Ribs are out

[Chancellor Mobley]

I have a challenging client who was gifted a # of sessions with me by an acquaintance of hers. Although these sessions were given to her at the end of last summer, she is only now getting around to seeing me due to the constraints “imposed” upon her by her workman's comp doctor. She has been suffering from severe upper thoracic dorsal pain for the past three years. She is now on limited duties as a dog groomer which she has been doing the last twenty years. She now sees only one or two dogs every other day. She says it doesn't hurt while grooming but later in the day it flares up.


I've seen her twice with minimal hands on work offering mainly pain ed, feldenkrais and taping.


The challenging part is that she feels her pain is due to her ribs continually going out. She is able to get immediate relief from her chiropractor who she sees twice a week and has been doing so for at least the past year.


Sitting down in my intake room at the beginning of our last session she informed me that her ribs were out, that she woke up this way and that she felt as if a knife were stabbing her in her rhomboids. I continued to go over and expand upon the pain ed that I had started during our first session and after about 20 minutes invited her to the hands on and movement room. During this transition and before starting the hands on movement work, I again asked her about her symptoms. She said there was no pain.


This morning rescheduling over a phone conversation she told me how she felt relief after our last visit for a day until again her ribs went out again after grooming a couple of dogs. Subsequently, she didn't find relief until her chiropractor was able to put them back in. I recounted the above scenario to her letting her know that we didn't put any ribs back either.


I am looking to help her downregulate with some tools of self-correction. I feel that one of the things that gives her immediate relief(chiro) may also be hampering her. I feel like I'm walking a tight rope here. Does anyone have any suggestions as to how I can help her move beyond the “ribs out” meme while also being sensitive to her need for immediate relief and support?


Chance

[Diane]

It's a tightrope many of us have walked on a daily basis. Uncoupling mesodermal belief systems are quite difficult but highly recommended. You need to have established good rapport, good therapeutic relationship with the patient first.

Here are some suggestions.

1. Ask her, "When your ribs go out, where do they go?" (facetious and not really recommended). Do tell her that her nervous system can give her pain all by itself, especially if it's been a long time since the precipitating injury - e.g., nociceptive drivers and neurotags..

2. You might sit with her and the neuromatrix diagram, and point to the part labeled "cognitive evaluative." Mention (as you explain the diagram and neuromatrix theory of pain in general to her) that any fears she has about "ribs" being "out" belong in that category, and might well be a belief contributing to the pain experience/hindering her from downregulating her pain successfully.

3. Point to the "action program" portion of the model and mention that feeling she has to go to the chiro to have her ribs "put in" is another belief that doesn't benefit her long term (based on her lack of overall progress so far), i.e., help her brain learn to downregulate pain by itself, but rather would appear to benefit the chiro who may well have inserted himself into her cyclical pain experience by providing a (relatively) short term pain modulation experience, and simultaneously reinforcing the "rib out" belief. Let her know that other "actions" can be developed instead. Like constructive rest, graded exposure, neurodynamic exercise which counters the dog grooming movements which bring on the pain experience.

In my experience, having that diagram and referring to it really bumps up the success rate. I've even used it (successfully I think) on an actual chiropractor (retired) who came to me for treatment.

[Kriskul]

the chiro who may well have inserted himself into her cyclical pain experience by providing a (relatively) short term pain modulation experience, and simultaneously reinforcing the "rib out" belief.

In my view, this amazing skill is what makes chiros successfull (business-wise) . It is also the reason why any therapy based on flawed theoretical constructs should be considered nothing but nocebo. Its a short term painrelief, followed by long term passive treatment dependence and disempowerment- Its a strategy thats comparable to charging money for peeing on somebody who is freezing cold.

[kongen]

Kriskul,

Well said. Although manipulation is very effective in certain cases, one of it's major drawbacks is the seeds of nocebo it plants. Especially if one is not able to get the "pop".

[BB]

I feel that the "bone out of place" meme is the worst/most damaging one for our patients to have as the "energy medicine" one is possibly the worst for our colleagues to have. Bone out of place is probably even more sticky.

I personally don't feel I've ever successfully gotten somebody turned around when they are convinced that a rib is "out" and have experienced somebody putting it "in." At best, I've been appeased probably. It goes like this:

Patient
"So, what do you think is causing my rib to keep going out?"

Me, giving a look of growing concern:
"what do you think is causing the pain in your back?"

Patient
"Oh yeah. It's that nervous system stuff, huh."

In other words, they still think their rib is going out but they know what I want to hear and even understand it. But, the "bone out of place" experience is just too powerful for them to overcome. It's not a fair fight, in my opinion.

[EricM]

This is a perception that I too find expressed by my patients on a daily basis, whether it's the ribs, intervertebral joints, or pelvis. The next most common misperception I hear all the time is the "it's my ____ muscle."

I do find I can change this perception with a simple, confident "no, it isn't," if followed by a successful 'ectodermal' treatment.

[nari]

This is an age-old problem; one of those urban myths that is perpetuated by both health professionals and the media. Even chiros who do not support the subluxation thingy, talk about bones out of place, because they know it can happen, particularly with hips, shoulders, patellae and vertebrae.
Another silliness is that in someone over 50 with reduced ROM and pain at EOR in the hip - it is automatically labelled OA.

I recollect a nice 65 yo fellow who was a bit cross with me because I didn't manipulate the hip - it was 'out', he said. He had felt pain off and on for about six months, early XRs were NAD. Chiros had given some relief for a few days at a time, and it was now getting worse. (He stopped going to the chiro because of the cost). There was something odd about the end-feel, so I asked him to return for more investigation.
Unfortunately, it was a metastasis, and his IFJ was probably about to shatter.

