Comment Corner: Structuralists Run Amok?

I harvested this comment from my last post. It intrigued me for several reasons. I have edited it down a fair deal. Take particular note of the bolded points, which are discussed later:

I have knee/leg problems including chrondromalacia patella, weak VMO, tight ITB. I used to run in college but since then have spent most of my life sitting down. I attribute my problems to the sitting, not the running.

After having no improvement with PT (leg lifts, quad strengthening, stretching, partial squats, balancing, patellar taping) I got synvisc in one knee in January. Wow, it worked!
Since I felt much better (down to 2-4 extra strength ibuprofen a day) I figured I had a window to get my legs stronger before the synvisc wears off. So I did bodyweight squats and 20 pound goblet squats, one-sided calf raises, lots of stretching, and some very light jogging. I also tried walking around in vibram "5 fingers" barefoot shoes to give my feet and ankles exercise.

Now my leg muscles are all noticeably bigger and stronger - but my knee joints themselves HURT much more!

My guess is I made my quads and calves too strong and now they are yanking more on my patella causing cartilage damage. I also have some muscle soreness on my anterior thighs right above where VMO meets my knee joint. I don't know if that means my VMO is weak compared to my other quads or too tight or what. I also get ankle pain now!

My question is - how can I get my legs back into alignment? Should I avoid strength exercises and let the quads weaken? I have been taking it easy but still have joint and muscle pain.

I saw you recommend low load high rep for knees, does that advice apply even when I have pretty strong legs that might be causing the problem?

Before we walk through this, my standard disclaimer: I'm not a doctor, of course. I don't even play one on TV. Nor am I a physical therapist. I did, however, heal my own knees -- which both my doctors and physical therapists had given up on -- after much research and experimentation (the full story of which I recount in Saving My Knees).

So consider the following just "interesting things to think about and discuss face to face with a medical professional."

Now, here are the bolded parts of the anonymous commenter's story that caught my eye:

1. weak VMO, tight ITB

Who said you had a weak VMO (a physical therapist, I bet)? Do you really believe that building up your VMO vis-a-vis the other muscles in your quadriceps is possible? Because that's the trap you find yourself in -- if you think you need to strengthen only the VMO, then you have to believe that you can successfully strengthen this muscle in isolation. But here's the problem, according to Doug Kelsey, chief therapist at Sports Center:

This is the number one myth of knee rehabilitation ... isolated strengthening of the vastus medialis oblique (VMO) ... The VMO is one of four muscles which all share the same nerve: the femoral nerve. Muscles contract when nerves tell them to contract. Since the VMO has the same nerve as the other three thigh muscles, it will contract along with the others ... there is no anatomical support for the idea you can isolate and strengthen the VMO ...

As for the tight iliotibial band: what was causing it to be tight? After all, maybe you were told to stretch it (which is a waste of time, for starters), but my first rule of healing is that you not only have to find out what's wrong, but also what's causing it to be wrong. Here's Kelsey on a big reason for a tight ITB:

... pain felt on the outside of [the] knee may be due to swelling from inside the knee. The fluid accumulates in the small pocket under the IT Band. The tendon then rubs on the swollen tissue causing pain. The solution is to improve the health of the joint and reduce the swelling instead of stretching the IT Band.

So if you can't build up the VMO in isolation -- and if your tight ITB is caused by a bad joint -- then the solution isn't to improve your body mechanics (which is probably what a "structuralist" physical therapist would advise). The key is to get that knee joint healthier. However, here's what I bet your PT prescribed: exercises to build up your VMO and stretches for your tight ITB. If so, you were already probably heading down the wrong path ...

2. but since then have spent most of my life sitting down

Ah. There's an interesting clue.

Here's what I'm guessing: you got a Synvisc injection into a joint where the cartilage had significantly softened/degraded. After the injection, instead of thin, watery synovial fluid passing over and into damaged/soft cartilage, you had thicker but synthetic "synovial fluid" passing over and into damaged/soft cartilage. Notice the one unfortunate constant in both before and after: "damaged/soft cartilage."

3. I felt much better (down to 2-4 extra strength ibuprofen a day)

Whoa! To me, having to take 2-4 extra strength ibuprofen a day isn't a sign that I'm feeling great. Sounds more like I'm soldiering through pain. You may be a tough guy. That can be good sometimes. But it can also lead you to push too hard -- that's a common tough guy mistake with bad knees.

4. I figured I had a window to get my legs stronger before the synvisc wears off

Uh oh. Now I'm getting a bad feeling. You know, you sort of sound like I once did -- because that was precisely my thinking once upon a time, when I considered getting a Synvisc injection. The trouble is Synvisc doesn't last all that long: generally five weeks at least, and up to six months. So here's the situation: you're someone who, since his running days, has spent "most of my life sitting down," you're about to embark on an ambitious muscle strengthening program (for someone who hasn't done much for the preceding x years, full-body squats and goblet squats certainly strike me as ambitious), and you want to acquire that muscle strength before the Synvisc wears off, in as little as five weeks ...

