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Chiropractic Examination

Chiropractic Examination:

An initial chiropractic examination for musculoskeletal disorders will typically have four parts: a consultation, case history, and physical examination. Laboratory analysis and X-ray examination may be performed. Our office provides additional Functional and Integrative Wellness Assessments in order to bring greater insight into a patients physiological presentations.

The patient will meet the chiropractor which will assess and question a brief synopsis of his or her lower back pain, such as:
Duration and frequency of symptoms
Description of the symptoms (e.g. burning, throbbing)
Areas of pain
What makes the pain feel better (e.g. sitting, stretching)
What makes the pain feel worse (e.g. standing, lifting).
Case history. The chiropractor identifies the area(s) of complaint and the nature of the back pain by asking questions and learning more about different areas of the patient’s history, including:
Family history
Dietary habits
Past history of other treatments (chiropractic, osteopathic, medical and other)
Occupational history
Psychosocial history
Other areas to probe, often based on responses to above questions.

Physical examination:
 We will utilize a variety of methods to determine the spinal segments that require chiropractic treatments, including but not limited to static and motion palpation techniques determining spinal segments that are hypo mobile (restricted in their movement) or fixated. Depending on the results of the above examination, a chiropractor may use additional diagnostic tests, such as:
X-ray to locate subluxations (the altered position of the vertebra)
A device that detects the temperature of the skin in the paraspinal region to identify spinal areas with a significant temperature variance that requires manipulation.

Laboratory Diagnostics:
 If needed we also use a variety of lab diagnostic protocols in order to determine complete clinical picture of the patient. We have teamed up with the top labs in the city in order to give our patients the optimal clinical picture and appropriate treatments.

Arachnoiditis and Constant Pain In The Low Back El Paso, TX.

Arachnoiditis and Constant Pain In The Low Back El Paso, TX.

Arachnoiditis arach·​noid·​itis (ə- rak-nȯid-ˈīt-əs) is a condition that is characterized by stinging, burning pain and neurological problems.

A common symptom is chronic and persistent low back pain, lower limb pain.

It is inflammation of the arachnoid lining. This is one of three linings that surround the brain and spinal cord.

This inflammation causes:

  • Constant irritation
  • Scarring
  • Binding of nerve roots
  • Binding blood vessels

In the intradural space 3 meninges or protective membranes that surround the brain and spinal cord.

  • Dura mater
  • Arachnoid
  • Pia Mater

11860 Vista Del Sol, Ste. 128 Arachnoiditis and Constant Pain In The Low Back El Paso, TX.


Symptoms of Arachnoiditis

Predominant symptoms are chronic pain in the:

  • Low back
  • Lower limbs
  • In severe cases the entire body

Other symptoms can include:

  • Leg tingling, numbness, and weakness
  • Weird sensations like the feeling of insects crawling on the skin or water running down the leg
  • Shooting pain like an electric shock sensation
  • Muscle cramps, spasms, and twitching
  • The bladder, bowel, and possible sexual dysfunction

Progression of the disease can make symptoms more severe and possibly permanent.

The pain is constant and incurable, which makes the disorder very debilitating. Those with arachnoiditis usually cannot work and have a disability.

11860 Vista Del Sol, Ste. 128 Arachnoiditis and Constant Pain In The Low Back El Paso, TX.



Three main causes of arachnoiditis are:


Arachnoiditis has been recognized as a rare complication of spinal surgery usually after multiple or complex surgeries.

It can also be caused by trauma to the spine.

Similar causes include:

  • Multiple lumbar punctures
  • Advanced spinal stenosis
  • Chronic degenerative disc disease


Myelograms have come under scrutiny as being a possible cause of the condition.

A myelogram is a test where a radiographic contrast dye is injected into the area around the spinal cord and nerves.

The dye becomes visible on:

  • X-rays
  • CT
  • MRI scans

Used by physicians to diagnose spinal conditions.

Now there is a concern that repeated exposure to some of these dyes may cause arachnoiditis.

There is also a concern of the preservatives found in epidural steroid injections, that they may cause the condition, especially if the steroid medicine accidentally enters the cerebral spinal fluid.


The disorder can also be caused by certain infections that affect the spine like:

  • Viral and fungal meningitis
  • Tuberculosis



Currently, there is no cure for arachnoiditis.

Therefore, treatment is aimed at pain relief and is similar to how other chronic pain conditions are treated.

Examples include:

  • Spinal cord stimulation: is one of the best treatment options. Spinal cord stimulation runs on a device that transmits electrical signals to the spinal cord for relief.
  • Lidocaine intravenous infusions: Lidocaine is a powerful anti-inflammatory.
  • Ketamine infusions: Ketamine is an anesthetic, that also helps with pain relief.
  • Low-dose naltrexone is an anti-inflammatory for chronic pain management.
  • Pain medications like:
  • NSAIDs
  • Corticosteroids either taken orally or injected
  • Anti-spasm drugs
  • Anti-convulsants for burning pain
  • Physical therapy based on a doctor’s recommendation like:
  1. Hydrotherapy
  2. Chiropractic
  3. Massage
  4. Hot/cold therapy

Surgery is not recommended because it causes more scar tissue to develop and makes the irritated spine susceptible to more trauma.

Living with the Arachnoiditis

  • This condition can be extremely disabling.
  • Living with chronic pain is not an easy thing to do.
  • It affects the body and also causes mental stress.
  • People with the condition are encouraged to join support groups or find therapeutic outlets for stress.
  • Treatment plans are focused on pain relief and keeping a high quality of life.
  • Research is ongoing to find a cure.


*CHRONIC* pain Chiropractic Relief | El Paso, Tx



Patients with chronic pain discuss how their symptoms have affected their overall health and wellness. With chiropractic care, patients describe how Dr. Jimenez, a doctor of chiropractic or chiropractor in El Paso, Texas, has helped them recover their original quality of life.

Chiropractic care is an alternative treatment option that focuses on the diagnosis, treatment, and prevention of a variety of health issues, including chronic pain and personal injuries. Patients highly recommend Dr. Jimenez and his staff as the non-surgical choice for auto accident injuries and slip-and-fall accidents.


NCBI Resources

Those who continue to deal with the pain after a few weeks’ time may choose to look for other solutions. This is also true for people who experience repeated flare-ups, or chronic lower back pain. One of the best and most popular options is chiropractic care. Chiropractic care doesn’t focus solely on the pain but helps the body heal itself. Chiropractors understand the bones, muscles, discs, and nerves in the back, and can figure out the reason for the pain.

From there, they can create a customized treatment plan from compresses to spinal manipulation to exercises that help heal the area and reduces the pain.


Foot/Heel Pain & Chiropractic Orthotics El Paso, Texas

Foot/Heel Pain & Chiropractic Orthotics El Paso, Texas

Around 3 million individuals suffer from plantar fasciitis


11860 Vista Del Sol Ste. 128 Foot/Heel Pain & Chiropractic Orthotics El Paso, Texas


  • Heel pain
  • Foot pain
  • Spurs
  • Tight tendons
  • Stiffness


Signs of a long day, wearing the wrong shoes, both or you may have a condition known as plantar fasciitis. We don’t take our health seriously until we go through excruciating pain or some form of debilitation. Feet are the foundation of the body and when they are not at 100% there are going to be problems.

Identifying, diagnosing, and treating plantar fasciitis can be fast and easy with chiropractic orthotics!


What is it?

Plantar Fasciitis is inflammation of the tissues in your foot.

People think it only affects the heel, however, it can affect any or all of the bottom of the foot. Because it’s the tissue between the toes and heel that gets inflamed.

  • The tissue is called “fascia” hence the name of the condition: plantar fasciitis.
  • Heel spurs were once thought to be the cause of the discomfort, but now is a symptom of plantar fasciitis.
  • Many people who have plantar fasciitis wake up with stabbing pain in the bottom of their feet during the first few steps of their day.
  • Early morning pain and stiffness is a big indication of PF.
  • Also called “policeman’s heel,” pain and discomfort also arise after long periods of standing, walking, exercise.
  • The fascia in the foot acts as a shock absorber, which helps support the arch of the foot.
  • With time, increased tension, small tears begin to happen in the fascia, that leads to the inflammation.

11860 Vista Del Sol Ste. 128 Foot/Heel Pain & Chiropractic Orthotics El Paso, Texas


Who gets Plantar Fasciitis?

People that stand on their feet for long hours, such as:

  • Factory workers
  • Teachers
  • Doctors
  • Nurses
  • Retail employees

Are at a higher risk of developing plantar fasciitis.


Improper Footwear/Posture

Wearing improper shoes, meaning too tight, too loose is another contributing factor.

Shoes that have arch support and heel protection are considered best and help to avoid pain and discomfort.

  • Poor posture
  • Abnormal walking gait

When heel or foot pain is not treated, it can lead to

  • Back
  • Knee
  • Hip problems 

Many adjust their walking to compensate for the pain and discomfort that can lead to more problems.

Being flat-footed raises the likelihood of developing plantar fasciitis regardless of age or lifestyle.


11860 Vista Del Sol Ste. 128 Foot/Heel Pain & Chiropractic Orthotics El Paso, Texas


Other Contributing Factors

Weight also contributes to plantar fasciitis because it puts greater stress and tension on the feet as they hold the body. Exercise can help, but be sure that they are exercises specifically designed to help treat plantar fasciitis. Because certain types of exercise like running, aerobics, jumping, and dance-based workouts can lead to heel pain and plantar fasciitis.


Identifying and diagnosing plantar fasciitis is straightforward and relatively easy. Diagnosing plantar fasciitis does not require an X-Ray or MRI, which is one reason many people avoid seeking treatment. But it’s best to seek the advice of a trusted healthcare professional.


There are several ways to treat plantar fasciitis:

  • Rest is one of the best remedies, especially if it is caused by exercise or excessive stress.
  • Icing the area can help manage the pain
  • Stretching and/or light physical therapy
  • Stretches that focus on the Achilles tendon and lower leg muscles help stabilize and strengthen the ankles and heels.

This helps to:

  • Stand
  • Walk
  • Workout
  • Move around

Chiropractic and physical therapy can help with:

  • Stretching the muscles and tendons
  • Work out and tension
  • Provide day-to-day stretches



  • Kinesio taping along the bottom of the foot, heel, and lower leg but should be done first by a professional like your chiropractor to show the proper and most effective method then you can do it yourself.
  • Chiropractic orthotics, or custom insoles, can help immensely because they are custom made to each individual.
There are a variety of types designed for various types of pain and discomfort.


Custom chiropractic orthotics can work in nearly any type of shoe.

  1. Athletic/Tennis/Skate shoes
  2. Work Shoes/Boots
  3. High heels
  4. Sandals

They are easily and custom made specifically to your body, which factors in your weight, posture, and gait.

If you’re experiencing any of the symptoms like heel pain, throbbing pain when you wake-up, or pain along the arch of your foot, then don’t hesitate and make an appointment with us today!

Our chiropractic/physical therapy team will teach you how to make small adjustments to your lifestyle, show you how to stretch properly, and how to use custom chiropractic orthotics to get you back on your feet with comfort, control and freedom to live your life.


Manage *PLANTAR FASCIITIS PAIN* with Custom Foot Orthotics | El Paso, TX (2019)



Gloria underwent foot pain that stretched throughout her body. Her plantar fasciitis developed because of her regular activities. Gloria explains how her well-being has been influenced by her afflictions. The custom made foot orthotics supplied for her by Dr. Alex Jimenez, a chiropractor in El Paso, TX, tremendously helped relieve her foot pain and plantar fasciitis symptoms. Gloria explains the comfort that the custom-made foot orthotics supplied for her symptoms. Gloria highly recommends Dr. Alex Jimenez as the non-surgical selection for foot pain and plantar fasciitis treatment, among other problems.


What’s Afoot

Particularly true with foot dysfunction is when the mechanics of the foot are off, which can throw off the alignment of the entire body. Overpronation and oversupination in the foot can lead to severe and chronic back pain. Ankle pain refers to any type of pain or discomfort in the ankle. This pain could generally be due to an injury, such as a sprain, or due to another health issue. As stated by the National University of Health Sciences, or NUHS, an ankle sprain is one of the most frequent causes of foot pain, making up 85 percent of all ankle injuries. A sprain occurs when the ligaments tear or are overstretched.

Chiropractors utilize a combination of treatment techniques and methods to ease ankle and foot pain. Chiropractic care is a safe and effective, alternative treatment option which focuses on the diagnosis, treatment, and prevention of a variety of injuries and conditions associated with the musculoskeletal and nervous system, including foot and ankle pain.


VasyliMedical Manipulation of the Ankle_PF


NCBI Resources

Plantar fasciitis/heel pain syndrome is the most common cause of heel pain, that results from a gradual degeneration of the plantar fascia or sudden trauma. Individuals describe the pain like sharp stabbing or deep aching in the middle of the heel or along the bottom of the foot that happens when walking or standing. Pain arises in the morning after taking the first few steps or after extended periods of sitting/lying down/non-activity.


First Time Chiropractic Patients What to Know and Expect

First Time Chiropractic Patients What to Know and Expect

If you have never been to see a chiropractor before, you may be wondering what you should expect. You likely have seen a video or heard someone talk about a chiropractic adjustment. Having your back or neck adjusted is definitely a big part of the process—but what else do you need to know? Continue reading to discover the basics of chiropractic and what you have to look forward to.

 Chiropractic Guide for First Time Patients

11860 Vista Del Sol, Ste. 128 First Time Chiropractic Patients What to Know and Expect

Your visit begins with a thorough examination.

Don’t expect to walk through the door of the chiropractor and get your back cracked. Chiropractors are highly-trained professionals that focus on individualized treatments and getting the best possible results. That means getting a clear picture of what your condition is and identifying the ideal treatments before starting with the adjustments.

The chiropractor will conduct a full physical examination to identify your injuries, any movement difficulties, etc. He or she will also ask a number of questions to find out how you feel and why you think you feel the way you do.

You might get an adjustment.

There are a lot of ways to adjust the human body, which are not limited to the standard adjustments you may have seen on TV or in movies. Your chiropractor can adjust not only your back but all of your joints, including knees, ankles, elbows and more. He or she can also use different tools to facilitate adjustments and employ techniques that range from extremely gentle to more forceful.

The adjustment you get will be based on your unique circumstances and the opinion of the chiropractor.

You might not get an adjustment.

It can be surprising to be told by the chiropractor that you won’t get an adjustment during your visit, but it does happen. Your chiropractor may determine that other therapies are better for your current condition. The adjustment may have to wait until your body is ready for it.

You will be offered alternative therapies.

Chiropractors focus on getting the best results for patients, which often means employing supplemental and complementary therapies in addition to chiropractic adjustments. Some common therapies include massage, decompression, electrical stimulation and more. Massage can relax soft tissues to allow for better adjustments, or to help adjustments stay in place. Decompression can increase blood flow to discs. Electrical stimulation can increase healing times.

You always have the final say in your treatment plan.

While the chiropractor will certainly have recommendations on which therapies are best suited to your needs, in the end, it is you who decides what happens. After your examination, the chiropractor will present the recommended options and let you decide if you want to start treatment.

You will experience improvements sooner rather than later.

Many patients are pleasantly surprised by how effective their chiropractic treatments are. Often after the first visit, you will feel less pain, more mobile and more at ease. A good adjustment and supplemental therapies can do a great deal to alleviate discomfort and stiffness. The good news is that each successive visit will only add to the good feelings you experience.

Getting Safe, Highly Effective Treatment

According to the American Chiropractic Association, chiropractic care is one of the safest drug-free, non-invasive treatments available for injuries and degenerative conditions related to your muscles, joints and skeletal system. There are so many benefits, and so few potential downsides, that it is hard to find a reason not to try chiropractic!

Please contact our team today to schedule an appointment with a chiropractor. Discover why so many people choose chiropractic for their healthcare needs.



Gait Related Lower Back Pain


31 million Americans experience low back pain at any given time. This condition affects many, but finding the exact cause can be a challenge. Chiropractors are spinal specialists that are trained to not only alleviate pain but also find and help correct the cause of the problem.  Prevention is the best cure for any condition/ailment. When someone sees a chiropractor, they not only find relief for their condition, but they learn ways to prevent their symptoms in the future. Using proper exercise and ergonomics, they can ease the discomfort before it starts.

VasyliMedical Gait Related Lower Back Pain

NCBI Resources


chiropractor is the ideal medical professional to consult with for any unexplained pain in the musculoskeletal system. They are highly qualified professionals that their specialty is treating conditions like lower back pain and they are very affordable. If you or a loved one have pain in the lower back, gives us a call. We’re here to help!



Regular Chiropractic Adjustments & 3 Benefits  El Paso, TX.

Regular Chiropractic Adjustments & 3 Benefits El Paso, TX.

Most people think that chiropractic care is something to do if they experience back or neck pain, and rightly so, as these are the most common reasons people visit a chiropractor. But chiropractic does way more than that.

Chiropractic helps with a variety of ailments from headaches to digestive issues and addresses problems like sports injuries, work injuries, arthritis, and injury prevention. Regular trips to the chiropractor are a good idea. Here are three important benefits that you can get from regular chiropractic adjustments.

What Taking an Active Role in Your Health Can Do

Chiropractic is a holistic kind of care that has a chiropractor serve as a guide as your own body uses its own innate ability to heal itself. When you see a chiropractor on a regular basis, even if there is not a pressing problem, you are taking an active role in assuring you are in the best health you can be.

Chiropractic adjustments correct misalignments in the spine that may be blocking nerve function and causing pain to muscles, joints, and ligaments. When you are adjusted by a chiropractor, these blocks are removed and you are able to move and function better than you did before.

A chiropractor can also provide you with nutritional and lifestyle advice, including exercises you can do between visits that will improve strength, flexibility, and various other functions. Without your active participation and cooperation, the success of chiropractic diminishes, so you can feel good about taking responsibility for your own health.

