You Have Arthritis
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With a look of resignation my patient explains that their family doc told them their knee pain was arthritis and they could only manage it with anti-inflammatory meds and eventually surgery. I asked them, as I ask many patients, “what do you think arthritis actually is?”. Most patients look at me, somewhat perplexed, and give a variety of answers hovering around the idea of joint damage. In the most simplistic terms osteoarthritis is excess wear and tear on a joint, it’s not congenital, auto-immune, infectious or most importantly it is not an uncontrollable condition. For the average person (average meaning without major trauma, surgery etc) it’s the result of their sports, work and day to day activities compounded over their lifetime. Excess wear and tear.

Early signs of arthritis in the knee

Patients actual xrays with subtle loss of space between her femur and tibia. Thicker white lines on the joints surface of the femur and tibia.

Luckily this patients had been referred for knee xrays, so we took a look at her films together. I showed the patient the space between the bones in her knees and where I’d look to see bony indicators of degenerative change. We could both appreciate that the changes were subtle. We read the report together, “signs of early arthritic change” was the key line in the two sentence report on otherwise normal knees. So I asked another question “do you think arthritis is still the only reason you might have knee pain”. With a little more optimism she started to question the original diagnosis. For the sake of comparison the image on the right shows moderate to severe osteoarthritis.

This is more significant arthritic change. There is an obvious difference when comparing to our "arthritic" patient.

This is more significant arthritic change. There is an obvious difference when comparing to our “arthritic” patient.

 

 

 

Let’s look back at that simple definition, osteoarthritis is the result of excess wear and tear. Excess wear and tear is often the result of poor joint movement. Maybe the balance of leg/hip strength, flexibility and coordination has forced or allowed her knee to move poorly and now painfully. Maybe she wasn’t feeling the pain of worn cartilage but the pain of stressful movement.

 

What’s the point?

Worn cartilage and arthritis feels very much out of our control. Strength, flexibility and movement is something we can control, work on and ultimately improve. Arthritis is an effect of poor joint movement.  If you feel like throwing in the towel because you’ve been told or think you have arthritis it might be time to reconsider your understanding of this process. Take charge by truly understanding the source of your pain, not just the symptoms. Invest time moving your body and getting stronger.

Dr. Budgell

Shovel Right, Shovel Light

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Most people warn that shoveling to hard will give you a heart attack. While that risk is present the most common result of snow shoveling is a sprain or strain injury and it affects more people than you’d expect. Here are some tips to better prepare you for that next day in the driveway.

Shoveling is exercise

Accept this fact and you’ll fair much better. Getting out for a good shoveling session starts with the right gear. Warm, comfortable clothes and shoes with good traction is an important start. Like any other exercise it’s best to begin with a warm up. Take a brisk walk up and down your street and follow that with some light stretching. This could be as simple as giving yourself a nice big hug to jump start those shoulders, some light bending from side to side to loosen up that torso and take a few long strides steps to get those legs prepared.

Know your limits and rest when you need it. Each lift of the shovel should not feel like you’ve just set a personal best in weight lifting. Stay within your limits. Once you’ve done a dozen or so snow pushes or shovel lifts take a short break and strike that classic ‘elbow on shovel’ pose. This will let you recharge for the next round.

Finally, end that workout with an appropriate cool down. Take another stroll down the street and let those muscles relax with a light stretching session.

 

Out-smart snow

Your trusty shovel may be your greatest ally or leave you feeling better off with a spoon. Selecting a good shovel is key. Consider these points when selecting your shovel.

  • push style shovels are your best bet
  • a modest size blade helps you lift light
  • an ergonomic handle does make a difference
  • pick a handle length that lets you stay upright as your work
  • a slippery blade coating will keep snow from weighing you down

Plan ahead for the next snowfall and be proactive by heading out for a light shoveling session every 5cm or less. This will let you shovel lightly more often and take good size breaks in between. This will help you avoid trying to take 20cm or more of snow at once. Most often it’s large snowfalls that lead to shoveling related injuries.

Finally, there is always bad techniques in shoveling that can lead to injury even with the best of shovels. These technique tips can help you become more efficient and reduce your risk of injury.

  • Keep your nose between your toes to avoid twisting your back
  • Push the snow instead of throwing when possible
  • Bend your knees to let your legs do the work
  • Keep your head up to help you maintain good back posture

If done right shoveling can be a rewarding and healthy activity. Remember to treat shoveling like exercise by using the right gear, warming up and cooling down. Outsmart the snow by planning ahead, shoveling small amounts often and using the right shovel to it’s full potential. Like all activities you can expect some mild soreness that day and the next, if it goes beyond a couple days, seek professional care.

