Saturday, December 31, 2016

Another Success Story, With a Twist

I love success stories. I share them as often as I can. I know readers of this blog are hungry for clues as to how to heal their ailing knees. So I’m happy to share one today that popped up in the comments section. However, I do so with a big caveat.

It’s basically a “train through the pain” approach. This is NOT how I healed, and it could further damage your knees. Just be aware of the risk.

Why share it then?

Because, honestly, one thing I’ve gotten more humble about: healing knee pain can be very tough, and different knees sometimes respond well to different things. Also, author Tim Howell is clearly a really bright guy who thought a lot about what was wrong with his knees and how to fix them, and I think hearing from people like that is always valuable.

It’s possible someone out there may see himself/herself in this story, and what Tim did could help that person. I can think of at least one comment I’ve gotten on this blog in the past six years where a person said that his knees benefited from a pretty vigorous, heavy-load workout.

So here it is below, edited some for space (Tim wrote it quite well, so it was hard to edit.) To read the full version, just go here to the top of the comments section.
"I've been checking in on your blog ever since I first developed my knee problems. First, I should say that I did not get better use the low-load, high-rep motion approach that you advocate. Direct heavy strength training is what has eventually cured me and it was a long road (3 years) of trying everything else first.

"My patellofemoral pain began a month following 'routine' meniscus surgery. Initially it was palmed off by doctors as normal post-surgical pain. But it began to get worse. The pain was directly behind the patella, very sharp in nature and the knee would give way going downhill /downstairs. Any movements placing load on the patella (leg extensions/ squatting) were impossible due to the pain, and the knee would often get hot and achy at night. Walking on the flat or uphill produced no symptoms.

"I spent one year being a good boy and doing everything the physios told me to. Nothing worked. Hip strengthening, ankle strengthening, lots of semi-squat variations, VMO contractions. As I began to get desperate and my mental health took a dip, I lost faith in the patellofemoral diagnosis and began to see it as a way for people to say they had no idea. I spent a few months just trying to completely rest. This made my painful symptoms worse. At this point I had discovered your blog and book.

"I abandoned my doctors and physios, self diagnosed myself as having chondromalacia and made a plan to walk myself better. This was a major error on my part (don't get me wrong Richard, your blog/book helped in many other ways). I had no imaging evidence to suggest I had chondromalacia and was going purely off symptoms and presentation.

"Fast forward one more year. I had put myself on 'cartilage time' and had accepted that it was going to take a while to improve, but nothing was happening, no signs of improvement. Plus I never had any trouble when walking (first red flag) in the first place so there was no way to see the pain going down as I increased my step count etc. I also experimented with very light cycling and swimming, but also had no improvement.

"I tried a bunch more things, all getting more bizarre (think pulleys and carabiners) to try and gradually load my patellar cartilage and coax it to regenerate, before eventually throwing in the towel and having a long hard look at the situation. At this point I made my first good decision and got imaging done (X-ray, MRI, ultrasound). Shocker = everything inside looks perfectly healthy. No chrondromalacia.

"So spending a bunch of money to get those two words of information changed everything. I decided
A. to have a really good second look at patellofemoral pain syndrome and find out if it really was just a catch-all and
B. I was gonna find a health care professional who actually knew what they were talking about. I saw A LOT of different people. I gradually worked up the pyramid of expensiveness until I was seeing doctors of national sports teams.

"Things learned on this leg of the journey:

"1. Some people will have no idea about knees, will quote the textbook to you and will pretend to demonstrate how badly your patella is 'mal-tracking' and will give you the same 4 hip, ankle and VMO exercises that everyone else does. They cannot help you. Ditch and move on.

"2. Some will suggest that you go and have surgery again, and will be very convincing. My advice - put this as a last resort and try everything else before you let them cut you open.

"3. Some will advocate stem cells, PRP, prolotherapy or viscosupplementation. I say go ahead with trying any of these that you can afford, but say no to cortisone. If they offer you cortisone, you say no. Do some research. I could only afford an ostenil injection; it made no difference.

"4. Very few doctors will suggest a change from the standard knee rehab rubbish. But those who do may ask some VERY IMPORTANT questions: What have you already tried? Have you tried training strength through the point of pain? What happened? What changes in your knee after a good warm up?

"I didn't know it at the time but those questions are the key (or at least were for me) to beating the mystery that is patellofemoral pain.

"-Have I tried training through the point of pain? Yes, in the early days of flailing around. What happened? I was in worse pain than before for about a day afterwards and then back to normal pain levels. I assumed this was a bad sign so did no more.

"- What changes in your knee after a good warm up? I had no idea, so I tried. I did a 30 minute 'patella-focused' warm up (look up sissy squats). Minutes 1 - 15 were very painful. Minutes 25 - 30 were surprisingly more comfortable and I could bend the knee a tiny bit further. Gradually over two months I noticed that although my knee was as bad as ever normally, that towards the end of the sissy squat warm up they would feel much better. Additionally the giving way would stop happening by the time the knee was all warmed up. Worryingly I did seem to have more pain than usual later in the day after a session, but overall I wasn't declining so I carried on.

"Time to test the next question - What happens if you train beyond the point of pain? So following a good warm up of sissy squats (was now taking about 15 mins to get to the point where my knee wouldn't give way due to the pain.) I would try and do a single pistol squat. To my surprise I could do it. It was painful but I could do it. Again I was in more pain for a day following these sessions, but the rest of the time I actually seemed to be improving.

"I continued to warm up and try pistols until one day I found I could do them without without a warm up and they were almost pain free. From there it was plain sailing as I just gradually increased training load and volume until I was doing 3x15 pistol squats no warm up wearing a 20kg vest. At this point I was completely pain free in all parts of my daily life and was very, very happy.

"I should also say that I stretched regularly, foam-rolled my newly appearing (and thus easily knotted) quads. I didn't follow a specific diet, and to deal with anxiety I took up meditation as per Richard’s advice along with the Wim Hof method. The mental health aspect of this battle is no joke and should certainly be addressed proactively.

"So I think if I had to give myself from 3 years ago some brief parting advice:

"1. Don't jump to conclusions about chondromalacia without any evidence, but if you truly do have it then be careful and measured.

"2. It might be worth trying to train through pain just once as an experiment to see what happens. Do you definitely get worse or is it only a short after-effect that then goes away? Be sure about this before you decide to throw strength training out the window.

"3. See what changes in your symptoms after a thorough warm up.

"4. Keep seeing different people UNTIL someone helps you, there are people out there who know what they're doing; they are just hard to find.

"5. If you get better share your success story."

Amen! Share your story! In the comments section below, if Tim’s around (hello?), maybe he can answer questions anyone has.

Saturday, December 17, 2016

Why Knee Pain Turned Out to Be a Blessing in Disguise

Go ahead, roll your eyes. That would be my initial reaction too: “Oh no, here comes the maudlin essay on how suffering through pain strengthened his character, gave him courage and made him a better person blah blah blah.”


That’s not where this is going. Rather, I have more rational reasons for making that headline statement. My experience with knee pain taught me some excellent lessons:

* Doctors aren’t always right.

I had never thought of getting a second opinion before. Now I always consider it, especially if I have a difficult-to-diagnose problem that a doctor could easily get wrong.

* Surgery is often the best option when it’s the last option.

If not for my knee pain saga, I probably would’ve had surgery on my foot a couple of years ago. I had a problem misdiagnosed as Morton’s neuroma. I’m now convinced surgery would have been the wrong thing to do (as it would have been for my knees). Sometimes you need to be patient.

* I learned how to read clinical studies.

This is important. There are many good studies out there, some of which conflict with prevailing thinking in the medical profession. Read them. Figure out what they mean. You'll be glad you did.

* I learned to be skeptical of the “things just wear out” reasoning.

As patients age, doctors tend to be more likely to say, “Oh, that just comes with age.” Sure, some unpleasant changes in your body do come with getting older. But many can be delayed (if not prevented completely) if you take good care of your body.

* You need to be a smart patient because the problems will keep coming, especially as you age.