11860 Vista Del Sol, Ste. 128 Regular Chiropractic Adjustments & 3 Benefits  El Paso, TX.

Improved Neurological Conditions

The spine connects to several different areas of the body, including the brain. Adjustments have been shown to increase blood flow to the brain, which in turn improves function in many areas.

The brain and spine are frequent communicators, and the nervous system is often the “wires” that are used to assure proper communication. Stress can trigger misalignments and the breakdown in these systems. Chiropractic is able to identify when stress is placed on these nerves and has even been shown to increase white blood cell count in some patients.

Eliminated Need for Pain Medications

One of the cornerstones of chiropractic is that it does not rely on pain medications or surgery in order to treat pain. Instead, it is designed to trigger your body’s own ability to heal itself without drugs and surgery.

Through methods such as manual adjustment, massage, and electrical muscle stimulation, chiropractic strengthens communication throughout the body in order to help it heal naturally. Chiropractors use important diagnostic tools such as x-rays, laboratory analysis, and reviewing your health history to pursue a treatment plan.

Conversely, when misalignments are allowed to build up over time, there is a greater risk that you will be tempted to seek out pain medications in order to mask the pain temporarily. While occasional use of these is okay, over time they can build up in the system and damage liver function, so it is important to find other methods of pain management whenever possible.

In closing, chiropractic benefits the overall health of people that utilize it consistently. So if you’re ready to experience these benefits yourself, just pick up the phone and give us a call. We’re here to help!

Benefits of Custom-Made *ORTHOTICS* | El Paso, Tx


99% of the population has some degree of foot pronation.

11860 Vista Del Sol, Ste. 128 Regular Chiropractic Adjustments & 3 Benefits  El Paso, TX.

Foot pronation occurs when the foot/feet roll inwards.

People with excessive pronation may experience inward rotation of the knee and forward tilting of the pelvis, which causes pain in the:

  • Feet
  • Knees
  • Hips
  • Back
  • Shoulders
  • Neck


11860 Vista Del Sol, Ste. 128 Regular Chiropractic Adjustments & 3 Benefits  El Paso, TX.

Foot Orthotics

Foot Dysfunction can very easily cause a domino effect that extends all the way to the back. The feet are the foundation of the body and when there is a problem with the way they function it can cause the entire body to shift out of alignment.


Pronation & Misalignment

For the foot to function correctly, there must be a significant degree of pronation. However, excessive pronation, or overpronation, can cause injury and damage to the foot and ankle. It creates the arch in the foot to flatten, and the ligaments, tendons, and muscles under the foot overstretch.

VasyliMedical Pronation

NCBI Resources

Chiropractic seeks to find the cause of the conditions it is used to treat, including pain, instead of just treating symptoms. Because of this, the chiropractor will work to find the cause of the pain.


Three Spine Abnormalities That Chiropractic Helps El Paso, TX.

Three Spine Abnormalities That Chiropractic Helps El Paso, TX.

Sometimes there are abnormalities of the spine and it causes a misalignment of the natural curvatures or some curvatures may be exaggerated. These unnatural curvatures of the spine are characterized by three health conditions called lordosis, kyphosis, and scoliosis.

It is not intended to be naturally bent, twisted, or curved. The natural state of a healthy spine is somewhat straight with slight curves running front to back so that a side view would reveal them.

Viewing the spine from the back, you should see something completely different – a spine that runs straight down, top to bottom with no side to side curves. This doesn’t always happen though.

The spine is comprised of vertebrae, small bones that are stacked on top of each other with impact cushioning discs between each one. These bones act as joints, allowing the spine to bend and twist in a variety of ways.

They gently curve, sloping slightly inward at the small of the back, and again slightly at the neck. The pull of gravity, combined with body movement, can put a great deal of stress on the spine and these slight curves help absorb some of the impact.

Different conditions for different types of spinal curvatures

spinal abnormalities that chiropractic can help el paso tx.

Each of these three spinal curvature disorders affects a certain area of the spine in a very specific way.

  • Hyper or Hypo Lordosis – This spinal curvature disorder affects the lower back, causing the spine to curve inwards or outwards significantly.
  • Hyper or Hypo Kyphosis – This spinal curvature disorder affects the upper back, causing the spine to bow, resulting in that area rounding or flattening abnormally.
  • Scoliosis – This spinal curvature disorder can affect the entire spine, causing it to curve sideways, forming a C or S shape.

What are the symptoms?

spinal abnormalities that chiropractic can help el paso tx.

Each type of curvature exhibits its own set of symptoms. While some symptoms may overlap, many are unique to the specific curvature disorder.

  • Lordosis
    • A “swayback” appearance where the buttocks stick out or are more pronounced.
    • Discomfort in the back, typically in the lumbar region
    • When lying on a hard surface on the back, the lower back area does not touch the surface, even when attempting to tuck the pelvis and straighten the lower back.
    • Difficulty with certain movements
    • Back pain
  • Kyphosis
    • A curve or hump to the upper back
    • Upper back pain and fatigue after sitting or standing for long periods (Scheuermann’s kyphosis)
    • Leg or back fatigue
    • The head bends far forward instead of being more upright
  • Scoliosis
    • Hips or waist are uneven
    • One shoulder blade is higher than the other
    • The person leans to one side

What are the causes?

Many different health issues can cause the spine to become misaligned or to form a spinal curvature. Each of the spinal conditions mentioned is affected by different conditions and situations.

  • Lordosis
    • Osteoporosis
    • Achondroplasia
    • Discitis
    • Obesity
    • Spondylolisthesis
    • Kyphosis
  • Kyphosis
    • Arthritis
    • Tumors on or in the spine
    • Congenital kyphosis (abnormal development of the vertebrae while the person is in utero)
    • Spina bifida
    • Scheuermann’s disease
    • Spine infections
    • Osteoporosis
    • Habitual slouching or poor posture

Scoliosis is still a bit of a mystery to doctors. They are not certain what exactly causes the most common form of scoliosis that is typically seen in children and adolescents. Some of the causes that they have pinpointed include:

chiropractic can help el paso tx.
  • Hereditary, it has a tendency to run in families
  • Infection
  • Birth defect
  • Injury

Spinal curvature disorders & Chiropractic

Spinal manipulations for spinal curvature disorders have been shown to be very effective. Chiropractic helps restore the spine’s natural balance even if the patient has one of these types of conditions.

There are screenings available for both children and adults to identify any spinal curvatures in their early stages through your chiropractor. Early detection of these disorders is crucial in identifying them before they become too serious.

Personalized Spine & *SCIATICA TREATMENT* | El Paso, TX (2019)

Dermatomes and Myotomes: What Are They And How Do They Work?

Dermatomes and Myotomes: What Are They And How Do They Work?

The spinal cord and brain make up the central nervous system while the spinal nerves that branch to the spinal cord and cranial nerves that branch to the brain makes up the peripheral nervous system.

There are thirty-one sets of nerves that extend out of the spinal cord and are connected to it by the nerve root. Each nerve branches out about a half inch from the spinal cord before dividing into smaller branches. The dorsal rami are on the posterior side of the branch while the larger ventral rami are on the anterior side.

dermatomes myotomes injury medical chiropractic clinic el paso, tx.

The dorsal rami provide nerve function for the skin of the trunk and posterior muscles. The ventral rami from T1 to T12 provide nerve function to the skin of the trunk as well as the lateral and anterior muscles. The anterior divisions that remain for plexuses, networks that provide nerve function to the body. Each plexus has specific areas on the body for skin sensitivity as well as certain muscles. Their point where they exit the spine determines how they are numbered. The four primary plexuses are:

  • Cervical plexus, C1 – C4, innervates the diaphragm, shoulder, and neck
  • Brachial plexus, C5 – T1, innervates the upper limbs
  • Lumbar plexus, T12/L1 – L4, innervates the thigh
  • Sacral plexus, L4 – S4, innervates the leg and foot.

These spinal nerves have two sets of fibers: motor and sensory. Motor fibers facilitate movement and provide nerve function to the muscles. Sensory fibers facilitate sensitivities to touch, temperature and other stimuli. They provide nerve function to the skin.

dermatomes myotomes injury medical chiropractic clinic el paso, tx.

What are Myotomes and Dermatomes?

A group of muscles that are innervated by the motor fibers that stem from a specific nerve root is called a myotome. An area of the skin that is innervated by the sensory fibers that stem from a specific nerve root is called a dermatome. These patterns of myotome and dermatome are almost always identical from person to person. There are occasionally variances, but that is rare.

This consistency allows doctors to treat nerve pain in patients. If a specific area is hurting, they know that it is attributed to a certain myotome or dermatome, whichever the case may be, and its corresponding nerve root. Problems with nerve damage are often the result of stretching the nerve or compressing it.

When the nerves are injured in specific areas like the lumbosacral or brachial plexus, it presents as sensory and motor deficits in the limbs that correspond to them. Myotomes and dermatomes are used to assess the extent of the damage.

How are Myotomes and Dermatomes used to Assess Nerve Damage?

dermatomes myotomes injury medical chiropractic clinic el paso, tx.

When a doctor tests for nerve root damage in a patient, he or she will often test the myotomes or dermatomes for the nerves assigned to that location. A dermatome is examined for abnormal sensation, such as hypersensitivity or lack of sensitivity.

This is done by using stimulus inducing tools such as a pen, paper clip, pinwheel, fingernails, cotton ball, or pads of the fingers. The patient is instructed to provide feedback regarding their response. Some of the abnormal sensation responses include:

  • Hypoesthesia (decreased sensation).
  • Hyperesthesia (excessive sensation).
  • Anesthesia (loss of sensation).
  • Paresthesia (numbness, tingling, burning sensation).

A myotome is tested for nerve damage in the muscles which presents as muscle weakness. This grading scale, which assigns a rating to the degree of muscle weakness, is often used:

  • 5 – Normal – Complete range of motion against gravity with full resistance
  • 4 – Good – Complete range of motion against gravity with some resistance
  • 3 – Fair – Complete range of motion against gravity with no resistance, active ROM
  • 2 – Poor – Complete range of motion with some assistance and gravity eliminated
  • 1 – Trace – Evidence of slight muscular contraction, no joint motion evident
  • 0 – Zero – No evidence of muscle contraction
thoracic spine chiropractic treatment el paso tx.

During a typical chiropractic exam, your chiropractor will assess both dermatomes and myotomes for potential neurological problems. This gives them additional insight on how to treat your condition, whether it’s related to a subluxation of vertebral bodies or other, other disease processes.

Back Pain Chiropractic Treatment | El Paso, Tx

4 Benefits Of Scoliosis Screening From A Chiropractor

4 Benefits Of Scoliosis Screening From A Chiropractor

It is estimated that scoliosis affects anywhere from 2 to 3 percent of children and adults in the United States. That is roughly six to nine million people. While it seems to develop most commonly within specific age ranges for boys and girls, it can also develop in infancy. Every year, approximately 30,000 children are fitted with a scoliosis back brace while 38,000 people have spinal fusion surgery to correct the problem. Scoliosis screenings can have tremendous benefits by identifying both risk factors for scoliosis and allowing for early treatment.

The earlier you detect scoliosis, the easier it is to treat.

Scoliosis typically develops in childhood. For girls, it usually occurs between 7 and 14 years of age. Boys develop it a little later, between 6 and 16 years of age.

Getting a scoliosis screening each year during these critical age ranges allow doctors to identify the condition early and begin treating it before it gets serious. Advanced scoliosis can require extensive treatments, bracing, and even surgery.

Chiropractic has been shown to help scoliosis, as do stretching, special exercises, and physical therapy. There are spinal adjustments that chiropractors do that are specific to the treatment of scoliosis.

When addressing the condition early on, the Cobb angle can be stopped from progressing and even reduced so that the spine has a more natural curve. Non-surgical treatments tend to be much more effective in the earlier stages of scoliosis, so early detection and early diagnosis are critical.

scoliosis screening chiropractor, el paso, tx.

Identifying high-risk cases early can address current issues and prevent future ones.

Chiropractors can identify certain scoliosis risk factors in children before the condition even develops. A scoliosis screening allows them to spot tension in a child’s spinal cord – a common sign that they will develop scoliosis.

When parents are aware that their child is in a high-risk category for developing scoliosis, they can take proactive measures with home monitoring for the signs of scoliosis as well as keeping up with the course of recommended screenings. They will know to look for the signs and can address them quickly so that treatment can be started at the earliest possible time.

Help researchers and doctors become more effective in treating scoliosis.

The early stages and development of scoliosis are still shrouded in mystery for researchers and doctors. While there have been great strides made in better understanding the condition, there is still much left to learn.

There have been many studies that have aided doctors in identifying high-risk children and making early stage diagnoses, such as how the angle of the ankle and foot are linked to scoliosis. However, screening, diagnosis, and treatment are vital to maintaining the flow of data for more studies to be conducted and more research to be done.

More mainstream screenings mean identifying more cases of scoliosis at the early stages. This would have a two-prong effect on research. It would provide more data to be reviewed and studied, and it would increase interest in the condition as more cases of early stage scoliosis is found. This would further spur research.

Avoid the “waiting game” of seeing if scoliosis will progress.

Any parent who has had to wait for the results of a test or to see if a condition will develop or worsen knows well the anxiety of playing that waiting game. A family is usually the first person to discover scoliosis in a child.

While they may suspect a problem, or know that a problem exists, they may take a “wait and see” approach in getting treatment. If the curve worsens they may eventually seek treatment, but the constant nagging of not knowing if the curve will get worse – and the anxiety it produces – can impact not only the parents’ peace of mind but the child’s as well.

Scoliosis screenings provide peace of mind and monitor the child’s development so that if their scoliosis does progress or become a problem it can be addressed in the quickest, most efficient way possible.

Massage Rehabilitation


Diagnosis and Management of Rheumatoid Arthritis

Diagnosis and Management of Rheumatoid Arthritis

About 1.5 million people in the United States have rheumatoid arthritis. Rheumatoid arthritis, or RA, is a chronic, autoimmune disease characterized by pain and inflammation of the joints. With RA, the immune system, which protects our well-being by attacking foreign substances like bacteria and viruses, mistakenly attacks the joints. Rheumatoid arthritis most commonly affects the joints of the hands, feet, wrists, elbows, knees and ankles. Many healthcare professionals recommend early diagnosis and treatment of RA.  


  Rheumatoid arthritis is the most commonly diagnosed systemic inflammatory arthritis. Women, smokers, and those with a family history of the disease are most often affected. Criteria for diagnosis include having at least one joint with definite swelling that is not explained by another disease. The likelihood of a rheumatoid arthritis diagnosis increases with the number of small joints involved. In a patient with inflammatory arthritis, the presence of a rheumatoid factor or anti-citrullinated protein antibody, or elevated C-reactive protein level or erythrocyte sedimentation rate suggests a diagnosis of rheumatoid arthritis. Initial laboratory evaluation should also include complete blood count with dif- ferential and assessment of renal and hepatic function. Patients taking biologic agents should be tested for hepatitis B, hepatitis C, and tuberculosis. Earlier diagnosis of rheumatoid arthritis allows for earlier treatment with disease-modifying antirheumatic agents. Combinations of medications are often used to control the disease. Methotrexate is typically the first-line drug for rheumatoid arthritis. Biologic agents, such as tumor necrosis factor inhibitors, are generally considered second-line agents or can be added for dual therapy. The goals of treatment include minimiza- tion of joint pain and swelling, prevention of radiographic damage and visible deformity, and continuation of work and personal activities. Joint replacement is indicated for patients with severe joint damage whose symptoms are poorly controlled by medical management. (Am Fam Physician. 2011;84(11):1245-1252. Copyright © 2011 American Academy of Family Physicians.) Rheumatoid arthritis (RA) is the most common inflammatory arthritis, with a lifetime prevalence of up to 1 percent worldwide.1 Onset can occur at any age, but peaks between 30 and 50 years.2 Disability is common and significant. In a large U.S. cohort, 35 percent of patients with RA had work disability after 10 years.3  

Etiology and Pathophysiology

  Like many autoimmune diseases, the etiology of RA is multifactorial. Genetic susceptibility is evident in familial clustering and monozygotic twin studies, with 50 percent of RA risk attributable to genetic factors.4 Genetic associations for RA include human leukocyte antigen-DR45 and -DRB1, and a variety of alleles called the shared epitope.6,7 Genome-wide association studies have identified additional genetic signatures that increase the risk of RA and other autoimmune diseases, including STAT4 gene and CD40 locus.5 Smoking is the major environmental trigger for RA, especially in those with a genetic predisposition.8 Although infections may unmask an autoimmune response, no particular pathogen has been proven to cause RA.9 RA is characterized by inflammatory pathways that lead to proliferation of synovial cells in joints. Subsequent pannus formation may lead to underlying cartilage destruction and bony erosions. Overproduction of pro-inflammatory cytokines, including tumor necrosis factor (TNF) and interleukin-6, drives the destructive process.10  

Risk Factors

  Older age, a family history of the disease, and female sex are associated with increased risk of RA, although the sex differential is less prominent in older patients.1 Both current and prior cigarette smoking increases the risk of RA (relative risk [RR] = 1.4, up to 2.2 for more than 40-pack-year smokers).11 Pregnancy often causes RA remission, likely because of immunologic tolerance.12 Parity may have long-lasting impact; RA is less likely to be diagnosed in parous women than in nulliparous women (RR = 0.61).13,14 Breastfeeding decreases the risk of RA (RR = 0.5 in women who breastfeed for at least 24 months), whereas early menarche (RR = 1.3 for those with menarche at 10 years of age or younger) and very irregular menstrual periods (RR = 1.5) increase risk.14 Use of oral contraceptive pills or vitamin E does not affect RA risk.15   image-16.png



Typical Presentation

  Patients with RA typically present with pain and stiffness in multiple joints. The wrists, proximal interphalangeal joints, and metacarpophalangeal joints are most commonly involved. Morning stiffness lasting more than one hour suggests an inflammatory etiology. Boggy swelling due to synovitis may be visible (Figure 1), or subtle synovial thickening may be palpable on joint examination. Patients may also present with more indolent arthralgias before the onset of clinically apparent joint swelling. Systemic symptoms of fatigue, weight loss, and low-grade fever may occur with active disease.  

