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)


  1. I am very grateful to TriAgain and to Richard for bringing Dr Scott Dye's work to my attention. I am hoping to arrange a remote assessment with him, because I truly believe this is the last and best hope for my knees!


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  3. That is spot on Sveto, and it was always lurking in the back of my mind that cartilage alone could not be my main problem - mostly because it just happened way to0 quickly, and in both knees. The chronic synovial inflammation theory is a much better fit for my experience (tingling, burning, aching, stiffness that it not in one concentrated spot like my meniscus tear was, but moves around, sometimes even into areas just above or below the knee joint).

    And yet the mainstream medical world largely has no answer for this other than surgery or quad strengthening - both which make the pain worse. I even had a physio tell me he heard about Dr Dyes theories over a decade ago, but it sure has not hit the mainstream yet. Just so pleased I found it through this blog. Everything he says fits my experience perfectly.

  4. Hi All,

    I've been reading this blog for the past few months and have gained a lot of useful information to help treat my own knee issues, all of which began after an acl recon nearly 2 years ago. Since then, I have developed problems in my other knee (soreness and crepitus under and around the knee cap). After being sent down the traditional PT route and not getting anywhere, I am slowly working my way through a rehab programme, primarily based on Doug Kelsey's ebook. I also eat a vegan whole foods diet, as advocated by Dr Mcdougal and am experimenting with the Wim Hoff (the iceman) method to see if that can aid my healing. For those of you who don't know, he's the mad dutchman who has broken countless world records for feats performed in sub-zero temperatures (half marathon in shorts at the north pole etc).

    Anyway, I came across a really interesting blog written by a guy who went through an absolute nightmare after injuring his knee. After being diagnosed with patellafemoral syndrome and being prescribed the usual PT treatment, he got an appointment with Dr Dye and was diagnosed chronic synovitis. He gives full details of his journey in his blog but he is now well on the road to full recovery. Here is the link to his blog:

    Well worth a read in my opinion.

    All the best,


    1. Thank you Gary for sharng this useful information, I am keen to dive into your link.

  5. Hi Gary

    I also found themindfulcaveman blog a while ago. It is good info and again supports the Dye theories. It also shows just how hard it is to beat chronic synovitis. I've just added Curcumin (the anti-inflammatory ingredient from Turmeic) to my supplements to see if i helps. Racer-X had previously recommended this supplement.

  6. Hello everyone,

    I am struggling with an ulcer on my cartilage knee.
    Apparently it is only Condropatia II, but I can't hardly walk or stay standing.

    I have read how important movement is for cartilage repair, but...
    in my case... movement gives me more pain, invalidating pain that stops me from walking...

    I only can do some walking without bad consequeences in the pool, without setbacks.

    Any particular advice?

    I do appreciate.
    I am 40 years old and my life is on hold for nearly a year.

    I have read about the Cartilage implant with stem cells but I find it too aggressive.

    I appreciate any help and advice you can provide.


    1. Maya - I've found I have to do what doesn't hurt, even if the constraints are ridiculous. If you can only walk in a pool, that means you walk in a pool.

      Also, have you considered crutches? You don't need a doctor's permission to buy them, you can just get them. They're not that expensive. And they'll take the weight off your knee.

    2. Thank you Amy for your kind reply.
      In my case I used one crutch for a period but now I was able to walk without it (only short distances).

      I try to avoid both as the other knee is sore after so much imbalance.

      I wish you best of luck with your visit to the Doctor, hope he can give you a solution.

      In my ccase it does not hurt sitting or lying, just with weiight and movement.

      As you said, the pool is the best to help us.


    3. You are very lucky - I get injured sitting and lying (in fact, my problems started there, standing/walking only became an issue many months later). So your cure should be pretty straightforward: take weight off the knee. Do you have any way of logging this?

      It's a pity our pedometers can't track standing, LOL

  7. Just adding, that not like most of you, my pain is very spot concentrated, down under left side of the patella.
    The other knee instead is irritated all around, because of the whole imbalance walking for more than one year.

