The Knee Bone, the Thigh Bone, and Adventures in Structuralism

After my last post, I got this comment:

Hi Richard, what do you think of the hip (especially abductor) strengthening exercises that are now being commonly prescribed for chondromalacia/PFPS? Seems like the dominant advice is shifting away from quad strengthening and towards hip strengthening. Have you tried it or done any research on it?

After reading this, that children’s song, “Dem Bones,” began running through my head:

The leg bone's connected to the knee bone,

The knee bone's connected to the thigh bone,

The thigh bone's connected to the hip bone …

Truly, we are all biological marvels. The way locomotion has evolved is astounding. I don’t profess to have much of an understanding of how, exactly, we walk and how this process can be both fluid and stable, but I know that it’s complex. Walking, running, jumping … our bodies have to recruit a bunch of different muscles and rely on certain supportive tissues to accomplish these activities.

Unsurprisingly, there appear to be some physical therapists who are fascinated by the biomechanical interplay that lies behind the movement of our lower limbs. They are fascinated by the connections, by how one thing seemingly remote from our knees (our butt muscles, e.g.) can influence a joint that is a couple of feet away.

A lot of them are structuralists (not my word, rather, the writings of Doug Kelsey first introduced me to the concept). Structuralism is the subject of this rather long post. Kelsey defines it as "a school of thought that believes the genesis of musculoskeletal complaints is from one or more biomechanical abnormalities."

And, for a structuralist trying to diagnose the source of patellar pain, abnormalities of interest include “a laterally tracking patella, weak medial quadriceps, tight hamstrings, tight iliotibial band, tight calf muscles, weak or tight hip rotator muscles and over pronation of the foot,” he informs us. (There’s our hip!)

One glaring problem with the structuralist story of knee pain, though, is that nobody has ideal biomechanics, yet most of us do just fine anyway. For example, I’m pretty sure I have a mild leg-length discrepancy. Yet it didn’t bother me for decades. Then, in my forties, I wound up with serious, chronic knee pain.

So was it because of my leg-length discrepancy? Or because I had been cycling recklessly up small mountains in Hong Kong, then piled on a long endurance hike on top of that one day, and that pushed my knees over the tipping point?

I think you’ve figured out where I stand on this. I’m not a fan of structuralism. There could be cases where it makes sense, but I would expect them to be a small minority. If your knee hurts – d’oh – why not start with where the pain is coming from? The knee? That’s more logical to my brain anyway.

I urge you to read that earlier post I linked to about structuralism, and especially take note of a study cited that looked at knee cap mistracking. Hell, that’s an instance of structuralism that even seems to make sense. A mistracking kneecap should cause issues, right?

But a study was done. And it found, basically, that whether a kneecap tracked improperly was no predictor of knee pain. You could have knee pain and a perfectly tracking kneecap, or no pain and a mistracking kneecap.

Physical therapists, in my experience, have been the biggest fans of structuralism. I had one who liked to have me do one-legged dips to check my alignment. I don’t think he ever figured out anything about my alignment. However, by putting so much force on what were bad knees at the time, he did manage to set me back in my healing.

Fighting Through That Hopeless Feeling

I got this comment from my latest blog post, and I imagine a lot of people here can relate:

I’ve been suffering from knee pain for 8 weeks now. I fell into the trap of “resting” and immobilizing because I was scared of pain, and because I couldn’t get free of the pain. Along the way I found your blog, and decided to try your methods. I finally got free from the pain 2 weeks ago. I walked 1,500 steps in the course of a day. Doing 50 to 100 steps every hour. And I woke up the next day with a return of pain. I’m so crushed and in disbelief. How did I go from walking 6 miles a day to unable to walk barely half a mile without pain? I feel so hopeless. I’m only 25.

Setbacks. They are ugly and so, so depressing. This fact has come into greater focus for me now, as I try to recover from whatever is ailing my left foot (maybe plantar fasciitis?). Twice, I thought I had this foot problem licked. And twice, I have had setbacks. Ugh.

So what should be said to someone who is only 25 and is unable to walk barely half a mile without pain? And who feels like everything is hopeless?

