Saturday, May 23, 2015

If Your Knees Heal, How Do You Go Back to Doing the Sports You Love?

Someone reached out to me recently, asking (basically) the question above.

It’s a very good one. After I got better, my brother said that if he were me, he wouldn’t go back to the intense cycling I enjoy so much. Yet I did. And so far, my knees have been fine.

Was I foolish to do so?

I don’t think so. Here’s why:

* You should never go back to doing exactly what you were doing that caused the knee injury. That seems kind of stupid. For instance, if you decide to train by jumping off the roof of your shed, then springing up and running three miles, and you hurt your knees one day jumping off the shed -- why the heck would you keep doing that after your knees healed? :)

Or, in my case: I was cycling up steep hills, doing short sprints on those climbs, all while dehydrated -- and doing this back-to-back on Saturday and Sunday mornings. Would I do that again? Nope. I wouldn’t sprint uphill. I would carry more water. I wouldn’t do a max effort on Saturday and try to do a max effort again on Sunday.

* You have to get smarter in general. I still ride really, really hard. But I’m smarter about making sure I warm up properly. And in temperatures below 55 degrees, I always put on knee warmers (sleeves that cover the knees and a bit of the legs). Always.

Being smarter doesn’t mean I can’t charge up the hill with the rest of the pack on a ride. It does mean that I’m more careful about exercising in a knee-friendly way.

* I still listen carefully to my knees. There isn’t much to listen to now, thankfully. But I’m ever alert to early warning signs. If my joints started getting really noisy and crunchy again, you better believe I’d modify my behavior.

Knowing how to listen to your knees is especially important if you return to the activity that injured them in the first place. You don’t want to be grounded with chronic knee pain again. One reason you may not be is because you know what the danger signs are that you ignored the first time around. The key is not to do so the second time.

Saturday, May 9, 2015

The Fine Art of Playing Medical Detective

If nothing else, I hope one message in my book is crystal clear: You have to get involved in fixing your knees.

Why? Here are three reasons: (1) Your particular problem has a particular solution; what worked perfectly for me (or someone else) probably won’t be exactly what you need. (2) A doctor or other medical professional trying to advise you will never gain as complete an understanding of your symptoms as you have, even if he spent five hours with you. You ultimately know better what you can and can’t do. (3) You need to be able to monitor and adjust your rehabilitation program in real time and your orthopedic doctor won’t be on call, 24/7, for every small question you have.

Part of getting more involved in fixing your knees means honing your skills at playing medical detective. Think of your evolving symptoms as a nonstop “Who dunnit?” (or “What dunnit?” may be more apt). If you want to avoid pain/flare-ups of symptoms, avoid doing the thing that triggers them. (Note: Believe me, I realize sorting out cause and effect isn’t always easy, especially when there are renegade inflammatory processes in the mix.)

The good thing is, once you develop “medical detective” skills, they’ll come in handy. In my case, they helped me solve (and heal) a couple of mysterious injuries in the past few years.

The Case of the Sore Index Finger:

This was a strange injury that kind of crept up on me. Quite simply, I began noticing my left index finger was sore, in the joint nearest the fingernail. Whenever I I pressed down on something with my fingertip, the joint would hurt.

What the heck? Was I just getting old, I wondered. Maybe starting to develop some arthritis?

But then I started thinking. “Hmm. Why is this joint -- and only this joint -- sore?” My right index finger was fine. Then I discovered something: The joint was being strangled twice a day. And I was responsible!

What I figured out was that, for my twice-a-day flossing, I was wrapping one end of the string around -- you guessed it -- the last joint of my index finger. I didn’t notice any pain or discomfort while flossing, but the soreness was evident later.

After realizing this, I started wrapping the floss away from the joint. Today my index finger is perfectly fine again.

The Case of the Sore Thumb

More recently, I had a problem with soreness around the base of my thumb joint. It was a nagging minor pain. As with the index finger, I couldn’t recall precisely when the pain began, or an injury that may have precipitated it.

Again I wondered: What’s going on? Is this age-related?

