Expert: Dr. Victor Dolan, DC, DACBSP - 5/22/2009

Question
I am 18 years old and have had left knee pain for the last two years and two months. I went from being a very active person to not being able to do the things I use to do because of the pain. The doctors diagnosed it as patella femoral pain. They said that the muscle was wrapped so tightly around the bone that it was pulling my kneecap and causing bone to rub against bone. I was born with cerebral palsy which makes treatment of the knee pain even harder and especially this type of knee pain because of the spasicity that comes with the cerebral palsy. The cerebral palsy mainly affects my lower legs causing severe spasticity and weakeness. As a result of the decreased strength in my hips and legs I have had to use a walker to get around on a daily basis since I was born. About a year and half ago I had femoral osteotomy to fix the deformity in my femur with the hopes that, that would make the knee pain go away, but no such luck. The osteotomy improved the turning in of my left knee a little bit, but it still is not lined up completely straight due to years of it rotating inward when I walk. Five months later I had my knee scoped. They found nothing except for a contusion underneath my kneecap, but nothing that would fix the pain. Then I had a cortisone injection that provided complete relief for just a few hours the following day due to the litocane. After that I had euflexa injections, but got no relief at all. The doctors considered doing a lateral release, but after my visit to the mayo clinic they decided this would probably put me in a wheelchair for the rest of my life due to the lack of strength i have in my hips and legs. I have also done physical therapy, but that was not successfu do to how tight my patella tendon is.The phsical therapists were not successful in manually trying to stretch that out. I have also taken many different medications that included: codeine, celebrex, alieve, advil, and amitriphilin, but had no luck with any of those either. I have never received any type of chiropractic treatments, but decided to give the option a try after all the previous failed options. I read up on acupuncture and went to my local chiropracter to give it a try. I have received about 16 treatments and had no luck yet. He also adjusted the cartilage in my knee. What else can the chiropractor do for the knee pain??? Is it normal for the acupuncture to take this long to be effective??? Also I recently started having si joint pain. My chiropractor confirmed this to be facet joint pain after seeing that my mri of my lower back and pelvis was normal noticing only that I had a few dark spots in the joints do to lack of motion. How is si joint pain related to facet joint pain? What is facet syndrome?  What is the difference between the two things? Is the pain going to go away in time with stretching?? Thank you for taking the time to read and or comment on what I wrote. Any comments or answers to questions you can provide would be more than helpful.

Answer
Hello Heidi,

I am sorry to hear of your condition.

You state you are 18y/o - this is helpful= you are young.  Young = greater ability to heal.  You also state you have C.P., so you have had a problem your entire life- 18 years.  You have a complicated problem.

As a Doctor of Chiropractic I am partial towards 'physical medicine'.  Chiropractic, physical therapy, massage therapy- approaches done with the hands, exercises, different therapy machines- these approaches are safe and effective when dealing with physical/ mechanical problems.

As a Doctor of Chiropractic, I must admit my bias against surgical intervention unless ABSOLUTELY necessary.  Surgery PERMANENTLY changes the  architecture, the structure, the entire situation.  Sometimes this change in structure is for the good, unfortunately sometimes it changes things for the worse,,, but that change cannot be undone.

I recommend continuing conservative Chiropractic, Physical Therapy, Massage, rehab, exercise - these approaches make take a LONG period of time, may require effort on your part, may even be occasionally almost painful; but everything done conservatively can be 'undone'.

".....About a year and half ago I had femoral osteotomy to fix the deformity in my femur with the hopes that, that would make the knee pain go away....."- you have had a surgery to take your pain away.  You still have pain.  Want to try more surgery?  What happened to the first surgery to fix the problem?

".....Five months later I had my knee scoped. They found nothing except for a contusion underneath my kneecap, but nothing that would fix the pain....." another invasive intervention.  No luck?
Why?

".....Then I had a cortisone injection that provided complete relief for just a few hours the following day due to the litocane...." another medical intervention with little good result.

