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.

36 comments:

  1. I honestly don't know which is the egg or the chicken but... I have noticed that every time I do pilates focused on hip and glut strengthening, my knees have felt better. I've noticed that every time I lock my pelvis (a collateral to giving birth twice), my knees get extremely painful too. I've noticed that when I visit the osteopath, he works on my upper body and my lower body feels better almost instantly. I don't think my hips caused the problem in my knees, but I know one thing: the PT who only looks at my knees when I come for a knee pain won't see me again in his practise

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  2. Hi. I'm a seventeen year old British girl who suffers from chondromalacia. I was diagnosed in Feb 2013, during training for my first half marathon. I considered myself a pretty serious runner, and paid attention to injury prevention. I did lots of injury prevention conditioning, as well as avoiding concrete (my background was cross country racing), and making sure I did not over stride. Unfortunately, I was underweight and I think that a lack of muscle mass, and by implication a lack of knee stability, plus overtraining was the cause of my condition. I haven't been able to run since then, despite following the advice of my physio and ignoring the advice of my incompetent doctor ("you're young, just run through the pain"). My condition has worsened to the extent where I'm unable to even walk around the house without pain, and I've had to move colleges in order to minimise the distance I had to walk each day. As somebody who loves being active, I find this condition more psychologically painful than physically; frankly, it's making me incredibly unhappy to the extent where I have no motivation to do anything. I swam when I first had the condition, which was not painful, but when I started doing yoga earlier this year my knees deteriorated and I have not been able to get rid of the pain since. I saw that you recovered walking, as you injured yourself cycling. I have been walking in circles around the garden every hour or so recently to heal, but we do have an exercise bike- would it be better for me cycle with no resistance for a few minutes every hour instead, as I injured myself with the walking motion? I understand you're not a doctor but you seem like my only option for advice considering I am staying with my grandparents who I think regard my pain as teenager-esque hyperbole and i no longer trust my physio or doctor enough to ask, as I consider them partly responsible for exacerbating my condition by giving me the wrong advice. Thank you, Daisy

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    1. Hi Daisy, my name is D. and I have a similar story. I usually do not leave comments, but your story resonated with me. I am 18 years old and have been diagnosed with chondromalsia of the patella 7 monthes ago. Since a young age, I have always been very competitivly active. Throughtout all four years of highschool I ran track and cross country. The idea was no pain no gain. If I ever had any stiffness, I waved it as a normal order of events. That's not to say I wasn't careful. I understood the importance of streching, etc. Senior year, however, I tried a field event (high jump). After a couple of days my right knee started to stiffen and throb. At this point, I can not describe the feeling accurately. But it definitly felt abnormal to my healthy left knee. When the pain did not go away after a couple of weeks, I became concerned. I left my docter feeling frustrated. Like in your case, their advice was counterproductive. When I should have stopped running, they said I could continue, which only made matters worse. 7 monthes have passed (5 without strenous activity). My knee is still sensitive, but not as stiff as before. The pain flares up time to time. Self diagnosing myself, I believe this is what happened: I was running great distances. Consequently, I was underweight in muscle mass and didn't have great support in my knees. Making the same motion such as running was fine, but when I intoduced a new motion (jumping off my right foot repeatedly, the shift and abnormal twist must have disrupted the integrity of my knee. I must have bruised my meniscus (because there was some swelling) as well as roughened my cartilage. By not being informed I did not take the correct measures. I did not allow my body to heal. You see, intense phslysical activy and strain have always been part of my life. Pushing my body and breaking a sweat was the best feeling in the world. It was difficult to rewire my body to behave otherwise. After weeks, I was frustrated that I could not control my body the way I wanted to. A mistake I made that I hope others don't make is I also started walking differently to ease the initial pain. This caused some of my back thigh muscles to weaken in my right leg than in my left leg and my ankle to start hurting. One thing I am worried about are the bone spurs Richard mentioned. Has anyone here gotten them/gotten them removed? Like someone mentioned, chondromalsia is both mentaly and physically depressing. I start college in a week. I realize I will have to be very careful in my physical activities and mentally positive. After reading Richard's book though, I have some hope/direction. It was nice to find this supportive community of people who are in similar situations. I hope everyone the best in their journey to health. -♡PS. Daisy, I feel like we have a lot in common. It would be nice to talk to someone who is close to the same age as I, going through the same ordeal. I feel like we could really help each other out and build on one anothers progress. My email is dolshevskaya@gmail. com if you want to contact me. I hope to hear from you!

