Saturday, April 14, 2012

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. :)


  1. Hi Richard. Thank you so much for your book. In time, I'll share my entire story with you. But for now, know I too was diagnosed with the bogus patellofemoral pain syndrome for the past year. After reading your book, I began riding my bike religiously to work over the past four months, and I've noticed a huge improvement.

    You state you're back to riding your bike as strong as prior to your knee incident. May I ask, what are you doing differently now so your knee pain doesn't repeat?

    I'm also curious why you haven't followed up with a second MRI to quantify your improvement? With your cult following, it seems this would be very beneficial.

    Thx, -Erik

  2. That's great, Erik, and I'm glad you're having success on the bike.

    What am I doing differently on my bike? In short: (1) I ALWAYS keep my knees covered in cold or even cool weather (below 60 degrees) (2) I always warm up slowly. (3) I try harder to stay hydrated while riding. (4) I take each winter off (4 months) and focus on doing easy base miles on a stationary bike.

    Why no second MRI? Many reasons really, including: (1) These tests cost $1,000. (2) The MRI I had done I don't think even caught the worst of my knee problems, because it was performed in September of 2007 (I didn't quit work until almost 7 months later, and during that period, I did the disastrous weightlifting that really set me back, and I'm quite sure, caused more damage (3) The MRI isn't even really a dependable test for knee pain -- remember, my original MRI said I had mild chondromalacia. It wouldn't surprise me if I had a new MRI and it too said I had mild chondro.

    The big difference is I feel 100% better, and that's all that matters. The bottom line is you want to feel better. If you do, who cares what the tests show?

    1. So you're not riding quite as hard/often as you were previous to injuring your knees. But I agree you've made a significant recovery and that gives me hope!

      Agree the goal is to feel better and not much else matters. My MRI was taken at the height of my pain and may be a better metric than yours due to timing. So I plan on paying the $1k (unless my doc agrees to submit for insurance) for the second MRI if my pain eventually completely goes away. I'll keep you in the loop for sure.


  3. I'm riding as hard as I ever did (after I warm up), but I'm not riding year-round (it would be hard anyway, because of the Northeast winters). Sure, definitely keep in touch! I'm interested in how your case turns out. I think biking is a great knee-friendly activity, if you do it right.

    1. Just an update, sir. I'm up to eight months of riding. This past couple weeks my knee really seems to be making progress. I even completed two hikes this of them consisted of 10 miles over 1k ft elevation gain. My knee was a little sore towards the end of that hike but felt great the remainder of the week. I'm still taking it easy, but am very excited! Sorry I have yet to post my full story. -Erik