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.