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    2. Hi, it's good to hear from someone a similar age. I'll reply properly via email, Daisy

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  3. Daisy, you are bang on: the pain is more psychologically debilitating than physically. I too injured my knee while training for a marathon, but cycling doesn't work at all for me. I used to cycle a lot for commuting, but even cycling on 1st gear, no incline (or even a small slope) is painful. Having said that, some people find it useful. I can only advise that you try it for yourself, and see how it feels. Just don't overdo it even if it feels good
    Walking for me is the most helpful, I walk very slowly, a couple of steps every 15-20 min

    Good luck!

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    1. i'm a little scared of trying anything other than what i do now, just in case i set myself back weeks- i haven't got that much time before i return to sixth form, where i have less control over the movement i do during the day. that said, nothing ventured, nothing gained- i'll try cycling with no resistance for a few minutes at a time and see if it exacerbates the pain. thank you for the reply, it's nice to be heard by someone who experiences the same frustrations. i hope your walking regimen bears some fruit soon- good luck to you too!

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  4. I feel your pain Daisy - the psychological pain of not being able to do the sport you love, the loss of simple things most people take for granted, the disruption to lifestyle and the erosion of trust in your medicos. I've felt all this. And it should not be happening to a 17 year old.

    I also suspect my knee damage too was caused by not having enough muscle bulk in my legs, pushing too hard in triathlon training/racing, and too much cycling in sub-zero temps.

    Drawing on my own experience, it is so hard to say what you should do regarding walking vs easy cycling. For me, walking works, cycling aggravates. Swimming is OK, but I limit my kicking by doing around 50-70% of my swim workouts with a pull buoy between my legs. The other thing that gives me some psychological relief is going to the gym to do some of the hip/core/knee/glute strengthening exercises in Doug Kelseys knee arthritis book, plus some boxing on the speedball and bag (this is quite aerobic). None of this substitutes for the endorphins I got from triathlon, but it is better than nothing and helps with motivation in the rest of my life.

    Like you, I've found the exercises recommended by PTs, GPs and even specialists are usually too much - they make things worse. But all of them have said don't do the exercises if they cause pain - so running through pain is probably bad advice! Even so, I think some exercises (e.g. full body weight squats) which my medicos prescribed will cause pain later, even if not during them.

    In summary, I've discovered that through trial and error, I need to work out exercises I can handle without increasing my pain and stick to those - walking, swimming, and the Kelsey exercises on machines which mean I'm using less than full bodyweight.

    My pain specialist also prescribed a book on managing chronic pain by Nicholas Michael which might be helpful to you.

    All the best, hang in there, have faith. At 17, your potential for healing is huge.

    TriAgain

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    1. is the Kelsey book worth buying- have the excercises improved anything, or is it too early to tell? as it turns out we have very similar circumstances leading up the injury- i too was training in very cold conditions (probably without adequate warm up in retrospect). how far can you walk at the moment? thank you for such positive advice, i'm hanging onto the hope that being seventeen will prove more of an advantage than it has so far. good luck with kneehab, daisy

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    2. The Kelsey book is worth buying. The exercises are based around the theory that knee cartilage responds to gentle motion, which is progressively increased. So it sets out a program on how to determine your starting level, and how to progress. But as I said elsewhere, I found I had to re-read it several times to get my head around it. The other issue is for the bilateral and single leg squats, he recommends buying a machine called a Total Trainer. I did not - instead, I prop the end of a rowing machine up on stands of differing heights, sit on the sliding seat and push go back and forth on that with my legs - seems to work OK, albeit not with the finer levels of bodyweight adjustment you get with the TT machine. But the idea is you do squats, but not using full bodyweight like many medicos/PTs will get you to do - which is too much = more damage.

