Happy Holidays, My Facebook Policy, and Good Cheer to Share!

We're almost at the end of another year!

First, a quick note about Facebook: If you want to message me there, or friend me there, I wouldn't advise it. I'm trying to get off Facebook as much as possible and rarely use it.

An incident last weekend is one reason why. I clicked a link from a long-ago friend, and it turned out to be a virus. My life is already busy enough without having to fend off Facebook viruses.

Most friend requests, I ignore. Virtually all messages, I ignore. If you want to talk to me ... well, there's this blog, and that's probably the best way.

Happy holidays! We're almost at Christmas, and let me ask you: what are YOU grateful for as this year comes to an end? Me, I'm so happy to have knee pain way behind me in the rearview mirror. It's just a fast-receding speck, and I'm delighted about that.

I'm not so cocky as to think I'll never have knee pain again ... maybe someday ... but this time, I feel like I'm prepared, if I do face that demon again.

So once again: what are you grateful for, in your knee pain battle? No need to say "this blog." I appreciate such sentiments, but I'm really not that needy. 😃

And finally, the good cheer: I was looking through the comments, deleting the junk commercial messages, and I came upon a comment from someone I would never recognize in person, as I've never met her, but that I have a soft spot for nevertheless.

She was here in the early days of this blog, and I admire her courage and perseverance and spirit. I really feel like a slacker compared to her, considering what she has been through. She goes by the moniker "Knee Pain," and she made this comment a week or so ago:

My back story is that I had a very, very long struggle with debilitating knee pain. Previously it was so bad I could sometimes barely walk -- even to the point of using a wheelchair on multiple occasions. But, now my knee is doing so well that I can hike for miles! I can road bike up hills! I can do open water swimming for over a mile. I can do swing dancing and rotary waltzing. In 2020 I started a new hobby of backpacking which you can imagine is very hard on knees, but, I can do it. It's amazing.

Love it! Knee Pain, keep sharing your message of hope and triumph! Everyone else: never give up!

Best,

Richard

On Knee Pain and Arbiters of Truth

I want to talk about something a little different today. At first it won’t seem at all related to my experience with knee pain, but I promise to connect the dots.

I want to talk about truth, and about arbiters of truth, and about powers given to those arbiters.

We’re still in the middle of a pandemic that has badly frightened and confused many of us. We are scared of getting the coronavirus and are desperately searching for guidance on what to do.

I’ve been vaccinated: both shots, and the second one walloped me. But I’m a data and science guy. I’ve read enough about Covid, and long Covid, that I don’t want to take my chances with either one.

Yes, the vaccines in rare cases can cause bad side effects, but if you’re playing the odds, Covid has a much higher chance of leading to serious damage.

Nationwide, there’s been a push to get more people vaccinated. Amid that has been an alarming rise of disinformation about the vaccines. On social media sites now, like Twitter, staffers have begun to label tweets that are considered false or misleading.

Apparently too, according to this ABC news story, people won’t be able to comment on, like, or retweet certain messages, such as “vaccines cause autism.”

As a guy who likes data and science, I suppose I should be delighted. But honestly, this entire project makes me deeply uncomfortable.

Yes, we have a bad problem in the United States right now. The inability of many Americans to evaluate arguments, in a logical, methodical way, is stunning. We’ve increasingly abandoned reason for tribal affiliations. We’ve become a nation of Team Democrat vs. Team Republican.

And your team apparently determines how you perceive truth, as insane as that sounds.

Still, this idea of “truth arbiters” cleaning up content bothers me. “Truth” is not a static, fixed thing. It changes. And “official truth” is even more suspect. Do you recall the early days of the pandemic when the country’s top health officials told us not to wear masks, that they weren’t effective?

Imagine if the Twitter truth sanitizers had gone through tweets, labeling any pro-mask tweets as “misleading.”

As for the Covid vaccines being safe: I honestly think they are. Am I 100% sure? Of course not. Could we find out, in some longitudinal study conducted in 30 years, that people who got these vaccines had a 60% higher risk of kidney disease, or some other thing?

It seems unlikely, but possible. We’re in the early days with these rapidly developed vaccines. I don’t regret for a moment getting one, but I also don’t know what the future holds.

Imagine that there was some terrible, as yet unknown side effect of getting these shots. And that a small number of people began to tweet about it. The self-appointed truth minders at Twitter would put a damper on that dialogue, fast.

Again, I want to be clear: I’m pro-vaccine. But I also look at things with a kind of radical open-mindedness. Anything I know, I realize, might be false. It doesn’t mean that I quickly ditch any well-founded beliefs that I hold in the face of a few bits of contravening evidence.

But part of me, deep inside, says: Anything is possible. That’s why I don’t like people who screen what’s true/not true for me.

Sure, you might be thinking, good for you. But not everyone asks the right questions, analyzes critically, weighs the evidence and probes for weaknesses in it.

