Another Study That Says ACI Isn’t as Good as Advertised

Autologous chondrocyte implantation, as I described in Saving My Knees, is an extensive procedure: harvest good chondrocytes from your knee, grow hundreds of thousands more of them in a lab, then fill the holes in your cartilage with the cultured tissue.

A while ago, I came across a study of the surgery suggesting that its benefits may fall short of what’s advertised. (More than a year ago, some of you may recall, I looked at ACI vs. microfracture, and which is better.)

Here’s the study if you want to peruse it yourself. If you’re thinking of undergoing ACI, take a look at the graphic color photos. This isn’t “keyhole” type surgery. ACI is a major operation.

This particular study followed 19 patients, average age 32, who were professional soldiers and athletes -- and who thus put high physical demands on their knee joints. This was a hard-luck group to begin with: all but two had had either a microfracture or a “clean up” of their ragged cartilage.

After having the ACI performed, 11 of the 19 (more than half) underwent “second-look arthroscopy” because of “persistent pain, decreased range of movements, and mechanical symptoms.” (Which tends to support my belief that, unfortunately, surgery often begets surgery.)

The results? Well, the authors of the research note that previous studies have found ACI to have a success rate of up to 90 percent -- pretty impressive. In this study, however, only 31%, or 1 in 3 subjects, “returned to prior levels of athletic performance.”

The conclusion was that “in high-demand patients who have a longstanding disability, large defects, and failed previous cartilage techniques, the results of autologous chondrocyte implantation may not be as good as those reported or expected.”

That should give those pondering ACI, or even a lesser surgery, something to mull over.

Surgery is sometimes very successful. You’ll find people who come out the other side of the operating room wishing they had done it earlier.

But it’s never a slam dunk of a decision. It’s not to be taken lightly. In particular, listen to your doctor when he says after assessing your bad knee, “I wouldn’t advise surgery for you right now.” Because this is someone who has an economic incentive for performing surgeries -- if he opposes it, that should tell you something.

I’d never advise anyone to have surgery or not to have surgery. However, I would say it’s never a bad idea to think twice about it, and to make sure you’ve exhausted other options.

Celebrating “Take Knee Pain Seriously Day"

Today is “Take Knee Pain Seriously Day.”

If you’re puzzled because you’ve never heard of this special day, that’s understandable. I just invented it myself a few moments ago -- but for a good reason.

One thing I learned, after overcoming chronic knee pain, was that early on I wasted months thrashing about, unsure of what to do. While this may sound bad, I’m convinced that most people with similar knee pain waste years.

One mistake I made (and that I bet many others make too) is that I didn’t take the pain seriously enough, especially during those first few months. Acting early is the best, easiest way to escape being stuck with a long-term condition that just worsens and worsens.

Here are some signs you may not be taking your knee pain as seriously as you should:

You’re willing to modify your physical workouts/lifestyle ... but not by much.

You decide not to run for a week. Or you shave a few miles off your run. Or, in my case, I resolved to keep cycling over the same challenging routes, and the same steep climbs as before, only “taking it easier” (which I sometimes did and sometimes didn’t). The radical step of abandoning the bike completely didn’t come until later.

You tell yourself “I’ll just give the knee a few weeks to get better, no problem.”

This is a typical early-stage reaction to knee trouble. But most knee issues don’t occur overnight -- and the cure certainly doesn’t either.

So if you’re serious about getting better, you need to give yourself enough time (and have a long-range plan too by the way).

You don’t bother to educate yourself about your condition.

In my eyes, this is another sign of a lack of seriousness, especially after doctors tell you they can’t help -- or what help they do suggest (short of surgery) just doesn’t prove that satisfying.

In that case, you absolutely have to make every effort to help yourself. You have to try to understand better what you’re suffering from and the various explanations of and treatments for it.

Finally, in closing, here’s the irony of “Take Knee Pain Seriously Day.”

At least 90 percent of people reading this blog post, I’m willing to bet, are taking their knee pain seriously. They know they’re in trouble, and they’re willing to be patient about achieving a solution.

The irony is that the people who most need to hear this message don’t even know it yet.

A Story About Healing Naturally

At some point, when you have chronic knee pain, you consider surgery or medication to help you through the ordeal. I know I did. I badly wanted my knees to be fixed, or at least, for the pain and discomfort to go away.

Luckily I figured out a natural way to heal (which took a lot longer than an hour-long surgery, but worked better, and didn’t leave me with scars or side effects). Partly I put faith in my body to “figure out” how to get better, if given enough time and gentle coaxing in the right direction (which for me translated into lots of slow, careful walking, with a very gradual build in intensity).

The virtue of a “natural approach” to healing was underscored for me by a recent article in the New Yorker entitled “Germs Are Us.” The tease: “Bacteria make us sick. Do they also keep us alive?”

The article considers the beneficial role played by the thousands of microbes that inhabit our bodies. Buried toward the end is a neat anecdote that serves as a reminder that sometimes a cure doesn’t come at the end of a scalpel or in a bottle of medication.

The story is about, of all things, earwax.

A man was suffering from a chronic infection in his left ear. His doctors were stymied. They tried different antibiotics, antifungal drops. Nothing worked.

Then one day the man showed up at the clinic, smiling. He was fine. “Do you want to know what I did?” he said. His doctors assumed that one of the drugs had finally found its mark.

But no.

The ear pain sufferer had taken a piece of earwax from his good ear and inserted it into his bad one. Apparently the bad ear lacked certain good bacteria that arrived on the transplanted earwax, and these microbes promptly went to work (doing whatever they do) and cured him!

Pretty cool, huh?

I’ll admit there can be a mysterious aspect to healing naturally. Something works, but why? Now, I’m a hyper-rational guy, always on the hunt for cause and effect, but maybe there are times you just have to allow that there are things we don’t fully understand yet, and trust that your body can work out problems if given the right conditions.

When my knee pain was at its worst, I remember a few times dropping defiantly into a deep crouch (“Ah screw it, who cares,” I was usually thinking). From the uncomfortable squat, I pushed upward into a standing position. And you would not believe the hideous sound something in or around my knees made. It was like someone ripping a wet sheet of canvas.

I never focused on eliminating that sound. I never even focused on figuring out what it was. Rather, when I was pretty sure I had discovered the right way to heal my knees, I threw myself entirely into that effort and more or less trusted that my problems -- the inflammation, the noisy cartilage, that godawful ripping noise -- would get better, all together.

And they did.

That's pretty cool too.

Is Vigorous Physical Activity Bad for Your Knees?

I have Google scrape the Web for me each day for news about knee pain. Lately articles reporting on this study have been filling up my news alerts.

Very high and very low levels of physical activity can both accelerate the degeneration of knee cartilage in middle-aged adults, according to a new study.

Researchers Thomas M. Link and colleagues tracked changes in the knees of 205 adults (45-60 years of age, with no knee pain reported at outset), using MRI exams over a four-year period. The result: Subjects who participated more frequently in high-impact activities (such as running or playing tennis) or who were sedentary had their knee cartilage degenerate more than those who were moderately active physically.

Before we go further, I have to include a disclaimer: Once again, I couldn’t access the full study. So, for instance, I don’t know exactly what “moderate activity” means, which is annoying. But from context I’m going to guess it translates into lower-impact exercise, such as swimming or walking.

What I like most about this study:

* It shows (yet again) that being sedentary is bad for knee joints.

* It underscores my belief that there are joint-friendly exercises (assuming I’ve interpreted “moderate activity” correctly), such as walking. They combine high-repetition and low impact, and subjects in the "moderate activity" group saw little change in their knee cartilage over four years.

* The study looked at subjects with a BMI of 19-27, thus excluding overweight to obese knee pain sufferers. This makes the results cleaner to analyze.

What I like least about this study:

Basically, one thing: the insinuation that hard exercise will ruin your knees. I just don’t think this is true. Earlier, I wrote about a study that showed that longtime marathon runners -- a group that, if any, should have creaky, decaying knees if high-impact sports are bad -- were found to have better joints than non-runners.

Then, there’s this article, saying that “recent research finds jogging might be good for your knee cartilage and joints.”

It cites a Swedish study that discovered that the biochemistry of cartilage improved in the knees of runners vs. non-runners (the belief is that the high impact occurring when your feet strike the ground increases the production of proteins that make cartilage stronger). Other studies (one of Massachusetts residents, and one by Stanford University) concluded that runners were no more likely to develop arthritis than non-runners.

So does this mean there’s no objective, found truth on whether vigorous exercise helps or hurts or does neither? Where does the truth lie?

This is what I think:

If you are older (say between 45 and 60, which was the age range for the subjects in Link’s study), you must exercise smarter if you’re going to do high-impact sports. If you’re going to do low-impact, lower-intensity activities (such as walking), you can afford to be dumber about your approach.

What do I mean by “exercise smarter”? Well, (1) maintain a healthy weight (2) warm up before working out (3) be fairly consistent in your routine.

Number 3 is very important, in my estimation. It means don’t start running twice your normal distance, for example, without giving your body a period of time to adjust. It means don’t think you can hike uphill six miles without problems just because you play a lot of tennis and you’re fit.

