Sunday, January 15, 2017

On Skepticism About Cartilage Healing

Recently I’ve seen some comments popping up questioning the idea that cartilage can heal. So I wanted to devote a post to that. Some of what I’m about to say will sound a bit different from what’s in Saving My Knees, because my thinking has changed somewhat. However, my belief that damaged cartilage can improve remains as strong as ever.

First, what’s changed: I don’t see knee pain through such a cartilage-centric lens anymore. Knee pain sufferers often do fine with some cartilage defects, and curing these shouldn’t become an obsession. I did note in the book that some people with cartilage defects have no knee pain; others that appear to have fine cartilage have lots of knee pain. Cartilage flaws and knee pain certainly don’t correlate perfectly.

Do I still think my problem was my knee cartilage? I think that was at least some of it, yes. My knees made awful crunching noises; they are much quieter now. But how much of that could be from improvements in the synovial fluid and how much from better cartilage? On that, I honestly don’t know. What’s changed now: I think some of my problem lay in the bone endings and could have been detected with a bone scan.

Again, these are just theories. What I do know is I had knee pain that the best doctor I saw said would never get better, and I smiled outwardly and inside I said, “Screw you, I think you’re wrong.” And I devoted more than a year of my life to proving he was. Recovering from chronic knee pain was the hardest thing I’ve ever done, and the achievement I’m most proud of (getting into Harvard was only about doing well on some tests and writing a good essay by comparison; I am extremely proud of my children, but they are their own accomplishment).

Occasionally – and I must say very occasionally, because this blog has some really terrific followers – I catch a whiff of a newcomer probing, trying to figure out what kind of fraud I might be. “Hmm, cartilage can heal? Curious that this fellow says so, when my doctor says it can’t, and my physical therapist says it can’t. But I bet you can sell a lot of books that way. So let’s see if he can produce some evidence that his cartilage regrew.”

(Please check out this post where I address head on the question “Why don’t you get a second MRI to show all the cartilage healing that you claim occurred?”)

My more expansive reply to a skeptic is: Don’t get distracted by thinking your end goal is to walk out the other end of the tunnel with pristine cartilage. That’s a waste of time. You need for the cartilage to get stronger, more resilient, more capable of handling day-to-day loads. Whether it’s once again as smooth as a baby’s bottom ... that’s not the main issue.

Today, I feel confident that mine is much stronger than it was than when I had constant knee pain.

But let’s backtrack for a moment and tackle the tough question directly. Can cartilage improve? Can it be restored in spots where it’s vanished? On this, don’t waste your time looking at my knees. Just consider the studies I cited in the book. There were two that I recall; they’re in the bibliography for anyone to track down.

Let’s consider one briefly. It’s called “A Natural History of Knee Cartilage Defects and Factors Affecting Change.” You can find it here (at least until it disappears behind a paywall, which I hope it never does, but one never knows).

What amazed me about this study, and I hope this came across in the book, is that researchers found that cartilage defect scores got better at about the same rate they got worse. Also, this was the same for knee pain sufferers as for pain-free subjects. At the time, the implications seemed mind-blowing. Changes in cartilage are a two-way street. You don’t just get worse.

So you may wonder: Well, those that got better, what were they doing differently? Answer: we don’t know. Notice this study is called a “natural history.” That means the point wasn’t to test whether walking or Pilates is better for rehabilitating bad knees; it was simply to observe the knees of more than three hundred subjects over a longish (two-year) period and see how they changed naturally.

Do you get why that’s so great? Think about it for a moment. People who weren’t trying to do anything in particular to “save their knees” saw an improvement in cartilage defects over this period. Imagine what they might have accomplished had they actually been trying to save their knees! I can’t tell you how much this study buoyed my hopes. I drank it down like a thirsty man with a glass of cold water and, once I fully grasped the implications, thought to myself, “Damn, I really can do this.”

And then there's also this other study (“Factors Affecting Progression of Knee Cartilage Defects in Normal Subjects over 2 Years”). It showed five cases where researchers saw bare bone on an MRI and two years later, in four of those cases, some cartilage had appeared (Rheumatology 2006, 45:79-84, page 81). That table I reference is in the upper left; an image showing improvement is below. Check it out.

Could it be that all these MRI readings were wrong, that the researchers are fraudulent, that the whole thing is some lousy hoax? Of course, but it’s also possible that my mild-mannered mother is secretly a Russian agent. Lots of things are possible. But what makes more sense: that we’d be created with bodies containing some tissue that just wears out, and that’s it, or that it have some capacity to heal, at least slowly? (After all, most of the rest of our body can heal; even neural networks can rewire after damage.)