      I don't do all the exercises in his book, but the most important exercises are the bilateral & single leg squats, the hip burners, the quad setting, tailgaters and supermans. I also do single leg deadlifts with light dumbells, which really work hips/glutes, but they can be too much if your knees are really sore. For people like us (i.e. skinny), I think building hip & glute strength is important to help protect the knees (the hip burners and supermans help there).

      Even if the Kelsey exercises are doing nothing for my cartilage, they are definitely helping me keep some strength in the entire glute-hip-quad-knee-calf-foot chain. But I think they are helping the cartilage.

      I can do quite a bit on my knees, could walk for hours if needed, can even jog for several 30sec bursts, but my problem is different in that I don't get much pain during exercise, it comes on in the hours and days after overdoing it.

      I'd say I have general degeneration of most of my kneecap cartilage (from age and hammering it for 40+ years), where as you probably have a more focused area of damage (perhaps from overuse? perhaps from mal-tracking?). Have you ever had an MRI scan to check what sort of damage you have?

      Regardless, my view is at your age, you need to stay away from surgery like the plague, very carefully increase your mobility (as per Richards advice), find an activity that does not aggravate it more (easy spinning on a bike?, swimming with a little kicking?, walking in a pool?), and gradually/carefully strengthen the knees, hips, glutes (and perhaps feet and calves) to build more overall strength to protect knees.

      It took me 2 years to get into the mindset that fixing my knees was my new Ironman race. At first, all I wanted to do was race again and finish my first Ironman, but gradually the realisation hit me that I had a whole new type of Ironman to run to get my life back - and that was fixing my knees if I did not want another 40years of pain and misery. There are setbacks, days when I think I'm wasting my time, it is boring, but I have realised most medicos have no idea how to deal with chronic kneepain caused by cartilage damage, and I had to look for clues from non-medical people who had suffered and worked it out themselves.

      The only exception to that is possibly PRP injections - though my PRP treatment is only in its early stages, so hard to say yet.

      All the best, TriAgain

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  5. I had an MRI to diagnose the chondromalacia, after pushing the doctor to refer me (he was originally content to diagnose me with PFPS and tell me 'most teenage girls get it at some point, it will go away by itself'). Perhaps excusable, to an extent, from a GP- I didn't expect to get the same poor advice from a 'renowned' knee specialist, but shit happens.
    I agree with you completely about surgery, and I'll ask about PRP injections if I ever go back into the system. As of right now, I'm going to just build up my motion slowly. Since I've been walking around the garden every hour or so and stopped physio my pain has changed from stabbing pain to more of an ache, with sharp pain only when I'm turning or ascending/descending. I think I've stopped inflaming it and now it's beginning to heal, with the ache being residual damage and inflammation. It's brilliant progress considering my pain level has been static for months!
    What you said about learning to regard recovery as your new Ironman is so accurate; one of the biggest challenges for me has been an attitude change, and considering you were training more intensely over a longer period, it must have been much more difficult for you. (Kudos for training for an ironman by the way, I was always in awe as a little kid whenever I saw people with the tattoo!)
    It's really quite scary how wrong the general consensus on how to deal with cartilage problems is. My dad's girlfriend is an actively researching doctor, and she never questioned the programme I was on, despite me querying how strange it was that my friend has been issued the same physio exercises as me- she has a completely different condition (Elos Danlos syndrome, a connective tissue disorder)- as well as telling me I could continue running despite being in considerable pain on a daily basis. It's bordering on misconduct that they do not offer up to clients what studies (and anecdotal evidence) show about how cartilage degeneration can heal.
    Thanks for the review on Kelsey's book, I'll definitely buy it soon. And thank you generally for replying, it's made me more hopeful and determined to stick with this incredibly boring, but clearly effective, route to recovery.
    Daisy

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    1. I bought the Kelsey book and I am a little intimidated by both the initial tests and drills he suggests as physio. Hasn't what has been suggested been to stop physio, and just focus on motion? I'm conflicted, because although I am aware my leg muscles are quite weak at the moment, the idea of exacerbating my pain when I have only got a month till college is a little worrying?