Well, first, I guess I'd say: look on the bright side. You're 25. That may be seen as a curse (what 25-year-old is cursed with chronic knee pain?). But it can also be viewed as a blessing. Younger bodies generally heal better. I would not write off being able to heal at any age, but it gets harder as a 65-year-old.

Then: have you seen a doctor or therapist? It might be time, if not. Sure, a doctor might leave you frustrated and confused. But it's possible that this doctor -- or an imaging test that's done -- may discover something going on in your knee that, in the end, will put you on a smoother glide path to healing. It always helps to have a professional examine your bad knees and question you about them and offer an opinion about what's going on.

And then, on your setback: I know how this feels. I remember trying to heal my knees, and the times when I pushed them a little too hard and suffered a setback. It was always crushing. That's a reason why, to this day, I say that healing my knees was by far the hardest thing I did in my life (and, as a result, the thing that I'm most proud of).

If walking bothers you now, you might think of trying gentle cycling (a stationary bike is generally better, as it's easier to control the force applied) or gentle movement in the water (is there a pool nearby?). And, if it makes you feel better, make yourself a big "I've Fought Through a Setback" badge and wear it proudly. You'll have more. That's typical of healing through knee pain.

Lots of luck, and don't give up!

Why to Be Optimistic About Recovering from Knee Pain

Right now I can't ride my bike. I'm frustrated.

But all this has absolutely 0% to do with my knees. Rather, the weak link in the biomechanical chain for the past month has been a sore left foot. Why is it hurting? I don't know. Part of me thinks that it's the dreaded PF: plantar fasciitis.

Of course because exercising becomes addictive, I was slow to walk away from the bike and my active lifestyle (sound familiar? welcome to how Type A people deal with sports injuries). I don't have easy access to a pool (and am a poor swimmer), so I'm casting about for some other cardio activities. I am toying with the idea of buying a rowing machine.

Anyway ...

That's just a quick update of me, and where I'm at currently: great knees, lousy left foot. During this self-imposed period of being on the sidelines, I've had more time to reflect. I don't contribute much to this blog anymore, but then I see a little spurt of book sales (kind of amazing that the book still sells, even in modest numbers), and I think of the "knee journey."

I know occasionally I post about it, the Big Picture Overview, for people who may have just stumbled onto this blog. I know how they feel, and how they're struggling with trying to digest so much advice, some of it conflicting. I know that in a fresh way too (with my left foot, I'm seeing "walking barefoot is good" and at the same time "don't walk barefoot," e.g.).

Today I just want to talk about one uplifting, inspiring part of my journey: realizing that the old doc's line that "bad knees can't heal; they'll just get worse and wear out over time" was a load of crap.

The thing is, the more I thought about it, the less sense it made. Our bodies are designed to heal. Even brains adapt after horrible traumatic brain injuries. How can a knee joint -- a joint that has evolved to take a lot of pounding force, day after day -- not have any capacity to improve?

But what happens is bad knees have a much smaller "envelope of function." They can't tolerate as much stress. So when you subject them to the normal forces that normal knees can withstand, yes, they do get worse. And yes, if you continue to do that, you won't get better.

The first problem is, most of us are great at digging holes, and not the good kind. We feel twinges of pain and we think, "Oh, I'll exercise through it" or "It'll go away soon." We don't try to modify whatever behavior is contributing to that pain for a while, and sometimes a long while. We dig a giant hole for ourselves, where we unhappily find ourselves at some later time, desperate for the solution to our nagging knee pain.

It can require radical changes to get your knees back within that "envelope of function" that will allow healing to begin, very slowly. Most people, I'm now convinced, lack the patience and determination and sheer willpower to heal their bad knees.

But even before you set out on the journey, you have to start with that little seed of optimism: that it's possible. I did it. Someone who posts here under the name "Knee Pain," she did it. And "TriAgain," who also posts here, he did it. I have more respect for these people than for myself, and my journey, because theirs took longer and seemed to me to be more difficult.

But it all starts with a simple premise: bad knees can get better. You have to believe that. I did, not because I'm some kind of starry-eyed optimist, but because the rational part of my brain told me that this was the only viewpoint that really made sense.

How the Idea of 'Sunk Cost' Relates to Recovering From Knee Pain

I was thinking of the idea of "sunk cost" a few days ago while trying to fix the vent for my dryer.

