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.

31 comments:

  1. Hi Richard. This post is a happy coincidence for me. I read your book several months ago. Just this week, through Paul Ingraham's e-book, I discovered the research of Dr. Dye, and I've been wondering what you thought about it since your experience seems to be consistent in key ways with his model. I was particularly intrigued by Dye's position on chondromalacia--that it's not necessarily the cause of the pain, since some people with confirmed chondromalacia are completely asymptomatic. I have chronic anterior knee pain from running and was diagnosed with moderate chondromalacia through an MRI. The doc said it was caused by patella maltracking and sent me to physical therapy to strengthen my leg muscles. After nearly six months of physical therapy I have strong legs but still cannot do simple things like long gentle walks or the elliptical machine for 10 minutes without soreness and stiffness afterward.

    From the beginning I felt like things just didn't add up. Both the doc and the physical therapist were very vague when trying to explain to me where the pain was coming from exactly and what my patella had to do with it. For example, the physical therapist said that my patella was tracking laterally (toward the outside of my knee), but the MRI report said that the cartilage degeneration was located on the inside of my knee joint. If my patella is rubbing against the outside of my knee joint, then why is the damage on the other side? Also, the doc told me that according to the x-rays, both my patellae are tiled outward. So if that's the problem, why don't BOTH my knees hurt? I asked the doc that question, and he just shrugged.

    Reading about tissue homeostasis has finally given me some answers about what might be going on in my knee. I think it sounds completely reasonable that there may simply be a chronic irritation that has never had an opportunity to heal because I've never rested my knee. I stopped running a year and a half ago when the pain got bad but continued to do things in my day-to-day life that irritated my knee.

    I plan to ask for bone scans and in the meantime rest, paying close attention to my envelope of function. I'm really curious to see if that helps.

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    1. That story is so common, and mirrors my experiences. This whole PFPS treatment paradigm is pretty much back in the middle ages where they used to treat almost every ailment by bleeding the patient.

      What amazes me is I have reputedly good physiotherapists telling me they heard about Dr Dyes work years ago, but they continue to ignore it almost entirely and head down the well trodden 'strengthen your quads/VMO' path.

      My OS went to a conference where they had a session on PFPS and agreed they were still pretty clueless about it - and yet complete beginners like us can find the clues quite easily.

      Some serious re-training of medicos is required in this area.

      BTW, I had (still have?) mild-severe patella chondromalacia in one spot on my right kneecap (MRIs always showed it). My OS even expressed surprise I could do long triathlons on it, but it never put me out of action for more than a few days, and the symptoms (a sharp focussed pain when the knee performed certain bent actions) was very different to what I now have (diffuse chronic burning/aching in both knees, even when at rest).

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  2. Fascinating stuff. Thank you for sharing, TriAgain!

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  3. Hi there. Great video. My own experiment with ignoring the initial pain flare as per the Osteoarthritis and Cartilage Journal paper I gave a link to previously - has ended in disaster. I am now much much worse than I was previously. Knees hips shoulders the whole works are much worse. I think I had already progressed beyond reparable joint damage into early arthritis but it had stabilised in a sort of tolerable homeostasis but now I am in a new world of pain. Proceed with caution! Never risk leaving homeostasis!

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    1. It may not be irrepairable joint damage, it may be systemic inflammation of some type. I'm only now (after 4yrs of knee pain) finally getting tested for auto-immune diseases.

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    2. Hi TriChat. I came out negative for RA and Psoriatic Arthritis on the tests though apparently they are not 100% conclusive and they're going to put me on a trial for a Psoriatic Arthritis drug. 20% of people with psoriasis get an inflammatory arthritis at some point in their lives and it's unrelated to the severity of the skin condition.

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  4. I didn't think I would ever look back at my previous pain levels with a fond sense of nostalgia but it is possible...

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  5. Richard: So how do you feel about his thoughts and how they relate to Doug Kelsey's approach to healing this? It seems to me that they line up pretty well, although I don't think I've ever really heard either mention the other. In Doug Kelsey's "The Runner's Knee Bible" he discusses a "goldilocks zone" to therapy that basically states "too much will hurt you, but not enough will not heal you".