I operated on the optimistic premise – not because I’m some dumb Pollyanna. I actually skew more toward the dark-humored pessimistic end of the spectrum. I operated on the optimistic premise because, at the end of the day, it seemed most rational. And it was.

Saturday, December 31, 2016

Another Success Story, With a Twist

I love success stories. I share them as often as I can. I know readers of this blog are hungry for clues as to how to heal their ailing knees. So I’m happy to share one today that popped up in the comments section. However, I do so with a big caveat.

It’s basically a “train through the pain” approach. This is NOT how I healed, and it could further damage your knees. Just be aware of the risk.

Why share it then?

Because, honestly, one thing I’ve gotten more humble about: healing knee pain can be very tough, and different knees sometimes respond well to different things. Also, author Tim Howell is clearly a really bright guy who thought a lot about what was wrong with his knees and how to fix them, and I think hearing from people like that is always valuable.

It’s possible someone out there may see himself/herself in this story, and what Tim did could help that person. I can think of at least one comment I’ve gotten on this blog in the past six years where a person said that his knees benefited from a pretty vigorous, heavy-load workout.

So here it is below, edited some for space (Tim wrote it quite well, so it was hard to edit.) To read the full version, just go here to the top of the comments section.
"I've been checking in on your blog ever since I first developed my knee problems. First, I should say that I did not get better use the low-load, high-rep motion approach that you advocate. Direct heavy strength training is what has eventually cured me and it was a long road (3 years) of trying everything else first.

"My patellofemoral pain began a month following 'routine' meniscus surgery. Initially it was palmed off by doctors as normal post-surgical pain. But it began to get worse. The pain was directly behind the patella, very sharp in nature and the knee would give way going downhill /downstairs. Any movements placing load on the patella (leg extensions/ squatting) were impossible due to the pain, and the knee would often get hot and achy at night. Walking on the flat or uphill produced no symptoms.

"I spent one year being a good boy and doing everything the physios told me to. Nothing worked. Hip strengthening, ankle strengthening, lots of semi-squat variations, VMO contractions. As I began to get desperate and my mental health took a dip, I lost faith in the patellofemoral diagnosis and began to see it as a way for people to say they had no idea. I spent a few months just trying to completely rest. This made my painful symptoms worse. At this point I had discovered your blog and book.

"I abandoned my doctors and physios, self diagnosed myself as having chondromalacia and made a plan to walk myself better. This was a major error on my part (don't get me wrong Richard, your blog/book helped in many other ways). I had no imaging evidence to suggest I had chondromalacia and was going purely off symptoms and presentation.

"Fast forward one more year. I had put myself on 'cartilage time' and had accepted that it was going to take a while to improve, but nothing was happening, no signs of improvement. Plus I never had any trouble when walking (first red flag) in the first place so there was no way to see the pain going down as I increased my step count etc. I also experimented with very light cycling and swimming, but also had no improvement.

"I tried a bunch more things, all getting more bizarre (think pulleys and carabiners) to try and gradually load my patellar cartilage and coax it to regenerate, before eventually throwing in the towel and having a long hard look at the situation. At this point I made my first good decision and got imaging done (X-ray, MRI, ultrasound). Shocker = everything inside looks perfectly healthy. No chrondromalacia.

"So spending a bunch of money to get those two words of information changed everything. I decided
A. to have a really good second look at patellofemoral pain syndrome and find out if it really was just a catch-all and
B. I was gonna find a health care professional who actually knew what they were talking about. I saw A LOT of different people. I gradually worked up the pyramid of expensiveness until I was seeing doctors of national sports teams.

"Things learned on this leg of the journey:

"1. Some people will have no idea about knees, will quote the textbook to you and will pretend to demonstrate how badly your patella is 'mal-tracking' and will give you the same 4 hip, ankle and VMO exercises that everyone else does. They cannot help you. Ditch and move on.

"2. Some will suggest that you go and have surgery again, and will be very convincing. My advice - put this as a last resort and try everything else before you let them cut you open.

"3. Some will advocate stem cells, PRP, prolotherapy or viscosupplementation. I say go ahead with trying any of these that you can afford, but say no to cortisone. If they offer you cortisone, you say no. Do some research. I could only afford an ostenil injection; it made no difference.

"4. Very few doctors will suggest a change from the standard knee rehab rubbish. But those who do may ask some VERY IMPORTANT questions: What have you already tried? Have you tried training strength through the point of pain? What happened? What changes in your knee after a good warm up?

"I didn't know it at the time but those questions are the key (or at least were for me) to beating the mystery that is patellofemoral pain.

