Friday, December 24, 2010

Best Christmas Wishes to All

I had an ambitious blog post in the hopper along the lines of "How do you heal through pain-free motion when you're always in pain?" And I will get to it. Next week.

That's because -- alas -- my body has been steadily running downhill since about 10 p.m. last night, when a bit of viral grinchitude derailed my ambitious plans for Christmas Eve. Yes, I have a cold, with the raw throat and swollen sinuses as proof. My productivity, not surprisingly, has dropped off a cliff.

So I thought I'd weigh in briefly now with the obligatory holiday wishes and come back, hopefully recharged and restored, with some thoughts next weekend about exercising when you're in pain but don't want to exercise through pain. I began stitching together a post on that very topic this morning, but when you're not feeling good, it doesn't take long to run out of gas.

The good news is "Saving My Knees" is still on schedule. It looks like it'll be ready about January 8th as an electronic book through I'll have a lot to say about that in a few weeks -- why only an e-book, how someone without a Kindle can read an e-book (short answer: there are lots and lots of ways).

But for now, I'm just eyeing the bed, after a call to the wife (who's still in China, a piece of my personal story I'll talk about some other time). It's been a good year for me and my knees. In about August 2010, I reached the point where not only was the knee pain that forced me to quit my job in April 2008 gone, but also I was back to racing my bike up hills with guys 20 years younger than me -- and most of the time, I was beating them.


So take care all. Keep your knees warm. Try to enjoy Christmas. If you're frustrated by your physical therapy, by your doctors, by yo-yo'ing back and forth and never really feeling like you're getting anywhere, there is a better way out there. That's what I discovered, the hard way, and why I wrote "Saving My Knees."

Blessings to you all.

How Is It Possible to Exercise Without Pain When Pain Is All You Know?

This question got me thinking a lot recently. Because when you have to move to heal your knees, but you want to avoid movement that causes pain, and you're always in pain ... well, how do you ever get out of the starting blocks?

While catching up recently on Doug Kelsey's great blog, I noticed he said this in November about pain, while counseling a hurt runner on how to return to his sport:
You have to go hunting for the point where symptoms show up, adjust, re-train, and go again. This is where people make mistakes. They fail to edge the training. They fear the pain. Pain is the guide; not the problem.
So if you're always in pain, is the answer to just exercise anyway and accept that there will be a certain amount of pain?

This is a very tricky question. Anyone who's been reading my blog/comments elsewhere (such as on KneeGuru) knows that two keys to saving my knees were: (1) Going slowly and being patient (2) Modifying activity when pain and even mild swelling occurred.

Here's what I did, and what worked for me, with regard to pain and exercise and daily activities:

First, I listened very carefully to my knees. Bad knees throw off many different kinds of unhappy signals. I worked hard to figure out which ones meant impending problems and which were just the background grumblings I had to live with. I reacted quickly to the pain/discomfort signals that I thought spelled trouble.

If I awoke and my knees felt subpar, for example, I might cut back my step count that day from 6,000 to say 3,000 or 4,000 (I'd also try hard to figure out what caused the backsliding in the first place, so as to change my future behavior.) But my adjustment was usually only for a few days at most. It doesn't do much good to be on an exercise "program" that consists of lurching about; consistency is good.

I learned, too, that pain signals can arrive a full TWO DAYS AFTER the offending activity (hyaline articular cartilage has no nerves -- that's a BIG issue when you're trying to heal). Once I had knee pain two days after moving a heavy fan. Puzzled, I studied my knee journal to see what else could have caused the pain. Nothing -- I'm 99 percent sure it was moving that fan.

My recovery was a matter of learning how to recognize pain signals (delayed and otherwise), backing off, strengthening my joints, then pushing the envelope again.

That's right: I was always pushing the envelope. I never thought to myself, "Okay, I'll just get to the point where my bad knees can walk two miles without too much of a problem, then that'll be good enough -- I'll just accept I have bad knees that can walk only two miles." I wanted to heal and make my knees strong again, so I could resume the intense cycling I loved. I had big goals.

This is what Kelsey is talking about with that nice phrase, "edge the training." You have to push yourself beyond what's safe and comfortable.

The preceding reflects my personal experience. I realize I had a certain luxury though: my knees weren't absolutely shot by the time I intervened and managed to rescue them. Other people aren't so lucky. They're at the point -- because of failed physical therapy, or too much progressive damage over the years, or the severity of their initial injury -- where they simply can't get free of the pain.

So that brings us back to the original question: how do you exercise if everything always hurts?

Here are some of my thoughts for those with fairly constant pain. Discuss these with a medical professional to see if he/she thinks they make sense for you, in your situation:

* Can you do short bursts of activity? There was a period of my recovery, when I was half-convinced my doctors were right and I'd never get better, when I just did "walkarounds." Every ten minutes, I'd walk for a minute. It was a strange and boring regimen (bring a book!). For example, I'd go to a small park and walk around for a minute, then sit on a bench for nine minutes, then slowly walk for a minute, then sit back down etc.

Are there any motion-based activities your knees like? Moving in a swimming pool? Cycling backwards on a stationary bike (it requires less force and takes pressure off the joints)? At one point -- when I thought maybe I needed to go back to square one with my poor joints -- I even contemplated buying a continuous passive motion machine, secondhand, and just using that to give my joints frequent motion without too much strain.

* If nothing works for you -- you're still always in pain! -- you could experiment. I became a world-class experimenter. In fact, this helped stave off the boredom from what is, in the best of circumstances, a very, very slow recovery. Dedicate a week to a program of movement -- keep it at the same level all week (obviously if your knees start sliding downhill, adjust).

You do need to be fairly scientific-minded when you experiment, I found (buy a pedometer to track your steps!). If you don't keep as many day-to-day variables as constant as you can, then it'll be hard to tell whether your program of walking 4,000 steps a day is causing the problems, or whether it was that ill-advised trip to the racetrack when you had to stand for two hours in the same spot. In my book, I talk about how I became a guinea pig of my own making.

Also, I discovered that, with recovery from a slow-healing injury, it's best to focus on trend lines, not individual data points. In other words, say you start exercising Monday. On Tuesday, you say, "Eh, I feel about the same." Wednesday, you say, "I feel just a little worse." Thursday, you say, "It's been three days, overall I feel a little bit worse, I'm going to try something different."

The problem is, you may not have given your new regimen enough time. Try it for a couple of weeks. If, at that point, you say, "I'm definitely worse and going downhill," then maybe you are going in the wrong direction. But if you say, "I feel about the same," then you're probably winning. Why? Because you feel about the same but you're moving a lot more. That extra movement is laying the base for even more movement, and that's the path to healing bad knees.

* If experimenting isn't your cup of tea, or you don't feel you're getting anywhere, I'd look for a good physical therapist who is equipped to measure, scientifically, the strength of your bad joints and help you fashion a program to improve them. This involves more than someone examining your knees and saying, "Okay, do 10 of these and 20 of these" and so on. You need a physical therapist who can tailor a specific, joint-friendly exercise program for you.

Okay, that's a long-enough entry. I'm sure I'll return to this subject later. Now back to the book -- I'm coming down the home stretch and think we'll be ready to launch next weekend. Exciting moment! More information to come later and I will reveal why it's coming out only as an e-book. Stay tuned! :)

Saturday, December 18, 2010

Beating Knee Pain: The Attitude Re-Alignment

As I said here, I'm not at all convinced that issues of physical misalignment (the patella incorrectly tracking) usually explain knee pain. However, another kind of misalignment can be a big obstacle to getting better.

This kind of "misalignment" I came face to face with on one of the message boards I now frequent, where knee pain sufferers gather to share stories, advice, and from time to time, a little encouragement. Someone recently posted asking to hear from others who had "end-stage chondromalacia."

That phrasing intrigued me. Think about it for a moment. If you have "end-stage" anything, you're pretty much finished, right? If I came to you and said, "I have end-stage skin cancer," your reaction would probably be to clutch my hand, quietly murmur "I'm so sorry," then wait for me to disclose how much time I had left on this earth.

Well, it turns out there is no such thing as "end-stage chondromalacia." Or at least I've never heard of it, or read of it. I Google'd the phrase as well. Not a single hit. I doubt that a physician ever said to anyone, "You have end-stage chondromalacia."

However, I don't doubt that this person is in a lot of pain and missing a lot of knee cartilage. He or she is thinking: "My cartilage will just keep wearing down. It's not coming back. I'll just have to wait for a total knee replacement. Things won't get better."

Once you're convinced you have an end-stage condition, what does your life become? Answer: a matter of dreading the inevitable. Forget about hope. Negative thoughts dominate. Bad days are expected. Good days (or good moments) are explained away as flukes; they don't really matter because you're on a one-way street called Misery Lane.

I've been there. Early on, I was determined to beat knee pain. But I couldn't, even following my physical therapist's advice to the letter. A doctor told me my knees would never get better. And, not unexpectedly, my attitude -- little by little -- reset on me. Eventually I became an intensely negative ball of energy.

Part of healing meant doing an attitude re-alignment. It's not easy. It's hard as hell. Especially for someone like me -- I'm not by nature anything resembling a blithe optimist. But I realized my mind was working against me, and that wasn't good, so I began meditating. I just wanted to find some quiet interior space where I didn't hurt and wasn't angry all the time.

Of course meditating alone doesn't do it. You also need a plan -- a really good one if you've got "end-stage chondromalacia." You have a small margin of error.

What would I do if I were in that position?

