A Good New Year's Resolution: A Vow to Be Patient

I was out doing my twice-a-day walk recently and a thought struck me, as I kicked a rock out of the way.

If you found a rock, and put it outside, and took a close-up photo of the rock once a month for ten years, you would have 120 photos, and would probably arrive at an interesting conclusion:

Rocks don't change over time. The rock in the first photo would look identical to the rock in the last.

But we know that rocks do indeed change over time. It's just that it takes a long time, usually, for visible changes in a rock to appear. Most don't look any different after 10 years, or even 100 years.

Similarly, healing from chronic knee pain can be maddening, because it's so slow. On any given day, it can seem that there's been no progress.

In fact, in a way, it's worse than watching a rock, waiting for some change to occur. With a bad knee, you will have good days and bad days and in-between days, and you'll feel like you're going forward and then sliding back a few days later. In the end, you may feel so confused you want to give up.

That's why, as we approach the new year, I think the best thing many knee pain sufferers can do is adopt an attitude of patience. Healing is usually not quick. Go into your knee rehabilitation program with that mindset, and you can only be surprised pleasantly if healing is faster than expected.

But if you go into your program thinking, "I can fix this in a few weeks," you risk being so frustrated that you lose hope.

So, I'm wishing everyone out there with knee pain some patience in 2021. Good things can happen. Just look at the many success stories on this blog (there was just one posted in the comment section last week).

But patience is often necessary. And that patience will be tested severely, so be prepared for that too.

Open Comment Forum: How are YOU doing?

I figured I'd do an open comment forum today, hopefully to stir up some discussion.

As usual, feel free to bring up whatever you want in the comment section below: new studies, vexing knee problems, lingering frustrations, what's working, what's not working.

If you don't feel the need to say anything in particular, then if you've been a knee pain sufferer for a while (and a visitor here), it would be nice to hear an update of how you've been doing. Often, I've been happily surprised to hear from people who started leaving comments seven or eight years ago, then disappeared for a while, and later resurfaced to share their stories.

Mine is, unfortunately, a rather boring story at this point. I feel like a bit of an impostor sometimes. See, I have this blog about chronic knee pain, but I don't have chronic knee pain anymore. Now, knock on wood, I'd like to keep it that way and don't want to tempt fate. I'm aware that circumstances can change swiftly.

But it's a relief not to have to plan my life around a pair of complaining knees. Yesterday I rode hard on Zwift (virtual reality cycling!), banging out close to 3 watts per kilogram for two and a half hours. Today I meant to go easy on Zwift, then got suckered into trying to catch a large group of riders climbing a long, steep mountain road, and so I had another intense session.

And my knees are fine. No ice. No stabbing pains. Nothing. I know I'm lucky that my knee pain story has become boring.

But what about you? Anything to share? Please leave a comment below!

'I'm Only 18. I Have Knee Pain. What Now?'

Recently, an 18-year old suffering from knee pain left some questions in the comment section.

A brief synopsis of this case:

I have been experiencing patellofemoral pain (as well as achy quads and calves, and some sharp medial pain that comes and goes a bit too much for me to fully attribute to a meniscus tear) for 7 weeks now. ... I am only 18 years old, was previously fairly active on a day-to-day basis, and a runner and casual player of many sports. I can work out why my pain (probably) started - a sudden fitness obsession after months of a mainly sedentary lifestyle brought on by the pandemic and moving from a relatively flat area to a rather hilly one.

Then, the person asked:

After reading your book and Paul Ingraham's, I have some questions. Firstly, I know that both of you encourage rest and many doses of light exercise to slowly build up joint strength. This seems reasonable. But what did you do (or what do you recommend) when you were *not* able to rest and *had* to push that envelope of function? Does this mean constant setbacks, or is it possible to push it a bit and then rest/light exercise for a longer period of time?

This reminds me of something that of course should be quite obvious: We live imperfect lives in an imperfect world when it comes to developing programs to heal. We have to sit too long at desks at work. We have to climb hills sometimes to get to the commuter train station. We have small children who insist on being carried around.

What's the answer to all these knee-unfriendly obstacles that are part of everyday living?

I wish I knew. Luckily, when I lived in Hong Kong, I was largely able to control my healing program. But I quit my job and had no family at the time! This enabled me to conduct a scientific-like experiment, and not many have that luxury.

My best thoughts on this are that people should control what they can, closely monitor what they can't, and try to learn from mistakes. So for instance, if I know that I have to walk up a couple of hills just to get to my train station (which I can't control), then maybe I don't take a long walk at lunch and instead do something less intense (which I can control).

Also, if I'm doing something that turns out to really bother my knee (in other words, I made a mistake), I should try to learn from that. But what if it's something I can't control, like walking up those hills? Well, humans are quite ingenious and can often solve difficult-seeming problems.

So maybe I try walking up the hills much more slowly. Or I hitch a ride with someone. Or?  

And then this question:

Secondly, do I have a chance of this not lasting as long as your pain and the pain of some others in this blog, as I am starting my attempt at recovery (hopefully) early and because of my age?

I think your age is definitely a positive factor, being only 18. And if you've only had your knee pain for seven weeks, and you're already serious about fixing it, you should be in very good shape indeed.

Try to be positive! Which leads us to:

Thirdly and finally, what advice do you have about the emotional side of pain? I was very depressed and anxious for over a week after one of the remissions and I am now grimly aware that this recovery may be a long, non-linear process and I may never get back to running or competitive sport again.

Well, heck, that sounds grim! I already sense a lot of negativity here. So I would tell myself:

I'm only 18. I haven't had knee pain that long. I have a great chance of beating this, and I will.

What I might do, if I were you, as you seem to like to be very active: Figure out a new knee-friendly sport to throw yourself into (well, ease yourself into may be a better phrasing). I think cycling, if you can tolerate it, can do wonders for bad knees. Some people like swimming, or exercising in the pool.

Again, try to be positive! I've read a lot of very tough, hard-luck cases in the years doing this blog. And yours, be thankful, isn't one of them. You seem like a great candidate for figuring this out and being able to do a lot of the activities that you did before this pain crept into your life.

