Popular Knee Surgery Works No Better Than a Placebo

Couldn’t resist writing this one up. The results of the following study have been making the rounds lately, in publications from the Wall Street Journal to the New York Times:

A popular surgical procedure worked no better than fake operations in helping people with one type of common knee problem, suggesting that thousands of people may be undergoing unnecessary surgery, a new study in The New England Journal of Medicine reports.

Specifically, researchers wanted to know about the effectiveness of arthroscopic surgery for patients with a torn meniscus, a crescent-shaped wad of cartilage in the knee. The operations are very common. About 700,000 are performed in the U.S. yearly, at a total cost of $4 billion.

But how much do they help?

A Finnish study set out to find the answer: 146 patients, from age 35 to 65, who had wear-induced tears of the meniscus and knee pain (but apparently not arthritis) took part. About half had mechanical issues such as locking or clicking in their joints.

The last-minute way that subjects were directed into one of the two groups was kind of cool:

Most patients received spinal anesthesia, remaining awake (one hospital used general anesthesia). Surgeons used arthroscopes to assess the knee. If it matched study criteria, nurses opened envelopes containing random assignments to actual or sham surgery. In real surgery, shaver tools trimmed torn meniscus; for fake surgery, bladeless shavers were rubbed against the outside of the kneecap to simulate that sensation. Nobody evaluating the patients later knew which procedure had been received.

Then, after a year ...

Each group reported a similar improvement. (That sound you just heard was billions of dollars flushing down the U.S. health care toilet.)

Of course the New York Times quotes surgeons defending the procedure for certain patients. And of course the surgeons have a point: for certain people, especially those who are young and in much pain from a major tear in the tissue, surgery is no doubt the best option -- maybe the only option.

But always remember: Surgeons are part of their own SIG (special interest group). They have been trained in, and have acquired expertise in, the act of performing surgery. They make their money doing so (not exclusively, true, but still, the honest, thoughtful ones realize the conflict this leads to).

It’s like when a member of the Avocado Growers Association says more Americans should be eating avocados -- for their health, of course.

So Frederick Azar, first vice president of the orthopedic surgeons academy, not surprisingly finds grounds to dismiss the study's results. He tells us he operates mostly on patients outside the study's purview, who have mild to moderate arthritis and meniscal tears that appear to be painful.

He might be wise to take a glance upstory at Dr. Kenneth Fine, an orthopedic surgeon also quoted. Of 100 people with knee pain, Fine says, a “very high percentage” will also have a tear in their meniscus. He goes on:

People love concreteness: ‘There’s a tear, you know. You have to take care of the tear.’ I tell them, ‘No. 1, I’m not so sure the meniscal tear is causing your pain, and No. 2, even if it is, I’m not sure the surgery’s going to take care of it.'

That’s the kind of wisdom we need more often.

Oh, did this news seem kind of, well, familiar to regular readers here?

If so, you may be remembering this post from May in which I reported another study showing that this kind of surgery was ineffective. For that study, the patients did have arthritis.

Now that we’ve covered the arthritis and non-arthritis sufferers, casting doubts about the usefulness of the procedure generally, maybe we can finally shave a billion or two off that annual $4 billion medical bill.

Happy Holidays

Best wishes from me, Congyu, Joelle and Elliot!

This is my annual "Merry Christmas" (or whatever holiday you celebrate) post.

I hope everyone out there is finding some success in healing their bad knees. What I can tell you (from my own experience) is that it's incredibly slow, and that's even if you're doing everything right.

The right attitude, and a spirit of determined optimism, help tremendously. The holidays are a good time to gather strength from friends and family and to vow to renew lapsed commitments (you know, you planned to start a movement program, but then things kind of happened, and you only half-heartedly followed through).

And, after a few guilty swigs of eggnog, you might think again about weight loss as a way to reduce knee pain.

There's a lot that knee pain sufferers can do! Damaged knees don't have to be forever. That's my message.

Well, that, and have a great week everyone. :)

Time to Hit the Bottle to Banish Knee Pain?

Okay, this week we go a bit tongue in cheek. For all you boozehounds out there, I got this comment recently:

I don't mean for this as a cure of PFPS (obviously) but has anyone else noticed a remarkable reduction of symptoms after consuming (small/moderate) amounts of alcohol. The effect seems to last for at least a day after consumption!

This comment brought to you by the Whiskey Distillers of America!

Seriously, is there any reason for alcohol to have such a happy effect on someone’s grumbling knee tissues? I think there are in fact two good reasons (though I’m doubtful either would last for an entire day after one stops imbibing -- so it’s possible that there’s something completely unrelated going on with this guy).

For one, alcohol dulls all sensations. Sometimes drunk people walk into walls and hardly feel the impact. Now, the comment made reference to “small/moderate amounts of alcohol” -- so that’s not getting blotto clearly -- but the nerve-deadening effect of alcohol would just be played out on a smaller scale.

Now, that’s the more obvious reason -- which I’m sure the commenter has already taken into account. The not-so-obvious reason is the one I find more interesting.

Alcohol relaxes you. In doing so, it relaxes muscles. And some of those looser muscles naturally belong to your upper legs.

Why does that matter? Knee pain while seated (the so-called “moviegoer’s sign”) is a hallmark symptom of patellofemoral pain syndrome. What’s happening typically is the cartilage in your knee joint isn’t strong enough to handle the additional force that comes with bent-leg sitting. You wouldn’t think merely sitting is that physically stressful. But it’s enough to send weak knees over the edge.

If you want to increase that pain, just tighten those thigh muscles -- through stress or nervousness or whatever -- and that will pull your kneecap a tad closer to your underlying femur, which should increase your discomfort. However, if you relax, by having a drink (or two or three), the opposite should occur: a lessening of symptoms.

I think this is the same reason that stretching feels good. You loosen muscles and take pressure off that sensitive junction where kneecap-cartilage-femur meet.

In my opinion, neither stretching nor having several Corona Lights is really a lasting solution for knee pain. But might they be good for temporary relief? Could be.

The Final Word on Glucosamine and Knee Pain

That, at least, was what one reader sought in a recent question to the New York Times’s Gretchen Reynolds, for her Ask Well column. He was understandably confused.

While his orthopedic surgeon scoffs, “Don’t waste your money,” a physician’s assistant swears that “I couldn’t get in the car and drive to work in the morning if I didn’t take glucosamine for joint pain.”

I’ve written a few times about glucosamine: here, here, here and most recently here, for starters. Today I thought I’d take a deeper dive on the subject, on a molecular biology level, because that’s where things truly get interesting.

I first became skeptical of glucosamine’s efficacy when it did nothing for me when I had constant knee pain. I took the supplement daily for months. No perceivable benefit. None. At. All.

I didn’t research glucosamine intensely though until I was well into writing Saving My Knees, which was my ambitious quest to rectify what I thought was a lot of wrong-headed information about treating chronic knee pain -- including the pernicious notion that bad joints could never heal. That just wasn’t true, and I was living proof.

At some point, I became aware of a massive, well-run trial, the results of which were published in the New England Journal of Medicine in 2006, that found glucosamine and chondroitin sulfate don’t work. Well, the study did show a benefit for those with moderate-to-severe pain who took both supplements. However, a doctor specializing in biostatistics quoted by the New York Times at the time said, “This is a spurious subset result if I’ve ever seen one.” He turned out to be correct -- the “advantage” for this subgroup washed out on further examination.

So glucosamine is a dud, right? Case closed?

It sure seemed that way to me. Didn’t help me. Didn’t help subjects in a large, well-conducted clinical trial. Sure, some people claim they can’t function without it. But some people would probably report less knee pain if you gave them “magic Ritz crackers” that they really believed were magic. Plus, why is it that glucosamine advocates claim to get relatively fast relief from a supplement that’s supposed to be restoring their cartilage, which is a long-term, months-long process?

But I’m a curious guy. I wanted to know exactly where the glucosamine story broke down. And where the story broke down, it turned out, was where glucosamine itself broke down.

To wit (and now I’m going to start quoting, so you can follow my journey of discovery better):

Orally ingested glucosamine “appears to undergo a significant first-pass effect in the liver, which metabolizes a significant portion of the dose to CO2, water and urea.” (Source: “Arterial Smooth Muscle Cell Proteoglycans Synthesized in the Presence of Glucosamine Demonstrate Reduced Binding to LDL” in Journal of Lipid Research)

Uh oh. That doesn’t sound good. But what does that mean in practice?

Fortunately, there's a clinical study that shows us: 18 subjects, all with osteoarthritis, took 1,500 milligrams of glucosamine sulfate. Then their blood was drawn at periodic intervals. The concentration of glucosamine peaked from 90 minutes to three hours after the supplement was taken, with the amounts ranging from 1.9 to 11.5 micromoles.

From an article summarizing the results:

At best, some patients had about 11 micromoles of glucosamine circulating in their blood several hours after taking the pills. Yet previous studies suggest that it may take glucosamine concentrations of about 10 times that amount to rebuild cartilage. Even at the highest concentration, the typical supplement would contribute only a small percent of the glucosamine needed to build stronger joints.

Taking higher doses of these supplements might increase glucosamine levels to the point needed to fight arthritis, but ... getting too much of this sugar may raise the risk of diabetes.

One of the study’s researchers, Timothy McAlindon, said patients were probably safe using small amounts of glucosamine, while tartly concluding, “The main injury is primarily to the wallet.”

