Saturday, December 6, 2014

When It Comes to Knee Pain, What’s Your Religion?

When I read an expert’s answer to how to deal with knee pain, the question above is always forefront of mind. What is their belief framework for analyzing and treating the underlying condition?

Mostly I find experts are structuralists of some stripe. In other words, they believe “your knee cap is mistracking and that’s why you have pain and that’s what you have to fix.” Some are more hard-core than others.

Take “Running Doc,” for instance, who tries to help Laura G. here who has been told she has “Runner’s Knee.” But her only exercise consists of shopping expeditions at the mall!

Well, the doc describes her problem instead as “Maller’s Knee” (for anyone curious about who the great physician “Maller” is, I think this is just an attempt to be clever). He then goes on to equate “patellofemoral syndrome” with “chondromalacia patella” (as I note in my book, they’re not technically the same, but it’s a revealing confusion).

He does promise the reader that “understanding the real cause makes treatment easy and pain relief possible in a short period of time.” To me, after hearing so many stories from knee pain sufferers engaged in a frustrating battle to beat their problem, this phrasing sounds a bit glib, to say the least.

The underlying cause, he tells us, is your ....

Feet.

And your parents stuck you with those feet, so your pain is -- well, sorry bub -- your biological structuralist destiny, you might say.

How does he get from your feet to your knees?

Here’s one example he gives:

Your foot rolls in (pronates), leading to your kneecap mistracking and scraping along one side of the patellar groove, leading to the cartilage under your kneecap getting eroded away, leading to ... pain.

So what’s the solution? Interestingly, one would assume -- after such a bleak kind of structuralist analysis -- that nothing short of surgery to fix the cursed defect would do much good.

But actually, he states that arthroscopic surgery helps maybe one out of 100,000 sufferers (a bit hyperbolic I’d say, and I’m no fan of surgery either). No, the real solution: orthotics.

His apostolic faith in orthotics made me smile. Here is the New York Times telling us that a longtime researcher into orthotics has found they don’t really work and when they do, it’s not clear why. And so, “The idea that they are supposed to correct mechanical-alignment problems does not hold up.” (After reading the article I bravely gave up the shoe orthotics I thought I couldn’t live without, and I’m perfectly fine today without them).

As for Running Doc’s “first mover” in his chain of events resulting in knee pain misery -- that maltracking patella -- that too may not be the problem for a large number of cases of knee pain. (See this study I’ve linked to about a kajillion times.)

So at this point you may be thinking, “Okay smarty pants who isn’t a doctor, what’s your religion?” And I’d have to say my thinking aligns best with that of Dr. Scott F. Dye and his thinking on “envelope of function” (see here). Basically, when you exceed that envelope over a period of time, you’ll get knee discomfort then pain. If I were talking to Laura G. about her problem, I’d be more curious about the following than what her feet are doing:

What’s your weight? Is it where it needs to be? Has it changed recently? By how much?

Did your amount of non-exercise movement change before the onset of knee pain?

Were there any traumatic knee events you suffered in the year or two preceding the knee pain?

Can you describe how you use your knees, 24/7, during a typical week?

Of course I could be off base with this line of inquiry in Laura G.’s particular case. It’s always possible that she was born with crappy feet and is now paying the price for it. But somehow I doubt that’s the real problem.

Saturday, November 22, 2014

Old, Bad Beliefs Die Hard

I came across this Internet article on the VMO (vastus medialis oblique), one of the four muscles that, collectively, are known as the quadriceps. About halfway through, I noticed an interesting assertion:
... patellofemoral pain syndrome. A misaligned patella results in pain on the front of the knee, ultimately caused by a weak VMO.
My initial reaction was along the lines of “Whoa, back that truck up!” For one, if you read a lot of the literature on patellofemoral pain syndrome (PFPS) from informed sources (as I’ve tried to do), you’ll discover there’s much confusion about what indeed does cause PFPS. (Actually, to take a step back, it’s not even clear that this is a meaningful diagnosis in the first place.) So this article’s pat suggestion that your knee pain is caused by a misaligned patella that in turn is caused by a weak VMO is venturing way out on a limb.

For starters, the role of a mistracking kneecap in causing pain may have been oversold. This study (rather small but intriguing) found no relationship between the amount of patellar mistracking and reported knee pain.

Then there’s the problem of strengthening the VMO in isolation. That, by implication, is what someone with a weak VMO in this scenario needs to do. After all, if your problem is maltracking, and you strengthen all the muscles equally, then it seems you would have the same amount of maltracking, only with stronger muscles causing it.

So how do you strengthen the VMO in isolation?

