ULTRASOUND IMAGING OF THE

TRAPEZIOMETACARPAL ARTICULAR CAVITY TO

INVESTIGATE THE PRESENCE OF
INTRAARTICULAR GAS BUBBLES AFTER
CHIROPRACTIC MANIPULATION
Allan R. Jones, MT, a Christopher J. Yelverton, MT, b and Charmaine Bester, MT c

ABSTRACT

Objective: The purpose of this study was to investigate the presence of intraarticular gas bubbles in the
trapeziometacarpal joint cavity after chiropractic manipulation with audible cavitation and to assess the state of the gas
bubbles after a 20-minute refractory period.
Methods: This investigation included 18 asymptomatic male and female participants between the ages of 21 and
26 years. High-resolution (15 MHz) sonograms of the trapeziometacarpal articular cavity were obtained by an
experienced musculoskeletal ultrasonographer at 3 intervals: premanipulation, within 30 seconds postmanipulation,
and at 20 minutes postmanipulation. The sonograms were saved as digital copies for subsequent reports that were
correlated with reports compiled during dynamic visualization of the articular cavity. Data were extracted from the
reports for analysis.
Results: The premanipulative sonograms showed that 27.78% of joints contained minute gas bubbles, also known as
microcavities, within the synovial fluid before the joint was manipulated. The remaining 72.22% of joints contained
no intraarticular microcavities. All of the postmanipulative sonograms revealed numerous large conspicuous gas
bubbles within the synovial fluid. The postrefractory sonograms showed that, in 66.66% of the synovial fluid, gas
bubbles were still visible, whereas the remaining 33.34% had no presence of gas bubbles or microcavities, and the
synovial fluid had returned to its premanipulative state.
Conclusion: The findings of this study suggest that synovial fluid may contain intraarticular microcavities even
before a manipulation is performed. Numerous large intraarticular gas bubbles are formed during manipulation due to
cavitation of the synovial fluid and were observed in the absence of an axial distractive load at the time of imaging. In
most cases, these gas bubbles remained within the joint for longer than 20 minutes. (J Manipulative Physiol Ther
2014;37:476-484)
Key Indexing Terms: Manipulation; Chiropractic Manipulation; Synovial Fluid; Ultrasonography

he audible sound associated with manipulation of practitioners consider that an audible clicking or cracking

T spinal and extremity synovial joints is familiar

to most practitioners of manual medicine. Some
a in the clinical setting, few authors have focused their attention
Chiropractor, Department of Chiropractic, Faculty of Health
Sciences, University of Johannesburg, Doornfontein, South Africa.
b
Head of Department, Department of Chiropractic, Faculty of
Health Sciences, University of Johannesburg, Doornfontein,
South Africa.
c
Lecturer, Department of Chiropractic, Faculty of Health
Sciences, University of Johannesburg, Doornfontein, South Africa.
Submit requests for reprints to: C. J. Yelverton MT (Chiro),
University of Johannesburg, P.O. Box 17011, Doornfontein,
Johannesburg, 2028, South Africa. (e-mail: chrisy@uj.ac.za).
Paper submitted June 20, 2011; in revised form June 24, 2014;
accepted June 30, 2014.
0161-4754
Copyright © 2014 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2014.06.002
sound indicates a successful procedure, 1 and some may repeat
the manipulation if an audible sound is not obtained. 2
Despite the perceived importance of the cavitation sound
on investigating the intraarticular fluid mechanics occurring
during manipulation. 3 Cavitation of synovial fluid is still
poorly understood and requires further investigation. 4
Research on the theory of cavitation has suggested that,
as the pressure is reduced in a film of synovial fluid between
the surfaces of a joint simulator, gasses are liberated from
the synovial fluid, in which there is a phase transformation
from liquid to vapor. Just as rapidly as this cavity forms, it is
theorized that the cavity collapses, thus setting the tissues
into vibration, and a sound is released. The gas bubble then
returns to ambient pressure and is thought to remain for
approximately 20 minutes, after which it dissolves back into

476
Journal of Manipulative and Physiological Therapeutics
Volume 37, Number 7
Fig 1. Inclusion and exclusion criteria for participant selection.