Dr. Budgell

Heat or ice for back pain

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heating padThis may be the most common question that comes up during a new patient visit. So doc, should I use ice or heat on my back when it hurts? My answer, with consideration of the literature that has been published over the last few decades, my clinical experience and the understanding of patient preferences is to use heat for diffuse muscular stiffness and ice for sharp localized pain.

 

How does heat help 

Heat is a natural by-product of muscle activity and the support systems for that muscle (blood/oxygen supply, nerves, lubricants, hormones) act differently to help as the heat rises. Heat opens blood vessels which means more blood carrying oxygen and nutrients to fuel and rebuild injured muscle as well as take away toxins and damaged tissue. A warmed muscle is more able to slide along muscles/bones/tissues in the area giving you decreased resistance or stiffness. Much like a warm up for sport heat can help bring muscles to a point where the muscle contraction and release is more efficient, bringing relief to that sense of stiffness.

05-ice-pack-lgn

 

How does ice help

Ice is very effective as a numbing agent to reduce localized pain, especially near the skins surface. Rather than popping pain killers and waiting, ice can often provide immediate pain relief to superficial regions like your tail bone. Opposite to heat, ice encourages blood vessels to constrict and reduce blood flow which can be valuable if swelling or bruising is an issue.

 

effective delivery

Your body is excellent at regulating its temperature. So that hot water bottle may bring your skin temperature up but an inch below the surface that extra heat is dissipating quick. The same idea applies for ice. If your target is superficial an ice or heat pack will work well with continuous heat for up to 30 minutes or ice applied in intervals of 10 minutes on, 10 minutes off. If the target is deeper or thicker tissue you may want to drive up your whole body temperature with a hot shower.

 

Quick summary

Heat works well for diffuse muscle stiffness when used for up to 30 minutes continuously.
Use heat packs for smaller superficial areas and a hot shower for deeper/thicker muscles.

Ice works well for superficial sharp localized pain.
Use ice packs in intervals of 10 mins on, 10 mins off for pain relief and to reduce swelling/bruising.

Always be cautious applying extreme temperatures directly on your skin.

 

Dr. Budgell

The Canoe

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Think about this situation and what you might do differently.

John loves to go fishing in his canoe. He’s got a great canoe. Lately when he launches his canoe it rubs on a few jagged rocks coming on and off the water. At first he didn’t see the wear, now he can see the worn surface and torn fiberglass. When he pushes on the worn area he feels the weakness in the structure. John kept on the same routine day after day. Finally the side wall gave and water would leak through, slowly sinking his canoe. Even with a little leak he could stay out 2 hours. When the leak got bigger could barely do any fishing before there was too much water.

At what point does the damage become more difficult to repair?
What if John just started launching his canoe away from the jagged rocks?

More importantly what if you were the canoe?
Would you think differently about how to care for your own injury?

Let’s flip the story:

John works building cabinets. He’s a great craftsman. Lately he’s had to bend awkwardly to pull some materials from behind a saw they’d recently moved. At first he didn’t notice his back, now he feels a pull along his spine. He feels tenderness when he presses on his low back. John kept on the same routine day after day. Finally during one awkward bend he felt a stronger pain that wouldn’t go away. Despite the pain he could get through about 2 hours work. When the pain worsened he needed help operating the machinery and could barely work.

Caring for your own health can be as simple and as logical as caring for anything you hold dear.

Dr. Budgell

A simplified balance

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Talk to a nutritionist and their most simplified approach to weight loss is that if the calories you use up exceed the calories you take in you’ll lose weight. Flip that equation and you’ll gain weight. Often you can simplify injuries to this level as well. Every activity places a certain level of demand on your body and everyone has a certain physical capacity. If the demands exceed the capacity you’ll eventually hurt yourself. If you flip that equation you may enjoy an injury free existence.

 

Demands greater than Capacity = Injury

Understand demands and capacity

Your body is constantly adapting to the demands consistently placed on it and will be expertly prepared for those demands. If your life consists of getting up, driving to work, sitting all day and then watching tv for the night your body will only remain strong enough to roughly keep your body upright while standing or sitting. If you only expose yourself to small physical demands you’ll only maintain a small capacity. If you always take the elevator you’ll always get tired climbing stairs.

Infrequent activities do not last

You stress your body, maybe you do 10 lunges. Your muscles and connective tissues are stretched and strained. The repair process takes 24 to 48 hours and your body adds some extra muscle and connective tissue fibers in case you need them for the next time you do 10 lunges. After a couple of days if you don’t do any more lunges those fibers may not be maintained and are re-absorbed and their materials used elsewhere. 2 weeks later you do 10 lunges and they’re no easier.