That’s because:

Yes, your knees can adapt to more stressful demands put upon them. (The reason marathoners don’t have knee problems, it has been hypothesized, is that the joints get into a “motion groove” where they acclimate to the rigors of long-distance running.) But the adaptation is best when gradual and consistent (don’t run as if you’re training for a race in June, vegetate for July and August, then in September try to resume where you left off in June).

Maybe I’m a dumb optimist, but I think you can be a 60-year-old marathoner with perfectly healthy knees. You just have to be smarter about it than the guy who enjoys walking for exercise.

Reflections on Turning 50

Earlier this year, I reached one of those dreaded milestones. I turned 50 years old.

Five decades. Half a century. Wow.

When you turn 30, you’re jokingly referred to as “over the hill.” But it’s only joking.

At 40, the joking has a hollow ring. You have the uncomfortable feeling that you've probably lived half your life already. The sense of a midlife crisis can become intense.

Then, there’s 50. All of a sudden, you qualify for your first AARP card. And the minor aches and pains you felt before can become lingering, even chronic issues if you’re not careful.

I’ve thought a lot about age and healing, especially after an orthopedist in Hong Kong cheerily told me about five years ago, after I described my knee pain symptoms, that I was over 40, my body was just going to go downhill, and I should accept that.

Fortunately, I didn’t accept that. I was convinced that there wasn’t some “ability to heal” switch that toggled to the off position when I reached a certain age. And, sure enough, after much perseverance, I managed to get better.

That’s not to suggest though that I believe in the saying “Age is just a number.” A realist has to concede age does indeed matter. Senescence is a real phenomenon. Older muscles, for example, don’t recover from hard exercise as quickly and are more prone to injury.

But that doesn’t mean age is a defining number. People can forestall and mitigate the effects of aging -- and it’s not that hard to do.

Vigorous exercise is a good way to slow the advance of the calendar. But, as you get older, it’s good to get smarter about how you exercise.

For example, in the weightroom, I warm up by doing 50 repetitions of an easy weight that’s one-half to one-quarter of the maximum I lift. When I bike in cold weather, besides warming up, I take care to keep my knees comfortable (unlike some cyclists I go out with, who wear jackets and arm warmers while leaving their knees bare!)

Also I’m more careful about taking part in impact sports or activities that involve a lot of jumping or running. It’s not that I can’t do them; it’s just I try to do them smarter (in my younger days, playing softball, I sometimes made leaping catches where I landed on my head -- these days, I’d let the ball drop :)).

So if your knees are bad, and not getting better, don’t blame your age. Blame your weight. Blame your job. Blame the fact that you don’t have a recovery plan, or if you do, it’s not the right one or you’re not following it closely enough.

Because age doesn’t matter nearly as much as others will tell you it does. Trust me here. This is something I happen to know firsthand.

Do You Train for Work?

I remember mentioning this concept to a colleague once. We were talking about our tiring 10-hour-a-day desk jobs. So I said that I “trained for work.” He gave me a sideways smirk, as if to say, “Yeah right. Like there’s a workout routine designed for someone who sits like a rock in a chair all day.”

But I was actually serious.

It’s not that you have to train to be able to do nothing but wiggle your fingers over a keyboard. It’s that you have to train to counteract the deleterious effects of doing nothing, for such long periods, but wiggling your fingers over a keyboard.

Sitting can be poisonous for our bodies, which were designed for movement. Doug Kelsey at Sports Center in Austin once wrote that an old teacher said something to the effect that sitting does for your spine what putting a plastic bag over your head does for your breathing.

So I actually do train for work. Every workday morning I do this “bird dog” exercise for three and a half minutes, to keep my back muscles strong. I also do this “rock ‘n roll” exercise (another great recommendation by Kelsey) for five minutes, for my neck, which is a little crackly and has given me minor problems in the past.

What about my knees?

Actually, what I do for my knees probably benefits my neck and back too. First, on the way to work, I walk a good three-quarters of a mile to my subway stop (bypassing two closer stops, just so I can get in some beneficial movement). During daily snack breaks (Bloomberg has lots of free food on the premises), I eat while slowly strolling the floor. And at lunch, after a quick, light meal, I head for the exits and walk the streets for a good 10 or 15 minutes.

So, in sum: I move as much as possible during work breaks, to try to negate the effect of all the toxic sitting. And early in the morning, I do various exercises to help prepare me to withstand all that sitting without discomfort.

Our bodies need movement. Our 21st-century jobs often don’t accommodate that need so well. So a little special effort is required to keep all our body parts running smoothly.

What Causes Patellofemoral Pain Syndrome and Chondromalacia, Part II

Last week I shared a “unified theory of chronic knee pain” -- basically, that bad cartilage was involved much of the time.

Let me be clear what we’re talking about: diffuse, achy pain generally. There are other, more specific pains when a doctor pokes something and you go “ouch.” Different structures are probably involved there (e.g., I wouldn’t consider “patellar tendinitis” to be PFPS -- I could be wrong here -- because patellar tendinitis diagnoses a clear, identifiable problem).

Now what are some objections to this “unified theory”?

An MRI shows that my cartilage is fine but I have knee pain! So how can the source of pain be the cartilage?

Remember, a typical MRI takes a picture that is imperfect. (Two wood-frame houses may look identical in a photograph, but if the beams of one have been hollowed out by termites, they will not perform the same structurally.)

Initial cartilage damage associated with chondromalacia starts deep within the tissue -- and so, it appears, would not be detectable by a standard MRI.

In chondromalacia of the patella, the initial lesion is a change in the ground substance and collagen fibers at the deep levels of the cartilage. It is a disorder of the deep layers of the cartilage that involves the surface layer only late in its development. (Weinstein, Stuart L. and Buckwalter, Joseph A., eds. Turek’s Orthopaedics: Principles and Their Application.)

Some people with cartilage lesions have no pain, and others with lesions have pain -- if that’s the case, how can bad cartilage be to blame?

Partly the answer appears to be that thin cartilage becomes a problem at some point, despite a knee pain sufferer having a number of initially non-painful lesions:

A recent study proved that one can have as much as Grade III wearing without pain. So, pain is variable. The source of chondromalacia pain is not the articular cartilage itself, but the thinning of it, which transfers loads onto the underlying subchondral bone, which is pain-sensitive. (UCSF School of Medicine, Physical Therapy and Rehabilitation, on patellofemoral pain)

Another important thing to consider here, it seems, is the quality of the remaining cartilage. Recall that chondromalacia literally is an abnormal softening of cartilage. It may have minor wear and be soft (and hurt more), or may have more wear but be fairly stiff (in a good way) and resilient (and hurt less).

Still, if you have a lot of deep lesions, chances are good you have more pain than someone with less damage.

The severity of cartilage lesions detected at arthroscopy highly correlates with incident pain (Aaron, Roy K. and Ciombor, Deborah M. “Pain in Osteoarthritis.” Medicine and Health Rhode Island, July 2004) 

How can damaged cartilage cause pain if the tissue has no nerves?

The key thing to remember here: the source of the pain sensation isn’t the cartilage itself.

Because there are no nerves in cartilage itself, the pain must emanate from subchondral bone, which is experiencing deficient conduction of stress through mechanically inadequate cartilage. ... Fibrillation of articular cartilage usually follows fissuring with progression to ulceration in some cases. When fibrillation progresses to a larger area of the patella, bone may begin to experience abnormal pressure increases or irritation from flaps of cartilage that are placed under pressure. (Fulkerson, John Pryor. Disorders of the Patellofemoral Joint.)

Or, here are some other ways bad cartilage triggers pain sensations:

The articular cartilage is not sensitive to stimulation, but ... the adjacent synovium is the primary pain source [fragments of cartilage can migrate through the synovial fluid to the synovium, irritating it]. The subchondral bone ... is another likely source of pain from excessive load on an unprotected bone surface. Finally, the resulting effusion [swelling] caused by articular breakdown may itself be a source of pain. (Johnson, Donald H. and Pedowitz, Robert A., eds. Practical Orthopaedic Sports Medicine and Arthroscopy)

And as for inflammation:

... Cartilage debris and sulfated polysaccharides liberated from cartilage breakdown have been shown to be inflammatory in joints and to stimulate the release of proinflammatory cytokines. (Aaron, Roy K. et al. “Pain in Osteoarthritis.” Medicine and Health Rhode Island, July 2004)

Then, if you happen to believe that where there’s smoke there’s fire, well, osteoarthritis and cartilage damage go hand in hand:

This loss or damage of articular cartilage is an early finding in osteoarthritis. Chondromacia patella is thus an arthritis involvement of the patella. (MDGuidelines, entry on patella chondromalacia)

But there are other things going on inside bad knees. How can you blame poor cartilage for everything? For example:

The association of bone marrow edema with pain in osteoarthritis of the knee has recently been emphasized. Bone marrow edema was found in 78% of patients with pain compared to 30% of patients without knee pain. The presence of bone marrow edema is associated with progression of cartilage degradation. (Aaron, Roy K. et al. “Pain in Osteoarthritis.” Medicine and Health Rhode Island, July 2004)

Here’s where a careful person has to admit, “Yeah, there's plenty going on that we don’t fully comprehend.”