"-Have I tried training through the point of pain? Yes, in the early days of flailing around. What happened? I was in worse pain than before for about a day afterwards and then back to normal pain levels. I assumed this was a bad sign so did no more.

"- What changes in your knee after a good warm up? I had no idea, so I tried. I did a 30 minute 'patella-focused' warm up (look up sissy squats). Minutes 1 - 15 were very painful. Minutes 25 - 30 were surprisingly more comfortable and I could bend the knee a tiny bit further. Gradually over two months I noticed that although my knee was as bad as ever normally, that towards the end of the sissy squat warm up they would feel much better. Additionally the giving way would stop happening by the time the knee was all warmed up. Worryingly I did seem to have more pain than usual later in the day after a session, but overall I wasn't declining so I carried on.

"Time to test the next question - What happens if you train beyond the point of pain? So following a good warm up of sissy squats (was now taking about 15 mins to get to the point where my knee wouldn't give way due to the pain.) I would try and do a single pistol squat. To my surprise I could do it. It was painful but I could do it. Again I was in more pain for a day following these sessions, but the rest of the time I actually seemed to be improving.

"I continued to warm up and try pistols until one day I found I could do them without without a warm up and they were almost pain free. From there it was plain sailing as I just gradually increased training load and volume until I was doing 3x15 pistol squats no warm up wearing a 20kg vest. At this point I was completely pain free in all parts of my daily life and was very, very happy.

"I should also say that I stretched regularly, foam-rolled my newly appearing (and thus easily knotted) quads. I didn't follow a specific diet, and to deal with anxiety I took up meditation as per Richard’s advice along with the Wim Hof method. The mental health aspect of this battle is no joke and should certainly be addressed proactively.

"So I think if I had to give myself from 3 years ago some brief parting advice:

"1. Don't jump to conclusions about chondromalacia without any evidence, but if you truly do have it then be careful and measured.

"2. It might be worth trying to train through pain just once as an experiment to see what happens. Do you definitely get worse or is it only a short after-effect that then goes away? Be sure about this before you decide to throw strength training out the window.

"3. See what changes in your symptoms after a thorough warm up.

"4. Keep seeing different people UNTIL someone helps you, there are people out there who know what they're doing; they are just hard to find.

"5. If you get better share your success story."

Amen! Share your story! In the comments section below, if Tim’s around (hello?), maybe he can answer questions anyone has.

Saturday, December 17, 2016

Why Knee Pain Turned Out to Be a Blessing in Disguise

Go ahead, roll your eyes. That would be my initial reaction too: “Oh no, here comes the maudlin essay on how suffering through pain strengthened his character, gave him courage and made him a better person blah blah blah.”


That’s not where this is going. Rather, I have more rational reasons for making that headline statement. My experience with knee pain taught me some excellent lessons:

* Doctors aren’t always right.

I had never thought of getting a second opinion before. Now I always consider it, especially if I have a difficult-to-diagnose problem that a doctor could easily get wrong.

* Surgery is often the best option when it’s the last option.

If not for my knee pain saga, I probably would’ve had surgery on my foot a couple of years ago. I had a problem misdiagnosed as Morton’s neuroma. I’m now convinced surgery would have been the wrong thing to do (as it would have been for my knees). Sometimes you need to be patient.

* I learned how to read clinical studies.

This is important. There are many good studies out there, some of which conflict with prevailing thinking in the medical profession. Read them. Figure out what they mean. You'll be glad you did.

* I learned to be skeptical of the “things just wear out” reasoning.

As patients age, doctors tend to be more likely to say, “Oh, that just comes with age.” Sure, some unpleasant changes in your body do come with getting older. But many can be delayed (if not prevented completely) if you take good care of your body.

* You need to be a smart patient because the problems will keep coming, especially as you age.

I’m on the wrong side of fifty now. In the past few years, I’ve had an issue with my foot, with my shoulder, and I expect more parts of my body will ache and complain in the years to come. I need to be smart about evaluating the doctors who evaluate me because there’ll be plenty more.

These are a few reasons why having knee pain was a good thing for me. I still wish I hadn’t gone through it. But it did make me better equipped to go through the rest of my life.

Saturday, December 3, 2016

Open Comment Forum: Your Turn to Speak!

We haven't done one of these in a while, it appears, and they have been hugely popular (much more than my blog posts, I must confess).

So go ahead: Discuss whatever you want to below. It's open mike night at the SMK blog. :)

If -- and by no means feel bound by this -- but if you're looking for a subject to kick things off, what about this, for those of you who have had surgery:

If you could do it over, would you? What do you wish you had known going in that you know now? What's the most important thing you would pass along to others thinking about having that same procedure done?

