Sunday, June 3, 2012

Three Reasons Why “Let Pain Be Your Guide” Can Be Bad Advice

At first I was going to title this “Three Reasons Why ‘Let Pain be Your Guide’ Is Bad Advice.” But, although provocative, that title is rather misleading. You do need to listen to those pain signals coming from your knees and react smartly to them.

So what am I objecting to now? This, in a nutshell: The all-too-hasty examination of a bad knee (or knees) by a medical professional, who concludes with some breezy advice to be careful and “let pain be your guide.”

What’s wrong with that?

* If pain is all you know, it’s probably dead-end advice.

Think about it. Your knees always hurt. You try to minimize the pain (“Let pain be your guide”) by using them less. Before you know it, you’re caught in a death spiral.

The death spiral goes like this: 1. Your knees hurt so you move them less. 2. Because you move them less, over time, they hurt even more.

Now, go back to #1 and repeat the cycle, ad nauseam, until you have a pair of completely wrecked joints.

What can you do if you do hurt all the time? There are ways to move a lot without over-stressing your knees, as I discuss here.

* The advice needs to be more nuanced, to account for the delayed symptom effect.

Knee cartilage has no nerves. When I discovered this, I remember thinking, “Wow. That’s huge.” Indeed, it’s very, very significant for a number of reasons.

One of them: You can overstress and damage knee cartilage and not even know it until sometime later.

Here’s a real-life example (from my own experience): You move a heavy object, such as a pedestal fan, down a couple of flights of stairs. Your knees feel okay at the time. Two days later, you’re out casually strolling and you notice one of your knees is aching.

“Let pain be your guide” suggests that the casual strolling is the activity that should be curtailed (to be fair, you probably do want to take it easy on your walk, even if it didn’t cause the problem). You felt no pain while carrying that fan down the stairs, right?

But when you have bad cartilage, and it’s overstressed, symptoms can take a day or even two to appear.

So, in this example, you run the risk of learning the wrong lesson. Instead of resolving not to carry heavy objects on the stairs until your knees get stronger, you decide your joints can’t handle easy walking.

* The advice needs to be more nuanced, to make more-subtle distinctions.

One thing I learned from battling knee pain: your joints will throw off lots of different sensations. Sure, there’s outright pain, but you need to be able to parse all the sub-pain signals, because some of them indicate that pain, while not present, will be soon if you don’t change what you’re doing.

So, instead of “Let pain be your guide,” I’d suggest “Let sensations from your knees be your guide.” I can imagine someone reading that sentence and rolling his or her eyes. How is that any more helpful?

Well, it isn’t and it is.

Because the next step involves doing some work. You need to figure out what various signals from your particular knees mean. There’s only so much you can learn by studying medical articles about how the knee works and how pain and discomfort arise from damage to cartilage and soft tissue.

Those are general guides. You have a pair of specific knees, with specific problems that will result in an array of weird tinglings and sensations. You need to understand what they all mean. You have to learn the language of “knee,” as it applies to your knees.

If you really do follow “Let pain be your guide,” in a simple way, you’ll probably make the same unfortunate discovery I did. By the time you’re in pain, it’s already too late. You screwed up. You went backward. You need to figure out how to gradually work your way out of pain -- and then, once there, stay there.


  1. I have been following your blog and have read your book, they are great! I recently had a snyovectomy/chrondoplasty on my right knee, and now my left knee has synovitis. I am youngish and slender and don't fit the typical profile for having such bad knees. I really want to avoid another surgery, and am thinking about how long I should give my left knee to heal. You have mentioned that cartilage healing time is very slow. Do you think the same very slow healing timeline applies to soft tissue inflammation like synovitis? I have been told that the body cannot always get rid of synovitis because it is tissue that has physically grown, and that the only way to resolve the inflammation is to surgially remove it. It is hard to know how true this is.

  2. Thanks for the kind words. I don't really know much about synovitis, but it's inflammation of the synovium, right? First, are you sure the tissue has physically grown? Has a doctor seen (on some kind of scan) or otherwise detected evidence of this? Now, if you've just got inflammation, the question is, what's causing the inflammation? Cartilage degradation isn't painful until fragments of the tissue ... reach a nerve-rich environment, such as the synovium. Could that be causing it? If I were you, I'd want (a) more than one doctor agreeing that my problem was synovitis (b) speculation about what was causing the synovitis.

    If I say you've got headache-itis, for instance, that diagnosis is of limited utility if it just means you get lots of headaches. You need to know what's causing the headaches. As for how long it will take to cure -- I would think that all depends on what's causing it, but it probably won't be quick.

  3. Thanks for the advice. You are correct that synovitis is inflammation of the synovium. I have had many tests run and the docs have not been able to figure out why both knees have synovitis. I have been seeing my "second opinion" knee doctor now for a while but I think your idea is a good one about getting a second opinion as I have not seen another knee doctor in quite a while. Just as an interesting tidbit, I have been having led light therapy at a physical therapy office and it may be having a gentle positive effect on my left knee. Through all my knee research I hadn't heard about light therapy until very recently. Not alot of physcial therapy offices have the machine, but some do.

  4. I love your book and I'm reading through your blogs now. I'm 44, weigh 119 lbs, and hurt my knees running marathons 6 yrs ago. Thank you so much for helping the rest of us! You've mentioned "pushing the envelope" and I'd like to know how to plan my recovery. Do you suggest increasing the # of steps by a certain amt/% each week? I feel lost in knowing what to do - I would like a plan. I wear a pedometer and it's showing my daily steps are around 10,000. That seems like a lot compared to what you've mentioned. I don't feel any better (I'm in discomfort all day) but also not worse - you've said that is ok, right? Or should I do less steps until I feel better and then increase my steps? How does one know how to "push the envelope" without causing further harm? Thanks!!! Theresa