Snap! Crack! Pop! Why Your Joints Make Noise with Andrew Bang, DC

Podcast Transcript

John Horton:

Hey there, and welcome to another Health Essentials Podcast. I'm John Horton, your host. You hear snaps, cracks and pops whenever you get out of a chair. I know I do. Those noises from my knees, ankles and other joints seem to be getting louder and more frequent as time passes. So, here's the question: Is that normal and is it a reason to worry? That's what we're going to find out today from chiropractor Andrew Bang, one of our regular guests on the podcast.

Dr. Bang is one of the many trusted experts at Cleveland Clinic who chats with us every week to help us better understand how our bodies work. Now, let's learn the reason behind all those creaky sounds we've been hearing whenever we move around. Dr. Bang, welcome back to the podcast. I always know we're in for an enjoyable chat when you're joining us.

Dr. Andrew Bang:

Thanks, John. I love hanging out with you, man. We got to do this in person sometime.

John Horton:

We definitely do. So today, in researching this, we're talking about cracking joints. I always love oddball facts, and I actually found where they said, "Cracking joints could get as loud as 83 decibels, which is the equivalent of a garbage disposal or a diesel truck rolling along at 40 miles per hour." Have you ever heard them that loud?

Dr. Andrew Bang:

Probably. I think the novelty of it wears off a bit, as I've been working on so many patients over the years. But yes, when it's your first time, it can be a little scary, and we do try to warn patients, but there are sometimes a few gasps in the office when the patient doesn't realize that it's going to be that loud. I wonder how they measure that because it seems when you're the patient receiving that, it sounds way louder than garbage disposal. Especially when it's in your neck because it's so close to your ears compared to you or I who might be listening to that patient get work done.

John Horton:

Well, it definitely can be loud. So, we'll get into all the fun with this stuff, so let's just start with a basic thing: Why do our joints make all this noise? I mean, what is going on there?

Dr. Andrew Bang:

Well, the good thing is, it's safe. Let me start with that. So, the noise you're hearing is safe, and it helps restore a range of motion. It helps decrease pain and all that good stuff. And essentially, there's like three kind of things that are happening, potentially making that sound. So, the first one is the one we're most interested in that we want to, that most people talk about when you YouTube: "OK, what is all the cracking sound I'm hearing?"

Well, usually the joints we manipulate on a patient are synovial joints. That's where we have two kinds of joint bones, that soft and very smooth cartilage where they meet together, and there's a joint capsule that goes around this joint. And inside of that there's synovial fluid and that synovial fluid helps - it's like motor oil essentially for our joints, right? Lots of lubrication, so things are slick and move nicely so your joint, it's freely moving, and you can do what you want to do.

Well, when we move that joint where it's restricted, there creates a negative pressure inside this capsule, and then when you pull it apart, it makes that cracking sound because you're creating a negative pressure inside of that synovial joint space. So, you get that sound.

John Horton:

So, what might be some examples of those joints? I'm thinking that's elbows, knees, stuff like that?

Dr. Andrew Bang:

That's part of it, too. Elbows, knees and joints - those are all synovial joints. Also, some of the joints inside of our spine are that same kind of makeup. Some of our finger joints, and these are here, those are those kinds of joints based where they meet together. So, manipulation can occur in lots of different areas inside of our body.

John Horton:

OK, so those are the synovial joints. I don't know if I said that right. Hopefully, I didn't mess that up. But what are the other two causes of that popping sound that you hear?

Dr. Andrew Bang:

We have ligaments, right? Ligaments are bands of connective tissue. We also have tendons. Tendons are connective tissue that are really strong. And tendons, where it comes from turn from a muscle into that hard white-like ligament, connective tissue, very strong that attaches to a bone. And ligaments are just that white, hard connective tissue that attaches bone to bone. Well, these ligaments and tendons can roll over each other.

I always give the example of patients where, if I was to take my fingers and do this, it sounds like a crack you might hear in a chiropractic office. The thing is, that's not the joint, that's the ligaments flipping over each other. That happens when we're moving and doing different things. You may feel a lot when you're moving your ankle and you hear a crack or your knee when you go to stand up, that's usually a ligament passing over another ligament, all right?

John Horton:

It's like guitar strings.

Dr. Andrew Bang:

So, you'll hear cracks now. And then, there's a third way. We have different layers of tissue, right? We have our skin, and then below that we have what we usually call the fascial layer. That's a bunch of really soft connective tissue that forms in a protective layer and a lubrication layer between skin, fascia, muscle because we want things to glide over each other.

