Arthritis: What’s It All About: Part 1

Joint arthrosis

This is a three part series about arthritis. The next two parts are sources of inflammation and how to treat joint degeneration.

Arthritis is a broad term encompassing over 100 different conditions that effect the joint(s). The word is broken down into “arthr” defined as “joint” and “itis” translated to “inflammation.” You might come across the word “arthrosis.” This is a more accurate term to what is occurring at the joint. The suffix “osis” is interpreted as “condition.”

The diagram above is an overall view of the progression of arthritis beginning with the health joint on the left. The light blue is the cushion part (hyaline cartilage) of the joint.  It is firm, but with a very smooth surface. In addition, the surface is covered with a very greasy substance called synovial fluid. It is produced by a layer of cells inside the joint called the synovial membrane. As the joint begins to wear (degenerates), the hyaline cartilage becomes thinner and develops small “pot holes” in the surface. This produces a rough surface that further accelerates the degeneration which eventually leads to bone on bone.

Inflammation is the kingpin as to what is producing the pain at the joint. How that inflammation gets to the joint is the difference. Situations that produce inflammation outside the joint and work inward would be injuries effecting the ligament, tendon, bone or muscle. If not treated and healed properly, it can lead to long term stress and cause the joint to wear out early.

As the inside of the joint begins to wear down, inflammation now becomes generated from within the joint. Whether generated from the outside or the inside of the joint, inflammation will produce pain.

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It’s Never Too Late to Exercise!

Movement is key to a healthy lifestyle. We hear it all the time, yet it is hard to get started! Maybe this little bit info might get you going.
This study was published in the JAMA Internal Medicine in December 2018. The investigators reviewed various studies that were particular to exercising for about 1 year. The average training program was 50 minute sessions at 2-3 times per week. It consisted of aerobic activities, balancing movements and resistance training.
The results showed a 12% decrease in the amount of falls and a 26% decrease having an injury due to the fall.
These are good numbers! Let’s get started and put one foot in front of the other.
Long-term Exercise Lowers Fall, Injury Risk Among Elderly – Medscape – Dec 31, 2018.
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Pain: The Great Deceiver!


      I am often asked, “I’m not in any pain now, so can I go back to my routine?” The answer is, soon, but not quite yet! This is a dangerous point when you feel as though you’re a 100%, but are basing it on pain level. This is certainly the first goal; getting you out of pain. However, it is most often a poor predictor of when you can resume regular activities.
     Patients are commonly very anxious to get back to “normal” and start doing regular things again. The key is to slowly ramp up the intensity, duration and frequency. This applies to whether it is exercises, hobbies, household chores, work or sports.
     Using pain as an indicator of being at 100% is very misleading because pain is the first to flee and the last to show up. Most injuries are the result from repetitive trauma or other musculoskeletal insults that take time for the the inflammation to build up and create pain (a few hours up to 2 days).  In these cases, the injury to the tissues have already occurred and have no correlation to when the pain is felt! The pain is the last to show up.
     The reverse is also common. Pain typically leaves before the tissues are at 100%. Getting back into your usual routine might be appropriate at this time, but not at the same intensity, duration and frequency.
     My suggestion is to start at 30% of what you would do at 100% and increase 15%-20% every 3rd day. If it is too much then you should feel the pain within this time frame.
     Please contact me if you have questions. I would be glad to talk with you!
Dr. Dalton
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The Tissue Test


As you know, videos are an excellent tool for learning. I made one to help visualize some traits of a muscle injury. Before looking at the video, a brief discussion should be done fist.

The technical term for a muscle injury is called a strain. More specifically it is divided into grades I, II and III. Grade III is when the muscle is completely separated into two parts. Grade II is when the muscle is still intact but, partially torn. Grade I is the most common type and is characterized by having portions of the muscle torn, yet fully intact. In other words, in grade 1 injuries, various types of x-ray or MRI studies do not show rips or tears in the muscle.  The injury occurs to small, deeper portions of the muscle and are not easily seen in studies. However, all three grades produce inflammation, swelling and pain.

Some of the common or instinctive things an injured person will do is to stretch and put ice (hopefully!) on the area. Ice is always a good treatment to decrease the swelling and pressure created by inflammation. Stretching is the point where further injury can occur.

As the muscle swells, there are pressure nerve endings which are stimulated that give a feeling of stiffness to the muscle. So, the instinctive thing to do is to stretch the muscle to help lessen the tightness and hopefully make it feel better. Though it can help decrease the pain and tightness, it is typically very temporary and might help for a few minutes. The problem is that there is a high chance it will lead to further tearing of the muscle.

The reason is that the stretch is way too aggressive, even though it might not be painful when stretching. Instead, a very slight awareness of a stretch should be sensed. This awareness is typically much less than when the muscle is not injured. It’s very easy to over do it. You have to be careful and have a lot of patience.

Take a look at The Tissue Test video to drive home this point.

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Steroid Injections For Back Pain: How Effective Is It?