I’m on the wrong side of fifty now. In the past few years, I’ve had an issue with my foot, with my shoulder, and I expect more parts of my body will ache and complain in the years to come. I need to be smart about evaluating the doctors who evaluate me because there’ll be plenty more.

These are a few reasons why having knee pain was a good thing for me. I still wish I hadn’t gone through it. But it did make me better equipped to go through the rest of my life.

Saturday, December 3, 2016

Open Comment Forum: Your Turn to Speak!

We haven't done one of these in a while, it appears, and they have been hugely popular (much more than my blog posts, I must confess).

So go ahead: Discuss whatever you want to below. It's open mike night at the SMK blog. :)

If -- and by no means feel bound by this -- but if you're looking for a subject to kick things off, what about this, for those of you who have had surgery:

If you could do it over, would you? What do you wish you had known going in that you know now? What's the most important thing you would pass along to others thinking about having that same procedure done?

Okay, I'll step aside and get out of the way now. Cheers!

Sunday, November 20, 2016

That “I’m Just Getting Old” Misconception About Knee Pain

As many of you know, I have Google scrape the web daily for news about knee pain. Recently the search turned up a column from the Flathead Beacon, a newspaper out of northern Montana. There are two huge national forests there; it looks like a beautiful place to live.

The writer is a devoted outdoorsman worried about how many more bird-hunting expeditions he has left in his failing knees. “I have become increasingly aware that there’s a hunting life expectancy in this body of mine,” he laments.

He had surgery on the right knee after a marathon quail hunt about 15 years ago. Then the second knee started going downhill, and what can you do? Here’s the money paragraph that had me ready to slap my palm against my forehead:
When knee No. 2 went south this spring, my doctor speculated that I just had joints built in a way that eventually wore out that knee cartilage. Like the right knee, the left seemed to just fail over time. It started aching last spring, after a casual jog with my daughter. It was fine the day of the run, but I couldn’t walk the following morning.
First, I’d get a new doctor. Yes, aging does have an effect on our bodies; that’s undeniable. But properly cared for knees don’t have to wear out over time. More typically, they fall apart because of benign or not-so-benign neglect.

Notice that the left “start aching last spring, after a casual jog.” I don’t know what happened, but a picture comes to mind, of someone attempting a little exercise after a relatively inactive winter and too many holiday treats consumed.

Of course the knee probably wouldn’t hurt during the run; that’s the problem with cartilage. But the next day – oh yeah – you’d feel it, full force. And if it was occasionally unhappy before, that casual trot could be the tipping event that pushes you into the land of chronic misery.

To be fair, the writer seems to understand the crux of the problem:
But the 10 to 20 pounds I’ve been trying to lose since, well, forever, that’s no longer a matter of just trying to look good.
If you’re carrying an extra 20 pounds (most men who say they want to lose 10 to 20 actually need to lose more like 20 to 30), you’re begging for knee trouble. If you do everything right, your knees may be fine. But you’re at risk if you lurch between sedentary and active states. What you need to do is obvious, though hard: Lose weight. That’s one piece of advice no one would dispute.

Sunday, November 6, 2016

That “Come to Jesus Moment” About the Strength of Your Knees

A “come to Jesus moment” (which originally meant that moment when you accept Jesus as your savior) has entered the popular vernacular to represent more broadly an epiphany or a flash of enlightenment.

Have you had your “come to Jesus moment” about the strength of your knees?

Not having this moment, I think, is a great impediment to getting on track with a successful plan of long-term healing.

What happens is you muddle along, believing the right things, doing many of the right things, but they’re all geared for a knee that’s about two or three times as strong as your knee actually is.  You may not realize it, but your progress is constantly being undermined.

It’s all because you don’t realize how weak your bad knee is. So you’re always being careful, but you’re also often outside of your proper “envelope of function.”

When my come to Jesus moment came, I remember thinking: “No, no. My knees aren’t really that weak. It’s impossible. I can’t be that bad.” But then I remember this sick feeling, “Yes they are, and yes you have to accept this. You have to start at the bottom to get to the top.”

That’s when I started walking around a swimming pool every ten minutes. Walking, then resting, walking, then resting. Nothing more strenuous than that. And after a few weeks, I noticed that I was getting better, but at the same time, it was depressing to realize the depth of the hole I was in.

Still, if you ask me, “When did you really get on a  long-term path to healing?”, I would identify walking around that swimming pool as the beginning. The later successes built off that. But to start there, I had to have a “come to Jesus moment” about the strength of my knees.

Have you had yours?

Saturday, October 22, 2016

ACI vs. Microfracture, Revisited

I originally wrote this post, which garnered a good deal of attention, about these two procedures.

I said that if forced to choose between the two, I’d rather have the less-invasive (and less-expensive) microfracture, which may even be more effective. In the comments section, several people disagreed. One commenter said that, over the long-term, ACI (or autologous chondrocyte implantation) leads to a better result.

Uh, maybe not.

This study (published in August in the reputable Journal of Bone and Joint Surgery) looked at large lesions treated with either ACI or microfracture. The 80 subjects were evaluated after 15 years (a suitably long timeframe, I think all would agree).

Check out the highlights:

* There were 17 failures in the ACI group compared with 13 for those who had microfractures.

* Total knee replacements: six in the ACI group, three in the microfracture.

* X-ray evidence of early osteoarthritis: 57 percent in the ACI group vs. 48 percent in the microfracture.

Luckily I don’t have to choose between either. But if I did, I think I’d stick with my original answer.

Saturday, October 8, 2016

Knee Pain and the Weather

Here’s a rather in-depth article about the relationship between pain and weather. The authors pored over a lot of different studies to reach their conclusions. Which are ...

That the link betwen the two is unclear. Actually, to be more accurate, it appears rather weak.

They looked at a number of painful physical conditions, from arthritis to migraine pain. I’m going to stick with the osteoarthritis end of things, as that’s what those of you with bad knees care most about.

Why should the weather influence perceptions of knee pain in the first place? Some theories:

* When bad weather moves in and barometric pressure drops, the surrounding air pushes on the joint with less force, allowing tissues to expand and causing uncomfortable pressure.

* Or, an alternative theory is changes in barometric pressure “may augment cytokine pathways.” More cytokine activity may damage host cells.

* A combo of rain, cold temperatures, and low pressure may cause pain by increasing swelling in the joint.

I encourage you to read the whole article, if you want more. I’m going to jump to the conclusion and in particular this line.
Studies that typically report the strongest correlation between meteorological phenomena and onset of pain are often poorly designed, utilizing self-report mail surveys and small sample sizes, not blinding participants to the research hypotheses, or relying on subjective memory recall.
Okay, that’s not hopeful if you’re trying to prove a connection between weather and pain. Still, the authors note that the issue is far from settled. At the least, certain individuals could be more sensitive to changes in the weather.

I’m not sure myself. I did think my knees were a bit crankier in Hong Kong when a big storm was nearing. And weather effects on one level make sense to me: the lousier the weather, the more likely you are to be unhappy, and there is a definite link between depression and pain.

What about everyone out there? Do changes in the weather affect how your knees feel?

Saturday, September 24, 2016

If Your Doctor Can’t Figure Out Why Your Knees Hurt ...

You might want to get a bone scan to  look for abnormalities.

The more I watch Dr. Scott F. Dye speak (thanks to TriAgain for yet another link), the more I’m convinced that knowing what's going on with the bone behind the cartilage is often critical to understanding knee pain. That’s what Dye thinks, and he makes a good case.

He attacks a lot of the received wisdom on what causes knee pain. He’s refreshingly unorthodox. For instance: what surgeon hates surgery? But he pretty much does, except for limited instances, and he appears to favor the least amount of surgery possible.

He’s also almost vitriolic in his dislike of structuralists. You know, the dozens of doctors who tell you your problem is because your kneecap is mistracking. I remember my first orthopedic doctor cited this as a reason for my pain, then when I queried him further on the point, he kind of mumbled it away. That’s probably because my kneecaps sat quite normally in their groove on my X-ray. So he probably realized that that standard argument was absurd.