".....After that I had euflexa injections, but got no relief at all...." , you seem to have given the medical/  surgical approach repeated tries at your complaint.  Good.  You have done the best you can with the best information available to you, and you have not caused any permanent (possibly poor) changes to your structure.

".....The doctors considered doing a lateral release, but after my visit to the mayo clinic they decided this would probably put me in a wheelchair for the rest of my life .....", thank goodness you went for a second opinion.

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&"....I have also taken many different medications that included: codeine, celebrex, alieve, advil, and amitriphilin, but had no luck with any of those either....."- on medication:

(this is an information handout I use in my office)




PAIN


Pain is a ‘red light on the dashboard’.


Pain is your body telling you that something is wrong.


That RED LIGHT on the dashboard of your car-
-- do you ignore it until the car breaks down,
or do you get it checked and correct the problem?

Pain,
pain in your body-
-- do you ignore it until your body breaks down,
or do you get it checked and correct the problem?


Pain,
do you cover up the pain by taking a painkiller?
Take a painkiller,
mask the pain,
and allow a problem to progress in your body?



NOTICE ON PAIN RELIEVERS:

Label changes ORDERED by FDA; the FDA announced proposed label changes for OTC over-the-counter pain relievers to include the potential for stomach bleeding and liver damage (FDA news 206- 207; 12-9-06) ;

The American Heart Association issued a scientific statement recommending medical doctors change the way they prescribe OTC pain relievers from a first choice to an alternate of recommending non-pharmacologic treatment (AHA statement 2-26-07).

NSAID Acceleration of ARTHRITIS; an important side effect of Aspirin and other NSAIDS is that it will inhibit cartilage repair and accelerate cartilage  destruction ( Journal of Rheumatology, 1982; 9: 3- 5 ). Many times people take NSAIDS for the pain of Arthritis, not realizing these drugs may make the underlying condition worse. These medications cover up the pain, and cause the problem to worsen.



Pain can often be the result of the Vertebral Subluxation Complex.


Vertebral Subluxation ( ‘VSC’ , ‘subluxation’ )
Vertebral Subluxation is actually a quite common condition. Doctors of Chiropractic look for pathological conditions which may require referral to other specialties, and also look for ‘Subluxation’. Other disciplines look for pathology, but overlook the importance of alignment and movement in the spine which affects our nervous system (the master control system- ALL health disciplines learn this). VSC- ‘Subluxation’ – can be the cause of many symptoms and conditions.



Only a Doctor of Chiropractic will evaluate and treat for VSC, as
well as other pathology.


The course of VSC is highly variable. Some patients with VSC literally cannot walk, yet other patients with similar test findings may be able to run marathons or lift heavy weights. Some patients immediately develop symptoms related to the VSC, some patients take years to develop symptoms. Some people suffer for only a few days with pain and symptoms, some people suffer for months. Some
people recover in days, some take months or years, depending upon severity of the condition.

A subluxation interferes with the proper functioning of the nervous system (the master system which controls and coordinates all function within the body) and may cause various other conditions, symptoms and problems.


The Vertebral Subluxation Complex describes what happens when spinal bones lose their normal movement patterns and position. When subluxated, joints are in a stressed, vulnerable, compromised condition. Subluxation may cause Arthritis, Disk Herniation, or aggravate such conditions.

Vertebral Subluxation cannot be corrected through chemicals
(medicine), stretching, yoga, vitamins or physical therapy alone.
Subluxation- a neuro/skeletal/muscular- mechanical- problem requires a mechanical correction- - - a manipulation, best performed with
the chiropractic adjustment.
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"....Is it normal for the acupuncture to take this long to be effective?....", I am sorry, I do not practice acupuncture, I do not feel qualified to comment here.  I would recommend asking your Acupuncturist to explain more to you.  I would recommend patience; natural, conservative approaches sometimes do take time.


