"What to do About Weak Knees?" Revisited

This was a popular blog post. A commenter had complained of “weak knees” -- no pain, no instability -- just general weakness. I went out on a limb and surmised that this person was overweight and inactive. Showing that I have no future as a carnival weight guesser, the commenter wrote again to say that he/she was five-ten and 135 pounds (which may qualify as underweight, if anything) and likes to ride a bicycle and ski cross-country. Okay, zero for two -- hey, it happens ... :)

Today I thought I’d return to this odd case once more, seeing if any readers have insights or suggestions. First I’ll give you all three comments this anonymous person has left (settle in, because they're long):

Have you or anyone had just "weak knees?" For over 7 years, I have had this issue and have seen a variety of doctors, multitude of tests, physical therapy and still...same old..same old thing. I was wearing a rocker type shoe from Kmart for about 6 months and my weakness went away, but...then my feet started to tingle and get sore from them. It became too much...so...I tried the Sketcher brand and the weakness came back. So now, I am back to a good pair of running shoes with good support wit weak knees. I am considering on seeking out another orthopedic surgeon's thoughts, but...because I am not in pain they feel nothing is wrong. If I wear knee supports the feeling goes away, but in several days, I get tingling in my feet. One doctor thought that since my knees are OK with supports that by realigning and tightening the knee cap, the problem would be solved. I should be happy that I don't have pain...but...a weakness all day can be just as brutal. No medication works on weakness...so...I manage through the day. When I relax at home on the couch, the feeling will go away in about an hour and then the problem starts all over again the next day.

... I am the one with this strange condition. I could type you a long story...but I will be brief. Prior to this condition, I have been physically active (road by bicycle, cross-county skiing and such. I am 5'10 and weigh about 130 lbs. This weak knee condition slowing emerged about 10 years ago. Initially I was instructed to do circuit training at my gym and such. It seemed to help...but...as the months/years crept up, this weakness was more constant. The feeling in the knees are exactly that...a weakness within the knee area. They never feel like they are going to give out...just a darn feeling of weakness. I could be sitting at work and have that annoyance. Have tried pain meds, but..it's not pain, so nothing helps. And, I am not overweight, was physically active and have mystified doctors. As these years have transpired, I noticed that the rocker shoe removed this condition. I did have tingling in the feet with these shoes and was told that my shoe size 8 1/2 or 9 which was the wrong size, thus creating a tight foot-bed. Once I went up to a size 10 1/2 with an orthotic, the tingling subsided. Would bore you with more details, but had to resort to a normal shoe style. Recently, I had to adjust my new orthotics with my shoes due to smaller toe box and foot soreness. So,they reduced the arch material so my foot would not hit the seems within the shoe. Two days after the adjustments, the weakness in my knees came back. Two days ago, I purchased a shoe with a wider foot-bed and they built up the arch support and fingers crossed in day 2, the weakness in my knees are dissipating. So as you can see, their is a connection between the angle/alignment of the foot and my knees. I believe that my knees are slightly misaligned, thus creating the condition. Several summers ago, I rode my bicycle to and from work. It seemed to keep things in check, but as soon as the weather changed and I had to resort to driving...the weakness reappeared. In the past, the 3 P.T.'s were always mystified during the sessions and how my weakness would disappear and reappear. From all the orthopedic surgeons I have visited, only 1 suggested that I wear knee supports. During this 1 month trial, my weakness went away. Due to this, he had a plan of operating on the knees that would essential tighten the knee cap and properly re-align them for support. It's difficult to reach that decision, since other doctors said my knees are fine, but...the weak knee symptoms are quite debilitating. Through these years of experimentation, I now know there is a link between the alignment of my feet and my knees. So...I hope this addresses your logic. If anyone know of a good knee specialist in Ohio that has dealt with this condition I would appreciate a response.

