Pain perception

Some people are stoic and some aren't. … Maybe there's a plausible biological reason for that difference.
---Dr. Geoffrey Woods, Medical geneticist, Cambridge University

My patient's face was all pinchy with pain, an expression not generally seen in a 20-something year old lady. She'd visited Walmart the previous day (an outing that always makes me pinchy with impatience as my husband meanders through every last aisle). While there, she bent over to examine some wonderful find and skewered her forehead on a metal hook.

"Ew," you're thinking, which is what I would've thought if there had been a ragged tear in her face, or any kind of mark whatsoever. Her forehead, however, was completely smooth and unblemished.

"So," I said, "where did it snag you?" And I touched the indicated spot, sending her recoiling in pain, pinchier than ever. The area wasn't red, abraded, swollen, or bruised. I told her that while I appreciated she was in a lot of pain, my examination indicated no serious injury. I then assured her that her pain should diminish greatly in the following days.

As usual, when confronted with pain reports that seem to far outstrip apparent injury, I wished I could walk a mile in her forehead. What was she really feeling in there? Real pain, real drama, a need for sympathy, worried sick, or what?

Dr. Woods and company also wondered why humans demonstrate such a wide spectrum of pain perception. They already knew from previous research that three rare mutations in the SCN9A gene are a serious problem insofar as such genetic changes can cause persons to be either too sensitive or completely oblivious to painful stimuli. In the first case, the faulty SCN9A gene allows sodium ions to flood through channels in the surface membranes of cells in the central nervous system. As a result, these neurons painfully overfire in response to minor daily occurrences such as bumping a shoulder against a wall when taking a corner too close. At the opposite extreme, SCN9A gone haywire in a different way prevents the perception of pain altogether. Affected persons, consequently, receive no signals say from a fracture or sprain and, therefore, have no cue to stop moving and get off the injured joint.

The Cambridge team went looking for subtle, more common mutations in the SCN9A gene, namely substitutions of a single nucleic protein (SNP) in the gene's sequence(1). They studied a group of subjects with osteoarthritis of comparable severity to see if these SNP variations correlated with differing levels of pain perception. One variation present in a small subset of the group was indeed associated with the highest pain perception in those who carried it. The scientists then looked in other people with other common pain syndromes such as sciatica and lumbar disk disease, again finding that "the statistical link between having the rare SNP and feeling more pain was impressively strong." In other words, those persons with lower pain thresholds were significantly more likely to have this particular SNP variant.

The researchers found that just under 20% of their subjects carried one copy of this particular SCN9A mutation, but only 2-3% had two defective copies, and these were the people most likely to react strongly to their painful conditions. Further testing suggested that this mutation renders them incapable of squeezing their sodium channels shut so wave after wave of pain news just keeps rolling in.

Obviously, this genetic test is not available for clinical use, and there's nothing to be done about it anyway. Those of us in the medical business and everyone involved in the sympathy business can now appreciate, however, that some persons are hard-wired for more pain than others; for such persons, that 'stiff upper lip' advice may be harder to follow. And my hapless Walmart shopper was back two days later, her forehead no longer tender but her head now clamped in the vise of a secondary tension type headache brought on by scrunching her brow over the original hooking.
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1) Woods, GC, et al. "Pain perception is altered by a nucleotide polymorphism in SCN9A," Proceedings of the National Academy of Sciences.

Occipital neuralgia and Lyrica

Maureen periodically flinched while we talked as searing pain shot up the back of her head. Short but severe, these jolts of pain were diagnostic of neuralgia, a condition wherein a single nerve-- the greater occipital in this case-- seizes with pain. As a result, my patient was experiencing show-stopping discomfort from the base of her skull over the back of her head, sometimes on the left and other times on the right.

She spent her days hunched, like so many of us, over a computer and desk. On standing, she carried her head forward and her shoulders rounded reflecting the anterior thrust of her daily activities. All this was aggravated by breasts so large that her bra straps had dug permanent grooves in the top of her shoulders.

