Friday, December 26, 2014

Happy Holidays to All!

I ate a huge dinner yesterday cooked by my 72-year-old Mom, who is still an amazing cook. My wide-eyed five-year-old daughter described how she heard Santa's reindeer on the roof on Christmas Eve. My 18-month old son crawled onto my lap with one of his dozen board books and stabbed his little index finger at pictures of tarantulas and dolphins and panthers and told me what they were -- or what he thought they were.

The sun broke out after several days of rain, and everyone was glad for the brighter skies. It was nice to be on the leading edge of a long weekend. I've got a few around-the-house projects to occupy me and a leak I'm watching (the joys of owning a house built at the end of the Roaring Twenties). I think water may be dripping from the shutoff valve under the main kitchen sink. I just finished wrestling off the corroded, leaking faucet on the prep sink and replacing it, so this isn't a project I'm looking forward to.

So there's plenty of stuff to think about. But one thing I'm not thinking about: my knees.

They work fine. They have been working pretty well, in fact, since I published Saving My Knees. After I made the book available, I had a little nagging doubt: "What if the knee pain returns? Will I be some kind of a fraud, peddling a story that doesn't really have a happy ending? Will I have to contact everyone who bought the book and refund their money?"

But that never happened, thank God. My knees just kept getting better.

So my holiday wish to all of you is don't give up hoping. I made it through. There is a way.

Saturday, December 20, 2014

On Writing a Book and a Blog, and Learning Humility

After I finished writing (and rewriting) Saving My Knees -- and extensively fact-checking the entire manuscript -- I felt kind of giddy. This was a unique book, I felt. It was a first-person, well-documented story of how someone failed -- then succeeded -- in fixing bad knees his doctor said would never get better. My story vividly demonstrated the shortcomings in the traditional approach to treating chronic knee pain (of the sort sometimes caused by osteoarthritis, but sometimes not).

Bestseller lists, here I come!

Then reality bit down. Hard.

The book has sold well, all things considered, but never got close to being a bestseller. Reviews trickled in -- many positive, but others sour and dismissive.

The most humbling experience though has been writing this blog and coming into contact with so many people with knee pain who are really struggling -- and who appear to be doing many of the right things too. They’re desperately seeking the path to healing, just as I was. And they’re discovering that’s not an easy path to find.

Ah. Theories are neat; reality is messy. I still believe that switching from high load/low repetition activities to low load/high repetition makes much more sense for fixing achy knee joints. But I also recognize that while this may be necessary for some people to get better, it may not be sufficient. Big difference.

The problem is, there are different causes of knee pain (in need of different solutions), as well as various mysteries about what’s really going on in the first place. For instance, is there something weird and systemic that sets in when you have chronic knee pain that goes on week after week? I had a doctor tell me unequivocally “no.” But I’m not sure I believe him.

Sometimes I had the sense there was a poltergeist of inflammation loose in my body, and while it may have first appeared in my knees, later it began to roam at will. Apparently it wasn’t just me either who felt this way. I’ve been surprised at the number of people with symptoms similar to mine who went so far as to be tested for rheumatoid arthritis (just as I did).

So what was all that systemic stuff? I honestly don’t know. But, even though it’s gone today, I think it was real.

So yes, there are lots of mysteries about knee pain, as you’re all finding out. It’s good to stay humble -- even if you succeed in beating knee pain -- because no one has all the right answers.

Saturday, December 6, 2014

When It Comes to Knee Pain, What’s Your Religion?

When I read an expert’s answer to how to deal with knee pain, the question above is always forefront of mind. What is their belief framework for analyzing and treating the underlying condition?

Mostly I find experts are structuralists of some stripe. In other words, they believe “your knee cap is mistracking and that’s why you have pain and that’s what you have to fix.” Some are more hard-core than others.

Take “Running Doc,” for instance, who tries to help Laura G. here who has been told she has “Runner’s Knee.” But her only exercise consists of shopping expeditions at the mall!

Well, the doc describes her problem instead as “Maller’s Knee” (for anyone curious about who the great physician “Maller” is, I think this is just an attempt to be clever). He then goes on to equate “patellofemoral syndrome” with “chondromalacia patella” (as I note in my book, they’re not technically the same, but it’s a revealing confusion).

He does promise the reader that “understanding the real cause makes treatment easy and pain relief possible in a short period of time.” To me, after hearing so many stories from knee pain sufferers engaged in a frustrating battle to beat their problem, this phrasing sounds a bit glib, to say the least.

The underlying cause, he tells us, is your ....


And your parents stuck you with those feet, so your pain is -- well, sorry bub -- your biological structuralist destiny, you might say.

How does he get from your feet to your knees?

Here’s one example he gives:

Your foot rolls in (pronates), leading to your kneecap mistracking and scraping along one side of the patellar groove, leading to the cartilage under your kneecap getting eroded away, leading to ... pain.

So what’s the solution? Interestingly, one would assume -- after such a bleak kind of structuralist analysis -- that nothing short of surgery to fix the cursed defect would do much good.

But actually, he states that arthroscopic surgery helps maybe one out of 100,000 sufferers (a bit hyperbolic I’d say, and I’m no fan of surgery either). No, the real solution: orthotics.

His apostolic faith in orthotics made me smile. Here is the New York Times telling us that a longtime researcher into orthotics has found they don’t really work and when they do, it’s not clear why. And so, “The idea that they are supposed to correct mechanical-alignment problems does not hold up.” (After reading the article I bravely gave up the shoe orthotics I thought I couldn’t live without, and I’m perfectly fine today without them).

As for Running Doc’s “first mover” in his chain of events resulting in knee pain misery -- that maltracking patella -- that too may not be the problem for a large number of cases of knee pain. (See this study I’ve linked to about a kajillion times.)

So at this point you may be thinking, “Okay smarty pants who isn’t a doctor, what’s your religion?” And I’d have to say my thinking aligns best with that of Dr. Scott F. Dye and his thinking on “envelope of function” (see here). Basically, when you exceed that envelope over a period of time, you’ll get knee discomfort then pain. If I were talking to Laura G. about her problem, I’d be more curious about the following than what her feet are doing:

What’s your weight? Is it where it needs to be? Has it changed recently? By how much?

Did your amount of non-exercise movement change before the onset of knee pain?

Were there any traumatic knee events you suffered in the year or two preceding the knee pain?

Can you describe how you use your knees, 24/7, during a typical week?

Of course I could be off base with this line of inquiry in Laura G.’s particular case. It’s always possible that she was born with crappy feet and is now paying the price for it. But somehow I doubt that’s the real problem.

Saturday, November 22, 2014

Old, Bad Beliefs Die Hard

I came across this Internet article on the VMO (vastus medialis oblique), one of the four muscles that, collectively, are known as the quadriceps. About halfway through, I noticed an interesting assertion:
... patellofemoral pain syndrome. A misaligned patella results in pain on the front of the knee, ultimately caused by a weak VMO.
My initial reaction was along the lines of “Whoa, back that truck up!” For one, if you read a lot of the literature on patellofemoral pain syndrome (PFPS) from informed sources (as I’ve tried to do), you’ll discover there’s much confusion about what indeed does cause PFPS. (Actually, to take a step back, it’s not even clear that this is a meaningful diagnosis in the first place.) So this article’s pat suggestion that your knee pain is caused by a misaligned patella that in turn is caused by a weak VMO is venturing way out on a limb.

For starters, the role of a mistracking kneecap in causing pain may have been oversold. This study (rather small but intriguing) found no relationship between the amount of patellar mistracking and reported knee pain.

Then there’s the problem of strengthening the VMO in isolation. That, by implication, is what someone with a weak VMO in this scenario needs to do. After all, if your problem is maltracking, and you strengthen all the muscles equally, then it seems you would have the same amount of maltracking, only with stronger muscles causing it.

So how do you strengthen the VMO in isolation?

Well, you can’t, as Doug Kelsey has observed a number of times, such as in this passage:
The VMO is one of four muscles which all share the same nerve: the femoral nerve. Muscles contract when nerves tell them to contract. Since the VMO has the same nerve as the other three thigh muscles, it will contract along with the others. You cannot make the VMO contract by itself.
Strengthening the VMO to correct a mistracking patella is a typical old school recommendation for treating chronic pain from achy knees. Tease the reasoning apart, bit by bit, and it falls to pieces. Yet the advice lives on in many corners of the Internet.

Saturday, November 15, 2014

Of Goats, Noses and Knees

Here’s a novel location to pinch a little cartilage for rejuvenating a worn-out knee joint:

Your nose.

Apparently a study on goats (I know, from weird to weirder) showed that the cells in their noses that make cartilage could perform the same function in their knees.

So now researchers are seeing if they can replicate the results in a human trial. Full results weren’t available when the summary linked above was written, though we were told the patients were doing “extremely well.”

This story somewhat surprised me. I would have guessed that knee and nose cartilage are from two different families, so to speak, and one wouldn’t be able to properly substitute for the other. But looks like I would be wrong. :) In any event, if you have bad (or no) cartilage in your knees, in another 10 or 20 years, doctors may be assessing your schnoz as a potential donor site.

Saturday, November 8, 2014

Platelet-Rich Plasma Therapy Wins Some Fans

This article recently caught my eye.

A Utah doctor told assembled colleagues at the annual meeting of the American Society of International Pain Physicians that studies are showing the efficacy of platelet-rich plasma (PRP) therapy for various conditions, including knee osteoarthritis.

