Friday, August 26, 2016

Another Open Comment Forum, Jump In!

It seems it's about time to do one of these. The first two were enormously popular. Also, it's fun for me to sit back and watch everyone talk.

How's everyone doing? Summer is almost over. Was it a good one for your knees, or was the warm weather too tempting and did you try to do too much? (I realize this should be completely flipped on its head for our handful of Australian contributors, who are probably sitting inside waiting for the snow to end.)

If anyone's looking for a topic: Are there any changes in footwear that have helped you? I relate the story in the book of those special, expensive shoes I bought that were supposed to be the greatest for joint pain ... and turned out to be an absolute flop.

Or talk about whatever! Cheers.

Saturday, August 13, 2016

Don’t Rush Back Into Hard Activity After Knee Surgery

I’m a Boston Red Sox fan – a bit of a closet one, now that I live just outside of New York City.

Some big offseason news for the baseball team was when they acquired Craig Kimbrel from the San Diego Padres. Kimbrel is a “closer,” a pitcher who enters the game in the late innings to shut down the opposing batters from scoring any runs. In the world of closers, Kimbrel is a pretty darn good one too.

Once the season started, there were a few bumps for him in making the transition from one team to another (and one league to another), but everyone agreed that he threw an assortment of filthy pitches that could leave opposing hitters flailing at air. It looked like the Red Sox at last had the ace reliever they sought.

Then, in July, we got some uh-oh news:
The Red Sox have placed closer Craig Kimbrel on the disabled list with a medial meniscus tear in his left knee, the team announced.
I’m not a surgeon of course, but I’m kind of a knee guy, and I thought, “Ah, hope the team is smart enough to handle this well.” Kimbrel was scheduled to have surgery and miss three to six weeks. I thought to myself, “Give him a couple of months.” Knee surgery isn’t a walk in the park, even for a young (Kimbrel is 28) elite athlete.

Then, on Aug. 1, my heart sank when I saw this:
Closer Craig Kimbrel returned to the Boston Red Sox on Monday, three weeks after surgery to repair a medial meniscus tear in his left knee.
I’m thinking, “No, give him more time. Sure, he feels great. Lots of people feel great right after surgery. But the truth is, they’re more frail than they realize.”

But Kimbrel took the mound and performed brilliantly. However, things didn’t go so well for him during a game after that:
Craig Kimbrel had the worst outing of his career Tuesday night, walking four batters ... the Boston Red Sox closer spoke of knee soreness after the outing.
Oh boy, I thought. This was completely avoidable. Now, to be fair, his manager said that the next day Kimbrel reported no knee soreness at all. True? I don’t know. But even if so, I’d say that knee soreness after surgery should be treated like a wildly flashing red light.

Post knee surgery, don’t rush things. Don’t be deluded by the fact that, when you walk, there isn’t knee pain anymore. Well of course not: you’ve been lying around for weeks, not putting any weight on your joint. Meanwhile, the cartilage cushioning your knees has been getting softer.

Obviously, the last chapter in this story hasn’t been written. And obviously, I’m not the Red Sox trainer overseeing Kimbrel’s rehabilitation program. If I were though, I’d try to go easy on that knee through the end of this season (which ends in late September for teams that don’t make the playoffs).

Then, during the next offseason, I’d consider getting him going on some gradual leg/joint strengthening. Maybe buy him a high-end bicycle and a plane ticket to southern California and tell him to start nice and slow, then perhaps work up to climbing some of those mountain foothills by the time spring training for baseball players rolls around next March.

Knee surgery is a big thing. Give it the respect, and time for recovery, that it deserves.

Sunday, July 31, 2016

Yet Another Study Weighs in Against Surgery for Knee Pain

On knee pain, two solid, almost unassailable truths have emerged:

(1) If you want to reduce your pain and you’re overweight, lose weight. I’ve given up citing all the new studies that link excess weight to knee pain, as I could probably mention one every month, but what’s the sense? The message is always the same. If you’re still debating this one, you probably still think the earth is flat too.

