Saturday, March 3, 2012

Of Breakdown Points and Discontinuities in Healing, Part I

Now for something completely different.

During the many months when I had no job, when my sole focus was on fixing a pair of bad knees -- could it really be done? -- I did a lot of thinking. Not surprisingly, much of it was about damaged knees. My internal dialogues became more interesting when I realized my personal experiment was succeeding -- I was getting better -- even after a doctor (and not any doctor, but the best of the four I had seen) told me my knees were a lost cause.

At that point I could stand back (in a metaphorical sense) and survey the long timeline of my recovery. And one thing that struck me as curious was how incredibly lumpy it was, even though I was steadfast, meticulous, careful, diligent.

There were ups. And downs. All over the place.

So I began pondering more deeply what was going on with wear-and-tear injuries, and the long-term healing process, and I had the following thoughts:


Say there's an old country bridge over a river with a five-ton weight limit, and the limit is absolutely, precisely real. And say a dedication ceremony for a park on the river's north bank is held on the bridge, because of the astonishing scenic view from there. Dignitaries and various paraphernalia are packed onto the structure.

Soon the bridge is supporting 9,999 pounds, but no one appears worried. Indeed, it seems stable. Then someone remembers a two-pound cake he forgot and rushes off, then returns with it.

And the bridge collapses.

Or consider a ceramic cup that's held x inches off the ground. If you drop it, you've got a dirty cup -- but nothing worse. Hold the same cup x + 4 inches off the ground, drop it, and you've got pieces of a cup.

So there's a point at which an object or structure breaks. When it does, it undergoes a significant change of state -- in the case of the cup, from "whole" to "pieces."

What's happening at the pre-breakdown point? What's the bridge like, a few pounds shy of its weight limit, or what's the condition of the cup on impact when dropped from x inches, not x + 4? Outwardly, either appears fine. However, both may be very stressed internally. Further, the unseen stresses may contribute to an overall weakening of either (next time you drop the cup at x inches, it may break instead of just getting dirty).


What I think is a fascinating paradox lies at the heart of these observations:

(1) Small factors can have huge consequences (a two-pound cake causes a bridge to collapse).

(2) Small factors don't really have huge consequences (that two-pound cake becomes a problem only if you've unwisely loaded the bridge with 9,999 pounds of other stuff).

Our knees are structures, of a biological sort (the distinction is important, because they're not brittle, in the same way a concrete bridge is, and they have a capacity for self-repair, but I still think the analogy broadly holds).

If you have a wear-and-tear or overuse injury that results in knee pain (as opposed to having knee pain from a sudden, traumatic accident), there is probably a crossover point where your joint goes from being extremely stressed with no pain to being extremely stressed with pain. It could be a slender crossover point, that is covered quickly, leaving you suddenly wondering, "Why do my knees hurt today? What did I do wrong? What should I do now?"


Okay, here's the point of these musings:

To me the idea of breakdown points, and the central paradox of them (outlined above), suggests that many of us suffer two delusions early on with knee pain.

(1) Delusion #1: "I must be in pain because of that hike (or whatever) yesterday, so I'll just take it easy for a week or two, and I'll feel better."

So you blame a proximate cause for the breakdown. But that's like saying the two-pound cake brought down the bridge. It did, but it really didn't when you look at the larger picture.

Based on this delusion, you reason that a week or two will suffice to fix a sore knee. This is a short-term fix to a long-term problem. It usually doesn't work.

The problem is, you've deluded yourself into thinking the problem is smaller than it is. Why? Because, during the preceding months, when your joint was being quietly stressed and damaged in small ways, you still hadn't hit that breakdown point and crossed the pain threshhold, so you never realized how close to trouble you were.

(2) Delusion #2: If you're lucky enough that your knees do feel better in a few weeks, you think, "Phew! They healed. Glad that's over!"

But what if you just crossed that threshhold from pain to no pain in a small way, and the truth is the accumulated defects and stresses in the joints are just waiting to cause more problems? Two months later, you feel pain and say, "Darn, my knees again."

But it's not again. It's the same problem as before. Instead of trying to fix it with a long-term plan, you hoped it would go away. And now it's back.

Part II (in a few weeks -- I'm off to Florida on vacation next week ;)) will look at the mirror image of this concept. If there are such things as breakdown points with our knees, might there also be "mending points"? If so, what implication does that have for the healing process?


