From Dr. Edzard Ernst’s classic 2000 article in the British Medical Journal:
“Those who believe that regulation is a substitute for evidence will find that even the most meticulous regulation of nonsense must still result in nonsense.”
This is often quoted, but rarely with the source cited or a link to the full article. It’s short, accessible and well worth a read. Here it is:
Iliotibial band syndrome (runner’s knee) is usually treated as if it were a tendinitis. In a recent post, I explained how two recent surgical studies (see Michels and Hariri) have produced strong evidence that “tendinitis” isn’t quite right: it’s not the IT band itself, but something under it. So … what? These are the possibilities as I see them:
Hint: all of these bullet points contain the word “bursa”! A bursa (plural bursae or bursas) is a peculiar bit of anatomy: a small sack of slimy (synovial) fluid, like raw egg white, which reduces friction between structures, such as between skin and bone, or between a bone and a tendon. The name comes from the Latin for purse.
Historically, many professionals also thought of iliotibial band syndrome as a bursitis. For a long time, that idea seemed to be doomed. For instance, the lack of a bursa under the IT band at the knee was reported by three other groups of researchers focussing on this issue:
Yet Hariri et al operated on what they called “bursae,” provided nice pictures of the inflamed bursae that they removed from people’s knees, and got good results. So what is going on here? Clearly not all of this can be quite right! Is there a bursa in there or not? What gives?
This is simply a nice little unsolved mystery, a good orthopedic puzzle.
Personally, I rather like this notion of a pathological bursa that grows in response to stresses, like a callus. I actually had no idea that any such thing existed until I read about it (in Hariri) … but the moment I read about it, it made perfect sense. Why wouldn’t the body do exactly such a thing? Clearly body parts toughen up in all kinds of ways in response to stress: why not internally?
On the other hand, if the point of forming a callus is to cope with stress, it doesn’t seem to be doing a very good job in people with iliotibial band syndrome! Perhaps there are simply limits? A pseudo-bursa can only do so much, and then it gets irritated? Perhaps without it people would get even worse pain, and sooner?
Many questions! Few answers! But it’s all interesting. (To anatomy geeks. And people with knee pain.)
In 2009, Belgian surgeons got great results with 35 cases of iliotibial band syndrome not by “loosening” the IT band with the conventional surgical approach, but by removing irritated tissue from under the IT band (see Michels). Their research was a milestone in the science of runner’s knee pain. My iliotibial band syndrome tutorial now includes detailed information about this procedure, as well as a list of a few surgeons around the world who offer it.
It was an important study, but still just one study. I was eager to see another.
Another was published a few months later. An American group took a slightly different approach, but also operated without cutting the IT band, and also removed irritated tissue from under it (see Hariri). Like the Belgians, they got excellent clinical results, once again validating the concept that ITBS is not a tendinitis — the IT band itself is not the irritated anatomy.
Two studies still isn’t proof, but it’s getting there. And these surgical experiments were inspired by quite a bit of prior evidence, especially Fairclough et al’s important paper in 2007 (“Is iliotibial band syndrome really a friction syndrome?”). This is shaping up to be a tidy little triumph of scientific medicine, of careful and expert exploration for the real “root cause” of a painful problem.
In contrast, the effort to identify a biomechanical risk factor for ITBS — hopefully a treatable one — has just bombed. After decades of perpetually underwhelming research and dozens of pet theories, we still can’t predict who will get this condition, and there is still no clearly effective manual therapy for it.
Therapists really need to stop thinking in terms of “what’s crooked or out of whack” to explain and treat iliotibial band syndrome.
Ask any judge or lawyer: people are not reliable. What people report as “witnessed” is rarely accurate.
In health care, half of all recovery times from illness and injury are above average — and many of those people will say nice things about whatever therapy they were spending money on at the time. But their stories are only half the story.
To our great peril, the limitations of anecdotal evidence are not understood by most health professionals. It is still routine to find health professionals giving anecdotes vastly more clinical weight than they deserve, as though hearing a handful of positive case reports is really all they need hear to be convinced. There is an epidemic failure to respect the well-known fallibility of human perception and testimony, so obvious to us in so many other ways.
A personal post today, which will also explain the silence on this blog lately:
After three weeks of post-surgical rehab at Aek Udon International Hospital in northern Thailand (read what happened), Kim and I flew home from Thailand to Vancouver on March 1 and 2, with the help of the medical transport company Fox Flight Air Ambulance and their excellent nurse escorts. Kim did remarkably well, and got through the trip with almost no pain — far better than we dared hope. And it was a fascinating experience to:
It was the medical transport service that was what really made the trip interesting. The basic problem of medical transport is that airlines don’t really want to take injured passengers. From the airline’s perspective, Kim was a legal disaster just waiting to happen. People like to sue airlines. Pilots have the legal right to refuse any passenger, and they do. We heard horror stories about this before we left.
