Is Knee Pain in Runners Really All About the Hips?

Today's question:

Are stronger hips the cure for a weak-hipped runner who has bad mechanics and is trying to beat knee pain?

The argument goes like this: If key muscles that stabilize the hip (when the foot strikes the ground while running) are weak, runners are prone to knee overuse injuries. That's because the thigh rotates too far inward, producing a knock-kneed stride.

So, armed with this knowledge, you strengthen your hips, and strengthen your hips, and ...

Nothing happens:

Researchers at Ohio University and the University of Delaware recently put the hip strengthening solution to the test. The study involved 20 uninjured women who exhibited abnormal adduction during running and single-leg squatting … Half of the subjects underwent a six-week training program of hip strengthening and single-leg squat technique instruction. The other half continued their normal training programs …

Despite improving hip strength and single-leg squat mechanics significantly, the strengthening program caused no change to the subjects’ running mechanics. Those who underwent the strengthening program continued to run just as knock-kneed as the women who had not.

Update: I had trouble finding the study online, but "Anonymous" below located it. Thanks! So here's a link for anyone wishing to look over the abstract.

What can be concluded from the study's findings?

Hip strengthening didn't fix bad running mechanics -- which suggests that hip strengthening didn't fix other bad mechanics either. So does that mean the underlying analysis that pinpoints weak hips as a problem is flawed? Not according to Fitzgerald:

These findings do not necessarily suggest that weak hip stabilizers are not the true underlying problem. More likely, they are evidence of the old principle, “Practice makes permanent.” While weak hips may cause certain runners to run with funky form in the first place, long-term repetition of this movement pattern gives it a life of its own. It becomes programmed into the motor cortex of the brain, so that even when the original cause (weak hips) is addressed, the pattern remains.

Further evidence in support of this conjecture comes from previous work by Irene Davis … Davis has shown that gait retraining -- a program of using biofeedback to teach better running mechanics -- does in fact correct internal thigh rotation and abnormal adduction, and it also helps alleviate knee pain.

I'm a bit suspicious of this "motor cortex programming" argument. It's not because I doubt that our brains can get in "ruts." I'm sure they can. In high school, I failed to make the baseball team after developing a hitch in my hitting swing from spending hours tossing small rocks in the air and batting them down the driveway, into the woods.

The trouble I have with this "motor cortex" reasoning is that it smacks too much of the ghost in the machine. You can't really prove or disprove it. Anyway, let's set aside that objection for the moment because Irene Davis apparently has shown that gait retraining does work -- and that naturally raises other questions.

Why strengthen the hip muscles at all? Why not just do the gait retraining? Does strengthening hip muscles have any beneficial effect? If it does, why was none of this effect captured in the Ohio University study? And what are the limitations of gait retraining?

Questions, questions. I'm always a bit suspicious of people who want to fix hurting knees by fixing something removed from the actual knees. (Strengthen your VMO/stretch your iliotibial band to bring your kneecap into alignment!) They often tend to be structuralists, who place an excessive importance on muscle imbalances and anatomical irregularities to explain away pain. What if the solution is simpler? If you have a weak, hurting knee, start on a program (long and boring, but it can be done) to strengthen the joint. It worked for me.

Why I Will No Longer Be Posting on the KneeGuru Forum

For anyone who wants to attract my attention with a "shout out" over on KneeGuru, I have two words for you: Don't bother.

Unfortunately, it appears I have been banned from the site.

Honestly, this decision left me quite puzzled. In the interest of being open, I'm going to share with you the e-mail exchange I had with the site's founder (my screen name is rbcyclist, though I signed my posts with my real name), then explain a few things, and you can judge for yourself:

Sent: Thu, July 14, 2011 10:40:13 AM
Subject: Spam on KNEEguru

Dear rbcyclist

I am very unhappy that you are using my site, which has taken 13 years for me to develop the FREE content to my readers, in order to excessively promote the sales of your own book.

I have removed your account.