Organized demands

You do 10 lunges. 2 days later you do 10 more lunges. Every 2 days you take the new tissue your body has added and stress them. In turn your body adds more tissue and you stress that tissue. Suddenly you have greater muscle strength and connective tissue that can better resist that stress and strain of 10 lunges 2 weeks later you do 20 lunges and they feel as easy as 10. More importantly when you decide to move a few heavy boxes in the basement you’re less likely to injure yourself thanks to this new capacity.

 

10-15 minutes of smart physical activity done every other day is a great starting point to reduce your risk.

 

The blunt truth

You need to give your body a capacity beyond the demands you may place on it. If you’re facing a physical demand that you know is greater than your capacity; expect injuries. Maybe not the first time but you’re poking a sleeping bear. You don’t need to hit the gym and squat 300lbs. You need to be good at movement, you need to be practiced at lifting, pushing and pulling things that weight as much as things you interact with regularly. This could mean a shovel full of snow, a basket full of laundry a couple 2 by 8 boards or a heavy bag far in the back your car trunk. If you’re not preparing for the demands, prepare to call my office.

Dr. Budgell

Joint Alignment

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In my experience most patients are inherently aware of this concept before they ever set foot in my office. There is also a very large contingent of doctors and therapists who don’t appreciate or understand the importance of joint alignment.

The feeling of misalignment

At some point in your life (maybe your day) your knee, shoulder, wrist, elbow, ankle, hip, back, neck etc. has suddenly become limited in their normal motion. You feel resistance, locking, pain or pressure right in the joint preventing you from moving further. Maybe you try to check your blind spot and you feel like something in your neck blocks you. You try to squat down and stiffness quickly develops in your knee to prevent you from completing that movement.

Many times (by many health professionals) this gets chalked up muscular tightness. You can’t turn your neck because the muscle is tight or is in spasm. You can’t complete a squat because your quads are tight. This might explain mild cases where you can feel a stretch develop and slowly work through that tightness. You typically don’t feel that pain at the joint.

Altered Joint mechanicsPosterior Knee joint

This can be a complicated topic and is often missed during assessments. Your knee joint makes for an excellent example with a lot of research behind the concept. It’s construction leaves it to act much like a door hinge, pivoting primarily around just one axis with some extra cushioning inside. If the top and bottom of the joint line up well the movement is typically free of crunching or creeking and at the end of bending or straightening there are two cartilage surfaces still in contact with one another. If the door hinges are installed correctly there’s good contact between the metal pieces and they slide well over one another.

Quite commonly misalignment will develop at the knee joint where the shin bone is turned outwards compared to the thigh bone. This is commonly seen in Helfet’s test when the tibial tuberosity (center-line of the shin bone) is too far lateral compared to the center of the knee cap. Because of this subtle twist the cartilage surfaces don’t align perfectly and so towards the end of straightening or bending those cartilage surfaces slide off one another forcing your to stop your movement. Those cushions between bones are being repeatedly pinched. Now one half of the door hinge is slightly angled. It creeks as it opens since now only parts of the hinge are touching with far greater pressure.

Normal reactions to joint pain

Joints have powerful control over their surrounding muscles. They contain nerves that are highly sensitive to any compression or stretching of it’s tissues or cartilage. Joint misalignment compresses and tensions those tissues causing signalling to muscles in the area to relax or tighten to try and improve the joint position. This is where many assessments start and finish. “You can’t squat fully and your quads have become tight, they must be preventing you from squatting fully. Let’s do some stretches.” Too often the underlying issue is missed. Correct the knee alignment and the signalling to other muscles fades. Quads get back to a normal length and tension without unnecessary work.

Long terms changes

Quite often misalignment develops without traumatic injury. A long day at costco, vigorous hike or a hard leg day can often be enough. This will leave people assuming their joint is unaffected despite their pain because there was no trauma. So they deal with the issue for weeks or months. They stretch, they exercises, they deal with the pain. That joint has been signalling surrounding muscles to fire harder or stop firing for days or weeks. The tissues of the joint have been bearing higher than normal tension and the cartilage has been repeatedly rubbed hard in certain places. Why do you think it’s so common to develop arthritis in just one knee even if you’ve never had a significant knee injury?

 

Dr. Budgell

No pain, no gain.

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This is a very slippery slope that I strongly hope you’re not sliding. I especially hope your personal trainer or therapist isn’t pushing you down that hill. You really only have two options when thinking about pain. You either have pain or you don’t have pain.