And that’s a deep, deep problem in America today. But I think the answer lies in lifting people out of ignorance, even though that’s a harder thing to do. If you simply stamp that ignorance “false” or “misleading,” you drive them underground, into their little warrens of like-minded conspiracy theorists.

What does this have to do with bad knees?

My book, that I felt so strongly about writing, represents a minority viewpoint. I’m sure if it were passed around to many physical therapists and doctors, they would be inclined to label it “false” or at least “misleading.”

And because of that label, many people who might benefit from Saving My Knees would have been discouraged from reading it.

So just keep in mind: today’s “truth” may not be tomorrow’s. That’s one thing that my chronic knee pain experience taught me.

Okay, I’ve gone on far too long! If you have questions about your knees, leave them below. Or, if you have a good knee story, leave that too and I’ll devote a post to it.

Cheers!

Be Careful Not to Become a 'Knee Obsessive'

There were a lot of comments after the last post I made. That's great! I'm sure a lot of you are benefiting more from talking with each other than listening to me, as my bad knee experience fades from memory.

One comment struck me as especially interesting, because "Lindsay" listed some things that have helped her. What got me thinking was what she put near the top of the list:

2. Having time in a day where I do not research cartilage/chondromalacia/patient forums etc.

3. Exploring new interests: photography/more reading/films/kayaking

4. Not telling friends too much about my condition ...

I could definitely relate to this. When I had bad knees, I was scouring the internet constantly, looking for advice, for research, for anything I could learn from. If someone wrote a 20-page paper on "the effects of pickle juice on chondromalacia," I probably would have read every single word.

As you all know, I followed my knee progress, during my recovery, with an uncommon obsession. When people asked me casually at work, "How are your knees?", I would answer them as if they really wanted to know, when usually they were just making the equivalent of small talk.

After a while, I figured out I had become a "Knee Bore" and started to limit my responses so as not to drive away my colleagues. Who wants to chat with a guy who's always yapping on about his knees, and his latest ideas for how to heal them?

I also realized, after I wrote my book, that I may have done some harm along with some good. A knee journal was a great idea for me, and I do believe in carefully listening to one's knees, but ...

At some point, you do have to take a deep breath. And exhale. And relax. And try not to think about your knees every hour of the day. My book tends to encourage the idea that you have to be scribbling notes about your knees and running experiments on them all the time.

So, to address that, I want to point out that I found meditation useful. I'm not a natural meditator, so it didn't really come naturally to me, but I could feel the benefits.

Obsessing over your knees can be bad, if for no other reason, because healing takes so long. If you're just sitting around all the time, wondering about your knees, thinking about your knees, you're doing the equivalent of standing in a room watching paint dry.

Anyway, I thought it was worthwhile to give a thumbs up to this idea of exploring new interests. Try to take your mind off your knees for a while. Be knee conscious, but try not to be too knee obsessive.

I think it's a good distinction. 😊 (Boy, the blogger emojis are really bad, huh?)

Mastering the "Goldilocks" Problem With Bad Knees

I found this recent comment interesting, as one of the most frustrating aspects of healing bad knees is getting the "Goldilocks principle" right: You don't want to move too much. But you don't want to move too little either.

I find your book useful as you say that during your initial months, you were not sure if you were improving or not and it was by month 7 that you knew your plan was working.

So you need to move your knees. To me, that's like a First Principle, not open for debate. Knees that don't move at all will only get worse.

But then how much do you move them if they hurt all the time/most of the time/some of the time? And how can you tell you're on the right track with your program?

This is very, very hard to do. It's where many people fail, I'm sure. There is no "Just do this" blueprint. Just imagine how easy healing would be if the prescription was something like, "Take 800 steps a day for the first four weeks, then increase that by 200 steps a day for the next four weeks, etc."

The problem is, that may be just right for your knees. Or too much. Or too little. Or your best approach to healing may not be through walking at all.

There can be a lot of experimentation during those first few months that feels more like flailing around. It's important not to push your knees too hard. But you do have to push them at least a little.

So what does that mean?

What helped me the most was when I decided to err on the conservative side, in a big way. I started slow, very slow, then chose to build from there. That's not always an easy path to follow, especially for a Type A personality, when you feel you should be doing more.

But the unfortunate reality is that, yes, there can be entire months where you can't tell if you're getting better, backsliding, or simply moving in place. It's frustrating. But you can take some solace in knowing that many others go through the same thing. You're not alone!

Will Quad Sets Help Your Knees?

This came up recently in the comment section.

I remember doing quad sets during my recovery, and my knees didn't like them much. So I stopped doing them and got better anyway. Because of my personal experience, I never really looked that closely at quad sets.