Well, if I was to, let's say, stretch my skin kind of like this on an area around where you could grab a lot of skin - your back is usually an area this happens at - and I was to lift quickly, you'll actually hear a popping sound, and that's not your joints or ligaments. It's the skin separating from the fascia that is connected to the muscle layer, and you'll hear a pop. And it's similar in the fact of the synovial joint where you're creating this negative pressure inside of a tightly sealed kind of area, and you hear this pop sound.

John Horton:

I did not think that would happen just by pulling your skin up, that you'd be getting that sort of pop.

Dr. Andrew Bang:

So that's kind of why I try to explain to patients when they come to the office, "Hey, it could be one of three things." The good thing is typically all three of, the reason we do the manipulation is beneficial, even in all three of those situations. So, when I get, let's say a patient who has low back pain, I'm stretching through those synovial joints of their lumbar spine. I might hear some cracking, or we stretch, and we do some adjustments. We increase the range of motion. They feel the relief that comes from the adjustment, but they're still experiencing pain in the muscle.

I realized that they were working out or doing something very strenuous and their back muscles are so tight, I can then do another manipulation with their skin in that fascia layer. They'll hear more clicking and popping and be like, "Whoa, you're cracking the same spot." "No, no, it's totally new. It's a totally different area." But it's all to restore range of motion, that's usually our number one goal. Because as we've talked before lots of times, pain and range of motion are like a teeter totter, all right?

So, you remember when you were a kid playing in the school gymnasium outside in a park?

John Horton:

We're going up and down. We're going up and down together.

Dr. Andrew Bang:

If I go up, you go down. So, pain and range of motion are similar. If pain goes up, range of motion goes down, which means you're stiff. But if the range of motion goes up or you get more flexible, usually pain goes down. And that's why we're trying to do this cracking and popping. We want more range of motion. We want our range of motion to go up and our pain to go down.

John Horton:

What a great way to explain it. So now, I do have to say, when I was younger, I remember my joints cracking a little bit. I'd do it when I was sitting in Mr. Troupe's social studies class, I'd crack some knuckles and things like that. But I'm getting older and I'm adding more birthday candles and I just seem to be snapping and popping and cracking every time I move. Is that just a gift that comes with the years?

Dr. Andrew Bang:

Well, yes and no. So, you are probably experiencing also what's called crepitus, OK? So, I suppose maybe we should categorize this under the fourth potential way to hear cracking and popping.

John Horton:

OK.

Dr. Andrew Bang:

So, when we crack and pop, and it's not meant to be therapeutic with a chiropractor, a physical therapist or an osteopathic physician who all, by the way, do manipulation. Usually this crepitus is where - let's use that synovial joint again, right? We use the example that two bones are coming together. A very smooth surface, very nice, hard, hardened, smooth cartilage so they slide against each other.

Well, as we age, that cartilage isn't so smooth. It isn't so perfectly buffed. There isn't as much liquid in between that synovial joint, that fluid, so that motor oil is starting to dry out, as if it were. And now, you hear clicking and popping, that's happening because things aren't sliding well. And that crepitus. Let's have an old knee injury or wrist injury or a neck injury and you're aging, and now you turn, and you hear click, click, click or grinding or a scraping kind of noise. It'll be a little startling, but as long as it's not hurting, we usually aren't super concerned because it's a natural part of joint aging.

And so that's a little different than manipulation that is used as a treatment. So, as we get older, we'll get more crepitus, but the thing I'll tell you is the satisfying joint release as you get older, that unfortunately kind of goes away as well. Because the reason we have that sound is because we have fluid inside of a joint capsule, and when we stretch the capsule, that negative pressure inside with the fluid creates the popping sound. Well, as we lose fluid and joint space, we don't typically hear that sound anymore.

So, when I adjust patients who are older, I try to remind them, "It's OK if we don't hear any clicking or popping." It doesn't mean we're not moving the joint and stretching the tissue, which is the goal that helps you with pain relief. The popping sensation, our sound isn't what gives you the pain relief, it's the stretching of the tissue as we do these manipulations and stretches, et cetera. So even though you might be advancing in years, getting wiser - this is the right way to say it, right? Not hearing the clicking and popping sound when you're with the chiropractor or the PT or the osteopath physician, know that the treatment's still working, even though you don't hear that cool sound you did when you were in your 20s and 30s.

