Saturday, November 24, 2012

Do You Train for Work?

I remember mentioning this concept to a colleague once. We were talking about our tiring 10-hour-a-day desk jobs. So I said that I “trained for work.” He gave me a sideways smirk, as if to say, “Yeah right. Like there’s a workout routine designed for someone who sits like a rock in a chair all day.”

But I was actually serious.

It’s not that you have to train to be able to do nothing but wiggle your fingers over a keyboard. It’s that you have to train to counteract the deleterious effects of doing nothing, for such long periods, but wiggling your fingers over a keyboard.

Sitting can be poisonous for our bodies, which were designed for movement. Doug Kelsey at Sports Center in Austin once wrote that an old teacher said something to the effect that sitting does for your spine what putting a plastic bag over your head does for your breathing.

So I actually do train for work. Every workday morning I do this “bird dog” exercise for three and a half minutes, to keep my back muscles strong. I also do this “rock ‘n roll” exercise (another great recommendation by Kelsey) for five minutes, for my neck, which is a little crackly and has given me minor problems in the past.

What about my knees?

Actually, what I do for my knees probably benefits my neck and back too. First, on the way to work, I walk a good three-quarters of a mile to my subway stop (bypassing two closer stops, just so I can get in some beneficial movement). During daily snack breaks (Bloomberg has lots of free food on the premises), I eat while slowly strolling the floor. And at lunch, after a quick, light meal, I head for the exits and walk the streets for a good 10 or 15 minutes.

So, in sum: I move as much as possible during work breaks, to try to negate the effect of all the toxic sitting. And early in the morning, I do various exercises to help prepare me to withstand all that sitting without discomfort.

Our bodies need movement. Our 21st-century jobs often don’t accommodate that need so well. So a little special effort is required to keep all our body parts running smoothly.

Saturday, November 17, 2012

What Causes Patellofemoral Pain Syndrome and Chondromalacia, Part II

Last week I shared a “unified theory of chronic knee pain” -- basically, that bad cartilage was involved much of the time.

Let me be clear what we’re talking about: diffuse, achy pain generally. There are other, more specific pains when a doctor pokes something and you go “ouch.” Different structures are probably involved there (e.g., I wouldn’t consider “patellar tendinitis” to be PFPS -- I could be wrong here -- because patellar tendinitis diagnoses a clear, identifiable problem).

Now what are some objections to this “unified theory”?

An MRI shows that my cartilage is fine but I have knee pain! So how can the source of pain be the cartilage?

Remember, a typical MRI takes a picture that is imperfect. (Two wood-frame houses may look identical in a photograph, but if the beams of one have been hollowed out by termites, they will not perform the same structurally.)

Initial cartilage damage associated with chondromalacia starts deep within the tissue -- and so, it appears, would not be detectable by a standard MRI.
In chondromalacia of the patella, the initial lesion is a change in the ground substance and collagen fibers at the deep levels of the cartilage. It is a disorder of the deep layers of the cartilage that involves the surface layer only late in its development. (Weinstein, Stuart L. and Buckwalter, Joseph A., eds. Turek’s Orthopaedics: Principles and Their Application.)
Some people with cartilage lesions have no pain, and others with lesions have pain -- if that’s the case, how can bad cartilage be to blame?

Partly the answer appears to be that thin cartilage becomes a problem at some point, despite a knee pain sufferer having a number of initially non-painful lesions:
A recent study proved that one can have as much as Grade III wearing without pain. So, pain is variable. The source of chondromalacia pain is not the articular cartilage itself, but the thinning of it, which transfers loads onto the underlying subchondral bone, which is pain-sensitive. (UCSF School of Medicine, Physical Therapy and Rehabilitation, on patellofemoral pain)
Another important thing to consider here, it seems, is the quality of the remaining cartilage. Recall that chondromalacia literally is an abnormal softening of cartilage. It may have minor wear and be soft (and hurt more), or may have more wear but be fairly stiff (in a good way) and resilient (and hurt less).

Still, if you have a lot of deep lesions, chances are good you have more pain than someone with less damage.
The severity of cartilage lesions detected at arthroscopy highly correlates with incident pain (Aaron, Roy K. and Ciombor, Deborah M. “Pain in Osteoarthritis.” Medicine and Health Rhode Island, July 2004) 
How can damaged cartilage cause pain if the tissue has no nerves?

