If You’re Resolved to Have Surgery or Medical Treatments, Here Are Options to Consider

I’m not a big fan of surgery for chronic knee pain, to put it mildly. Some procedures absolutely make me shudder (“lateral release,” e.g.). Others I imagine could be useful, in certain circumstances.

If I were desperate enough to seek a medical intervention, I’d favor something as natural as possible. That means a procedure that encourages my own body to turbocharge the healing process.

With that in mind, here are treatments worth looking at (Note: that’s not an endorsement of any of these, and anyone with knowledge of, or experience with, any of the following, please add your thoughts below). Also, important caveat: These procedures are more for problems with tendons and ligaments than cartilage, as far as I can tell.

(1) Prolotherapy

I was first introduced to this on Doug Kelsey’s (now defunct) blog, The View. As many of you know, I have tremendous respect for Kelsey, whose thinking about chronic knee pain greatly influenced me during my recovery.

Kelsey’s genius on matters of physical therapy probably derives in part, unfortunately, from his own misfortune -- he has a number of ailments, including a knee problem of his own. Anyway, he underwent prolotherapy.

My understanding is that the treatment involves a series of shots that cause an inflammatory response in the body’s tissues that spurs healing. It is painful, apparently! (Inflammation often is.)

(2) Injections of platelet-rich plasma

Scientific American took a look at this treatment almost three years ago (not the freshest information, but a decent place to start). A small vial of your blood is spun in a centrifuge to separate out the platelet-rich plasma, which is then injected into the injured tissue.

The theory behind why this should work: The injured areas, such as tendons, have a poor blood supply, so healing sometimes becomes difficult. The concentrated platelets in the plasma bolster the nutrients and growth factors at the site, aiding healing.

Notice the word “theory.” “PRP” has its skeptics. Still, the doctor in the Scientific American article said that, of his patients who have undergone it, maybe 60 percent have gotten better.

(3) Whatever Kobe Bryant had done

Bryant, of course, is the NBA superstar who plays for the Los Angeles Lakers. His right knee, under the kneecap, is missing so much cartilage that it’s practically bone on bone, he has said. He flew to Germany for treatments that apparently worked wonders, leading other athletes to make the pilgrimage to the same doctor, hoping for similar results.

What’s the procedure? Apparently it’s a more vampiric undertaking than PRP (“as much blood as they took the first day, I didn’t think I’d have any left,” said this patient). Again, the blood is centrifuged, but heated first, because the objective is to capture anti-inflammatory proteins, rather than platelets. The resulting orange serum is then injected into the ailing joint.

So there you have it. Three novel treatments worth a look (if you’re resolved to have some kind of treatment anyway). Anyone familiar with any of them, feel free to share your thoughts below.

The Importance of Setting Realistic Goals

Not long ago, a colleague at work turned to me and said, “I’m going to lose 20 pounds by July.”

I had a pretty good idea what was going on.

Most of us employees had signed up for free, company-provided health screenings. These consisted of a finger-prick blood test for cholesterol and glucose levels, a blood pressure check, and a weighing.

His weighing showed that a sedentary desk job and a fondness for pistachios had caught up with him. (Note: If you want to gain weight, just eat in front of your computer while working. You’ll enjoy the food less and eat more. I guarantee it.)

Losing a few pounds is certainly a laudable goal, especially when you find yourself on the wrong side of your ideal weight. But in his case, he had given himself two months to achieve something that most people would find extremely difficult to accomplish in six.

I remember expressing skepticism that he could lose so much weight so fast. Inside though, I was thinking something more like, “If you do lose 20 pounds in two months, I’ll eat my keyboard.”

About a week later, it was clear my keyboad would remain intact. I spied him gobbling pistachios again, the weight-loss resolution apparently a dim memory already.

When you set an unrealistic goal, I think you’re basically setting yourself up for failure. Further, failing at something is no fun, and just erodes your self-confidence.

With overcoming knee pain, this issue is particularly acute. That’s because the key bit of traditional advice for beating knee pain -- “strengthen your quads” -- mentally conditions you to expect a recovery on the wrong time scale.

Muscles strengthen relatively quickly. Knee joints don’t.

So, not knowing any better, you think: “I have chronic knee pain. If I strengthen my quad muscles, I can escape it. I’ll devote myself to a two- to three-month quad-strengthening routine. Then I’ll feel fine again!”