  1. I will share my story as briefly as possible. At 31 I was diagnosed with Stage 3 breast cancer. This is important because of the treatment I received: chemotherapy, a total hysterectomy at the age of 34 (which is not good for bone health), and daily doses of arimidex, an anti-cancer drug for post-menopausal women which the side effects of increased joint pain.
    I used to be a runner. I would run 5-9 miles, even though every time I ran it was painful. I had to give up running completely once my runs were leaving me unable to walk afterwards.
    So, I took up walking long distances. It wasn't long before that form of exercise took its toll and I had to quit for the same reasons that forced me to give up running.
    Over the years I have seen many doctors. Osteoarthritis is the agreed upon diagnosis. Many times I’ve been tested for Rheumatoid Arthritis, but the blood work has always been negative.
    A few years ago I started cycling. I was immediately hooked. I signed myself and my husband up to ride in a fundraising ride, the Tour de Pink, which supports young women with breast cancer. I loved training for it and loved riding the three day, 220+ mile ride even more. My knees hurt, but ibuprofen, ice packs, and the infrequent cortisone injection helped. I rode again the next year and the year after that. But each year has been more difficult. This year was the worst. My training was difficult and unenjoyable, even though I focused solely on keeping a high cadence to reduce the stress on my knee. Every ride left my knee swollen and painful. Often the inflammation was so bad that my entire leg would swell, and the pain would keep me awake at night.
    My doctor found that my joint is so bad that I developed a bone spur under the side of my kneecap. I underwent a series of injections with cortisone plus a synthetic compound that is supposed to lubricate the joint. It didn't help.
    Due to inflammation in other joints AND the fact that my knee will swell to monstrous proportions with no activity, my Rheumatologist again tested me for RA, with the same result: negative. She put me on a trial of steroids to see if they helped with the inflammation. They did, and I felt fabulous. This confirmed that I have Psoriatic Arthritis (another auto-immune arthritis similar to RA for which there is no diagnostic test.) I am on a trial of low dose Methotrexate...unfortunately any improvement won't be seen for months.
    I have been taking it easy in the off season. I have my bike on a trainer and I work on spinning at a high cadence (trying to stay around 90 RPMs). Unfortunately even spinning hurts, although much less than if I was not: I am pretty sure this is due to the bone spur. I work largely behind a desk. My office is on the 2nd floor with no elevator: just a steep flight of stairs. OUr house has two sets of stairs. I constantly beg my husband to sell so we can live on one floor. My doctor doesn't want to do any surgery because I’m only 43. Thankfully, he supports my cycling as it is "the best exercise for bad knees". His prescription: cycling at a high RPM, cortisone injections to relieve pain and reduce inflammation and swelling every three months, working with the Rheumatologist, and well, coping.
    I am in some pain all of the time. It makes me depressed and grumpy. I know there is no quick fix, but I refuse to be an inactive blob. I am wondering if I need to pursue surgery just to remove the bone spur on my kneecap. If you have any experience or insight on this, I would love to hear it.

  2. I read your book and am now embarking on a program of low load, high rep exercise. To do this I had to reframe my entire concept of exercise. I've always though of exercise as something to burn calories and/or build muscle and aerobic conditioning. Low load/high rep does neither but you make a strong case for how it can promote knee cartilage regrowth.

    I didn't get to this point through overtraining injury like you. Instead I got to it by walking incorrectly for decades, made worse or caused by feet as flat as a sheet of paper.

    I had two wakeup calls and ignored them both, or at least didn't know what to do about them.

    The first was when my husband and I were dating. He used to tease me about the way I walked. He said it looked like a cartoon character walking. In retrospect, a walk that is comical like a cartoon character is inevitably putting strain on joints.

    The second was when my feet started to really hurt. I went to a podiatrist. Plantar fasciitis. He had me walk up and down the hall. He said I walked like an elephant-putting all my weight right in the middle of my foot where there was no arch. Elephants can do that because their feet are circular. He said I should be walking heel to toe and also made custom orthotics for me. For a time I practised walking heel to toe but the orthotics felt so good and in a couple months my plantar fasciitis went away and I stopped being conscious of my walk.

    So for many years after that I walked incorrectly but on orthotics so no plantar fasciitis. Then the knee pain crept in. Since I never really corrected my walk (except for a couple weeks), the shock got transferred up to my knees and that damaged them over the years. So said my doctor.

    Then I went the same route as you of exercises to build up leg muscles that support the knee. Oddly, there was no mention of correcting my walk. Only the podiatrist pointed that out.

    My knees hurt more and more. I started using my hands to support my weight going up and down stairs and getting up out of chairs and got tendonitis in my wrists- a compensation injury similar to yours. I googled around for help and found your e-book and got it. You seem to be the only one who talks at length about compensation injuries that come from prolonged use of coping strategies.

    So now I will abandon the heavy leg weight exercises and walk and use the exercycle (which I can do since I didn't get this cycling). I am also committed to walking correctly heel to toe all the time, not like a cartoon elephant, so this can finally heal. Wish me luck.

  3. Thanks for writing! You conjure up a vivid image with the "cartoon elephant" description -- though I'm sure your walking is not really that comical. :)

    Yes, you are rethinking the concept of exercise, but what you need to do right now isn't really exercise, right? You need to heal a couple of bad knees, then you can go back to the hard, aerobic exercise you like (if you want to). When I talk about what I did to get better, sometimes I avoid the word "exercise" -- it's such a loaded word, with connotations of gyms and thrusting plates of weights in the air -- and just say "movement". Not as sexy, but probably more accurate.

    On plantar fasciitis, Doug Kelsey has a great piece on this, about how people get the story wrong with this condition, and that's why it's often hard to heal from the problem:

    Best of luck! Check back in later and let us all know how you're doing with the cycling program!