Saturday, February 22, 2014

Thinking About Knee Design

Why were knees “designed” the way they were? Why does articular cartilage lack a blood supply and nerve endings -- the former, if present, would facilitate healing and the latter would warn us away from activities that are causing further damage?

I often pondered such questions during the year I spent in Hong Kong without a job, when I was concentrating full time on healing my bad knees. My focus had turned completely to all things knee.

At first when your knees hurt, and they prove stubbornly resistant to getting better, your inclination is to think, “Stupid knees! These dumb joints always wear out. Why couldn’t they be better designed?” But then, as I took a closer look at the inner workings of the human knee, I was surprised at how ingenious the design actually is.

Some of this I captured in Saving My Knees, in a chapter I’m sure half of readers skipped over, eyes glazed. It was the chapter that took a sort of Fantastic Journey through knee cartilage and introduced proteoglycans, chondrocytes and glycosaminoglycans. While writing it, I tried to keep a sense of wonder at how well all of articular cartilage’s adaptations actually worked.

But no nerves, no blood vessels -- how could this be a good thing? As I thought this over, an answer began to take shape: Of course it could be.

Imagine you’re designing a very tough cushion, to insert in a joint, that can withstand big impacts. Would you want to lace this tissue with delicate blood vessels and sensitive nerves? Or would that make a simple stroll across the room feel like walking on broken glass -- a refrain of “ouch, ouch, ouch” with each step?

I don’t know, but it’s something interesting to ponder.

To me, the real fatal design flaw in knees would have been if they had no capacity to self-repair, considering all the abuse they take. Happily, as I found out during my recovery from chronic knee pain, this is not the case.

Saturday, February 15, 2014

How Should You Descend Stairs If You Have Knee Pain?

The question of how to descend stairs without aggravating existing knee pain came up in a reader question to the Ask Well blog on the New York Times website.

Several suggestions followed.

One: Strengthen your quadriceps or thighs. An exercise to do so (the straight-leg raise) was described.

Well, if your knees tolerate well quad-strengthening exercises, great. If not, you may be buying yourself a ticket to the land of Even Worse Knee Pain.

But let’s say you want to do something to get stronger, and walking isn’t enough to prepare you for the dreaded stair challenge. My thought: do unloaded squats. Find a machine (or build a DIY setup in your Mom’s garage as I did, using bungee cords and a mountain-climbing harness :)), and do lots of easy repetitions of a squat, at an easy load. Functionally, I think that’s closer to a stair-step motion than a straight-leg raise anyway.

Two: Avoid prolonged sitting.

While this strikes me as a fine idea, it’s good advice generally for just about anyone, whether they have bad knees or not. So I’m a bit less impressed by this recommendation.

Three: Descend stairs backwards. (That sound you just heard was thousands of knee pain sufferers tumbling down a flight of stairs.)

Needless to say, if you crack your crown doing this, don’t come looking for me. I’m skeptical that people with weak knees and a probably degraded sense of balance should be trying to navigate stairways in reverse.

The rationale for this advice, by the way: “Descending stairs backwards reduces loads across the knee joint,” according to orthopedic surgeon Kevin J. Bozic. A 2010 study showed that, when subjects went down stairs backward, the forces generated migrated toward the hip rather than knee.

So theoretically this approach may make sense, though in practice, I’m not so sure.

Finally: What would my suggestion have been on this matter, had I been polled?

That’s easy: Don’t.

In other words, to avoid pain while descending stairs, don’t descend stairs (or descend stairs as infrequently as possible).

Think of it this way: If you went to a doctor and said, “Doc, my knees hurt whenever I play soccer,” his perfectly reasonable response might be, “Listen, you might have to give up soccer for a while, until your knees get stronger.” So why should that sort of advice be considered strange when you simply substitute “stairs” for “soccer”?

This isn’t about avoiding stairs forever. Or even avoiding all stairs. There will inevitably be some stairs to descend, and once your knees are stronger, you can go up and down stairs all you want. In the meantime, you may have to alter your lifestyle a bit, such as by moving your second-floor bedroom onto the first floor, or taking a pass on going to the football game and sitting in the bleacher seats that are a 56-row climb to the top of the stadium.

Saturday, February 8, 2014

Comment Corner: A Torn Meniscus and the Dangers of ‘Quadriphilia’

I thought this week I’d do a “Comment Corner,” using a story that a reader shared. “Quadriphilia” is a neologism -- or not exactly a neologism, as the word already exists, it turns out, but I’m adding a new meaning for it.

Quadriphilia: An irrational obsession with strengthening one’s quadriceps to overcome knee pain.

Now, on to the story (slightly edited for length etc.):
I am a 47-year-old female, had an injury seven months ago in the gym working out on the elliptical machine, and ever since my life has stopped.

The MRI result says that I have a complex tear of the posterior horn of the medial meniscus. Tear of the free edge of the body of the lateral meniscus.

I was able to resume walking and some normal routine work after being bedridden for the first three months.

I had two flare ups in between which got better in one week of rest.

But I had a recent setback just two weeks ago. I thought I could start doing my quad exercise which doctors gave me five months ago. Did two minutes of single leg quads exercise and felt some burning after that. Next day, I went for my normal walk, and some Christmas shopping.

On Dec. 20th, I felt horrible burning and weakness in my knee and in bed since then. It's been two weeks, not much difference. Keeping leg straight and elevated in bed only helps me.

Right now, I cannot do even 5 min walk due to burning in my knee and weakness. It is not able to bear my weight.