Nari

[Jason Silvernail]

This is a tough thing, and the only time I've ever been able to turn a patient around on this issue is to do exactly what Eric said.
To state confidently that that isn't the problem, then successfully treat them with something else or show them how to self treat.

I say often that we used to believe that ribs and bones were out of place but then we did research on it and found that wasn't the case. Also that they didn't need to hear the pop to feel better. I find the only thing more powerful than the bone out of place meme is the constant advance of knowledge - especially if you can throw in some cool technology and a machine that goes "ping".
I tell people that imaging studies have been done before and after that haven't shown these things out of place, but that not everybody keeps up on the latest research - the previous provider is doing their best, but the explanation they have is out of date.

Of course there are some people who are simply convinced that nothing will do but that their ribs are out and if that's the case I tend to fall back on sarcasm and humor a bit.
"Well, if that's the case I guess we'll just have to keep putting them back in, I suppose. This isn't contagious, is it? Sounds like a pain in the butt to me. A lifetime of getting ribs popped back in that come out for no reason randomly, with no signs of it on the Xray. I'm sure glad MY ribs don't do that. If you ever get tired of this and want to learn how to treat yourself and keep the pain under control with self treatment, just let me know. Otherwise I guess we could set up a monthly appointment or something. [they protest] Hey, it's OK. Doesn't bother me. I get paid the same every month whether you think your ribs are out or not. I just want you to feel better and understand what's really going on, that's all. I want the best treatment for you - and this idea of ribs coming out is an obstacle to your recovery that I'm trying to help you with."

[Luckbox]

Mobley,
These types of cases are challenging, especially three years out. Maybe I can offer some insight.
Sounds like she needs a different POR. What type of constraints is he/she "imposing"?

Could you tell us a little more about her WC injury? What is the Dx?
How did you find the upper extremities; loss of strength, DTR's, numbness/tingling, distal pulses... etc.

Imaging? plain film, MRI... if so, what area? A thoracic MRI would be nice.

Regarding the ribs. No, they're not 'out'. Good luck conveying that to the patient. It can be done, you just have to do so in a non-condescending way.

Is the chiropractor the POR? Is WC covering her visits? What other types of care has she received?

Cases like this are frustrating; knowing the only relief you can provide with an adjustment is short lived.
What I would NOT do is the same thing over and over again expecting a different result.

Wow, that's a lot of questions I just peppered at you.

[Jason Silvernail]

Luckbox-
What's a POR?
Sounds to me like she has a mechanical pain syndrome, and whatever diagnosis she has is probably something like "thoracic back strain" or "myofascial pain" or "myositis" or words to that effect. Not of much use.
Also sounds like imaging results are not likely to be useful, especially MRI. Especially in the absence of any clear radiating pain or nonmusculoskeletal symptoms.

Chance - have you tried my suggestion of sarcasm? (jk)

[Chancellor Mobley]

Yes, I did mean to get back to this sooner and many thanks to all the responses and suggestions.


I saw the lady on Monday and clearly told her that her ribs were not going out. I told her again that we were dealing with a hypersensitive nervous system. I do think that we made some progress with her understanding but I also feel that she is quite stuck on the notion of getting her rib back in. Right now I think its back and forth with her. I mentioned to her that some people may not feel better if they don't hear the pops that often go with the spinal manipulation and that this may actually hinder their recovery. She says that she doesn't always hear the pops but that she feels her rib go back in place. Unfortunately, feeling her rib go back in with the s.m. doesn't always bring relief. This, I let her know was a sure sign that it wasn't her rib that was causing her pain but the inconsistencies of a cranky, sensitve nervous system. She also told me how the night before she got her rib back in by doing some contorsions over the arm of her chair. With this maneuver of hers she felt relief as she felt her rib go back in. Regardless, I felt this was a step in the right direction bc she was administering her relief.


Diane, I didn't ask where her rib went but your suggestion reminded me of the puzzle of where does your lap go when you stand up? For the first time I did use Melzacks's neuromatrix model as you suggested but I feel like I could have done a better job of it with a better understanding of it myself. Your examples of how she was coping in relation to the model helped. Thanks.


Kriskul, you nailed it. I found myself in our discussion getting almost angry with this chiropractor who's office is just around the corner from mine.


Cory, I can relate. She is holding on hard to the feeling of her ribs being out and that her musculature is too weak to hold them in but I think she may be letting go of some of that. Is your picture from the book We are smarter than, me ?


Eric, I like your approach.


Nari, I get people telling me their hips are out or that they are uneven or such. I tell that that doesn't matter as long as they feel good in them. What is EOR and OA?


Jason, I try to let humor come in as often as possible but most times I just fall flat on my face. I mentioned the imaging studies(not specifically) to no real affect because she feels the ribs go back in. I do think mechanical deformation is a part of it but being three years in the making and probably longer I'm guessing that some of her brain's maps are a bit incongruent. I guess there is no real way to know though. I also find her tissues to be a bit soggy and boggy. At our second session I asked her about her water retention and she mentioned that was in menses during our first session. Every session I have noticed that she has edematous quality to her. Would this perhaps denote some chemical irritation too? Her whole system seems to be hypersensitive for she can not even take ibufrofen with out some adverse systemic response. Pain medication which she has tried is out of the question, too.


