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.


  1. Richard, I read that review of your book on Amazon. Now, I must confess that I sometimes questioned your story, because I found the term 'strengthening the joints' difficult to grasp if not in relation to the muscles, ligaments and tendons not only surrounding the joint but being part of it. 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? But in moving, you also move your muscles. I'm not talking about doing squats to develop strong quads, etc, but moving will HAVE to work these muscles.
    I think that's where the confusion lies. 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, and I have also be given some exercises on land. In fact, the book Heal Your Knees also explains the same: the less you move, the more the whole structure of your knee weakens. But that book definitively considers the whole surrounding of the knees as part of the joint.
    In short: I think I know what you mean about strengthening the joint through movement, by bathing the joint into synovial fluid, but the wording might be too misleading for a lot of people
    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?

  2. I agree with what you say. Doing what feels right for you may not be right for someone else. Everyone has to work out their own rehabilitation path. Your book was a great example of that. As to pain killers and ant-inflammatories, I steered away from them when they did not address my pain effectively and made me feel ill. I have found taking proteolytic enzymes before I go to bed has been quite useful in settling pain down and getting a good night;s healing rest. I also steer away from physiotherapists who in my experience have taken such a narrow view of what I needed to do to fix my pain, it resulted in other pain (for example, quad strengthening without similarly strengthening hamstrings can put your back out). My particular rehabilitation path has been to take a whole of body/mind approach involving investing in stem cell therapy for my knees, mixing up my exercises and doing less hard impact and more low impact exercises, keeping to a good diet, getting enough rest/sleep, keeping hydrated, and reducing stress where possible.

  3. Read the negative review of "Saving My Knees" and either that person misunderstood SMK, didn't read it entirely, or had some ulterior motive to misconstrue the message. Because my interpretation of Mr. Bedards central thesis in SMK, and "take away," is not just that cartilage can heal, but that what works in healing one person's knees, might not work for another. AKA, here's an alternate template to the arthroscopic paradigm. It's a big bad world out there: Cartilage maybe heals and if not there are people that believe it cannot and who will absolutely, for better or for worse, do something about it. Choose carefully. Maybe a disclaimer should be written with UPPERCASE LETTERS in the foreword of (which hopefully will be written by an MD) the revision of "Saving My Knees."

    Will spare folks the details (here at least) of my chondral shave and subsequent cartilage saving odyssey. Only to say I am almost 3 years into saving my knee(s) and I am saving them... SLOWLY... Could have had a TKR, 7 months post-op, but partly because I read SMK, decided to try save my knees. Which considering the alternative, is no easy task.. The swimming against the tide of a vested Orthopaedic industry.

    My take on NSAIDs: Yes, but only as a stopgap measure and not as a long term policy/strategy. This is my reasoning: Ibuprofen is a "non-selective" cyclooxygenase (cox) 1 and 2 inhibitor. Cox 1 and 2 play profound roles with respect to healing, not only at the site of repair, but because Cox 1 inhibition causes digestive disruption, it attacks the body's immune system. And because I believe that cartilage degeneration is often only some part structural and also some part immunological (amongst other factors) and since proper gut function plays an important role in immune function, I believe that systematic NSAID usage takes a dim view on alternate, possibly confounding variables, that might contribute to cartilage degeneration and so to potential therapies and solutions for its regeneration.

    Which makes perfect sense. The vast majority of orthopedic surgeons don't think cartilage (arthritis) degeneration can heal. So maybe a good question is, why does anyone with arthritic degeneration go to a Orthopedic surgeon in the first place as opposed to a last resort?

    Good luck to everyone healing their knees, Racer-X (R-X)

  4. One of the things I always ponder when reading posts of fellow knee sufferers is what does their pain feel like? I ponder this because it leads me to wonder two further things:
    1. How does the pain limit what they can do?; and
    2. Does the type of pain give any hints to what the underlying problem might be?

    I sometimes read of people whose pain is so severe they can hardly walk more than a few steps. This suggests to me there is some very acute major structural damage (e.g. a big hole in the cartilage).

    My pain is not like that. I could go out and run 5kms tomorrow but I would pay for it for months/years after. Putting my foot down hard does not cause a sudden stab of pain which I imagine you get with a big hole in the cartilage.

    My pain sounds exactly like Richard described in his book - it feels like the back of my kneecaps and some surrounding structures are severely sunburnt. They sting. They get quite stiff. Sometimes they ache. It's as if the cartilage on the back of both kneecaps suddenly spontaneously combusted for some unknown reason....though the reason seems to have been a fairly simple arthroscopy/menisectomy on just one knee (in fact the knee not operated on is worse). It's as if the entire area of cartilage is damaged or gone (I've not had another MRI to see since the problem started, but am getting tempted to ask for one so at least then I'd know what I'm dealing with)

    I think there is some type of medical phenomenon the medical world does not know about - a rapid degeneration of knee cartilage (or is it other structures - synovial lining perhaps?) that occurs in some people. It seems it can be reversed in some cases (i.e. Richard), but it a terribly tricky beast to beat.