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  6. Hi Daisy

    The Kelsey approach seems to say if it hurts just once, don't do it. I found the hip burners, quad sets and planks put the least pressure on my knees. Maybe just stick to them? Bilateral squats are also good, but I use the rowing machine setup so it is not full bodyweight. It is probably a matter of trial and error though - no one will be the same.

    If walking has reduced things from stabbing to a dull ache, that sounds promising. Perhaps stick with that for a few months before progressing to Kelsey? I can well understand you don't want to stir it up starting college (I have 2 daughters who have done the starting college thing (= University here in Oz), and you don't need the stress of pain when starting out).

    Medicos think 17yos are bullet-proof, which is probably why you got bad advice. At 50, they start to believe you might be wearing out!

    cheers, TriAgain

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    1. Just to add, I found the number of exercises in Kelsey a bit intimidating, so just regularly do a sub-set of them. I find them to be different to what physios/GPs suggest in that they are not full bodyweight. That seems to be the key - they give you motion, but with less pressure on the knee. I also like the tailgater exercise.

      Our eldest daughter is currently doing a gap year in the south of the UK (Hurstpierpoint) and our youngest did her gap year in Holt (Norfolk). We visited her in Holt and absolutely loved it.

      I also coached our youngest to her first half marathon at age 17 (her goal was sub 2hrs and she hit 1:58 - my fastest was a 1:33 on the Gold Coast, and about 1:44 as part of a Half Ironman). She still runs regularly, though after my knee experiences, I'm trying to encourage her to run more on grass/trails than the bitumen/concrete.
      TriAgain

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    2. I think doing a few long runs on concrete/bitumen was actually what pushed my knees over the edge. I trained for the half marathon when I was 15. My target was late 1 : 40's and I was doing stupid things like double days on hilly ground, the day after interval sessions. My dad's an ultramarathon runner so he didn't see anything wrong with the training load, but in retrospect it's not surprising I've ended up trashing my knees. Gah, so much regret. I skimmed your comment briefly a couple of days ago, and was indignant when I saw 'stick with walking for a couple of months'- I was so excited to get some exercises to do. Fast forward a few days and I'm a little crippled... I think I'll take your word for It and continue walking for a while, without adding any exercises. Thank you again for the advice, Daisy

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    3. Yes, it is so frustrating. After my first platelet injection, I got huge relief so over the past 6 weeks started doing 5x30sec jogs on my 30min walks, and had 2x10min sessions on the eliptical in the gym plus increased the length of my boxing circuit. The last few days I've gone backwards.

      It is good to have a portfolio of things you can do, but if you try one and it sends you backwards, it probably means it is too much for now, so staying with the walking sounds like a good plan.

      I think I had a bit of a warning that I missed with my knees, because for a few years before they blew, they would always feel stiff and weird if I just did a straight run, and it got to the stage I tried to do most of my runs off a bike ride so my knees felt warm and loose and 'normal'.

      TriAgain

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    4. Despite not changing my routine massively, my knee pain has changed to a burning/swelling sensation that peaks in the afternoon. This is not what I expected, and am not sure if this is part of the healing process or I am regressing. They are not hot to the touch and I seem to have less pain during movement? Do you have any experience of pain like this? Hope your recent flare up has dampened down, Daisy

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    5. Yes, my pain is mostly like that - plus often stiffness, and a deeper ache - but no actual swelling. Sometimes my knees get hot to touch, but mostly they are cold (and often purple/blue with red blotches = nerve involvement reducing blood flow).