Well, you can’t, as Doug Kelsey has observed a number of times, such as in this passage:
The VMO is one of four muscles which all share the same nerve: the femoral nerve. Muscles contract when nerves tell them to contract. Since the VMO has the same nerve as the other three thigh muscles, it will contract along with the others. You cannot make the VMO contract by itself.
Strengthening the VMO to correct a mistracking patella is a typical old school recommendation for treating chronic pain from achy knees. Tease the reasoning apart, bit by bit, and it falls to pieces. Yet the advice lives on in many corners of the Internet.

Saturday, November 15, 2014

Of Goats, Noses and Knees

Here’s a novel location to pinch a little cartilage for rejuvenating a worn-out knee joint:

Your nose.

Apparently a study on goats (I know, from weird to weirder) showed that the cells in their noses that make cartilage could perform the same function in their knees.

So now researchers are seeing if they can replicate the results in a human trial. Full results weren’t available when the summary linked above was written, though we were told the patients were doing “extremely well.”

This story somewhat surprised me. I would have guessed that knee and nose cartilage are from two different families, so to speak, and one wouldn’t be able to properly substitute for the other. But looks like I would be wrong. :) In any event, if you have bad (or no) cartilage in your knees, in another 10 or 20 years, doctors may be assessing your schnoz as a potential donor site.

Saturday, November 8, 2014

Platelet-Rich Plasma Therapy Wins Some Fans

This article recently caught my eye.

A Utah doctor told assembled colleagues at the annual meeting of the American Society of International Pain Physicians that studies are showing the efficacy of platelet-rich plasma (PRP) therapy for various conditions, including knee osteoarthritis.

Dr. Richard Rosenthal cited for example a paper showing that patients (the subjects were age 45 to 85) had a significantly smaller chance of reinjuring their rotator cuff after a massive tear if they received PRP gel. A different study demonstrated a salutary outcome for lower back pain sufferers.

Caveats are in order of course, as the article notes. PRP is still a relatively young procedure. Issues remain to be sorted out, from the proper protocol for treatment to identification of differences among some 40 products currently on the market.

One voice of caution, Wellington Hsu of Northwestern’s school of medicine, notes that there are “holes in the evidence for PRP in the management of osteochondral lesions and knee osteoarthritis.”

So, expect further studies. The good news is, if PRP continues to shine in clinical trials, insurers may agree to pick up the tab for the procedure -- some $750 per injection -- which (at least in the U.S.) they won’t do now.

Saturday, October 25, 2014

Clarification Corner: On Muscle Strength and Anti-Inflammatories

Recently I read some criticism of my book that had me grinding my teeth because it was just so wrong.

So let me clarify a few things for the record.

Saving My Knees is my story. It’s what I did to save my knees. What you should do may be exactly the same. Or, most likely, what’s best for you will differ in some ways. In the book, I simply tried to expose some of the wrong thinking that held me back while giving credit to some of the right thinking that helped me overcome my condition.

To quote from my own introduction:
I don’t include twenty pages of illustrated exercises . . . My preference would be to call Saving My Knees broadly prescriptive. I lay out what I tried, how I succeeded, and what I learned. My goal is to show how knee pain sufferers have to start thinking about their knees and what’s important for those ailing joints to heal.
Another thing:

I am not against strong legs to support weak knees. Strong muscles supporting the knee joint are wonderful. If you have bad knees, and you can do quad-strengthening exercises -- squats, straight leg raises, whatever -- without worsening your symptoms, do them, by all means.

But I couldn’t.

And when I finally recovered from knee pain, I found Doug Kelsey (he of Sports Center, who is the smartest guy I know of when it comes to rehabbing bad knees) nailed it with this observation:
Having stronger muscles is helpful but weak muscles are not the primary problem.
The strength of that knee joint is the main problem, I realized, and so I focused on that through a program of movement. My legs in fact got weaker as my knees got better.

And finally:

You may decide to take nonsteroidal anti-inflammatory drugs. That’s fine. They didn’t work out well for me. Here are four things to consider if you are thinking of taking NSAIDs.

(1) Anti-inflammatories can mute constructive pain signals that are telling you “don’t do that; it hurts.” For example, as I describe in the book, I took an arthritis drug that helped me get through an afternoon sitting at work, but the next morning my knees felt worse because they really weren’t strong enough for prolonged bouts of bent-leg sitting.

So the upshot was I could take a drug to make the discomfort go away, but underneath it all, my knees were still too weak to do what I was making them do. Fixing that weakness was my main challenge.

