What Does Your Doctor or Physical Therapist Really Believe About Bad Knees?

I thought I’d try something different today -- a very basic, bird’s-eye view of beliefs about chronic knee pain and the appropriate treatment.

Hopefully, this will help clarify why I succeeded in my long battle to overcome burning and aching in my knee joints, after a doctor -- the best of the four I saw -- told me in a grave voice that I would never get better. He was very much wrong.

First, take a look at this simple diagram, what I call the distilled matrix of beliefs both about the proper treatment for bad knees and about their capacity to heal:

That first line represents treatment. Let’s start there.

To treat bad knees, you will believe in an approach that's either “Joint Focused” or “Not Joint Focused.” (True, you may adopt a blend of the two, so you may want to think of these as endpoints on a spectrum).

“Not Joint Focused” largely equates to “Muscle Focused.” Every time you hear a doctor or physical therapist say that, to overcome your pain, “you must strengthen your quads, your hips, your glutes” -- you’re receiving “Muscle Focused” advice. (Also, the advice to stretch belongs in the “Not Joint Focused” box -- you can’t stretch a joint, but you can stretch muscles, for example).

So that’s the box on the upper right.

One of my huge revelations was that I needed to be in the upper left quadrant. That is, I needed a “Joint Focused” treatment regimen.

So for months, while trying to heal my bad knees, I didn’t worry about my weakening quadriceps muscles. I didn’t care if my quads turned to butter. I walked very slowly, often for short distances (too short to be of much benefit to muscles). I knew that if I fixed the joints first, I could strengthen the muscles later.

Now here’s the weird thing: Most of the current thinking about how best to fix aching, grumbling knees fits in the upper righthand box. But, if your knee joints hurt, common sense dictates that you focus on fixing them, not some nearby (or not so nearby) structure in your body. So this should make you wonder why that box on the upper right is so darn crowded.

(Of course part of the reason has to do with a preponderant structuralist view that seeks reasons for knee pain outside the joint, in imbalances and misalignments, instead of from injury or normal wear-and-tear inside the joint. I don’t want to get sidelined into a long discussion of structuralism today; there’s more on what I think of structuralism here and here.)

Now move down to the second line. This stands for beliefs about the capacity of bad joints to heal. (Be careful here -- this doesn’t mean “the capacity of bad joints to hurt less.” Someone in the upper right corner may argue that strengthening quads results in “less pain,” because stronger leg muscles better protect the weak joint. At the same time, that same person may argue that the joint itself hasn’t improved because it can’t.).

Now, for this line, two states of the world again exist. You’re either optimistic that knee joints can get better, or you’re pessimistic (or, once more, you may be somewhere in between).

Now here’s an interesting thing: You may think it makes more sense for the second line (beliefs about the joint’s capacity to heal) to be swapped with the first line (beliefs about the appropriate treatment regimen) -- because which logically comes first? But I used this order for a reason. The second line goes a long way to explaining where you find yourself on the first line.

It helps explain the mystery of why that “Not Joint Focused” treatment box in the upper right is so darn crowded. “Not Joint Focused” seems irrational until you drop down one box to the south, into “Joint Pessimistic” territory. Ahah! If you believe knee joints can’t improve (“Joint Pessimistic”), why would you advocate “Joint Focused” treatment? That’s just banging your head against the wall!

“Joint Pessimistic” shows up in many forms. Doctor to patient: “Your knees eventually just wear out and that’s life” or “You’re getting old and your knees won’t get any better.” Scientific literature (and popular medical thinking): “Cartilage has a very limited ability to heal” or “Damaged cartilage can’t heal.” The physical therapy profession (speaking to its members): "Patients should be told that treatment is aimed at structures surrounding the joint, rather than the joint itself" (which is presumably beyond hope).

On the bottom half of this matrix, I lodged myself squarely in the leftside quadrant, “Joint Optimistic.” I did so not from a sense of wild, hopeful desperation. Rather, I did so after a lot of reading, partly of new medical studies from the past decade. I found evidence that damaged cartilage apparently did heal, more frequently and more dramatically (even over bare bone!) than anyone had ever suspected.

Once you’re “Joint Optimistic,” it makes sense to target the joint in your recovery efforts. That’s what I did, and it worked extremely well in the end (though very slowly, and my healing occurred in a lumpy, nonlinear fashion -- but joints are just tough to rehab).