    Quick update for me:
    I've been dealing with my knee pain for a touch over a year now. I've been working with one of "DK's coaches" for about 7 months. I think I'm seeing some progress. That's what the total trainer seems to be showing anyway, although I don't always feel it. I suppose if you're pushing your limits without crossing them into setback city that some soreness is to be expected though. Sometimes when I'm working with my coach I'm concerned if I'm giving them the proper feedback, or pushing myself too hard.

    Brandon

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    1. Yes, I think Kelsey and Dye would recognize each other as kindred spirits. I would in fact be surprised if they haven't heard of each other. The Goldilocks zone isn't exactly the envelope of function, but they're consistent on what happens when you push yourself out of the proper range.

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  6. Saw a new GP today. Finally getting tested for auto-immune diseases (e.g. RA etc) as I have been getting some pains in other joints (but nothing like the knees at their worst). I'm guessing they will come back negative, but worth ruling it out for peace of mind.

    Also trying anti-inflams (Celebrex) for a month as I've read some other evidence (Dr Dye) that it may help as a 'circuit-breaker' if chronic synovitis is my main problem. I've never tried anti-inflams for more than a few days. At the same time will not push my activity levels any higher as don't want any pain masking to lead to a setback, as I have made considerable progress now.

    This new GP has the goal of getting my knees beyond their current level of 50-60% 'fixed'. He is also a good listener & reader (I typed out 2 pages of dot points summarising my 4yr journey & he read it all, plus 2 letters from specialists and admitted as a lowly GP, he might not be able to add more than the specialists. But I'd prefer that type of honesty than quick in and out BS).

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    1. I was getting pain in other joints as well just like you mentioned. It was much lesser pain than what I had in my knees 6 months ago. I got tested for RA with all the regular tests and everything came out negative. At this point the doctors tell me everything is normal and my pain could be psychological. Ofcourse, I know what I am feeling is not psychological because its directly coorelated to my level of activity (biking more than 12km causes knee pain, similar story for elbows, wrists, ankles).

      My best guess is there is some systemic inflammation going on that cannot be picked up in traditional tests. After watching DrDye's video I am going to push my doctor for a bone scan of my joints. Not sure if he will be able to interpret the results but I am hoping for the best.

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    2. Please, PLEASE consider food intolerances as a cause of your joint pain and inflammation. This turned out to be the cause of my problem after my tests for all the autoimmune diseases came back negative. I was convinced I had RA because I never knew the effect foods have on the body is as powerful as that of medicines. - Amy

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  7. Be very careful TriAgain. I got in a major mess with anti-inflammatory drugs for ten days. It is very easy to forget what you can handle. I ended up crawling to the toilet and much worse in general. I feel it is worth trying but do not amend your daily routines by any means. Please report what is the outcome.
    Cheers,

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    1. Sveto, can you explain this some more.

      Did it mess up your digestive system? Or did it mess up your knees even more?

      cheers

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    2. I am okay with my digesting, which seems to be functioning well due to good diet. I was having a major, major 3 months of knee improvement at the time when living in the Tropics and bathing my joints with ocean water regularly. Then came back in Europe and the OS suggested 10 days anti-inflammatory. I decided it is a good idea because I still could feel a lot of limitations and thought that can help out. It felt quite okay initially. However, the drugs coincided with a major shift in routines and habits due to change of countries. And also at that time I was not familiar with the concept of envelope of function and did not suspect how serious things are. So I got again on my bike. And it all felt perfect initially but it was a huge mistake. When the drug effects subsided I suffered a devastating blow and could barely walk for days. I am much worse than my initial injury now and in despair that I may have phonologically altered my knee because I now have annoying knee cathches. At least they are not painful. My hope is that they are due to muscle imbalances and inflammation because they come and go. However, you never really now what is really happening in the knee.
      In any case we do what we can pray for the best. It is pointless to wallow in regrets.
      Just proceed with great caution and never alter your joint loading during this 30 days no matter how good you feel. That is what I can tell from my experience.
      Good luck!