I would seriously think about getting on crutches for a while and getting access to a continuous passive motion machine. Robert B. Salter did an incredible experiment in the early 1980s that showed an astounding rate of healing of full-thickness cartilage defects (yup, that's right down to the bone) among rabbits that were hooked up to a continuous passive motion device.

But here's the rub: at the same time, you'd probably have to go non-weight-bearing on those knees for a while, then gently introduce weight-bearing activities. I don't know exactly how this plan would be carried out. Right now this is just me musing aloud, trying to find a solution. Because trying to find a solution is positive at least.

I hope this knee pain sufferer can connect with a really smart physical therapist, someone like Doug Kelsey at Sports Center. If I were this person, I would even consider moving to Austin, Texas (where the clinic is). As I say in my book, a good physical therapist is worth his (or her) weight in gold.

That's because the best way to kill a negative attitude is with a plan that shows there is a path to getting better. Who cares if it's a long one? As long as you can see the light, and see the way to move toward it, you have some hope. And that's really important.

Saturday, December 11, 2010

What Are You Doing for Your Knees the Other 98% of the Time?

Anyone who reads my book (to be available the first week in January, it appears) will see me, in chapter eight, engaging in a bit of "medical study deconstruction" -- namely, taking apart a large study that was done about the effect of physical exercise on knees and showing how it comes up short in a number of ways.

It was a fun and illuminating exercise (fun because, to my wife's dismay, I spend a lot of time with my brow furrowed, thinking about things). To those who wonder what insight a layman could possibly have into a formal medical study, well, you might be surprised. The application of basic logic will get you far in analyzing complex subjects, even without specialized knowledge. For instance, judging the truth of the statement "the green disarticulation contours were green" doesn't require an understanding of what disarticulation contours are, why they are drawn, how they are drawn, whether they should or should not have been drawn in this specific instance. To recognize the sentence is true, you just need to identify an identity: "green equals green."

Okay, that example may seem a bit trite, but my advice is not to let the "experts" scare you away from examining their work, cloaked in all its jargon and statistical raiments. At the very least, after a thoughtful examination, you'll be in a position to ask some good questions.

And one question I asked, regarding this study, was "What were somebody's knees doing the other 98 percent of the time?"

Let me explain: The study looked at people who exercised, to see if they were less likely to develop osteoarthritis of the knee later in life. One category of exercise, fittingly enough, was walking. They were asked if they walked for exercise, and if they did, if they went less than, or more than, six miles a week.

Through how the categories were constructed, the researchers made it sound as though six miles a week was a lot of walking. So I decided to do a little math.

Let's say Joe Smith walks six miles a week for exercise. How long does it take to walk a mile? Well, I've walked one in 13 minutes before, but the average is probably closer to 20 minutes. So that equals two hours a week total. How many hours is Joe awake each week? Let's say Joe gets a full eight hours of sleep a night -- an optimistic assumption, but we'll go with it. That means Joe is awake 112 hours (16 hours x 7 days).

Divide 2 by 112 and you get 1.8 percent: That's right, Joe spends less than 2 percent of his waking hours on walking for exercise. Why does that matter? I hope you can see now where I'm going with this. What's happening with his knees the other 98 percent of the time? That's HUGE. (And the study in question makes no mention of this as a potential issue.) After all, his knees don't just magically detach from his body whenever he happens not to be exercising.

One of my complaints about physical therapy stems from this 2/98 problem. My therapist laid out a program of exercises and stretches that took me ... about two hours total, each week. Yet he didn't seem concerned about what my knees were doing the rest of the time! He never asked me questions that I would ask any knee patient, knowing what I know now. (Do you lug things to work? Do you often carry a loaded backpack? If so, about how much does it weigh? Do you often carry a child around the house? If so, how big is the child? Do you navigate a lot of steps during a typical day? Do you run for a bus? Do you run at all during a typical day? If so, for what distance and how often? Do you squat a lot at work? Do you stand a lot at work? Etc., etc.)

These questions are important because they are the other 98 percent! If your PT isn't asking about the other 98 percent, I believe you need to do the asking and thinking yourself. Because your job/house/lifestyle/whatever greatly affects how you use your knees. And how you use your knees -- over 100 percent of your waking hours, not just 2 percent -- is a big determinant of how your knees feel (and heal), I learned during my recovery.

Saturday, December 4, 2010

I Followed Your Advice, So Why Aren't My Knees Getting Better?

Sometimes I imagine this question, in a slightly querulous tone, coming from someone who has read either my entry here about what I did to save my knees, or this loonnnggg thread here, on Knee Guru's bulletin boards, that also reveals how I got better. (Quick disclaimer: I steer away from giving advice, so I took some poetic license with the title of this post.)

At Knee Guru, several smart people greeted me by peppering me with questions, curious about my "exercise regimen." How did I do this, how did I do that, what did I mean by this, what did I mean by that? And then, I have no doubt, they tried what worked for me: lots of easy, joint-friendly motion (for example, I did "walkarounds" in my apartment, where a wind-up timer would go off every 15 minutes, to alert me I needed to get up and walk a little, about 70 steps. Cleaving to that routine kept dosing my knees with movement).

After a few days of copying everything I did, I'm guessing many of them gave up in frustration, because their knees felt about the same.

So let me take a moment to make a few more in-depth observations about how I healed.

First, and it's hard to overstate the importance of this: recovering from a slow-healing injury isn't linear. What that means: you don't feel 15 units of healthy today, 16 units of healthy tomorrow, 17 units the day after that, and so on until you're at 100 percent again. If only healing were like a smoothly ascending straight line on a sheet of graph paper! Because then, as soon as you discovered the proper solution to getting better, you would know immediately that you'd found it because you would begin feeling an improvement every day forward.

Unfortunately, on the long road to saving my knees, there were ups and downs. Over a single month, I might happen to feel worse on the 22nd than on the 5th -- even though I was getting better over the entire month. So I learned that what I really needed to focus on was the trend line of healing. I had to be patient and squint hard to see that line. It only becomes clear over the course of some time.

Which brings me to point two: whatever path you choose to heal, it will probably take many months to bring you to your destination. For me, it took the better part of two years. This too has enormous implications, because early on (if you're like I was), you're casting about in frustration and desperation for a solution, any solution. So you try different things, in the same manner that a clotheshorse swaps out hats -- okay this guy says if I eat asparagus, that's good for the joints, I'll do that, wait this guy says I need to squeeze a beach ball between my knees, okay let's see if that works, now this guy says ...

Essentially you're a butterfly in the garden of healing, flitting from flower to flower, never committing to anything. Will you get better this way? I doubt it. You need to find a path, stick with it for a while (to verify that it's the right one), and then persist to the end.

Last observation on healing: the worse off you are, the longer it will take to make a few small gains. This too is critical to know. If your knees are really bad, it could take five or six months to make them just a little better. During this time, sadly, you may be tempted to just give up, thinking, "If it takes this long to go a little way, it will take me 20 years to get better!"

But what I observed about healing: it starts going faster as your knees get stronger.

I quit my job right at the end of April 2008. I had to; I couldn't sit in one place, with my knees bent normally, without a lot of uncomfortable burning, and my joints were going downhill fast. As soon as I quit, I devoted myself to a program of gentle motion, in amounts that my knees could tolerate. I focused like a laser on my goal.

Four and a half months later, I felt a little better, but not much. I began to have serious doubts. Would I really be able to beat this thing? What I didn't know was that my dedication to slow and steady motion was already helping my knees prepare for the next level of my program -- that November, I started walking on hilly trails, very carefully at first. Had I not spent the summer building up my knees, I don't think they could have withstood the rigor of that kind of exercise.

So if you're wondering why you're not getting better, even though you think you're doing what you should be, just consider these points above. Healing isn't linear. It's not swift. And, early on, it can be really, really slow. This is all important to know to win the battle.

Friday, November 26, 2010

Keep Running Past the Age of 40 and Your Knees Will Fall Apart! True or False?

I'm an enemy of received wisdom, especially on the subject of what constitutes proper care of one's knees, because there are so many mistaken beliefs out there.

For example, you often hear: Keep running long enough and you'll wreck your knees.

After all, how can all that pounding be good for joints where bones meet, their endings protected only by thin pads of cartilage? And if your knees naturally wear out over time, why hasten the inevitable by subjecting them repeatedly to the high-force activity of distance running?

That's the received wisdom on knees and running. The truth appears to be quite different.

While assembling a bibliography for my book about recovering from chronic knee pain, and sorting through my many files, I came across an article by Gretchen Reynolds that I saved a while ago. Dated Aug. 11, 2009, it appears online at the New York Times Well blog. The provocative title: "Can Running Actually Help Your Knees?"

The opening is attention-grabbing:
An article in Skeletal Radiology, a well-respected journal, created something of a sensation in Europe last year. It reported that researchers from Danube Hospital in Austria examined the knees of marathon runners using M.R.I. imaging, before and after the 1997 Vienna marathon. Ten years later, they scanned the same runners’ knees again. The results were striking. “No major new internal damage in the knee joints of marathon runners was found after a 10-year interval,” the researchers reported.
At first blush, this seems incredible. Of all classes of runners, marathoners train the longest; the race itself of course covers 26.2 miles. Over many years of running, their cartilage should be pounded to dust, right?

To be fair, a skeptic might say, "Not so fast! Perhaps the marathoners were relatively young and thus better able to withstand the stresses (just wait til they get older!). Or they may have been the equivalent of professional athletes, with efficient and streamlined bodies. Who else could run so far, so often?"