the synovial fluid. The process of gas bubble formation is
called cavitation. 5
Liquids can withstand moderate tensile loading and
negative pressures. Rapidly stretching a liquid beyond its
saturated vapor pressure will result in an explosive liquid-
to-vapor phase transition. 6 Cavitation is the process of
cavity formation in a fluid when subjected to negative
pressure that surpasses the vapor pressure of the liquid. 7
Cavitation occurs in various situations, but the formation of
the vapor cavity is incited by a local reduction in pressure. 8
Cavitation can be visualized using diagnostic imaging
methods. Using plain film radiography, several authors 5,9-11
have demonstrated the presence of an intraarticular
radiolucent space in a metacarpophalangeal joint after
cavitation. The metacarpophalangeal joint was always
manipulated with an axial distractive load. The singular
radiolucent cavity was only shown to be visible if an axial
distractive force was acting across the joint at the time of the
postmanipulation radiograph. Magnetic resonance imaging
has been used to demonstrate an increase in the lumbar
zygapophyseal joint spaces (0.7 mm) after spinal manipu-
lation vs the control group (0.0 mm increase). The observed
increase in joint space was the primary aim of the study done
by Cramer et al, 12 but no reference was made to the presence
of an intraarticular gas bubble or any apparent changes in
joint space density on postmanipulation magnetic resonance
imaging scans. The authors attributed this increase in joint
space to the breaking of intraarticular adhesions. Computed
tomography and radiography have been used in an attempt
to demonstrate gas bubbles in the cervical spine facet joints
after manipulation. However, Cascioli et al 13reported that
no postmanipulation gas bubbles were visualized, with or
without traction.
Currently, there have been no published studies using
high-resolution (15 MHz) diagnostic ultrasound to evaluate
manipulation of the trapeziometacarpal joint. 14 Imaging the
Jones et al 477
Intraarticular Gas Bubbles
joint in the absence of an axial distractive load might
provide an answer to the question: “Do postmanipulation
gas bubbles exist in a joint when there is no axial distractive
loading of the joint?” This could possibly indicate an
intraarticular pressure change, which in turn might
influence joint physiology. Therefore, the purpose of this
investigation was to assess cavitation gas bubbles in the
trapeziometacarpal joint after chiropractic manipulation and
assess the state of the gas bubbles after a 20-minute
refractory period using high-resolution ultrasound.
METHODS
Recruitment of Participants
This investigation recruited 20 participants selected from
the University of Johannesburg Chiropractic and Homoeo-
pathy student population. Participants were examined using
specific inclusion and exclusion criteria to eliminate
possible confounding variables (Fig 1).
Screening Consultation
The screening consultation was conducted at the
University of Johannesburg Chiropractic Clinic. Partici-
pants signed an informed consent form to participate in this
study. A medical history was obtained, and a pertinent
physical examination and regional examination of the hand
and wrist were performed. Provided no clinically concern-
ing abnormalities were detected, the trapeziometacarpal
joint was palpated, and manipulation was performed at the
end of the screening consultation. Only participants from
whom an audible cavitation was attainable were asked to
attend the imaging consultation. This ensured that the
researcher was able to manipulate the participants’
trapeziometacarpal joint with relative ease at the imaging
478 Jones et al
Intraarticular Gas Bubbles
Fig 2. Chiropractic manipulation of the trapeziometacarpal joint.
The line of drive is toward the floor. The joint is taken further into
extension, as the base of the first metacarpal is simultaneously
translated toward the floor (medially) as a high-velocity, low-
impulse thrust is delivered.
consultation (some trapeziometacarpal joints may not
cavitate with this manipulation).
Chiropractic Manipulation of the Trapeziometacarpal Joint
Figure 2 illustrates the chiropractic manipulation used to
cavitate the trapeziometacarpal joints in this research.