(2) NSAIDs can have unpleasant side effects that, for example, affect the cardiac and digestive systems. This shouldn’t be a problem for most people for short-term usage, but the more you take, and the longer you take them, the more it becomes an issue.

(3) If you take two aspirin -- or Advil or whatever -- twice a day now to manage the pain, then a year from now, you may be swallowing three aspirin four times a day. Often, the drugs lose efficacy with constant, repeated use, necessitating higher doses -- which boosts the likelihood of those unpleasant side effects.

Now for #4, which is the real kicker.

(4) I asked my doctors if anti-inflammatories would slow the progress of cartilage loss or fundamentally improve my underlying condition. I was told they would not. This is the common thinking among doctors and medical professionals. Here is one site weighing in; I could find a dozen others saying essentially the same thing:
Anti-inflammatories do not alter the course of painful conditions such as arthritis. They just ease symptoms of pain and stiffness.
I’m not denigrating the benefit of easing symptoms. Still, ultimately, what matters most is fixing what’s causing the symptoms. And when it comes to mending what ails you, anti-inflammatories appear to have no effect.

To be fair, I’ve had some exchanges with a blog reader on whether just suppressing inflammation should be beneficial, by slowing the degradation of cartilage. There seems to be a logic to that, but I’m not sure if NSAIDs significantly affect cellular processes or just mainly calm nerves. I do think that if they had clinically proven powers to stop or slow disease, drugmakers would be boasting about this is 30-foot-high advertisements -- which they’re not. (An aside: I’m talking about NSAIDs here and not the more powerful DMARDs used for treating rheumatoid arthritis.)

If in the future NSAIDs are found to help beat arthritis -- not just mute the symptoms -- I’ll be sure to share that on this blog.

However, even if they do, you still have to wonder if the negative effect from NSAIDs blunting pain signals would outweigh what may be a small benefit that the drugs would have in preserving cartilage.

So there you have my clarifications. I hope that's clear now. :)

Update: I received a good comment below from a frequent reader. I know she’s spent a long time (just as I did), thinking about healing bad knees. She writes (excerpted here; in full below):
I must confess that I sometimes questioned your story, because I found the term 'strengthening the joints' difficult to grasp. I clarify: to strengthen your joints, you moved them. Moving them will also stretch the tendons and ligaments, rendering them more flexible and better at keeping your knee stable and mobile. Right?
This isn’t quite what I mean. By “strengthen” the joint, I refer to making the non-muscular soft tissues stronger and more resilient. Take cartilage, for example. If Joe does nothing but sit on his couch, while Tim (sensibly) runs 40 miles a week, Tim will have stronger (more resilient, tougher, better-performing, more able to withstand shock) cartilage in his knees after a year. For purists who object to my usage here, “strong” is a versatile word in the English language; it can be used to describe everything from muscles to one’s resolve to do something. Just Google “stronger joints”; many people use the word as I am here.
I found with the walking programme and hydro that I eventually have to strengthen my muscles around my knees, and again I'm not talking quad sets or squats, just making my legs stronger because I experienced something in the last few months. I was able to manage the pain and sometimes be pain free for days. But when my legs muscles really started to weaken, the pains became continuous. Only now that I have started a programme of hydrotherapy do I see a slight improvement. ... In fact, the book Heal Your Knees also explains the same: the less you move, the more the whole structure of your knee weakens.
First, I completely agree with the “the less you move, the more your knee weakens.” Use it or lose it. Absolutely.

But there are two kinds of exercise that can be done.

(1) High load, low repetition (better at strengthening muscles)

(2) Low load, high repetition (better at strengthening cartilage)

What I found, at least with my own bad knees, was that gains came by focusing much more on exercises of type #2 than type #1. My joints weren’t strong enough to withstand the force needed to effectively build muscle. (And evidently, as stories from other readers such as Luis here describing his wife’s recovery indicate, I’m not the only one who found success with this formula).

I’m certain my leg muscles got weaker during my program to heal. But I was moving a lot (walking as much as my knees could stand), so I never felt worried that my legs were getting too weak. Deloupy says “I found with the walking programme and hydro that I eventually have to strengthen my muscles around my knees, and again I'm not talking quad sets or squats, just making my legs stronger because I experienced something in the last few months ... when my legs muscles really started to weaken, the pains became continuous.” If strengthening muscles around your knees helps with that pain -- and those exercises don’t worsen symptoms -- that’s great. Keep doing ‘em! :)
On the inflammation: I am taking some NSAIDs for the first time in 14 months, and I don't think they blunt the pain at all. However, I have noticed that the inflammation has lessened a bit, allowing me to walk better. If you can't walk, you are not going to achieve much with a strengthening programme through movement, are you?
Yes, people with bad knees do need to move. If NSAIDs help you get off the couch and into reasonable activities for your particular joints (“reasonable” is the operative word), then taking the drugs for that reason makes sense to me. (I like Racer X’s suggestion below in the comments section, to use them as a “stopgap measure”; by the way he notes some other interesting reservations about using NSAIDs). Just remember: NSAIDs themselves don’t fix what’s wrong with your knees. And not taking them, by extension, doesn’t ruin your knees either.