But consider for a moment swelling of the bone marrow. The first matter to ponder: Does this contribute to cartilage degeneration or is this caused by cartilage degeneration? To me, the latter sounds more plausible. Still, let’s posit the former: that the bone marrow swelling is responsible for cartilage damage -- or that a third, even larger unknown force causes both the cartilage degeneration and the bone marrow swelling.

Okay then, where does that leave us, in terms of finding a path toward healing?

If your main problem is bone marrow swelling (or intraosseous hypertension, or focal osteonecrosis, or bone marrow lesions), then it seems you’d want a more bone-oriented treatment regimen. Now, I am way out on a limb here (I’ve done very little reading on this subject), but bone resembles cartilage a lot more than muscle. So I would think a gentle, joint-friendly program of high-repetition movement would be a smarter way to go than a “strengthen your quads” approach.

So even if the “unified theory” is wrong -- even if cartilage isn’t involved in much of all chronic knee pain -- I think the same activities that would strengthen and help repair this tissue would probably also benefit the joint overall.

What Causes Patellofemoral Pain Syndrome and Chondromalacia?

I got this question recently.

It’s a good one because, unfortunately, the answers aren’t easy. But they are important to seek out. As I mention in Saving My Knees, my first law of healing is:

Before devising a plan to heal, you need to know what’s wrong and what’s causing it to be wrong.

So let’s start with what causes patellofemoral pain syndrome (often abbreviated “PFPS”).

Ah, that’s easy! It’s psst ... psst ... psst.

Seriously: there are two ways to answer this question.

One is that no one knows what causes it. No one knows because no one can know. There is no such thing as PFPS. PFPS is an overly broad, useless pseudo diagnosis that, when translated to its constituent parts from the bewildering medical terminology, means:

You have knee pain (of unknown origin).

An analogy: Your elbow hurts. You see me, a learned doctor, and I say, in tones most grave and dignified, that you have “humeroulnar pain syndrome.” You leave my office, distraught, then do some research, and find out that I’ve told you:

You have elbow pain (of unknown origin).

Not too helpful, huh? Same with PFPS.

The second answer is a bit more sophisticated. PFPS does mean “knee pain,” but it does align with a certain set of symptoms (difficulty sitting and walking up and down stairs, for example). So what’s the most likely cause of that symptom set?

In a moment, I’ll offer an, um, “unified theory of chronic knee pain.”

But first, let’s look at chondromalacia in the knee joint. What is that? It’s an abnormal softening of cartilage. That literal definition is rather abstract though. More commonly, it can be thought of as “a condition in which the cartilage ... becomes worn from age or is damaged from injury.”

Now there's one more thing to introduce at this point: patellofemoral pain syndrome and chondromalacia are often used interchangeably. They are NOT the same thing, but the fact that this confusion exists is very interesting. It suggests that one (chondromalacia) may have something to do with the other (PFPS).

Which brings me to a unified theory of chronic knee pain.

Cartilage problems are involved in much of this kind of pain. So bad cartilage would be implicated in many cases of PFPS. What causes bad cartilage, or chondromalacia, in the first place? I doubt there’s a simple answer. It could be anything from an injury to overuse to obesity -- whatever causes wear or damage to the tissue.

Next week: Objections to the unified theory. A response to each objection. Finally, even if bad cartilage isn’t causing your knee pain, why it may not matter in terms of what you need to do to get better.

A Few Words About Hurricane Sandy (And What It Meant for My Knees)

For anyone living in the New York City area, there’s been only one story this week: Hurricane Sandy.

The weekend before the storm, I said to an acquaintance, “I’m worried less about the wind than the possible flooding.” I had seen water gushing from the ceiling of subway tunnels during no more than a heavy thunderstorm.

Sure enough, the big story turned out to be disruptions related to the incredible storm surge (not that the downed trees were minor -- strolling around my neighborhood post-Sandy, I counted 10 trees within an hour that had either fallen across the road or had crushed a car or smashed into a house).

Manhattan, as I’m sure most are aware, is an island. Those of us who live in the outer boroughs (such as Queens, where my family has an apartment) board long silver subway trains and are magically whisked through the bedrock, and under the East River, to arrive at our workplaces in the heart of the city.

Monday morning, there was no magic. The tunnels under the river had been overwhelmed by a wall of water and closed indefinitely. Whereas I usually walk three-quarters of a mile to a subway stop (not the nearest one either -- I just like to walk a little) and choose from E, F, M, and V trains, suddenly I had no choices.

Monday and Tuesday I worked at home. Wednesday, however, I had to get to work to lay out the weekly publication that I edit. I had no other option. My company was providing a bus shuttle, but it wasn’t conveniently located, so I thought:

What the heck.

I had for a while pondered what it would be like to walk to work. Make no mistake: it’s a serious walk to my office building in Manhattan from the east end of Forest Hills, where I live. Door to door, the distance is 8.4 miles, according to a Google estimate of the route.

So I set out at 6:42 a.m., into the pre-dawn, as the city was just rustling into life. I went most of the way down Queens Boulevard, then turned onto a street that took me (and lots of other New Yorkers, on bicycle and foot) over the Queensboro Bridge. By the way, on the bridge there were no slackers: everyone kept a brisk pace.

At 9:02 I walked through the doors of Bloomberg’s offices at 731 Lexington Avenue. At the end of the workday, I wound up walking back (I did the return leg in 2 hours and 18 minutes, 2 minutes faster, because I was motivated due to some of the neighborhoods I had to walk through ;))

So that’s 16.8 miles (actually probably 17, because I took a wrong detour on the way back and, on the way in, took the wrong approach to the bridge and had to double back a little).

The good news: I had a little sore spot on the back of my left heel, but my knees did just fine. That, I figure, is because I have spent the last three years strengthening them with 60 miles of vigorous cycling each Saturday, powering over the small hills of western Long Island.

I can remember a day, that seems not so long ago, when I lived in Hong Kong and was trying to heal my bad joints and would force myself to stop walking on trips after about 3,000 steps. I would make myself sit down and go no further because I knew I had to be very, very patient to restore my knees to good health.

Walking 17,000 steps in the morning -- and then 17,000 more in the evening -- would have been unthinkable. But that’s the nice thing about beating knee pain. Your knees get stronger. They no longer tell you what to do. You tell them what to do.

And that’s a great freedom, because it allows you to do something a bit offbeat and crazy -- like walk 8.4 miles to work when there’s no public transportation.

(By the way, for anyone thinking, “That’s dumb -- why didn’t you just take a taxi?”, the roads were clogged and a co-worker who did hire a car into work got stuck in traffic and ended up getting out and walking at the end -- and he arrived half an hour later than I did going the entire way on foot!)

Beating Knee Pain: Do You Have a Plan?

A while ago, while working out at the gym, I heard a canned announcement over the PA system designed to sell the services of the on-site trainers.

“Do you have a plan to get fit?” a pleasant voice asked.

At the time, it struck me as deeply ironic.

We accept the need for a plan to build muscle strength and improve cardiovascular fitness. But that’s child’s play compared with managing knee pain, with an eye toward actually getting better. If the former requires a half-page plan, the latter demands something like three pages of detailed notes.

Yet how many knee pain sufferers are there who just muddle along, day to day, and never try to plot a path toward healing?

Broadly, what should go into a plan for beating knee pain?

I think it helps to start with a realistic appraisal of your condition. And be willing to be humbled. You may want to start out walking three miles a day; your knees may quickly tell you that they can only do half that much comfortably.  

Also, of course, you have to decide what your regimen will consist of, day to day, in terms of walking/cycling/swimming/other joint-friendly activities, and how much of each.

Not too hard so far -- rather like designing a workout program in fact. Here’s where it gets tough. You need to be able to adjust on the fly, and play medical detective.

Example: You wake up one morning during week five and your bad knee is really stiff. Oh no! What do you do? You have to be able to ease off for a few days -- or even a few weeks, if needed. Also you need to try to figure out what may have caused the stiffness, so you can avoid doing that again.

So you want to keep some kind of knee journal, to make sure your plan is working and help guide you in revising your plan as your knee gets stronger (yay!) -- and also help you figure out what went wrong when your knee gets worse (ugh!).

To beat knee pain, I’m convinced you need a thorough, though flexible, plan. It may sound challenging. But the rewards are great if you succeed!

Yet More Proof Your Doctor Isn’t Infallible

One of the first criticisms I got about Saving My Knees went like this:

“This is a lousy book. All he does is complain about how all his doctors and physical therapists are wrong and I can’t tell if he got better anyway.”

(By the way, if anyone else is similarly puzzled on that last point, I can unequivocally state that yes, I got a whole lot better. My knees are fine today.)

Read between the lines, and the reviewer appears to be annoyed that I have the temerity to suggest there’s something wrong with the expert advice I was given on treating knee pain.

Why such a harsh reaction?

I think among certain people there is a reflexive, total deference to the opinions of “experts,” even though what is accepted as truth by one generation of experts may be soundly rejected by the next. (History is full of examples; in Saving My Knees I mention the once widespread medical practice of bloodletting to cure a host of ailments, which has been debunked as nonsense.)

