A new review of how specialists and primary care doctors treat knee osteoarthritis (OA) finds that the use of pain-relieving prescriptions has risen dramatically, while lifestyle recommendations and physical therapy (PT) referrals have dropped.The next sentence provided needed context: doctors appear to be increasingly concerned with “symptom control” rather than treating the underlying issue. The analysis was based on data collected from national surveys conducted by the Centers for Disease Control and Prevention.
The lead author on the study, which was published last month in Arthritis Care & Research, rightly says we need to shift our thinking away from taking care of the immediate pain and toward preventing a further decline in physical health.
Well, yeah. Short-term fixes for hard-to-solve, long-term problems aren’t a good idea. It’s like using zip ties to hold your car’s battery cables together (I’d link to the YouTube video where I saw this “fix,” if I could only remember where – I discovered the video when I had to replace my own battery cables.) Short-term fixes are sometimes necessary of course because you need some way to get your car home, or in the case of your knees, to manage pain that's reached unbearable levels.
But, once the pain abates, you should start thinking of a long-term plan to take care of the problem.
Below are more details from the study, which I found mildly horrifying. The researchers discovered that:
* In the 2007-2009 period, orthopedic doctors referred patients to physical therapy 15.8% of the time. Less than a decade later, in 2013-2015, that figure dropped almost by half, to 8.6%.
* Many of these doctors also abandoned “lifestyle counseling” (e.g., exercise recommendations, advice about managing weight). Specifically, lifestyle counseling fell from 18.4% of all visits to less than half of that, or 8.8%.
So what were these poor patients leaving with, if not referrals to physical therapy or good advice about the importance of controlling their weight? You guessed it: little pieces of paper for their local pharmacy.
The number of prescriptions written by orthopedic specialists for nonsteroidal anti-inflammatory drugs (NSAIDs) more than doubled, from 132 per 1,000 visits to 278 per 1,000, and tripled for narcotics, going from 77 per 1,000 to 236 per 1,000.
Personally, I think what many of these orthopedic doctors are doing is shameful. I’m not sure how much of it is because of the long-legged twentysomething drug reps showing up every few weeks with new pills and free goodies to shower on power prescribers, but I think there’s a better way.
True, it’s a harder way, a longer way. Still, if you minimize the pills, and stick to a careful regimen, you can actually improve the health of your bad knees. This isn’t just my story anymore, but the story of a fair number of other people who are regular visitors to this blog!
Has anyone on here heard of ARP Wave? Some sort of electrical stim device. https://arpwaveusa.com/ I'm skeptical but a friend swears by it and has offered to let me try it free. I'm wondering if it can help with chronically inflammed synovium.
ReplyDeleteWhen I was living in Italy I saw an orthopedist who prescribed a kind of electrical stimulation therapy called tecar therapy, along with muscle strengthening physical therapy, for my patello-femoral pain. I was amazed. After starting the tecar therapy my pain was gone within just a few days. I don't know how it works, but it did (at least for me). The technician that performed it said it helps heal the tissues, but I suspect it may have more to do with the Gateway Theory of Pain. After moving back to the U.S. shortly thereafter I didn't continue the treatment because I figured my health insurance probably wouldn't pay for it. In any case, it's not a permanent fix. It's a temporary pain control measure.
DeleteCheers,
Pax
When I was living in Spain, my PT clinic hooked me up several times to what was basically a giant TENS machine. I agree with Pax that it's not a permanent fix, but it is a baseline to activate muscles so you can start building again. I also struggle with chronically inflamed knee, and it has been the most frustrating thing by far because one step too many in a day and I'm back on crutches. Your comment actually piqued my interest in calling Arpwave and I found the one PT clinic in my city that has the machine. I made an appointment for next Monday, and can let you know how it goes. It's supposed to be 250 times more powerful than the signals the brain sends when doing exercise, so I'm hoping it will be a jump off point for building some more muscle. It's hella pricey, unfortunately. $2500 for 20 sessions and they don't take insurance. Sounds scammy but I'll try it anyways.
