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New Physical Therapy Program for Those Aching Joints

Note: This article is over 60 days old, and may contain information that is out of date, or has been superseded by newer information.

Peripheral joint pain (shoulder, elbow, hip and knee) is the second most common reason that North Americans go to see their doctor. Though some people have pain due to a significant trauma, the majority of these problems develop spontaneously or during activity that is considered normal or typical for the individual.

So, what causes most joint pain? Here’s what we know to be true: mechanical factors are the leading cause of painful joints and the most significant mechanical change is the decrease in the ability to move the joint through its full range of motion. This gradual loss of motion begins in the middle age years as a result of the routine movement patterns occurring in our daily activities. Only 50-60% of joint range of motion is utilized during walking, sitting and lying and the other portion of the range of motion is seldom ever used. It’s the lack of movement that tends to start our journey towards stiffness in our joint structures. This change is typically not recognized because most people never pay attention to how well their knee, hip, etc. moves, especially near the end of the range of motion. This is the basis for the adage of "If you don’t use it, you lose it."

So if joint pain develops, should I have an MRI? The problem with imaging is that 60% of people over 50 years old without joint pain have a meniscus tear or torn rotator cuff present on their image. What that means is that these conditions can be present and are often not the cause of pain which leads to confusion and the potential for unnecessary treatment.

Should I have surgery if I develop joint pain? The good news is regardless of the findings on your imaging study or how painful a joint becomes, most people do not require surgery to improve their symptoms. Joint pain can be resolved with end range stretching, strengthening and restoration of joint mechanics. A joint that moves well, through full range of motion are less likely to hurt. Joints that stiffen or lose motion become painful. Scientific studies and clinical trials demonstrate that there are effective methods of management for these problems and have lead to improvements in care for musculoskeletal pain and injury.

CHP in cooperation with The Center for Orthopedic and Sports Physical Therapy (COSPT), has developed the Hip and Knee pilot program to provide additional access to evidence-based therapy for joint pain. COSPT is located at 1834-A Jaclif Court and their phone number is 656-1837. They currently employ 8 physical therapists trained to deliver care for musculoskeletal pain and injury. Ask your PCP if this type of program can be of help in the treatment of your musculoskeletal pain or injury.



Ask Dr. Nancy: Osteoarthritis

Note: This article is over 60 days old, and may contain information that is out of date, or has been superseded by newer information.

My knees hurt more and more as the years go by. How would I know if I have osteoarthritis?

Osteoarthritis (OA), also called degenerative joint disease, is the most common type of arthritis. It is caused by a breakdown of the cartilage that cushions the ends of bones. As that cushion wears down, the tendons and ligaments around the joint may weaken and the bones may rub together which causes pain, stiffness and swelling.

Because cartilage wears down over time, osteoarthritis is more common in older people and in people who have had a previous injury to a joint. Joints that bear the weight of the body such as knees and hips are affected the most. Finger joints at the middle and ends of your fingers can also be affected. Unlike other types of arthritis, osteoarthritis only leads to joint problems; it does not cause problems with the skin, internal organs or any other part of the body. Often there is a family history, and it appears that some people have cartilage that is more prone to wear-and-tear than others.

A recent panel with osteoarthritis experts from 12 countries found that 3 symptoms and 3 signs lead to the diagnosis of osteoarthritis with 99% accuracy. The 3 symptoms are: pain on use, short-lived morning stiffness, and limitations on how the joint functions such as stiffness. The 3 signs on exam are: crepitus (a grinding noised with bending of the joint), restricted movement, and bony enlargement. The most obvious place that bony enlargement can be seen is in the finger joints. When bony knobs form on the middle joint of the finger they are called Bouchard’s nodes and when they form on the end joints they are called Heberden’s nodes. You might want to think about whether or not these symptoms sound like ones you have and check in with your primary care physician.

Treatment for osteoarthritis has more to do with lifestyle than medical intervention. The Agency for Healthcare Quality and Research ( recently published a guide, “Osteoarthritis of the Knee”, based on available scientific evidence.