I am that person with weak knees. I am 5'10' and weigh about 135 lbs. I was always been active...riding my bicycle, cross-country ski, enjoyed working out in the yard...and 8 or so years ago, I started to feel a weakness in both knees. Started to workout and it seemed to help a bit. But...as time transpired, nothing seemed to work. As the day progresses, my knees start to feel weak. Through these years, I have seen 3 different P.T.'s and they are uncertain about my condition. When I work Kmart rocker shoes, by weakness went away..but still had tingling in the feet. Went to a shoe store and was told that my 8 1/2 shoes should be 11 B. So....I went that direction and tingling went away, but...they had me wear their shoe orthotic over the insole to take up room. I started to supinate and ended up with nerve pain. So...I had to get orthotics and scrap the rocker shoes. I have tried several orthotics and have not found one yet that has helped me. While I was being fitted with one...they were trying to fit the orthotic with the shoe vs. my foot. And, during that course, I first had no weak knees, but by the time the removed much of the original support, the weakness returned in my knees. If I go home and crash out for an hour or so, the weakness will go away. When I wake up, I am OK..but..then the day starts all over again.

Here are a few of my thoughts, in no particular order:

(1) Someone who has weak knees and accompanying pain might say there’s a word for people like Anonymous: lucky. :) I too had weak knees. But I also had burning, aching, and even some swelling in the joints.

Have other people out there had “just weak knees” that don’t seem unstable (remember, they don’t feel as if they are “going to give out”)? If so, what exactly do they feel like? Because my second observation is:

(2) You say to-may-to, I say to-mah-to.

What does “weak” mean in this context? “Weak”, by itself, can be a hard descriptor to parse. For example: You’re sitting. Your knees feel weak. What exactly is that sensation? When I’m sitting nowadays, I either (a) don’t feel any sensation from my knees or (b) feel a slight sensation, such as an occasional tingle.

My hunch is that 10 people who had the same sensation in their knees as Anonymous would find different ways to describe it besides “weak.” It’s not that I distrust Anonymous, it’s just that (to get philosophical for a moment) words are imperfect vessels to contain our thoughts and impressions, and I suspect that this feeling of weakness is a bit more complex or nuanced.

(3) Could this be a neural issue? Or something systemic? I’m just throwing out ideas here, because of the odd and strangely asymptomatic nature of the problem. Or perhaps it is an imbalance issue, though I tend to be skeptical of misalignment as a cause of knee pain, as I think this reason is cited too frequently and doesn't answer the question of "Why now?" In other words, why does alignment suddenly become a problem -- unless you were say in a car crash and your body got knocked out of alignment?

(4) Has Anonymous tried building up to intense physical activity of the sweating variety? By that I mean really working out aerobically (I can’t tell how intense the bike riding and cross country skiing were). I’m a believer in vigorous physical activity banishing all sorts of strange little aches (if it’s the right joint-friendly activity -- say swimming or cycling). And the intensity should be increased gradually.

(5) At one point in the narrative, Anonymous claims to have been wearing size 8 1/2 shoes on size 11 feet. Hmm. I can usually tell immediately if I’m off by only one shoe size. So Anonymous, this leads me to a final thought:

(6) The power of self-awareness, creativity and a commitment to problem solving.

The power of self-awareness, if you’re Anonymous, is to pay special attention to your environment and what may be causing issues. Keep a knee journal. It's not just shoes that can contribute to the onset of symptoms.

Creativity is using the ol’ noodle to solve problems -- biking was helping Anonymous with the weak knees, then the weather got cold, and that was that. ??? Gyms have stationary bikes. Buying a bike roller or a trainer allows you to ride indoors. Heck, with under-the-desk pedal exercisers, you can ride at work! So a change of seasons doesn’t qualify as a reason to stop doing what your knees like.

And the commitment to problem-solving is the determination to get this right yourself, if need be. The docs don’t know what’s wrong and can’t help. Now you need to help yourself.

Experiment. See what works. And, if you're Anonymous, say a little prayer of thanks that at least you’re not in pain yet. :)

P.S. One other thing I would be remiss not to note. The observation by Anonymous that "When I wake up, I am OK..but..then the day starts all over again" could have just as easily been made by me a few years ago. Each morning, when I awoke, it was like I started the day with a set of brand new knees, that gradually wore out as the day went on -- by mid-morning on a bad day, by mid-afternoon on a good day. This I believe is a classic symptom of knees that aren't strong enough to endure what is required of them -- i.e., the normal sitting and walking and standing that we do, day to day.

