Are Your Knees So Bad They’re Beyond Hope?

The idea for this post comes from a recent comment that went like this: “My doctor is negative about my knees, talking about bone on bone and osteoarthritis. Can I still benefit from your experience and methods and heal my knees?”

In other words, is there realistically any hope for knees that feel lousy pretty much all the time, that are missing a lot of cartilage, that are already osteoarthritic?

OPPORTUNITIES WASTED

First, a quick rant (some of you know this one by now).

I doubt that terrible, crippling knee pain (short of that caused by a traumatic accident) just steals into your joints in the middle of the night. It’s generally preceded by annoying, persistent knee pain. That in turn is preceded by occasional, nagging knee pain. And so on.

That means that, with knee pain that has steadily worsened over many years, opportunities have been squandered. Why do people waste good chances to get better early on? For many reasons, I suspect, but partly because of a grim fatalism that nothing can be done, that knees “just wear out.”

Of course that’s not true. You can reclaim a pair of bad knees (as I did), but it helps to act sooner, not later. You may have to swim upstream against the prevailing advice (with its focus on strengthening your quads, stretching your ITB, etc.). But you can do it.

Still, if you didn’t seize that optimal window to heal early on, are you doomed? I don’t think so.

THINKING OUTSIDE THE BOX

While struggling with my own recovery, I thought a lot about knees (way more than any human being should), and about how the body heals, and grappled with tough questions. For example: If damaged knees can heal (I firmly believe they can, after mine did), why don’t people who have really bad knees ever seem to get better?

Hmm.

If you believe that knees “just wear out,” it’s no mystery. The really bad knees never get better because that’s the immutable law of the universe, for them to get worse and worse, just as gravity exerts a pull that can’t be denied, no matter what your belief system. Case closed!

But if you’re an optimist on the subject, like me, the answer turns out to be more complex. I think people with really bad knees don’t heal for a variety of reasons: They become mired in pessimism. Their knees have changed permanently (bone spurs, for example) in ways that complicate or thwart healing. Or they’re not patient enough, radical enough, or creative enough.

The third reason (by the way -- that list above is not meant to be exhaustive, just a sampling of reasons) is the one I want to explore (the meaning of the other two, after all, is kind of obvious).

ON BEING PATIENT, RADICAL AND CREATIVE

Patient enough means girding yourself for a long process to heal. It took me the better part of two years. For someone with severe chondromalacia, I’m guessing it may take 4, 5, 6 years. And the hardest part would be the first year or two, I would bet.

That’s because the worse your knees are, the slower your gains. That was my experience. Early on, there were weeks, even months, when I wasn’t convinced I was really making significant progress. After about seven or eight months though, I could tell my plan was definitely working, and my rate of improvement was faster too.

Radical enough means you may have to make big life changes. I quit my job -- I know, not many people can afford to do that -- but sitting at my desk was contributing to the chronic inflammation that kept my knees weak. I couldn’t convince my doctors of that, but by then it was okay: I had done the research and felt confident that I was right. For other people, radical enough may mean giving up that second-floor bedroom for a while if your knees aren’t strong enough to climb and descend stairs.

Finally, creative enough is all about finding innovative solutions to vexing problems. You want to find a way to lighten the load on your knees? One commenter recently described how, for a while, he decided to use crutches. And he used a Bosu Ball at work to get in regular flexing of his bad knee. That’s creative!

When I wanted to move my knees a lot, but couldn’t do so without discomfort, I thought of making a poor man’s continuous passive motion machine (and went so far as to sketch out designs on paper). I never did try to construct it, but did create a rock-climbing-harness-and-bungee-cord setup in my mother’s garage that allowed me to do hundreds of deep-knee bends at a time, with little strain on my recovering joints.

PARTING THOUGHTS

Finally, if your knees are really bad, I would develop a long-term plan -- you’ll need it, because there aren’t any short-term fixes (short of surgery, which may or may not work). And I’d seek out a good physical therapist, someone who believes what Doug Kelsey and others at Sports Center in Austin believe -- that you can get better -- and knows the right path to take too.

For some more thoughts, check out this blog post. It’s my most popular ever, so it must’ve struck a chord with a few people. It will give you hope about cartilage repairing itself, even when you’re down to the bone.

One last observation: Even for the very worst knees, I’d be surprised if some improvements couldn’t be made. Even if your ceiling isn’t full healing, but rather living with 50 percent less pain, that’s an improvement!

How Worried Should You Be About That Creaking From Your Knees?

The crackling noise -- which in Saving My Knees I likened to that of someone sitting on a bag of potato chips -- is called "crepitus." This medical term means a "grinding, crackling or grating sensation or sound," so says this arthritis Web site.

The site also declares, incorrectly I think, "If it occurs without any pain, it is unlikely to be caused by arthritis or any medical condition, and is usually meaningless." A popular "save your knees" book on the market also asserts that that noise from your knees, unaccompanied by pain, isn't significant. I think that's wrong thinking, and dangerous.

What if you were a ship's captain and spotted a strong beam of light through the fog? If you continued on your way without incident, you might conclude that the light was meaningless. However, if you strayed too close to the light's source -- and wrecked your ship on the rocky shores that this lighthouse was trying to warn you of -- I think you'd argue the opposite: that the light was quite meaningful indeed.

Similarly, crepitus of the knee (note: I'm talking about a certain kind of noise here, not the airy pops or harmless cracks that all joints make from time to time) is a warning that something is amiss. Before I developed knee problems, I heard (and ignored) crepitus in my joints because there was no pain (so I figured, as the writer above tells us, that it was meaningless).

Big mistake. A few months later, I was in the fight of my life to rescue a pair of burning, aching knees.

So then am I advocating that knee crepitus become an obsession as you try to recover? Nope, not that extreme either. For two big reasons:

(1) You don't have to eliminate all crepitus to have happy joints again.

My knees still crackle some, though certainly less than before. Perhaps they always will. That's okay by me, if I'm not in pain. I do, however, make a point of listening closely to the crepitus occasionally, because when it starts getting louder, I know my knees are probably going in the wrong direction.

Remember, over the age of 30, most people have cartilage defects in their knees, and probably a lot have some kind of related crepitus. (You can hear minor crepitus if you bend over a subject's knee, so your ear is just above the joint, and have that person do a leg extension.) Back when I was thinking about doing a rugged mountain climbing event on my bicycle, someone who did the climb every year (and so trained a lot on hills) reported on a forum that his knees were very noisy. But he had no pain.

(2) Monitoring crepitus smartly is really, really hard.

Readers of my book will recall that knee noise was one of the variables I tracked and scored. In retrospect though, I'm not sure how useful that was.

Why?

Because the condition of damaged cartilage changes very, very slowly, so you're not likely to find significant differences, day to day. Because the noise appears to be a function of a variety of things (such as the quality of the synovial fluid at a given instant). From my experience, these other things are quite variable over the short term in ways that aren't easy to understand.

For example, even after an easy cycling session, my knees sound crunchier than usual. If my primary objective were to eliminate all noise from my knees at all times, maybe I'd stop cycling -- which would be a bad thing.

So, in conclusion, I think crepitus associated with cartilage damage is absolutely meaningful, even if you're pain-free. Ignore it at your own peril. But should getting rid of crepitus be the be-all, end-all of a program to heal bad knees? Absolutely not, in my opinion. I would focus on getting rid of pain. Strengthening my knees. Engaging in lots of knee-friendly movement and exercise.

And, in the end, after doing all the right things and getting better, I bet you'll find the crepitus has improved along with the rest of the joint.

Merry Christmas to All!

Yes, I know ... I'm a week early with the holiday wishes.

But let me explain.

My life has become very time-starved, with a 10-hour-a-day job and a sometimes difficult two-year-old now living with me (Joelle is the most beautiful little creature on earth, but when she does NOT want to do something, she summons the strength of a dozen grown men and lets loose a wail to wake the dead).

Not having enough time has encouraged me to be efficient. I try to maximize every minute of the day. During my half-hour lunch break at Bloomberg, I usually find a spot on a bench at the officer tower and write out blog entries, longhand.

I actually rather enjoy it, so no need to feel sorry for me (if anyone was). I start a post on Monday, scribble and revise and scribble some more until I finish, usually by Wednesday or Thursday. Then I tear the pages out of my notebook, tuck them into my backpack, and bring them home for typing up (and posting on the blog) over the weekend.

At least I usually do. This week I goofed. My entire mini-essay on crepitus is, as I write this, sitting in a desk drawer on the empty 25th floor of 731 Lexington Avenue. It never made the trip home because I got distracted right after lunch and forgot it.

So I decided to flip things around. Next week I was going to do the "Ho, ho, Merry Christmas, and may all your knees stop complaining for one weekend!" Instead, I'll do that now -- consider it done -- and next week, I'll let you know what I think about crepitus.