Diagnostic Criteria

  In 2010, the American College of Rheumatology and European League Against Rheumatism collaborated to create new classification criteria for RA (Table 1).16 The new criteria are an effort to diagnose RA earlier in patients who may not meet the 1987 American College of Rheumatology classification criteria. The 2010 criteria do not include presence of rheumatoid nodules or radiographic erosive changes, both of which are less likely in early RA. Symmetric arthri- tis is also not required in the 2010 criteria, allowing for early asymmetric presentation. In addition, Dutch researchers have developed and validated a clinical prediction rule for RA (Table 2).17,18 The purpose of this rule is to help identify patients with undifferentiated arthritis that is most likely to progress to RA, and to guide follow-up and referral.  

Diagnostic Tests

  Autoimmune diseases such as RA are often characterized by the presence of autoanti- bodies. Rheumatoid factor is not specific for RA and may be present in patients with other diseases, such as hepatitis C, and in healthy older persons. Anti-citrullinated protein antibody is more specific for RA and may play a role in disease pathogenesis.6 Approxi- mately 50 to 80 percent of persons with RA have rheumatoid factor, anti-citrullinated protein antibody, or both.10 Patients with RA may have a positive antinuclear antibody test result, and the test is of prognostic impor- tance in juvenile forms of this disease.19 C-reactive protein levels and erythrocyte sedimentation rate are often increased with active RA, and these acute phase reactants are part of the new RA classification criteria.16 C-reactive protein levels and erythrocyte sedimentation rate may also be used to follow disease activity and response to medication. Baseline complete blood count with differential and assessment of renal and hepatic function are helpful because the results may influence treatment options (e.g., a patient with renal insufficiency or significant thrombocytopenia likely would not be prescribed a nonsteroidal anti-inflammatory drug [NSAID]). Mild anemia of chronic disease occurs in 33 to 60 percent of all patients with RA,20 although gastrointestinal blood loss should also be considered in patients taking corticosteroids or NSAIDs. Methotrexate is contraindicated in patients with hepatic disease, such as hepatitis C, and in patients with significant renal impairment.21 Biologic therapy, such as a TNF inhibitor, requires a negative tuberculin test or treatment for latent tuberculosis. Hepatitis B reactivation can also occur with TNF inhibitor use.22 Radiography of hands and feet should be performed to evaluate for characteristic periarticular erosive changes, which may be indicative of a more aggressive RA subtype.10  

Differential Diagnosis

  Skin findings suggest systemic lupus erythematosus, systemic sclerosis, or psoriatic arthritis. Polymyalgia rheumatica should be considered in an older patient with symptoms primarily in the shoulder and hip, and the patient should be asked questions related to associated temporal arteritis. Chest radiography is helpful to evaluate for sarcoidosis as an etiology of arthritis. Patients with inflammatory back symptoms, a history of inflammatory bowel disease, or inflammatory eye disease may have spondyloarthropathy. Persons with less than six weeks of symptoms may have a viral process, such as parvovirus. Recurrent self-limited episodes of acute joint swelling suggest crystal arthropathy, and arthrocentesis should be performed to evaluate for monosodium urate monohydrate or calcium pyrophosphate dihydrate crystals. The presence of numerous myofascial trigger points and somatic symptoms may suggest fibromyalgia, which can coexist with RA. To help guide diagnosis and determine treatment strategy, patients with inflammatory arthritis should be promptly referred to a rheumatology subspecialist.16,17  
Dr Jimenez White Coat
Rheumatoid arthritis, or RA, is the most common type of arthritis. RA is an autoimmune disease, caused when the immune system, the human body’s defense system, attacks its own cells and tissues, particularly the joints. Rheumatoid arthritis is frequently identified by symptoms of pain and inflammation, often affecting the small joints of the hands, wrists and feet. According to many healthcare professionals, early diagnosis and treatment of RA is essential to prevent further joint damage and decrease painful symptoms. Dr. Alex Jimenez D.C., C.C.S.T. Insight


  After RA has been diagnosed and an initial evaluation performed, treatment should begin. Recent guidelines have addressed the management of RA,21,22 but patient preference also plays an important role. There are special considerations for women of childbearing age because many medications have deleterious effects on pregnancy. Goals of therapy include minimizing joint pain and swelling, preventing deformity (such as ulnar deviation) and radiographic damage (such as erosions), maintaining quality of life (personal and work), and controlling extra-articular manifestations. Disease-modifying antirheumatic drugs (DMARDs) are the mainstay of RA therapy.  


  DMARDs can be biologic or nonbiologic (Table 3).23 Biologic agents include monoclonal antibodies and recombinant receptors to block cytokines that promote the inflammatory cascade responsible for RA symptoms. Methotrexate is recommended as the first- line treatment in patients with active RA, unless contraindicated or not tolerated.21 Leflunomide (Arava) may be used as an alternative to methotrexate, although gastrointestinal adverse effects are more common. Sulfasalazine (Azulfidine) or hydroxychloroquine (Plaquenil) pro-inflammatory as monotherapy in patients with low disease activity or without poor prognostic features (e.g., seronegative, non-erosive RA).21,22 Combination therapy with two or more DMARDs is more effective than monotherapy; however, adverse effects may also be greater.24 If RA is not well controlled with a nonbiologic DMARD, a biologic DMARD should be initiated.21,22 TNF inhibitors are the first-line biologic therapy and are the most studied of these agents. If TNF inhibitors are ineffective, additional biologic therapies can be considered. Simultaneous use of more than one biologic therapy (e.g., adalimumab [Humira] with abatacept [Orencia]) is not recommended because of an unacceptable rate of adverse effects.21  

NSAIDs and Corticosteroids

  Drug therapy for RA may involve NSAIDs and oral, intramuscular, or intra-articular corticosteroids for controlling pain and inflammation. Ideally, NSAIDs and corticosteroids are used only for short-term management. DMARDs are the preferred therapy.21,22  

Complementary Therapies

  Dietary interventions, including vegetarian and Mediterranean diets, have been studied in the treatment of RA without convincing evidence of benefit.25,26 Despite some favorable outcomes, there is a lack of evidence for the effectiveness of acupuncture in placebo-controlled trials of patients with RA.27,28 In addition, thermotherapy and therapeutic ultrasound for RA have not been studied adequately.29,30 A Cochrane review of herbal treatments for RA concluded that gamma-linolenic acid (from evening primrose or black currant seed oil) and Tripterygium wilfordii (thunder god vine) have potential benefits.31 It is important to inform patients that serious adverse effects have been reported with use of herbal therapy.31  

Exercise and Physical Therapy

  Results of randomized controlled trials sup- port physical exercise to improve quality of life and muscle strength in patients with RA.32,33 Exercise training programs have not been shown to have deleterious effects on RA disease activity, pain scores, or radiographic joint damage.34 Tai chi has been shown to improve ankle range of motion in persons with RA, although randomized trials are limited.35 Randomized controlled trials of Iyengar yoga in young adults with RA are underway.36  

Duration of Treatment

  Remission is obtainable in 10 to 50 percent of patients with RA, depending on how remission is defined and the intensity of therapy.10 Remission is more likely in males, nonsmokers, persons younger than 40 years, and in those with late-onset disease (patients older than 65 years), with shorter duration of disease, with milder disease activity, without elevated acute phase reactants, and without positive rheumatoid factor or anti-citrullinated protein antibody findings.37 After the disease is controlled, medication dosages may be cautiously decreased to the minimum amount necessary. Patients will require frequent monitoring to ensure stable symptoms, and prompt increase in medication is recommended with disease flare-ups.22  

Joint Replacement

  Joint replacement is indicated when there is severe joint damage and unsatisfactory control of symptoms with medical management. Long-term outcomes are support, with only 4 to 13 percent of large joint replacements requiring revision within 10 years.38 The hip and knee are the most commonly replaced joints.  

Long-Term Monitoring

  Although RA is considered a disease of the joints, it is also a systemic disease capable of involving multiple organ systems. Extra-articular manifestations of RA are included in Table 4.1,2,10 Patients with RA have a twofold increased risk of lymphoma, which is thought to be caused by the underlying inflammatory process, and not a consequence of medical treatment.39 Patients with RA are also at an increased risk of coronary artery disease, and physicians should work with patients to modify risk factors, such as smoking, high blood pressure, and high cholesterol.40,41 Class III or IV congestive heart failure (CHF) is a contraindication for using TNF inhibitors, which can worsen CHF outcomes.21 In patients with RA and malignancy, caution is needed with continued use of DMARDs, especially TNF inhibitors. Biologic DMARDs, methotrexate, and leflunomide should not be initiated in patients with active herpes zoster, significant fungal infection, or bacterial infection requiring antibiotics.21 Complications of RA and its treatments are listed in Table 5.1,2,10  


  Patients with RA live three to 12 years less than the general population.40 Increased mortality in these patients is mainly due to accelerated cardiovascular disease, especially in those with high disease activity and chronic inflammation. The relatively new biologic therapies may reverse progression of atherosclerosis and extend life in those with RA.41 Data Sources: A PubMed search was completed in Clinical Queries using the key terms rheumatoid arthritis, extra-articular manifestations, and disease-modifying antirheumatic agents. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were the Agency for Healthcare Research and Quality evidence reports, Clinical Evidence, the Cochrane database, Essential Evidence, and UpToDate. Search date: September 20, 2010. Author disclosure: No relevant financial affiliations to disclose. In conclusion, rheumatoid arthritis is a chronic, autoimmune disease which causes painful symptoms, such as pain and discomfort, inflammation and swelling of the joints, among others. The joint damage characterized as RA is symmetrical, meaning it generally affects both sides of the body. Early diagnosis is essential for treatment of RA. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 . Curated by Dr. Alex Jimenez Green Call Now Button H .png  

Additional Topic Discussion: Relieving Knee Pain without Surgery

  Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.  
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EXTRA EXTRA | IMPORTANT TOPIC: El Paso, TX Chiropractor Recommended


1. Etiology and pathogenesis of rheumatoid arthritis. In: Firestein GS, Kelley WN, eds. Kelley’s Textbook of Rheu- matology. 8th ed. Philadelphia, Pa.: Saunders/Elsevier; 2009:1035-1086.
2. Bathon J, Tehlirian C. Rheumatoid arthritis clinical and
laboratory manifestations. In: Klippel JH, Stone JH, Crofford LJ, et al., eds. Primer on the Rheumatic Dis- eases. 13th ed. New York, NY: Springer; 2008:114-121.
3. Allaire S, Wolfe F, Niu J, et al. Current risk factors for work disability associated with rheumatoid arthritis. Arthritis Rheum. 2009;61(3):321-328.
4. MacGregor AJ, Snieder H, Rigby AS, et al. Characteriz- ing the quantitative genetic contribution to rheumatoid arthritis using data from twins. Arthritis Rheum. 2000; 43(1):30-37.
5. Orozco G, Barton A. Update on the genetic risk fac- tors for rheumatoid arthritis. Expert Rev Clin Immunol. 2010;6(1):61-75.
6. Balsa A, Cabezón A, Orozco G, et al. Influence of HLA DRB1 alleles in the susceptibility of rheumatoid arthritis and the regulation of antibodies against citrullinated proteins and rheumatoid factor. Arthritis Res Ther. 2010;12(2):R62.
7. McClure A, Lunt M, Eyre S, et al. Investigating the via- bility of genetic screening/testing for RA susceptibility using combinations of five confirmed risk loci. Rheuma- tology (Oxford). 2009;48(11):1369-1374.
8. Bang SY, Lee KH, Cho SK, et al. Smoking increases rheu- matoid arthritis susceptibility in individuals carrying the HLA-DRB1 shared epitope, regardless of rheumatoid factor or anti-cyclic citrullinated peptide antibody sta- tus. Arthritis Rheum. 2010;62(2):369-377.
9. Wilder RL, Crofford LJ. Do infectious agents cause rheu- matoid arthritis? Clin Orthop Relat Res. 1991;(265): 36-41.
10. Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010;376(9746):1094-1108.
11. Costenbader KH, Feskanich D, Mandl LA, et al. Smoking intensity, duration, and cessation, and the risk of rheu- matoid arthritis in women. Am J Med. 2006;119(6): 503.e1-e9.
12. Kaaja RJ, Greer IA. Manifestations of chronic disease during pregnancy. JAMA. 2005;294(21):2751-2757.
13. Guthrie KA, Dugowson CE, Voigt LF, et al. Does preg-
nancy provide vaccine-like protection against rheuma-
toid arthritis? Arthritis Rheum. 2010;62(7):1842-1848.
14. Karlson EW, Mandl LA, Hankinson SE, et al. Do breast- feeding and other reproductive factors influence future risk of rheumatoid arthritis? Results from the Nurses’ Health Study. Arthritis Rheum. 2004;50(11):3458-3467.
15. Karlson EW, Shadick NA, Cook NR, et al. Vitamin E in the primary prevention of rheumatoid arthritis: the Women’s Health Study. Arthritis Rheum. 2008;59(11):
16. Aletaha D, Neogi T, Silman AJ, et al. 2010 rheumatoid
arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative [published correction appears in Ann Rheum Dis. 2010;69(10):1892]. Ann Rheum Dis. 2010;69(9):1580-1588.
17. van der Helm-van Mil AH, le Cessie S, van Dongen H, et al. A prediction rule for disease outcome in patients with recent-onset undifferentiated arthritis. Arthritis Rheum. 2007;56(2):433-440.
18. Mochan E, Ebell MH. Predicting rheumatoid arthritis risk in adults with undifferentiated arthritis. Am Fam Physi- cian. 2008;77(10):1451-1453.
19. Ravelli A, Felici E, Magni-Manzoni S, et al. Patients with antinuclear antibody-positive juvenile idiopathic arthri- tis constitute a homogeneous subgroup irrespective of the course of joint disease. Arthritis Rheum. 2005; 52(3):826-832.
20. Wilson A, Yu HT, Goodnough LT, et al. Prevalence and outcomes of anemia in rheumatoid arthritis. Am J Med. 2004;116(suppl 7A):50S-57S.
21. Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheu- matic drugs in rheumatoid arthritis. Arthritis Rheum. 2008;59(6):762-784.
22. Deighton C, O’Mahony R, Tosh J, et al.; Guideline Devel- opment Group. Management of rheumatoid arthritis: summary of NICE guidance. BMJ. 2009;338:b702.
23. AHRQ. Choosing medications for rheumatoid arthritis. April 9, 2008. ehc/products/14/85/RheumArthritisClinicianGuide.pdf. Accessed June 23, 2011.
24. Choy EH, Smith C, Doré CJ, et al. A meta-analysis of the efficacy and toxicity of combining disease-modify- ing anti-rheumatic drugs in rheumatoid arthritis based on patient withdrawal. Rheumatology (Oxford). 2005; 4 4 (11) :1414 -1421.
25. Smedslund G, Byfuglien MG, Olsen SU, et al. Effective- ness and safety of dietary interventions for rheumatoid arthritis. J Am Diet Assoc. 2010;110(5):727-735.
26. Hagen KB, Byfuglien MG, Falzon L, et al. Dietary inter- ventions for rheumatoid arthritis. Cochrane Database Syst Rev. 2009;21(1):CD006400.
27. Wang C, de Pablo P, Chen X, et al. Acupuncture for pain relief in patients with rheumatoid arthritis: a systematic review. Arthritis Rheum. 2008;59(9):1249-1256.
28. Kelly RB. Acupuncture for pain. Am Fam Physician. 2009;80(5):481-484.
29. Robinson V, Brosseau L, Casimiro L, et al. Thermother- apy for treating rheumatoid arthritis. Cochrane Data- base Syst Rev. 2002;2(2):CD002826.
30. Casimiro L, Brosseau L, Robinson V, et al. Therapeutic ultrasound for the treatment of rheumatoid arthritis. Cochrane Database Syst Rev. 2002;3(3):CD003787.
31. Cameron M, Gagnier JJ, Chrubasik S. Herbal therapy for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2011;(2):CD002948.
32. Brodin N, Eurenius E, Jensen I, et al. Coaching patients with early rheumatoid arthritis to healthy physical activ- ity. Arthritis Rheum. 2008;59(3):325-331.
33. Baillet A, Payraud E, Niderprim VA, et al. A dynamic exercise programme to improve patients’ disability in rheumatoid arthritis: a prospective randomized con- trolled trial. Rheumatology (Oxford). 2009;48(4): 410-415.
34. Hurkmans E, van der Giesen FJ, Vliet Vlieland TP, et al. Dynamic Exercise programs (aerobic capacity and/or mus- cle strength training) in patients with rheumatoid arthri- tis. Cochrane Database Syst Rev. 2009;(4):CD006853.
35. Han A, Robinson V, Judd M, et al. Tai chi for treat- ing rheumatoid arthritis. Cochrane Database Syst Rev. 2004;(3):CD004849.
36. Evans S, Cousins L, Tsao JC, et al. A randomized con- trolled trial examining Iyengar yoga for young adults with rheumatoid arthritis. Trials. 2011;12:19.
37. Katchamart W, Johnson S, Lin HJ, et al. Predictors for remis- sion in rheumatoid arthritis patients: a systematic review. Arthritis Care Res (Hoboken). 2010;62(8):1128-1143.
38. Wolfe F, Zwillich SH. The long-term outcomes of rheu- matoid arthritis: a 23-year prospective, longitudinal study of total joint replacement and its predictors in 1,600 patients with rheumatoid arthritis. Arthritis Rheum. 1998;41(6):1072-1082.
39. Baecklund E, Iliadou A, Askling J, et al. Association of chronic inflammation, not its treatment, with increased lymphoma risk in rheumatoid arthritis. Arthritis Rheum. 2006;54(3):692-701.
40. Friedewald VE, Ganz P, Kremer JM, et al. AJC editor’s consensus: rheumatoid arthritis and atherosclerotic cardiovascular disease. Am J Cardiol. 2010;106(3): 442-447.
41. Atzeni F, Turiel M, Caporali R, et al. The effect of phar- macological therapy on the cardiovascular system of patients with systemic rheumatic diseases. Autoimmun Rev. 2010;9(12):835-839.

