Saturday, February 25, 2012

On Getting Comfortable With the Time Frame for Healing Bad Knees

The New Yorker recently ran a short piece in the front of the magazine entitled "Countdown." The theme was unpredictability, but I took away a different message.

In 1927, we are told, a physics professor in Australia by the name of Thomas Parnell set up an experiment to demonstrate how viscous a fluid can be. "He poured hot pitch into a glass funnel, let it cool, then waited."

And waited.

And waited.

Eight years later, a drop fell. Nine more years passed before the second drop. All in all, there have been eight drops at an average interval of ten years. It takes very little time for a drop to descend: about one-tenth of a second. No one has actually seen one falling.

Sometime in 2013, the ninth drop of pitch is expected. Then, after it falls, there will be a good decade of waiting until the next one.

How's that for slow?

Still, what I found most interesting about the experiment wasn't how long it takes for a drop of pitch to separate out from the mass it's a part of. Rather, it was the idea that pitch -- like a pair of bad knees -- has its own scale of time on which it changes. Someone who failed to appreciate this might have packed up the pitch experiment after five or six years, deeming it a failure.

Similarly, in nursing my knees back to health, I realized the importance of "cartilage time." Some readers of Saving My Knees may naively interpret this term simply as advice to "be patient." The truth is, "cartilage time" is something more subtle.

It's a recognition that your treatment plan must be based on the right time scale -- the time scale for what you're trying to heal. How long is that, for cartilage and soft tissues inside a joint? What I found: Not days. Not weeks. But many months, or even years.

What happens when your expectations aren't "in sync" with this reality? For one, you get frustrated. For example, suppose you go to a physical therapist and are told, to heal your grumbling knees, you must strengthen your quadriceps and other muscles. So you embark on a muscle-strengthening program.

Many frustrations may follow (partly because you're focused on strengthening the wrong thing). But one reason you'll be unhappy after a couple of months (when your knees feel no better) is because you mistakenly expect to improve on a muscle-strengthening schedule (which is over weeks, or a few months). Actually you need to adjust your expectations to a much longer time frame.

Getting the time scale wrong can be an incredible source of frustration. Early on in my struggle, my knees would feel a little better one week, a little worse the next. That proved maddening. I felt lost. Was there never going to be an end to this misery?

But when I realized I wasn't going to recover in a few weeks -- or even a few months -- my outlook changed. I made my peace with the fact it was going to take a while. I became more patient. My program to heal became more gradual. And that was a good thing.

Friday, February 17, 2012

Arthritic Knees Are in Constant State of Repair, Study Finds

Just call this "Good News February."

A couple of weeks ago, I ran a success story from Ron, who credited his recovery to the same approach that helped me heal.

Of course, much of the medical profession still seems to doubt that bad knees can repair themselves. This pessimism, not surprisingly, has resulted in a prevailing treatment regimen that emphasizes stretching and strengthening muscles, to prevent bad knees from getting worse. Oddly absent from the protocol: activities designed specifically to strengthen the knee.

But what if bad knees can repair themselves? Ah, then the game changes completely (as I've said many times). Then you probably need a plan that, at least broadly, resembles what I did to heal.

Well, check this out, hot off the press (my bold):
Researchers at Duke University Medical Center used new tools they developed to analyze knees and hips and discovered that osteoarthritic knee joints are in a constant state of repair, while hip joints are not.

"This suggests the knee has capacity for repair we didn't know about and the main treatment strategy probably would need to focus on turning off the breakdown of knee tissue," said Virginia Kraus, MD, PhD, professor of Rheumatology and Immunology at Duke. "I was hugely surprised to find this."
Maybe Kraus was hugely surprised. I'm not at all. This is the driving idea behind Saving My Knees -- your knees stand a good chance of healing if you do the right things and are very patient -- and there are medical studies over the last decade that show why (which Kraus may be unfamiliar with, but others of us know about).

The article on the Duke University web site goes on to note:
Perhaps the natural repair response would be sufficient to lead to a reversal or halting of the disease process in the knee if the joint breakdown could be halted, Kraus said.
Note the language is carefully couched -- "perhaps ... would be sufficient ... reversal or halting of the disease process." But I can assure you, from having parsed plenty of medical studies, that all researchers speak with this same abundance of caution. My own experience was that "the natural repair response is sufficient to lead to a reversal of the disease process in the knee" -- because my conviction is that I was in the early stages of a bad disease process that I managed to turn around.

All in all, I was happy with this article, except for this part:
The knee is very accessible for injections, so it would make sense to inject the knee with agents that could turn off the degradative processes, and these could be delivered periodically with close monitoring, Kraus said. "That seems like a very viable strategy."
Argh. (That sound you hear is me banging my head against a wall.)

Somehow we've gone from "the knee has a naturally robust repair response" to "what artificial agents can we inject into the joint?" What's frightening is I don't think Kraus even realizes the irony. Maybe, on a deeper level, her strategy of choice just reflects the times we live in -- when there's a problem, we immediately seek to harness our superior technological knowledge in service of a solution.

