Friday, December 24, 2010

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! :)


  1. Woops, did I understand right, that I need to buy Kindle (or somekind of device) that I can buy and read your wonderful book? :/

  2. Not at all! That's originally what I thought, but guess what: if you've got a Kindle, Kindle DX, iPad, iPhone -- or even just an ordinary PC -- you can read "Saving My Knees." (Kindle for PC -- free download; takes a few seconds -- will set you up on an ordinary PC). I'm a computer geek at heart and so starting next week I'll walk people through the world of getting set up to read electronic books. Stay tuned!

  3. Dear Richard, your book is the only thing that gives me some kind of hope. I don't know how to exercise since I have "permanent" swelling - water on the knee for two and a half months now - i.e. the beginning of the symptoms. NSAID did not make much difference. I had a cortisone shot which provoked 5 day worsening followed by an improvement (though swelling never went away), and now I am worse again. I am not sure how to exercise at all if my only reference point is if it swells a bit more. I am doing an MR the day after tomorrow, but I am not considering an Op unless absolutely necessary. Anyway, thank you for keeping this blog. I read a recent post and I beg you not to shut it down. My best wishes for a long and pain-free life.

    1. Thanks, Paula! Appreciate the message. Yes, you're in a tough spot now, it sounds like. You definitely don't want swelling, but you need to move. You might want to look into some of the easy exercises Doug Kelsey prescribes, such as the "Tailgater." Also have you considered water therapy? Good luck, cheers.

    2. Thanks a lot Richard, what do you mean by water therapy, please?

    3. Just doing exercises in the pool. There's a book that's full of water exercises called "Heal Your Knees" (, but you could also probably find some good ones if you Google'd around.

  4. Dear Richard, I'm sure you've heard it million times but your story and Dr. Kelsey's theory you referred to are the only hope left to save my knees. Here is my brief story, skipping common details such as numerous unsuccessful doc visits:

    Unlike you I was a very sedate person. During my pregnancy I got very stressed in my work, and moving, plus a lot of other unwanted physical loads, and one day I was sentenced to bed rest as a result of non-stoppable premature contractions. I was there for two and half month, distressed, worrying about my baby and not being able to even turn my body from side to side without causing a contraction. The only body movement I had was to almost crawl to the bathroom.

    After the delivery I thought all the misery was over and got excited to be able to walk again, so I did, so much. The next couple months saw almost no sleep and regular nutrition intake because of the baby. But the worst thing was my epidural shot during delivery started to hurt like crazy so I had to stand most of time while feeding her, hating lying down so much.

    So one day my left knee start clicking. Soon after my right knee. Since I knew nothing about joints I seeked help in doctors. Over the past 13 months I saw 3 PTs and 3 doctors and followed their changing advice. But life has many other variables than knees. I had to leave US for a while, we moved again, etc. Plus, I also got serious Dry Eye Syndrome(yes another syndrome) almost the same time I started having knee problems. And don't please forget my hurting back. So over the course my attention was shifted among my baby, house hunting, and which ever body part that bothers most lately.

    The problem with my eyes limited my internet activity, so it was very late until I finally learned enough about my knees and reach your book(for a long time I was told my pain was due to elastic ligaments).

    I hope it's not too late. I too share so many questions as all the other knee pain sufferers. As for now I had to send my baby to day care since she's starting to walk better and faster than I do. I also quit my job. I reached the point where almost everything I do with my knees hurts. But I haven't lost hope. I'm on a plan to make a plan of my long-time recovery. In the last couple of days I started to do hundreds of unloaded knee bends and limiting all my other activities as much as I can. Will do that for a week or so and see what that feels.

    As a former scientist, I got very curious how my problems all of sudden emerged(I also have pain and clicks in most of my other joints, but they are not disabling for now). I hope one day it'll be revealed to satisfy my curiosity. But as the time move away from those miserable months, the chance is getting lower and lower.

    1. That's a tough story, and I wish you much luck in your efforts to get better. Patience is important, and also there will be ups and downs no doubt, so be aware of that. I hope you're successful. Please check back in later and let us know how you're doing and what you've learned. Cheers.

    2. Thank you for your reply Richard. Well to make my story tougher, during the same time my dad got cancer and passed away. There were many moments I didn't know how to keep living. At first I wanted to know why dad and I got sick, and it quickly lead to basic questions like the meaning of life. I'm starting to believe everything has an emotional side which might be more fundamental. True that I did something dumb to make my knees all of sudden go wild, but long before that I was already soaked in depression and some kind of self blame(mostly unnecessarily). It seems like such emotions finally found a way out. I don't know which is easier, to fix the emotional side or the physical side? Or could it be that they have to be done the same time?

    3. It will help a lot if your mental state is good. Unhappy people feel pain more acutely, I'm convinced. Try meditation? I did and I once thought I was the last person on earth who would ever meditate!