Yes, good points, but what about this second study that Reynolds cites:

Stanford University followed middle-aged, longtime distance runners (they didn't have to be marathoners). They were largely in their 50s and 60s (no spring chickens there). The trial went from 1984 to 2002. At the end, the knees of the runners were compared with those of a control group, about the same age, who didn't run.

At the time of their first exams, 6.7 percent of the distance runners had mild arthritis in their knees, as opposed to none of the control group subjects. Which seems to be an argument for inactivity.

Except, by the end of the study, the results reversed. Only one in five runners showed signs of arthritic changes in their knee joints; that contrasted with one in three non-runners. Severe arthritis hobbled almost one in ten non-runners, but only one in fifty runners.

What could explain this?

The article suggests that the knee may develop a "motion groove" (those who read my book will discover me discovering that movement is the magic ticket to knee health). Cartilage adapts to the load of running. I would add further: the tissue gets stronger and stiffer and better able to cope with ordinary daily activities without complaining and becoming sore.

Reynolds tosses in a caveat at the end of her article. Once a runner becomes injured, the "exquisite balance" implied by that "motion groove" can become disrupted, leading to a "degenerative pathway" that causes cartilage to wear down and fall apart -- and then comes pain and arthritis. (I've purposefully put some of these phrases in quotations because I'm not totally on board with the author's analysis here -- I smell a Structuralist lurking -- but that's for another time.)

Injury risks do abound for runners and must be guarded against at every turn. Gaining too much weight is a no-no. Being an inconstant runner -- someone who takes off a few months, then tries to pick up at his old level of intensity -- could lead to problems. Ambition can get you in trouble (for example, suddenly going from running three miles twice a week to ten miles three times a week as you begin training for a race). Stubbornly running through early pain signals is stupid.

But running sensibly doesn't appear to be a knee killer. It may help your joints, in fact (though my exercise of choice is cycling, which is easier to do within knee-safe bounds).

SKEPTIC'S CORNER: If you read the comments after the Reynolds article (299 of them!), you will see skeptics weighing in with arguments that can be summarized along these lines: (1) there is selection bias at work, as the runners were all healthy individuals (2) the runners weighed less than the subjects in the control group (3) anyone who is in their 50s or 60s and still running long distances has, through genetics and anatomy, superior knees and cartilage to begin with.

My thoughts, point by point: (1) The study's authors did recognize the possibility of selection bias, as the runners were indeed all healthy, but two things should be noted. First, could running be part of the reason for that good overall health (exercise has been proven to boost the immune system)? Second, osteoarthritis of the knee isn't considered systemic (unlike, say, rheumatoid arthritis), and so how much effect does good health have on one's knees, if any?

(2) The runners had only a "slightly lower BMI," according to the authors. Yet that difference at the outset is a BMI of 22.3 for runners vs. 24 for non-runners (the gap is maintained through the study), according to a table included with the report. For two six-foot men, that translates into a 164.5 lb. runner and a 177-lb. non-runner. That is significant, unfortunately, and I would say is the biggest flaw in the methodology because of the well-established relationship between excess weight and arthritis.

(3) This, to me, is the least convincing argument. Remember, at the outset, 6.7 percent of the runners had mild arthritis, while none of the non-runners did. If the runners really benefited from superior cartilage/knees, then why did they have worse knees at the beginning and better knees at the end? Also, if you drill down into the results, 44.4 percent of the runners complained of a previous knee injury versus 35.9 percent of the non-runners. So why was that injury figure 20 percent higher for the runners if they started out with superior knees and cartilage?

Saturday, November 20, 2010

Is Your Knee Doctor (or Physical Therapist) a Structuralist?

And why should you care?

Doug Kelsey, chief therapist at Sports Center, defines structuralism as "a school of thought that believes the genesis of musculoskeletal complaints is from one or more biomechanical abnormalities."

Further, he says:
For patella pain, the biomechanical abnormalities include a laterally tracking patella, weak medial quadriceps, tight hamstrings, tight iliotibial band, tight calf muscles, weak or tight hip rotator muscles and over pronation of the foot. A Structuralist view would then be to set the mechanics "right" and symptoms would subside.
Sound familiar? Pay close attention to that first one: "a laterally tracking patella." That is, in layman's terms, a kneecap that isn't perfectly centered in the trochlea, or the groove that it's supposed to slide through with the greatest of ease. We'll return shortly to that mistracking patella.

So if your doctor (or physical therapist) says your problems are caused by a poorly tracking patella -- or that you must strengthen hip/butt/quad/whatever muscles and stretch the IT band/quads/hamstrings/whatever in order to redress your body's imbalances -- chances are excellent you have a Structuralist.

But does Structuralism make sense as a model to analyze and treat the majority of people who suffer from chondromalacia or patellofemoral pain syndrome? Logically (and instinctively), the answer is no for several reasons.

(1) Can stretching, one of the solutions in the Structuralist toolkit, really correct biomechanical abnormalities? Stretching temporarily lengthens muscle fibers. Then they contract again. How long must you stretch to achieve a lasting, beneficial effect? Answer: it's unclear. Paul Ingraham, massage therapist and stretching skeptic, does quote this therapy-exercise textbook (in his comprehensive online essay looking at how stretching fails to deliver what it promises):
Several authors have suggested that a period of 20 minutes or longer is necessary for a stretch to be effective and increase range of motion when a low-intensity prolonged mechanical stretch is used.
That's a lot of time to devote to a single stretch, for a single muscle, as he notes. Then how often would you have to stretch like that? Once a day? Once every ten hours? Six hours? And, even supposing that stretching can change your biomechanics, how are you supposed to be able to tell when you've reached the sweet spot, of just the right amount of change, and not too much (after all, you don't want to have your patella start tracking to the left because you overcorrected for its tracking to the right, and too much flexibility does lead to unstable joints)?

(2) If the Structuralists are right -- if your biomechanics are at fault -- why do chondromalacia and PFPS usually strike at older ages: 30, 40, 50? Let's look at the commonly blamed factor of kneecap mistracking. If that's to blame for knee pain, wouldn't it become a problem soon after you learn to walk? Why aren't there more three-year-olds with PFPS?

Okay, that seems a bit silly. Let's take a charitable view of Structuralism. Let's say patella mistracking doesn't manifest until the skeleton has finished growing, in the mid to late teens for most people. Fine. Then why isn't there an onslaught of cases of PFPS when people reach their early twenties, as their adult frame finishes growing and their badly tracking patella dooms them to a life of pain?

(3) Finally, here's the big problem with Structuralism, as Kelsey observes: Nobody has perfect biomechanics in the first place. Yet most of us do fine anyway.

Those are three reasons that logically (and instinctively) Structuralism doesn't make sense. But in the world of evidentiary medicine, musings and common sense alone don't constitute grounds for overturning a prevailing paradigm. In the medical world, physicians turn to clinical studies. So let's look at one.

This study ("Patellofemoral Joint Kinematics in Individuals with and without Patellofemoral Pain Syndrome", published in 2006) included three groups: 1. 20 people with PFPS who had clinical signs of patellar malalignment (as evidenced by tests performed during a physical exam) 2. 20 people with PFPS who had no clinical evidence of malalignment 3. 20 people with no knee problems.

An MRI captured images of their knees in various stages of being flexed, to note "patellar motion" as a function of the particular angle their knees were bent. So the MRI could see, for example, whether the kneecap was perfectly centered in the trochlear groove or sliding out to the right or to the left.

If Structuralism was the correct paradigm for understanding PFPS, what would we expect to find? Easy: that the patients with knee pain tended to have kneecaps with the worst tracking.

What the researchers actually found:
No differences in the overall pattern of patellar motion were observed among the groups ... It is clear from the data that an individual with patellofemoral pain syndrome cannot be distinguished from a control subject by examining patterns of spin, tilt, or lateral translation of the patella.
(If you're a Structuralist, that sound you just heard is the floor collapsing beneath you.)

In other words, if you just look at MRIs of how someone's patella tracks, you'll have no idea whether they have PFPS. Someone with a kneecap that tracks perfectly may have PFPS. Someone with no knee pain may have a patella that mistracks. The authors make the point more bluntly in a follow-up letter to the journal where the study was published: "Our findings add to the evidence that patellar mistracking is not a clinically significant factor for most individuals with patellofemoral joint pain."

So there you have it, a crumbling edifice called Structuralism, that your doctor and physical therapist are probably using right now to analyze why you have knee pain and how you should fix it. And is it any wonder that more people aren't healing? And is it any wonder that, in order for me to heal, I didn't need a visit from the angels from above, but rather a cold-eyed rejection of this whole Structuralist approach (I got better through a simple, long process: I strengthened my knees).

So when I ask, "Is your doctor (or physical therapist) a Structuralist?", it's not an idle question. The fate of your knees may hang in the balance.

Sunday, November 14, 2010

So What Exactly Is Knee Cartilage Anyway?

In my last blog post, I dropped a rather long, important-sounding word: glycosaminoglycans.

These polysaccharides help to keep cartilage elastic and resilient. And, according to a Swedish study, their content increased in the knee joints of people who exercised.

Now I want to take a whirlwind tour through the make-up of cartilage, which I studied when I was battling knee pain, to put that fifty-cent word in some meaningful context.

First, hyaline articular cartilage (that’s the kind we're looking at, because it pads the ends of the bones that meet in the knee joint) is like a tough, rubbery, wet sponge. It’s four-fifths water (showing you why it’s important to stay hydrated).

Take out the water and what do you have left? There’s a tough, ropy protein called collagen that is found in higher concentrations on the surface than deeper in the tissue (to keep your cartilage tear-resistant where it matters most). Then you have molecules that weave around that collagen skeleton that are called proteoglycans.