Good luck!

If anyone else has any thoughts, please chime in below, thanks. 

When Knee Pain Comes With Golfer's Elbow

 I got this comment recently:

Hey Richard, funnily enough I have now developed that elbow pain you were talking about in your book. Has yours healed now? Any tips?

That "elbow pain," for me anyway, was "medial epicondylitis," also known as golfer's elbow.

Some context: I had had the knee pain for a while. The golfer's elbow just came out of the blue. There were no identifiable triggers for it. None at all.

Of course, as many of you know, this led to a lot of musing on my part about the ghost of inflammation loose in the haunted mansion of the body (if you want to ladle on those Halloween metaphors).

In other words, once inflammation takes up shop somewhere, in a matter of time you can develop other weird, seemingly unrelated problems in distant areas of your body. And I think the problems may be connected.

I have not seen a lot of science on this, so I could easily be wrong here. But I find it very odd that, as my knee pain deepened and persisted, various other ailments began to plague me, from the golfer's elbow to back pain (though that had a proximate cause, because I was sitting in an unnatural position).

Anyway, to the question: what to do?

I had terrific success with eccentric bicep curls (look them up on YouTube; you'll find lots of videos).

We're all accustomed to regular bicep curls, where the effort is expended in curling the weight up. For the eccentric version, the emphasis is on slowly releasing the raised weight back down to the starting position.

Over time, I really think this rebuilt the chaotic tendon fibers. My tendons went from being painful and dry and crackly feeling (they were almost like parched sticks, it seemed) to normal. I have no problems today and there's no reduced tendon strength as far as I can tell.

Be patient though. It does take time.

That's my experience, at least. Anyone else with any other ideas?

Some Good News About Cartilage's Ability to Rebuild Itself

I’ve said before that there won’t be a third edition of Saving My Knees because I expect that what lies between the covers will eventually no longer seem that radical and will become widely accepted.

And, happily, along comes a New York Times article to underscore that very point.

To recap, what I’ve said (in the book and on this blog):

The cartilage in your knees doesn’t simply “wear out.” It’s not like the tires on your car. It has an underappreciated ability to adapt and even repair itself (though very slowly).

To be clear, these insights don’t originate with me.

Doug Kelsey, an Austin physical therapist and author, was the first person to really awaken hope in me when I was struggling with a pair of bad knees while living in Hong Kong.

The gist of what he said: Don’t believe pessimistic doctors who say bad knees never get better. They certainly can.

I also uncovered scientific studies showing natural changes in cartilage that indicated the tissue, over a period of several years, showed signs of getting worse, yes, but also of healing. Places in the knee joint that were bone-on-bone often had cartilage filling in the holes when examined by MRI a few years later.

Okay, that’s a bit of a long windup for this New York Times article. The Times was looking at  running and the hoary myth that running is bad for your knees (to be clear, it can be, if you run when injured or don’t train properly).

Ross Miller, an associate professor of kinesiology at the University of Maryland, was involved in a study to try to figure out a puzzle: why, if running pounds knees so hard, don’t more runners develop conditions like osteoarthritis?

He knew that some recent studies with animals intimated that cartilage might be more resilient than researchers previously had believed ... animals that ran tended to have thicker, healthier knee cartilage than comparable tissues from sedentary animals.

The study looked at what would theoretically happen to the healthy knee cartilage of two groups: one would walk six kilometers (roughly 3.7 miles) a day for years, the other instead would walk for three kilometers and run for three.

It’s admittedly a bit confusing to follow what was going on: volunteers were going around a track that had embedded force plates, which measured the impact of running and walking. The collected data was fed into complex computer simulations, that drew on lots of other data too.

Now, here’s the really interesting part, and the Times explanation is a bit confusing, so I'm going to simplify.

There are three possible scenarios for cartilage and how it responds to running:

(1) The cartilage can’t change to adapt to the harsh forces (and therefore would be expected to deteriorate over time).

(2) The cartilage can slightly repair itself after repeated minor damage.

(3) The cartilage can remodel itself and adapt to the intense forces, growing thicker and stronger, just as exercise builds up muscles.

If you were to poll most orthopedists, I bet their beliefs would fall mainly into scenario (1) and (2), but certainly not (3).

Surprise.

If you assume (1) is true, runners have a 98% chance of developing arthritis in their knee joints, the study found. Even if you assume (2), the slight repair taking place isn’t enough to counter the frequent running, and their chances of arthritis decline only a bit, to 95%.

But if you assume (3), they have a 13% chance of eventually suffering from arthritis, which is the same as for the people who were walkers only. This does seem to match up with evidence that the incidence of arthritis among dedicated runners isn’t higher, and may be lower, than for the rest of the population.

The article concludes:

What these results suggest is that cartilage is malleable, Dr. Ross says. It must be able to sense the strains and slight damage from running and rebuild itself, becoming stronger. In this scenario, running bolsters cartilage health.

I can’t say this would surprise me.

I just hope orthopedic doctors see this article too.

Could Turmeric Be Useful for Muting Knee Pain?

The latest study making the rounds is about the possible health benefits of turmeric for knee arthritis sufferers.

Turmeric, a yellow spice with a bitter taste that most people probably know as the flavoring for curry, is believed to be an anti-inflammatory.

The study took 70 people with knee pain and gave half of them a capsule full of an extract from turmeric every day for three months. The other group received a placebo.

After the trial concluded, the people taking the turmeric extract had more improvement in pain than the placebo group. The typical benefit was described as “modest.”

One red flag with this study: a supplement maker supplied the pills for the study and some of the funding. Knowing the history of glucosamine, and the early poor-quality and conflicted studies that were done looking into its efficacy, I would urge an appropriate dose of caution because of that.

Someone involved in the study does acknowledge that more research needs to be done.

That leaves me curious: Has anyone out there had success with using turmeric?

I suppose I should share my own experience. When I was in Hong Kong seeking to heal from my chronic knee pain, my mother sent me a bottle of pills, and I remember that turmeric was touted as one of the main ingredients.

I took all the pills. I noticed no difference in how my knees felt.

But that’s just my own experience. Anyone else out there have a story about turmeric, good or bad?

