Hey, What's Your New Year Resolution?

Happy holidays everyone!

Some of you have been frequent visitors, and frequent commenters, and I thank you for your involvement.

Others of you drop by for a while, ask a few questions, then fade into the background. That's fine, I know what you're going through. I spent many afternoons of my recovery ricocheting around the internet like a pinball, seeking bits of insight that might help explain what I was going through and how I could get better.

Sometimes, someone buys one of my books from Amazon or Smashwords. And every so often, someone returns a book (it's so much easier to return an electronic book!) And -- this will probably sound weird -- I think that's great. It's great Amazon has a policy that, if you don't like something, you can get a no-questions-asked refund. I love that. When I wrote "Saving My Knees," I really, really believed in the message. Still, I realized later after reading a few reviews that it wasn't for everyone.

Now, on to the new year! I hope that this will be a year of steady, gradual improvement for thousands of knees out there. I know that sounds boring, but sometimes slow and boring is the way to win the race.

So let's talk! Do you have a resolution for your knees, or for your recovery program? If so, share it below. I'd love to hear what's on everyone's mind.

Cheers, and best wishes.

Richard

Don’t Take That Meniscus in Your Knee for Granted

I just read an article about the meniscus, that rubbery, crescent-shaped piece of cartilage that helps absorb impact between the long leg bones that meet in your knee.

Decades ago, the common medical wisdom was that the meniscus wasn’t all that important, and when it was torn, surgeons simply took it out.

Of course common medical wisdom was wrong.

Patients who had their meniscus removed often developed arthritis in their knee later. That suggested the meniscus actually played a critical role.

Now we have new, and quite sobering, details about what happens when the meniscus is extracted from the knee.

According to a new study, “extensive cell death occurs within hours during vigorous exercise.”

Researchers used a powerful microscope to observe what was happening, minute by minute, as the vigorous activity was occurring. The article says that half of the cells that create new knee cartilage were dead within four hours (I assume these cells were chondrocytes?).

Whoa. That’s really grim.

Now, an intriguing question (that the article doesn’t pose, but that occurred to me): Are people who have an injured/torn meniscus also susceptible to a certain amount of cartilage cell death? Because their meniscus isn’t working as well as it should?

For me, the bottom line is that I don’t find this study surprising. What I find more surprising is that medical savants of 40 years ago could have looked at a rubbery cushion in the knee joint and decided that it really wasn’t that significant.

Medical hubris at its finest.

One Reason Bad Knees Don’t Heal

So I found out that my brother, he of the torn meniscus, decided against surgery for now. He learned that his health insurance would leave him exposed on thousands of dollars of the cost and decided to take a pass. But his doctor told him he should expect to have a knee replacement in ten years.

How’s that for a future? Ugh.

Now, if I were him, I would not accept that. I can imagine a doctor saying the same thing to me about ten years ago, and today my knees are fine. But I also know that a lot of bad knees never heal. For us active types, there’s a very good reason for that.

Quite simply, it’s because we can’t give up what we love doing most. For me, it was cycling. For him, I think it’s hiking and weightlifting.

With knee pain, I think there has to be a sort of “come to Jesus” moment. Your knees have to get so bad, your misery so complete, that you resign yourself to the fact that everything must change.

Everything. And that means that sport that you love has to go.

I know I clung to cycling for as long as I could. I convinced myself I’d pedal differently, or stop going up mountains, and gradually the pain would go away. It did not. But I labored under this delusion for as long as possible, unwilling to face the truth.

Unwilling to have that “come to Jesus” moment.

I believe one key turning point in my recovery was fully, and unconditionally, accepting this statement:

I will stop riding my bicycle, and I may never ride it again, and I’m okay with that.

That was both a depressing and liberating realization. The sweaty physical activity I took part in, those wonderful, heart-pumping, intense workouts, involved cycling. Losing that seemed terrible.

But it was necessary.

I switched over to easy, high-repetition motion. For some people, that can be cycling. For me, it wasn’t. I found my body liked slow walking the best. I structured a program around that.

And, over the course of many months (as I detail in my book), I healed.

I’m not sure if my brother is at that point yet, where he can say, “I may never go hiking again, and I don’t care.” I don’t think so. But I think that’s the beaten-down point you have to reach, and in some odd way, embrace, before you can begin the journey up and out of a pit of despair.

What about those of you out there who are active? How have you dealt with this problem of resisting facing the reality of your limitations?

Healing Your Knees With ‘Virtual Reality’ Cycling

Okay, a confession up front: I know this won’t be the most popular post of all time, or even in the top 20. Still, I have been to other (virtual) worlds on my bike, and I want to share what I have discovered, and how it may apply to people recovering from knee pain.

The backstory: On Aug. 11, I crashed on my bike in the rain and broke the fifth metacarpal in my right hand, badly (I also broke the tip of my ring finger, but the orthopedist pointed out that was essentially small potatoes compared to the oblique displaced fracture of the metacarpal).

I was very, very morose about this turn of events, as this apparently meant I would miss the best cycling month in the New York City area: September (as well as August naturally). And I did miss it. I wasn’t cleared to ride my road bike outside until last month.

But I was determined to do something, even while wearing a cast. While encasted, I was advised not to sweat excessively (bacteria flourish on dirty, sweaty skin), but I couldn’t see myself spending Saturday mornings taking leisurely walks to Main Street. I evaluated some options (believe it or not, I had my eye on a fast recumbent bike, and was getting close to pulling the trigger on the purchase, then I found out that basically everyone would drop me on climbs.)

I ended up buying a smart trainer instead and joining the community of “Zwifters” and riding in my basement. The Zwift subscription costs $15 a month. The Zwift setup can range from a few hundred dollars to a few thousand; you can find the breakdown on YouTube videos.

What is Zwift? It’s a virtual world where you pedal on your bike, which is attached to a trainer, which in turn communicates your level of effort to the Zwift software. The software may be on an iPad or a PC (and if you want to add another layer of complexity, that device may in turn be hooked up to a smart TV that shows you cyling in the Zwift world.)

The harder you pedal in real life, the faster your bike-riding avatar goes.

The native Zwift world (called Watopia, which is probably meant to sound like a utopia for cyclists as all the roads are bereft of cars) has a variety of geographical features. There are underwater roads that travel through transparent tunnels, a volcano that can be climbed to the summit, and a rather daunting “hors category” Alpe mountain climb.

The cool thing about using a smart trainer is that Zwift tells the trainer if you’re going uphill or downhill, and how steep that grade is, and the trainer adjusts accordingly. So it’s quite hard to push up a 13 percent incline, but of course you’ll pedal down that grade with no effort at all.