Doug Kelsey does so here, though, in "The Ultimate Guide to the Most Misunderstood Exercise for Knee Pain." He makes some interesting observations:

(1) That quad sets are sometimes prescribed for a mistracking patella. And he dashes some cold water on doing quad sets for this reason.

(2) That quad sets are sometimes recommended to strengthen the thigh muscles. But, alas, they're not really great at this, because they generally don't stress the muscle enough.

(3) That quad sets are definitely useful for something else: thickening the synovial fluid that helps cushion impacts in the knee joint and just makes movement easier in general.

For this use, he advises 100 repetitions a day, in sets of 10. Patience is helpful too: beneficial effects probably won't appear for two months.

What is the science behind this? I'm always curious about that. It appears that the seminal study, which Kelsey himself cites, goes back to 2003. The sample size was a bit small (20 subjects, with a total of 28 bad knees), which isn't optimal, but what they found was without a doubt impressive.

The subjects did an isometric exercise that involved keeping their leg straight and raising it. Patients were told to do the exercise 90 times a day. Joint fluid was taken from their knees at the beginning of the trial and after 12 weeks.

What researchers discovered:

Joint fluid viscosity increased from 45.8±7.6 to 59.8±8.6 mPas (P<0.05). In contrast, there were no significant changes between at baseline and after 12 weeks in the patients without any treatment.

A roughly 33% improvement is really good. Note that these aren't exactly quad sets that the patients did, but I have to assume the benefits are similar.

Anyone out there who has a story to share about quad sets, good or bad?

'I'm Not Dead Yet,' as Monty Python Once Said

Reading all the comments come in after I announced an easing away from the blog was almost like having a ringside seat at my own funeral. Part of me wanted to shout, "Hold on, hold on! I'm still here!"

Yes, my posting from now on will be more sporadic. The blog might go dark for months at a time, or maybe for good at some point. But we're not at that point yet.

If you want to keep the blog alive in some form, go ahead and post questions you have, and I'll answer them (and invite others to help me do so).

Finally, I did want to post this comment from Knee Pain. I realize to many of you reading this, "Knee Pain" is just another online moniker. But she's been with me almost as long as this blog's been around.

She is one of the original hard-luck cases. Look up her success story and you'll be amazed. Her comeback is much more inspiring than mine.

She left a very kind comment, and a great update on how she's doing.   

Hurrah for 10 year anniversary!! I'm very grateful that I found your book.

I remember I practically read it in one sitting. It was very encouraging and great to find someone who could RELATE to this tricky problem of finding just the right amount of movement BUT not too much that would cause a flare up

I remember stories that you shared that I could relate to like the one where you carried something kinda heavy around Hong Kong (maybe it was a fan?) and that caused a flare up. I carried a computer monitor down several flights of stairs and that caused a flare up and I also remember pulling a suitcase on a leash and somehow even that caused a flare up (I think because the act of pulling something heavy with just arm changed my weight distribution on my legs?) Argh.

I was just reflecting recently that my bad knee now seems totally reliable. I'm doing lots of walking and hiking and biking and even backpacking and.... I've stopped worrying that it is going to have a flare up. It doesn't even send me little grumpy warning signals anymore.

That said, I feel it's important to stay vigilant and keep moving and exercising and not get complacent. I don't want a relapse.

Excellent! That's the kind of comment that brightens my Sunday!

Have a good knee day, everyone. 

An Update On the Blog (and a Few Basic Rules)

I'm heading off on a weeklong vacation, so I thought I'd do a quick update on the blog.

I always planned to keep this blog going for a few years, then let it quietly fade away. Part of the idea was to continue the blog while the knee books were selling, as a way to support readers who had questions. At long last, knee book sales are tapering off, so I'll soon transition to a much more occasional blog.

I never thought sales would continue for this long! It's been a pleasant surprise. The message of Saving My Knees isn't probably for everyone, but some people have apparently found it valuable. But now that sales are dropping off, and I find myself increasingly pressed for time to devote to other projects, I will soon transition to spottier posting.

Also, there are few rules here. But these are a couple:

(1) I have a lot of people reach out to me. I don't really want to become anyone's knee counselor. I'm not qualified for one, and two, I barely have enough time (with two young kids and an old house) to take care of everything in my life as it is!

So the best way to ask questions is right here, on the blog. There are several advantages to that: (1) The answers to your questions may help other people who have a similar problem. (2) If I don't know how to answer your questions, I bet someone else here will.

(2) Please don't post spam comments. I just delete them. I don't mind people posting links, in the context of a comment that's related to a post (or an issue someone has), but there are comment spammers that I delete quickly. They post "thin" comments that don't really directly engage with anything on the site.

They often look something like:

Great info! I loved what you said. If you want to take care of your knee pain, try the Magic Sleeve (with a link to the bogus Magic Sleeve).

One last thing: If anyone does have questions related to knee pain, please drop them in the comments. I'm at the point where I'm mostly foraging in there to find things to post, as I get closer to this blog going semi-dark.