One last thing: a huge thank you to all who have dropped by this site over the past year, and who have taken the time to review Saving My Knees on Amazon. Even if a single copy of the book never sells again, its popularity has exceeded my expectations.

And, finally: Does anyone out there have an uplifting story they want to share? I'd love to hear from others who have had success with their knees. How? What did you do? Please let me know below. I'd love to do a blog post on this. Let's share our knowledge of what works!

The Last Ride of the Season

On Dec. 4, at quarter to noon, I unclipped from my bicycle for the last time in 2011.

November turned out to be a better month than expected. I managed to ride every weekend. I stretched my rule of thumb on weather a little ("never go out on a day when the temperature is below 40 degrees"), as I found that through smart layering of the right clothing and diligently keeping extremities (toes, fingers, head) as warm as possible, the cold didn't bother me as much as last year.

Still -- there reaches a point when all the bundling gets to be a bit much, and the quality of the ride deteriorates anyway (I was out in front Sunday, doing no more than 22 to 24 miles an hour for a stretch, and looked back to see the group had lazily drifted off my back wheel -- that never happens on a July ride).

So now I plan to take at least four months off, to focus on easy spinning in the gym, on a stationary bike. It gives my knees a bit of a breather. Because here's the dirty secret: the kind of intense once-a-week riding that I do is not the best thing for a pair of knees fresh off recovery from chronic pain.

I do it because I love it so much -- and I love the super feeling that comes from this high level of conditioning. I do it because I'm confident I can recognize the danger signs, if my knees start to get in trouble again. This year, I was heartened by the fact that, when the season ended, my knees felt better than a year ago at the same time.

And yet -- a couple of weeks ago, I happened to bend down after a cycling session and heard some extra crunchiness from my right knee. That got my attention.

Which brings us to:

What is that crunchy noise from your bad knees? How concerned should you be about it? How important is it to monitor that crunch, as you try to heal? What's it trying to tell you?

Next week, I'll give you answers based on my own experience.

What's Going on With Chronic Inflammation?

Sometimes you ask a question rhetorically, to make a point. Other times you ask out of legitimate curiosity, like today.

When I had constant knee pain, I was pretty certain that chronic inflammation had set in, from the burning sensations that plagued me so much of the time. And I was quite curious about what that implied for my prospects for healing.

Nothing good, I concluded after doing some reading about inflammation. There are a couple of types, almost like cholesterol. There's the good inflammation, that occurs in the aftermath of an injury and signals the body to speed "troops" to the area to spur healing. Then there's the bad kind that spirals out of control and leads to further problems (arthritis pain research has shown that a pro-inflammatory molecule called Interleukin-1 stimulates the synovial cells to produce more of the enzymes that degrade cartilage, and also inhibits the creation of new tissue).

My research into inflammation never went very deep though. I did learn enough to know that there are plenty of mysteries about chronic inflammatory processes. Battling bad knees, I became preoccupied with two questions. They are below, and anyone with insights (or other questions), please feel free to chime in.

1. Can chronic inflammation in the knee joint spread to other parts of the body and even become systemic on some level?

I once mentioned this to a general physician, who quickly pooh-pooh'ed the idea. But I still wonder. The internal plumbing of our bodies is all connected, after all. The knee -- or any other part of the body -- isn't "firewalled" off from any other part.

Readers of Saving My Knees will understand why I'm asking this. The book describes my battle with problems in multiple joints -- elbow tendons, back, knees. Were they all really completely unrelated? Or did the chronic inflammation in my knees, after a long enough period of time (about a year) make me more susceptible to other joint issues?

At one point I thought I had rheumatoid arthritis! So did my father, frankly (a blood test ruled it out). While writing the book, I was a bit worried that the multiple joint problems would somehow undermine the authenticity of my story, or lead people to think, "Oh, he didn't have chondromalacia, he had something else." Then, months later, when discussing the book online, I found lots of other knee pain sufferers who thought they too might have had rheumatoid arthritis (but didn't). My story become more authentic, not less.

2. If chronic inflammation is bad, then shouldn't anti-inflammatory medication be good, if you want to heal?

I began by asking doctors a variation of this question. I wasn't interested in anti-inflammatories for their ability to mute pain signals (which is why most people like them). I knew they did that. I wanted to find out if they'd help my injured knees to heal. On this, the doctors seemed uncertain.

The more I thought about it, the more I saw evidence of a tradeoff. Perhaps anti-inflammatories would slow the degradation of cartilage, all else being equal. But all else wouldn't be equal. Anti-inflammatories would trick my knees into thinking they felt better than they really did, and thus might encourage me to do stupid things (walk too far, sit too long) that I otherwise wouldn't. These activities might cause further damage inside the joints.

I did take a prescription anti-inflammatory once, an experience I mention in the book. It allowed me to sit at work with less discomfort, but the next day my knees felt a little worse. Had I taken enough of the pills, I probably could have run a road race, but what price would I have paid afterwards?

Still, I think an intriguing question remains: If it were possible to take anti-inflammatories that didn't dull the important signaling to "not do this and not do that" that's coming from your knees (of course this would be medicine that didn't offer pain relief, so who'd take it?), would the medicine then help slow the rate of tissue breakdown, or help you heal?

Maybe yes, maybe no. I'm not sure.

On Cynicism, Skepticism and Pessimism

Oscar Wilde once said that a cynic knows the price of everything and the value of nothing.

What I’m going to say later about cynicism -- and its two cousins, skepticism and pessimism -- probably won’t surprise anyone. What I’m going to say next, however, may.

I am a skeptic -- and proud to be one. Don’t tell me something works and assume I’ll believe you; show me it works and tell me why. I am also, not so proudly, somewhat of a cynic. And my inner nature tends toward pessimism.

So, in other words, I’m probably the least most likely person to write an uplifting story of triumphing over adversity. I’m not a “rah, rah, go team go!” kind of guy. Of everyone in my work pod, I’d be the last choice to lead a pep rally.

In fact, writing this blog isn’t a natural fit for me. Initially, I struggled with the “voice,” if you will. That struggle arises partly from my desire to say something meaningful without sounding too confident/too authoritative (I’m not a doctor or physical therapist, after all, plus I am willing to accept the uncertainty of much of the knowledge we humans possess). But I also just find it challenging to find the proper tone -- my natural voice tends to be darker and more irreverent.

So why do I do it? And why did I write Saving My Knees in the first place?

Well, there’s something that motivates me powerfully, almost absurdly so, that enables me to overcome my natural shyness about talking about myself and my tendency toward negativity. And that’s a conviction that we must celebrate truth over lies, knowledge over ignorance, light over darkness.

When I succeeded in healing a pair of bad knees after traditional physical therapy failed, and doctors said I’d never get better, I had a few emotions.

Gratitude. Relief. Anger.

I was angry because I was confident that many chronic knee pain patients could benefit from using the same framework I used to get better, and benefit from the many things I learned (which weren’t in any “heal your knees” book on the market and which weren’t being said by most doctors and physical therapists in the field). So I said to myself: “I’m going to write this book. I’m also going to start a blog to open a dialogue of sharing.”

My passion for getting the truth out there is what motivates me, as well as my fervent wish that my message reach someone else who can be helped.

Which brings us full circle, I suppose, to skeptics, cynics, and pessimists.

If you want to heal your knees, go ahead and be a skeptic, though of the open-minded variety. While you should be willing to try things, and experiment, it's also okay to ask up front: Does this approach/treatment make sense? Why should it work? You have an optimal window to rescue your knees; there’s nothing wrong with trying to seek out the “best of class” of solutions for your problems, and experimenting smartly.

If you want to heal your knees, I’d say be careful of cynicism and pessimism though. If you distrust the motives of everyone, if you believe nothing will work because nothing has so far, don’t be surprised when, after half-heartedly “trying” a few things, you don’t get better.

The journey to recovery is a long one (it was many months for me). You will be tested more than once. You will need to be determined -- and you will need to draw upon optimism, to overcome the funks of negativity and doubt, and to enable you to push on with your plan to heal.

How I Saved My Back

While fishing through the comment section recently, I found this:

I recall you mentioning either in your book [or] on the blog injuring your back in the aftermath of trying to manage the injury. Have you been able to remediate that yet and if so how?

And I thought: what great timing. Because it recently occurred to me that this would make a good topic for the blog. True, it’s not knee-related, at least not directly, but I’m sure there’s lots of overlap between the knee/back pain groups.

I messed up my back, as I explain in Saving My Knees, after sitting for months with my legs raised and extended -- a position I had to assume because of knee pain. On my worst days in the Hong Kong newsroom, I’d have to get up and walk around for a while because my back felt so tight and painful. At the health club, I’d stand in the shower for 10 minutes with the water as hot as I could stand, letting the flow from the showerhead massage my backside. I wasn’t in good shape.