So Anonymous, you may not be as alone as you think.

Buying "Saving My Knees": the Value Proposition

It’s been a year since Saving My Knees became available on Amazon.com. Sales have exceeded my expectations. I’ve gotten a great, heartening response from readers. Life is good.

Yet ...

There’s a criticism of the book that I’ve heard a few times that goes like this:

This book is overpriced. The message can be boiled down to “move a lot and listen to your knees.” And who knows if you can get better doing what the author did anyway? Every knee problem is different. Don’t waste your money.

So I thought I’d try something different this week, on the book’s (more or less) one-year anniversary. I thought I’d give you the “value proposition,” if you will, for shelling out $9.99 for an electronic book that you can’t even resell at Sam’s Secondhand Bookstore.

Because Saving My Knees contains information that I would’ve paid $100 for when I had knee pain and was thrashing about, frightened and helpless, trying to figure out why healing was so difficult.

Yes, it’s my story, but I think many people suffer from basically what I did. True, they may be a little worse or better than I was, may have cartilage flaws in different places that throw off different symptoms, may be sedentary instead of weekend athletes.

But I don’t think those differences matter so much, because what I advocate isn’t a one-size-fits-all solution to knee pain. Rather, it’s an approach or framework that can be tailored to someone’s specific needs, with a little imagination.

But ah, I’m starting to wander! So without further digression, here are a baker’s dozen of reasons (as opposed to a banker’s dozen ;)) for buying Saving My Knees.

1. You’ll find a dynamic explanation of how cartilage works inside a knee joint, in a way that I’ve never read before. It’s not the dry textbook “this is this and this is the other and blah blah blah.” It’s as detailed as it needs to be (if you’re going to understand medical studies that reference glycosaminoglycans, you need to know what they are), while not bogging down in pointless details. I tried to write the science so it doesn’t read like science.

2. You’ll read about my one-year scientific experiment into saving a pair of knees -- that worked. I didn’t get lucky. And I was carefully tracking variables throughout this whole time, so this is a high-quality study. Now, what about the fact that I’m a one-man sample size? I’d argue that that may not be exactly the case, as the Sports Center clinic in Austin has helped many knee pain sufferers, and its approach appears to be similar to mine (no surprise there -- the writings of its founder greatly inspired me!).

3. You’ll find out about the weaknesses inherent in certain knee studies. You may have heard of a famous study that claimed, “Exercise doesn’t improve bad knees.” That may have discouraged you from an exercise program. In this book, you’ll learn exactly how such a study can be flawed in serious ways. This will help you analyze the worth of similar studies yourself.

4. You’ll read about hard evidence that cartilage can heal! I’ve NEVER read about these clinical studies in any book about healing knees (if a reader knows otherwise, please point out the book and I’ll give due credit). Once cartilage can heal, that changes the whole ballgame. That makes what I did not only possible, but the most sensible approach!

5. You’ll discover why glucosamine most likely doesn’t work, and so can save money on pills that won’t rebuild your cartilage after all. How much is that worth? According to the online CVS site, a two-month supply of glucosamine is $8.99. So the book pays for itself in less than three months. ;)

6. You’ll see how to play medical detective. This is a great skill to have. The human body is a tremendously complex machine. You want to be able to help figure out what’s wrong with you, and what makes it worse, and what makes it better -- whether it’s knee pain or some other ailment. This is a very useful skill that I draw upon today.

7. You’ll learn about how to keep a knee journal. This is a super way to navigate a long-term recovery. You can’t just bump along, week to week, hoping you’ll get better. You need to be aggressive about taking matters into your own hands. The knee journal helps you figure out what’s working and what isn’t -- and helps you transition to successively harder stages of your recovery program.

8. You’ll get access to a valuable bibliography that lists a wide-ranging sampling of technical books and articles I used. If you like doing your own research, dig right in. There are a lot of sources here, enough to keep you busy for weeks.