Let’s look up close at those proteoglycans. They’re large molecules that consist of a protein core and many long-chain sugar molecules (if you want to visualize a proteoglycan, the easiest way is to imagine a bottle brush -- the spine of the brush is the protein core, and the many bristles are the sugar chains).

What are the sugar chains called? Go to the head of the class if you've already figured this out: glycosaminoglycans. (A quick aside: if you were to tear apart a glycosaminoglycan in your molecular toolshed, you would find it's composed of sugars such as glucosamine. Ah, so you now you know where that glucosamine you’re swallowing for your joint pain is supposed to be going! But unfortunately it never gets there, making glucosamine supplements useless -- more on that some other time).

So why should you give two hoots if your cartilage has a low content of glycosaminoglycans or a high content?

Well, when you subject your knee to load, that tough, rubbery tissue that is cartilage gets compressed. Remember, it’s not like a plate of metal, but rather a tough sponge with a high proportion of water. It needs some way to protect itself from intense forces being transmitted through the knee joint during everyday activities. Otherwise, your cartilage could get chewed up pretty fast.

Of course, there is that tough collagen, which helps. But the glycosaminoglycans also play a key role. On the atomic level, they carry a negative charge. So they repel each other when pushed closer together.

So let’s say you jump in the air to grab a Frisbee. When you land, knee cartilage has to absorb that load of your body hitting the ground. The pressure will expel water and synovial fluid from the tissue and push the glycosaminoglycans closer together. But as they’re pushed closer, that negative charge causes them to repel each other more strongly (you know how intense this pushback can be if you've ever tried to place the like poles on a pair of magnets in contact with each other).

So having plenty of glycosaminoglycans is critical for keeping the tissue resilient.

Knee cartilage 101! Important stuff to know.

Saturday, November 6, 2010

You Can Strengthen Knee Joints: Scientific Proof

Check out this hard-luck group of 30 people:

They're all between 35 and 50 years old. They've all undergone surgery to repair a torn meniscus (a disk of cartilage in the knee joint). 87 percent of the group are aware of their knee problems at least monthly, and most have pain, stiffness and functional limitations.

Not a happy bunch.

They were subjects in a Swedish study to gauge the effect of exercise on something called "glycosaminoglycans" in knee cartilage. Big word, but important stuff: these polysaccharides are critical for keeping cartilage elastic and resilient.

The subjects were split into a control group (whose level of activity didn't increase over the course of the study) and a group that exercised. Each week, the exercisers were expected to go to at least three group classes, supervised by trained physical therapists.

The classes consisted of warm-ups, such as cycling, rope skipping and jogging on a trampoline. After that the subjects did "individually progressed weight-bearing strengthening exercises." These included such activities as repeatedly sitting down and standing up while holding a barbell bar (with no weight on it) and doing lunges while holding dumbbells.

After four months, researchers used a special enhanced MRI to peer into the joints of all the subjects.

The exercisers were found to have a significantly higher content of glycosaminoglycans than members of the control group. Also, they had improved scores on a special scale designed to assess pain, joint function and quality of life for people with troubled knees.

In Arthritis & Rheumatism (the November 2005 issue), the study's researchers, Ewa M. Roos and Leif Dahlberg, wrote that:
The changes imply that human cartilage responds to physiologic loading in a way similar to that exhibited by muscle and bone.
So weak or damaged cartilage can change, and for the better. Furthermore:
In a cartilage matrix with low [glycosaminoglycan] content, as in cartilage disease, insufficient viscoelasticity may cause cause progressive denaturation of collagen molecules, collagen loss, and subsequent development of [osteoarthritis].
Is having more glycosaminoglycans all that matters in beating knee pain? Of course not. But if you want robust knees that can withstand the rigors of daily living -- and that includes the "rigor" of sitting -- you need good, healthy shock absorbers, or cartilage. And good cartilage needs plenty of glycosaminoglycans to keep it stiff and functioning well.

So what the heck are glycosaminoglycans, and why do they sound so suspiciously like "glucosamine"? Ah, not a coincidence at all. I'll look at that next time, because answering the question properly requires a bit of a "fantastic voyage" into cartilage, on a cellular level.

(Note: observant readers will wonder about the exercises prescribed in the Swedish story. Aren't some of them "quad strengthening" -- which I've made no secret of disliking? Yes, but a few things: 1. They were done after a period of supervised warm up. 2. They were done under the supervision of physical therapists, who were monitoring each individual's form (a breakdown in form signals someone is doing an exercise beyond his or her capability). 3. They were specifically tailored to individual patients. 4. I'm not saying I endorse these particular exercises for knee pain sufferers; I'm just saying knees benefit from movement -- and here's evidence.)

Saturday, October 30, 2010

Another Reason Not to Like Standard Physical Therapy for Chronic Knee Pain

A quick recap: Standard physical therapy's answer for PFPS (or chondromalacia, or runner's knee) is to try to strengthen the quads, the hips, the butt -- anything but the knee.

Why is this so bad? After all, some patients do get better under this regimen, right?

Well, if you believe what I do, it's bad because with difficult cases of chronic knee pain, this approach has a very high fail rate. It's bad because muscle-strengthening exercises can be too much for a weak joint to tolerate, injuring a patient even further (as happened with me).

And this week I thought of a new reason why it's bad: Because the clock is ticking for a knee pain sufferer ...

That means, from the onset of pain, you have an optimal window for finding the right path and getting on it. It could be a window of years, depending on the individual and the condition. But eventually, that window will start to close a little, then a little more.

I'm using this metaphor to refer to the threat of structural changes in the joint itself that throw up obstacles to healing. My greatest fear, when I had knee pain, was that I'd develop knobby bone spurs interfering with the knee's range of motion. In other words, I'd become full-blown arthritic and my best chance at winning the battle would fast recede.

The prospect of structural changes transforming my joints, in ways that could not be fixed short of surgery, scared me the most.

I recall listening to my left knee bend once, and it was if I had a band in there that would make a little dull snapping noise as it passed over some other object. Luckily, the "band" never hurt or impeded my normal motion. I proceeded with my program to get better, and whatever was causing the problem, now appears to be gone.

But for a while, I thought it was a permanent structural change. The longer hurt knees hurt, the greater the chances of the joint degrading in significant structural ways. That's why it's important to take advantage of that window of opportunity early on, when the pain first appears and it's easiest to get better. Unfortunately, that's exactly the time when Joe Patient, knowing nothing about his condition, wanders into a physical therapy clinic and gets a bunch of bad quad-strengthening advice.

My first visit to a physical therapist was June of 2007 (I'd have to consult my files to be sure of the month, but that's about right). The physical therapist treated me off and on until sometime in January of 2008. He urged me to strengthen my leg muscles; I did exercises he prescribed, sometimes feeling a little better, sometimes a little worse.

At one point, my knees blew up following his advice to lift weights in the gym, and I took a long downward slide. Basically, if my knees were about a 5 on a scale of 1 to 10 when I first visited him, by the time I left, they were a 3 or 4. So he left me in a deeper hole than he found me.

Meanwhile, this whole time, the clock was ticking. My joints were in danger of becoming permanently worse. Luckily I saw the light in time, the scales fell from my eyes, and I realized that the path away from pain was to fix the thing that hurt: to strengthen my knees first and forget about my quads for a while.

But if you're reading this, and you have painful knees, you may be thinking: What if I've passed the point of no return? What if it's too late? Well, it probably isn't. That thought is just one of many negative thoughts that flit through your head all day long because you're struggling so much with pain and discomfort. I've been there.

Next time: We'll look at a clinical study that shows you can strengthen knees. Scientific validation! Time to get geeky. Stay tuned.

Saturday, October 23, 2010

Why Patellofemoral Pain Syndrome Is Poorly Understood

I came across this on the Internet the other day -- the observation that patellofemoral pain syndrome (henceforth "PFPS" -- usually I hate acronyms, but I don't want to wear out my fingers typing that grandiose-sounding name again and again) is poorly understood -- and I thought I'd take a whack again at one of my favorite pinatas: the PFPS "diagnosis."

First, I don't argue with the statement that the condition is poorly understood. Just consider this observation from a July 2006 article in the New Zealand Journal of Physiotherapy Association: "Despite its prevalence, there is no clear consensus in the literature regarding terminology, the aetiology or treatment for PFPS."

So why is medical science baffled by PFPS so much? The kneecap almost sounds like the body's Bermuda Triangle, where a normal disease process goes and gets lost and becomes God knows what.

Here's my theory: PFPS is poorly understood partly for the same reason leg pain syndrome is poorly understood.

For those unfamiliar with leg pain syndrome (LPS), it's a collection of symptoms that describes certain aches and pains in the leg. They can appear in the arch of the foot, the back of the heel, the knee, the hip, the front of the leg -- in a number of places, really. The pain is often brought on by exercise or rapid movements of the limb.

The condition is poorly understood and hard to treat. What works for one case of LPS may not work for another. For instance, one sufferer of LPS may have a tear in the muscle in the arch of his foot, while another may be suffering from a sore tendon in the front of his knee. The two, of course, need different treatment modalities, making it difficult to devise standard practices for handling cases of LPS.

If you haven't figured it out by now, the last two paragraphs are bullcrap. There is no such thing as LPS.

It's just an exaggeration of what PFPS is: an overly broad and not-too-useful diagnosis that ends up confusing the patient. Because, to start with, PFPS simply means "knee pain." Actually, to be fair: "pain around the kneecaps with certain characteristics."