I read an interesting research article in the January 2018 of The Spine Journal [1] This paper was looking at a time period of 5 years after the last injection of steroid to the intervertebral foramen (IVF) to assess the lasting effects of decreasing leg pain. The IVF is an area of the spine where the nerve exits to go throughout the body and is often a source of pain.

The criteria for this study were people 18 years or older, the presence of a single level disc herniation as identified by MRI, radiating single leg pain for less than 6 months, a pain rating of equal to or greater than 4 out of 10 and having completed a program of conservative treatment.

The study followed 78 subjects. Of which, 58 received injections only, 14 underwent surgery only and 6 were not able to be contacted.

The overall results for both groups showed that most had excellent decrease in pain for about 6 months. However, recurrent episodes of the pain after 6 months were present for most of the subjects, regardless of the getting surgery or steroid injection. For the recurrences, subjects chose opioids, additional injections or surgery.

The authors of the study concluded that the initial effects of the the steroids are active several days yet the benefits continue for months. They conclude that the recurrences are not due to the lack of effectiveness of the steroids. Instead, factors are particular to each individual such as varied rates of degenerative changes of the disc, lifestyle activities and biomechanical factors of the subjects.

On a practical basis, if faced with this situation, an important question to ask yourself is, “Should you have surgery or injection?” Both appear to have the same long term outcome. The risk verses benefits is an important point to discuss and evaluate with your provider.


[1] Kennedy, D. J., Zheng, P. Z., Smuck, M., McCormick, Z.L., Huynh, L., & Schneider, B.J. (2017).  A minimum of 5-year follow-up after lumbar transforaminal epidural
steroid injections in patients with lumbar radicular pain due to intervertebral disc herniation. The Spine Journal, 18. 29-35.

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Things to Know About Stretching: Functional Stretching-The New Way Of Warming Up!


Functional Stretching

Functional stretching is a relatively new concept that’s replacing the traditional static type stretching for pre-activity warm-ups. As the name implies, functional stretching deals with movement related stretching that is similar to dynamic stretching, but includes sport or activity specific mimicking. More traditionally, we tend to think of this as the warm-up exercises prior to some event. Examples of functional stretching would be a sprinter that’s jogging in place or a baseball player in the on deck circle swinging the bat.

It has been interesting to read some of the recent research on static stretching versus functional stretching. One of the papers I read that was published earlier in 2014. It was analyzing athletes and comparing them between static stretching and functional stretching with emphasis placed upon muscle strength post stretching. It was shown that muscle strength decreased after static stretching, especially with regard to vertical jumping. Functional stretching actually showed an increase in strength as compared to the non-stretching control group.

These new revelations emerging about stretching will profoundly affect warm-up activities prior to sporting events. Static stretching really needs to be replaced with functional stretching in order to provide more power, increased flexibility and potentially better activity performance.

So, what kinds of activities could actually be done. It’s obvious answer seeing the baseball player or the sprinter in some of their normal pre-activity warm-ups as mentioned above, but what about if going to work out with weights or doing some kind of gym activity. A great overall body warm-up activity that’s functional, yet covering a variety of joint ranges of motion would be the jumping jack (this is a good 1:17 min YouTube video with some variations).  Other functional stretching you might consider would be to imitate punching a bag, throwing a ball or kicking a soccer ball.

As a general rule of thought, start with smaller ranges of motion and gradually increase the movement as the tissues become more flexible. This might take 30 seconds, a minute or even longer. You’ll develop a sense and feel as the tissues become more flexible and warmed up. Just don’t overdo it.

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Things to Know about Stretching: Dynamic Stretching

Snapshot 1 (10-28-2014 5-15 PM)       snapshot-2-10-28-2014-5-15-pm-e1414531119807


Click photos for video

Dynamic Stretching

This type of stretching is very similar to the active static stretch except that dynamic stretching, the joint is going through a range of motion. By this I mean that you are actually moving the joint at the same time while sensing a little bit of a stretch on the muscle. It’s a good, simple stretch to do as a warm-up prior to your event. Be cautious with this particular type of stretching because you can actually strain the muscle if you go too quickly. This is actually a common stretch that’s often done incorrectly.

If you ever watch athletes doing some of their warm-up activities, quite often we will see them bending forward to stretch out the back of the legs and at the end range of motion are bouncing up and down reaching for the ground or toes. Now, this might be OK the well conditioned athlete and an acceptable thing for them to do, but for the vast majority of individuals bouncing at the end range of motion can only lead to an injury. The better way of doing this would be to start from an upright standing posture position and bend forward to the floor backup then return to the upright position again. Gradually you get a little further each time. Bouncing at the end range of motion can only lead to an injury.

My suggestion is to go through a small range of motion first (video above). Gradually increase the range as a muscle starts to feel more warm up. This might take 10 to 20 seconds to gradually increase that range of motion. For instance, stand up straight then bend forward a little bit and return to upright. Go slightly further each time until you can bend forward as far as you can comfortable (see diagrams above). It’s a gradual increase in the range, so don’t overdo the pull.

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