It's That Time of Year Again!

Yes, time for my annual holiday message.

First, I hope you're all looking forward to the Christmas break. It's a great time to celebrate family and community. Smiles and kindness and hugs and good cheer have their own healing power.

As the old year turns to a new one, for knee pain sufferers it's a good opportunity to look back and assess, and then gaze hopefully forward.

Are you in a better place on Dec. 31 than you were on Jan. 1? What was the dumbest thing you did to your knees this year? What was the best thing? What was the best lesson you learned? Did you find a low-stress, high-repetition activity and figure out how to make it work for you?

Looking ahead: Do you have a plan? Even better, maybe you have a Plan A, a Plan B, a Plan C, and even a Plan D if none of those work out. Are you feeling optimistic? Remember, negativity exacts a tax on the healing process.

Also, something I consider very encouraging: Any time you're in a better place on Dec. 31 than you were on Jan. 1, guess what? You're getting better! It may not be much better, and maybe you wanted to be all healed in three months, but it's a gain, no matter how small.

Next year, I'm going to talk about a few things other than my knees. For one, I now have a "frozen shoulder" that I'm dealing with :(. But, on the happier side of things, the Morton's neuroma I was diagnosed with in my right foot is no longer an issue.

I'm going to share some of my other ordeals here, because for example the odd tale of my Morton's neuroma really should be told. I came to understand a LOT about the Morton's neuroma diagnosis in the past couple of years. So if you've been told you have MN, stay tuned.

Okay, that's it from me for now. All my best, and a big thank you to all the good people who take the time to comment here, and help others!

More Evidence That Cartilage Can Heal

As you all know, nothing cheers me like a good success story – or even a small yet significant victory on the long road to healing.

Well, one member of our small community here who uses the handle gcoza posted this comment this week:

Today I went on my second MRI of my left knee. The first was prior 27 months and showed significant chondromalatia patella on the upper medial side of the patella in the area of 12x9 mm. New MRI medical report showed no sign of chondromalacia patella. Nothing!!!

He even posted the before and after images of his knees here.

This is great news, but if the irregular cartilage has really filled in, I’m not that surprised. As I mention in my book, clinical studies show that cartilage defects can change A LOT over two years. Places where the cartilage is worn almost to the bone can suddenly look almost as good as new.

I can remember reading all this and thinking, “Damn, this is big. I’m reading all these articles and books about healing bad knees. Why doesn’t anyone mention this?” Instead, much of the prevailing thinking cleaved to a sort of “car part” model, if you will. That is, you could think of your knee cartilage like the tread on your brand-new tires. After time, it simply wears down.

It’s a simple, fatalistic, and profoundly flawed way to analogize about human bodies, which are full of cells that are constantly renewing. Hell, if we weren’t built that way, all of us would die of senescence at the age of three or so.

So congrats to gcoza. He is quick to note that he hasn’t beaten knee pain yet. He’s better, but still has a good way to go. But man, it must feel unbelievably good to stare at an MRI that essentially says, “Hey, all your hard work at recovery is paying off.”

Now, granted, that fill-in cartilage is probably of the inferior fibrocartilage variety that’s less durable than the original. But as I have mentioned before, over time fibrocartilage has been shown to begin to take on characteristics of normal hyaline articular cartilage.

Update: I feel that I should share this. Gcoza has now said that the MRI was faulty and that the cartilage didn't completely heal. Here are some excerpts from his latest comment:

Unfortunately, I went for another MRI because my orthopedist said that the pictures are not of sufficient quality. This time images are much better quality and revealed chondromalacia patella 1b.- 2 grade on both knees. Im feeling about the same. Neither better nor worse. Status quo. My next step would be stem cells treatment because I tried more-less every other possible option ... Conclusion is: chondromalacia is irreversible, but with time one can feel better. Now, three years from the beginning of my knee problems , constant pain was reduced by at least 50-70%, and the function of the knee is also improved by at least 50%. Now I can squat. Three years ago I could not walk up and down stairs.

Okay, so this isn't the success story I was hoping for. However, he has reduced his pain and improved the function of his knee. That's some progress. Getting better can take a long time unfortunately. Maybe he'll have success with stem cell treatments. If he does, I'll report back.

Hey Look! We’re No. 1! :(

I could almost present this image below without comment. It was tweeted by Conrad Hackett of the Pew Research Center.

So who leads the world in knee replacement surgeries?



In the U.S., 226 people out of 100,000 had knee replacement surgery in 2013 (at least, that’s how I read that statistic). That’s more than one out of five hundred people.

Now, the good part of that statistic: To some degree, it undoubtedly reflects the advanced state of medical care in the U.S. Where patients in other countries have to suffer with terrible knee pain, in America they can get a brand-new pair of joints.

But it also undoubtedly reflects the fact that the U.S. is full of a lot of overweight, even obese, people who are not moving enough and who are wearing out their knees prematurely.

The good news is, if you’re reading this right now, you’re probably part of the percentage of the population that’s working really hard not to wind up on the operating table.

So keep moving. And I know I’ve said it here and here and here and here and here, but:

Lose some weight.

How to Run With Ridiculously Little Impact

Here’s something cool, though I just discovered it’s been around for more than six years! It’s called a “gravity-reducing” treadmill. A company called AlterG (Alter Gravity -- get it?) makes the machines.

Here’s an image I lifted from AlterG’s website (I doubt they’ll mind, as I’m basically doing free publicity by writing about their space-age treadmill). Cool but a bit weird-looking, eh?



So, you may be thinking, what’s going on in that strange-looking closed compartment below the runner’s waist?

Well, after the user is zipped into place, the air pressure is increased in that chamber, to simulate the effects of low gravity. A control panel allows a user’s body weight to be decreased in 1 percent increments, up to 80 percent.

Imagine that. A two-hundred-lb. man running on a treadmill as if he weighed no more than a five-year-old!

If this approach to exercise sounds kind of familiar, it should. I’ve mentioned plenty of times the idea of “unloading your joints.” Doug Kelsey is a huge proponent of this approach to make exercise pain free.

So naturally, I’m delighted to see anti-gravity treadmills. It’s a perfect machine for a knee pain sufferer looking for a way to get active again.

Well, almost perfect. Forget about buying one of these little workout gems. A recent Businessweek article priced them at $36,900 to $80,000. Ouch. But it sounds like they’re popping up in physical therapy clinics and tony gyms, so sniff around and you might find one near you.