That’s a damning comment, certainly. But there’s more. In 2009, Jeremiah E. Silbert wrote “Dietary Glucosamine Under Question” in the journal Glycobiology. Up front, he makes clear his credentials, “Our laboratory has focused its work on glycosaminoglycan metabolism for many years.”

Warning: His article is technical and dense -- about what you’d expect from someone who speaks chondroitin sulfate cellular biosynthesis as a second language. I struggled with a number of paragraphs, but even so, it was clear that he wasn’t impressed by the idea of popping glucosamine pills.

For one, the glucosamine is diluted hugely:

We found that the radioactive glucosamine [externally introduced] was diluted many fold by glucosamine formed from glucose [naturally occurring] ... dilution by glucosamine derived from glucose was 160- to 635-fold.

At the low levels that glucosamine is found in the bloodstream, it appears to be useless, unfortunately:

We have concluded that insignificant trace amounts of glucosamine enter human serum after ingestion of a standard oral dose of glucosamine sulfate or glucosamine chloride (1500 mg), far below any amount that might contribute directly to chondroitin synthesis. Moreover, this level is limited to a few hours after ingestion, with no establishment of any substantial lasting concentration. It is far below most of the concentrations used for in vitro cell or tissue culture incubations by others, usually for days or weeks, in proposing mechanisms to protect chondrocytes, inhibit chondroitin degradation, diminish inflammation, or provide imunosuppression in articular cartilage mechanisms ... Until consistent actions on cartilage can be demonstrated at the low concentration and limiting time periods that we found, claims of a meaningful direct effect on cartilage or chondrocytes are questionable.

And, at the conclusion, he sounds a warning note that the supplement may not even be as harmless as portrayed:

There were statistically significant glucose elevations with glucosamine ingestion by three subjects who were found by the glucose tolerance test to have previously undiagnosed diabetes. This is the first time that results of this sort have been found with diabetics that were not under treatment and warrant further investigation.

So there you have it. Way more than you ever wanted to know about glucosamine, on a microscopic cellular level.

What then should be the final word on glucosamine? You’re probably expecting me, like the orthopedic surgeon earlier, to scoff and say, “Don’t waste your money! It flat-out doesn’t work!”

I think that a wiser final word comes from the Ask Well column when a doctor observes that at recommended doses, glucosamine is generally safe and some people do say they benefit, so he tells patients “it’s up to them” if they want to buy the supplements.

But he also advises people to keep their expectations low. “In my experience, most people do not benefit.”

Sounds like a good final word to me.

A Call for Success Stories

My intention has always been to retire -- or actually, semi-retire -- this blog eventually. I don’t want to start unconsciously repeating myself. Note I use the word “unconsciously,” as there are some messages well worth repeating to knee pain sufferers (“lose weight!” being one).

Lately I’ve been thinking about this, as I’ve grown a bit tired of hearing my own voice here all the time. It sometimes feels like everyone by now knows by story, and my beliefs, and can predict what I’m going to say.

But what about your stories?

What has worked for you?

I’m hereby putting out a call for success stories from others. And, to lower the bar a little, it’s fine to “play” even if your knees aren’t completely healed. Please include (1) Some details about yourself (age, sex, overweight or not -- but no names required!) (2) Some details on the nature of your knee problem (3) Some details about how you healed -- or what you’ve had success with to treat your pain.

Either leave a comment below or e-mail me at rb409699 [at symbol here] yahoo.com (my correct e-mail address; sorry, the one in the book contains a typo). I’ll use some of the stories in future posts.

Failed Treatments for Knee Pain, Electricity Edition

TENS (transcutaneous electrical nerve stimulation) is a process whereby a device produces a mild electric current to stimulate nerves to block pain signals.

Does it work for knees with osteoarthritis?

Apparently not.

That’s according to a U.K. study of 224 osteoarthritis patients who were 61 years old on average.

They were split into three groups, all of which received education and physical therapy. One group also got TENS treatments, another got sham TENS therapy (the device looked authentic but produced no electrical current), and the rest got nothing additional, beyond the education and exercise.

If the first group had improved the most, that would be evidence that TENS is effective. If the first and second groups improved more than the third, that would suggest that TENS doesn’t work, but there’s an associated placebo-type effect that does.

Instead we got option three: all three groups were found to have improved the same amount after six weeks, then 24 weeks.  (Their levels of pain, stiffness and joint function were assessed; presumably they all benefited from the education and exercise.)

So don’t expect to get pain relief by having someone zap you around your ailing knee.

Of course my new standard disclaimer applies here (in anticipation of the inevitable person who will protest, “But TENS helps me with MY knee pain”).

While this study shows no positive benefit, your mileage may vary. If TENS makes your knees feel better, and the treatment isn’t doing any harm, you might as well keep getting it.

What Does the Post-Recovery Period From Knee Pain Look Like?

I’ve yakked a lot about my recovery from chronic knee pain.

But it’s been almost three years since Saving My Knees was published. What have my knees been like since then?

I’m prompted to write this because here’s how most people would address someone who “beat” knee pain:

“Glad to hear you’re doing better. Hope your knee pain doesn’t bother you too much anymore, and hope you keep improving!”

Actually ...

My knees feel fine. I cycle hard again. I ride as much as 70 miles in one day, on the weekends. I’m right there in the thick of the sprints, and plenty of times I win too. When I return from cycling, I don’t ice my knees. I don’t take a couple of aspirins for “the pain.”

There is no pain. Period.

My knees still crackle a little, but much less than before. If I drop into a deep squat and straighten up, there isn’t an awful ripping sound from my joints.

There’s no sound. Nothing.

Maybe you’re thinking, “Great, so the post-recovery period is totally smooth, no bumps, no problems.”

Nope. If that were so, I wouldn’t bother writing this post. The truth is, the post-recovery -- like the recovery itself -- is a process. I remember taking a bus from Boston to New York City for job interviews in the fall of 2009 -- a full year and a half after I quit my editing job in Hong Kong so that I could focus on healing my knees -- and my joints grumbled some on the four-hour bus ride. And they did as well after I rejoined Bloomberg and had to sit, once again, at a desk for 10 hours a day.

Around that time, there were also moments, now and then, when I felt instability in my knee joints. There were times when, descending an escalator to the subway platform at day's end, I could feel that my knees weren't 100 percent yet. Last year I had some occasional and mild burning in my knees while sitting at work (I had a little this year too, though less). I closely monitored the situation, and it never got worse. In fact, I’m pretty sure it was related to the intense cycling, because during the off-season, my knees went back to feeling 100 percent normal.

Anyway the point is simply that healing knees is a long, long process. I know no one likes to hear that, in an age of instant gratification. But I really believe it’s the right message, because it's true.

Why It’s Good to Know If You’re Type A or Type B

Most of us are familiar with the two major personality types.

Type A: Intense. Ambitious. Goal-oriented. Competitive.

Type B: Laid back. Less rigid. More reflective.

I’m definitely more Type A than B (though I consider myself to be reflective and creative too, so there’s some bleed-over between the categories).

One thing I found interesting during my knee pain recovery was that knowing which “type” you are is actually useful.

Why?

Well, it suggests which kind of traps you have to be particularly careful about.

For instance, take a Type B personality. You are more likely to make one of these mistakes:

* Not faithfully sticking to the movement program, that involves slowly building intensity over many weeks, that is the best way to heal (or so I found).

* Not observing closely enough (through a knee journal or otherwise) the condition of your knees, day to day, with the aim of figuring out what they like and don’t like, and how fast to proceed with a program to heal.

The Type A personality must guard against different risks, I found out (as a mainly Type A’er).

* Always wanting to push harder, to scoop up gains faster, often with the goal of returning to a much-missed athletic lifestyle. A typical Type A comment would go like this: “My knees were definitely getting better, so on Saturday, I ran four miles, even though I haven’t run that far in eight months. Judging from the way my knees feel today, I think it was a mistake.”

Of course!

* Not being able to take a day off. Or maybe even several days off. Or admit that (for reasons that aren’t maybe even understood), your knees have suffered a setback and you need to hit the reset button. Sure, you’ve been walking two miles a day for the past month, but for now you have to reduce that to one mile for a while.

* Making knee pain recovery a joyless drudgery. I know I was occasionally guilty of this. Counting steps, taking notes -- it’s all good, but don’t forget to smell the flowers. Don’t become a prisoner of your “my plan to heal” spreadsheet.

Healing knees is a long, challenging process. There will be pitfalls along the way. Knowing which personality type you are -- A or B -- can help you avoid some of those pitfalls.

What’s Your ‘Viewing Frame’ for Understanding Knee Pain?

I came across a cool story not long ago in a New Yorker article. The larger article was called “Giving Voice,” about how a surgeon pioneered methods to help singers regain the richness of their voices.

The story concerns the surgeon, Dr. Steven Zeitels, and a surgical laryngoscope -- a device that holds the throat open during operations -- that he designed.

The typical scope had an oval viewing area, even though the vocal cords (when viewed down the throat) form a triangle. His laryngoscope had a triangular opening. That meant he could see areas that were obscured before.

Using the old equipment, surgeons had concluded that cancers in the front of the vocal cords were especially deadly.

“The reason was, they didn’t see them in the first place,” Zeitel says. “They attributed a biologic process to the fact they never saw them!”

A beautiful story, for what it says about how we can unknowingly misinterpret the world because of the limitations of our viewing frame.

