As acupuncture practitioners, we have an opportunity to incite curiosity and realistic hope into our nation's aging population. The progressions of hip, knee and shoulder degeneration are encroaching upon the quality of life of so many that the general public is reaching out to our professions to assist them.1
Certainly, many clients/patients come to us with pain and reduced range of motion associated with these joints. According to a physician who reviewed this article, Dr. Daniel Herlihy D.O., his clinical experience suggests that patients often present with the signs of these degenerations as young as their early 40s.
The essential question is whether each of us has the skill sets to screen for early indicators that these joints may be progressing toward degeneration. The following are my time tested screenings for the shoulder, hip and knee. Following these descriptions will be a discussion of anatomical relationships that contribute to the degeneration of these joints.
Shoulder Screening
For the shoulder, have the patient seated. Passively move the compromised arm and shoulder into abduction guiding their arm over their head, as you feel for ease of the humeral head gliding under the shelf of the acromion. If the range feels restricted, tremors or abruptly stops, this may be an indication that a degenerative process has begun. Encouraging your patient to schedule a more formal orthopedic evaluation may serve to preserve future quality of life.
Hip Screening
For the hip, have the patient lie on their side with their bottom leg and thigh extended. Place your foot on the table with your knee bent to 90 degrees and lift the top thigh and leg of the symptomatic hip, balancing it on your thigh. Grasping just above the ankle, passively lift the leg into abduction. As you guide the hip joint into internal rotation palpate the greater trochanter and feel for the range and quality of the movement through both of your hands. Most commonly, if someone's hip joint has started down the path of degeneration, you will feel not just a restriction to motion, but also an abrupt stop to the motion. In my experience, this lack of internal rotation has been my most reliable indicator that degenerative progression, especially if my best efforts to mobilize the joint are minimally effective.2
Knee Screening
Evaluating knees is trickier because degeneration can create either an advancing immobility to flexing and extending normally, or the joint can become destabilized to the point where a client reports that it feels as if the knee is going to give out on them with increasing regularity. In both cases if the patient doesn't exhibit improvement, it is best to encourage seeking further medical evaluation.
Functioning as part of your patients' early detection team is a golden key to preserving their quality of life even if you treat them only once. You touched them; you cared enough to express concern; trust that the seed was planted. This will serve our professions to do so.
Understanding the Linkage Between the Hip, Knee, and Shoulder
Osteopathy has long held that there exists a lateral fascial integration: from the latissimus dorsi's attachment to the humerus downward throughout the torso via the sacroiliac joints, blending into the lateral hamstrings, then into the peroneal muscle group descending along the lateral ankle and crossing across the foot to the base of the first metatarsal and the medial cuneiform bones.3 This one construct gives us a fascial linkage between the three joints that most commonly need to be replaced.1
Empirical observations within my clinical practice of thousands of clients has evidenced the discovery that the shoulder has a tendency to slip forward in its socket while the femoral head slips posterior in relationship to the acetabulum. Naturally, their myofascial structures spring into protective contraction and spasm. As these protective contractions become chronic their tension reduces adequate blood flow to the joints leading to compression, congestion, degeneration, reduced range of motion, and ischemic pain.4
My speculation is that nature evolved this flexibility in the shoulders and hips as a survival edge when we fall from any degree of height activating the subcortical reflex to "tuck and roll." Additional righting reflexes can be activated by falling, whiplash, and impact injuries of all varieties. One that I commonly find in clients with these progressions was described by Thomas Hanna PhD as the Lateral Trauma Reflex.5-6
Let's recognize the simple fact that the femur at its proximal end forms the hip joint with the acetabulum while the condyles of its distal end interface with the plateau's of the tibia to form the knee joint. When the head of the femur slips posterior, it also twists to some degree. This twist is communicated down its length distorting the tracking of the interfacing surfaces of the knee joint. Again, compression, congestion, protective contraction, and friction, provoke inflammatory cycles that result in loss of coordinated motion, range of motion, instability, and eventually ischemic pain. Therefore, it is no surprise that the number of knee replacement surgeries is approximately double the number of hip replacements each year.7
Structural Distortions
What is remarkable is how adaptable our bodies are to these structural distortions providing us at least some degree of ongoing function for decades until the joint cartilages thin to the dreaded diagnostic statement that you have a joint that is "bone on bone." Ironically, little Orthopedic attention or screening is given to how the degeneration of these joints contribute to arthritic progressions within the axial skeleton, especially the low back. If you have a patient with chronic low back pain, please do these screenings. You may be surprised just how often one or more will exhibit signs of degeneration.8
Another overlooked variable is that our feet, legs, thighs, hips and pelvis are designed to bear weight. The axial spine is not. It functions as a relay team passing the baton of the forces of movement and weight bearing through the spaces of their joints in the cross-crawl pattern of walking.3
The next article of this series will explore the more intrinsic relationships of anatomy and physiology that I have clinically correlated to contribute to the progression of degeneration within these joints. Reflect for a moment, our quality of life really does depend upon the normal functioning of our hips, knees and shoulders.
References
Chronic pain afflicts over 20% of the adult population. Sadly, most MDs have essentially no education in treating pain, beyond offering a few toxic medications. Then they tend to steer people with pain away from those health practitioners who are trained. This puts the acupuncture community on the front lines for addressing this epidemic.
When the body is going through a stressful event, the sympathetic system is activated. This activation will help the body with a life-threatening situation. If this state is activated for prolonged periods of time, it starts to consume energy. These traumatic events that generate stressors in the autonomic nervous system (ANS) will eventually become internalized.
| Digital Exclusive
One of the things that makes acupuncture so difficult to measure is that the medicine actually does contain some esoteric aspects. There have been numerous studies that demonstrate the neurochemical reasoning behind why acupuncture points stimulate the autonomic nervous system to enact change However, not all the benefits of TCM can easily be measured by randomized, controlled trials. But does that make them fundamentally and definitively untrue?
| Digital Exclusive