Friday, April 22, 2016

When Physical Therapy and Steroid Injections Don’t Seem to Matter

I came across an interesting study not long ago – not about knees, but tennis elbow (it's no longer up, so I can't link to it).

It turned out that about three-quarters of people with tennis elbow (who have damage to tendons in their forearm) recovered on their own after about a year.

Okay, maybe not surprising. The next part is though:

There was no significant difference between people who received no medical intervention and spontaneously got better and those who had both steroid shots and physical therapy sessions.

After a year, both groups were doing roughly the same.

The study involved 157 people, from ages 18 to 70. One group received six weeks of physical therapy and two steriod injections (the second group had the therapy and placebo injections). Then the third group got no special treatment.

The most aggressive combo, of physical therapy and steroid injections (to knock down the inflammation), showed a marked benefit at six weeks, no improvement at 12 weeks, and worse symptoms at 26 weeks.

Then, at the one-year mark, this article tells us:
Overall, improvement with physical therapy plus placebo injection or steroid injection was about the same as with no treatment at all.
Okay, now here’s my take.

First, steroid injections are dangerous. I really believe these are a deal with the devil: a quick “ah” sensation of relief, at the cost of leaving damaging chemical residue in your joint that weakens it.

As for physical therapy, good physical therapy can be a life saver, but all too often we get bad physical therapy. For example, I recall my own experience when I had knee pain and along the way developed tendinitis diagnosed as golfer’s elbow (which is similar to tennis elbow).

Here’s some of what was done and prescribed:
(1) electrical stimulation (worthless for me, I’m quite sure – but others have had success with this)
(2) stretching exercises (may have damaged the tendon further – how much sense does it make to stretch a cold tendon? Doing so may have created a few microtears in the tissue.)
(3) exercises that were probably too low repetition to stimulate constructive tendon healing.

If that’s similar to the physical therapy that someone gets for tennis elbow, then I wouldn’t be in the least surprised to find out it’s basically ineffective.

However, the right physical therapy can change your life. I devised a program of eccentric exercises, thanks to Doug Kelsey and other sources online, that I’m pretty sure helped me rescue the tendons in both arms. That program I bet would’ve changed some outcomes in this study.

Anyway, for knee pain the right move is not to do nothing and hope it resolves. Don’t take away that message. The point is rather that the solutions we’re directed to, such as conventional physical therapy and high-powered anti-inflammatories, may not be good solutions at all.

Saturday, April 9, 2016

A Bike Is a Bike Is a Bike -- Or Is It?

Here’s a short post in reaction to something I read in the comments. Someone was frustrated about how his knees reacted badly to a session on a stationary bike but were okay on a real bike, out on the road. Which makes no sense at all, right?

After all, a bike is a bike is a bike. Right?

Ten years ago, before my experience with knee pain, I would have said reflexively, “Sure. No appreciable difference.”

But once you have knee pain ... well, I’m not so sure. Your knees in this state are more tender and more easily disturbed. You start to appreciate subtleties, slight differences between Activity A and Activity B that actually can matter.

Personally, I’ve noticed differences in how my knees react to riding a stationary bike versus a bike on the open road.

The stationary bike has certain advantages. It’s easier to control the force exerted. You can simulate an 18-mile stretch of easy, flat road if you want to. Hell, you can even spin backwards.

But what I find more interesting is that riding on the open road may have certain advantages too. It’s easier for my knees to ride hard on the road than on a stationary bike. Why? Maybe because I’m shifting my body around, moving on the seat more, slightly altering the way that my joints take the pedaling force. Or maybe because sometimes I’m slowing (or even stopping for traffic lights), other times accelerating. Or maybe because occasionally I’m standing up on my pedals. I don’t know.

Then there are the bike setups to consider. Chances are very good that your stationary bike and road bike aren’t configured exactly the same way, in terms of distance from seat to pedal, for example. Does that matter? If you’ve got great knees, probably not. If you don’t, it might.

Anyway, this is just my way of urging you to stop and think a bit if you’re doing two things that you think are basically the same and one bothers your knees and one doesn’t. Maybe they aren’t really the same. And maybe that slight difference is actually important.

Saturday, March 26, 2016

Inflammation in Early Ostoearthritis: It's Not Your Imagination

After my “Ghost in the Machine” post, I received a link to an interesting paper (published in Therapeutic Advances in Musculoskeletal Disease only a few years ago). It isn’t a meta-study, but more a state-of-what-we-know summary.

First, you have to understand a little background. The prevailing paradigm is that rheumatoid arthritis is the inflammatory arthritis. The immune system goes beserk in an RA patient, and a blood test shows high levels of inflammatory markers, such as C-reactive protein.

