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.