Of Breakdown Points and Discontinuities in Healing, Pt. II

At last, I get around to finishing this post.

In Part I, I looked at the concept of a breakdown point and the implications for knee pain sufferers. In an example I gave, a two-pound cake triggers the collapse of a bridge with a five-ton weight limit. But is the cake really to blame, and what mistakes do we make by focusing too much on proximate reasons for knee pain that has been setting up in our joints for a long time?

Today is the curious mirror image of that discussion, the movie reel played backward, if you will. In one direction, the bridge falls apart into hundreds of chunks, while in reverse, the pieces knit back together to form an intact whole again.

Crazy stuff, as applied to bridges, certainly.

But a living, biological structure has the capacity to heal. So might there be points -- call them “mending points” -- where healing suddenly seems to accelerate? As a bridge has a catastrophic moment when it crumbles -- and your knees have a point when they lurch from highly stressed with no pain to highly stressed with pain -- might there be a healing point, or points even, when you feel considerably better than you’d expect from the preceding day?

And what does this tell us about what to expect during the healing process?

Well, here’s a scenario: You seem to be stuck in a rut for two or three months. You’re doing all the right “smart knee” things. But you don’t think you’re getting better -- or much better. Then, one day, you wake up  and your knees feel much improved. It’s like you went from being a “4” to a “7” overnight.

A DANGEROUS JUNCTURE

Chances are, you’re actually at a very dangerous point in your recovery. You may be delirious with joy, thinking, “What’ll I do to celebrate? Go for a run? Climb a mountain?” But if the theory I’ve outlined here is true, your gains are fragile indeed. You haven’t healed. You’ve merely taken a step toward healing. You have to focus on “locking in your gains,” you might say.

The idea of mending points might help explain one thing: why healing damaged knees is so hard.

Just as you might be tempted to blame the two-pound cake for taking down the bridge with a five-ton weight limit, in trying to figure out why you feel better, you might also tend to overcredit recent activities. You might falsely attribute your improvement to the lakeside stroll you took two days ago, when in truth, the healing has been a slow, cumulative process that you didn’t notice until you reached a “mending point.”

What’s unfortunate is that, if this is indeed how long-term healing happens, our effort to link cause-and-effect becomes that much more complicated. As I’ve noted repeatedly, it’s hard to make definitive cause-and-effect linkages when analyzing knee pain, because cartilage has no nerve endings, so symptoms are often delayed. If healing is lumpy and non-linear as well, that makes charting a path to recovery -- and staying on it -- hard.

Still, it can be done. It's just good knowing the challenges going in. :)

Using Creativity to Solve Problems

A couple of weeks ago, I had a breakthrough with an Excel problem I had been trying in vain to solve. The problem went like this: Anytime a value in column S equals “true,” launch a message box warning that a duplicate ID exists in the spreadsheet. Unfortunately, because the contents of column S were the result of an embedded formula, there were complications.

All my potential solutions were taking me deeper into the swamp of having to program in Visual Basic. I was once a computer science teacher, so programming doesn’t scare me, but doing so seemed like overkill in this case.

Then, finally, a realization -- I didn’t need a message box. At some point, early on, someone suggested using a message box for the warning, and that got stuck in my head. Once I abandoned that idea, I was able to widen my focus -- what was my objective? -- and then reattack the problem using different tools.

I then hit upon a solution (actually, it had been lying within Excel the whole time, waiting to be discovered!) rather quickly and, even though that Friday was a miserable day due to a head cold, I left the office with a great feeling of accomplishment.

That got me thinking about creativity, and my battle with chronic knee pain. Winning this battle demanded a lot of creativity, which requires opening your mind and daring to look at things in completely novel ways.

There’s a story I put in Saving My Knees, then took out in the editing process because (a) I was concerned it would sound like I was simply celebrating my own cleverness, which was not the point (b) it interrupted the flow of the larger narrative.

But here it is now:

After I quit my job in Hong Kong to focus full-time on healing my knees, I had a miserable summer. One reason had nothing to do with my joints: A particularly tenacious mold took over my apartment.