Luckbox, I asked her about her pain. As far as she is concerned she is Dxed with rib out syndrome and weak muscles. Her imaging was all negative. She has been to PT and found the massage there helpful as well as the work out machines. She felt that her home program was lacking because it wasn't expleained well and therefore did it wrong and hurt somewhere else as a consequence. She is loosing strength in her hands. Her numbness and tingling isn't bad now but she did get some referrals into her arm during the hands on work.


Again, thanks for all the suggestions.


Chance

[nari]

Chance,

EOR = end of range and OA = osteoarthritis.

Self-manipulation is at least useful in the sense they are independent of being fixed up by another person. It also seems addictive, and I met a fellow once who self-manipulated his own neck about every waking hour, after visiting a PT MS specialist who 'resolved all pain with a manip'. I asked him was this a useful thing to do when it lasted only one hour. After a good deal of thought, and some education, he realised it wasn't much of a solution. He still believed his neck was out of place, but self-manip didn't really help matters usefully.
After some trials with neurodynamics, he stopped self-manips and found he achieved up to a day of painfree living, which then stretched to weeks. Don't know what happened after that.

Nari

[Mary C]

Many of my patients would tell me, "What cracks (or pops) doesn't break."

I learned to answer, "No, but it wears out."

I then go on to explain that snapping your fingers requires pressure. Sliding them does not. That type of pressure is more than the structures were designed to cope with, and this is usually relieved by stopping the movement just before the snap and waiting for the resistance to fade away. Sometimes they will feel a pull, but not always. It's not necessary. The wait is. The movement will flow when the body is ready to allow it to.

I also compare this to a speed bump in the lane. The slower you go, the less you are bounced around, the better for the suspension.

[Luke Rickards]

That type of pressure is more than the structures were designed to cope withMary,

I'm not sure what you're saying here. It seems to imply that joint cavitation requires compression of the joint surfaces (and this wears them out).

In fact, the exact opposite is true. Joint cavitation is the result of separation of the joint surfaces. Oh, and there's no evidence that people who crack their fingers are more prone to OA than people who don't.

[nari]

A long time ago, I read a paper which indicated that sedentary people are significantly more liable to develop OA than those who are active, which throws a lot of doubt on the 'wear and tear' snap answer to OA.
It may well be that athletes develop joint degeneration in a relative sense - it's not the high activity, it is the relatively sedentary lifestyle which follows that does the damage.

I'll try and find the study..

Nari

[Mary C]

Luke, I've noticed that people who snap, crackle and pop also often complain of multiple aches and pains. Once their flexibility improves, both the noises and the pains are gone. Now this is certainly not true for all of them.

Since shoulder impingement is one of the places where there is often a thinning of the supraspinatus tendon, it is one area where I am fussy about stretch instead of snap.

Painful snapping can often be relieved by a pre-snap stretch. These images I use are an attempt to teach the patients to pay attention to how they move.

[pht3k]

wow there is a bunch of nice tips in this thread :) thanks everyone!!!
i had a patient too who self-manipulate her own neck almost every waking hour.
she were around 15 years old and were complaining of very severe headache.
she saw many 'specialists' and had more than one MRI without any clear diagnosis.
the first time i saw her all i did is education about the negative side effects of self-manip.
in that time i was not informed like now about ectoderme.

so what i was explaining and sometime still do is that when you self-manip it necessarly manip at the hypermobile segments. i compare the vertebral articulations to springs. imagine many springs attached all together with one spring much more easier to stretch than the other. if you stretch the total length of springs together, which one will mostly stretch? the soft one or the other rigid ones? easy to imagine that it will be the softer one. so, now which vertebra will move more than the other? the hypermobile one, if there is an hypermobile vertebra of course. so where will it pop when you self-manipulate? when a PT do a manip he can decide which one to manipulate but when you auto-manip you just cant. well its maybe not exactly true but it works well to make them stop auto-manip.

when i saw her the second time, two weeks later, she was totally pain-free!

[Luke Rickards]

I've noticed that people who snap, crackle and pop also often complain of multiple aches and pains. Once their flexibility improves both the noises and the pains are goneI've noticed that people who S,C & P are almost always on the very flexible side of the bell curve already.

[Jason Silvernail]

I've noticed that people who S,C & P are almost always on the very flexible side of the bell curve already.
Or those who have had a traumatic injury to the area or who have had many years of serial manipulative therapy.
On the other side there seem to be some who never get that noise, and they seem anecdotally to be on the stiff side of the flexibility curve.

Good thing the pop isn't related to pain relief, huh?

I use the tendency to self-manip to teach Wall's stages of resolution from pain, and that the need to do this is an attempt to generate the motor response their brain is looking for. As we all know, this is rarely helpful for more than a few minutes, so redirecting them to other movement (usually ideomotor) is often helpful.

[marcelk]

" all i did is education about the negative side effects of self-manip."

" which one will mostly stretch? the soft one or the other rigid ones? easy to imagine that it will be the softer one. so, now which vertebra will move more than the other? the hypermobile one, if there is an hypermobile vertebra of course. so where will it pop when you self-manipulate? "

Hy,

I told pt's a similar explanation.

When reading this the first thing that came to mind was :
do we have references for this? (evidence that this actually is true)

Seems very logical that automanip. most probably takes affect on
hypermobile segments. But still is only hypothesis.