So, to sum up, in this matrix the right-side quadrants go together logically, as do those on the left side.

Now, within the “Joint Optimistic” believers and “Joint Focused” treatments, there can be differences. For example, Doug Kelsey of Sports Clinic was a huge inspiration to me. But he thinks nutritional supplements such as glucosamine are beneficial for joints; I’m a lot more skeptical that they do much good, if any.

Anyway, the point of this matrix is to give you a fuller understanding of the belief system of your doctor or physical therapist, and what it means. You should feel free to ask that person: Are you optimistic about bad joints healing, or pessimistic? (Hardly anyone will say, “Oh, I’m pessimistic,” so you’ll have to read their body language, or carefully parse their answer.) Also, from the exercises you’re given to do, figure out whether you’ve been assigned a “Joint Focused” treatment regimen or a “Not Joint Focused” one.

All this really, really does matter. For me, the first step to beating my chronic knee pain was realizing I needed to be on the left side of this matrix -- and I needed to stop listening to people who were on the other side.

What’s the One Piece of Advice That All Knee Pain Doctors and Experts Agree On? (Part II)

Last week I revealed (to a chorus of groans, I’m sure) that the one, simple thing that everyone agrees on for reducing knee pain is:

Lose weight.

This week, I’m going to provide more evidence (I say “more” because I’ve already visited this topic, here and here, bearing lots of evidence.) But the “lose weight” message is important enough to merit periodic revisits.

So here you have yet more proof, in round-up fashion:

* A report published in the August 2009 issue of the periodical Radiology linked obesity with the rapid progression of knee osteoarthritis and cartilage loss.

All 336 subjects, though overweight, started out with minimal or no loss of knee cartilage. During the 30 months they were monitored, one-fifth of the patients lost cartilage slowly and 5.8 percent lost it rapidly. For every 1 point increase in body mass index, the risk of rapid cartilage loss jumped by 11 percent.

* A 16-week diet that included protein shakes and soups helped people lose weight, lessening joint pain, according to findings published in the December 21, 2011, issue of the European Journal of Clinical Nutrition.

The 175 obese people in the study lost an average of 26 lbs. in the first eight weeks. Dropping all that weight had a significant impact; it “helped more than 60 percent of the participants reduce their knee pain and improved their ability to walk.”

* Another study looked at morbidly obese patients who underwent surgery (such as bariatric) to spur weight loss. A year later, they had lost almost 51 lbs. on average and reported significant improvement in knee function and less pain.

* A higher BMI means more knee pain among women -- whether or not they have osteoarthritis -- according to a study published July 7, 2011, in Arthritis Care & Research.

The 594 women who took part were examined over 14 years. “Significant predictors” of pain were found to be greater initial weight and weight gain. (Curiously, the relationship applied only to patients with pain in both knees, not just one.)

* A study of 20 morbidly obese youngsters, average age 14.2 years old, showed that each had a cartilage lesion in at least one knee region, as indicated by MRI.

The defects (surprising in adolescent children) were similar to those found in victims of “various accidents” or in older people.

It was unclear, at least at the time of this 2005 report, whether the cartilage damage was due simply to mechanical overload or whether metabolic factors might also be to blame.

* And, just in, published December 27 in Arthritis Care & Research:

196 subjects (from 25 to 60 years old) were split into three groups: those who lost 5 percent or more weight during two years, those who gained 5 percent or more and those whose weight remained stable (everyone in between).

Those who put on extra pounds reported stiffer, more painful, worse-functioning knees, whereas those shed weight boasted of the opposite.

So there you have it.

Evidence -- pretty much overwhelming at that -- that losing weight is one of the smartest things you can do to beat knee pain.

What’s the One Piece of Advice That All Knee Pain Doctors and Experts Agree On? (Part I)

Occasionally, as I’ve noted before, I get a taste of how confusing it must be for a new knee pain sufferer seeking relief. Chase a few helpful-looking links on the Internet and your head will be set awhirl.

Stretching should be part of a program to beat knee pain! Stretching is useless! Take glucosamine for proven relief! Glucosamine is a placebo! Ice your knees to subdue inflammation! Inflammation is good; it’s a necessary part of the healing process! Strengthen your quads! Don’t worry about strengthening your quads!