DeleteHi Richard, my name is Caroline. I read your book a couple months ago, and it was deeply inspiring for me, as I also injured myself badly while living abroad (in Spain). I hope this is a place where no one minds that I share my story. If it isn't, I apologize. I know knee stories can be precarious. I am 29 years old and have been housebound for about a year and a half due to knee OA. A childhood history of knee injuries and dislocations (born with patella alta) finally caught up with me in summer 2018 when I tried to start a running regimen and then had to walk around on injured knees for several months for work. I regret this everyday, but work to accept what it is.
ReplyDeleteI have been active with cycling, dance, gymnastics, and yoga my whole life, but the majority of my muscle atrophied from being on bedrest for so long. My MRI last year showed Chondromalacia grade 2/3 in both knees, trochlear dysplasia, femoral rotations, and Hoffe's fatty pad syndrome. My doctor in Spain threw some glucosamine chondroitin at me, said he didn't believe in turmeric/anti-inflammatory food, and said to return if I wasn't better in 3 months. 3 months went and passed, and I still struggled with unbearable chronic inflammation in my right knee and pain in both. A hyaluronic acid injection helped some. I moved back stateside in March, immediately started physical therapy with a very "pro-muscle" guy who had me aggravating the inflammation with squats, static bicycle, and elliptical. My elbows and wrists began aching after starting to rigorously swim, and the X-Ray I got shows I have now developed CPPD (pseudogout; calcium crystal buildup) and bone spurs. They said my MPFL ligaments are scar tissued over from childhood dislocations. I stopped seeing the PT. My doctor here at Vanderbilt threw some NSAIDs and uncomfortable robot knee braces at me, and refused me a hyaluronic injection because he had other patients to attend to.
I am feeling completely desperate, to say the least. I struggle with walking around the house. Mere leg lifts are painful. I do not trust western doctors. Stem cell therapy is outrageously expensive. Acupuncture and massage help the pain but are also expensive. I fear so much structural damage has been done. I can barely get around my house these days, and I constantly retrigger injury by totally innocuous things like taking a step the wrong way. It feels like a bone bruise that isn't healing. I was told I am a poor surgical candidate for even a total knee replacement because of the muscle atrophy. I have decided to not take the NSAIDs anymore because of the gut damage/inflammation link.
The two good things are that I have seen big inflammation decrease success with an anti-inflammatory diet (no sugar/gluten/dairy) for a month, and that I just got a work from home job with benefits to hopefully procure a new MRI soon. But I still can't stand or walk long distances at all. I'm struggling with cooking for myself.
I don't know what to do. Doctors have told me that I'm both overreacting, and also that this is degenerative arthritis/exceedingly difficult/we can't get our hopes up. I used to be an athlete and now I'm disabled at age 29. I fear I have so many things wrong with my knee that things will only get worse from here. If anyone has any words or nudges in a certain direction, I am open to anything. I am hopeful about geniculate artery embolization and starting PT with a new manual therapist again who takes my emotions seriously and isn't "muscle-first."
Thank you so much for reading my story.
Caroline,
DeleteI am so sorry to hear about your troubles. Similar to you I am younger (38 now) and was very active with cycling, fitness and sports until my knees started to bother me. At first it was only a little and then over time they would hurt/feel inflamed daily without even having worked out. Like many here, I got mixed reviews from several Orthos and no real successful treatment plan which landed my here on Richards site. Now I am not claiming a cure (yet) as I am still working through my knee issues, but after doing much of the stuff Richard and others do for 14 months I have made some significant strides in the right direction. And you have already started some yourself:
-Embrace an anti-inflammatory diet like you are doing. I don't know which is best, but avoiding all sugar and wheat products has been a huge help to me too. Jury is still out for me on dairy and non-gluten grains (rice, oatmeal, etc.). Doctors don't always believe it, but I swear that if I eat bread or wheat crackers, then the next day the sides of my knees feel like they are on fire. My celiac blood test came back negative and did not show a wheat allergy, but I still think I have a sensitivity.
-Structured walking, similar to Richard I made it a point to walk numerous times a day. Started with 7min super flat and slow 3x daily, and it didn't always feel good. I am now up to 15-20min at a normal pace 3-4x daily, still pretty flat. It takes time, you might have to back off sometimes, but being consistent (rain or shine literally) will help, plus it is always great to be outside!