It’s true literally -- as with a piece of medical equipment -- and figuratively -- as with a set of beliefs that leads to restricted vision.

What does this have to do with knee pain?

In brief: everything.

One thing I discovered during my own odyssey with bad knees:

What your doctor or physical therapist believes about chronic knee pain -- what causes it, what are the chances of a bad joint healing -- matters a whole heck of a lot, because such beliefs directly influence what that person will advise you to do about the pain.

But, what I came to realize, is that they often see the problem through a certain view-restricted frame, sort of like that oval laryngoscope. That’s the frame of imbalance/crookedness. E.g., your knee pain is being caused by hip muscles that are too weak, or a hamstrings-quadriceps strength ratio that’s out of whack.

If you’re a doctor or rehabber, and you view knee pain this way, chances are very good for example you’ll believe that the origins of knee pain are a mistracking patella. But the important thing for patients to know (when your doctor or physical therapist presents this analysis as fact), is that this is just a theory.

Mistracking kneecaps may cause most patellofemoral pain. Or not.

Here’s a study (that I’ve cited a few times before) that provides evidence contradicting that theory. Researchers carefully observed a group of subjects and found no correlation between the degree of kneecap mistracking and knee pain. (Sure, it’s a small study. But the results are intriguing, certainly.)

The trouble is, if you believe that crookedness/imbalances are basically the source of knee pain (and that constricts your viewing frame), you’re going to waste a lot of time with subjects like me, who don’t have mistracking kneecaps, or other structural issues.

Of course, you might just conclude “patellofemoral pain syndrome cases that don’t have a clear cause related to muscle or structural imbalances are very hard to treat” (aping the language of our oval laryngoscope users). You might even venture that my condition is “unfixable” (I felt that my physical therapist, after a while, basically gave up on me).

And that would be a shame, because you would’ve given up on someone who eventually healed his knees.

(So what is the correct way to view knee pain with the aim of overcoming it? I would argue a perspective such as “envelope of function” makes much more sense. For more, see here and here.)

Which Supplements Work Best for Osteoarthritis?

The October issue of Nutrition Action Newsletter looked at pills that claim to reduce pain associated with osteoarthritis. As I’ve said before, I like Nutrition Action Newsletter for its level-headed, science-based analysis (its bias, if it has one, is for sensible eating and exercise and weight reduction -- and what’s not to like there?)

First, obesity was identified by an assistant research professor at University of Michigan’s School of Public Health as “the number-one risk factor for osteoarthritis.”

What’s so bad about excess weight, according to this article:

(1) Each extra pound increases the load across the joint “three to five times,” says an arthritis expert.

(2) The heavier you are, the higher your risk of injuring your joints, which can lead to osteoarthritis.

(3) Heavier people have higher levels of inflammatory chemicals circulating in their body, which can break down cartilage.

Now, what about their verdict on those “pills for pain”?

* Glucosamine

“Glucosamine doesn’t work, period,” David Felson of the Boston University School of Medicine says. Nine trials that found a benefit for glucosamine were run by the supplement industry. Still, despite the lack of evidence, Felson says if patients “think something is working and it’s not dangerous, I don’t discourage its use.”

That’s a wise stance for a doctor to take, I think.

* Chondroitin

Like glucosamine, chondroitin is an essential element in cartilage. Taken as a supplement, however, it is no more effective at relieving pain than a placebo, rigorous trials have found.

* Glucosamine and chondroitin

The combination didn’t work better than a placebo in the National Institute of Health’s large GAIT trial. At first it appeared to benefit a subset of subjects with moderate to severe pain. But, as I wrote in Saving My Knees, “this may just be a statistical anomaly.”

Yup. That’s exactly what it was. When researchers monitored the patients for two more years, they saw no benefit.

* MSM (methylsulfonylmethane)

MSM is sometimes substituted for chondroitin (which is more expensive) in supplements. In three trials, researchers question whether MSM would make much of a difference, if any, for treating arthritis.

* Avocado and soybean unsaponifiables (ASU)

The one good study from the last 11 years found no benefits for pain, stiffness or joint function.

* Vitamin D

A two-year study showed vitamin D was no better at reducing pain and slowing cartilage loss than a placebo.

* SAM-e

In half a dozen trials, 1,200 mg of SAM-e (S-adenosylmethionine) provided as much pain relief as anti-inflammatory drugs such as Celebrex or ibuprofen. However, a rheumatology professor cautions that the trials were small and characterizes the results as showing only a “small pain relieving effect.”

Then there’s the price: $80 to $110 for a month’s supply of 1,200 mg a day. That’ll put a dent in your household budget.

So, all in all, a fairly dismal showing for supplements that aim to reduce knee pain. SAM-e looks the most promising. Of course, if something seems to work for you, even if medical science says it’s useless, you might as well keep taking it.

Beating Knee Pain: Exercise More and Eat Less

How should you try to reduce your knee pain?

Lose weight?

Or exercise more?

It turns out, not surprisingly, that the correct answer is both combined.

Researchers at Wake Forest University conducted a study that showed diet and exercise together proved “superior in virtually every outcome,” according to Stephen Messier, the lead investigator.

The 454 subjects, who were over 55 and either overweight or obese with mild or moderate arthritis of the knee, were instructed to either lose weight, exercise, or both, over an 18-month period.

Some of the findings:

* The diet group subjects (who lost an average of 20 lbs.) saw bigger reductions in “knee compressive force” than the exercise-only group (where weight loss averaged only 4 lbs.).

* Both the diet and diet and exercise groups had greater reductions in the inflammatory marker Interleukin 6 than the exercise-only group.

* The diet and exercise subjects had less knee pain, better function and better quality of life than those who only exercised.

Okay, here’s my take on all this.

Yes, it does somewhat seem like “No kidding, Sherlock” stuff, if that’s what you’re thinking. If doing one thing is good for you, and doing another thing is also good for you, why wouldn’t doing both be best for you?

True, but what I find interesting is (and I can’t be sure of this; this observation comes simply from reading some bullet points on the study’s results), losing weight may be even more important than exercise for beating knee pain (note: if you’re overweight, of course). For one, inflammation was tamed best by those subjects in the study who were either dieting and exercising or just dieting.

“Losing weight” is such a critical message to communicate to knee pain sufferers that, even though I’ve promised you all I’ll try to avoid repeating myself on this blog, on this point I’ve happily repeated myself: just go here and here and here to read more.

Also, the strategy of losing weight has a simplicity that exercising doesn’t. With exercise, there are a lot of questions that lack clear answers: What kind of exercise? How much? What if your knee hurts as you’re exercising? What if it doesn’t hurt during, but afterward? Etc.

Losing weight is comparatively simple. You’re 160 pounds. You should be 140. So lose 20 pounds.

“Simple” in this context refers to an absence of ambiguity about what needs to be done. Don’t misunderstand me. I don’t mean to imply losing weight is easy. It can be very, very difficult.

But the question is: How motivated are you? I can assure you, I was extremely motivated.

Here’s a photo of what I looked like around the time of my knee pain battle. Not a lot of fat on this frame.

But I still managed to lose about three pounds, believing that every little thing mattered if I was going to overcome my knee problems. Where there’s a will, there’s a way!

With Knee Studies, It Pays to Read the Fine Print and Do Some Digging

Last summer, I wrote this post:

News Flash: Injections of Hyaluronic Acid May Do Your Knees More Harm Than Good.

That, at least, was the conclusion of a “meta-analysis” by Swiss researchers of 89 clinical trials that looked at the effectiveness of “viscosupplementation.” This procedure aims to bolster a knee pain sufferer’s synovial fluid, which when healthy is a viscous lubricant that acts like a cushion too. When unhealthy, it thins out and performs its essential functions poorly.

The Swiss researchers found that, in 18 large-scale trials, viscosupplementation made such a small difference as to be “clinically irrelevant.” What’s more, some studies suggest the procedure can lead to a higher risk of cardiovascular and gastrointestinal problems.

So that’s settled?

Not quite.

Along comes a new meta-analysis of 29 studies that finds “intra-articular hyaluronic acid injections provided significant improvement in pain and function compared to saline injections.” The authors of this analysis note that all products in these studies were FDA-approved, unlike in the earlier Swiss investigation.

So whose meta-analysis is correct?

Well, the most recent one has a couple of big red flags that should give anyone pause.

* Follow the money.

The end of the Business Wire release for the latest meta-analysis contains an interesting disclosure:

The meta-analysis was supported by the Hyaluronic Acid Viscosupplementation Coalition, a collaborative of hyaluronic acid injection marketers.

Hmm. That doesn’t smell good.

Let’s face it: Viscosupplementation has grown into a sizable medical business. When a meta-analysis claims that this procedure -- which a number of companies have probably spent millions of dollars developing and testing products for -- is useless, well, what do you expect them to do? Fight back.

Now it could be that the first meta-analysis got everything all wrong. Sure, that’s possible. But I’d rather that a set of neutral, disinterested researchers determine that than a couple of what appear to be Phd consultants.

And how was their meta-analysis “supported” (a lovely weasel word, with positive connotations and an utter lack of specificity)? Were they paid to do the meta-analysis? And what guidance were they given by the coalition, if any?

* Consider the source.

At least the results of the meta-analysis were published in the New England Journal of Medicine, right?

Uh, not quite.

