Kellgren Lawrence Grading Scale (Keywords: Kellgren Lawrence Grading Scale, chiropractic books, hip arthritis, femero acetabular

impingement syndrome, developmental hip dysplasia, Pincer, Cam) Kelgren and Lawrence have produced a useful, and relatively straight forward grading system for X-rays of the arthritic hip. Their system considers: 1. 2. 3. 4. Joint space narrowing Osteophytic lipping Sclerosis Bone contour deformity

Kellgren-Lawrence Grade 1: "Doubtful narrowing of joint space and possible osteophytic lipping."

Note in the above X-ray:

The presence of a short leg. Research indicates a higher prevalence of hip (and knee) arthritis associated with a leg length inequality. LEG LENGTH INEQUALITY Research ...

In the right hip, the "unroofed" hip and the inclined acetabulum. Developmental hip dysplasia. DEVELOPMENTAL HIP DYSPLASIA ...

In the left hip, the presence of a Pincer deformity: FEMERO ACETABULAR IMPINGEMENT SYNDROME. FEMERO ACETABULAR IMPINGEMENT SYNDROME ...

There is "doubtful" narrowing of the joint space in both hips, and certainly osteophytic lipping in both hips. Clinically, this 50-year old patient had fairly severe right hip pain, restricted hip flexion and internal rotation and pain in the groin with walking for four years. After 810 chiropractic treatments of the hip and sacroiliac joint he says the pain is 70-80% less, and he can walk relatively normally for the first time in several years. FEMERO ACETABULAR IMPINGEMENT SYNDROME CASE FILE ... Kellgren Lawrence Grade 2:

"Definite osteophytes, definite narrowing of joint space." Notice again the presence of a "Pincer" deformity. Earlier this was simply categorised as early osteoarthritis. Now we know it's simply a feature of Femero Acetabular Impingement Syndrome, a condition that in it's early phase responds extremely well to Chiropractic management of the hip, and even in it's more advanced phase, responds moderately well. Prevention, it's better than a cure.

Kellgren Lawrence Grade 3: "Moderate multiple osteophytes, definite narrowing of joints space, some sclerosis and possible deformity of bone contour."

"I'm a 52 yr old female diagnosed with severe osteoarthritis of the hip last year. I first realised all was not well last year when, after bathing I attempted to stand upright with feet together and noticed that my right knee protruded a fair way. The medical treatment I have received to date has been very lacking and I've been very unimpressed. I was recommended by a good friend to see her chiropractor and I readily agreed as was in a lot of pain with a very pronounced limp. After only a couple of sessions, the pain and the limp are virtually gone. I now only attend on a as and when basis and the relief is almost immediate. I cannot thank my chiropractor enough for the help and advice he has given me. I dread to think what sort of condition I would be in by now had I not consulted him. I have found your website invaluable for information on my affliction. Many thanks." J These are the X-rays that J sent me: I suggested she send her chiropractor a bottle of excellent red wine. Maybe a case! Notice the multiple osteophytes, the loss of joint space and the deformity of bone contour of the femoral head. This is verging on Grade 4. Well done, doc! Notice too the CAM deformity: Femoral Acetabular Impingement Syndrome FAIS, in my opinion should be part of the routine chiropractic examination of each and every patient, especially the young patient. It takes only 60 seconds to do range of motion tests of the hips after all. Detected at 25, with the correct chiropractic management, I believe this progression to the pain and disablility of an arthritic hip, and likely total hip replacement could be prevented.

Kellgren Lawrence Grade 4: "Large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour."

The next two views are not from a Chiropractic clinic. Frankly I think it unlikely that Chiropractic can help a Kellgran Lawrence Grade 4. Time to find a good orthopaedic surgeon. If you have a short leg, ask him if s/he can compensate for it. If your pelvis is level, plead with him to make sure that are still level after the surgery!

LEG LENGTH INEQUALITY ... the significance of a short leg.

In both these two X-rays we see the typical features of a Kellgren Lawrence Grade 4: This large osteophytes, the dramatic sclerosis, the complete loss of joint space superiorally, altered bony contour and cysts within both the acetabulum and ball. And in the first the presence of Developmental Hip Dysplasia, and the second a CAM deformity in Femoro Acetabular Impingement Syndrome. In the examination of the hip, DDH has a pronounced INCREASED range of motion, whereas in FAIS the ROM is DECREASED. In the young adult, a decreased Hip ROM should immediately raise suspicion of FAIS. Treated promptly with chiropractic... a stitch in time... LEVEL OF ACTIVITY Kellgren Lawrence Grading Scale Sometimes it may be tragic if FAIS or DDH is detected in a young sportsman or woman, but in my opinion they should be immediately advised to live a normal active life, but extreme sports are strictly contraindicated. The child with DDH is often hypermobile and will excel at gymnastics, but later in life.... OBESITY Kellgren Lawrence Grading Scale I have taken an active interest in treating the arthritic hip for more than five years now. I have no figures or research to back me up, but in my experience the obese patient is not likely to respond to the chiropractic management of the arthritic hip. Nor any other treatment, apart from surgery of course. Unless they are ready to commit to a weight loss programme, I will no longer accept them as a patient. It's a waste of their money, and our time. Sometimes you have to be cruel to be kind... FREE WEIGHT LOSS PROGRAMS ...