Now here's the tragedy. If traditional physical therapy were correct -- if the key to beating chronic knee pain lay in muscle strengthening -- you'd be golden. Your analysis would be dead on. But, if your knee joints are too weak, muscle strengthening is yet another kind of trap, and a frustrating one at that. And even with a Synvisc injection -- it will help, but remember you still have some bad/soft cartilage in your joints, most likely -- you can still plunge headfirst into that trap.

If muscle strengthening is the correct approach, then congrats! You've just escaped knee pain. But if it's not, and your joints are weak, then you've probably exacerbated the knee pain you're trying to overcome. And you do admit that, while you now have strong thighs, your knees hurt much more.

5. My guess is I made my quads and calves too strong and now they are yanking more on my patella causing cartilage damage.

Hmmm. That's not my guess. That's certainly a structuralist sort of guess -- that you've strengthened yourself out of alignment. I find another theory much more likely: you seized a window of opportunity (granted by the Synvisc), as you should have. Good move. But you seized it by going full-tilt on muscle strengthening when you should have dialed back a bit and instead gone full-tilt on joint-strengthening. Synvisc, along with some handy ibuprofen, pushed you to greater levels of leg strength. Meanwhile though, you were doing more damage to your joints.

Again, I simply present these as things to ponder. I could be right, I could be wrong. But I found that joint-first was the way to go in my recovery. It's slow, admittedly -- you're not going to get all the way to where you want to be in two to three months -- but you certainly can make good headway and get on the right path.

Why Do Bad Knees Rarely Heal, If They Can?

This weekend I was in full problem-solving mode. I needed to sink anchors into concrete to hang a bicycle rack on the kitchen wall, set up a wireless router for my computer, and replace the (broken) deadbolt lock on my apartment door. Phew!

Each job could have been relatively easy. As (bad) luck would have it, none was. I finished all three, but only after briefly staring into the abyss of failure on each one. The deadbolt lock -- surely this task has to be easy, I thought, after struggling mightily with the router and with anchors that kept sliding out of their holes -- proved to be my last challenge, and tricky in its own way.

In the end, I replaced the deadbolt key cylinder but wound up retaining the old lock mechanism (the new lock wouldn't marry up with the existing strike plate that was embedded in the door frame). Keeping the old lock was an ironic twist, as it was the source of the original problem. Basically, the sliding bolt didn't turn.

So how did I fix a broken lock? I took it completely apart. I got up close and personal with the innards of a deadbolt lock, for the first time. I stared hard at it, made it move (with difficulty), tried to figure out why it didn't like to move, then set about jiggering and oiling and ... well, now it moves like butter. Knock on wood.

So now I can sleep at night without that nightmare that someone is breaking into my apartment. :)

Solving these three problems put me in a somewhat reflective mood (and gave me a gigantic headache, if you want to know the full truth). Because these problems, as difficult as they were, pale in comparison with the greatest challenge of my life: fixing my bad knees. And I began to think: Why do so many people try so hard, but yet fail to fix their knees?

I look at this question in Saving My Knees, but I think it's such a good one -- if you're a "knee optimist," as I am -- that it deserves a full-fledged blog entry.

So here's why I think the failure rate is so high.

PEOPLE FOLLOW THE WRONG PLAN

Traditional physical therapy encourages knee pain sufferers to strengthen muscles to beat knee pain. This can be a prescription for disaster (in my book, I recount my own failed experience).

The correct prescription is strengthening the joint first. Otherwise, if you have bad-enough knees, the muscle strengthening will simply put you on a carousel ride of frustration. Sometimes you feel a little better, sometimes a little worse, and you never make sustained progress. That's because your joints are too weak for muscle strengthening to be effective.

PEOPLE CAN'T FIGURE OUT WHERE TO START WITH THE RIGHT PLAN

Okay, you believe in high-repetition, low-load activity to strengthen the joints. So far, so good. Where do you start?

Do you go 3,000 steps on a long walk twice a day? Or 4,000 steps once a day, then 2,000 steps on "off" days? Should the terrain be flat? Or can it be mildly hilly? How long do you wait until increasing the number of steps? Or should you not be walking but riding a bike instead to get high-repetition motion that way?

This is where I think good physical therapists will become invaluable. They can help you figure out where to start with the right plan. It's important to stay within the envelope of function, if you will, that your knees can tolerate -- but then, gradually push that envelope. Or as Doug Kelsey of Sports Center says, "edge the training."