In fact, I was left scratching my head after reading the title of the publication: Clinical Medical Insights: Arthritis and Musculoskeletal Disorders. I’ve perused lots of medical papers related to knee pain and treatments for the problem. So I’m familiar with many of the names of publications. But not this one.

Who’s behind Clinical Medical Insights (it appears a number of sister publications use this same moniker)? This is where things get interesting.

An outfit called “Libertas Academia” puts out the Clinical Insights series. It belongs to the ranks of so-called open access publishers. In theory, the concept of “open access” sounds great, especially if you (like me) have run headfirst into a paywall when trying to get a copy of the published results of a particular medical study. What’s more, the per-article rates for regular journals are invariably steep ($30 to $40 say). But with open access, the publisher makes the content free.

Great -- except where does the money come from to support such an operation? Answer: the authors seeking publication. Libertas Academia says here that it charges from $950 to $1,980 as an “article processing fee.” (Which raises a curious question: Who paid for the report on this latest meta-analysis that found positive benefits of viscosupplementation? Maybe the Hyaluronic Acid Viscosupplementation Coalition?)

If this business model is starting to make you squirm, you’re not the the only one. This writer, in reviewing nine open-access publishers (including Libertas Academia), labels them “predatory.” He explains, “Their mission is not to promote, preserve, and make available scholarship; instead, their mission is to exploit the author-pays, open-access model for their own profit.” The publishers provide “little or no peer-review,” he alleges.

Also they “spam” academics, inviting them to submit articles which sometimes aren’t even in their field, according to this frustrated researcher who said he got eight spam e-mails from Libertas Academia, despite requests to stop. Not surprisingly, open-access publications have acquired the nickname “vanity journals.”

If you’re still not convinced, check out this tale of a nonsense-filled, spoof academic paper submitted by a Science magazine editor to open-access journals. More than 100 accepted it despite errors so blatant, “Any reviewer with more than a high-school knowledge of chemistry and the ability to understand a basic data plot should have spotted the paper's short-comings immediately.”

Anyway the point here:

Just as not all knee studies are created equal, so all meta-analyses are not either. Caveat emptor (or whatever the “patient beware” version of that Latin saying is). Viscosupplementation may help your particular knees, true. But be wary of “research” supported by makers of the products. They may not be the best neutral source of information, to say the least.

Why I Conducted the Knee Experiment I Did

The most valuable part of my story about healing my knees is this, I think:

I devoted one year of my life to an intensive, well-documented experiment to “save” a pair of knees that a doctor grimly informed me were beyond saving.

I was so serious about this experiment that I even quit my full-time job (sitting too much was one of the obstacles to healing, I had discovered).

Why did I do all this?

Chiefly, for two reasons:

(1) I wanted to prove that doctors (and others) who say damaged cartilage and joints can’t heal are just plain wrong.

(2) I wanted to prove that the right way to heal was not to worry about your muscles (at least not initially), but to focus on easy, high-repetition exercises that your joints like (this is an approach I took directly from the writings of Doug Kelsey at Sports Center).

And here I am, some five years later, with two knees that feel perfectly normal.

The fact that I had success, bucking conventional wisdom, made me want to shout my story from the rooftops (hence the book and the blog).

But let me be clear about what that one-year experiment meant, as I see it. It wasn’t “You too can heal your bad kness if you quit your job and do exactly what I did.”

I see it more like “proof of concept.” I went to extremes (quitting my job, manically counting the steps I took, keeping a highly detailed knee journal) to show bad knees can heal naturally.

That doesn’t mean you can’t heal yours unless you quit your job and log every step you take. Rather, it means, simply, that healing is possible -- and I would argue, the right program is one of light-load, high-repetition motion. As for the particular details of what you need to do, well, that depends on your particular knees, doesn’t it?

I realize that’s frustrating for some people to hear. Many knee pain sufferers want a specific blueprint for getting better: what kind of exercises, how many of each, how many times a week. I don’t offer a blueprint, but rather an outline into what matters -- and the insight into why I think it’s important.

Knowing you can get better -- that the pessimism and negativity and “surgery is your only option” attitudes are wrong -- isn’t that a great message?

On Hope, and One Reason I Write This Blog

I got a really neat comment recently (edited a tad for length etc.):

I stumbled upon your book whilst spending hours online searching for advice on chronic knee pain. You have given me a sense of hope I had all but lost. I have recently been told I have irreversibly damaged the cartilage in my knees, told there is nothing I can really do, advised to take glucosamine and to strengthen my quads with exercises I cannot possibly contemplate at the moment. It seems such a relief to hear your story.

I am in the depressed, downward spiral of thinking that, at the age of 41, is this it? How am I going to live like this when even climbing a set of stairs is a challenge? I used to thrive on exercise and being active. To have this unwelcome change in my lifestyle has been extremely difficult to cope with, especially as I have two young children and a wonderful husband I want to be enjoying life with. I just want to thank you for taking the time and effort to share your story. You have given me a glimpse of a hope I had all but lost and well-balanced, well-researched advice I am going to attempt to follow. I know the road is very long with many likely falls along the way but to hear that it can be done inspires me in a way I haven't been for some time. Thank you.

Wow. Thank you.

Sometimes, I confess, I feel a bit remote from this blog. Namely: I had chronic knee pain. But I managed to fix it. And the memory of the hole I was in has started to recede.

Then, every once in a while, I get an uplifting, heartwarming comment like this that says to me:

There are millions of people out there who are going through what you once did. They’re scared too, trying to figure out what to do. Some are over 40, as you were, and maybe they too were essentially told, “Ah, you’re just getting old; learn to live with the pain.” Many are getting the same bad advice you did (such as to focus on “strenghtening the quads” when, as Doug Kelsey of Sports Center notes, “having stronger muscles is helpful but weak muscles are not the primary problem”). So don’t stop spreading a message of hope!

I still recall a phone conversation I had with my father, back when I was living in Hong Kong, trying like hell to heal my bad knees -- and succeeding.

My voice was shaking with anger. I was talking about my experience with my knee doctors. I was most upset with them because, after a physical exam would reveal no major structural problems, each would more or less shrug when asked what could be done about my knee pain.

Of course one said that sometimes patients with knee pain get better, sometimes they don’t. So I followed up with what seemed like a logical question: Why do some get better? But he wouldn’t answer.

Later, thinking about that scene, I got irritated. Hell, if I was a knee doctor, and my mission was to heal, and some of my patients improved while others got worse, I’d be lying awake in bed every night, thinking:

Why? What are the ones who heal doing differently? Or what’s different about them?

One of the most inspiring messages I got from Doug Kelsey early on was this response to an imaginary comment from a doctor:

"Well, you have arthritis. Your knees are just wearing out and there's really not much you can do about it."

Hogwash. Hooey. Balderdash. It's just nonsense.

Kelsey's rejection of the gloomy fatalism that bad knees will be bad knees, and only get worse if anything, was for me very encouraging. It helped convince me that I could heal. And I did.

Taking away hope, wrongly, from a suffering patient is a terrible thing to do.

Wedge Shoe Inserts: Another Dud for Those Seeking Knee Pain Relief

One purpose of this blog is to celebrate what medical science shows works for knee pain while deprecating what doesn’t. (Note: with the caveat, of course, that even treatments/supplements/devices that have failed to withstand the withering scrutiny of scientific researchers will still have adherents who swear that “X” helps for their particular knees, science be damned.)

In that spirit (my addition in brackets), note the lead of this article:

Lateral wedge shoe inserts don’t appear to relieve knee pain in patients suffering osteoarthritis of the knee [that happens to be on the inner part of the joint], a new study finds.

Now, this wasn’t just any old study. Rather, it was the more powerful variety: a “meta-analysis” of existing studies. Such a review is potent, when done well, as those conducting it can choose to discount or disregard studies that are somehow flawed, leaving them to analyze the highest quality data. So the findings of a meta-analysis generally should carry more weight.

Why in the first place did anyone think lateral wedge shoe inserts would relieve knee pain?

Well, the thinking goes like this:

A wedge for the outer part of the foot will reduce the load on the inner part of the foot (and hence the inner part of the knee joint). Simple enough. And not such a far-fetched notion. It reminds me of the argument for kneecap taping to remove some stress from the injured area.

But when the researchers evaluated 12 studies involving 885 subjects, they found no proof that lateral wedges, inserted in shoes, were effective for knee osteoarthritis. So now you can save $10 to $500 (the price for wedges, from the cheapest off-the-shelf insoles to an expensive customized pair).

However, it may still make sense for doctors to recommend the inserts on a “case-by-case” basis, says Robert Shmerling, an associate professor of medicine at Harvard Medical School. “Even though the average response was no different between wedge insole users and non-users, individual response can vary.”

Yup. I’m a science-minded guy, but he’s got a point. Treatments that don’t work for 99 percent of us may work for some people in the other 1 percent.

For example, evidence is building that glucosamine is probably ineffective, yet some people still claim to be unable to function without it. I recently complained about physical therapists who prescribe one-legged squats for weak knees, which I think is pretty stupid, but a commenter said doing one-legged squats fixed his ailing knees. If someone were to advise knee pain sufferers not to do jumping jacks while wearing a backpack full of lead, I’m sure someone else would protest that he healed his bad knees by doing jumping jacks while wearing a backpack full of lead.

When it comes to ways to beat knee pain, it just goes to show you can never say never.