Doctor position: standing facing the patient. Patient
position: the patient was seated facing the doctor. The
right elbow was flexed to 90°, and the forearm was held
midway between pronation and supination (such that a line
joining the heads of the second to fifth metacarpophalangeal
joints was perpendicular to the floor and the nail of the
thumb faced superior, much like placing out ones hand for a
hand shake). Contact hand: right thumb pad contacted the
lateral aspect of the base of the first metacarpal in the distal
angle of the anatomic snuff box after proximal-to-distal skin
slack was removed. Indifferent hand: the left thumb pad was
used to reinforce the contact and the fingers of the left hand
hooked around the medial aspect of the fifth metacarpal.
Line of drive: the line of drive was toward the floor
(medially). The joint was taken further into extension, as the
base of the first metacarpal was simultaneously translated
toward the floor, as a high-velocity, low-amplitude impulse
thrust was delivered. In this way, no distractive loading was
placed on the trapeziometacarpal joint.
Imaging Consultation
The 2010 model Philips iU22 (Philips, Bothell, WA)
ultrasound unit was used in conjunction with the Philips
L15-7io’s transducer to obtain sonograms for this study.
The group of 20 participants was randomly divided into 3
smaller groups for conducting premanipulation and post-
manipulation ultrasonography. Group 1 consisted of 6
participants and groups 2 and 3 consisted of 7 participants
each. The ultrasonographer scanned the trapeziometacarpal
Journal of Manipulative and Physiological Therapeutics
September 2014
Fig 3. Sonogram of the trapeziometacarpal joint. (1) Volar aspect
of the trapeziometacarpal joint capsule, (2) base of the first
metacarpal, and (3) distal articular surface of the trapezium.
joint and obtained the first (premanipulation) image. The
researcher then manipulated the trapeziometacarpal joint.
As the joint cavitated, a timer was started by an assistant.
The ultrasonographer scanned the joint and obtained a
second (postmanipulation) image within 30 seconds of joint
cavitation. The participant then waited for a 20-minute
refractory period to elapse during which time the joint was
under normal resting physiologic conditions (ie, neither
overused nor immobilized). The initial scan, manipulation,
and the postmanipulation scan for all participants in each
group were completed before the 20-minute refractory
period was complete for the first participant of that group.
As the participants’ timer approached the 20-minute mark,
the assistant alerted the researcher, and the participant was
positioned so that the third (postrefractory period) image
could be obtained as close to the 20-minute mark after the
manipulation as possible. This allowed for a small margin
of variation (the maximum of which was approximately
30 seconds). The postrefractory period image was thus
obtained at 20 minutes (± 30 seconds). This procedure was
repeated for each of the 3 groups.
All images were obtained by a qualified ultrasonogra-
pher who is a specialist in musculoskeletal ultrasonographic
imaging. All 3 scans were conducted with the participants’
hand in a standard position to obtain similar images for each
participant and thus eliminate potential variables. The
patient was seated across a plinth from the ultrasonographer
with their forearm fully supinated such that the hand rested
on the plinth with the volar surface facing upward. The
transducer head was placed at 45° to the forearm on the
thenar pad. The participants thumb was then passively
moved so that extension and adduction of the trapeziome-
tacarpal joint occurred. This opened the anterior portion of
the articular cavity such that a triangular wedge of the
trapeziometacarpal joint was visible on the sonograms.
Figure 3 demonstrates the articular cavity, which was the
primary field of interest for this study.
Journal of Manipulative and Physiological Therapeutics
Volume 37, Number 7
Fig 4. Premanipulation sonogram of intraarticular microcavities.
Observe the microcavities (circled) scattered throughout the
articular cavity. These microcavities were clearly demonstrated
during dynamic visualization.
Data Collection and Analysis
The data collected from this research was stored onto the
ultrasound unit’s hard drive in the form of digital images. At
the end of the imaging consultation, the images were
written to compact disc and then printed as a hard copy.
Imaging Evaluation
The reports were compiled by the ultrasonographer both
during and after the imaging consultations. The researcher
recorded any commentary made by the ultrasonographer
during dynamic visualization of the articular cavity. The
images were printed, and a formal report was compiled by
the ultrasonographer and researcher several days later. Of
the 19 trapeziometacarpal joints manipulated for this study,
18 produced an audible click when manipulated. This
audible click was confirmed by a qualified chiropractor
who attended the research trial. Only these participants’
images were included in the results. Therefore, 56 images
(3 per participant) were assessed by the ultrasonographer
for presence of gas bubbles. With assistance from the
ultrasonographer, the researcher compiled a report for each
image with specific attention to intraarticular changes.