If I have a chance to try out the treadmill -- you know, semi-popular bloggers sometimes get the chance to sample merchandise for a review ;), I’ll let you know. Or, if by chance any of you out there has used this anti-gravity device, let us know below what it was like.

Old Bad Beliefs Die Hard: The Story of the Q Angle

Recently I found it curious that my Google search net snared a knee pain article from a physical therapist urging people to correct their “Q angle.”

It was like coming upon one of those stories about Japanese soldiers being discovered in the jungle decades after World War II ended, skulking about in camouflage, believing that they were still actively fighting the United States.

“Q angle” certainly has an air of mystery and mathematically infused importance, just by the very term. It ought to mean something. Something really important.

Anyway, this is one of those terms that you can spend 1,000 words defining and still fail to make clear. Or you can simply borrow an image and voila:



This physical therapist blogger -- whose clients include “numerous pro athletes from the NFL, NBA, MLS, and the WNBA” -- tells us:

When I see a Q angle that is off, I also see an excessive amount of rotational force absorbed by the knee. Furthermore, the meniscus and other internal structures of the knee are compromised more when the Q angle is increased.

Let me cut to the chase here, because the author doesn’t clearly state the “issue”: He’s basically saying a Q angle that is too large is probably the source of your knee problems. Women tend to have larger Q angles, due to natural anatomical differences, such as wider hips.

A few decades ago, the Q angle was the hot go-to theory among structuralists looking for causes for your aching knee. The thing is though, there’s evidence a bad Q angle is not the boogeyman it’s been made out to be.

If you recall my blog post about the study called “Hip Strength and Hip and Knee Pain Kinematics During Stair Descent in Females With and Without Patellofemoral Pain Syndrome,” perhaps you recall this line I quoted from the researchers’ report:

Many studies have not supported the relationship between an increased Q angle and PFPS [patellofemoral pain syndrome].

Paul Ingraham, who I often cite here, delves into the Q angle more deeply and also bashes the idea that it’s some kind of “aha” measurement for discerning and fixing knee pain. He asks the big question: Does the size of the Q angle reliably measure how the quadriceps is pulling on the kneecap?

He cites a study that looks into this question, and ends up concluding, “Clinicians are cautioned against using the Q-angle to infer patellofemoral kinematics.”

So among researchers, the Q angle theory of knee pain has been discredited. But old theories die hard. That’s a good thing to keep in mind if someone starts in about how your knee problems are due to your Q angle. They may be fighting some long-ago war.

Here’s One Neat Trick to Beat Insomnia

There. I’ve always wanted to write a click-bait headline. ;)

But seriously, there is a payoff here. We’ll get there in a moment.

Insomnia, especially as you grow older, can be a serious problem. Once you have knee pain, it gets even worse.

Insomnia, or difficulty falling asleep, is an enemy to someone trying to heal their knees. Sleep is your friend. Sleep allows your body to rest and recover. Also, at sleep, your body is relaxed and your legs fairly straight, both of which should make you feel more comfortable.

Now, on to how to beat occasional sleeplessness. To be fair, I’m talking more about mild insomnia. Mine often comes after waking up around three a.m. to use the bathroom, then settling back into bed and lying there awake for 10, 15, 20 minutes, thinking, “Why can’t I drop back asleep?”

This trick has to do with breathing.

In the sleep state, you take longer, slower breaths. One night, as I was having difficulty falling asleep, I challenged myself to start breathing as if I were sleeping. That is, I tried to make my breathing slower and deeper.

Within minutes, I actually fell asleep.

I found this experiment quite interesting, so I repeated it another night. When I couldn’t sleep, I just focused on my breathing. Slowly in, slowly out, slowly in, slowly out.

Again, I fell asleep after a few minutes.

Now, the thing is, you actually have to focus on your breathing. You can’t just say, “I’m breathing more deeply now,” then let your mind wander. You have to concentrate on breathing in and out slowly, as if you’re sleeping.

And I’m finding that when you do that, sleep will usually follow.

Anyway, as everyone who reads this blog knows, I’m extremely curious and love to experiment. This is one case where it really paid off well for me. I sleep better now. I don’t need the sleep because of bad knees anymore, but because I have a 10-hour-a-day job and a one-and-a-half hour commute to work. That’s good enough reason for me!

What I Hope Will Become a Full-Fledged Success Story

I found something buried below a recent post that I wanted to share.

TriAgain, as anyone who regularly dives into the comment section knows, has been participating for a long time in the dialogue here about how to heal painful knees. His interest, like that of so many others, arises from his own struggles.

Over the course of many months, he has shared his story with all of you in bits and pieces. Recently he set down the long version in a forum for triathletes. (U.S. English speakers, note that the Australian usage of “trannie” differs from ours ;). Also, TriAgain says there's a little "salty language" in his account FYI).

First, here’s a trimmed-down version of where he says he’s at right now:

3.5 years into the journey, pain down by 70-90% (varies a bit), function up by about 50% ... Day-to-day living/tasks much better. I do think prolonged sitting was a major factor in my demise.

This sounds pretty good. Not victory yet, but a lot closer. Note that he’s been working on healing his knees for 3.5 years. That will no doubt sober up first-time visitors to this blog. But sometimes the process takes a long time as you navigate setbacks and figure out what works and what doesn’t.

His full story is extremely detailed and quite interesting (I had to skim some parts, as I read it on a workday morning over breakfast and my train schedule is unforgiving). He credits Scott F. Dye with helping him arrive at a good framework for understanding what was going on. Dye’s common-sensical idea of “envelope of function” I wrote about here.

One thing I find interesting about TriAgain’s story is that he can wade about for hours, fly fishing, while on a rocky riverbed -- and his knees aren’t bothered.

Why?

I wonder if: (1) fly-fishing is something he enjoys, so he’s relaxed (2) the walking is slow, at a sort of aimless wandering pace, which when combined with some standing, makes for a winning combination of easy movement and rest (3) water helps a lot by cushioning the impact on his joints: walk over a rocky field and you’ll find the activity is very knee unfriendly, but walk over those same rocks under a few feet of water (which effectively unloads the force that your body lands with) and the experience is quite different.

Anyway, I encourage everyone to read this story. It’s broken up into pieces, and you can tell by the interspersed comments that TriAgain quickly manages to hook his audience. A good read (and encouraging for others worried about how long their knee program is taking).