The key thing to remember here: the source of the pain sensation isn’t the cartilage itself.
Because there are no nerves in cartilage itself, the pain must emanate from subchondral bone, which is experiencing deficient conduction of stress through mechanically inadequate cartilage. ... Fibrillation of articular cartilage usually follows fissuring with progression to ulceration in some cases. When fibrillation progresses to a larger area of the patella, bone may begin to experience abnormal pressure increases or irritation from flaps of cartilage that are placed under pressure. (Fulkerson, John Pryor. Disorders of the Patellofemoral Joint.)
Or, here are some other ways bad cartilage triggers pain sensations:
The articular cartilage is not sensitive to stimulation, but ... the adjacent synovium is the primary pain source [fragments of cartilage can migrate through the synovial fluid to the synovium, irritating it]. The subchondral bone ... is another likely source of pain from excessive load on an unprotected bone surface. Finally, the resulting effusion [swelling] caused by articular breakdown may itself be a source of pain. (Johnson, Donald H. and Pedowitz, Robert A., eds. Practical Orthopaedic Sports Medicine and Arthroscopy)
And as for inflammation:
... Cartilage debris and sulfated polysaccharides liberated from cartilage breakdown have been shown to be inflammatory in joints and to stimulate the release of proinflammatory cytokines. (Aaron, Roy K. et al. “Pain in Osteoarthritis.” Medicine and Health Rhode Island, July 2004)
Then, if you happen to believe that where there’s smoke there’s fire, well, osteoarthritis and cartilage damage go hand in hand:
This loss or damage of articular cartilage is an early finding in osteoarthritis. Chondromacia patella is thus an arthritis involvement of the patella. (MDGuidelines, entry on patella chondromalacia)
But there are other things going on inside bad knees. How can you blame poor cartilage for everything? For example:
The association of bone marrow edema with pain in osteoarthritis of the knee has recently been emphasized. Bone marrow edema was found in 78% of patients with pain compared to 30% of patients without knee pain. The presence of bone marrow edema is associated with progression of cartilage degradation. (Aaron, Roy K. et al. “Pain in Osteoarthritis.” Medicine and Health Rhode Island, July 2004)
Here’s where a careful person has to admit, “Yeah, there's plenty going on that we don’t fully comprehend.”

But consider for a moment swelling of the bone marrow. The first matter to ponder: Does this contribute to cartilage degeneration or is this caused by cartilage degeneration? To me, the latter sounds more plausible. Still, let’s posit the former: that the bone marrow swelling is responsible for cartilage damage -- or that a third, even larger unknown force causes both the cartilage degeneration and the bone marrow swelling.

Okay then, where does that leave us, in terms of finding a path toward healing?

If your main problem is bone marrow swelling (or intraosseous hypertension, or focal osteonecrosis, or bone marrow lesions), then it seems you’d want a more bone-oriented treatment regimen. Now, I am way out on a limb here (I’ve done very little reading on this subject), but bone resembles cartilage a lot more than muscle. So I would think a gentle, joint-friendly program of high-repetition movement would be a smarter way to go than a “strengthen your quads” approach.

So even if the “unified theory” is wrong -- even if cartilage isn’t involved in much of all chronic knee pain -- I think the same activities that would strengthen and help repair this tissue would probably also benefit the joint overall.

Saturday, November 10, 2012

What Causes Patellofemoral Pain Syndrome and Chondromalacia?

I got this question recently.

It’s a good one because, unfortunately, the answers aren’t easy. But they are important to seek out. As I mention in Saving My Knees, my first law of healing is:

Before devising a plan to heal, you need to know what’s wrong and what’s causing it to be wrong.

So let’s start with what causes patellofemoral pain syndrome (often abbreviated “PFPS”).

Ah, that’s easy! It’s psst ... psst ... psst.

Seriously: there are two ways to answer this question.

One is that no one knows what causes it. No one knows because no one can know. There is no such thing as PFPS. PFPS is an overly broad, useless pseudo diagnosis that, when translated to its constituent parts from the bewildering medical terminology, means:

You have knee pain (of unknown origin).

An analogy: Your elbow hurts. You see me, a learned doctor, and I say, in tones most grave and dignified, that you have “humeroulnar pain syndrome.” You leave my office, distraught, then do some research, and find out that I’ve told you:

You have elbow pain (of unknown origin).

Not too helpful, huh? Same with PFPS.

The second answer is a bit more sophisticated. PFPS does mean “knee pain,” but it does align with a certain set of symptoms (difficulty sitting and walking up and down stairs, for example). So what’s the most likely cause of that symptom set?