Ethical Approval
All aspects of the study protocol were evaluated and
approved by the Higher Degrees and Academic Ethics
Committee of the University of Johannesburg (clearance
reference no AEC 59-01-2010) in accordance with the
Helsinki Declaration of 1975. Informed consent for
participants was obtained before commencement of the
study. Participant autonomy and confidentiality was
ensured. Participation in the study was completely
voluntary, and participants were free to refuse participation
or withdraw from the study at any stage.
Jones et al 479
Intraarticular Gas Bubbles
Fig 5. Premanipulation sonogram with no intraarticular micro-
cavities. In addition, there were no microcavities reported during
dynamic visualization.
RESULTS
Exclusion of Participants
Of the 20 participants selected to attend the imaging
consultation, 2 participants were excluded from the research
for the following reasons: one participant was unable to
attend the imaging consultation as a result of transportation
difficulties and thus withdrew from the study; one partici-
pants’ trapeziometacarpal joint did not cavitate when
manipulation was attempted at the imaging consultation.
Therefore, 19 participants were screened but 18 included
in the results.
Participant Age, Sex, Height, and Weight
The average age of participants was 23 years with a
range of 21 to 26 years. There were 6 men and 12 women
who participated in this research. The average height of
participants was 1.73 m with a range of 1.53 to 1.94 m. The
average weight of the participants was 74.21 kg with a
range of 53 to 102 kg.
Premanipulation Sonograms
The results for the premanipulation sonograms showed
that 5 of 18 joints contained microcavities (Fig 4), whereas
13 of 18 joints contained no microcavities as illustrated in
Figure 5. On dynamic visualization, these microcavities
moved, shifted, or flowed between the articular surfaces
from dorsal to palmar side of the joint, as the joint was
passively moved between flexion and extension.
The Postmanipulation Scans
Numerous gas bubbles, seen as echogenic cavities, were
present in all 18 of the trapeziometacarpal joints on
postmanipulation sonograms. This is illustrated in the
example in Figure 6. The gas bubbles were multiple and
480 Jones et al
Intraarticular Gas Bubbles
Fig 6. Postmanipulation sonogram showing 3 intraarticular gas
bubbles (arrows). During dynamic visualization, the gas bubbles
displaced frrm the dorsal to the palmar side of the joint, as the
researcher passively moved the joint.
were displaced with movement of the joint. On extension,
they moved toward the palmar side of the joint, with flexion
they moved to the dorsal side of the joint, and out of the
field of view in the “on screen” image when scanning.
In the case of 5 participants with intraarticular micro-
cavities on premanipulation images, the microcavities
enlarged significantly, often to several times the premani-
pulation volume.
Postrefractory Period Scans
After the 20-minute refractory period, intraarticular gas
bubbles were still present in 12 of the 18 joints (Fig 7),
whereas the remaining 6 joints contained no intraarticular
inclusions and had returned to their premanipulation
state (Fig 8).
DISCUSSION
This study showed that intraarticular gas bubbles could
be visualized in a joint space other than a metacarpopha-
langeal joint and with high-resolution ultrasound imaging.
The technique used to manipulate the trapeziometacarpal
joints for this research was a high-velocity, low-amplitude,
impulse thrust involving a direct contact over the skin
surface and was therefore similar to manipulation used by
chiropractors in the clinical setting. Most importantly, the
presence of numerous intraarticular gas bubbles after
manipulation has now been visualized in a joint in a
physiologic position (in the absence of an axial distractive
load), which strongly suggests an intraarticular pressure
change after cavitation of the synovial fluid.