Now for the quick bullet points, to get to the heart of the matter: How well does virtual reality cycling (like Zwift) work for knee rehab?

* First, virtual cycling keeps you engaged. Unlike a stationary bike, where you better bring something to read or have a fertile imagination, the Zwift landscape is always changing. And other cyclists, from all over the world, are passing by (sometimes Zwift feels like a geography test of “name the country that flag next to that person’s name belongs to”).

Also, there are group rides segregated by level. The riders “virtual chat” back and forth (you can see their messages come up on the Zwift screen, even when you’re not part of the dialogue).

* But Zwift worlds are not flat. I’ve noticed that the default route choices in the software never send you up a mountain, but they can still send you up some steep hills. This isn’t optimal for someone healing from knee pain. You do have the choice of making a U turn anywhere to avoid an ugly ascent, and I suppose you could make an effort to stick with flattish roads.

Or, if you’re not on a smart trainer, I guess you could just stick with easy pedaling, even though it’ll take a while to get up that hill.

* One negative is that Zwift tends to bring out your inner competitor. It’s very much geared to more-intense athletes who like to monitor their personal records, and want to see if they can beat their last record on a timed hill climb, or if they can pass that guy four seconds in front of them.

* Another possible negative: A lot of these Zwift athletes are pretty damn good. Example: I began climbing a big Zwift mountain in August, trying to hold 230 watts or so. Then I got better. Recently I was trying to hold 280 or 290 watts on the climb, and I broke my previous record and passed a lot of people on my way up.

Intrigued, I checked my personal record for the Zwift climb, to see how I compared with the others. I felt pretty good about myself until I found out I was about 25,000 out of 176,000. Ugh. Are the others really that fast? Or are some of them “digital doping” (i.e. lying about how much they weigh to go faster). I suspect it’s some of both.

* Another Zwift negative: The software forces you to ride in a certain world anytime you log in. Zwift controls which world everyone will ride in on a given day. I’m surprised that riders have no choice, as Zwift just created a “New York City” world that’s frankly awful.

Anyway, my feeling on Zwift as a rehab tool is it could be helpful, but more for people who are at a more advanced stage of their recovery. It is an interesting world to ride in. I know that I’ve gotten noticeably stronger on climbs. But I wouldn’t want to tempt the Knee Gods with some of those efforts unless I felt pretty good about how my joints felt.

If You Take Painkillers, Opioids May Be a Poor Choice

I spotted this article about a pain medication study a while back (underlining is mine):

A yearlong study offers rigorous new evidence against using prescription opioids for chronic pain. In patients with stubborn back aches or hip or knee arthritis, opioids worked no better than over-the-counter drugs or other nonopioids at reducing problems with walking or sleeping. And they provided slightly less pain relief.

The opioids that were tested included the generic version of Vicodin. The nonopioids they were up against included generic Tylenol and ibuprofen.

So, basically, Tylenol beat Vicodin. Sounds like a good reason to chuck the Vicodin in the trash. After all, as a doctor quoted in the article says, if opioids don’t work better, there’s no reason to use them considering “"their really nasty side effects -- death and addiction.”

In case you’re wondering, the study randomly put patients in either the opioid taker or non-opioid taker groups. Further details:

Patients reported changes in function or pain on questionnaires. Function scores improved in each group by about two points on an 11-point scale, where higher scores meant worse function. Both groups started out with average pain and function scores of about 5.5 points. Pain intensity dropped about two points in the nonopioid group and slightly less in the opioid patients.

Many of you already know my position on medication for chronic knee pain. Personally, I took as little as I could. I wasn’t worried about becoming a drug addict, but rather the fact that the drugs muted the signals from my knees that I was trying to listen to in order to figure out how to get better.

Is a Knee Replacement Worth It?

This was the subject of a recent New York Times column. I like the Times columns on health topics; they’re generally smart and well-balanced and backed up by good studies.

The author of this one was no less than Jane Brody – former (and presumably reformed) glucosamine enthusiast – who had both knees replaced. She has no regrets, though is quick to note that there are some limitations with artificial knees.

The upshot of the article is that more people are undergoing this major surgery, and at a younger age – and it’s not always medically justified:

One recent study conducted by Daniel L. Riddle, a physical therapist at Virginia Commonwealth University, and two medical colleagues, for example, examined information from 205 patients who underwent total knee replacements. Fewer than half — 44 percent — fulfilled the criteria for “appropriate,” and 34.3 percent were considered “inappropriate,” with the rest classified as “inconclusive.”

A knee replacement is definitely major surgery. If you don’t believe me, Google it and check out some images. And that new knee doesn’t come with a lifetime warranty. On average, artificial knees apparently last only from 10 to 15 years.

But for some people, it will make sense. I think though, like much surgery, it should be looked upon as a last resort. That's my opinion. I’d be interested in hearing below from people who have had the surgery, and finding out whether the experience was good or bad.   

(By the way, thanks for all the good thoughts in the comments section regarding my hand. I still have a splint on my ring finger, which was turning into a mallet finger – ugh – so I’m not a full-fingered typist yet. Hopefully I’ll get there in a few weeks. Patience! Not as much needed as when healing from knee pain, but still, a displaced fracture is no picnic.)

How Would You Treat a Torn Meniscus?

I’m still in a hand cast (with my right thumb, index finger and thumb wriggling free, but my pinky encased and my ring finger barely visible, like a pig in a blanket). So I’m going to keep this short.

I figured I’d try something different. Often you ask me questions, which I spin into blog entries. This time I’m going to ask all of you a question.

My brother, who loves to hike and work out at the gym, has a torn meniscus. Apparently he injured it when shoveling snow. He turned to pitch a load of snow, and the torque on his knee and weight of the loaded shovel must have combined in a bad way to tear his meniscus.

In the immediate aftermath of the injury, he had difficulty walking for a couple of weeks. Since this happened, the knee has never been the same.

He has scheduled surgery for November. Now you probably know where I stand on that. In the world of knee studies, you can throw a stone and hit three or four clinical trials that say surgery for a torn meniscus is no better than physical therapy.

However, that’s fine in the abstract, but when you’ve got the torn meniscus, and PT hasn’t done you a lot of good, surgery starts to look very tempting.

So here’s my question for all of you out there: Anyone have a torn meniscus that they recovered from? What kind of rehabilitation program worked for you?

Okay, all from me for now. This cast (fingers crossed) should be history next week, as long as the bone healed properly. Because of the nature of the break, that’s not a given. Still, my doctor seemed fairly confident.

(Oh, I’m still riding my bike, only indoors. If any of you are on Zwift, that’s me in the blue-and-white jersey, trying to hold 240 watts going up that giant mountain in Watopia.)