Dye also doesn’t think much of blaming cartilage defects for your pain. On this, I’m not quite convinced – the cartilage does attenuate forces traveling through the joint, and if it’s damaged or missing, well, that seems significant. And Dye himself (through self-experimentation – now that’s dedication!) identified the synovium as being highly innervated, and a possible source of knee pain. So perhaps fragments of damaged cartilage could migrate through the synovial fluid to the synovium, irritating it?

Still, in his defense, he claims to have grade three chondromalacia in one of his knees – and it’s totally asymptomatic. So maybe I’m guilty of overselling the line “heal your cartilage.” Even so, I think my program for getting better would have fit a lot of his criteria for what makes sense for fixing bad knees: go slow, and stay within your “envelope of function.”

Curious about Dr. Dye, and what the heck I’m talking about? Check out these links:

Why You Need to Know About the “Envelope of Function”

What Implications Does “Envelope of Function” Have for Designing a Plan to Beat Knee Pain?

Scott F. Dye on Why Your Knee Pain Diagnosis Stinks (And Why You’re Not Getting Better)

Sunday, September 11, 2016

Decoding What Those Crackly Knees Mean

I found this research study interesting and wanted to share:
Engineers are developing an acoustic knee band equipped with microphones and vibration sensors that can listen and measure sounds inside the joint — and could lead to a way to help orthopedic specialists assess damage after an injury and track recovery progress.
Hmm. Apparently the listening device on the knee band was created by combining microphones with piezoelectric film, which is very sensitive to vibrations. The microphones are placed against the skin.

Of course all knees make noise: pops, creaks, crackling. Often these are benign. But when you have knee pain, they're called "crepitus" and take on a new significance. It turns out, even if the noises are hard to make sense of, there is at least one message in there:

An injured knee makes markedly different sounds than a normal knee. “It’s more erratic,” according to Omer Inan, an assistant professor of electrical and computer engineering at Georgia Tech. “A healthy knee produces a more consistent pattern of noises.”

Inan, in recording the sounds knees make, has encountered challenges. Fluid that surrounds the joint interferes with sound waves, and moving your knees causes its own kind of noise that can drown out other noises that are more important.

As someone who listened hard to his injured knees, I’m interested in what they find. I do think knee sounds are meaningful, but I also think it’s very hard to figure out that meaning.

Friday, August 26, 2016

Another Open Comment Forum, Jump In!

It seems it's about time to do one of these. The first two were enormously popular. Also, it's fun for me to sit back and watch everyone talk.

How's everyone doing? Summer is almost over. Was it a good one for your knees, or was the warm weather too tempting and did you try to do too much? (I realize this should be completely flipped on its head for our handful of Australian contributors, who are probably sitting inside waiting for the snow to end.)

If anyone's looking for a topic: Are there any changes in footwear that have helped you? I relate the story in the book of those special, expensive shoes I bought that were supposed to be the greatest for joint pain ... and turned out to be an absolute flop.

Or talk about whatever! Cheers.

Saturday, August 13, 2016

Don’t Rush Back Into Hard Activity After Knee Surgery

I’m a Boston Red Sox fan – a bit of a closet one, now that I live just outside of New York City.

Some big offseason news for the baseball team was when they acquired Craig Kimbrel from the San Diego Padres. Kimbrel is a “closer,” a pitcher who enters the game in the late innings to shut down the opposing batters from scoring any runs. In the world of closers, Kimbrel is a pretty darn good one too.

Once the season started, there were a few bumps for him in making the transition from one team to another (and one league to another), but everyone agreed that he threw an assortment of filthy pitches that could leave opposing hitters flailing at air. It looked like the Red Sox at last had the ace reliever they sought.

Then, in July, we got some uh-oh news:
The Red Sox have placed closer Craig Kimbrel on the disabled list with a medial meniscus tear in his left knee, the team announced.
I’m not a surgeon of course, but I’m kind of a knee guy, and I thought, “Ah, hope the team is smart enough to handle this well.” Kimbrel was scheduled to have surgery and miss three to six weeks. I thought to myself, “Give him a couple of months.” Knee surgery isn’t a walk in the park, even for a young (Kimbrel is 28) elite athlete.

Then, on Aug. 1, my heart sank when I saw this:
Closer Craig Kimbrel returned to the Boston Red Sox on Monday, three weeks after surgery to repair a medial meniscus tear in his left knee.
I’m thinking, “No, give him more time. Sure, he feels great. Lots of people feel great right after surgery. But the truth is, they’re more frail than they realize.”

But Kimbrel took the mound and performed brilliantly. However, things didn’t go so well for him during a game after that:
Craig Kimbrel had the worst outing of his career Tuesday night, walking four batters ... the Boston Red Sox closer spoke of knee soreness after the outing.
Oh boy, I thought. This was completely avoidable. Now, to be fair, his manager said that the next day Kimbrel reported no knee soreness at all. True? I don’t know. But even if so, I’d say that knee soreness after surgery should be treated like a wildly flashing red light.

Post knee surgery, don’t rush things. Don’t be deluded by the fact that, when you walk, there isn’t knee pain anymore. Well of course not: you’ve been lying around for weeks, not putting any weight on your joint. Meanwhile, the cartilage cushioning your knees has been getting softer.

Obviously, the last chapter in this story hasn’t been written. And obviously, I’m not the Red Sox trainer overseeing Kimbrel’s rehabilitation program. If I were though, I’d try to go easy on that knee through the end of this season (which ends in late September for teams that don’t make the playoffs).

Then, during the next offseason, I’d consider getting him going on some gradual leg/joint strengthening. Maybe buy him a high-end bicycle and a plane ticket to southern California and tell him to start nice and slow, then perhaps work up to climbing some of those mountain foothills by the time spring training for baseball players rolls around next March.

Knee surgery is a big thing. Give it the respect, and time for recovery, that it deserves.

Sunday, July 31, 2016

Yet Another Study Weighs in Against Surgery for Knee Pain

On knee pain, two solid, almost unassailable truths have emerged:

(1) If you want to reduce your pain and you’re overweight, lose weight. I’ve given up citing all the new studies that link excess weight to knee pain, as I could probably mention one every month, but what’s the sense? The message is always the same. If you’re still debating this one, you probably still think the earth is flat too.

(2) Surgery is a bad idea for most cases of chronic knee pain. This is more an emerging truth, but the evidence just keeps stacking up. Most recently was a study summed up by the Washington Post with the headline “Maybe You Don’t Need That Knee Surgery After All.”

The study included 140 adult subjects, averaging 50 years in age, with knee pain from a tear in the meniscus. (Important: the tear was degenerative, as opposed to the result of a specific injury.) The participants either had arthroscopic surgery followed by a daily exercise regimen or worked with a physical therapist on neuromuscular and strength exercises a few times a week for 12 weeks.

At the final two-year checkup, the researchers found basically no difference between the surgery and physical therapy groups in their level of pain, ability to function in sports, and quality of life.

For the full study (as of this writing, it’s not paywalled), go here.

Saturday, July 16, 2016

Scott F. Dye on Why Your Knee Pain Diagnosis Stinks (And Why You’re Not Getting Better)

You MUST watch this. Honestly. TriAgain left the YouTube link in the comment section. When I finally got time to view the whole thing, Dr. Dye's remarks left quite an impression and actually left me wanting more.

This is unvarnished, straight-talking Scott F. Dye, who has been described as a “renegade knee theorist.” He calls himself a “surgical minimalist” as well. Most importantly, he has thrown his weight behind the only medical theory of understanding chronic knee pain (“the envelope of function”) that makes sense, at least to me.

The YouTube video is a 56-minute presentation (and q&a session) that he gave that I could write pages and pages about. Instead, I’ll just touch on some highlights.

* The worst cases of knee pain he sees are “iatrogenic.” That’s a very significant word to know. Because it means, basically, the surgeon caused the problem. Well, not the initial knee pain, but the surgery to “correct the problem” made it worse.

He shows a slide of several knees that went through multiple surgeries. Each knee got worse after all the operations.