On the Virtues of Going Slooooowwwww

My contributions to this blog will soon become less frequent. Honestly, I just don’t have as much left to say. I don’t want to become like that tiresome grandparent who’s always telling the same story, as if you haven’t heard it eight times before.

Of course, I’ll always be monitoring the comments. And the best way to reach out to me, as I’ve said before, is to leave a comment.

Occasionally, when thinking up ideas for blog posts, I ask myself which messages are worth repeating -- what have I said that should be said again and underscored, with a few exclamation points added at the end? One such message, I believe, is lose weight.

Another is this: you won’t believe how slow healing a pair of bad knees is.

No, really. You. Have. No. Idea.

Now some of you, whose knees aren’t too bad, will be on the comeback trail in a few weeks and may be much better after a month or two. If so, congratulations and utter a small prayer of thanks. Because you got off really easily.

Most of you won’t be so lucky. You’ll spend months tinkering with a recovery program, changing diets, exercises, and all sorts of variables. You will wonder if you’re making progress. Self-doubt will sometimes become intense.

The problem is, often it can be hard to tell if you’re moving forward or running in place, going nowhere. I think this is especially true for people with really bad knees, who most likely need to spend a few years just to get them to improve from terrible to bad.

I know there are a lot of mysteries about how healing occurs. But I think it can. That, to me, is a tremendously inspiring message.

But it’s always good to keep in mind that slow, gradual progress -- even slower than you think is slow -- is the best way to go.

Why Hot Showers Help With Knee Pain and Stress Hurts

I was reading comments on this blog a while back and came across a knee pain sufferer parsing his symptoms for meaning. One thing that helped with the pain, he noted, were hot showers.

Yup. Makes sense.

But why?

Well, I thought I’d share my analysis of this phenomenon (“The Hot Shower Effect”), as others have no doubt noticed the same thing. Of course, my standard disclaimer: I’m not a doctor (nor do I play one on TV).

Anyway, I think hot showers confer a similar feel-good benefit as light stretching (which made my bad knees feel better). Namely, they loosen the muscles in the leg, so that when you sit, for example, your kneecap isn’t pushed so tightly against the damaged cartilage in your joint.

Stress would naturally work in the opposite direction, by tightening the muscles and placing the joint under more irritating force.

Of course there’s most likely an additional effect at work that has to do with mood and brain chemicals. Stress correlates with unhappiness, anger, frustration, anxiety -- all negative emotions. A hot shower is tranquil and relaxing.

Having a bad knee is a difficult, depressing experience. Whatever can get you out of that zone even for a little while -- taking a hot shower, meditating, laughing at the antics of some squirrel on YouTube -- should be helpful, even if it there’s more you need to do eventually to address the root cause of your pain.

The Dangers of Our Little Delusions

A couple of months ago, I got a really fancy bike computer that syncs up with a satellite in space somewhere, to monitor everything from distance traveled to speed. It can capture dozens of bits of data, including heartrate.

I ride hard once a week and easy three other days, so I assumed my aerobic conditioning would be between very good and excellent.

Boy, was I wrong. I wore the monitor one day on a challenging Saturday ride. I was alarmed at how quickly my heartrate jumped beyond my aerobic threshold. Even at what felt like low levels of exertion, my heart was beating about 145 times a minute.

It turned out that my “easy” rides had been too easy. I was riding a stationary bike in my basement and rarely clearing a pulse of 100. So I started going on long, easy rides outside, wearing the monitor and watching it like a hawk, keeping my heartrate from 120-135.

Now my aerobic conditioning is improving, and I’m riding better.

Still, I had really misjudged my conditioning. It reminded me of when I had bad knees, and I did something similar.

My legs were strong. I liked to walk. I knew movement nourished sick knee joints.

So I walked and walked and walked. Slowly. No uphills. And with some interspersed sitting. Still, my knees got worse.

It turned out that I had fallen victim to what is surely one of the most common delusions among knee pain sufferers:

Many people think their knees are stronger than they actually are.

I can remember becoming incredibly frustrated, because I was moving, which I knew was the right thing to do, and I was moving slowly and carefully, and I was taking occasional breaks too. But I wasn’t getting better.

That’s when I had a radical rethink of how strong my knees were. That’s when I came up what I thought was a program so simple and easy that my knees could not possibly be bothered.

I started going to the swimming pool, walking around the pool, then sitting backwards on a pool chair, with my legs elevated in a position that reduced the burning I experienced constantly. I’d repeat this endlessly -- walk around pool, rest with legs elevated, walk around pool, etc.

I did that for weeks. Boring as hell. But my knees actually began to feel better.

I talk about this in the book. An experience like that is both encouraging and depressing. Encouraging, because you see progress at last. Depressing, because you see what a deep hole you’re in.

But sometimes you have to come to grips with your little delusions in order to find a better way forward.

On Wearing Supports for Knee Pain

I enjoy the Ask Well column at the New York Times website. It’s well-written and does a nice job of summarizing important research/studies and doesn’t blindly follow the fad of the day. I was intrigued when the idea of knee supports came up for discussion.

My completely unresearched position is that knee supports could make sense. After all, one challenge for a patient is unloading the joint. Wouldn’t a good support do just that?

So I was curious about what this (rather short) column found.

First, the most common, cheaper supports, the elastic sleeves that you tug over your aching joints, probably don’t provide meaningful mechanical support. Which means they don’t work? Not necessarily.

Neoprene sleeves are thought to help by aiding proprioception, according to   Dr. Robert A. Gallo, an associate professor of orthopedic sports medicine. Proprioception is the body’s sense of where it’s positioned in space (interestingly, this ability appears to decay among knee pain sufferers).

We are told:

In theory, improved proprioception around the knee joint could augment knee stability by improving your balance.

Of course there’s another reason why they might work: the placebo effect. The placebo effect can be very powerful. I think it’s behind a lot of glucosamine’s perceived benefits, for example. I’m very skeptical of the glucosamine story, after the supplement did absolutely nothing for me and my research uncovered no reasons why it should have.

But back to knee supports: So let’s say neoprene doesn’t mechanically unload the joint (which isn’t surprising, if you think about it -- that a small piece of synthetic rubber could significantly alter the alignment or movement of a joint that regularly handles loads of your body’s weight plus; it would be kind of like expecting a reed of straw to hold up a brick). What then would help?