NUTRITION Kellgren Lawrence Grading Scale For the hyaline cartilage to regenerate, which research in the Netherlands proves it can, it needs to be "unloaded" (= weight-loss), the joint needs to be set in movement (= Chiropractic) and the synovial fluid must contain the right ingredients. A rich soup, fully oxygenated (I have no figures, but I'm fairly sure smokers are less likely to respond well to the chiropratic management of hip arthritis) and rich in glucosamine and chondroitin sulphate.

Unfortunately research shows that patients with hip arthritis do not respond any better with glucosamine chondroitin suplphate in tablet form, than patients on a placebo. GLUCOSAMINE CHONDROITIN sulphate ... So my nutritional programme for patients with hip arthritis is: 1. A home-made chicken bones extract (research from Harvard), CHICKEN BONES bouillon...

2. Omega 3 capsules 3. A tablespoon of ground flax seed CHIROPRACTIC HELP Obesity in the Chiropractic clinic /Flax seed.

4. Regular, at least 2-3 times per week, fatty fish. Definition of knee osteoarthritis Osteoarthritis (OA) is the most common joint disorder, characterised by an imbalance between the synthesis and degradation of the articular cartilage, leading to the classic pathologic changes leading to destruction of cartilage [1]. The breakdown and deterioration of cartilage leads to the formation of new bone at the joint surfaces (sclerosis) and margins (osteophytes) [2]. This process often results in joint pain and loss of mobility, which may lead to long-term disability. Although OA is considered a non-inflammatory form of arthritis, there can be a small inflammatory component. Knee OA characterises all degenerative changes of the knee joint and is a disease with a multi-factorial aetiology. A primary and secondary form of knee OA may be differentiated [3]: primary (idiopathic) knee OA: Osteoarthritis is classified as primary when aetiology and pathogenesis are unknown. The reasons for an endogenous cartilage formation defect are under discussion. Clinical manifestations start increasing from the age of 40, heredity has been described. secondary knee OA: The causes are mechanical or metabolic risk factors such as aberrance of the axis, haemophilia, rheumatoid and bacterial arthritis, osteochondrosis dissecans, dysplasia of the joint, injury of the knee joint, etc. For patients with cartilage defects in their medical history,

clinical studies demonstrate multiple risks for early onset of arthrosis [4]. Animal experiments indicate that even minor untreated cartilage injuries of a critical size greater than 5 mm may result in persistent damage of the joint [5,6]. People who repetitively stress one joint or group of joints (e.g. foundry workers or coal miners) are particularly at risk. Much of the risk of osteoarthritis of the knee comes from occupations that involve repetitive bending of the joint [7]. Obesity may be a further factor in the development of osteoarthritis, particularly of the knee and especially in women [8]. However, once osteoarthritis has developed, the work-related repetitive movement often makes the disorder worse. OA is normally classified in different grades. With regard to the knee, the use of a four-grade classification based on Outerbridge [9] is common for arthroscopic findings. Thus, the arthroscopic classification used in this study is defined as follows (Fig. 1):

Figure 1. Schematic drawings to illustrate the grading of cartilage diseases as described by Outerbridge [9]. Grade I: Softening and swelling of the cartilage. No damage of cartilage surface. Grade II: Fragmentation and fissuring in an area half an inch or less in diameter. Only shallow damage of cartilage. Surface is fringed, shredded and resembles crab meat. Grade III: Fragmentation and fissuring in an area more than half an inch in diameter. Deep damage of cartilage down to bone, visible to the naked eye. Grade IV: Erosion of cartilage down to bone. Complete destruction of cartilage. Large damage of joint, cicatricial tissue, cartilage bald. For the documentation of knee damage based on radiological findings, the four-grade classification of Kellgren and Lawrence [10] is commonly used. Thus, the radiological classification used in this study is defined as follows:

