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!).