    Like R-X, I'm fast approaching the 3 year mark with this problem and still struggling. The only things that definitely give some relief are:

    1. PRP injections - though I suspect that is short-term relief not a long-term fix;
    2. Avoiding aggravating activities - which is easier said than done as everyday chores can be a problem. e.g. I've spent a few hours over the past week on a stepladder re-painting the roof of my old Hilux - 'Saving My Hilux', but not 'saving my knees' as they don't like it and it's been a fair setback.
    3. Swimming with my ankles tied together and a pull buoy between my thighs. This is the only aerobic thing I can do to stay fit and get at least a few endorphins flowing. Endorphin withdrawal is very rough.
    4. Gently wandering about fly-fishing in NZ (often up to my knees is cool water).
    5. A gentle flat walk for 20-30mins - sometimes this really helps with the stiffness/pain, sometimes not.

    For 3 & 4, I suspect cold water helps, as well as mentally switching off from constant knee pain.

    I'm about to see my physio again for the first time in 2 years, but I don't hold out much hope she'll have any new ideas. This type of long-term extreme knee sensitivity appears to be beyond the training and experience of all medicos. The likely solution (if one exists) is probably a Richard-like program of getting obsessive about avoiding anything that aggravates. But when normal everyday activities aggravate, that is very tricky.

    BTW I tried the Kelsey-type program from about 2 months. It did not improve my situation, though my leg strength certainly improved. Perhaps I progressed too fast or started too hard. Maybe it needs another go with a much easier start and slower progression?

    cheers, TriAgain

    1. Tri,
      Yes, I think there is some mystery to be riddled and solved post-op and perhaps bilaterally with cartilage run amok. I too had that experience.

      And have met people around my town that have had similar experiences, but apparently they do not want to post about their bad result. That, perhaps is another study or two in human nature: The proclivity to conform and accept norms, of which I see the sense in neither.


  5. Hi Great efforts for saving my knees, Richard i know you are not a professional doctor but you did research allot that's why i am sharing my problem with you may be you guide something...
    I am 26 years old male from Pakistan.i am facing weak knees issue from 3 years when i was 23. i visited 2 orthopedic doctors and 1 physiotherapist and 1 general physician and 1 neurologist also :) but could not heal my weak knees.

    History: One day when i take 3 year child with me on my shoulders suddenly i feel some joint pain on my right knee.but i ignore and that night when i sleep i feel allot of pain in that knee and was thinking allot that why i get this pain and also got some fever. well at next day i got some pain relief medicine and massage for few days and in few days i got relief pain from my joint pain but my leg was getting weak day by day so i go to doctors time by time and do as those said but no one could heal every one tried different ways and diagnosis was different so i lost hope from doctors.and also research things on internet. so i don't have any more pain on my knees but now my both knees are weak and now i can not stand on one place not more than 30 seconds and i feel little pain on joints but no swelling ,no sound and not pain after rest .but i also feel not conformable during walk it looks my quads muscle get weaker.
    So can you tell me what actually problem i have.Should i see any doctor or not further.?

    1. This sounds like a curious case. It reminds me of this other reader I wrote about here:

      Honestly, I don't know what problem you have (and if I said I did, you should be suspicious, considering I'd be basing an opinion on no more than several paragraphs of description and I'm not a doctor). However, in this case, if everyone is stymied -- maybe you won't get the exact answers as to what's causing your condition after all, but perhaps you should take advantage of the fact that you're relatively pain-free to build up some strength in your legs (and knees). Can you ride a bike? Swim? I'd look for some way to get some movement in, working my way up to sweating activity, and for the moment not try to figure out the mystery. (I know, that runs counter to my usual impulse of "figure out the problem first" but you appear to be suffering from a strange, diffuse feeling of weakness with no or little pain -- so why not behave as if there's knee damage, but not bad damage, and go about trying to get stronger legs/joints?)

  6. Hi everyone,

    Hope that everyone is doing great! I’m Luis Gonzalez, my wife is the success story that Richard posted some a couple of months ago. First, I’ll like to thank Richard for sharing the story in his blog, I just wrote it because I think that people that had found success in their recovery path, they just keep going with their lives and leave behind all the sad memories. When I started to share the story, I just stared by posting it in different sites but it never came to my mind on posting it in Richards blog, and I think that is just the perfect place to be in.

    About the Muscle strength and Anti-Inflammatories.
    I’ll just need to agree that in order get the people out of the chair, sometimes the use of anti-inflamatories are necessary but just for a short period of time, because in the long run they are going to do more harm on the body than good. In my wives case, she didn’t even felt the difference when she used them.

    PRP shots – She did received 4 shots in 5 months (but focused on the rotulian tendon, on both knees, because at that time the knee specialized Dr. was sure that the problem was because the rotulian tendon started to teared and it was too stiff, to his belief that because of that the patella started to misstracking), she said she experience some relief, but I really didn’t felt she experience a real recovery.