John Horton:

Now, is there ever a reason when you should worry when you start hearing these sorts of cracks when you move around and it's not just a natural sound of being manipulated or just getting off the couch if you're me?

Dr. Andrew Bang:

OK. That's a great point, John. And there's kind of two caveats. Because let's stick with the wise, the aging wise generation, right? So, when you're getting up and you get off the couch and you hear a lot of clicking and popping, and you start to feel some pain with that. And then, let's use a knee for an example, just because it's an easy joint to think about, you get up, it hurts, you hear some clicking and popping, and as you get moving, the joint seems to feel better.

John Horton:

OK.

Dr. Andrew Bang:

And the pain is usually what really is an indication that it's time to do something. Also, let's say you go to stand up and your knee gets almost caught. You can't even stand up straight. It kind of catches, you move it around a bit and then, it's free to move. There's usually some pain associated with that as well. Those two instances, you really need to see, there's a variety of physicians.

You could start with your primary care doctor. If you're already seeing a chiropractor or a physical therapist, ask them to give you some advice on who to see next. And ultimately, you're probably going to end up in an orthopedics' office who specializes in knee treatments. And at that point, they're going to want to make sure there's no loose bodies in that joint. That's where a fragment is broken off and that loose body can get in the way and actually prevent you from moving your knee or can cause a lot of cooking and popping because there might be an old tear or a new tear that you're experienced.

Then, that's where we're going to need to do either aggressive therapy to help stabilize that area and create range of motion or have a surgical consultation if the doctor knows that's the only thing that's going to help you feel better.

John Horton:

Listen to your body, is what you're saying. If you get that crack and then there's a pain that hangs around, that's not a good sign.

Dr. Andrew Bang:

No, that's not a good sign. The pain associated with that is not a good sign. A little bit of clicking and popping when you get up and you get moving, that's pretty normal. Especially if you have a job or you do activities or hobbies where you sit a lot or you're very stationary, even standing stationary. Our joints get a lot of pressure on them from that continuous sustained standing. You start moving, they click and pop. That's a normal part of life. OK? That's the way the body kind of releases its own pressure and gets back to status quo as it were, OK?

Also, even when we're just sitting still, or sleeping is another one. John, when you first wake up in the morning, do you feel like you're the tin man? Right?

John Horton:

Yes.

Dr. Andrew Bang:

Most of us do. And that's because as we sleep, our ligaments around our synovial joints — and all of our joints — they start to creep back to their original length. Which is a good thing. It means we don't wake up, we're, I don't know, Raggedy Ann.

John Horton:

I'll fall all over the place. Right.

Dr. Andrew Bang:

Right. Our ligaments naturally creep back to where they're supposed to be. They're nice and tight, so when you get back up, you're stable, OK? But then, they'll stretch out as the day goes, and that's the little clicking and popping you hear, and that's also normal. That's good. That's a normal part of physiology. Pain associated with that is where we don't want.

So, to answer your question, when it comes to this other group of people who kind of crack all the time, this tends to be in the demographics of teenage, college age. And I suppose it could be any age of life where people are cracking their own joints, they're doing self-manipulation. There's a reason they're doing this because they're doing an activity like sitting at a computer or looking down at their phone or whatever their job may be that's repetitive, that puts pressure on the joint continuously. And when there's a lot of pressure on a joint for a period of time, then your body feels the need to crack it. OK?

Well, it does it naturally on its own. It relieves the pressure. You feel better. When you keep doing that offending behavior, working on your computer or whatever your job is that's repetitive in nature, you start cracking that more frequently, more regularly. Before you know it, know it's a habit. And we've all seen that teenager or that other cracking their knuckles all the time or we have a friend or family member.

John Horton:

I did it all the time growing up.

Dr. Andrew Bang:

OK, well, so again, the cracking itself isn't an issue. If it was once or twice, it happens naturally on your own in a given day, right? It's when that cracking becomes repetitive. Every hour, every few minutes. We need to reevaluate. What are we doing that's causing pressure on the joint that's wanting us to feel that sensation of cracking? So, if we can identify what it is that we're doing that puts pressure there and we stop that behavior, we end up feeling no need to crack our neck or our finger or elbow or whatever anymore. So that's a big thing to help people self-educate.

