Saturday, January 26, 2013

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.


  1. My knee is hurting so much now that walking is usuallu uncomfortable/painful. I still walk slowly, but what works better for mo to get the knee joint gently moving is a stationary bike for 5 minutes. But, it's a pain to go to the gym to bike for just 5 minutes and yet buying a stationary bike is expensive and would take up a lot of space in my tiny home.

    Instead, I bought at "medical pedal exerciser." they cost between $20-$40 and it's just the pedals. I can just use my own chair. It takes up very little space. This makes it easy to pedal for just 5 or 10 minutes and i can get the knee joint moving and then stop. So far it is working because it's very convenient and hurts less than walking. (well, doesn't hurt at all, actually.)

    Search for "medical pedal exerciser" if you want to see a photo of one.

  2. Knee Pain, I'm watching you. :-) How's your recovery coming?

    I have a 12 hour/day 6 day/week desk job and was diagnosed with PFPS nearly two years ago. I've been riding my bike for the past 10 months after reading Richard's book, and am almost pain free now.

    Since exercise is working for me, I'm curios if exercise is working for you. Thank you so much for contributing to this blog to give is all inspiration.


  3. Thanks Erik! :)

    My knee did respond to exercise over the summer... So basically March thru October I gently increased my exercise from gentle water therapy to biking & walking on land. I was able to build up to biking 20 miles including gentle rolling hills or 10 miles including steeper hills. I could go up and down(!!) 5 flights of stairs without any pain. I could walk up to 3 miles including hills. I had not yet built up to jumping, hopping or waltzing or lindyhopping, but that was next on my list.

    But then in October I had a giant flare up which threw me back into "the well" -- meaning I was returned to the state of screamingly stabbing pain where i have to just sit with ice and have the inflammation calm down and my emotional fortitude recover before trying to claw my way out of the well.

    . By early November the pain seemed to disappear, but arose again in Decrmber and January back to the screamingly painful state. I've been doing the medical pedal exerciser twice per day. I've been stretching all the muscles in my legs. I've been icing. I've been diligent about getting out of my desk chair every 30-60 minutes for at least 5-10 minutes of getting the knee moving. I've been seeing an Active Release Technique practitioner who is working on getting my muscles in my leg to relax and move more fluidly. I am now up for walking slowly up to about 0.5 miles -- it's at a state where even if it is bothering me at the beginning of the walk, it starts to feel better (as compared to when it's really bad where walking just makes the pain worse and becomes impossible.)

    Now at beginning of Feb it is feeling sufficiently calmed down, so next week I want to try to get back to the gentle water therapy and see if I can build myself back up through gentle careful motion in the water.

    For my particular knee situation, gentle motion without strain on the joint is key, ice is key. And stretching is key. If I don't stretch then the tight muscles seem to tug on my knee cap and drag it painfully into the raw patches inside my knee. So I need to keep the muscled loose to let the raw wound heal up inside my knee -- at least that's what it feels like.

    So! Wish me luck as I embark on my self water therapy! The book that is guiding me is called The Complete Waterpower Workout and it has sections devoted to people with knee problems! Imagine that! :)

  4. i have a question I got major problems in left hip joint think could get that to heal up? cartilage has worn away and dr just mentioned bone is dieing did not say anything else i refuse to do joint replacement looking in to all other posabilitys

    1. I'm going to be honest with you: I really have no idea. I have read that it's harder to naturally regenerate hip cartilage than knee cartilage. But I just don't know. I read intensely about knees, and knee cartilage, and knee problems. But not hips.

      My suggestion though: There's a clinic called Sports Center in Austin, Texas. The man running the operation, Doug Kelsey, is the smartest guy around that I know of for physical rehab of injuries. I'd try to get down there, if at all possible -- or do a phone consult if they'll let you.

      Good luck!

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