Well, I knew age hadn’t been the issue with my index finger, so once more, I began paying close attention to the unnatural forces on that thumb. And I found one -- but it was so minor I couldn’t believe it was the culprit.

I wear a backpack to work -- except usually it’s not on my back. I sling it over my right shoulder. And I caught myself, more than once, absent-mindedly pressing my thumb against the strap, stretching the digit back.

That can’t be what’s to blame, I thought. How can a little thing like that cause a problem? Still, I made myself stop pressing my thumb against that strap when I walked with my backpack.

And the pain went away.

The funny thing is, had I gone to a doctor for either of these problems, I probably would not have gotten a helpful analysis or solution. It’s not his fault; I wasn’t doing anything obvious that was causing either of these two joints to be sore. Further, a doctor might have put me in that “old guy” box (“You’re on the wrong side of 50; it’s just some inflammation that may eventually become arthritis; if it really bothers you, I can write a prescription for some pills.”)

But the cool thing is, I managed to figure it out by myself. And I got better. I’ll take that outcome any time.

Update: Oops, I see that this post is open to misinterpretation. My fault. To be clear: I don’t mean to imply that you don’t need doctors or physical therapists at all. I don’t mean to imply that you’re your own best doctor (in the end, you may be, but please don’t start out with that assumption).

I do believe that you need to get involved in helping solve the mystery of your knee pain. In other words, don’t go to a professional when you have chronic, hard-to-treat pain and expect to be handed a perfect solution on a silver platter. This goes to the heart of one of my beefs with people today: I think they look too often to the quick, easy, other-provided solution: a pill, a surgical operation, 35 leg lifts at dawn every other day, etc.

Here is why I would always start my knee pain journey with doctors and physical therapists: (1) They’re usually pretty smart people and good, careful thinkers. (2) They have extensive training and a broad understanding of a human body’s biomechanics that I’m betting you don’t have. (3) They have experience treating bad knees just like yours. (4) They (doctors anyway) have access to diagnostic equipment that can help shed light on what’s going on with your bad knee(s).

The first step to fixing a bad knee is figuring out what’s wrong with it!

Ah, but what if they don’t find anything? This is where things get more complex. If your doctor shrugs and basically says, “You’re getting old and your knees are just wearing out” -- well, that’s not too helpful. So here are my main complaints about many doctors and physical therapists: (1) They’re too fixated (physical therapists especially) on this idea that if your knees hurt, the underlying cause must be an imbalance/crookedness. (2) They’re too pessimistic (doctors) about the prospects of your knees getting better. (3) The exercise routines they prescribe (physical therapists) are usually too hard because they focus on muscles when they need to focus on joints. (4) They don’t work hard enough to help you craft a sensible, go-slow program to improve.

But -- and here comes a huge but -- this isn’t always true. Celebrate when you find a good physical therapist (I believe they can save you; a doctor’s usefulness tends to be limited after he shrugs and says “I can’t find anything wrong, so just try not to aggravate the joint.") A smart, patient, dedicated physical therapist is worth his or her weight in gold. I said that in the book, because I really believe it’s true. Just be careful: A bad physical therapist can mess up your knees really, really fast.

Finally: a nod to Doug Kelsey who is hands down the best physical therapist I know of (disclosure: I base that solely on his writings; I’ve never been a patient of his). He wrote a great book here. If you want good insight into chronic knee pain and illustrated exercises that will help you get better, check it out.

Saturday, April 25, 2015

Is Yoga a Good Idea for Bad Knees?

This is a short post mainly meant to spark a dialogue.

Have you found yoga to be useful in taming chronic knee pain? I’m interested in comments from people who have tried it, with success (what kind of yoga did you do and which poses, and how often?), as well as from those whose experience has been that it’s useless/harmful.

I never did yoga for my knee pain. I can imagine reasons why it would be beneficial; I can also imagine reasons why it might not be. Anyway, the University of Minnesota did a study (small, and apparently with no control group) that found that the 36 participating women reported better knee health after taking a one-hour yoga class each week for eight weeks. The women were 65 to 90 years old; they all had knee osteoarthritis. Most of the subjects had less pain and stiffness at the end of the two months.