But do we really need to inject foreign substances into our knees to "turn off the degradative processes," as if these processes are biochemical toggle switches waiting for the right substance to float by to trigger a shutdown?

I really don't think so (and to explain in depth why I think this is a flawed approach would take another blog-length entry). Let me just observe: I had destructive chronic inflammation in both my knees. I managed to turn it off without jabbing a needle into the joint capsule.

How? The simple version: I focused on stopping activities that my knees didn't like, and weren't strong enough for (such as periods of bent-leg sitting) and starting activities that my joints craved (lots of gentle motion), and on strengthening my knees over time.

And guess what? My body apparently figured out how to flip that biochemical toggle switch on its own. Which is really the best way to go, if you ask me.

Friday, February 10, 2012

My "Radical" Discovery About How to Beat Knee Pain

Sometimes I imagine what this blog must look like to someone who has stumbled upon it by accident, maybe after a long afternoon chasing hyperlinks, trying to figure out: Why do my knees hurt? How do I fix them?

And occasionally, I like to write something specifically for this first-time visitor whose head is spinning from all the advice and information he/she has been absorbing.

So this visitor arrives at a blog called "Saving My Knees" and wants to know: What does this guy believe in? What makes him different from everyone else out there, with all their theories and ideas and suggestions? What's his magic prescription for healing?

Well, at heart I believe in something so simple it's practically radical:

When you have knee pain, the problem you should focus on -- believe it or not -- is your knees.

Not your quads. Or your hips. Or your glutes.

Not the fact that your hamstrings aren't too flexible, so might they need to be stretched? Not your VMO muscle, which you think may be too weak. Not your iliotibial band, which seems tight.

If you want to heal bad knees, you need a plan that puts those knees front and center.

I'm not sure at what point in history doctors and physical therapists began going down the other path, of trying to heal bad knees by focusing on things that are non-knee -- or things that are knee (slightly mistracking patella) that usually don't matter much.

That philosophy is known as structuralism. While the idea that misalignment is the root of all evil has a superficial, intuitive appeal, I'm skeptical that it applies for most knee pain sufferers. In many cases, I'm convinced, knees go bad just because of injury or good old-fashioned wear and tear or some combination of the two, seasoned with time and inactivity (or foolish activity).

In which case the million-dollar question becomes: How do you treat knees as opposed to the many surrounding muscles that you've been told to stretch and strengthen and massage and whatever?

My experience: Low load, high repetition. Making very, very slow gains -- and building on those. Monitoring your knees very closely. Resigning yourself to what is probably a multi-year healing process.

Here's a little more about how I did it:

What I Did to Save My Knees

Saturday, February 4, 2012

Another Success Story to Brighten Your Day

Fishing through the blog's comment section each week, I never know what I'll find. Usually it's a complaint about balky knees or a plea for advice. But sometimes it's a jewel -- a success story -- and one recently got me excited enough to burst in upon my wife and 2-year-old daughter, while they were taking a bath, to tell Congyu, "Honey, listen to this."

Here's the longish story -- in full -- from someone named Ron. I'll return at the end to comment on a few things:
I wanted to let you know that I have runners knee and I am 56 years old. I have had the signs of it for about 5 years. In the beginning I can remember the movie goer stiffness. I did not know at the time what it was. I had to stop running over 2 years ago do to the pain in my left knee that seemed to come out of no where at the time. After I stopped running I figured out what I had, self diagnosis, Runners Knee.

So I did the exercises, foam roller and stretching. Sources were youtube and others on the internet. I was thinking I was getting better so I went for a run about 6 month's later. I ran about 1 1/2 miles and limped/walked for the last 1/2 mile. I was nearly on crunches the next day and it took about a week to walk normal.

At this time I decided to see a doctor and get the knee fixed. I was not getting any where. The doctor took x-rays and said the cartilage looks remarkably well and conferred with me on the runners knee diagnosis. He gave me a prescription for physical therapy. I'm thinking wow the professionals are going to fit it. They looked at the knee and did not see anything unusual. Next they iced, massaged, stretched, exercised and ultra sounded it. After 2 months of this and no improvement I got a second opinion from a orthopedic surgeon with great recommendations.

He looked at my knee and the X-Ray of it. He then had me do a couple of things and felt around and told me I had runners knee and told me to take Ibuprofen for the pain if I wanted to run. He spent about 5-10 minutes on me.

Afterwards I decided I to quit the therapy after 2 months of it. I worked on the exercises the therapist had me doing and iced a lot. Guess what after another 2-3 months no help. My knee was no better off. IT would swell if I did to much on it or had a sudden jolt like slipping on the ice or tripping and catching my self on the bad leg. I was getting bummed.

I started looking for the magic bullet on the internet, hours and hours. I finally ran across the Runners Bible, I think I paid $70.00 for it. I was desperate. I started doing the exercises, total gym mainly. Thousands of repetitions. I also gave up all the recommend exercises from the therapist. No help in first month.