Grade I: Doubtful narrowing of joint space and possible osteophytic lipping. Grade II: Definite osteophytes and possible narrowing of joint space. Grade III: Moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone ends. Grade IV: Large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone ends. Prevalence and findings regarding knee symptoms The considered studies showed a prevalence of knee OA between 2790% in people of 60 years or older [3]. Approximately 1012% of all individuals suffer from cartilage lesions [11]. In a cross-sectional study among 1,000 employees doing mainly office work, a 12month-prevalence of symptoms was reported between 2228% with only slight differences in age groups (<25, <35, <45, <55 and 5565 years). In the same study, employees who worked in the laboratory, storehouse or in production as well as in the office reported slightly increased values [12]. A survey in more than 200 employees in emergency medical services revealed an age-dependent 12-month prevalence between 1735%. In this case, and in contrast to the previously mentioned study in office workers, the frequency of knee joint disorders correlated significantly with age. Moreover, the prevalence of disorders was partially associated with the high physical stress of lifting and carrying heavy loads (e.g. patient + stretcher) [13]. Several occupational risk factors such as working in kneeling or squatting posture, heavy lifting and carrying of weights are discussed as being related to the development and progress of knee joint diseases [14-20]. The diagnosis-related analysis of work incapacity days from a German health insurance database of 18.5 million employees revealed that a higher risk appeared for a number of occupations involving knee-straining activities [21]. As study results are not identical, the importance of specific risk factors of knee OA and the possibilities of prevention are currently under discussion. In Germany, so far several contradictory study results regarding the correlation between occupational stress factors and the appearance of knee joint diseases have been published [22-30]. The relevance of physical

stress for initiating or aggravating knee OA is being controversially discussed [25]. However, besides the occupational risk factors, a number of individual factors (e.g. obesity, gender, leisure time behaviour, genetic disposition, metabolic syndrome, smoking behaviours or the regular practice of extreme sports [2,3,26]) may play a role. The distinction between workrelated and individual factors is crucial for assessing the very risk and for deriving preventive measures in general and in the field of occupational health. Relationship Between Cartilage Volume Using MRI and Kellgren-Lawrence Radiographic Score in Knee Osteoarthritis With and Without Meniscal Tears 1. 2. 3. 4. 5. 6. 7. Yuko Harada1, Osamu Tokuda1, Kouji Fukuda2, Gen Shiraishi3, Tetsuhisa Motomura3, Motoichi Kimura4 and Naofumi Matsunaga1

10.2214/AJR.09.3556 AJR March 2011 vol. 196 no. 3 W298-W304

Fig. 1A Knees with Kellgren-Lawrence (KL) scores of 14. Anteroposterior radiograph shows knee in 62-year-old man with KL score of 1 with minimal osteophytes at lateral tibial condyle (arrowhead).

Fig. 1B Knees with Kellgren-Lawrence (KL) scores of 14. Anteroposterior radiograph shows knee in 74-year-old man with KL score of 2 with small but definite osteophyte (arrowhead) and sharpening of tibial spine (arrows) without reduction of joint space.

Fig. 1C Knees with Kellgren-Lawrence (KL) scores of 14. Anteroposterior radiograph shows knee in 35-year-old woman with KL score of 3 with definite narrowing of medial joint space (arrow) and osteophyte (arrowhead).

Fig. 1D Knees with Kellgren-Lawrence (KL) scores of 14. Anteroposterior radiograph shows knee in 38-year-old woman with KL score of 4 with gross loss of lateral joint space (white arrow), marked osteophytes (arrowheads), and sclerosis of subchondral bone (black arrow).

Fig. 2A 62-year-old man with Kellgren-Lawrence score of 1. Medial (A) and lateral (B) sagittal images of femoral and tibial compartments outlined over fat-suppressed 3D spoiled gradient-echo images (TR/TE, 39/6.9; flip angle, 45; and slice thickness, 2 mm) are shown. Numbers 1 and 2 indicate outlines of femoral and tibial cartilage, respectively.

Fig. 2B 62-year-old man with Kellgren-Lawrence score of 1. Medial (A) and lateral (B) sagittal images of femoral and tibial compartments outlined over fat-suppressed 3D spoiled gradient-echo images (TR/TE, 39/6.9; flip angle, 45; and slice thickness, 2 mm) are shown. Numbers 1 and 2 indicate outlines of femoral and tibial cartilage, respectively.

Fig. 2C 62-year-old man with Kellgren-Lawrence score of 1. Three-dimensional reconstruction of femorotibial articular cartilage obtained by segmentation of serial MR image data.

Fig. 3 Sagittal fat-suppressed 3D spoiled gradientecho image (TR/TE, 39/6.9; flip angle, 45, and slice thickness, 2 mm) obtained in 62-year-old man with Kellgren-Lawrence score of 1 to calculate femoral condylar bone volume (outline).