"...He also adjusted the cartilage in my knee. What else can the chiropractor do for the knee pain??....".  Chiropractic is ESPECIALLY related to spinal vertebral subluxation and the adjustment of this spinal condition.  Adjustments are also applied to any/ all joints in the human body that maybe 'subluxated'.  This is the main treatment of the Doctor of Chiropractic.

Along with the adjustment, most DCs also utilize exercises, stretches, massage, physical therapy such as muscle stimulation, ultrasound, etc.

I would think your chiropractic doctor should adjust your patella, perhaps your tibial-femoral portion of your knee joint; AND utilize stretching, massage, and perhaps some adjunctive physiotherapy modalities.


"....Also I recently started having si joint pain....", not surprising, your altered gait will cause spinal joint dysfunction (subluxation).

"....My chiropractor confirmed this to be facet joint pain after seeing that my mri of my lower back and pelvis was normal noticing only that I had a few dark spots in the joints do to lack of motion. How is si joint pain related to facet joint pain? What is facet syndrome?  What is the difference between the two things? Is the pain going to go away in time with stretching??...."- will your pain go away with stretching ALONE?, no.  Misalignment, dysfunction, subluxation, mechanical problems require a mechanical correction- a manipulation, an adjustment.

Can facet joint cause/ refer pain to an SI joint- possibly.

Can you have concurrent Facet joint dysfunction AND Sacro-Iliac (SI) joint dysfunction? yes.  

Facet problems:
-----Most patients will have a persisting point tenderness overlying the inflamed facet joints and some degree of loss in the spinal muscle flexibility (called guarding).
-----There will typically be more discomfort on slightly leaning backwards than on leaning forwards.
-----Low back pain from the facet joints often radiates down into the buttocks and down the back of the upper leg. The pain is rarely present in the front of the leg, or rarely radiates below the knee or into the foot, as pain from a disc herniation often does.


SI joint pain will hurt over the SI joint.  The pain is typically worse with standing and walking and improved when lying down. Inflammation and arthritis in the SI joint can also cause stiffness and a burning sensation in the pelvis.


Your knee, even your spinal problems are caused/ aggravated/ perpetuated by your underlying complicated CP condition.  I treat patients in my office for symptoms related to their CP.  The treatment , unfortunately , will never end.  They have problems due to their underlying condition that requires treatment, unfortunately, throughout their lives.  Please do not get upset with the messenger; but you will require Physical Therapy, massage therapy AND/or Chiropractic treatment for a long, long time.

Many people have problems that require a lifetime of treatment.
Some people take injections every day for diabetes.  Some people take blood pressure pills- forever.  Those of us who want to keep our smiles- we brush our teeth three times a day, forever, for the rest of our lives.  Unfortunately people have bodies with imperfections.  Almost everyone needs some kind of treatment to 'stay healthy' or prevent deteriorating into ill health.

Given your complicated case- I would recommend a Chiropractic Doctor (DC) with additional specialty credentials- such as orthopedics, neurology, rehabilitation, perhaps sports injury; yes DC's have specialties- please go to  http://www.acatoday.org/pdf/ApprovedChiropracticSpecialtyPrograms.pdf to view the various recognized specialties.

You have been patient with medicine, please be patient with natural alternative therapies.  If you had diabetes or high blood pressure, please face that you may be under treatment,,,, and people hate to hear his,,,, 'for the rest of your life', or at least as long as you hope to reduce symptoms.  Your body is your body- whether or not you brush your teeth is up to you.

If the time comes for invasive intervention, be aware your outcome may be good, or poor.  If poor, that change may be permanent.
 
Thank you for the question.  I am sorry for your complicated condition.  If further information is needed,,,
please do not hesitate to REcontact me here at AllExperts.com : -
http://allexperts.com/ep/965-100794/Chiropractors/Victor-Dolan-DC-DACBSP.htm

I hope this helps. Do not shoot the messenger.


Thanks,

Dr. Victor Dolan, DC
http://drvictordolan.chiroweb.com (Email NewsLetter)