No easy fix for Maureen. I assumed that she, like many people, would not embrace the idea of medication, particularly over the long haul. I told her my plan--a short term fix to improve things quickly with a medication called Lyrica coupled with a larger plan to improve her posture, strengthen her supporting abdominal and back muscles, and perhaps consideration of breast reduction surgery.

Lyrica (pregabalin) is indicated for the treatment of seizures, diabetic neuropathy, nerve pain following seizures, and was recently approved for the treatment of fibromyalgia. Its use for occipital neuralgia, therefore, is 'off-label' but experience confirms that it soothes hypersensitive nerves no matter their location. Unfortunately, it's not without side effects, causing sedation, dizziness, and dysequilibrium, but its analgesic benefits can far outweigh these problems in patients whose daily lives are completely turned upside down by pain.

Maureen headed out with samples plus referrals to a physical therapist and a plastic surgeon and a written copy of the plan. Here's the phone message I received the next day:

Patient doesn't want to take Lyrica over a long period of time, was looking for a quicker working solution to pain. Advise.

Argh. Message back to patient:

Lyrica is a quicker working solution. Physical therapy, posture work, and possible surgery is the longer term answer.

The next message from Maureen sent the following day:

Pain free for the first time in weeks!

These glasses have got to go!

I've just returned from a round trip drive to the East coast. Don't ask why, just know that the last time I did that journey, I was 19, and it's quite a different matter to sit in a car that long that far nearly 4 decades later.

We were equipped with snacks, books on tape, and my favorite pair of sunglasses. When I tried them on at the sporting goods store, I was impressed with their style and comfort. I wore them for six months before I noticed that they had skulls embossed on the ear pieces--perhaps some sort of extreme sports insignia? Actually my son brought the look to my attention.

Well I can live with the skull thing, but I discovered during hours of driving into the late afternoon Kansas sun, these shades simply don't fit. The beskulled left ear piece digs painfully into my very own skull just above and behind my ear. So what misery to pick--squinting into the sun (wrinkles! cataracts! an inability to see the road!) or incessant fiddling with the way glasses meet head?

On top of that, my left shoulder began hurting terribly. I'm picturing my aging, degenerating neck sinking into my torso, pinching a nerve on its way to the bucket seat, and I add massaging the shoulder to sunglass fussing to my general in-car fidgets. After ripping the stupid things off when the sun went behind a cloud, I discovered that my shoulder pain resolved within minutes.

I've always told my patients that muscle tension in the neck can easily cause a headache. Apparently pounding plastic into the temporalis muscle on the side of the head can reverse the pain flow down the neck to the shoulder.

Flector patch

Looking for the anti-inflammatory relief of Advil or Aleve without the stomach distress? If you're injured and hurting, check out Flector Patch for a brand new alternative in pain control

Voltaren Gel

This is a great idea, but the logistics are awkward.

Voltaren is an non-steroidal anti-inflammatory (NSAID) pain reliever, and a rather effective one at that. It is available in pill form as the generic diclofenac. The downside of any NSAID is its adverse effect on the stomach and intestinal tract, causing pain, gastritis, ulcers, and diarrhea. In addition, the drugs can increase the risk of stroke and heart attack, and, in susceptible individuals, can decrease blood flow to the kidneys thus increasing the risk over years of use of decreased kidney function. Specific to Voltaren is the risk of "severe hepatic reactions, including liver necrosis, jaundice, fulminant hepatitis with and without jaundice, and liver failure" per www.voltarengel.com. Well shoot, who wants any of that?

We do, however, want arthritis pain relief, and Voltaren does that well. So Novartis minced it up and put it in an alcohol-based gel so that we could smear it right on our throbbing joints. Once absorbed through the skin, it reduces arthritic hand pain 46% after 6 weeks of use, and pain levels plunge 51% after 3 months of slathering it on arthritic knees. Drug levels reaching your stomach, kidneys, and liver are 6% that of an oral dose so, while the risks are not nothing, they're a whole lot less than the pill delivers.