The Treadmill Desk, and the Importance of Motion

There was a cool article in the New Yorker earlier this year titled “The Walking Alive” by Susan Orlean.

It was about what appeared to be a small movement in the workplace to ditch the traditional sit-down desk in favor of moving while working.

The centerpiece of the article, the “treadmill desk,” isn’t a piece of heavy-duty cardio equipment. You walk at a pace of only one to two miles an hour, so you shouldn’t be laboring for breath or having trouble typing while at your “walking workstation.”

The first official treadmill desk was introduced by Steelcase, an office furniture company, in 2007. It costs more than $4,000. Other manufacturers include TreadDesk, TrekDesk and Exerpeutic.

Dr. James Levine -- who specializes in “inactivity studies” -- helped design the original Steelcase model. Levine, the article tells us, began thinking about walking back in 1999, after he did a study at the Mayo Clinic.

The study looked at why some people gained weight while others didn’t, even when they ate the same amount (and presumably “exercised” the same amount too). The subjects were observed with what Levine refers to as “an atrocious amount of detail.”

A curious finding was made. The non-weight gainers did move more than the others, though in subtle ways. They fidgeted, jiggled their legs, paced, stood on the balls of their feet. All this quiet restlessness burned as much as 800 calories a day!

So the treadmill desk puts sedentary office workers into motion. Why that matters is beautifully captured in this passage about the harmful effects of sitting a lot.

Sitting puts muscles into a sort of hibernation, cutting off their electrical activity and shutting down the production of lipoprotein lipase, the enzyme that breaks down fat molecules in the blood. Your metabolic rate drops to about one calorie a minute -- just slightly higher than if you were dead. Sitting for more than two hours causes the presence of good cholesterol to drop, and, in time, insulin effectiveness plummets. This can lead to cardiovascular problems, certain kinds of cancer, depression, deep-vein thrombosis, and type-2 diabetes.

I like the idea of the treadmill desk, partly because it’s easy motion. Easy motion, small steps, light loads on the joints -- all seem smart to me.

Now, is a treadmill desk a good idea if you have chronic knee pain?

Maybe, but I’m guessing probably not.

The desk may be a good idea to prevent chronic knee pain, but when you already have it, too much movement can overwhelm tender joints. I recall my own experience in Hong Kong when I realized that motion was critical to healing bad knee joints. I tried moving pretty much nonstop: shuffling along, walking for hours. And my knees got worse.

Still, I really like the idea of the treadmill desk. Get off your butt. Start moving. And meanwhile, get all the desk work done that you need to.

What’s not to like? And if the price tag is too daunting, the New Yorker tells us that a number of Web sites offer instructions on building your own model, using an ordinary treadmill and IKEA components or even milk crates and doors.

When Doctors Don’t Give You the Information You Really Need

A personal story:

My wife recently took our son Elliot (the latest addition to the family!) in for his two-month checkup. The pediatrician pronounced him healthy, then out came the needles. The two-month checkup could be called the Vaccine Barrage: he got a total of four.

Congyu received a four-page document titled “Your Baby’s First Vaccines.” It contained a lot of information: how vaccines work, which diseases they prevent, when children should get routine vaccines, the various risks of different ones.

The handout also included this:

Most vaccine reactions are mild: tenderness, redness, or swelling where the shot was given; or a mild fever. These happen to about 1 child in 4. They appear soon after the shot is given and go away within a day or two.

The pediatrician told my wife (I was at work at the time) that our son might develop a fever later that day.

Then she left the doctor’s office, missing at least one crucial bit of information.

Can you spot it?

Hint: It has to do with that fever.

Give up? Okay, here it is:

If he does have a fever -- which appears to be not uncommon -- at what point should we be concerned? And here, I’m talking about a real, concrete number. 100? 101? 102? 103? 104?

After all, some children have severe allergic reactions to vaccines, with dangerous fevers that can spike to 105. Also, Elliot is at an age when what would be a “mild” fever for an adult is considerably more serious. Plus, Congyu said that after giving birth, and before her discharge from the hospital, a doctor told her that a temperature exceeding 100.4 degrees was very dangerous for our small child.

I think you can tell where this is going.

Sure enough, that afternoon his temperature was elevated. That evening, a rectal reading (which is regarded as the most accurate way to measure) indicated he was running a fever of 100.9.

So, as concerned parents, what should we have done? Should we have heeded the warning of that first doctor who somberly informed Congyu that a temperature of more than 100.4 was very bad for an infant? Or should we have just accepted that Elliot had a fever, as was predicted, and it was no big deal? Might it be that a 100.9 degree virus-induced fever was a matter of concern, but not a vaccine-induced fever at the same temperature?

How could we know? We were never told.

So we did what most responsible parents would do: We called our pediatrician’s 24-hour help line. The doctor on call heard me out, as I related the details of my son’s condition, then told me not to worry. If we wanted to bring down the fever, we could give Elliot a lukewarm sponge bath, or a small amount of children’s Tylenol (which, incidentally, are other helpful details that we never got -- what to do for the fever, if the child has one).

So there you have it: A four-page handout, a doctor’s advice ... neglecting a critical piece of information -- the actionable “what do I do if a certain condition exceeds a certain level”? Because if I had called that help line, and told the doctor my son’s temperature was 103, or 104, I bet I would have gotten a different reaction. Because clearly the doctor had some (undisclosed) algorithm at work in his head that went like this, “A fever of less than X, just tell the patient not to worry.” What was the magic number X though?

Again, we were never told.

Now what does this have to do with bad knees?

Have you ever been to a doctor who, after examining your knees, recommends that you “avoid activities that cause pain.”

You nod. Sounds sensible. Then, sometime after leaving, you start to wonder: “What the hell does that mean exactly?”

Does he mean just intense pain? What about the mild pain you experience from climbing stairs? And if you have to avoid climbing stairs, what do you do exactly? Or what about if you don’t have pain during an activity, but immediately afterward? Or what if you don’t have pain until the next day?

Granted, these are harder questions than, “At what temperature should I seek medical help if my two-month-old child has a vaccine-induced fever?” But they’re some of the most important questions facing patients whose knees hurt all the time.

Back when I had bad knees, I don’t recall ever getting any good guidance from doctors on how best to “avoid activities that cause pain” while going about my everyday life. That’s a shame. Whether it’s this sort of information -- or specific advice about when to be concerned about vaccine-induced fever in a young child -- I think physicians can do better.

Chronic Knee Pain: The Great Impostor (and Mystifier)

In the comments section, TriAgain (a regular reader) recently asked me an interesting question. Do I think I might have had “complex regional pain syndrome” when I was struggling with a pair of knees that often burned?

“Complex regional pain syndrome” ... it faintly rang a bell. My curiosity piqued, I looked up this definition:

Complex regional pain syndrome (CRPS) is a chronic pain condition most often affecting one of the limbs (arms, legs, hands, or feet), usually after an injury or trauma to that limb.  CRPS is believed to be caused by damage to, or malfunction of, the peripheral and central nervous systems.

Yeah, but what are the symptoms, I wondered. So I read on:

The key symptom is prolonged pain that may be constant and, in some people, extremely uncomfortable or severe. The pain may feel like a burning or “pins and needles” sensation ... The pain may spread to include the entire arm or leg, even though the precipitating injury might have been only to a finger or toe. Pain can sometimes even travel to the opposite extremity.

Okay, with you so far. Then I hit this section:

People with CRPS also experience constant or intermittent changes in temperature, skin color, and swelling of the affected limb ... The skin on the affected limb may change color, becoming blotchy, blue, purple, pale, or red.

Other common features of CRPS include:
* changes in skin texture on the affected area; it may appear shiny and thin
* abnormal sweating pattern in the affected area or surrounding areas
* changes in nail and hair growth patterns
* stiffness in affected joints
* problems coordinating muscle movement, with decreased ability to move the affected body part, and
* abnormal movement in the affected limb, most often fixed abnormal posture (called dystonia) but also tremors in or jerking of the affected limb.

Uh, nope. Pretty sure I didn’t have that.

So why did I describe TriAgain’s question as “interesting” if this syndrome appears to have no relevance to my former condition? Because I know exactly what’s he’s going through.

When I had knee pain all the time, I Google’d everything under the sun, trying to figure out what was going on with me. I skimmed articles about conditions with long Swedish names that contained funny-looking vowels. I even had a blood test for rheumatoid arthritis (which I passed with flying colors), as a I recount in my book.

Why so much confusion about a pair of damaged joints?

Here’s my best guess as to what happens with a lot of chronic knee pain patients (note: of course some may have complex regional pain syndrome, or rheumatoid arthritis -- or some other condition -- as their primary problem; I don’t mean to discount that possibility).

You start out by having simple knee pain, but as time goes on -- and as your body enters a long-term inflammatory state -- you notice other problems that seem more systemic, or not related to your original localized pain, and you discover your knees seem sensitive to non-physical stressors, such as emotional stress or depression.

Okay, I’m kind of spitballing here, making a guess based on my own experience and personal accounts I’ve read by others. But it seems this progression, from basic knee pain to something more elusive and insidious, is not uncommon.

Now, what if this is indeed true? What if many of us suffer from bad knees + something systemic that is weird and hard to figure out? (note: again, this assumes that the systemic stuff isn’t your main problem -- e.g., you don’t have a disease like rheumatoid arthritis). What to do?