    Whilst you have proved cartilage repair for general degeneration, any light out there for a focal ulcer?

  8. I am almost certain that my Patellofemoral Pain Syndrome is actually chronic synovitis since reading Dr Dye's work. I actually get slight swelling on the medial side of my patella in both knees when I've been active outside my envelope of function (which is now an extremely small envelope!) When I push gently on the swollen area with my fingers, it really hurts. When I've been completely resting my knees for several days, this pain and swelling goes away. The swelling is so localised to that one medial spot and appears so exactly from under the side of the patella that it makes a lot of sense for it to be swollen synovium. Sadly, this has been carrying on for 2 years with no end in sight. It's ruined my life!


    1. Amy - I don't know what you mean by "small envelope" but mine was basically nil.

      I’ve made progress by spending as much time as I can floating in water (where there's no gravity and basically no load on the knees). I quit work (including housework) and moved to crutches to help resist gravity during the hours I can't be floating. Moving out of my 3rd floor walk-up wasn't an option (poverty! rent control!), but I just scoot up and down on my butt like a toddler. IDGAF what anybody thinks, I am serious about this.

      IDK if you could or even need to take such drastic measures, but my situation was especially fucked: my knees get injured by me sitting or lying down (!), and after several months of that standing and walking were injurious too. At my worst point, the only things I could do without making it worse were floating, brief walks, and changing position/activity every 10 minutes.

      Anyhow, I did that for 3 weeks and have managed to - if not pull myself out of the rabbit hole - at least stop my downward spiral.

  9. I live in SF and am seeing Dr. Dye now. (He’s accepting new patients and I was able to get an appointment within a week.) He did order a bone scan which (for me) wasn't all that illuminating - seems like I have chronic synovitis too, and bone scans don't show that.

    1. Amy, your experience is humbling for all of us who like to complaint about having wonky knees. Crossing fingers you get better.
      Maybe you should send Dr. Dye greetings from our small online community. Also it will be interesting if you can ask him what is the success rate of treating synovitis in his experience.

    2. Hi Sveto,

      I saw Dye yesterday and asked him. Like most "science-y" people, he hemmed and hawed a lot*. He said it depends on a lot of factors, but most people eventually get better. This can take anywhere from a few months to a decade.

      I didn't get a chance to bring up our community, he was growing quite impatient with my questions by that point :) But I have his email address. Is there some way of getting that to you without publishing it here?

      *Science is very particular about what giving "true" answers: any response that is inaccurate is a "lie", and any person who is not careful to reply "truthfully" is risking their credentials. Any question that does not provide sufficient detail is impossible to answer accurately, ditto any question with a sufficient degree of uncertainty, and this had both.

      Given this constraint, I would say Dye's response means we have better-than-even odds and stand a better chance at recovery than people with pathologies in tissues with poorer circulation, such as ligaments and cartilage.

    3. Interesting Amy.

      I like the sound of this "He said it depends on a lot of factors, but most people eventually get better. This can take anywhere from a few months to a decade."

      I may be only half way through the journey, but there is still hope!

    4. Hope is good!
      BTW, thanks for all your updates. They have been very helpful to me.

  10. Sure, I could do that! I'll bring this thread in on my tablet LOL.

    I didn't put the question to him that way, but he seemed to think it was very curable.

    You know, I could ask him. I have his email address.

    1. Let us know how your appointment went Amy

    2. See above. Also I'll chime in on the next open thread (since this one is so busy).

  11. Hang in there Amy.

    At 2-3yrs into my journey I'd had almost no improvement & I'm now convinced my problem is also chronic inflammation of synovial lining. At 4+ yrs I'm 50% better, but still nowhere near pain free and limited with activities.

    I'm now trailing anti-inflams (pharmaceutical = Celebrex plus natural = Curcumin) to see if I can knock out the remaining 50% when combined with reduced activity but still trying to retain some fitness (difficult)

    1. I have read wonders about curcumin.
      I dont take AINES because they upset my stomach.

      Does synovites show in XRays?