Today I’m going to show you that your doctor is very much human -- and not an infallible expert at all -- with a bit of math. It’s taken from Fooled by Randomness by Nassim Taleb, who himself has borrowed the anecdote from Randomness by Deborah Bennett.

Medical doctors were given this problem to solve:

A test of a disease presents a rate of 5% false positives. The disease strikes 1/1,000 of the population. People are tested at random, regardless of whether they have the disease. A patient’s test is positive. What is the probability of the patient being stricken with the disease.

(If you want to try to figure it out yourself, go ahead. I start to disclose the solution immediately below.)

Most doctors -- more than four out of five -- got this wrong. They answered 95% because they focused solely on the accuracy rate. But the question being asked isn’t, “How accurate is the test?” The question, stated more fully, is “What’s the probability the patient has a somewhat rare disease if a test that’s wrong 5% of the time says he does?” And the answer to that question is very different: less than 2%.

Taleb explains how he arrives at that figure:

Assume no false negatives. Consider that out of 1,000 patients who are administered the test, one will be expected to be afflicted with the disease. Out of a population of the remaining 999 healthy patients, the test will identify about 50 with the disease (it is 95% accurate). The correct answer should be that the probability of being afflicted with the disease for someone selected at random who presented a positive test is the following ratio: number of afflicted persons/number of true and false positives. Here, 1 in 51.

Got that? The difference between the right answer and the most commonly mistaken one is very significant. It’s the difference between “you almost surely have the disease” and “you almost surely don’t have the disease.”

Wow.

There are a few points worth making here. The less interesting one, to me, is that doctors often can be mistaken.

The point that I find more interesting (and empowering) is that you don’t have to be a medical school graduate and a practicing physician to analyze information about medical conditions (claims, studies, empirical evidence) and come to conclusions that, in some cases, may be superior to those held by so-called experts.

What’s more, when it comes to your bad knees, you do know more than your doctor on one very important subject: how your knees behave (what they like and don’t like, what causes pain, etc.)

So if a doctor says, “Ah, your knees will never get better” (which is what I was wrongly told), remember: doctors can be wrong -- very wrong.

After all, four out of five missed the correct answer to a basic statistics problem. :)

Extra credit: Did you notice Taleb's approach to solving the problem? Out of a population of 1,000, he removed the person who has the disease (remember, it strikes 1 out of 1,000 people), then calculated that 5% of the remaining 999 were false positives (49.95). So the chance of having the disease is 1/50.95 or 1.9627%.

Alternatively, you could apply the 5% rate of false positives to the population of 1,000, resulting in 50 people who wrongly test positive for the disease, then add the one person who actually has it. So the chance of having the disease this way is exactly 1/51 or 1.9608% -- a bit different.

So, given the information as laid out in the problem, which answer is correct, and why?

Note: The difference in the results from the two approaches is trivial, so you may think it hardly matters which one is correct. While that's true for this example, it wouldn't be for another, say where 30% of the population has some disease and the test has a rate of say 20% false positives.

Glucosamine Sulfate and the Placebo Effect

I was doing some housekeeping recently on the computer, cleaning out old files, when I came upon this:

In a landmark meta-analysis of 10 placebo-controlled trials of glucosamine and chondroitin that researchers said should “close the book” on whether these popular supplements actually help arthritis sufferers, Peter Juni, MD, of the University of Bern in Switzerland, and colleagues concluded, ”Our findings indicate that glucosamine, chondroitin, and other combinations do not result in a relevant reduction of joint pain or affect joint-space narrowing compared with placebo … We believe it unlikely that further trials will show clinically relevant benefit of any of the evaluated preparations.”

The article isn’t that old (from last year), but it did manage to transport me back to the summer of 2007, and the early days of my struggle with knee pain.

My very first orthopedist introduced me to glucosamine. At the time, I was afraid I had some sort of damage inside my knee joints. I liked the idea of rebuilding my cartilage using natural supplements that supply a key ingredient for ensuring the tissue’s strength and elasticity.

By 2007, glucosamine had been the subject of a number of flattering books and articles. A decade earlier, in 1997, New York Times health columnist Jane Brody spurred sales after writing about how glucosamine and chondroitin supplements helped her arthritic dog. She then thought, “Hey, what if they can help my arthritic knees too?”

According to this Web site:

She limped, had difficulty with stairs, and with playing tennis ... After a year of taking glucosomine sulfate and chondroitin sulfate she is not totally pain free but neither is she disabled. Jane Brody now plays singles tennis two to four times a week, skates four or five times a week, and takes brisk 3 miles walks.

As for me, sadly, glucosamine had no perceivable effect on my knee health, as I note in Saving My Knees. After many months, I stopped taking it, convinced it was doing nothing. Eventually, I got around to investigating why it had done nothing for me.

That glucosamine is vital for ensuring healthy cartilage isn’t in dispute. Also, it’s been shown in studies to have a salutary effect, when additional amounts are introduced to cartilage sitting in petri dishes. But the glucosamine story goes awry at this point: in the real world, your knee cartilage isn’t conveniently lying in a petri dish -- you have to swallow tablets of the supplements, which unfortunately (as at least two studies have shown) get pretty well whacked apart by the liver.

An insignificant amount of glucosamine winds up making its way into your knee joints (here's one study that found that: "Low Levels of Human Serum Glucosamine After Ingestion of Glucosamine Sulphate Relative to Capability for Peripheral Efffectiveness," Annals of the Rheumatic Diseases 2006).

So why do so many people exult about the benefits of glucosamine? The closer you look, the more the answer appears to be the placebo effect. Still, what’s wrong with a placebo? Less pain is less pain, after all. I think this is a valid point, but a big caveat should accompany it.

The reason for that caveat I can illustrate with the story of my “Superman pill.”

A man seeks relief from chronic back pain. I give him a bottle of “Superman pills,” which (known only to me) are nothing more than super placebos. Anyone who ingests one feels a lessening of pain and believes he or she has a healed back as strong as Superman’s.

What happens next? Well, the back pain sufferer thinks he’s cured, decides to help his brother move a wood stove up three flights of steps (or something equally ambitious), and ends up really damaging his spine.

That, to me, is the big danger of the placebo effect: thinking you’re actually healed (or are healing) when you haven’t (or aren’t).

Which brings us back to Jane Brody. What the Web site I directed you to earlier doesn’t say (even though it claims to have been updated in 2011!) is that Brody had a double knee replacement, apparently in 2004 (which she discusses, in frank detail, here). Did taking glucosamine cause her to over-exert herself? Did she wrongly believe she could indulge freely in skating, tennis playing and brisk walking because the glucosamine supplements were busily repairing her bad cartilage?

I don’t know. But her story is certainly a cautionary tale for glucosamine enthusiasts.

Do Flat Feet Cause Bad Knees?

This article would have you think so.

I was initially drawn to the story by the breathless tease on the top:

Having flat feet can destroy your knees: Many think wonky feet are a joke -- but the effects are often crippling.

Granted, this isn’t the New England Journal of Medicine. It’s Britain’s Daily Mail. Still, I was curious how flat feet could destroy a pair of perfectly good knees.

The story is that of Arti Godkhindi, 34, who describes her knees as “chronically bad.” The 5-foot-7-inch IT consultant weighed about 10 stone (140 lbs.) and got pregnant and gained two stone (28 lbs.) -- or 20 percent of her original weight. (For me, that would be like going from 175 lbs. to 210!)

During her pregnancy, she walked an hour a day to stay fit. After her daughter was born, she had trouble shedding her excess weight, so she joined a gym. “I started gently,” she says, then adds, “But as soon as I tried to do any running or stretching, I felt this excruciating pain on the inside of both knees.”

So she had an MRI done, which showed tears in the meniscus (pads of cartilage in the joint that absorb shock) in both knees. She was diagnosed with patellofemoral pain syndrome (which is pretty much a worthless diagnosis, I found: see here).

What’s the cause of her “permanent, disabling knee pain,” according to this article?

Her flat feet! Because, we are told, people like her (the quotes are from her doctor):

“... may have been living with faults in the way they walk, such as overpronation — also known as flat feet (which cause the feet to roll inwards) — or supination, where the feet roll outwards. They manage perfectly well until there is weight gain.”

Flat feet or other faults cause you to carry your weight through the wrong part of the foot, he [Dr. David Jones] explains, setting off a chain reaction upwards through the body.

“Where the knee cap connects with the thigh bone or femur, there is a V-shape groove, to help the knee cap glide up and down.

“If your feet roll inwards, the knee cap doesn’t move smoothly through this groove. We call this bad tracking and, over time, it leads to damage of the cartilage and pain.”

This is a conventional, structuralist sort of explanation for knee pain. However, as I’ve noted before, maltracking kneecaps may not be a significant predictor of knee pain (according to this study). And orthotics (which are recommended for flat feet sufferers later in the article), may be useless anyway, according to the New York Times ("The idea that they are supposed to correct mechanical-alignment problems does not hold up").

(Note: It is a good idea, of course, to wear proper-fitting shoes with good cushioning; that's common sense.) 

So, if I’m Arti’s flat feet, I’d start looking for a good defense attorney. After all, her Dad also has flat feet -- but no knee pain. What else may have caused her knee pain?