Sadly, most physical therapists aren't as enlightened as Doug. But if my knees were bad, and I was mired in despair, I would consider relocating to Austin, Texas, (home of Sports Center) to work with someone there. I think their approach is that good. They can help you to figure out where to start and guide you on the way.

PEOPLE DON'T GIVE THE RIGHT PLAN ENOUGH TIME

You have to develop a plan. You have to count your steps, the way other people count their calories. And then you have to execute that plan, over the course of many months. You won't notice a huge difference immediately. It takes time. In fact, the worse your knees are, the longer it will take to climb out of the hole you're in.

PEOPLE HAVE STRUCTURAL PROBLEMS THAT INTERFERE WITH EXECUTING THE RIGHT PLAN

I've come to appreciate that the right plan alone doesn't always suffice. Sometimes there are structural obstacles. They can be bone spurs. Or they can be scar tissue, inflamed fat pads, or that something, whatever it is, that causes a clicking or popping each time you bend the joint.

In some cases, if you're patient and diligent, and don't try to rush your recovery, the problem will go away. (I had a band that seemed to slide over something in my bad left knee ... while it alarmed me at the time, today I think it's largely gone or has subsided or whatever).

Other times, the structural problem will be a real, ongoing issue.

PEOPLE ARE DISCOURAGED FROM FOLLOWING THE RIGHT PLAN

Unfortunately, there are lots of doctors who don't believe bad knees can heal. They don't know of the studies (I can cite three) that show cartilage can heal naturally over time. These doctors tend to shrug when faced with a set of bad knees, not offering much advice beyond, "If you feel pain, don't do whatever you're doing, but try to keep moving."

Gee. Thanks a lot.

When doctors are pessimistic, their patients not surprisingly become so. And so a ceiling of expectation is put in place. I went through the ceiling. I refused to believe my doctors. But I bet many others are trapped below the ceiling of what they're told is the best-case scenario for their ailing knees.

Three Interesting Things I Left Out of "Saving My Knees"

Well, one of them I didn't leave out of Saving My Knees. I just underplayed it, I think.

Here they are:

1. Getting proper sleep is important.

I mentioned in the book that during my recovery I was always careful to drink lots of water (cartilage is largely composed of water) and to get plenty of protein (which contains the building blocks for repairing injured tissue).

What I neglected to include: I was also diligent about getting enough sleep. When my knees were in a fragile state, they often reacted badly to a lot of seemingly minor or unrelated things, such as a change in the weather or a bit of emotional stress.

In fact, the extreme sensitivity of my knees led me to investigate whether I might have a systemic condition, such as rheumatoid arthritis. It turns out I didn't, thankfully. But I realized that, to improve my chances of healing, I had to do as many things right as I could.

Getting enough sleep was critical. A full, restful night's sleep (that's about 7 1/2 hours for me) helped me in several ways: (1) My whole body felt better, including my knees (they gave me negative feedback when I got too little sleep) (2) Sleep is downtime that your body needs to rest and repair itself (3) The sleep position -- relaxed body, legs extended -- was also good for not stressing my joints.

2. I did do certain exercises that appeared more "quadriceps focused" than just walking about.

Readers of my book, if asked to distill the message of how I recovered, might say, "Go slow and walk a lot." Of course that's a vast oversimplification. Still, the truth is, I did walk a lot -- and I think this high-repetition, low-load activity did much toward helping me heal.

But I also did some lower-repetition activities that seem rather close to the quad-strengthening exercises that I regularly disparage. Here are the three main ones: (1) the "monster walk" (or what I call the "crab walk") -- you put a looped Theraband around both ankles and, pushing against the resistance, walk side to side. (2) unloaded knee bends (I'll return to these in a moment) (3) unloaded squats (using bungee cords and a mountain-climbing harness, I did squats -- the bungee cords effectively reduced my weight significantly, so it was as if I was doing squats in a low-gravity environment).

The unloaded knee bends I did one knee at a time. I would do a fairly deep bend while being partly supported by a "giant rubber band," if you will. The exercise was a poor man's adaptation of something Doug Kelsey recommended on his Web site. What I did: I pounded a heavy nail on top of a tall bookcase. I took an old bike tube tire (stretchy but tough) and attached one end to the nail and the other to a belt tightly cinched around my waist). The tube was at a right angle to my position as I did the knee bends. (Picture a "T" -- I'm the top bar of the T; the long bar is the bicycle tube).

Why didn't I mention these exercises in the book (actually I did mention two of them, but fleetingly)? Several reasons: I didn't do them consistently; I didn't think they contributed all that much to my getting better; also the key thing with two of them is that they're unloaded -- so they're really joint-focused, not quad-focused.