If you contact Google Adwords, you will be able to pay them for an Ad that they will distribute to all relevant knee sites for you, and put the matter into a proper commercial context.

Sheila

And my reply:

Dear Sheila,

I'm sorry that you feel that way, and it certainly wasn't my intention to "spam" your site. I wish that you had quietly approached me and asked me not to post any more messages about my book -- I certainly would not have done so. I didn't realize this had become such an irritant.

In any event, the reason that I did post so much about my book, and about the contents, was because I think the message is important to people who suffer from knee pain. My mission is much more evangelical than marketing/promotional, I assure you. I think there will be a dramatic re-think in the next few decades about treating knee pain, and it will center around the realization that damaged cartilage can heal, under the right conditions.

In any event, I respect your decision -- it's your site, after all -- and wish you luck in building the community there. It's good for knee pain sufferers to have somewhere to go to share ideas, feelings and opinions.

Best,

Richard

Okay, what did I do that was considered so offensive? Most recently, I started two threads over there to let people know that Saving My Knees was available through Amazon and then Smashwords (the first thread in January, then the second one six months later, in July). Within those threads, I had great discussions with forum members who were curious about my story and had their own thoughts to share. Sometimes I mentioned the book, but not in a promotional, in-your-face way (e.g., "Buy my book! It will solve all your knee problems! Only $9.99!).

One more thing: As part of my signature, I included my website address. So I would sign my posts, "Richard," then on the line below I'd add, "www.savingmyknees.com." But that's common for someone who has a Web site. I doubt that's a hanging offense.

Now someone might say, "Well, why start a thread in July that the book's available on Smashwords too? Isn't that a bit much?" Two things: (1) There are a lot of e-reading devices other than Amazon's Kindle, and Smashwords distributes in pretty much all formats. (2) On another forum that I belong to (chondromalacia community) someone asked if the book would be available for her Nook (which it should be now through Smashwords, though wasn't before), and I thought others might have the same question.

Even so, I admit it might have been overstepping the bounds of good forum decorum. If Sheila had shot me an e-mail and said, "Hey, I appreciate what you bring here -- I think your message of cartilage healing deserves discussion, and readers can benefit from an inspiring story -- but I'd rather not have this forum be at all commercial, so please stop mentioning your book," I would have apologized to her and stopped mentioning the book.

Now here's why I think the spammer charge is way off-base:

I started several threads over there. I had long conversations, if you will, with other members of the forum. My first thread was called "My Success Story Beating Chronic Knee Pain" and had a large number of hits. I wanted to share a message of hope. I wanted to inspire people by telling them how I healed. I wanted to warn them about bad advice I got from my doctor and physical therapist -- bad advice that they might be getting too.

If you were to read this long, long thread, I don't think your first impression would be, "God, what a spammer." And I don't think your reaction would be, "Yeah, this guy just wants to sell a lot of books." I think (and hope) it would be more like, "Wow, this guy fully healed, and he did a helluva lot of research, and experimenting, and learned a lot -- and he wrote a book and now wants to reach out and help others." (If you don't care to buy a book, that's no problem, as I've always said -- the blog's 100% free, 24 hours a day.)

BAD CARTILAGE CAN HEAL. YOU DON'T HAVE TO LIVE IN PAIN.

That's my banner message. I'd link to all my threads on KneeGuru -- again, in a spirit of openness, to allow readers to judge for themselves whether my posted content was too promotional -- but unfortunately Sheila has deleted them.

KneeGuru has a fantastic community of people. I wouldn't not recommend it now because of spite. Go there, talk to members, learn what you can about your knee condition. It's the best knee site I know of.

I'm a little disappointed that the site's founder didn't have the courtesy to send me a warning, "Please stop talking about your book or I'll have to ban you." I am left to conclude that she feels none of my posts over there contained any value to her community -- and honestly, that really, really puzzles me.

Because it's so obviously not true.

So there you have it. That's the full story of why I'm no longer part of the KneeGuru community.