I seen your kindle book. I was on the see saw about buying it. Finally I bought it. As I read the book I'm waiting for your magic bullet to fix the knee. When I finished and there was no magic bullet! I was disappointed. But the more I thought about the studies you presented and how you cured yours, eureka the light bulb went off. Its up to me to get well. I needed to move and monitor and be in the Goldie locks zone(runners bible)to heal.

Well I am a over achiever when it comes to exercising. I must have set my self back a dozen or times by over doing it. I did not keep a dairy, but had to remember several times at what I did to cause the pain a day after it happened. The pain is delayed like you said.

Walking has done the most for me. I walk our dog 2 miles every night. I have a desk job, but I will get up and walk around if I sit for a long period. I also ride my bicycle some. I have pushed to hard in the knee strengthening areas and set myself back many times. I finally got it through my thick head to back off and gradually increase the weight and volume. Slower than paint drying like you said in you book, I would say much slower than that even.

I am not cured but I am starting to run a little and am really working both legs out hard with no pain or swelling. I'm expecting to enter a 5 K in June. 2 1/2 years after I had to stop running. I have to give your book and also the Runners bible credit for my healing. I Gotta thank GOD too. I prayed a lot...:)

If I had to give anyone advice I would say create a knee dairy(I did not),get a pedometer and walk a lot also be perceptive about what causes pain and gradually increase or maintain exercise level. When in pain rest but keep the knee moving some, Know your limits and don't be a man to the point it sets you back in your progress.
(1) The first impression an unknowing reader takes from this is: "Wow, this guy really went through the mill." But if that reader has sought treatment for Runner's Knee (or chondromalacia, or patellofemoral pain syndrome), that initial reaction is probably closer to, "That sounds about right."

Because the exasperating experience above, I'm willing to bet, closely tracks what millions of other have gone through. In some significant ways it mirrors my own frustrations (they tried ultrasound on me too and one of my doctors also thought my cartilage looked good, according to an X-ray -- but a regular X-ray can't even see cartilage; the tissue's presence (or absence) is simply implied by the distance between bones!)

(2) Finally Ron gets on the right path (with Doug Kelsey's The Runner's Knee Bible, and I'm proud to say, an assist from Saving My Knees). And he's getting ready to run a 5K in June. Which is how long after he had to stop running? A few weeks? A few months?

Nope. Two and a half years.

Which is why I think it's so important for people to rethink their time horizon for healing. Get on cartilage time, as I say. If you expect to be back competing in your favorite sport after a few months, you're setting yourself up for disappointment.

(3) Setbacks, setbacks, setbacks.

Healing is not smooth. Healing is not linear. Every week will not necessarily be better than the preceding one. You will screw up -- I guarantee it -- and your knees will let you know when you do.

If you're smart, you'll learn from the setbacks. If you're not, you'll shrug and say to yourself, "I guess my knees will never get better." And if that's your approach, guess what? They won't.

It's very hard to stay within what Doug Kelsey calls "The Goldilocks Zone" (I refer to the same thing as the "sweet spot" of movement -- not too much and not too little -- and have seen it referred to more technically as the "functional envelope.") Nobody hands you a manual that says, "Right now your knees can do x steps daily, then you should increase that by 1,000 steps every two weeks." You have to figure that out.

(4) Why do you have to work so hard?

Well, look at Ron's experience with the orthopedic surgeon who came with "great recommendations." He spent 5 to 10 minutes on Ron and recommended Ibuprofen (an over-the-counter anti-inflammatory) to combat the pain from running. First, setting aside whether trying to run through pain by using medication makes sense (I would say no, no, and no again), look at that number -- 10 minutes -- and really think that over.

How much time is 10 minutes? That's about the length of a coffee break or a water cooler chat about the Super Bowl.

Now, I don't mean to denigrate surgeons. They have hard jobs and see a lot of patients. But in 10 minutes even the most brilliant surgeon can't extract enough information to understand the complexities of what's going on with your knees -- and these complexities hold the key to your getting better.

What a good surgeon will do: inspect the joint, bend your knee, and ask you "Does this hurt? What about this?" as he probes. But once he determines there isn't an obvious overlooked problem, and you really do have the kind of nagging knee pain common to cartilage damage, he's gonna kind of shrug.

What else can he do?

Once the damage is bad enough, and you need some kind of surgery just to make life tolerable, he figures he'll see you again.

Again: this isn't meant to be an indictment of surgeons. Because at this point, a surgeon isn't who you need anyway. You really need two people on your case. One is a smart physical therapist who believes that knees can heal (not just that muscles can get stronger), and knows how. The other -- more important -- is yourself.

P.S. I'll throw open the comment section below to Ron and others who want to ask him questions (assuming Ron checks in regularly, and I think he does). People always want to know more about success stories. All yours, Ron!