      I think that sensation is a negative thing, not positive. It is for me. And sometimes, I get flare ups wen I've been doing less rather than more - very confusing.

      TriAgain

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    6. Interesting you should say your flare ups can occur when you've been doing less, considering that the burning occurs in the late afternoon when I'm still moving but less so. That might be the reason. Has your pain always been like that, or did it progress from more acute pain into that- I was wondering if it was an intermediary of sorts (I guess when the healing/formation of fibrocartilage is happening) between the initial injured cartilage and stronger, stiffer cartilage, although I realise nobody's knees and perceptions are the same!

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    7. Hi Daisy

      I've been battling this for 2+yrs, so my memory is a bit hazy, but I think it went like this:
      - some chonrdomalacia pain under the right kneecap for may years, which never knocked me out of racing/training for more than a few days
      - sudden tear of medial meniscus in right knee when running = acute stinging pain and knee 'catching' (following some pain in that area 6-12mths beforehand which settled
      - surgery to remove tear
      - aching in medial areas of both knees a month or so after
      - continued to train, aching became a constant burn/stiffness/ache in both knees, mostly anterior (under kneecap) but also medial
      - stopped training 4mths after this, but these types of pain have persisted, with the exception of a few weeks here and there (one which involved a lot of gentle walking in NZ)
      - have always walked for 15-60mins after stopping training
      - have trialed some more aggressive leg strengthening with a coach (e.g. single leg squats) which went OK for a few weeks (though never pain-free), then pain started to increase
      - started doing Kelsey type exercises a few months ago, plus started PRP injections. Significant reduction in pain (up to 90% reduction) - but is it the Kelsey or the PRP or both?
      - also finding hamstring stretches, and stretching the inner side of the thigh - the area which runs down to the VMO seems to give relief during flareups.
      - my knees are virtually pain-free after sleeping, then generally get sorer as the day wears on.

      I think the homeostatis of both knees got way out of whack until nearly everything I did aggravated them. I think the PRP the PRP has helped knock down the inflammation, giving homeostasis a chance to return. In Richards case, I think extreme rest interspersed with very light motion helped him achieve homeostasis again. The trick seems to be to avoid aggravation for a very long period. Kelsey's exercises may be too much for many people once they reach our stage. Or perhaps you just need to do a tiny amount of them, added to a little walking. I think most people are facing over a year of this to recover. Mine has been longer because I was too impatient. For people like me, PRP may be the best bet.

      Or you could try PRP?

      cheers, TriAgain

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    8. Walking is so painful for my left knee it feels futile. I've seen a degree of result with my right knee, but my left seems to be getting progressively worse. I walked around the supermarket yesterday and I've been in constant pain today, which is ridiculous- I could do that a few weeks ago with less of an after effect. I don't understand why I'm in so much pain at seventeen, or how the hell I'm going to continue achieving at college when I'm like this. I have stinging pain when my knees are elevated and they are sore upon waking up, yet I've never trained to your extent? The brief reprise I had a few weeks ago seems anomalous because I can't actually attribute it to anything specific! I am going to contact a doctor when my dad comes back from his holiday, where I'll inquire about PRP. Maybe it can help me too. Thanks, Daisy

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    9. Also, how variable were your pain levels over month periods? Was it a linear upward trend or did you often feel Like you'd reached a platea

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    10. My pain levels were very variable. I had the odd few days/weeks where the pain was almost zero & I thought at last I was on the mend, but alas it would come back. And even when the pain was there it varied from barely noticeable to highly annoying and affecting my natural movement. I could always do things, but the pain made me not want to. I'd say the pain definitely plateaued, though I think that was because I learned to stop doing things that sent it upwards - but still did things which kept it more or less on the plateau.

      I think you could consider seeing a pain specialist - it was not till I made my Doctor listen to a page and a half of what I'd been through and what I was feeling that he started to take me seriously and gave me a referral to the pain specialist (who I'd found online myself!).