“Why are you cracking your neck all the time?” “Well, I don't know. It feels like I need to." OK, well, let's figure out why you have pressure on your neck to begin with. And maybe we adjust their computer to monitor, or when they're using their cell phone, we have them go from looking down in their lap to holding the cell phone up at eye level point of view. Then, the pressure is not getting put on the joints, then you're not feeling the need to crack your joints because there's not excessive pressure there.

John Horton:

So, should you avoid trying to crack your own joints? Because I know a lot of people, they do that. My son grosses me out all the time. He cracks his neck and it — honest to God — it sounds like he's breaking a branch. It's so loud, and should you not do that and instead look for why you feel the need to?

Dr. Andrew Bang:

Yes. The short answer is yes, because what happens is, let's say he just did it once, OK? You heard him do it once. That wouldn't be damaging to the joints or the muscles or the ligaments. The problem, John, is he does that repeatedly. Now, he creates a little too much laxity in the joint and the muscle surrounding that joint. Remember, we talked about the teeter totter example, right? Increased range of motion means decreased pain. Well, if we go too high on that teeter totter, what happens? You get thrown off, right?

John Horton:

Yes, always.

Dr. Andrew Bang:

If our joint is too loose, now it sets us up to get injured doing a normal activity of daily living. Now you pivot too quick on the stairs, or you roll your ankle off a curb, and instead of that ligament being tight and protecting your joint from getting hurt, now, because your kind of continuously cracked them, they're too loose. They don't do their job. And now you actually get really injured. And cracking your joints all the time can become counterproductive when it's happening all the time.

And that's another, just for a professional point of view, chiropractic, physiotherapy or osteopathics who use manipulation, this is why we say, "Don't come every week." Or excuse me, why we say, "Don't come every day to an appointment." Or we may say, "We're going to do a treatment plan of once a week for four weeks or for six weeks." That's plenty. If someone is telling you you need to get adjusted three or four times a week, there's a problem because that's going to create too much joint laxity in those areas.

So that could be a red flag when you're, let's see, not knowing a provider and they're giving you a treatment plan. "Oh, well, for your back pain, you need to come three or four times a week for three to four weeks." That's 30-some adjustments. That's too much. What needs to happen, they need to do once a week, twice a week at most, and then follow up with training. "Why does my back continue to hurt? What do we need to adapt in our life?" We get the pressure off the joints.

John Horton:

Can over cracking also lead to arthritis because that's something you hear a lot. I mean, your parents would always tell you about cracking your knuckles. "If you do it, you're going to have arthritic fingers." I mean, is there any truth to that?

Dr. Andrew Bang:

I suppose there's never been, that I know of, a super good research study that said, "OK, we're going to take someone at age 18 that cracks their joints and then see what they look like at age 50." It'll take the same 18-year-old and not have them crack their joints and look at their joints at age 50. But when we just talk about physiology in a joint itself, when we have too much excessive play in a joint, that's when we start to get micro damage. And when you have micro damage in a joint, that's what creates a tiny bit of bleeding. And then, blood inside of a synovial joint can then cause degradation of the joint itself.

Then that's what leads to osteoarthritis. Osteoarthritis is, think of wear and tear, and so maybe a good example could be, is your car. Your four tires, and let's say one of those is misaligned. Let's say you live here in wonderful Cleveland where we have potholes on every street. And you've hit a pothole and now your tire's misaligned. You can continue to drive, right, John?

John Horton:

Right.

Dr. Andrew Bang:

You can drive. It may wobble a little bit when you're driving on the freeway. You may hear a little clunking, but you could still drive. Your joints are different. If you constantly crack that one joint, you'll function fine. But over time, that micro trauma will probably be what causes the arthritis. Not the popping itself, but the effects of too loose of a joint.

John Horton:

So, it sounds like it might not cause it, but it's going to put you on the road there.

Dr. Andrew Bang:

That's probably a good way of describing it. It's not going to, in and of itself, is not going to cause a problem, but the repetitiveness of that continuous cracking will cause too much micro trauma. Then, you maybe walk off a curb. You get a little strain on the knee, then that starts that little bit of bleeding, which then degrades that smooth part of the joint. And that smooth part's not so smooth and that rubs funny, so then, that irritates this side. Now it bleeds a little and then that, it's just this vicious cycle that happens over a long period of time.

John Horton:

So, if you're cracking regularly as you're moving around and it feels a lot, is there anything you can do within your lifestyle that might make your joints a little less musical all the time?