But what's missing here? The same thing that makes the LPS diagnosis pretty worthless: any kind of explanation as to what's causing the knee pain. What use is a diagnosis that regurgitates the symptom cluster, then folds up its tent and goes home, finished?

What if you had a high temperature and visited a doctor who pronounced your problem as, "feverish head syndrome," or FHS. Pretty soon, as cases of FHS became widespread, you'd be reading sentences like, "Despite its prevalence, there is no clear consensus in the literature regarding terminology, the aetiology or treatment for FHS."

Because FHS isn't really a diagnosis (American Heritage dictionary: "the act or process of determining the nature and cause of a disease or injury).

Neither is PFPS.

Saturday, October 16, 2010

How Traditional Physical Therapy Almost Ruined My Knees

This is the story that I figured, one of these weekends, I'd get around to telling.

It's the story that explains why, in preceding posts, I may sound a tad bitter when I disparage those who believe in "quad-strengthening" to relieve chronic knee pain.

Yeah, I'm a little bitter -- a little angry even -- because of a bad personal experience, which showed me in convincing fashion why this "strengthen the quads" focus is pretty dumb.

Here's what happened:

I had just returned from a two-week vacation with my fiance in Tibet. Beautiful countryside, and we ambled about at a slow pace (Lhasa, where we spent most of our time, is a two-mile-high-plus city, which left us gasping for oxygen much of the time). At that point, I'd been battling knee pain for about five months. So it was still early days for my condition, you might say.

When I flew back from Tibet, my knees felt pretty decent. I even started to wonder: "Could I be cured?" (Of course now I know joint problems don't mysteriously resolve in two weeks, but in Tibet I did manage to find, by accident, a sweet spot of motion interspersed with non-stressful resting positions.)

Soon after my return, I marched into my physical therapy appointment with a big grin: "I feel pretty good," I said. My therapist responded with a broad smile and said, "It's time to hit the weights!"

Of course, I thought. This is the perfect opportunity to build up my quads, at last! For months I had been thwarted in my efforts to do so -- my knees reacted badly to the exercises that my PT prescribed. He had modified my daily exercise regimen, ad nauseam, to no avail. But my joints feel better now, I thought triumphantly.

He showed me a "safe range" for doing leg presses and seated leg lifts. For example, with leg presses, he told me to push the chair on the machine as far back as possible and to focus on doing the exercise at a nearly full extension, so as not to put pressure on the kneecap. He also showed me a "safe range" for the leg lifts.

I began visiting a gym during my lunch hour. During the exercises, my knees felt fine. My muscles would burn a little and I thought, "This is great, I'm finally getting my quad strength back." But I soon noticed something rather odd. The next morning after my little workout, I would wake up with a small, focused, intense burning in my knee joints -- a symptom I'd never had before.

My PT didn't seem worried by this, so I kept doing the exercises. Unfortunately I began noticing more of the next-day symptoms, and what's more, the overall condition of my knees took a dip for the worse. It soon became obvious that my problems were roaring back. So I stopped doing the leg presses, thinking they might be too stressful. Then, after a while, I noticed for the first time my knees were becoming uncomfortable DURING the seated leg lifts. I took this as a bad sign. Plus, I had developed a small amount of swelling in the joints.

But you know what I was thinking, in the back of my mind, this whole time? I can't give up; I need to strengthen my quads ... once my quads are strong enough, this swelling and pain and discomfort will go away ... my physical therapist must be right about this; after all he studied anatomy and went to school to help people like me and besides everywhere you look online, the advice for cases like mine is "strengthen your quads!"

Then one day I stopped kidding myself. I wasn't getting better. I was getting worse -- a lot worse. Whatever hole I had been in before had become about twice as deep. Occasionally I would leave my desk during the workday and slowly shuffle around nearby streets, just to try to relieve, a little bit, the awful burning in my joints. And that's when I began to realize that the traditional approach of physical therapy to treating bad knees -- those with chondromalacia, PFPS -- was badly flawed.

Now if there's a PT reading this, I bet that person is thinking, "Well, the problem was that your physical therapist had you doing too much! You were lifting too much weight, or lifting weights too often."

To which I would reply: I could have done less weight, and probably it would've taken longer for the symptoms to arise. But why not face the real issue: my knees were still weak. Strengthening muscles requires a lot of force (relative to strengthening joints), and one thing that weak knees can't tolerate, is a lot of force.

About that time, I began to drift away from physical therapy (until then, I had been the perfect patient, doing my stretches and exercises every morning). I began crafting my own program to save my knees, a program that took almost a couple of years, but that gave me back my knees and the physically active lifestyle that I missed so badly.

That's my story. Anyone else want to share?

Saturday, October 9, 2010

Some Good Knee Advice From a Surprising Source

I've started venturing onto message groups, to share bits of my story, hoping to help others who are being failed by their doctors and physical therapists, as I once was.

I joined Yahoo's "chondromalacia community" as a recovered chondromalacia sufferer, a very rare species indeed. On joining, I was welcomed with a short e-mail that included 5 DOs and 5 DON'Ts for anyone coping with chondro. I didn't expect much from a "welcome to our group" message, but I was pleasantly surprised. The advice is better than you'll get from most physical therapists and doctors.

Below (and I would credit the author, but the note was unsigned) are the recommendations, with some brief comments from me after each:

--- Chondromalacia Do's

1) Keep searching until you find a doctor who will give you a thorough exam (1 - 2 hours), looking at the entire body. You'll probably have better luck with a pain specialist, osteopath (D.O.), doctor of applied kinesiology or a really good physical therapist. Most orthopedic surgeons give you about 10 minutes.

(RB: Yes! My experience is that doctors tend to give patients who have bad knees, but basically a normal range of motion and no noticeable swelling, the bum's rush, to put it bluntly. They will make a non-specific diagnosis, such as the dreaded "patellofemoral pain syndrome." Why getting a specific diagnosis matters: To fix what's wrong with you, you first need as much detail as you can get about what's wrong. Is there a problem with your meniscus? Plica? Cartilage? Tendon? So yes, do get a doctor who will investigate thoroughly.)

2) Become your own doctor. Do as much research as you can about knees, doctors and all the different treatment options there are. Concentrate on what is "wrong" with you, not just controlling the symptoms. This is a great resource to get started. Read each section on the patella:

(RB: This is a great idea on two fronts. First, you need to understand how knees work to understand and take control of your treatment, instead of putting yourself passively in the hands of someone else -- a physical therapist or doctor -- who, in the best-case scenario, will see you for half an hour once a week. You need to know enough about knees to be smart about them the other 167 1/2 hours. Also, "don't just control symptoms" is spot on. Don't become a "med head." Drugs make you feel better, but do nothing for restoring your knee health.)

3) Try to keep moving your knee as best as you can. Try swimming, no-resistance cycling or walking if you can tolerate it.

(RB: The right kind of movement is absolutely critical. I designed my whole recovery program around this idea. But it has to be easy-enough movement so that your knees tolerate it well.)

4) Start with the least invasive treatments first.

(RB: Yup. One thing I learned, when investigating surgery: surgery begets more surgery. That should give you pause.)

5) Keep thinking positively! You need to have the attitude that you WILL get better.

(RB: Very true. At some point, I became an intensely negative ball of energy. I hated my life because I hated this hurting person I had become. But plastic happiness isn't the answer either, I don't think. Rather, it's attaining inner peace while finding a good, sensible recovery program that gives you hope. I started meditating and found it beneficial.)

--- Chondromalacia Don'ts

1) Don't simply accept that you "just have to live with it." Chronic knee pain can often be fixed.

(RB: Agree 100%. Mine was fixed completely, no surgery. So call me Exhibit A for that point.)

2) Don't even consider surgery until you've exhausted every other, less-invasive option and cannot function in your daily life.

(RB: This advice may sound harsh, but I think it's dead right. Surgery simply isn't much good for cases of chondromalacia. A famous New England Journal of medicine study discovered that knee-pain patients who underwent sham surgeries (the surgeon only pretended to operate and did nothing to the joint) did just as well, if not better, than those who had an arthroscopy that included trimming rough cartilage and flushing the joint with saline solution.)

3) Don't exercise through severe pain, even if the exercises are prescribed by a physical therapist. Pain is the body's way of telling you something is wrong.

(RB: This is where I'd modify the advice a bit. Don't exercise through ANY pain is closer to what I believe. Also, another tweak: Don't exercise through pain, or do exercises that cause pain the next day. This "next day" part is what trips up almost everyone, I've learned. Most people don't understand well enough how cartilage damage occurs and fail to connect next-day pain with the exercises they did the day before. Or if they make the connection, they just try to shrug it off. Bad move.)

4) Don't blindly accept your diagnosis. Doctors make mistakes, especially when it comes to knees.

(RB: Yes, I can attest to this. Doc 1 told me: You have arthritis. Doc 2 told me: No, you don't have arthritis (but he said I would if my joints kept deteriorating). So doctors aren't infallible.)

5) Don't stop exercising. Even if you can only work the upper-body or exercise in a pool, you've got to try to stay healthy and strong. Don't immobilize the leg - that could make your situation worse.

(RB: I would modify this one slightly too. When I suffered from knee pain, I gradually became a bit leery of the word "exercise," though I confess I use it a bit loosely myself. If you have bad knee pain, you need movement/motion. "Exercise" in too many people's minds suggests hopping up and down in an aerobics class or doing squats, which is not a good idea for bad knees, I found. But you do need to move your knees as often as possible; immobilization to "let it heal" is totally wrong-think with cartilage issues. I also would hesitate to use the word "strong," because it's a "save the knees by building up the quads" code word. The truth is, you need to be patient and restore the health of the joints. During that time, your legs may not be strong at all. But if the joint is getting better, you're moving in the right direction.)