Dr. Richard Rosenthal cited for example a paper showing that patients (the subjects were age 45 to 85) had a significantly smaller chance of reinjuring their rotator cuff after a massive tear if they received PRP gel. A different study demonstrated a salutary outcome for lower back pain sufferers.

Caveats are in order of course, as the article notes. PRP is still a relatively young procedure. Issues remain to be sorted out, from the proper protocol for treatment to identification of differences among some 40 products currently on the market.

One voice of caution, Wellington Hsu of Northwestern’s school of medicine, notes that there are “holes in the evidence for PRP in the management of osteochondral lesions and knee osteoarthritis.”

So, expect further studies. The good news is, if PRP continues to shine in clinical trials, insurers may agree to pick up the tab for the procedure -- some $750 per injection -- which (at least in the U.S.) they won’t do now.

Saturday, October 25, 2014

Clarification Corner: On Muscle Strength and Anti-Inflammatories

Recently I read some criticism of my book that had me grinding my teeth because it was just so wrong.

So let me clarify a few things for the record.

Saving My Knees is my story. It’s what I did to save my knees. What you should do may be exactly the same. Or, most likely, what’s best for you will differ in some ways. In the book, I simply tried to expose some of the wrong thinking that held me back while giving credit to some of the right thinking that helped me overcome my condition.

To quote from my own introduction:
I don’t include twenty pages of illustrated exercises . . . My preference would be to call Saving My Knees broadly prescriptive. I lay out what I tried, how I succeeded, and what I learned. My goal is to show how knee pain sufferers have to start thinking about their knees and what’s important for those ailing joints to heal.
Another thing:

I am not against strong legs to support weak knees. Strong muscles supporting the knee joint are wonderful. If you have bad knees, and you can do quad-strengthening exercises -- squats, straight leg raises, whatever -- without worsening your symptoms, do them, by all means.

But I couldn’t.

And when I finally recovered from knee pain, I found Doug Kelsey (he of Sports Center, who is the smartest guy I know of when it comes to rehabbing bad knees) nailed it with this observation:
Having stronger muscles is helpful but weak muscles are not the primary problem.
The strength of that knee joint is the main problem, I realized, and so I focused on that through a program of movement. My legs in fact got weaker as my knees got better.

And finally:

You may decide to take nonsteroidal anti-inflammatory drugs. That’s fine. They didn’t work out well for me. Here are four things to consider if you are thinking of taking NSAIDs.

(1) Anti-inflammatories can mute constructive pain signals that are telling you “don’t do that; it hurts.” For example, as I describe in the book, I took an arthritis drug that helped me get through an afternoon sitting at work, but the next morning my knees felt worse because they really weren’t strong enough for prolonged bouts of bent-leg sitting.

So the upshot was I could take a drug to make the discomfort go away, but underneath it all, my knees were still too weak to do what I was making them do. Fixing that weakness was my main challenge.

(2) NSAIDs can have unpleasant side effects that, for example, affect the cardiac and digestive systems. This shouldn’t be a problem for most people for short-term usage, but the more you take, and the longer you take them, the more it becomes an issue.

(3) If you take two aspirin -- or Advil or whatever -- twice a day now to manage the pain, then a year from now, you may be swallowing three aspirin four times a day. Often, the drugs lose efficacy with constant, repeated use, necessitating higher doses -- which boosts the likelihood of those unpleasant side effects.

Now for #4, which is the real kicker.

(4) I asked my doctors if anti-inflammatories would slow the progress of cartilage loss or fundamentally improve my underlying condition. I was told they would not. This is the common thinking among doctors and medical professionals. Here is one site weighing in; I could find a dozen others saying essentially the same thing:
Anti-inflammatories do not alter the course of painful conditions such as arthritis. They just ease symptoms of pain and stiffness.
I’m not denigrating the benefit of easing symptoms. Still, ultimately, what matters most is fixing what’s causing the symptoms. And when it comes to mending what ails you, anti-inflammatories appear to have no effect.

To be fair, I’ve had some exchanges with a blog reader on whether just suppressing inflammation should be beneficial, by slowing the degradation of cartilage. There seems to be a logic to that, but I’m not sure if NSAIDs significantly affect cellular processes or just mainly calm nerves. I do think that if they had clinically proven powers to stop or slow disease, drugmakers would be boasting about this in 30-foot-high advertisements -- which they’re not. (An aside: I’m talking about NSAIDs here and not the more powerful DMARDs used for treating rheumatoid arthritis.)

If in the future NSAIDs are found to help beat arthritis -- not just mute the symptoms -- I’ll be sure to share that on this blog.

However, even if they do, you still have to wonder if the negative effect from NSAIDs blunting pain signals would outweigh what may be a small benefit that the drugs would have in preserving cartilage.

So there you have my clarifications. I hope that's clear now. :)

Update: I received a good comment below from a frequent reader. I know she’s spent a long time (just as I did), thinking about healing bad knees. She writes (excerpted here; in full below):
I must confess that I sometimes questioned your story, because I found the term 'strengthening the joints' difficult to grasp. I clarify: to strengthen your joints, you moved them. Moving them will also stretch the tendons and ligaments, rendering them more flexible and better at keeping your knee stable and mobile. Right?
This isn’t quite what I mean. By “strengthen” the joint, I refer to making the non-muscular soft tissues stronger and more resilient. Take cartilage, for example. If Joe does nothing but sit on his couch, while Tim (sensibly) runs 40 miles a week, Tim will have stronger (more resilient, tougher, better-performing, more able to withstand shock) cartilage in his knees after a year. For purists who object to my usage here, “strong” is a versatile word in the English language; it can be used to describe everything from muscles to one’s resolve to do something. Just Google “stronger joints”; many people use the word as I am here.
I found with the walking programme and hydro that I eventually have to strengthen my muscles around my knees, and again I'm not talking quad sets or squats, just making my legs stronger because I experienced something in the last few months. I was able to manage the pain and sometimes be pain free for days. But when my legs muscles really started to weaken, the pains became continuous. Only now that I have started a programme of hydrotherapy do I see a slight improvement. ... In fact, the book Heal Your Knees also explains the same: the less you move, the more the whole structure of your knee weakens.
First, I completely agree with the “the less you move, the more your knee weakens.” Use it or lose it. Absolutely.

But there are two kinds of exercise that can be done.

(1) High load, low repetition (better at strengthening muscles)

(2) Low load, high repetition (better at strengthening cartilage)

What I found, at least with my own bad knees, was that gains came by focusing much more on exercises of type #2 than type #1. My joints weren’t strong enough to withstand the force needed to effectively build muscle. (And evidently, as stories from other readers such as Luis here describing his wife’s recovery indicate, I’m not the only one who found success with this formula).

I’m certain my leg muscles got weaker during my program to heal. But I was moving a lot (walking as much as my knees could stand), so I never felt worried that my legs were getting too weak. Deloupy says “I found with the walking programme and hydro that I eventually have to strengthen my muscles around my knees, and again I'm not talking quad sets or squats, just making my legs stronger because I experienced something in the last few months ... when my legs muscles really started to weaken, the pains became continuous.” If strengthening muscles around your knees helps with that pain -- and those exercises don’t worsen symptoms -- that’s great. Keep doing ‘em! :)
On the inflammation: I am taking some NSAIDs for the first time in 14 months, and I don't think they blunt the pain at all. However, I have noticed that the inflammation has lessened a bit, allowing me to walk better. If you can't walk, you are not going to achieve much with a strengthening programme through movement, are you?
Yes, people with bad knees do need to move. If NSAIDs help you get off the couch and into reasonable activities for your particular joints (“reasonable” is the operative word), then taking the drugs for that reason makes sense to me. (I like Racer X’s suggestion below in the comments section, to use them as a “stopgap measure”; by the way he notes some other interesting reservations about using NSAIDs). Just remember: NSAIDs themselves don’t fix what’s wrong with your knees. And not taking them, by extension, doesn’t ruin your knees either.

Sunday, October 12, 2014

Time for Another Personal Note

Some of you may have noticed that I have been posting less frequently.

Well, in April of this year -- for the first time in my life -- I became a homeowner. My family now lives on Long Island’s north shore. Our community boasts its share of the affluent; I like to joke that we’re the poorest people in town. The major attractions included the excellent schools and low crime and short distance to beaches and water. Our house -- as befits a house belonging to people who aren’t among the nouveau riche or the nouveau near riche or anything like that -- has its share of problems. Windows that won’t open (normally). Leaking tubes in toilet tanks. A broken air conditioner in the basement. Etc.

So now, along with having two kids who constantly clamor, in their own ways, “Play with me!” I have an equally insistent house clamoring “Work on me!” So I’ve repainted a room, replaced door locks and fixed leaks in a toilet tank. When your home was built on the cusp of the Great Depression, in 1928, there’s never a shortage of things to do.

However, I’m still actively monitoring the blog, even on weeks when I don’t put up anything new. Recently a post attracted 36 comments! While that had more to do with people talking amongst themselves than the actual post, I think it’s great that a small community of (pretty smart) knee pain sufferers has cohered around this blog.

As for my future plans:

I’d like to get out a second edition of Saving My Knees in 2016. Why?

Among other things, I want to update readers on how my knees have been since I published Saving My Knees (basically, great). Partly I want to do this because I still get e-mails from well wishers that contain lines like, “I hope your knees are feeling better.” Also I want to talk about what I’ve learned since that publication day, back in January of 2011. And I want to address frustrated readers who complained that they couldn’t figure out how I healed my knees from the book (it isn’t all that exciting, as I’ve said before on this blog, but I never meant to leave this as a mystery).

