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.


  1. This is a really important issue Richard, and one I made in a respone to capojay below. How did my knees go from being able to smash out a hard 120km bike ride followed by a 20km run, to hobbling around like a 90yo in constant pain in the space of a month or so?

    There is no doubt I already had some patella cartilage damage (everyone in their late 40's would have) but it only caused intermittent problems, and certainly not chronic pain/burning/stiffness which could be made worse by the most benign of everyday activities.

    Something (I supect meniscus surgery, but possibly combined with other systemic infections or stressors) pushed me across a threshold making the knees extremely fragile (what Dr S Dye calls 'loss of tissue homeostasis').

    This has more than just a cartilage damage component - there are biochemical/inflammatory processes going on, which in my case also led to CNS changes (CRPS/fibromyalgia type symptoms).

    Surgery, physiotherapy, chiropracters, oseteopaths etc. can't fix this. In fact they will probnably make it worse as their exercises take you beyond your envelope of function and worsen the inflammation.

    Richard/Kelsey/Ingrham are on the right track with a massive reduction in exercise/activity, but keeping the knees moving and very gradually increasing what you can do. However, there may also be other systemic problems in your system which need addressing (in my case, I also think the high chemical, possibly high fungal load pool where I swam may have been an additional stressor which pushed my knees over the threshold. I won't swim there anymore).

    I also believe you cannot rely entirely on someone elses exercise/recovery program. Use them by all means, as they will have valuable clues and you'll learn some good exercises, but be ready to modify them if you feel they are making your worse. You are the best gauge of what works for you/what does not, and everyone will be different (e.g. I can do deadlifts and kettlebell swings, but I can't do Kelseys back-sliders).

  2. Triagain...I'm very intrigued by your post and mentioning of CNS changes with fibromyalgia (FM) like symptoms as a potential response (or cause) to the chronic knee pain. I would have never expected anyone with PFS/cartilage damage to suggest that FM could arise from knee pain onset (or vice-versa) and could potentially be contributing to the chronic knee pain condition. Frankly, it would seem odd to me that FM like symptoms would ever be related to an actual diagnosed knee condition. What's interesting to me, and as I discussed in that long post Richard mentioned above, I too had similar FM symptoms near the onset of my PFS/knee pain. However I had never thought to put the two together in some symbiotic relationship. I just assumed that the onset of the FM was due to depression or anxiety brought about by my mental outlook on new diminished physical lifestyle, (and perhaps it is/was). But seeing your comments today made me rethink that perhaps my on-going chronic knee pain that seems to improve then relapse only to improve again in such very short periods for the most simple daily activities, that perhaps there is a correlation of the CNS/FM playing into this pain cycle. Honestly I would have never thought that someone else would have symptoms manifest in such similar path as mine, I'd be curious to know more about your story.

    1. Fibromyalgia or neuropathy is a very common side effect of knee pain. Subchondral bone nerves get irritated and inflamed.
      Irritation spreads further on tendons, ligaments or muscles or even the central nervous system.
      Nerve medications can help with that. NSAID doesn't help at all. Burning knees (constant pain 24/7) is mainly subchondral bone nerve pain. There can be large chondromalacia without constant pain symptoms and vice versa. No one knows the reason for that.
      That is my experience.
      I'm in a constant pain for over two and a half years and I did lot of research during that period and visited many doctors or medicine professionals.
      They simply don't have answer!
      Considering knee pain, modern medicine is still in dark ages. You have to find your own solution to deal with problem.
      Human body is too complex for fast and easy answer.
      I'm constantly improving my condition. My story is very similar to Triagain's story. Only difference is that I'm not an ex athlete.

    2. What gcoza says is exactly right. I've had two pain experts tell me I had a pre-CRPS condition triggered by knee pain, and was very lucky not to get full-blown CRPS. I also got some fibromyalgia-type symptoms (e.g. aches and pains elsewhere in my body, esp shoulders, back, toes, thumbs).

      Hal.L - my full story is here on a triathlon forum if you have the patience:

  3. I've been through different pain type cycles since the diagnosis, however in the last 3 months the pain profile has changed to mostly a constant 24/7 burning pain; especially when the leg is bent. I can't figure out why the pain switched to a burning sensation but based on Gcoza comment perhaps I have finally hit the patella subchondral bone layer? I had not heard about specific pain "type" (such as as burning sensation) based on the origin (there is so much that doctors aren't telling me). The thought that I've possibly reached the subchondral layer on my patella scares me a bit, as it's only been about 15 months and my cartilage has noticeably deteriorated in that short period. Now that I think about, I have had fewer "good" days in the last 3+ months. I'm curious if anyone has had success treating the burning pain, especially if you are a chondromalcia patient? If you are taking a nerve pain medication which type has worked for you? Has anyone had success with stem cell injections (such as Regenexx) or PRP? Thanks again to everyone for your input!