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How Arthritis Can Affect the Knee

How Arthritis Can Affect the Knee

Arthritis is characterized as the inflammation of one or multiple joints. The most common symptoms of arthritis include pain and discomfort, swelling, inflammation, and stiffness, among others. Arthritis may affect any joint in the human body, however, it commonly develops in the knee.   Knee arthritis can make everyday physical activities difficult. The most prevalent types of arthritis are osteoarthritis and rheumatoid arthritis, although there are well over 100 distinct forms of arthritis, affecting children and adults alike. While there is no cure for arthritis, many treatment approaches can help treat the symptoms of knee arthritis.


Anatomy of the Knee

  The knee is the largest and strongest joint in the human body. It is made up of the lower end of the thigh bone, or femur, the top end of the shin bone, or tibia, and the kneecap, or patella. The ends of the three bones are covered with articular cartilage, a smooth, slippery structure which protects and cushions the bones when bending and straightening the knee.

  Two wedge-shaped parts of cartilage, known as the meniscus, function as shock absorbers between the bones of the knee to help cushion the joint and provide stability. The knee joint is also surrounded by a thin lining known as the synovial membrane. This membrane releases a fluid which lubricates the cartilage and also helps reduce friction in the knee. The significant kinds of arthritis that affect the knee include osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis.



  Osteoarthritis is the most common type of arthritis which affects the knee joint. This form of arthritis is a degenerative, wear-and-tear health issue which occurs most commonly in people 50 years of age and older, however, it may also develop in younger people.

  In osteoarthritis, the cartilage in the knee joint gradually wears away. As the cartilage wears away, the distance between the bones decreases. This can result in bone rubbing and it can create painful bone spurs. Osteoarthritis generally develops slowly but the pain may worsen over time.


Rheumatoid Arthritis

  Rheumatoid arthritis is a chronic health issue which affects multiple joints throughout the body, especially the knee joint. RA is also symmetrical, meaning it often affects the same joint on each side of the human body.

  In rheumatoid arthritis, the synovial membrane that covers the knee joint becomes inflamed and swollen, causing knee pain, discomfort, and stiffness. RA is an autoimmune disease, which means that the immune system attacks its own soft tissues. The immune system attacks healthy tissue, including tendons, ligaments and cartilage, as well as softens the bone.


Post-traumatic Arthritis

  Posttraumatic arthritis is a form of arthritis that develops after damage or injury to the knee. By way of instance, the knee joint may be harmed by a broken bone, or fracture, and result in post-traumatic arthritis years after the initial injury. Meniscal tears and ligament injuries can cause additional wear-and-tear on the knee joint, which over time can lead to arthritis and other problems.


Symptoms of Knee Arthritis

  The most common symptoms of knee arthritis include pain and discomfort, inflammation, swelling, and stiffness. Although sudden onset is probable, the painful symptoms generally develop gradually over time. Additional symptoms of knee arthritis can be recognized as follows:


  • The joint may become stiff and swollen, making it difficult to bend and straighten the knee.
  • Swelling and inflammation may be worse in the morning, or when sitting or resting.
  • Vigorous activity might cause the pain to flare up.
  • Loose fragments of cartilage and other soft tissue may interfere with the smooth motion of the joints, causing the knee to lock or stick through motion. It could also creak, click, snap or make a grinding sound, known as crepitus.
  • Pain can cause a sense of fatigue or buckling from the knee.
  • Many individuals with arthritis may also describe increased joint pain with rainy weather and climate changes.



Diagnosis for Knee Arthritis

  During the patient’s appointment for diagnosis of knee arthritis, the healthcare professional will talk about the symptoms and medical history, as well as conduct a physical examination. The doctor may also order imaging diagnostic tests, such as X-rays, MRI or blood tests for further diagnosis. During the physical examination, the doctor will search for:


  • Joint inflammation, swelling, warmth, or redness
  • Tenderness around the knee joint
  • Assortment of passive and active movement
  • Instability of the knee joint
  • Crepitus, the grating sensation inside the joint, with motion
  • Pain when weight is placed on the knee
  • Issues with gait, or manner of walking
  • Any signs of damage or injury to the muscles, tendons, and ligaments surrounding the knee joint
  • Involvement of additional joints (an indicator of rheumatoid arthritis)


Imaging Diagnostic Tests


  • X-rays. These imaging diagnostic tests produce images of compact structures, such as bones. They can help distinguish among various forms of arthritis. X-rays for knee arthritis may demonstrate a portion of the joint distance, changes in the bone as well as the formation of bone spurs, known as osteophytes.
  • Additional tests. Sometimes, magnetic resonance imaging, or MRI, scans, computed tomography, or CT, scans, or bone scans are required to ascertain the condition of the bone and soft tissues of the knee.


Blood Tests

  Your doctor may also recommend blood tests to determine which type of arthritis you have. With some kinds of arthritis, such as rheumatoid arthritis, blood tests can help with the proper identification of the disease.


Dr Jimenez White Coat
Although the knee joint is one of the strongest and largest joints in the human body, it is often prone to suffering damage or injury, resulting in a variety of conditions. In addition, however, other health issues, such as arthritis, can affect the knee joint. In network for most insurances of El Paso, TX, chiropractic care can help ease painful symptoms associated with knee arthritis, among other health issues. Dr. Alex Jimenez D.C., C.C.S.T. Insight


Treatment for Knee Arthritis


Non-surgical Treatment

  Non-surgical treatment approaches are often recommended before considering surgical treatment for knee arthritis. Healthcare professionals may recommend a variety of treatment options, including chiropractic care, physical therapy, and lifestyle modifications, among others.

  Lifestyle modifications. Some lifestyle modifications can help protect the knee joint and impede the progress of arthritis. Minimizing physical activities which aggravate the condition, will put less strain on the knee. Losing weight may also help lessen stress and pressure on the knee joint, resulting in less painful symptoms and increased function.

  Chiropractic care and physical therapy. Chiropractic care utilizes full body chiropractic adjustments to carefully restore any spinal misalignments, or subluxations, which may be causing symptoms, including arthritis. The doctor may also recommend physical therapy to create an individualized exercise and physical activity program for each patient’s needs. Specific exercises will help increase range of motion and endurance, as well as help strengthen the muscles in the lower extremities.

  Assistive devices. Using assistive devices, such as a cane, shock-absorbing shoes or inserts, or a brace or knee sleeve, can decrease painful symptoms. A brace helps with function and stability, and may be particularly useful if the arthritis is based on one side of the knee. There are two types of braces that are often used for knee arthritis: A “unloader” brace shifts weight from the affected section of the knee, while a “support” brace helps support the entire knee load.

  Drugs and/or medications. Several types of medications are useful in treating arthritis of the knee. Since individuals respond differently to medications, your doctor will work closely with you to determine the medications and dosages which are safe and effective for you.


Surgical Treatment

  The healthcare professional may recommend surgical treatment if the patient’s knee arthritis causes severe disability and only if the problem isn’t relieved with non-surgical treatment. Like all surgeries, there are a few risks and complications with surgical treatment for knee arthritis. The doctor will discuss the possible problems with the patient.

  Arthroscopy. During arthroscopy, physicians use instruments and small incisions to diagnose and treat knee joint problems. Arthroscopic surgery isn’t frequently used in the treatment of arthritis of the knee. In cases where osteoarthritis is accompanied with a degenerative meniscal tear, arthroscopic surgery may be wise to treat the torn meniscus.

  Cartilage grafting. Normal cartilage tissue may be taken from a tissue bank or through a different part of the knee to fill out a hole in the articular cartilage. This process is typically considered only for younger patients.

  Synovectomy. The lining damaged by rheumatoid arthritis is eliminated to reduce swelling and pain.

  Osteotomy. In a knee osteotomy, either the tibia (shinbone) or femur (thighbone) is cut then reshaped to relieve stress and pressure on the knee joint. Knee osteotomy is utilized when early-stage osteoarthritis has damaged one facet of the knee joint. By changing the weight distribution, this can relieve and enhance the function of the knee.

  Total or partial knee replacement (arthroplasty). The doctor will remove the damaged bone and cartilage, then place new plastic or metal surfaces to restore the function of the knee and its surrounding structures.

  Following any type of surgery for knee arthritis will involve a period of recovery. Recovery time and rehabilitation will depend on the type of surgery performed. It’s essential to talk with your healthcare professional to determine the best treatment option for your knee arthritis. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

  Curated by Dr. Alex Jimenez  


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Additional Topic Discussion: Relieving Knee Pain without Surgery

  Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.


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EXTRA EXTRA | IMPORTANT TOPIC: El Paso, TX Chiropractor Recommended

The Basic Science of Human Knee Menisci Structure, Composition, and Function

The Basic Science of Human Knee Menisci Structure, Composition, and Function

The knee is one of the most complex joints in the human body, consisting of the thigh bone, or femur, the shin bone, or tibia, and the kneecap, or patella, among other soft tissues. Tendons connect the bones to the muscles while ligaments connect the bones of the knee joint. Two wedge-shaped pieces of cartilage, known as the meniscus, provide stability to the knee joint. The purpose of the article below is to demonstrate as well as discuss the anatomy of the knee joint and its surrounding soft tissues.




  • Context: Information regarding the structure, composition, and function of the knee menisci has been scattered across multiple sources and fields. This review contains a concise, detailed description of the knee menisci—including anatomy, etymology, phylogeny, ultrastructure and biochemistry, vascular anatomy and neuroanatomy, biomechanical function, maturation and aging, and imaging modalities.
  • Evidence Acquisition: A literature search was performed by a review of PubMed and OVID articles published from 1858 to 2011.
  • Results: This study highlights the structural, compositional, and functional characteristics of the menisci, which may be relevant to clinical presentations, diagnosis, and surgical repairs.
  • Conclusions: An understanding of the normal anatomy and biomechanics of the menisci is a necessary prerequisite to understanding the pathogenesis of disorders involving the knee.
  • Keywords: knee, meniscus, anatomy, function




Once described as a functionless embryonic remnant,162 the menisci are now known to be vital for the normal function and long-term health of the knee joint.§ The menisci increase stability for femorotibial articulation, distribute axial load, absorb shock, and provide lubrication and nutrition to the knee joint.4,91,152,153


Injuries to the menisci are recognized as a cause of significant musculoskeletal morbidity. The unique and complex structure of menisci makes treatment and repair challenging for the patient, surgeon, and physical therapist. Furthermore, long-term damage may lead to degenerative joint changes such as osteophyte formation, articular cartilage degeneration, joint space narrowing, and symptomatic osteoarthritis.36,45,92 Preservation of the menisci depends on maintaining their distinctive composition and organization.


Anatomy of Menisci


Meniscal Etymology


The word meniscus comes from the Greek word mēniskos, meaning “crescent,” diminutive of mēnē, meaning “moon.”


Meniscal Phylogeny and Comparative Anatomy


Hominids exhibit similar anatomic and functional characteristics, including a bicondylar distal femur, intra-articular cruciate ligaments, menisci, and asymmetrical collateral.40,66 These similar morphologic characteristics reflect a shared genetic lineage that can be traced back more than 300 million years.40,66,119


In the primate lineage leading to humans, hominids evolved to bipedal stance approximately 3 to 4 million years ago, and by 1.3 million years ago, the modern patellofemoral joint was established (with a longer lateral patellar facet and matching lateral femoral trochlea).164 Tardieu investigated the transition from occasional bipedalism to permanent bipedalism and observed that primates contain a medial and lateral fibrocartilaginous meniscus, with the medial meniscus being morphologically similar in all primates (crescent shaped with 2 tibial insertions).163 By contrast, the lateral meniscus was observed to be more variable in shape. Unique in Homo sapiens is the presence of 2 tibial insertions—1 anterior and 1 posterior—indicating a habitual practice of full extension movements of the knee joint during the stance and swing phases of bipedal walking.20,134,142,163,168


Embryology and Development


The characteristic shape of the lateral and medial menisci is attained between the 8th and 10th week of gestation.53,60 They arise from a condensation of the intermediate layer of mesenchymal tissue to form attachments to the surrounding joint capsule.31,87,110 The developing menisci are highly cellular and vascular, with the blood supply entering from the periphery and extending through the entire width of the menisci.31 As the fetus continues to develop, there is a gradual decrease in the cellularity of the menisci with a concomitant increase in the collagen content in a circumferential arrangement.30,31 Joint motion and the postnatal stress of weightbearing are important factors in determining the orientation of collagen fibers. By adulthood, only the peripheral 10% to 30% have a blood supply.12,31


Despite these histologic changes, the proportion of tibial plateau covered by the corresponding meniscus is relatively constant throughout fetal development, with the medial and lateral menisci covering approximately 60% and 80% of the surface areas, respectively.31


Gross Anatomy


Gross examination of the knee menisci reveals a smooth, lubricated tissue (Figure 1). They are crescent-shaped wedges of fibrocartilage located on the medial and lateral aspects of the knee joint (Figure 2A). The peripheral, vascular border (also known as the red zone) of each meniscus is thick, convex, and attached to the joint capsule. The innermost border (also known as the white zone) tapers to a thin free edge. The superior surfaces of menisci are concave, enabling effective articulation with their respective convex femoral condyles. The inferior surfaces are flat to accommodate the tibial plateau (Figure 1).28,175





Medial meniscus. The semicircular medial meniscus measures approximately 35 mm in diameter (anterior to posterior) and is significantly broader posteriorly than it is anteriorly.175 The anterior horn is attached to the tibia plateau near the intercondylar fossa anterior to the anterior cruciate ligament (ACL). There is significant variability in the attachment location of the anterior horn of the medial meniscus. The posterior horn is attached to the posterior intercondylar fossa of the tibia between the lateral meniscus and the posterior cruciate ligament (PCL; Figures 1 and and2B).2B). Johnson et al reexamined the tibial insertion sites of the menisci and their topographic relationships to surrounding anatomic landmarks of the knee.82 They found that the anterior and posterior horn insertion sites of the medial meniscus were larger than those of the lateral meniscus. The area of the anterior horn insertion site of the medial meniscus was the largest overall, measuring 61.4 mm2, whereas the posterior horn of the lateral meniscus was the smallest, at 28.5 mm2.82


The tibial portion of the capsular attachment is the coronary ligament. At its midpoint, the medial meniscus is more firmly attached to the femur through a condensation in the joint capsule known as the deep medial collateral ligament.175 The transverse, or “intermeniscal,” ligament is a fibrous band of tissue that connects the anterior horn of the medial meniscus to the anterior horn of the lateral meniscus (Figures 1 and and2A2A).


Lateral meniscus. The lateral meniscus is almost circular, with an approximately uniform width from anterior to posterior (Figures 1 and and2A).2A). It occupies a larger portion (~80%) of the articular surface than the medial meniscus (~60%) and is more mobile.10,31,165 Both horns of the lateral meniscus are attached to the tibia. The insertion of the anterior horn of the lateral meniscus lies anterior to the intercondylar eminence and adjacent to the broad attachment site of the ACL (Figure 2B).9,83 The posterior horn of the lateral meniscus inserts posterior to the lateral tibial spine and just anterior to the insertion of the posterior horn of the medial meniscus (Figure 2B).83 The lateral meniscus is loosely attached to the capsular ligament; however, these fibers do not attach to the lateral collateral ligament. The posterior horn of the lateral meniscus attaches to the inner aspect of the medial femoral condyle via the anterior and posterior meniscofemoral ligaments of Humphrey and Wrisberg, respectively, which originate near the origin of the PCL (Figures 1 and and22).75


Meniscofemoral ligaments. The literature reports significant inconsistencies in the presence and size of meniscofemoral ligaments of the lateral meniscus. There may be none, 1, 2, or 4.‖ When present, these accessory ligaments transverse from the posterior horn of the lateral meniscus to the lateral aspect of the medial femoral condyle. They insert immediately adjacent to the femoral attachment of the PCL (Figures 1 and and22).


In a series of studies, Harner et al measured the cross-sectional area of the ligaments and found that the meniscofemoral ligament averaged 20% of the size of the PCL (range, 7%-35%).69,70 However, the size of the insertional area alone without knowledge of the insertional angle or collagen density does not indicate their relative strength.115 The function of these ligaments remains unknown; they may pull the posterior horn of the lateral meniscus in an anterior direction to increase the congruity of the meniscotibial fossa and the lateral femoral condyle.75


Ultrastructure and Biochemistry


Extracellular Matrix


The meniscus is a dense extracellular matrix (ECM) composed primarily of water (72%) and collagen (22%), interposed with cells.9,55,56,77 Proteoglycans, noncollagenous proteins, and glycoproteins account for the remaining dry weight.¶ Meniscal cells synthesize and maintain the ECM, which determines the material properties of the tissue.


The cells of the menisci are referred to as fibrochondrocytes because they appear to be a mixture of fibroblasts and chondrocytes.111,177 The cells in the more superficial layer of the menisci are fusiform or spindle shaped (more fibroblastic), whereas the cells located deeper in the meniscus are ovoid or polygonal (more chondrocytic).55,56,178 Cell morphology does not differ between the peripheral and central locations in the menisci.56


Both cell types contain abundant endoplasmic reticulum and Golgi complex. Mitochondria are only occasionally visualized, suggesting that the major pathway for energy production of fibrochondrocytes in their avascular milieu is probably anaerobic glycolysis.112




In normal, healthy menisci, tissue fluid represents 65% to 70% of the total weight. Most of the water is retained within the tissue in the solvent domains of proteoglycans. The water content of meniscal tissue is higher in the posterior areas than in the central or anterior areas; tissue samples from surface and deeper layers had similar contents.135


Large hydraulic pressures are required to overcome the drag of frictional resistance of forcing fluid flow through meniscal tissue. Thus, interactions between water and the matrix macromolecular framework significantly influence the viscoelastic properties of the tissue.