What could be useful, Ask Well says, are bulkier braces that really do unload the joint. These are more complex (and expensive) and sort of make you look like a cyborg. These braces have been shown in studies to help people with knee arthritis.

Me, I never used a brace/support. I did try patellar taping. Once that seemed to work really well. And on other occasions it didn’t work at all.

Oh well. Maybe that was the placebo effect too.

Forbes on Hyaluronic Acid Injections: Don’t Waste Your Money

I found this article by a Forbes writer (who suffers from knee pain) to be a good read.

Readers of this blog may recognize that meta-study he references that’s critical of hyaluronic acid injections. I wrote about it back in July 2012.

I then followed a year later with this post, which in many ways was more interesting, as it deconstructed a counterpoint meta-study that found the injections provided “significant improvement in pain.”

So was it simply a matter of warring meta-studies, with nothing resolved in the end? Well  . . . the second meta-study, it so turned out, was “supported” to some unclear degree by makers of viscosupplements and put out by an “open access” publisher. Lots of funny odors coming off that one.

So is hyaluronic acid -- a kind of synthetic synovial fluid, which is the “oil” that your knee joints need to stay lubricated and easy moving -- a waste of money?

Judging from anecdotal evidence, I don’t know. I’ve read comments from some patients who claim to experience a lessening of symptoms after the procedure. However, the effect of the shots can wear off in as little as three or four weeks. And then, you have other patients who claim that they felt worse after getting the shots.

So it’s kind of a crapshoot. Anyone considering viscosupplementation should look long and hard at the treatment. This is a moneymaker for a number of drug companies, and for doctors who give the injections. Make sure that when they recommend what to do with your knees, they’re looking out for you, and not their own wallets.

Do Your Knees a Favor and Get Enough Sleep

Here’s a study, the results of which (published in Arthritis Care & Research) surprised me not at all.

Researchers discovered poor sleep habits among people with knee osteoarthritis (OA) appear to increase their sensitivity to pain resulting in an amplification of discomfort.

The study included 208 subjects (72 percent of whom were female). They were split into four groups: osteoarthritis patients with insomnia, OA patients with normal sleep habits, then two control groups of healthy subjects -- half with insomnia, half who slept normally.

The group with knee OA and insomnia had the greatest degree of “central sensitization” -- a condition of the nervous system where pain signals are amplified.

I’ve mentioned before how important getting a good night’s sleep is. I think it does wonders on different levels: It gives your body downtime to mend, puts your legs in a relaxed, non-stressful position, and improves your outlook on life in general.

So if you’re trying to win the knee-pain battle, and you’re not getting eight hours a night (or whatever constitutes a full night of rest for you), maybe you need to rethink your schedule to give yourself enough good, restorative sleep time.

The Importance of Taking Charge of a Plan to Improve

I’ve written about this before, but I really think a turning point is when people with bad knees take charge of a plan to get better.

With a chronic condition, people often go through the same maddening series of doctor and specialist visits and receive the same unsatisfying answers. Day to day, the symptoms improve a little, then worsen, then improve, then worsen, and on and on. You don’t seem to be going in a particular direction -- except down, though slowly. You feel helpless, like a leaf being tossed about in a tempest.

This is a terrible place to be. It’s where most knee pain sufferers find themselves. Eventually, they say with a shrug, they’ll just get a total knee replacement.

Contrast this with having a goal -- healing your knees and having a plan to get there. It may be a four-month plan. It may be a four-year plan. It may be an eight-year plan. It may be a plan that turns out to have more curves and changes in direction than a mountain switchback road. Still: It’s a plan. There is a goal. That’s better than being a leaf thrown about by a random gust of wind.

To me, this is so important. This is the common thread among all the inspiring success stories I know about beating chronic knee pain. At the center of each is a person who refuses to go quietly into the night and throws himself/herself into some kind of program to improve.

I also believe that taking charge of the plan to heal greatly improves your outlook. Imagine you develop constant, nagging knee pain in March. You see doctors and physical therapists during the year. But they don’t really help and some days you feel better, some days worse. Now, on Dec. 31, as you look forward to a new year and think about your knees, how do you think you feel?

Probably scared. Uncertain. Fearful that your bad knees will just get worse.

But what if, during that same year, you develop a plan to heal. You’re not sure if it’s the right plan -- but it is a plan. Even if you don’t make a whole lot of progress, I think you’re in a different place mentally on Dec. 31. I think you’re more likely to be hopefully strategizing when you consider the year to come. Your thinking may sound like this: “Okay, I didn’t do as well as I had hoped this year. But I know that A, B, and C are definitely bad for my knees. I can’t do exercises D and E, but the bad knees seem to like F. So I’ll start on a program of G, increasing the repetitions about 10 percent every two weeks, then see where I am by the end of March. If this doesn’t work, I can always try H and I.”

The plan doesn’t need to be of your own devising. A smart physical therapist may help you design it. But you should understand it, own it, be committed to it -- and be willing to change it as soon as you can tell it’s not working. And then you should try something different. The path to healing is not straight, it’s not easy, but I’m convinced there is one.

Knee Studies That Make Me Nervous

A lot of articles about knee pain studies land in my e-mail inbox. Recently I came across one with this provocative title:

Osteoarthritis Patients Will Benefit From Jumping Exercise

The English is a bit shaky in spots (perhaps it was translated?), but the findings are clear enough:

Progressive high-impact training improved the patellar cartilage quality of postmenopausal women who may be at risk of osteoporosis (bone loss).

Specifically, 80 women from 50 to 65 years old, who also had knee pain, participated in this Finnish study. They all had “mild knee OA,” it’s important to note. One set of subjects underwent a “supervised progressive high-impact exercise program” three times a week for 12 months. The quality of their patellar cartilage (which is located under the kneecap) improved with jumping and exercises that required “versatile rapid movements.”

Jump for better knee health! Uh, yeah sure ...

Jumping around with bad knees is not the first thing I would do. What we don’t know here is significant, I suspect. That “mild OA” may correlate with milder knee pain and minor damage, which makes more vigorous activities possible. I know plenty of regular readers of this blog who would shudder at the idea of “jumping” their way to knee health; their pain is brought on by much less strenuous exercises.

Also, it’s hard to tell what “supervised progressive high-impact exercises” means, but “supervised” and “progressive” suggest that subjects with bad knees weren’t cut loose to do jumping jacks during the first week.