The problem is in the how much cream how often department. The web site recommends 2 gm four times daily to upper extremity sites and 4 gm four times daily for the lower extremity. A tube of toothpaste is 170 gms so that amount of Voltaren Gel would get you through just over ten days of knee treatment. The stuff is definitely gooey, lightly but pleasantly scented, and dries within 4-5 minutes leaving a light sheen but no residual sticky stuff. I cannot imagine using it during the workday if I wore pantyhose. Pulling them back up again after gelling your hip would be like getting a wet bathing suit back on a small child. But then again, who wears pantyhose anymore? What about for one throbbing , chronically hyperextended index finger swollen from years of writing chart notes and prescriptions? The very thing I think, but you can't wash the area for 1 hour after each application.

The other problem is cost. By my calculations, you would apply your way through $172 worth of gel to service one bum knee for a month. Does insurance pay? Dunno, but I kind of think not.

Tumor necrosis factor

This sounds like a good thing, right? Produced by cells of the immune system, this protein's name implies that it is a sort of cellular "ace-in-the-hole," inducing death in wayward cells and their mutant offspring before a cancerous tumor is formed.

When first discovered in 1975, tumor necrosis factor (TNF) was noted to induce death in malignant cells in laboratory studies. Unfortunately, it is most complex in its actions, proving toxic to healthy cells and actually promoting the growth of certain kinds of cancer. TNF in the wrong place at the wrong time causes unwanted inflammation. This little troublemaker is a destructive party crasher in the joints of persons with rheumatoid arthritis, It also has destructive, pro-inflammatory effects in Crohn's colitis, smoking-related lung disease, atherosclerosis, Alzheimer's disease, and doubtless much more of that which ails us. It contributes to the profound wasting of AIDS and induces fever and shock in the face of overwhelming bacterial infections.

TNF is a good thing if you happen to do battle with a saber-toothed tiger, accidentally drive a Folsom point into your leg, or fall off your bicycle and scrape your knee. TNF is known as an 'acute phase reactant'; as the body's own EMT, it is one of the first responders at the scene of injury or infection. Produced by activated white cells and the endothelial cells that line blood vessels, TNF attracts bacteria-killing white cells known as neutrophils, promotes the passage of these cells through the blood vessel lining into damaged tissues, alerts the liver to produce pro-inflammatory molecules such as c-reactive protein or CRP, suppresses appetite, and promotes fever.

If TNF and company are activated, however, by cigarette smoke, doughnuts, McDonald's french fries, or too much waisted fat, this same immune response sets off a world of trouble in our arteries. Likewise, auto-immune diseases such as lupus or rheumatoid arthritis cause TNF inflammatory responses in joint spaces and other body tissues.

Body balance or homeostasis depends on equilibrium between troubleshooters such as TNF and peacemakers such TNF inhibitors. Therapies directed against TNF have changed the long-term outlook for patients with rheumatoid arthritis. These new drugs include TNF antibodies such as Remicade and Humira, and proteins that fuse with TNF such as Embrel. Early suppression of the joint-destroying inflammation associated with RA can prevent skeletal deformities and pain, markedly improving a patient's quality of life. Unfortunately, blocking a bad actor such as TNF which also has essential immune functions is not without problems. For one thing, TNF has an active role in the body's response to mycobacterial infections. As a result, cases of active tuberculosis have been reported with the use of anti-TNF agents.

A dark patch on the skin

A thirty-something year old lady came in today for her physical. Among other things, she complained of a dark patch on the outside of her left ankle along with pain in the same spot. Dark patch and pain, no connections so far.

So I check it out. The patch is slightly irregular and brown with faint overtones of red. It looks like nothing familiar so far, not fungal, not eczema, not psoriasis. Not tender to touch nor hot in an inflamed sort of way.