Collagens are primarily responsible for the tensile strength of menisci; they contribute up to 75% of the dry weight of the ECM.77 The ECM is composed primarily of type I collagen (90% dry weight) with variable amounts of types II, III, V, and VI.43,44,80,112,181 The predominance of type I collagen distinguishes the fibrocartilage of menisci from articular (hyaline) cartilage. The collagens are heavily cross-linked by hydroxylpyridinium aldehydes.44


The collagen fiber arrangement is ideal for transferring a vertical compressive load into circumferential “hoop” stresses (Figure 3).57 Type I collagen fibers are oriented circumferentially in the deeper layers of the meniscus, parallel to the peripheral border. These fibers blend the ligamentous connections of the meniscal horns to the tibial articular surface (Figure 3).10,27,49,156 In the most superficial region of the menisci, the type I fibers are oriented in a more radial direction. Radially oriented “tie” fibers are also present in the deep zone and are interspersed or woven between the circumferential fibers to provide structural integrity (Figure 3).# There is lipid debris and calcified bodies in the ECM of human menisci.54 The calcified bodies contain long, slender crystals of phosphorous, calcium, and magnesium on electron-probe roentgenographic analysis.54 The function of these crystals in not completely understood, but it is believed that they may play a role in acute joint inflammation and destructive arthropathies.



Noncollagenous matrix proteins, such as fibronectin, contribute 8% to 13% of the organic dry weight. Fibronectin is involved in many cellular processes, including tissue repair, embryogenesis, blood clotting, and cell migration/adhesion. Elastin forms less than 0.6% of the meniscus dry weight; its ultrastructural localization is not clear. It likely interacts directly with collagen to provide resiliency to the tissue.**




Located within a fine meshwork of collagen fibrils, proteoglycans are large, negatively charged hydrophilic molecules, contributing 1% to 2% of dry weight.58 They are formed by a core protein with 1 or more covalently attached glycosaminoglycan chains (Figure 4).122 The size of these molecules is further increased by specific interaction with hyaluronic acid.67,72 The amount of proteoglycans in the meniscus is one-eighth that of articular cartilage,2,3 and there may be considerable variation depending on the site of the sample and the age of the patient.49



By virtue of their specialized structure, high fixed-charge density, and charge-charge repulsion forces, proteoglycans in the ECM are responsible for hydration and provide the tissue with a high capacity to resist compressive loads.‡ The glycosaminoglycan profile of the normal adult human meniscus consists of chondroitin-6-sulfate (40%), chondroitin-4-sulfate (10% to 20%), dermatan sulfate (20% to 30%), and keratin sulfate (15%; Figure 4).65,77,99,159 The highest glycosaminoglycan concentrations are found in the meniscal horns and the inner half of the menisci in the primary weightbearing areas.58,77


Aggrecan is the major proteoglycan found in the human menisci and is largely responsible for their viscoelastic compressive properties (Figure 5). Smaller proteoglycans, such as decorin, biglycan, and fibromodulin, are found in smaller amounts.124,151 Hexosamine contributes 1% to the dry weight of ECM.57,74 The precise functions of each of these small proteoglycans on the meniscus have yet to be fully elucidated.



Matrix Glycoproteins


Meniscal cartilage contains a range of matrix glycoproteins, the identities and functions of which have yet to be determined. Electrophoresis and subsequent staining of the polyacrylamide gels reveals bands with molecular weights varying from a few kilodaltons to more than 200 kDa.112 These matrix molecules include the link proteins that stabilize proteoglycan–hyaluronic acid aggregates and a 116-kDa protein of unknown function.46 This protein resides in the matrix in the form of disulfide-bonded complex of high molecular weight.46 Immunolocalization studies suggest that it is predominantly located around the collagen bundles in the interterritorial matrix.47


The adhesive glycoproteins constitute a subgroup of the matrix glycoproteins. These macromolecules are partly responsible for binding with other matrix molecules and/or cells. Such intermolecular adhesion molecules are therefore important components in the supramolecular organization of the extracellular molecules of the meniscus.150 Three molecules have been identified within the meniscus: type VI collagen, fibronectin, and thrombospondin.112,118,181


Vascular Anatomy


The meniscus is a relatively avascular structure with a limited peripheral blood supply. The medial, lateral, and middle geniculate arteries (which branch off the popliteal artery) provide the major vascularization to the inferior and superior aspects of each meniscus (Figure 5).9,12,33-35,148 The middle geniculate artery is a small posterior branch that perforates the oblique popliteal ligament at the posteromedial corner of the tibiofemoral joint. A premeniscal capillary network arising from the branches of these arteries originates within the synovial and capsular tissues of the knee along the periphery of the menisci. The peripheral 10% to 30% of the medial meniscus border and 10% to 25% of the lateral meniscus are relatively well vascularized, which has important implications for meniscus healing (Figure 6).12,33,68 Endoligamentous vessels from the anterior and posterior horns travel a short distance into the substance of the menisci and form terminal loops, providing a direct route for nourishment.33 The remaining portion of each meniscus (65% to 75%) receives nourishment from synovial fluid via diffusion or mechanical pumping (ie, joint motion).116,120



Bird and Sweet examined the menisci of animals and humans using scanning electron and light microscopy.23,24 They observed canal-like structures opening deep into the surface of the menisci. These canals may play a role in the transport of fluid within the meniscus and may carry nutrients from the synovial fluid and blood vessels to the avascular sections of the meniscus.23,24 However, further study is needed to elucidate the exact mechanism by which mechanical motion supplies nutrition to the avascular portion of the menisci.




The knee joint is innervated by the posterior articular branch of the posterior tibial nerve and the terminal branches of the obturator and femoral nerves. The lateral portion of the capsule is innervated by the recurrent peroneal branch of the common peroneal nerve. These nerve fibers penetrate the capsule and follow the vascular supply to the peripheral portion of the menisci and the anterior and posterior horns, where most of the nerve fibers are concentrated.52,90 The outer third of the body of the meniscus is more densely innervated than the middle third.183,184 During extremes of flexion and extension of the knee, the meniscal horns are stressed, and the afferent input is likely greatest at these extreme positions.183,184


The mechanoreceptors within the menisci function as transducers, converting the physical stimulus of tension and compression into a specific electrical nerve impulse. Studies of human menisci have identified 3 morphologically distinct mechanoreceptors: Ruffini endings, Pacinian corpuscles, and Golgi tendon organs.‡‡ Type I (Ruffini) mechanoreceptors are low threshold and slowly adapting to the changes in joint deformation and pressure. Type II (Pacinian) mechanoreceptors are low threshold and fast adapting to tension changes.§§ Type III (Golgi) are high-threshold mechanoreceptors, which signal when the knee joint approaches the terminal range of motion and are associated with neuromuscular inhibition. These neural elements were found in greater concentration in the meniscal horns, particularly the posterior horn.


The asymmetrical components of the knee act in concert as a type of biological transmission that accepts, transfers, and dissipates loads along the femur, tibia, patella, and femur.41 Ligaments act as an adaptive linkage, with the menisci representing mobile bearings. Several studies have reported that various intra-articular components of the knee are sensate, capable of generating neurosensory signals that reach spinal, cerebellar, and higher central nervous system levels.‖‖ It is believed that these neurosensory signals result in conscious perception and are important for normal knee joint function and maintenance of tissue homeostasis.42

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The meniscus is cartilage which provides structural and functional integrity to the knee. The menisci are two pads of fibrocartilaginous tissue which spread out friction in the knee joint when it undergoes tension and torsion between the shin bone, or tibia, and the thigh bone, or femur. The understanding of the anatomy and biomechanics of the knee joint is essential towards the understanding of knee injuries and/or conditions. Dr. Alex Jimenez D.C., C.C.S.T. Insight


Biomechanical Function


The biomechanical function of the meniscus is a reflection of the gross and ultrastructural anatomy and of its relationship to the surrounding intra-articular and extra-articular structures. The menisci serve many important biomechanical functions. They contribute to load transmission,¶¶ shock absorption,10,49,94,96,170 stability,51,100,101,109,155 nutrition,23,24,84,141 joint lubrication,102-104,141 and proprioception.5,15,81,88,115,147 They also serve to decrease contact stresses and increase contact area and congruity of the knee.91,172


Meniscal Kinematics


In a study on ligamentous function, Brantigan and Voshell reported the medial meniscus to move an average 2 mm, while the lateral meniscus was markedly more mobile with approximately 10 mm of anterior-posterior displacement during flexion.25 Similarly, DePalma reported that the medial meniscus undergoes 3 mm of anterior-posterior displacement, while the lateral meniscus moves 9 mm during flexion.37 In a study using 5 cadaveric knees, Thompson et al reported the mean medial excursion to be 5.1 mm (average of anterior and posterior horns) and the mean lateral excursion, 11.2 mm, along the tibial articular surface (Figure 7).165 The findings from these studies confirm a significant difference in segmental motion between the medial and lateral menisci. The anterior and posterior horn lateral meniscus ratio is smaller and indicates that the meniscus moves more as a single unit.165 Alternatively, the medial meniscus (as a whole) moves less than the lateral meniscus, displaying a greater anterior to posterior horn differential excursion. Thompson et al found that the area of least meniscal motion is the posterior medial corner, where the meniscus is constrained by its attachment to the tibial plateau by the meniscotibial portion of the posterior oblique ligament, which has been reported to be more prone to injury.143,165 A reduction in the motion of the posterior horn of the medial meniscus is a potential mechanism for meniscal tears, with a resultant “trapping” of the fibrocartilage between the femoral condyle and the tibial plateau during full flexion. The greater differential between anterior and posterior horn excursion may place the medial meniscus at a greater risk of injury.165



The differential of anterior horn to posterior horn motion allows the menisci to assume a decreasing radius with flexion, which correlates to the decreased radius of curvature of the posterior femoral condyles.165 This change of radius allows the meniscus to maintain contact with the articulating surface of both the femur and the tibia throughout flexion.


Load Transmission


The function of the menisci has been clinically inferred by the degenerative changes that accompany its removal. Fairbank described the increased incidence and predictable degenerative changes of the articular surfaces in completely meniscectomized knees.45 Since this early work, numerous studies have confirmed these findings and have further established the important role of the meniscus as a protective, load-bearing structure.


Weightbearing produces axial forces across the knee, which compress the menisci, resulting in “hoop” (circumferential) stresses.170 Hoop stresses are generated as axial forces and converted to tensile stresses along the circumferential collagen fibers of the meniscus (Figure 8). Firm attachments by the anterior and posterior insertional ligaments prevent the meniscus from extruding peripherally during load bearing.94 Studies by Seedhom and Hargreaves reported that 70% of the load in the lateral compartment and 50% of the load in the medial compartment is transmitted through the menisci.153 The menisci transmit 50% of compressive load through the posterior horns in extension, with 85% transmission at 90° flexion.172 Radin et al demonstrated that these loads are well distributed when the menisci are intact.137 However, removal of the medial meniscus results in a 50% to 70% reduction in femoral condyle contact area and a 100% increase in contact stress.4,50,91 Total lateral meniscectomy results in a 40% to 50% decrease in contact area and increases contact stress in the lateral component to 200% to 300% of normal.18,50,76,91 This significantly increases the load per unit area and may contribute to accelerated articular cartilage damage and degeneration.45,85



Shock Absorption


The menisci play a vital role in attenuating the intermittent shock waves generated by impulse loading of the knee with normal gait.94,96,153 Voloshin and Wosk showed that the normal knee has a shock-absorbing capacity about 20% higher than knees that have undergone meniscectomy.170 As the inability of a joint system to absorb shock has been implicated in the development of osteoarthritis, the meniscus would appear to play an important role in maintaining the health of the knee joint.138


Joint Stability


The geometric structure of the menisci provides an important role in maintaining joint congruity and stability.## The superior surface of each meniscus is concave, enabling effective articulation between the convex femoral condyles and flat tibial plateau. When the meniscus is intact, axial loading of the knee has a multidirectional stabilizing function, limiting excess motion in all directions.9


Markolf and colleagues have addressed the effect of meniscectomy on anterior-posterior and rotational knee laxity. Medial meniscectomy in the ACL-intact knee has little effect on anterior-posterior motion, but in the ACL-deficient knee, it results in an increase in anterior-posterior tibial translation of up to 58% at 90o of flexion.109 Shoemaker and Markolf demonstrated that the posterior horn of the medial meniscus is the most important structure resisting an anterior tibial force in the ACL-deficient knee.155 Allen et al showed that the resultant force in the medial meniscus of the ACL-deficient knee increased by 52% in full extension and by 197% at 60° of flexion under a 134-N anterior tibial load.7 The large changes in kinematics due to medial meniscectomy in the ACL-deficient knee confirm the important role of the medial meniscus in knee stability. Recently, Musahl et al reported that the lateral meniscus plays a role in anterior tibial translation during the pivot-shift maneuver.123


Joint Nutrition and Lubrication


The menisci may also play a role in the nutrition and lubrication of the knee joint. The mechanics of this lubrication remains unknown; the menisci may compress synovial fluid into the articular cartilage, which reduces frictional forces during weightbearing.13


There is a system of microcanals within the meniscus located close to the blood vessels, which communicates with the synovial cavity; these may provide fluid transport for nutrition and joint lubrication.23,24




The perception of joint motion and position (proprioception) is mediated by mechanoreceptors that transduce mechanical deformation into electric neural signals. Mechanoreceptors have been identified in the anterior and posterior horns of the menisci.*** Quick-adapting mechanoreceptors, such as Pacinian corpuscles, are thought to mediate the sensation of joint motion, and slow-adapting receptors, such as Ruffini endings and Golgi tendon organs, are believed to mediate the sensation of joint position.140 The identification of these neural elements (located mostly in the middle and outer third of the meniscus) indicates that the menisci are capable of detecting proprioceptive information in the knee joint, thus playing an important afferent role in the sensory feedback mechanism of the knee.61,88,90,158,169


Maturation and Aging of The Meniscus


The microanatomy of the meniscus is complex and certainly demonstrates senescent changes. With advancing age, the meniscus becomes stiffer, loses elasticity, and becomes yellow.78,95 Microscopically, there is a gradual loss of cellular elements with empty spaces and an increase in fibrous tissue in comparison with elastic tissue.74 These cystic areas can initiate a tear, and with a torsional force by the femoral condyle, the superficial layers of the meniscus may shear off from the deep layer at the interface of the cystic degenerative change, producing a horizontal cleavage tear. Shear between these layers may cause pain. The torn meniscus may directly injure the overlying articular cartilage.74,95


Ghosh and Taylor found that collagen concentration increased from birth to 30 years and remained constant until 80 years of age, after which a decline occurred.58 The noncollagenous matrix proteins showed the most profound changes, decreasing from 21.9% ± 1.0% (dry weight) in neonates to 8.1% ± 0.8% between the ages of 30 to 70 years.80 After 70 years of age, the noncollagenous matrix protein levels increased to 11.6% ± 1.3%. Peters and Smillie observed an increase in hexosamine and uronic acid with age.131


McNicol and Roughley studied the variation of meniscal proteoglycans in aging113; small differences in extractability and hydrodynamic size were observed. The proportions of keratin sulfate relative to chondroitin-6-sulfate increased with aging.146


Petersen and Tillmann immunohistochemically investigated human menisci (ranging from 22 weeks of gestation to 80 years), observing the differentiation of blood vessels and lymphatics in 20 human cadavers. At the time of birth, nearly the entire meniscus was vascularized. In the second year of life, an avascular area developed in the inner circumference. In the second decade, blood vessels were present in the peripheral third. After 50 years of age, only the peripheral quarter of the meniscal base was vascularized. The dense connective tissue of the insertion was vascularized but not the fibrocartilage of the insertion. Blood vessels were accompanied by lymphatics in all areas.†††


Arnoczky suggested that body weight and knee joint motion may eliminate blood vessels in the inner and middle aspects of the menisci.9 Nutrition of meniscal tissue occurs via perfusion from blood vessels and via diffusion from synovial fluid. A requirement for nutrition via diffusion is the intermittent loading and release on the articular surfaces, stressed by body weight and muscle forces.130 The mechanism is comparable with the nutrition of articular cartilage.22


Magnetic Resonance Imaging of The Meniscus


Magnetic resonance imaging (MRI) is a noninvasive diagnostic tool used in the evaluation, diagnosis, and monitoring of the menisci. MRI is widely accepted as the optimal imaging modality because of superior soft tissue contrast.


On cross-sectional MRI, the normal meniscus appears as a uniform low-signal (dark) triangular structure (Figure 9). A meniscal tear is identified by the presence of an increased intrameniscal signal that extends to the surface of this structure.



Several studies have evaluated the clinical utility of MRI for meniscal tears. In general, MRI is highly sensitive and specific for tears of the meniscus. The sensitivity of MRI in detecting meniscal tears ranges from 70% to 98%, and the specificity, from 74% to 98%.48,62,105,107,117 The MRI of 1014 patients before an arthroscopic examination had an accuracy of 89% for pathology of the medial meniscus and 88% for the lateral meniscus.48 A meta-analysis of 2000 patients with an MRI and arthroscopic examination found 88% sensitivity and 94% accuracy for meniscal tears.105,107


There have been discrepancies between MRI diagnoses and the pathology identified during arthroscopic examination.‡‡‡ Justice and Quinn reported discrepancies in the diagnosis of 66 of the 561 patients (12%).86 In a study of 92 patients, discrepancies between the MRI and arthroscopic diagnoses were noted in 22 of the 349 (6%) cases.106 Miller conducted a single-blind prospective study comparing clinical examinations and MRI in 57 knee examinations.117 He found no significant difference in sensitivity between the clinical examination and MRI (80.7% and 73.7%, respectively). Shepard et al assessed the accuracy of MRI in detecting clinically significant lesions of the anterior horn of the meniscus in 947 consecutive knee MRI154 and found a 74% false-positive rate. Increased signal intensity in the anterior horn does not necessarily indicate a clinically significant lesion.154




The menisci of the knee joint are crescent-shaped wedges of fibrocartilage that provide increased stability to the femorotibial articulation, distribute axial load, absorb shock, and provide lubrication to the knee joint. Injuries to the menisci are recognized as a cause of significant musculoskeletal morbidity. Preservation of the menisci is highly dependent on maintaining its distinctive composition and organization.