[Luckbox]

wow there is a bunch of nice tips in this thread :) thanks everyone!!!
i had a patient too who self-manipulate her own neck almost every waking hour.
she were around 15 years old and were complaining of very severe headache.
she saw many 'specialists' and had more than one MRI without any clear diagnosis.
the first time i saw her all i did is education about the negative side effects of self-manip.
in that time i was not informed like now about ectoderme.

so what i was explaining and sometime still do is that when you self-manip it necessarly manip at the hypermobile segments. i compare the vertebral articulations to springs. imagine many springs attached all together with one spring much more easier to stretch than the other. if you stretch the total length of springs together, which one will mostly stretch? the soft one or the other rigid ones? easy to imagine that it will be the softer one. so, now which vertebra will move more than the other? the hypermobile one, if there is an hypermobile vertebra of course. so where will it pop when you self-manipulate? when a PT do a manip he can decide which one to manipulate but when you auto-manip you just cant. well its maybe not exactly true but it works well to make them stop auto-manip.

when i saw her the second time, two weeks later, she was totally pain-free!


This is very similar to my explanation to my patients that self-manipulate.

[Jon Newman]

This is fascinating to me. Why do you think it's necessary to propagate/sustain the cultural myth (I'm under the impression that that is a myth) that we target a specific vertebral segment with manipulation? Why do you think that they're own self-manipulation is pain sustaining in and of itself?

Luke, do we have the reference(s) here about joint cavitation=joint distraction? For those that have researched this more than I, has there been any work that has determined whether a "popping" sound (or popping feeling) is necessarily or even likely due to joint distraction versus any other sort of arrangement (e.g. tendon snap, joint shear, etc.)? I feel the need to explain that last question a little more. While joint cavitation is defined as joint distraction, I'm wondering if all popping noises/feelings=joint cavitation=joint distraction.

[Mary C]

Jon

I like your questions. The SC and P patients that I was referring to snap at ankles, shoulders, elbows, etc. Or they deliberately snap their finger joints repeatedly.

The crackles can be palpated in the soft tissues of the arms in a few. I really had to learn to slow down with these patients. If I stretched fast enough to produce a crackle, they had a lot of post-treatment pain.
My own neck crackles like cellophane. And I can feel the soft tissue pulling hard at the same time. It's a stiffness I'd dearly love to get rid of.

The spinal "poppers" set my nerves on edge. That's why I told them about the risk of increased wear and tear. Now I've got some more ammo, thanks to pht3k. They need an over-riding reason to stop. "Just because I say so" is not enough.

Gentle, persistent stretching helps eliminate these phenomena. So does IM.
Could we add belief in popping the joints to the list of erroneous beliefs to be corrected?

[Luke Rickards]

Luke, do we have the reference(s) here about joint cavitation=joint distraction?Hi Jon,

Attached is an interesting breakdown of the likely mechanics of SM. Reference is made to most important research in this area. In answer to your question, I confess I'm taking their word for it (I haven't down a complete lit. review) -In every study to have studied cavitation in MCP joints, cavitation was achieved by distraction translation in the neutral position (which, in the MCP joint, is the midpoint of the neutral zone).

Also, here (http://www.ncbi.nlm.nih.gov/pubmed/12435975) is the abstract for their ref. #2.

[Luke Rickards]

That's why I told them about the risk of increased wear and tear. Now I've got some more ammo...Mary,

What risk of wear and tear is that? There is evidence that there is no increase in damage to joint cartilage or degenerative change in habitual knuckle crackers.

[Mary C]

Luke, it's structures that hurt when they snap that worry me. Esp the rotator cuff.
Another snap I shudder at is in the ankle. I have one patient that I can't identify the source of the snap, but I can identify the malalignment in the leg. Decreasing that sure helped the pain in her knee. I won't look for the source of the snap in the ankle, but I will hope that finishing the correction in her knee will eliminate it.

And how many "knuckle crackers" do we see in physio for shoulder, neck and elbow problems? I've never seen any for hand problems, but I have for other UE problems.

Call me bigoted if you want, and unscientific, too, but IMO snaps, crackles and pops do not belong in ordinary movements. If the wheel bearings do it, best to haul your car off the road. If your body does it, watch out for loss of flexibility. The consequences may be a long way down the road, but that's were I usually meet these people--after one or more decades of pain.

[Diane]

Perhaps it isn't the "joints" popping at all. Perhaps it is a small tendon or neural structure nearby slipping and twanging like a banjo string over a boney prominence presented to it from beneath. That's something I wonder about sometimes ... if that turns out to be true, that would irritate/exacerbate things (like increase neurogenic nociceptive input) over time.

[Luke Rickards]

Mary, I'm starting to get the feeling we aren't talking about the same thing.

[Mary C]

Luke, I think Diane has a good explanation. Tendons snap in the extremities all the time. When my neck crackles, I wonder if it isn't the same type of noise. I know my EOR really pulls.

[Jon Newman]

I crack my knuckles. Not obsessively (surprising for me) but weekly if not more frequently. I don't do it because they hurt and I don't hurt anyplace else either. When I crack my knuckles I almost always crack the PIP as far as I can tell and I do it by pressing on the dorsal surface of my finger just proximal to any given PIP. I can crack my thumb by simply flexing at the IP (no external forces required.)

I can make some impressive cracking noises (again no external forces required) with my ankle (for as long as I can remember) but have no pain with cracking or any place else in my leg.

My left great toe cracks with simple flexion of the IP. No pain anyplace in that leg.

I can feel cracking type sensations when I extend my spine isometrically in standing and sometimes in sitting. I sometimes do this if I'm feeling some form of discomfort from postural fatigue but producing the sensation doesn't change that sort of sensation. Luckily the discomfort goes away with simply moving.

Maybe I'm a persistent pain patient waiting to happen. I suppose we all are but I think much of it has to do with particularly bad luck and/or false beliefs (which I suppose could be considered to be bad luck in itself.)