Saturday, October 2, 2010

Why Drugs Aren't the Answer to Knee Pain

I think everyone fighting chronic knee pain at some point reaches that dark place where they think, "God, if only this pill were more effective! If only it could drown out the pain for a little while and let me once again do the things I love!"

Be careful what you wish for.

Pfizer developed a potent arthritis drug called tanezumab. They began to put the experimental medication through studies to test its efficacy. And this unfortunately is what they discovered, according to a Bloomberg News story (the bold is mine):
An experimental arthritis drug from Pfizer Inc. reduced pain more than researchers anticipated, doctors said. It also allowed previously hobbled patients to overuse and permanently damage their joints.
Bone destruction developed in 16 of 6,800 patients taking the medicine, tanezumab, as part of Pfizer’s development program, and they all needed a complete joint replacement for the affected knee, hip or shoulder, according to a report in the New England Journal of Medicine. Pain-free patients may have put excessive pressure on their fragile joints because they weren’t getting natural pain signals to take it easy, said the lead researcher, Nancy Lane.
There was no dispute over whether the drug worked:
Reduction in knee pain ranged from 45 percent to 62 percent in those given the Pfizer drug, depending on the dose, compared with 22 percent for those given placebo.
But its larger failure -- the "rapid progression of arthritis" that occurred in 16 subjects -- may cause a rethink about chronic inflammatory pain:
“Pain has an important role in the avoidance of self-harm, but chronic inflammatory pain has generally been considered to be wholly undesirable,” said John Wood, professor of neurobiology at University College London, in an editorial that accompanied the research. “The study by Lane et al. suggests that a complete quenching of pain in patients with osteoarthritis may not necessarily be a good thing.”
Here is one of those places where medical science is going to get smarter in the next decade or two, I predict. I think chronic inflammation is wholly undesirable. But I think the associated pain, at least within reasonable limits, is actually desirable. The burning has levels of intensity, which are a way of providing invaluable feedback, telling you what not to do. Drugs to mute that pain -- to mask it, to immerse a knee pain sufferer in a cloud of false, pleasant feelings -- are simply obstacles to healing.

When I was frustrated and desperate, seeking to beat patellofemoral pain syndrome and tame a pair of knees that were constantly inflamed while sitting, I was given drugs by a doctor who said I had arthritis. One afternoon at work, I took the pills -- one was to combat inflammation, the other was to combat the effects on my stomach of the first pill. I have to admit, they did make normal bent-knee sitting easier.

And the next morning, when I woke up, I noticed my knees felt worse than normal.

Why? Because the arthritis drug allowed me to ignore the inflammation pain signals and engage in an activity (sitting) that I simply wasn't strong enough to do yet. When I realized what was happening, I swore I'd never take one of those damn things again. And over the next two or so years -- which included more than a few bad days, and a long recovery from knee pain -- I never did.

Anti-inflammatories allow knee pain sufferers to do things they shouldn't. For example, on a message board once I read about how someone had trouble climbing and descending stairs, so he just popped a couple of Advil for the pain ... and I just shook my head. Sure, the Advil will enable someone to climb stairs better. But if your knees can't handle stairs, why not try to figure out how to strengthen them so that they can, and in the meantime -- I know it's hard -- avoid stairs. It can be done.

Do you really want to heal? Or do you just want to forget you hurt?

One last important note: I know there are people who have knees that hurt terribly, and having gone through my own hell, I wouldn't take pain drugs out of their hands. It's awful when your knees hurt all the time. I've been there. But if you want to heal -- and you can; that's my message of hope -- beware of medication. I think it does much more harm than good.

Sunday, September 26, 2010

If Standard Physical Therapy Doesn't Work for PFPS, Why Does It Sometimes Work?

I'm not a believer in standard physical therapy, with its muscle-oriented approach, to treat PFPS (patellofemoral pain syndrome). So if I'm right, and it doesn't work, why then does it sometimes work? (Thus the paradoxical title of this entry.)

I think the easiest way to understand what's going on is through what I call the "socket wrench analogy."

Let's say you're trying to remove a nut from the end of a bolt. You're up on a ladder and you've spotted the bolt, attached to a brace that helps hold in place the rain gutter, which you're trying to rehang in a different location.

As any casual weekend handyman (or woman!) knows, removing the nut can be accomplished several ways. You can get a pair of pliers, squeeze the jaws around the sides of the hexagonal nut, and try to loosen it. Or you can use a socket wrench, a tool that has various snap-on pieces that fit various-sized nuts. A socket wrench is expressly designed to loosen and tighten nuts.

Here's what will happen if you reach for the pliers: In a certain number of cases, you'll succeed just fine. Pliers aren't designed to remove nuts from bolts, but they'll do the trick in a pinch. But then sometimes you'll come across that hard case, where the nut is stubbornly frozen. Using the pliers, you stand a good chance of not only failing but stripping the sides of the nut, thus making it almost impossible to remove some other way.

Now, with the socket wrench, you stand a much better chance of achieving your goal. Because this tool is specifically designed for the task.

So if your success rate with pliers is 55 to 65 percent, then your success rate with the socket wrench would be higher, maybe 90 to 95 percent.

With PFPS, if the success rate with standard physical therapy is 55 to 65 percent, then I would estimate that with a joint-focused approach, it would be significantly higher.

Standard physical therapy tries to save your knees through your leg muscles. I think it does work sometimes, and I suspect it works best for the milder cases of PFPS (just as that pair of pliers will remove the nuts that aren't too stuck). Strong legs do protect weak knees, so it's not as though having stronger muscles is a bad thing. Quad-strengthening exercises may overtax a weak knee, but if the joint isn't too weak (as with mild PFPS), perhaps no damage will be done.

Once you get a hard case of PFPS though, I bet that standard physical therapy often fails. Why? It's the wrong tool to fix the problem. Your problem isn't your leg muscles; it's your joints. So why not apply the right tool (joint-friendly exercises) in the first place to fix what ails you?

Sunday, September 19, 2010

What I Did to Save My Knees

That's an ambitious title for a post -- too ambitious really (that's why I wrote a book) -- but I just realized that, through several months of entries, I haven't been very clear about how I saved a pair of knees that my doctors said would never get better. At the time I was in my 40s with chronic pain that one doc even diagnosed as arthritis.

Here's my short answer: Joint-friendly motion. A lot of it.

When I realized my hurting knees had to move, and had to move a lot, the first thing I did was jettison all the advice of my physical therapist. Because he wanted to improve my knees by strengthening the muscles around the joint. Anyone who's done exercises to build up muscles knows that they respond best to low repetitions of high force.

For a while, I struggled with my physical therapist's recommended exercise program, wondering why I wasn't getting better. My muscles weren't getting stronger; my weak joints sabotaged my attempts to bulk them up. Then, as I researched the science of joints more deeply, I realized: damn, this guy has been giving me lousy advice.

Strengthen the quads is the wrong prescription. Strengthen the joints is the right one.

My first invaluable insight into restoring bad knee joints came via Doug Kelsey, who is by far the smartest guy I've read on rehabbing injuries. He suggested that a soft tissue like cartilage (which is often implicated in knee joint pain and mine was definitely damaged) responds best, in a positive, adaptive way, to high repetitions of low force. High repetitions = thousands of times.

So that got me thinking. Hmm. What exercise gets you high repetition, low force? You may think: well, there's lifting a really light weight. Unh unh. Tried that. You'd be surprised how heavy a five-lb. weight becomes after you extend it with your bent leg 100 times. There really aren't many activities that are high repetition, low force. Two however came to mind: flat-stage, easy walking (for me, 2,000 steps equals about a mile) and gentle cycling.

Cycling was out. I hurt my knees cycling hard up mountains, and my knees got irritated and inflamed with even easy cycling on a stationary bike. I suspect this was because of the peculiar cartilage damage pattern (it was worst under the kneecaps and I think mirrored the contact points of my cartilage for the pedal stroke). Walking though was different: I had retained a decent ability to walk.

So I kept a knee journal as I began walking and increased my step counts, from week to week. It was slow. There were setbacks. But eventually I could hike for five miles in the mountains. Then a full thirteen months after I seriously began my rehabilitation, I climbed back on a bicycle. My back felt stiff and I was wobbly, like an old man, not like the guy who took second place in his age category two years running in a time trial series in South Florida just five years previous.

That return to the bike came 15 months ago. Now, finally, I'm back cycling at full intensity. My knees feel really good. They also make less-crunchy noises (indicating the cartilage has probably healed somewhat).

So why was I convinced that motion was so important for knees (I think it is the single most important thing, by far, to effect healing)? I did much, much research -- which is what I'll get into in future entries. And what do you do when your knees hurt too much to walk a few miles a day? Ah, I've been there. There are answers. When my joints were really weak, I used to walk around a pool, 101 steps, every 10 minutes, just to give them periodic "dosed" motion.

The key thing is to get on the right path to healing. That path, I'm convinced, involves just the right amount (and right kind) of motion. Moving is how you win the battle.

Sunday, September 12, 2010

What's Your Knee Pain Personality?

While writing my book about recovering from chronic knee pain, I had a flash of insight: There are two dominant "knee pain personalities," if you will. They are both extreme, in their own fashion. Each personality type presented an obstacle to healing.

I call them the "Humpty Dumpty" and the "Warrior" (other colorful nicknames can be devised; these are the two that I happened to like best).