In conclusion, the knee is the largest and most complex joint in the human body. However, because the knee can commonly become damaged as a result of an injury and/or condition, it’s essential to understand the anatomy of the knee joint in order for patients to receive proper treatment.  The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .


Curated by Dr. Alex Jimenez


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Additional Topic Discussion: Relieving Knee Pain without Surgery


Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.


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EXTRA EXTRA | IMPORTANT TOPIC: El Paso, TX Chiropractor Recommended

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146. Roughley PJ. Changes in cartilage proteoglycan structure during aging: origin and effects: a reviewAgents Actions. 1986;518:19 [PubMed]
147. Saygi B, Yildirim Y, Berker N, Ofluoglu D, Karadag-Saygi E, Karahan M. Evaluation of neurosensory function of the medial meniscus in humansArthroscopy. 2005;21(12):1468-1472 [PubMed]
148. Scapinelli R. Studies on the vasculature of the human knee jointActa Anat. 1968;70:305-331[PubMed]
149. Schutte MJ, Dabezius EJ, Zimny ML, Happe LT. Neural anatomy of the human anterior cruciate ligamentJ Bone Joint Surg Am. 1987;69:243-247 [PubMed]
150. Scott JE. Supramolecular organization of extracellular matrix glycosaminoglycans, in vitro and in the tissuesFASEB J. 1992;6:2639-2645 [PubMed]
151. Scott PG, Nakano T, Dodd CM. Isolation and characterization of small proteoglycans from different zones of the porcine knee meniscusBiochim Biophys Acta. 1997;1336:254-262 [PubMed]
152. Seedhom BB. Loadbearing function of the menisciPhysiotherapy. 1976;62(7):223. [PubMed]
153. Seedhom BB, Hargreaves DJ. Transmission of the load in the knee joint with special reference to the role in the menisci: part II. Experimental results, discussion and conclusionEng Med. 1979;8:220-228
154. Shepard MF, Hunter DM, Davies MR, Shapiro MS, Seeger LL. The clinical significance of anterior horn meniscal tears diagnosed on magnetic resonance imagesAm J Sports Med. 2002;30(2):189-192[PubMed]
155. Shoemaker SC, Markolf KL. The role of the meniscus in the anterior-posterior stability of the loaded anterior cruciate-deficient knee: effects of partial versus total excisionJ Bone Joint Surg Am. 1986;68(1):71-79 [PubMed]
156. Skaags DL, Mow VC. Function of the radial tie fibers in the meniscusTrans Orthop Res Soc. 1990;15:248
157. Skinner HB, Barrack RL. Joint position sense in the normal and pathologic knee jointJ Electromyogr Kinesiol. 1991;1(3):180-190 [PubMed]
158. Skinner HB, Barrack RL, Cook SD. Age-related decline in proprioceptionClin Orthop Relat Res. 1984;184:208-211 [PubMed]
159. Solheim K. Glycosaminoglycans, hydroxyproline, calcium, and phosphorus in healing fracturesActa Univ Lund. 1965;28:1-22
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165. Thompson WO, Thaete FL, Fu FH, Dye SF. Tibial meniscal dynamics using three-dimensional reconstruction of magnetic resonance imagingAm J Sports Med. 1991;19:210-216 [PubMed]
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Why Gait Analysis Is Important With Chiropractic Care | El Paso, TX.

Why Gait Analysis Is Important With Chiropractic Care | El Paso, TX.

The way a person walks, their gait, can be very telling. It can reveal problems in the feet, ankles, knees, and hips – even in spinal alignment. A problem with gait can indicate pain in a patient as well as serious conditions like diabetes and arthritis. It, is a diagnostic tool for many conditions, injuries, and syndromes including autism. When it comes to chiropractic care, a patient’s gait can offer critical clues regarding the root of their complaints, allowing for a more well-rounded, whole body approach to treatment. If you think that the way you walk or moves doesn’t matter, think again. It most certainly does matter.

What is Gait Analysis?

Gait analysis is a set of tests that are designed to provide a comprehensive evaluation of a person’s gait. It is a systematic study of human motion that involves observation as well as the use of instruments that measure body movements, muscle activity, and body mechanics.

It is intended to be used as an assessment tool and provide insight into devising a treatment plan for people who have conditions or injuries that affect their ability to walk. It is often used in sports biomechanics to aid athletes in more efficient movement and to identify problems with movement or posture, particularly those with injuries.

During the analysis, the patient may walk in a prescribed pattern or on a treadmill, that is often connected to a computer, while the chiropractor observes them from various angles. Often cameras are used, places at multiple points to capture different views including the anterior, posterior, and sides.

The patient may have markers applied to specific points on the body such as the knee, ankle, pelvis, and other areas. As they move, the computer captures specific data of the movement, providing a three-dimensional calculation of each marker. It then applies a model to assess the movement of the skeletal structure, resulting in a detailed analysis of each joint’s movement.

gait analysis chiropractic care el paso tx.

Factors that Affect Gait Analysis

Certain factors affect a person’s gait, and that information must be included for the gait analysis to be accurate. The gender, age, height, and weight of the person is vital because men and women move differently and as a person ages their structure changes.

Excess weight or they physique can affect a person’s posture and their gait. The individual’s shoes (or lack of shoes) is essential, as is their clothing, the terrain they are walking on, and anything they may usually carry, such as a purse. Other factors include:

  • Physiological factors such as body proportion
  • Psychological factors such as their state of mind, emotions, stress level, and personality type
  • Pathological factors such as neurological diseases, psychiatric disorders, trauma, and musculoskeletal anomalies

It will also measure and factor into the analysis data that includes the patients:

  • Length of stride
  • Cadence
  • Hip angle
  • Foot angle
  • Step length
  • Walking or movement speed
  • Other areas as needed

Advantages of a Gait Analysis

Getting a gait analysis can be very advantageous because it can provide invaluable insight into how your body is aligned and how it moves. It is an excellent diagnostic tool for identifying health issues related to the gait, spine, and feet and can also help provide early detection of health issues before the onset of symptoms.

If your chiropractor recommends that you get a gait analysis, it could be that he or she suspects that something is going on, or it could simply mean that they want to examine you to provide optimal care more thoroughly. If you have any concerns, you should sit down with your chiropractor and ask them any questions that you have before undergoing the analysis. Stress and anxiety can put tension on the muscles and body, affecting the results.

Sports Injury Chiropractic Treatment

Evaluation of Patients Presenting with Knee Pain: Part II. Differential Diagnosis

Evaluation of Patients Presenting with Knee Pain: Part II. Differential Diagnosis

The knee is the largest joint in the human body, where the complex structures of the lower and upper legs come together. Consisting of three bones, the femur, the tibia, and the patella which are surrounded by a variety of soft tissues, including cartilage, tendons and ligaments, the knee functions as a hinge, allowing you to walk, jump, squat or sit. As a result, however, the knee is considered to be one of the joints that are most prone to suffer injury. A knee injury is the prevalent cause of knee pain.

A knee injury can occur as a result of a direct impact from a slip-and-fall accident or automobile accident, overuse injury from sports injuries, or even due to underlying conditions, such as arthritis. Knee pain is a common symptom which affects people of all ages. It may also start suddenly or develop gradually over time, beginning as a mild or moderate discomfort then slowly worsening as time progresses. Moreover, being overweight can increase the risk of knee problems. The purpose of the following article is to discuss the evaluation of patients presenting with knee pain and demonstrate their differential diagnosis.


Knee pain is a common presenting complaint with many possible causes. An awareness of certain patterns can help the family physician identify the underlying cause more efficiently. Teenage girls and young women are more likely to have patellar tracking problems such as patellar subluxation and patellofemoral pain syndrome, whereas teenage boys and young men are more likely to have knee extensor mechanism problems such as tibial apophysitis (Osgood-Schlatter lesion) and patellar tendonitis. Referred pain resulting from hip joint pathology, such as slipped capital femoral epiphysis, also may cause knee pain. Active patients are more likely to have acute ligamentous sprains and overuse injuries such as pes anserine bursitis and medial plica syndrome. Trauma may result in acute ligamentous rupture or fracture, leading to acute knee joint swelling and hemarthrosis. Septic arthritis may develop in patients of any age, but crystal-induced inflammatory arthropathy is more likely in adults. Osteoarthritis of the knee joint is common in older adults. (Am Fam Physician 2003;68:917-22. Copyright© 2003 American Academy of Family Physicians.)


Determining the underlying cause of knee pain can be difficult, in part because of the extensive differential diagnosis. As discussed in part I of this two-part article,1 the family physician should be familiar with knee anatomy and common mechanisms of injury, and a detailed history and focused physical examination can narrow possible causes. The patient’s age and the anatomic site of the pain are two factors that can be important in achieving an accurate diagnosis (Tables 1 and 2).  


Table 1 Common Causes of Knee Pain


Children and Adolescents

Children and adolescents who present with knee pain are likely to have one of three common conditions: patellar subluxation, tibial apophysitis, or patellar tendonitis. Additional diagnoses to consider in children include slipped capital femoral epiphysis and septic arthritis.

Patellar Subluxation

Patellar subluxation is the most likely diagnosis in a teenage girl who presents with giving-way episodes of the knee.2 This injury occurs more often in girls and young women because of an increased quadriceps angle (Q angle), usually greater than 15 degrees.

Patellar apprehension is elicited by subluxing the patella laterally, and a mild effusion is usually present. Moderate to severe knee swelling may indicate hemarthrosis, which suggests patellar dislocation with osteochondral fracture and bleeding.

Tibial Apophysitis

A teenage boy who presents with anterior knee pain localized to the tibial tuberosity is likely to have tibial apophysitis or Osgood- Schlatter lesion3,4 (Figure 1).5 The typical patient is a 13- or 14-year-old boy (or a 10- or 11-year-old girl) who has recently gone through a growth spurt.

The patient with tibial apophysitis generally reports waxing and waning of knee pain for a period of months. The pain worsens with squatting, walking up or down stairs, or forceful contractions of the quadriceps muscle. This overuse apophysitis is exacerbated by jumping and hurdling because repetitive hard landings place excessive stress on the insertion of the patellar tendon.

On physical examination, the tibial tuberosity is tender and swollen and may feel warm. The knee pain is reproduced with the resisted active extension or passive hyperflexion of the knee. No effusion is present. Radiographs are usually negative; rarely, they show avulsion of the apophysis at the tibial tuberosity. However, the physician must not mistake the normal appearance of the tibial apophysis for an avulsion fracture.  


Table 2 Differential Diagnosis of Knee Pain


Figure 1 Anterior View of the Structures of the Knee


Patellar Tendonitis

Jumper’s knee (irritation and inflammation of the patellar tendon) most commonly occurs in teenage boys, particularly during a growth spurt2 (Figure 1).5 The patient reports vague anterior knee pain that has persisted for months and worsens after activities such as walking down stairs or running.

On physical examination, the patellar tendon is tender, and the pain is reproduced by resisted knee extension. There is usually no effusion. Radiographs are not indicated.

Slipped Capital Femoral Epiphysis

A number of pathologic conditions result in referral of pain to the knee. For example, the possibility of slipped capital femoral epiphysis must be considered in children and teenagers who present with knee pain.6 The patient with this condition usually reports poorly localized knee pain and no history of knee trauma.

The typical patient with slipped capital femoral epiphysis is overweight and sits on the examination table with the affected hip slightly flexed and externally rotated. The knee examination is normal, but hip pain is elicited with passive internal rotation or extension of the affected hip.

Radiographs typically show displacement of the epiphysis of the femoral head. However, negative radiographs do not rule out the diagnosis in patients with typical clinical findings. Computed tomographic (CT) scanning is indicated in these patients.

Osteochondritis Dissecans

Osteochondritis dissecans is an intra-articular osteochondrosis of unknown etiology that is characterized by degeneration and recalcification of articular cartilage and underlying bone. In the knee, the medial femoral condyle is most commonly affected.7

The patient reports vague, poorly localized knee pain, as well as morning stiffness or recurrent effusion. If a loose body is present, mechanical symptoms of locking or catching of the knee joint also may be reported. On physical examination, the patient may demonstrate quadriceps atrophy or tenderness along the involved chondral surface. A mild joint effusion may be present.7

Plain-film radiographs may demonstrate the osteochondral lesion or a loose body in the knee joint. If osteochondritis dissecans is suspected, recommended radiographs include anteroposterior, posteroanterior tunnel, lateral, and Merchant’s views. Osteochondral lesions at the lateral aspect of the medial femoral condyle may be visible only on the posteroanterior tunnel view. Magnetic resonance imaging (MRI) is highly sensitive in detecting these abnormalities and is indicated in patients with a suspected osteochondral lesion.7  


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A knee injury caused by sports injuries, automobile accidents, or an underlying condition, among other causes, can affect the cartilage, tendons and ligaments which form the knee joint itself. The location of the knee pain can differ according to the structure involved, also, the symptoms can vary. The entire knee may become painful and swollen as a result of inflammation or infection, whereas a torn meniscus or fracture may cause symptoms in the affected region. Dr. Alex Jimenez D.C., C.C.S.T. Insight


Overuse Syndromes

Anterior Knee Pain. Patients with patellofemoral pain syndrome (chondromalacia patellae) typically present with a vague history of mild to moderate anterior knee pain that usually occurs after prolonged periods of sitting (the so-called “theater sign”).8 Patellofemoral pain syndrome is a common cause of anterior knee pain in women.

On physical examination, a slight effusion may be present, along with patellar crepitus on the range of motion. The patient’s pain may be reproduced by applying direct pressure to the anterior aspect of the patella. Patellar tenderness may be elicited by subluxing the patella medially or laterally and palpating the superior and inferior facets of the patella. Radiographs usually are not indicated.

Medial Knee Pain. One frequently overlooked diagnosis is medial plica syndrome. The plica, a redundancy of the joint synovium medially, can become inflamed with repetitive overuse.4,9 The patient presents with acute onset of medial knee pain after a marked increase in usual activities. On physical examination, a tender, mobile nodularity is present at the medial aspect of the knee, just anterior to the joint line. There is no joint effusion, and the remainder of the knee examination is normal. Radiographs are not indicated.

Pes anserine bursitis is another possible cause of medial knee pain. The tendinous insertion of the sartorius, gracilis, and semitendinosus muscles at the anteromedial aspect of the proximal tibia forms the pes anserine bursa.9 The bursa can become inflamed as a result of overuse or a direct contusion. Pes anserine bursitis can be confused easily with a medial collateral ligament sprain or, less commonly, osteoarthritis of the medial compartment of the knee.  



The patient with pes anserine bursitis reports pain at the medial aspect of the knee. This pain may be worsened by repetitive flexion and extension. On physical examination, tenderness is present at the medial aspect of the knee, just posterior and distal to the medial joint line. No knee joint effusion is present, but there may be slight swelling at the insertion of the medial hamstring muscles. Valgus stress testing in the supine position or resisted knee flexion in the prone position may reproduce the pain. Radiographs are usually not indicated.

Lateral Knee Pain. Excessive friction between the iliotibial band and the lateral femoral condyle can lead to iliotibial band tendonitis.9 This overuse syndrome commonly occurs in runners and cyclists, although it may develop in any person subsequent to activity involving repetitive knee flexion. The tightness of the iliotibial band, excessive foot pronation, genu varum, and tibial torsion are predisposing factors.

The patient with iliotibial band tendonitis reports pain at the lateral aspect of the knee joint. The pain is aggravated by activity, particularly running downhill and climbing stairs. On physical examination, tenderness is present at the lateral epicondyle of the femur, approximately 3 cm proximal to the joint line. Soft tissue swelling and crepitus also may be present, but there is no joint effusion. Radiographs are not indicated.

Noble’s test is used to reproduce the pain in iliotibial band tendonitis. With the patient in a supine position, the physician places a thumb over the lateral femoral epicondyle as the patient repeatedly flexes and extends the knee. Pain symptoms are usually most prominent with the knee at 30 degrees of flexion.

Popliteus tendonitis is another possible cause of lateral knee pain. However, this condition is fairly rare.10


Anterior Cruciate Ligament Sprain. Injury to the anterior cruciate ligament usually occurs because of noncontact deceleration forces, as when a runner plants one foot and sharply turns in the opposite direction. Resultant valgus stress on the knee leads to anterior displacement of the tibia and sprain or rupture of the ligament.11 The patient usually reports hearing or feeling a “pop” at the time of the injury and must cease activity or competition immediately. Swelling of the knee within two hours after the injury indicates rupture of the ligament and consequent hemarthrosis.

On physical examination, the patient has a moderate to severe joint effusion that limits the range of motion. The anterior drawer test may be positive, but can be negative because of hemarthrosis and guarding by the hamstring muscles. The Lachman test should be positive and is more reliable than the anterior drawer test (see text and Figure 3 in part I of the article1).

Radiographs are indicated to detect possible tibial spine avulsion fracture. MRI of the knee is indicated as part of a presurgical evaluation.