Now, contrast that with the traditional understanding of osteoarthritis: It too causes havoc in a knee joint, but it’s a “wear and tear arthritis” and noninflammatory. And so, when I asked my doctor if my knee pain might be implicated in inflammation elsewhere in my body, he more or less scoffed.

That paradigm is now shifting, it appears, so if you’re one of those knee pain sufferers who is wondering about an onset of other aches and sorenesses, you’re not crazy. Medical thinking may be just slow to catch up with what we’ve long suspected: there probably is a ghost in the machine when someone has chronic, low-grade inflammation.

But I may be crossing a bridge too far (at least for this paper). Let’s look at what it actually says, using a few snippets:
Although rheumatoid arthritis is clearly associated with higher levels of inflammation, osteoarthritis is by no means a “noninflammatory condition.”
No surprise to most of us. But what’s more:
Inflammation is present in osteoarthritic joints well before the development of significant radiographic change . . . Cartilage breakdown products in synovial fluid as well as microfissures in articular cartilage are present long before any degeneration can be noted using current MRI technology or gross arthroscopic visualization.
Translation: Inflammation and other bad stuff is going on in your joints WELL BEFORE you can see anything on an X-ray or an MRI. So if you go to your doctor with burning, aching knees, and he says (after studying your X-rays and MRI), “Well, they look fine,” don’t be fooled. That doesn’t mean they are fine.
The development of chronic inflammation in OA following joint trauma or overuse can be understood as a vicious, self-perpetuating cycle of local tissue damage, inflammation, and repair, such that the osteoarthritic joint has been likened to a chronic wound.
This is IMPORTANT. Note the operative phrase “vicious, self-perpetuating cycle.” This is the cycle you somehow have to break. I had a sense of this when I quit my job and devoted myself to the full-time pursuit of healing my bad knees. To me, I was fast running out of time and needed to take a dramatic step to get on top of my chronic inflammation.
These studies, demonstrating significant synovial inflammation in early osteoarthritis, suggest a window of opportunity may exist in which disease-modifying interventions targeting inflammatory processes might be the most efficacious for the prevention and treatment of osteoarthritis.
Okay, this is the part I’m somewhat tepid about, but I understand the authors’ proclivity for a solution that comes in a neat little pill (that some pharmaceutical company can charge $800 a month for). I would modify their conclusion somewhat, saying instead that there’s a window of opportunity to subdue that inflammation. You may benefit most from a drug (but be careful, as some will degrade cartilage and what’s more encourage you to do things that are too taxing for your weak joints). Or you may need a tonic that’s free: the proper amount of easy, appropriate motion, and the ability to keep your knees in non-stressful positions.

For more, please check out the study. The second half dives deep into the weeds, flinging about terms that I expect most of us will struggle to comprehend, as the authors look at particular pathways of inflammation. If you have an appetite for such, go for it. Mine is somewhat limited, I confess. :)

Saturday, March 12, 2016

Open Comment Forum, Dive In!

Today I’m going to do something different. Today I’m going to turn the mike around, so to speak. I’m going to let all of you “talk amongst yourselves” (I’m sure some of you remember the original context for that phrase!)

A while ago, someone suggested doing this, so people could share and help each other. It made perfect sense to me.

Before we begin, I think there are four things we all share:

(1) We believe there is good reason to be optimistic about the prospect of damaged cartilage healing, or at least improving.

(2) We accept this will probably take a long time (maybe years).

(3) We believe that getting better requires movement.

(4) We believe “envelope of function” is the best framework for understanding and dealing with knee pain.

Okay, that’s it. You can start talking now. Since it might be useful to have a subject, I’ll throw one out there (but feel free to ignore or modify): What are some things you’ve done that have helped you with your knee pain?

Sunday, February 28, 2016

The Curious Tale of Morton’s Neuroma, Pt. II

Finally here it is, the second part of the tale about my bad foot.

If you haven’t read the first part, go here.

Today I want to talk about something that I find ultimately more interesting: the process of diagnosing a Morton’s neuroma. Morton’s neuroma is described by one podiatrist as a “perineural fibrosis, sort of a misplaced overgrown protective ‘scar’ tissue surrounding and compressing an otherwise normal nerve.”

Here’s the fascinating part of making the diagnosis, which really got my mind whirring when I fully realized the implications:

Morton’s neuroma is typically a diagnosis of exclusion.

So a podiatrist will check for multiple issues when the patient complains of ball-of-the-foot pain. Is there swelling? A bone fracture? A possible tear in the plantar plate? Etc., etc.

If nothing is found, many doctors will diagnose the problem as Morton’s neuroma. But it’s important to appreciate why: Probably not because there is definitely evidence of a neuroma, but because all other suspects were eliminated. So you may have capsulitis or some difficult-to-detect issue. But the diagnosis: Morton’s neuroma.