Well, I’m not sure what you can do about the systemic issues or even what they are exactly. However, fixing the damaged knees -- that (once again) I think requires a long, slow program of gradually increasing load on the joints.

My best guess is that, if you fix the bad knees, the weird systemic stuff (the nettlesome “ghost in the machine”) will go away, at least in most cases. It did for me anyway!

Does Sleeping Poorly Worsen Knee Pain?

Variations of this story popped up recently in my Knee Alerts from Google.

In brief, University of Alabama at Birmingham researchers are recruiting patients with knee osteoarthritis for a study looking at how sleep problems may influence knee pain.

“There is growing evidence that poor sleep can itself lead to an increase in pain,” according to Megan Ruiter, who’s involved in the effort.

“Treating sleep to modify pain may allow more options than simply treating pain at the source, which is often extremely difficult,” she said.

Welllll ... I’m not sure that treating knee pain at the source is “often extremely difficult.” There are challenges; it takes a while to achieve real, lasting gains. But what’s that saying about if you’re a hammer, everything looks like a nail? Well, whatever the sleep researcher version of that adage is, that may be good to keep in mind here.

Still, I wouldn’t be at all surprised if the study finds a link between sleeping issues/disorders and higher levels of knee pain. I think bad knees can be highly sensitive to a whole bunch of things, from approaching storms to not getting a full night’s rest. Plus, remember: our bodies need those hours of sleep to rest and recover when injured anyway.

Which reminds me: Someone once asked me which sleeping position I think is best for bad knees. My answer (from my own experience) is here; this became one of my most popular posts. In short: I found that, at least with my knees, it didn’t matter too much which position I slept in (besides, you can fall asleep on your right side and wake up on your back anyway).

The important thing, to me: Make sure you get enough sleep, whether you prefer sleeping on your side, your back, or upside down on your head. Try to stay well-rested. It may seem like a little thing, but the little things count.

Yet Another Study Showing Why It’s Smart to Lose Weight

Yeah, I know I’ve beaten on this drum many times.

I know many people react to the advice “lose weight” with an eyeroll, because it’s not as though they haven’t heard that before.

But it’s sometimes useful to show that excess weight does more than simply worsen pain. It causes actual physical damage inside your joints, as this study shows:

Higher levels of body fat were tied to greater knee cartilage losses in older adults, a recently published study found.

There were 395 adults who took part, average age 62. They had changes in the cartilage volume of their right knee measured over three years. Their fat and muscle mass levels were also recorded.

Subjects who lost the most cartilage had a higher BMI and more body fat and trunk fat. On the other hand, muscle mass was found to be protective against cartilage loss.

(Note on the second point: no big surprise there. As I’ve said before, it would be a big surprise only if stronger leg muscles didn’t to some degree protect your knees. However, again, the real question is what you should do once your knees are injured -- and focusing on your, say, quad muscle mass shouldn’t be your chief concern at that point, it seems.)

So once more, this time with feeling: Lose weight for happier knees! As an added benefit, you’ll look and feel better overall.

ARGH!!! Your Blog Looks Different!!!!

Anyone with this reaction?

So: I got tired of the rather dull look of the old blog and decided to spiff it up a little. (I'm more of a blue guy than a pale orange guy, or flesh-colored band-aid guy, or whatever that old color was.)

Now, as a former newspaper man, I know that whenever a familiar design is changed, the complaints pour in. Just try to go easy on me. I'm not a design whiz at all. I can barely color co-ordinate my wardrobe in the morning.

The font is bigger for those with weaker eyesight (bigger font sizes are cool, I think, whereas who wants to go to a website and squint all the way through tiny, closely packed text?)

If there are issues with readability though, please weigh in. Or, if any of the new colors induce epileptic seizures, well, that would be another reason to weigh in. Or, if you just think you have a better idea (narrower columns! wider columns!) about how to improve the appearance, let me know about that.

Otherwise, well, life is all about change, right? :)

Update: I changed the image in the borders. That blue was too overpowering. This design feels a bit more soothing.

What Is the Relationship Between Bad Cartilage and Knee Pain?

Everyone who knows my story of recovery knows this part:

I finally surmised, based on the evidence, that cartilage damage was causing my knee pain. I then set about trying to heal and strengthen the tissue through a long, slow program of high-repetition movement -- easy at first, then progressively harder. Happily, I succeeded.

When I share with others this cartilage-centric view of the origins of knee pain, I sometimes get a response like this:

How can you say cartilage problems necessarily cause knee pain? People with significant defects can have no pain, while others who have cartilage that looks normal have lots of pain. That shows that cartilage isn’t the problem!

I thought it would be good to address this line of thought, head on. After all, even Scott F. Dye, whose “envelope of function” perspective I much admire, noted (in support of the anti-cartilage viewpoint) that he has “documented grade III chondromalacia” (one level from grade IV, or worn to the bone) that is “totally asymptomatic.”

True, cartilage probably isn’t a factor in all chronic knee pain. However, I think it often is, and the argument above (in italics) misses several critical points.

(1) The correlation between the apparent condition of someone’s knee cartilage and pain in that same joint isn’t perfect, but it undeniably exists.

Quick test of common sense: You have 100 people who have thin knee cartilage that’s pockmarked with lesions. You have another 100 people who have normal-looking knee cartilage. Which group do you expect to have more cases of knee pain?

Okay, that answer is glaringly obvious. Even so, why isn’t the correlation between the presence of lesions and the incidence of pain closer to 1? I think there are several reasons, such as #4 (below).

(2) Bad cartilage is so consistently found in osteoarthritic knees that on the MDGuidelines website it says “loss or damage of articular cartilage is an early finding in osteoarthritis.”

Still, is all chronic knee pain osteoarthritis, or a precursor to osteoarthritis? Not necessarily. However, listen to a description of why chondromalacia causes pain:

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)

Got that? So the problem isn’t the cartilage, but the bone. But the bone is a problem because the cartilage is too thin. So the problem actually is the cartilage.

(3) Sometimes quality matters more than quantity.

This may answer the question: How could someone with cartilage that appears normal have knee pain that’s caused by bad cartilage? Two things to note here:

First, I bet that the normal-looking tissue isn’t being directly inspected, but rather viewed indirectly such as by an MRI. MRIs are good, though imperfect -- so they may not detect some early-stage defects.

Second -- the big point -- a test such as an MRI (at least a traditional MRI) will not give you very good feedback about the stiffness of that cartilage or its other qualities. Why that matters: An athlete may have asymptomatic lesions because the rest of his cartilage is pretty stiff (I use “stiff” to mean in a good way), while someone with lesser defects may have problems because the tissue is too soft and beginning to flake apart, or is poorly mediating the forces being transferred into the joint.

(4) Cartilage has no nerves!!!

This greatly complicates the effort to draw lines between cause and effect. Example: I stab you in the arm with a needle; you cry “Ouch!” I stab your articular cartilage with a needle; you feel nothing.

So it’s not the existence of a hole in the cartilage that causes problems, it’s the impact of the existence of that hole (and what’s going on in the tissue around the hole) on nearby structures that causes problems. And that is more difficult to suss out.

All the reasons above, I think, provide good support for the position that cartilage damage often does contribute to long-term knee pain. And even a skeptic has to admit that cartilage plays a critically important role in a knee joint. So keeping it in good health -- and knowing how to (slowly) make it stronger -- matters a lot.

So What’s a Nice Financial Journalist Like You Doing in a Blog Like This?

Recently I was amused to discover my story being discussed here, among what appears to be a group of Australian triathletes. Many were dismissive.

The criticisms of the writing at this site (“so annoying”, “punishing to read”, “I could not make it through the first two paragraphs of that guys blog”), well, what can I say? I try not to be insufferably dull, or frightfully obvious, but look: I never promised you guys Faulkner. Remember, I write most of this at work, during my lunch break. :)

The other criticisms were familiar. One went along these lines:

Great, the guy rested his knees, gradually went back to a pain-free activity (walking), and got better. Whoop dee doo. Seems like common sense to me. Listen to your knees, time heals, be patient, yadda yadda. Not gonna blow 10 bucks on that book, mate.

Well, sometimes common sense can be surprisingly uncommon. But it’s not like you can sit around and rest for two weeks, then start a walking program, and a year later -- presto! -- you’re all better. Beating knee pain is much, much trickier than that. (I won’t rehash all the obstacles to getting better; here’s my latest summary on what I did.)

One quick example: “Listen to your knees” won’t work if you don’t account for the “delayed symptom” effect. When I felt miserable because my knees burned all the time, I would’ve happily paid someone $20 for an explanation of how that works, as it shows the damnable difficulty of listening to your knees the right way. (Most people, I think, “listen to their knees” the wrong way -- if the knee hurts during an activity, or right after, don’t do the activity. I never would have healed had I remained at that basic level of understanding.)

The other criticism (the one I really want to write about) goes like this:

The guy’s a financial journalist. Give me a break. You’re taking advice about how to heal your bad knees from some journalist who just surfed the Internet for a while. Good luck with that!

Ah. So the degree from Harvard merits no love. ;) (Okay, okay, it’s in government, not in orthopedics.)

Anyway, anyone about to write me off as someone blogging about things that he can’t possibly know about should consider the following:

(1) I quite regularly cite experts, and clinical studies, to support what I say. Much of what I believe comes straight from these sources.

It’s not like, in Joseph Smith-like fashion, I had a miraculous revelation of how to heal bad knees. Hell no. I did a lot of high-quality reading.