Okay, I'll step aside and get out of the way now. Cheers!

Sunday, November 20, 2016

That “I’m Just Getting Old” Misconception About Knee Pain

As many of you know, I have Google scrape the web daily for news about knee pain. Recently the search turned up a column from the Flathead Beacon, a newspaper out of northern Montana. There are two huge national forests there; it looks like a beautiful place to live.

The writer is a devoted outdoorsman worried about how many more bird-hunting expeditions he has left in his failing knees. “I have become increasingly aware that there’s a hunting life expectancy in this body of mine,” he laments.

He had surgery on the right knee after a marathon quail hunt about 15 years ago. Then the second knee started going downhill, and what can you do? Here’s the money paragraph that had me ready to slap my palm against my forehead:
When knee No. 2 went south this spring, my doctor speculated that I just had joints built in a way that eventually wore out that knee cartilage. Like the right knee, the left seemed to just fail over time. It started aching last spring, after a casual jog with my daughter. It was fine the day of the run, but I couldn’t walk the following morning.
First, I’d get a new doctor. Yes, aging does have an effect on our bodies; that’s undeniable. But properly cared for knees don’t have to wear out over time. More typically, they fall apart because of benign or not-so-benign neglect.

Notice that the left “start aching last spring, after a casual jog.” I don’t know what happened, but a picture comes to mind, of someone attempting a little exercise after a relatively inactive winter and too many holiday treats consumed.

Of course the knee probably wouldn’t hurt during the run; that’s the problem with cartilage. But the next day – oh yeah – you’d feel it, full force. And if it was occasionally unhappy before, that casual trot could be the tipping event that pushes you into the land of chronic misery.

To be fair, the writer seems to understand the crux of the problem:
But the 10 to 20 pounds I’ve been trying to lose since, well, forever, that’s no longer a matter of just trying to look good.
If you’re carrying an extra 20 pounds (most men who say they want to lose 10 to 20 actually need to lose more like 20 to 30), you’re begging for knee trouble. If you do everything right, your knees may be fine. But you’re at risk if you lurch between sedentary and active states. What you need to do is obvious, though hard: Lose weight. That’s one piece of advice no one would dispute.

Sunday, November 6, 2016

That “Come to Jesus Moment” About the Strength of Your Knees

A “come to Jesus moment” (which originally meant that moment when you accept Jesus as your savior) has entered the popular vernacular to represent more broadly an epiphany or a flash of enlightenment.

Have you had your “come to Jesus moment” about the strength of your knees?

Not having this moment, I think, is a great impediment to getting on track with a successful plan of long-term healing.

What happens is you muddle along, believing the right things, doing many of the right things, but they’re all geared for a knee that’s about two or three times as strong as your knee actually is.  You may not realize it, but your progress is constantly being undermined.

It’s all because you don’t realize how weak your bad knee is. So you’re always being careful, but you’re also often outside of your proper “envelope of function.”

When my come to Jesus moment came, I remember thinking: “No, no. My knees aren’t really that weak. It’s impossible. I can’t be that bad.” But then I remember this sick feeling, “Yes they are, and yes you have to accept this. You have to start at the bottom to get to the top.”

That’s when I started walking around a swimming pool every ten minutes. Walking, then resting, walking, then resting. Nothing more strenuous than that. And after a few weeks, I noticed that I was getting better, but at the same time, it was depressing to realize the depth of the hole I was in.

Still, if you ask me, “When did you really get on a  long-term path to healing?”, I would identify walking around that swimming pool as the beginning. The later successes built off that. But to start there, I had to have a “come to Jesus moment” about the strength of my knees.

Have you had yours?

Saturday, October 22, 2016

ACI vs. Microfracture, Revisited

I originally wrote this post, which garnered a good deal of attention, about these two procedures.

I said that if forced to choose between the two, I’d rather have the less-invasive (and less-expensive) microfracture, which may even be more effective. In the comments section, several people disagreed. One commenter said that, over the long-term, ACI (or autologous chondrocyte implantation) leads to a better result.

Uh, maybe not.

This study (published in August in the reputable Journal of Bone and Joint Surgery) looked at large lesions treated with either ACI or microfracture. The 80 subjects were evaluated after 15 years (a suitably long timeframe, I think all would agree).

Check out the highlights:

* There were 17 failures in the ACI group compared with 13 for those who had microfractures.

* Total knee replacements: six in the ACI group, three in the microfracture.

* X-ray evidence of early osteoarthritis: 57 percent in the ACI group vs. 48 percent in the microfracture.

Luckily I don’t have to choose between either. But if I did, I think I’d stick with my original answer.