Saturday, February 28, 2015

Corrective Exercises: A Waste of Time?

I found a very interesting article not long ago. It very much reminded me of my “awakening” during my struggle with knee pain.

First, start with the entrenched thinking (flawed) on what causes “patellofemoral pain syndrome.”
American Family Physician describes the cause of PFPS as an imbalance of the forces that keep the kneecap in alignment during knee extension and flexion. This imbalance can increase the risk of muscle dysfunction, poor quadriceps flexibility, overuse, trauma and a host of other musculoskeletal problems. In other words, during PFPS, the kneecap does not glide back easily on its “track” to the femur. ... Some health professionals, such as physical therapists and athletic trainers, recommend corrective exercise as a self-care method for patients.
Sounds simple, straightforward, reasonable. Except:
Despite the prevalence of corrective exercise prescriptions, current evidence shows that this intervention may not always effectively treat knee pain and could be a waste of time.
The problem is, the idea behind corrective exercise is that you’re crooked (your kneecap is mistracking) or that various muscles or tissues are too tight or too loose. But “studies have shown that PFPS may not always be a biomechanical problem.”

A 2006 Swedish study is then described, one that I was previously unaware of. Eighty patients with PFPS were examined. Of those, 29 had no identifiable cause of their PFPS (the others either had “slow bone turnover disease” or a type of pathology of the knee, and a small number dropped out.) For the 29 who didn't have a clear cause for their pain, “researchers could not differentiate between [them and] the control group that had no knee pain and were not diagnosed with PFPS.” So they weren’t identifiably crooked or imbalanced in a way that the control group was not.

Of course there is evidence that exercise can reduce knee pain, but as Paul Ingraham says in the article, that’s “probably not because it’s ‘correcting’ anything.”

I’ve linked to Paul’s website a few times over the years, such as to this essay where he examines the obsession that physical therapy has with crookedness/imbalances. I like his thinking and he’s a good writer. In the article above he is quoted saying, regarding the misalignment theory (the underlining is mine):
Exercises are prescribed in the hope that such things can be corrected, usually by strengthening and stretching.  Unfortunately, a lot of exercising for these goals is often out of tune with how exercise actually does help patients.
I couldn’t agree more with that. And, finally, he does well to note that knee pain comes in many stripes, with many possible causes. So, he notes:
Exercise is no kind of magic bullet. Patellofemoral pain has many faces, many possible causes and complications, and some cases do not respond to any kind of exercise, ‘corrective’ or otherwise.

Saturday, February 14, 2015

Read On for the Top Risk Factor for Knee Pain

“Broken record” has a pejorative connotation. No one likes a “broken record” who harps about one thing in particular, all the time.

When it comes to knee pain though, I’d argue that it’s not bad to be a broken record about one thing anyway. And that’s the single factor that, more than any other, predicts whether you’ll have knee pain.

It’s simple:

Being overweight.

A new meta-analysis of existing studies found that “one-fourth of cases of onset of knee pain could be attributable to being either overweight or obese,” according to researchers at the Arthritis Research UK Primary Care Centre.

That may elicit a yawn from you, especially if you think I’m a bit of a broken record on this subject. But here’s the part I found shocking:
5.1 percent of new knee pain/knee osteoarthritis could be attributed to a previous injury and 24.6 could be attributed to being overweight or obese.
Wow! Didn’t see that coming. What a disparity. If anything, I would have expected a previous injury to be a more significant contributor to the onset of knee pain. But it isn’t. And it’s not even close.

If I were an orthopedic doctor, and I had a patient with knee pain who was overweight and who claimed to be serious about doing whatever it takes to get better, I’d say:

“Lose x pounds. That will show that you’re really serious.”

Because if you are serious, and you are overweight, shedding some pounds has to be a No. 1 priority. On this point, the evidence isn’t debatable.

Saturday, January 31, 2015

Knee Pain and the Influence of Genetics

Is knee pain a family affair?

A recent study shows there’s apparently a gene-related link to the development of knee pain associated with osteoarthritis.

The study included 219 subjects, average age 48. Roughly half were the children of parents who had knee replacements; the rest belonged to the control group. The knee pain of all subjects was assessed three times: at baseline, two years later, then eight years later.

Even after the proper adjustments were made to control for such factors as age, sex and BMI, “individuals with a parental history of knee replacement had a more than twofold greater likelihood of worsening total knee pain.”

