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.