    2. Watching Dr Dye's videos I was thinking about the following:
      What role would PRP Injecctions would play in Omeosthasis...
      Do you think that would help?

    3. I had PRP injections about 2-3yrs into my journey. While I got some temporary relief from them, it was not long-lasting. They are supposed to assist with cartilage healing, but I think my issue was more about general inflammation of knee structures such as the synovial lining.

    4. I had then too, with no effects.
      but the theories state that it is the health of the bone that affects the cartilage, so instead of intraarticular shots, they are injecting PRP to the bone.
      That was the prescription I got from one of the best Doctors for the knee in Europe

      I might try it as it is a non invasive technique, and I think it makes sense with DR. Dye's theory.

    5. One final question, so how do we know if it is Synovial veersus cartilage: is the first all around the knee symptoms as opposed to spot located pain?

      thank you!

    6. Hi Mayita

      Yes, I think synovial inflammation is around a larger area (for me the front and sides of knee) and it also moves around a bit, sometimes into the areas just above/below the knee joint. Also, it has a definite burning/tingling component.
      When I tore my cartilage (medial meniscus) that was a far more focused stinging pain on the side of my knee but nowhere else.

      The thing is, I think (and some recent research supports) that chronic synovial inflammation can lead to more widespread cartilage degeneration (eg. the cartilage behind the kneecap, on the ends of the femur and the meniscus), so you could end up with two sources of pain from the synovial lining and the bones.

      So you end up in a knee death spiral which goes like this - some initial trauma/overuse causes some cartilage damage - continued overuse causes synovial inflammation - which leads to more cartilage degeneration (or lack of cartilage healing) - which leads to more synovial inflammation and so on.

      Getting out of that death spiral requires incredible patience and care. I now also believe anti-inflammatories can play a critical role in helping to break the cycle, but they have to be combined with all the other things Richard/Kelsey/Ingraham talk about. Just taking anti-inflams and still pushing your knees too hard won't work.

      I resisted anti-inflams for 4yrs, and got some gains, but was still doing too much on my knees. No trailing the combination of anti-inflams with a measured level of activity.

    7. Hello Trichat for your kind reply and information.

      "I just did not understand the last paragraph:
      I resisted anti-inflams for 4yrs, and got some gains, but was still doing too much on my knees. No trailing the combination of anti-inflams with a measured level of activity."

      Could you please clarify?


    8. Hi Mayita
      My last response to this disappeared so I'll try again.

      There was a typo in my post - should say "Now trailing the combination of anti-inflams with a measured level of activity".

      I still think my activity level is too high though (some due to exercise, some due to requirements of daily living).

      Interestingly, was talking to a woman I used to race with who has had a knee problem for years. She recently retired after 40yrs in a desk job and said her knee is significantly better from not sitting so much. Pretty sure that a desk s not helping me either.

  12. Wow, Amy, my envelope is almost as small as yours! You have my complete sympathy. - Amy S

  13. Haven't delved into the detail of this but Richard might be worth a look. Someone has done their thesis on Patellofemoral Pain: Where does the pain come from?