This seems like a very short, maybe not-that-rigorous study, so that’s why I offer the results more as a conversation starter. Yoga for bad knees? Yes or no? What do you think? Please weigh in below.

Friday, April 10, 2015

The Dark Side of NSAIDs

Some months ago, I wrote about an unhappy reader of my book who berated me for my “horrible advise to not use NSAIDs” (nonsteroidal anti-inflammatory drugs). Following my various “instructions,” she said, caused her to destroy her knees and life.

My immediate reaction was: (1) I try not to give advice in general, and regarding NSAIDs, I explained in my book how they didn’t work well for me and why taking them might not be such a good idea anyway. (2) There are good arguments for not taking NSAIDs, and you don’t have to look far to find them.

Prolotherapy proponents (who believe in using irritation of tissues to induce natural inflammation that leads to repair) are well-versed in the hazards of NSAIDs, I found.

Here is a good start. Scan this article by Ross Hauser, who is a doctor, and you’ll see concern about “the potential for significant side effects of these medications on the liver, stomach, gastrointestinal tract and heart.” Also, one of the “best documented” long-term side effects is “their negative impact on articular cartilage,” leading to this claim: “the preponderance of evidence shows that NSAIDs have no beneficial effect on articular cartilage in osteoarthritis and accelerate the very disease for which they are most often used and prescribed.”

To elaborate:
NSAIDs have been shown to accelerate the radiographic progression of OA of the knee and hip. For those using NSAIDs compared to the patients who do not use them, joint replacements occur earlier and more quickly and frequently.
So Hauser concludes that anyone using such medications should do so “with the very lowest dosage and for the shortest period of time.” To me, that advice makes sense; I also like how Racer X, who sometimes comments here, describes such drugs as best used as “bridge” solutions -- meaning, again, rely on them no longer than necessary. To be fair, for some people they may be needed, so an outright “Thou shalt never” prohibition seems too harsh.

If you want to read some hair-raising stuff about the perils of drugs that aim to suppress inflammation (in this case steroids, which are the stronger stuff), take a wander through this long article (also by Hauser). Some highlights:

* Impartial organizations such as the American College of Rheumatology know there may be a problem. The rheumatology group carefully notes:
It is generally recommended, although not well supported by published data, that injection of corticosteroids in a given joint not be performed more than three to four times in a given year because of concern about the possible development of progressive cartilage damage through repeated injection in the weight-bearing joints.
* Hauser speculates that the “alarming” rise in hip and knee joint replacements may be related to the greater use of corticosteroids that are leading to cartilage degeneration. (I find this point a bit conjectural, as there are many changing variables that affect the number of joint replacements -- but the relationship is certainly worth exploring.)

* “Many research papers have documented that corticosteroids reduced radiosulfate uptake into chondroitin sulfate, thereby decreasing cartilage growth and repair.”

* After use of steroids, one study of joint changes found “the articular cartilage became thin, the matrix near the surface lost its hyaline appearance and became fibrous, the surface fibrillated...”

* A study involving young adult horses discovered that “chondrocyte cytotoxicity was found as the steroid concentration was increased.” Chondrocytes, if you recall from my book, are critical cartilage-making factories.

* In another animal study, “all knees injected with cortisone showed cartilage deterioration, but severe cartilage damage was seen in 67% of animals that exercised and also received cortisone.”

* And, in a study of people (average age 60 at the beginning of the study), “knees injected with intra-articular steroids deteriorated at a rate twice that of non-injected knees.”

* The International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine has also weighed in on the subject, warning, “Although an extremely useful technique, the intermittent use of intra-articular cortisone should be deployed with caution. The potential risks of provoking hyaline cartilage degeneration, the hazards as they relate to joint infections, and the limitations of cortisone should be fully discussed and disclosed to the patient.”

Again, I’m not absolutely against taking NSAIDs -- or even SAIDs for that matter. But the best patient is a knowledgeable patient. Know well what the benefits -- and the risks -- are.

