Ep 280: Should I worry about noisy joints? With Dr Danilo De Oliveira Silva

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Because one of the biggest frustrations of patients, when they ask about that sign, is that people say, "Oh, well, I'm not really sure." The most common complaint is that, "Oh, I talk to my clinician and I get nothing." And then they go to the internet, they get nothing. Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Clara Dern, the editor-in-chief of the Journal of Orthopedic and Sports Physical Therapy. It's great to have you listening today. Hipcrepidus. What does it mean? Is it an issue? And how do we talk about it with our patients? Today, we're going to dive deep into this with none other than Dr. Danilo, Dei Olivera Silva. Dr. Danilo is an associate professor and NHMRC Emerging Leadership Fellow at Latrobe University in Melbourne, Australia. Dr. Danilo is not only a physiotherapist, but also a PhD in his research focuses on biomechanics, psychological and pain characteristics of people with musculoskeletal conditions across the lifespan. Today, we will be discussing his recent publication in JOSPT Open. Entitled, self-reported hipcrepidus is prevalent in football players with hip and groin pain, but is it associated with early hip osteoarthritis structural features? My name is Dan Chapman, owner of Summit Physical Therapy and Performance in Baltimore, Maryland. I'm Marquis Santa Rice. I'm a doctor of physical therapy in Baltimore, Maryland at Summit Physical Therapy and Performance. Dr. Danilo, thank you so much for taking the time to join us. It's my pleasure. Thanks for having me. So let's just jump into it. Can you give our listeners a little bit of background into what inspired this study and what you were expecting when you were really first getting into it? The story is really interesting and how it all started. It actually started with kneecrepidus. I was one day in my lab doing my KHD back in Brazil and my main area of research is Patelofemro pain. I was reading a paper about Patelofemro pain from Claire Robertson from the UK and she did a qualitative study in kneecrepidus. I was just like reading all the quotes and everything about kneecrepidus. One quote really stood out to me. One of the participants of the study said "I loved doing yoga but then I had to stop because my joint was too loud and people were making fun of me." Like if you really reflect on that, that is huge. Someone stopped doing the activity that they love. They were being physically active going out doing things because of the noise in their joints. We should do something about it. There is something there and then I started a side hustle, a line of research looking at kneecrepidus and I've done multiple studies about knee crepidus. Going to the gym and talk to people, they said "Oh, my hip also clicks when I do some lunges, some exercises." Then I said "Oh, maybe there's something on the hip as well. People could change the way they do things about the hip." Then I had a PhD student just starting with me for Nanda Ciri Gally and I said to her, "What about we explore and dive deep into this hip crapses world to try to understand that a little bit better." Then I'm lucky enough to work at Lathrop University Melbourne which is in a research center led by Kay Crowdley and she had a big cohort here with football players with FAI syndrome. Then we had access to these very large database to explore and answer some research questions. Then we started from there but that's what inspired this study. As somebody that treats a wide variety of adults over the age of 50, I'm very much looking forward to hearing what you have to say about crapidus because we get those questions all the time every day. I am curious, what were your expectations as you were delving into this research? What did you think was going to come about? Look, a bit inspired by what we found in the knee which was pretty much the joint in young people at least. They make some noise but they don't mean much in terms of relationship with symptoms, relationship with structure in young people. There's no much correlation, no other people is a bit different but I thought we wouldn't find many associations regarding the heap but if we take a step back and try to understand crapses a little bit because that's the problem of crapses. Many clinicians say that to me, I don't know what that means and patients as well. I think we don't know much about the different types of crapses as well because there are people that click, there are people that make the grinding sound so it's all different. For this study in particular, we are looking to self-reported crapses so people that say, "Oh, my heap joint clicks." So we are going from there. It's a self-reported. In the knee, we can put our hand there and feel it but in the hip, we can't because it's such a deep joint. So we rely on self-reported. So from this study, we are assuming that all crapses are the same and when we start discussing more about that, I will try to prove to you that it's not with a lot of evidence but we can we can chat and make some assumptions here. My hypothesis was I think heap crapses won't have any relationship with anything in the hip. I started like that but then we did find a few things. Hip crapses, knee crapses, it's definitely something that we hear very often from our patients and I don't know if it's the association with, "Hey, my car makes this noise and there must be something wrong with it." And it's like my hip is making this noise, there must be something wrong with it too. So it's definitely something that people come to us very often and they have questions and concerns with this and it can even create fear. In this study, can you walk us through a little bit of what you guys ended up finding and with any results that kind of stood out to you or perhaps challenged what you expected when you were going into the study? So this was the first study of Fernandez PhD. So we needed to start somewhere and we had to ask the first question, "Is heap crapses common?" That was the first question and our cohort was footballer. So we had the symptomatic group, 178 participants and the healthy control group, asymptomatic people, is some football players, 66 people. And what we found was that crapses was five times more common in people with symptoms. That doesn't tell a lot but it is an important