    1. Thanks CRM. I had a skim through it. Main conclusions seem to be:

      1. We have no idea what the best form of physical therapy (exercise regime) is for PFP - hence my belief that everyone has so figure out their own path as to what they can and can't do. Though they do suggest that adding 'hip and knee' strengthening exercises rather than just quad exercises may be beneficial. Also that exercises seemed to be more beneficial for less active patients than for active ones or athletes (not a good finding for me!)
      2. Structural abnormalities on an MRI have no correlation with PFP - hence Dr Dyes conclusion that most knee surgeries for PFP are not needed (and in my view they border on medical mal-practice).
      3. There is no difference in patello-femoral cartilage composition between people with PFP and those with no pain - which suggests to me the problem may be more in the synovial lining than the cartilage, though the MRIs for structural issues of people with PFP showed only a very small % (<5%) showed abnormalities of the plicae (but can the plicae be irritated, but this does not show up on an MRI?)
      4. Increased blood perfusion in patellar bone leading to increased pressure in the bone may be correlated with PFP but this requires more investigation.
      5. PFP leads to increased sensitivity to pain - correlates well with my experience. Exercise may assist with this. And intense exercise (to overcome fear avoidance) may be better than low intensity exercise - this correlates somewhat with my experience (e.g. my short fast gym routine which is quite intense and includes deadlifts, kettlebell swings, skipping does less damage than 30-60mins of easy-moderate cycling
      6. Strong (active) PFS suffers may get less benefit from strengthening regimes (seems obvious, and this had me scratching my head when physios told me to strengthen my VMOs. I cycled 200+kms hard every week. How the Hell could my quads/VMOs be weak?)
      7. The current hypothesis for the cause of PFP is high loading of the PF joint which leads to loss of tissue homeostasis (I agree). Loss of tissue homeostasis may, once initiated, persist indefinitely (Oh no! - but we know of people like Richard who have overcome it, so hope persists).
      7. "Our studies showed that neither full or partial thickness cartilage defects nor minor cartilage defects were associated with PFP. Together with the previous studies, there seems to be conclusive evidence to state that patellofemoral cartilage damage is not associated with PFP. Therefore, ‘retropatellar chondropathy’ and ‘chondromalacia
      patellae’ are incorrect synonyms for PFP and from now on should not be used anymore. Furthermore, our study showed that structural abnormalities on MRI of patellar retinacu-lum and plica, such as increased thickness or high signal intensity, were not associated with PFP. These abnormalities were, in fact, rarely seen in this population" - this blows my synovial inflammation theory out of the water?
      8. Exercise therapy is better than doing nothing BUT it is unknown which exercises are best - this is where I think your own trial and error is critical in working out what your knees can handle.

    2. The conclusion:

      For now, the pathophysiology of PFP is still a black box. Nevertheless, according to the results of this thesis one pathophysiologic mechanism can be ruled out. Structural ab-normalities, visible on conventional MRI or a diminished cartilagecomposition, are not associated with PFP. Therefore, conventional MRI should not be acquired to diagnose patients with PFP and ‘chondromalacia patellae’ and ‘retropatellar chondropathy’ should
      not be used as synonyms for PFP anymore.
      Furthermore, based on the results of this thesis, there is no evidence to suggest that
      PFP pathophysiology differs between adolescent and adult patients. Both groups are comparable concerning the amount of structural abnormalities, cartilage composition and pain perception.

      My interpretation - there are a lot of 'experts' out there making a lot of money out of you and doing things that will either not work, or have a high chance of making your knees worse. Oh, and that Dr Scott Dye is pretty much on the money with the state of play with PFPS.

      And that your best source of help is the learnings of people who've had PFPS and have beaten or at least improved it.

    3. We all agree that this is a tricky syndrome.
      Each one is different and I agree on some of the main conclusions, unfortunately there is a common mistake on the diganosis.

      As for exercise, the therapist Richard speaks of works mainly on sit-downs and load... if you have an injury like an ulcer on your cartilage, believe me those kind of exercise can only make you worse.
      So finding that envelope of function is not easy...
      In my case, just walking some extra steps per day can leave me limping for a few days...
      so its really frustration to find that amount of exercise without going backwards.

    4. Yes Mayita, this is the hardest part of PFPS. Every time I think I have it figured regarding activity levels/exercises, it throws a curve ball at me and I've been trying for 4+yrs. Often after a setback (like I'm having now), I back right off on some activities I've been able to get away with (eg. gym circuit) and my knees seem to get worse/feel weaker? So I then get back into the gym etc., but often wonder what would happen if I backed off for a really long time - as in 6-12mths - which I've not had the patience to try yet.

    5. TriAgain, I backed off for a long time. I stopped exercising a year ago. Now, my constant pain is even more reduced. I believe , that is the answer to your question.

    6. I'm sure you are right gcoza. I really struggle to do that though as regular exercise has been my way of life for more than 25yrs.