      And even the pain specialist who is doing the PRP has no magic bullets - the process is still slow. There is a large amount of self discovery/experimenting in all this. But (as my doctor told me), brief pain reprises mean you can be healed!

      TriAgain

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    11. Daisy, I feel your pain. I have the same symptoms, my knees feel stiff in the morning, then after warming up they settle, only for the pain to reach a peak in the evening. I too had weeks when I felt little or no pain, only to come back again. Sometimes the reason was obvious, like the time I taught my daughter to cycle, I knew I would pay for it. Sometimes I can't see a trigger, but there is one. I know one I hadn't considered until now is the fact that I sleep on my side, with my legs bent. Wearing tight trousers that press on the pattela is painful. Eating too much sugar. Little things that you can only find after a few weeks of careful observation and recording.
      Use a walking stick, even if it feels silly at first. It will give your left knee (the one that's my most painful too, I think it's because the muscles in my right thight are so much stronger) a rest. I've been using mine non stop for the last 2 weeks and my knee is so much better now, and I will continue to use it regardless of the improvement so that my knee gets a chance to properly heal.
      And I would definitively follow TriAgain's advice and visit a pain specialist. Even if you have no nerve damage, it's worth getting advice on how to deal with chronic pain

      Another last point: I've noticed that when my mind is distracted from the knee issue, I feel much better. I had dinner with friends last night and was able to sit for 2 hours with my knee bent at 90 degrees, I only noticed afterwards that I had felt no pain whatsoever, I was so engrossed in the conversation. I'm not saying it's all in our mind, but obsessing about it (like I do) seems to increase the pain somehow

      Hope you feel better soon

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    12. deloupy, your last paragraph is really interesting, because exactly the same thing happens to me. I asked the pain specialist about this, and did it mean it was ''all in my head'' - a mental thing. He said with chronic pain (> 3mths of pain), definitely not. It is caused by changes in the spine and brain - basically they over-amplify the pain signals.

      My pain is bizarre - I can spend 4-5hrs walking up a stream fishing, moving over some quite rugged ground and be OK. But if I even look sideways at my triathlon bike or running shoes, the pain flares. To me that sounds like a mental issue, but the specialist says not - it seems to be the way the spinal and brain nerve pathways react to specific activities.

      It is a nerve issue, not a mental issue (according to the expert). But the nerve issue was initially triggered by underlying knee cartilage damage.

      TriAgain

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    13. My brothers science teacher was saying a similar thing last week. According to him, the brain gets 'conditioned' to feel pain- it's not psychological in the way people usually associate psychology and pain (as in its not simply psychosomatic), but it's what I think you're talking about, neural pathways. It makes sense in a way, as everything habitual or persistent must be forming neural pathways in the brain, and as we have suffered for an extensive period of time these pathways must be constantly used. I also saw something yesterday which evaluated all the usual factors we are told can lead to PFPS or cartilage degeneration- hip weakness, inflexibility, vmo firing etc- and they found that the one factor that had a significant correlation between it and pain was the extent of the anxiety that person had about exercise and working. I guess we could interpret that as those people moved less due to fear and thus their knees never got the right treatment and their pain increased, but it could also back up the idea that the mind has a hell of a lot more to do with than is generally assumed. Deloupy- your suggestion about the cane was great, I've asked a family friend (a nurse) if she could get me some crutches. Thanks! I would definitely try sleeping with your legs straight, as when I started doing that a year ago I noticed less stiffness in the morning. I also totally concur with the excess sugar worsening it all, as I reckon diet can be a brilliant way of easing inflammation. Hope you're feeling better soon too!

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    14. To add to that diet comment, try making some bone broth if you haven't heard about it already. It's not just paleo hype- there was a study where seventy eight RA sufferers saw a massive reduction in pain when they consumed chicken bone broth for a few weeks. It's got the genuine glucosamine and other glycosaminoglycans, as well as amino acids and gelatine etc.

