First things first: No, the holes in your cartilage don’t have to heal for your knees to feel better. This is absolutely not a prerequisite. There are many people walking about with cartilage defects and no knee pain. That’s not a bad club to be part of. After all, you just want to be rid of knee pain, right? Who cares if your cartilage is as smooth as a baby’s bum?
Second thing: I am occasionally asked if I have a follow-up MRI in my possession to prove that my cartilage did, indeed, heal. See my post here about why, no, I haven’t done this and why I don’t think it matters much anyway.
Another reason it doesn’t matter much: there appears to be much stronger evidence out there than a single MRI from yours truly. That takes us back to the original point: Why do I think cartilage can heal?
Take a good hard look at the table below. I copied it from a study, “Factors Affecting Progression of Knee Cartilage Defects in Normal Subjects Over Two Years.” The 86 people who participated had MRIs done of their knees at the start of the study, then two years later. (Yes, these were “healthy subjects,” but I’ve seen another study that includes knee pain sufferers that came to similar conclusions.)
The condition of each subject’s cartilage was graded for five different knee compartments. The scoring again goes like this:
Grade 0 = normal
Grade 1 = focal blistering
Grade 2 = irregular surface and loss of thickness of less than 50%
Grade 3 = deep ulceration with loss of thickness of more than 50%
Grade 4 = full-thickness wear of cartilage with bone exposed
But what actually happens? Yes, three of them stay at Grade 3, and five worsen to Grade 4. Yet four improve to Grade 2, and two of them – one in seven – improve all the way to Grade 1.
Yes, the sample sizes are small. Still, the pattern is repeated elsewhere (the extremes, at Grade 4 and Grade 0, suffer from the floor and ceiling effect, of course). Look at the 88 defects that started out as Grade 2. A full 31 percent of them, or almost a third, improve to Grade 1.
Yes, there are valid questions to raise. What is the nature of this new cartilage? Is it weaker fibrocartilage (actually, another researcher has found that though new cartilage starts out that way, over time it begins looking more like regular hyaline). Also, could there be misreading of results? (My take: yes, probably some, but I doubt on this extensive a scale.)
To me, this constitutes very interesting, and compelling, evidence that cartilage changes are a two-way street. Cartilage doesn’t just get worse. It’s always getting worse and getting better. And if it can get better, then why not try to enhance that ability? (Note: this was a “natural” study, meaning that some subjects saw positive changes in the tissue, and they weren't even on a special regimen!)
Hi Richard, thank you SO much for taking the time to write your book and post on this blog. I believe you have saved my knees as well. I’m 42 and have had bad patellofemoral pain for 4 years. At this point it hurts even to walk around the house. I’ve tried physical therapy for much of the last 4 years, had surgery (only removed plica being pinched), acupuncture, dry needling, ultrasound and a bunch of other stuff. I was pretty much at my wit’s end and after a lot of prayers I found your book a few weeks ago. It makes so much sense. When my pain first started I was flabbergasted that at PT they wanted me to do exercises to “improve my patellar tracking”. I was in the best shape of my life, and every muscle in my legs were so strong and I had great flexibility. Why were they having me do easier exercises than I was already doing? Wasn’t my joint just sore? Couldn’t I do some things to fix the joint, not the muscles around it? And of course, I just got worse and worse the last 4 years because no matter how careful I was, many of the exercises were outside my knee’s envelope of function. I had a MRI 3.5 years ago and I had no chondromalacia. Then 2 years ago my MRI showed grade II chondromalacia in the trochlea groove. Last week I had another MRI and now the chondromalacia is grade I. Very interesting. Also I wanted to note that my mother has grade IV and she has no pain. I bought a fitbit and am tracking my steps now. After I determine what my baseline is, I’m going to start adding in light walking or something else if walking bothers my knee. Very slowly, I will add steps weekly if my knee allows. And that’s all I am going to do. Maybe in several months I can try squats with a Total Gym, but at this point even moving my leg hurts so it may be awhile. I just know that following the ideas in your book that I will recover. Thank you for all of your work, and for today's blog post because I was just fretting about my knee cartilage and feeling stressed about it. --Amy
ReplyDeleteThanks for dropping by! Trying to "improve patellar tracking" has probably led to a lot of wasted time and frustration for many patients. It sounds like you've got a sensible plan. Please come back and update us on how you're doing.
DeleteFirst off, more and more I suspect that cartilage is just the holy cow of old school orthopedia. That doesn't mean that a lot of folks are not in need to heal their cartilage to become better. Although it is quite likely that if you become better your cartilage will heal as well. You can change the order as much as you like.
ReplyDeleteI have two MRI with multi local Grade I softening 1.5 and 1 year ago and a cartilage related crepitus for months.
Following an operation last month, the surgeon wrote in the official notes "pristine articular surfaces".
Dunno if MRI is not reliable or the tissue healed. The crepitus is gone though.
So my hunch is that everyone looking to heal their cartilage should be at the very least agnostic about the prospects and actively search for ways to help the body.
I'm already back on my bike (trainer) after 17 months. Building up my spinning practice and cadence. This was previously unavailable due to a severely adhesive plica.
I know that a lot of people on this site do have bias against surgeries. I am one of them. So I need to say that although it is still early days, I already feel my operation put me in a much better fighting position. And this is despite that it was not entirely successful in removing all important adhesions.
To be back on my bike feels like pure magic and my heart is singing at the moment:)
However, there is a lot of work ahead to the joint homeostasis heaven.
Good luck to everyone healing their knees.
S.