My takeaway from this study is probably different from what the authors intended. I’m far from sold on advising knee pain patients to engage in jumping activities to improve their kneecap cartilage. I bet there are less impactful activities that would achieve the same end. However, if you’ve got good knees, exercises that stress your cartilage such as those that involve a reasonable amount of jumping are probably a good idea. They can help you develop stronger joints and ward off problems in the future.

An ounce of prevention!

If Your Knees Heal, How Do You Go Back to Doing the Sports You Love?

Someone reached out to me recently, asking (basically) the question above.

It’s a very good one. After I got better, my brother said that if he were me, he wouldn’t go back to the intense cycling I enjoy so much. Yet I did. And so far, my knees have been fine.

Was I foolish to do so?

I don’t think so. Here’s why:

* You should never go back to doing exactly what you were doing that caused the knee injury. That seems kind of stupid. For instance, if you decide to train by jumping off the roof of your shed, then springing up and running three miles, and you hurt your knees one day jumping off the shed -- why the heck would you keep doing that after your knees healed? :)

Or, in my case: I was cycling up steep hills, doing short sprints on those climbs, all while dehydrated -- and doing this back-to-back on Saturday and Sunday mornings. Would I do that again? Nope. I wouldn’t sprint uphill. I would carry more water. I wouldn’t do a max effort on Saturday and try to do a max effort again on Sunday.

* You have to get smarter in general. I still ride really, really hard. But I’m smarter about making sure I warm up properly. And in temperatures below 55 degrees, I always put on knee warmers (sleeves that cover the knees and a bit of the legs). Always.

Being smarter doesn’t mean I can’t charge up the hill with the rest of the pack on a ride. It does mean that I’m more careful about exercising in a knee-friendly way.

* I still listen carefully to my knees. There isn’t much to listen to now, thankfully. But I’m ever alert to early warning signs. If my joints started getting really noisy and crunchy again, you better believe I’d modify my behavior.

Knowing how to listen to your knees is especially important if you return to the activity that injured them in the first place. You don’t want to be grounded with chronic knee pain again. One reason you may not be is because you know what the danger signs are that you ignored the first time around. The key is not to do so the second time.

The Fine Art of Playing Medical Detective

If nothing else, I hope one message in my book is crystal clear: You have to get involved in fixing your knees.

Why? Here are three reasons: (1) Your particular problem has a particular solution; what worked perfectly for me (or someone else) probably won’t be exactly what you need. (2) A doctor or other medical professional trying to advise you will never gain as complete an understanding of your symptoms as you have, even if he spent five hours with you. You ultimately know better what you can and can’t do. (3) You need to be able to monitor and adjust your rehabilitation program in real time and your orthopedic doctor won’t be on call, 24/7, for every small question you have.

Part of getting more involved in fixing your knees means honing your skills at playing medical detective. Think of your evolving symptoms as a nonstop “Who dunnit?” (or “What dunnit?” may be more apt). If you want to avoid pain/flare-ups of symptoms, avoid doing the thing that triggers them. (Note: Believe me, I realize sorting out cause and effect isn’t always easy, especially when there are renegade inflammatory processes in the mix.)

The good thing is, once you develop “medical detective” skills, they’ll come in handy. In my case, they helped me solve (and heal) a couple of mysterious injuries in the past few years.

The Case of the Sore Index Finger:

This was a strange injury that kind of crept up on me. Quite simply, I began noticing my left index finger was sore, in the joint nearest the fingernail. Whenever I I pressed down on something with my fingertip, the joint would hurt.

What the heck? Was I just getting old, I wondered. Maybe starting to develop some arthritis?

But then I started thinking. “Hmm. Why is this joint -- and only this joint -- sore?” My right index finger was fine. Then I discovered something: The joint was being strangled twice a day. And I was responsible!

What I figured out was that, for my twice-a-day flossing, I was wrapping one end of the string around -- you guessed it -- the last joint of my index finger. I didn’t notice any pain or discomfort while flossing, but the soreness was evident later.

After realizing this, I started wrapping the floss away from the joint. Today my index finger is perfectly fine again.

The Case of the Sore Thumb

More recently, I had a problem with soreness around the base of my thumb joint. It was a nagging minor pain. As with the index finger, I couldn’t recall precisely when the pain began, or an injury that may have precipitated it.

Again I wondered: What’s going on? Is this age-related?

Well, I knew age hadn’t been the issue with my index finger, so once more, I began paying close attention to the unnatural forces on that thumb. And I found one -- but it was so minor I couldn’t believe it was the culprit.

I wear a backpack to work -- except usually it’s not on my back. I sling it over my right shoulder. And I caught myself, more than once, absent-mindedly pressing my thumb against the strap, stretching the digit back.

That can’t be what’s to blame, I thought. How can a little thing like that cause a problem? Still, I made myself stop pressing my thumb against that strap when I walked with my backpack.

And the pain went away.

The funny thing is, had I gone to a doctor for either of these problems, I probably would not have gotten a helpful analysis or solution. It’s not his fault; I wasn’t doing anything obvious that was causing either of these two joints to be sore. Further, a doctor might have put me in that “old guy” box (“You’re on the wrong side of 50; it’s just some inflammation that may eventually become arthritis; if it really bothers you, I can write a prescription for some pills.”)

But the cool thing is, I managed to figure it out by myself. And I got better. I’ll take that outcome any time.

Update: Oops, I see that this post is open to misinterpretation. My fault. To be clear: I don’t mean to imply that you don’t need doctors or physical therapists at all. I don’t mean to imply that you’re your own best doctor (in the end, you may be, but please don’t start out with that assumption).

I do believe that you need to get involved in helping solve the mystery of your knee pain. In other words, don’t go to a professional when you have chronic, hard-to-treat pain and expect to be handed a perfect solution on a silver platter. This goes to the heart of one of my beefs with people today: I think they look too often to the quick, easy, other-provided solution: a pill, a surgical operation, 35 leg lifts at dawn every other day, etc.

Here is why I would always start my knee pain journey with doctors and physical therapists: (1) They’re usually pretty smart people and good, careful thinkers. (2) They have extensive training and a broad understanding of a human body’s biomechanics that I’m betting you don’t have. (3) They have experience treating bad knees just like yours. (4) They (doctors anyway) have access to diagnostic equipment that can help shed light on what’s going on with your bad knee(s).

The first step to fixing a bad knee is figuring out what’s wrong with it!