Dr. Andrew Bang:

Yes. Yes. If you don't want to be a joint performer, a musician performer, yes, there are some things you can definitely do. And first of all, most of it becoming aware of your situation. So, take an example of, OK, let's say it's my neck that seems to crack every time I'm in the car and I turn one way or the other to look behind me, I get a lot of cracking sensation. I got to go to where I spend the most time, OK? Start there and usually you get the answer to your question.

So, for most of us, it happens to be work, OK? We spend most of our waking hours at work, and for the vast majority of us, that's at a computer. If it's not on a computer, maybe you drive for a living or you're doing some kind of service-oriented job where you're looking down. So, the computer, we often look down. Driving, we often look down and forward. Service jobs. Cooking. Jobs like what I do, manual jobs, physicians, chefs, service in a restaurant, grocery stores, we're looking down a lot. That could put pressure onto our neck joints. Pressure builds up, that pressure builds up over time. We feel the need to crack.

So, if we can reevaluate some of our setup and we not put pressure on the joint to begin with, we won't feel that sensation, I need to crack my joint. This being the neck as the example. So that is a huge one. Becoming aware. "What am I doing? Oh, on my computer." I'm using a laptop, which is on my desk because I'm working from home two days a week, let's say. Well, if I take and put that on a laptop stand, get a separate keyboard or mouse. Now I'm looking forward at my screen instead of looking down at my screen and I'm not putting excessive pressure on my neck joints. I won't even think to crack my neck because I won't be feeling anything.

Now, not all jobs are, you're able to vary your task. So then, in that event, you try to switch your task more frequently. Instead of doing one thing continuously, you might do one task that requires you to look down for a number of minutes, then switch to a task that lets you look up for a while and then go back and forth a second.

John Horton:

It kind of varies your motion a little bit. Make sure you're not locked into one spot for too long. OK.

Dr. Andrew Bang:

OK, John, this is going to test our friendship right here. I always have this funny catch line when I say, "Do you remember what that funny catch line is when it's related to motion?"

John Horton:

“Motion is lotion.”

Dr. Andrew Bang:

Yes.

John Horton:

The Dr. Bang trademark line.

Dr. Andrew Bang:

Trademark line. I have done my job. You remember my most famous saying. Yes. It's such a funny term, but it's so true, and people literally get it when I tell them that. Motion is lotion. If your joint in your neck is not moving, it's getting stuck in one position, it tightens up, you feel like you need to crack it. You're creating your own lotion motion; you're trying to move your neck. So that's the natural process. So, if we just avoid putting pressure on there, you're not going to feel like you need to.

John Horton:

Well, Dr. Bang, we've covered a lot of ground and laughed a lot, so is there anything else we need to touch on before we leave this topic?

Dr. Andrew Bang:

When it comes to your musical joints, cracking and popping them? No, no, I think we've covered it all. I think remembering to avoid excessive pressure on your joints is essential. To make sure you're moving and stretching.

Oh, you know what? All right, so let's say you've just figured out your workstation set up, how to avoid pressure on the neck joints and you're still feeling some sensation to crack your neck occasionally. The next thing to attack would be the tightness in the muscles themselves.

And so, what I would say is, you're trying to break this habit of like, "Oh, I've been cracking my neck a lot." You're trying to break that habit. Then, what you need to do is get that workstation set up properly. Change your position in your car so you're not looking down. Hold your cell phone better and now start stretching the neck muscles that surround that joint or any joint, I suppose. If you're having cracking in your knee, well, let me start stretching my hamstring, my quadricep, the muscles that are above it and below it and around it, OK? That's the big take home. You got to stretch all four quadrants.

So, with my neck, let's say my neck tight. I want to stretch this side, this side, but I also want to stretch the front neck muscles and the back neck muscles. That will also release and then, I won't feel like I need to crack it either. So, changing our position and then stretching the connective tissue around that joint is going to be vital for making you not crack as much.

John Horton:

Well said as always. So, thanks again for stopping by, and I look forward to having another chat soon!

Dr. Andrew Bang:

Awesome. Thanks so much, John, for having me, and good luck to you patients out there.

John Horton:

Joints that pop and crack are pretty normal and usually nothing to worry about. Even if they do sound alarmingly loud, consider it a musical soundtrack for getting older or just moving around during the day. Till next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.