Medial Collateral Ligament Sprain. Injury to the medial collateral ligament is fairly common and is usually the result of acute trauma. The patient reports a misstep or collision that places valgus stress on the knee, followed by the immediate onset of pain and swelling at the medial aspect of the knee.11

On physical examination, the patient with medial collateral ligament injury has point tenderness at the medial joint line. Valgus stress testing of the knee flexed to 30 degrees reproduces the pain (see text and Figure 4 in part I of this article1). A clearly defined endpoint on valgus stress testing indicates a grade 1 or grade 2 sprain, whereas complete medial instability indicates full rupture of the ligament (grade 3 sprain).

Lateral Collateral Ligament Sprain. Injury of the lateral collateral ligament is much less common than the injury of the medial collateral ligament. Lateral collateral ligament sprain usually results from varus stress to the knee, as occurs when a runner plants one foot and then turns toward the ipsilateral knee.2 The patient reports acute onset of lateral knee pain that requires prompt cessation of activity.

On physical examination, point tenderness is present at the lateral joint line. Instability or pain occurs with varus stress testing of the knee flexed to 30 degrees (see text and Figure 4 in part I of this article1). Radiographs are not usually indicated.

Meniscal Tear. The meniscus can be torn acutely with a sudden twisting injury of the knee, such as may occur when a runner suddenly changes direction.11,12 Meniscal tear also may occur in association with a prolonged degenerative process, particularly in a patient with an anterior cruciate ligament-deficient knee. The patient usually reports recurrent knee pain and episodes of catching or locking of the knee joint, especially with squatting or twisting of the knee.

On physical examination, a mild effusion is usually present, and there is tenderness at the medial or lateral joint line. Atrophy of the vastus medialis obliquus portion of the quadriceps muscle also may be noticeable. The McMurray test may be positive (see Figure 5 in part I of this article1), but a negative test does not eliminate the possibility of a meniscal tear.

Plain-film radiographs usually are negative and seldom are indicated. MRI is the radiologic test of choice because it demonstrates most significant meniscal tears.


Infection of the knee joint may occur in patients of any age but is more common in those whose immune system has been weakened by cancer, diabetes mellitus, alcoholism, acquired immunodeficiency syndrome, or corticosteroid therapy. The patient with septic arthritis reports abrupt onset of pain and swelling of the knee with no antecedent trauma.13

On physical examination, the knee is warm, swollen, and exquisitely tender. Even slight motion of the knee joint causes intense pain.

Arthrocentesis reveals turbid synovial fluid. Analysis of the fluid yields a white blood cell count (WBC) higher than 50,000 per mm3 (50 􏰀 109 per L), with more than 75 percent (0.75) polymorphonuclear cells, an elevated protein content (greater than 3 g per dL [30 g per L]), and a low glucose concentration (more than 50 percent lower than the serum glucose concentration).14 Gram stain of the fluid may demonstrate the causative organism. Common pathogens include Staphylococcus aureus, Streptococcus species, Haemophilus influenza, and Neisseria gonorrhoeae.

Hematologic studies show an elevated WBC, an increased number of immature polymorphonuclear cells (i.e., a left shift), and an elevated erythrocyte sedimentation rate (usually greater than 50 mm per hour).

Older Adults


Osteoarthritis of the knee joint is a common problem after 60 years of age. The patient presents with knee pain that is aggravated by weight-bearing activities and relieved by rest.15 The patient has no systemic symptoms but usually awakens with morning stiffness that dissipates somewhat with activity. In addition to chronic joint stiffness and pain, the patient may report episodes of acute synovitis.

Findings on physical examination include decreased range of motion, crepitus, a mild joint effusion, and palpable osteophytic changes at the knee joint.

When osteoarthritis is suspected, recommended radiographs include weight-bearing anteroposterior and posteroanterior tunnel views, as well as non-weight-bearing Merchants and lateral views. Radiographs show joint-space narrowing, subchondral bony sclerosis, cystic changes, and hypertrophic osteophyte formation.

Crystal-Induced Inflammatory Arthropathy

Acute inflammation, pain, and swelling in the absence of trauma suggest the possibility of a crystal-induced inflammatory arthropathy such as gout or pseudogout.16,17 Gout commonly affects the knee. In this arthropathy, sodium urate crystals precipitate in the knee joint and cause an intense inflammatory response. In pseudogout, calcium pyrophosphate crystals are the causative agents.

On physical examination, the knee joint is erythematous, warm, tender, and swollen. Even minimal range of motion is exquisitely painful.

Arthrocentesis reveals clear or slightly cloudy synovial fluid. Analysis of the fluid yields a WBC count of 2,000 to 75,000 per mm3 (2 to 75 􏰀 109 per L), a high protein content (greater than 32 g per dL [320 g per L]), and a glucose concentration that is approximately 75 percent of the serum glucose con- centration.14 Polarized-light microscopy of the synovial fluid displays negatively birefringent rods in the patient with gout and positively birefringent rhomboids in the patient with pseudogout.

Popliteal Cyst

The popliteal cyst (Baker’s cyst) is the most common synovial cyst of the knee. It originates from the posteromedial aspect of the knee joint at the level of the gastrocnemio-semimembranous bursa. The patient reports insidious onset of mild to moderate pain in the popliteal area of the knee.

On physical examination, palpable fullness is present at the medial aspect of the popliteal area, at or near the origin of the medial head of the gastrocnemius muscle. The McMurray test may be positive if the medial meniscus is injured. Definitive diagnosis of a popliteal cyst may be made with arthrography, ultrasonography, CT scanning, or, less commonly, MRI.

The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.

In conclusion, although the knee is the largest joint in the human body where the structures of the lower extremities meet, including the femur, the tibia, the patella, and many other soft tissues, the knee can easily suffer damage or injury and result in knee pain. Knee pain is one of the most common complaints among the general population, however, it commonly occurs in athletes. Sports injuries, slip-and-fall accidents, and automobile accidents, among other causes, can lead to knee pain.

As described in the article above, diagnosis is essential towards determining the best treatment approach for each type of knee injury, according to their underlying cause. While the location and the severity of the knee injury may vary depending on the cause of the health issue, knee pain is the most common symptom. Treatment options, such as chiropractic care and physical therapy, can help treat knee pain. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez  


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Additional Topic Discussion: Relieving Knee Pain without Surgery


Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.



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EXTRA EXTRA | IMPORTANT TOPIC: El Paso, TX Chiropractor Recommended

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2. Walsh WM. Knee injuries. In: Mellion MB, Walsh WM, Shelton GL, eds. The team physician’s hand- book. 2d ed. St. Louis: Mosby, 1990:554-78.
3. Dunn JF. Osgood-Schlatter disease. Am Fam Physi- cian 1990;41:173-6.
4. Stanitski CL. Anterior knee pain syndromes in the adolescent. Instr Course Lect 1994;43:211-20.
5. Tandeter HB, Shvartzman P, Stevens MA. Acute knee injuries: use of decision rules for selective radiograph ordering. Am Fam Physician 1999;60: 2599-608.
6. Waters PM, Millis MB. Hip and pelvic injuries in the young athlete. In: DeLee J, Drez D, Stanitski CL, eds. Orthopaedic sports medicine: principles and practice. Vol. III. Pediatric and adolescent sports medicine. Philadelphia: Saunders, 1994:279-93.
7. Schenck RC Jr, Goodnight JM. Osteochondritis dis- secans. J Bone Joint Surg [Am] 1996;78:439-56.
8. Ruffin MT 5th, Kiningham RB. Anterior knee pain: the challenge of patellofemoral syndrome. Am Fam Physician 1993;47:185-94.
9. Cox JS, Blanda JB. Peripatellar pathologies. In: DeLee J, Drez D, Stanitski CL, eds. Orthopaedic sports medicine: principles and practice. Vol. III. Pediatric and adolescent sports medicine. Philadel- phia: Saunders, 1994:1249-60.
10. Petsche TS, Selesnick FH. Popliteus tendinitis: tips for diagnosis and management. Phys Sportsmed 2002;30(8):27-31.
11. Micheli LJ, Foster TE. Acute knee injuries in the immature athlete. Instr Course Lect 1993;42:473- 80.
12. Smith BW, Green GA. Acute knee injuries: part II. Diagnosis and management. Am Fam Physician 1995;51:799-806.
13. McCune WJ, Golbus J. Monarticular arthritis. In: Kelley WN, ed. Textbook of rheumatology. 5th ed. Philadelphia: Saunders, 1997:371-80.
14. Franks AG Jr. Rheumatologic aspects of knee dis- orders. In: Scott WN, ed. The knee. St. Louis: Mosby, 1994:315-29.
15. Brandt KD. Management of osteoarthritis. In: Kel- ley WN, ed. Textbook of rheumatology. 5th ed. Philadelphia: Saunders, 1997:1394-403.
16. Kelley WN, Wortmann RL. Crystal-associated syn- ovitis. In: Kelley WN, ed. Textbook of rheumatol- ogy. 5th ed. Philadelphia: Saunders, 1997:1313- 51. 1
7. Reginato AJ, Reginato AM. Diseases associated with deposition of calcium pyrophosphate or hy- droxyapatite. In: Kelley WN, ed. Textbook of rheumatology. 5th ed. Philadelphia: Saunders, 1997:1352-67.
Close Accordion

Evaluation of Patients Presenting with Knee Pain: Part I. History, Physical Examination, Radiographs, and Laboratory Tests

Evaluation of Patients Presenting with Knee Pain: Part I. History, Physical Examination, Radiographs, and Laboratory Tests

Knee pain is a common health issue among athletes and the general population alike. Although symptoms of knee pain can be debilitating and frustrating, knee pain is often a very treatable health issue. The knee is a complex structure made up of three bones: the lower section of the thighbone, the upper region of the shinbone, and the kneecap.

Powerful soft tissues, such as the tendons and ligaments of the knee as well as the cartilage beneath the kneecap and between the bones, hold these structures together in order to stabilize and support the knee. However, a variety of injuries and/or conditions can ultimately lead to knee pain. The purpose of the article below is to evaluate patients with knee pain.


Family physicians frequently encounter patients with knee pain. Accurate diagnosis requires a knowledge of knee anatomy, common pain patterns in knee injuries, and features of frequently encountered causes of knee pain, as well as specific physical examination skills. The history should include characteristics of the patient’s pain, mechanical symptoms (locking, popping, giving way), joint effusion (timing, amount, recurrence), and mechanism of injury. The physical examination should include careful inspection of the knee, palpation for point tenderness, assessment of joint effusion, range-of-motion testing, evaluation of ligaments for injury or laxity, and assessment of the menisci. Radiographs should be obtained in patients with isolated patellar tenderness or tenderness at the head of the fibula, inability to bear weight or flex the knee to 90 degrees, or age greater than 55 years. (Am Fam Physician 2003; 68:907-12. Copyright© 2003 American Academy of Family Physicians.)


Knee pain accounts for approximately one-third of musculoskeletal problems seen in primary care settings. This complaint is most prevalent in physically active patients, with as many as 54 percent of athletes having some degree of knee pain each year.1 Knee pain can be a source of significant disability, restricting the ability to work or perform activities of daily living.

The knee is a complex structure (Figure 1),2 and its evaluation can present a challenge to the family physician. The differential diagnosis of knee pain is extensive but can be narrowed with a detailed history, a focused physical examination and, when indicated, the selective use of appropriate imaging and laboratory studies. Part I of this two-part article provides a systematic approach to evaluating the knee, and part II3 discusses the differential diagnosis of knee pain.



Pain Characteristics

The patient’s description of knee pain is helpful in focusing the differential diagnosis.4 It is important to clarify the characteristics of the pain, including its onset (rapid or insidious), location (anterior, medial, lateral, or posterior knee), duration, severity, and quality (e.g., dull, sharp, achy). Aggravating and alleviating factors also need to be identified. If knee pain is caused by an acute injury, the physician needs to know whether the patient was able to continue activity or bear weight after the injury or was forced to cease activities immediately.


Mechanical Symptoms

The patient should be asked about mechan- ical symptoms, such as locking, popping, or giving way of the knee. A history of locking episodes suggests a meniscal tear. A sensation of popping at the time of injury suggests liga- mentous injury, probably complete rupture of a ligament (third-degree tear). Episodes of giving way are consistent with some degree of knee instability and may indicate patellar sub- luxation or ligamentous rupture.


The timing and amount of joint effusion are important clues to the diagnosis. Rapid onset (within two hours) of a large, tense effusion suggests rupture of the anterior cru- ciate ligament or fracture of the tibial plateau with resultant hemarthrosis, whereas slower onset (24 to 36 hours) of a mild to moderate effusion is consistent with meniscal injury or ligamentous sprain. Recurrent knee effusion after activity is consistent with meniscal injury.

Mechanism of Injury

The patient should be questioned about specific details of the injury. It is important to know if the patient sustained a direct blow to the knee, if the foot was planted at the time of injury, if the patient was decelerating or stopping suddenly, if the patient was landing from a jump, if there was a twisting component to the injury, and if hyperextension occurred.

A direct blow to the knee can cause serious injury. The anterior force applied to the proximal tibia with the knee in flexion (e.g., when the knee hits the dashboard in an automobile accident) can cause injury to the posterior cruciate ligament. The medial collateral ligament is most commonly injured as a result of direct lateral force to the knee (e.g., clipping in football); this force creates a val- gus load on the knee joint and can result in rupture of the medial collateral ligament. Conversely, a medial blow that creates a varus load can injure the lateral collateral ligament.

Noncontact forces also are an important cause of knee injury. Quick stops and sharp cuts or turns create significant deceleration forces that can sprain or rupture the anterior cruciate ligament. Hyperextension can result in injury to the anterior cruciate ligament or posterior cruciate ligament. Sudden twisting or pivoting motions create shear forces that can injure the meniscus. A combination of forces can occur simultaneously, causing injury to multiple structures.


Medical History

A history of knee injury or surgery is important. The patient should be asked about previous attempts to treat knee pain, including the use of medications, supporting devices, and physical therapy. The physician also should ask if the patient has a history of gout, pseudogout, rheumatoid arthritis, or other degenerative joint diseases.

Dr Jimenez White Coat

Knee pain is a common health issue which can be caused by sports injuries, automobile accident injuries, or by an underlying health issue, such as arthritis. The most common symptoms of knee injury include pain and discomfort, swelling, inflammation and stiffness. Because treatment for knee pain varies according to the cause, it’s essential for the individual to receive proper diagnosis for their symptoms. Chiropractic care is a safe and effective, alternative treatment approach which can help treat knee pain, among other health issues.

Dr. Alex Jimenez D.C., C.C.S.T. Insight

Physical Examination

Inspection and Palpation

The physician begins by comparing the painful knee with the asymptomatic knee and inspecting the injured knee for erythema, swelling, bruising, and discoloration. The mus- culature should be symmetric bilaterally. In particular, the vastus medialis obliquus of the quadriceps should be evaluated to determine if it appears normal or shows signs of atrophy.

The knee is then palpated and checked for pain, warmth, and effusion. Point tenderness should be sought, particularly at the patella, tibial tubercle, patellar tendon, quadriceps tendon, anterolateral and anteromedial joint line, medial joint line, and lateral joint line. Moving the patient’s knee through a short arc of motion helps identify the joint lines. Range of motion should be assessed by extending and flexing the knee as far as possible (normal range of motion: extension, zero degrees; flex- ion, 135 degrees).5

Patellofemoral Assessment

An evaluation for effusion should be conducted with the patient supine and the injured knee in extension. The suprapatellar pouch should be milked to determine whether an effusion is present.

Patellofemoral tracking is assessed by observing the patella for smooth motion while the patient contracts the quadriceps muscle. The presence of crepitus should be noted during palpation of the patella.

The quadriceps angle (Q angle) is determined by drawing one line from the anterior superior iliac spine through the center of the patella and a second line from the center of the patella through the tibial tuberosity (Figure 2).6 A Q angle greater than 15 degrees is a predisposing factor for patellar subluxation (i.e., if the Q angle is increased, forceful contraction of the quadriceps muscle can cause the patella to sublux laterally).

A patellar apprehension test is then performed. With fingers placed at the medial aspect of the patella, the physician attempts to sublux the patella laterally. If this maneuver reproduces the patient’s pain or a giving-way sensation, patellar subluxation is the likely cause of the patient’s symptoms.7 Both the superior and inferior patellar facets should be palpated, with the patella subluxed first medially and then laterally.


Cruciate Ligaments

Anterior Cruciate Ligament. For the anterior drawer test, the patient assumes a supine position with the injured knee flexed to 90 degrees. The physician fixes the patient’s foot in slight external rotation (by sitting on the foot) and then places thumbs at the tibial tubercle and fingers at the posterior calf. With the patient’s hamstring muscles relaxed, the physician pulls anteriorly and assesses anterior displacement of the tibia (anterior drawer sign).

The Lachman test is another means of assessing the integrity of the anterior cruciate ligament (Figure 3).7 The test is performed with the patient in a supine position and the injured knee flexed to 30 degrees. The physician stabilizes the distal femur with one hand, grasps the proximal tibia in the other hand, and then attempts to sublux the tibia anteriorly. Lack of a clear end point indicates a positive Lachman test.

Posterior Cruciate Ligament. For the posterior drawer test, the patient assumes a supine position with knees flexed to 90 degrees. While standing at the side of the examination table, the physician looks for posterior displacement of the tibia (posterior sag sign).7,8 Next, the physician fixes the patient’s foot in neutral rotation (by sitting on the foot), positions thumbs at the tibial tubercle, and places fingers at the posterior calf. The physician then pushes posteriorly and assesses for posterior displacement of the tibia.


Collateral Ligaments

Medial Collateral Ligament. The valgus stress test is performed with the patient’s leg slightly abducted. The physician places one hand at the lateral aspect of the knee joint and the other hand at the medial aspect of the distal tibia. Next, valgus stress is applied to the knee at both zero degrees (full extension) and 30 degrees of flexion (Figure 4)7. With the knee at zero degrees (i.e., in full extension), the posterior cruciate ligament and the articulation of the femoral condyles with the tibial plateau should stabilize the knee; with the knee at 30 degrees of flexion, application of valgus stress assesses the laxity or integrity of the medial collateral ligament.