* Chondromalacia is not a death sentence (he has asymptomatic grade three chondromalacia, he tells us). Also it’s not the same thing as patellofemoral pain syndrome. This common confusion clearly irks him; he even mentions that the Mayo Clinic website wrongly uses the two as synonyms.

“This is total and utter nonsense,” he says.

* Patellofemoral pain syndrome does NOT correlate with malalignment. There’s one study I usually cite as evidence to support this; he lists what appears to be a dozen or so studies.

What’s more, he makes the point that it’s dangerous to try to make adjustments based on perceived malalignment. He shows an X-ray where the kneecap looks tilted – but if you look at a different image that includes the cartilage too, you see the cartilage on the patella and end bone actually mate perfectly.

So what if a surgeon had gone in and tried to shave off some cartilage or perform a lateral release to “fix” that kneecap, which was actually perfect for that particular person? That’s how you get iatrogenic problems.

* He believes the key to understanding what’s wrong with painful knees is through a bone scan. This I find quite intriguing. I often thought that some kind of bone scan would have revealed the problem in my knees that the X-ray and MRI didn’t really detect.

(Yes, I blamed bad cartilage, and I still think there’s some truth to that, as excessive force on the joints may reduce the ability of cartilage to absorb shock, but I think a bone scan may have found other problems.)

* He is incredulous when talking about “PT Nazis,” who encourage patients to work through their pain threshold. I almost stood up and cheered. This approach is just nuts. I know it now, you should too, and Dye remarks, “This is just sickening.” He’s right. “No pain, no gain” makes sense for muscle growth, but not for a sore and aching joint.

* Then, finally, on being a surgical minimalist, he says “less is more.” He also conjures up a really neat image when he says, “Sometimes we surgeons have to get the pebble out of the shoe.” Notice the implied modesty there. This isn’t surgeon as superman, trying to remodel your entire joint. Rather, he’s trying to remove something small that doesn’t belong in a well-functioning joint.

Watch it. You’ll be glad you did.

Saturday, July 2, 2016

Acupuncture Is Probably Another Dud for Treating Knee Pain

I have a colleague at work who swears by “needles.” When he’s tired and stressed, he vanishes for an hour or so and returns from his acupuncturist feeling revived.

Is acupuncture useful for knee pain?

Evidence-based science indicates probably not. Here’s a summary for a recent study, published in a very reputable periodical (the Journal of the American Medical Association). Now of course it’s only one study, but everything on the subject that’s landed in my inbox over the last few years generally agrees with these conclusions.

First, 282 patients over age 50 with chronic knee pain were divided into four groups. The researchers were interesting in finding out whether traditional acupuncture or laser acupuncture helped alleviate pain. So two of those four groups were controls that received either no acupuncture or sham laser acupuncture.

Over the course of three months, patients received as many as 12 20-minute treatments.

After a year, there were “no differences between any of the groups on measures of knee pain and function.” The researchers suggest there were no real or direct effects of the acupuncture sessions.

I found this quote, from Rana S. Hinman, the study's lead author, most telling:
"Acupuncture tends to be more effective for people who believe in the benefits of acupuncture."
In other words: this is classic placebo effect.

One footnote that may comfort acupuncture believers: it was suggested the treatment may be effective for some people with neuropathic (nerve-related) pain. They weren’t included in this particular study.

And also, let me chime in: If acupuncture works for you, keep doing it! There’s no harm that I can tell. Even if 80 scientific studies say it’s worthless, if your knees feel better after being stuck with needles, that’s good enough. Who cares if it’s the placebo effect, really?

Saturday, June 18, 2016

The Post-Recovery Period: It’s Not Always Smooth Sailing Either

I’ve been meaning to post this for a while.

One thing I’ve always tried to be is honest about my experience with my knees. What I went through, and what I learned, may help you. Or it may not. But at the least, you deserve an honest account. No one out there should find out I’m limping around on crutches and waiting for a total knee replacement, and that’s the coda to my book, because nothing worked out the way I thought it would and I hid that from everyone for years etc. etc. etc.

Today I’m here to talk about an occasion since 2011 when things were not great. Last year, I felt some light burning in my knee joints during a six-week stretch, while sitting at my desk at work.

Oh no, I thought. Am I going down this road again?

I’m fairly certain I know what precipitated it. One day I decided to do an insane session of short sprints, followed by quick recoveries, on my stationary bicycle. I had never done that before nor have I since. I think it just tipped my knees into a bad place – out of homeostatis, Dr. Dye might say.

But here’s the thing: I’m a whole lot smarter about knees now. So what I did:

* I dialed back on my bicycle riding for a few weeks. I still went out long miles, but alone and at an easier pace.

* At work, I said: You gotta get up and move! I had fallen into a bad routine where I never left the office. I worked at my desk for 10 hours straight, with a few breaks, such as for lunch, which I ate on site (my employer provides some free food and soups). So I resolved from then on, every day without fail, to LEAVE the building and WALK through the city for about 20 or so minutes (I’ve missed maybe one day, when the rain was just coming down too hard).

And those burning knees went away.

I’m sharing this with all of you in the interest of full disclosure, and because I really don’t know what’s happened in my knee joints, in terms of healing. Maybe there is some residual change in there that makes me susceptible to slipping back into an inflammatory cycle. But I am very sure that something got better, much better. I really do ride hard now: I sprint, I climb painfully long hills, I motor along at 28, 29 miles an hour -- and it feels really good.

Part of the reason I’m sharing this too is because I think that had I stuck with easy riding -- no more sprinting, go out with the “old timers group,” never break much of a sweat -- I doubt I ever would have had a problem again. Seriously. But I wanted to get right back at doing what I loved most, riding hard.

So I think my own story is useful as a cautionary tale. Perhaps you can return to your former activity, but you have to be vigilant. Bad knees that went south once can go south again.

And now a happy postscript: This year has been a very good one for my knees. Today I went on a 74-mile bike ride -- a very hard 74-mile bike ride -- and my knees are fine. (My legs? Eh.) We powered up a lot of small hills. At the end, as we approached a final half-mile hill at an 8 percent grade, I told another rider, “I’m less than zero.” I was completely exhausted.

But I felt great later. And right now, if I suddenly had amnesia and someone reminded me that I’d had knee problems in 2007, I’d probably say, “You have to be joking.” Because everything feels pretty normal.

Saturday, June 4, 2016

Welcome to the Blog! A Few Things …

I thought it was about time to do one of these posts, following a recent complaint I got about "commercial marketing" on this site (I'm assuming in the comments section).

There are very few ground rules here for people who want to leave comments/ask questions, but for anyone curious:

* Spam comments will be deleted.

These by the way have become harder to detect. At first spam comments were along the lines of “Great post!” with the commenter embedding a url in their profile name. The url generally led the clicker to some clinic that had most likely paid the spammer to drive up its traffic count.

Once the spammers figured out they were getting deleted this way, the tactics evolved. So now they sort of pretend to be engaging with the post for a couple of lines, often in a fairly transparent and superficial way. And of course, the url is still buried in there somewhere.

Again, I don’t mind at all if you link to a web site, an essay that helped you, a book, whatever – as long as you’re here to participate in the dialogue. If you’re a drive-by spammer, who is just looking for a way to staple an advertising flier to the nearest utility pole then move on, that’s different.

I check the comments weekly and try to clean up the ones that don’t contribute to the dialogue. As I said, advertisers are getting more sophisticated. But be forewarned: if you’re a first-time commenter and include a short comment and a prominent url, you will be looked upon with suspicion.

* The best way to ask me a question is in the comments section.

I get a lot of requests for advice/consultations, and many make me more than a bit uncomfortable. I wrote a book to tell my story, thinking it would help a lot of people with similar problems and also, as much as anything, offer hope when all seems hopeless. To me there was huge value in just documenting well the story of someone who beat knee pain when he was told he couldn’t and exposing all the untruths out there, about everything from “damaged cartilage can never get better” to “you need to focus on strengthening your quads.” Pernicious myths abound when it comes to knee pain.