(2) Surgery is a bad idea for most cases of chronic knee pain. This is more an emerging truth, but the evidence just keeps stacking up. Most recently was a study summed up by the Washington Post with the headline “Maybe You Don’t Need That Knee Surgery After All.”

The study included 140 adult subjects, averaging 50 years in age, with knee pain from a tear in the meniscus. (Important: the tear was degenerative, as opposed to the result of a specific injury.) The participants either had arthroscopic surgery followed by a daily exercise regimen or worked with a physical therapist on neuromuscular and strength exercises a few times a week for 12 weeks.

At the final two-year checkup, the researchers found basically no difference between the surgery and physical therapy groups in their level of pain, ability to function in sports, and quality of life.

For the full study (as of this writing, it’s not paywalled), go here.

Saturday, July 16, 2016

Scott F. Dye on Why Your Knee Pain Diagnosis Stinks (And Why You’re Not Getting Better)

You MUST watch this. Honestly. TriAgain left the YouTube link in the comment section. When I finally got time to view the whole thing, Dr. Dye's remarks left quite an impression and actually left me wanting more.

This is unvarnished, straight-talking Scott F. Dye, who has been described as a “renegade knee theorist.” He calls himself a “surgical minimalist” as well. Most importantly, he has thrown his weight behind the only medical theory of understanding chronic knee pain (“the envelope of function”) that makes sense, at least to me.

The YouTube video is a 56-minute presentation (and q&a session) that he gave that I could write pages and pages about. Instead, I’ll just touch on some highlights.

* The worst cases of knee pain he sees are “iatrogenic.” That’s a very significant word to know. Because it means, basically, the surgeon caused the problem. Well, not the initial knee pain, but the surgery to “correct the problem” made it worse.

He shows a slide of several knees that went through multiple surgeries. Each knee got worse after all the operations.

* Chondromalacia is not a death sentence (he has asymptomatic grade three chondromalacia, he tells us). Also it’s not the same thing as patellofemoral pain syndrome. This common confusion clearly irks him; he even mentions that the Mayo Clinic website wrongly uses the two as synonyms.

“This is total and utter nonsense,” he says.

* Patellofemoral pain syndrome does NOT correlate with malalignment. There’s one study I usually cite as evidence to support this; he lists what appears to be a dozen or so studies.

What’s more, he makes the point that it’s dangerous to try to make adjustments based on perceived malalignment. He shows an X-ray where the kneecap looks tilted – but if you look at a different image that includes the cartilage too, you see the cartilage on the patella and end bone actually mate perfectly.

So what if a surgeon had gone in and tried to shave off some cartilage or perform a lateral release to “fix” that kneecap, which was actually perfect for that particular person? That’s how you get iatrogenic problems.

* He believes the key to understanding what’s wrong with painful knees is through a bone scan. This I find quite intriguing. I often thought that some kind of bone scan would have revealed the problem in my knees that the X-ray and MRI didn’t really detect.

(Yes, I blamed bad cartilage, and I still think there’s some truth to that, as excessive force on the joints may reduce the ability of cartilage to absorb shock, but I think a bone scan may have found other problems.)

* He is incredulous when talking about “PT Nazis,” who encourage patients to work through their pain threshold. I almost stood up and cheered. This approach is just nuts. I know it now, you should too, and Dye remarks, “This is just sickening.” He’s right. “No pain, no gain” makes sense for muscle growth, but not for a sore and aching joint.

* Then, finally, on being a surgical minimalist, he says “less is more.” He also conjures up a really neat image when he says, “Sometimes we surgeons have to get the pebble out of the shoe.” Notice the implied modesty there. This isn’t surgeon as superman, trying to remodel your entire joint. Rather, he’s trying to remove something small that doesn’t belong in a well-functioning joint.

Watch it. You’ll be glad you did.

Saturday, July 2, 2016

Acupuncture Is Probably Another Dud for Treating Knee Pain

I have a colleague at work who swears by “needles.” When he’s tired and stressed, he vanishes for an hour or so and returns from his acupuncturist feeling revived.

Is acupuncture useful for knee pain?

