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.)


  1. Before I comment on this post, I want to thank you for your book and this website. I had almost resigned myself to a life of pain and limited mobility before I 'found' you. Your story and advice have given me hope. I cannot thank you enough for this.
    I won't go into too much detail, but I have also had a hard time getting on the right path toward healing my knee pain. For three months I've been keeping a journal and trying to determine the right amount of walking to keep pain at bay. I really haven't found it, but I have had some puzzling experiences along the way. For instance, after suffering with severe knee pain for about six months, I had a brief period of relief where I was able to jog and cycle again. I have no idea why this occurred, and after a few weeks, one day the pain was back just as before.
    And then more recently (over a year after the pain began), I went to NYC for a weekend and walked a total of about 13 miles, with essentially no negative effect on my knee. This makes no sense considering that I cannot even walk 1.5 miles more than two days in a row without a setback. I'd love to understand this! Has anyone else had experiences like these?
    In any case, I'd love to hear input from anyone who's had a hard time finding the right amount of walking to help and not hurt their knee. For the last three months I've had basically the same amount of pain and haven't been able to increase my walking distance. Has anyone else had 'progress' this slow?

  2. Yes Lisa, my experience is exactly the same & I've been at this for 2+yrs now. My knee pain reprieve was fly-fishing. I could be on my feet for hours (i.e. 4-6hrs) wading through rivers, walking over unstable ground, up banks, even jumping the odd fence & my knees felt much better - nearly normal. But back home, at work, after running or riding or kneeling or squatting, they hurt.

    Last week I went to a pain specialist. He diagnosed quite severe chondromalacia, but also nerve pain (at a level just below what they would call CRPS). He has devised a 3-pronged attack:

    1. PRP (platelet) injections to help the cartilage damage.
    2. Drugs (some natural, some not) to beat the nerve pain.
    3. Exercises (gentle) to re-build knee strength.

    I'd already been doing No.3 with some success, but kept over-doing it and going backwards. However gradually I'm learning how to do the exercise progression right.

    If you have constant pain (i.e. not just pain when using your knee), nerve involvement might be worth looking into.

    cheers, TriAgain

  3. Hi Lisa, same here. I know I tend to overdo it when I feel better, and I really must learn to be wiser and more patient! But sometimes, the pain pattern puzzles me. I'd be walking 12000 steps and have no pain. Or sometimes I walk just 4000 steps and am in pain. However, I discovered that it's not so much the number of steps, but also how long I stay sitting without moving, what I carry, whether I go up or down the steps too often, what type of shoes I wear, what I eat and drink. And how long I sleep for, as well as the weather. It's very complex, which is why keeping a diary of not only your exercise but everything else might help

    For instance, I was in Rome recently, the weather was very hot. I had flown for 3 hours and sat on a bus for one hour with no pain whatsoever. As soon as I stepped off the bus, however, the heat made my knees unbearable. I also slept little during that stay and found the pain pretty bad. A week later, I was staying at my parents, the weather was cooler, I slept a lot, and took small strolls at a very leisury pace. The knee pain was gone completely for the 5 days I was there.
    Stress seems to be playing a big role too. I find that if I'm tense, the muscles around my knees tense up and the pain gets worse.

    I also think that even without realising, when I feel better, I instinctively increase the intensity of my activities. I might be still walking the same amount of steps as the previous days, but I'd be walking faster. Or hit the ground with a bit more energy than intended.
    It's sometimes also worth using a podometer inside the house. I found yesterday that by just tidying up a bit, going to different rooms to get things, etc, all normal things that I'd not classify as 'exercise', I clocked up about 2000 steps.

    TriAgain, if walking in rivers helped, have you never considered water therapy?

  4. Deloupy, that is exactly my experience. Frame of mind has a big impact on pain levels.

    I think the pain reduction when fishing was more due to being on my feet, gentle walking, doing something I enjoy and not sitting at a desk for hours. The cold New Zealand water probably helped too, but I suspect it was mostly about lots of regular gentle movement. I often wonder how much better would I be without a desk job?

    I was talking to an (ex-) runner in the gym y'day who has had bad back problems for the past few years. He experiences similar confusing pain signals - fine for a while, then bad & he can't figure out what he has done to make it bad. But he thinks sitting most of the day is a major problem.


    1. yes, I can relate to this too. Despite taking regular walking breaks through the day, I feel more pain the days I work from my office. Funnily enough, when I work from home, still sitting at my desk, the pain is not so bad. I wonder if it has to do with the sit position itself.
      The pain for me is mostly felt in the evening. Some days, I can't feel anything all day but in the evening there is the dreaded burning sensation.
      I think most of the issue for me is not so much the pain, which is never too debilitating, but the frustration of the set backs and not understanding what triggers the pain.

