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. :)


  1. I reckon you've nailed it here Richard. Ed from California also sent me the papers on this issue, and the theory accords very strongly with my experience. Like you, early on I asked one of the top Sports Drs in this country if I had synovitis and he prodded around a bit and said no. I'm 100% sure I did, as well as inflammation of other structures. By that time however, my MRI was showing fissures in the kneecap cartilage, which he was the first medico to notice.

    1. Yes, TriAgain, I got this paper from Ed. He's been chasing some hunches down some interesting alleyways.

    2. I've sent the link to that paper to my OS, Sports Dr, Physio & Pain Specialist, along with a link to the Dr Dye paper on envelope of function. Asked them if they think the treatment of severe PFPS needs a big re-think - re standards VMO etc exercises makes PFPS worse, esp. if there is a significant systemic inflammatory component. Will be interesting to see if any respond.

      I also got a response from another physio whom I have a lot of time for and he said the problem is if you tell a keen athlete to do nothing but gentle walking for 6-12mths, they'll think "this guy is no good, I'll find a better medico". They want a fast active fix. Problem is, in some cases the fast fix sends you deeper down the rabbit hole. But I guess they are between a rock and a hard place.

    3. Tri, I think that's true, we obsessive exerciser types don't want to be told to "go take a hike," aka to go employ "The Envelope of Function" (EOF) for 12 months. My hunch though is that there is a type of P.F.P.S. sufferer, the "inflammatory receptor," who no matter how much active rest they take will still find themselves in P.F.P.S. free-fall, or at best in cartilage stasis predicated on the constant maintenance of reduced loads.

      Spoiler alert... Rabbit hole ==>

      In my case I think I was exposed to something in my environment (possibly mold) that initiated an inflammatory response, a cycle once started that predisposed me to other sensitivities and tendencies toward inflammation, including the usual over-use suspects generally remedied by E.O.F. protocols. Somewhere in there (and had a crappy, bad-result surgery too) I discovered I was a "methyl mutant," meaning I lack the enzyme to break down folic acid in the liver, so I avoided (and still do) foods enriched with folic acid, which seemed to help (too complicated to discuss here). In the least I discovered that enriched pasta and most bread was literally making me sick, so I found other ways to meet my folate requirements. Thankfully mostly simple greens: lots of salads and spinach. For me, less was more with folate, with 5-methyl supplements causing increased inflammatory response.

      Because I think there is a relationship between inflammation, gut function and immune response (positive feedback loops), I went down the rabbit hole to try to ferret out dietary choices that seemed possibly (some for practical and some for esoteric reasons) related to body and gut ease/inflammation. Ahead of the paradigm or off in the weeds? Some unknown admixture of both?

      The bottom line is that my knees, from my low 3 years ago, of being unable to walk down my driveway or ride my bike without severe bilateral pain- To these days taking a hike of my own volition, cycling on fast paced club rides and getting ready to race some old guy stuff this summer. I still battle my type A exercise demons and half jokingly refer to myself as in a 12 step cartilage recovery program- One day at a time, with one eye on an awareness of potential relapse. Maybe for the rest of my life?

      Is it possible that if I had actively rested 5 years ago instead of trying to ride through my P.P.P.S. on a reduced program (to a super-fit, the word reduced has no relationship to cartilage healing load requirements), that I might have healed and forgone the ordeal of surgery and the subsequent express elevator down to cartilage degenerating purgatory? I think it is possible. I can imagine ways to replicate my experiment, but am not eager to do so.

      A peak into a few routes (alleyways) I explored.

      Salt shaker here ===>

      Good luck to all healing their knees, Racer-X(Ed)

      April 4, 2016 at 10:29 AM

  2. Richard,

    Do you recall how many months it took before you started to feel a big decrease in the burning achy feeling? I suspect when this happens; inflammation is under control or at least not causing further damage to the joint.

    1. I don't know exactly how many months. I did notice, about eight months after I started working on improving my knees, that I had kind of jumped to another level and could do a lot more (longer, more strenuous hikes, for example).

  3. Hi all, Did anyone have the popping sounds in knee joints during the terminal extension of knee when walking. Was it painful and if so how were you able to deal with it? I have that and was wondering if my walking was altered i.e either I was hyperextending my knee joints or if I had always been walking with few degrees of knee bending due to pain and inflammation - Pri

  4. Awesome post Richard. Mostly, noted that Dr´s dont know everything and sometimes they even know less than that. You only have to listen to your own body. Stay proactive in helping yourself get better. Glad I came across this.