Does Thinner Cartilage Cause More Knee Pain?

Here’s a study that could be of interest, as it casts doubt on the relationship between cartilage loss and knee pain.

The researchers found that a thinning of cartilage was associated with only a modest increase in knee pain. The writeup was published in the Annals of the Rheumatic Diseases.

There were 600 subjects who either had, or were at risk of, osteoarthritis of the knee. MRIs were taken of their knees at the outset, after one year, and after two years, then the images were compared.

Loss of cartilage thickness was significantly associated with a small degree of worsening knee pain over 24 months.

David Felson, one of the researchers, did note that an “indirect path” exists between cartilage loss and knee pain. The relationship could be through nerve-rich structures, such as the synovium and bone marrow.

Good news, right?

My first inclination is to say: sort of.

I wonder if the condition of the cartilage is more significant than the thickness. If the cartilage is thinner, but is stiff enough to absorb shocks well, it seems logical that someone would not feel pain.

But, to be fair, there is good news here. The welcome implication is that you don’t have to restore your knee cartilage to normal for your pain to go away.

Finding the Numbers to Your Combination Lock

I went on a 103-mile bike ride yesterday -- phew! Some say it's not the heat ... but yes, it's the heat! It's hard to stay properly hydrated when the temps climb into the upper 80s. This morning I'll be in the basement, riding the stationary bike, trying to make up for the fact that yesterday's ride burned up most of my day.

Now then, here's a reader comment that put me in mind of something Dr. Scott Dye once said:

I have no idea what is the matter with my knees, have had no diagnosis and have kind of given up on that front, though I'm convinced it started mentally as i was suffering from chronic stress at the time, I also have a raised vein or nerve in leg so could be that WHO KNOWS. They do improve a lot with motion though, and lately on my walks ive just had the urge to start gently jogging, its like my body wants to take off, whats your advise on that? I havent jogged but i really want to.

Here's what Dr. Dye said that I found to be very true, though curious coming from a physician. It concerns the difficulty of finding the right program to heal a person's bad knees:

“It is not unlike trying to find the numbers to a combination lock.”

We tend to naturally attribute shaman-like qualities to our doctors, believing they have an almost magical power to heal us. How strange it is, then, to hear a doctor compare what he's doing to cracking a safe. It's perhaps a bit unsettling. Aren't doctors supposed to be supremely confident in their diagnoses?

But I think Dye's observation is quite perspicacious. He nails it. The fact is, there is no manual on healing knees that will work equally well on all knees. A certain amount of experimentation is in order.

Partly I have come to that realization from listening to all of you while writing this blog. As I've said before, I wrote my book naively assuming that what I did would be useful to the same degree for everyone. I still think the book has enormous value, and broadly the approach is the correct one, but I've also tempered my position somewhat, so that now I'm closer to Dye's thinking:

Healing your knees will involve finding a solution that will probably be, to some degree, unique to your particular knees.

So why does this reader comment put me in mind of Dr. Dye?

Because here's someone who has bad knees, it appears, but who wants to "start gently jogging." How could that be a good idea?

But suppose this person is right: that stress contributed to the knee issue in the first place. Maybe a little gentle jogging, getting the heart pumping and the body sweating, would help lower his stress levels -- and it might not be harmful to his knees too.

Maybe?

I am opposed to giving advice, but if I were this person, I might try an experiment: maybe try a short jog, very slow, maybe up a hill as that's less stress on the joints, and then monitor my knees for a couple of days. Do they feel better or worse?

If they feel better, maybe try it again, for a little longer, being careful of course and not pounding down hills.

Do I think this would have helped with my own knee pain? No, not really. But then again, if we are all trying to find the numbers to our personal combination locks, when it comes to beating knee pain, we have to be open to trying different things.    

A Goldilocks Theory of Cartilage Damage

Here’s a study I can’t access (without paying for), but I found the main conclusions interesting. The researchers decided to look at the following:

Knee cartilage damage is often linked to mechanical overloading. However, cartilage requires mechanical load to remain healthy, suggesting that underloading may be detrimental.

So there you have it. Essentially, they’re testing what we’ve talked about repeatedly here: trying to find a motion “sweet spot,” if you will. If you subject your knees to too much load, they will get worse. If you don’t subject your knees to any load, they will get worse too.

The key is finding that elusive “sweet spot” where they can handle the proper amount of load, which can be gradually increased over time. However, of course, this is no simple thing.

So what did the study consist of?

The researchers looked at how the load on a person’s knees correlated with worsening cartilage damage over a two-year period. There were 964 subjects, including 62% women. The average age was 66.9 years old, and the average BMI 29.7 (this borders on obese and roughly equates to weighing 220 lbs. for someone who is six feet tall).

People who walked a moderate or high number of steps each day (at least 6,000) and who had a high BMI (more than 31) had a greater risk of worsening damage of the cartilage in the medial part of their tibiofemoral joint, compared with those who were thinner.

But people who walked less than 6,000 steps a day and who had a low BMI were at higher risk of worse damage in both the medial part of the tibiofemoral joint and lateral (outside) part of their patellofemoral joint (where the kneecap meets the femur). They were compared to a group that also had a low BMI but walked more steps.

Clearly, one takeaway is that weight has a big influence on how much walking you can safely do.

But the results also do suggest that there is an optimal level of motion: too much will cause further damage, and not enough is harmful too.

The trick is finding that proper balance. What’s scary for people with bad knees is that finding that balance becomes a really hard task when your knees don’t seem to like to move much at all.

It will frustrate you endlessly, I guarantee. But when you do figure out the right balance, you are suddenly in a position to get better, slowly but surely.

And that's a great feeling, when you realize you're starting to make progress toward healing.

Knee Pain Recovery: When to Return to the Sport You Loved?

Someone left this question recently (edited for brevity):

My side question to you is, how/when did you decide cycling was reasonable to try again? It has been 2+ years since I have been on the bike. My knee pain/symptoms have improved. I can now go on 2 mile walks, use a rowing machine for 15 min, even do gardening & housework. Of course if I overdo it, my knees will remind me and I can have a setback. So day to day life is so much better than two years ago, so I don't want to risk losing that. ... What was your indication that gave you confidence to try cycling again?