Lateral Collateral Ligament. To perform the varus stress test, the physician places one hand at the medial aspect of the patient’s knee and the other hand at the lateral aspect of the distal fibula. Next, varus stress is applied to the knee, first at full extension (i.e., zero degrees), then with the knee flexed to 30 degrees (Figure 4).7 A firm end point indicates that the collateral ligament is intact, whereas a soft or absent end point indicates complete rupture (third-degree tear) of the ligament.


Patients with injury to the menisci usually demonstrate tenderness at the joint line. The McMurray test is performed with the patient lying supine9 (Figure 5). The test has been described variously in the literature, but the author suggests the following technique.

The physician grasps the patient’s heel with one hand and the knee with the other hand. The physician’s thumb is at the lateral joint line, and fingers are at the medial joint line. The physician then flexes the patient’s knee maximally. To test the lateral meniscus, the tibia is rotated internally, and the knee is extended from maximal flexion to about 90 degrees; added compression to the lateral meniscus can be produced by applying valgus stress across the knee joint while the knee is being extended. To test the medial meniscus, the tibia is rotated externally, and the knee is extended from maximal flexion to about 90 degrees; added compression to the medial meniscus can be produced by placing varus stress across the knee joint while the knee is degrees of flexion. A positive test produces a thud or a click, or causes pain in a reproducible portion of the range of motion.

Because most patients with knee pain have soft tissue injuries, plain-film radiographs generally are not indicated. The Ottawa knee rules are a useful guide for ordering radiographs of the knee10,11.

If radiographs are required, three views are usually sufficient: anteroposterior view, lateral view, and Merchant’s view (for the patellofemoral joint).7,12 Teenage patients who report chronic knee pain and recurrent knee effusion require a notch or tunnel view (posteroanterior view with the knee flexed to 40 to 50 degrees). This view is necessary to detect radiolucencies of the femoral condyles (most commonly the medial femoral condyle), which indicate the presence of osteochondritis dissecans.13

Radiographs should be closely inspected for signs of fracture, particularly involving the patella, tibial plateau, tibial spines, proximal fibula, and femoral condyles. If osteoarthritis is suspected, standing weight-bearing radiographs should be obtained.


Laboratory Studies

The presence of warmth, exquisite tenderness, painful effusion, and marked pain with even slight range of motion of the knee joint is consistent with septic arthritis or acute inflammatory arthropathy. In addition to obtaining a complete blood count with differential and an erythrocyte sedimentation rate (ESR), arthro- centesis should be performed. The joint fluid should be sent to a laboratory for a cell count with differential, glucose and protein measure- ments, bacterial culture and sensitivity, and polarized light microscopy for crystals.

Because a tense, painful, swollen knee may present an unclear clinical picture, arthrocentesis may be required to differentiate simple effusion from hemarthrosis or occult osteochondral fracture.4 A simple joint effusion produces clear, straw-colored transudative fluid, as in a knee sprain or chronic meniscal injury. Hemarthrosis is caused by a tear of the anterior cruciate ligament, a fracture or, less commonly, an acute tear of the outer portion of the meniscus. An osteochondral fracture causes hemarthrosis, with fat globules noted in the aspirate.

Rheumatoid arthritis may involve the knee joint. Hence, serum ESR and rheumatoid factor testing are indicated in selected patients.

The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.

In conclusion, knee pain is a common health issue which occurs due to a variety of injuries and/or conditions, such as sports injuries, automobile accidents, and arthritis, among other problems. Treatment of knee pain depends largely on the source of the symptoms. Therefore, it is essential for the individual to seek immediate medical attention to receive a diagnosis.

Chiropractic care is an alternative treatment option which focuses on the treatment of a variety of injuries and/or conditions associated with the musculoskeletal and nervous system. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

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Additional Topic Discussion: Relieving Knee Pain without Surgery

Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.


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EXTRA EXTRA | IMPORTANT TOPIC: El Paso, TX Chiropractor Recommended




1. Rosenblatt RA, Cherkin DC, Schneeweiss R, Hart LG. The content of ambulatory medical care in the United States. An interspecialty comparison. N Engl J Med 1983;309:892-7.

2. Tandeter HB, Shvartzman P, Stevens MA. Acute knee injuries: use of decision rules for selective radiograph ordering. Am Fam Physician 1999;60: 2599-608.

3. Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: part II. Differential diag- nosis. Am Fam Physician 2003;68:917-22

4. Bergfeld J, Ireland ML, Wojtys EM, Glaser V. Pin- pointing the cause of acute knee pain. Patient Care 1997;31(18):100-7.

5. Magee DJ. Knee. In: Orthopedic physical assessment. 4th ed. Philadelphia: Saunders, 2002:661-763.

6. Juhn MS. Patellofemoral pain syndrome: a review and guidelines for treatment. Am Fam Physician 1999;60:2012-22.

7. Smith BW, Green GA. Acute knee injuries: part I. History and physical examination. Am Fam Physi- cian 1995;51:615-21.

8. Walsh WM. Knee injuries. In: Mellion MB, Walsh WM, Shelton GL, eds. The team physician’s hand- book. 2d ed. St. Louis: Mosby, 1997:554-78.

9. McMurray TP. The semilunar cartilage. Br J Surg 1942;29:407-14.

10. Stiell IG, Wells GA, Hoag RH, Sivilotti ML, Cacciotti TF, Verbeek PR, et al. Implementation of the Ottawa knee rule for the use of radiography in acute knee injuries. JAMA 1997;278:2075-9.

11. Stiell IG, Greenberg GH, Wells GA, McKnight RD, Cwinn AA, Caciotti T, et al. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med 1995;26:405-13.

12. Sartoris DJ, Resnick D. Plain film radiography: rou- tine and specialized techniques and projections. In: Resnick D, ed. Diagnosis of bone and joint disor- ders. 3d ed. Philadelphia: Saunders:1-40.

13. Schenck RC Jr, Goodnight JM. Osteochondritis dis- secans. J Bone Joint Surg [Am] 1996;78:439-56.

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What is a Quadriceps Tendon Rupture?

What is a Quadriceps Tendon Rupture?

The tendons are powerful soft tissues which connect the muscles to the bones. One of these tendons, the quadriceps tendon, works together with the muscles found at the front of the thigh in order to straighten the leg. A quadriceps tendon rupture can affect an individual’s quality of life.

A quadriceps tendon rupture can be a debilitating injury and it usually requires rehabilitation and surgical interventions to restore knee function. These type of injuries are rare. Quadriceps tendon ruptures commonly occur among athletes who perform jumping or running sports.

Quadriceps Tendon Rupture Description

The four quadriceps muscles come together above the kneecap, or patella, to form the quadriceps tendon. The quadriceps tendon joins the quadriceps muscles into the patella. The patella is connected to the shinbone, or tibia, by the patellar tendon. Working collectively, the quadriceps muscles, the quadriceps tendon, and the patellar tendon, straighten the knee.

A quadriceps tendon rupture can be partial or complete. Many partial tears don’t completely disrupt the soft tissues. However, a full tear will divide the soft tissues into two parts. If the quadriceps tendon ruptures entirely, the muscle is no longer attached to the kneecap or patella. As a result, the knee is unable to straighten out when the quadriceps muscles contract.

Quadriceps Tendon Rupture Causes

A quadriceps tendon rupture frequently occurs due to an increased load on the leg where the foot is planted and the knee is somewhat flexed. By way of instance, when landing from an awkward jump, the power is too much for the soft tissues to bear, causing a partial or complete tear. Tears may also be due to falls, direct impacts to the knee, and lacerations or cuts.

A weakened quadriceps tendon is also more likely to rupture. Several factors may result in tendon weakness, including quadriceps tendinitis, the inflammation of the quadriceps tendon, called quadriceps tendinitis. Quadriceps tendinitis is one of the most common sports injuries in athletes who participate in sports or physicial activities which involve jumping.

Weakened soft tissues may also be brought on by diseases that interrupt blood flow to the knee or patella. Utilizing corticosteroids and some antibiotics have also been connected to weakness associated with quadriceps tendon ruptures. Immobilization for an extended period of time can also decrease strength in the quadriceps tendons. Finally, quadriceps tendon ruptures can occur due to dislocations and/or surgery.

Quadriceps Tendon Rupture Symptoms

A popping or tearing feeling is one of the most common symptoms associated with a quadriceps tendon rupture. Pain followed by swelling and inflammation of the knee might make the individual unable to straighten out their knee. Other symptoms of a quadriceps tendon rupture include:

  • An indentation at the top of the kneecap or patella of the affected site
  • Bruising
  • Tenderness
  • Cramping
  • Sagging or drooping of the kneecap or patella where the tendon tore
  • Difficulty walking because the knee is buckling or giving away



Quadriceps Tendon Rupture Evaluation

The healthcare professional will perform an evaluation to diagnose a quadriceps tendon rupture by first discussing the patient’s symptoms and medical history. After talking about the patient’s symptoms and medical history, the doctor will conduct a comprehensive evaluation of the knee.

To ascertain the precise cause of the patient’s symptoms, the healthcare professional will examine how well it is possible to stretch, or straighten, the knee. Although this area of the evaluation can be debilitating, it’s essential to diagnose a quadriceps tendon rupture.

To verify a quadriceps tendon rupture diagnosis, the doctor may order some imaging tests, like an x-ray or magnetic resonance imaging, or MRI, scan. The kneecap moves from place once the quadriceps tendon ruptures. This can be quite evident on a sideways x-ray perspective of the knee.

Complete tears may frequently be identified with x-rays alone. The MRI can reveal the quantity of tendon torn along with the positioning of the tear. From time to time, an MRI will also rule out another injury with similar symptoms. Diagnostic imaging is helpful in the evaluation of sports injuries.

Dr Jimenez White Coat

The quadriceps tendon is the large tendon found just above the kneecap, or patella, which allows us to straighten out our knee. While the quadriceps tendon is a strong, fibrous cord which can withstand tremendous amounts of force, sports injuries or other health issues may lead to a quadriceps tendon rupture. Quadriceps tendon ruptures are debilitating problems which can affect a patient’s quality of life.

Dr. Alex Jimenez D.C., C.C.S.T. Insight

Quadriceps Tendon Rupture Treatment

Non-Surgical Treatment

A majority of partial tears react well to non-surgical treatment approaches. The doctor may advise the patient to utilize a knee immobilizer or brace to allow the quadriceps tendon to heal. Crutches will help avoid placing weight onto the leg. A knee immobilizer or brace is used for 3 to 6 months.

Once the initial pain, swelling, and inflammation have decreased, alternative treatment options, such as chiropractic care and physical therapy, can be utilized. A doctor of chiropractic, or chiropractor, utilizes spinal adjustments and manual manipulations to carefully correct any spinal misalignments, or subluxations, which may be causing problems.

Furthermore, chiropractic care and physical therapy can provide lifestyle modifications, including physical activity and exercise programs to help speed up the recovery process. The patient may be recommended a variety of stretches and exercises to improve strength, flexibility and mobility. The healthcare professional will determine when it’s safe to return-to-play.

Surgical Treatment

Many individuals with complete tears require surgery to repair a quadriceps tendon rupture. Surgical interventions depend on the patient’s age, actions, and prior level of function. Surgery for quadriceps tendon ruptures involves re-attaching the tendon to the kneecap or patella. Surgery is carried out with regional spinal anesthetic or general anesthetic.

To reattach the tendon, sutures are put in the tendon and then threaded through drill holes at the kneecap. The stitches are attached in the base of the kneecap. The physician will tie the sutures to find the ideal tension in the kneecap or patella. This will also make sure that the place of the kneecap closely matches that of the uninjured patella or kneecap.

A knee immobilizer, brace or a long leg cast may be utilized following the surgery. The patient may be allowed to set weight on their leg by means of crutches. Stretches and exercises are added into a rehabilitation program by a chiropractor or physical therapist after a surgical intervention.

The precise timeline for chiropractic care and physical therapy following a surgery for those patients that require it will be individualized personally. The patient’s rehabilitation program will be contingent upon the kind of tear, their surgery, medical condition, along with other requirements.


The majority of patients can return to their original routines after recovering from a quadriceps tendon rupture. The individual’s return will be addressed very carefully by the healthcare professional. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

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Additional Topic Discussion: Relieving Knee Pain without Surgery

Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.




blog picture of cartoon paper boy


EXTRA EXTRA | IMPORTANT TOPIC: El Paso, TX Chiropractor Recommended

What is Knee Plica Syndrome?

What is Knee Plica Syndrome?

The knee is a made up of a variety of complex soft tissues. Enclosing the knee joint is a fold at its membrane known as the plica. The knee is encapsulated by a fluid-filled structure called the synovial membrane. Three of these capsules, known as the synovial plicae, develop around the knee joint throughout the fetal stage and are absorbed before birth.

However, during one research study in 2006, researchers found that 95 percent of patients undergoing arthroscopic surgery had remnants of their synovial plicae. Knee plica syndrome occurs when the plica becomes inflamed, generally due to sports injuries. This often takes place in the center of the kneecap, known as medial patellar plica syndrome.

What are the Symptoms of Knee Plica Syndrome?

The most common symptom of knee plica syndrome is knee pain, although a variety of health issues can also cause these symptoms. Knee pain associated with knee plica syndrome is generally: achy, instead of sharp or shooting; and worse when using stairs, squatting, or bending. Other symptoms of knee plica syndrome can also include the following: 

  • a catching or locking sensation on the knee while getting up from a chair after sitting for an extended period of time,
  • difficulty sitting for extended intervals,
  • a cracking or clicking noise when bending or stretching the knee,
  • a feeling that the knee is slowly giving out,
  • a sense of instability on slopes and stairs,
  • and may feel swollen plica when pushing on the knee cap.

What are the Causes of Knee Plica Syndrome?

Knee plica syndrome is commonly caused as a result of an excess of stress or pressure being placed on the knee or due to overuse. This can be brought on by physical activities and exercises which require the individual to bend and extend the knee like running, biking, or utilizing a stair-climbing machine. An automobile accident injury or a slip-and-fall accident can also cause knee plica syndrome.

Dr Jimenez White Coat

Knee plica syndrome, commonly referred to as medial patellar plica syndrome, is a health issue which occurs when the plica, a structure which surrounds the synovial capsule of the knee, becomes irritated and inflamed. Knee plica syndrome can occur due to sports injuries, automobile accident injuries, and slip-and-fall accidents, among other types of health issues. The symptoms of knee plica syndrome may commonly be mistaken for chondromalacia patella. Diagnostic imaging can help diagnose the problem to continue with treatment.

Dr. Alex Jimenez D.C., C.C.S.T. Insight

How is Knee Plica Syndrome Diagnosed?

In order to diagnose medial patellar plica syndrome, the healthcare professional will first perform a physical examination. They will use the evaluation to rule out any other potential causes of knee pain, such as a torn meniscus, tendonitis, and broken bones or fractures. Be sure to talk to your doctor about any physical activities you participate in along with any recent health issues. The healthcare professional might also utilize an X-ray or MRI to have a better look at your knee.



What is the Treatment for Knee Plica Syndrome? 

Most instances of medial patellar plica syndrome respond well to alternative treatment options, such as chiropractic care, physical therapy or even a physical activity or exercise plan at home. Chiropractic care uses spinal adjustments and manual manipulations to safely and effectively correct a variety of health issues associated with the musculoskeletal and nervous system. Moreover, chiropractic care and physical therapy can include a series of stretches and exercises to help restore strength, mobility, and flexibility to the hamstrings and quadriceps. These stretches and exercises are described below.

Quadriceps Strengthening

The medial plica is attached to the quadriceps, a major muscle on the thighs. An individual with weakened quadriceps has a higher chance of developing knee plica syndrome. You can strengthen your quadriceps by performing the stretches and exercises as follow:

  • quadriceps sets or muscle tightening
  • straight leg raises
  • leg presses
  • mini-squats
  • biking, swimming, walking, or use an elliptical machine.

Hamstring Stretching

The hamstrings are the muscles which extend down the back of the thighs, from the pelvis to the shin bone. These help flex the knee. Tight hamstrings place more stress and pressure on the front of the knee, or the plica. A chiropractor or physical therapist will guide the patient through numerous stretches and exercises which may help unwind the nerves. As soon as the patient learns these moves, they may perform them a few times each day to keep the muscles relaxed.

Corticosteroid Injections

Some healthcare professionals may provide corticosteroid injections for the knee if the pain and inflammation causes a restriction in function. Corticosteroid injections can help temporarily reduce painful symptoms, however, it’s essential for the patient to continue with treatment to heal knee plica syndrome. The painful symptoms may return when the corticosteroid burns off if not treated.


If chiropractic care, physical therapy, or the treatment described above does not help heal knee plica syndrome, a procedure known as arthroscopic resection may be needed. To perform this process, the doctor will insert a small camera, called an arthroscope, via a tiny cut at the side of the knee. Small surgical instruments are then inserted through a second small cut to take out the plica or correct its position.

After surgery, your doctor will consult with a chiropractor or physical therapist for a rehabilitation program. Recovering from surgery for knee plica syndrome is dependent upon many factors, including the patient’s overall health and wellness. The patient may recover within a few days in case the knee has been changed. Remember to wair a few weeks before returning to a routine levels of exercise and physical activity.

Living with Knee Plica Syndrome

Plica syndrome is generally easy to treat with chiropractic care, physical therapy, and other treatment approaches, as described above. Should you need surgery, the approach is minimally invasive and requires less recovery compared to a number of different types of knee surgery.

Talk to your healthcare professional to determine the best treatment choice for your knee plica syndrome. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

Curated by Dr. Alex Jimenez

Green Call Now Button H .png


Additional Topic Discussion: Relieving Knee Pain without Surgery

Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.


blog picture of cartoon paper boy


EXTRA EXTRA | IMPORTANT TOPIC: El Paso, TX Chiropractor Recommended