information. So this clinical sign is more common in people that have hate pain. And then we said, "Let's look for some things to explain from where that noise or sensation is coming from." And the obvious thing you think about anatomy, you think about the structure of the joint. So that was where we went the first. All these cohorts, they had x-rays and MRIs. So we had to explore the association between the presence of creptus and also the severity of creptus. How severe those noise and sensations are, again, also reported. What we found was no association with x-ray variables if we think about like alpha, angle, lateral center, edge, angle. So no association with that. But then MRI is a bit more sensitive to show those early signs of osteoarthritis. So we look to cartilage defects, we look to live rotares and explore things in a different way. Like the presence of cartilage defects. The worst part of cartilage defects. And the number of subur regions affected by those defects as well. So we explored the joint a little bit. And what we found there was that creptus was in association with labor authors whatsoever in any variable. But there was an association between the presence of creptus with the number of cartilage subur regions affected. And what that tells me, if we make an analogy, let's say you're driving your car in a road, and that road, it's very inconsistent that a lot of holes in in there in that road. So it's very bumpy. That's associated with creptus, the bumpiness, the number of holes in that road. But if there's only one big hole in there, and your archive just goes through, it's not associated. So if you have one sub-region really bad, that's not associated with the presence of creptus. But if you have many, even with the small defects, because then you create that friction environment, that is just, and that's associated, but we didn't find the association with the severity of creptus. But then we said, okay, this is cross-sectional. I'm moment in time, a photography there. Let's look at how it is associated with how the structure progresses over time. So we got the MRI after two years in these same food bowlers, and we explored the association, and we didn't find an association anymore, but there is a catch in there, and without going to dipping stats and things, we didn't find an association with the number of sub-regions, with the change in number of sub-regions. But when we looked to the number, the strength of the association that we found in that cross-section, in that photography analysis, it was the same that we found with the change, but it wasn't significant, because we had less people in the follow-up. We lost a few on the way, so our analysis was not that powerful to detect the significant association, but the association is pretty much the same, the one that is with the number of sub-regions, and with the change in cartilage effects, but it's not a strong association. So we need to take those findings with a grain of salt. - If I'm understanding you correctly, it seems like if you're an athlete, you have hip pain. We're more likely to have hip creptis, but that is not essentially correlated to degeneration or defects in the joint, or in some of the surrounding capsule, laborum, but it is associated with the number of regions affected for the sub-conjule, regions affected. - Yep. - How should clinicians kind of reconcile some of those differences? - Yeah, we have to have pain. We're likely to have more hip creptis, but it maybe is not associated with any long term or at least some kind of sub-short term changes over the next couple of years. How should clinicians kind of reconcile that? - If we stick to the paper, if we don't go any broader than the paper itself, the main take-home message here is that, okay, creptis is common, but it's not explained or it's not too much associated with the structure in the joint. Even though we've found some associations, they're not that strong. So someone with creptis would be two times more likely to have this association with the number of cartilage sub-origins, which is not a big association. So the information for the patients here is, hey, you are all right, there are some noises, there are some sensations in there, but it doesn't mean your joint is worse than someone that doesn't have those sensations. I think that's the take-home message if we go by the paper itself. But we need to go a bit broader than that and we need to consider, again, that we are asking creptis in a self-reported way. We are not doing a deeper clinical exam. I'm saying that because we did a qualitative study in Fernandez PhD and we went to those athletes with hip creptis and asked them like, how do you feel, what do you think you have it? And we explored everything about their knowledge beliefs and how they perceived themselves with that clinical sign. And we found two clear distinct subgroups. One, with people that had some clicking in their hip and a tightness association with that clicking and another group that they had paying in their hip associated with that grinding sensation. So all of them, they would have clicked. Yes, I do have noise or clicks or a creptis sensation. So we got those two big subgroups and we launched them together in this paper that we are discussing today. And for me, there are completely different. One has like this bad experience in sensation with grinding and paying. The other one just clicks. I changed the way I moved here and there and I fixed this clicking. But the others, they struggle and they consider surgery because it's so annoying. So it's a bit more complex than a blank state. It doesn't matter. And do we have any further information on those subgroups in terms of like those who reported painful grinding and what their hip looked like under imaging versus those who had maybe like an inconvenient click but no real symptoms related with it? That's an amazing question and no. We don't have any information because the participants from that qualitative study, they are not the same participants as this study here that we are discussing today. And it was just a qualitative study. We didn't do an MRI on them. But that's my next research question. Like we need to explore the different types of creptis because some of them, they may matter. They may be associated with symptoms. I'm going to be on the lookout for that paper because we do have those different