One place it flourished: the bathroom. In the bathroom, some months before, I had constructed toothbrush holders (there were none originally) out of cardboard tubes from toilet paper rolls, wrapped in duct tape. Yeah, kind of ugly, plus they turned out to be mold magnets.

So I set myself a challenge: How could I make new toothbrush holders (remember, I had no job and income at this point, but plenty of time on my hands). I would use only objects in my possession and would buy nothing.

So I started thinking. What would the optimal toothbrush holder look like? For one, it would be simple, as simple as possible -- no big, ugly rack hanging off the side of the medicine cabinet. For another, the wet head of the toothbrush would be exposed to air as much as possible, and so come into contact with as small a surface as possible. (With a typical toothbrush holder, the bristles sit right on the metal, leaving a whitish deposit after a few weeks.)

It took me a while to figure this one out. When I did, I was pleasantly surprised by how simple, elegant and effective the solution was. Which was? Adhesive-backed plastic hooks for hanging things, such as clothes. It looked sort of like this, but with a lip on the tip:

How do you hang a toothbrush from a hook?

You don’t. You rethink the hook.

When the hook is hung horizontally (on the underside of the medicine cabinet), not vertically, it can function differently. It’s easy to slide a toothbrush in there (head goes at the hook end). The brush just seems to dangle at an angle in the air. Cool looking, lots of air circulating around the head, surprisingly stable, and didn’t cost me a cent (I had extra hooks on hand).

Creativity also served me well in trying to heal my knees. I could mention a bunch of examples, but I’ll stick with one: How did I figure out a way to do hundreds of deep-knee bends at a time when my knees weren’t strong enough to handle the exercises at full body weight?

Hmm.

Bungee cords! I decided to use bungee cords to “unload” weight while doing the knee bends. I had to find pretty sturdy bungee cords (which I did at a marine supply store). I needed something to attach them to (a rock-climbing harness was perfect). And, it turned out, I discovered I needed a little padding here and there (pieces of foam I shaped to my purpose). The exercises I did in a garage, throwing the ends of the bungee cords over some overhead 2 x 4’s, then attaching them to my harness.

It worked! (And the exercises were kind of fun to do.) I didn’t end up doing them for long (my knees had already improved a lot by that point, and I was just trying to grab the last few gains to get back to normal), but I could’ve done my "bungee squats" for months, or even years, had I needed to. That happened to be the kind of exercise that makes sense for knee pain -- high repetition, low load.

So today's message is: Be creative. Dare to think outside the box!

Musings Over Criticism of My Latest Huffington Blog Post

Last week my second blog post about knee pain appeared on the Huffington Post: “When ‘Strengthen Your Quads’ Is Bad Advice for Beating Knee Pain.”

A few days after it went live, I was intrigued to find a couple of people discussing my case in the comment section. They seemed in agreement that I got lousy medical advice, but their thinking reminded me a lot of the Structuralists I got the lousy advice from. It felt like Structuralist A was saying Structuralist B did a terrible job, when my larger message was, “Hey, maybe the Structuralist approach, and its obsession with alignment and muscle strengthening, doesn’t make much sense in the first place.”

Being analyzed in absentia (I had a busy workweek, and was unable to reply for a few days), made me feel sort of like that character in the sitcom at his own funeral who’s listening to friends lament his passing, while he’s concealed behind a curtain. “Yoo hoo! Here I am!” So I jumped in the fray, finally, and was barraged with skepticism that I found interesting enough to want to address on my blog -- where my comments aren’t restricted to the 250 word limit that HuffPo imposes.

Below are the skeptical points in bold and my replies:

1. How can you be sure you had cartilage damage? And even if you did, how do you know yours caused your pain? Cartilage defects don’t always correlate well with pain.

True, they don’t always correlate. But it's worth noting that a standard definition of osteoarthritis is "joint inflammation that results from cartilage degeneration."