She gained a lot of weight during her pregnancy. Weight gain should always be a suspect in a knee pain whodunnit, whether you have flat feet or perfect arches.

Changes to her body during pregnancy (softening of muscles and ligaments, altering biomechanics, e.g.), as mentioned in the article, may have predisposed her to knee pain.

Her efforts to lose weight after the pregnancy should be strongly considered as possible culprits. Did she go from being fairly inactive to suddenly active? It wouldn’t need to take much either -- notice how a reference to running (“As soon as I tried to do any running or stretching, I felt this excruciating pain ...”) is quietly slipped into a quote.

But that’s huge! Running can be very hard on joints, especially if you’ve never done it before or are resuming the activity after a long layoff.

I’m not saying her flat feet are necessarily totally blameless. But I suspect their role in this misfortune has been much overstated.

The ‘Friend’ No Longer at My Side

First, to reassure you all: No, this isn’t a weepy or sentimental piece about the death of a loved one.

I’ve been on vacation this week. We had a quiet, family-oriented, stay-in-New-York vacation.

My wife, daughter and I went to the 9/11 Memorial, rode the Staten Island Ferry, visited the Metropolitan Museum, and stopped at about four playgrounds on the east side of Central Park.

And we walked. A lot. Sometimes, what’s more, I was carrying a tired three-year-old. I have no idea how many steps I took over the course of the last seven days.

There was a day, not so many years ago, when saying that would have been unthinkable. When I was battling knee pain, I never went anywhere without my pedometer. In fact, I remember on more than one occasion leaving my Hong Kong apartment without it, and rushing back, as if I had forgotten my wallet or keys.

Why?

Because I’d reached the conclusion that knee pain wasn’t random, as one of my doctors seemed to suggest when he shrugged and said, about my knees that he deemed beyond hope, “You’ll have good days and bad days.”

It made no sense to me that the rest of the physical world is governed by laws of cause and effect, but my knees existed within some strange Bermuda Triangle where “cause and effect” just went and vanished, without a trace.

In my attempts to decipher patterns in the apparent randomness, I knew I had to closely monitor how many steps I took. Gradually, it became an obsession. I seriously tracked and logged the steps I took outside, on shopping trips and walks and so on (note: I didn’t use the pedometer around the apartment, or if I was just going to say the post office.)

That blue clip-on pedometer really was a friend at my side. It told me when I had done enough walking and needed to rest (for a few minutes, or even for the day). It provided a sense of security, of structure. I was no longer free-floating in some nightmare world called “knee pain forever;” rather, there was a way to escape this place, but I had to be patient and get stronger, always conscious of my limits -- even though, I knew in my heart, they would be temporary.

Indeed they were. The last time I remember that pedometer getting a workout was when I came to New York to hunt for an apartment, in December of 2009. I remember too that my step total for one day was off the charts. Something like 20,000, or maybe 21,000 -- the equivalent of more than 10 miles of walking.

Wow. Even though by then I had been biking pretty hard, and was more than a year and a half into my recovery effort, I still thought, “Oh boy, you’re going to pay for this.”

And the next day ... I opened my eyes, climbed off my hotel bed ... and felt fine.

After that trip, I retired my pedometer.

When I needed it, it was invaluable. I would strongly recommend using one to others, because you don’t get better from knee pain just by crossing your fingers and hoping against hope. You need a plan. And ways to measure and monitor how well you’re doing within that plan.

But eventually, this is one friend at your side you’re going to outgrow, if all goes well. And that’s a good thing.

On Taking Nutritional Supplements for Knee Pain

A question came up recently in the comments section that went like this: I know you admire Doug Kelsey. What do you think of his recommendation that people with stiff joints take SAM-e and omega three supplements?

First, I do have tremendous respect for Kelsey. More than anyone, he helped put me on the right track to healing my bad knees -- and we don’t know each other and have never so much as exchanged a single word about knee pain or anything else for that matter.

However, I diverge from his thinking somewhat when it comes to supplements. To be fair, I haven’t done much research into supplements, with one notable exception: glucosamine. So the following is based on my own limited personal experience with supplements and my own reflections on how I healed. Take it for what it’s worth.

Here are four reasons I’m not a big believer in them:

(1) Glucosamine, the all-star of the bunch, is most likely a dud.

Sentiment in the medical community is starting to swing around on glucosamine, which in the early 2000s looked like it might be a wonder supplement to rebuild worn-out cartilage. Larger, better-run, more independent studies show that it’s probably just a placebo.

The fatal chink in the glucosamine story (as I observe in Saving My Knees) is that orally swallowed glucosamine is largely banged apart by your liver, leaving only inconsequential amounts to circulate intact through your bloodstream to your knee joints. This has been shown by at least two medical studies I’m aware of.

(2) I suspect the benefits of supplements are marginal, if anything.

I took several different types of “stop knee pain now!” and “rebuild your bad knees!” pills during my battle with chronic knee pain. I also ate a lot of garlic (touted as a natural anti-inflammatory). And of course I popped glucosamine for months, as I mention in Saving My Knees.

I experienced no discernible benefits from any of the above.

However, sticking to a good, sensible diet strikes me as a good idea. I do recall a few occasions when, after eating too much fatty, greasy, high-calorie food, I had more knee discomfort than normal.

(3) If you get the physical part right, I think the chemistry will follow.

Which means: A lot of these dietary supplements aim to reduce pain and inflammation. Certainly there is a biochemical basis for pain and inflammation. And you can choose to fight those problems on that level.

But in most cases, I suspect, the physical stuff (how you move, how often you move, what kind of load is on your joints when you move) greatly influences all of that biochemistry. In other words: If you want less inflammation in your knee, make sure you’re committed to a program of the right kind of motion, in the right amount. And the biochemical part will fix itself. (Note: this doesn’t apply, unfortunately, the same way to knee issues stemming from a systemic auto-immune disorder.)

(4) Focusing on healing through motion is simpler and cheaper.

Of course it’s not exactly simple -- you still have to figure out what activities, in what amounts, make your knees happy, and help restore them to good health.

But supplements, at least in my opinion, come with a difficult set of questions. Which supplements? How much of each? Does the brand matter? Do they interact with anything you’re already taking? Do they have side effects? And so on.

And the biggest question: How can you tell if they’re working and worth all the money you’re shelling out for them? Even if you’re certain that a particular one reduces pain and inflammation, is it really helping improve the strength of your knees? Because, ultimately, your goal isn’t just to be pain free, but to have stronger knees so you can hike up a mountain or bike to the shore without having problems.

Those are my thoughts on supplements. During my recovery, I did take extra protein, thinking my diet might not be providing enough, and my body needed more protein than normal anyway to assist in healing. But my (limited) experience with supplements was generally disappointing.

Anyone else want to share? Which ones worked or didn’t for you? Please chime in below!

Update: Readers, since posting this, I came across this New York Times piece about knee pain that suggests that SAM-e probably doesn't work:

Well-designed clinical studies have shown no significant relief of arthritic knee pain from supplements of glucosamine and chondroitin sulfate, taken alone or in combination, though Dr. Felson said that if people feel better taking them, he does not discourage the practice. Nor is there good evidence of benefit from methylsulfonylmethane, SAM-e or acupuncture.

A Note of Appreciation ... to All of You

I’ve been meaning to write this for a while.

Way back (well, closing in on two years now), I made Saving My Knees available as an electronic book on Amazon.com. I hoped the message would spread far and wide: that there really was hope for chronic knee pain, and the best kind of hope -- informed hope. I weaved that message through a telling of my own story, from the depths of despair to the joy of recovery.

I figured, though, I had to be realistic about sales. Amazon is choking on thousands of titles, on just about every conceivable subject. Worse-case scenario, I might move 10 to 20 copies, with Mom, Dad and acquaintances accounting for a handful of those. My middle scenario -- which I deemed most likely -- involved sales of 100 to 200 books.

My “home run” scenario was 500 to whatever. For a $10 electronic book, cast asea with tens of thousands of other electronic books (many with publicists and publishing houses behind them), that seemed pretty good.

Well, we’ve entered the “home run” scenario. The last two months, a steady stream of readers has been finding Saving My Knees. That’s gratifying.

Even more gratifying: the quality of comments on the blog has soared. That shows me that the book (and blog) are reaching the right audience: smart, open-minded, curious knee pain sufferers who still dare to be optimistic (even after many setbacks). That’s terrific.

I recently got an e-mail from a woman in Slovenia. I wanted to excerpt parts of it (anonymously), but she described herself as a private person, which I respect. Anyway, she’s in the thick of what I can tell will be a challenging struggle with knee pain. She was grateful for stumbling upon Saving My Knees.

She wrote, “It is like a revelation to me, it fills me with hope I’ve been searching for for so long.” Hearing those words from someone half a world away made my day.

So thanks to all of you for your support (and great questions and comments)! :)

How I Healed My Knees, In One Phrase

This blog, in aggregate, is a lot of words.

Me talking about stretching. About structuralists. About glucosamine. About hope, despair, and all sorts of feelings in between.

Sometimes I like to cut through the verbiage and get back to the simplest, most basic question a first-time visitor will have about my recovery from chronic knee pain.