The vent is a four-inch wide tube, made of thin metal, through which the dryer's hot air whooshes outside. Ours is old (like everything in this old house) and I had to replace the cracked cover. Among other things, the cover keeps small animals (and insects) from entering your house through the vent.

I bought a replacement cover at Home Depot for five or six bucks. But when I got home, I immediately noticed problems: It wouldn't fit over the existing, slightly crumpled end of the vent. Also, the screw holes to hold the cover in place weren't aligned with the existing holes.

I started thinking about how I'd have to drill new holes through the siding and into the house. I'd have to get a smaller vent pipe, that would fit my new cover. I went to a hardware store in that frame of mind ... and then ...

Voila! There was a vent tube for sale with an already attached cover. At first I passed it by -- after all, I already had a cover. But then I realized: No, wait a minute. This might be exactly what I need. So I bought it, took it home, and it fit just about perfectly, no new holes needing to be drilled.

The vent cover I had just bought? I realized it was a "sunk cost" (I couldn't really return it by then, because it had been scratched up after my attempts to jam it onto the existing vent). I had to write it off and move on.

Swallowing a sunk cost can be very, very hard to do. It's in human nature not to want to give up on something that we're invested in. I know five or six bucks isn't much at all, but my thinking had completely swung around to, "How do I make this work because I've already bought it?"

Similarly, with knee pain, if you're experimenting with ways to heal, you will sometimes have to accept the harsh reality of a sunk cost. As readers of my book know, I followed a very structured plan to get better.

But sometimes that plan just wasn't working, for whatever reason.

In the book, I described going to Tibet, doing some very slow walking with my wife (fiancee at the time), and feeling like my knees had been reborn. I was getting better! So when I returned to Hong Kong, I vowed to strengthen my leg muscles, as my physical therapist had been urging, to make sure my knee pain didn't come back.

But instead of the gym exercises pushing me beyond knee pain, they pushed me back into knee pain. My old problems returned. I stubbornly persisted with the exercises until it became impossible to ignore: they were hurting me. I couldn't continue that way.

In essence, I was staring at a sunk cost of sorts. I had invested heavily in this "strengthen your quads" approach. I was religiously going to the gym, lifting leg weights, trying to get stronger. Meanwhile, my knees were getting worse. To continue doing the same thing would be insanity.

I did walk away from that approach, but it was hard. It felt like I was giving up in a way. I had sunk my time and faith into something that didn't work. It's difficult to accept that, first of all, then summon the strength to move on.

Still, there will be moments in the journey to recover from knee pain where I think we do have to write off an approach, a belief, or whatever -- as a "sunk cost." We invested in it, sometimes to an extreme degree. But if it's not paying dividends, then the smart thing to do: go ahead and write it off and accept the loss (of money, time, or whatever).

Then find a new way forward.

'Your Knees Will Never Get Better'

No, no. A thousand times no. If your doctor is saying this, you need to find another doctor. This is the one thing I am convinced of, after a months-long personal struggle with knee pain that I won.

I thought that today -- a day when I honestly wasn't sure whether to write a blog entry, or just disappear into the basement and do an hour or two of easy cycling -- I would make a short post on this subject.

It is really the "raison d'etre" of this blog, and of my book. I wanted to counter the pessimism because I heard the same "your knees will never get better." And they most emphatically did.

I know that some doctors say "your knees will never get better" because they don't want to sugarcoat the reality of knee pain, because they truly believe they are speaking the truth. Maybe that's the saddest part, that they just aren't aware of how aching knees can heal.

It's not easy, but it can be done.

Here are some posts I've written on the subject:

How I Saved My Knees (in Dialogue Format)

What I Did to Save My Knees

Plus, as a bonus, for anyone who has an aching back ... 

How I Saved My Back

All free posts! (The blog is always free!)

And: anyone with a success story they want to share? (I always love to get those stories out there.)

A Success Story: Gradual Strengthening and a 'Reconditioned Brain'!

It's a new year, so what better way to start than with a success story? This one I got in the comment section. I edited it lightly:

I'm a long time reader. I first had knee pain in 2018 and lived with it through lockdown. It was agony. For much of it, I was ready to just chop my leg off.