Comment Corner: Sleeping Position, Signals From Bad Knees

I received the comment below recently. By the way, if you're trying to get my attention about your knee issues, here are a few helpful ground rules :):

1. The best way is to leave a comment after one of my blog posts (I check the comments each week and sometimes cull future posts from them.)
2. If you leave a comment, another helpful reader may be able to provide you with some good insight that I either don't happen to have or that I simply overlook. The hive mind is always superior to that of the individual! :)
3. I'm not a doctor or physical therapist (though I did learn a LOT healing my own knees, an experience I recount in Saving My Knees). Whatever thoughts I have are simply "things to think about and discuss with a qualified medical professional."

Here's the comment; I've whittled it down to the questions mainly:

I'd like to thank you for your blog. :) It has given me hope since I injured my knee about a year ago and after that I developed chondromalacia or something like that, well I have pain in my knee and a tiny crepitus, some cracks also. I guess it happened during and after the time I limped. :( I'd like to get my active life back. I have read everything I have found about chondromalacia but the things you and Doug [Kelsey] say make the most sense.

If you have time, I'd like to ask some questions.

1. During the time you had knee problems, when you slept, how did you position your leg? I'm trying to sleep with my knee straight. There's still some motion and I'm wondering if that's bad for the knee.

2. What do you mean with negative signs that one's knee gives? I've been trying to cope with my knee so that it doesn't actually hurt (I avoid things that make it hurt like crossing it) but it does have some strange sensations every now and then like something tickling it from the inside. Do you think that it's better to try to avoid all the sensations that differ from what my healthy knee feels like or only the pain? My pain isn't that bad but it's annoying, a dull ache.

3. What do you think of prolotherapy? I think Doug uses it...

Okay, answering your questions, one at a time:

1. How to position a bad knee while sleeping?

I didn't obsess too much over how I slept (except for not sleeping face down -- neither my knees nor back liked that position too much). But that's because my knees were basically happy in most sleeping positions. After all, they liked to be fairly straight and elevated -- or at least not lower than the rest of my body -- and that describes how most of us sleep.

(By the way, if you do want elevation when you sleep, you might try resting a pillow under your bad knee.)

But otherwise: I think you're naturally going to move when you sleep, short of donning a straitjacket before turning in. You dream, you move. You'll end up tossing and turning without even realizing it. So attaining the perfect sleep position may not do much good if your body (once asleep) decides to thrash about.

What strikes me as more important: Making sure you get enough sleep in the first place. When I had bad knees, I took special care to ensure I got a full eight hours every night. Your body needs "down" time to repair injuries. That's my best insight on the subject of sleep.

2. What exactly are the negative signs from a bad knee to be watchful for?

That's a great question with no easy answer. Just think of all the sensations from a bad knee: sharp, dull, aching, stabbing, pulsing, intermittent, etc. And think of all the places you can experience those: deep in the joint, near the front of the knee, near the back, on the medial side, on the lateral side, a little above the knee, a little below.

Obviously a doctor examining you can map certain pain/discomfort signals to specific injuries. But I found that, with bad knees, there are a lot of weird sensations that come and go of unclear origin. Some hurt. Others just annoy you. All the while, you're wondering, "What does this mean, and how should I modify my behavior?"

A couple of thoughts:

A. You need to learn to listen to your knees (see the "Four Golden Rules" chapter in my book) and become a first-rate translator of the language that your bad knee speaks. Try to figure out which sensations signal that you're heading for trouble if you keep doing "x", and which are more or less normal grumblings from an unhappy joint. I think this is where knee patients have to be much more involved in their own recovery.

B. Your bad knee will grumble. That's inevitable. You can't cease all leg movement until you're sensation-free, or your joints will rot away. So, again, you have to get busy decoding the signals from your joints -- for example, which activities bring on the tickling and what happens when you ignore it -- does it get better or go away, and under what conditions? How painful is it? Etc., etc.

Learning how to listen to your knees can be aided with the use of a knee journal (I jotted down daily observations and even assigned scores to how my joints felt, twice a day). Working with a smart physical therapist (like Doug Kelsey) would be optimal.