  5. Check this out. Osteoarthritis is systemic like RA. Damage to one joint can spread to other joints via nervous system signalling.

    1. Good find CRM - and this was hypothesised 8 years ago! I've not heard one of my medicos mention this. Then again, even if they did know, would they want to tell a patient as the outlook appears a bit bleak, unless there is an intervention available to stop the pain and hence further joint damage. This also makes neuroplasticity techniques to 'switch off' pain look like a viable treatment.

    2. It's not exactly a happy finding TriAgain! And obviously it's just one paper but it does explain Richard's and other's multijoint symptoms. On the other hand there are quite a few folk who just have localised OA/joint damage. It hasn't spread. But yes on the more positive note if you can switch off pain can you stop the spread? Can you literally think your way out of it? Have you read Norman Doidge the Brain's Way of Healing Itself where he writes about Michael Moskowitz who every time he feels pain focusses on visualising an image and after 3 weeks his pain is gone? There's also the Great Pain Deception by Steven Ozanich in which his strategy is to ignore the pain - don't give it your attention. There's something a little Shroedinger's cat about this whole area. Is your observation of pain affecting the outcome of a disease process in your joints? Fascinating though I'd rather be doing triathlons...

    3. Hi CRM, Yes I've read Doidge's book, and even set up my own Powerpoint animation of a brain with the pain centres gradually decreasing. I think this helped somewhat. Also, I used to go to the gym and just do upper body work because I was worried about making my knees worse. One day out of frustration I threw in some light (25kg) deadlifts, and it went well. I think my CNS started to re-wire itself on that day. But by then, my brain had also decided I'd not done anything triathlon-like for 3yrs, so surely my cartilage must have healed to some extent - and the deadlifts sort of validated that. I'm sure the pain & joint disease have some level of positive (or negative) feedback loop going on.

      TBH, the biggest breakthrough was getting over my triathlon obsession, and being satisfied with doing enough to stay reasonably fit. Also, triathlon got me fit - but weak. Getting back into weights has been a Godsend for strength and everyday activities. And I discovered MTB, which might be my new sport if my knees continue to head in the right direction.

    4. TriAgain,

      You've presented so many helpful insights that I have incorporated into my healing regiment! So thank you for sharing your story!

      I particularly identify with "triathlons got me fit - but weak." I feel the same way about all the Crossfit I used to do.

      Take care!

  6. I suspected that inflammation was generalised, I didn't feel the need to fo extensive search as I know there are so many contradictory studies. I just thought I know my own body, and I know something else is at work than just my bad knees. Turned out I was right, when my knees got better, so did my back, and my hands. Now, back, hip and neck pain can be structurally linked to a limping knee, but the hands?

  7. True, Since I had my bilateral knee issues, sometime or the other I have pain in hip, back, neck and hands. Probably along with the generalised inflammation it could also be due to compensatory or trick movements that we tend to do in protecting or avoiding too much pressure on the knees as the alignment of the body changes. Deloupy, in the case of hands I think as we use hands to take of pressure on the knees especially for activities like standing from a chair or getting up and down the stairs putting pressure on hands to reduce weight on knees could be a possibility.


  8. Hi Richard, I am currently reading your book (saving my knees). It is very interesting that I am experiencing many of the details that you provided. It also feels good that someone has already gone a similar road and is willing to share his experience. Great book btw...

    I have a question for you and other folks here. If inflammation causes more damage to the joint and cartilage, shouldn't I take anti-inflammatory pills when I feel pain? per my preliminary research, anti-inflammatory drugs (like Advil) does not affect the nerve system and targets the substance that causes inflammation. This way at least inflammation itself will not further damage the cartilage. I know you wrote something in your book saying anti-inflammatory causes you avoid the signals that knees send. What if I don't put any pressure on my knees after I take advil and try to rest my knees at the same time.

    1. This is a good question. It has come up before (notably, from an Australian triathlete who goes by "TriAgain"). While steroids have been shown to have deleterious effects on cartilage, I'm not sure about over-the-counter anti-inflammatories. Here are some of my thoughts on NSAIDs (see near the end):