Because I think Saving My Knees is about 10 to 20 years ahead of its time (in the rejection of structuralist tenets and in the level of justifiable optimism in cartilage healing, or at least improving substantially), I think the message on its pages will continue to be fresh for another couple of decades. We’ll see.

In closing, there’s one other cool thing I wanted to mention: Sometime recently, while I wasn’t paying attention, this post of mine became the most read on this blog:

Here Are My “Radical Beliefs” About Healing Bad Knees

I love it. This short post shows the reader, largely using common sense, that what I believe about healing bad knees isn’t crazy. What’s really crazy is the traditional treatment protocol (and underpinning beliefs) that doctors and physical therapists advocate.

Saturday, October 4, 2014

How You Feel Affects How You Heal

Here’s a study that tells us something rather intuitive.
People who tend to blame others for their suffering and think setbacks in their lives are irreparable tend to report more pain after knee replacement surgery, according to a new study.
Ordinarily, I’d deride this sort of finding as one for the annals of Captain Obvious. Nothing surprising here.

But the larger point is worth underscoring.

People who are gloomy fault finders, looking to blame others for their misfortune, are most likely going to do worse at everything from healing and managing pain to standing in a long line for pizza without exploding. When it comes to one’s health, there is such a thing as a “negativity tax.” I’m convinced of that.

Attitude matters. If yours is, “Okay, I’m going to try X to heal my knees, but nothing else has worked and this probably won’t either,” then guess what? It probably won’t. Because you’ll undertake the program half-heartedly, with the built-in expectation of failure. How many people do you know who have achieved a difficult goal have an approach of “Oh well, let’s see what happens, but I’m really pessimistic?”

Now, for those interested, some details on the study:

A group of 116 men and women (age 50 to 85) who were scheduled for knee surgery took part. Before the surgery, they filled out questionnaires that assessed “perceived injustice, how much they think about or worry about pain and their fear of movement or re-injury.” A year after surgery, they were surveyed again. Those who (before surgery) felt helpless because of their pain and judged life as unfair did worse after the operation, even after controlling for such factors as age, sex, and prior pain levels.

To be fair, there is a wrinkle here:
Researchers don’t yet know if people with more negative outlooks only perceive their pain as worse than others or if their psychological state affects the physiology of healing and actually leads to more pain.
Still, pain is pain, and I’m not sure it’s much different to have level 5 pain and think it’s level 9 than to have level 9 pain in the first place.

Sunday, September 21, 2014

Is Water Therapy Good for Your Knees?

I recently came across the question above in the comment section.

My answer is scattered all over this blog, but I don’t think I’ve dedicated an entire post to the subject.

So here’s my opinion:


In fact, if I were to suggest a “Holy Trinity” of the most excellent knee exercises -- those where you can get in lots of nourishing high repetition movement with little strain on the joint -- it would look like this (in no particular order):

(1) easy walking (initially stay on flats, take breaks every 20 minutes or so, and don’t let your legs slam down -- ever)

(2) easy cycling (a stationary bike though more boring is better as it’s easier to control the force you exert; cycle backwards if your knees are really weak)

(3) easy water movement (careful -- swimming may be a very bad idea if you’re kicking vigorously with your legs; you’ll need exercises designed for people with tender knee joints)

The right kind of water exercises can be a great way to heal bad knees. Water provides gentle resistance and support when you're moving about. Of course just jumping in and doing the overhead crawl from one end of the pool to the other usually won’t be a smart idea.

Where do you find good exercises?

Heal Your Knees is a book that contains many water exercises designed for those with hurt knees. A frequent commenter here likes The Complete Waterpower Workout Book (both books share an author, who evidently has made water therapy a key part of her physical therapy treatments).

My biggest reservation about telling people to try to heal through water therapy:

Most of us simply aren’t close enough to pools, or can’t afford pool memberships, or can’t align our schedules with pool hours, to make this a really practical option. A nice thing about a walking regimen is that walking can be done anywhere, anytime.

The other thing to note: Water therapy may not be the best treatment plan for you, regardless of whether there's a convenient pool nearby. I did try it for a while and had some good results. But then I had a setback and found I wasn’t getting the same benefits as before, so I changed to a walking-centered program.

Sunday, September 7, 2014

More From Last Week's Success Story

Last week, I posted a great story of recovery from knee pain, as told by “Luis” about his wife. The story was so long (even after being edited for length) that I decided to dispense with any of my own comments. Also, I trimmed out a couple of sections.

This week I wanted to quickly comment on a few things, then include the sections I omitted last time.

One thing that struck me as interesting about his wife’s pain early on:

The doctors found nothing wrong.

MRI fine. Bloodwork fine. Alignment fine.

This, I imagine, is very common. It was my situation as well.

So what did doctors diagnose her with?

That terrible, kitchen sink, pseudo-diagnosis of “patellofemoral pain syndrome”.

I wish more patients who were told they had PFPS would gently challenge their doctors by saying, “Right, but what’s causing my knee pain?” Because the PFPS “diagnosis” neatly evades that answer.

Here’s another thing that resonated about his wife’s story: she noticed that walking uphill was okay, but downhill was painful.

When I was engaged in my recovery, I remember striding uphill, but descending very, very gingerly. Uphill is good for you, downhill is poison. Going uphill, your legs are working hard and gravity is slowing you and minimizing the pounding your knees are taking. Downhill, just the opposite: no muscle benefit and a lot of joint abuse.

Now back to Luis.

In the original telling of his story, he described how he developed a classification system to identify where his wife was in her recovery. When I saw this, and the level of detail, I knew Luis and I were kindred spirits. :) Anyway, I include it here because it shows that to heal from knee pain, you often have to really get involved in your own treatment and it helps to be a bit analytical and even anal (the first four letters of “analytical” -- hmmm, coincidence?)
We tried to identified the percentage of recovery.
    STAGE 1. 0-20% - When she couldn't even walk a couple of steps on flat surfaces.
    STAGE 2. 20-40% When she was able to walk continuously for at least 50-100 m without starting to feel pain, on flat surfaces.
    STAGE 3. 40-60% When she was able to walk continuously with discomfort, but no more than 300 m (600 steps), on flat surfaces.
    STAGE 4. 60-80% When she was able to walk continuously with a bit of discomfort on uneven surfaces for 2-2.5 km (4000-5000 steps) (avoiding downhills or with assistance going down)
    STAGE 5. 80-90% When she was able to walk continuously without discomfort on uneven surfaces for 4-5 km (8000-10,000 steps) (avoiding downhills or with assistance going down)
    STAGE 6. 90-95% When she was able to walk continuously pain free on uneven surfaces for 5-8 km (10,000-16,000 steps) (avoiding downhills or with assistance going down)
    STAGE 7. > 95% When she was able to walk continuously pain free on uneven surfaces for 8 to "X" km (till her body started to feel tired instead of her knees)
Last, here is the advice that Luis gave to others.
    1) Read to understand, not to find a magical cure.
    2) Develop an achievable plan depending on your observations, reward yourself and feel proud about it.
    3) If you are overweight, there are no excuses nowadays not to reach an ideal weight. Just go for it with a balanced diet.
    4) Walk every day. If you were able to walk before, is there a reason why you can’t do it now?
    5) Find the cause. In the case of my wife, she spent 2 years almost doing nothing. The biggest impact was when we returned from the mountain that we jogged-hiked in June 2012. If we have known that this could have happened, we should have focused on a minimum of 6 months covering 10,000 steps per day before even starting running.
    6) Use shoes that suit you and don't use different shoes when walking, stick to the ones that suit you.
    7) At the beginning if you have to use braces, but once you get into a more comfortable point try not to.
    8) Does this only help for PFS? I'll say that it can work with any other knee problem, just like for me it worked as well.
    9) Don't let anyone tell you that there is no hope, because there is.
    10) Listen to your knees and avoid what they don't like. Do not jump, do not run, go slowly when going down stairs. If there is a handrail, use it and put most of your weight on it. Plan your walking routes and walk only flat and slightly uphill, avoid stiff hills, do not fully stretch your quads until STAGE 3.

Saturday, August 30, 2014

Success Stories: A Plan, Determination and Unwavering Focus Go a Long Way

I found a great success story about beating knee pain that cited my book. Originally I wrote a post that had my comments interspersed. But the story is so long, and so good, that I’m just going to stand back and let the author (Luis) tell it. I’ll follow up later with some comments. (Note: I did some editing for length and because the author isn’t a native English speaker. The original version is here.)

Let me share my wife's experience. I always refer to her as a fighter. She is 35 at the moment, and in her youth, was a professional athlete who represented her country (Bolivia) in several Pan American games. She used to run 800 and 1,500m races.

Her problem in her knees started just after she recovered from a compression on her sciatic nerve that didn't allow her to walk more than 50m without feeling a sharp pain in one of her feet. She was starting to run again after 2 years of not being able to walk at all.

Her problems started when we decided to start doing hikes. In June 2012, we went on a really stiff hike (not just hiking, jogging). After two days, she started to feel some discomfort in her knees (the usual swelling under the kneecap). She didn't pay too much attention and kept training for the next month, until one day the pain was so sharp and strong that her knees started to lock with sharp pains.

We did all the medical checks. The results: blood tests fine, no deficiencies in vitamins. The MRIs showed everything was alright. Our chiropractor said there are no misalignments in the way she walks and how her body aligns, so doctors diagnosed her with PFS [patellofemoral syndrome -- also called patellofemoral pain syndrome]. Some doctors recommended surgery for a lateral release, but we didn’t follow that advice because it didn't make any sense.