Also (and I’m not exactly proud of this), I was full of anger about the way I was treated as a knee pain patient, and I’m sure others can speak of a similar experience: shrugging doctors who can’t recall what your issue is from one visit to the next, bouncy physical therapists who have never suffered a day of knee pain in their lives and all work from the same tired playbook, an industry of snake-oil supplements that has sprung up that studies have shown have no clinical efficacy, a roster of more serious drugs to keep the pain at bay and the knee pain sufferer on a dazed eventual walk toward surgery, which is where you wind up when you don’t take charge of a program to get better.

But I never claimed to be a doctor or a physical therapist myself, so I try to avoid giving advice. I try to avoid suggesting much in the way of exercises, except for the most simple ones. In fact, I got better doing an extremely simple exercise: walking, in slow, measured doses, with breaks, always listening to my knees.

So when you come to me and want to share your story via e-mail, my inclination is naturally to shrink away. It’s very flattering, but I’m not the guy you want. Doug Kelsey’s clinic has coaches who are very well-equipped to counsel and advise, and they work by phone now I understand. That’s really who you want. This is why I say “no” when people want to e-mail me with long descriptions of their problems. If they offered to pay me by the hour, I wouldn’t say “no,” I would say “hell no.” Because that would be even more wrong.

So what should you do? Leave your comments below a recent post. A lot of smart people now are regular visitors to this blog. A community has developed here of people who look out for each other, share what has been working/not working, and in many cases, have thoughts/insights that I would not have or that would simply be more appropriate or helpful for you. So share, by all means. But let’s keep the dialogue open and public (you can remain anonymous behind a screen name; that’s fine). You might be surprised at the volume of excellent suggestions (and all the support) you get from others on this site. Plus, I’ll see your comment too, of course, and might have some ideas as well.

Last, let me close on a positive note: Thank you all for reading. Honestly, I figured I’d have shuttered this blog by now. I don’t contribute to it as regularly anymore. But it always gives me pleasure to see all the people chatting below the posts, and I know I’ve created a kind of valuable if small ecosystem on the vast Internet, where intelligent people can talk about knee pain and feel free to shred some of the myths that hold us back from healing – and talk about the difficulties of their personal struggles too.

Healing bad knees isn’t easy. But I’m convinced it can be done. I did it. :)

Sunday, May 22, 2016

Another Open Comment Forum

Someone suggested I do these periodically, and it seems like a good idea. (Gives me a break too, and my life just keeps getting busier, so I'm good with that!)

As usual, I'll flip the mike around so everyone out there can talk in the comment section about what they want to.

If you're stuck for a subject, here's an idea: Discuss what you find most puzzling about your knee pain. Of everything that doesn't make sense, what's the biggest mystery you wish you had an answer to?

And, of course, if you don't like that suggested topic, feel free to disregard. Cheers, and hope everyone is having a good spring!

Saturday, May 7, 2016

Why Do So Many Physical Therapists Want to Hurt Us?

A recent experience with a frozen shoulder prompted this post. It also also relates very much to my days with knee pain because I noticed a similar dynamic at play.

First: the frozen shoulder is almost unfrozen now. That’s the good news. Frozen shoulder by the way is a term for adhesive capsulitis, a condition where the movement of the shoulder becomes quite restricted and simple tasks – such as threading your belt through loops with an arm behind your back or extending your arm over your head – become difficult or even impossible.

Before I knew it was a frozen shoulder (I thought I had torn my rotator cuff), my doctor advised physical therapy. Okay, that’s fine I thought. I waited however until I got a diagnosis, thinking that it made no sense to begin physical therapy before we even knew the exact problem. After frozen shoulder was diagnosed using an MRI, I made the appointment with the therapist.

His advice: perform stretching and range-of-movement exercises. In a variety of exercises, I was challenged to move my arm to the extreme that I comfortably could, and even try to go a little further. We did some exercises together. He also kneaded the tissue a little, then photocopied a couple of pages of exercises for me to take home.

Okay, I thought. Got a plan. That’s good.

There were about eight different stretches/exercises. I did them each morning. My range of motion began to improve.

But I felt terrible. Immediately after the exercises, I would notice a clicking/snapping of a tendon in my shoulder. This may have been the byproduct of inflammation. At night, I often had trouble sleeping. Once I had to take some Advil to get through the night.

A few days after that I had this realization: this just isn’t working. Sorry, but I’ve seen this same bad movie before, when I had knee pain. Sometimes it takes courage to reject a failed course and rip up what seems like a solid plan and come up with a better way forward.

But if I couldn’t even get a good night’s sleep, I knew I wasn’t getting better.

So I poked around online, looking for exercises for frozen shoulder. I found some illustrated on YouTube that were super easy. Swing your arms, loose and easy, like a pendulum, trying to let gravity do most of the work. Swing them up and down. Swing them back and forth. Swing them in circles.

Okay, I’m going to do that, I figured. It’s motion. Motion is good for joints, I learned from having bad knees. I tried to swing my arms 10 to 15 minutes every morning.

And the frozen shoulder began to get better, over the course of weeks. Now I’m almost over it. Thank goodness.

All it took was easy, gentle motion. Sort of like slow walking, or pool walking, or easy cycling to heal a pair of bad knees.

Maybe you’re thinking: Fine. It worked for you. But this stretching regimen surely makes the most sense for most patients with frozen shoulder.

Maybe not. From a paper, Adhesive Capsulitis: Use the Evidence to Integrate Your Interventions (Phil Page and Andre Labbe):
It has been suggested that “gentle” therapy (painfree pendulum and active exercises) is better than “intensive” therapy (passive stretching and manipulation up to and beyond the pain threshold.
Anyway, this post is getting long. Let's return to the original question: Why do so many physical therapists try to hurt us to make us better, when gentle therapy might produce better results? Here are some quick theories:

* Physical therapists tend to be young, healthy individuals. They know of your condition through what they’ve read in textbooks; they haven’t actually suffered your condition. They are missing an experiential bit of knowledge that may be quite useful.

* Physical therapists tend to be well-schooled in muscle groups, in forces and opposing forces, and various stresses on different parts of the body. They sometimes sound like physics nerds. That may encourage them to focus on stretching/working muscles in a more intense manner than may be warranted.

* Physical therapists tend to be in good shape, not surprisingly. I suspect a lot of them work out. People who work out are familiar with that old saying, “no pain, no gain.” They may carry a bit of that bias into the practice of their profession.

In any event, in this case, I found what was effective turned out to be easy motion. I wouldn’t be surprised if we find that to be a more successful intervention for many joint issues.

Friday, April 22, 2016

When Physical Therapy and Steroid Injections Don’t Seem to Matter

I came across an interesting study not long ago – not about knees, but tennis elbow (it's no longer up, so I can't link to it).

It turned out that about three-quarters of people with tennis elbow (who have damage to tendons in their forearm) recovered on their own after about a year.

Okay, maybe not surprising. The next part is though:

There was no significant difference between people who received no medical intervention and spontaneously got better and those who had both steroid shots and physical therapy sessions.

After a year, both groups were doing roughly the same.

The study involved 157 people, from ages 18 to 70. One group received six weeks of physical therapy and two steriod injections (the second group had the therapy and placebo injections). Then the third group got no special treatment.

The most aggressive combo, of physical therapy and steroid injections (to knock down the inflammation), showed a marked benefit at six weeks, no improvement at 12 weeks, and worse symptoms at 26 weeks.

Then, at the one-year mark, this article tells us:
Overall, improvement with physical therapy plus placebo injection or steroid injection was about the same as with no treatment at all.
Okay, now here’s my take.

First, steroid injections are dangerous. I really believe these are a deal with the devil: a quick “ah” sensation of relief, at the cost of leaving damaging chemical residue in your joint that weakens it.

As for physical therapy, good physical therapy can be a life saver, but all too often we get bad physical therapy. For example, I recall my own experience when I had knee pain and along the way developed tendinitis diagnosed as golfer’s elbow (which is similar to tennis elbow).

Here’s some of what was done and prescribed:
(1) electrical stimulation (worthless for me, I’m quite sure – but others have had success with this)
(2) stretching exercises (may have damaged the tendon further – how much sense does it make to stretch a cold tendon? Doing so may have created a few microtears in the tissue.)
(3) exercises that were probably too low repetition to stimulate constructive tendon healing.