Ah, but what if they don’t find anything? This is where things get more complex. If your doctor shrugs and basically says, “You’re getting old and your knees are just wearing out” -- well, that’s not too helpful. So here are my main complaints about many doctors and physical therapists: (1) They’re too fixated (physical therapists especially) on this idea that if your knees hurt, the underlying cause must be an imbalance/crookedness. (2) They’re too pessimistic (doctors) about the prospects of your knees getting better. (3) The exercise routines they prescribe (physical therapists) are usually too hard because they focus on muscles when they need to focus on joints. (4) They don’t work hard enough to help you craft a sensible, go-slow program to improve.

But -- and here comes a huge but -- this isn’t always true. Celebrate when you find a good physical therapist (I believe they can save you; a doctor’s usefulness tends to be limited after he shrugs and says “I can’t find anything wrong, so just try not to aggravate the joint.") A smart, patient, dedicated physical therapist is worth his or her weight in gold. I said that in the book, because I really believe it’s true. Just be careful: A bad physical therapist can mess up your knees really, really fast.

Finally: a nod to Doug Kelsey who is hands down the best physical therapist I know of (disclosure: I base that solely on his writings; I’ve never been a patient of his). He wrote a great book here. If you want good insight into chronic knee pain and illustrated exercises that will help you get better, check it out.

Is Yoga a Good Idea for Bad Knees?

This is a short post mainly meant to spark a dialogue.

Have you found yoga to be useful in taming chronic knee pain? I’m interested in comments from people who have tried it, with success (what kind of yoga did you do and which poses, and how often?), as well as from those whose experience has been that it’s useless/harmful.

I never did yoga for my knee pain. I can imagine reasons why it would be beneficial; I can also imagine reasons why it might not be. Anyway, the University of Minnesota did a study (small, and apparently with no control group) that found that the 36 participating women reported better knee health after taking a one-hour yoga class each week for eight weeks. The women were 65 to 90 years old; they all had knee osteoarthritis. Most of the subjects had less pain and stiffness at the end of the two months.

This seems like a very short, maybe not-that-rigorous study, so that’s why I offer the results more as a conversation starter. Yoga for bad knees? Yes or no? What do you think? Please weigh in below.

The Dark Side of NSAIDs

Some months ago, I wrote about an unhappy reader of my book who berated me for my “horrible advise to not use NSAIDs” (nonsteroidal anti-inflammatory drugs). Following my various “instructions,” she said, caused her to destroy her knees and life.

My immediate reaction was: (1) I try not to give advice in general, and regarding NSAIDs, I explained in my book how they didn’t work well for me and why taking them might not be such a good idea anyway. (2) There are good arguments for not taking NSAIDs, and you don’t have to look far to find them.

Prolotherapy proponents (who believe in using irritation of tissues to induce natural inflammation that leads to repair) are well-versed in the hazards of NSAIDs, I found.

Here is a good start. Scan this article by Ross Hauser, who is a doctor, and you’ll see concern about “the potential for significant side effects of these medications on the liver, stomach, gastrointestinal tract and heart.” Also, one of the “best documented” long-term side effects is “their negative impact on articular cartilage,” leading to this claim: “the preponderance of evidence shows that NSAIDs have no beneficial effect on articular cartilage in osteoarthritis and accelerate the very disease for which they are most often used and prescribed.”

To elaborate:

NSAIDs have been shown to accelerate the radiographic progression of OA of the knee and hip. For those using NSAIDs compared to the patients who do not use them, joint replacements occur earlier and more quickly and frequently.

So Hauser concludes that anyone using such medications should do so “with the very lowest dosage and for the shortest period of time.” To me, that advice makes sense; I also like how Racer X, who sometimes comments here, describes such drugs as best used as “bridge” solutions -- meaning, again, rely on them no longer than necessary. To be fair, for some people they may be needed, so an outright “Thou shalt never” prohibition seems too harsh.

If you want to read some hair-raising stuff about the perils of drugs that aim to suppress inflammation (in this case steroids, which are the stronger stuff), take a wander through this long article (also by Hauser). Some highlights:

* Impartial organizations such as the American College of Rheumatology know there may be a problem. The rheumatology group carefully notes:

It is generally recommended, although not well supported by published data, that injection of corticosteroids in a given joint not be performed more than three to four times in a given year because of concern about the possible development of progressive cartilage damage through repeated injection in the weight-bearing joints.

* Hauser speculates that the “alarming” rise in hip and knee joint replacements may be related to the greater use of corticosteroids that are leading to cartilage degeneration. (I find this point a bit conjectural, as there are many changing variables that affect the number of joint replacements -- but the relationship is certainly worth exploring.)

* “Many research papers have documented that corticosteroids reduced radiosulfate uptake into chondroitin sulfate, thereby decreasing cartilage growth and repair.”

* After use of steroids, one study of joint changes found “the articular cartilage became thin, the matrix near the surface lost its hyaline appearance and became fibrous, the surface fibrillated...”

* A study involving young adult horses discovered that “chondrocyte cytotoxicity was found as the steroid concentration was increased.” Chondrocytes, if you recall from my book, are critical cartilage-making factories.

* In another animal study, “all knees injected with cortisone showed cartilage deterioration, but severe cartilage damage was seen in 67% of animals that exercised and also received cortisone.”

* And, in a study of people (average age 60 at the beginning of the study), “knees injected with intra-articular steroids deteriorated at a rate twice that of non-injected knees.”

* The International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine has also weighed in on the subject, warning, “Although an extremely useful technique, the intermittent use of intra-articular cortisone should be deployed with caution. The potential risks of provoking hyaline cartilage degeneration, the hazards as they relate to joint infections, and the limitations of cortisone should be fully discussed and disclosed to the patient.”

Again, I’m not absolutely against taking NSAIDs -- or even SAIDs for that matter. But the best patient is a knowledgeable patient. Know well what the benefits -- and the risks -- are.

Not So Fast on That Knee Replacement

Here’s a short piece by the New York Times that’s well worth the read if, driven to desperation by pain and a bleak prognosis, you’re considering the ultimate in knee surgery: a total replacement of the joint.

You wouldn’t be alone -- far from it. More than 600,000 of the surgeries were performed in 2012. That’s a big jump from the 250,000 of 15 years ago. But what’s most interesting is where the most rapid growth is: among those 45 to 64 years old, who had triple the number of operations as before.