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    15. Hey Daisy, I've got an idea. Instead of becoming a vet, how about you become a medical researcher who cracks this knee-pain conundrum!

      It's pretty clear the main-stream medicos are clueless. I can see a real need here.

      cheers, TriAgain

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    16. I've actually very recently set myself on environmental science/conservation biology, but if I had no idea what I wanted to be i would definitely consider that! I actually plan on emailing the doctor who gave me the bad advice with mine and others stories, as well as the link to this website (when I'm recovered). Unless he's as dodgy as I've joked he could be, deliberately giving poor advice to secure himself future arthroscopy patients, then I'm sure he will advise other patients with cartilage issues to follow suit! I live right next to one of the best knee and hip places in the country (apparently) so you never know, it could start to change the consensus as I guess they have leverage in the knee world! It's so bloody sad.. The time and money spent on shit physio and unneeded ops worldwide must be huge. I've actually just started to see progress by the way, after replacing my short walks with short stationary bike rides backwards. It's actually amazing how much less pain I am getting already, although I'm being careful to not get too cocky. Might have cracked it! All the best, Daisy

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    17. Spinning backwards! Now that is something I have not tried, will give it a go.

      You can email your Drs in the UK! Here is Oz, you have to either book an appointment or you might get lucky on the phone, they don't give out emails. I'm not convinced he will take it on board - a lot of surgeons are arrogant know-it-alls - but do it anyway, you never know.

      My surgeon and GP are actually quite open-minded about the info on here (I've discussed it with them), and the surgeon actually admitted they discussed PFPS at a recent conference and it has them baffled.

      cheers, TriAgain

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    18. Yeah, it's completely free of resistance, see if it helps! Usually it's a bit more cut off than that, but I'm pretty sure I can get his email off the physio. If not, I'll contact his receptionist or alternatively send him a letter. I agree that they're often incredibly arrogant. Although I'm lucky enough to have the NHS here, the consulting service is poor and this is not the first time I have been disappointed with the doctors. What you said before about lack of homeostasis in the tissues makes a lot of sense, especially since that doctor who had his knee opened and poked around found that it doesn't hurt when cartilage is poked but all the surrounding tissues do respond painfully. That and the fact that (certainly with me) the pain is not localised or standardised- you'd expect if it was a spot of softening/fibrillation, there would be a particular sore spot. Whatever the hell it is, I wish they would actually investigate it properly instead of constantly studying the same bloody variables with little change or confidence in results that basically say the status quo might well be a load of bull! One of these days eh. Good luck, hope that backward spinning has a positive effect, Daisy

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  7. Daisy, I could be wrong, but my advice is to look at what your primary goal is. You sound like your main goal is to get better (i.e. sort it out) before you start college. But may be your goal should be 'take the time to really and fully heal'.
    When I was 17, I got very sick. I denied it and hid it as best as I could because I was afraid to miss my leaving cert. I collapsed, had pains, headaches, etc... Passed my leaving cert, and started college. 3 weeks after starting college, I could barely stand, I was finally admitted to the hospital. I carried a suitcase of law books with me, the nurse took a look at it and ordered my parents to bring them home. My stay in the hospital was to heal myself, not to study. I cried, I thought it was the end of the world. Eventually I understood that I would not be in a state to study and that I should make the most of it. It took me 7 months to heal. I had missed almost a whole year in college, I had to start all over again. And I didnt. I realised that I hated law, I joined a art course and 5 years later got my degree, happier and healtier than ever.

    All this to say that you could try and rush through the healing process, but I doubt it will work, and when you start college you'll put more pressure on your knees as you rush from one class to the other, or join other kids in their outings. I didn't understand until now how much pressure on your knees every day life can put. I visited a new physio yesterday to start some hydrotherapy, and when I told her: 'but I don't do anything', she said: 'yes, you do. You push a trolley, you walk your kids to school, you drive, you vacuum the house'. She gave me a programme that is quite similar to Kelsey's, only to do in the water so there is the least body weight on the joint, but the muscles benefit from the water resistance. I only started yesterday so it's impossible to gauge the benefits, but I know that being in the pool always helped so I have great hopes.