Viewed narrowly, this is a question about cycling. When can someone return to cycling after a bout with knee pain? But I think it’s a question that could be asked more broadly: During your recovery from knee pain, when is it appropriate to return to your favorite sport, “x”? (Here’s more musing on that question by the way.)

Answering this should force you to confront an unpleasant question: Was sport x somehow involved in your developing knee pain? Chances are it was. And when that’s the case, you might have to be even more careful about returning to that activity.

For me, cycling was something I really loved. I loved the intensity of the workouts, climbing hills and pushing myself to the limit, trying to set personal records on courses. I also knew I was a pretty good rider – nowhere near good enough to ride with the best, but competitive on a local level.

After developing knee pain, I had a tough time giving up riding my bike. A few times, when my knees felt a little better, I would get back on the bike, thinking, “Maybe, just maybe, they’re fine now.” Of course they weren’t, and a few minutes later I would get off the bicycle, miserable, wondering if my knees would ever heal.

Finally, I reluctantly gave up cycling. I said, “I just can’t do this and get better.”

For me, getting better was partly about accepting a grim truth: I might never be able to ride my bike again. In fact, I think it’s almost easier if you manage to convince yourself that that part of your life is history. When you accept that, you’re not always trying to climb back on your bike on the first day you have pain-free knees.

But at some point, I did of course.

It was after I returned to America from Hong Kong. I knew my recovery was well in hand, and I felt confident it was just a matter of time before my knees were normal again.

I can’t tell you I reached this decision about returning to cycling after x weeks of no pain from my knees, or after two months of being able to do x. Heck, I don’t even remember now.

What I do recall about the decision: As I said, I had pretty much given up on cycling, after failing on multiple occasions to ride without triggering the burning in my knees. Instead, I was just focusing on getting better. And, at some point, when I felt like my knees were really stronger, and that I wasn’t at risk of backsliding, I rolled the bike out, took a deep breath, and went on a very, very slow ride. And my knees were fine.

Open Comment Forum: What Was the Biggest Mistake You Made?

Of course the normal open comment forum rules apply: Feel free to ignore my suggested topic, and talk among yourselves about whatever you'd like.

But for anyone who wants to go along:

What was the biggest mistake you made when it comes to managing or dealing with your knee pain?

This is probably a moderately hard question. I pondered it myself. I couldn't think of a single event.

As in, I can't really say, "The biggest mistake I made was seeing Doctor X and taking his advice to do Y."

Rather, I think the biggest mistake I made was not taking my knee pain seriously for months, and assuming it would go away, because I was healthy and had always recovered well from minor injuries.

By the time I did take it seriously, I was in a really deep hole. And then, at that point, unfortunately I kept digging that hole. I knew I had a problem with knee pain. I knew it wasn't going to magically resolve itself. But still, I tried to keep semi-active. I stressed my knees more than they could handle.

Then, finally, I hit that low point where I conceded how bad things were, and with that knowledge, I could chart a path to recovery.

What about you? What was the biggest mistake you made?

Anyone Want to Talk About Using a Walking Desk?

I got this comment recently. Lately I have been trying not to sound like a broken record (it feels like I've written about so many topics already on this blog), so I've been sifting through the comment section for ideas for new posts.

Richard - Thank you for publishing your experience and being a resource for us. I've been dealing with pfp for 2 years and it's when I'm sitting at my desk that it's worst. Recently I fashioned a DIY cycling desk at my apartment, which has been effective but nothing helps as much as walking. Curious if you, or others, have invested in a walking desk?

Anyone want to share their experience with a "walking desk"?

I was curious about walking desks -- no, I've never used one -- so I did a quick Google search. They look like a treadmill married to a small, simple table at the proper height. See here for an example.

Hmm. Looks interesting. Prolonged sitting is poison after all, right? I really do believe that.

So here are a couple of quick thoughts from me about "walking desks," and I warn you again: this is coming from someone who has never tried one:

* They look like an interesting idea for people who are already fit. I noticed that in the images that Google brought up, most everyone pictured looked like they could go out and run about 5 miles, no problem.

* For people with bad knees, I'm not so sure, but I guess it depends on how bad your knees are. They remind me too much of my early failed experiment with walking constantly, after I realized that the key to rehabbing bad knees was motion. But I overdid the walking. In a big way.

* So with a walking desk, what happens when you need to take a break? After a while you will get tired. Your muscles will be tired. Your feet will be tired. Maybe your knees will be tired too. Do you shift over to your non-walking desk nearby? Or are you supposed to be walking for an entire eight-hour day? Not sure I'd be keen about that.

Who out there has tried a walking desk, or a similar setup? Want to share what you learned?

When Your Doctor/MRI Speaks a Foreign Language

I got this comment recently:

Hi Richard, not sure if you have any suggestions or experience on exercises or treatments regarding diagnoses of focal chondrosis, narrowing of the patellofemoral joint, subluxed patellas or joint effusion?

Well, that's a mouthful certainly. What's all this clinical jargon mean? (And why do medical technicians and professionals always speak in some baffling foreign language?)

Anyway, here's my take. If I'm wrong, someone feel free to correct me, but I think I'm in the ballpark:

"Focal chondrosis" appears to be simply a loss of articular cartilage. "Focal" suggests a particular location (or locations).

"Narrowing of the patellofemoral" joint is what it sounds like, and was perhaps seen on an X-ray. If there's loss of your protective cartilage, an X-ray will simply detect that the joint space has narrowed. That's because the cushioning cartilage has thinned, showing the bones closer together. Remember: an X-ray can't actually see the tissues, so basically someone infers what's going on based on how far apart the bones are.

"Subluxed patella" seems to be a patella that's mistracking or becoming partially dislocated. On this point, I'd be curious. Is this something that's just been "clinically observed"? Or what exactly is the evidence of this?

There are plenty of reasons to be skeptical when it comes to the role of patella mistracking when it comes to knee pain. See here, here and here, for instance.