Today I feel fine, with no lingering issues.

What happened between then and now?

Well, first of all, I was fortunate in that the back problems weren’t too far advanced when I quit my job and dedicated myself to saving my knees. So that was good. But I knew I had to act. I didn’t want to be that guy in his 50s who’s laid up on the couch half the day after an energetic snow-shovelling session. I began reading my favorite physical therapist, Doug Kelsey, curious about what he had to say about fixing a bad back. (And I would advise all you back pain suffers to check out his writings, such as this one.)

Doug advocates strong muscles in the core, or mid-section of the body, to support the spinal column. He recommends “lock and load,” or walking around with your stomach muscles always in a state of partial tension, to engage the muscles that stabilize the spine. Personally, I couldn’t imagine having to spend the rest of my life remembering to keep my abdominals clenched. Too much work.

My compromise to take care of those muscles: a form of sit-up. Kelsey hates sit-ups, for good reason: there are plenty of ways to do a sit-up that will injure your back further. Mine are less sit-ups than isometric exercises. I lie on my back, legs folded over the couch, then sit partway up and hold that pose for three minutes -- no twisting, no violent motions. It works for me (though may not for someone with a weaker back, I suppose).

What else I do:

1. What I believe helped me the most is doing planks or bird dogs, every day (well, I take off weekends). The plank:
The bird dog:







I do a bird dog each day for 3 1/2 minutes, alternating legs, but otherwise just freezing in the pose. These are yoga positions. They will do a world of good for your back muscles, but be patient. Same as with bad knees, bad backs heal over months, not weeks.

2. Movement. Doug Kelsey once said on his blog something to the effect that (according to an old teacher) sitting does the same thing for your spine as putting a plastic bag over your head does for your breathing. Get moving! Your knees and spine will thank you. I try to get in as much walking as possible; I even take a more-distant subway train to ensure I walk a mile to work (and back) each day.

3. Weightlifting. This isn’t a must, and not a good idea early on, but I wanted a strong back that wouldn’t complain whenever I had to carry my 28-lb. 2-year-old daughter. Of course be careful. I didn’t start my back rehab with weightlifting (and honestly, I don’t do that much now anyway). I waited until my back basically felt okay, and I always, always warm up, by doing 50 repetitions of an easy weight. Plus, I don't lift too much.

3. Sweat. “Huh?” you may be thinking. What’s sweat got to do with this? But I really believe -- and I’ve probably not written enough about this -- that sweat-producing activity (when your body can tolerate it! -- e.g., don’t run four miles on bad knees just so you can break a sweat) is like getting in the fast lane for healing. This is based on Doug Kelsey’s writings and my personal experience in Hong Kong -- when I was able to walk hard enough to regularly break a sweat, I seemed to get better faster.

How long did it take my back to improve? It’s hard to say exactly (unlike with my knees, I wasn’t keeping a “Back Journal”), but I’d say a year or two. Part of what makes estimating so difficult: what’s the meaning of “improve”? After 7 or 8 months, I was certainly improved, but still had issues to work through.

Today, a full 3 1/2 years later, my back feels fine -- in fact, it’s probably stronger than before. I can ride 3 1/2 hours on a bike, bent over, with no problem. I helped a mover transport a big, heavy sleeper sofa into our apartment over the summer -- which involved moving it from the apartment of its previous owners, into an elevator, out of an elevator, into his van, etc. And when I took Cong and Joelle to Maine in September for Jo’s 2-year birthday party, at several times during the journey by train, I was loaded up, carrying luggage, like a Tibetan pack mule.

But no problem.

My spine's happy again.

What Angers Me About a News Article I Largely Agree With

The Salt Lake Tribune ran an article recently about how important it is not to sit around moldering on the couch when you have arthritis.

"Remaining sedentary actually increases the risk of injury and pain," the author writes. Through movement, a woman by the name of Margaret Crowell was apparently able to reverse symptoms of osteoarthritis in her thumbs and hands. She now leads a class in modified yoga and tai chi moves.

"Great, wonderful," I'm thinking -- this is the right message. Heal through motion! It's one of the key themes in Saving My Knees.

And then I got angry.

Because this isn't the first article I've read espousing gentle motion for arthritis pain sufferers. So the arthritis experts are figuring this out, that lots of easy movement is a good thing, but ...

Once you have arthritis, your joint (knee, finger, whatever) has undergone significant changes, some of which aren't reversible (such as bone spurs). You're already fairly damaged.

However, no one wakes up one morning with osteoarthritis (I'll limit myself to this common wear-and-tear form of the disease), completely taken by surprise ("What! Last night when I went to bed I felt fine!"). For example, if you have osteoarthritis of the knee, you've already spent a fair bit of time -- years, most likely -- coping with and complaining about your joint pain. And, getting back to the original point, this is what made me mad.

There is a wonderful window for intervention early on with knee pain! You can heal, even if your cartilage crackles every time you bend down to pick up your slippers. I know you can because I did (and because medical studies show the tissue can heal, and because a very smart physical therapist by the name of Doug Kelsey has shown at his Austin practice that patients with knee pain can get better).

But what typically happens early on, with the first onset of knee pain? You flail around for a while on your own. Maybe you see a doctor, who just shrugs if your knee moves normally and advises you (if you're a sporting type) to take it easy for a while. Or you see a physical therapist who recommends stretching and quad strengthening (the first of which doesn't help fix the underlying problem, and the second may make it worse).

Gradually, you resign yourself to your bleak fate (and your cartilage breaks down some more, and osteophytes form and get larger, and your range of movement becomes restricted, and ...)

Crazy! Because what those arthritis patients are doing at age 65 when their joints are trashed is what they should've been doing at age 45 when their joints were starting to give them problems! Lots and lots of gentle movement is a great prescription, but it's coming too late.

That's what infuriates me -- that knee pain isn't being treated seriously, systematically and properly early in the disease cycle of arthritis.

Seriously means doctors should stop shrugging helplessly and saying there's nothing they can do yet for hurting knees and should start focusing on early intervention to stave off arthritis.

Systematically means the design of a user-specific movement program aimed at gradually strengthening the bad knee.

Properly means the right kind of motion -- not high-load, low-repetition (quad strengthening) but low-load, high-repetition (knee strengthening).

My Most Popular Blog Posts

I thought I'd try something a little different this week. Namely, I'm going to whisk back the curtain and let everyone have a glimpse of information that's normally available only to me, as the author and manager of this blog.

At first I thought listing the most popular posts would just be an amusing bit of trivia, but then I realized the list serves a larger function. Basically, it's a "vote" by readers on what they found most useful on this site. So if you've landed here for the first time, here are five past pieces of writing you may want to check out.

1. Comment Corner: Can Even Badly Damaged Knee Cartilage Heal? (469 views)

This blog post was prompted by some smart reader questions left in a comment section. The surprising answer to the headline question: in at least two studies, areas of cartilage with the worst damage had the highest rates of improvement.

2. "What Should I Do If I Have 'Weak' Knees?" (343 views)

This comment from a reader puzzled me initially, and honestly, still puzzles me somewhat. The anonymous writer didn't have pain so much as "weak knees" -- but they didn't feel like they were going to give out. So, if there's no pain and no instability, I wasn't sure what to think -- except that it would be wise to strengthen those knees, because otherwise there probably will be pain at some not-so-distant point in the future.

3. What Does "Knee Strengthening" Mean Exactly? (196 views)

While it's fairly obvious what strengthening quadriceps muscles refers to, what about strengthening knees? What does it mean for a knee to become stronger? This was an important topic to cover on the blog, I thought, because focusing on strengthening my knees was how I escaped my chronic pain.

4. If Strengthening Quads Was Really the Answer to Beating Knee Pain, I Wouldn't Exist (148 views)

I'm pleased that this post made the top five, because it's probably my most convincing effort to show that "strengthen your quads" shouldn't be the prime focus of a patient with chronic knee pain. I discussed how I healed my knees as my quads got weaker (in fact, when I threw all my energy into strengthening my quads, I almost trashed my knees -- a not uncommon experience with traditional physical therapy, sadly).

5. How Can You Read "Saving My Knees," an Electronic-Only Book, If You're Kindle-less? (129 views)

No great insights, just practical advice on how to read a book that's available only in electronic form. (Note: I'd love to find a way to allow people to make paperback copies from their Kindle versions. Unfortunately, all the print-on-demand outfits I've reviewed so far require various set-up fees from me, north of $100, as well as a separately formatted .pdf. But if anyone knows of a service that can print books off a Kindle copy, with no one-time startup/set-up fees, let me know!)

One Reason I'm So Optimistic About the Ability of Knee Cartilage to Heal ...