Cheers!

Open Comment Forum: What’s the Greatest Achievement of Your Recovery?

I’m going to throw the blog open for comments for a few weeks (popping in to clean up spam comments on weekends, as usual).

I’m having trouble typing right now because I crashed my bike on Aug. 11. I broke two bones in my hand. The money break, as the ortho put it, was the displaced fracture of the fifth metacarpal. It’s in my right hand, which is my dominant one, so that’s unfortunate.

But it will heal, and hopefully be close to what it was.

Okay, enough about me. Below feel free to post comments, solicit advice, provide updates ... all those great things that the open comment forum is good for. In short, talk to and help each other. There’s a lot of accumulated wisdom in this blog’s readership.

If anyone wants a subject to discuss: What about something upbeat? Try this: What’s the greatest achievement you can point to during your recovery? And to what do you attibute it?

Okay, all from your left-handed typist for now. Cheers!

Do Bad Bugs in an Obese Gut Cause Knee Pain?

So just when I thought I had formulated the authoritative take on why obesity causes knee pain (namely, that the excess weight places too much force on vulnerable knees), along comes this study:

The gut microbiome could be the culprit behind arthritis and joint pain that plagues people who are obese, according to a new study.

Hmm. Interesting.

The study appeared in a relatively new publication called JCI Insight. You can find it here. The subjects were mice (so, possible objection number one: mice aren’t humans).

One group of mice ate high-fat foods similar to a “cheeseburger and milkshake” diet for a few months. The other group consumed low-fat, healthy meals. After 12 weeks, the chubby mice were carrying nearly twice the body fat of their lean counterparts.

Researchers noted:

Pro-inflammatory bacteria dominated their colons, which almost completely lacked certain beneficial, probiotic bacteria, like the common yogurt additive bifidobacteria.

Here’s the money paragraph of the article:

Changes in the gut microbiomes of the mice coincided with signs of body-wide inflammation, including in their knees where the researchers induced osteoarthritis with a meniscal tear ... compared to lean mice, osteoarthritis progressed much more quickly in the obese mice, with nearly all of their cartilage disappearing within 12 weeks of the tear.

The researchers discovered they could prevent the destructive effects of obesity on gut bacteria, inflammation and osteoarthritis by adding oligofructose to the diet of the fat mice. Interestingly, the mice didn’t lose weight – they remained obese – but this additive preserved their knee cartilage, so it looked the same as that of the skinnier mice.

Before my heavier readers make a dash to the store, hunting for foods containing oligofructose, a word of caution:

The bacteria that protected mice from obesity-related osteoarthritis may differ from the bacteria that could help humans.

Apparently, studies using people will be forthcoming. The future studies are worth keeping an eye on. I still think the mechanical effect of obesity on knee cartilage is significant, but this at least introduces the possibility that another mechanism may be an equally big – or bigger – culprit.

Musings on Complex Systems

No, not primarily my own musings. I’m linking to this essay, which someone pointed out recently. The title is “A Systems Perspective on Chronic Pain.” The piece is nicely done, with cool visuals and some observations that will make you stop and think.

A few parts I liked:

Some pains are more simple and local while others are more global and complex.

This is very true. But there’s a deeper truth here too.

I think a lot of knee pain starts simple, then becomes complex over time. This leads to much frustration. Often knee pain sufferers wonder if they have an immune system disorder, such as rheumatoid arthritis, as chronic knee pain seems to “wander” around their body, afflicting other joints.

Unless you do have a verifiable immune system problem, doctors tend to scoff at such theories (mine did anyway). But after I developed issues with multiple joints, and I heard story after story of similar problems on this blog, I’m convinced this is really a thing.

Because complex systems often change in a non-linear fashion, we can expect progress to be non-linear as well. That means getting better is often a question of moving two steps forward and one step back. In the short term, this makes it difficult to discern positive change. But over a larger timeframe, a pattern of progress may become clear.

 Ha! This almost feels like it could be a direct quote from my book (or blog). Yes, healing is definitely nonlinear, with little steps forward, then little steps backward, then repeat. It can drive you crazy. That’s why it’s best to take the long view. Once into your recovery program, ask if you’re better this month than a month ago, or two months ago. Try not to get too hung up on the day-to-day details.

Changes are often nonlinear, which means that small perturbations to the system can produce large changes, or that large perturbations might produce very small changes. A significant non-linear change is called a phase shift.

This is also an interesting point. As an example of a phase shift, he cites water suddenly turning from a liquid to a solid at 32 degrees Fahrenheit.

I discussed a similar kind of thing in two posts: one on breakdown points, and the other mending points. These remain two of my favorite posts, though I’m not sure they got much attention.

To me, a sort of phase shift may occur between pain and no pain. On a continuum, there may be a point where these two states lie very close to each other. In other words, you can have pain but be very close to a non-painful state. Or the converse could be true.

So let’s say you’re not in knee pain, but you have subjected your joints to repeated stress and are close to being hurt. It may take only a small stressor to nudge you over the edge. That, to me, is the idea of a “breakdown point.”

The example I give in the post involves a ceramic cup. You drop it from x inches, and it makes a loud thud, but doesn’t break. Yet if you drop it from two inches higher, suddenly you’ve got pieces of a cup. You’ve broken it.

Hurting yourself may involve sudden, catastrophic breakdown points. Sometimes, it’s clear what precipitated an injury. But other times you may lurch into a painful state despite not being able to pinpoint an obvious cause.

Similarly – and this is a good thing to know when trying to heal – there may be analogous mending points. You work for months on getting better, with seemingly disappointing results, then suddenly experience a big gain almost overnight.

Above are some of my thoughts on this essay, but I invite you all to read it for yourself and leave comments below.

Review of the Schwinn 170 (MY17) Exercise Bike

I’m doing something different today. I’m reviewing an exercise bike I bought recently, with a section at the end especially for people with knee problems.

First, cycling can be a great activity for bad knees. However, a few things are important before you make cycling your knee rehab activity: (1) Your knee must have good range of motion, so that you can go through the full pedal stroke without discomfort during or after (2) Your knee must “like” cycling – different knees like and don’t like different activities (3) You need to be able to control the effort expended so you don’t overdo it.

Number three is why you should consider using an exercise bike as opposed to cycling around the neighborhood, especially if the neighborhood happens to be hilly, or has a lot of traffic lights that cause you to stop and go a lot. Generally, cycling steadily at a low resistance (or backwards for no resistance at all) is much easier to do on an exercise bike.

