic help? THINK!

Books

Nothing on health books this month, I confess, nothing new on diet. I've just finished Michener's epic Caribbean. All 800 pages, it comes highly recommended from me.

Till next month, then...

Yours in better health,

Bernard Preston DC

PS. Feel free to forward this to family and friends, your chiropractor and even your medical doctor!

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