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    3. Yes, I agree good advice Sveto and during the 30 days I plan to stick to my current level of exercise. Interesting you mention cycling caused your knee to start catching. It does the same to me - sharp catching pain right on front of kneecap - which to me feels like my old chrondromalacia pain. Yet running does not cause this. Sounds like in your case it was not the anti-inflams that were the problem, but a change in activity level.

      I'm wary on long-term anti-inflam use though as there is some evidence (though conflicting) that it can stop cartilage regeneration.

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    4. Celebrex definitely making a positive difference - has probably reduced the pain/burning sensations another 50%. I'm holding my exercise constant at where it was before I started taking it. Will be interesting to see what happens when the month of taking it is up, as I'm not keen on being on it long term.

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  8. I'm about 40 min in to that video, at the part where he's telling the story of the school teacher who got worse and worse. I'm still in the middle of the story so I don't know how it ends, but hearing what she was told by her therapist and surgeon I had to pause it because a) it made me extremely thankful I didn't put up with my old therapist for that long, and b)it made me sick to my stomach because I felt so bad for that lady, and I realized the very same thing could have happened to me had I not been researching like crazy.

    Finding this blog, your book, Doug Kelsey, Paul Ingraham and others has been the best things I've done since the onset of my knee pain. Hopefully I can recover using these methods.

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  9. New Dannish study implies collagen has no significant chance to regenerate. More hope in glycosaminoglycans. Cannot read the original because it is paid content. Here is an abstract http://chinese.eurekalert.org/en/pub_releases/2016-07/aaft-rds070516.php
    Here I read that they found more potential in glycosaminoglycans. But for some stupid reason I cannot access the site again to look more carefully. http://www.medpagetoday.com/rheumatology/arthritis/58941

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    1. And then there's this, which indicates the opposite.

      https://www2.rsna.org/timssnet/Media/pressreleases/14_pr_target.cfm?id=1848

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  10. I saw it when someone, perhaps you, posted it previously. Very interesting. It is interesting that the Dannish research suggests that collagen carries traces of the nuclear madness in the 50s and 60s. Then they deduce that it is the same collagen. I do not have a background in biochemistry or carbon dating to grasp that fully, but it seems plausible for me to speculate that it could be that just radioactive traces make permanent memory imprints on the cell structure of collagen. Like a radioactive tattoo. Because a tatoo is inked on a skin and although the skin regenerates all the time, the ink traces are always passed to the new skin cells.
    Cheers!

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  11. I think it's important to not get too caught up in the debate over whether cartilage regenerates because a moderate amount of cartilage degeneration may not be the cause, or primary cause, of the pain. There's a lot of new research out there on the multiple possible factors in chronic anterior knee pain. "Chondromalacia" is simply an observation, not a disease or diagnosis in and of itself. Dr. Dye offers interesting insight into this, as well as into possible factors like chronic inflammation of the synovium or irritation from impingement of the fat pad or medial plica, or overload distress of the subchondral bone, which may or may not be related to cartilage lesions.

    A good tool for educating yourself about the latest theories and research on patellofemoral pain is the book "Anterior Knee Pain and Patellar Instability". The second edition was published I think in 2011. It's a collection of essays and reports on patellofemoral pain by experts around the world. It's probably the single most important resource I have found so far in my search for an explanation and appropriate therapy for my knee pain. It's prohibitively expensive, but you can rent it for your kindle for a smaller cost. That's what I did.

    Richard may have recovered because his cartilage regenerated, or he may have recovered for a different reason. Maybe he had had some kind of chronic inflammation or irritation that resolved on its own from rest and gentle joint-friendly exercise. I think the important thing to remember is that he got better (and without surgery), and that should give hope to the rest of us.

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    1. Yes, I fully agree and I think that is where the medicos I've dealt with have gone astray. They have a fixation on cartilage damage (which then leads them to believe once that happens, you are stuffed) and muscle strengthening (to fixed perceived imbalances) when in fact the cause could well be chronic inflammation/loss of homeostasis (which involves a nightmare of near impossible patience to correct, but can be done).