    Instead of anti-inflammatories we tried different supplements and the ones we both think did make some difference were:
    - Wobenzym'N supplement - it is advertised as a joint support, so we decided to try it with good results, she would experience less pain especially when we started the long walk plans. (she will limit the doses to 1 tablet per day, way less than the recommended).
    - Neocell Super Collagen Type 1 and 3, 6000mg plus Vitamin C – after doing a research about what could help her in order push a little of extra collagen, we ended up picking this supplement.
    - B12 multivitamin and B7 Biotin – For support of the nervous system.
    I must say that the combination of these 3 supplements was what gave her some support during her recovery, she will even hear less pop from her knees. She has suspended the use of them already since she doesn’t seem to need them anymore, but they were a good support for her recovery without the undesirable adverse effects of anti-inflamatories.
    Now muscle strength, I think that strengthening the quads can bring some relieve for knee pain in some cases, but is definitely not a core or a solution for the long run, just imagine ourselves with 30 years or more and following the same reasoning of strengthening the quads all of our lives just to not feel pain (like I’ve read in a lot of forums following the same ideas), it doesn’t sound coherent and natural for me. Rather than idea of always keeping an active lifestyle (as walking) make more sound to me.

    Luis Gonzalez

  7. Continue...

    This time I’ll like to share you my knee problem, it was even close as painful as my wives but it was like having a constant pressure at the interior part of my right knee focused a little more on my tibia bone. After training hard in 2012 for 5k and 10k races, I developed that problem that usually get worst when extending my stride while running faster (which my guess was that it was just increasing the stress due to the increase impact). It bothered me all the 2013 (it bothered me almost everyday), and a couple of months in this 2014. I tried strengthening the quads, which will help for a day or two but eventually it returned. In 2013 I couldn’t train too much as I would have liked to because of that problem and my wives problem. So when we develop my wives walking plan I decided to follow it as well, I started to take care of my knees just as she was taking care of hers. Bang!!! Eventually the pain went away, for me it took like 4-5 months until it went away completely. But my training approach in this year changed a bit as well on my running technique, I started to run with a high cadence (lower strides but at a higher rate) and it didn’t came back. Similar like doing high repetitions with low impact. Just as a reference, a month ago with the training I performed this year, I was able to break my PB in the 5k that I had done 2 years back, and this year I trained for a half marathon.

    I used to think that some people were just born to run and some not, I used to think I was not one of those, just like some coaches or personal trainers had advised me before. I used to think that running was bad for the knees and that eventually a runner will develop such knee problems, but when I started to make a reflection on all of those people that ran 4 to 10 marathons per year, it makes me think that they are doing something I’m just not aware, and my guessing is that they have learned (aware or not) how to run properly and the key is that they have kept moving every year.

    As for my wife, she has started to run at least once per week with really good results. Of course avoiding down hills and keeping a high cadence, everything without having a setback and even doing a 5k in 26:47 min! I’m just very surprised about it. But we still do a minimum of 12,000 steps per day.

    So my conclusion is that high repetition with low impact exercises helps a lot in the process recovering the joint healthiness, so Richards formula may be applicable to more knee related cases than everyone will think it will. But it is not only repetition involved in the process of recovering, and paying attention to other factors (like wearing the appropriate shoes, with the adequate type of support, correct walking alignment) that may affect the process of recovery and are the ones that could make the difference.
    Wish all of you the best on everyone’s recovery and do not hesitate to contact me for any doubt related to my wives recovery.

    Luis Gonzalez

    1. Paragraph 1 - "my pain was not as close as my wives" instead of "my pain was as close", hahaha, sorry for the mistake.

  8. Thanks Richard for your clarification. I'm French, and we would apply a different word to designate strengthening of the muscles or strengthening of the cartilage. Now, it makes more sense!

  9. Hi all, I am the person who usually posts with username moniker "Knee Pain."

    I'm going to try Luis' anti - inflammatory ideas. Thank you Luis.

    Also interesting, recently a new doctor I saw suggested tumeric in the form of curcumin complex capsules and also fish oil. She also suggested I try to follow the Dr Weil Anti- Inflammatory diet.

    I'm going to do all these things. Doesn't seem like there is any downside.

    -- KneePain

  10. There is another important reason to avoid taking over the counter anti inflamatories as well as cortisone shots. They have been shown to contribute to cartilage degeneration. Yikes! Check out the following articles
    Please note that I cite these articles NOT because I endorse prolotherapy but because they provide comprehensive summaries of the scientific literature on the cortisone and nsaids. From what I understand there have been few if any well designed studies that prove the efficacy of prolotherapy.
    When I went to my knee doctor the first thing he suggested was a cortisone shot for my knees. Thankfully, I rejected this because I wanted to research it first. Now that I have done my research I am shocked and appalled that any doctor would ever prescribe a cortisone shot for cartilage damage. It's totally unethical given that the research is crysal clear on the subject. Crazy!