Now a short lead-in, explaining how this Schwinn wound up in my basement’s exercise room:

The death of my old stationary bike, a Bodyfit 90x (that came with the house that we bought in April 2014) made buying a replacement necessary. The drive belt frayed apart. (As I had a little free time, I disassembled the bike, scavenging interesting-looking bolts and other pieces. There was a beautiful cast-iron flywheel inside, but even thinking creatively, I could see no future use for it, so reluctantly placed it curbside with the trash.)

On to the review:

The Schwinn 170 (MY17) plugs into the wall and has a detailed console. A user can choose from a selection of rides, from mountains to light cruising through the park (or you can just start spinning away on a flat course, if you wish). The Schwinn is Bluetooth enabled (for geeky super-connectivity). It also supposedly syncs with some virtual reality devices (which I think is cooler).

The seat adjusts for varying heights (warning: it’s a bit limited on the top end – a proper cyclist sets up a seat for a near-full leg extension, and following that rule of the thumb on the Schwinn will only get you to a 6’ 2” or 6’ 3” person, it appears. I’m 6’ 0”, and my seatpost setting is only one hole above the safety warning.)

Set up: It comes in a heavyish box. I set up mine in one hour forty minutes and easily could have done it faster, had I needed to. Unpacking the pieces and laying them out on the floor (always your best strategy) took a good fifteen to twenty minutes of that assembly time. The nice thing is there aren’t too many parts to deal with. Some negatives on the assembly: the included Phillips-head screwdriver on the multi-purpose tool isn’t a good fit for the screws, so be careful not to strip them (I used a smaller screwdriver from my toolbox). Also, like most exercise bikes in this price range, it has its share of cheapish molded plastic. The main shroud, for example, isn’t designed particularly well and doesn’t fit as well as it should.

Pros:
* Very quiet and smooth.
* Value: It was $324 on Amazon with free shipping (when I bought it). I would call that a good value for an exercise bike that has all these features. 
* The resistance spans an impressive range: 1 is very easy (my wife, a non-cyclist who gets little exercise and who kind of has a bum knee, thought 4 was fairly easy). At the high end, level 25 will grind even a Tour de France rider into dust in short order.

Cons:
* The pedaling speed measurements are terrible. On a regular bike, I can sprint at 30 miles per hour or higher; if I crank up the resistance and put forth the same effort, this bike registers about 24 mph (my old Bodyfit was much more accurate). On the low end, I can barely pedal and still get credit for 10, 11 mph. Because the speed is close to useless, I wouldn’t put much credence in the reported distance (as distance is a function of time multiplied by speed, and we already know the speed is off).
* The seat is spongy and looks ample for the largest of derrieres, but not that comfortable. I did gradually get used to it.
* The “media tray” is friendly to the iPad user or DVD watcher; it is not very good for physical books.
* I think the console could be better laid out. For example, the right side is devoted to showing what percentage of your maximum heartrate you’re at, in 10% increments. To save space, just put that number in a box. Also, a better system would allow the user to input their own maximum heartrate, as there can be high variability here (I know a 56-year-old who has a max heartrate of 185, when “normal” for a man that age is about 165!)

For the knee pain sufferer: Yes, you can pedal backwards with no resistance, if you want to. If you can handle the lowest level of resistance, or 1, you should be able to get in a nice, easy ride. Also, the bike’s smooth ride is favorable for knee rehabbing.

So that’s my take on the Schwinn 170 (M17) – and if you’re wondering why the “MY17”, it apparently signifies the later edition of the bike.

Hopefully I’ll be able to do a few more cycling-related reviews in the months to come. I’d love to review Zwift, which is kind of like an immersive cycling world, but the monthly fee of $15 has put me off. If I’m going to spend money for indoor cycling equipment, I really don’t want to be shelling out for montly subscriptions on top of that, unless they’re really cheap.

When You Lose the Thread Between Cause and Effect

Knee pain is often a strange, baffling thing.

I tried to figure it out. I eventually healed my own hurting knees, and learned enough that I was motivated to write a book about my experience.

But at the same time I knew there was a whole lot I didn’t understand (and neither did the smart people out there who study the origins and treatment of knee pain).

One thing I always tried to do: draw lines between cause and effect, especially when I had a setback on the long road to getting better. For me, setbacks were like small teaching moments: my body teaching me something, very important, about how I should go about healing.

Sometimes it’s easy to draw that line. If you carry a heavy backpack up six flights of stairs, then have knee pain the next day, or a couple of days later, what caused it isn’t much of a mystery.

But what’s frustrating are those setbacks when you can’t point to a likely culprit. What then do you do? What if your knees hurt worse then ever, out of the blue, and you can’t figure out why?

These are the good, hard questions. I’ve thought about them more since I started the blog, as a stream of readers have confronted me with issues that weren’t always ones I had to deal with, but that usually made me think.

My gut feeling – and this may work for you, or may not – is to hit the reset button and scale back your activity significantly. Maybe try returning to your activity level from a couple of months before?

But I would be reluctant to go “full couch potato.” I’m not saying it doesn’t work for some people, because apparently it does. But I’d rather find a way to get in some motion, even if I’m seated and resting my feet on a wheeled dolly that I slide back and forth, back and forth.

It can be maddening to be racking up small wins over three or four months then have a weird, sudden, inexplicable setback. But they happen. I think there is a reason for all setbacks, because I’m that kind of logical “things happen for a reason” kind of guy.

But let’s face it: the human body is a very complex stew of chemicals and cellular processes, all interacting in complex ways. It shouldn’t surprise us that the results of some of these interactions are close to unknowable. And some of them probably lead to unpleasant knee pain symptoms.

So, even if you can’t figure out what caused your setback, carry on. Don’t get too discouraged. Try to figure out what you can, but I think there will always be mysteries.

On Experts, and a Growing ‘Antipathy to Expertise’

A recent article in Harvard Magazine, “The Miracle of Knowledge,” gave me occasion to reflect on my ordeal with knee pain. A political scientist by the name of Tom Nichols has noticed in American public discourse “a new and accelerating – and dangerous – hostility toward established knowledge.” The article refers to it as an “antipathy to expertise.”

The article caught my eye, because in a sense I suppose my knee pain recovery can be construed as an “antipathy to expertise.” Ultimately I rejected what my doctors and physical therapists – the true experts – told me about my prognosis for healing, and about what my treatment should consist of. I became a Google’ing omnivore, devouring all I could find about knee pain similar to mine, and sifting for clues about how I could beat this condition.

In the end, I think I proved the experts – at least those in my immediate circle – wrong. I healed, when I was told I couldn’t, and did so by rejecting the core muscle-strengthening advice of my physical therapist. If there were a parade of “don’t trust the experts” activists you might expect me to be right up front.