Premanipulation Scans
Microcavities were present in 5 TMC joints and were
approximately one-10th of the size of the postmanipulation
Journal of Manipulative and Physiological Therapeutics
September 2014
Fig 7. Postrefractory period sonogram of intraarticular gas
bubbles (arrows). These gas bubbles were still present in the joint
after the 20-minute refractory period had elapsed.
gas bubbles. To the authors’ knowledge, the presence of
microcavities in synovial fluid of normal joints has not been
documented before. A possible explanation for these
microcavities is that that they were formed during the
manipulation at the screening consultation and had not yet
entirely dissolved back into solution at the time of the imaging
consultation. However, the time frame between the screening
consultation and the imaging consultation was in excess of
3 days for all participants. Previous authors state that air
injected into a joint as a contrast medium often remains in the
joint for several days and is visible on subsequent
radiographs. 10 The type of cavitation occurring in a joint
where there are inclusions such as preexisting microcavities in
the fluid is termed heterogeneous cavitation. Such inclusions
lower the cavitation pressure threshold of the fluid. 8
Manipulation
Previous authors 5,9-11,15 have used a longitudinal
distractive load to cavitate metacarpophalangeal joints for
radiographic imaging investigations. However, longitudinal
distraction is not the primary vector used when manipulating
zygapophyseal joints of the spine in the clinical setting. This
research involved a chiropractic manipulation similar to
those delivered in the clinical setting in that the line of drive
was primarily a shear vector and involved a high-velocity,
low-amplitude, impulse thrust.
There was no noticeable difference between joints with
or without preexisting microcavities with regard to ease with
which the joint cavitated. This was surprising considering
the work of previous authors 5,9-11 suggests that a joint with
a preexisting gas bubble will not cavitate. Perhaps, the
microcavities noticed on premanipulation scans of this
research were too small to expand when increased capsular
volume is required during normal activities of daily living.
The synovial fluid with microcavities therefore cavitated
similarly to synovial fluid in which microcavities are absent.
Journal of Manipulative and Physiological Therapeutics
Volume 37, Number 7
Fig 8. Postrefractory period sonogram with no intraarticular gas
bubbles. The articular cavity of this joint had returned to
premanipulation state, and no intraarticular inclusions were
observed during dynamic visualization.
Postmanipulation Scans
Cause of the Intraarticular Gas Bubbles. Cavitation occurs when
a fluid is subjected to a negative pressure, which exceeds
the saturated vapor pressure of that fluid. 7 Negative
pressure is generated upon movement of the joint, as a
greater capsular volume is required in certain joint
positions. Initially, there is an invagination of the capsule
into the joint space. 16
When the volume of the capsule is increased further, the
synovial fluid is thought to cavitate and the new gaseous
phase (readily expandable), which theoretically could allow
for a greater capsular volume, thereby preventing ligamen-
tous injury. Throughout the literature regarding this topic, the
gaseous cavity is always described as a singular entity and is
only visible when an axial distractive load is either
maintained after joint cavitation or reapplied to a joint in
the refractory period. This research shows that there are in fact
numerous gaseous cavities, which are present in a joint in the
absence of an axial distractive load (position of trapeziome-
tacarpal joints during all scans was extension and adduction).
These cavities were also visible when the joints were in their
loose-pack position during dynamic visualization.
Effect of the Intraarticular Gas Bubbles. The effect of an
intraarticular gas bubble and its influence on synovial fluid
turnover are described in detail below. When investigating
cavitation of a fluid in a sealed system, previous authors 6
noticed a pressure change from a negative to a positive
value, which indicated the formation of a gaseous phase in
the fluid within the system. The articular cavity is
essentially a sealed system containing a minimal amount
of synovial fluid. The intraarticular pressure of most resting
joints is negative (subatmospheric). A pressure change is
likely to occur as synovial fluid cavitates during manipu-
lation, and the intraarticular gaseous phases is formed.
Jones et al 481
Intraarticular Gas Bubbles
Although several authors 5,9 are aware of this
pressure change, any potential therapeutic value has
been overlooked.