Do you think this kind of flare up is something normal and it takes a few weeks to get better in order to even do a slow walk? Why I became so bad in 2 min of single exercise, and then keeping up with my normal one hour walk and 2 hour shopping? Why did I get so much burning?

I wonder why my knee is taking so much time to even reach a point where I can do a little walk without burning?

Do you think this kind of setback is common and it does not have any pattern in terms of how long it will last?

Every morning I get up thinking today my burning will go away and I will resume my life. But it is not happening even after resting (most of the time) for the last two weeks. :(

I am feeling very low and I guess looking for some word of comfort to stay positive. Seeing a doctor is no good since they did not do anything when I had this injury first time other than giving me a print out of a few quad exercises and an IT band stretch.

I would highly appreciate if you can please provide some insight and advice.

First, some quick thoughts on the questions raised. (By the way: usual disclaimer that I’m not a doctor or physical therapist, plus I’ve never had a torn meniscus.)

Why did the knee become so bad after two minutes of exercise, followed the next day by a normal one-hour walk and two hours of shopping?

Hard to say for sure -- but I’m guessing the normal walk wasn’t to blame. My bet is the two minutes of exercise coupled with the two hours of shopping the next day overloaded a still-weak joint.

Is two minutes of exercise really long enough to cause a serious problem? Sure. Just think about the original injury -- it may have occurred in the space of mere seconds. Remember, this wasn’t two minutes of exercise with a healthy knee; this was two minutes of exercise with a recently injured and still healing knee.

Are such setbacks common?

My experience: incredibly common. As common as sea shells on the sea shore.

How long will the pain last?

That, unfortunately, is more of a mystery, I imagine, as it depends a lot on what kind of further damage you did.

Should it take a few weeks to reach the point where you can do a slow walk?

Maybe. It could take a few months, or longer, depending on what’s going on inside your knee. But if the question’s intent is more along the lines of, “Does this mean I can’t get better and should consider surgery?” -- that is a decision it seems you’ll want to make with a qualified doctor’s input.

Now here’s the part of the story that grabbed my eye (and why I really wanted to do this blog post):
I thought I could start doing my quad exercise which doctors gave me five months ago. Did two minutes of single leg quads exercise and felt some burning after that ... On Dec. 20th, I felt horrible burning and weakness in my knee and in bed since then.
This, to me, is classic “quadriphilia.” The patient shouldn’t be blamed for it either, but rather the doctors who apparently carelessly prescribed quad strengthening for a weak, damaged knee.

I can fully empathize with this part of her story because I went through almost exactly the same thing. My physical therapist too believed I should strengthen my quads. So, once my knees were feeling relatively good, that’s what I tried to do. And I almost succeeded in ruining them.

Why is “quadriphilia” an irrational obsession?

Here’s one way to answer that:

For your knees to work properly, and assist you in any number of different movements (take walking e.g.), there’s an interlocking chain of muscles and tissues that have to be able to function correctly. For example, if I remove your quadriceps, you won’t be able to walk anywhere, no matter how strong your knee is. Similarly, other structures -- other muscles, tendons, ligaments, cartilage -- play their role in making activities such as walking possible.

One way of looking at knee pain is this: The weak link in that complex chain has become your knee(s). With that in mind, here’s why I think “quadriphilia” is crazy.

Most exercises that strengthen your quad muscles will overwhelm your weak knees. (I first came across this logical observation in the writings of Doug Kelsey, who astutely notes about treating knee pain: “having stronger muscles is helpful but weak muscles are not the primary problem”). You can find other, milder movement that will nourish the joint without taxing it too much (like the walking that Saroj was doing, that her knees apparently liked.)

Yet “quadriphilia” persists.

It persists partly because, in my opinion, a whole bunch of studies have been done showing strong quads protect weak knees, but few people have thought deeply enough (“Why That Study About Quad Strength Doesn’t Mean What You Think It Does”) about what these studies are really saying -- and what that implies for treating already injured knees (NOT healthy knees you’re trying to prevent from becoming injured -- big difference).

Saturday, February 1, 2014

5 Dumb Things People Think About Their Bad Knees

1. “I might as well go out and do my five-mile run. My knees can’t get any worse.”

Sure they can. Trust me.

2. “My knees really aren’t that bad -- I just pop some Advil, do my workout, then ice them for half an hour. I don’t feel much pain.”

Right -- and if you took twice as much Advil and iced them twice as long, you could probably succeed in doing twice the damage that you’re probably doing now.

3. “I have chondromalacia. I’m doomed!”

Not at all. Plenty of people have asymptomatic cartilage defects. There’s even good evidence that damaged cartilage can heal, if nurtured properly.

4. “Knees just wear out over time. There’s nothing you can do about it.”

You’re a living organism, not a whitewall tire. Your body has an amazing capacity to heal. Would our knee joints really have evolved to take as much pounding as they do and not have the capacity to often get better after being injured? And, it goes without saying, there’s a lot you can do to strengthen your legs and joints so you don’t get injured in the first place.

5. “Some days my knees feel a little better, some days they feel a little worse. That’s just something I have to accept now.”

If you do accept that -- with the all the “nothing can be done” fatalism that this thought implies -- over time your knees will probably get steadily worse. But if you try to find cause-and-effect patterns and modify your behavior based on them -- e.g., more than 20 minutes on your knees gardening produces symptoms the next day, so don’t do that for now -- you stand an excellent chance of reducing those “bad knee” days and increasing the good ones.