Then you have the many unorthodox methods for overcoming knee pain, from acupuncture to squeezing an inflatable ball between your knees while sitting. And, even when a piece of advice seems to be consistent across practically all web sites (you need to move!), there’s much disagreement on how to interpret this in practice (what kind of movement? how much?)

So, considering the welter of conflicting, confusing signals about how to treat your bad knees, when there’s a bit of simple advice that’s easy to interpret that everyone agrees upon, shouldn’t we sit up and take special notice?

I would certainly think so.

At this point, I hope I’ve piqued your curiosity. The idea behind the buildup of suspense is to engage you the reader in really thinking about, “What can this be? And why doesn’t everyone do it?”

Because, once I draw back the curtain, you’ll probably react with a deflated, “Oh, he means that.”

So here goes.

100 percent of everyone out there agrees, for relief from knee pain ...

Lose weight.

Okay. I’m imagining the hue and cry already. Some of you are probably protesting: But I’m not overweight! Doesn’t apply to me!

My guess, however, is that it does. As I’ve said before, I think more than 90 percent of knee pain sufferers (and maybe more than 99 percent) could benefit from losing at least a little weight. I was skinny when I battled knee pain. Still, I forced myself to shed about three pounds. And I think it helped.

Knees are extraordinary in many ways, but one of the most remarkable has to be how knee cartilage has evolved so many mechanisms for surviving and thriving based on mechanical feedback, i.e., based on forces and pressures exerted on it. And that’s going to be influenced by how much you weigh. That’s not a conjecture on my part. That’s simple physics.

Here’s a quote I recently came across from orthopedic surgeon Ronan Banim that starkly (and effectively) summarizes the problem:

In clinics we are seeing knees that are literally being crushed by excess weight.

How's that for graphic imagery?

Next week, it’s time for the evidence. I’ll provide a roundup that further illustrates why losing weight = a smart way to start addressing that knee pain that’s been bothering you for so long.

For Happier Knees, Avoid Soda, Cigarettes

When we’re young and ridiculously healthy and generally pain-free, we beat up our bodies a lot. That abuse partly comes in the form of junk we stuff into our mouths (as a college freshman, I liked to go into an “all nighter” with a full box of Entenmann’s soft chocolate-chip cookies by my side -- a box that would be depleted well before sunrise).

Some of us drink too much. Some of us take up smoking, with little thought to the long-term consequences.

When we get older, we usually get smarter about the self-abuse. When we get older and injured, it’s wise to be especially careful about bad diets and bad habits.

Take something as seemingly innocuous as soda. A study by researchers at Harvard Medical School showed that drinking soda may worsen knee pain -- and not because the sugary beverage tends to pack on excess weight. Rather, according to this short article, “one theory is that ... chemicals in soda may affect bone health in joints.”

Or consider an activity that we all know is definitely harmful: smoking. Indulging in this habit has been shown to be bad for your knees.

The January 2007 issue of Annals of the Rheumatic Diseases included results of a study of 159 men (12 percent of whom started out as smokers) that looked at the relationship. The men who had knee osteoarthritis who also smoked  sustained “greater cartilage loss” with “more severe knee pain.”

The researchers wrote that the harmful effect of smoking on articular cartilage “may be greatest when cartilage is already damaged by other mechanisms.”

So what’s going on here, on a cellular level?

The authors note that investigations into smoking and back pain have found that “components of tobacco smoke have a deleterious effect on chondrocyte function in discs, inhibiting cell proliferation and extracellular matrix synthesis.” Remember, chondrocytes play a critically important role as the cellular factories that produce more cartilage.

In their discussion section, they expand further. A study on smoke-exposed rats showed “disordered chondrocytes” in their intervertebral discs. In a separate study, on bovines, nicotine inhibited the proliferation of chondrocyte cells and impaired their ability to make new cartilage.

What causes such problems?

For one, smoking increases oxidant stress, and “oxidant stress may contribute to cartilage loss.” Then there’s this: “Cigarette smoking also increases carbon monoxide levels in arterial blood, contributing to tissue hypoxia, which may, in turn, impair cartilage repair in smokers.”

What this all adds up to is clear. What you put into your mouth (or suck into your lungs) can matter a great deal if you have chronic knee pain.