And finally we have "joint effusion." "Effusion" is just swelling. So you've got swelling in your joint. D'oh! No big revelation there, I'm guessing.

At this point, what exercises might be suitable?

Well, "effusion" suggests that the joint is being stressed beyond what it can handle. That means that, whatever exercise regimen you choose, it should probably be fairly easy, at least in the beginning.

As for the cartilage loss, this bears repeating: cartilage loss, by itself, doesn't have to be a sentence of knee pain and misery. It does often correlate with knee pain and misery, true. But someone can have knees that feel healthy while having pockmarked cartilage.

What exercises are good for these conditions? You might want to consider activities that slowly build the strength of the remaining cartilage. They could be low-load, high-repetition. And, of course, you want them to be easy (see "joint effusion" above).

Finally, what about the "subluxed patella"? Hmm. A couple of quick thoughts:

(1) It's not really medically significant, even though some misguided doctor/physical therapist thinks it is. In that case, you might want to just try the light-load, high-repetition, and see how it goes ...

(2) It is medically significant. In that case, honestly, you might not get any satisfactory results apart from surgery. "Muscle strengthening" programs probably won't do the trick.

So those are a few thoughts. Others are welcome to comment below. And, of course, remember: none of us has seen your knees. We're just throwing out things to consider. Your best advice, in the end, is really to see another doctor and get that second opinion.

What Footwear Should a Knee Pain Sufferer Look for?

A short post today, drawn once again from the comment section.

Someone threw out the question: What’s the best footwear for someone with knee pain?

Ah yes. This is familiar territory. In Hong Kong, one of my experiments was with a pair of fancy $100 shoes that promised to lessen my knee pain by some impressive percentage.

I was really eager to try these out, thinking they might even shorten my time to healing. So I put them on and ... it was a disaster. They didn’t help at all. $100 down the toilet.

Now, sometimes I suppose that your physical therapist might advise special footwear to correct some “imbalance” in your step or stride.

I would be rather skeptical about this. That’s me anyway. Physical therapists all too often like to put forth theories of pain resulting from crookedness and imbalances.

I’m doubtful that malalignment is a significant problem for most knee pain patients, as I’ve said repeatedly before. Dr. Scott Dye, who I respect greatly, is also skeptical that it lies at the root of as much knee pain as the therapeutic community would have us believe.

So back to footwear: Does it matter at all?

Yes, I think it does, and maybe a lot. But my requirements would be simple: comfortable and well-cushioned shoes, such as for running. Running shoes are designed to lessen impacts on the joints, absorbing some shocks before they reach your knees.

To me, that’s a pretty good match for what I’d want.

The person who wrote the comment also asked about going barefoot around an apartment or wearing slippers. Hmm. Not sure there’s a big difference there, but thoughts from others are welcome.

Stay safe all!

Could I Have Healed My Knees Without Quitting My Job?

This question occasionally comes up. It was in the comments section recently, and since I’ve decided to try to flip as many comments into posts as possible, I thought, “Why not?”

So, could I have gotten better without quitting my job?

The honest answer, really, is I just don’t know. I’m doubtful. But maybe I could have. It would have been much harder certainly.

But let’s unpack this one for a moment. Because, partly what I was doing by leaving my job to try to heal my knees, was establishing “proof of concept.”

Remember: the only doctor I had faith in, while living in Hong Kong, had told me flat out that my knees would never get better. “Never” is a big, final-sounding, devastating word. I’m sure he saw himself as a truth teller, trying to dissuade a naive patient of notions he could still heal.

But I took this as a challenge, because I’m that kind of guy. Could my knees heal under the most optimal conditions – if I quit my job, devoted my life to what I was convinced it would take to get better? If I succeeded, it would show that at least some of those dire verdicts that doctors deliver to patients are unwarranted.

In the end, it was a great feeling of vindication when I realized I was right, and I was going to heal all the way. I felt as if I had won my life back.

But what about you? That’s really what you want to know, even though you’re asking about my knees. Can you heal without quitting your job?

And, my wishy-washy answer is, it probably depends. On how bad your knees are. On what you do at work to try to alleviate the stress of sitting. On your own inner fortitude and will to beat this thing.

I’m not advocating that everyone quit their job to fix their knees. It may work, but it may not. First, I’d try everything possible to heal my knees while staying employed (ahem, especially right now). Then, if you have to confront that hard decision, give it a lot of thought.

I also got this question:

Light flat gradual building up walking is the way to go. My question to Richard is how do you know what’s too much? As long as there is no pain during and after is that ok?

Well, no pain during and immediately after is, I would say, the minimum. But you also have to monitor for delayed onset symptoms, which can pop up a couple of days later. So this can be a very, very frustrating exercise, determining “how much is too much?”

So I would think of starting at a low base. What’s the easiest walking that doesn’t bother your knees at all? Then maybe cut that in half. One of the hardest lessons I learned early on was that my knees were much weaker than I thought, and I had to go more slowly than I expected.

Okay, that’s it for now. Take care everyone, and be careful. I know the warm weather is tempting all of us into going outside, but the world is not a completely safe place yet.

Simple Guidelines for Walking With Bad Knees

I thought I’d do something short on some things that I learned about walking with bad knees. A few simple rules (or since “rules” seems a bit strong, let’s say “guidelines,” with the caveat that this is what worked for me personally).

1. Movement is very, very important, so walking is often a good idea for people trying to recover from knee pain. But if you walk too far, and too fast, your knees will just get worse.

2. In the beginning, when you decide to “walk your knees back to good health,” you will almost invariably walk too much. This is partly because you will have forgotten that you now have a pair of bad knees and that walking can be a very stressful activity for them.

3. Go flat for a while. Choose a walking path that has no inclines, no declines. Avoid steps. That will lessen the impact on your joints.

4. Walking downhill is more dangerous than going uphill. Your body weight tends to drop harder on your vulnerable knee joints. I used to pretend, when going downhill, I was stepping on eggs and trying not to break them.

5. Walking is a great idea! It’s one of those functional knee exercises that’s perfectly suited to something you’ll have to do, again and again, for the rest of your life. Sure, you can do all sorts of odd exercises intended to strengthen your knees, and the muscles around them. But it’s hard to beat walking for something practical that you need to master to be able to live a normal life!