Except I wouldn’t be. Not at all.

In fact, I pretty much agree with Nichols. I'm also worried about the erosion of belief in experts, which is all too often replaced by the conviction that an ignorant opinion, or a private consensus reached after consulting the Google hive mind, works just as well. “Who needs doctors, climate scientists, whatever?” This attitude frightens me because today, more than ever, a cavalier disregard of facts and truth is becoming acceptable.

So to be clear (and some of you have heard this before):

* If you have knee pain, I would always start by seeing a doctor. In comments on this blog, I’m careful to say that. At the least, a doctor can order imaging and other tests that can shed light on what’s going on in your joint. But more than that, a doctor will typically have the intelligence, breadth of knowledge, and experience (gained from examining scores of patients like you) to make a better diagnosis than Mr. Google.

* My rejection of the experts wasn’t knee-jerk and immediate. It arose from three main things:

(1) Doctors never gave me a plan for getting better. A plan – “do this, then this, then this” – I would have respected. A fatalistic shrug, or the tepid suggestion to avoid activities that bother my knees – that feels like a dereliction of duty.

(2) In other cases, the plan I was given failed. At some point, when confronted with repeated failure, you have to wonder, “Is it just me or could the advice I’m getting be faulty?”

(3) I tried to approach the puzzle of my knee pain in a scientific-minded way. If my doctors knew X and Y, I looked for Z, the thing that perhaps clinical trials had discovered, but that wasn’t commonly accepted when my doctors were being taught in medical school, five, 10, 20 years ago. An example: I located a clinical study where cartilage defects improved, at a significantly high rate. This is part of what informed my optimism about my knees getting better. And I also looked for smarter, out-of-the-mainstream experts. I was lucky to find a few.

So with experts, I would not reject their opinions out of hand. Experts are experts for a good reason. But there are times when they are wrong, and that possibility, no matter how small in a given instance, can’t be overlooked. They are not some monolithic, omniscient body. They are people. And people are fallible.

Open Comment Forum: Anyone Want to Discuss Setbacks?

So I got this comment recently, and thought the writer made a good point:

I have not seen much detail on setbacks in the book and here. You and others mention them, but I am always hungry for more detail to help manage my expectations (do they last days or weeks for others? What works when they happen? etc.) I wonder if another Open Comment Forum on this topic would be useful at some point.

Yes, setbacks are incredibly frustrating for someone working to rehab bad knees: you're slowly getting better, getting better, getting better ... then all of a sudden, you slide backwards. Healing then becomes something like a cruel mirage. Will you ever be pain-free?

So, below, I invite all of you out there to discuss setbacks. It would be especially useful to hear from those people who successfully battled through them: How frequently did you find yourself dealing with setbacks, how long did they last, what did you find was the best approach to overcoming them (regarding state of mind, reduction in movement, etc.)? What caused your setback in the first place (if you know)?

Or, again, feel free to talk about whatever. Open comment forum! I'm out!

Why Knee Pain May Be the Best Thing That Ever Happened to You

I’ve written a post similar to this before, but decided to revisit the topic to share a new anecdote.

First, for those who don’t know me well, this isn’t some sentimental wallow that someone might expect to go like this:

You'll look back on your knee pain and feel grateful for it, because you develop an inner strength to cope with adversity and discover the truly meaningful things in life etc.

Honestly, by dealing with knee pain, you may learn you possess an inner fortitude, and I’m not saying that’s a bad thing, but you might realize the same thing after climbing a really tall mountain, and that’s what I’d much rather do.

Constant knee pain is miserable.

So how can it be the best thing that ever happened to you? Well, that’s conditional on two things: (1) You escape your knee pain (2) You become smarter about this complex machine you happen to be dragging around, tethered to your consciousness, that you call your body.

I feel that I scored big on (1) and (2) both, so I’m a pretty lucky guy.

What does (2) mean exactly? To me, it means that, during your recovery, you evolved skills in playing “medical detective” – figuring out, sometimes with creative thinking, cause and effect when something on your body starts hurting. You no longer give a fatalistic shrug and say, “I’m just getting old.” You painstakingly try to figure out what’s causing your pain, and you experiment with ways to get better.

Now here’s the anecdote that led to this post.

A month or so ago, I noticed occasional sharp pain in the side of my left knee when descending stairs. I have to confess, I did wonder if the chronic knee pain that I thought I had beaten had returned. Was it possible that I was wearing out the cartilage in the joint through strenuous biking?

But the pain was on the side of the knee. It wasn’t burning. And it came and went, but seemed to be getting worse.

Well, what could be going on, I wondered.

It just so turned out that a few weeks earlier, I had started a new job that features long hours and full days at my desk. And, one day at work, I happened to notice that I was crossing my ankles when I felt tension, in a way that was torquing my knee slightly.

Not much. And the knee never hurt when I was doing it.

Still, I consciously forced myself to stop. Whenever I saw my legs in that crossed-ankle position, I put my feet flat on the floor and relaxed.

And I think you know what's coming: the knee pain gradually went away. It’s gone now.

The point is that's exactly why knee pain – again, if you recover – can be a good thing. You become much more attuned to your body and can turn into a rather savvy medical detective.

Had I gone to a doctor about this side-of-knee pain, I guarantee he never would’ve figured out the reason.

And if I had never gone through that miserable ordeal with knee pain, I probably wouldn’t have either.

TriAgain's Success Story (Part III)

Here’s is the third (and last) part of TriAgain’s story. If you skimmed the others, today's is the one to read closely! This is lessons learned. I find these quite interesting, so I’m just going to let him tell you what worked for him and either didn’t work or made his knee pain worse, and get out of the way!

The Bad

* Full-body-weight, leg-muscle strengthening exercises: too much load and frequency, so exceeded my envelope of function [i.e., capacity of the knee to handle the load]

* Anti-inflammatories: a short-term solution only and can cause long-term problems

* Stairs

* Knee taping

* Crouching, squatting, bending forward too much

* Icing: I had no swelling, but iced to relieve the pain. I was doing this a lot before the real chronic pain struck. I’ve since read that icing can cause CRPS

* Glucosamine (supplements): did nothing

* Iron (supplements): did nothing

* Body awareness: one thing triathlon can do is make you hyper-aware and paranoid of every little ache and pain in your body. You can focus on things too much, until they do become a problem, or become harder to solve.

The Good

* Becoming OCD about monitoring your knees, figuring out what makes them worse, what makes them better, and sticking to that, while gradually edging up your activity levels. For many, this will mean forget triathlon for the foreseeable future

* Walking

* Stretching

* TENS machine: my physio got me onto this and it was a Godsend for reducing the constant pain. I suspect it was working on the near-CRPS component of my pain and helping rewire neural pathways.

