Bone on Bone
Hey All, to follow up on my first post “More Movement, More Life” I decided to make my second post about something I often hear from people who come into the clinic. I am sure as I write more posts I will speak of other phrases often used to describe one’s health which flat out annoy me. Misconceptions about one’s health are everywhere, the internet is filled with them! Is it the person’s fault for such? Not necessarily. I blame the medical community (and the internet). For a long time, Orthopedic Western Medicine has relied on a Biomechanical model or Cause and Effect in regards to tissue damage and pain. To use an analogy, because I love them, the medical community has often tried to associate someone’s body to a car. If there is something wrong with your car you take it into your mechanic, he or she fixes it, and boom your car is good again. Makes sense right? Well guess what, we are not cars! (shocking I know). A car does not have one of the most perplexing groupings of matter we have ever found in the universe: the human brain. The brain has a say in nearly every process which goes on in our bodies and is why we are not as straight forward to fix as a car [sometimes]. Such perplexity ties in nicely with the topic of this post: “Bone on Bone”. “Bone on Bone” is a phrase I often hear from those coming in with knee pain and sometimes hip pain.
Random Person: “Well so and so said I had bone on bone in that knee and that’s why it hurts, nothing will change that so I guess it is something I have to live with until I get surgery”.
It drives me nuts and while the phrase frustrates me I am not frustrated with the person saying it, but instead the label. This label is not temporary, it is permanent. Currently, Western Medicine has nothing to replace the lost cartilage in someone’s knee permanently. The Hyaluronic Acid shots we offer here at Aspire replace some of the lost cartilage but the benefits are not lasting (especially when he or she does not do their exercises which go with the HA shots). Thus the person then has the thought in his or her head “unless I get a total knee operation my knee will always hurt”. Once this kind of thinking begins it can be difficult to overcome. It is based off the cause and effect model. Remember as I mentioned earlier our bodies to do not work in such a way. The brain is a very very powerful and complex structure. One of the things research has shown in recent years is the brain works in ways we are only beginning to understand, if even that. Let’s look at a very condensed version of non-persistent knee pain. Some structure in the knee which is having an issue sends the problem message to the brain. Keep in mind this problem message isn’t necessarily pain, we call it “nocioception”. The brain receives the problem message and then makes the pain decision. The decision being “Should this hurt or not?” If the brain feels the issue is threating to the individual then it will create a pain signal for the area, if it does not, then there is no pain signal. This is all done subconsciously without the individual knowing it is occurring. How do we know it is true? A study was done which looked to identify if there is a correlation between increased severity of osteoarthritis and knee pain.1,2 The research shows there is no correlation between the two. Thus, increased osteoarthritis appearing on an X-Ray does not mean more pain. If osteoarthritis is not the true cause of someone’s pain in his or her knee, what is?
Muraki et al did a large study in Japan with the idea to find what has a strong positive correlation with osteoarthritis related knee pain. They used 2,152 subjects who suffered from knee pain and observed quadriceps strength, lower extremity muscle mass, grip strength, knee radiographs and the degree of knee OA, and pain levels. They found an independent positive correlation of quadriceps muscle strength (the muscle located in the front of your thigh) and knee pain. With such being found it suggests improved quadriceps strength will decrease knee pain and prevent it from happening in the future. With a decrease in strength of the muscles around your knee and hip, the body is increasingly forced to rely on the passive structures of your ligaments, bones, and cartilage. With age your ligaments and cartilage show signs of use and are not as strong as they were in youth. An instability [problem] is perceived by the brain and a pain signal is created to bring it to the attention of the individual to either solve the problem or take caution. By strengthening the muscles we can help to solve such an instability. Improving the strength of muscles in your legs provides a lasting stability to aid your ligaments and cartilage. From the Muraki et al study we know strengthening can help to decreased knee pain but it does not always solve the issue completely. I have worked with numerous individuals in which strengthening, while beneficial (you usually cannot go wrong with being as strong as an Olympian), did not provide the best results. Thankfully we have other options.
For those individuals who do not have the desired improvements with exercise (and the Hyaluronic acid shots as part of our knee program) there is another option. Courtney et al posed the question “Does manual therapy (joint mobilizations) help to decreased knee pain”3. They studied 40 individuals with moderate to severe knee osteoarthritis and found most of whom (73% of them) had an abnormal conditioned pain modulation. In other words, the system for perceiving pain by the brain was sensitized. For these individuals it took less of a “nociceptive input” for his or her brain to register the pain signal. In the study Courtney et al performed joint mobilizations on all 40 individuals and found manual therapy aided in reduction of knee pain. By providing the sensory system with the feedback of manually moving the painful joint the brain was able to retrain its abnormal pain system.
The research tells us strengthening the muscles of the hips and knee and performing joint mobilizations help to decreased osteoarthritic related knee pain. We as individuals are not as straightforward as machines. We are much more. Plus everyone is a little different, obviously. Thus what may work for one person may not work for another. My job as a physical therapist is to find what works best for you! I love it. It provides variability to my day and many unique challenges. In conclusion, “bone on bone” is not game over. GAME ON WAYNE! It means it is the fourth quarter and the opponent has been on the upswing and we have to try something new to win.
Until next time,
Thomas Hunt, DPT