But -- having said all that -- I considered the unloaded exercises, at least, a good idea. Why? Because I believe you have to train your joints to move through the range they will need for day-to-day activities. An exercise program consisting only of walking doesn't move your knees through the deeper range of bending (that you need for getting in and out of ordinary chairs, for example). So if you can find a (gentle, unloaded) way of doing high-repetition deep knee bends, I think that's a good thing.

3. Sweating is really, REALLY important.

I touched on this in my recovery chapter, but I may have undersold it. If I had bad knees, one of my objectives would be to get my joints/body strong enough to do sweating exercise. My strong suspicion is that it helps your body heal faster. (Doug Kelsey delves into this somewhat on his blog and refers to "perfusion rates," but I never really explored the subject). Personally, I noticed a real jump in improvement once I reached the point where I could walk up hills and work up a sweat.

How do you get there if your knees hurt all the time? Partly I think it's a matter of patience. Rome wasn't built in a day, as that tired cliché goes. But don't discount creativity either. At one point I considered buying one of those arm-pedal bicycles.

I've often thought that, if I were more the inventor type, I would devise a kind of "taffy" exercise device for people with bad joints. The exerciser would be somehow ensconced in a web of Theraband and could work his good joints vigorously (the bad joints could remain still, or would be used only lightly). The objective: to get that person sweating and moving, even if the bad joints don't move that much. In my mind, it would be a sort of resistance-based tai chi if you will. Or it would kind of mimic the gentle resistance that water provides when swimming.

If Strengthening Quads Was Really the Answer to Beating Knee Pain, I Wouldn't Exist

How's that for a provocative title?

On a number of occasions, I've weighed in against the "strengthen the quad(ricep)s" mantra for overcoming knee pain (realizing the wrongheadedness of this approach is my big epiphany in Saving My Knees). I'm not against strong leg muscles. I just think physical therapists have it bass ackwards, if you will.

Strengthen your joints, THEN strengthen your quads. It's very, very, very important to get this sequence right. Sort of like if you decided to start putting on your shoes, and then your socks, before going to work each day. After a while, you might wonder why your feet always hurt and why you were wearing out socks so fast.

Today I'm going to prove the weakness of the "strengthen your quads" school of thought, using my own story as an example. If "strengthen your quads" is correct -- if it's impossible to heal damaged knee joints and your only hope lies in bulking up your leg muscles, to prevent further injury -- then I guess I don't exist.

Why? Because my knees healed while my quads got weaker.

I'm a numbers and logic kind of guy, so I'm going to do some numerical simplification. When the chronic pain began in my knees, my legs were quite strong. I had been powering up steep hills and low mountains on my titanium Litespeed bicycle for months. So I'm going to guess that my quads were at roughly 95% of their maximum strength.

So here's the situation: My knees start burning. I have "patellofemoral pain syndrome," I am told. What's the solution for this condition? Strengthen the quads! (according to the old school physical therapists). So if my quads are at 95%, my only salvation (it appears) would be to get them even stronger -- to say 97% or 98%.

I should've been on a one-way rocket sled ride to the land of endless pain. That's because I had to curtail my cycling for a while, to give my knees a rest. But they didn't heal. Then I tried doing less-intense cycling. They still didn't get better. Meanwhile, my quads were steadily weakening.

After floundering around for more than a year -- seeing a handful of doctors, trying standard physical therapy, trying ANYTHING I could find that promised the least bit of relief -- I quit my job to try to recover on my own. If my quads had been 95% of maximum strength when knee pain set in, they were probably no more than 60% at this point.

But the type of exercise I chose to do during my recovery wasn't quad strengthening at all -- not at first. I was just slowly walking around. I was moving my joints, trying to strengthen them. I had knee pain symptoms whenever I tried quad strengthening, so I focused first on rehabbing the joints themselves.

And I made progress. I started feeling a little better, by degrees. Meanwhile, my quad strength was still declining.

But this can't be, if you believe in "strengthen the quads to escape knee pain." How could I be getting better while my quads were getting progressively weaker? That would make me, by the standard thinking in physical therapy circles, a living contradiction. Therefore, I don't exist. :)

Or there's the alternative explanation, if you prefer common sense:

When your knee joints are in bad-enough shape, you CAN'T exercise vigorously enough to build up your quads. You get caught in a cycle of frustration. But when you focus on strengthening the joints first -- then you can make real progress, to the point where you can then strengthen the quads.

(For the right approach, listen to physical therapist Doug Kelsey at Sports Center on the topic of "patellofemoral pain syndrome." For example, he notes, "Almost every exercise program that you find for PFS targets muscle (quadriceps strengthening, stretching of the hamstrings, etc.) and having stronger muscles is helpful but weak muscles are not the primary problem.")