Luke, thanks for the papers. I'll be sure to check them out.

[Diane]

Jon, would you call yourself addicted to this process? Dependent perhaps?
If you try to stop, do you find tension builds and obsession takes over, until you just have to do it, so you can forget about it for awhile?

[Jon Newman]

Hi Diane,

I know exactly what you're describing. No I don't have it that bad for cracking/popping. These are just things I've noticed over the course of my lifetime. But you are right that there is a compelling sensation to crack my fingers when I get the notion to do it. It certainly isn't because of pain and I can't say that it is because any joint feels tight (my ankle cracks simply going down the steps (sometimes)). It's more of a sensation that they'll crack if I do it. So I do it. I have, in fact, experimented with what happened when I didn't. Life went on no problem. But since it's a habit, I have to actually think not to do it. Since I can't see any reason not to, I don't expend any effort trying not to.

[pht3k]

personnaly, i will suggest to stop auto-manip if the segment is painfull and i can fell hypermobility. diane explanation fits well here. otherwise i dont really care about sounds. do you have this expression in english: what is cracking is not breaking...
and i can feel too in my neck a 'sandpaper' sound when rotating, especially in extension. i interpret this sound as articular surfaces (not smooth anymore - aging) gliding...
pht3k

[Mary C]

pht3k
Ce qui craque casse pas, eh?

Nope, the English don't use that expression. I learned it from my French patients in Gaspe.

Jon, you don't reveal your age, so you may or may not be headed for trouble. ;)

We have to remember that the people who come to see me are in trouble, and it's usually serious.

[Jon Newman]

42. Which happens to also be the answer to the ultimate question of life, the universe, and everything, so I feel pretty confident (:D--see signature line).

[pht3k]

pht3k
Ce qui craque casse pas, eh?

Hehe :) that's it and it'S a pretty good expression. it comes from the trees in fact. we all hear sounds from trees when they move freely pushed by the wind. wood fibers are actually sliding vertically, producing this sound by friction. if the fibers couldn't slide, the tree would broke...

[Jason Silvernail]

Mary-
I think with a lot of these noises we're just not sure where they come from, and therefore not sure if they are really a reason for concern or not. Maybe the noise is from the joint, maybe from an external structure such as a tendon.

I at times habitually pop either my cervical or thoracic spine - I have the same feeling Jon has in that it occurs to me to do it, so I do it, but not forcefully and I certainly don't see a reason to try to stop if there's no damage being done.
In my extremities, my right patellofemoral joint has a great deal of crepitus after I dislocated it at age 18, though I don't think that's the kind of popping you mean.

My right elbow and right ankle pop when I extend/plantar flex them, but this only happened after joint injuries, and before I do that, it does feel as if there is some sort of mechanical block to the motion that resolves with the popping.

So I think here are several examples of popping noises that may have different mechanisms and different pro/con lists.

I think that in many cases, this desire to pop something is driven by discomfort and could easily be thought of as part of Wall's instinctive consummatory act - certainly I do this sort of thing almost non-consciously now, and that makes the most sense to me in terms of the 'why'.

With most of these things I really don't see that they are necessarily a bad thing - with patients I usually tell them that it isn't wrong to "pop" things in response to discomfort, but to primarily focus on the non-choreographed correction of ideomotion that leads to characteristics of correction. Usually, they have experienced some longer term relief with that rather than the popping which seems a very temporary solution.
When I pop my ankle or elbow, it usually feels better the rest of the day, whereas with my neck or Tspine, its only several minutes. ?Different mechanism?

[nari]

I tend to agree with Jon and Jason.
Popping of joints does result in a satisfactory feeling, hence the likelihood of being a consummatory act.
My knees have had crepitus for as long as I can remember and they are totally painless, with full function. It probably distracts people who walk with me up stairs (or down) to have to listen to them. if they hear anything in the first place - to me it's loud.
My ankles and fingers crackle and pop each time I stretch them into full extension and back into full flexion.
They have always done that, and as I am painfree with full ROM, it seems that it's quite OK. Well, my CNS seems to think so.

My cevical spine creaks and squeaks on movement, and then shuts up after a few casual short range functional movements.

Being painfree and with quite reasonable adaptive potentials, I live happily with my noises. If the Rice Bubbles effect was deleterious, I think after 50 years it would have shown up....n'est pas?

Nari

[Mary C]

Well, I'm really glad none of you are in trouble. (But I'm sorely tempted to add the qualifier "yet!")

Nari, I would tell you that your neck is caught between your hands. Has anyone done an ULNTT on you? A simultaneous bilateral stretch might find some stiffness in the flexor chain. It's one of the stretches I use for stiff, painful necks. Your finger joints are at the ends of the "chains" where the shortening can jam the joint surfaces together. I see this the way a mechanic tests the spacing around bearings. There are min and max tolerances for spacing. Below the min, the increased friction shortens the life of the bearings. Above the max, the shear forces from too much movement also shorten the life of the bearings.

It's only an unknown percentage of people actually do get into trouble from their stiffness. So I'm biased by the ones I do see, not by the ones I don't.

[Mary C]

Jason wrote My right elbow and right ankle pop when I extend/plantar flex them, but this only happened after joint injuries, and before I do that, it does feel as if there is some sort of mechanical block to the motion that resolves with the popping.

It's just that feeling of blockage that I would target with stretching. Instead of continuing through the movement and the consequent pop, I would stop right there and wait for release. Like Diane says, it takes patience and persistence. Adding gentle stimulation to the skin helps speed up the process. Like giving a tortoise an accelerator.