* Meditation: good for pain control

* Hoka shoes: they look ridiculous, but the difference in knee impact even when walking is noticeable and they help you get gentle knee movement without more damage

* Topical ointments (Lawang oil, emu oil, Tui cream): I think these work by relaxing the muscles/joint. There is also some evidence the menthol in these helps distract you from pain and has positive neuroplasticity impacts

* Stretching: as for above

* Hot baths/showers: as for above

* Fish oil: not sure about this one, but I continue to take it

* Losing the triathlon obsession: this took almost three years, but once I started getting some decent pain reduction, that became far more important than my need to race again. In fact, it made me realise how stupidly obsessed I’d become with the sport.

* PRP injections: I’m sure these helped, but were not the silver bullet

* Fly-fishing: the gentle walking with frequent stopping seemed to agree with my knees, as did being away from a desk, being in a nice outdoor environment, and wading in cool water

Weird things that worked

* Acupuncture: no idea why this works, but my Chinese medicine guy put the needles in my elbows as apparently that opens up the healing channels in the knees. I also meditate and relax a bit during these 30-45 minute sessions so maybe that is the thing?

* Neuroplasticity exercises: have a look at this and this. These indicate that you don’t have to just “manage” (i.e. live with) your pain, but can beat it my rewiring the CNS. I set up a little animation in Powerpoint which showed the pain centres in my brain shrinking, and it definitely had a positive effect.

* Backballs: these are self-massaging balls provided by my physio for your back which you lie on and they massage either side of the spine. I found there were some spots high up in my back which when massaged resulted in a noticeable reduction in knee pain. This could have been related to CRPS and changes in ganglia in the spine.

TriAgain's Success Story (Part II)

Now for part two of TriAgain’s knee pain story. There is a large section of his account where he talks about finding my book and blog, which I will not include here, so as not to (1) be accused of self-stroking :) (2) repeat what those of you who read my book already know.

He also mentions finding other success stories: “Ted” from California, Luis and his wife from Bolivia, and Terry42 from KneeGeeks.
 
And he talks about three other big influences (you’ll find all three on this blog; just do a search):

(1) Scott Dye and his framework for understanding knee pain in terms of “tissue homeostasis” and “envelope of function”
(2) Paul Ingraham, a really cool writer, hard-nosed skeptic, and myth buster
(3) Doug Kelsey, an Austin, Texas, physical therapist whose thinking is like a breath of fresh air in a stuffy attic

Instead of condensing what he wrote about Dye and the others, I’d like to focus on a diagnosis he said he received. I think it’s useful partly because this was NOT my diagnosis (nor do I think I had it, based on the symptom set), but I bet a lot of other knee pain sufferers would find it relevant.

The condition is called “complex regional pain syndrome,” which sounds like phantom pain at first – but it definitely is not. So here’s TriAgain (again):

“Some posts on KneeGeeks suggested I should research CRPS.

CRPS stands for Complex Regional Pain Syndrome. It sounds like some BS that is all in your head (you are imagining and/or making more of the pain than you should) – except it is not. It is real neurological changes in the ganglia of the spine and brain, and sometimes the local nerves in the affected area. What this does is massively increase your sensitivity to pain.

The 13-year-old daughter of one of my board members got CRPS after hurting her knee at soccer – except the pain was in her foot. She was in agony with terrible burning pain, and even the light touch of a sheet on her foot made it worse. She spent two weeks on a ketamine drip (nasty stuff) and had mirror therapy and other interventions to rewire her neural pathways. It was a 12-month recovery process.

Full-blown CRPS has symptoms including burning pain, discolouration of the skin, clammy or sweaty skin, extreme sensitivity to touch and pressure. I had the burning pain and discolouration in my kneecaps, so thought I should ask my GP about it. He agreed it was a distinct possibility. In the meantime I’d found a top pain specialist and got a referral to see him.

The pain specialist diagnosed patella chondromalacia (which I already knew, but don’t think is my main problem), muscle wasting around the knees (not surprising) and pre-CRPS, which meant not full blown CRPS, but getting there.

He prescribed a whole host of things:

* A book on pain management (good, but seemed to be suggesting the need to accept your pain and get on with life. I later found material which indicated through neural exercises you can overcome pain.)

* Natural supplements to reduce pain

* A nerve pain medication (Lyrica) which is pretty nasty. It made me very hazy and though I got some initial relief, weaned myself off it after a few months as I couldn’t function at work

* PRP injections – I had three in each knee and this guy only charged $110/pop. These gave some almost immediate relief, I’m sure helped with cartilage healing, but were not the magic bullet. I still had to be very careful.

* The only negative – the dreaded single-leg shallow squat within the range of no pain to re-build my VMOs. As stated above, impossible and counter-productive, though to be fair you can’t expect a pain specialist to be a knee expert and know the theory of envelope of function.

* One other treatment for CRPS is a controlled and graduated return to activity to rewire the central nervous system to learn that the physical activity causing you pain is not actually doing you physical damage. This led me into some very useful material on neuroplasticity (anyone see the Todd Sampson program ‘Redesign My Brain’?).

The take-home message: the whole CRPS experience led me to some excellent work on central nervous system rewiring techniques, and while not the entire answer, had a host of benefits.

Having figured out the conventional wisdom (leg muscle strengthening) was not working, I had to find another way.

Before the move, I’d long since given up cycling and running, and even kicking while swimming was starting to look highly suspect. At the new flat, there was a little 15 min walking circuit I would do every morning.

One positive to come out of my tri training program was lots of pull and band swimming, so I did nearly all swimming like that to limit kicking. Several times I tried getting back on the bike and for a few weeks, thought I was getting on top of the pain, but then went backwards again.

So I walked for 20-30 mins every morning before work, and either swam, did the little gym circuit, walked on a treadmill for another 15-20 mins, or did upper body weights at lunch/on weekends. I did this for about 12 months.

Between then and now, I’ve had up to a 90% improvement in the knee pain level, and a 50% improvement in function. However, it can fluctuate and go backwards at times.”

End Part II

TriAgain’s Success Story (Part 1)

I’m trying something different for this post and the next two.

Over the years, I’ve hit a lot of the high and low notes of my own story. I always encourage others to tell their stories too – while you may learn something from me, you may learn a lot more from someone else whose symptoms and experiences are more similar to yours.

One of the first regular readers of this blog was an Australian triathlete posting as “TriAgain.” Early on, I could tell that he was deeply committed to fixing his knee pain. Over time, his story emerged in bits and pieces.