...is that (as I've written before), in this medical study, cartilage did appear to heal, and at a surprisingly high rate: 37 percent.

What's more, that figure almost certainly under represents the true rate. I'll get to why in a moment (the why is the reason for this post). The explanation is a bit wonky, but well worth the effort to understand.

First though, that tantalizing 37 percent. What does that mean? That 37 percent of all subjects with bad cartilage were totally healed by the end of the study (two years later)? Nope. Sorry, but nothing so dramatic. Rather, it means that 37 percent of the subjects experienced an improvement in a cartilage defect somewhere in their knee.

Ahah. Now we're getting somewhere. But still -- what's an "improvement in a cartilage defect"? Well, first, areas of knee cartilage were examined by MRI. Then a common scoring system was used to evaluate the tissue, where "0" is normal, "2" is some wearing away with at least 50 percent thickness remaining, and "4" is eroded to the bone (so you have five possible scores: 0, 1, 2, 3, 4).

So for your right knee, for example, you may have a spot that's graded "4" (no cartilage), and at the end of your tibia a place that's a "3," and then a location on the inside of your femur that's a "2." Two years later, the defects were reviewed again. A difference in the score was either an improvement or a worsening, depending on which way the number changed.

Up to this point, you may be thinking you've already read on this blog about the 37-percent-of-defects-healing study, so what's new? Answer: the 37 percent number is almost certainly not accurate. It's too low! "Why" is something I discuss in the book, but have never written about on my blog.

So let's delve into the reason. First, you have to appreciate a subtle truth about measuring rate of change: the amount of change that you find always depends on the accuracy of the measuring instrument.

Confused? Well, in Saving My Knees, I illustrate why this is true with a hypothetical world where you can determine people's heights using only devices that measure in increments of one foot. In this population, everyone has a height of 1 foot, 2 feet, 3 feet, etc. There are no inches.

Suppose you have three teenagers: Mary, Ted, and Fred. Mary (according to our Earth measuring tape) is 5' 6", Ted is 5' 9", and Fred is 5' 11". A study is undertaken to see what percentage of our three subjects grows over the course of 12 months. After a year, Mary is 5' 7", Ted is 5' 9.5", and Fred is 6' 1".

What percent of the population has grown, if we're measuring them with a device that has only feet, and no inches?

Only 33 percent! (Fred was "6 feet" before, because he was between 5 and 6 feet in height, so now that he's between 6 and 7 feet, he's considered 7 feet tall.) What about Mary, who grew an inch? No, she didn't grow at all using our rough measuring stick -- she went from 6 feet to 6 feet. No change. Same for Ted.

Seems crazy, huh? But that's what you get when using an imprecise measuring device.

Now what happens when you measure the difference in cartilage defects using only five grades? You're going to miss change that you would capture were you able to use 10, 20, or 50 grades. Consider: Cartilage at a given location that has worn 95 percent away is rated a "3." Two years later, if that same location is 55 percent worn away, that should be considered an improvement, right? But 55 percent still falls within the classification of a grade "3" defect. So, using this crude measuring system: no change!

If it were possible to make finer measurements with confidence, we'd expect to see a higher rate of change, all else being equal. Take a moment to ponder that. Once you fully grasp the implications, you'll never look at a study that involves rate of change the same again.

What I've explained above, you don't need an MD to understand. This isn't knowledge that's privileged to the cognoscenti of the field, who have examined thousands of knees. This is simple math and logic. But what's the main takeaway?

This: Cartilage is a dynamic tissue, often changing for the worse -- and for the better!

Insert thunderclap here. Because, honestly, too often changes in knee cartilage are seen as a one-way (downhill) process. But that doesn't accord with the reality discovered in this study (and there was another that found similar evidence that defects often improve).

Cartilage is constantly trying to heal: that's what this study suggests to me, when you explore the ramifications. And that should give you encouragement on the long road to recovery.

If You're Overweight and Have Knee Pain, You Need to Read This

Below are my top four recommendations for people who are overweight and who suffer from chronic knee pain:

1. Lose weight.

2. Lose weight.

3. Lose weight.

4. Lose weight.

No, I'm not trying to be clever here.

I'm convinced that controlling one's weight is critically important for overcoming knee pain. It's not an instant miracle cure -- after losing 30 pounds, you may not be able to leap up and shout, "Hallelujah, I'm healed" (you still need to work at it), but you'll be in a much better position to succeed.

If you don't believe that excess weight can have a huge effect on knee health, well, there's the anecdotal evidence.

For example, take a look at the picture below that ran with a newspaper article about aging baby boomers and knee surgery. This woman had a total knee replacement. Does anything jump out at you?


Obviously, she's nowhere near her ideal weight.

Here's another bit of anecdotal evidence to mull over: some months ago, while browsing the comment section below an Internet article about knee problems, I was struck by a remark posted by an orthopedic doctor. His comment went something like this: "In all my years of practice, I've never had a patient who had osteoarthritis of the knee who was also thin."

Of course there are thin people with knee pain and/or osteoarthritis (I was the former). But the fact that a doctor who sees dozens of patients a week would make such a comment tells you that they're more the exception than the rule.

The relationship between carrying around too much weight and knee problems doesn't surprise me. During my research for Saving My Knees, I was impressed by how human knee cartilage has made a lot of neat adaptations -- related to obtaining nutrients, dumping waste products, growing stronger -- based on movement and load (i.e., weight). The right amount of loading encourages the tissue to strengthen. Excessive load starts to break it down.

Researchers know this weight-knee pain link exists. During my recovery, while reviewing scientific studies about knee cartilage, I noticed the first thing that researchers did when organizing the results was separate the heavy subjects (higher BMI) from the thin ones. Which is basically a way of acknowledging that of course extra pounds put you at higher risk, so to keep the results relatively clean (and unskewed by this variable), the large people should be segregated out.

What if you can't lose weight? A while back I read a complaint from a girl with knee pain that went like this: "Don't tell me to lose weight! Every time I try to exercise in order to lose weight, my knees hurt!"

Ahem. Reality check. While it's certainly easier to lose weight through vigorous exercise, the best exercise is the one you don't do: repeatedly raising your hand to your mouth to insert food. Eat smarter, better, healthier, and you can lose weight. I managed to do so while living in Hong Kong, and that was at a time when I really had no extra weight to lose.

Why I Think Cycling May Be the Best Activity for Rehabbing Bad Knees

A bold claim! And somewhat ironic, I suppose, as readers of Saving My Knees know I damaged my knees cycling and was unable to ride my bike again for many months, even as I plowed forward with my recovery. So in my case, I got better largely off the bike.

Also, time for the disclaimer dance: I don't think cycling is the best activity for everyone suffering from chronic knee pain. It's dangerous to generalize in the world of knee pain, because different knees often respond best to different things.

For example, one thing needed to ride a bike: good range of motion. If, every time you push your bad knee through the pedal stroke, you experience a painful clicking, or some other type of discomfort that recurs with each revolution, cycling most likely isn't a good activity for you, at least right now. That's partly because good cycling form is about spinning, or making lots of revolutions, every minute (Lance Armstrong, if I recall correctly, used to time trial at 110 rpms -- try doing that on a stationary bike and watch your legs fly!) So you need a decent range of motion that your knees can move through without hurting or "catching" too much, because they will be repeating that motion, again and again and again.

Okay, now that the big caveats are out of the way -- why am I such a big fan of cycling for bad knees?

(1) You want a high-repetition, low-load activity. That's exactly what easy cycling is.

Notice the word "easy." No hills, no sudden accelerations! A moderate rate of spin will get you 80 rpm on a bike -- that means you're flexing your knees 800 times in 10 minutes, or 2,400 times in half an hour. If your cartilage needs thousands of repetitions to spur positive adaptation (i.e. strengthening), this is an ideal exercise, it seems.

(2) Cycling is not a "bone accretive" activity.

If you need stronger, denser leg bones, one activity that won't be prescribed for you is cycling. Riding a bike is a low impact form of exercise that uses a smooth, fluid stroke. It doesn't build up bone mass. (Which leads to the paradox that the cyclist with the heavily muscled thighs who just blew by you on your daily walk may have lousy bone density.)

That can be a good thing, if you've got bone spurs in your knees already from arthritis, which is common with chronic knee pain. Bone spurs can interfere with the normal movement of a knee joint and can be an impediment to the healing of cartilage (as shown in this study: Ding C. et al., “Natural History of Knee Cartilage Defects and Factors Affecting Change”). Cycling should help you strengthen the soft tissue without promoting the formation of unwanted bone.

(3) It may cause your knee cartilage to thicken.