Are all these surgeries beneficial, especially among younger patients?

Researchers analyzing data from major studies found that people with really bad knees were helped by surgery. “Really bad” in this case means advanced arthritis: in other words, severe pain and impaired physical function, like an inability to climb stairs. But others with less serious arthritis saw only a very small benefit.

The upshot? According to Daniel Riddle, the professor of physical therapy and orthopedic surgery who led the studies:

If you do not have bone-on-bone arthritis, in which all of the cushioning cartilage in the knee is gone, think about consulting a physical therapist about exercise programs that could strengthen the joint, reducing pain and disability.

Amen. Surgery sometimes is the best option. But it’s often the best option when it’s the last option.

Three Reasons Why “Mistracking Kneecaps” Probably Isn’t the Reason for Your Pain

Last time I mentioned in passing an interesting Swedish study. It found clinical tests perceived no significant differences between subjects who had knee pain of unclear origin and a control group. So, in other words, the knee pain sufferers weren’t crooked or imbalanced in some way the control group was not.

Intrigued, I managed to locate the study (most are behind paywalls, but luckily, this one was not). It begins with a fairly broad discussion of patellofemoral pain syndrome that won me over with these two lines:

Some practitioners who find no identifiable cause to the pain use both the term PFPS as well as the term AKP (anterior knee pain), but the terms are best reserved to describe the patient who has yet to be evaluated. If no causative explanation for the pain is found, despite a thorough investigation, the term idiopathic anterior knee pain (IAKP) seems reasonable.

Yes, yes, yes! Let’s stop pretending PFPS is a real diagnosis. “Idiopathic anterior knee pain” is more honest and useful. Basically, it means “you have pain in the front of your knee and we don’t know why.”

There is another discussion section, at the report’s end, that is well worth perusing too. The researchers’ skepticism about catchall explanations for PFPS that cite mechanical abnormalities is virtually palpable.

Here are three big problems with the “oh, you’re crooked/imbalanced” line of thinking.

(1) There’s no accepted definition of what constitutes crooked in the first place -- or more precisely “meaningfully crooked” if you will, because I’m sure very small discrepancies in the length of someone's legs (or in whatever) wouldn’t be considered important even by diehard structuralists.

To make this more concrete: Say you believe patellar maltracking causes most cases of PFPS. Well, if a kneecap doesn’t track perfectly by 1/100th of a millimeter (the width of a thin hair), that’s not enough to be significant. But then, what is? 2 millimeters? 6? 10, 20? The fact is, no one has set forth an assertion on this that’s supported by clinical evidence. So we don’t even know what crooked is.

(2) Also we can’t measure it well anyway (a related, overlapping issue). The Swedish researchers report:

“Fitzgerald and McClure (1995) studied four different manual clinical tests for patellofemoral alignment where measurement reliability ranged from poor to fair ... they were unable to find a reliable clinical method for assessing alignment.”

So there’s no accepted definition of malalignment and no good way of measuring it anyway. But wait, it gets worse:

(3) “Fairbank, Pynsent, van Poortvliet and Phillips (1984) reported that in pain-free subjects, between 60% and 80% of the population fall into what is generally classed as lower extremity malalignment.”

So, even when someone does take a stab at defining malalignment, it turns out -- surprise -- that most of us who are pain-free share this “problem.” In that case, if almost everyone is crooked/imbalanced, what’s so special about it?

And the answer just may be: not much at all.

Corrective Exercises: A Waste of Time?

I found a very interesting article not long ago. It very much reminded me of my “awakening” during my struggle with knee pain.

First, start with the entrenched thinking (flawed) on what causes “patellofemoral pain syndrome.”

American Family Physician describes the cause of PFPS as an imbalance of the forces that keep the kneecap in alignment during knee extension and flexion. This imbalance can increase the risk of muscle dysfunction, poor quadriceps flexibility, overuse, trauma and a host of other musculoskeletal problems. In other words, during PFPS, the kneecap does not glide back easily on its “track” to the femur. ... Some health professionals, such as physical therapists and athletic trainers, recommend corrective exercise as a self-care method for patients.

Sounds simple, straightforward, reasonable. Except:

Despite the prevalence of corrective exercise prescriptions, current evidence shows that this intervention may not always effectively treat knee pain and could be a waste of time.

The problem is, the idea behind corrective exercise is that you’re crooked (your kneecap is mistracking) or that various muscles or tissues are too tight or too loose. But “studies have shown that PFPS may not always be a biomechanical problem.”

A 2006 Swedish study is then described, one that I was previously unaware of. Eighty patients with PFPS were examined. Of those, 29 had no identifiable cause of their PFPS (the others either had “slow bone turnover disease” or a type of pathology of the knee, and a small number dropped out.) For the 29 who didn't have a clear cause for their pain, “researchers could not differentiate between [them and] the control group that had no knee pain and were not diagnosed with PFPS.” So they weren’t identifiably crooked or imbalanced in a way that the control group was not.

Of course there is evidence that exercise can reduce knee pain, but as Paul Ingraham says in the article, that’s “probably not because it’s ‘correcting’ anything.”

I’ve linked to Paul’s website a few times over the years, such as to this essay where he examines the obsession that physical therapy has with crookedness/imbalances. I like his thinking and he’s a good writer. In the article above he is quoted saying, regarding the misalignment theory (the underlining is mine):

Exercises are prescribed in the hope that such things can be corrected, usually by strengthening and stretching.  Unfortunately, a lot of exercising for these goals is often out of tune with how exercise actually does help patients.

I couldn’t agree more with that. And, finally, he does well to note that knee pain comes in many stripes, with many possible causes. So, he notes:

Exercise is no kind of magic bullet. Patellofemoral pain has many faces, many possible causes and complications, and some cases do not respond to any kind of exercise, ‘corrective’ or otherwise.

Read On for the Top Risk Factor for Knee Pain

“Broken record” has a pejorative connotation. No one likes a “broken record” who harps about one thing in particular, all the time.

When it comes to knee pain though, I’d argue that it’s not bad to be a broken record about one thing anyway. And that’s the single factor that, more than any other, predicts whether you’ll have knee pain.

It’s simple:

Being overweight.

A new meta-analysis of existing studies found that “one-fourth of cases of onset of knee pain could be attributable to being either overweight or obese,” according to researchers at the Arthritis Research UK Primary Care Centre.