Then, a couple of years ago, he detailed his entire experience in a triathlete forum. I asked him if I could use an edited-down version here, while linking to the full account, and he agreed. Little did I know his story, once I had cut and pasted all the pieces, comprised almost 10,000 words (by way of comparison, a short novel is 60,000)!

It’s all very good, and I encourage you to read the full version here (warning: it is scattered over multiple posts). For my blog, I decided to run a much-abbreviated account in three parts: (1) the early days: pain, diagnoses, frustration (2) the turnaround (3) lessons learned.

I chose to do it in three parts, for one, because I just got a new, demanding job, so I have less time to devote to the blog right now.

Here’s the first installment of TriAgain’s story below. Note that he started writing this on Sept. 1, 2015, more than two years ago. Since then, his condition has improved a lot.

"I’ve not been able to train or race for over 3.5 years now due to chronic anterior knee pain, burning and stiffness in both knees. The chronic pain came on within a month of having a piece of torn meniscus removed from my left knee (it tore unexpectedly while running). This happened within two months of my best race ever at Gundi in 2012, at age 48.

By the end of 2012, I had the knees of a 90-year-old. They ached, burned, were stiff. I could not kneel, squat, crouch, jump. Sitting at my desk was hell. I put boxes under the desk to sit with my legs out straight, as they were worse when bent. In addition, my kneecaps were often cold and discoloured blue/purple with red blotches.

We had to sell our house because I could not maintain the large garden anymore.

Straight after surgery, I'd asked my orthopaedic surgeon (OS) who had trimmed the meniscus what I could do and he said “anything you think you can cope with.” In hindsight, and given what I now understand, this is the worst possible advice.

But I happily took his advice and was back on the bike for one hour rides at 50-70% of pre-surgery effort within six days of surgery in late May 2012. By June 2012 I was in constant pain in BOTH knees. In fact the knee I'd not had surgery on was the worst.

After several months of pain, stiffness and loss of function, which I thought would abate if I backed off but did not, I started seeking more medical advice.

My OS started talking lateral releases (the good old misalignment or patella maltracking theory), but by this time, I must have done enough research to be very wary of surgery.

My GP referred me to a sports doctor. He diagnosed chondromalacia patella – which is essentially degeneration of the cartilage behind the kneecap, and was correct (I did have damage behind the kneecap), but not I believe the cause of such constant pain and loss of function.

Chondromalacia patella was not new to me. My father was a GP and diagnosed it in my right knee as young as 14. I smashed the hell out of my knees as a kid, played rugby league and later union from ages 5 to 22 and took some massive front-on kicks to my kneecaps.

The first sports doctor suggested microfracture surgery (which incidentally, he’d had successfully himself) or PRP (blood platelet injections which he could do at $500 a pop). Again, it was more surgery, so I decided against it.

During this time, I was still visiting my physio and GP. Their view was that my patella was maltracking laterally, and I needed to strengthen my vastus medialis oblique (VMO) muscle to pull the kneecap back into alignment. This was despite my physio previously putting a machine on my VMO and concluding that it fired just fine.

So it was off to single-leg squat land, and sitting down with a leg out while tensing the VMO, focusing on firing the VMO at the same time as the outer quad. All of this had to be done within the boundary of zero pain. So only squat to an angle where no kneecap pain occurred. This was absolutely impossible, because my knees hurt all the time.

During this time, I’d been posting about the problem, and it was suggested I see a sports doctor at a different club who was a knee expert. He concluded there was nothing wrong with my VMOs at all, and there was minimal patella maltracking. The problem he felt was hip and glute instability.

So I did the glute/hip exercises prescribed, improved my strength and function quite a bit, but the knee pain did not resolve one iota. He also suggested I stop running (which I had anyway) but continue cycling (which, in my view, produced more pain than running).

Life became depressing. I had constant pain. All I wanted was to lie down with my legs up to reduce the pain. The mood was pretty dark. I wanted to drink alcohol as it reduced pain. The joy went out of everything. I was completely obsessed with the knee pain and sinking into mental illness."

End of Part 1

Why I’m So Optimistic About Cartilage Healing, Take 2

I got a comment from a reader below this post. If you remember, I was looking at a two-year study that showed a surprising number of improvements in cartilage defects (well, I found the number surprising anyway). This reader was less enthusiastic:

If 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 abysmal.

First, let me address a couple of quick things: (1) Yes, I’ve seen a study too where defects in the patella cartilage didn’t improve as often as defects in cartilage elsewhere in the knee – but still, there were some instances where they did improve. (2) To clarify, the study I reference in the post isn’t looking at just defects in the cartilage behind the patella, but rather, throughout the knee.

Okay, a quick recap:

The table below is 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.

The condition of each subject’s cartilage was graded for five different knee compartments (at baseline, and after two years). 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

Okay, so did most of the defects in the study progress? Well, yeah. Of course. But it doesn’t matter because you have to adjust for the “floor” and “ceiling” effect.

In this case, “floor” means a defect can’t get worse. “Ceiling” means it can’t get better.

Example: If a defect is graded “0” at baseline, two years later, it can only be “0” or worse. It can’t get any better than 0. There is no -1! Conversely, a defect graded “4” at baseline can only stay the same or (if indeed cartilage can heal) can get better.

Now, look at the number of defects that have a “ceiling” effect (grade of 0) or a “near ceiling” effect” (i.e., defects initially graded 1).

There are 117 that start out with a “ceiling” effect (just add the numbers in the first row) and 196 with a “near ceiling” effect (that's the second row). So for this group of 509 defects, there’s a high chance they’re going to get worse. Sure enough, we find a whopping 389 got worse. Awful, right?

Not at all.

Look at the bottom of the table. Here, our attention turns to the “floor” effect (defects with an initial grade of 4) and “near floor” effect (initial grade of 3). There are 5 defects with a “floor” effect and 14 with a “near floor” effect.

How many defects improved? Only 10 – which seems like a small number compared with 389, but consider that we started with only 19 (yes, I know, “small sample size” alert).

Of course, when you look at the number of changes overall, many more defects got worse because most faced the ceiling effect. But look at raw percentages, and the story becomes more interesting:

Defects that started in the “ceiling” or “near ceiling” effect categories
Got worse: 76%
Stayed the same or got better: 24%

Defects that started in the “floor” or “near floor” effect categories
Got worse: 26%
Stayed the same or got better: 74%

Wow! Almost a perfect inversion!

Now, why does this matter (once again) if you really care about cartilage healing (which, again, you shouldn’t obsess about in the first place, because pristine cartilage isn’t a sine qua non for eliminating knee pain).