[Bas]

Pain free "pops" in my MCP when I extend them far; crunchy crackle in my right shoulder with any kind of throwing motion; toes that "pop" at the MTP with full flexion, and mildly crackly neck - noisy man, but 56. And no pain with any of those. I am positive there are no tendons or other soft tissues snappig, although I have heard and felt those in patients. The most notorious is the un-contained tib posterior tendon in one of them -loud and snapping over the medial malleolus (standing on toes), and strangely enough - not painful for her.

Just body noises of a socially acceptable kind....

[EricM]

I'm starting to feel like I might be the odd duck out on this one. Nothing pops or cracks on me, and my hands and feet frequently hurt quite a bit. Just the thought of them cracking does nothing for me either. :shade:

[Mary C]

EricM, you'd fit right in around here. ;)

"Step into my parlour," said the spider to the fly....

[Diane]

Lately I've developed a loud gunshot like noise in my neck, which is completely painless while being impressively loud. I'm pretty sure it's 1. age, 2. arthritic changes, 3. avoidable by not staring at a computer screen for too long at a time/moving my neck more frequently. So it's likely #1, eh Bas?

[Bas]

...yessss....That would be my guess. I really have no pain at all with these noises. And it started in my early 20's, but only occasionally - since then, locations have increased in number and frequency as well. Strangely in step with the number under my avatar....

[Jon Newman]

Lately I've developed a loud gunshot like noise in my neck

Is this noise like a loud gunshot to others around you? I find that when I crack my knuckles by pressing them against my chin the sound is understandably much louder and strangely more satisfying in some way.

[Diane]

So far it has only occurred when I'm alone. Maybe it only sounds loud because my left ear is nearby. (It happens on the left, around what feels like about C3-4 level.)
I don't find this satisfying. Maybe because it is spontaneous rather than deliberate. Nor do I on the other hand find it discomforting. I'm pretty neutral about it, as all it bothers is my sense of quietude, and only very briefly. The first time it happened my locus ceruleus went a bit loco, but with subsequent exposures it seemed to lose interest.

[kongen]

I also tend to pop my joints from time to time... lower back, thoracic, cervical.. my left hip "snaps" and "grinds" in certain movements.. never painful..

But the last few days I've been bothered with right upper cervical "pinching" type of pain when extending, right rotating and right lateral flexing my neck.. very localised pain around c3-c4? .. the movement just feels "blocked".. Have I fallen victim to a good old ortho-facet-problem? Isolated movements are just fine, it's the combined movement that is "blocked".. Do I need my spine "popped".. :) Any ideas how to resolve this?

[Diane]

Any ideas how to resolve this?
Non-"manipulative" manual therapy. :)

[Mary C]

Anders, you could try stretching to the opposite side a few times, then check to see if it changed anything.

[nari]

Mary, thanks for your kind suggestions. I've self treated with all 4 ULNTTs for various reasons since the 1990s, and always negative. Possibly that is why I'm painfree - who knows.
Having lived with my rice bubbles for waaay over half a century, I'm rather attached to them. ;)

Nari

[Mary C]

Rice Krispies, anyone? I like mine with blueberries and brown sugar.

[gilbert thomson]

I think similarly to Jason, that there are several different causes of snaps crackles and pops. One I see fairly often seems to be due to instability. I know that my (L) ankle after I sprained it years ago started to "crack" and it's the one joint that consistently produces noise. I usually tend to ignore painless S,C, &P in my patients.

[Diane]

q6TIsxTdrCU

[Mary C]

:clap2: Diane, you're a riot. :clap2:

[Jon Newman]

Mary, I'm curious about your concerns about joint cracking. Is there some literature of one sort or another that informed this concern?

I'm interested in hearing more about the association between hypermobility (or instability) and popping noises from those mentioning this. Any good reading?

Luke, I haven't read those papers yet but will.

[Mary C]

Sorry, Jon, nothing but anecdotes and experience so far.
Unfortunately, I'm nowhere near a medical library with a PT section, so I can't cruise the journals.

I've been known to pay attention to weird stuff, set my own selection criteria, and often just go with my gut and try to reason back after, especially if it works.

I'll also grasp at straws in the off chance one might be effective. When my patients try hard to manage their problems, I am willing to go out on a limb sometimes. I will not try that for someone who frequently does foolish things.

So, I pay attention to SNP's and the trail they leave often leads to key areas neding stretching. Sorry I can't be at all scientific about this.

[Jon Newman]

That's ok Mary. I asked, you answered. :thumbs_up

[Jon Newman]

So far it has only occurred when I'm alone. Maybe it only sounds loud because my left ear is nearby.I'd be surprised if bone conduction didn't have something to do with it. Maybe my sense of satisfaction is similar to how animals react with clicker training except the click is the end of the reward, at least for me. It does make me wonder why I experience it as "rewarding" in the first place.

[gilbert thomson]

Jon, OK an extreme example of hypermobility and noise would be a young person with multidirectional instability at the shoulder subluxing it voluntarily. Sort of taking the self-manip thing to a new level. I had one young man who said, "yes I get a lot of clunking, see I can do this: "CLUNK" "
So I say 'STOP doing that please' !! ;)
(That's not cavitation I guess, just the unstable joint surfaces moving against each other)

[Jon Newman]

Hi Gilbert,

I suppose I would advise against constant self manipulation (i.e. cracking one's PIPs) for someone with rheumatoid arthritis and swan neck deformities. Especially if it is simply habit and not particularly pain relieving.

