The current party line in the US allopathic medical community is that we don't know what causes osteoarthritis. Except that we do know. If we do know, why do we say we don't?
Oh: money.
Specifically joint replacements. Hips, knees, shoulders, arthroscopy, metal, yee-ha.
Forbes says here that the median salary for an orthopedist in 2012 is $519,000.00. Hmmm.
In medical school (89-93) I am taught that we don't know the cause of osteoarthritis. The cartilage begins to wear out in the joint, the joint space narrows on x-ray and then when the cartilage is gone, the person has bone-on-bone and the bones start wearing out. The end of the bone looks like it's been chewed by rats.
We are taught about rheumatoid arthritis, which we know starts because the person has made antibodies to their own body, chewing up the joint. More female than male, can start in people's 30s, we know it is antibodies though we don't know WHY they show up. Well, we know more now than in 1989.
Osteoarthritis appears later, 50s, 60s, 70s. Injured joints tend to go first and be worse. That should be a hint.
Now, let's think. What can you see and what can you NOT see on an xray?
You can see bone.
You cannot see cartilage. The radiologist measures the space between the bones and compares it to normal.
You cannot see muscle. We don't talk about muscle much.
Most of the pretty pictures of skeletons show the skeleton all by itself. So, does it float inside your body? No. What is attached to the skeleton? Ah, grasshopper..... muscles. Tendons. Ligaments.
I pull out my Netter Anatomy and show people the bones. The iliac bones. Muscles are attached all over those iliac crests: on the inside the psoas, on the outside the gluteus maximus, gluteus medius, gluteus minimus and then that lovely fan of muscles under those three that allow you to walk. Ralph Netter MD did fabulous drawings of the bones and then the bones with the muscle insertions in blue and red. Some bones are plastered with blue and red.
The shoulder blade has the entire rotator cuff attached to it. On the underside the subscapularis, on the upper back the supraspinatus, on the lower back the infraspinatus and then the deltoid all along it and look! The long head of the biceps attaches to it and then a huge mess of ligaments and tendons holding the structure together. Think about a chicken breast: the muscle is attached all over the bone, right?
Now, what happens when you injure a muscle? Tear a muscle?
Patients look at me with incomprehension.
Ok, I say, think about the fibers in a piece of raw steak. What happens when you cut it?
Less then half get it.
It bleeds, right? Injure muscle, injure ligament, injure tendon, it bleeds.
What does the muscle DO when it is injured?
Tightens up, right? Why? The muscle is trying to stop from being torn more. It tightens up, the blood causes an inflammatory response to try to heal it and it's a normal healing reaction. The muscle has a freak out "I am torn!" and tells all the other muscles around it. "Hell!" they say and also tighten.
Usually the peak of muscle tightness and bleeding and swelling and bruising is about 48 hours from the injury. We say no heat for the first 48 hours, because that can make it bleed worse, more inflammation. If there is a broken bone, or a really big muscle tears or tons of muscles are crushed or injured, well, it can keep bleeding. Ice it to reduce pain and swelling and bleeding.
Now, the muscle is tight to protect itself. After 48 hours, it will start to loosen. Put heat on, gentle stretching, then ice. Your job is to convince the muscle that it can gently relax and stretch out to the normal length, not scar, and go back to functioning correctly.
But people often don't do that. They either do too much or too little. They come see me two months after a muscle injury and say they haven't lifted their arm since the injury because it hurts. Um. The muscles can scar. If they scar in a shortened tight position... ok, what were they attached to? Bones, right? If the muscles are really tight they pull on the bones. The bones respond by attempting to fix the joint which is now not moving functionally. The bones grow towards the tight muscle: grow teeth. And then the xray has abnormal extra bone spurs and joint narrowing. Meanwhile, the joint is not moving correctly, so the cartilage gets worn out. And then when the cartilage is gone, the bone gets worn. And it's pissed. It hurts.
And there you have osteoarthritis. Remember that it happens earliest in the injured joints. Something got torn. Or a ligament had to be repaired by surgery: now the surgeon is cutting through muscles. The muscles are understandably grumpy about this and they do try very hard to communicate this to us. Pain. Inflammation. Think of this as your muscles shouting at you: "HELP HELP I AM HURT HELP ME!" A dysfunctional response is to drug them to shut up and keep doing whatever injured them in the first place.
The muscles are complicated. There are three types of muscle. We can't see the types on an x-ray. We can't see the types on an MRI. And guess what: an MRI is pretty poor for looking at the muscles. It can see a really big tear if there is a pool of blood or the muscle is entirely torn off the bone. But it cannot see small tears and it can't see which muscles are tight. You have slow twitch muscles, for posture. Fast twitch fatigable and fast twitch non-fatigable. They are all mixed in muscle bundles and right now I don't know of any imaging that can see them. We can tell at the microscopic level.
Orthopedics focuses on joints, bone, cartilage and pretty much ignores the muscles. We send people to physical therapy, but we don't EXPLAIN. I get better at explaining. I don't like muscle relaxants, because hello, the muscle has tightened up because it's injured. You want to kick the legs out from under it? Bad idea. And pain medicine: I have had a person literally say he wants more oxycodone so that he can lie on the concrete in his driveway working on his car for more hours without it hurting. Uh, sure, why don't I drug you so you can do more damage to your back?
The other day a patient told me that the president has promised to find a medicine that will stop pain and not be addictive. The patient was dead serious. I just clammed up. I wanted to yell, actually. Your body has to feel pain because otherwise it cannot tell you when it is injured. Otherwise it cannot heal. Otherwise it breaks down: sure, go ahead, abuse it all you want and have a joint replacement or all the joints. Jack your brain into a computer and feel no pain.... no joy and no love and no grief either.
This is related to the armour suit I've written about: the smooth muscles locking into position from habit or trauma.
Don't drug your body, don't shut down your senses, don't shut down your feelings, numbness is death. You will get to die, don't worry....meanwhile, listen to your muscles and joints and bones....
Iron Noder: Tokyo Drift 9