My bet is you won’t though. My bet is (if you really have chronic knee pain that’s been troublesome for a while), you’ll need six months. 9 months. 12 months. A year and a half. Two years.

But suppose you proceed with this unrealistic goal of healing in two or three months. After a month, when you realize you’re nowhere near being halfway healed, you may despair and think, “That’s it. There’s no way my bad knees can be fixed.”

So you give up, having decided you can’t reach a goal that was never realistic to begin with.

Of course your problems are really twofold. Your larger problem is arguably that you’re following the wrong path (focusing on strengthening muscles instead of the joint). Still, even if you get on the right path, chances are good you’ll flub your recovery if you begin with the promise of unrealistic expectations.

Why Many Knee Studies Are Seriously Flawed

I’ve cited many knee studies on this blog, usually to buttress some point I’m making.

But I’ve also come to the conclusion that a certain kind of knee study has to be approached with much caution. That’s because it suffers from serious and intrinsic flaws.

First, let me be clear what I’m not talking about: so-called “natural” studies that, instead of testing a hypothesis, look at say how knee cartilage changes over a two-year period, and how characteristics of subjects such as age and BMI influence those changes. (Fortunately, one of my favorite studies falls in this category: the two-year study by Australian researchers showing that, in a whopping 37 percent of subjects, a cartilage defect actually improved somewhere in their knee.)

The kind of study I'm talking about is more ambitious. It attempts to prove a link between some activity X and the health of your knees. And it suffers from serious limitations.

To see the issues, let’s create a fictitious study that has a sensible premise: it sets out to prove that walking benefits bad knees.

Researchers round up 600 subjects with knee pain and split them into three groups. Group A doesn’t walk at all for exercise, Group B walks 1-7 miles a week (as much as a mile a day), Group C walks more than 7 miles. And, to better capture long-term changes, the researchers decide to observe the subjects’ knee joints at the beginning and end of a 10-year period.

Okay, why is this study already in trouble, just by design?

(1) There’s no way to account for “category drift.”

Lives can change a lot over 10 years. A moderate walker may become a super walker -- or a nonwalker. Or someone may jump back and forth between these three categories quite a bit.

What if a moderate walker for nine years becomes a nonwalker in year 10 -- which happens to be the same year he’s surveyed by our researchers about his level of physical activity? If his joint health turns out to have improved, the results would be recorded under “Being a nonwalker is good for your knees.”

That makes no sense, because for 90 percent of the study’s duration he was a moderate walker!

(2) The big problem: Exercise is only a small part of how someone uses their knees in daily activities.

Consider this math: Let’s say you’re awake 16 hours a day. Let’s say you walk a mile a day for exercise and that takes 20 minutes (that’s a three-mile-an-hour pace -- not too demanding). So if you do the math, how much of each waking day are you exercising by walking?

Barely 2 percent.

Which raises the question -- what are your knees doing the other 98 percent of the time? This matters hugely! Because if "walking for exercise" is the variable that is being studied, then what's going on during the other 98 percent of the day is going to contribute to “variable pollution," contaminating the findings.

(Question to ponder: If subject A has a job where he walks several miles at work, but doesn’t walk for exercise, while subject B is deskbound but walks a mile a day for exercise -- who’s really doing more walking?)

(3) The study never makes adjustments for what level of activity (and type of activity) is appropriate for each particular subject.

Say Mary walks one mile a day, which puts her in the “moderate activity” category. At the end of the 10-year period, an MRI reveals her knees have gotten worse. So should her example be used to support the thesis that “moderate walking is harmful for people with bad knees”?

Not necessarily.

Maybe Mary’s joints are so bad that she needs less walking, or shorter bursts of walking, until she can strengthen them. Maybe, had she been in a group that walked only one-quarter mile daily, while taking 60 steps around her room every half hour, her knees would have gotten better.

It’s sort of useless to create a study to draw conclusions about how much of activity X is beneficial when you have no idea how much of activity X each particular subject should be doing (which depends on the strength of their particular joints).

Okay, those are some reasons why I consider many knee studies badly flawed.