Humpty Dumpty types manage the long-running knee pain battle by being ultra-conscious of their fragility. These people have suffered enough setbacks to adopt caution as a byword. If they make a dash for the bus, and their knee swells/aches that day or the next, the lesson they take away is not to run for any more buses. Which at first seems sensible.

Notice though that they don't think, "How can I strengthen my knees so that they can tolerate an occasional sprint to catch a bus?" Instead they pencil "running for bus" on their mental list of "things that people with knee pain like mine shouldn't do." Over time it becomes a long list. A Humpty Dumpty is, in fact, prone to falling into the "bad knee death spiral":

Do less physical activity and --> your knees become weaker and --> your weak knees hurt more and --> because your knees are weak and hurt you do less physical activity and --> your kness become weaker and --> on and on and on ... until you've got a pair of really bad knees.

A Humpty Dumpty probably believes that knees are sort of like that brand-new car that, once rolled out of the showroom, has only so many miles on it. After time, knees simply wear out, as that car does, and there's not really anything that can be done about it. So a Humpty Dumpty is an interesting mix of prudence and resigned pessimism.

Ah, you may think: I'm not one of those! I know I have bad knees, but I'm still running/playing volleyball/hiking mountains/participating in the weekend touch football tournaments.

You may be the other extreme: a Warrior. That probably described my personality early in my battle with chronic knee pain.

Warriors have sporting lives full of props, and I'm not talking about running shoes or tennis raquets. Ice, that's a prop they like. (Over time, my bags of ice melted to the inverse shape of my knees as I stubbornly tried to continue my cycling-in-the-mountains routine.) Ice will quiet inflamed joints (until you remove it, I discovered). Or aspirin, or Advil -- those are good props that let you exercise through the pain (or help you through the post-exercise pain). Knee braces: yet another prop.

They accept their knee pain. They're tough.

And their knees don't get better either. Just as Humpty Dumpty's don't.

When I finally recovered, it was by cleaving to the middle path. I looked for ways to be active, but through gentle motion, and not too much at once. That was anathema to the Warrior in me -- I remember laughing scornfully at my doctor the first time he suggested that I cut back my cycling to ten minutes a session for a while, because my body was conditioned to going out hard for up to two and a half hours.

But later, when I began to learn more about what I needed to do to get better, in a real and lasting way, I realized I couldn't be a Humpty Dumpty and sit back and rest and do nothing and hope my knees would somehow improve on their own. And I knew that Warrior behavior was destructive too. By working out through knee pain, all I'd ever get would be a life sentence of more knee pain.

Those are big realizations to make. If you've got problem knees and are trying to chart a way forward, figure out your knee pain personality. Then ask yourself: Is my personality working against my long-term goal to get better?

Monday, September 6, 2010

Good (Knee) Habits

After a punishing, fast bike ride on Saturday morning (about 63 miles), I had just dropped onto my bed for a moment, post-shower, when everything I wanted to do that afternoon started clicking through my mind, like a slideshow at high speed. First, I was going grocery shopping -- that's a 1.5-mile trek to the nearest Trader Joe's and the same distance back, except the return leg includes carrying 10 to 15 lbs. of groceries in a backpack. Then I had to buy energy gels at the bike shop. Then there was the check to deposit at the bank.

And yet, I lounged around my Forest Hills apartment for a full hour before setting out for the grocery store. Why was I dawdling? I'm usually quite driven, with a fairly structured life.

Why? Good knee habits.

Three years ago, I couldn't have ridden 10 minutes on my bicycle, even at a ridiculously slow pace, without my knees burning. Cartilage under my kneecaps was damaged, seriously enough that it transformed my life. I couldn't endure bent-leg sitting. At home, I would have my legs extended and propped up on boxes. At work, I had them straight out too, hanging in a sling on the underside of my desk.

I did a lot of things to engineer a long, slow comeback. One thing I realized was important at the outset: good knee habits.

For example: When the temperature is below 60 degrees, I cover my knees when cycling (I own both knee warmers and leg warmers). During my recovery, whenever I went for long walks, I would stop halfway through and rest for ten minutes -- not because my knees hurt, but simply because I wanted to ensure they didn't start to hurt. Saving your knees is about being proactive, and smarter than simply following the adage, "If it hurts, don't do it." Once it hurts, you've already screwed up (a little secret that doctors and physical therapists don't tell you).

When I finally got back into shape cycling -- when my joints were strong enough to tolerate the 50-, 60-mile rides at high intensity that I loved so much -- I acquired a new habit. After a hard ride, once I dismount, I take at least one hour of down time before asking my knees to go for a long walk or do anything strenuous. So that means I return from cycling, exhausted, and lie on my bed for a little while or tap away at the computer or read a book. I give my knees a chance to take a breather.

Not because they hurt.

But because I don't want them to hurt again.

Sunday, August 29, 2010


Your knees will never get better.

I remember the moment the orthopedic doctor said that. It was after I had dropped into a squat from a standing position, as if I were sitting in an invisible chair, and both of my knees produced the loud, wet, crunching noise of significant cartilage damage. It was after I had told him, with passionate earnestness, that I was prepared to do anything to get better -- anything.

And he told me, flat out, that there wasn't anything I could do.

I know what he was probably doing. This was my second visit to him, separated by many months, and there I was, complaining of the same knee pain as before. I had seen a physical therapist for months, to no avail. I had tried glucosamine sulfate; it didn't work. I had tried, it seems, everything I could -- but nothing helped. My knees still hurt much of the time.

Faced with this set of facts, he probably put on what he thought was his truthteller hat. He probably saw me as not so much determined, but rather stubborn and deluded. When I dropped into that squatting position, and he heard the awful noise my joints made, he didn't say anything. But he was probably thinking: Those knees are beyond saving. They won't get better.

So he said as much.

I can remember how depressing that felt, to be told there was no hope. Luckily, I didn't accept his verdict. I decided to wage this fight on my own, and after a couple of years, I emerged the winner, with a pair of knees that now feel as normal as before.

But being robbed of hope, even if only briefly ... that's something I'll never forget. I realize there is a time for a good medical doctor to disabuse a patient of his or her unrealistic expectations. But having bad knees isn't like having a body overrun with terminal cancer. Bad knees can be coaxed back to good health.

Hope is powerful medicine. I won't say that hope healed me. I had a program of action, and I cleaved to it as if my life depended on it (and maybe it did). But having hope, the promise that next month would be better, and the month after that better still -- that was what sustained me through some gloomy times.

A real, lasting recovery is not fast. It is slow, slow, slow. But on that long journey, you'll need your hope, shining bright, to help you see the way.

Sunday, August 15, 2010

Yes Virginia, Damaged Cartilage Can Heal

In my blog "mission statement," if you will, I set out four beliefs about how to treat bad knees that I think are wrong, but that are also (unfortunately) widely held by physical therapists and medical doctors. In this July 3rd entry, I expanded on why I think this particular statement is false:

A plan to heal bad knees should focus on strengthening the quadriceps muscles.

This dictum fails the common sense test, as I noted. Your quadriceps don't hurt. Your knees hurt. If your knees are the problem, why not not make them the focus of the treatment? Why not try to strengthen your knee joints?

This seems so obvious that you have to wonder, "What's the catch? Surely, thousands of smart physical therapists and doctors wouldn't blindly ignore a course of action that appears so logical. There must be some explanation for why they don't try to strengthen the joints."

Yes, and that reason is probably this other wrong-headed belief:

Damaged knee cartilage doesn't heal; at best you can prevent it from getting worse.

This is what your physical therapist probably believes (though, in the interest of keeping up your spirits, most likely doesn't speak aloud). Given that belief, quad-directed treatments make more sense. After all, if damaged knee cartilage can't heal, then maybe the best hope is to try to bulk up the muscles around the knee, so that they can cushion the joint from harmful impacts. (Ignore, momentarily, the paradox that with a very weak joint, you can't build up the muscles without further breaking down the joint itself.)

Suppose though that damaged knee cartilage stands a reasonable chance of healing.

Then the whole ball game changes. Then ignoring the joint in favor of the muscles seems downright foolish.

The scientific evidence, in fact, does show that knee cartilage apparently can heal. Now, if it healed at a very low rate -- say, a percent or two of all cases -- then you still might hesitate to embark on a program to strengthen the joints, because the odds of success would seem too low.

But it turns out, the rate is considerably higher.

Like 37 percent.

Here's the evidence:

A study conducted in 2000 by researchers in Southern Tasmania used MRIs to assess the knee joints of 325 subjects, to detect changes over a two-year time span. They found that 33 percent of the subjects had a worsening of cartilage defects in one of their knee compartments, but 37 percent had an improvement!

Note: these subjects whose cartilage got better weren't on any special exercise program, or taking any special supplements, or receiving any special kind of treatment. They were, for the most part, simply people going about their lives -- some had knee pain and some didn't, some probably exercised and some didn't -- and almost two in five had the condition of the cartilage in their knee joints improve.

(Actually, in a future entry, I'll show you why the rate was almost certainly higher than 37 percent. But that proof involves a little deep thinking, so I'll reserve it for a later entry, to keep these blog postings short.)

So next time your physical therapist says (or implies -- they don't really come out and say it), "Well, we have to focus on the muscles, because the cartilage can't heal," you should say, "And what do you base that on?"

Because this one study -- and I've got two others I could cite as easily -- shows that cartilage does appear to heal. So not only does it make sense to strengthen the joint because that's the source of the problem, but also because a key tissue in the joint -- the cartilage that is the critical shock absorber for your knees -- can get better.