If that’s similar to the physical therapy that someone gets for tennis elbow, then I wouldn’t be in the least surprised to find out it’s basically ineffective.

However, the right physical therapy can change your life. I devised a program of eccentric exercises, thanks to Doug Kelsey and other sources online, that I’m pretty sure helped me rescue the tendons in both arms. That program I bet would’ve changed some outcomes in this study.

Anyway, for knee pain the right move is not to do nothing and hope it resolves. Don’t take away that message. The point is rather that the solutions we’re directed to, such as conventional physical therapy and high-powered anti-inflammatories, may not be good solutions at all.

Saturday, April 9, 2016

A Bike Is a Bike Is a Bike -- Or Is It?

Here’s a short post in reaction to something I read in the comments. Someone was frustrated about how his knees reacted badly to a session on a stationary bike but were okay on a real bike, out on the road. Which makes no sense at all, right?

After all, a bike is a bike is a bike. Right?

Ten years ago, before my experience with knee pain, I would have said reflexively, “Sure. No appreciable difference.”

But once you have knee pain ... well, I’m not so sure. Your knees in this state are more tender and more easily disturbed. You start to appreciate subtleties, slight differences between Activity A and Activity B that actually can matter.

Personally, I’ve noticed differences in how my knees react to riding a stationary bike versus a bike on the open road.

The stationary bike has certain advantages. It’s easier to control the force exerted. You can simulate an 18-mile stretch of easy, flat road if you want to. Hell, you can even spin backwards.

But what I find more interesting is that riding on the open road may have certain advantages too. It’s easier for my knees to ride hard on the road than on a stationary bike. Why? Maybe because I’m shifting my body around, moving on the seat more, slightly altering the way that my joints take the pedaling force. Or maybe because sometimes I’m slowing (or even stopping for traffic lights), other times accelerating. Or maybe because occasionally I’m standing up on my pedals. I don’t know.

Then there are the bike setups to consider. Chances are very good that your stationary bike and road bike aren’t configured exactly the same way, in terms of distance from seat to pedal, for example. Does that matter? If you’ve got great knees, probably not. If you don’t, it might.

Anyway, this is just my way of urging you to stop and think a bit if you’re doing two things that you think are basically the same and one bothers your knees and one doesn’t. Maybe they aren’t really the same. And maybe that slight difference is actually important.

Saturday, March 26, 2016

Inflammation in Early Ostoearthritis: It's Not Your Imagination

After my “Ghost in the Machine” post, I received a link to an interesting paper (published in Therapeutic Advances in Musculoskeletal Disease only a few years ago). It isn’t a meta-study, but more a state-of-what-we-know summary.

First, you have to understand a little background. The prevailing paradigm is that rheumatoid arthritis is the inflammatory arthritis. The immune system goes beserk in an RA patient, and a blood test shows high levels of inflammatory markers, such as C-reactive protein.

Now, contrast that with the traditional understanding of osteoarthritis: It too causes havoc in a knee joint, but it’s a “wear and tear arthritis” and noninflammatory. And so, when I asked my doctor if my knee pain might be implicated in inflammation elsewhere in my body, he more or less scoffed.

That paradigm is now shifting, it appears, so if you’re one of those knee pain sufferers who is wondering about an onset of other aches and sorenesses, you’re not crazy. Medical thinking may be just slow to catch up with what we’ve long suspected: there probably is a ghost in the machine when someone has chronic, low-grade inflammation.

But I may be crossing a bridge too far (at least for this paper). Let’s look at what it actually says, using a few snippets:
Although rheumatoid arthritis is clearly associated with higher levels of inflammation, osteoarthritis is by no means a “noninflammatory condition.”
No surprise to most of us. But what’s more:
Inflammation is present in osteoarthritic joints well before the development of significant radiographic change . . . Cartilage breakdown products in synovial fluid as well as microfissures in articular cartilage are present long before any degeneration can be noted using current MRI technology or gross arthroscopic visualization.
Translation: Inflammation and other bad stuff is going on in your joints WELL BEFORE you can see anything on an X-ray or an MRI. So if you go to your doctor with burning, aching knees, and he says (after studying your X-rays and MRI), “Well, they look fine,” don’t be fooled. That doesn’t mean they are fine.
The development of chronic inflammation in OA following joint trauma or overuse can be understood as a vicious, self-perpetuating cycle of local tissue damage, inflammation, and repair, such that the osteoarthritic joint has been likened to a chronic wound.
This is IMPORTANT. Note the operative phrase “vicious, self-perpetuating cycle.” This is the cycle you somehow have to break. I had a sense of this when I quit my job and devoted myself to the full-time pursuit of healing my bad knees. To me, I was fast running out of time and needed to take a dramatic step to get on top of my chronic inflammation.
These studies, demonstrating significant synovial inflammation in early osteoarthritis, suggest a window of opportunity may exist in which disease-modifying interventions targeting inflammatory processes might be the most efficacious for the prevention and treatment of osteoarthritis.
Okay, this is the part I’m somewhat tepid about, but I understand the authors’ proclivity for a solution that comes in a neat little pill (that some pharmaceutical company can charge $800 a month for). I would modify their conclusion somewhat, saying instead that there’s a window of opportunity to subdue that inflammation. You may benefit most from a drug (but be careful, as some will degrade cartilage and what’s more encourage you to do things that are too taxing for your weak joints). Or you may need a tonic that’s free: the proper amount of easy, appropriate motion, and the ability to keep your knees in non-stressful positions.

For more, please check out the study. The second half dives deep into the weeds, flinging about terms that I expect most of us will struggle to comprehend, as the authors look at particular pathways of inflammation. If you have an appetite for such, go for it. Mine is somewhat limited, I confess. :)

Saturday, March 12, 2016

Open Comment Forum, Dive In!

Today I’m going to do something different. Today I’m going to turn the mike around, so to speak. I’m going to let all of you “talk amongst yourselves” (I’m sure some of you remember the original context for that phrase!)

A while ago, someone suggested doing this, so people could share and help each other. It made perfect sense to me.

Before we begin, I think there are four things we all share:

(1) We believe there is good reason to be optimistic about the prospect of damaged cartilage healing, or at least improving.

(2) We accept this will probably take a long time (maybe years).

(3) We believe that getting better requires movement.

(4) We believe “envelope of function” is the best framework for understanding and dealing with knee pain.

Okay, that’s it. You can start talking now. Since it might be useful to have a subject, I’ll throw one out there (but feel free to ignore or modify): What are some things you’ve done that have helped you with your knee pain?

Sunday, February 28, 2016

The Curious Tale of Morton’s Neuroma, Pt. II

Finally here it is, the second part of the tale about my bad foot.

If you haven’t read the first part, go here.

Today I want to talk about something that I find ultimately more interesting: the process of diagnosing a Morton’s neuroma. Morton’s neuroma is described by one podiatrist as a “perineural fibrosis, sort of a misplaced overgrown protective ‘scar’ tissue surrounding and compressing an otherwise normal nerve.”

Here’s the fascinating part of making the diagnosis, which really got my mind whirring when I fully realized the implications:

Morton’s neuroma is typically a diagnosis of exclusion.

So a podiatrist will check for multiple issues when the patient complains of ball-of-the-foot pain. Is there swelling? A bone fracture? A possible tear in the plantar plate? Etc., etc.

If nothing is found, many doctors will diagnose the problem as Morton’s neuroma. But it’s important to appreciate why: Probably not because there is definitely evidence of a neuroma, but because all other suspects were eliminated. So you may have capsulitis or some difficult-to-detect issue. But the diagnosis: Morton’s neuroma.

If this sounds familiar to a knee pain sufferer, there’s a reason. Patellofemoral pain syndrome is a similar kind of diagnosis, in a way. If your knee doesn’t have a clear structural problem, if an orthopedist can’t figure out what the issue is, you may be told you have patellofemoral pain syndrome. But notice my qualifying phrase “in a way” -- Morton’s neuroma is actually more dangerous as a catch-all diagnosis because it purports not to be one. In other words, it claims to know what the underlying problem is (unlike the infuriatingly vague “patellofemoral pain syndrome”).