    If you find that walking helps, I'd recommend to stick with it for a while, but don't be tempted to increase the speed of the lenght of your walkarounds now. I made that mistake many times (definition of insanity: repeat the same thing again and again and expect a different result!). Walk in a pool (also advise by Kelsey), then very, very gradually increase your exercises and assess regularly how your knees accept the new workout. Don't despair if you suffer drawbacks, learn from your mistakes and start again. It takes ages but your age is your friend: your cells will heal far more quickly than ours

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    1. It's more not wanting to exacerbate it before going to college, not heal/be pain free. I've realised that's a bit of a pipe dream, at least in the next few months! I understand completely about what you said about repeating the same thing and expecting different results, but unfortunately we make the choices we do for a reason and the thought processes that lead to them don't tend to go away overnight I guess. I've just had a set back actually, and my knees have been very painful today, at rest and when moving. Its sad that one poor decision can negate a weeks work. But you're right- they're to be learnt from. Your story about the illness you had when you were seventeen is interesting, as it sounds like it was a blessing in disguise in the end. I live in hope that this will end up being just as beneficial to my life.. It's certainly going to make me neurotic about eating properly and exercising sensibly if I'm ever active again, which is a plus. I'll be damned if I do this twice! Dragging your law books to the hospital sounds like something I would do, and funnily enough I've rethought my future whilst doing this (I'm no longer pursuing Veterinary). I hope my cells and chondrocytes are as peppy as they should be! Thank you for the advice, Daisy

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  8. Hi, this is Richard, waving at you all from the sidelines! Have enjoyed following the voluminous comment stream here ... all I can say is, Daisy, you're in good hands! A lot of great advice from many smart people who have been struggling with knee pain for a while. Daisy, I love the fact that you're seeing some gains cycling backwards. Which of your physios would've recommended that? Probably none! Just remember to keep taking it slow. Everyone always, ALWAYS, screws up by ramping up too fast once they get a few consecutive good days. Bite back hard on that temptation!

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    1. Duly noted! It's difficult because you naturally move more when you have less pain, but I realise I'm going to have to restrain myself. Nope, my physio would never have recommended it, but luckily I've got this brilliant website to refer to! I'll be sure to note speed, footwear, frequency and all other variables as hopefully I'll be able to supply you with another success story for others to take info from in year or so. Thanks, Daisy

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    2. "Brilliant website" ... we'll get that into the next marketing campaign. ;) Anyway, keep us updated, Daisy. Right from the outset, you impressed me as a pretty smart young lady, and it sounds like you're doing the right things. Cheers.

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  9. Hi! This is "Knee Pain." I was sort of excited to see Richard refer to my moniker in his blog post! But, yes indeed, I'm still here but haven't posted in a while since i got a bit discouraged for a bit! ( though I just posted a reply on the blog post about Luis' wife's success story. )

    I was intruiging to read about the idea of cycling backwards. I am going to try that. Slowly. On the recumbent bicycle.

    I've overall been feeling better. As i mentioned in my reply in Luis' post, this past weekend I walked 6 miles slowly on flat. That's amazing!!! But. I Still have a ways to go to get back to the activities I most want to do: hiking, dancing Lindyhop & waltz, road biking.

    In a previous post Richard had made a good point about the ROI (return on investment) of various knee therapy activities. So, for example, maybe one feels thay exercising one's hips mmakes ones knees feel better. But.... What if you use that time instead on slow biking on the recumbent bike in the gym. The thought is that this would have a greater impact on your knee health & recovery.

    So. That is what I'm aiming for. Maybe there are a variety of things that could make my knee feel better, but, I want to spend my time on the ones with the greatest influence. Slowly. And with great care & patience.

    "Knee Pain"

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