Because if cartilage really can’t heal, all those defects graded 3 or 4 should be staying the same or getting worse; three-quarters of them shouldn’t improve!

One last fun thing in closing: is there a line in the table (you’ve probably already spotted it) where we can escape the “floor” and “ceiling” effects as defined here? Sure: at baseline, 88 defects landed smack dab in the middle of the table, receiving a score of 2. That means a loss of thickness of less than 50 percent.

Now notice what happened to them two years later. Yes, eight were found to be worse. But more than three times as many, or 27, improved to a grade of 1.

So that’s why I see the glass as half full (even though, for the umpteenth time, don’t obsess over cartilage healing!).

Open Comment Forum: What’s the (Surprising) Thing That Your Knees Hate?

It seems like we’re overdue for another open comment forum. Talk among yourselves in the comment section below!

What you can use this forum for: (1) Introducing yourself, and some of the knee pain challenges you’re grappling with (some other readers may have a thought or two about what might help you (2) Including a status update of how you're doing (3) Writing about anything else you want to!

If you’re stuck but want to contribute something, here’s a question to get the ball rolling: What’s the (surprising) thing your knees hate? In other words, if you say your knees hate carrying an 80-lb. safe up six flights of stairs, no one is going to be surprised. If, however, your knees hate warm massages, well, that’s a bit odd.

So there you go! I hope everyone is doing well. I just finished riding 52 miles on my bike; the legs feel tired, but in a good way. The knees continue to be happy. Cheers!

Unloading Your Joints: More Proof It’s the Way to Go

I’m a fan of Boston professional sports teams, so I follow a lot of news about them. That includes injury reports, unfortunately.

In October – exactly six minutes into the NBA basketball season – the Boston Celtics lost forward Gordon Hayward for the season. He broke his ankle in a gruesome injury.

Hayward is slowly, slowly rehabbing. He recently posted an account of what his recovery is like, and I thought it worth mentioning for a couple of reasons.

One: Does this sound familiar?

The hardest part of all of this is the mental grind. It's a lot of time doing pretty boring things to get the slightest bit better every day, and of course, sometimes I don't get better. Sometimes I take a small step back because my ankle didn't react well to the thing that I did the day before. And so we have to walk it back a little. That's the hardest part, and the most frustrating part for sure.

Anyone in a long-term recovery program for chronic knee pain can identify with this agonizingly slow pace of healing. Still, recognizing this is how healing happens -- little steps forward, then backward, then repeat -- is useful to avoid getting too discouraged.

Also, of course, notice his mention of those nagging setbacks that you're going to face. You will make mistakes, and push a little too hard some days, and that will lead to frustrating delays.

Two: Listen to how Hayward is exercising his ankle.

... I am slowly progressing with the AlterG. This is the first time I’ve ever used the AlterG, and if you don’t know what it is, it uses air pressure technology to allows you to rehab without putting your full body weight on your legs. It’s like you don’t have the full effect of gravity on you (which is where the name comes from).

We all know what AlterG is, right? (I wrote about it here.) AlterG is a rather expensive piece of equipment that allows you to run and walk on a treadmill at less-than-normal forces. While it costs more than a total trainer, the objective is similar, and involves lightening the load on your hurting knees (or ankle).

Gordon Hayward is a $30 million-a-year man. That’s a big contract. He could afford any kind of rehab he and the Boston Celtics wanted. That they chose a piece of technology that’s essentially a cousin of the total trainer should convince you that the joint unloading approach really works for the smartest, quickest recovery.

It’s not just Doug Kelsey and me saying it – it’s the medical staff of the Boston Celtics, dealing with athletes who make far more money in one year than I’ll ever see in my lifetime!

Osteoarthritis, and a Post-Industrial Era Mystery

The latest issue of Harvard Magazine looks at a curious mystery.

Two biology researchers from Harvard University discovered the mystery after visiting medical institutes across the country and examining skeletons over the centuries.

They were searching for evidence of knee osteoarthritis (bone-on-bone rubbing in places where the cartilage has completely eroded, which leads to polished bone surfaces that are a telltale sign of the disease).

When they compared the skeletons from the prehistoric and industrial eras to those from the postindustrial, they found that the prevalence of knee OA has more than doubled since World War II.

You might think: Sure, of course it’s higher. People live longer. More people today are obese.

But controlling for age and body mass index didn’t make the difference go away. To be sure, obesity contributes hugely to knee OA. But it wasn’t causing the spike in cases.

The researchers still aren’t sure what’s going on, but they’re testing a hypothesis that I think will yield their answer.

Physical inactivity, they speculate, may be what’s to blame. The mid-twentieth-century shift to service-sector jobs put more people in workplaces where they got less movement. The modern desk rat was born.

We sit, and sit, and sit, and sit, and then wonder one day why our knees hurt.

Because our knees weren’t designed to do nothing at all for long stretches?

Or, as the article says, in more prolix language: there’s a “suspicion that OA is a case of human physiology being partly maladaptive to modern environments.”

Healthy, joint-nourishing motion IS important.

This, I believe, is the key to preventing knee pain, or once you have it, recovering your pain-free knees once again.

The Difficulty of Taking a Step Backwards to Move Forward

With New Year’s resolutions thick in the air, I thought this might be a good time to talk about what might be the hardest thing to do when trying to heal aching knees.

A lot of people, especially fit people, quickly take to heart my message of “motion” when it comes to healing. After all, living things that stay at rest gradually become weak and begin to fall apart.

So athletic people immediately want to go outside and start walking 5,000 steps a day to recover their knee health.

But the motion imperative can be very dangerous, as too much motion just leads to more knee pain. The key, I strongly believe, lies in figuring out the “proper amount” of appropriate motion. And, as I've said many times before, determining the “proper amount” can be very, very hard, especially initially.

What’s sometimes needed is a willingness to go backwards to go forward.

For me, that involved scaling my program way, way back. I went from walking thousands of steps a day to simply walking once around a pool and resting for ten minutes, then repeating the sequence. Talk about boring! This also represented a kind of “rock bottom” moment for me – if that’s all the movement my knees could tolerate, they must be much weaker than I imagined.

As it turned out, hitting rock bottom was one of the best things that happened to me. I needed to accept where I was – where I really was, and not where I thought I was – to start improving. Those simple pool walkarounds made my knees feel consistently good, and I needed that. I needed to escape the frustrating swings of emotion, where my knees felt good for a few days, then bad for a few, and my progress seemed to stall.

Going too fast, too aggressively, can leave you baffled and frustrated. Sometimes it pays off to go backwards – figure out the least strain you can put on your joints, while having them consistently feel better.

Once you establish that baseline, then you can start to move forward.