If this sounds familiar to a knee pain sufferer, there’s a reason. Patellofemoral pain syndrome is a similar kind of diagnosis, in a way. If your knee doesn’t have a clear structural problem, if an orthopedist can’t figure out what the issue is, you may be told you have patellofemoral pain syndrome. But notice my qualifying phrase “in a way” -- Morton’s neuroma is actually more dangerous as a catch-all diagnosis because it purports not to be one. In other words, it claims to know what the underlying problem is (unlike the infuriatingly vague “patellofemoral pain syndrome”).

My first diagnosis was made by a podiatrist using an ultrasound. He showed me the fat nerve and his diagnosis seemed like a slam dunk. There was the evidence, on a medical imaging device. Not until a year and a half later did I ask a general physician, “How can you tell the difference between a neuroma and a nerve that’s simply inflamed because you’re injured?” His reply to me:

You can’t.

Wow. That was a revelation.

If Morton’s neuroma is a diagnosis of exclusion for many podiatrists, it almost surely is overdiagnosed because of that alone. Further, here are five more reasons to believe it is overdiagnosed.

* Podiatrists, in reflective moments, are themselves wondering as much. Check out this long online discussion between foot doctors that was prompted by one’s question, “Am I overdiagnosing Morton’s neuroma?”

* Some aren’t even wondering: they’re pretty sure they know. Listen to this comment: “It has been my experience in 44 years of practice that this is the most overdiagnosed foot malady. In the years that I have been in practice I have found no more then 10 true neuromas.” Think about that -- that’s about one case every four and a half years.

* Follow the money: extracting a “neuroma” is a surgical procedure that probably pays well. Might this influence doctors, especially those trained to remove neuromas, to find more of these than otherwise?

* There are various comments online about about surgeons cutting open a foot to find a “no roma” or a very small neuroma, or about surgeries that fail to end the patient’s pain, or about neuromas that podiatrists say “grew back,” which doesn’t even make sense.

* Also you’ll find a number of people online who claim to have “healed” from their neuromas. This strikes me as implausible for a true neuroma. Once you have scar tissue hindering a nerve in your foot, I don’t see how it can just disappear, though of course you can take pressure off the nerve for temporary relief. But heal? If you healed, I’m betting you had some other issue.

As for what was wrong with my foot, I don’t know. I’ll probably never know. I did have a long period of the nerve being irritated, so it’s possible the nerve did change in some way. But I don’t think that was my main problem.

Anyway, the important thing is, thankfully I’m no longer contemplating neuroma surgery!

Update: The question was asked below how I healed my “neuroma.” I didn’t get into that originally, as this blog is “Saving My Knees,” not “Saving My Feet,” and most people who drop by aren’t that interested in foot pain issues.

But in brief, I did the following:
(1) Tried to avoid activities that stressed my foot.
This is kind of obvious, but worth mentioning. So, for instance, I tried not to stand around too long on the bad foot.
(2) Put better padding (Spenco insoles) in some of my shoes.
(3) Modified my cycling shoes and socks. This may have helped a fair bit. I cut a slit in the side of the right shoe, to relieve the pressure. Also I “faked up” a cycling sock. They tend to be tight, so I cut a comfortable white athletic sock off at the low ankle to make it look like a cycling sock.
(4) Modified my other walking shoes. I actually cut holes out of the side of them at first (to copy someone on the Internet who did this). But then I realized – d’oh – all you have to do is cut a slit in the side; it accomplishes the same thing without looking so ugly.
(5) Modified my dress socks. I actually stretched them out overnight on the end posts of exercise equipment so they wouldn’t be so tight.
(6) Bought new footwear. This, I think,  was important. I bought some Altra Instinct 2 Zero Drop sneakers to walk to work in (very wide toe box, great cushioning, and zero drop too of course) and to wear on weekends. Also bought some Crocs. Fell in love with the Altras; they are superb.

I also used Hapad pads for a while, but toward the end (the period when real healing took off), I wasn’t using them, as they got hard to position exactly right and tended to annoy my foot.

Saturday, February 13, 2016

Knee Pain and the Ghost in the Machine

I’m going to delay part two of the Morton’s neuroma thriller just once more, which I imagine no one will protest, as I’ve received no comments specifically on the issue of neuromas.

I want to go back to last week’s subject, because TriAgain made an important comment.

First, I have a fear sometimes of becoming facile, of lapsing into can-do boosterism and tired platitudes (“Just move! You just need to move!”). That’s one reason that I liked last week’s subject, on breakdown points, because I remember doing some hard, original thinking for the first post, a few years ago.