Interestingly, the adjustments were even made for radiograpic and MRI abnormalities. So that meant researchers were comparing people of similar age, sex and BMI who also had similar-looking MRIs and X-rays. Even then, the offspring of the knee replacement group had a twofold greater likelihood of worsening pain.

The study’s authors speculated that “implies that the genetic contribution to knee pain may be mediated through factors outside the joint, possibly involving pain processing.” I interpret that to mean that, if you’re a child of a patient who had a knee replacement, you may be more likely to experience a worsening of pain simply because you may be more sensitive to it -- an interesting and curious finding.

In any event, I’d argue that the takeaway is that, if you’re in this high-risk group, being proactive about not developing knee pain in the first place makes a lot of sense. Build up the leg muscles around your knees. Find good joint-friendly activities (cycling, walking). Take good care of your knees before they start to hurt.

Saturday, January 17, 2015

Did My Knees Really Get Better Or Do They Just Feel Better (And Does It Matter)?

A long title but I couldn’t think of a good shorter one.

After reading my story, some people say something like this:

Why don’t you get another MRI (or some other test) that shows whether your knees really healed? That would prove whether your program really worked.

To be sure, this kind of comment has never been phrased in a hostile way. There’s no implication I’m a liar or fraud. Rather, people have a deep curiosity -- the same as I do actually -- about what changes physically occurred in my knee joints between the worst days of my condition (when I was suffering each day in Hong Kong) and now.

If I could do such a test (for cheap), and it could measure such a thing, I’d do it in a heartbeat. Hell, I’d love to know. Armed with the test results, I could probably sell five times more books. ;)

But it’s not possible. Here’s why.

(1) Simply having an MRI done would cost a lot; I’m guessing at least $1,000. And my health insurance company isn’t going to pay for a “there’s nothing wrong but I’m curious about what my knees look like” MRI.

(2) I don’t have an ideal MRI to compare it against anyway. True, I had images taken in Hong Kong in early September 2007, but that was before my disastrous experiment with weightlifting to strengthen my quads (which really trashed my knees). An MRI done in November or December of 2007 might have shown more damage.

But here’s the big reason:

(3) My original MRI exam was only somewhat useful in identifying my problem and determining the extent of it. Actually, “somewhat useful” may be a too-kind phrasing. My MRI basically said I had changes consistent with mild chondromalacia. So it found no giant potholes in my cartilage that a subsequent exam might show had healed.

My suspicion is that if a surgeon had cut open my knee, he would have spotted some kind of more obvious cartilage damage not detected by the MRI. But I never went that route (thank God). So, like many knee pain sufferers, I don’t have a good baseline test that says, “Wow, your cartilage is really messed up!” I suspect I was on the verge of going downhill fast, but I was fortunate to fix my knee pain in the relatively early stages.

So how do I know there was damage in the first place and I didn’t just suffer from some weird neurological ailment?

Well, as I relate in the book, there was a lot of noise from my knees when I dropped into a squat (as if I were about to sit in an invisible chair). My knees were so loud that my doctor felt compelled to be blunt and opine that the joints would never get better. Also, when I went into a deep crouch -- which was hard to do and uncomfortable -- and then straightened up, there was a loud, ugly “ripping” noise.

But now those disconcerting sounds, whatever they indicated, are either gone or much quieter (I can still hear a little crunchiness in my knees, but it’s not painful at all). I’m back on the bicyle, riding as hard as ever. I can sit at my desk again through a long 10-hour-plus day without issues.

Do I have a before/after set of tests that shows the improvement? No. But even if I did, would it matter? I’m not so sure it would. Just from the way I feel, I know something in my bad knees sure as hell healed/improved significantly. And I’m pretty confident of that, whether or not those changes could be detected by an MRI or some other test.

Friday, January 2, 2015

Running Not Only Doesn’t Ruin Your Knees, But May Help Them

One of the most persistent knee pain myths is that, if you're a runner, the sport will eventually exact its due and lead to sore, aching joints. If you run long enough, the pessimists warn, you’ll pay the price.

A recent study (the results of which were presented at the American College of Rhematology’s annual meeting) came to a much different conclusion.

Namely, 29.8 percent of non-runners in the study had symptomatic osteoarthritis compared with 22.8 percent of the runners (I have to assume they controlled for weight in their calculations, as that’s a Statistics 101 sort of thing to remember to do.)

