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.


  1. Thank you for sharing this success story. I was misdiagnosed as having chondromalacia by a local orthopaedic surgeon and so I believed this diagnosis until Dr Scott Dye took a look at my MRI images and declared that my cartilage is healthy. Proper imaging investigations are very important, as long as your doctor doesn't rely on the radiologist's report for diagnosis. (My first diagnosis was 'ACL sprain' despite the absence of acute injury, and the treatment I received for this first of two incorrect diagnoses was what left me with such severe chronic knee pain.)

    It's amazing how differently individual people's knees respond to different treatment approaches. Every time I have given 'training through the pain' a serious try, I have been reduced to using crutches to get around for a week afterwards. The only approach that improves my knee pain is avoiding all aggravating activities, NEVER bending my knees (which means sitting with my feet elevated), and restricting myself to less than 5000 steps per day.

  2. This sounds a little bit like the cure I used for my arms. I had RSI and found that strength training helped a lot. I've also gotten relief from lower back pain by doing a few heavy leg presses.

    However, in both cases, they weren't pains that were very responsive to rest. I wonder whether Tim had the pattern of healing overnight the way some of us do.

  3. I've been experimenting with sissy squats for the past few weeks after reading Tims original comments. I do them in a frame at the gym so I can take a little weight on my arms. They certainly blast your quads, but as I only go to about 70deg knee flexion, don't load the knee so much. As I found with some other heavier load/low rep exercises, they seem to cause me less bother on subsequent days than say moderate cycling. I'll let you know how it goes over the longer term.

  4. I've been experimenting with sissy squats as well for warmup. I go down to about 90 degrees knee flexion. My knees are mildly painful during the first 5-10 mins but they stop hurting after the quads are warmed up. Going to see how it feels over long term.

  5. Yeah I had an mri and determined to have bone bruise on mfc and small lesion and mild bruise on patella. Was limping badly, back hurt. Got better at 4 month point just walking - then overdid it and had a huge setback.. still not that good at 6 month point. Def don't want to make that mistake again. Going to do pt to work on strengthening knee.

  6. So happy to hear you found healing! A win for anyone suffering knee pain feels like a win for us all.

    I considered working through my pain until I realized I was dealing with a bone contusion, also known as a bone bruise. In my case specifically it's an interosseous bruise, but there are a couple other types of bone bruise.

    A small part of the inner part of my medial femoral condyle is injured, which is causing pain. Some of the trabeculae (erratic web compartments in layman's terms) are broken or injured. It's basically the period of weakness before a stress fracture, so working through it would actually cause me more damage unfortunately.

    Congratulations again on your progress! I'm happy for you :)


  7. A pistol squat? I can only dream... My hamstrings would snap!