When the knee cartilage of triathletes was studied, an interesting discovery was made. The patellar cartilage was slightly thicker than normal (Muhlbauer R. et al., "Comparison of Knee Joint Cartilage Thickness in Triathletes and Physically Inactive Volunteers Based on Magnetic Resonance Imaging and Three-Dimensional Analysis"). Assuming this was a solid finding that will be reinforced by other studies, what might it tell us?

Well, triathlons generally consist of three activities: swimming, running and cycling. I doubt that swimming, in particular the overhead crawl stroke that you'd expect a triathlete to be doing, promotes the formation of more cartilage under the knee cap. Nor would I expect running to achieve this effect, with its harsh impacts absorbed mainly by cartilage at the end of the leg bones.

Cycling appears most likely to be responsible. Just look at the angle of the knee during the force-exerting part of the pedal stroke. Hopefully future studies will clarify whether cycling does encourage cartilage growth.

(4) Strong quads!

Anyone who reads this blog regularly may be thinking, "But wait a minute -- aren't you the guy who thinks focusing on strong quads is a mistake for people who have chronic knee pain?"

Yup. That's right. But these are two different things.

Having strong quads is great and surely does protect against developing knee pain. Acquiring strong quads through exercise, when your knees tolerate that exercise well, is also great. What doesn't make sense to me: Focusing on strengthening your quads when your knees are damaged and weak and the quad-strengthening exercises only cause more pain.

One nice thing about a cycling program, if you're patient, is that the gentle cycling that you start out doing, to heal your joints and strengthen your knees, can gradually be intensified to the kind of workout (which I do now) that will really develop your quads. Trust me, I know. :)

Reasons Why You Should (or Shouldn't) Keep a Knee Journal

In Saving My Knees, I described my experience keeping a knee journal, and how it helped me. Since then, I've been flattered to learn that at least a few readers of the book have chosen to do the same.

Perhaps one day knee journaling will even be widespread. While excited by this possibility (an idea goes viral in the knee pain community!), I also feel a little trepidation. That's because I can imagine some people taking up the activity with a half-hearted shrug -- "Ah okay, I'll give it a try, what the heck" -- then losing interest some weeks later, muttering, "Well, that was a waste of time."

So I thought I'd write about what makes a useful knee journal, in my opinion. Note at the outset, I'm saying "in my opinion." You may feel otherwise. If you want to include the dates of lunar cycles and observations about local flora and fauna, well, hey: It's your knee journal.

Still, I think the best use of such a journal is to pretend you're a scientist, you've just been given these things called "knees" that don't work all that well (and which unfortunately have been implanted in your body), and you're undertaking a study to try to determine what makes them feel bad, what makes them feel good, and how you can transition from the first (undesired) state to the second.

With that objective, a knee journal becomes a place not to kvetch aimlessly about your aching joints ("Ah, another miserable day in the wretched land of knee pain, as I regard the wind-swept fields from my balcony!"), but an aid to healing. Your knee journal should be working for you, not lying there passively to record random thoughts about your pain. How?

(1) If you use a knee journal smartly, it should give you a fairly detailed picture of where you are in your recovery and what your knees can and can't do.

If you're trying to heal your knees on your own, you face at least two big challenges: (a) figuring out a "baseline" level of activity your knees can handle, without getting worse (b) figuring out how much and you quickly you can push beyond this baseline, in an attempt to strengthen the soft tissues in the joints.

A good knee journal can help because you should be wearing a pedometer (mine was practically bolted to my hip) and scoring, or otherwise quantifying, how your knees feel day to day (and throwing in notes about your daily activities and the nature of the pain sensations from your knees).

(2) As you experiment, trying to find the right exercises to do, in the right amount, a knee journal provides invaluable feedback. (Note: a big benefit of working with a good physical therapist is that you shouldn't have to experiment nearly as much.)

I often tweaked my regimen, such as by introducing a new type of exercise that I thought might help. Later, I could look back in my journal and get a sense of what effect that exercise had, good or bad.

(3) Inspiration!

So there is a soft, fuzzy reason to keep a knee journal after all. :) There were times (after the first three or four months of my recovery program) when I was discouraged and felt I hadn't made much progress at all. My knee journal lifted my spirits by showing me that yes -- even though progress was slow -- I was getting better. I could look at entries and summaries from my first few weeks, and see my limitations then, and be grateful I had gotten beyond some of those problems at least!

How to Heal Bad Knees: A Reader Shares a Story

I'm going to get off the soapbox this week (I had planned to write about the purpose of keeping a knee journal -- I'll save it for next time) because I found a wonderful story waiting for me in the comments section of a past post.

So I'd like to turn the podium over to this unnamed commenter (with a few of my remarks at the end):

A few years ago I too was diagnosed with patellafemoral syndrome (chondromalacia of patella) and was only able to shake it after reading Doug's blog on articular cartilage. Like the above emailer, mine was so bad I couldn't walk for more than a minute or two without increased pain.

So here's what I did:
1)crutches with no weight bearing on affected leg for 3 days.
2)crutches with putting some weight (maybe 50%) on my affected leg for another 5 days. By now the knee was largely pain-free, but I could tell if I did too much it would start hurting again.
3)took it easy for the next couple of weeks by only walking for a few minutes per pop, made sure when on stairs to only take the initial step up with my good leg.
4)built up my walking stamina and using both legs for stairs over the next 5 months. was back to running at month 6, doing the couch to 5k program. A few years later now, and I'm back to marathon training, 100% pain-free knee.

Now, I also had a 40 hour/week desk job during this ordeal. I basically just made sure to flex and extend my knee (pain-free range, which started off with maybe 10 degrees of movement!) every few minutes on a small bosu ball I brought to work (like Doug's skate board recommendation). I also lightly (10% of strength) pushed my foot into the floor or wall of cubicle starting at about 100 times a day, up to 1000 times (and built up the pressure used as long as it didn't hurt the next day). I also did squats at around 4 weeks, but did them with reduced weight bearing (kind of like dips for your chest but with my feet on the ground), and not to sound like a broken record, but built up my weight bearing on this as well.

I'd be interested to try my experiment again without the use of crutches - maybe my decreased weight bearing, high rep exercises would've been enough.

By the way, I was so psyched by my results and by Doug's blog, I decided to switch careers; now I'm just a few weeks away from graduating from PTA school.

Beautiful story -- I love it, especially the crowning touch "now I'm just a few weeks away from graduating from PTA school." Because we need more physical therapists who are this smart about healing chondromalacia-related knee pain!

What this person did reminds me a lot of my own recovery: doing lots of high-repetition, low-load movement. Pushing the envelope on the exercise program, but very slowly, so as to get stronger while avoiding a relapse. Carefully monitoring for symptoms -- not during exercise or 15 minutes later, but the next day (your damaged cartilage has no nerve endings, remember!). Overcoming the ultimate "bad knee environment," the white-collar workplace (I finally had to quit my 50-hour-a-week job; I congratulate this commenter on resolving the problem of prolonged bent-knee sitting through doing quiet exercises in the cubicle).

That this person could return to running in six months struck me as impressive. My objective was to ride my bicycle again, pain free, and it took me more than 13 months to achieve that. Anyway the upshot is the same: healing from chronic knee pain has to be measured in multiples of months (five or six at least), so patience is needed.

Your aching knees can heal! It's not just my story anymore; I'm convinced there are many more happy stories out there too, and my fervent wish is that someday -- SOMEDAY -- the medical community will become curious enough about how cartilage heals naturally to launch some good studies that will lead, hopefully, to a revision of the gloom-and-doom thinking about the outlook for patients with chronic knee pain.

Is Knee Surgery for Cartilage Lesions a Waste of Time?

From the world of science comes this study :

A long-term follow-up of 43 patients who were treated for ACL tears but untreated for associated knee cartilage lesions showed that the group did just as well as patients without cartilage lesions who underwent similar ACL treatments.

The defects were either grade 3 or 4 -- indicating that at least half the cartilage was gone, if not all. They were at least 2.6 square centimeters in size (that's a bit bigger than a circle with a diameter of half an inch). So these weren't teeny, tiny lesions.

For the study, patients were evaluated 10 and 15 years after having surgery for ACL tears. Those who, during surgery, were found to have the severe lesions had the same clinical outcomes (following the same rehab regimen after the operation) as those who didn't have lesions.

Conclusion (according to one of the researchers, Wojciech Widuchowski):

"Our study seems to reinforce the question whether treatment of a symptomatic lesion provides improvement over that of the natural history."

Further:

Widuchowski noted that applying these findings could represent significant cost savings for health care systems and possibly reduce the tens of thousands of knee arthroscopy procedures done annually in the United States alone.

Where I stand on all this is not hard to guess. I'm a "surgery as a last option" kind of guy. In Saving My Knees, I cite two studies, including a bombshell one from the New England Journal of Medicine, showing that surgeries to clean up bad cartilage are pretty much useless.