subgroups present in the clinic quite often. The person who says, yeah, I can squat down and pick something up and these are really loud. And the follow question from us is obviously, hey, do you have pain with that sound, right? And the answer is no. And then you also have that other subgroup that come into the clinic and they're like, yeah, ow, every time I hear or feel that grinding, that's what hurts, right? So I'm excited to see that come out. How would you say that this paper should really influence the conversations that we have about joint creptis with our patients? - I think for now, it's just having a information to discuss with them because one of the biggest frustrations of patients when they ask about that sign is that people say, oh, well, I'm not really sure. The most common complaint is that, oh, I talk to my clinician and I get nothing. And then they go to the internet, they get nothing. We did a study on that, the information is bad. Well, what is out there talking? So now we have something to start the conversation. Look, they have done this study more than 200 participants. So you can really trust that data. It seems there's no clear association with how your joint actually is. So let's try to keep herself active. Let's focus on on your symptoms and getting yourself out there and doing exercise. Don't worry too much about these at the moment. So I think that paper helps with that helps with the information and if there was a very clear big association, we would have seen in this data to explore it a bit further. So it's nothing clear. It doesn't mean if you have creptis your joint is terrible. So we can start the conversation with that. It's a powerful tool to discuss with patients. Yeah, I think it is extremely powerful. It's especially to just be able to resolve people's worries and to be able to resolve people's fears because I know that that's a big part about this. We even kind of mentioned that, hey, we have pain somewhere. You're likely going to be more vigilant to maybe some of the sounds that we kind of hear. So being able to give them a little bit of ease is certainly very, very helpful. From a clinical perspective, how should these findings kind of change the way that we as physical therapists, that's our trainers, anyone who is evaluating someone who has hip creptis, how should this change how we evaluate and manage them and how does this change the examination process and how we kind of lead or guide an athlete through their plan of care? I think creptis is not something that we think about straight away when we are assessing a patient. So I think this paper also shows, hey, it's very common. So maybe we should assess that for the hip. We don't have a specific clinical test to assess it, but we could even start making the question, hey, does there make any noise in sound when we do some type of exercise? Do you do something about it? Just to understand where they are coming from and if that happens. So I would say it changes by saying that we should perhaps consider and asking the questions should the patient including that as part of our assessment. And when I say assessment is not like perhaps firmly assessing, but part of the conversation because that creates an opportunity for you to educate and reassure them about that. So I think that's a big way to change it. Consider it when it's not something that's really considered in the heat. I would say in my past, I've kind of let the patient bring that up to me if it was something that was bothering them, but after reading your paper, it's something that I'm gonna be more proactive in saying, hey, does your hip make noise? Oh, it does. How does that make you feel? What are your thoughts on that and kind of bring that conversation up front so that we can talk about it and make sure that I'm not avoiding or not having a conversation that could actually be really freeing or helpful for the patient. I've found this paper very, very valuable, especially when it comes to the patient education aspect which is such a crucial part of our evaluation and the whole plan of care all the way through it. Is there anything that we haven't covered that you really want to make sure our listeners take a while. way. We covered the paper really well. It's just that this is one piece of study we did more to understand Crafters, you know, our broader way that that's why we discussed more studies. And it was funny that you mentioned I will bring that up because if you don't, the internet will, a family member will, a friend will, and maybe not in a nice way. They will make joke of them and they will feel bad about it because others perception maybe doesn't bother them. But others will say, hey, like, you are such a node person with these crappy joints. I spoke with my thesis, it doesn't matter. It doesn't mean I have crappy joints. So then it becomes like more light. Like you said, it's like not avoid the conversation, just go and explain it about it. I think we should make it a positive thing that some people are just more musical than others. Dr. Denelo, thank you so much for all of the work that you and your team have done on this paper. Thank you for your time. Big thanks for the opportunity to discuss. I love your work guys. I'm a listener of the podcast. So thanks a lot for for bringing fun to the boring scientific articles. And thank you. And we will absolutely be having you back if you dive further into those subgroups. We are, I know our listeners are going to be very, very excited to learn more about this line of research. So we're looking forward to having you back in the future. Sounds great. Thank you. We want to thank Dr. Denelo de Oliver Silver one last time all the way over in Australia. I do believe it was beyond 11 p.m. his time when we finished recording. So thank you so much for all the time and effort you put into this paper and for staying up late to share it with all of us here on the show. As always, we want to thank you for listening to JOSPT Insights. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights. On Apple podcasts, Spotify, TuneIn, Stitcher, Google or your favourite podcast app. If you like JOSPT Insights, help others find us. Tell your friends and colleagues and read and review us. To keep up to date with all the latest JOSPT content, be sure to follow us on Twitter. We're @JOSPT and Facebook. We're JOSPT official. Talk with you next time.