I'm curious if others feel that sort of satisfied feeling when they crack their own joints and even more curious if that feeling occurs when you crack the joints of another. For instance, if you attempted to illicit elicit a cavitation is there a subtle (or not so subtle) sense of dissatisfaction if you don't (relative to successfully producing a cavitation)?

[Bas]

Jon, "illicit" cavitation is only done by PTs in Arkansas....:D

But yes, there must be something crossing over at that time of "pop" when manipulating another person. Maybe the feeling is boosted by a sense of accomplishment - an audible result as proof of instant effectiveness?

[Mary C]

I once saw a chiro really frustrated by her inability to obtain a pop from my thoracic spine. And that was AFTER I told her it could not be done.

[Jon Newman]

Hilarious. Thanks Bas. I'm correcting it but leaving the error visable for posterity. I got a million of them.

[Jon Newman]

I read this How Stuff Works (http://health.howstuffworks.com/question437.htm) article that states there is a refractory period for joint cavitation. If the article is accurate in it's explanation of joint cracking, including the bit on a refractory period, maybe that would be a way of distinguishing whether a particular cracking sound is a cavitation or something else. My great toe cracking has a refractory period that is very short while my ankle doesn't seem to have any refractory period.

Anyone else?

[Mary C]

It seems there is increased movement for joints that have just been popped.
I still maintain there are better ways to do it. :)

[Jon Newman]

Mary, you might want to look up their reference (see underlined)

As for the harms associated with this habit, according to Anatomy and Physiology Instructors' Cooperative, only one in-depth study regarding the possible detriments of knuckle popping has been published. This study, done by Raymond Brodeur and published in the Journal of Manipulative and Physiological Therapeutics, examined 300 knuckle crackers for evidence of joint damage. The results revealed no apparent connection between joint cracking and arthritis; however, habitual knuckle poppers did show signs of other types of damage, including soft tissue damage to the joint capsule and a decrease in grip strength.for your own personal red file. Mary I don't see a strong reason to advocate for or against joint cracking at this point. It seems to be largely irrelevant.

[Mary C]

Jon, I did read the file.
habitual knuckle poppers did show signs of other types of damage, including soft tissue damage to the joint capsule and a decrease in grip strength.

I don't usually get to see hand patients until their hands have deteriorated beyond recovery. I don't have a "number needed to treat" to avoid this type of destruction, nor do I have a longitudinal study to demonstrate where knuckle popping leads to when a person reaches their 50's and 60's.
I have personally destabilised my L index MCP by popping the knuckle and now have a swan neck deformity of the IP's. Predisposing factors were the positive rheumatoid factor and a weakness of connective tissue, so that does make me a an oddball. Anecdotes are there to prod us to question what we see. I question the wisdom of cracking joints.

Can we at least agree to disagree?

[Jon Newman]

Can we at least agree to disagree?

Sure, but I don't think I'm disagreeing really. To be clear, I'm not saying you're wrong and I'm right. I'm just suggesting that there isn't a whole lot of compelling evidence out there to inform us one way or the other. I actually agree with you here

Anecdotes are there to prod us to question what we see.

Knuckle cracking is such a common habit that maybe a well designed trial would be able to be funded, especially if that habit is possibly detrimental. Maybe they'll find, like many things, there are a sub-group of people for which knuckle cracking is detrimental. In fact, I'd be surprised if they didn't find such a group. Or maybe it would be shown to be universally detrimental and everyone should be advised against the practice.

[Jono]

Sorry i haven't read all the previous replies... but just my 2c worth re the original post.

It is hard to change these stubborn memes... especially when her "rib out of place" has had lots of validation from the chiro and her own experience of it feeling temporarily better when it's "put back in"

I guess my approach would be to say "Well it's not good enough to just pop your rib back in because your Chiro has tried this 100 times and it's not actually getting better. What we need to do is find out what's causing this feeling of the rib being out and address that. The 'rib out' feeling is a symptom- we need to find and address the cause"

Then i'd proceed with neural mobs, postural correction, pain education etc.. but always from the perspective that this is addressing the CAUSE not just the SYMPTOM.

[Jon Newman]

Hi Jono,

Yes we did go off on quite a tangent and I think you've got a reasonable strategy. This person should find you.

Mary,

In the spirit of our upcoming book club I thought this statement from Nortin Hadler's book, The Last Well Person probably describes your current position.

From page 20

Furthermore, if any medical procedure has no ascertainable value for the patient, there is no acceptable risk--zero

I have to agree with him (and you.) The rub is how one measures "value for the patient." Maybe we can get into that in our book club discussion. My own habitual joint cracking has virtually no value to me whatsoever. At least non that I'm aware of. Although adding one more behavior in need of modification to my list (I don't know many people who don't have a behavior they either want to do more of or less of) does seem like a burden so not changing it becomes a value in a way. A perfect circle.

[gilbert thomson]

Jon

That's where I think we as therapists need a lot of wisdom.

For a behaviour that is really a problem we can say "I'll try to help you change that behaviour", while for one that is not a real problem we can reassure the patient "That is not really a problem, so let's not worry about it."

Both of these strategies can be a big help, in my experience, provided we apply the right one in the right situation!!!!

[Pernkopf]

I'll throw in and say I have a habit of neck cracking. Started shortly after I stopped chiro treatments back in 96'. I feel the need to relieve a tightness and it usually involves multiple cavitations. I am not specifically targeting a vertebrae when I do it. Most frequently it is the right side that I crack, done by side bending my head. Results are generally unsatisfactory and short lived relief of the sensation or pain. I have tried to stop and it is like smoking; stress and pain brings it back. I tried replacing it with DMN and met with some success. At worst I think it is stretching the vertebral ligaments and leaving my CS open to structural/stability weakness that could lead to degenerative processes. In the end it is probably a good idea to stop. See PDF in post 10 in this link (http://www.somasimple.com/forums/showthread.php?p=59904#post59904)


1: Spine. 2004 Jul 1;29(13):1452-7. Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific?