How did you do it?

My shortest answer is that I followed this prescription:

The proper amount of appropriate motion.

Now here’s the unpack of that phrase, starting at the backend.

Motion means moving. It doesn’t necessarily mean exercising. “Exercising” is a loaded word that conjures up images of buff fitness freaks. It also suggests vigorous activities that may not be good for weak knees.

“Appropriate” is a significant modifier because there are lots of activities that I don’t think are suitable for people with weak knees. They include many low-repetition exercises aimed at strengthening the quadriceps muscles in the front of the thigh. My knees weren’t strong enough for such exercises (in some cases, where the knee pain isn’t too bad, your joints may be able to handle them).

To get enough “appropriate” motion, I considered three options: (1) something in the water (2) easy cycling (3) easy walking. Why those three in particular? They’re all gentle on the joints and good for doing high repetitions.

(1) was out -- water simply wasn’t convenient enough, plus I had some knee problems while moving about in a swimming pool. (2) didn’t work either -- I had messed up my knees cycling and they protested when I tried even easy spinning. That left (3). I built a recovery plan around appropriate motion that my knees liked: walking.

Now, what about those two words, “proper amount”? Why are they important?

Because there will be a sweet spot of the right amount of motion for your knees -- not so much that they get worse, but not so little that they fail to improve. Determining where that sweet spot is will be a difficult thing -- no sugarcoating here -- unless you’re working with a smart physical therapist who actually believes in measuring what kind of load your knee can tolerate (as Sports Center in Austin does) and who designs a program around that.

Warning: I’m aware of very, very few physical therapists that do such a measurement, in a scientific and quantitative manner. This is one reason why I think, for chronic knee pain, we’re still in the Dark Ages.

Further complicating matters, that “sweet spot” of motion is somewhat of a moving target. You must occasionally push your knees to meet more demanding tasks, to ensure they keep getting stronger. Figuring out how much, and how often, to push is yet another challenge.

All these challenges demand a sustained, concentrated effort at healing. Use tools that help you monitor progress and maintain consistency, such as a knee journal and pedometer. And be prepared to experiment, in a smart way. All of this I did -- and I got better, even after a doctor told me I never would.

A Reader Writes: Is It Best to Stay in a Completely “Pain-Free” Zone?

Someone posed these questions recently.

1. Did you try to stay in a completely "pain-free" zone for as long as you could? Or did you look for the point of little pain that marks the edge of your ability so that you push it further? (not sure if I wrote that clearly enough)
 2. Could you share some of the exercises you did that worked (beside walking)? 

I’ve answered these questions in places before, but from time to time, I like revisiting certain subjects, figuring some people have arrived at this blog for the first time.

On #1 -- Is there such a thing as good, or at least acceptable, pain? Should you expect to live with a certain amount of pain to “edge your training,” so to speak, in recovery? And how to figure out where to draw the lines?

Great, tough questions. What’s somewhat surprising: I’ve yet to find much in the way of answers either, in my wanderings on the Internet. What follows are my opinions, based on my own research and experience.

If you have a “pain-free” window each day, try to enlarge that window.

Which generally means: Stay in the “pain-free zone” as much as possible. So, very short bursts of walking may be better than long walks at first. Gradually re-introduce your bad knees to the rigors of daily living (long periods of sitting, climbing stairs).

What’s a pain-free window?

Well, if you’re lucky (as I was), you do wake up each morning with your knees feeling better. Someone once described this as “It’s like I wake up with a brand new set of knees each morning.”

But you really don’t because those knees wear down all too quickly -- in an hour, two hours, three -- because they’re not that strong.

Anyway, that pain-free window, of a few hours or however long it is, is what you want to try to enlarge, in my opinion.

If you don’t have a pain-free window, you want to work toward getting one.

If you’re always in pain, a good plan for recovery becomes more complicated (see here). In that case, if you’re too focused on avoiding all pain, your tendency is to move less -- which isn’t good. So you have to very very very slowly work on healing those knees: using some experimentation, quite possibly creativity -- and lots of patience.

Swelling is pretty much always bad.

That’s my opinion anyway. Swelling seems to me to be your angry joint screaming, “You overdid it, doofus. Now I hurt and can’t move through my normal range of motion!” If, however, the swelling isn’t mechanically induced, but caused by say an autoimmune disorder, the analysis about how to prevent it changes -- because it’s much less clear to me how you deal with that kind of problem, unfortunately.

You don’t necessarily need pain to “edge your training” when healing bad knees.

Again: my opinion. But joints aren’t muscles. After a hard run, during your preparation for the local 5k, maybe your muscles burn, in a good way that signifies you’re getting stronger. That same “burn” in your joints after a hard hike, because you’re trying to strengthen them, isn’t a good thing. In my opinion.

I got better by pushing my knees to do more, sure. But I pushed slowly, and carefully. To me, the ideal recovery is one in which you improve, and steadily push your knees to do more, while experiencing as little pain as possible.

As for that second question, about what other exercises I did: I have spent little time talking about them because, honestly, I don’t think they mattered much in my recovery. But here are my three favorites:

The “monster walk” (I call it the “crab walk,” which is think is more descriptive.) Knot the ends of a Theraband together, roll the loop up over your ankles, then walk side to side, against the band’s resistance. This exercise didn’t put much strain on my knees, I found.

Unloaded forward knee bends (Doug Kelsey describes these here.)

Unloaded squats (I invented one particular variety, using bungee cords and a rock-climbing harness -- more details here.)

UPDATE: There's a great comment below by "Knee Pain" that I urge everyone to read. It adds a lot to the discussion.

If You’re Resolved to Have Surgery or Medical Treatments, Here Are Options to Consider

I’m not a big fan of surgery for chronic knee pain, to put it mildly. Some procedures absolutely make me shudder (“lateral release,” e.g.). Others I imagine could be useful, in certain circumstances.

If I were desperate enough to seek a medical intervention, I’d favor something as natural as possible. That means a procedure that encourages my own body to turbocharge the healing process.

With that in mind, here are treatments worth looking at (Note: that’s not an endorsement of any of these, and anyone with knowledge of, or experience with, any of the following, please add your thoughts below). Also, important caveat: These procedures are more for problems with tendons and ligaments than cartilage, as far as I can tell.

(1) Prolotherapy

I was first introduced to this on Doug Kelsey’s (now defunct) blog, The View. As many of you know, I have tremendous respect for Kelsey, whose thinking about chronic knee pain greatly influenced me during my recovery.

Kelsey’s genius on matters of physical therapy probably derives in part, unfortunately, from his own misfortune -- he has a number of ailments, including a knee problem of his own. Anyway, he underwent prolotherapy.

My understanding is that the treatment involves a series of shots that cause an inflammatory response in the body’s tissues that spurs healing. It is painful, apparently! (Inflammation often is.)

(2) Injections of platelet-rich plasma

Scientific American took a look at this treatment almost three years ago (not the freshest information, but a decent place to start). A small vial of your blood is spun in a centrifuge to separate out the platelet-rich plasma, which is then injected into the injured tissue.

The theory behind why this should work: The injured areas, such as tendons, have a poor blood supply, so healing sometimes becomes difficult. The concentrated platelets in the plasma bolster the nutrients and growth factors at the site, aiding healing.

Notice the word “theory.” “PRP” has its skeptics. Still, the doctor in the Scientific American article said that, of his patients who have undergone it, maybe 60 percent have gotten better.

(3) Whatever Kobe Bryant had done

Bryant, of course, is the NBA superstar who plays for the Los Angeles Lakers. His right knee, under the kneecap, is missing so much cartilage that it’s practically bone on bone, he has said. He flew to Germany for treatments that apparently worked wonders, leading other athletes to make the pilgrimage to the same doctor, hoping for similar results.

What’s the procedure? Apparently it’s a more vampiric undertaking than PRP (“as much blood as they took the first day, I didn’t think I’d have any left,” said this patient). Again, the blood is centrifuged, but heated first, because the objective is to capture anti-inflammatory proteins, rather than platelets. The resulting orange serum is then injected into the ailing joint.

So there you have it. Three novel treatments worth a look (if you’re resolved to have some kind of treatment anyway). Anyone familiar with any of them, feel free to share your thoughts below.

The Importance of Setting Realistic Goals

Not long ago, a colleague at work turned to me and said, “I’m going to lose 20 pounds by July.”

I had a pretty good idea what was going on.

Most of us employees had signed up for free, company-provided health screenings. These consisted of a finger-prick blood test for cholesterol and glucose levels, a blood pressure check, and a weighing.

His weighing showed that a sedentary desk job and a fondness for pistachios had caught up with him. (Note: If you want to gain weight, just eat in front of your computer while working. You’ll enjoy the food less and eat more. I guarantee it.)

Losing a few pounds is certainly a laudable goal, especially when you find yourself on the wrong side of your ideal weight. But in his case, he had given himself two months to achieve something that most people would find extremely difficult to accomplish in six.

I remember expressing skepticism that he could lose so much weight so fast. Inside though, I was thinking something more like, “If you do lose 20 pounds in two months, I’ll eat my keyboard.”

About a week later, it was clear my keyboad would remain intact. I spied him gobbling pistachios again, the weight-loss resolution apparently a dim memory already.