The only procedure we tried was the PRP (platelet-rich plasma) shots, which from my perspective helped her a bit with her tendon because it was kind of torn. Every time she tried something like strengthening the quads, the results were just the same endless cycle of pain. So from July to December 2012 she didn't really improve much.

It was really sad hearing more than 10 doctors opine that she was not going to run again and always telling her to lie down for a couple of weeks in bed with painkillers until she stopped feeling sharp pain. After the first two weeks of taking painkillers and seeing that they didn't help, we realized they weren't the solution.

There was a physiotherapist that didn't have a degree, but his therapies were comfortable. He gave us really valuable advice. "Walk as much as you can everyday.”

After paying attention to when she was feeling more pain, she ended up using hiking boots. The boots provided more stabilization. Another thing that seemed to help at night was using a pillow below her knees. She realized her knees hurt while walking down stairs, but not up, so she started to be really careful when walking down stairs.

Before we went on our vacation trip at the end of the year, we bought some knee compression braces. She could walk for less than 250m before feeling her knees lock and sharp pain. At that time we were living in Mexico. We traveled at the end of the year to Bolivia for a three-week vacation, where her family lives. To get to the flights I was always asking for a wheelchair so we could make the connections.

We had a job opportunity to work in St. John's, Canada. We relocated in winter (snow everywhere). It was hard to enjoy walking outside so we signed up right away in a gym. We kept walking, but still had the idea that sooner or later we should be improving quad strength, so from February to April, we followed a gym routine of walking on a treadmill for 30 to 40 min, biking 10 min in the special stationary bike for knees and always focusing on strengthening the core.

I was always researching information. I used to always search on Google for exercises to help PFS, but one day I tried "save knees" and there was a book called "SAVING MY KNEES." My wife was of course skeptical because no one could find anything at this point and doctors couldn't find anything either. I read it the first time in 4 hours and was feeling more excited than ever!

Before we started to develop a plan based on his book, we still had the quad strengthening idea. In August, some friends from Mexico were going to visit us and we started to plan hiking routes. One month before, we decided to start doing leg extensions in the gym, and all of a sudden the work of 6 months started to vanish. She returned to the state that she was in in January, feeling a sharp pain just after walking 150m. She had a huge setback.

After her setback, we started to read his book over and over to see what we could come up with that could help on her recovery. We developed a plan based on walking. She couldn't walk much, but we started to do it every day, like 300 steps, and with stopping. Days passed; she started to feel better. It was funny because even though she was in pain at the beginning while walking, the next day she could feel the difference when trying to walk the same distance and felt progressively better. After 4 weeks we reached a point in which she was able to walk between 4,000 to 5,000 steps per day.

Our friends arrived in August and we started to go on hikes again, with the fear that she could have another setback (we did like 4-6km hikes), so we followed some golden rules:

1) Never go downhill unassisted or without a support that would help reduce the impact of her body being absorbed by her knees.
2) She decided not to wear the knee brace in order to be able to hear her knees.
3) Take breaks every 2km, no matter if she was feeling alright or not.

After focusing on her recovery, she has not had another setback since then. We had a great time in August and September doing short hikes and walks and were prepared for the next step. Since she was able to do 4,000 to 5,000 steps per day, our new target was 10,000 steps. Between September and December, we increased the amount of steps from 4,000 to 8,000 just progressively. At the same time we did tons of core exercises, stretching and short squats. At this point she started to feel pain free!!

Between December and January, we took 3 weeks of vacations. We went to Bolivia again and kept our religious daily walks that would get us the 8,000 steps. But for New Year, we went to Brazil for 5 days. We had no other option than to walk every day if we wanted to have fun. We walked 4 days an average of 22,000 steps per day, and every time, pain free.

Since we returned from those vacations, which were from January 2014 till today, we had been walking around 12,000 to 18,000 steps per day. But we've reached a time constraint -- it takes around one hour to cover 6,000 steps, so doing 18,000 consumes like three hours in a row. So now, we just bought some weight belts and are starting to walk with just a little bit more weight and do between 10,000 to 15,000.

In April 2014, we started to do moderate hikes with the club. At this time my wife is able to do them completely unassisted. She is really excited about running, but has learned from this experience that patience is your best ally, so she has started to jog distances between 200 to 300 meters, but just for fun. She is waiting till next year to start running long races again. She even ran with me last week 500m at a pace of 6:00min/km. And the best thing, completely pain free!!

If you want to e-mail me, for some additional advice or explanation of something that wasn’t clear, write me to


Next time: More from Luis, including his advice.

Saturday, August 23, 2014

Do You Really Want to “Freeze Away” Your Knee Pain?

Recently I spotted this: a short and not very detailed article about freezing nerves to quiet persistent knee pain.

The treatment, called Iovera, uses nitrous oxide canisters to freeze tiny needles to minus 126 degrees. Once injected into the skin, the needles freeze the nerves that are firing off pain signals. Apparently, instant relief follows.

I like that phrasing: “instant relief.” It sounds so uncomplicated. If only!

The problem is, nerves are generally useful, even when bearing bad news (i.e. tidings of pain in this case). The best thing is not to shoot the messenger, but rather work to change the message!

The downside of numbing nerves (whether using this method or taking pain pills or undergoing serious joint icing) is that you may not get some helpful pain signals that would prompt you to avoid activities that are simply bad for your particular joints. There’s a tradeoff, for sure.

But, to be fair, there are times when overactive nerves may be a problem in and of themselves. They may go renegade and start relaying sensations that are not consistent with any damage being done (or NOT being done for that matter).

All of which is my way of trying to strike a nuanced stance here: Freezing nerves doesn't have to be a bad thing. But I’d think it over long and hard first.

Sunday, August 10, 2014

Stay That Knife, Surgeon

Anyone else see this?
Over a third of the total knee replacements in the U.S. are inappropriate, according to researchers who found that many patients had pain and other symptoms that were too mild to justify having the surgery.
Actually, uh, it’s worse.

Along with the 34 percent of subjects for whom a total knee replacement was deemed inappropriate, there were 22 percent for whom the evidence was “inconclusive.” That leaves only 44 percent of the 175 subjects whose replacement surgery was definitely judged to be “appropriate.”

In other words, less than half.

Why that matters becomes clear when you see the statistics. More than 600,000 knee replacements are performed each year. That’s a big number, considering how extensive this operation is. What’s more, the number of the surgeries is on the rise.
In the past 15 years, the number of total knee replacements (TKR) has grown significantly, with studies showing an annual increase of nearly 100% in surgeries between 1991 and 2010. The number of Medicare-covered TKR surgeries grew by 162% annually over the same period.
It should go without saying that a total knee replacement should be considered a last resort. With biomechanical structures, even if they don’t work well, they’re still part of a dynamic, changing system that perhaps can heal. Once a surgeon starts sawing out a chunk of your femur to install a plastic-and-metal knee, that biological system is gone. The car-knee analogy then does become relevant. Your new knees will slowly start to wear out, just as a new car driven off the lot does. Plus, possible complications from surgery and the effectiveness of surgery are always two big unknowns.

Which all adds up to: There should be plenty of concern about unnecessary total knee replacements. In an editorial, Dr. Jeffery Katz, a professor at the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston, expresses concern that “doctors were offering TKR surgeries to patients who had mild pain and little loss of function in their knees.” He further writes:
As a community of providers, we implore our patients and the public at large to engage in exercise and physical activity in order to delay functional decline and to preserve and augment functional status. We must consider whether it is advisable and affordable to use costly technology such as TKR in the same fashion.

Saturday, July 26, 2014

Is Hip Weakness Just Another Structuralist Bugbear?

A longtime reader who uses the moniker “Knee Pain” first got me thinking about weak hips and knee pain. Physical therapists were blaming weak hips for her pain. To me, that reasoning smelled a bit funny, right away.

My skepticism about “structuralism” immediately kicked in. In brief, my thinking about the structuralist tendency to blame imbalances and crookedness for knee pain goes like this:

1. At the extremes, structure definitely matters. If your right leg is two inches shorter than your left, you will have problems running a marathon for sure.

2. The majority of people, by definition, aren’t at the extremes, so structuralist explanations aren’t significant, or aren’t very significant, for most of us.

3. Structuralist reasoning doesn’t correctly explain the majority of knee pain problems.

Anyway, “Knee Pain” inspired me to write a couple of loooong posts more than a year ago that I think are among my best, which are here and here.

A big point in the first one: weak hips are probably not a cause of knee pain, but a result of it. Just because 30 knee pain patients happen to have weak hips does not allow you to conclude, “Ah hah, their weak hips caused their knee troubles!” In my corner of the world (financial markets), people like to quote a saying from the realm of statistics: “Correlation does not imply causation.” And pity the investing fool who doesn’t understand that elemental truth.

Anyhow, that’s a bit of a long windup to the introduction of a sort of meta-meta study done recently that supports what I suspected. It consisted of a review of 24 papers that looked at the relationship between hip strength and knee pain.
Michael Skovdal Rathleff, Ph.D., from the Department of Health Science and Technology at Aalborg University in Denmark, and his colleagues found “moderate-to-strong evidence from prospective studies indicates no association between isometric hip strength and risk of developing PFP [patellofemoral pain].”
As for why so many people with bad knees have weak hips ... well, that too is pretty much what I figured as well, according to Rathleff:
Hip weakness may not be the cause of knee pain — in fact, it is more likely to be a result.
Now, to be clear: Rathleff, who is quoted at some length in this article, isn’t saying hip strength doesn’t matter at all. In fact, he speculates that better hip strength, say, may allow a runner to withstand more loading on his or her knee joint before developing pain. This, to me, is the part of the structuralist perspective that does make some sense. Whatever you’re doing (running, walking, high jumping, etc.), a weakness in a muscle or tendon or other structure that is involved in that activity can affect your performance. Seems logical enough.

