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.