Synovial fluid production is governed by the “starlings
pressure” principal of microvascular fluid exchange. The
filtration rate of synovial fluid at the capillaries of the
synovial intima is determined by the following equation: 17
Net filtration rateðinto articular cavity Þ
¼ ðcapillary hydrostatic pressure–intraarticular pressureÞ
–ðoncotic pressure differenceÞ
The oncotic pressure difference is the pressure gradient
established by differing amounts of protein in the articular
cavity and the capillaries of the synovial intima: 17
Oncotic pressure difference
¼ blood oncotic pressure–intraarticular oncotic pressure
The change in intraarticular pressure that occurs as a
result of manipulation may theoretically affect synovial
fluid turnover in the following way:
• The normal negative intraarticular pressure is now
closer to atmospheric pressure as a result of the
intraarticular gas bubbles, which are liberated from
solution as the synovial fluid cavitates.
• The difference between the capillary hydrostatic
pressure and the intraarticular pressure is therefore
not as substantial as before the manipulation.
• Theoretically, this could result in a decrease of the net
filtration rate of synovial fluid into the articular cavity
(less synovial fluid would be produced in a joint while
in the refractory period).
Movement of a synovial joint results in changes to the
intraarticular pressure. Traction or shearing of the joint
surfaces reduces the intraarticular pressure due to the
inability of synovial fluid to expand substantially. This
results in suction on the capsule and the net filtration rate of
synovial fluid into the joint increase. 18 However, when
intraarticular gas bubbles are present, and a joint is moved
into extension, expansion of these cavities occurs to
accommodate an increased capsular volume. Thus, less of
a “suction force” is exerted on the capsule, and less synovial
fluid is drawn into the joint space than would occur for a
joint in which there are no gas bubbles.
In addition, synovial fluid drainage is determined by
changes in the intraarticular pressure. Increased intraarti-
cular pressure results in compression of synovial fluid,
which increases drainage into the lymphatic plexus of the
subsynovium. Such increases have been measured in canine
knee joints, where flexion was used to increase the
intraarticular pressure, and the synovial fluid turnover was
482 Jones et al
Intraarticular Gas Bubbles
recorded. 19 Theoretically, the increased intraarticular
pressure occurs after a manipulation favors synovial
fluid drainage. 20
It could be proposed that this pressure change restores or
shifts the physiologic equilibrium of the joint by reducing
synovial fluid production and increasing synovial fluid
drainage. It could also be proposed that the range of motion
increase after a manipulation may be attributed to the
presence of intraarticular gas bubbles, which expand when
the joint is moved. This could allow for a greater capsular
volume with a consequent increase in articular
surface separation.
Postrefractory Period Scans. In 13 of the 18 postrefractory
period scans, gas bubbles were still visible at 20 minutes
postmanipulation. This suggests that most participants
could have a longer refractory period than suggested by
prior authors, who reported a maximum of 22 minutes and a
minimum of 17 minutes before their participants’ meta-
carpophalangeal joints could be cavitated a second time. 9
This research shows that the intraarticular gas bubbles
and the effects thereof are present for longer than
previously thought.
It has been shown that, on average, a 68.33-minute
interval must elapse before a second set of cavitations may
be obtained from the zygapophyseal joints of the
lumbar spine. 21
Factors Affecting Cavitation of Synovial Joints. Synovial fluid is
contained within all synovial joint cavities, within bursae
and tendon sheaths. The primary functions of synovial fluid
are joint lubrication and nourishment of chondrocytes
located in the avascular matrix of articular cartilage. 22 As
the synovial fluid cavitates during a manipulation, the joint
is taken beyond the elastic barrier of resistance. 5 This could
pose the question as to whether the elastic barrier of
resistance is always in the same position in a synovial
joints’ range of motion. In the authors opinion, the elastic
barrier of resistance is the point at which cavitation of
synovial fluid occurs and may therefore vary. Cavitation of
the synovial fluid is determined by the viscosity of the
synovial fluid, the state of the joint at the time of the
manipulation, the relative laxity of the periarticular
ligaments, and velocity of the manipulation.
Viscosity of Synovial Fluid. Viscosity is the resistance of a
liquid to flow. A fluid with a higher viscosity demon-
strates a slow flow rate, whereas a fluid with a low
viscosity will flow with ease. Synovial fluid is thixo-
trophic (non-Newtonian) in its response to stress. 23
Velocity of joint motion or rate of joint shear affects the
viscosity of synovial fluid. When articular surfaces are
moving rapidly, synovial fluid has a low viscosity.