Now it's true that this particular study wasn't designed specifically to answer the question, "Is surgery for knee cartilage lesions effective?" Remember, the patients were already being operated on to fix the ACL tears, and so the surgeons simply had to choose whether or not to "clean up" nearby cartilage problems (probably by smoothing out the tissue, or even using microfractures to generate new cartilage). Normally, it appears the bias is toward intervention -- doing something. But this time the surgeons refrained from treating the large defects. And the outcomes (one infers) were the same (if not better) than if they had tried to fix the cartilage.

So these poor patients were stuck with those lesions? That doesn't sound good. But remember -- cartilage can heal. Also, a lesion isn't necessarily your problem, pain is.

After all, over the age of 30, more people have cartilage lesions in their knees than don't. The mere existence of a defect doesn't automatically signify knee pain. Why should you care? Because if you do have knee pain -- and if you hear that dreaded crackle-crunch when you bend your knees -- you don't have to completely eliminate that noise to achieve a good life again.

The Response to Saving My Knees: Two Things That Surprised Me

Writing a book is an odd endeavor, as any author can attest. You spend hours alone, playing with words on a page, trying to find places where clarity has eluded you, where important material facts have been omitted, where unimportant material facts have been included, where sentence rhythms falter, and where a word simply doesn't fit.

After the long, solitary act of writing, an author releases this much-fussed over creation to the world at large, at which point what happens is anyone's guess. That's part of the fun (and the anxiety) of the craft.

I thought today I'd share two surprises, for me, on the reaction to Saving My Knees.

1. The positive response of people who completely identified with my knee pain woes.

Obviously, I thought Saving My Knees contained a message that transcended the particulars of my own story, or I wouldn't have bothered writing the book. However, I didn't expect people to relate so thoroughly to my struggles as to say, "I feel like you were writing my own story." But that's exactly the reaction I got from a handful of readers.

That's something I find quite gratifying, for the most part (I tack on "for the most part" simply because of the implication that others are getting much of the bad advice I got). It shows me that the things I did to heal my troubled knees can probably benefit lots of others.

2. No one has come out and said, in so many words, "You're an idiot and here's why."

This is without a doubt the biggest surprise post-publication of Saving My Knees. I've shared my experience (and somewhat controversial beliefs) on two forums that attract thousands of people suffering from the same kind of knee pain I had. I have written this blog for over a year. I have penned a piece about cartilage healing for Huffington Post, a site that ranks in the top 25 in the U.S. in popularity.

I figured at some point an informed critic -- maybe a doctor or physical therapist -- would emerge from the shadows and challenge me: "I'm sorry, Mr. Bedard, but your beliefs about X are wrong because of this and that."

For example, everywhere you look on the Internet, experts are advising patients with chronic knee pain to focus on strengthening their quads -- a potentially disastrous bit of advice, I think, when stronger knees should be the objective. And I've written as much, repeatedly. Yet a believer in the "strengthen your quads" philosophy has never told me I'm an idiot, and knees can't be strengthened, and here's why "strengthen your quads" makes the most sense.

Why? I'm sure part of the reason is that I'm still shouting from atop a very small platform. I don't have the highly visible profile that invites attack. And, since I'm not a doctor, people may tend to dismiss me as "just some guy who got lucky and fixed his bad knees." Which, if you read Saving My Knees, you will know is not true. I did fix my bad knees, but luck had nothing to do with it.

But I wonder too if there's another reason: that, even among the experts, there's a lot of doubt about whether the conventional advice for treating chronic knee pain really does make sense. Maybe there are suspicions that the prevalent thinking -- including the "strengthen the quads" prescription -- is lacking, and there must be a better way, because so many patients don't get better.

An Update on Where I Am, Post-Recovery

Just back from vacation! Joelle's American relatives finally got to meet our funny, special, high-energy little daughter. The occasion was Jo's two-year birthday party. We visited the Maine beaches a few times and I ate way too many chocolate chip cookies that my mother baked ...

This week's entry will be an update on where I am, post-recovery. Occasionally I interject some comments on this blog about what I'm doing, physically, to maintain good knee health going forward. Sometimes I mention a little problem, then forget to close the circle and let everyone know how it was resolved.

On March 27, for example, I mentioned on the blog taking a few extra weeks to "break in" my knees for a new cycling season, after feeling a few twinges and tinglings when I ramped up my stationary bike workouts a bit too fast. And I sort of left that storyline dangling (which I only realized some time later, when someone who wrote to me about a knee problem added the question, "So how did all that work out?")

Well, today I rode my bike, quite hard, and felt great. I've been riding every Saturday since late April. Same group, same intensity, and same punishing workout I remembered from last year. Right now is the toughest time, because everyone's strength is peaking, as this is about the end of the racing season up here.

How are the knees holding up? Really well. Even better than last season, when my left knee felt like it was getting a little sore at times during the long rides. Apart from riding, my knees seem to be making less noise too. Everything is pointing in the right direction at the moment. Life is good.

Besides the Saturday ride, what else do I do for my knees each week?

Sunday: 60 minutes on a stationary bike, easy pedaling.

Tuesday and Thursday: 45 minutes each day on a stationary bike that includes 10 easy minutes of warm up, then 35 minutes of slightly harder but still not intense riding. (So each week I ride hard only once -- Saturday -- which usually features about 40 fast miles, then 20 or so miles at an easy pace.)

Other than that, each workday morning I walk not to the closest subway station, but to the next-next closest stop, which (when added to the walking I do to get to work), gives me roughly one mile (or two miles each day). I make a point of doing this, every day, because I have one of those dreadful desk jobs that keeps me in front of a computer screen for a good 10 hours.

Where I'm at right now is basically where I should be at if everything in Saving My Knees -- everything that I felt more and more convinced was true, during those grueling days of my slow recovery -- really was true. I hope there are others out there who are finding relief for their bad knees through a motion-based program that gradually increases in intensity. It's worked really great for me.

Comment Corner: "How Do I Devise a Plan to Heal?"

Healing from chronic knee pain isn't like healing from an ankle sprain, where you can just take it easy and wait for your body to mend itself. You need persistence -- and a plan.

Recently I got a comment from a reader -- actually a series of questions -- about how I healed (this person is trying to develop a plan for getting better). The questions impressed me, partly because the reader (henceforth "Anonymous") had obviously gone through Saving My Knees very carefully. I thought my answers would be of interest to others familiar with the book, so here they are:

1. It’s not clear how much walking you did throughout your recovery. You say you did approximately 70 steps every 15 minutes at first. But did you do only that? Or did you do 2x or 3x daily 1000 steps walks per day in addition to the 70 steps every 15 minutes?

And if at first you only did 70 steps every 15 minutes, when did you determine that you could add 1000 steps walks, and how many times a day?

As readers of my book know, I healed through a program that emphasized an appropriate amount of high-repetition, low-load movement. I did a lot of walking, as my knees tolerated that low-load activity best (gentle cycling is another option for people).

When I committed myself to a round-the-clock effort to save my knees, I was lucky in that the joints hadn't degraded to the point where all movement was painful. I was able to walk a few thousand steps at a time without ill after-effects. (By the way, I always took a 10-minute break at the halfway mark.)

So early on, I was walking about two to three thousand steps (a mile to a mile and a half, roughly), twice a day (for a total of 4,000 to 6,000 steps) in the form of "long walks." Then, while in my apartment during the rest of the day, I did periodic walkarounds every 15 minutes. (More details can be found in the appendix to Saving My Knees, where I have included entries from my knee journal.)

But Anonymous, don't get too hung up on exactly what I did. Everyone needs a different plan.

2. Earlier in your recovery, during the “pool phase” at Bloomberg, you had tried straight leg raises and found it affected your control knee. But, later in your year at home, you did other exercises (unloaded leg squats, crab walks). When did you incorporate them in your program? How did you determine it was ok?

Actually, the leg raises affected my non-control knee (the control is the unchanged variable), but I know what you mean. Yes, I did "crab walks" (also known as "the monster walk") and unloaded leg squats.

How did I know they were safe? I didn't! I tried many things, slowly, then monitored for symptoms. That's how I figured out which exercises I tolerated best. The advantage of working with a smart physical therapist is that that person can eliminate some of the trial-and-error process that's typical when you're experimenting on your own.

3. What was your diet? Had you calculated your daily caloric intake? How did you do that?

Diet questions! I can tell Anonymous is serious! My diet was rather dull actually. I ate a lot of brown rice and garlic, because it was cheap to prepare and garlic is a natural anti-inflammatory. I didn't count calories, but did watch my weight carefully.

Honestly though, I think diet had little to do with my success in healing (weight control, however, was very important). And if it did, I have good news for all of you: With little effort, you can adopt a diet that's a significant improvement over what mine was.