But it’s a long way from accepting that proposition to blaming those weak hips for your knee pain. It may make more sense to fault your knee pain for your weak hips instead.

Saturday, July 19, 2014

Six Things I Like About Doug Kelsey’s New Book

I first mentioned Doug Kelsey’s latest book, The 90 Day Knee Arthritis Remedy, here. Kelsey, as anyone who read Saving My Knees knows, is the person that I credit the most with helping me figure out how to fix my knee pain -- and giving me the hope that I could be successful.

I planned to write a book review but -- yawn -- those are so 20th century, right? :) Plus, I can’t pretend impartiality here; I clearly owe him a large debt.

So instead, I give you this list of what I liked most about the book.

(1) The writing includes many examples. I like this style for a few reasons:

It makes for smoother reading.

It helps reinforce a sense of authority -- he can cite so many relevant examples because he’s seen so many patients.

It’s effective when showing how conventional wisdom for treating bad knees falls short, as with “Sue,” whose condition doesn’t improve when Kelsey, early in his career, tries applying the standard muscle-strengthening approach to fix her pain.

(2) He attacks foolish myths and exalts logical truths. For example, he talks about how, many years ago, he was perplexed by the idea that cartilage is inert and just wears out and nothing can be done -- end of story. He realizes something: This makes no sense. And it makes no sense, understandably, because it’s simply not true.

(3) You want exercises? You got exercises.

The book has plenty, with photos and video links too. Kelsey even includes multiple exercises to choose from when you have a highly sensitive and easily overwhelmed knee joint.

(4) The writing is smartly footnoted.

So Kelsey’s not just saying, “Here’s what I think” but “Here’s what I think and here’s some hard evidence why I think that.”

(5) There’s a little something for everyone.

There are abundant exercises if you’re just interested in therapeutic movement. There’s an analysis of dietary supplements if that’s what you want to know about. There’s Kelsey’s easy-to-digest explanation of the biomechanics of the knee joint.

(6) Plus, something I really like at the end: Kelsey concludes by taking a long look at “stumbling blocks.” Why, after trying so hard, have you failed to get better? This is the section that emphasizes the importance of getting your head right. How do you deal with doubt, impatience, failure to focus, worry? For some people, this part will be even more important than the description of all the exercises.

Last thing: I saw that “TriAgain,” who’s made some great, interesting contributions to this blog, made some remarks about what he saw as flaws in the book. I just wanted to say that, to be fair, Kelsey’s not a professional writer and he most probably didn’t have a professional editor helping to shape his prose. I happen to like Kelsey’s style, but that’s just me.

Also, try not to be too hard on him if he doesn’t respond to questions (or suggests you may need a “consultation,” probably at some cost). :) I can tell you, as someone who wrote a what-to-do-about-bad-knees book, that even though I lack the expertise to advise anyone, readers have approached me about essentially becoming their coach and sounding board. I always try to decline with tact and modesty, because really, I’m not qualified. So I imagine someone like Kelsey -- who clearly is very qualified -- gets scores of questions and requests. It would be overwhelming, I’m sure, for him to try to engage with everyone who wants to.

Still, I’m sure Doug Kelsey is as open to comments as I am, so anyone wishing to express an opinion on The 90 Day Knee Arthritis Remedy, whether good or bad, feel free to leave your thoughts below.

Saturday, July 5, 2014

More Evidence That Running Doesn’t Destroy Your Knees

What group would you expect to suffer the worst repercussions from the relentless pound-pound-pound act of running?

What about marathoners -- and not only marathoners, but first-timers?

Surely, they must be asking for trouble, right?

Apparently not.

A study of five men and five women (yes, small sample size) showed that:
High-impact forces during long-distance running are well tolerated even in marathon beginners and do not lead to clinically relevant cartilage loss.
The researchers from Germany’s Freiburg University Hospital measured cartilage volume and thickness, using the very precise 3-D quantitative MRI, before the runner’s training began and immediately after the marathon. The small changes that were detected were not judged to be meaningful.

Incidentally, the subjects averaged 40 years of age, with a mean BMI of 25.9.

To be sure: running a marathon, especially if you’ve never done one before, can be disastrous for your knees. But the good news appears to be, with some sensible training, it doesn’t have to be. Running isn’t bad for your knees per se. Running dumb is what’s bad.

Saturday, June 28, 2014

Studies That Probably Didn’t Need to Be Done: Knee Pain Causes Activity Avoidance

Today, we’re on the lighter side.

This just in, from the annals of Captain Obvious:
Patients with early symptomatic osteoarthritis (OA) of the knee avoid performing normal daily physical activities because they are experiencing pain, findings of a large, longitudinal study suggest.
I found this amusing and will bite back on my natural inclination toward sarcasm. I do find rather intuitive the concept that if someone has been banged in the kneecaps with a lead pipe his appetite to weed the flowerbed or climb a set of stairs will rapidly diminish.

There were 828 subjects in the study aged 45 to 65 years (yes, it is somewhat of a shame that this huge sample size went to waste.)

You might say the study helps confirm the vicious cycle that when your knees hurt, you move them less and so your muscles weaken, which leads to your knees hurting more, so you move them even less and etc. You get the picture.

I will say, in this study’s defense, that one admirable thing about scientists is that they don’t take accepted wisdom for truth. Some studies reveal curious, unlikely things, but others simply look at something that we think should be true and confirm it.

In this case:
“The results support the validity of the avoidance model in persons with early symptomatic knee OA,” said study author Jasmijn Holla, from the Amsterdam Rehabilitation Research Center in Reade, the Netherlands.
True. But I’m just not convinced we needed a full-blown study to tell us that.

Sunday, June 22, 2014

Comment Corner: ‘To Heal My Knees, How Often Should I Increase Light Activity?’

We get mail. (Well, sort of.)

Recently someone left this comment:
I have been scrolling through your entire blog for the day and reading all of your posts. I even bought your book! I'm a 20 year old female who led a VERY active life. I underwent a bilateral knee athroscopy to obtain a final diagnosis of my knee problems AND fix any issues that are able to be fixed.

The surgeon removed a medial plica, a piece of cartilage the size of a pinkie nail that was floating around the knee joint and another piece of cartilage that was flapping around inside the knee joint from my left knee. However, I was diagnosed with softening of the articular cartilage behind my RIGHT kneecap (chondromalacia patella).

My father (who is a GP) told me it will get better if I do light exercise (e.g. walking to the toilet) at regular intervals throughout the day (e.g. every 30 minutes). I had also undergone physio for several months but this exacerbated the problem. After reading your blog, it has given me new hope in healing the cartilage in my right knee.

The only thing that I'm unsure of, is how do you know when and how much to increase light activity. I understand there is no magic answer, everyone is different. But did you increase your activity slightly when the pain had remained relatively stable or did you slightly increase your activity when the pain had improved slightly? After you had increased your activity slightly, would there be a few days where you experienced a little more pain than usual and persisted for a few days before determining whether to decrease or maintain the new level of activity.
First, note that physical therapy made her knee worse. No surprise there. When misguided physical therapy (strengthen muscles! strengthen muscles!) meets very weak knees, it’s about what should be expected. I know that all too well from my own experience.

Now on to the questions. And they’re the hard questions, make no mistake about it. If they were easy, I daresay there would be many fewer cases of knee pain. I've already tried to answer such questions before (based on my experience), but they’re well worth revisiting.

First, she’s right of course. There is no magic answer. I wish it were as easy as saying, “Do x repetitions of exercise y for 2 weeks, then add 5 repetitions every week.” But you have to figure out exactly what works best for your knees.

However, here are three guidelines that worked for me:

(1) If possible, try to enlarge pain-free, or relatively pain-free, windows. So try to find a place of no pain/little pain, and go from there. This may require a radical readjustment: your knees may be too weak to do much more than walk around your apartment (or house) for short bursts at regular intervals. That then becomes your baseline.

Between the choice of (a) “increase activity when pain was stable” and (b) “increase activity when pain had improved slightly,” I guess -- if I had to choose -- I’d take (b) in most cases, as that’s the least-pain route.

(2) I had success operating on a weekly schedule. Each week I decided on my plan for the following week (based on how the current week had gone). And I tried to stick to the same regimen for at least one week.

Why weekly, not daily?

For me, it reinforced my belief that I had to go slow and get on cartilage time, where progress would be measured in weeks and months, not days. Also though, I found it easier to isolate cause and effect, when troubleshooting little issues with my knees, when I kept my program fairly constant.

(3) Err on the “go slow” side.

Say you’ve spent four weeks doing 2 one-mile walks each day. Your knees feel a little better, but not much, and could the “improvement” be just your imagination? Now you’re thinking: “Week 5. Time to step it up (so to speak)! I need to dial up the intensity. So I’ll start walking 1 1/2 miles twice a day!”

Time out. There’s no rush. If in doubt on increasing activity, I would give that stage of the program (assuming you are active, which is important), another week or two, or month even.

My hunch is that, while you’re going slow and thinking “I really ought to be doing more,” you’re actually building a nice “motion groove” for your knee that will help ensure success when you do step up to the next level.