The study was huge (2,683 people, who had an average age of 64.5), which is good, but it did have a kind of squishy longitudinal component. Anyone who was a regular runner at some stage in their life, even if it was only between the ages of 12 and 18, was tagged as a “runner.” That can be problematic, as anyone knows who remembers my analysis in the book of one longitudinal study in particular. Still, this would not be the first study to suggest running is beneficial for knee joints, so I think the conclusion makes sense.

One of the study’s authors does raise a caveat: “This does not address the question of whether or not running is harmful to people who have pre-existing knee OA,” according to Grace Hsiao-Wei Lo.

But that’s okay. That’s a lesser issue. Running generally isn’t a good idea if you already have osteoarthritis in your knees, especially if it’s painful (there are better activities that are lower impact on the joints). The good news is that evidence increasingly shows that running doesn’t cause that osteoarthritis.

Friday, December 26, 2014

Happy Holidays to All!

I ate a huge dinner yesterday cooked by my 72-year-old Mom, who is still an amazing cook. My wide-eyed five-year-old daughter described how she heard Santa's reindeer on the roof on Christmas Eve. My 18-month old son crawled onto my lap with one of his dozen board books and stabbed his little index finger at pictures of tarantulas and dolphins and panthers and told me what they were -- or what he thought they were.

The sun broke out after several days of rain, and everyone was glad for the brighter skies. It was nice to be on the leading edge of a long weekend. I've got a few around-the-house projects to occupy me and a leak I'm watching (the joys of owning a house built at the end of the Roaring Twenties). I think water may be dripping from the shutoff valve under the main kitchen sink. I just finished wrestling off the corroded, leaking faucet on the prep sink and replacing it, so this isn't a project I'm looking forward to.

So there's plenty of stuff to think about. But one thing I'm not thinking about: my knees.

They work fine. They have been working pretty well, in fact, since I published Saving My Knees. After I made the book available, I had a little nagging doubt: "What if the knee pain returns? Will I be some kind of a fraud, peddling a story that doesn't really have a happy ending? Will I have to contact everyone who bought the book and refund their money?"

But that never happened, thank God. My knees just kept getting better.

So my holiday wish to all of you is don't give up hoping. I made it through. There is a way.

Saturday, December 20, 2014

On Writing a Book and a Blog, and Learning Humility

After I finished writing (and rewriting) Saving My Knees -- and extensively fact-checking the entire manuscript -- I felt kind of giddy. This was a unique book, I felt. It was a first-person, well-documented story of how someone failed -- then succeeded -- in fixing bad knees his doctor said would never get better. My story vividly demonstrated the shortcomings in the traditional approach to treating chronic knee pain (of the sort sometimes caused by osteoarthritis, but sometimes not).

Bestseller lists, here I come!

Then reality bit down. Hard.

The book has sold well, all things considered, but never got close to being a bestseller. Reviews trickled in -- many positive, but others sour and dismissive.

The most humbling experience though has been writing this blog and coming into contact with so many people with knee pain who are really struggling -- and who appear to be doing many of the right things too. They’re desperately seeking the path to healing, just as I was. And they’re discovering that’s not an easy path to find.

Ah. Theories are neat; reality is messy. I still believe that switching from high load/low repetition activities to low load/high repetition makes much more sense for fixing achy knee joints. But I also recognize that while this may be necessary for some people to get better, it may not be sufficient. Big difference.

The problem is, there are different causes of knee pain (in need of different solutions), as well as various mysteries about what’s really going on in the first place. For instance, is there something weird and systemic that sets in when you have chronic knee pain that goes on week after week? I had a doctor tell me unequivocally “no.” But I’m not sure I believe him.

Sometimes I had the sense there was a poltergeist of inflammation loose in my body, and while it may have first appeared in my knees, later it began to roam at will. Apparently it wasn’t just me either who felt this way. I’ve been surprised at the number of people with symptoms similar to mine who went so far as to be tested for rheumatoid arthritis (just as I did).

So what was all that systemic stuff? I honestly don’t know. But, even though it’s gone today, I think it was real.

So yes, there are lots of mysteries about knee pain, as you’re all finding out. It’s good to stay humble -- even if you succeed in beating knee pain -- because no one has all the right answers.