The pain occurs while walking, so I ask to see her walk barefoot across the room. Bingo. We have a too many toes sign signaling flat feet, flatter left than right. No wonder her collapsing left ankle hurts. But what about the dark patch?

Does it itch? You bet, she says. Do you scratch it? Are you kidding, she counters, all the time. Ah ha, it's that hyperpigmented Iscratchtoomuchandirritatemyskin chronic skin change sort of look. I see that lots in the middle of the back in older people still limber enough to reach around to scratch.

Patches of skin near the spine itch due to a radiculopathy (now how good a word is that) meaning that a little nerve branch going to the skin called a radicular nerve gets pinched as it passes out of an arthritic spine. The skin supplied by this nerve starts to itch or burn, the patient scratches it lots, and the skin gets dark from chronic irritation. Then I look like an amazing medical intuitive when I ask if that area bothers them.

The brown discoloration of chronically scratched at skin is caused by hemosiderin. This pigment is a breakdown product of hemoglobin. As people dig at itchy spots over time, tiny blood vessels rupture and release hemoglobin into the skin. This iron-carrying molecule from blood is deposited into the space between cells and is subsequently broken down into hemosiderin, leaving a permanent discoloration to the skin. You often see this same blotchy brown residue in the lower legs of elderly persons with varicose veins who develop an itchy condition known as stasis dermatitis.

Risk factors for gout

About once a month, some aging fellow (sorry guys, it's more prevalent in men than women) hot foots it into my office with a hot foot. Gouty feet do not like to be touched; that joint at the base of the big toe--the most commonly affected site--is red, hot, swollen, and strictly hands-off on exam.

Gout is an inflammatory arthritis caused by the precipitation of uric acid crystals in the tissues in and around the affected joint. Uric acid is a metabolic waste product produced during the breakdown of purines which are compounds present in foods such as meat and seafood.* High intake of these foods in susceptible individuals can increase the risk of a gout attack; one study of middle-aged health professionals found that those who chose beef, pork, or lamb as a main dish 2 or more times weekly doubled their risk of gout vs. the group that hardly ever ate meat. On the other hand, those old guys who drank low-fat milk thrice daily were half as likely to suffer from gout attacks compared to those who had none. No mention made of those individuals who both ate meat and drank low-fat milk.

I've just learned about another dietary risk factor for this painful condition, namely sugar-sweetened soda. Now no one ought to be drinking this garbage, and here's another reason why. Investigators made another pass at the health professional data with respect to pop preference. Compared to those who never drank the stuff, those who consumed one can daily were half again more likely to get gout and those who had two or more servings daily nearly doubled their risk.

I ask a lot of people about what they eat and drink, and, believe it or not, two sodas per day is not that unusual.
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*Purine-rich vegetables such as peas, beans, and mushrooms do not increase risk of gout.

"My little toenail looks gross!"

I came back in the room after my patient was dressed for the last word on her physical. She had shoes and socks off, a sure sign that she'd just remembered some foot issue.

Her toenail did indeed look gross. The toenail was split all the way down, and the skin around it was heavily calloused. Not a wart, as she theorized, but the result of narrow shoes smashing her 5th toe beneath her 4th.

I asked her to stand up with her bare foot next to her stylish brown leather heels. There was no relationship whatsoever between the shape of her foot and those lovely stilettos. I indicated my stumpy black Merrill's, suggesting that a better match between shoe shape and foot would heal up that toenail. Not only was the shoe too narrow, but the height of the heel was forcing her forefoot to be solidly crammed into the pointy toe.

She stopped short of gagging at my footwear choice and agreed to seek a more practical shoe.

Wise words from an orthopedist

My patient was worried about her knees. Pain prevented her from getting down into a squatting position. Shoot, I haven't been able to do a deep knee bend for years, but I certainly could relate to fretting over aging joints. So I sent her off to Western Orthopedics where she met with Dr. Raj Bazaz.

