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.

Saturday, December 6, 2014

When It Comes to Knee Pain, What’s Your Religion?

When I read an expert’s answer to how to deal with knee pain, the question above is always forefront of mind. What is their belief framework for analyzing and treating the underlying condition?

Mostly I find experts are structuralists of some stripe. In other words, they believe “your knee cap is mistracking and that’s why you have pain and that’s what you have to fix.” Some are more hard-core than others.

Take “Running Doc,” for instance, who tries to help Laura G. here who has been told she has “Runner’s Knee.” But her only exercise consists of shopping expeditions at the mall!

Well, the doc describes her problem instead as “Maller’s Knee” (for anyone curious about who the great physician “Maller” is, I think this is just an attempt to be clever). He then goes on to equate “patellofemoral syndrome” with “chondromalacia patella” (as I note in my book, they’re not technically the same, but it’s a revealing confusion).

He does promise the reader that “understanding the real cause makes treatment easy and pain relief possible in a short period of time.” To me, after hearing so many stories from knee pain sufferers engaged in a frustrating battle to beat their problem, this phrasing sounds a bit glib, to say the least.

The underlying cause, he tells us, is your ....

Feet.

And your parents stuck you with those feet, so your pain is -- well, sorry bub -- your biological structuralist destiny, you might say.

How does he get from your feet to your knees?

Here’s one example he gives:

Your foot rolls in (pronates), leading to your kneecap mistracking and scraping along one side of the patellar groove, leading to the cartilage under your kneecap getting eroded away, leading to ... pain.

So what’s the solution? Interestingly, one would assume -- after such a bleak kind of structuralist analysis -- that nothing short of surgery to fix the cursed defect would do much good.

But actually, he states that arthroscopic surgery helps maybe one out of 100,000 sufferers (a bit hyperbolic I’d say, and I’m no fan of surgery either). No, the real solution: orthotics.

His apostolic faith in orthotics made me smile. Here is the New York Times telling us that a longtime researcher into orthotics has found they don’t really work and when they do, it’s not clear why. And so, “The idea that they are supposed to correct mechanical-alignment problems does not hold up.” (After reading the article I bravely gave up the shoe orthotics I thought I couldn’t live without, and I’m perfectly fine today without them).

As for Running Doc’s “first mover” in his chain of events resulting in knee pain misery -- that maltracking patella -- that too may not be the problem for a large number of cases of knee pain. (See this study I’ve linked to about a kajillion times.)

So at this point you may be thinking, “Okay smarty pants who isn’t a doctor, what’s your religion?” And I’d have to say my thinking aligns best with that of Dr. Scott F. Dye and his thinking on “envelope of function” (see here). Basically, when you exceed that envelope over a period of time, you’ll get knee discomfort then pain. If I were talking to Laura G. about her problem, I’d be more curious about the following than what her feet are doing:

What’s your weight? Is it where it needs to be? Has it changed recently? By how much?

Did your amount of non-exercise movement change before the onset of knee pain?

Were there any traumatic knee events you suffered in the year or two preceding the knee pain?

Can you describe how you use your knees, 24/7, during a typical week?

Of course I could be off base with this line of inquiry in Laura G.’s particular case. It’s always possible that she was born with crappy feet and is now paying the price for it. But somehow I doubt that’s the real problem.

Saturday, November 22, 2014

Old, Bad Beliefs Die Hard

I came across this Internet article on the VMO (vastus medialis oblique), one of the four muscles that, collectively, are known as the quadriceps. About halfway through, I noticed an interesting assertion:
... patellofemoral pain syndrome. A misaligned patella results in pain on the front of the knee, ultimately caused by a weak VMO.
My initial reaction was along the lines of “Whoa, back that truck up!” For one, if you read a lot of the literature on patellofemoral pain syndrome (PFPS) from informed sources (as I’ve tried to do), you’ll discover there’s much confusion about what indeed does cause PFPS. (Actually, to take a step back, it’s not even clear that this is a meaningful diagnosis in the first place.) So this article’s pat suggestion that your knee pain is caused by a misaligned patella that in turn is caused by a weak VMO is venturing way out on a limb.

For starters, the role of a mistracking kneecap in causing pain may have been oversold. This study (rather small but intriguing) found no relationship between the amount of patellar mistracking and reported knee pain.

Then there’s the problem of strengthening the VMO in isolation. That, by implication, is what someone with a weak VMO in this scenario needs to do. After all, if your problem is maltracking, and you strengthen all the muscles equally, then it seems you would have the same amount of maltracking, only with stronger muscles causing it.

So how do you strengthen the VMO in isolation?

Well, you can’t, as Doug Kelsey has observed a number of times, such as in this passage:
The VMO is one of four muscles which all share the same nerve: the femoral nerve. Muscles contract when nerves tell them to contract. Since the VMO has the same nerve as the other three thigh muscles, it will contract along with the others. You cannot make the VMO contract by itself.
Strengthening the VMO to correct a mistracking patella is a typical old school recommendation for treating chronic pain from achy knees. Tease the reasoning apart, bit by bit, and it falls to pieces. Yet the advice lives on in many corners of the Internet.