Ross JK, Bereznick DE, McGill SM.
Spine Biomechanics Laboratory, Faculty of Applied Health Sciences, Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.
STUDY DESIGN: Sixty-four asymptomatic participants, ranging in age from 22 to 49 years, volunteered to act as patients for the study. Twenty-eight different clinicians performed thoracic and lumbar spinal manipulative procedures. The range of clinical experience was 1 to 43 years. OBJECTIVES: The purpose of this study is to first locate the joints that produce an audible sound in response to manipulation (cavitation) during spinal manipulative procedures so that the accuracy and specificity of manipulation can be assessed. SUMMARY OF BACKGROUND DATA: Clinicians utilizing spinal manipulative therapy (SMT) claim to be very specific and accurate with the delivery of their dynamic thrust. It has been suggested that the clinical success of SMT is dependent on the accurate delivery of that therapy to the target spinal joints. METHODS: Asymptomatic participants received SMT to either the thoracic or lumbar regions of their spine. Accelerometers were secured to the skin over the spinal column, and the relative time at which each accelerometer detected the vibration from the cavitation associated with the SMT was used to calculate the source of the vibration. The site of cavitation was then compared with the target location. RESULTS: For lumbar SMT, the average error from target of 124 cavitations in lumbar procedures was 5.29 cm (at least one vertebra away from target), with a range of 0 to 14 cm. Of these cavitations, 57 were deemed to be accurate and 67 were deemed to be inaccurate. The average error from target of 54 cavitations in the thoracic spine was 3.5 cm, with a range of 0 to 9.5 cm. Of these cavitations, 29 were deemed to be accurate and 25 were deemed to be inaccurate. In most cases, individual manipulative procedures were associated with multiple cavitations ranging from 2 to 6. CONCLUSIONS: In the lumbar spine, SMT was accurate about half the time. However, because most procedures were associated with multiple cavitations, in most cases, at least one cavitation emanated from the target joints. In the thoracic spine, SMT appears to be more accurate.


1: J Manipulative Physiol Ther. 2004 Feb;27(2):e2.

Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sounds.

Beffa R, Mathews R.

Department of Chiropractic, Technikon Natal, Durban, South Africa. robmat@iafrica.com
BACKGROUND: The cavitation sounds heard during chiropractic adjustments of the spine are common phenomena; yet, their location relative to the technique used is relatively untested. OBJECTIVE: The purpose of this study was to locate the cavitation sounds during the L5 spinous hook adjustment and a lower sacroiliac adjustment. The sounds were analyzed for significant difference in location relative to the 2 techniques. METHODS: Thirty asymptomatic volunteers were randomly divided into 2 equal groups. Each group represented either the spinous hook adjustment or lower sacroiliac adjustment. Subjects had 8 microphones taped to their skin, over the relevant facet and sacroiliac joints. Radiographic confirmation was used to ensure optimal placement of the microphones. Sound signals produced during the adjustments were digitized, recorded, and analyzed statistically. RESULTS: The results indicated that no statistically significant correlation existed between the anatomical location of cavitation sounds and the adjustment technique selected. CONCLUSION: Location of cavitation sounds does not appear to have a relationship with type of manipulative technique selected. Further studies using other techniques need to be performed.


Karen

[ginger]

I allus finds me wooden leg makes the wierdest snaggly sound as it drifts across the deck, sometimes drops into the gaps in the planks and plum nearly keels me over.Then I pulls it off and bangs it on the gunwale , just for the pleasure of the sound it makes. Arrrrr.

[Kharma44]

I all

My take on the rib being out of place or any other joint for that mather is that the joint is probably not really subluxed or anything like it. I think it's probably more a compression of the joint that is caused by an hyperactive musculature around the joint itself. Thus, the joint being compressed will have a diminished mobility. Now this joint is probably compressed because of a sensitization of the CNS. The pain felt in this area could very well be because of the sensitization itself or for a vascular pain of the overactive muscles of this particular area. The manip used to «correct» the «subluxed» joint would then be aiming more at creating sometype of neuro-reflex that would alter that sensitization.

I think the manip is usefull in a condition like that so long as it is done for an acute and rare occurance of the problem. A more repetitive problem like the one in that patient on that thread seems less likely to benifit from the manip since it doesn't seem to help on the long run and is probably a symptom of a bigger dysfonction of the CNS (or something else, maybe mechanical or discal-cervical discs do refer pain in ribs areas).

That's my take on it anyways.

As for knuckles, I too have noticed looser MCP joints since my nasty habit of cracking them all the time:(. But it is mostly my index mcp and they are more stressed than the other ones in many manual therapy technics that I do. So it is again just an anecdote.

Frédéric

[nari]

Ginger, you will just have to fix the gaps in your decking.

A stiff joint may or may not be painful. Or a stiff joint or two may have little or nothing to do with pain in the area. If a manip appears to resolve pain, with or without cavitation, this can appear to be temporary or permanent. The only sense one can make out of this is that movement can restore painfree function. The nature of the most effective movement is what's uncertain, and it would take a massive series of studies to indicate which type of movement works best, starting with nonconscious movement right through to Gr Vs - and including functional movements such as walking and swimming, etc....

Nari