Sunday, August 7, 2011

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?

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?

1 comment:

  1. 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.

    Hope some of this helps.