What TriAgain put his finger on (“there may also be other systemic problems”) was a really difficult, intriguing piece that I honestly don’t have much of a clue about (and neither do your doctors, I suspect). Yes, there are breakdown points, and when you lurch beyond one, you can suddenly go from the blissful absence of any pain whatsoever to a nagging injury that just gets worse and worse.

But once you’re on the wrong side of no pain/pain, is it simply a matter of fixing an overstressed structural component (cartilage or whatever) to return to a previous healthful, pain-free state?

Maybe not. As anyone who read my book knows, I turned into a bit of a mess. At one point, it wasn’t just my knees but tendinitis in both forearms, along with terrible back pain. Happily, once I conquered the knee issue, I also managed to get on top of the other problems. So I did succeed in crossing the no pain/pain divide in the right direction.

But what exactly were those other problems? Were they related? And, if they were, perhaps once some malevolent systemic genie has been released from its cave, it can be really hard to get that thing quieted down and back inside again.

I know TriAgain suspects that complex regional pain syndrome is at least partly to blame for what his knee pain has morphed into. After checking out the CRPS symptoms, I can say that most of them don’t align with what I had.

But still.

When I had the chronic knee pain inflammation/irritation, I started to get the feeling that I was chasing a poltergeist that was loose in a many-roomed house. If my knees felt a little better on a particular day, some other joint would feel a little worse. Very weird, I thought. So I asked my general physician if all the joint pain could be related, and he assured me “no,” with this look as if he were humoring a naive child.

But the more I read everyone’s stories here, the more I am convinced that there is very often something systemic that slips in through the back door with chronic knee pain. It isn’t there at first. And it isn’t there for everyone. But I almost get goose pimples on my arms on reading all these accounts of knee pain sufferers who thought they too had rheumatoid arthritis.

So sometimes, when I’m rattling off my thoughts on healing and feeling a bit facile (in that way you can be when your chronic pain recedes to a distant memory), I get a little jerk-back to reality and sense of humility on realizing there’s a whole lot I never did understand. Like whatever that systemic issue was.

With knee pain, I believe there can be a kind of ghost in the machine, a nasty something rattling around inside you, wreaking havoc. But how that thing works, I really don’t know. Hopefully, in the years to come, someone in the medical field will discover some answers to the questions we have about that systemic part, and I can report back the findings.

Saturday, January 30, 2016

Why Did My Knee Pain Come Out of Nowhere?

I’ll run Part II of Morton’s neuroma next time. I realize that since this isn’t a “Saving My Feet” blog, people aren't so interested in trouble-shooting problems with their metatarsals. However, I will note that PFPS is mentioned briefly in the second installment :).

Anyway I recently got a long comment at the end of “On the Virtues of Going Slooooowwwww” that included a line I found interesting:
It just seems strange that I had zero issues with my knees up until someday 15 months ago and they were to never be the same.
Yes, this does seem strange, I agree.

But yes, this is also very common, I’m convinced as well.

I referred the commenter to another post I did, one of my favorites. Sometimes I like to scratch an epistemological itch and try to figure out something important. In Saving My Knees, such a moment occurred when I realized that when measuring rate of change, the perceived rate will be greater as your measuring instrument becomes more precise. (I’m sure others have noticed this same phenomenon, and some statistician’s name is appended to a law stating as much.) This has huge implications.

Anyway, back to the matter of knee pain coming out of nowhere. The post I referred to is about breakdown points. The knee is a load-bearing structure, subject to forces in multiple planes. Physical structures can have breaking points, or tipping points, up to which everything may seem fine externally. So just before that tipping point is reached, there may be the absence of any discomfort whatsoever. But there could be a fine line between no pain and the emergence of some pain that then goes on to worsen to chronic pain rather quickly, which then proves practically incurable.

The tipping point analogy is intriguing, I think, because it can be analyzed in a number of ways in the context of structures. Imagine a cup that withstands the impact from being dropped say 16 inches, but from 17 inches shatters into pieces. Obviously, that’s a dramatic change in state, from whole to irreparably broken, that's caused by a small shift in our initial variable (the height from which it's dropped). That’s not what happens to your knees (especially because they’re not inaminate objects with no ability to heal), but if your knees exist in a condition of precarious homeostasis when you are pushing them too hard, maybe you are close to crossing a thin line that will send you into a downward spiral of pain and misery.

And once you hit that tipping point – once you land on the wrong side of that slim divide that separates no pain and pain – the unfortunate thing is it can take a long time to get back on the right side. But I would argue that your knee pain didn’t exactly come out of nowhere. Instead,  you approached a dangerous line, probably multiple times, that you didn’t even know you were nearing – and finally pushed across it, with disastrous results.