I suffered a severed bone bruise and a small osteochondral lesion of the cartilage on the weight bearing part of the FMC as a result of my knee getting whacked by a heavy household appliance last year. Bone bruise took about 10 months or so to get over. This was a terrible injury that affected my whole body causing my leg and some back core muscles to shut down. But I got over it basically by giving it time and going my own way on it - by avoiding nsaids and physical therapy - both of which seemed to makes things much worse... and just did my own activities .. I had read that it can take up to 2 years to get over a severe bone bruise so I kept that in mind. Anyway, now my knee a year + later is fine and gives me no issues and has no limitations. I think if I hadn't been patient and took initiative, I might have been convinced to deal with the "lesion" with some surgical procedure like microfracture etc since often this issue is blamed for pain even though studies show that people have them with no issues. It was tempting at the 6 month mark (since many recover from bone bruise at this point) to think I think I will need surgery to deal with this cartilage boogeyman (so many doctor sites and other sites are so negative regarding cartilage injuries and issues - they create so much nocebo) and the OS was open to this but I stuck it out and now knee is fine like nothing ever happened. Of course everyone is different and what works for one may not work for another but this is how it played out for me.
ReplyDeleteNocebo is a splendid word that captures a lot of what is wrong with orthopedia.
ReplyDeleteI think cartilage damage is often not the main problem, though it may trigger the main problem which is loss of tissue homeostasis (i.e. inflammation of the synovium, plica, other structures). And it is this later issue which becomes a chronic problem - and ironically may slow/halt cartilage healing, or even accelerate cartilage degeneration in a sort of negative feedback effect downward spiral.
ReplyDeleteAs TJ said, if you can be patient (unlike me!) and just gently let healing take its course (can take years), you can return to homeostasis. Having the OS's and PT's weigh in with their mis-guided 'quick fixes' usually makes things worse - and perhaps eventually irreversible?
Just want to echo what TriAgain said about cartilage degeneration: it's often not the main problem, or even a problem at all. I've had patellofemoral pain in my left knee for about two and a half years that emerged during a period of intense hill running. An arthroscopy confirmed that I have full thickness of cartilage (although doc did report some softening). So in my case, the issue is not cartilage degeneration. Doc performed a partial synovectomy, which really helped with range of motion and ability to sit comfortably with my knee bent. But the weight-bearing symptoms persist. The pain seems to be related to friction between the patella and the trochlea. In my case I do think patella maltracking is a factor. I can actually feel my patella getting stuck in a weird position in the trochlea, and it really hurts until it clicks into place. Daily gentle walking is therapeutic, but it doesn't cure the underlying problem. The only way to correct it (short of re-alignment surgery, which I'm opposed to) is physical therapy to strengthen and stretch the quads, hamstrings, hips, and glutes. It's important to remember that anterior knee pain can be caused by different things in different people. "Patellofemoral pain syndrome" and "chondromalacia" are not diagnoses. They're just vague catch-all terms for chronic anterior knee pain with no obvious cause.
ReplyDeletePax
Hey Pax, how long was your recovery time for the partial synovectomy?
DeleteReader278
In my case it was a relatively minor procedure. I was walking on it the next day. It took a few weeks to get back to my normal routine and for the stiffness to go away. I'm not saying it "cured" my patellofemoral pain because as I said in my post, it didn't change the symptoms I was having with weight bearing activities like brisk walking and descending stairs, but I'm definitely glad I did it because of the improved range of motion and relief I got from the constant burning when sitting with my knee bent.
DeletePax
not sure if you've seen this video about cartilage regeneration procedure in Japan. thoughts?
ReplyDeletehttps://youtu.be/izk-6acVEaU
"Professor Mitsuo Ochi, one of the world's leading knee surgeons and a revered figure in the world of regenerative medicine, has been pioneering a new technique to repair damaged knees.
By cultivating cartilage and using magnets to guide the cartilage to the damaged area, he has been able to heal damaged cartilage."
Interesting. It is true that scarring is a big problem with the standard autologous cartilage implantation procedures. But I'd want to see an impartial study done before trumpeting this as a great solution. Nothing ever works as smoothly as these videos suggest. Still, has anyone out there tried this? Some other reader may have a better response.
DeleteIf I am interpreting the study correctly, most of the defects of the patella actually progressed. For younger people, perhaps for the majority of this site readers, this is bad news. Perhaps, I am wrong, but it seems to me that most of us here suffer from chondromalacia, of one degree or another, and as it is about patella cartilage damage, there isn't much joy in that study. There's another one from 2008, where the level of degradation of patella lesions was high compared to all the investigated knee compartments and the percentage of cases where improvement of a lesion was observed was abismal.
ReplyDeleteSee this week's post; there was too much to explain here for a short comment. Also, remember this was a natural study -- so there was a significant number of improvements that occurred even though the subjects weren't in a specific "heal your knees" regimen.
DeleteHi Richard,
ReplyDeleteThanks for your blog. I am 60 years and recently we completed a house move.
The day after we moved house I experienced a bad knee wobble ( lack of stability) in my left knee which had some years back been subjected to an arthroscopy. I have no pain in the knee but a lack of stability.
I have seen a chiropractor for the last month who has brought it back to a point where I can climb up and down stairs but walking is a still a challenge without feeling the knee is going to buckle under. I feel a small tightness at the back of my knee and when try to straighten it I feel a pinch on either side of my knee. I have been asked to ice the knee.
I haven't taken a MRI as I have been told it's not necessary. I can do a 15 squats ( repeat 3 times) free standing without pain.
I am not sure how long before I can walk well and get back to go on my cross trainer and treadmill for my exercise. Thanks for any response in advance.