(Oh, the commenter also asked if, after I increased the level of activity, were there a few days of increased pain? Honestly: not really. I tried to stay at a given level long enough, and increase intensity so gradually, that the transition was fairly uneventful.)

Friday, May 23, 2014

Grapes to Lessen Knee Pain? What About Bee Venom?

The odd things that, um, cross my desk:
New research presented last week at the Experimental Biology conference in San Diego, California, suggests that regular grape consumption may help alleviate pain associated with symptomatic osteoarthritis of the knee, and improve joint flexibility and overall mobility. Researchers attribute these potential benefits to the polyphenols found in grapes.

Well, at first glance, it sounds more or less like a real study.

For 16 weeks, 72 men and women with knee osteoarthritis either consumed whole grape freeze-dried powder, or a placebo powder. The study, conducted by researchers from Texas Woman’s University, found that subjects on the grape-rich diet “had a significant decrease in self-reported pain related to activity and an overall decrease in total knee symptoms.”

Further, at least for the men, there was also “evidence of increased cartilage metabolism.” They had higher levels of an important cartilage growth factor.

Also, the serum marker for inflammation was elevated for both groups, but less so for the grape-powder takers.

Now on to the bee venom:

A study being undertaken in Oklahoma City aims to find out whether bee venom will “take the sting out of knee pain,” as this article reports.

The venom is mixed with the anesthetic Lidocaine so the injection won’t hurt.

Apparently the use of bee venom to treat joint pain and arthritis goes all the way back to Hippocrates, the Greek physician.

So will bee venom work?

Are grapes really worth adding to your diet to treat aching knees?

I don’t know. Honestly, there are so many foods/supplements/substances that are supposed to relieve knee pain that it’s just about impossible to keep track of them.

Of course some may be genuinely beneficial. But I start at a position of skepticism from personal experience: no supplement or herb or fruit or vegetable ever helped me with my knee pain.

But even if they did, in the long run, you want more than intermittent relief of symptoms. You want to cure the problem. You want a stronger knee that doesn’t hurt as much in the first place. If your knee isn’t as painful, you won’t have to worry about taking powdered grapes or getting shot up with bee venom to get through the night. And the best way to get healthier knees, I’m convinced, is through a smart, motion-based program.

Saturday, May 17, 2014

Why Saving My Knees Doesn’t Contain a Glossy Photo Section Showing Knee Exercises

One common complaint is that Saving My Knees doesn’t include knee exercises. There are a number of reasons why, and I thought they would be worth reviewing, so readers (or would-be readers) can appreciate that this wasn’t a gratuitous exclusion.

* I’m not a physical therapist or doctor, as I’ve said repeatedly. To me, once you start including pages and pages of knee exercises, that suggests the kind of authority of a professional who knows that exercises X and Y work. I don’t have that confidence, partly because I’m not a specialist in rehabbing bad knees.

* Saving My Knees was mostly my story -- with a lot of information and studies packed in, showing why what worked for me probably would work for a lot of people. And honestly, what worked best for me was nothing that came out of an exercise guide. I did a lot of slow walking -- and most people learn how to do that exercise by the age of 15 months.

* I like simple. I like an Occam’s razor type of approach. What’s the simplest way to achieve a desired result? I get a kick out of seeing physical therapists and personal trainers standing around swapping favorite stretches and exercises. God, there seem to be dozens and dozens of stretches alone. Seems complicated to me.

I’m well aware that the knee doesn’t bend and twist in a vacuum; it’s one piece of a complex biomechanical system. Still -- what if, with knee pain, the most important thing to focus on is your knees (not hips, gluteus, trunk, whatever)? What if your knees deserve 95 percent plus of your attention? What would happen if you just tried to focus on getting in lots of easy, beneficial motion and let your knees sort out the healing part?

That’s basically what I did.

* This may come as no surprise, but I’m not convinced that most knee exercises are that valuable anyway. I could be wrong but:

I remember Doug Kelsey making the statement that the health of cartilage can be improved, but the tissue adapts best under light loads and thousands of repetitions. Thinking about that really opened my eyes. Picture all the pages of knee exercises you’ve ever seen and ask yourself: How many of those could you do 3,000 times in a row? Or even 300 times in a row? I’m guessing roughly zero.

So where does that leave you?

Well, I’d say with a few high-repetition activities you probably don’t need instructions to know how to do.

Walking. Swimming. Cycling.

(All to be done gently, of course, at least initially.)

And if you don’t have the knee strength to do these, you can do modified versions: e.g., cycling backward or swimming with floatbands on your ankles (what I did). The key thing is getting in lots of easy repetitions without further injuring your knees.

Saturday, May 10, 2014

Of Book Reviews: Brickbats, Bouquets and Everything in Between

I thought this week we’d have a little fun. Instead of listening to me drone on about cartilage defects, and glycosaminoglycans, and flaws in clinical studies that purport to show a link between X and Y, you can listen to me drone on about ... book reviews.

I’ve gotten 53 now at Amazon, which is kind of cool. A few authors say they never read their book reviews. Personally, I suspect that’s a rare few. I’ll confess that I read all of mine.

The first few were kind, even glowing: five-star raves about Saving My Knees and its message. Great, I thought. Then I looked at another knee book, this one by a doctor, that also had a few five-star reviews.

After the gushing endorsements were comments like this:

Nice try, doc. Five-star reviews by people with no prior history of reviewing anything on Amazon. What do you think we are, stupid?

Uh oh.

A few mouse clicks later, I discovered that my reviewers too, as luck would have it, hadn’t written about any other book or product on Amazon. You might say that only shows the brilliance of Saving My Knees -- that it stirs timid, often unopinionated people into lusty cheers of affirmation and joy. :)

But I realized most people would not arrive at that conclusion. Rather, they’d assume the same as the commenter for the other book: that I was somehow involved in fraudulently obtaining five-star reviews.

Clearly, I needed some non-five-star reviews (“Yeah, a great read, with really good insights into beating knee pain, but I didn’t like his usage of semi-colons and what’s up with the mold in his camera?”)

Soon, my wishes were granted -- almost.

A couple of reviewers, it so happened, didn’t think the book deserved five stars. They didn’t think it deserved even two. Their comments went like this:

No substance. Too expensive. Way too long. Waste of money.

Be careful what you wish for, huh?

Anyway, the good thing about amassing 53 reviews is that the criticism -- agree or disagree with it -- looks authentic.  

Sometimes I do want to disagree. Some comments leave me scratching my head or wanting to scream something like, “Page 37! Reread page 37!”

Then there are those ambiguous comments like “reads like fiction.”

In a five-star review, it comes across as high praise. In a two-star review, it carries an entirely different sense, suggesting I’m a breezy wannabe novelist, sacrificing useful information for the sake of indulging my creative whimsy to create narrative tension or capture the hue of a character’s eyes.

Finally, let me tell you about my favorite review. It’s not one of the most admiring. In fact, when the writer initially posted his thoughts, he gave the book one star or two -- I forget. In any event, I remember kind of shrugging. Can’t win ‘em all.

Then something really nice happened. He changed his review completely. It turned into a sort of mini-journal of his progress, following the ideas in the book.

And here’s what he wrote, over the course of several months: 
6/20/2013 - I am a 57 year old ex-athlete with very serious chronic knee injuries and recently my left knee has taken a turn for the worse, leaving me with crippling pain and difficulty walking. I am still experimenting with the recommendations made in this book for my knee problem. The best way to tell if the advice given here is worth anything is to see if it actually works so I will let you know later what my results are...

8/20/2013 - OK, it is now 2 months later and I used the advice in this book to devise my own knee rehabilitation program centered around a stationary bike. My arthritic knee is definitely improving as I can now walk a lot easier and no longer need to use a cane. I also don't lie in bed every night moaning in pain as I was doing before - it's nice to get a good night's sleep again. I am also completely off pain killers for more than a month. My knee still has a long way to go but I am really hopeful now. I'll update in a couple of more months...

9/11/2013 - The author is really onto something here as my knee continues to improve. Before reading this book I was preparing to do a lot of weight training to rehab my knee and I would have unwittingly destroyed the joint. Glad I found this book just in time to save my knee. The author gives sound advice with undeniable logic behind it. If I don't post here again it will be because my knee has recovered enough where I just don't think about this anymore.
That’s really, really cool. Yeah, there are still some one-star reviews. But there are always going to be one-star reviews on Amazon that say things like “tiresome, tedious,” “disjointed,” “rambling,” “rubbish,” “worst book I have ever read.”

By the way, those descriptions aren’t for Saving My Knees. They were used in one-star reviews of James Joyces’s Ulysses. ;)

Saturday, May 3, 2014

Good News: Doug Kelsey Has a New Book

I recently got an e-mail from Doug Kelsey (a pleasant surprise). He wanted to tell me about his new electronic book, The 90 Day Knee Arthritis Remedy. The book is being offered for sale here.

First, I prefer this choice of title to his earlier Runner’s Knee Bible. No, it’s not that I’m a deeply devout Christian who believes the word “Bible” must be reserved solely for The Book. Rather, I see the words “Runner’s Knee” in the title and think that many would-be readers -- in fact, should-be readers -- will turn away, thinking, “I’m not a runner.” And that’s unfortunate because runner’s knee afflicts more people than runners.

“Arthritis” though is more of a catchall word that will attract many of exactly the sort of people who would benefit from Doug’s message about exercising the right way, in the right amounts, to build up your knee instead of further breaking it down (he also addresses strengthening the core muscles, something that I’ve never really gone into).

And for those who didn’t like my book (or liked it less) because of the lack of exercises, Doug includes plenty of those, with links to videos showing you how to do them.