Saturday, March 28, 2015

Not So Fast on That Knee Replacement

Here’s a short piece by the New York Times that’s well worth the read if, driven to desperation by pain and a bleak prognosis, you’re considering the ultimate in knee surgery: a total replacement of the joint.

You wouldn’t be alone -- far from it. More than 600,000 of the surgeries were performed in 2012. That’s a big jump from the 250,000 of 15 years ago. But what’s most interesting is where the most rapid growth is: among those 45 to 64 years old, who had triple the number of operations as before.

Are all these surgeries beneficial, especially among younger patients?

Researchers analyzing data from major studies found that people with really bad knees were helped by surgery. “Really bad” in this case means advanced arthritis: in other words, severe pain and impaired physical function, like an inability to climb stairs. But others with less serious arthritis saw only a very small benefit.

The upshot? According to Daniel Riddle, the professor of physical therapy and orthopedic surgery who led the studies:
If you do not have bone-on-bone arthritis, in which all of the cushioning cartilage in the knee is gone, think about consulting a physical therapist about exercise programs that could strengthen the joint, reducing pain and disability.
Amen. Surgery sometimes is the best option. But it’s often the best option when it’s the last option.

Saturday, March 14, 2015

Three Reasons Why “Mistracking Kneecaps” Probably Isn’t the Reason for Your Pain

Last time I mentioned in passing an interesting Swedish study. It found clinical tests perceived no significant differences between subjects who had knee pain of unclear origin and a control group. So, in other words, the knee pain sufferers weren’t crooked or imbalanced in some way the control group was not.

Intrigued, I managed to locate the study (most are behind paywalls, but luckily, this one was not). It begins with a fairly broad discussion of patellofemoral pain syndrome that won me over with these two lines:
Some practitioners who find no identifiable cause to the pain use both the term PFPS as well as the term AKP (anterior knee pain), but the terms are best reserved to describe the patient who has yet to be evaluated. If no causative explanation for the pain is found, despite a thorough investigation, the term idiopathic anterior knee pain (IAKP) seems reasonable.
Yes, yes, yes! Let’s stop pretending PFPS is a real diagnosis. “Idiopathic anterior knee pain” is more honest and useful. Basically, it means “you have pain in the front of your knee and we don’t know why.”

There is another discussion section, at the report’s end, that is well worth perusing too. The researchers’ skepticism about catchall explanations for PFPS that cite mechanical abnormalities is virtually palpable.

Here are three big problems with the “oh, you’re crooked/imbalanced” line of thinking.

(1) There’s no accepted definition of what constitutes crooked in the first place -- or more precisely “meaningfully crooked” if you will, because I’m sure very small discrepancies in the length of someone's legs (or in whatever) wouldn’t be considered important even by diehard structuralists.

To make this more concrete: Say you believe patellar maltracking causes most cases of PFPS. Well, if a kneecap doesn’t track perfectly by 1/100th of a millimeter (the width of a thin hair), that’s not enough to be significant. But then, what is? 2 millimeters? 6? 10, 20? The fact is, no one has set forth an assertion on this that’s supported by clinical evidence. So we don’t even know what crooked is.

(2) Also we can’t measure it well anyway (a related, overlapping issue). The Swedish researchers report:
“Fitzgerald and McClure (1995) studied four different manual clinical tests for patellofemoral alignment where measurement reliability ranged from poor to fair ... they were unable to find a reliable clinical method for assessing alignment.”
So there’s no accepted definition of malalignment and no good way of measuring it anyway. But wait, it gets worse:

(3) “Fairbank, Pynsent, van Poortvliet and Phillips (1984) reported that in pain-free subjects, between 60% and 80% of the population fall into what is generally classed as lower extremity malalignment.”

So, even when someone does take a stab at defining malalignment, it turns out -- surprise -- that most of us who are pain-free share this “problem.” In that case, if almost everyone is crooked/imbalanced, what’s so special about it?

And the answer just may be: not much at all.

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.