The same clinical studies your orthopedist has access to, I managed to dig out of the crevasses of the Internet. And while your orthopedist might have read the study once, I maybe read it five times. Because I had a lot at stake. I simply couldn’t imagine spending the rest of my life with chronic knee pain.

I found experts -- minority voices, true, but very intelligent people -- who suggested a better way than that espoused by traditional physical therapists. People like Doug Kelsey, and recently, doctor Scott Dye. The gist of their thinking was pretty much common sense. Instead of focusing on your quads, hips, butt (or whatever seems too weak or too tight or out of balance), you need to slowly improve the health of your knee joints, so they can comfortably tolerate greater and greater loads.

(2) If you’re the type that emphasizes degrees and qualifications above all, well, it’s not like you're listening to an illiterate street sweeper opine about the best way to do open-heart surgery.

For more than two decades, I’ve been a professional journalist. Every day, we journalists read and analyze and synthesize disparate bits of information from a multitude of sources. By occupation, and often by nature, journalists are reasonably bright generalists with some talent in using language well and precisely.

Now, admittedly, Saving My Knees isn’t only me writing as an objective journalist. The subjective me is present throughout, because it’s unabashedly my story. But I did try to choose my words carefully, and at the book’s conclusion, I undertook a weeks-long checking of facts, line by line, to ensure the material was accurate.

(3) The traditional view held by a majority of experts can be wrong. They’re only human, after all.

Image this conversation at Ye Olde Boar’s Head, say from the year 1820.

Nathaniel: Abigail! How are you?
Abigail: (coughing) Not so good. Still the pneumonia.
Susan: But surely you have been seen by a doctor.
Abigail: Yes, just this week, Doctor Perkins. He advised bloodletting.
Susan: And what were the results?
Abigail: (looking guiltily away) I don’t know. I didn’t have it done.
James: Monstrously stubborn woman you are, Abigail Smith! Perkins is the third physician to advise bloodletting for your pneumonia. And you refuse to listen. I have little sympathy for you, ignoring modern medical thinking. Everyone knows bloodletting is the best way to cure pneumonia. Why such obstinacy, woman?
Abigail: Well, I was talking to Horatio Adams, and he professed the belief that bloodletting was probably useless for pneumonia. He said a few doctors he’s spoken to are questioning the practice. He cured his pneumonia, he said, without bloodletting.
Susan: Horatio Adams! My goodness!
James: Horatio Adams, who writes for the Gazette, all those gasbag stories about how many tons of flax and tea moved through the port over the past month!
Abigail: Yes, he explained everything to me, the research he’s done --
James: Poppycock! Don’t listen to a financial journalist who tells you bloodletting is useless for pneumonia. Listen to your doctors, woman!
Susan: Bloodletting useless for pneumonia? What a crazy idea.

Okay, obviously I’m having some fun here.

The bottom line is this though:

At the end of the day, I could be completely wrong about everything I believe about healing bad knees. But so could the experts. It’s happened before.

What’s the Biochemical Basis for the Success of Continuous Passive Motion?

When it comes to dealing with knee pain, I believe strongly in the beneficial effects of motion. I often prefer the word “motion” to “exercise,” as the latter conjures up images of fitness buffs doing strenuous activities that may not be good for bad knees. Move, move, move (in the proper amounts, in the proper ways).

For those recovering from surgery (or maybe even for those who just have really bad knees), I think continuous passive motion can be a great idea. In Saving My Knees, I mention the experiments on rabbits that Robert Salter performed more than three decades ago. Salter discovered that the cartilage fell apart in rabbit knees that were immobilized, while the tissue improved in knees that were constantly flexed using a CPM device.

So continuous passive motion works. But why?

Well, one advantage of having a blog that’s read by lots of smart, well-informed people is that I’m constantly being alerted to interesting studies. Like this one from 2005: "Anti-Inflammatory Effects of Continuous Passive Motion on Meniscal Fibrocartilage." It’s another rabbit study, and one of the researchers is Salter.

Arthritis was induced in all the rabbits’ knees. It appears that the knees of half the animals received CPM for 24 or 48 hours, while the joints of the others were immobilized.

While rabbits certainly aren’t people, one “advantage” of experimenting on them (or disadvantage, if you’re one of the rabbits) is that their cartilage can be “harvested” for close-up, thorough inspection at the study's end because they’re generally euthanized.

What the researchers discovered were changes that may shed light on the biochemical reasons that CPM works (caveat: again, I’m reduced to summarizing an abstract because the full study lies behind a paywall).

Even after a timeframe as short as a day or two, the study noted significant differences between the knees that moved all the time and those that didn’t move at all.

The immobilized knees:

* Showed “marked GAG degradation.” GAGs, of course, are glycosaminoglycans, which contribute to the strength and resiliency of cartilage (Saving My Knees explains in more depth why glycosaminoglycans are important).

* Had higher levels of three different molecules that contribute to inflammation.

Knees that underwent continuous passive motion exhibited the converse of both these trends: there was a “rapid and sustained decrease” in glycosaminoglycan breakdown, and fewer molecules involved in inflammation were found. What’s more, CPM led to synthesis of an anti-inflammatory molecule.

The researchers conclude:

These studies explain the molecular basis of the beneficial effects of CPM observed on articular cartilage and suggest that CPM suppresses the inflammatory process of arthritis more efficiently than immobilization.

Now here’s my hunch:

Those molecular-level benefits of continuous passive motion will be found, in future studies, to apply to motion more broadly, and to knees more broadly (not just the ones that are post-surgery or arthritic). And that would be pretty good news for people battling chronic knee pain who are looking for a way out of the trap they’re in.

To Beat Knee Pain, You Don’t Have To Be Crazy, But It Helps

Time to tell a story on myself.

A friend of mine works out at the same gym I do. She often hops on one of the many cardio machines arranged in long rows near the front desk -- giving her a vantage point that lets her observe the club’s members as they first enter the workout area. Not long ago, she said to me something like:

“Every time you come in, you get some paper towels, then weigh yourself. Every single time. It’s funny.”

Yep.

It’s very much true. I’m a creature of habit.

Partly, I think, this sort of behavior arises from a desire to know what to expect in life. This pays off in mundane ways. For example, I don’t enjoy hunting high and low for lost keys. So I put them in a special place in the apartment. All the time.

So instead of muttering about my lost keys and roaming rooms in a fit of pique for 10 minutes, I can scoop up the keys and spend those 10 minutes doing something I enjoy.

Of course, not to paint this characteristic as all virtuous: there is a decidedly anal tendency at work here. Sure, it makes sense to get your paper towels right before your workout, before you leave sweaty palm prints on the handlebars of the stationary bike. But, even if you believe it’s a good idea to maintain a stable weight, do you have to weigh yourself three times a week?

Nah. Not really.

I’m just curious about how my weight fluctuates and, well, it’s a habit. You know.

What does all this have to do with winning the knee pain battle?

A lot, actually.

I developed a number of “healthy knee” habits while I was hurt and trying to recover. Like, for example, wearing a pedometer. This became such an ingrained habit that if I left my apartment building to go on a journey of more than a few hundred steps, and I wasn’t wearing my little blue step counter, I would stop in mid-stride on realizing my error.

And turn around and go get it.

Another habit, of course, was my daily walking. I was consistent about doing it, and making sure I did exactly the self-prescribed amount (in other words, I wasn’t walking 4,000 steps one day, 6,500 the next -- I stuck to one distance, until my knees were strong enough to graduate to the next level). I also walked the same old routes (which sounds boring, but helped me because, if I had an onset of knee discomfort, I knew it wasn’t because I had strayed from my routine and say walked up hills instead of over flat terrain.)

Dull.

Predictable.

But effective.

I think it’s effective because your knees know what to expect (no surprise 10-mile hikes). At the same time, you come to know what to expect from your knees (what makes them happy, what makes them grumble). And step by step, they start to grow stronger.

Not everyone is as “crazy” as I am, I’m sure, when it comes to their daily routines. Still, if you’re trying to beat a stubborn foe like knee pain, being a little crazy may not hurt.

Does a Structuralist Viewpoint Sometimes Make Sense?

Here’s a different study from the kind I normally cite:

Researchers in Sweden followed 75 junior elite basketball players, ages 14 to 20, over the course of a year. At the outset, they measured each player’s range when flexing his or her foot toward the shin.

The less flexible subjects had as much as a 30 percent risk of developing “patellar tendinopathy” (also known as “jumper’s knee”), compared with a 2 percent risk among the players who were more flexible. A dramatic difference, surely.

So what accounts for this? Could the study itself be flawed? Is it significant that the subjects don’t represent the broad population, but rather a taller-than-average subgroup of still-growing teenagers who were subjecting their knees to harsh physical demands?

Maybe. But what if -- at least for this population, and this condition -- the structuralist analysis makes the most sense. And, moreover, what if they should stretch (something I generally don’t believe is worthwhile)?

Now here’s the crazy thing about me: At any time, I’m willing to concede that all of what I believe may not be true (or, more likely, some of it may not be true). The epigraph to my book, remember:

The greatest obstacle to discovery is not ignorance -- it is the illusion of knowledge.

So it behooves curious, truth-seeking creatures to embrace flexibility of thinking, instead of stubborn certainty. Anyone who reads this blog a lot probably thinks of me as “that guy who hates structuralism.” Which isn’t quite true.