In a moment, I’ll offer an, um, “unified theory of chronic knee pain.”

But first, let’s look at chondromalacia in the knee joint. What is that? It’s an abnormal softening of cartilage. That literal definition is rather abstract though. More commonly, it can be thought of as “a condition in which the cartilage ... becomes worn from age or is damaged from injury.”

Now there's one more thing to introduce at this point: patellofemoral pain syndrome and chondromalacia are often used interchangeably. They are NOT the same thing, but the fact that this confusion exists is very interesting. It suggests that one (chondromalacia) may have something to do with the other (PFPS).

Which brings me to a unified theory of chronic knee pain.

Cartilage problems are involved in much of this kind of pain. So bad cartilage would be implicated in many cases of PFPS. What causes bad cartilage, or chondromalacia, in the first place? I doubt there’s a simple answer. It could be anything from an injury to overuse to obesity -- whatever causes wear or damage to the tissue.

Next week: Objections to the unified theory. A response to each objection. Finally, even if bad cartilage isn’t causing your knee pain, why it may not matter in terms of what you need to do to get better.

Saturday, November 3, 2012

A Few Words About Hurricane Sandy (And What It Meant for My Knees)

For anyone living in the New York City area, there’s been only one story this week: Hurricane Sandy.

The weekend before the storm, I said to an acquaintance, “I’m worried less about the wind than the possible flooding.” I had seen water gushing from the ceiling of subway tunnels during no more than a heavy thunderstorm.

Sure enough, the big story turned out to be disruptions related to the incredible storm surge (not that the downed trees were minor -- strolling around my neighborhood post-Sandy, I counted 10 trees within an hour that had either fallen across the road or had crushed a car or smashed into a house).

Manhattan, as I’m sure most are aware, is an island. Those of us who live in the outer boroughs (such as Queens, where my family has an apartment) board long silver subway trains and are magically whisked through the bedrock, and under the East River, to arrive at our workplaces in the heart of the city.

Monday morning, there was no magic. The tunnels under the river had been overwhelmed by a wall of water and closed indefinitely. Whereas I usually walk three-quarters of a mile to a subway stop (not the nearest one either -- I just like to walk a little) and choose from E, F, M, and V trains, suddenly I had no choices.

Monday and Tuesday I worked at home. Wednesday, however, I had to get to work to lay out the weekly publication that I edit. I had no other option. My company was providing a bus shuttle, but it wasn’t conveniently located, so I thought:

What the heck.

I had for a while pondered what it would be like to walk to work. Make no mistake: it’s a serious walk to my office building in Manhattan from the east end of Forest Hills, where I live. Door to door, the distance is 8.4 miles, according to a Google estimate of the route.

So I set out at 6:42 a.m., into the pre-dawn, as the city was just rustling into life. I went most of the way down Queens Boulevard, then turned onto a street that took me (and lots of other New Yorkers, on bicycle and foot) over the Queensboro Bridge. By the way, on the bridge there were no slackers: everyone kept a brisk pace.

At 9:02 I walked through the doors of Bloomberg’s offices at 731 Lexington Avenue. At the end of the workday, I wound up walking back (I did the return leg in 2 hours and 18 minutes, 2 minutes faster, because I was motivated due to some of the neighborhoods I had to walk through ;))

So that’s 16.8 miles (actually probably 17, because I took a wrong detour on the way back and, on the way in, took the wrong approach to the bridge and had to double back a little).

The good news: I had a little sore spot on the back of my left heel, but my knees did just fine. That, I figure, is because I have spent the last three years strengthening them with 60 miles of vigorous cycling each Saturday, powering over the small hills of western Long Island.

I can remember a day, that seems not so long ago, when I lived in Hong Kong and was trying to heal my bad joints and would force myself to stop walking on trips after about 3,000 steps. I would make myself sit down and go no further because I knew I had to be very, very patient to restore my knees to good health.

Walking 17,000 steps in the morning -- and then 17,000 more in the evening -- would have been unthinkable. But that’s the nice thing about beating knee pain. Your knees get stronger. They no longer tell you what to do. You tell them what to do.

And that’s a great freedom, because it allows you to do something a bit offbeat and crazy -- like walk 8.4 miles to work when there’s no public transportation.

(By the way, for anyone thinking, “That’s dumb -- why didn’t you just take a taxi?”, the roads were clogged and a co-worker who did hire a car into work got stuck in traffic and ended up getting out and walking at the end -- and he arrived half an hour later than I did going the entire way on foot!)