    1. Hal, one and only thing that instantly helped me with my burning right knee are orthokine injections (70% less pain). Orthokine procedure (known as Kobe Bryant treatment) is more popular in Europe (I'm from Europe) than in rest of the world. Orthokine or Regenokine injections patented german doctor Peter Wehling.

      I have the impression that you had not fully understood my post, therefore I will repeat the fact that I have two different knees. Left one without burning pain but with pain under load, and right one with burning pain but tolerate load much better (Two years ago I could not bend my left leg, right one has almost 100% function).
      Conclusion : My left knee has larger cartilage defect but right one has burning pain. There must be something else going on besides cartilage lesion. I think that bad cartilage somehow triggered chronic nerve inflammation.
      Burning sensation is a sign of neuropathy.
      Nerve medication which helps me with my burning knee is ordinary alprazolam-benzodiazepin.
      (50% less pain for 5-6 hours)
      In fact, a month ago I visited a clinic that started to offer commercial stem cells treatment. It is called ¨Lipogems¨
      OS who examined me said that it would not help me, maybe I will experience little less pain but even stem cells are not the complete and ultimate answer for chondromalacia.
      Difference between Lipogems(Italian origin) and Regenexx(American origin) are source of stem cells. Regenexx- pelvis bone marrow, Lipogems-stomach fat.
      Here is one case of succesfull Regenexx treatment for chondromalacia:

  4. Hal
    My thinking (shaped by this paper send to me by R-X - ) is that the burning sensation is due to inflammation of the (mostly) synovial lining in the knee, and the presence of other inflammatory biochemistry.

    The thinking is that once this inflammatory process gets out of control, the cartilage can deteriorate further so it becomes a self-perpetuating downward spiral.

    This may have led to deterioration such that you have hit the patella subchondral bone layer (I'm pretty sure that happened to me - deep fissures in the cartilage), but that could be part of the larger inflammation issue.

    Most medicos are either unaware of this, or dismiss it focusing on just the structural (cartilage damage and muscular etc imbalance) issues. Early on in my nightmare, I asked one Sports Dr could I have synovitis (inflammation of the synovial lining). He prodded a bit and looked at my MRI and said no, but I'm sure it was (still is) present along with other inflammatory processes. And note my knees did not swell. Medicos seem to think there has to be visible swelling before they call inflammation.

    So I'm definitely a chondromalacia patient with burning pain. I had the chondro for decades, but something (meniscus surgery - nothing to do with chondro) took me over the threshold Richard discusses above which set up an inflammatory process, which made the chondro worse/more painful, which led to pre-CRPS type symptoms.

    The good news is you can beat it (Richard did), I'm about 50% of the way there, but it is tricky. Nerve pain medication helped the CRPS but not the inflammation/chondro.

    What helped my inflammation has been:
    * massive activity modification to avoid aggravators (i.e. walking and swimming with no kick rather than triathlon. The trick is to keep your knees moving, but at a level which does not make then worse. It has taken me years to figure out what I can/can't do (still learning)
    * the TENS machine
    * PRP injections
    * not sitting with legs bent
    * gentle wandering about in cool water fly-fishing
    * some creams (Emu Oil, Lawang Oil, Voltaren gel)
    * meditation/accupunture/relaxing
    * anti-inflammatories such as Neurofen & Mobic help, but are not a long-term solution

    I've not heard of anyone who has tried stem cells for this, but here it is still regarded as experimental and very expensive ($9,000/knee).

  5. I'm wondering if the tipping point is one of perception. You suddenly notice a bit pain or inflammation and then your mind sees this in a different light and once the danger signals are ignited in your brain then your brain becomes sensitised to it. It seems you can literally learn pain. It's not the actual level of damage but the change in perception of it. For me I remember my knees feeling a bit hot after a run for a year or so but it was kind of pleasant but then when my hips started to hurt, then I began to think arthritis, then a new perception emerged in my mind of what was happening to my knees and they began to hurt. Then other joints. Tests for rheumatoid arthritis and so on similar to Richard. I think the cascade of joint pain is a sort of brain panic. You become sensitised to sensory inputs that might normally not bother you. Pain science is a fascinating thing. I recommend looking at Lorimer Mosely's talks on youtube.

    1. Yes, I've read/seen a lot of Lorimer Mosely's work during my research into CRPS/chronic pain & I agree CartilageRepairMan.

