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Joint Cracking and Popping: Understanding Noises That Accompany Articular Release

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Joint Cracking and Popping: Understanding Noises That Accompany Articular Release CLINICAL PRACTICE Joint cracking and popping: Understanding noises that accompany articular release MARINA G. PROTAPAPAS, DO TYLER C. CYMET, DO Articular release is a physiologic event that may or may is what people notice in articular release; the subjective relief not be audible. It is seen in patients with healthy joints as it provides is secondary. well as those with somatic dysfunction. After an articular This subjective relief has not been scientifically evalu- release, there is a difference in joint spacing—with the ated, and terminology related to this process is confusing and release increasing the distance between articular surfaces. in need of clarification. In this article, we review the avail- Not all noise that emanates from a joint signifies an artic- able information on articular release and propose a reason ular release. A hypothesis about the noise that frequently for the physiologic change and the occurrence of sound ema- accompanies this release is offered and includes anatomic, nating from the joint. physiologic, and functional models of articular release. This physiologic event may be shown to have an impor- Repeated performance of articular release may decrease tant place in manipulation because it produces the effect of joint the occurrence of arthritis. Potential problems from repeated separation, or gapping of the joint.1 Osteopathic manipulative articular release (eg, hypermobility) are also examined. treatment techniques, such as facilitated positional release (Key words: articular release, cervical spine, hyper- and counterstrain, depend on local and central proprioceptive mobility, joint cracking, knuckle cracking, metacarpopha- effects for their effectiveness. Articular release may be part of langeal joint, osteoarthritis, osteopathic manipulative treat- the necessary response for effective treatment. Patients feel an ment, synovial joint) immediate release and relief, as well as temporary restoration of joint motion.2 n most clinical settings, the patient is often more concerned Iwith the obvious, audible change in the joint than is the Articular release and sound physician. It is a poorly understood response that is sought by The sound generated by joint manipulation has been classi- some patients and avoided by others. Articular release is a phe- fied variously throughout osteopathic medical literature, being nomenon that is widely familiar to osteopathic physicians as referred to as an “articular crack,” “articular pop,” “clunk,” well as other practitioners of manual medicine. “crepitus,” “joint click,” “snap,” “synovial grind,” and “thud,” Articular release is a repeatable phenomenon that can and it has been described as a “grating” sound in the general occur with or without an accompanying noise. It causes a medical literature (Figure 3). The articular release may be accom- freeing of motion and a release of joint tension (Figure 1). panied by a loud audible release or a soft joint sound—but it can However, the physiologic and anatomic explanation for what also be inaudible. happens during articular release is not fully understood. The regions of the body most commonly used to study What is known is that articular release occurs when joint articular release have been the metacarpophalangeal (MCP) motion extends past the physiologic barrier (Figure 2). This joints and the cervical spine. In much of the literature, methods extension may be accomplished by an outside force—as that have been used to measure the loudness of the “crack” that induced by a physician—or through muscle movement not accompanies articular release have not been clearly described. directly emanating from joint release. The sound, or the noise, Those practitioners who do elaborate on study approach have used equipment such as transducers over the skin. In particular, Meal and Scott2 mention that the method for recording a release Dr Protapapas is currently completing her internship at Good Samaritan Hos- is known as “phonoarthrography,” in which the joint sound is pital in Baltimore, Md, and is moving to Cambridge, Mass, this summer to begin picked up by an electronic stethoscope and passed through her residency in physical medicine and rehabilitation at Harvard University’s an amplifier to an electrograph (ultraviolet) recorder: “Best Harvard Medical School. Dr Cymet is a section head of family medicine at Sinai Hospital of Baltimore in Maryland. He is also an assistant professor of internal results seem to depend on excluding extraneous (or high fre- medicine at The Johns Hopkins University School of Medicine in Baltimore, quency) sounds in a time frame of 0.04 to 0.06 sec[onds].” Md. The model of Brodeur describes the sudden joint distrac- Address correspondence to Tyler C. Cymet, DO, 6 Tyler Falls Ct Unit A, Bal- timore, MD 21209-5227. tion during manipulation as occurring in a shorter time than that E-mail: [email protected] required