3. What do you think of prolotherapy?

Honestly, I don't know enough about it to have a strong opinion. But anything that Doug Kelsey likes is definitely worth a look. So, instead of blathering along in ignorance, I'll refer you to Doug discussing the subject here.

Next Week: Why I'm no longer being allowed to post on KneeGuru. What happened left me a bit stunned. I'll give you the full details; you can be the judge.

Microfracture vs. ACI: Which Makes More Sense?

If you must have knee surgery, which is better when you're missing a patch of cartilage: a microfracture or ACI (autologous chondrocyte implantation)?
With a microfracture, a surgeon pricks the bare, cartilage-less bone to create small holes, through which blood and bone marrow seep, forming a clot that releases cells that create cartilage. With autologous chondrocyte implantation, such as Carticel, your own cartilage (autologous) is basically grown in a petri dish, and the mature tissue (which has cartilage-producing cells, or chrondrocytes) is implanted in your knee.
The big knock against a microfracture: the cartilage produced isn't the good, mature variety, but rather a rubbery sort that's less durable (called "fibrocartilage").
ACI is the new, sexy, cutting-edge procedure. So if I had a choice, I would have a …
Microfracture.
Here are six reasons why:
1. The surgery is less invasive. ACI involves an operation that peels the knee wide open. Unfortunately, extensive surgery may entail a higher risk of something going wrong/side effects.
2. The cost is cheaper. It appears that the microfracture is a fourth or fifth the cost of an ACI.
3. The procedure is more "natural." The microfracture spurs the bone to form replacement cartilage on its own. The ACI requires cartilage to be grown in a laboratory, then inserted into your knee.
4. 100 NBA players can't be wrong. Okay, it's not a hundred -- more like a dozen or so -- yet the point holds. Professional basketball players make multimillion-dollar salaries. They are attended to by the finest trainers and doctors. They can afford any kind of surgery.
When was the last time you heard of an active player undergoing an ACI instead of a microfracture? Granted, the microfracture doesn't always succeed. Still, players such as Jason Kidd, John Stockton and Amar'e Stoudemire have regained their old form after the operation.
Today, Stoudemire is renowned for his athleticism and leaping ability. He's an all-star, pounding up and down the court for the New York Knicks in what may be the most demanding sport for knee joints. That he has maintained his skills, post-surgery, while putting his knees under such stress, shows microfracture can be effective.
(Update: As is obvious to anyone who follows the NBA, I might have chosen a better example here than Stoudemire, who had knee surgery again during the 2012-2013 NBA season. Oh well. Basketball is a very hard sport on the knee joints.) 
That leads us to my fifth reason …
5. This study
Which dispels the belief that the only cartilage you get with a microfracture is inferior fibrocartilage. (That never made sense to me anyway: how could NBA players compete in such an intense game if their replacement tissue was solely fibrocartilage?)
In a study published in Arthroscopy in April 2006, researchers who took biopsies to inspect the cartilage that was formed after a microfracture observed (my bold):

This healed tissue is a combination, or hybrid, of fibrocartilage and hyaline-like cartilage [note: that's hyaline articular cartilage, the good stuff]

What's more, they examined the tissue after only a year, leading me to wonder -- had they done a biopsy after two, three or four years, might they have discovered an even higher proportion of hyaline cartilage compared to fibrocartilage?
Why do I wonder this? Well, when Robert Salter did his famous continuous passive motion experiment involving rabbits 30 years ago (the animals had small holes drilled in their knee cartilage to simulate defects), he found a few curious things (besides the banner news that motion, of the continuous and passive variety, is great for knees post-surgery).
One was this: The cartilage that grew back to fill the holes was at first immature, then gradually took on the characteristics of mature cartilage, complete with chondrocytes.
6. And this study too

For the study, 33 patients had a microfracture and 34 the ACI procedure. Then, at various times over the next two years, the condition of their repaired knees was assessed. Their ability to do one-leg hops was measured. Also knee mobility and strength were checked.
The researchers expected to find the ACI patients with a decided advantage over the microfracture group after two years. But this is what they discovered instead:

The most important finding of the present study was that the functional recovery at 2 years is comparable for both groups. The results show no superiority of ACI over microfracture at 2 years.