- Definitely eliminate NSAIDS as much as possible. Continue to use glucosamine, I use Cosamin ASU, again it isn't a cure all, but if it is helping me 5% I will take it. Consider a collagen supplement, I use an unflavored one that I mix into my black coffee or tea every morning (it is tasteless). I use ProMix, but have tried several brands and think they are all the same, I am also considering switching to Marine or plant based. I think the thing with these is that you have to do them daily for a long time, think months to see any benefit. I found a book "Osteoarthritis: Preventing and Healing without Drugs" by Peter Bales, it is a little older but has a lot of diet and supplementation advice which I follow (to include dosages).
- Lastly, but probably the thing I have found to be most helpful is following the guidelines in Doug Kelsey's books. In addition I have been being coached by Laurie Kertz and strongly recommend her coaching services. I know that coaching isn't for everyone, but at a minimum I would get Doug's books and take a read. I started doing squats on a variable incline plane (VIP as Laurie & Doug call it, or the Chuck Norris gym as I see it) with just 15% of my body weight and still had symptoms. But I have used it religiously Monday, Wednesday, and Friday, every week for 1 year and now my knees can handle 60% of my body weight with less symptoms. This progression while seemingly slow has been both a help physically and emotionally.
This is a long post too, but feel free to reach out if you have any questions. Again I am not "cured" (yet!!) but my days have gone from dreading stairs and sitting at work with my knees on fire to days now where I can clean up around the house, go for walks, and not think about my knees. Heck I just had my honeymoon last month and went on a 2 mile hike in the Shenandoah Mts, my knees held up well, yeah they bothered me a little the next day, but the day after they felt good. Best of Luck!!
JFitz, thank you for such a considerate response. I genuinely appreciate it, as I'm feeling very much like "is my life over at age 29?" It is always so encouraging to hear people's success stories, and that's fantastic that you are making progress with the variable incline plank! I am currently looking for a new PT. Would you recommend one that works with a VIP? I was using the total body machine but it was difficult. However, I have to keep reminding myself that so much of my muscle has atrophied. In our privileged society, it has been tricky for me and others to wrap our heads around the idea of trouble with gaining weight/muscle.
DeleteI have set up a phone call appointment with Laurie, thank you! And I am getting an updated MRI. I am searching for a collagen that doesn't include heavy metals. I notice my pain/swelling is directly connected to how much sleep I get. But cutting out sugar the last month and a half has been enlightening. I actually am switching to more ancestral eating as my knees have never hurt more cutting out meat for the last month (no grains, high animal fats and organ meats, fermented vegetables, etc.) because I too have read many things listing carbs and refined/pseudo grains as inflammatory. Got some bone broth as well. Still keeping away from any processed sugar, gluten, trans fats, artificial flavors, corn and soy, but I'm adding in goat cheese and possibly raw dairy in the future. I will definitely check out the book by Peter Bales.
If you ever want to send anything interesting you find, my email is marolinegdon@gmail.com and I am always open to chatting with people who struggle with knee pain because we have to remember we aren't alone. Thank you again so much for your help, and congratulations I hope you had a fantastic honeymoon!
Hi Caroline, sorry to hear your difficult times with your knees. I can't say I'm in much of a better situation by any means but it's so important to be positive and cherish the smallest wins and enjoyments, so keep strong and they'll be better times ahead. I'm just 26 and after a skiing overuse injury three years ago I have been in chronic pain ever since. A 'warrior' attitude as Richard aptly names it in his book landed myself in quite serious difficulty a year ago through attempted strengthening (muscle focus), which forced me to work remotely for five months before I had to leave work. I have been on and off crutches for 8 months, unable to do much and facing such little improvements.
DeleteA couple of weeks ago I was starting to be able to walk a bit more freely, managing 5 minutes relatively comfortably. All this sudden change led me to book in a session with my physio, following which I followed his guidance and pressed forward with split leg squats. Of course, this is probably an exercise that is more like two years away from being suitable, and the all too familiar onset of pain and despair set in once again.