Through walking, and cycling, and following your advice I healed about 70% in 2022. However, my wife and I learnt that we would have a second child in 2023 and I was desperate to fix it even more.

I visited my 5th physio. The others hadn't helped at all, but this physio had been highly recommended and seemed, well, enlightened.

So we began a very, very gradual strengthening program, always playing it safe and being careful. The physio was convinced I'd been badly advised by a doctor (who said I had very cracked cartilage and was basically a lost cause). This time, my physio reassured me that they were wrong, and that nearly everyone my age (45) has wear and tear, but that lots don't feel pain.

The physio based her treatment around the concept that the pain I felt was a memory - something stuck in my nervous system.

By slowly strengthening, I both made my leg stronger, but also reconditioned my brain, telling myself that the knee was good now and the pain had gone.

After 6 months of this, I was able to return to light jogging in summer 2023. Jogging now is helping - my knee feels strong, pain free and functions so much better.

My physio now feels that it wasn't cracked cartilage that caused my agony, but patella tendonitis .. My tendon certainly feels stronger now, and doesn't complain when I kneel on hard floors.

I would never have believed I could get back to running and cycling. One physio told me that I'd been stuck with it for four years so it was 'chronic'. I hope my story gives hope to others, as yours did for me.

Great to hear! I don't know as I really have much to add. Very, very gradual strengthening? Great idea. Pain as a memory, stuck in someone's nervous system? Hmm ...

That part reminds me of a post I wrote last year, Rethinking Osteoarthritis Pain (a Recent Presentation Now on Video). The speaker in the video talked about how bad knees are about more than the knee, and more specifically, as I wrote then:

Chronic inflammation kicks off a process where pain signals being sent to the brain are intensified, and at the same time the ability of the brain to repress such signals is damped.

Interesting, and if that does happen, it wouldn't surprise me at all. I think the longer that someone lives with chronic inflammation, the more mischief it stirs up in the body.

And not in a good way.

What I've Learned About My Knees This Year

It's December, another year drawing to a close, and I'm grateful to be the owner of two well-functioning knees. I now know the danger of taking them for granted, of exercising through the warning signs of injury.

At this point I have normal, or probably better than normal, knees. But that doesn't mean there aren't some issues that pop up here and there.

I am a bit fanatical about getting in my exercise, and I like to do it intensely. That's great for my cardiovascular system, but as I get older, it can be a bit taxing on my joints.

I can give you an example that involves my favorite indoor cycling activity, "Zwifting." Zwift is a "game" where a stationary bike on a smart trainer is connected to, say, an iPad and the cyclist can see himself (or herself) on the screen, riding through video game-like courses alongside other riders.

The faster you pedal in real life, the faster you go in the game.

The only trouble with Zwift is, unlike cycling in the real world, you never have to stop. No red lights. No crashes. No flat tires. No pulling over to the side of the road so someone can photograph a sunset.

It's just pedal, pedal, pedal, pedal, and this can be rather intense for long rides. I started riding 100-mile centuries in Zwift. I did one yesterday: 4 hours, 20 minutes. Phew!

However, I've noticed my left knee bothers me sometimes after these long rides. I can't tell if it's because of the bike fit on the trainer, or just pushing so hard for so long, without a break. I never have a similar pain riding in the real world.

So I've tried to troubleshoot this, and this year I'm experimenting with ramping up more slowly to the long, really hard rides. Not sure how well it's working, as I always have to fight my natural inclination to zoom off with the fast riders; it's hard to hang back and take it easy in the beginning.

Other than that, my knees are good. I walk half a mile to catch the train when I commute to work; when I work from home, I take two breaks during the day and walk almost 40 minutes during each. Motion is good. Sitting too long is bad.

What I've learned about my knees this year, I suppose, is that taking good care of them is a lifelong project. I don't need the same constant focus as when I lived in Hong Kong and battled chronic knee pain, but I am still alert to little aches, or feelings of instability, and I try to modify my behavior a bit before things get worse.

What about all of you out there? Anyone have any good lessons from this year to share?

In the meantime, happy holidays to all, and if I were a drinker (which I'm really not), I would make a toast to your good knee health in 2024!