Covid-19 and Antibody Math (for English majors)

I’m taking a break from talking about painful knees today because, well, it’s coronavirus all the time for everyone right now, it seems.

As ordinary people push harder to be allowed to return to work, and for their lives to go back to normal, health experts have been puzzling over how best to accomplish this.

One idea involves widely testing for antibodies, to see who has had the virus (and maybe didn’t even know it). Anyone with antibodies would then get some kind of “free movement” badge, I guess, and could go wherever they want without fear of becoming infected.

But of course it’s not that simple, as we are being told:

... we still know very little about what human immunity to the disease looks like, how long it lasts, whether an immune response prevents reinfection, and whether you might still be contagious even after symptoms have dissipated and you’ve developed antibodies. Immune responses vary greatly between patients, and we still don’t know why.

And so: lots of questions being asked, good questions. But what I found more intriguing was a Twitter thread I stumbled upon recently talking about, let’s say, “antibody math.” It was written in Twitter shorthand, and flung about phrases like “Bayes theorem” and “Pr(are+|test+).”

So yeah: practically unreadable.

But I thought it would be fun to unpack its message about the reliability of antibody tests. After all, if you’re going to get a badge that says, “Hey, I’ve got Covid-19 immunity!” you’ll want to know if it’s worth the paper it’s printed on.

The accuracy of antibody tests, it turns out, is basically measured two ways: by “sensitivity” and “specificity.”

“Sensitivity” is the percent chance that, if you indeed have Covid-19 antibodies, the test will detect that. So if a certain test has a sensitivity of 95%, that means that out of 100 people that actually have the antibodies, it will correctly identify 95 of them (on average).

“Specificity” is the interesting flip side: the percent chance that, if someone doesn’t have the antibodies, the test will get that right as well. So a specificity of 95% means that the test will incorrectly report the presence of antibodies, when they’re not there, only 5% of the time.

Now, it so happens, that if you dial up the sensitivity on a test, the specificity drops, and the other way around. So there’s a tradeoff between the accuracy of the two variables.

Okay, now for the “antibody math,” using an actual FDA-approved test by a company called Cellex. It has a “sensitivity” of 93.8% and a “specificity” of 95.6%. That sounds pretty good! Suppose you were issued a Covid-19 antibody badge based on a Cellex test.

What are the chances that you actually have the antibodies, and the test didn’t make a mistake?

This is where things get really, really interesting.

First, we have to make an assumption: how prevalent is Covid-19 in the population being tested? For this example, let’s say it’s fairly rare, and only 1% of the population has had the disease.

Let’s suppose we’re testing 100,000 people (by using this number, the math works out more easily, and we don’t even have to use decimals!). Let’s take that population and divide it into 100 slices of 1,000 each (so each percentage point is represented by 1,000 people).

We expect that 1% of our population, or 1,000 people, have had the virus. The test will detect 938 of these people because it has a “sensitivity” of 93.8%.

Now for the “specificity.” Let’s take the next 1,000 people in line, all of whom have never had Covid-19. The test mostly gets this right, but mistakenly classifies 44 as having the antibodies. (If you’re unclear how I got there: it correctly identifies 95.6%, or 956 of the 1,000 people, as not having the virus. The remaining 44 thus become “false positives.”)

44 may not seem like much. But remember: this is only one percentile that we’ve looked at here. And 99% of people haven’t had Covid-19. So we have to multiply that 44 times 99. Suddenly – yikes! – we’ve got 4,356 false positives out of our population of 100,000.

Now it’s time to wrap this up. The test identifies 938 people correctly. But it messes up on 4,356 more. That means we’ve got 938 positive antibody test results that are correct out of a total of 938 + 4,356.

Do the division, and that gives you 17.7%, which means a positive result implies a less than one in five chance that you actually had Covid-19! It would be a disaster to release people into the workforce based on this scenario.

The problem is, the number of false positives really distorts the accuracy for a rare disease. But if we tweak the numbers, and assume 10% of the population has had Covid-19, the math becomes more comforting (I’ll spare you the steps, but they’re the same as above).

In this scenario, if you test positive, there’s a 70.3% that you did have the coronavirus. Maybe still not high enough to get comfortable with, but a step in the right direction.

So what can we learn from all this?

* Antibody tests will be more effective in areas where the Covid-19 infection is relatively high, such as New York.

* If we decide to make antibody tests a key part of our “return to normal” plan, it’s important to first do enough random sample testing to get a good handle on what percentage of a given population has actually had Covid-19, because that number is a key input for accuracy.

* We can overcome the inaccuracy problem, to some extent, by testing someone multiple times. For example, in the example above where the test is 70.3% accurate for finding Covid-19 antibodies, testing three times lifts that percentage to more than 97% -- which is pretty good.

Okay, I’m tapped out for now. Hope someone out there finds this edifying (and useful).

Cheers, and keep moving those knees!

How to Move Your Knees in Quarantine

First, an update from last time, and thanks to all those who have expressed concern:

We live on Long Island’s north shore, in Nassau County: a beautiful place, God’s own heaven on earth it sometimes seems.

But Nassau County, as of today, has almost 14,400 cases of Covid-19. That’s more than the vast majority of U.S. states. Per capita, that’s even more than New York City. All this infection has blown up in a county I can drive across in less than half an hour. It’s a bit frightening.

But I don’t feel stress. My family, for now, is healthy. My 6-year-old son, who has pronounced anti-social tendencies and sometimes lives in a box house I helped him build, is flourishing and doesn’t seem to care if he ever sees a school again. :)

My wife is Chinese, and her mother keeps calling and asking if she is okay. She said the Chinese don’t understand why America wasn’t more prepared for this. We saw the images coming out of Wuhan. But that’s a story for another day, and perhaps another blog.

Today I want to briefly address this problem: how do you move your knees enough when you’re inside most of the time?

This is the easiest question for me to answer, because early in my knee recovery, much of my self-administered treatment came in my apartment. When I realized that walking, walking, walking outside was actually making my knees worse, I realized I had to severely cut back.