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  12. Thank you for the book reference Anonymous. It is really expensive. I'll try your renting suggestion.
    I agree on the point you make. By the ugly sounds it makes, I think I have much more fucked up cartilage on one of my shoulders. With simple rotational exercises most of the time it maintains good homeostasis for now and it is pain free. So perhaps homeostasis is what we should aim for.
    However, the cartilage regeneration debate is interesting on its own right. Once you start reading that kind of stuff,it is amusing to ponder such quandaries .

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  13. Thank you thank you thank you - for saving my sanity!

    I've had a quick and excited look around your blog and have bookmarked many entries already.

    Thank you for doing the research and posting this information. The medical people I've seen have been so dismissive and all focus on the damn quad strengthening. I have been avoiding stairs for a long time, and doing dull simple twice daily walks for the last couple of years, and just listening to my knees, and sending the old girls a bit of love now and then, and looking for some solutions...

    I was told by a surgeon you'll need a full knee replacement in five or ten years. (I have chondro, had it since my thirties, but aggravated by a fall directly onto the knees two years ago - he ignored that! Seemed to think I'd imagined it.) I said, no way am I having a knee replacement! and he acted as if I was a crazy person. I've always believed there must be some way to heal these knees. Had a few good years with them by being careful with how I sat, etc, and just walking a lot before I fell on them.

    Thank you Richard, you've given me so much validation and hope.

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  14. Sorry, I neglected to include above something that I think is important to mention. The doc told me that I absolutely need to avoid irritating the joint. He said not to sit with my knee bent, descend lots of stairs, or walk too much. He said a little bit of walking is okay, but to not overdo it. And of course, no physical therapy exercises that irritate the knee (wish I had known that a year ago).

    He also said frequent ice application will help (which I already discovered on my own), but not heat (this surprised me; I guess it's bad because it excites metabolic activity of the tissues and therefore contributes to pain).

    Pax,
    S.A.

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    1. Weird. This comment above was an addendum to an original one I posted a few minutes earlier. The original comment disappeared. Anyone know why that happened and how I can avoid it?

      S.A.

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  15. i am sooo glad Mr.Richard took his time to watch the video and dedictae this page on the same.Dr.scott has reallly made a huge point in the video v all agree to it ,, v have lived thru it,, each time whn things aggrevated whn v crossed the envelope of function v have all been there,,,,bt i wud reallly love to knw abt his rehabilitative routine,,,,
    nw here is my story,,tryn to mak t as short as
    pos,,,,
    i am 27 years old , not an athelete or a sport person ,,2015 april one unfortunate day marked the begiining of ma knee issues , it actually sounds bit funny cz the root of my problem ws due to a las min rush i had to adjust sittin with one of ma cousin, hu turned out to be 20 poundsheavier than me .the very nxt day i had bad swelling of the whole limb and achy pain wich eventually ended up as sharp AKpain, MRI done showed nthn bt minimal fluid took antiinflam n 2 mnths ws absolutely fine.
    next few mnths ws very hectic to me,, loads of stair climbing , kneeling and sitting wid knees bent gave me back all symptoms back by late june same year i landed n dis misery all over again,,misdiagnosed once more and again a misinterpreted MRI jus made it worse ,,,by then i knew exertion ws doin no good to me,,so then rest fr a mnth gave me a lotta wasting,, finally met this new doc hu diagnosed fissuring n ma patellar cartilage and tight IT band,,physio for mnth intially did good bt latr gv me more trouble,, meanwhile saw this blog,,, and found peace ,,, i mnt exxagerating bt to listen to and talk to people wid similar experience can brimg peace into oneself,,,
    followed a lotta tips frm Richard ,,, walkin level ground , some elevation , some IT band stretches was doin better ,,, till recently due to wrong sitting tecnique developed lil bit of coccyx pain :( ....... jus hoping things work out for everyone else too,,, cz its too hard to remain patient and strong,,,.

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    1. posts by athenea , triagain , cartilagerepairguy have all helped me at different stages,,, thank u all,,, m nt back n full form bt then again it ws always reassuring to hear frm u,,, this blog has been ma therapy,, :) thank u all and keep updating us ,,,,

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