Sunday, October 12, 2014

Time for Another Personal Note

Some of you may have noticed that I have been posting less frequently.

Well, in April of this year -- for the first time in my life -- I became a homeowner. My family now lives on Long Island’s north shore. Our community boasts its share of the affluent; I like to joke that we’re the poorest people in town. The major attractions included the excellent schools and low crime and short distance to beaches and water. Our house -- as befits a house belonging to people who aren’t among the nouveau riche or the nouveau near riche or anything like that -- has its share of problems. Windows that won’t open (normally). Leaking tubes in toilet tanks. A broken air conditioner in the basement. Etc.

So now, along with having two kids who constantly clamor, in their own ways, “Play with me!” I have an equally insistent house clamoring “Work on me!” So I’ve repainted a room, replaced door locks and fixed leaks in a toilet tank. When your home was built on the cusp of the Great Depression, in 1928, there’s never a shortage of things to do.

However, I’m still actively monitoring the blog, even on weeks when I don’t put up anything new. Recently a post attracted 36 comments! While that had more to do with people talking amongst themselves than the actual post, I think it’s great that a small community of (pretty smart) knee pain sufferers has cohered around this blog.

As for my future plans:

I’d like to get out a second edition of Saving My Knees in 2016. Why?

Among other things, I want to update readers on how my knees have been since I published Saving My Knees (basically, great). Partly I want to do this because I still get e-mails from well wishers that contain lines like, “I hope your knees are feeling better.” Also I want to talk about what I’ve learned since that publication day, back in January of 2011. And I want to address frustrated readers who complained that they couldn’t figure out how I healed my knees from the book (it isn’t all that exciting, as I’ve said before on this blog, but I never meant to leave this as a mystery).

Because I think Saving My Knees is about 10 to 20 years ahead of its time (in the rejection of structuralist tenets and in the level of justifiable optimism in cartilage healing, or at least improving substantially), I think the message on its pages will continue to be fresh for another couple of decades. We’ll see.

In closing, there’s one other cool thing I wanted to mention: Sometime recently, while I wasn’t paying attention, this post of mine became the most read on this blog:

Here Are My “Radical Beliefs” About Healing Bad Knees

I love it. This short post shows the reader, largely using common sense, that what I believe about healing bad knees isn’t crazy. What’s really crazy is the traditional treatment protocol (and underpinning beliefs) that doctors and physical therapists advocate.

Saturday, October 4, 2014

How You Feel Affects How You Heal

Here’s a study that tells us something rather intuitive.
People who tend to blame others for their suffering and think setbacks in their lives are irreparable tend to report more pain after knee replacement surgery, according to a new study.
Ordinarily, I’d deride this sort of finding as one for the annals of Captain Obvious. Nothing surprising here.

But the larger point is worth underscoring.

People who are gloomy fault finders, looking to blame others for their misfortune, are most likely going to do worse at everything from healing and managing pain to standing in a long line for pizza without exploding. When it comes to one’s health, there is such a thing as a “negativity tax.” I’m convinced of that.

Attitude matters. If yours is, “Okay, I’m going to try X to heal my knees, but nothing else has worked and this probably won’t either,” then guess what? It probably won’t. Because you’ll undertake the program half-heartedly, with the built-in expectation of failure. How many people do you know who have achieved a difficult goal have an approach of “Oh well, let’s see what happens, but I’m really pessimistic?”

Now, for those interested, some details on the study:

A group of 116 men and women (age 50 to 85) who were scheduled for knee surgery took part. Before the surgery, they filled out questionnaires that assessed “perceived injustice, how much they think about or worry about pain and their fear of movement or re-injury.” A year after surgery, they were surveyed again. Those who (before surgery) felt helpless because of their pain and judged life as unfair did worse after the operation, even after controlling for such factors as age, sex, and prior pain levels.

To be fair, there is a wrinkle here:
Researchers don’t yet know if people with more negative outlooks only perceive their pain as worse than others or if their psychological state affects the physiology of healing and actually leads to more pain.
Still, pain is pain, and I’m not sure it’s much different to have level 5 pain and think it’s level 9 than to have level 9 pain in the first place.