Saturday, January 14, 2012

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?


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.


  1. Hi Richard,

    I have followed your blog since the KneeGuru days. Your synthesis of oft-neglected literature -- along with your well-earned road to recovery -- has given me hope. I am deeply thankful for your work.

    I was curious if you ever contacted the authors of the studies you cite in your book and on the website. I ask because I worked in science (yeast genetics; alas, not mammalian mechanobiology!) for a while, and what I do know is that scientists love talking about the theoretical implications of their work, particularly with curious, passionate, and intelligent people like yourself. I think both you and the researchers could gain a lot from starting -- or at least trying to start -- a dialogue. Not that I expect their work or your ideas to seep instantaneously into all physical therapy clinics. But it may just fuel the fire.

    Once again, thank you for your Herculean work!


    PS I have not been on KG in ages, but if you are interested in my story, my handle is SqshPlr8.

    1. Good to hear from you -- yes, I saw your posts under that handle on KneeGuru, and enjoyed your comments there. I'm banned from the KneeGuru site, so honestly I haven't been back -- or really even tried very hard to go back.

      Good question about contacting the authors of the studies. Yes, that has occurred to me -- not to contact them all, but one in particular: Flavia Cicuttini. She was involved with several studies I found interesting, including the one that discovered a surprisingly high rate of cartilage defects that naturally got better. I planned to e-mail her after I got a big-name publisher for the book, maybe to ask her to review a few chapters, then never got that big-name publisher and scaled back my plans and quietly put out Saving My Knees on myself. However I still may reach out to her with questions. If I do, I'll report back with what she says.