9. You’ll meet Doug Kelsey (if you haven’t already at his Web site), who was a terrific inspiration to me. Doug has refreshingly original insights into knee pain and believes you can escape it if you follow the right plan (and are patient). If you’re serious about healing, you definitely need to know what he says about nagging knee pain.

10. You’ll get a reasoned debunking of some of the common myths for treating knee pain: that your focus should be on strengthening your quadriceps, that your problems are caused by a mistracking patella, that stretching your iliotibial band is important.

11. You’ll get, as an added bonus, an example of how to heal a stubborn case of tendinitis (thanks again to Doug Kelsey). I healed bad tendons in my forearms that I thought would end up sending me into surgery.

12. You’ll find out why “just listen to your knees” and “move a lot” aren’t really the solutions to beating knee pain -- at least not as you properly understand both to mean right now. I moved a lot and my knees got worse. I listened to my knees and they got worse too. Yes, I eventually succeeded by doing both, but in a more sophisticated way, which I explain in the book.

13. You’ll learn about the “delayed symptom effect” with knees. Without understanding how this works, your prospects of figuring out how to heal are rather slim, because “bad knee days” will just seem like random events to you, rather than the logical outcome of something you did.

Of course, now that I’ve done my pitch for the book, a reminder: it’s not for everyone. If you want an other-directed solution (surgery, meds), or a very specific solution handed to you on a plate (“do this many repetitions of this exercise x times a week), please don’t buy Saving My Knees. It will just make you cranky.

And, if you’re interested in the message, but counting your pennies, as I’ve said many times before, the blog’s always free. :)

Knee Pain: The Dirty Little Secret

You have knee pain.

You got to a knee doctor. He examines you thoroughly, shrugs, and says, "I'm sorry, but you're not a candidate for surgery. I advise you to see a physical therapist."

So you go to a physical therapist, who prescribes some mixture of exercises and stretching. You dutifully follow the recommendations. You stretch quads. You stretch hamstrings. You even stretch something called an iliotibial band, which you didn't even know you had.

And of course you strengthen. You work on your quads. Maybe your hips and glutes too.

And you don't get better.

"Wow," you think. "I must be one of those really bad cases, one of the hopeless ones that can't be saved." You get kind of depressed. But then you cheer up a little. "Well, at least there's good pain relief medication nowadays," you think, chuckling blackly to yourself.

What can be done? After all, you've tried everything?

Right?

The only thing you haven't done is ask one simple question: "Why the hell am I doing all these things to fix my knees that don't seem to have anything to do with my knees?"

So you read some more, trying to make sense of a treatment protocol that never seems to try to repair what it should be trying to. Gradually, you gain an understanding of the model for knee pain: If you have knee pain, your body's out of whack! Your gait is wrong. Your patella doesn't track correctly. Certain muscles and tendons are too tight, or too loose, or too weak.

This explains all that advice to stretch and strengthen. Of course.

But then, you read and think some more. Are you really structurally out of whack -- or at least in a significant way that would cause problems? You find out a medical study discovered no link between mistracking kneecaps and knee pain. And why has following the recommendations of "structuralists" brought no relief?

Frustrated, you feel that you're right back at square one. Again you wonder: "If my knee hurts, why is my whole treatment regimen aimed at things that are not-knee?"

That's when you realize something. There are two good reasons for someone not trying to fix something that's a problem. (1) That person doesn't know how. (2) That person doesn't believe it can be fixed. And the second reason will reinforce the first. After all, why bother trying to find a way to repair bad knees naturally if you don't think such a thing can be done anyway?

Now you've discovered the dirty little secret in the world of knee pain. The prevailing school of thought is deeply pessimistic. Your knees aren't targeted directly because most doctors and physical therapists don't think that anything can be done to save them after the first signs of osteoarthritis appear.

Just listen to this guy:

Once [osteoarthritic] changes have started, there is no turning back unless there is a reconstruction of the bone surface with total joint implants, according to [Gregory Masiko, MSPT, Cert. ART, center manager at Excel Physical Therapy and Fitness in Glen Mills, Penn.] A treating [physical therapist] must tell patients that they are not affecting the arthritic changes within the knee directly, but instead are focusing on the tissue that both supports and governs motion at the joint, he stated.