It’s the job of the medical escort company to deal with all of that. Safety is job one, of course, but our nurses were also experts in cutting through red tape. For instance, we all made the decision together that we avoid the use of a stretcher, because Kim was doing so well, and because seeing a stretcher really makes an airline ask a lot more questions …
We faced a (minor) crisis when ticket agents spotted Kim being wheeled into the Bangkok Airport on a stretcher. The ambulance attendant thought he was being helpful bringing her all the way in to meet us, but our nurse escort muttered with mild alarm, “I told him not to bring her in here yet! I didn’t want them to see her on a stretcher!”
Sure enough, a supervisor hustled out when he saw the stretcher, and our escort had to play it cool and offer reassurances, even getting Kim to demonstrate her ability to walk. In this case, the supervisor was easily reassured, but it all depends on the person you’re dealing with. Sometimes, apparently, the nurses really have to get clever or pull rank — if necessary, they can even phone up some pretty serious people to tell lowly supervisors to back off.
It was a bit nerve-wracking to watch at time, because time and safety were interconnected for us. But they got us through all the hurdles, and Kim turned out to be surprisingly capable.
So Kim and her escort flew business class on Cathay Pacific Airways — highly recommended — and got utterly spoiled by amazing customer service and assorted luxuries. Some of that service extended to me, as I was a special guest in their section, permitted to visit my injured wife. During my drop-ins, I was offered things like hot towels and wine in an actual glass instead of a plastic cup. Ooh la la! Kim’s nurse even swapped seats with me for an hour, and I got to nap in his fully-reclining booth seat.
However, for 90% of the trans-Pacific flight, I was still stuck in economy class on a particularly crowded and baby-infested flight — as unpleasant as it usually is.
I did luck out a little though: two people were removed from the plane for security reasons at the last second (sucked to be them) … and they were in my row, so I suddenly got elbow room. A little elbow room makes a big difference on a 12-hour flight!
Somewhere in the neighbourhood of $30,000.
So buy travel insurance! And if you’re ever stuck abroad due to illness or injury, you will probably need a medical transport service to get you home. And ask your insurer to work with Fox Flight Air Ambulance — they were truly amazing. Even if you’re stuck without insurance, still contact them — they have the skills to get you home as safely as possible, and maybe for $30,000 instead of $50,000!
Well, this was probably inevitable.
Last summer a reader asked me what I think of platelet-rich plasma (PRP) injections — the injection of a concentrated preparation of your own blood into irritated tissue, usually a tendinitis or similar condition like iliotibial band syndrome or plantar fasciitis — to stimulate healing. I replied quite optimistically at the time:
Incredibly, I have no strong objection to PRP. This is rare! I am a grump and not easily impressed. The huge majority of therapies I get asked about strike me as mostly pointless shots in the dark. By contrast, PRP injections seem like they have a reasonable rationale, there’s a bunch of promising evidence, and they are quite unlikely to have any significant risks. Wow. Cool.
Of course, I would caution you against singing its praises: there’s a huge gap between “promising” and “proven.” If it works for you, great! But don’t promote it as a treatment that “works” — one experience means nothing. For all we know, future research will show significant problems and limitations. This is precisely what has happened with countless other therapies.
And that is precisely what just happened to PRP, only a few months later. Yesterday, the New York Times reported bad science news for platelet-rich plasma injection, and I am now once again just as unimpressed by PRP as I am by most other too-good-to-be-true treatments:
Now, though, the first rigorous study asking whether the platelet injections actually work finds they are no more effective than saltwater.
So another treatment bites the dust. I don’t want to completely dismiss a treatment like PRP just because one good study was clearly negative, but the results immediately and seriously afflict PRP with the how-good-can-it-possibly-be problem — how good can it be if it fails the best testing so far? Initially promising in many ways, PRP will now undoubtedly now be mired in years of controversy. Wait and see, check the evidence in five years: it will be a mess of contradictions and no clear answers. PRP will probably die a slow death, only beaten into submission over many years by a growing pile of underwhelming evidence, even as its proponents continue to overconfidently sell the service.
a webpage on ScienceBasedMedicine.org. a webpage on New York Times.
Dr. Harriet Hall, the SkepDoc, recently criticized The Graston Technique® in some detail. At the same time, I was responding to a reader request for more information about Graston for plantar fasciitis (“tendinitis” of the arch of the foot), a common treatment offering for that condition. It’s also commonly prescribed for iliotibial band syndrome (runner’s knee), another condition I have written a great deal about. I started to delve.