Evidence-based science indicates probably not. Here’s a summary for a recent study, published in a very reputable periodical (the Journal of the American Medical Association). Now of course it’s only one study, but everything on the subject that’s landed in my inbox over the last few years generally agrees with these conclusions.

First, 282 patients over age 50 with chronic knee pain were divided into four groups. The researchers were interesting in finding out whether traditional acupuncture or laser acupuncture helped alleviate pain. So two of those four groups were controls that received either no acupuncture or sham laser acupuncture.

Over the course of three months, patients received as many as 12 20-minute treatments.

After a year, there were “no differences between any of the groups on measures of knee pain and function.” The researchers suggest there were no real or direct effects of the acupuncture sessions.

I found this quote, from Rana S. Hinman, the study's lead author, most telling:
"Acupuncture tends to be more effective for people who believe in the benefits of acupuncture."
In other words: this is classic placebo effect.

One footnote that may comfort acupuncture believers: it was suggested the treatment may be effective for some people with neuropathic (nerve-related) pain. They weren’t included in this particular study.

And also, let me chime in: If acupuncture works for you, keep doing it! There’s no harm that I can tell. Even if 80 scientific studies say it’s worthless, if your knees feel better after being stuck with needles, that’s good enough. Who cares if it’s the placebo effect, really?

Saturday, June 18, 2016

The Post-Recovery Period: It’s Not Always Smooth Sailing Either

I’ve been meaning to post this for a while.

One thing I’ve always tried to be is honest about my experience with my knees. What I went through, and what I learned, may help you. Or it may not. But at the least, you deserve an honest account. No one out there should find out I’m limping around on crutches and waiting for a total knee replacement, and that’s the coda to my book, because nothing worked out the way I thought it would and I hid that from everyone for years etc. etc. etc.

Today I’m here to talk about an occasion since 2011 when things were not great. Last year, I felt some light burning in my knee joints during a six-week stretch, while sitting at my desk at work.

Oh no, I thought. Am I going down this road again?

I’m fairly certain I know what precipitated it. One day I decided to do an insane session of short sprints, followed by quick recoveries, on my stationary bicycle. I had never done that before nor have I since. I think it just tipped my knees into a bad place – out of homeostatis, Dr. Dye might say.

But here’s the thing: I’m a whole lot smarter about knees now. So what I did:

* I dialed back on my bicycle riding for a few weeks. I still went out long miles, but alone and at an easier pace.

* At work, I said: You gotta get up and move! I had fallen into a bad routine where I never left the office. I worked at my desk for 10 hours straight, with a few breaks, such as for lunch, which I ate on site (my employer provides some free food and soups). So I resolved from then on, every day without fail, to LEAVE the building and WALK through the city for about 20 or so minutes (I’ve missed maybe one day, when the rain was just coming down too hard).

And those burning knees went away.

I’m sharing this with all of you in the interest of full disclosure, and because I really don’t know what’s happened in my knee joints, in terms of healing. Maybe there is some residual change in there that makes me susceptible to slipping back into an inflammatory cycle. But I am very sure that something got better, much better. I really do ride hard now: I sprint, I climb painfully long hills, I motor along at 28, 29 miles an hour -- and it feels really good.

Part of the reason I’m sharing this too is because I think that had I stuck with easy riding -- no more sprinting, go out with the “old timers group,” never break much of a sweat -- I doubt I ever would have had a problem again. Seriously. But I wanted to get right back at doing what I loved most, riding hard.

So I think my own story is useful as a cautionary tale. Perhaps you can return to your former activity, but you have to be vigilant. Bad knees that went south once can go south again.

And now a happy postscript: This year has been a very good one for my knees. Today I went on a 74-mile bike ride -- a very hard 74-mile bike ride -- and my knees are fine. (My legs? Eh.) We powered up a lot of small hills. At the end, as we approached a final half-mile hill at an 8 percent grade, I told another rider, “I’m less than zero.” I was completely exhausted.

But I felt great later. And right now, if I suddenly had amnesia and someone reminded me that I’d had knee problems in 2007, I’d probably say, “You have to be joking.” Because everything feels pretty normal.