That may elicit a yawn from you, especially if you think I’m a bit of a broken record on this subject. But here’s the part I found shocking:

5.1 percent of new knee pain/knee osteoarthritis could be attributed to a previous injury and 24.6 could be attributed to being overweight or obese.

Wow! Didn’t see that coming. What a disparity. If anything, I would have expected a previous injury to be a more significant contributor to the onset of knee pain. But it isn’t. And it’s not even close.

If I were an orthopedic doctor, and I had a patient with knee pain who was overweight and who claimed to be serious about doing whatever it takes to get better, I’d say:

“Lose x pounds. That will show that you’re really serious.”

Because if you are serious, and you are overweight, shedding some pounds has to be a No. 1 priority. On this point, the evidence isn’t debatable.

Knee Pain and the Influence of Genetics

Is knee pain a family affair?

A recent study shows there’s apparently a gene-related link to the development of knee pain associated with osteoarthritis.

The study included 219 subjects, average age 48. Roughly half were the children of parents who had knee replacements; the rest belonged to the control group. The knee pain of all subjects was assessed three times: at baseline, two years later, then eight years later.

Even after the proper adjustments were made to control for such factors as age, sex and BMI, “individuals with a parental history of knee replacement had a more than twofold greater likelihood of worsening total knee pain.”

Interestingly, the adjustments were even made for radiograpic and MRI abnormalities. So that meant researchers were comparing people of similar age, sex and BMI who also had similar-looking MRIs and X-rays. Even then, the offspring of the knee replacement group had a twofold greater likelihood of worsening pain.

The study’s authors speculated that “implies that the genetic contribution to knee pain may be mediated through factors outside the joint, possibly involving pain processing.” I interpret that to mean that, if you’re a child of a patient who had a knee replacement, you may be more likely to experience a worsening of pain simply because you may be more sensitive to it -- an interesting and curious finding.

In any event, I’d argue that the takeaway is that, if you’re in this high-risk group, being proactive about not developing knee pain in the first place makes a lot of sense. Build up the leg muscles around your knees. Find good joint-friendly activities (cycling, walking). Take good care of your knees before they start to hurt.

Did My Knees Really Get Better Or Do They Just Feel Better (And Does It Matter)?

A long title but I couldn’t think of a good shorter one.

After reading my story, some people say something like this:

Why don’t you get another MRI (or some other test) that shows whether your knees really healed? That would prove whether your program really worked.

To be sure, this kind of comment has never been phrased in a hostile way. There’s no implication I’m a liar or fraud. Rather, people have a deep curiosity -- the same as I do actually -- about what changes physically occurred in my knee joints between the worst days of my condition (when I was suffering each day in Hong Kong) and now.

If I could do such a test (for cheap), and it could measure such a thing, I’d do it in a heartbeat. Hell, I’d love to know. Armed with the test results, I could probably sell five times more books. ;)

But it’s not possible. Here’s why.

(1) Simply having an MRI done would cost a lot; I’m guessing at least $1,000. And my health insurance company isn’t going to pay for a “there’s nothing wrong but I’m curious about what my knees look like” MRI.

(2) I don’t have an ideal MRI to compare it against anyway. True, I had images taken in Hong Kong in early September 2007, but that was before my disastrous experiment with weightlifting to strengthen my quads (which really trashed my knees). An MRI done in November or December of 2007 might have shown more damage.

But here’s the big reason:

(3) My original MRI exam was only somewhat useful in identifying my problem and determining the extent of it. Actually, “somewhat useful” may be a too-kind phrasing. My MRI basically said I had changes consistent with mild chondromalacia. So it found no giant potholes in my cartilage that a subsequent exam might show had healed.

My suspicion is that if a surgeon had cut open my knee, he would have spotted some kind of more obvious cartilage damage not detected by the MRI. But I never went that route (thank God). So, like many knee pain sufferers, I don’t have a good baseline test that says, “Wow, your cartilage is really messed up!” I suspect I was on the verge of going downhill fast, but I was fortunate to fix my knee pain in the relatively early stages.

So how do I know there was damage in the first place and I didn’t just suffer from some weird neurological ailment?

Well, as I relate in the book, there was a lot of noise from my knees when I dropped into a squat (as if I were about to sit in an invisible chair). My knees were so loud that my doctor felt compelled to be blunt and opine that the joints would never get better. Also, when I went into a deep crouch -- which was hard to do and uncomfortable -- and then straightened up, there was a loud, ugly “ripping” noise.

But now those disconcerting sounds, whatever they indicated, are either gone or much quieter (I can still hear a little crunchiness in my knees, but it’s not painful at all). I’m back on the bicyle, riding as hard as ever. I can sit at my desk again through a long 10-hour-plus day without issues.

Do I have a before/after set of tests that shows the improvement? No. But even if I did, would it matter? I’m not so sure it would. Just from the way I feel, I know something in my bad knees sure as hell healed/improved significantly. And I’m pretty confident of that, whether or not those changes could be detected by an MRI or some other test.

Running Not Only Doesn’t Ruin Your Knees, But May Help Them

One of the most persistent knee pain myths is that, if you're a runner, the sport will eventually exact its due and lead to sore, aching joints. If you run long enough, the pessimists warn, you’ll pay the price.

A recent study (the results of which were presented at the American College of Rhematology’s annual meeting) came to a much different conclusion.

Namely, 29.8 percent of non-runners in the study had symptomatic osteoarthritis compared with 22.8 percent of the runners (I have to assume they controlled for weight in their calculations, as that’s a Statistics 101 sort of thing to remember to do.)

The study was huge (2,683 people, who had an average age of 64.5), which is good, but it did have a kind of squishy longitudinal component. Anyone who was a regular runner at some stage in their life, even if it was only between the ages of 12 and 18, was tagged as a “runner.” That can be problematic, as anyone knows who remembers my analysis in the book of one longitudinal study in particular. Still, this would not be the first study to suggest running is beneficial for knee joints, so I think the conclusion makes sense.

One of the study’s authors does raise a caveat: “This does not address the question of whether or not running is harmful to people who have pre-existing knee OA,” according to Grace Hsiao-Wei Lo.

But that’s okay. That’s a lesser issue. Running generally isn’t a good idea if you already have osteoarthritis in your knees, especially if it’s painful (there are better activities that are lower impact on the joints). The good news is that evidence increasingly shows that running doesn’t cause that osteoarthritis.