My first diagnosis was made by a podiatrist using an ultrasound. He showed me the fat nerve and his diagnosis seemed like a slam dunk. There was the evidence, on a medical imaging device. Not until a year and a half later did I ask a general physician, “How can you tell the difference between a neuroma and a nerve that’s simply inflamed because you’re injured?” His reply to me:

You can’t.

Wow. That was a revelation.

If Morton’s neuroma is a diagnosis of exclusion for many podiatrists, it almost surely is overdiagnosed because of that alone. Further, here are five more reasons to believe it is overdiagnosed.

* Podiatrists, in reflective moments, are themselves wondering as much. Check out this long online discussion between foot doctors that was prompted by one’s question, “Am I overdiagnosing Morton’s neuroma?”

* Some aren’t even wondering: they’re pretty sure they know. Listen to this comment: “It has been my experience in 44 years of practice that this is the most overdiagnosed foot malady. In the years that I have been in practice I have found no more then 10 true neuromas.” Think about that -- that’s about one case every four and a half years.

* Follow the money: extracting a “neuroma” is a surgical procedure that probably pays well. Might this influence doctors, especially those trained to remove neuromas, to find more of these than otherwise?

* There are various comments online about about surgeons cutting open a foot to find a “no roma” or a very small neuroma, or about surgeries that fail to end the patient’s pain, or about neuromas that podiatrists say “grew back,” which doesn’t even make sense.

* Also you’ll find a number of people online who claim to have “healed” from their neuromas. This strikes me as implausible for a true neuroma. Once you have scar tissue hindering a nerve in your foot, I don’t see how it can just disappear, though of course you can take pressure off the nerve for temporary relief. But heal? If you healed, I’m betting you had some other issue.

As for what was wrong with my foot, I don’t know. I’ll probably never know. I did have a long period of the nerve being irritated, so it’s possible the nerve did change in some way. But I don’t think that was my main problem.

Anyway, the important thing is, thankfully I’m no longer contemplating neuroma surgery!

Update: The question was asked below how I healed my “neuroma.” I didn’t get into that originally, as this blog is “Saving My Knees,” not “Saving My Feet,” and most people who drop by aren’t that interested in foot pain issues.

But in brief, I did the following:
(1) Tried to avoid activities that stressed my foot.
This is kind of obvious, but worth mentioning. So, for instance, I tried not to stand around too long on the bad foot.
(2) Put better padding (Spenco insoles) in some of my shoes.
(3) Modified my cycling shoes and socks. This may have helped a fair bit. I cut a slit in the side of the right shoe, to relieve the pressure. Also I “faked up” a cycling sock. They tend to be tight, so I cut a comfortable white athletic sock off at the low ankle to make it look like a cycling sock.
(4) Modified my other walking shoes. I actually cut holes out of the side of them at first (to copy someone on the Internet who did this). But then I realized – d’oh – all you have to do is cut a slit in the side; it accomplishes the same thing without looking so ugly.
(5) Modified my dress socks. I actually stretched them out overnight on the end posts of exercise equipment so they wouldn’t be so tight.
(6) Bought new footwear. This, I think,  was important. I bought some Altra Instinct 2 Zero Drop sneakers to walk to work in (very wide toe box, great cushioning, and zero drop too of course) and to wear on weekends. Also bought some Crocs. Fell in love with the Altras; they are superb.

I also used Hapad pads for a while, but toward the end (the period when real healing took off), I wasn’t using them, as they got hard to position exactly right and tended to annoy my foot.

Saturday, February 13, 2016

Knee Pain and the Ghost in the Machine

I’m going to delay part two of the Morton’s neuroma thriller just once more, which I imagine no one will protest, as I’ve received no comments specifically on the issue of neuromas.

I want to go back to last week’s subject, because TriAgain made an important comment.

First, I have a fear sometimes of becoming facile, of lapsing into can-do boosterism and tired platitudes (“Just move! You just need to move!”). That’s one reason that I liked last week’s subject, on breakdown points, because I remember doing some hard, original thinking for the first post, a few years ago.


What TriAgain put his finger on (“there may also be other systemic problems”) was a really difficult, intriguing piece that I honestly don’t have much of a clue about (and neither do your doctors, I suspect). Yes, there are breakdown points, and when you lurch beyond one, you can suddenly go from the blissful absence of any pain whatsoever to a nagging injury that just gets worse and worse.

But once you’re on the wrong side of no pain/pain, is it simply a matter of fixing an overstressed structural component (cartilage or whatever) to return to a previous healthful, pain-free state?

Maybe not. As anyone who read my book knows, I turned into a bit of a mess. At one point, it wasn’t just my knees but tendinitis in both forearms, along with terrible back pain. Happily, once I conquered the knee issue, I also managed to get on top of the other problems. So I did succeed in crossing the no pain/pain divide in the right direction.

But what exactly were those other problems? Were they related? And, if they were, perhaps once some malevolent systemic genie has been released from its cave, it can be really hard to get that thing quieted down and back inside again.

I know TriAgain suspects that complex regional pain syndrome is at least partly to blame for what his knee pain has morphed into. After checking out the CRPS symptoms, I can say that most of them don’t align with what I had.

But still.

When I had the chronic knee pain inflammation/irritation, I started to get the feeling that I was chasing a poltergeist that was loose in a many-roomed house. If my knees felt a little better on a particular day, some other joint would feel a little worse. Very weird, I thought. So I asked my general physician if all the joint pain could be related, and he assured me “no,” with this look as if he were humoring a naive child.

But the more I read everyone’s stories here, the more I am convinced that there is very often something systemic that slips in through the back door with chronic knee pain. It isn’t there at first. And it isn’t there for everyone. But I almost get goose pimples on my arms on reading all these accounts of knee pain sufferers who thought they too had rheumatoid arthritis.

So sometimes, when I’m rattling off my thoughts on healing and feeling a bit facile (in that way you can be when your chronic pain recedes to a distant memory), I get a little jerk-back to reality and sense of humility on realizing there’s a whole lot I never did understand. Like whatever that systemic issue was.

With knee pain, I believe there can be a kind of ghost in the machine, a nasty something rattling around inside you, wreaking havoc. But how that thing works, I really don’t know. Hopefully, in the years to come, someone in the medical field will discover some answers to the questions we have about that systemic part, and I can report back the findings.

Saturday, January 30, 2016

Why Did My Knee Pain Come Out of Nowhere?

I’ll run Part II of Morton’s neuroma next time. I realize that since this isn’t a “Saving My Feet” blog, people aren't so interested in trouble-shooting problems with their metatarsals. However, I will note that PFPS is mentioned briefly in the second installment :).

Anyway I recently got a long comment at the end of “On the Virtues of Going Slooooowwwww” that included a line I found interesting:
It just seems strange that I had zero issues with my knees up until someday 15 months ago and they were to never be the same.
Yes, this does seem strange, I agree.

But yes, this is also very common, I’m convinced as well.

I referred the commenter to another post I did, one of my favorites. Sometimes I like to scratch an epistemological itch and try to figure out something important. In Saving My Knees, such a moment occurred when I realized that when measuring rate of change, the perceived rate will be greater as your measuring instrument becomes more precise. (I’m sure others have noticed this same phenomenon, and some statistician’s name is appended to a law stating as much.) This has huge implications.

Anyway, back to the matter of knee pain coming out of nowhere. The post I referred to is about breakdown points. The knee is a load-bearing structure, subject to forces in multiple planes. Physical structures can have breaking points, or tipping points, up to which everything may seem fine externally. So just before that tipping point is reached, there may be the absence of any discomfort whatsoever. But there could be a fine line between no pain and the emergence of some pain that then goes on to worsen to chronic pain rather quickly, which then proves practically incurable.