When you set an unrealistic goal, I think you’re basically setting yourself up for failure. Further, failing at something is no fun, and just erodes your self-confidence.

With overcoming knee pain, this issue is particularly acute. That’s because the key bit of traditional advice for beating knee pain -- “strengthen your quads” -- mentally conditions you to expect a recovery on the wrong time scale.

Muscles strengthen relatively quickly. Knee joints don’t.

So, not knowing any better, you think: “I have chronic knee pain. If I strengthen my quad muscles, I can escape it. I’ll devote myself to a two- to three-month quad-strengthening routine. Then I’ll feel fine again!”

My bet is you won’t though. My bet is (if you really have chronic knee pain that’s been troublesome for a while), you’ll need six months. 9 months. 12 months. A year and a half. Two years.

But suppose you proceed with this unrealistic goal of healing in two or three months. After a month, when you realize you’re nowhere near being halfway healed, you may despair and think, “That’s it. There’s no way my bad knees can be fixed.”

So you give up, having decided you can’t reach a goal that was never realistic to begin with.

Of course your problems are really twofold. Your larger problem is arguably that you’re following the wrong path (focusing on strengthening muscles instead of the joint). Still, even if you get on the right path, chances are good you’ll flub your recovery if you begin with the promise of unrealistic expectations.

Why Many Knee Studies Are Seriously Flawed

I’ve cited many knee studies on this blog, usually to buttress some point I’m making.

But I’ve also come to the conclusion that a certain kind of knee study has to be approached with much caution. That’s because it suffers from serious and intrinsic flaws.

First, let me be clear what I’m not talking about: so-called “natural” studies that, instead of testing a hypothesis, look at say how knee cartilage changes over a two-year period, and how characteristics of subjects such as age and BMI influence those changes. (Fortunately, one of my favorite studies falls in this category: the two-year study by Australian researchers showing that, in a whopping 37 percent of subjects, a cartilage defect actually improved somewhere in their knee.)

The kind of study I'm talking about is more ambitious. It attempts to prove a link between some activity X and the health of your knees. And it suffers from serious limitations.

To see the issues, let’s create a fictitious study that has a sensible premise: it sets out to prove that walking benefits bad knees.

Researchers round up 600 subjects with knee pain and split them into three groups. Group A doesn’t walk at all for exercise, Group B walks 1-7 miles a week (as much as a mile a day), Group C walks more than 7 miles. And, to better capture long-term changes, the researchers decide to observe the subjects’ knee joints at the beginning and end of a 10-year period.

Okay, why is this study already in trouble, just by design?

(1) There’s no way to account for “category drift.”

Lives can change a lot over 10 years. A moderate walker may become a super walker -- or a nonwalker. Or someone may jump back and forth between these three categories quite a bit.

What if a moderate walker for nine years becomes a nonwalker in year 10 -- which happens to be the same year he’s surveyed by our researchers about his level of physical activity? If his joint health turns out to have improved, the results would be recorded under “Being a nonwalker is good for your knees.”

That makes no sense, because for 90 percent of the study’s duration he was a moderate walker!

(2) The big problem: Exercise is only a small part of how someone uses their knees in daily activities.

Consider this math: Let’s say you’re awake 16 hours a day. Let’s say you walk a mile a day for exercise and that takes 20 minutes (that’s a three-mile-an-hour pace -- not too demanding). So if you do the math, how much of each waking day are you exercising by walking?

Barely 2 percent.

Which raises the question -- what are your knees doing the other 98 percent of the time? This matters hugely! Because if "walking for exercise" is the variable that is being studied, then what's going on during the other 98 percent of the day is going to contribute to “variable pollution," contaminating the findings.

(Question to ponder: If subject A has a job where he walks several miles at work, but doesn’t walk for exercise, while subject B is deskbound but walks a mile a day for exercise -- who’s really doing more walking?)

(3) The study never makes adjustments for what level of activity (and type of activity) is appropriate for each particular subject.

Say Mary walks one mile a day, which puts her in the “moderate activity” category. At the end of the 10-year period, an MRI reveals her knees have gotten worse. So should her example be used to support the thesis that “moderate walking is harmful for people with bad knees”?

Not necessarily.

Maybe Mary’s joints are so bad that she needs less walking, or shorter bursts of walking, until she can strengthen them. Maybe, had she been in a group that walked only one-quarter mile daily, while taking 60 steps around her room every half hour, her knees would have gotten better.

It’s sort of useless to create a study to draw conclusions about how much of activity X is beneficial when you have no idea how much of activity X each particular subject should be doing (which depends on the strength of their particular joints).

Okay, those are some reasons why I consider many knee studies badly flawed.

Now it’s time for a visit from my imaginary critic:

Great, so researchers shouldn’t undertake a study unless it’s perfect? Subjects’ environments must be totally controlled for all variables? That’s ridiculous. You can’t find any study that meets those high standards. Basically, you’re throwing a lot of good science out the window.

My response: Yes, the perfect is the enemy of the good.

But showing how the good can be flawed -- and sometimes, not be very good at all -- isn’t meant to be an exercise in nihilistic nit-picking. Recognizing that serious flaws exist for many knee studies, and knowing what they are, means you can better evaluate to what degree the study you’re looking at may have escaped those problems.

For instance, category drift will be a bigger issue with a longer term study that samples a subject’s activities at only one point in time. So that may argue for the superiority of a shorter term study (which has its own drawbacks, true).

My message here, once again, is about thinking critically. There’s so much bad and suspect information about healing chronic knee pain that we’re foolish if we don’t think critically.

Handling Setbacks on the Long Road to Healing

The question of how to deal with setbacks came up recently in the comments section. It’s a great question because I doubt even the smartest, most patient person can navigate a healing process that spans many months without a single setback.

First, why are setbacks so bad, when it comes to overcoming chronic knee pain?

They’re depressing. Really depressing. It’s not like you were healing that fast to begin with, right? So you feel a little better after two months of doing all the right things, then do something wrong -- you may not even be sure what -- and suddenly you hurt as much as you did before.

Argh. Bad knees are forever, you start thinking to yourself. At this point, you’re particularly prone to negativity, self-pity, and a bunch of other bad feelings.

Also, at this point, you’re prone to abandoning what works. After all, you tried to improve your joints very, very slowly, you were feeling somewhat better, then an ill-advised hike/long walk/sprint to catch the bus set you back.

Maybe you start thinking: “This program can’t be working -- it’s too slow and if my joints are getting stronger, how can a little x (whatever the offending activity was) cause such problems? Ah, forget it. It’s time for surgery/pain medication/a life of doing whatever I want because it doesn’t matter anyway.”

You feel lost, not knowing how far you were set back. To me, this is a big issue, especially when you’re measuring hard-fought gains in inches, figuratively speaking.

Obviously, you want to get back on track. But do you take a few easy days? An easy week? Should you return to your program of three weeks before, when you were taking 20 percent fewer steps each day? Or do you need to hit the reset button more dramatically, and go back three months, maybe to when you weren’t even taking long walks yet?

These are frustrating, demoralizing questions to deal with. You’ll want to downplay the significance of the setback. You’ll want to act as if you were less affected than you really were -- which raises the risk of doing more damage to your joints.

Okay, that’s why setbacks are bad, in my opinion. Now, how to deal with them?

Make sure they don’t happen.

No, that’s not meant to be a “d’oh” statement. Because I believe you really need to be thinking hard about not pushing your knees too much.

So this means (1) Err on the conservative side with activity. (2) Monitor your knees very closely. (3) Learn as much as you can from whatever setbacks you do have. Failures are never wasted when they’re recycled into knowledge (that in turn prevents future similar failures).

Recognize and accept the setback.

The worst thing, I think, is pretending it never happened and just merrily going on with your existing program, not changing a thing, not reflecting on how and why you screwed up. Because then your knees may just get worse and you’ll be no smarter for what you just went through.

Instead, my advice is to face it head on. You may be lucky -- maybe you just need to take an easy day or two and you’re right back on track. If not, you’ll probably have to experiment a little to figure out what level/type of activity your suffering knees are now happy with.

Know you’re in good company.

I had setbacks. And I bet that almost everyone whose knees healed over a 12-month-plus timeframe had at least one setback. They happen. So it’s good to be philosophical about something that’s practically inevitable.

Some years ago, I remember getting very angry at myself for losing/misplacing something. How could I be so stupid? Then I decided to take a larger view of the situation, and it relaxed me somewhat. The larger view was this: Over the course of anyone’s life, that person will lose or misplace a certain number of things. So, unless I lose personal items at an extraordinarily high rate (suggesting say Alzheimer’s), the occasional object that goes missing is just me filling my cosmic quota. :) No big whoop.

Cry if you need to.

Throw something across the room. Curse the unforgiving God of Bad Knees for not cutting you a break.

After all that, figure out how to get back on that slow path going forward. Because that’s the only way to go, isn’t it, if you want to win back your old life?

Healing Knees and Closed Chain Vs. Open Chain Exercises

This is a continuation of last week’s post, a success story with a twist near the end. Pat, who was suffering from knee pain, met a physical therapist who, upon hearing of how she improved by “walking small steps” around her apartment, approvingly said, “closed chain.”