  5. Have posted here as "Racer-X and R-X. Won't bore you with the details of my odyssey (how I got here). Someday I'll write Richard and he can cherry-pick the info, which after 3 years has the word count of War and Peace.

    Rebooted my routine 5 months ago, as per Richard Bedard at ground zero (cartilage): psychologically and physiologically. The good news is that I have made tremendous improvements, the bad news is, that when I look over my notes and review all of the possible confounding variables, I can't say, in all honestly, that the mechanism for healing is/was purely structural- Obviously, healing cartilage is much more complicated and an intuitive process than the state of the art and science allows.

    For example. I posted here a year and a half ago, maybe longer, about intuitions I had with the relationship between gut function and arthritis. Since then, there has been at least one study (check PubMed) done that demonstrates that possibility (with RA)- The recommendation being the development of a type of probiotic therapy. My point is, cartilage degeneration is multifactorial (a challenge to readers: discover how many causes there are for leaky gut and the potential ramifications leaky gut).

    That is just one example. So I believe quality probiotics can help heal cartilage, but it's not the end all. That's anecdotal, yes, but in a paradigm that says cartilage doesn't heal in middle-age, you try the anecdote, particularly if is benign? Is an arthroscopy benign? Mine wasn't. When I look back on it- why would I allow someone to operate on me who didn't think that cartilage heals?"

    Back on point. When I rebooted I didn't ride my bike for 6 weeks. After trying a rowing machine at a local gym, I bought one. I rowed every other day without bending my knees. It was a precarious scenario for my back. I took it easy and just enjoyed light sweating at 50-60% of my cardio max. Any port in a storm. During that first 6 weeks, I worked my way up to half a mile walking a day. Somewhere around 6 weeks I set my bike up on a wind-trainer with zero load for 20 minutes and the next day my knees were barking at me. I didn't ride for 3-4 weeks. Slowly I increased my walking load. I tried to walk mostly on dirt and over flat terrain. I introduced riding again and was able to tolerate 30 minutes with no/low load.

    Today I am riding my bike on the road for an hour every other day and walking about 5 hours a week. My knees are good, but not great, but way better than 5 months ago. Will I race my bike again? I don't know. It doesn't matter.

    Lisa: Try an elliptical machine. Doug Kelsey has an article about the virtues of ellipticals.

    TriAgain: I have CRPS too. 9 months post-op, an MRI showed severe bone loss and I had escalating muscle atrophy. Lucky for me it's CRPS type 2 and pushing against it makes it retreat. I have to honor my bad cartilage, so it is a high-wire act. Also, when my knees were really bad, I was more sensitive to barometric pressure changes and convinced that it was bad to exercise when the barometer was down. So I walked early in the morning and rested in the eves, as I noticed that there are natural cyclical pressure changes ("tides") during the course of a normal day.

    Delopuy, you make a lot of great points: I will single out stress- I absolutely agree with your intuitions about the relationship between stress and arthritis. How do you reduce stress when dealing with a health crisis? I found attempts at meditation to be helpful, although I doubt I ever actually meditated... I would turn up the Enya, light the fragrant candle and assume the ( although a very modified and comfortable) position for 20 minutes in the morning and evening. Maybe it was the discipline that helped?

    Good luck to everyone trying to heal their knees, R-X

    1. Keep posting R-X, I love your posts. Your situation is so similar to mine, I'm keen to hear more detail about what you did to get back to 1hr rides.

      If you don't want to post here, email me - david[at symbol here]

      Not sure if I have bone loss, but def have muscle atrophy that I'm doing my best to reverse. My CRPS is more like Type 1, but has also been diagnosed as CRPS-NOS (a sort of pre-full blown CRPS phase).

      I don't know if I'll ever race again either, but would be over the moon if I could ride a moderate 1hr 3-4x/week with our 19yo daughter. I really miss riding with her, it was our best quality time. We used to train and race together - halcyon days.

      Mine is also a hire wire act. The CRPS is supposed to respond to exercise, but the cartilage damage on the back of the kneecaps won't tolerate too much pressure.

      cheers, TriAgain

    2. Tri- Sorry, the perils of the long post- My crps is type 1 also, which is why I consider myself "lucky." 9 months post-op had severe muscle atrophy and moderate bone loss and it was uncertain which direction the crps was headed. Have since made muscle gains, but haven't had another MRI to check bone condition, but suspect because of the slow increase in activity, bone mass is improved. And of course I also must reckon with the chondromalacia. Enjoy your posts too, we have a lot in common. Thx for contact info. R-X