Now it’s time for a visit from my imaginary critic:

Great, so researchers shouldn’t undertake a study unless it’s perfect? Subjects’ environments must be totally controlled for all variables? That’s ridiculous. You can’t find any study that meets those high standards. Basically, you’re throwing a lot of good science out the window.

My response: Yes, the perfect is the enemy of the good.

But showing how the good can be flawed -- and sometimes, not be very good at all -- isn’t meant to be an exercise in nihilistic nit-picking. Recognizing that serious flaws exist for many knee studies, and knowing what they are, means you can better evaluate to what degree the study you’re looking at may have escaped those problems.

For instance, category drift will be a bigger issue with a longer term study that samples a subject’s activities at only one point in time. So that may argue for the superiority of a shorter term study (which has its own drawbacks, true).

My message here, once again, is about thinking critically. There’s so much bad and suspect information about healing chronic knee pain that we’re foolish if we don’t think critically.

Handling Setbacks on the Long Road to Healing

The question of how to deal with setbacks came up recently in the comments section. It’s a great question because I doubt even the smartest, most patient person can navigate a healing process that spans many months without a single setback.

First, why are setbacks so bad, when it comes to overcoming chronic knee pain?

They’re depressing. Really depressing. It’s not like you were healing that fast to begin with, right? So you feel a little better after two months of doing all the right things, then do something wrong -- you may not even be sure what -- and suddenly you hurt as much as you did before.

Argh. Bad knees are forever, you start thinking to yourself. At this point, you’re particularly prone to negativity, self-pity, and a bunch of other bad feelings.

Also, at this point, you’re prone to abandoning what works. After all, you tried to improve your joints very, very slowly, you were feeling somewhat better, then an ill-advised hike/long walk/sprint to catch the bus set you back.

Maybe you start thinking: “This program can’t be working -- it’s too slow and if my joints are getting stronger, how can a little x (whatever the offending activity was) cause such problems? Ah, forget it. It’s time for surgery/pain medication/a life of doing whatever I want because it doesn’t matter anyway.”

You feel lost, not knowing how far you were set back. To me, this is a big issue, especially when you’re measuring hard-fought gains in inches, figuratively speaking.

Obviously, you want to get back on track. But do you take a few easy days? An easy week? Should you return to your program of three weeks before, when you were taking 20 percent fewer steps each day? Or do you need to hit the reset button more dramatically, and go back three months, maybe to when you weren’t even taking long walks yet?

These are frustrating, demoralizing questions to deal with. You’ll want to downplay the significance of the setback. You’ll want to act as if you were less affected than you really were -- which raises the risk of doing more damage to your joints.

Okay, that’s why setbacks are bad, in my opinion. Now, how to deal with them?

Make sure they don’t happen.

No, that’s not meant to be a “d’oh” statement. Because I believe you really need to be thinking hard about not pushing your knees too much.

So this means (1) Err on the conservative side with activity. (2) Monitor your knees very closely. (3) Learn as much as you can from whatever setbacks you do have. Failures are never wasted when they’re recycled into knowledge (that in turn prevents future similar failures).

Recognize and accept the setback.

The worst thing, I think, is pretending it never happened and just merrily going on with your existing program, not changing a thing, not reflecting on how and why you screwed up. Because then your knees may just get worse and you’ll be no smarter for what you just went through.

Instead, my advice is to face it head on. You may be lucky -- maybe you just need to take an easy day or two and you’re right back on track. If not, you’ll probably have to experiment a little to figure out what level/type of activity your suffering knees are now happy with.

Know you’re in good company.

I had setbacks. And I bet that almost everyone whose knees healed over a 12-month-plus timeframe had at least one setback. They happen. So it’s good to be philosophical about something that’s practically inevitable.

Some years ago, I remember getting very angry at myself for losing/misplacing something. How could I be so stupid? Then I decided to take a larger view of the situation, and it relaxed me somewhat. The larger view was this: Over the course of anyone’s life, that person will lose or misplace a certain number of things. So, unless I lose personal items at an extraordinarily high rate (suggesting say Alzheimer’s), the occasional object that goes missing is just me filling my cosmic quota. :) No big whoop.

Cry if you need to.

Throw something across the room. Curse the unforgiving God of Bad Knees for not cutting you a break.

After all that, figure out how to get back on that slow path going forward. Because that’s the only way to go, isn’t it, if you want to win back your old life?