But wait, there is a silver lining. If I hadn't somewhat foolishly attempted the exercise that has exacerbated my issues so many times in the past, I wouldn't have landed on Richard's e-book and come to the realisation of what my situation actually entailed, not to mention the discipline I will need to employ to improve it.
So now I am more positive, believing I am better equipped to tackle this monster and embrace life once more (even if that might be in one, three or five years time!).
P.S. I have had MRIs on my knee and in fact there is nothing significant to note asides from a slight ACL sprain. The reason I am saying this is for so long I have been convinced my knees must be in pieces due to the crippling pain, believing if only I knew what was wrong I could settle and fix it. But I think searching so long for this (it took two years for me to obtain an MRI) and having so many people around me waiting on it was a real barrier to me digging deep and addressing the issue properly. On the flipside, with your case it may well be making it more difficult to hear of the diagnoses from doctors, and I think, as you are starting to find, discipline and diligence in research and self-help through diet is starting to change things against the odds.
I think I'll be sharing my story like you have in more detail as it's maybe interesting to hear a case where someone's knees are in a very painful state and yet the mechanics seem in order, potentially emphasising the importance of an aggravated joint in the genesis of pain and not simply structural deviations from the norm. I believe in you.
Caroline L sounds like you've had a terrible time, sorry to hear. Matthew C I am in a similar situation to you I guess although mich older than all of you (46) when I guess problems with wear and tear can start to be expected. I have been fit, strong and healthy for the last 20 yrs (more so than in my teens!) and live in the French Alps where I've spent the last fifteen years skiing a couple of times a week all winter. I had a ski fall in February this year and since then have had an ongoing battle with my left knee, with inflamation, difficulty walking for long, difficulty standing for any length of time. 1st MRI in May didn't really show any structural problems with knee, but I embarked on a rehab programme, and spent a lot of time in the sea (which I felt really helped with mobility even though I could not be described as 'swimming'!). By Sept I was defnitely a lot less 'precious' about my knee, it was starting to feel stronger although my quads, glutes etc. were still weak. I guess I'd got to a stage where I felt I could cope with it. Moved back to the Alps late Sept and started with a new physio who was horrified at lack of quad muscles etc. and immediately set me doing things I wasn't comfortable with, squats, one leg standing up from sitting etc etc. Surprise surprise, my knee filled with fluid again and was painful so I went to see a specialist doc that had been recommended to me, who on the 1st appt applied 'mesotherapy', which is basically micro injections into the knee. Didn't seem to do much so after ten days at follow up appt he drained some fluid from my knee and without asking or consulting with me first gave me a corticosteroid injection (even after doing he just told me it was a ''medicament' and it was only as I had the prescription to replace it that I looked it up and realised what he had given me. It may gave exacerbated my symptoms, hard to tell really as my physio by then had also backed off seeing how imflamed my knee was, and suggested I had another MRI. Result of this was chondromalacia stage 2-3 but otherwise structurally sound. Back to physio with MRI results and she immediately starts wanting me to do squats etc, which I have been told categorically not to do. I have now just found this blog and it basically validates everything I have felt instinctively for months now i.e. I've been going round in circles with overdoing physio etc. I no longer know who to trust and am so sick of docs and physios looking at my lack of quads and saying we must strengthen them but then my knee just blows up again. So it's been incredibly helpful to read others stories, although what this does tell me is that I possibly still have a long road in front of me. I will be moving forward with advice from this blog and the various books, workouts in the pool (which I've already been doing and always feels good) and cycle trainer (low resistance) which seems to be ok. Would love to hear how you are getting on Caroline L and JFitz too!
DeleteSorry about the long post and lack of paragraphs!
DeleteOh geez my comment was SO long. My apologies!
ReplyDeleteNo worries, a lot of people tell their stories here, and sometimes they do get long. I've noticed that the people who wind up on my site are usually the hard-luck cases, and hard-luck cases have no simple, easily condensed histories.
DeleteIt sounds like you're in a tough place right now. I would take a deep breath, find some blessings to count (I'm sure there are a few at least), and think about JFitz's recommendation above, to check out Doug Kelsey's book, The 90 Day Knee Arthritis Remedy. I just noticed it's selling on Amazon for Kindle for less than $10. Wow! That's a steal. Anyway, his book might give you more hope as well as a structured approach to a movement regimen that will help in healing.