So I started doing walkarounds around my apartment. I’d just walk back and forth, every 10 minutes, then rest my knees in a comfortable position (e.g., I’d lie on my back with my knees slung over the edge of a couch). I lived in a small apartment, so there wasn’t a lot of room to move. But you really don’t need a lot of room.

The thing is, it’s nice being able to walk outside. You can enjoy the sunshine, the flowering trees, the birdsong. But you can also move in a space as small as a jail cell. It just takes some imagination and persistence to find ways to move your knees.

So how about all of you? How have your activity routines changed during these unsettled times? Drop a comment below; I’d love to hear from you! 

The Only Post I Can Write Right Now

I was thinking about what to write about this week and realized there is only one thing to write about, and that’s what everyone is thinking and talking about.

I live on Long Island, in New York. In my county of some 1.4 million people, there were perhaps a handful of coronavirus cases a little more than a week ago. Today there are almost 2,000.

I have seen the panic: long store shelves completely bare of toilet paper; pasta and rice stocks wiped out. I have also seen the blithe indifference to the danger, in a video of a crowded Florida beach during spring break. College students milled about in close proximity to total strangers.

I have two thoughts, and there is a connection to knee pain, and getting yourself in the right frame of mind to win a long battle against what seems like a formidable foe.

First, this is a time to make decisions based on reason, not emotion:

This virus is only rarely a death sentence. Many mild cases aren’t being counted in the tallies of total cases because of poor testing. That skews the “case fatality rate” misleadingly higher. In South Korea, whose widespread testing has been praised, I recently saw a death rate of 0.7 percent, which means 7 people in 1,000 die. Many of those who don't make it are older or have underlying health problems.

One thing to take some solace in: there are either no, or very few, children under the age of 10 who are dying.

Yet this epidemic remains a very, very serious problem. A lot of people, young and old, are winding up in the hospital and are being put on ventilators to help them breathe. This is not a run-of-the-mill flu, and that cannot be overstated.

The nature of this crisis threatens to overwhelm the health care system in America. We don’t have enough ventilators, enough masks, enough tests. Our government, sadly, wasted a couple of months when it knew the virus was spreading abroad and when it could have been preparing.

Second, a for-profit health care system, like the one in the U.S., is the worst possible one to have at a time like this:

Americans who feel secure knowing they have employer-paid health insurance should pause and think again. What if they lose their job, as so many are now? Or what about the tens of millions of people who don’t have health insurance, who will avoid getting tested and try not to go to the hospital to avoid being saddled with a $34,000 bill they can’t pay?

They may be in the Target where you’re buying your groceries. They may be delivering that Amazon box to your doorstep, even if they’re sick, because they can’t afford to take a day off. They may contribute to the spread of the virus because they are effectively outside the health care system.

This is tragic, insane really (as I’ve said before) for a nation this rich to have health care that only works for part of its population. We really need to fix that. We need to take care of everyone. In addition to that, we can have an extra layer of private insurance, if people really want that.

In the meantime, much like conquering knee pain, it’s to our advantage to take a positive attitude toward beating this virus. Right now life is surreal. We’re living through what feels like a bad movie. But we shouldn’t panic. The road ahead may be tough at times, but we’re tougher.

And Now for Something Different ...

I thought I’d try something different today.

Every day, people who are brand new to the world of knee pain are anxiously sorting through advice and ideas from websites they have frantically skipped through, hoping to find the formula for what works.

So what I’d like to do is invite people to submit questions below, related to knee pain. They can be questions directed toward me, and my book, or can be just questions about knee pain, and any of the problems related to it.

Obviously, this exercise is more suited for first-time visitors, but others feel free to jump in as well.

Then, what I’ll do in successive weeks, is pull out questions and devote blog posts to them. In cases where I don’t have answers, I’ll invite other people here to chime in.

One of the strengths of this blog, I think, is the community of rational, inquisitive, determined knee pain sufferers who regularly drop in.

Let’s see how it goes! What people care most about, I’ve found, are specific answers to specific questions, and in many cases, their questions are shared by many others.

When a Bad Knee Just Gets Worse

I came across this tale recently. It begins with our protagonist limping a little.

A few Tuesdays ago, I noticed Joel limping a bit, dragging his right leg. I asked him what was the matter. “Knee’s a little sore. Don’t know what I did,” was his response.

“Maybe you should rest it,” I suggested. “Do you need some ice?” 

“No, I don’t need ice. Good grief. Geesh. You think I’m a weakling?” he grumped.

Now what happens?

This is an interesting juncture for someone who has just developed knee pain seemingly out of the blue. The sudden, unexplained onset of knee pain can be frightening. It’s one thing if you bang your knee hard against something and then it becomes sore. A simple line can be drawn between cause and effect.

But if you can’t even recall what you did? Yikes. That’s not a good sign.

Well, Joel decides his leg needs more exercise. He chooses to walk downtown to run errands instead of drive. The next morning? Yup, you guessed it:

The knee is swollen. The limping is worse.

So he drags himself around the house for a while. He rests on the couch, an ice pack over the hurting joint. He starts wearing shorts, because his jeans won’t slide up over his swollen knee. His wife (narrating all this) gets exasperated with him.

Finally he breaks down and sees a doctor. An MRI is done. The report comes back with a lot of impressive-sounding jargon like:

“Large joint effusion,” “periarticular fluid signal and edema, greatest in the popliteal fossa and lateral soft tissues,” “subcutaneous edema in the prepatellar region, complex cystic structure along the later [sic?] popliteal fossa, adjacent to the lateral head of gastrocnemius.”

Of course the effusion and edema just mean that Joel has swelling. His doctor tells him the test confirms that his knees are getting old and orders medication for swelling and pain. And that is pretty much where the story ends.

But after reading this, I found myself thinking: Where did things go wrong for Joel, and why?

Things really went wrong when he decided he needed more exercise. So think about this in terms that have become familiar to visitors to this website: Joel’s envelope of function had narrowed. His knee joint hurt. It was less capable of handling stress.

So what does he do? He goes out and stresses it more than he would during a normal day when it wasn’t hurting!