Sunday, August 1, 2010

Why "Patellofemoral Pain Syndrome" Is an Incomplete Diagnosis

This essay on out-of-control inflammation, by M.D. Mark Hyman over at Huffington Post, resonated deeply with me. In it, Hyman talks about how doctors are taught to shut off inflammation with medication. Sometimes the medication has serious side effects. What doctors aren't trained to do, he says, is "find and treat the underlying causes of inflammation in chronic disease."

Let me offer a word substitution for knee pain sufferers. Replace "inflammation" with the phrase "patellofemoral pain syndrome." Because you're basically talking about the same issue.

When my knees hurt much of the time, I was diagnosed as having "patellofemoral pain syndrome." To me, a rather naive patient still eager to learn everything I could about my condition, this seemed impressive, authoritative, definitive. Only later did I realize that the term meant very little.

"Patellofemoral pain syndrome" simply describes a bucket of symptoms. Here are some I found listed online:
* Aching pain in the knee joint, particularly at the front, around and under the patella.
* Swelling sometimes occurs after activity.
* Pain is often worst when walking up or down hills or stairs.
* A clicking or cracking sound may be present on bending the knee.
* Sitting for long periods may be uncomfortable. This is known as the theatre sign or movie-goer's knee.

It's a nice roundup, but misses a key element. What's wrong? And what's causing it to be wrong? And what can I do about it?

After finding no obvious reason for my pain, doctors were content to diagnose "patellofemoral pain syndrome" without exploring what was causing the problem and how it could be fixed. One simply said I was getting old (I was in my mid-40s at the time) and prescribed arthritis medication to combat the burning (i.e., inflammation) that plagued me in both knees.

I had to do a lot of research on my own and insist on an MRI to get a good grasp of the problem. It turned out I had damaged cartilage in both joints. So I needed to find a way to improve the health of the tissue.

It was that simple, and that complicated.

I succeeded (my knees feel normal again), through a long and patient exercise program that I developed myself. But it still irks me that doctors often look upon patients as a collection of symptoms that need to be subdued, neglecting the underlying source of pain. One thing I learned: you have to know what's wrong, and what's causing it to be wrong, to formulate a plan to make it right again. And "patellofemoral pain syndrome," by itself, is an incomplete diagnosis that ignores the "why?".

I'll end with Hyman, because his remarks below, though about inflammation, could be equally applied to a number of other medical conditions:
It you want to cool off inflammation in the body, you must find the source. Treat the fire, not the smoke. In medicine we are mostly taught to diagnose disease by symptoms, NOT by their underlying cause. Functional medicine, the emerging 21st [century] paradigm of systems medicine teaches us to treat the cause, not only the symptoms, to ask the question WHY are you sick, not only WHAT disease do you have.
What's more, for a knee pain sufferer, if the "source" happens to be damaged cartilage, that's not a death sentence. Contrary to what doctors may have you think, cartilage can be strengthened, healed, restored -- without $40,000 invasive surgery. It takes time, but it can be done.

Friday, July 16, 2010

Who Am I?

I'm posing this question because that's what a reader may wonder who comes across this blog.

Who is this guy, who brashly rejects accepted wisdom about healing achy knees?

First, what I'm not: I'm not a doctor. I'm not a physical therapist.

I am someone who struggled with chronic knee pain for more than a year. My diagnosis was patellofemoral pain syndrome (a terrible, say-nothing diagnosis ... and I'll go into that at some other time). I had bad cartilage lining my kneecaps, from cycling too hard up steep hills.

My credentials for writing this blog, I suppose, are that:

I am a skeptic by nature, a journalist by profession, and a pretty capable researcher with a talent for sifting through piles of research documents (medical textbooks, scientific studies) and extracting relevant information. I quickly learned that doctors weren't telling me the right story (or full story) about bad knees healing.

I am someone who believed strongly enough that his knees could get better that I quit my job and embarked on a year-long scientific experiment of sorts, testing all sorts of things, to find out what would help me heal. I recorded these observations in a detailed knee journal. I doubt that anyone has attempted such an experiment before (it's rather dull, for one thing), but what I learned was amazing.

And probably most important, I am someone who beat chronic knee pain, on my own, designing my own program for recovery.

No surgery, no magic pill in a bottle.

I want to share my story on this blog (I've also written a book). I wrote the book because, when my knees hurt much of the time, I searched everywhere for answers about what to do because my doctors weren't too helpful or optimistic. The books I found left me unsatisfied. They were written by doctors and physical therapists and were dry tomes chock full of the same advice that wasn't working for me and my really sensitive joints.

I wanted to read a story told by someone who had chronic knee pain that was like mine, hard to treat, yet who found a way to beat the condition, and what he learned along the way.

So I wrote "Saving My Knees," hoping it could inspire others.

Saturday, July 3, 2010

Dangerous Knee Myth #1: To Heal Bad Knees, Focus on Strengthening the Quads

My former physical therapist designed a treatment program around this belief, that the key to controlling my knee pain lay in strengthening the quads (the large muscles on the front of the thigh). I dutifully followed his advice and did the exercises he suggested. I made no progress for months in my battle with achy, painful knees, then eventually succeeded in damaging the joints further.

I started getting better when I rejected the "strengthen the quads" approach to beating knee pain, realizing that it didn't make sense.

It seems almost heretical to say that. If you search the Web for treatments for "chondromalacia patella" or "patellofemoral pain syndrome," you'll find the "strengthen the quads" advice doled out repeatedly.

Which is pretty remarkable, considering it fails the common-sense test. Here's why:

Just imagine you bang your elbow against something, really hard, and it begins to ache. After many weeks, your elbow still bothers you. So you go to see a doctor.

He takes X-rays and examines the joint. It's capable of moving through a normal range of motion. You tell him about the ache: low-grade and chronic, though sometimes it's worse than other times. There's nothing broken in there, he reassures you, and the joint pretty much behaves as a normal elbow would ... he sort of shrugs and sends you to physical therapy.

The physical therapist, after inspecting your elbow, recommends exercises to build up your shoulders and biceps. Having a strong shoulder and biceps will ease the load on the joint, he says. You leave his clinic with several sheets of diagrammed exercises that you are instructed to do 20 to 30 repetitions of, once daily.

What's wrong with this picture?

The problem isn't with your shoulders and biceps. It's with your elbow.

Likewise, I realized my problem wasn't with my quads, it was with my knee joints. Why not directly treat the problem? Why not focus on strengthening my joints, not my quads? Once my joints were strong enough, THEN I could worry about building up my quads. Sure, strong quads help protect knees, but their weakness isn't what's making you miserable.

Of course this raises some intriguing questions (that I'll return to in future posts): If this is such an obvious application of common sense, why don't orthopedists and physical therapists try to strengthen joints, first and foremost? Why do so many think the route to saving your knees goes through your quads? The answers are a bit complex, and I thought about them on many days during my recovery, as I focused on joint-strengthening exercises.

Some physical therapists do know better, like Doug Kelsey of Sports Center, whose writings were a beacon of hope to me during my bleakest days. Here's an excerpt from one of his blog essays:
Most of the medical profession believes that there is nothing that can be done, conservatively, for a joint with degenerative changes. The medical options are to quit doing things that make your knee hurt, use medications to control inflammation and pain and / or perform surgery - partial or total knee replacement ... Sometimes people will get sent to a physical therapist with instructions to strengthen their quadriceps muscles. Of course that often fails or is ineffective because the force needed to strengthen the muscle is beyond what the joint can withstand ... I've seen thousands of people with damaged cartilage over my career and a large percentage of them recover.
He's absolutely correct: people do recover. I did, and my crackly cartilage improved too. But I didn't get where I am now with a muscle-first approach to vanquishing knee pain. I realized it had to be joint-first. And that was a big first step.

Monday, June 14, 2010

Saving My Knees: An Introduction

Welcome to my blog about beating chronic knee pain. I did, after a doctor told me flatly, "Your knees will never get better." It was a long ordeal: I wound up seeing four doctors, two physical therapists. At some point, as weeks turned into months and then into a full year, and their advice and treatment failed to help me, I gave up on them and they gave up on me.

I had constant burning, aching and soreness around both of my kneecaps. The diagnosis was patellofemoral pain syndrome or chondromalacia. I was a hard-luck case with very sensitive joints. At work I had to sit with my legs elevated and extended, my feet propped in a sling under my desk.

When the medical professionals abandoned me, my resolve only stiffened. I wasn't a doctor, but I wasn't dumb either. I had an Ivy League education and more than a decade's experience as a journalist. I began devouring everything related to bad knees and damaged cartilage I could lay my hands on -- scientific studies, blog posts, chapters in medical textbooks, threads on bulletin boards about injuries.

Gradually, I discovered the path to recovery. While doing so, I got very angry because it became clear that a lot of thinking about "patellofemoral pain syndrome" (also known as "runner's knee," among other names) is dangerously bad. I started this blog to tell my story -- of what I learned, of what I did to get better. I also wrote a book "Saving My Knees" that I'll supply more information about later.

I want to challenge what you think you know about healing bad knees. For example, if you have knee pain (or if you're treating someone who does), chances are you believe at least one of the following:
(1) A plan to heal bad knees should focus on strengthening the quadriceps muscles.
(2) Knee pain sufferers trying to recover should make stretching an important part of their daily exercise routine.
(3) Taking glucosamine tablets helps bad knees improve.
(4) Damaged knee cartilage doesn't heal; at best you can prevent it from getting worse.

I think those four statements are false: every single one of them. In future blog posts I'll show you why I think that (and I'll share with you scientific studies that make my points).