4. You talked about moving to Austin. Why didn’t you do it?

Ah, the flirtation with Austin! Yes, I was quite taken with the writings of Doug Kelsey, at the Sports Center clinic there, who believes damaged cartilage can be strengthened (my experience would take that claim a step further -- I believe it can heal, because mine did). I was seriously considering buying a plane ticket from Hong Kong to Austin, Texas, to have my knee strength assessed and to get help developing a long-term plan to get better.

So why didn't I? I did call Sports Center and sent an e-mail, inquiring whether they would work with me if I could come to Texas for a few weeks. I received no reply. I was going to send a second e-mail, then I reasoned that they probably didn't want a fly-in, fly-out patient when rehab takes a good nine months or so (or the better part of two years, in my case). If that was their policy, I believe it has changed now, as a reader of this blog mentioned recently that she did a phone consultation with a therapist from Sports Center. If so, that's great news, as that's the first place I'd turn to for help treating a hard-to-resolve case of chronic knee pain.

5. How did you manage for everyday tasks while taking into account standing up and steps to be taken? By everyday tasks, I mean getting dressed, taking a shower, making lunch, cleaning up around the house, running errands. Things like cooking involve time standing up. How did you take that into account in your program?

I never really tried to account for every single step I took over the course of a day or every minute I spent standing. (It's hard to do -- do you go to sleep wearing a belt with a pedometer attached to catch that first step out of bed in the morning?) Mainly I tracked the long walking I did, my reasoning being that it stressed my knees the most. If I had done a lot of incidental walking around my apartment, I probably would have tried to measure it -- but I didn't -- so I didn't. Even my counting/scoring/scientific-minded brain has limits. :)

I did try to avoid standing in one spot any longer than necessary (a certain amount of standing is inevitable, as with cooking), because that caused my knees to burn, and reducing burning sensations is always a good thing.

6. How did your wife fit into your recovery program? How did she help you? What tasks did you split, that you determined she had to do because you couldn’t?

The short answer: My wife didn't really fit into my recovery program. She tended to believe my doctors were right -- that I'd never get better -- because, well, they were doctors. But that was fine. After doing extensive reading and research, I was pretty sure I could find a way to heal, given enough time. Because my wife didn't know what I knew, I don't fault her for being skeptical. Now she's a believer, I hope. :)

7. When did you stop sitting with your legs propped up? How did you determine it was ok?

Like so many things about my recovery, it was a gradual process. I didn't just suddenly stop sitting with my legs straight out. That position did serve a purpose. Broadly, my thinking went like this: The burning in my knees was probably the result of a chronic inflammatory process because the cartilage was damaged. This kind of inflammation is bad and works toward further deterioration of the joint. So I would reduce the inflammation (and get relief) by sitting with my legs extended.

After I quit my job and dedicated myself to a recovery program, I slowly got my knees accustomed again to sitting normally in a chair. I worked my way up to sitting comfortably for about 2 or 3 hours at a time, then that period of time lengthened as I got better.

So there you have my answers to some very good questions. I'm not sure how helpful some of my responses were. I wish I could say, "Do this for 12 days, or until you feel sensation X, then do this other thing for 27 days, and then you'll be fine" -- or something like that. But there is no precise, universal solution for chronic knee pain. Everybody's at a different place with their own pain. Which is why I believe so strongly in learning how to listen -- really listen -- to your knees.

Why I Avoid E-mail "Consulting" About Knee Problems

If you e-mail me, seeking advice on what to do about your bad knees, you will receive a reply similar to this:

Thank you for your e-mail.

I’m sorry to hear of your knee pain. However, I’d rather discuss ideas that may help you on my blog or a knee forum (such as chondromalacia community), as opposed to trading e-mails privately.

This is for several reasons: (1) I’ve been getting a lot of e-mail to my private account from people who have problems with their knees. (2) As I’m not a doctor or physical therapist, I want to avoid any kind of consulting/advice-giving relationship that would suggest that kind of authority. (3) If you post your questions on a forum, or my blog, and allow me to respond there, others may chime in as well -- with ideas I hadn’t thought of, that may work even better for you.

Please don’t misconstrue this as a lack of sympathy; I’m sending this note out to all who have been contacting me privately.

All my best wishes!

I thought today I'd take a moment to explain, in a bit more detail than the message above contains, why I send out a more or less form reply to often desperate knee pain sufferers (who could have been me only four years ago).

First, there's that small matter of not being a doctor. :) And, even if I were one, I'd be a fool to offer advice to a patient I had never seen (well, other than the most general sort of advice, which is why a lot of doctor Q and A's on the Internet may seem unsatisfying -- though actually the doctor who declines to say "do this," "take this," and "do that" to a person he's never examined is just being professional).

So I've avoided getting into advice giving/consulting/"what are your thoughts on?" e-mail relationships. It's not that I think I don't have anything to say. I wrote Saving My Knees because I had so much to say -- and no one else on the bookshelves of my local Barnes & Noble had the same perspective (that of someone who beat knee pain) and the same message (much of the current thinking on how to deal with patellofemoral pain syndrome is simply bad), with research to back it up.

Still, it's my story. Parts of my story may help you find a way to heal your knees, while other parts may not.

Which leaves us with the compromise I decided on, some time ago, when creating this blog. No one wants to read a blog called "Saving My Knees" about some guy who healed his bad knees who writes only about how great his life is now. Most people who stumble upon this blog are hurting. They feel bereft, forsaken and abandoned by a succession of doctors and physical therapists. I know. I've been there. And they want advice on how to stop hurting -- if that's possible.

So I developed a blog that is supported mainly by three content legs -- like a tripod, if you will. They are: (1) Information taken from my book (I can share my findings with people who aren't interested in buying Saving My Knees, for whatever reason) (2) Commentary on new medical studies/news stories/whatever (to keep things fresh) and (3) My sort of awkward attempt to share, with readers who have specific problems, the kind of thinking that helped me heal (my "Comment Corner" feature).

The third leg ("Comment Corner") makes me the most uncomfortable, really. That's why I so often caution that whatever remarks I make are "things to consider and discuss with a qualified medical professional who is examining your knees." What makes me a bit more comfortable with Comment Corner is that it's an open conversation -- I'm not swapping private e-mails -- and anyone who chooses to opine in the Comments section that I'm an idiot for reasons x, y and z has that opportunity.

In other words, I offer my thoughts on a case study of someone's troubled knees. Then a reader can chime in with perhaps a great idea I have overlooked (example: someone recently suggested getting an MRI to a knee pain sufferer -- I know many orthopedists think MRIs are overdone, but my first axiom of healing is that you need to know what's wrong before you can devise a plan to get better).

Hope this clarifies things a bit! In the meantime, keep movin'! That's one piece of general advice I do feel unequivocally confident about, when it comes to beating chronic knee pain.

Zen and the Art of Knee Maintenance

A few weeks ago, cycling with the guys (they mostly are) on my Saturday morning ride, my Litespeed began attracting attention. And not in a good way.

Something was rattling. Something was rattling loud enough, in fact, that other cyclists were riding up alongside me, saying, "Hey, what's that noise your bike's making?"

Having a rattling bike is bad on a number of fronts: (1) It can be dangerous, to you and to other members of the peloton. (2) It marks you as an idiot who can't take proper care of his bike. (3) It's just, well, uncool.

The thing is, I had noticed the noise before. I just hadn't paid much attention to it. It was just a background irritant during the ride. So when I finally realized, "Man, I gotta fix this," the first issue I had to confront: I hadn't gathered much useful intelligence about the rattling (which tended to come and go).

Meaning: What made it start? What made it worse? Did it matter which gear I was in? Whether I was pedaling? Did I have to be pedaling with great force (such as going uphill)? Did it make any difference whether the road was smooth or rough?

Well, I wish I could say that after observing my bike closely during a two-hour-plus ride, I made a bunch of observations that led me to figure out what was causing the rattle. Indeed, I did start paying close attention to the sound, and exactly when I heard it -- but another rider helped me out by surmising my cassette was loose.

The "cassette" refers to the multiple sprockets on the rear wheel that allow you to change into easier and harder gears.

When I got back, I checked the cassette and he turned out to be correct. It had a little wiggle -- not much, but enough to make a rattling sound and also to cause roughness in shifting gears, which I had noticed too. So I tightened it up and, in a matter of seconds, had a noise-free bike again.

What this anecdote has to do with knee maintenance is, well, everything.

Because when you have bad knees -- and you're not getting better, and doctors are shrugging and giving you unhelpful diagnoses, and physical therapists aren't helping either -- I believe you need to stop outsourcing responsibility for your bad joints to other people. You need to become a first-class problem solver. And that starts with learning how to listen.

