One of the most frequent questions I encounter from patients are those concerning crepitus, audible clicks/pops/snaps produced by bodily movement. It is rare that I make it through an entire day without at least one patient asking me about a weird sound coming from a particular joint or area. The ubiquitous nature of this question can leave the therapist feeling frustrated, which unfortunately is the surest path to well-intentioned dismissal.
"Does it hurt? Oh, well then it's nothing to worry about. Lots of people have this."
From an empathy perspective, it is important to understand that these noises can be distressing. Cognitively, they can make the patient think that something may be wrong with that body part, or that they may be causing damage. Since these sounds rarely improve, they can foster a sense of powerlessness / low self-efficacy. Emotionally, they can be a source of worry, anxiety, and frustration.
#1 Google Image result when searching for crepitus. Another shining example of a confidence-inspiring, worry-reducing image provided by the world wide web... (heavy sarcasm implied!).
The goal then, in these situations, should be to reassure the patient while working to change their beliefs about the nature of crepitus. However, it is important to understand that reassurance is much more than simply telling the patient that there is little/nothing to worry about it. Reassurance, in most situations, should involve making the patient feel as though you understand their concern and validating their perspective.
To this end, you need to be investigative, which ultimately involves utilizing good listening and interviewing skills. I like to begin by asking the patient to show me the crepitus (if they haven't already!) and confirming that I feel it / hear it. A well placed hand on that particular joint may improve your ability to feel the popping/cracking while enhancing therapeutic alliance through tactile touch.
Most commonly, a series of motivational-interviewing styled questions and validating statements should follow. Of course, these should not be rattled off like a list, but should be tailored to the individual patient and your interaction with them thus far. The goal here is to improve your understanding of the cognitive and emotional factors which are involved in the crepitus that this patient is experiencing.
"I hear/feel the snapping. I can see that it happens when you move your shoulder in a circular motion like that."
"It's pretty loud. That must be annoying to be feeling/hearing that all the time."
"It can be disconcerting hearing sounds like that coming from your body."
"Do you take that clicking sound to mean that something is wrong with your shoulder?"
"Are those sounds worrying/unnerving to you?"
Etc., etc., etc...
These types of statements should help you better understand the patient's viewpoint. When they talk: listen. Their word choice and body language will give you greater insight into their concern. You can later use this language back to the patient when providing an explanation.
Availability Heuristic
A concept that I find extremely illuminating when discussing crepitus is that of availability heuristics. Put simply, human beings all have a natural tendency to draw quick conclusions based on easily available/memorable parallel scenarios. Most objects and machinery, when broken, make strange sounds. Cars, lawnmowers, garbage disposals, etc. commonly make unnatural noises when something isn't working as intended. This is the heuristic from which most patients, without a second thought, apply to the pops, cracks, and snaps in their body.
I believe that reflecting this heuristic back to the patient is an effective way to help initiate a reconceptualization of the crepitus. Validation and reassurance can can also be applied during your explanation, as necessary.
"The thing about popping/snapping is that it can be really distressing/unsettling/etc. When your garbage disposal isn't working, doesn't it make weird sounds and clicks? When your car engine isn't firing correctly, what types of weird sounds does it make? Yes, exactly! It's really natural to apply that same logic to our own bodies. My shoulder is popping, so something must be wrong/out-of-place/etc. The truth is, that when it comes to the human body, a vast majority of these sounds are normal. They tend to occur more frequently as we get older, but are rarely if ever indicative of any pathology or dysfunction."
Of course, this is just an example. Situationally, it might be worthwhile to discuss how crepitus is frequently asymmetrical, or that it can often times occur after an injury due to changes in tone/movement/scar tissue/etc. Actual mechanical explanations of the causes of crepitus (cavitations, tissue interaction) can be provided, but I find that they are rarely necessary unless the patient specifically requests them or implies they would like more detail. Sometimes, I'll show patients the loud cracks that my left ankle makes in a show of solidarity or to further prove its normalcy.
Whatever your approach, the goal here is make the the patient feel that you've identified and understood their unique concern, assuage the concern through education/stories/discussion, and help the patient arrive at their own conclusion. "It's normal, don't worry about, keep on living life" is the ideal conclusion, but the art is helping the patient arrive at and internalize this conclusion. You can't tell people what to think or feel, but you can help guide their thought process.
Like pain, crepitus is unique to each patient because, despite its omnipresence, it is what the patient believes/thinks/feels about that crepitus that determines its effect and impact. Providing that reassurance and understanding can lead to long term reconceptualization, and helps build better rapport and subsequently, outcomes with individual patients.