He checked out her knees and declared them fit for service for years to come. His best advice to her? Don't do deep knee bends.

She was delighted with the visit.

Tart cherries, arthritis, and all that ails you

How good are Montmorency cherries? Well suffice it to say that at a certain point, I just had to stop reading the bushels of cheery cherry news in order to get this post written.

First of all, they're a wicked good source of melatonin. So much so that Dr. Russel Reiter, the so-called 'dean of melatonin research,' has now become the darling of U.S. cherry growers. Dr. Reiter has proven in his Texas neuroendocrinology lab that eating tart cherries replete in melatonin will make you replete in melatonin.

Hard to say what's next best about cherries. Probably their anthocyanin content. These cherry compounds are potent cyclooxygenase (COX) inhibitors. If that term rings a bell, it's because COX-2 inhibitors have been big news lately, first as miracle compounds that decrease arthritis pain without bothering the stomach, then as pharmaceutical villains for the faint of heart who wonder if Vioxx and Bextra caused their hypertension or heart attacks. For heart-safe and stomach-safe COX-2 inhibition, eat cherries.

After Michigan State University investigators patented a process to separate cherry from anthocyanin, the folks at Overby Farms used this technique to make cherry little dog biscuits for arthritic pooches. You will enjoy HipBones. The MSU investigators subsequently discovered that humans may lose weight, lower cholesterol, and increase insulin production with high anthocyanin-content foods, so buy some of those biscuits for yourself.

And now this final word about cherries from Iowa's Dr. Raymond Pohl, and then I'm plum cherried out. He writes that the perillyl alcohol in the fruit "shuts down the growth of cancer cells by depriving them of the proteins they need to grow. It works on every kind of cancer we've tested it against."

For a world of testimonials from aching humans and their canine companions, look around the web.

*This is the advertising slogan for "Tart is Smart" cherry juice. Check out tartissmart for more information on cherries than you could ever hope for, plus retail locations where you can buy this good red stuff. For those of you in Colorado, visit your local Albertson's!

SMURFS in your knees

If this title does not bring silly blue cartoon characters to mind, then you did not raise a small child in the '80's. Those of us who were child-rearers 2 decades ago may well be a subset of the aging population at risk for osteoarthritis of the knees. And now smurfs take on a whole new meaning.

In a degenerating knee sort of way, smurfs are enzymes also known as "Smad Ubiquitination Regulatory Factors." Turned-on smurf2 can turn cartilage cells into hard bone, a good thing if you happen to be a growing child. But smurf2 in an injured knee--say one that was pivoted in the wrong way whilst running cross a tennis court--can set off a chain reaction that ultimately results in the deterioration of the joint. Over time with repeated insults, poof! you got no cartilage but just the dreaded 'bone-on-bone' sort of painful knee joint that's destined for replacement. "Or," says Randy Rosier, MD of the University of Rochester "put another way, activation of smurf2 in the joint cartilage appears to significantly contribute to the onset of osteoarthritis."

Rosier and company are setting out to determine if patients with high smurf2 expression in an injured meniscus demonstrate accelerated wear-and-tear with loss of cartilage within 3 years of the injury. While the Rochester docs know of no way to halt the rampaging smurfs, they do think that the over-smurfed among us can be counseled to change their high impact activities and save their knees.
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*The meniscus is a C-shaped piece of cartilage on either side of the knee joint. These two wedges of cartilage cup the rounded end of the femur atop the flattened tibia below, stabilizing the two bones of the knee into a smoothly functioning hinged joint.

Why yoga makes me nervous

I find that a challenging yoga class brings a little thrill of fear to me which is not necessarily a pleasant sensation. Before you think me a total loser, check out this new study whose fancy brain-imaging techniques may explain the connection.