      I think there may be tipping points related to perception, and tipping points related to tissue being taken beyond its envelope of function.

      I think I had both happening simultaneously, though probably slightly led by loss of tissue homeostasis which was triggered by meniscus surgery.

  6. I would like to echo Triagains point in that you really have to be an advocate for your own health! Due to my age (26) no doctor/PT/medical professional takes my knee pain seriously. Even though I can barely walk, can't do stairs, can't ride a bike, etc. I also have chronic pain all over my entire body - FM pain and like Triagain said - mostly likely, medical professionals will make this pain worse.

    PRP injections did absolutely nothing for me, and I am also working with one of DK's coaches. While, she is the most intelligent health professional I've worked with, she has also sent me into some pretty brutal set backs from pushing my knees to much. I haven't progressed as much as I would have expected working with the coach. I really hope we can get things turned around, I can't imagine a lifetime of this.

    Take care,

    1. Oh man...sorry to hear about this. It sounded like you were making some pretty significant progress not too long ago. Heck, your input is what helped me make my decision to hire a coach. What is she saying about it? Are you still happy with your coach? Do you feel like you're in a better place now than when you started with your coach? Than when you first started hurting? You can get through it. Stay strong and remember that it may be slow, but you can get there.

      Hope you get it figured out. Try to retrace your steps as best you can would be my advice. Take that for what it's worth. Best of luck to you.


    2. Just responding again so I can get notifications on this thread. :)

    3. Alex, so sorry to hear about your huge setback :(
      Have your doctors tested you for inflammatory diseases by any chance? Just to rule it out.
      What is your coach saying about all this?

      All the best and stay strong!

    4. Yes, I've been tested - all negative. My FM symptoms are similar to Triagain's in that they stem from knee pain. There is some sort of relationship between chronic pain in one area "spreading" to others aka how the brain copes with pain....doctors just don't understand that relationship.

      I'm still better off now than I was before without my coach but my point is that you really have to know and listen to your own body! A coach can only do so much and he/she must work with what your body is telling you.

      How are you doing Athenea with your coach? Do you think you will be able to get back to 'regular' life soon? As in life again with functioning knees?!


    5. Athenea,

      I've asked a similar question to you before, but I went through the various threads on this page to sort of piece together your story and your experience with your coach. There's some things I wanted to ask you if you have some time...

      It appears that in January 2015 you began working with your coach. You had a post in March stating "I can squat with my right knee and have no pain". What kind of squat was that? Also, in April you noted that " right knee is awesome, all my symptoms have gone away". Was your right knee seriously feeling 100% after just 4 months?

      I ask because I've been working with my coach for almost 3 months, and while I appear to be tolerating more and more weight (I started at level 3 on the total trainer and am now on level 8 doing eccentric single leg squats) I really don't feel much better, and in some ways I feel worse. The symptoms sometime morph or move around still, and I'll get aches in spots I've never ached at before or things like that. I'm just trying to compare/contrast with your experience after about 3 months. I haven't done any PRP, but I do take supplements (I don't take Glucosamine but might start).

    6. Hey Lumpster,
      In response to your question, my right knee was feeling pretty good after just a few months of coaching. Of course after March I had some episodes of pain again, but it wasn't coming from the cartilage, it was mostly focused in the patellar tendon. And the way tendons heal is more similar to how a muscle heals than how cartilage heals. It means you can stress a tendon (of course don't go crazy about stressing it and start jumping around) and push a little bit more than you would do with cartilage. My left knee was the worst and it took a lot of time to recover, also because my quad was completely gone to the level that the knee was giving way because the quad couldn't hold it.
      So right knee feeling good after 4 months = Yes
      Left knee has been a different story

      Again, after a few months I stopped having pain in the patella or around, inside the knee and I only had pain in the tendons (both knees).


    7. Also, don't hold only on the comments I have posted here... I mean, not every time I had pain or didn't have pain I came here to report on my symptoms :)
      February 2016 - Started to dance again 16 minutes twice a week. So far, so good.
      Still some symptoms in my left tendon. But it's part of the process.
      Tendons and cartilage are different and I never had the burning pain some people in this forum have mention.
      Hope you are doing great progress!

    8. Hi Athenea,

      Thanks for the response. :) I totally understand that you wouldn't be on here reporting all the time. I just liked to piece your comments together because it gave me a general timeline for your recovery, and something I could hope for.