So what are “closed chain” exercises, and are they the key to chasing away knee pain?

I had come across the closed/open chain terminology before, but never bothered to really look into it. Generally, I distrust geeks bearing jargon. I’m an Occam’s Razor kind of guy. When simple reasons explain phenomena as well as complex, why not keep it simple?

So I delved a little into the book, Closed Kinetic Chain Exercise: A Comprehensive Guide to Multiple Joint Exercise. I was far from an expert on the subject, but the same surely couldn’t be said of authors Todd Ellenbecker and George Davies.

Open-chain exercises, they tell us, isolate joint and muscle movements. Further, the movement pattern is “often nonfunctional.” And the “distal end of the extremity is free in space.”

To understand these points better, consider a pure open-chain exercise -- the seated leg extension (that’s the one in the gym where you straighten your bent leg forward, against the resistance of weights). The “distal end” of the limb (that would be your foot) is out there in open space, not fixed to anything. The exercise recruits only a few muscles and joints. And functionally, well, it’s pretty much useless, unless your daily activities entail punting a football repeatedly.

So that brings us back to closed-chain exercises (such as squats). Are they then superior? Sure sounds like it.

However, it turns out that things aren’t that clear. Here I’m just going to step back and let the authors of the book explain.

First, the functional vs. nonfunctional distinction doesn’t exactly hold up after all:

One of the common arguments against the primary use of open kinetic chain exercises in the lower extremity is that they are not functional. For example, there are limited instances in the lower extremity where an individual functions in a seated position bending and strengthening the leg ... Closed kinetic chain exercises are considered to be more functional, because they closely simulate the actual movement patterns encountered in both sport and daily activities.

Analysis of most functional activities reveals that they are, in fact, a series of successive open kinetic chain and closed kinetic chain motions. An example is the normal gait cycle. During walking, approximately 65% of the gait cycle is weight bearing (closed kinetic chain) and 35% is non-weight bearing (open kinetic chain). Interestingly, during running, the percentages of closed and open kinetic chain motions essentially reverse.

Further complicating matters:

Activities progress along a continuum from closed to open kinetic chain, with many activities of daily living and sport activities incorporating components of both. For example, during the gait cycle, the stance phase is a closed kinetic chain pattern, whereas the swing phase is an open kinetic chain pattern. Another example that shows the interplay between these two movement patterns is riding a bike, during which the foot is fixed on the pedal in a closed kinetic chain pattern, yet the pedal and foot freely move in space. Another example is skiing, where the feet are fixed to the skis (closed kinetic chain), but the skis move on the snow and are not fixed to an object (open kinetic chain).

What’s more, some purported benefits of closed-chain exercises may not actually exist:

Many clinicians have assumed that in the closed kinetic chain position of the lower extremity there is automatically a resultant co-contraction of the muscles that should dynamically stabilize the knee joint. Although some studies did demonstrate this phenomenon, several recent studies actually refuted that significant co-contractions occur with some closed kinetic chain exercises.

Finally, in conclusion, I found this quoted comment (my bold) from other researchers (cited as Snyder and Mackler; sorry I didn't get the full footnote) quite interesting. It refers to rehabbing after surgery to repair the anterior cruciate ligament, but I think the phrase “after reconstruction of the anterior cruciate ligament” could easily be replaced by lots of other phrases, such as “for patients with chronic knee pain.”

Rehabiliation after reconstruction of the anterior cruciate ligament continues to be guided more by myth and fad than by science ... The present study ... suggests that closed kinetic chain exercise alone does not provide an adequate stimulus to the quadriceps femoris to permit more normal function of the knee in stance phase in most patients in the early period after reconstruction of the anterior cruciate ligament.

Now if all this “open chain” vs. “closed chain” stuff sounds a bit faddish, well, the physical therapy trends (according to the authors) looked like this:

1970s Functional rehabiliation
1980s Open kinetic chain exercises (with emphasis on isokinetics)
1990s Closed kinetic chain exercises

How’s that for inducing whiplash? The same physical therapist you saw in 1985 who was saying, “You gotta do open chain, open chain, open chain,” ten years later was probably saying, “You gotta do closed chain, closed chain, closed chain.”

My personal take is that you need to do gentle, high-repetition activities (and if they’re functional, so much the better) to heal bad knees, giving yourself lots of time to achieve results. I wouldn’t worry too much about where my activities lie on the open-closed chain continuum.

Full disclosure: I own a bike chain. I like it. It gets me places. :)

A Quick Note About Drive-By Comment Spam

Happily, the pageviews have been rising for this blog.

Unhappily, that has drawn some opportunist spammers. They leave what I consider "drive-by" spam. It usually goes like this: "I found this article informative and useful for knee osteoarthritis," with an embedded link on "knee osteoarthritis" that leads to some surgeon's website.

Whenever I find this kind of comment, I delete it immediately.

Here are the ground rules:

I have a high tolerance for many different kinds of negative and critical comments. You can even call me an idiot (I'd rather you didn't, but if you feel that strongly ...). As long as you're not offensively profane, I won't delete your comment.

And I don't mind if you make a remark relevant to the blog post and mention a book that helped you heal. Or even if you mention you wrote a book that might help others heal. Or even if you know a doctor who might help others, and include a link to his (or her) Web site.

I'm more interested in whether you're contributing in some way to the dialogue. But when someone writes a throwaway line like "Great post! I like it a lot." and scatters similar comments across multiple posts, with links to a Web site, it's clear they're not interested in participating in a dialogue. They've just been paid to hawk someone's product.


That, to me, is spam. I report it as such. So spammers be forewarned.

Yet Another Success Story

I love success stories. I especially love it, of course, when they validate my own thinking ;), but any good story will do. Let’s share what works!

Here’s a gem from “Pat” that I recently discovered among the comments. I’ve edited it a bit, mainly for length.

I had a Synvisc shot (3 in 1) November 30 and had virtually no relief. Regular PT of the quad strengthening type did not help. End of April of this year, I was certain I needed a total knee replacement (4 surgeons concurred I have patellofemoral arthritis of my left knee). 

By chance, I found your little ebook on Amazon at that time and read it in a couple of hours. I scoffed at the idea that I could recover as you had done because I couldn't really walk at all on hard ground without excessive pain. I had a limp. I had almost fainted from the pain at the market the week before. But I said what do I have to lose -- nothing else had worked -- so I started padding around my apt. wood floors in my bare feet, since barefoot had always felt better than shoes. 

At that time I was so close to scheduling TKR surgery that I had grab bars put in my shower in the beginning of May. Believe it or not, within a couple of days of starting to walk 60 steps every hour or so around my apartment, I started to feel much better -- almost right away, really. 

Then within a week or so by a great stroke of luck I met a woman who had been scheduled for TKR with my same surgeon (coincidence), and she had found a physical trainer very near where I live in Santa Monica, CA, at a place called Drive Cardio. This guy she said had virtually cured her -- she was leaving the next day on a 3-week hiking trip in Turkey. 

I started seeing him and told him that walking small steps had started to help me. He said "closed chain" (I don't know this stuff) and I have continued to see him once a week. He does different things every time -- uses a bosu ball, a stability ball (small "micropushes" with it against a wall), etc. Every week is usually a new series of movements in different order and different intensity. He says what's important is increasing "vascularity." 

I am doing more strengthening stuff each week but it's been very gradual. Certainly not the kind of quad strengthening I had been doing before. I continue to walk around my apt. but I can also walk outside now without pain and use cardio machines which I couldn't use before. 

My recovery was so fast after reading your book, maybe because I didn't have a long history of pain -- only since Nov. 2011. Last week I went on a short trip to Vegas and walked pretty much all day for 3 days. I still have a tiny bit of pain in my knee here and there but it's more like a 1/10 versus 6/10. Am even feeling well enough to plan a trip to Europe this fall. 

I feel so grateful for having chanced upon your book. I've recommended it to others. By the way, I'm a 66-year-old woman. I should say I was quite flexible and athletic for my age before my knee pain.

Hooray!

Okay, a few comments:

I’m glad that walking around the apartment in short bursts provided such rapid, positive results. Sounds like that therapy fit Pat perfectly! However, other knee pain sufferers won’t see benefits that are that fast or remarkable -- so keep that in mind, everyone. All bad knees are different.

My favorite part of the story: She’s 66! And considering a total knee replacement! This is someone at the age where I’m sure many doctors would wag their heads sorrowfully and say, “I’m sorry, you’re just too old, your knees will never get better.”

But they did.

Let me be clear. It’s not that I think age doesn’t matter. It’s that I think age matters much less than the medical community currently thinks it does. You don’t suddenly lose the ability to heal when you reach 40, or 50, or 60. Maybe you heal more slowly. But you can still heal.

Congrats to Pat on finding a physical therapist whose approach suits her (and her bad knee). The description that struck me the most about his program was “very gradual.” The proper way to heal knees, I’m convinced, is very, very slowly and very, very patiently.  

I was intrigued when she said he counseled “closed chain” exercises. I had heard some about these, but had never looked into them. So I did. Next week, I’ll tell you what I found.

Cheers!