Researchers at the University of Manchester used PET scan imaging to see what parts of the brain lit up when people ached in their arthritic old knees. This technique involves injecting a person with a tagged sugar molecule called F-fluorodeoxyglucose or FDG. FDG is concentrated in neurons as they suck up sugar while at work reacting to the task at hand.

Neurobiologists already know which brain pathways activate when volunteers are pinched or kicked or however it is that researchers induce experimental pain. This same 'pain matrix' is also activated by arthritic pain. These UK scientists were surprised, however, to find that pain from degenerative joints "was associated with increased activity in the cingulate cortex, the thalamus, and the amygdala. These areas are involved in the processing of fear, emotions, and in aversive conditioning."

So if yoga induces pain in degenerating knee joints--and despite all those gentle adjustments from the instructor, I find it often does--aging yoginis might feel fear.

Exercise that is good for the heart is not detrimental to the knee joint.
---Flavia M. Cicuttini, PhD and colleagues*

Well that's good news. I was just debating tonight whether to take my right knee to step aerobics tomorrow or not. One deep knee bend over the sprinkler system three weeks ago left me with screaming pain from the lateral meniscus. It's much better now--who knows why--and I wondered if it was sheer folly to step out to a little music much needed by me for the heart and the soul.

Dr. Cicuttini et al studied nearly 300 adults over 10+ years. At study's end, their knees were, on average, 58 years old. The investigators correlated their activity logs with the amount of cartilage still clinging to the top of their tibiae on the bottom of their knee joints. Those who particpated in more frequent vigorous exercise in the years prior to the study had a significantly larger chunk of residual cartilage compared with those who sat out the decade on the couch. And the best predictor of defect-free cartilage was each individual's current participation in vigorous exercise.
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*Racunica TL, et al "Effect of Physical Activity on Articular Knee Joint Structures in Community-Based Adults" Arthritis Rheum 2007; 57: 1261-1268.

Good IDEA-033

I am a great fan of delivering drugs through the skin. As we age and transdermal technology expands, we may tape ourselves together with patches containing hormones (for women and for men), antihypertensives, antidepressants, neurostimulants (Ritalin), and now this, slather-on pain relief:

IDEA-033 is a formulation containing ketoprofen in an ultradeformable vesicle aka Transfersome. Ketoprofen, a non-steroidal anti-inflammatory drug or NSAID (same class of drugs as Advil and Aleve) is loaded into these ultradeformable carrier particles and smeared on painful, arthritic knees.

Germany's Matthias Rother explains the idea behind IDEAs: "Once the Transfersomes are on the skin, water starts to evaporate and deprive carriers of their suspending medium. Carriers reaching their solubility limit are attracted by the higher water content in the skin, resulting in spontaneous migration of IDEA-033 through the skin barrier.

Now in the skin, the little Transfersomes migrate into the next structure down which is the unhappy knee joint. Once there, the ketoprofen goes to work on the inflammation, delivering pain relief equivalent to Celebrex.* Best of all, there's no associated stomach irritation as would be found with an oral NSAID.
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Ann Rheum Dis. 2007;66:1178-1183.

Posterior tibial tendon dysfunction

Overstretched and going to ground. Doesn't that about sum up this aging thing? Well here's another thing going wrong in the half-century set.

The posterior tibial tendon basically comes from the calf around the back of your inner ankle bone where it stretches over the inside edge of the foot and holds the arches up. Injure yours through overweight, overstress, or just plain too many years of living, and the little darling stretches or tears and poof! arch hits the floor. The loss of the arch stresses your ankles and drags your knees inward along with the feet and the ankles. The result? Foot pain, lateral knee pain, and an inability to stand on your toes.

Shoot, who knew? If you're wondering about the state of your arches, check out your wet footprint. Or look for the "Too many toes sign." Get a buddy to stand behind you and look at your feet. A positive 'too many toes sign' is present if more than the pinky toe can be viewed from the back. This toeful look is created by the outward splay of a foot caving inward due to a fallen arch.