What's more:

More patients in the microfracture group recovered overall functional performance at 9 and 12 months.

Okay, that's why I'd prefer a microfracture over ACI. What about you?

"Saving My Knees" Is Now on Smashwords

Happy Fourth to all!

Now then, moving along ... one thing I've learned having a young (less than two years old) child around the house -- it takes about nine times as long to get anything done.

And so that's why I'm announcing on July 4 (instead of a month ago, as I'd originally planned) that Saving My Knees is now available through Smashwords.com and all of the site's affiliated retailers (or will soon be; the current status appears to be "pending review.")

That means that people who aren't on Kindle -- who are using the Barnes & Noble Nook device, for example -- should be able to read Saving My Knees with the technology of their choice. (If you can't, post a comment below, and I'll look into it.)

A quick aside: I don't like the look of the Smashwords ebooks as much as the Kindle ebooks. With Kindle, I was able to tweak things (Amazon helpfully guides you to software that lets you preview your books) before uploading. Smashwords, unless I'm missing something, only lets you do a preview after their "meatgrinder" technology (not as ugly as it sounds) finishes converting your work to a format acceptable to them. I like many things about Smashwords, but their "one size fits all" meatgrinding, with the formatting limitations it imposes, isn't one of my favorites.

When It Comes to Healing Knees, Which Century Is Your Advice From?

June was a fantastic month for electronic sales of Saving My Knees. Thank you all.

Part of the reason: My essay on Huffington Post (showing that knee cartilage can heal) undoubtedly drove many readers to Amazon.com, in search of more details of my personal story.

As July arrived -- not content to rest on my laurels, of course :) -- I began researching upcoming blog posts. One topic I'll look at soon: "Which surgery is better, microfracture or ACI?" (I won't steal my own thunder by revealing which one I favor.)

Okay, this is where the story gets kind of funny ("a rabbi, a construction worker and a fireman walk into a bar" … no, not quite funny like that). I'm over at Wikipedia, the people's encyclopedia, checking out the "microfracture surgery" entry. And I come across this statement:

Chronic articular cartilage defects do not heal spontaneously.

And I think, "Aw, geez, didn't I just write a HuffPo essay showing this to be wrong?" But, you know, the nice thing about the people's encyclopedia is that the people are transparent. So I follow the page all the way to the bottom, to the footnote, to find the source for this assertion.

Hunter W (1743) "On the structure and diseases of articulating cartilages." Trans R Soc Lond 42B:514-21

See anything weird there? Like, umm, 1743? So I wonder: Is this really the year 1743? Like four years before citrus fruits were discovered to prevent scurvy? Like during a century when doctors supported bloodletting as a cure for various ailments? Is there really a Wikipedian trying to justify a claim by using science that's more than two and a half centuries old?

Part of me said, "Nah, it can't be. That string of digits must refer to something else." So I did a little more investigating and found Hunter W on the Internet. He's William Hunter, coin collector, physician, obstetrician. Here he is, the handsome gentleman in the old English barrister-type wig.

Born in 1718.

In his mid-twenties, he sealed his immortality on the as-yet undreamed-of Wikipedia by publishing some kind of serious work that declared that cartilage defects don't heal spontaneously.

So if you believe cartilage can't heal, based on what you read in this Wikipedia entry, you're relying on the medical judgment of a guy who was busy eyeing retirement villas by the time the first shot was fired for the Revolutionary War.

Does that make sense to anyone out there?

Now, here is my Huffington Post essay. All the studies cited were published in the last decade, using types of technology that lay well beyond the ken or imagination of Mr. W. Hunter. They indicate cartilage can heal and get stronger.

Welcome to the 21st century.