Conversely, when there is gradual movement of articular
surfaces, synovial fluid has a high viscosity. Thus, the
viscosity is inversely proportional to joint velocity or rate of
shear. This is referred to as thixotrophism. 24
Journal of Manipulative and Physiological Therapeutics
September 2014
Most chiropractic manipulation uses a high-velocity
thrust. 25 Because synovial fluid is thixotrophic in its
response to stress, as the velocity of joint motion increases,
so the viscosity of the synovial fluid decreases. The lower
the viscosity of a fluid, the less force (negative pressure) is
needed to induce cavitation of that fluid. 7 This could
explain why most chiropractic manipulations involve high
speed. The speed lowers the viscosity of the synovial fluid,
which concomitantly reduces the cavitation pressure
threshold of the synovial fluid, and cavitation is more
likely. The hyaluronic acid in synovial fluid is responsible
for this changing viscosity with changing rates of shear. 26
It could be proposed that a decrease in temperature of
synovial fluid results in a higher viscosity, and conversely,
an increase in temperature results in a lower viscosity. 27
Heating a joint may reduce the viscosity of the synovial
fluid, thereby facilitating an easier manipulation, as less
force is needed to cavitate the synovial fluid (less negative
pressure is needed to result in cavitation). Conversely,
cooling the joint may increase the viscosity of the synovial
fluid and result in difficulty cavitating the joint (more
negative pressure being required to cavitate the synovial
fluid when the viscosity is increased).
Sustained loading promotes movement of fluid and
small solutes from the synovial fluid within the articular
cavity into the extracellular matrix of the articular cartilage.
The hyaluronic acid protein complexes are too large to enter
the extracellular matrix of the articular cartilage and
therefore remain in the joint lumen. As a result, a protective
lubricating “gel” is formed at the articular surfaces, the
viscosity of which increases with time, as the synovial fluid
is progressively sieved. 23 Although sustained loading
increases the viscosity of the synovial fluid, the fluid
within these joints often cavitates as the joint is moved. The
synovial fluid therefore seems to cavitate more easily or
earlier in the joints range of motion. This may be explained
by understanding the adaptability synovial joints. If the
joint is loaded in a position that compresses the synovial
fluid, there is an initial increase in the intraarticular
pressure. With time, this increase in intraarticular pressure
subsides, and equilibrium is established as the intraarticular
pressure is reduced to its normal negative value. Essentially,
there is less fluid in a joint after sustained loading in a
position that caused an initial increase in the intraarticular
pressure. If the joint is now moved, the synovial fluid
cavitates earlier in the joint’s range of motion (as the
capsular volume increase necessary to generate the negative
pressure is less) due to less fluid in the joint after sustained
loading. The cavitation thus occurs earlier in the joints
range of motion.
The degree of inflammation also affects synovial fluid
viscosity. Within the lumen of an inflamed joint, neutro-
phils produce lytic enzymes, which disrupt hyaluronic acid-
protein complex formation, and the viscosity of the
synovial fluid is substantially reduced. Inflammatory
Journal of Manipulative and Physiological Therapeutics
Volume 37, Number 7
synovial fluid behaves in a manner similar to H2O and is
Newtonian in its response to stresses, that is, “thixotroph-
ism is absent. 27” Therefore, the synovial fluid of an
inflamed joint may cavitate with minimal force (negative
pressures). It is in the authors’ opinion that the negative
pressure needed to cavitate an inflammatory fluid is
encountered during normal activities of daily living. The
fluid is thus constantly in a cavitated state. The gas bubbles
(if present) would remain in the joint until a reduction in
inflammation would allow hyaluronic acid and proteins to
once again aggregate and increase the viscosity of the
synovial fluid, preventing cavitation under normal stresses.
A joint in which there is inflammation would be expected to
contain numerous gas bubbles and remain in the refractory
period (even without manipulating the joint) until the
inflammation subsides. This is, however, speculative and
would require significant basic research for verification.