And it's not necessarily just the midlife women suffering from PTTD. The other day, a phys.ed. teacher, male, 30 y.o., came in complaining of right ankle pain. This developed after he walked all day long on a trip in flip flops (no arch supports in those) carrying a backpack. Sure enough, this young fellow had 'too many toes' on his right foot and had injured his posterior tibial tendon through overuse/misuse during his daylong trek.

Builds stronger bodies 2 ways

If I had it to do over again, which thankfully I do not, I would take two specific supplements during pregnancy along with the old standby prenatal vitamin: vitamin D and omega-3 fatty acids.

The former improves bone health in a woman's offspring. British researchers studied nearly 200 children for bone mineral content at age 9 years correlated with their mother's vitamin D levels during pregnancy.(1) Those with D-ficient moms (defined as blood levels of 25(OH) vitamin D <11mcg/L) had significantly lower lumbar spine bone density compared with children of D-replete moms (vitamin D >20).

As most women get most of their bone mineralization in place by age 20, D supplementation in pregnancy can improve peak bone-mineral acquisition, perhaps reducing the risk of osteoporotic fractures in later life.

So D covers the bones, and omega-3 fatty acids improve developing brains. We're all fat-heads insofar as 60% of our brain is made up of lipids. Intake of DHA or docosahexaenoic acid during pregnancy, especially during the final trimester, pumps that baby's brain full of DHA which becomes an integral part of the neuronal or brain cell membranes. Rat moms rave about the cognitive and attentional abilities of their DHA-primed offspring.(2) Evidence suggests that such a strategy works well for humans too.
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1. Javid MK et al. Lancet. 2006;367: 36-43.
2. Levant B et al. Lipids. 2006 May;41(5):407-14.

Hip pain


Sometimes it's hard to tell what's what when hips hurt. Arthritis of the hip joint hurts in the groin or the front of the thigh. It increases over time, gets worse with activity, and limits the range of motion of the hip, particularly to internally rotate the joint (accomplished by turning the foot or knee inward towards the middle of the body).

Bursitis, or an inflammation of the lubricating lining of the hip, hurts at night, making sleeping on the affected side difficult. Bursitis also nags when you first rise from a seated position, but this pain subsides quickly.

Finally, pain from the sacro-iliac pain also is improperly identified as hip pain. Lie on your back bending the affected leg at the knee and placing the ankle on the opposite knee in a 'figure 4' configuration. If downward pressure on the knee of the affected side causes pain in the groin, it's the hip. If the pain is around back, the pain is probably from the sacro-iliac joint.

Quadriceps and independence in aging

No kneed to fear old age

Our independence is dependent on the simple ability to get out of a chair. And that, in turn, depends on our knee joints' ability to lever us off the chair (or the toilet seat for that matter) with the help of our quadriceps muscles.

I watch my mom struggle to accomplish this task, and imagine a spring-loaded chair that would catapult her to her feet while not pitching her forward face-first to the floor. An engineer acquaintance, however, is working on a better idea, one that will hopefully reach the doddering old baby boomer market in time for me.

This knee brace, slim and easy to use in a neoprene sleeve sort of way, will have a sensing device waiting for a muscular clue that it's time to rise from a sit to a stand. At that time, a teensy little motor will provide from 25-75% assist to creaky old knees to accomplish the task.

Add this to the padded hip protectors that cushion lateral falls so that crumbly hips don't break, and we're talking bionic old broads, living on their own!

Got foot pain?

Then first of all, check out your shoes! Put your bare feet next to the shoes you wear most often. Does the contour of your foot match the contour of the shoe? My experience at the office checking feet to shoes in footsore customers suggests that this is often not the case.

Does the shoe taper at the toe whereas your feet do not? Check out some of the 'new age' old lady shoe brands such as Merrell and Clarks. I actually had to spell Birkenstocks for one patient today; don't know what time warp she's been stuck in.