There is a lot of good information in that guide about what helps. The top recommendations are to lose weight, keep moving with low impact exercises, and take mild pain relievers. You might also ask your physician about physical therapy. Strengthening the muscles that move the knee, particularly the large thigh muscle in front, the quadriceps, can lead to improved function and support of the knee.

The guide also discusses other treatments that usually do not reduce pain or improve knee movement for people with osteoarthritis: Glucosamine/ chondroitin supplements, joint lubricant shots (not the same as cortisone shots) and arthroscopic knee surgery to smooth out cartilage.

Ultimately knee osteoarthritis can lead to surgery for joint replacement but it is best to put that possibility off into the future by protecting your knees now.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).


Ask Dr. Nancy: A Picture May Not Always Be Worth a Thousand Words

Note: This article is over 60 days old, and may contain information that is out of date, or has been superseded by newer information.

Everyone who is part of the CHP network wants patients to have good clinical outcomes. The crucial first step for any medical problem is talking to the patient, and the second step is examining the patient. The easiest way to get off on the wrong track is to skip or short-cut these essentials.

While technology has helped in the diagnostic process, all technology has limitations and needs to be considered in light of the first two steps or, specifically, what the patient is experiencing.

A suggestion often seen on a report of a CT scan, x-ray, or MRI is that the ordering physician correlate (compare to see if it makes sense) the imaging findings with the clinical situation of the patient. The reason this is such a good idea is that oftentimes abnormalities are seen on imaging studies that have nothing to do with the patient’s symptoms, or the imaging study cannot be used to make a definite diagnosis. Let’s look at some examples.

Knee Pain: An article published in the New England Journal of Medicine in September, 2008, showed that when knee MRIs were done in middle-aged and elderly persons, a cartilage tear was found in 63% of people with knee pain, BUT 60% of people in the same age group without knee pain also had a cartilage tear. The take-home message? Just because you have a cartilage tear doesn’t mean it has anything to do with your knee pain. Clinical correlation is the key.

Multiple Sclerosis: A study, published in the British Medical Journal in 2006, compiled the results from 29 previous clinical studies that assessed MRI results along with patient outcomes. Its findings were that, with a first episode of a neurological symptom, MRIs had “limited utility for both ruling in and ruling out multiple sclerosis.” The most important information came from the clinical course of the patient. With regard to multiple sclerosis, a second episode of neurological symptoms occurring at least a month after the first episode is necessary to make the diagnosis.

Low Back Pain: Low back MRIs (noted in the back pain article) are another example of how imaging studies can potentially lead down a path of treatment that may not yield good clinical results: “65 out of 100 adults without any back pain have abnormalities such as arthritis and bulging discs.” These imaging results make early clinical correlation problematic and can lead to inaccurate associations between chronic asymptomatic findings and acute pain.

COPD: The final example is Chronic Obstructive Pulmonary Disease (COPD), also called chronic bronchitis and emphysema. If COPD becomes severe, changes may appear on a chest x-ray, but for mild and moderate cases, the chest x-ray can easily appear normal. The way to diagnosis COPD is, once again, the duration of the patient’s symptoms, such as cough, along with pulmonary function testing (PFT) to measure the function of the lungs, rather than viewing the anatomy of the lungs. So the next time you hear from someone who smokes that they are fine because their chest x-ray is normal, ask them if they have had the appropriate history and testing that diagnoses COPD. As with many medical conditions, earlier diagnosis of COPD leads to more treatment options. Not being able to breathe is a bad outcome.

It’s not that there is anything wrong with images; it’s just that a picture doesn’t tell the patient’s story. Patients have to do that, and the best place to start is with your primary care physician. The last thing that anyone wants is to treat a radiological abnormality but end up with no relief from an underlying medical condition because the image told a different story. Remember, too, that keeping track of your symptoms in a diary—knowing the details of what you are experiencing—is invaluable to getting to the right next step.