I have pain. So therefore no pain, no gain.

Let’s say that lifting your arm in the air gives you shoulder pain. A very unique feeling that you could easily identify and would probably avoid certain activities to prevent. For now think of that as Pain. It is the signaling from valuable tissue in your shoulder that its very integrity is compromised. There is an injury and the way you just moved worsened it. You should stop. So how in this scenario could more Pain be of any value? Listen to your body.

Sometimes things aren’t that simple. Sometimes Pain doesn’t develop for a few hours or a even a day. That same shoulder Pain arrives 3 hours after you’ve unloaded the dishwasher and did laundry. The cumulative effect of those activities compromised the integrity of that very important tissue in your shoulder and now it’s signalling your brain with Pain. This really isn’t different, that injured tissue is compromised either by 1 movement or many movements and could be felt immediately or delayed.

Your rehabilitation should follow this concept. Movement does some amazing things. Even the slightly pull on tissue stimulates the production of connection tissue, new cell production and repair of existing tissue. Pain isn’t a requirement. Being able to perform movement that doesn’t create immediate or delayed pain should be a very simple definition of rehabilitation.

I don’t have pain. So therefore no pain, no gain.

Congratulations you’re pain free. Now you’re probably thinking about performance improvements. What is pain telling you about your performance? Let’s get back to tissue integrity. If you’re feeling genuine Pain, you’ve managed to compromise the integrity of a tissue. This doesn’t mean appropriate stress through microtrauma. This means damage. Injury. Sure it will likely heal over a few days and maybe even trick you into thinking that’s how ‘good’ sore feels. It’s not. Performing a movement that causes pain means you’ve exceeded the integrity of a tissue either by applying too much load or stretch. Maybe the movement was too fast, heavy, awkward, unpracticed, inappropriate (i.e. the continental lift) or you’ve progressed too quickly. That part could have many answers. Pain has one answer: stop, reassess your approach to learning/improving that movement and begin a new approach after you’ve healed.

Maybe you’re reading this and thinking if people stopped training a movement every time they approached pain their training would suffer. I completely agree. Wolfe’s law. Tissues respond to stress. Efficient training means getting tissue very close to the point of failure without crossing that line. I’m talking about to the person who feels their hamstring grab on deadlifts, whispers to themselves “no pain no gain” and bangs out 2 more sets. The person who progresses their squat weight too quickly and needs five days to recover before they can train again. If you’re training hard you will occasionally become injured and feel Pain. If you do re-read the previous section of this article then try not to make the same mistakes.

Caveats

[almost] Nothing is absolute. If you’re “into pain” or want to feel pain to better relate to others in pain my advice may not apply. There are treatment techniques that can be pretty painful. Shockwave treatment comes to mind. I do numerous muscle/tissue releases and adjustments that can at times be painful. Brief fleeting moments of pain applied by a qualified practitioner are an exception.

The vast majority of people out there aren’t qualified to make those exceptions so in your own rehab and training listen to immediate or delayed pain, assess the cause and work to keep moving without pain.

Dr. Budgell

There's nothing wrong with your…

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A phrase used regularly by many health professionals and generally rejected by patients with a problem. There’s nothing wrong with your back, neck, shoulder, knee etc. Chances are if you’re in their office you know that something is wrong. My advice on this one after hearing countless patients tell me their own “There’s nothing wrong” stories or similar “It’s in your head” tales is to keep in mind who is telling you that there is nothing wrong.

Everyone will examine you through their own professional lens. Here’s an example: let’s say you have low back pain and your family doctor has sent you to specialists for opinions and treatment options.

First it’s off to a surgeon, they examine you and determine your back pain doesn’t warrant surgery. Your back pain doesn’t require removing bone, cutting tissue or reshaping cartilage so from a surgeon’s perspective there’s nothing wrong with your back.

So now it’s on for some x-rays. The radiologist looks at your x-rays and she doesn’t see any fractures, dislocations or deformities so as far as she can report there is nothing wrong with your back.

You talk to a urologist they check your urine and bladder, the nephrologist looks at your kidneys and the enterologist checks on your digestive tract. None of them see your low back pain because through their respective professional lenses. Your back pain doesn’t show up because it doesn’t fit into their expertise or expectations.

If you’ve been through this I have an important translation for you: “There’s nothing wrong” really means “I can’t find your problem” or “I can’t treat your problem”.

Understanding this very important translation should help you realize that you are ultimately responsible for your own health and you may need to take the extra step to find the right health practitioner who can find and treat your problem.