Saturday, June 4, 2016

Welcome to the Blog! A Few Things …

I thought it was about time to do one of these posts, following a recent complaint I got about "commercial marketing" on this site (I'm assuming in the comments section).

There are very few ground rules here for people who want to leave comments/ask questions, but for anyone curious:

* Spam comments will be deleted.

These by the way have become harder to detect. At first spam comments were along the lines of “Great post!” with the commenter embedding a url in their profile name. The url generally led the clicker to some clinic that had most likely paid the spammer to drive up its traffic count.

Once the spammers figured out they were getting deleted this way, the tactics evolved. So now they sort of pretend to be engaging with the post for a couple of lines, often in a fairly transparent and superficial way. And of course, the url is still buried in there somewhere.

Again, I don’t mind at all if you link to a web site, an essay that helped you, a book, whatever – as long as you’re here to participate in the dialogue. If you’re a drive-by spammer, who is just looking for a way to staple an advertising flier to the nearest utility pole then move on, that’s different.

I check the comments weekly and try to clean up the ones that don’t contribute to the dialogue. As I said, advertisers are getting more sophisticated. But be forewarned: if you’re a first-time commenter and include a short comment and a prominent url, you will be looked upon with suspicion.

* The best way to ask me a question is in the comments section.

I get a lot of requests for advice/consultations, and many make me more than a bit uncomfortable. I wrote a book to tell my story, thinking it would help a lot of people with similar problems and also, as much as anything, offer hope when all seems hopeless. To me there was huge value in just documenting well the story of someone who beat knee pain when he was told he couldn’t and exposing all the untruths out there, about everything from “damaged cartilage can never get better” to “you need to focus on strengthening your quads.” Pernicious myths abound when it comes to knee pain.

Also (and I’m not exactly proud of this), I was full of anger about the way I was treated as a knee pain patient, and I’m sure others can speak of a similar experience: shrugging doctors who can’t recall what your issue is from one visit to the next, bouncy physical therapists who have never suffered a day of knee pain in their lives and all work from the same tired playbook, an industry of snake-oil supplements that has sprung up that studies have shown have no clinical efficacy, a roster of more serious drugs to keep the pain at bay and the knee pain sufferer on a dazed eventual walk toward surgery, which is where you wind up when you don’t take charge of a program to get better.

But I never claimed to be a doctor or a physical therapist myself, so I try to avoid giving advice. I try to avoid suggesting much in the way of exercises, except for the most simple ones. In fact, I got better doing an extremely simple exercise: walking, in slow, measured doses, with breaks, always listening to my knees.

So when you come to me and want to share your story via e-mail, my inclination is naturally to shrink away. It’s very flattering, but I’m not the guy you want. Doug Kelsey’s clinic has coaches who are very well-equipped to counsel and advise, and they work by phone now I understand. That’s really who you want. This is why I say “no” when people want to e-mail me with long descriptions of their problems. If they offered to pay me by the hour, I wouldn’t say “no,” I would say “hell no.” Because that would be even more wrong.

So what should you do? Leave your comments below a recent post. A lot of smart people now are regular visitors to this blog. A community has developed here of people who look out for each other, share what has been working/not working, and in many cases, have thoughts/insights that I would not have or that would simply be more appropriate or helpful for you. So share, by all means. But let’s keep the dialogue open and public (you can remain anonymous behind a screen name; that’s fine). You might be surprised at the volume of excellent suggestions (and all the support) you get from others on this site. Plus, I’ll see your comment too, of course, and might have some ideas as well.

Last, let me close on a positive note: Thank you all for reading. Honestly, I figured I’d have shuttered this blog by now. I don’t contribute to it as regularly anymore. But it always gives me pleasure to see all the people chatting below the posts, and I know I’ve created a kind of valuable if small ecosystem on the vast Internet, where intelligent people can talk about knee pain and feel free to shred some of the myths that hold us back from healing – and talk about the difficulties of their personal struggles too.

Healing bad knees isn’t easy. But I’m convinced it can be done. I did it. :)