Where the heck is the logic in that? What could have possessed the poor guy?

Here we can only speculate, but:

What’s the message you hear constantly from physical therapists trying to rehab bad joints? You need to strengthen your legs to protect the joint! Build up your leg muscles!

One can just imagine poor Joel Googling around for answers for his condition, landing on this message repeatedly – strong muscles protect weak joints! – and deciding, by God, he was going to strengthen those leg muscles and banish that knee pain!

Building up leg strength is a great idea ... before you have bad knees. Once you do, you need to move much, much more carefully. This is something that Joel has now presumably learned. That, and an MRI often isn’t really very useful. :)

Open Comment Forum: What Discovery Has You the Most Excited?

Okay, I'm going to hand the controls over to all of you.

As I've said a number of times, as I move farther away from my knee pain days, and as I exhaust new subjects to write about, and also -- frankly -- as I find myself increasingly strapped for time, I am writing shorter and also letting all of you talk among yourselves more often.

At this point, turning over the comment section to readers and letting you discuss issues that you're having, with people chiming in to suggest ideas, is probably most valuable.

So here's a question to get everyone started (or feel free to ignore this suggestion, and just talk about whatever you want to!): What's the discovery you've come across, say in the last five or six months, that has you the most excited when it comes to healing your knees?

It could be a scientific discovery. Or if you want to broaden the topic a bit, it could be an article you came across or a personal story you read about a knee pain sufferer who tried something that worked that you think may work for you too.

Anyway, open comment forum, so everyone's welcome to share their thoughts on anything!

Cheers, and I hope everyone is doing well in the new year.

The Villain in the Story: Inflammation

I’ve written about chronic inflammation a number of times. It’s sort of like writing about the hazards of being overweight, a subject that I think deserves multiple posts, even if they do become a bit repetitive.

My thoughts returned to inflammation recently because of an article in the New York Times that I happened to see in a newspaper I scavenged one day on my commuter train into the city.

Near the top is this paragraph, written with plenty of dramatic flair:

Specialists in the biology of aging have identified a rarely recognized yet universal condition that is a major contributor to a wide range of common health-robbing ailments, from heart disease, diabetes and cancer to arthritis, depression and Alzheimer’s disease. That condition is chronic inflammation, a kind of low-grade irritant that can undermine the well-being of virtually every bodily system.

Chronic inflammation is a dangerous beast. It’s hard to understate this. I had it. It started in my knees and, I’m convinced, spread in small, practically undetectable ways throughout my body. I say this because at one point (as readers of my book know), I went in for a blood test, thinking I might have rheumatoid arthritis, after experiencing weird problems with multiple joints.

My blood test was excellent: no signs of systemic inflammation. However, I am still convinced that there was something going on throughout my body that was related to my troubles with my bad knees. A knee doesn’t exist in perfect isolation. It’s not walled off from the rest of the body.

At one point I had bursitis in an elbow. And I had throbbing, constant back pain.

Now, being blissfully free of knee pain for a decade now, I see the inflammatory aspect of the condition as even more alarming than I did back then. To escape knee pain, I think it’s partly a race against time, if you have constant burning, or inflammation. You need to get beyond that, and as soon as you can.

Inflammation of course is a natural reaction by the body to injury, or even to vigorous exercise. What becomes a problem is when the inflammatory response doesn’t die down, when whatever is prompting the reaction continues to fire up the immune system. It becomes a problem as we age, the Times notes, because “immune responses become less regulated.”

So what’s the solution? The Times mentions five recommendations:

* Fix your diet. A diet focused on fruits and vegetables is less inflammatory than one full of foods that are heavily processed, deep-fried, or sugar-sweetened.

* Lose weight.

* Make sure you get enough sleep.

* Minimize mental stress in your life.

* Be careful about overuse of antibiotics, antacids and nonsteroidal anti-inflammatories. They can kill off good bacteria in your stomach and lead to a “leaky gut” that lets bacteria loose in your body that encourage inflammation.

* Exercise regularly.

How do you rank on these five recommendations? Personally, I know I could be better. My diet isn’t great, but I am very fastidious now about maintaining a lean weight. On sleep, I slip behind (like most people) during the workweek. Sometimes I feel stress building up.

Where I can excel now, thank goodness, is in exercising. I work out hard on the weekends.

What about you? What steps are you taking to control out-of-control inflammation?

The Best Knee Pain Book You Can Buy (No, Not Mine)

While poking around Amazon recently, I noticed that Doug Kelsey’s books are now listed there, and for less than $10.

Wow, I thought (for the record, as long-time visitors know, I’m certainly not Doug’s publicist, but I found a stirring message early on in his blog writings that convinced me my knees could heal and that sustained me through many bleak nights).

Kelsey was originally selling the “90 Day Knee Arthritis Remedy” for $28.95, as I wrote here in May 2014.

At that almost-30-bucks price, I thought it was already a bargain. I mean, you’ll typically pay $40 for a copay to see a specialist who will review your knee history for all of 5-10 minutes, then probably tell you to visit a physical therapist or write you a prescription.

But at $9.95, it’s a must buy if you’ve got knee pain. Kelsey’s book has lots of exercises. Plus, he understands the challenge of chronic knee pain and knows that the situation is far from hopeless. You can get better! And yes, without surgery.

At this point I probably am sounding too much like his publicist. But let me tell you why:

I wrote a book about my story that chronicles a long journey into and out of the depths of chronic knee pain. I certainly think it has a lot of value. But still, I’m not a doctor or a physical therapist. I’m a journalist: bright and curious, I hope, but not a trained medical professional.

Kelsey is though. And he’s a damn smart one.

Early-stage knee pain sufferers are beset by confusion and a welter of conflicting messages. Glucosamine works! No, it doesn’t! You should stretch! Stretching doesn’t matter! Take this supplement! Supplements don’t work!

Your head can start spinning. What you really need most, I’m convinced, are some ways to move and nourish that sick knee joint without causing pain. Kelsey’s book will give you the exercises you need and explain a whole lot more too about your condition.

My two cents anyway. Now, for 993 more cents, you can own his book in your Kindle library. ;)