The tipping point analogy is intriguing, I think, because it can be analyzed in a number of ways in the context of structures. Imagine a cup that withstands the impact from being dropped say 16 inches, but from 17 inches shatters into pieces. Obviously, that’s a dramatic change in state, from whole to irreparably broken, that's caused by a small shift in our initial variable (the height from which it's dropped). That’s not what happens to your knees (especially because they’re not inaminate objects with no ability to heal), but if your knees exist in a condition of precarious homeostasis when you are pushing them too hard, maybe you are close to crossing a thin line that will send you into a downward spiral of pain and misery.

And once you hit that tipping point – once you land on the wrong side of that slim divide that separates no pain and pain – the unfortunate thing is it can take a long time to get back on the right side. But I would argue that your knee pain didn’t exactly come out of nowhere. Instead,  you approached a dangerous line, probably multiple times, that you didn’t even know you were nearing – and finally pushed across it, with disastrous results.

Saturday, January 16, 2016

The Curious Tale of Morton’s Neuroma, Pt. I

In June of 2013, more than two years ago, anyone reading this blog for ideas on how to beat knee pain would have been astounded to see me in person. I was a mess -- a limping mess. At the time, I thought (my dark sense of humor) that if someone posted a video of me walking on YouTube, sales of Saving My Knees would evaporate overnight.

But it wasn’t my knees.

It was my right foot.

Here’s the narrative of what happened (which, during a search for a cure, I later repeated to three different podiatrists).

One Saturday morning in mid-June, I went for my usual grueling bike ride of 45 miles or so. That afternoon, about five hours after I climbed off the bike, I got out of a chair in my apartment and began limping. Right out of the blue. It felt like I had pulled a little muscle in the ball of my foot. I remember shrugging and thinking, “Ah, just walk it off.”

But the nagging little injury persisted. Over the next week, it got better, but didn’t go away. Then, the following weekend, I made what turned out to be a huge blunder. I was house hunting and ended up walking for hours, checking out homes and neighborhoods in a town we were thinking of moving to. The next morning, my foot was really hurting. I was limping badly.

Now let’s fast forward about six months, or this will get really long.

The foot still hurt, though the pain had subsided to an occasional numbness/soreness. During the summer, I had taken a month or so off from cycling (I should’ve taken a few months, right after the initial incident, but I was dumb in that macho male way). I had experimented with a few things, at one point even taping a partly inflated balloon to the bottom of my foot for relief (this actually wasn’t a bad idea, but I never found a balloon made of sturdy-enough material to avoid popping). Still, I had that numb feeling in the ball of my right foot that came and went, as if I were walking on a bunched-up sock.

So I went to see a podiatrist.

He checked me out, did an ultrasound, pointed to a shape on the scan and said, “There, you have a Morton’s neuroma.”

A what?, I’m thinking.

It turns out that Morton’s neuroma refers to a nerve in the ball of the foot that develops a bunch of scar tissue around it after chronic irritation. A numb feeling in the bottom of the foot is a typical symptom. Depressingly, once you have a neuroma, you always have it. It doesn’t magically vanish if you stay off the foot for a month or two.

I let the podiatrist shoot cortisone into the area (not without some reluctance, I might add). The cortisone did little good. So at this point I had a bad foot and cortisone residue in my joint. Great.

Of course by then I was reading a lot about Morton’s neuromas online. That led me to observe some oddities about my “neuroma.”

* A typical Morton’s neuroma (in fact, one podiatrist online claimed the only true Morton’s neuroma) occurs between the third and fourth toe joints. Mine was between the second and third.

* The same online podiatrist said a Morton’s neuroma is never the result of injury. I was pretty sure my condition was, even if it wasn’t a dramatic, foot-caught-in-the-door type of injury.

* This podiatrist also said a Morton’s neuroma becomes apparent very slowly, over months to years. My symptoms manifested themselves rather quickly.

* He maintained as well that a Morton’s neuroma is never accompanied by swelling. But at one point, a podiatrist observed swelling in my painful foot.

Had this been Me before my ordeal in Saving My Knees, I probably would have just gotten my three recommended cortisone shots, spaced weeks apart, then scheduled surgery to extract the nerve (the only permanent solution) when they failed (which I suspect they would have).

Instead, as a smarter patient who knows doctors can sometimes be wrong, I wound up seeing two other podiatrists.

#2 didn’t think it was a Morton’s neuroma and put me in a boot, which helped a lot. But, as luck would have it, she wasn’t in my PPO network, so I chose not to see her again. Some months later, still hurting, I saw #3. He didn’t think it was a Morton’s neuroma either, and ordered an MRI, which came back clean. The next time I saw him, he greeted me, looked at the test results, and changed his mind, telling me, “You have a neuroma!”

Argh. So I really did have a neuroma?

I began mentally preparing myself for some kind of surgery (I was leaning toward cryosurgery). In the meantime, I decided to try my hardest to beat this thing. I bought wide, well-padded shoes and Crocs to wear. I also bought a roll of Neoprene padding to cut out inserts for my shoes, for even more cushioning. I cut a slit in the side of my right cycling shoe, to give my foot more freedom.

I did more stuff, but I’ll spare you the details, as this post has already gotten really long.

The critical thing you need to know: My foot got better. It feels pretty much normal again.

So my neuroma healed?

I don’t think so. I don’t think I had a neuroma in the first place, or if I did, it wasn’t the primary issue.

If you’ve read this far, you’ll want to come back for Part II in a couple of weeks. I’ll explain what I learned about Morton’s neuroma. And, in doing so, I’ll tell you why Morton’s neuroma is almost certainly one of the most overdiagnosed conditions in podiatry offices everywhere.

Sunday, January 3, 2016

Sometimes It Pays to Keep Things Simple

I recently had Internet issues that reminded me of my old battle with knee pain.

My desktop PC connects wirelessly to our home router through an adapter that plugs into a USB port. The week before Christmas, my Internet browser started to hang after anywhere from three to ten minutes. This happened repeatedly. However, my laptop computer could still connect wirelessly.

Hmm, I thought. What the heck can be causing that?

I’m fairly good with computers, so I used Google to help me try to figure out what was going on. But my sleuthing proved frustrating. Possible causes abounded. Every time I eliminated one, another two or three would pop up.

The list of suspects was all over the map. Could it be a virus? A software conflict with my antivirus software? A power saver setting? An update from Windows that created issues? And on and on.

Then, while pinging websites from the command prompt, I discovered a significant amount of packet loss. That led me to connect the PC by cable. The Internet worked fine.

Ah hah.

I went to the back of my computer, where a wireless adapter smaller than my thumb, poking out of a spare USB port, should have been grabbing the Internet signal. I suspected it wasn’t – or at least not reliably.

So I replaced it, and everything was okay again.

What I realized later was it took me a long time to get to the solution. I should have investigated the faulty hardware as a culprit early on. I got that little device from the company that provides our Internet service; the installer handed it to me as if it were some throwaway lagniappe when I asked about connecting wirelessly.

That should have been a clue that it didn’t have much of a lifespan.

Instead of zeroing in on the adapter though, I chased a lot of other theories around, some a bit wild. I didn’t look at the simple thing first: namely, something that wasn’t built well in the first place just failed and needed to be replaced.

Similarly, when I had chronic knee pain, I remember Googling my symptoms a lot. I bet that anyone reading this right now will recognize themselves in that sentence. We all do it, desperate to find answers. In my book, I even mention getting tested for rheumatoid arthritis, wondering if I had some autoimmune disorder.

But Google can be more curse than blessing. It can lead you in a thousand different directions, none of them profitable. It will convince you that you have some extremely rare disease.

The simple thing to consider when you have grumbly, achy knees and medical tests don’t turn up a clear culprit, like a tear in a ligament, is that you simply have a damaged, weakened joint that can no longer tolerate the burden placed upon it.

In that scenario, you have to modify activity, scale back activity – but stay active somehow. You let go of all the weird little symptoms that don’t make much sense. You focus on bringing back your knee joint, little by little. It will take a long time. There will be more ups and downs than a world-class rollercoaster.

For a lot of us though, I think the simple approach makes a lot of sense. And, at least in my case, when I got better the weird little symptoms that made me suspect some systemic disorder went away anyway.