to complete the stretch reflexes of the periarticular Protapapas and Cymet • Clinical practice JAOA • Vol 102 • No 5 • May 2002 • 283 CLINICAL PRACTICE muscles. As a result, a high impulse is likely acting on the lig- aments and muscles associated with the joint involved. An articular release is a change in joint space. It can be: Brodeur’s study uses force-displacement curves of the third Ⅵ MCP joint. “A spring balance was used to measure the dis- audible or inaudible traction force applied to the joint.”3 Radiographs were taken at Ⅵ present in a healthy or diseased state specific joint tension intervals, allowing the joint displacement Ⅵ affected by a change in the external environment to be measured. Consequently, this system allowed researchers (eg, temperature, barometric pressure) to generate a force displacement curve, illustrating the sequence Ⅵ induced by motion or muscle activity without motion pattern of an articular release. Ⅵ the result of a rapid change in joint position The noises that accompany joint motion have not been studied extensively. It is uncertain whether there is any thera- peutic value attached to the crack and, conversely, whether there are any detrimental effects to the patient. This joint release Figure 1. Properties of articular release. may offer a clue as to the nature of joint pathology. Many the- ories have been proposed as to the reasons behind this noise. muscle activity, such as creatinine phosphate and creatinine Hembrow4 states, “Clicks result often from atmospheric pres- kinase, being extruded when the muscle stretches during joint sure correcting a vacuum produced by the traction, or by ten- manipulation.10 However, not much data are available on this dons snapping over.” Hutton5 “describes the articular click as mechanism. an indication of a bone being put back into place.” In 1871, Dr. The noises of normal and abnormal joints are built into the Wharton Hood6 attributed this sound “to the snapping of adhe- nature of the structures. To ignore these noises would be foolish, sions.” Hargrove-Wilson7 suggests that “the click is due to the as they might be used to help determine the effectiveness of breaking of the joint seal, at which time a small bubble of treatment. nitrogen is released in the joint.” According to Ehrenfeuchter and Nicholas,8 the facet joint space narrows, causing the syn- Paradigm: Anatomic model, physiologic model, and ovial fluid to be pushed into an already bulging capsule. Also, functional model of articular release Unsworth et al9 state that the noise emitted from a joint is The articular noises made by a joint vary depending on the dependent on the size of the joint. size of the joint, section of the body being moved or manipu- The primary explanation for this audible noise is that it lated, and the previous activity of the joint. A release or crack results from a change occurring at the joint. However, one will not occur without motion. More specifically, the physi- theory states that the noise may result from by-products of cian’s careful manipulation of different joints will vary in com- Figure 2. Hypothetical model of articular release. Step 1: 6 Preliminary tension mobiliza- tion. Pressure is applied to joint without a change in gap Step 4 between articular cartilage. 5 Step 2: Articular release. A Step 3 release occurs and a rapid change in gap range results. This step can be audible or 4 Trauma-tendon rupture inaudible. Step 3: Overshoot Ligamentous strain of release without increase in gap area. Step 4: Refractory Step 2 tension. Reduction in tension 3 with decrease in gap; not returning to baseline reading. metacarpophalangeal joint (mm) Estimated gap in articular cartilage, Step 1 2 Physiologic barrier 2 4 6 8 10 12 14 Tension (kg) Anatomic barrier 284 • JAOA • Vol 102 • No 5 • May 2002 Protapapas and Cymet • Clinical practice CLINICAL PRACTICE composed of 15% gas, 80% of which Term Definition is carbon dioxide. Roston and Wheeler-Haines12 verify this com- articular clunk A sound similar to a loud thud. This sound is most prevalent in position of joint spacing, stating that syndesmosis injuries (ie, osteoarthritic joint: sacroiliac or hip joint that may have chronic synovial dryness or eburnation).* the pressure in a joint right before This noise may have a single modal sound wave peak on a release is –3.5 atm. Atmospheric pres- sound frequency scale. sure is 1 atm. Consequently, a 2.5– articular crack A “breaking” noise that appears as a bimodal sound wave atm pressure change occurs after peak on a sound frequency scale. joint release, resulting in an audible articular pop A “popping” noise that can be expressed as a single modal emission of sound. curve on a sound frequency scale. Unsworth et al9 support this argu- articular release A physiologic event that occurs when a joint is positioned past ment, introducing the concept of cav- its physiologic barrier—but has not passed through its anatomic itation, a term used to describe the barrier—to cause a functional change, resulting in increased formation of vapor and gas bubbles freedom of motion for the affected joint.
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