Good luck!
Hi Richard, thank you for your response. Indeed, deep breaths and finding the appreciation for the little things have been vital to getting through this time. I actually did buy Doug Kelsey's 90 Day Arthritis Remedy right after I finished your book a few months ago, but got a little discouraged after I read the part saying the information is most applicable for those with stages 1-3 arthritis. I won't have an updated MRI for a little while longer, but my chronic swelling/inflammation seem to indicate stage 4. However, I will def push through and finish the book as I know there is more valuable information and exercises that might be available to me sometime in the future. Pardon my delay, and thanks again for creating such a supportive virtual community!
Delete- Caroline
Oh, also wanted to clarify that I walked on my injured legs for work for so long because I didn't have health insurance in the states, and I did in Spain. I had to stay to be able to get my MRI, CT scans and X-rays done. Just so I don't sound totally insane. :)
ReplyDeleteHey there. First of all: thanks for such an insightful book. It helped me a lot.
ReplyDeleteI got a question for you: do you know anything about pes anserinus (goose foot)?
I always had a little pain there. I can't remember since when. It looks like it's been there forever. I have some tiny lesions at my knee cartilage (kneecap and throclea) that used to swell my knees whenever I played soccer or did some hard exercises like box jumps or lots of squats (but I tolerate well hamstring exercises). Now that I adopted light motion and halted those kind of activities my knees feel really good, but I seem to notice more the pes anserinus.
So (finally) my question is: do you know any good treatment to them that won't hurt my recovering knees and also what kind of relationship this might have to all the knee problem?
Thanks in advance.
Bruno Feroleto, from Brazil.
Goose foot! That's a new one. Unfortunately I am unfamiliar with this condition, though someone else here may know something. Anyone?
DeleteBruno, I know exactly what you're talking about because I have a lot of symptoms in that area and have done a lot of research on this. For those of you who are unfamiliar with this, the pes anserinus is where three tendons converge just below the knee on the inner side of the leg. (It's called "goose foot" in some languages because that's what it looks like). This area is very tender for me and it's where I feel pain when I've done too much walking. I also feel pain beneath the kneecap during other activities, like sitting. I don't know whether or in what way the pain in the two areas is related (i.e. is the tendon problem making me feel pain in my kneecap area, or is some problem in my kneecap area referring to the nearby tendons?)
DeleteCheers,
Pax
Hey, there!
DeleteNice (and sad at the same time) to see I'm not alone, Pax.
Thanks for the replies.
I subscribed the Kelsey Report (Doug's newsletter may I say) and this week I received an e-mail about a free webinar by Laurie Kertz on "3 Reasons Why Traditional Rehab for Knee Pain Often Fails… and What To Do Instead".
There will be 3 dates:
Wednesday, November 20, 2019 at 12:00PM (CST)
Wednesday, November 20, 2019 at 7:30PM (CST)
Friday, November 22, 2019 at 2:00PM (CST)
So I reccomend you subscribe it too.
In my case, 5-6 months on pills (Celebrex) was the key to getting my synovial inflammation down to a point where I could think again! And work out what made it worse, what made it better. And get some of my life back.
ReplyDelete7.5yrs on, I'm 90% fixed. Not 100%, I can still feel those stiff/burning sensations lingering in the background sometimes, but much much better and back into intense exercise (though not running yet).
One thing I've discovered lately that I think helps is knee swings - just sitting on a table and gently swinging knees back and forth. I try to do this for 5mins before I ride and 5 mins after now. I also regularly ice if I think my knees are moving in the wrong direction again.
I think I could have done it without the pills if I'd virtually shut down my life like Richard did, but I was not patient enough to do that.
Gently swinging knees back and forth seem to be magic. I feel like my knees are "back to place" when I do that.
DeleteOne thing I was wondering is are we getting enough sleep?
Whenever I sleep more than I'm used to (weekends and holidays) my knees feel better. If I can sleep more for 3-4 days it feels like my knees are almost normal.
If I only could reduce my working hours...