I dislike structuralism as the grand omni-explanation for nagging knee pain. It basically had nothing to do with my knee pain or how I fixed it. And, after doing a lot of research on the matter, I’m pretty sure it has nothing to do with a lot of other cases of chronic knee pain.

Still, show me a man with one leg six inches shorter than the other, who decides to take up running regularly, and I’ll show you a man who’s on his way to developing knee (and other) problems. At the extremes, structure certainly does matter.

Then you have the rest of us.

There is an enormous amount of variability among human beings. Obviously, we easily perceive the difference between the physique of person A vs. person B. But the concept of variability also applies to within the same individual as well, with regard to symmetry.

A famous example relates to eyes: We all typically have one eye bigger than the other. But this touch of asymmetry is surely true to some degree of our arms, legs and other bilateral structures as well. And some of us have another kind of variability: stronger quads than normal vis-a-vis calf muscles, or weaker gluteus vs. hip muscles -- or whatever.

Extreme deviations from the norm will naturally cause problems (e.g., the leg that is six inches longer than the other). Minor differences (such as a leg only 1 cm longer than the other) have been shown usually not to matter. Could, however, a certain amount of deviation from the norm, for certain anatomical structures, predispose a person to injuries/problems, at least somewhat?

Hmm. It sure seems likely. It passes the common sense “smell” test, if you will.

Given that, imagine two people, Jack and Tom. Jack can train by running 50 miles a week, no problem. But say that Tom -- because of a small difference in leg lengths, a slightly abnormal curvature of his spine, thicker bones, and a few other factors -- can run only 35. But he gets inspired by his friend Jack and starts training like him, running 50 miles weekly, and winds up with painful knees.

Now comes the interesting part. I’ve created a scenario where structure does matter (some). But what’s the most sensible way to treat poor Tom?

(1) Painstakingly go through and try to identify all the structural influences that may have predisposed him to the injury, correct them when possible (obviously you can’t change the thickness of his bones), then cross your fingers that you identified all the important factors and hope he gets better?

(2) Get Tom to work within an “envelope of function” so he doesn’t overstress his joints, and try to slowly expand that envelope over time, so he is comfortably running whatever number of miles a week his particular body can handle?

To me, #2 seems generally like a much smarter, more practical approach -- even if you believe that biomechanical (or structural) factors contributed in some way to his injury.

On Being a Sample Size of One

I recently finished reading a statistics “textbook” for fun (“textbook” is in quotes because it was one of those “make learning enjoyable” books, thus diminishing the nerd factor of the achievement). I had always wanted to take a stat course before. Expectation, variance, binomial and Poisson distributions ... I thought it was all pretty cool stuff.

One thing you learn when studying statistics: How to quantify the probability that an observed outcome for a trial/study/experiment is significant. In other words, is it likely that some causal agent A led to some outcome B, or were the study’s results probably due to chance?

One thing that helps in making this determination: sample size. The larger, the better.

Which brings us to my personal knee experiment. What does it mean to be a sample size of one?

Well, from a professional statistician’s viewpoint: not much. A sample size of one is a joke. Where are your control subjects? How could you possibly calculate, say, margin of error?

So what does it mean to say that, in a tightly controlled experiment, I improved the state of my knees by doing x and y, when I was the only subject in the experiment?

Again, statistically: not much.

But there’s another way to look at this.

And that’s by considering the likelihood that a given experiment can actually prove cause and effect.

See, it doesn’t matter if you have 100,000 subjects in a study, if that study is poorly designed and/or poorly executed, making it impossible to isolate cause and effect with a high degree of confidence. The study’s researchers may think that they have reached a conclusion that A leads to B (or doesn’t lead to B), but this is a dangerous sort of illusion if the study is fundamentally flawed. Long-term knee studies of the type, “Activity X is good/bad for knees” are especially prone to this problem. In Saving My Knees, I take a close look at one.

I won’t retrace that ground here. But consider an example to help illustrate what I mean: Suppose you run a one-year study in Smallville to see if daily swimming helps really bad knees. You believe that to be true, but at the end of the trial, you’re puzzled to find the swimming group actually does worse than the control group -- in a statistically significant way too. You publish the results.

“Swimming adversely affects knee joint health,” you proclaim.

But -- what if you discover the Smallville swimming pool is on the sixth floor of a building that has no elevator? And for the subjects in the study, who have really bad knees, climbing all those steps is too much for their joints?

This is the kind of problem you face in a study when important variables aren’t tightly controlled. Granted, my example is a bit extreme and far-fetched, but what’s undeniable is that, in studies that attempt to show “Activity X helps/hurts bad knees,” for about 98 percent of the time (during waking hours), the knees of the subjects will NOT be engaged in Activity X. And what they’re doing during that 98 percent of the time -- whether it’s ill advisedly climbing six flights of stairs or kneeling to scrub a floor or running to catch a public bus -- can be vastly significant and skew the results in a big way.

There are other flaws of long-term knee studies that attempt to show causal relationships, which are independent of sample size. In Chapter 8 of Saving My Knees, I mention some more.

My experiment, on the other hand, was closely observed and very well-controlled when compared to a typical study into what helps/hurts knees. Now you can argue that doesn’t matter -- that I have the constitution of a space alien, or that my patellofemoral pain syndrome was wholly unlike anyone else’s, so what I did to cure my bad knees won’t help others.

Of course, I would disagree. Further, I’d argue that sometimes you can learn a lot more from a one-person experiment that’s very well-conducted than a multi-thousand subject trial that isn’t.

So maybe it’s not so bad after all being a sample size of one.

What To Do If Your Physical Therapist Recommends That You Do One-Legged Dips

As most of you know, I try to refrain from giving advice on bad knees. I'm not a doctor, nor am I a physical therapist. Then there's the fact that even if I were, I haven't examined or even laid eyes on your particular knees.

So, generally, I'm not going to second-guess a treatment regimen prescribed by someone who has actually inspected your knees and discussed them at length with you.

However ...

In creeps a little exception.

I have become aware of at least two cases where patients with painful knees have been told to do one-legged dips as part of their exercise routines. (If you've never done one: While balancing on one foot, you bend your leg, dipping down, while trying to maintain a straight line.)

Let's imagine that your buff physical therapist advises you to do one-legged dips to help fix your ailing knees.

Here's what you should do after he says this:
 
Look into his face. Is it flushed? Are his eyes bloodshot? His pupils dilated? His breathing stertorous? These all can be signs of recreational, judgment-impairing drug use.

Surreptitiously gauge the distance to the door. Could you beat him to the door, even with your bad knee(s), if he made a move to try to restrain you and force you to do a couple of one-legged dips "just for practice"?

If he does suggest you try doing one under his careful supervision, demur gently, perhaps with a line such as, "Oh, maybe not right now, I just ate -- why don't you show me and I promise I’ll do a few as soon as I get home?" (Make sure your fingers are crossed behind your back.)

After your visit ends, when the receptionist says, "And when would you like to schedule your next appointment for?", snap your fingers as if you just thought of something. Then say, "Ah, you know, I just remembered my work unit is being transferred to Tokyo. Oh well! Sayonara!"

Okay, seriously now: I can't think of a good reason why someone with chronic knee pain -- someone who probably has some difficulty climbing a set of stairs -- should be encouraged to do a tricky exercise that involves balancing while putting his or her entire body weight on a weak and possibly unstable knee joint.

Before anyone jumps up and says, "Oh, I know why physical therapists prescribe one-legged dips!" let me be clear: I'm pretty sure I know why they do. In brief, it's basically structuralist thinking run amok. So that's not the issue.

If you really care about fixing your bad knees, the issue is that you have to slowly ease them back to greater and greater strength. The key to getting better isn't doing some demanding exercise that many people would struggle to do with fully healthy knee joints. That just strikes me as absurd.

Can Prolotherapy Help With Knee Pain?

I’ve written very little about prolotherapy. The idea sounds intriguing and promising: Create a minor irritation in knee joint tissue, through injections of a substance such as sugar water, and stimulate the body’s own healing process. Doug Kelsey seems to be a fan, which is a good sign. But I’ve refrained from writing about it because I don’t know much about the treatment or how effective it’s proven to be.

Well, here’s some good news.

Knee pain appears to decrease up to one year after “prolotherapy,” a series of sugar water injections at the site of the pain, according to a new study.

The study included 90 knee osteoarthritis sufferers, ages 40 to 76, who were randomly assigned to one of three groups. The first group received sugar-water prolotherapy injections, the second salt-water placebo injections, and the last set of subjects were just shown how to do at-home exercises. The injection groups got at least three shots over 17 weeks, and were monitored over a year.

The results: The prolotherapy subjects improved 16 points on a 100-point scale for knee function (compared with a gain of 5 points for the saline group and 7 points for the exercisers). When it came to reporting less frequent and less severe pain, the prolotherapy group impoved 16 points on the same scale, compared with 7 points for the saline injected and 9 points for the exercise group.

Hmm. Sure sounds good. Also the researchers said the study, though small, was not too small.

Is it worth giving prolotherapy a whirl, if your knees are stubbornly resistant to getting better? I’d certainly consider it. Anyone out there who’s had prolo who wants to chime in?

Note: Unfortunately, I should add a bit of a negative footnote. Prolotherapy treatments cost $200 to $1,000 apiece, and they’re not covered by Medicare. I’m not sure about private insurance though.