You need to listen to your knees, in a way you've never listened to them before. You need to listen hard to try to learn as much as you can about how your bad joints communicate -- what certain signals of pain or discomfort mean, what makes your knees feel better, what makes them feel worse.

This has to be a sustained, full-time, learning effort. No more, "Well, the doctor told me I could ride a bike five miles three times a week, so that's what I'm doing, even if my knees don't feel so hot afterwards."

When you start listening to your knees -- really listening to your knees -- I believe you put yourself in control, acquiring the knowledge you need to make good choices. You can be smarter about deciding whether an activity or exercise program should be intensified, continued, or even stopped.

So trying to fix grumbling knees or a noisy bike starts with the same valuable skill: learning how to listen.

My Personal Experience With Structuralism

I've had a few negative things to say about structuralism, the view that muscular imbalances and biomechanical flaws are the root causes of chronic pain.

That's not to say that structure never matters at all. But an obsession with it isn't justified by the scientific evidence.

I encountered structuralism before even knowing what it was. My first orthopedist, whom I sought out because of my burning knees, initially said my problem was related to mistracking kneecaps. (Later, during our discussion, he either backed away from this diagnosis or forgot it -- I can't tell which -- because he didn't mention badly tracking kneecaps again.)

What was curious, he offered this diagnosis even before he saw my X-rays (which showed normally seated kneecaps that didn't appear at all prone to mistracking). I suspect now that he diagnosed me reflexively. Structuralist thinking is prevalent when analyzing causes of knee pain, and "mistracking kneecap" is high on their list of explanations of what's wrong.

My physical therapist also seemed to be a structuralist. He would occasionally take a few minutes of our session to study my gait and alignment, trying to find evidence my leg mechanics were out of whack. He never found anything, that I could tell. Later I realized my case probably frustrated him because I didn't fit the structuralist model.

My mechanics were fine. I just had bad knees.

In a previous post on this blog, I summarized a study that found no relationship between patella mistracking and the knee pain of patellofemoral pain syndrome. This is how I explained the study's conclusions (my bold):

… 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."

Since then, I've found an essay well worth reading by Paul Ingraham (a massage therapist, very bright guy, and voracious reader of medical literature). He wrote a long piece subtitled, "The story of the obsession with crookedness in the physical therapies."

He says:

In my opinion, most biomechanical problems are much less important than is generally supposed … Not only are structural explanations for pain generally unsupported by any scientific evidence, the last 25 years of research results mostly undermines them.

Read the whole piece. Ingraham hauls out a bounty of evidence that includes: a 1984 study in Lancet showing that leg-length discrepancies don't contribute to back pain, a European Spine Journal study that abnormal neck curvatures aren't connected to neck pain, and a British Journal of Sports Medicine article that major muscle imbalances in elite Australian-rules football players aren't related to the number of injuries they suffer.

The takeaway here is that, if you have bad knees that aren't getting better, you need to take control of your future and educate yourself in lots of ways. That includes understanding the framework for analysis that your doctor is using (which may not make sense). So learn to spot structuralist thinking (strengthen your VMO!), and when you hear it, ask some hard questions.

Certainly the road to recovery is long. But first, you need to be on the right road.

Comment Corner: How Do You Heal Through Movement When You're Always in Pain?

I got this comment below (edited down for length) recently. Again, I'm not a doctor or physical therapist, so my observations are best thought of as "things to discuss with a medical professional who is actually examining your knees." My experience healing my own knees -- after doctors said they'd never get better -- is fully told in Saving My Knees, for those of you dropping by for the first time.

The history of my knee pain is quite similar to yours, I used to do a lot of mountain biking and I think one particularly intense holiday in the Alps is what really damaged my knees. I also have a desk job with long hours so have the same problem you faced of knees constantly being in a painful position.

I have tried every possible position for my legs and haven’t found one yet which is pain free. The only respite I could get was when I got home and lay in my bed … However now even this does not take away the pain completely …

So my main question is:

If I have got to the point where I am almost constantly in pain, is it still possible to perform the movement which is necessary to heal my cartilage?

Even if I just walk around for 10 minutes or so, this is likely to result in the pain increasing a bit and sometimes my knees becoming inflamed for a day or two. Do you think that while I am feeling pain the cartilage cannot heal, or do you think that movement can still have a healing effect despite the pain, as long as in theory the movement should not be putting too much stress on the knee joint?

When you had a setback and felt pain, did you only return to movement once the pain was gone, or did you sometimes feel pain when exercising? In your reading about the healing of cartilage is there something that leads you to believe it cannot heal while you are feeling pain?

Alex

Some good, tough questions here. Here are my reactions; other readers feel free to chime in below, in the comments section.

1. Have you seen a doctor?

I see no mention of one. Maybe you have and just omitted that detail. But devising a plan to heal begins with knowing what's wrong. A doctor may or may not be very helpful in understanding what's going on. Still, a good doctor will order tests, seeking clarity, if he's unsure what your exact problem is.

2. "I also have a desk job with long hours"

Uh oh. That can be a problem if sitting causes inflammation and pain. I finally quit my job because I concluded that I would never heal if I couldn't get on top of the inflammation that caused my knees to burn while sitting. If recovery from chronic knee pain is about taking lots of little steps forward, constant inflammation is (in my opinion) about taking lots of little steps backward.

Unfortunately, my doctors disagreed with me that sitting long hours at work was an impediment to my recovery. I had to quit my job -- and fling away the safety net of health insurance and a steady income -- to prove I was right. So you may face a grim decision: if you choose to leave work to try to heal, you may or may not succeed, and you'll probably get no support from your doctors.

3. "The only respite I could get was when I got home and lay in my bed"

Yup, this sounds familiar. Sometimes I lay on the floor on my back and draped my legs over the couch cushions. My knees liked my legs to be straight and elevated, and it sounds as if yours have the same preference.

4. So how can someone who's always in pain perform the movement needed for healing bad cartilage?

This is the nub of the matter. I've got many thoughts on this. Where to start? As I said before, you may want to check out my earlier post, "How Is It Possible to Exercise Without Pain When Pain Is All You Know?"

After that, I'd go here, where Doug Kelsey (a really smart physical therapist) describes some very non-stressful activities for osteoarthritis sufferers, such as pushing a skateboard back and forth while seated and even using a rocking chair.

You may be wondering how you can heal with motion that's this non-stressful. But don't be scared off by how easy these exercises appear to be. Healing bad knees is a long process, and it's better to start out doing something too easy (my opinion) than too hard. Remember too, you're trying to strengthen your knees, not your muscles. What's easy for your muscles may be just right for your knees.

If I were Alex, I'd start with some ridiculously easy movement exercises (such as those Kelsey outlines). I'd monitor my knees closely for say a week while trying to hold variables constant (i.e., don't walk a mile a day Monday through Wednesday, then four miles on Thursday, as that will screw up the experiment), then see where I'm at. If my knees feel the same or better, that's progress.

Why is it progress if they feel the same? I'd argue because you are moving more -- and more motion makes it easier to graduate to even more motion, and that's ultimately the path to healing.

Should you keep going if there's pain? This is where, if I were you, I'd prefer to be working with a really good physical therapist. Because, let's face it, pain isn't pain isn't pain. When you say you're in pain, what does that mean? It's like if you were to walk up to me in the park and say, "I just saw an animal." What kind of animal? A dog, cat, raccoon? A grizzly bear? My reaction will differ, depending on what kind it was.

If you suffer from typical chronic knee pain (aching and burning, but not too intense), you may not be able to get completely rid of it before starting on a movement program. During my recovery, did I get free of pain? Not exactly, but I did get as free of pain as I could.

I used pain sensations to guide me when to alter my activities (when to take an easy day, for example). While I tolerated some sensations of pain and discomfort, I was strict about avoiding swelling. That, from what I've read, is a clear sign that your joints are doing too much.

I've read nothing that says cartilage can't heal while someone is in pain. But it's only common sense to assume that if that pain is tied to cartilage destruction, you're probably moving a few steps back for each step forward. How can you tell whether or not it is? It's not easy -- cartilage has no nerve endings.

Many, many challenges! Here are the takeaways I'd say:

* I'd make sure I saw a doctor (or two) and got his opinion about what's going on. Also think about trying to work with a really good physical therapist.

* I'd start with a lot of really easy motion and be prepared to spend a lot of time making just a little progress. You're in a deep hole, it appears.

* You may not be able to get completely rid of the pain, but minimizing it is probably wise. But don't do that by giving up motion; rather tailor the motion to your diminished capabilities (don't walk 10 minutes because that's too much for you; spend 10 minutes swinging your legs gently in the swimming pool perhaps).

These are some of my thoughts. Again, you should see a medical professional who can examine your knees and discuss with that person what to do.

Anyone else have any other ideas?