Graston Technique is an expensive and painful massage technique that uses savage-looking steel tools to apply achieve intense, scraping pressures that supposedly cure by breaking up scar tissue and fascial restrictions. The official website makes the deliciously silly claim that the expensive tools “resonate like a tuning fork,” guiding practitioners like dowsing rods. Really? Wow. How could I not write about this? As good as Dr. Hall’s analysis is, I just had to have one of my own. The bottom line: I can hardly imagine a dodgier treatment. Read all about it:
Steroid (cortisone) injections and iontophoresis (injection without a needle, using a small electric charge to drive a drug through the skin) are routinely prescribed by physicians for plantar fasciitis, and many other inflammatory conditions. They are often regarded as something of a magic bullet for inflammation, and not without good reason: cortisone has powerful anti-inflammatory properties, and it certainly has the potential to dramatically reduce pain, especially in the short term.
Steroid injections are certainly not an unreasonable treatment option for plantar fasciitis, especially for a stubborn case. And yet, as with many other popular therapies, there is shockingly little science to back it up, and there are also some concerns.
Only two proper scientific tests of steroid injections have ever been done, in 1997 and 1999. Both found the same results: steroid injections were helpful in the short term only.
What about the science since then? A decade has gone by — surely there’s more and better research by now? Unfortunately, no: we’re still waiting for that. All the studies done in the last ten years, about one a year — Yucel, Tsai, Frater are three recent examples — have not been serious attempts to show the efficacy of steroid injections, but instead have focussed on peripheral issues like what kind of injection-guiding technology works best. It’s all worthwhile stuff, but fairly useless in terms of finding out if steroid injections “really work.” They offer something like “circumstantial evidence” in a courtroom — it’s suggestive, but it’s not proof.
So, although there’s little doubt that they really do relieve at least some pain in the short term, it’s still a wide open question about lasting benefit. Can steroid injections alone solve plantar fasciitis? Nobody knows, but it seems unlikely. A comprehensive The Cochrane Collaboration review of the science in 2003 discouragingly concluded:
Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree.
And there’s danger! No injection of anything can be completely safe, and cortisone in particular — especially in this location — has the potential to do as much harm as good. Cortisone’s best-known problem is that it “eats” connective tissue with overuse, which can be bad news for any anatomy, but especially an anatomical structure like the plantar fascia, which is a high-performance piece of tissue, and already strained to its limit by definition in every case of plantar fasciitis, especially the bad cases. Plantar fascia rupture (yikes!) is one of the risks of steroid injection. Tatli et al describe a few other possible complications:
Your odds of avoiding these complications are good, but the stakes are high. They probably won’t happen, but it’s really bad news if they do. They can make a bad case of plantar fasciitis even worse, even permanent: “Fascial rupture and fat pad atrophy are especially serious complications as they can lead to intractable complications” (Tatli). If you thought you had a stubborn case of plantar fasciitis now, wait until you’re in that boat.
Given the known and plausible risks, you should never consider a cortisone injection until the virtually risk-free options discussed so far have already been tried. But let’s keep this in perspective: although the dangers are certainly real, they are not great, and they are probably well worth risking, especially if you’re already a mess and have nothing to lose.
Steroid injection in moderation may be a great way to reduce the pain in the short term, while other therapies take care of the longer term. My recommendations:
This blog will now go into stealth mode for a few (holi)days.
I won’t stop writing — never that! — but I will take a break from posting until 2010. This gives me a chance to focus on behind-the-scenes writing and research projects. For example, I posted recently about therapeutic ultrasound, but I still need to go back and finish the official, final ultrasound article, and then integrate all of that information into each of several tutorials — about 10 hours of work, at least. So there may not be anything new here for several days, but I’ll still be up at 6am every morning tappety-tap-tapping away — just with some Bailey’s in my coffee. 
Merry holidays, everyone, and thank you to all of my readers and customers. See you here in January.
Are elliptical machines okay for knees with patellofemoral pain syndrome?
My patellofemoral pain syndrome tutorial has been out “in the wild” for a few years now, and questions from readers have been slowing down to a trickle (because the tutorial now has answers to just about anything else you could possibly want to know about that condition). But a question about elliptical machines kept coming, one every couple months, until I finally got around to answering it. This comes up because I make an extremely detailed argument that patients with anterior knee pain need to be quite creative and determined in attempting to identify and eliminate knee stresses, and people often wonder if an elliptical machine is a way to get some exercise without pissing off their burning knees.
The short answer is no: don’t use an elliptical machine if you’re trying to avoid knee stresses. But …
Elliptical machines eliminate the jarring of running, but still involve knee loading — of course. As a risk factor for PFPS they seem to be in a strange gray area: quite a few people over the years have reported to me that they are actually okay with elliptical training (even when they have trouble with many other activities).
Elliptical machines are clearly not as hard on the knee as running for most people, and yet they’re certainly much harder on the knee than some other activities (knitting, say). Only your experience can guide you: if you have no symptoms after elliptical work you can assume that it is probably safe, but please remain alert. The more determined you are to eliminate all risk factors, the more you should consider eliminating elliptical machines one even if isn’t obviously doing harm.