I’ll be taking a deeper look at The 90 Day Knee Arthritis Remedy later, telling you what I like most about it. Doug floated me a review copy, and I’m finding it an inspiring, thorough and well-detailed read: the complete DIY knee repair kit for people with achy, grumbling joints.

One final thing.

The price.

At $28.95, it’s not the cheapest knee book out there certainly. But here’s how I look at that:

* I can find you cheaper how-to-fix-your-knees books that don’t work, or don’t work as well. So the question as I see it boils down to: Do you want to fix your knees or save a few bucks?

* Right now the specialist co-pay under my health plan is $40. So I could spend $40 to see an orthopedist (if I still had knee pain) who would say something like, “Your knees look fine” or “You’re not a candidate for surgery yet” or “There’s not much I can do” -- or some rather unhelpful combination of the above. So which would you prefer -- that or a detailed plan of action (note: of course you should always start by seeing a knee doctor, not by buying a book, but after your first or second doctor, chances are good they’ll start sounding pretty much the same).

* $28.95 is certainly cheap if your alternative is surgery. Now surgery, that’s expensive -- even if you have good health insurance. Start adding all your co-pays for an entire surgical procedure, plus the stuff that’s not covered, plus the bandages, rehab clothes/equipment (some not covered), the co-pay on your pain medication, then the harder-to-value opportunity cost of being laid up for x days ... that’ll make $28.95 seem like the price of a candy bar.

Saturday, April 26, 2014

Microfractures Revisited

This post that I wrote comparing whether to get a microfracture or ACI (autologous chondrocyte implantation) got a lot of reads. Perhaps surprisingly, I came down on the side of the traditional microfracture procedure. I partly based that on this study, which said that functional outcomes between microfracture and ACI patients were found to be about the same

I also happened to mention that, in support of microfracture, it’s the less extensive surgery that the NBA pros -- who could afford any kind of procedure -- choose. 

So recently, along comes this article featuring the NBA’s Greg Oden, a superstar talent felled at a young age by a pair of bad knees, that claims that doctors are moving away from microfracture to fix cartilage defects in NBA players. Among the alternatives, besides ACI: OATS (osteochondral autograft transfer, for small tears), platelet-rich plasma therapy and the Orthokine procedures that Kobe Bryant popularized that are similar to platelet-rich plasma therapy.

It’s certainly true that one or even all of these treatments may be superior to the old-fashioned microfracture, but a few points:

* The knees of NBA players take an epic amount of abuse. It’s important to appreciate that from the outset. It’s not just the jumping and running, but also the diving for loose balls, colliding with opponents in the normal course of play, making quick shifts in direction, etc.

* With that in mind, when someone writes, “the history of microfracture, especially among NBA players, has been dotted with success stories ... and failures,” I wouldn’t take that as necessarily an indictment. I’d be surprised if any knee operation ever had a 100 percent success rate, or even close to it, for such a subject population: too-tall men who bang their knees really hard every two or three days.

* The article tells us the problem is that the microfracture process (in which holes are drilled in bone, which creates bleeding that results in a new layer of cartilage) leads to rubbery fibrocartilage, not the good sort of hyaline articular cartilage. True, but interestingly enough, that fibrocartilage after a while can begin to take on characteristics of normal cartilage. In a study published in Arthroscopy in April 2006, researchers who took biopsies to inspect the cartilage that was formed after a microfracture observed that "this healed tissue is a combination, or hybrid, of fibrocartilage and hyaline-like cartilage."

So is fibrocartilage more of an intermediary state on the way to some form of cartilage that, if not normal, is at least much more normal in function and characteristics? Or what does fibrous cartilage created by a microfracture look like after 20 years, in a well-cared-for knee?

I don’t know. But I suspect that the answer may surprise some people who are critical of the procedure.

Saturday, April 19, 2014

A Plea for “Real” Knee Exercise Models

Are you also tired of seeing models that look like this demonstrating the proper exercises to rehabilitate your bad knees? (The headline for this article: Knee Pain? Start Doing These Exercises ASAP)

And of course demonstrating “these exercises” are a number of women who are very toned, with pleasant faces, wearing that kind of tight-fitting workout clothing that you don’t put on (if you’re smart) unless you have sub 6 percent body fat.

What do you think is the chance that the models shown here are actually battling the kind of chronic knee pain that causes them to dissolve into tears and wonder if their lives will ever be normal again?

Yup, I’d say one in a million sounds about right.

So I’d like to advocate for “real” knee exercise models. Models we can believe in. Models we can look at and silently cheer, “Yes, you can beat this thing, hang in there!”

Instead we get these cheery fitness freaks whose barely suppressed smiles seem to be saying, “God, if you only knew how pathetically easy this exercise is for me!”

You’ll see there are a lot of recommendations here, a full page. And all of the “knee pain” models handle the exercises with ease. But if you’ve got delicate knees and bad pain, I wouldn’t recommend doing a number of these unless you want to wind up with even worse pain.

Saturday, April 12, 2014

The Drumbeat of Studies Disparaging Glucosamine Keeps Getting Louder

I know, I know, I’ve written A LOT about the (probable) uselessness of glucosamine (unless you’re susceptible to the placebo effect)

Then along comes yet a new study slamming the supplement. The L.A. Times did a nice write-up here.

Below are the three most interesting things about the study, in my opinion. But first the study, in bare bones form, looked like this:

The 201 subjects were 35 to 65 years old and complained of knee pain. For six months, about half of them consumed a daily lemonade drink that contained glucosamine hydrochloride (which the study’s lead author notes doesn’t differ pharmacologically from the more common glucosamine sulfate). The others drank the lemonade but without the added glucosamine.

Drinking glucosamine-laced lemonade “failed to prevent deterioration of knee cartilage, reduce bone bruises or ease knee pain.”

Now on to my personal “three most interesting things.”

#1 "Roughly 10% of the U.S. population uses the supplement, study authors said."

Did not see that one coming. The U.S. population is, what, 310 million? So about 31 million people take glucosamine.

Hey, that gives me an idea. :) This is directed to those 31 million people spending $10 monthly on glucosamine pills:

You all need to buy this book, Saving My Knees (link on upper right). It will tell you why you shouldn’t bother taking glucosamine. You’ll recoup the cost of the book in one month and have a net savings of $110 the first year (and I’ll finally be a multi-millionaire, cough, cough).

#2 "The urine was tested for levels of C-terminal cross-linking telopeptide of type II collagen (CTX-II), a molecular marker for cartilage tissue degradation."

This is the first glucosamine study I’m aware of that analyzed urine samples to look at whether cartilage rates of deterioration had slowed. Why does that matter?

Well, it shows that attempts to ascertain whether glucosamine has any salutary effect are getting more sophisticated. And, whatever they look at, they’re still not finding a benefit.

#3 "Study authors said theirs was the first to use MRIs to evaluate glucosamine's effects on cartilage and bone marrow lesions."

So this study is the first, the authors claim, to use MRIs to peek directly at the condition of the cartilage and bone. And, using this more advanced technology, researchers still found no glucosamine-related improvement.

Saturday, April 5, 2014

Beware of People Bearing Slick Stories

This happened to me very recently:

I was sitting in a Dunkin’ Donuts, enjoying a guilty pleasure (actually two, both frosting-covered). I had planned to finish my food quickly, when I picked up the frequency of a rather interesting conversation behind me. Two young men were talking -- or actually, one was doing most of the talking. He seemed to be telling a long story in a patient, smooth way. I recognized the patter as a well-practiced sales pitch, so I waited to see what the payoff would be. His listener appeared to be Hispanic, maybe a manual laborer, kind of quiet -- the sort of guy used to taking orders, and maybe not too sharp.

Mr. Salesman was saying how it would be great to work for yourself, then I recall him mentioning how much Elvis and Tupac made last year -- north of $10 million -- and they were dead guys, dead, and his listener kind of chuckled, because the implication was: “Hey, you can make more than a couple of dead guys.” And then the story shifted focus to a couple of men who became successful selling a product that was recession-proof -- soap -- because no matter how poor you are, you’re still going to bathe, right? And his listener had to agree this was true.

The mostly one-sided conversation was ongoing when I left. But I stayed long enough to hear one word that explained where all this was leading: Amway.

Amway, which has been likened to a pyramid scheme, is a multi-level marking system. As I understand it, Amway has a kind of pyramidal structure, where salespeople earn a certain percentage of sales they make, and a fraction of the sales by people who they brought into the selling network, and a fraction of the sales by people those people brought in, and so on. So if you were among the first generation of say five Amway salesmen, who then each brought in five people, each of whom brought in five, each of whom brought in five ... well, you get the idea. All of a sudden you’re making thousands a month (assuming your salespeople are good) without having to lift a finger!

Wow -- it seems. Actually there are a number of problems with this sales model, which I won’t get into, because that’s not the point of this blog.

My point is there are lots of smooth stories out there, promising suspiciously high returns for low investment.

In the world of knee pain, the biggest slick story I would be wary of is that of glucosamine. A pill a day chases the knee pain away! Could it be that simple?

Actually, no, as I’ve noted here, here and here for starters. Glucosamine’s story is appealing -- the supplement supposedly helps rebuild lost cartilage -- but the latest studies are suggesting that it’s a dud.

(Next week: I review the most recent glucosamine-doesn’t-work study.)

So beware slick sales pitches for knee pain relief. Hope is good, but make sure it’s informed hope.

Saturday, March 22, 2014

What Do Success Stories Have in Common?