It is true that bone spurs can't be exercised away. But the belief that nothing can be done for any arthritic changes, such as runaway inflammation or a deterioration in cartilage -- that simply isn't. Studies show that cartilage can heal, and that exercise induces positive changes inside the joint.

But the practicing medical profession appears to be a few decades behind researchers in the profession, who have made their hopeful discoveries since 2000.

Now you know.

How Real Is the Placebo Effect?

Did anyone happen to see the article "The Power of Nothing" in last month's New Yorker? (Here's a link to the abstract, but the full story is paywalled unfortunately.)

Very, very interesting -- and I'll return to its possible relevance for knee pain in a bit.

But first: what are placebos? Well, when we think of them, what usually comes to mind are sugar pills, or dummy pills of some sort, that contain no active medicinal ingredients. So in a clinical trial of Lipitor, researchers would test the actual Lipitor against a dummy pill, with subjects not knowing which they got -- real Lipitor or fake Lipitor. If there's a significant improvement in the Lipitor group versus the takers of the dummy pill, the drug company knows it's got a winner.

But what if you gave 100 people sugar pills that looked like Lipitor, told them they were Lipitor, and their cholesterol improved as much as if they were taking the real thing? Then you'd have a placebo effect at work.

Here are some interesting takeaways from the article:

* Some people respond better to placebos than others (and it may be for genetic reasons). Also some illnesses and afflictions are more amenable to the placebo response than others.

* A lieutenant colonel made an intriguing discovery during the Second World War, when 75% of gravely wounded soldiers -- men who, by all rights, should have been begging for pain relief -- declined morphine. He was astounded and concluded that expectations explained their seeming stoicism: because they had survived terrible attacks, they had positive outlooks. And so, our expectations can have a profound impact on how we heal.

* Why do placebos work? One explanation: the brain "produces its own pharmacy," secreting substances called endorphins that are chemically similar to opiates, like morphine. (In fact, in one study, patients who were told they would receive a painkiller -- whether they actually did or not -- experienced the same relief as those who secretly got between 6 and 8 milligrams of morphine.)

* The appearance of a placebo pill can matter: Larger pills produce stronger effects. Capsules work better than pills. Colored pills are more likely to relieve pain than white ones.

* The concept of "placebo" is a bit slippery: "For many people a placebo is just a sugar pill. For others, the definition includes the entire ritual of treatment, the complete interaction between doctor and patient."

One more thing: you'll be interested to know that one meta-study -- a study of many other studies -- found no evidence of a placebo effect with a couple of notable exceptions, such as "trials involving the treatment of pain."

Okay, what's all this have to do with lousy knees?

A few things, I'd submit:

(1) Certain knee pain treatments are considered effective by certain people probably because of the placebo effect.

To me, glucosamine is a prime example. As I explain in Saving My Knees, there's no reason it should work because the supplement you swallow gets ripped apart by your liver and little of it remains to circulate in the bloodstream. Yet I wish I had a dime for every comment I've read from a knee pain sufferer that goes like this: "Boy, when I don't take my glucosamine, I really feel it." To me this sounds like a classic placebo effect at work.

(2) Placebos have their limits.

They don't magically cure cancer. They don't even work for some people. Their efficacy seems to be highest for certain kinds of subjective ailments (and perception of pain is very subjective), and for a certain subset of the population.

(3) Expectations really matter!

While I'm not a believer exactly in "you create your own reality" (a certain amount of reality just happens, and you have to deal with it), the mind can be a powerful force. The placebo effect, in cases where it does work, shows that the mind can aid in healing or make pain more tolerable.

So instead of coming up with three reasons why your knees will never get better, come up with four reasons why they will. Instead of dwelling on what you can't do, figure out what you can -- celebrate it -- then figure out how you might be able to get from "can't do" to "can do" for what matters most to you, and sketch out a long-term plan to make it happen.

Put your brain's pharmacy to work -- for you.