This size threshold for the intraarticular microcavities
before cavitation is most likely related to the viscosity of the
synovial fluid. Theoretically, viscous synovial fluid could
have a larger gas bubble and still cavitate due to a larger
surface tension. However, even a small gas bubble in a low
viscosity synovial fluid can easily enlarge (without a sound
emitted) when manipulation is attempted. This could occur to
a small bubble due to the low surface tension of fluids with
low viscosity.
Recommendations for Future Research
The following recommendations are provided for authors
who wish to further investigate the phenomenon of cavitation
at synovial joints. Future research using songraphic joint
space imaging should attempt to determine the prevalence of
microcavities in joints that have never been manipulated
verses joints, which are frequently manipulated such as those
of habitual “knuckle crackers.” A study to determine the
relationship between joint mobilization and gas bubble
formation would suggest that the gas bubbles are formed as
the joint is manipulated. The presence of intraarticular gas
bubbles in arthritic or inflamed joints would provide valuable
information regarding their role in joint pathology. The
chemical composition of the postmanipulation intraarticular
gas bubbles in normal joints has not yet been investigated.
Prior studies used synovial fluid aspirated from joints, where
trauma or arthritis had resulted in an effusion. Furthermore,
the intraarticular pressure change during a manipulation and
resultant influence on synovial fluid turnover should be
investigated. Future studies should consider blinding the
interpretation of the scans such that the ultrasonographer is
unaware if the scans being performed/interpreted are
premanipulation or postmanipulation.
Limitations
In this exploratory study, the ultrasonographer was not
blinded to the images in terms of image sets (premanipula-
Jones et al 483
Intraarticular Gas Bubbles
tion, postmanipulation, and postrefractory period) as most
of the report was conducted during dynamic visualization of
the joint space. Although all 18 of 18 postmanipulation
sonograms demonstrated intraarticular gas bubbles, in-
creasing the number of participants would strengthen the
statistical significance of the study. Data interpretation did
not include volumetric measurements of the postmanipula-
tion gas bubbles. Such measurements would be unreliable
as sonograms do not capture a 3D image of the joint, and
thus, not all of the intraarticular gas bubbles are present on
one image. The origin of the microcavities seen on
premanipulation sonograms is not certain.
CONCLUSIONS
The findings of this study provide insight into synovial
fluid cavitation and intraarticular changes in trapeziometa-
carpal joints postmanipulation. Synovial fluid may contain
intraarticular microcavities before manipulation. For the
subjects in this study, numerous large intraarticular gas
bubbles were formed during a manipulation due to
cavitation of the synovial fluid and may be present in the
absence of an axial distractive load at the time of imaging.
In most cases, gas bubbles remained within the joint for
longer than 20 minutes.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
The University of Johannesburg funded this study. No
conflicts of interest were reported for this study.
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
A.R.J., C.J.Y., and C.B.
Design (planned the methods to generate the results):
A.R.J., C.J.Y., and C.B.
Supervision (provided oversight, responsible for orga-
nization and implementation, and writing of the
manuscript): C.J.Y.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data):
A.R.J., C.J.Y., and C.B.
Analysis/interpretation (responsible for statistical analy-
sis, evaluation, and presentation of the results): A.R.J.,
C.J.Y. and C.B.
Literature search (performed the literature search):
A.R.J., C.J.Y., and C.B.
Writing (responsible for writing a substantive part of the
manuscript): A.R.J., C.J.Y., and C.B.
Critical review (revised manuscript for intellectual
content, this does not relate to spelling and grammar
checking): A.R.J., C.J.Y., and C.B.
484 Jones et al
Intraarticular Gas Bubbles
Practical Applications
• Microcavities may exist in a synovial joint
before a chiropractic manipulation of the joint
is attempted.
• Numerous large conspicuous gas bubbles
were visible in all joints from which a
cavitation was obtained.
• No axial distractive load was needed to
visualize the intraarticular gas bubbles.
• In 12 of 18 participants, the gas bubbles were
present after a 20-minute refractory period
had elapsed.
• This suggests that either (1) the refractory
period is longer than previously thought, or
(2) the gas bubbles do not need to completely
redissolve into the synovial fluid before the
joint may once again cavitate.
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