      I actually feel like I am starting to make some progress in terms of how I'm feeling. As I mentioned in my previous post, there is definitely some level of measured success there. Lately I've been feeling decent too but have a long way to go. I get some of the hot or burning sensations once in a while, but they aren't constant. Sometimes my knees get hot to the touch too but that's eased up lately. I get a bit of everything once in a while - aches in the knee, aforementioned burning/stinging, luckily they don't hit at once.

      I'll be hitting three months with my coach in about a week, so I'm cautiously optimistic that me feeling a little better lately is a sign of things to come, but we'll see.

      Thanks again! Hope you're doing well.

    9. Hey Lumpster,
      Well that sounds fantastic! The first six months are the most chaotic I would say! (I mean, from my experience...) but if you keep feeling better that is a very good sign. Big progress is made by a bunch of small progress.
      Keep up the good work!
      I'm doing pretty good, I'm now getting stronger than I ever was, I almost don't recognize my own body O.O
      We'll see how this year goes! Fingers crossed.


  7. I'm curious of those of you that have had fibromyalgia (FM) type symptoms if anyone has struggled with perceived imbalance and headaches? I've had a slew of symptoms, presumably related to a form of FM but wasn't ever formally diagnosed, that have come and gone over the last 12 months. My first and most chronic symptom has been this imbalance and head tension that persists 24/7 for over a year. I don't fall over or stumble but it feels like I'm swaying all the time. I've had blood work, MRIs, CTs, and tried several anxiety/depression meds (which made it all worse) and they can't find anything. Almost all of my other FM symptoms have disappeared (muscle twitches, pins and needles, random pain, etc) since I forced myself to get active again and dumped the meds, but the imbalance and forehead headache persist.

    I started to mix in some walking for the knees this week in addition to my typical PT exercises that my knees can handle. I've been on just one walk for a mile with a moderate pace and noticed mild pain about half way through. As per usual it's not until the day after or the second day that I discover my physical activities were to much for the knees, as was the case with this walk. It's still such a struggle to severely limit and baby the knees because I don't get immediate feedback with pain and they handling loading fairly well. I'm always overly optimistic while exercising that it will be different this time...but it's almost never the case and I over do it and learn I guess.

  8. I didn't really get those FM symptoms Hal, perhaps a little bit of the imbalance thing you talk about, but my main symptoms were aches and pains in other joints and feeling suddenly very old.

    Getting into the gym and doing some intense 20-30min circuits (but avoiding things my knees didn't like) saw these FM symptoms largely disappear.

    Recently have gone onto anti anxiety/depression meds, and mentally am feeling so much better it is incredible (in fact they started to work on me almost immediately, despite being told it can take 3-4 weeks).

    But my knees are similar to yours in that it can take a day or two to know if I've over-cooked it. And I think degree of flexion and repetition are more of a problem for me that load (so a little light jogging on a treadmill seems to work better than cycling - which defies all the advice of the 'knee experts' I saw) .

    It's just a long learning curve you have to keep climbing.

    I'm at a stage where I seem to be hitting new good peaks, I can have setbacks, but they don't last as long as they used to.

    I'm also experimenting with the fodmaps diet very recently, as I've had IBS type symptoms on and off for almost 30yrs. I think some food types inflame my guts, and I suspect that could spill over to my knees.

    1. Triagain, what depression meds have you found helpful? I tried Lexapro and buspar, the latter really messed me up. My symptoms kept increasing so the doctor slowly ramped up the buspar, only it was contributing to the problem. A very small dose of Xanax works really well but that med is not a long term solution. It seems that the mental aspects, brain fog, social withdrawal of the FM has hung with me far more than the physical so I know I could benefit from the right antidepressant, I just need to find it.

      I switched to a ketogenic diet as of Monday this week and have been very happy with the results. Mentally I'm much sharper, alert and lost 4 lbs in about 5 days. I have never lost weight that fast without partially fasting. You don't really cut the calories with this food plan so I always feel full and have adequate intake, but the carb intake has to be 30-50g per day max so no sugars, breads, etc.

      I have a very mild to moderate form of IBS since I was 18, which over the years has improved with age and likely weight loss and diet. I'm a skinny guy and have weighed about 195 lbs at my heaviest, currently I'm at 174lbs and 5'-11". Once I dropped that initial 15lbs I could really tell the difference on the IBS. I'm hoping to see some anti inflammatory benefits with this diet and some improvement in my knees.

  9. Hal

    My meds are called Citalopram. They inhibit the uptake of Serotonin (the happy hormone) so serotonin stays in your system longer = you feel better.

    I also take pro-biotics and change the brand every few months to help with gut health and nutrient absorption.

    I'm also taking a high grade gelatin powder (I got from my accupuncurist) which is supposed to help build joint cartilage (no idea if it works, but it is cheap).