I was reasonably sure cartilage damage was causing my problems, based on the pronounced crepitus in my knees, an MRI, and the nature of my pain symptoms: diffuse burning (inflammation). Readers of Saving My Knees may recall how the tissue (which has no nerve endings) can lead to pain sensations. One way: fragments of soft cartilage flake off and migrate through the synovial fluid, then reach the nerve-rich synovium, then ouch! Another way: damaged cartilage fails to cushion the subchondral bone properly, such as when you’re sitting -- more ouch.

Might I have had some other issue causing the pain though? A weird inflammation disorder? Well, anything’s possible -- and I may have had a combination of issues -- but, curiously enough, my knees got quieter (less crepitus) when I improved. As for out-of-control inflammation, I did have a test for rheumatoid arthritis that showed no systemic inflammatory problems at all.

2. How do you know you healed though? How can you be sure, without a second MRI to compare against the first?

Well, I feel a whole hell of a lot better! :) My knees feel normal again.

Do I still have cartilage defects? Absolutely. But as I’ve constantly noted on this blog, you don’t have to be defect-free to regain a good life. Lots of people are pain-free with cartilage defects.

3. Still, you developed a treatment without getting a proper diagnosis. You need to know what’s wrong to fix it.

Exactly. Couldn’t agree more (see my first axiom of healing in my book: Before devising a plan to heal, you need to know what’s wrong and what’s causing it to be wrong.). But here’s the travesty: In my experience (and that of others, from what I’m hearing), orthopedic doctors faced with aching, grumbling knees don’t care about providing a proper diagnosis. For example, I was told I had patellofemoral pain syndrome.

But that’s not a real diagnosis! Patellofemoral pain syndrome says nothing about what’s really wrong with you. Patellofemoral pain syndrome just says you’ve got knee pain with certain symptoms.

I spent a lot of time on my own figuring out what was going on with my knees. After a lot of research (including reading Doug Kelsey, who’s terrific), an MRI, and a careful consideration of my symptoms, it seemed likely I had cartilage damage. I designed a treatment plan based on that assumption. And the plan worked.

4. Even so, your plan was just a shot in the dark. Without scientific studies to back up your methods, you really can’t say your approach can help anyone else.

Well, I would be surprised if my broad approach couldn’t help anyone else, or if the information I uncovered for my book really wasn’t beneficial. Because, when my knees began hurting, I did a Google search and my symptoms were classic for what was being called chondromalacia patellae or patellofemoral pain syndrome. It sure sounded like I was one of an unfortunately rather large group.

As for “shot in the dark,” that makes my treatment sound rather like eating ground-up newt eyeballs and baying to the moon in my underwear, hoping to heal. Listen to these two approaches to beating knee pain: (1) Strengthening muscles around the knee that somehow influence its motion, such as in your butt, which is a good 20 inches from your knee (2) Focusing on high repetitions of easy movement to directly strengthen the soft tissues in the knee.

One approach aims to fix the knee itself. The other aims to strengthen stuff in the vicinity of the knee (and presumably hopes the knee will come along for the ride). Which sounds more like a “shot in the dark” to you?

5. I’m still not convinced. There’s no proof your pain was caused by cartilage damage. There’s no proof your cartilage healed either.

I think there’ll be people skeptical of my story, no matter what I say. So let’s consider the possibility I’m wrong about the diagnosis and about healing having taken place. Let’s stick to the observable, provable fact set. Here it is:

A. I had chronic knee pain.

B. My symptoms were consistent with those of people suffering from what is called patellofemoral pain syndrome or chondromalacia.

C. My knees got worse under standard physical therapy, where my therapist prescribed muscle strengthening and focused on alignment issues.

D. My knees got better after a long and closely documented program to slowly strengthen the joints through easy, high-repetition motion.

E. Whether my knees are completely “healed” or not, they feel the same as before and I can do the same type of vigorous activities as before.

Seems like a story worth sharing to me. :)

Check Me Out on the Huffington Post!

Here's my latest over at Huffpo. I'll have more to say later about an interesting thread that has popped up in the comment section below the post ...