For that subset of people who manage to beat knee pain, what are the common threads that run through their stories?

Of course I don’t know all the success stories out there, and I hate to generalize, but let me make some observations based on my experience (and that of a few others). I’m quite interested in success stories.

Here’s one (edited for length) that Larry Terbell recounted on Yahoo’s chondromalacia forum:
I had left knee cap pain that was getting worse. Resting my knee was not making it better, only weaker. Exercise aggravated my knee. I read articles by Doug Kelsey. His philosophy about joint motion interested me. I eventually went to Austin to have an appointment with Christine at Sports Center.

I started with 15 minutes of stationary bike, quad flex and one-legged leg presses on a Total Gym or Cybex Squat Machine (maybe about three sets of  15). After my appointment with Christine, I added the squat-hold exercise, hip exercise, and core exercises.

The first few months was the most difficult part. Too much load will set you back and too little load will not be helpful. I had to deal with the Goldilocks window also. I decided to try to stay in the pain-free zone. I began with a very light resistance and increased it very slowly. I only worked out about three days per week and often experienced delayed pain. I would simply lower the intensity or delay the next workout for a day or two. I avoided climbing up or down stairs. Doing a step-up on an 8-inch stair would cause pain. Jogging 10 feet was painful also, so I avoided activities such as these at first.

After about three months of low-resistance training, I was able to do a step-up with no pain. After about four months I could do the squat-hold exercise holding two 20-pound weights. After another month, I was doing step-ups while holding weights. The step-up turned out to be one of the best strength building exercises for me once my knee had enough strength. I found it  helpful to keep a workout log in which I monitored my exercises and how my knee felt.

Eventually I was able to resume full activities. Now I still do exercises to maintain my quad and hip strength.
So, based on Larry’s story and others, what are some recurring themes?

#1 It helps being methodical and detail-oriented.

One thing about Larry’s story that impresses me (and you have to kind of read between the lines) is that he sounds very much aware of the process he went through. He recalls precise details, and I sense he was quite deliberate in setting up his program -- everything from the amount of weight he used for squats to the height of the stair he stepped up on. Importantly, he had a plan. And it seems to me, he always had a good sense of where he was within that plan.

#2 It helps being very attuned to feedback your body is giving you.
I sense that Larry struggled the first few months (as did I), trying to figure out the right “baseline” of movement. As he says, too much load sets you back, and too little doesn’t keep you moving forward. Finding the right amount is very hard. God doesn’t toss you a manual that says, “For your particular bad knees, do x repetitions of y each day, then increase by z repetitions every two weeks.” You must figure this out (ideally with the aid of a physical therapist who is actually equipped to measure how much load your bad knees can tolerate).

If you don’t have that good physical therapist working with you, you’ll have to determine your baseline by yourself. Doing so will require being well attuned to the pain/discomfort signals your bad joint is throwing off.

#3 It helps being patient and accepting.

At first I just wrote “patient.”

But “accepting” is important too. Learning acceptance can be the result of a sort of “come to Jesus” moment. For example, your knees bother you after a seemingly innocuous activity and you have this epiphany: “Crap! My joints are really, really weak.”

Once you accept that, you can radically dial back on your program (if you recall from Saving My Knees, I spent weeks just walking slowly around a swimming pool every 10 minutes). “Accepting” means not fighting the fact that your knees are in bad shape; don’t pretend you feel okay after two weeks and go running a couple of miles.

And, if you’re patient enough, good changes should come!

One last thing: I was pleased to see Larry also kept a sort of “knee journal.” I thought mine was quite useful in helping me figure out where I should be going and keeping track of where I’d been.

Saturday, March 15, 2014

The One Thing I Hope We All Can Agree On

Anyone who’s been reading this blog for a while knows that I have a lot of, er, unconventional opinions.

Even those who largely agree with me probably draw a line somewhere: “I like his message about hope, and the ability of cartilage to heal, but his skepticism about stretching? Eh, I don’t know about that.” Or maybe you agree with me about stretching, but not about glucosamine most probably being a dud.

I hope there’s one thing -- or actually four things -- that we all can agree on. I made them into one short chapter in Saving My Knees. And, since the book’s publication three years ago, my conviction that these four matter hugely for those trying to heal bad knees has only increased.

These four things I mentioned in my “golden rules for fixing bad knees” chapter. To me they are almost like “Thou shalt” commandments. Of course you’d be hard pressed to find anyone sensible who disagrees with any of them, except I doubt you’ll find many people who believe in them with the same fervor I do.

#1 Use it or lose it.

In the immediate aftermath of a traumatic injury, when your knee has swollen to the size of a soccer ball, moving it admittedly isn’t a good idea. But when you have a more persistent, achy, low-grade knee pain, it seems to me that motion must be at the centerpiece of any plan to heal.

It has to be the proper amount of appropriate motion, for sure. But without movement, joints decay. Trying to avoid using your bad knees will only make them weaker, not stronger.

#2  Lose weight.

This is the easiest no brainer in the world of knee pain.

Don’t misunderstand me. I’m not saying losing weight is easy. It certainly isn’t.

What I’m saying: This is the one bit of advice no one disputes and there is no ambiguity about how to execute on this recommendation either.

For example, the advice to “strengthen your quads” is almost universally advocated (not by me, but by most everyone else). Still, there is considerable ambiguity about how to do this. What kinds of exercises? How often? When do you increase the intensity?

Taking glucosamine, on the other hand, doesn’t really involve ambiguity on the “how to execute” part -- you just take the required dose each day. With glucosamine, the problem differs; it’s that plenty of people dispute the supplement’s efficacy.

For losing weight, on these two points, there’s no dispute and no ambiguity. Many studies have shown that shedding pounds helps lessen knee pain and improve functioning of the joint. And losing weight is about as unambiguous a concept as they come. If you weigh 190 lbs. this week and 189 next week, you’re losing weight. If you still weigh 190 next week (or say 191), you’re not.

#3 Get on cartilage time (or however you prefer to express this).

In other words: Healing bad knees takes a long time (longer than doctors and physical therapists currently prepare you for, in my opinion). Make your peace with that upfront or you’re going to have a lot of frustration.

I still like the simple example I used in the book of hard-boiling an egg. Suppose you set out to discover whether such a thing is possible -- but you remove the egg from the boiling water after two minutes. Now, if you repeat the experiment 100 times, failing each time, should you conclude, “I’ve just proved it’s impossible to hard-boil an egg”?

Clearly, of course not. You’re judging success on the wrong time scale. Similarly, when trying to come to a fair judgment on whether bad knees can heal, you need to use the right time scale -- which my experience anyway showed is much longer than most people think.

#4 Listen to your knees.

I hope everyone who read my book at least came away with the message that “Listen to your knees” means much more than “If an activity hurts, don’t do it.” I think that often you may be further damaging your knees and setting back your efforts to heal even before you feel pain during an activity.

Sunday, March 9, 2014

Cherry Juice, Sesame Seeds for Knee Pain?

As many of you know, I get daily Google alerts related to knee pain. They do a decent job of capturing what’s being said on the Internet, from the latest knee pain studies to random knee chatter in various forums.

Here’s the type of thing I get links to periodically that I usually delete without a second thought:
Q: I am 55 years old and suffer from arthritis in my knees. One day I decided to try some unflavored gelatin with tart cherry juice because my nails were not growing as well as they used to, and gelatin is said to be a good anti-inflammatory. Much to my surprise, the pain in my knees subsided substantially within a week!
Then, recently, I thought: Why not? Why not write about whether tart cherry juice, or sesame seeds, blunt knee pain? Heck, I’ve written ad nauseam about glucosamine.

Now, if this were a different time in my life -- a time when I could take three or four hours to leisurely read studies and conduct research -- I’d probably do a different (and longer) blog post on this subject. But these days, I have an 8-month-old and a 4-year-old, both of whom want to be held or played with about 10 hours a day. So I’ll leave it to all of you (if you’re so inclined), to uncover the double-blind medical trials. :) I’m going to approach this from a different perspective: strictly my own.

While living in Hong Kong, trying to heal my knees, I tried a LOT of things. Remember, healing my knees was my full-time job for a year (I quit my regular job). So I tried to leave no stone unturned.

I did try natural anti-inflammatories. My main choice: garlic. I had read great things about this bulbous plant and its powers to suppress inflammation.

So I began garlic-bombing my dinners. Seriously. However much garlic you’re supposed to add to a meal, I must’ve thrown in 5, 10, 20 times that amount. I have memories of sitting on a chocolate-brown couch, slicing up garlic cloves by the pouch. My wife (at the time my fiancee) fortunately had no strong aversion to men who smelled like garlic, or I’d probably still be single.

After eating a lot of garlic, and monitoring how my knees felt before and after consuming it, how much do I think garlic was responsible for reducing my knee pain? In all honesty: I never detected any benefit related to a high garlic intake. Maybe there was a benefit, but it was so slight I just never noticed it.

In any case, my skepticism about garlic/tart cherry juice/sesame seeds stems mainly from this experience. During my travails, I was pretty sure that garlic was the knockout anti-inflammatory, and it just didn’t work for me.

To be fair, maybe garlic’s failure had something to do with my physiology. Or something to do with the nature of my burning pain. Or, then again, maybe garlic actually doesn’t do much, but other substances (cherry juice, sesame seeds) really do.

I’m not completely sure. And it’s always good to keep an open mind. So if you’re feeling relief from any of the above, or something else, and it’s not turning your face green or your skin blotchy or ... well, whatever ... you might as well keep taking it.