(Not fully dark! I want to be able to jump back in here from time to time, especially as studies pop up that validate the message of Saving My Knees!) 

The 10-Year Anniversary of 'Saving My Knees'!

I'm actually a bit late on this but:

January was the 10-year publication anniversary of "Saving My Knees," my account of beating chronic knee pain. That whole unhappy time feels so distant now, like a long-ago bad dream that I've finally managed to shake off.

Today, for example, I went on a 64-mile bike ride ... a hard 64-mile bike ride. I felt fine during the ride, and I feel fine now afterwards. No Advil. No ice packs. No anything (well, my quads did grumble this afternoon when I walked down the stairs from the second floor).

I realized that, even if my knees fell apart tomorrow (which I very much doubt), I will have had 10 great years that my old orthopedic doctors would never have guessed lay in my future. What's more, my knees have gotten stronger over the years.

For example, in the several years following the publication of the book, I did have some minor issues from time to time. Sometimes I would have a little burning sensation around the kneecaps, the same as when I was suffering from chronic knee pain. These episodes would be rare, and last only a few weeks, but I took the symptoms very seriously.

But in the last several years -- maybe even four? or five? -- I haven't had that burning sensation at all. In the future, I realize, it may come back. But for now, I take this as a sign that my knees have healed, and adapted to the intense stresses I regularly put on them.

Over the winter, for instance, I rode my bike indoors, in the basement, in virtual worlds created by Zwift. I rode with groups that were stronger than me; I would spend three hours, without stopping, pedaling like mad to stay with the "B" group. Sometimes I averaged about 230 watts over that period.

And ... the knees were fine, even though I pushed them harder than I probably should have.

Ten years after publishing the book, I've gotten smarter about a few things. For one, my story doesn't resonate with everyone (in the latest foreword to the book, I even tried to scare off people who I didn't think would care for it very much).

But I think the message is a powerful one. I don't pretend at all that it originated with me; Dr. Scott Dye and Doug Kelsey figured this out first, and I took liberally from Kelsey when trying to put together a program to heal.

In the book, I just wanted to tell my own story, hoping it would inspire others and, most of all, give them optimism. I suppose I took a chance; what if I had published the book and my knees had fallen apart two years later? I would've felt like a fraud.

Instead, everything worked out great for me, and I'm certainly grateful. If you have knee pain, you can beat it. Remember that. You can beat it. I did. And if you look for "success story" on the search bar for this blog, you'll find plenty of other people who did too. 

Of Magic Pills and Surgery

A brief post today about magic pills and surgery.

I saw this yesterday:

When it comes to battling with joint pain in a natural way, certain remedies like the use of methylsulfonylmethane (MSM) may be helpful.

That word is certainly an impressive concatenation of chemical prefixes, and gave me flashbacks to high school chemistry. I will add that I know nothing about methylsulfonylmethane.

(I have written extensively about glucosamine and chondroitin, which rigorous scientific studies have turned against as solutions to knee pain. They are most likely placebos, it appears.)

So why am I down on something that I know nothing about?

It's more like this: we want things to be easy. Take a pill. Or schedule a surgery. And whatever ails us is fixed.

Essentially, you hand over control of your knee pain to a surgeon, or to the researchers who came up with the formulation for the pill.

But I don't think it usually works out well with knee pain. My experience is that YOU have to get involved with YOUR knee pain. You can't outsource the problem to some nutraceutical company, or orthopedic surgeon.

You have to focus on beneficial movement, monitor symptoms closely, and not lose sight of the end goal, day after day after day.

But you may be thinking: What's wrong with taking a pill? Maybe it will help.

Maybe. But it may also lull you into thinking that you can be less vigilant in your own efforts to fix the problem.

Anyway, for the record, I took a number of different joint pills. I don't think any of them helped in the least. I also followed a strict program of movement that gradually increased in intensity, and that worked.

That's how I think knee pain suffers get better, not by popping something out of a bottle. (Note: there are times of course when surgery makes sense, but there are far too many knee surgeries for problems that can't easily be fixed by that kind of intervention.)

A Bad Knee, a Pessimistic Doctor, and a Muscle-Obsessed Physical Therapist

I got this comment -- a story really -- and it's a long one, so I've edited it down. You can find the full comment here. I've underlined some parts that I found interesting.

I am a 28 year old female, very active, but unfortunately twisted my knee 3 years ago getting ready to take off for a run on wet grass. The sharp pain was horrendous, as my leg twisted my knee tensed and it felt like I had torn everything in there. I carried on stupidly as I was in a bootcamp and embarrassed to highlight myself as injured!! As a 25 year old healthy girl at the time, I assumed it would fix itself and carried on about my life ignoring the niggle up the stairs and when hiking. I initially went to a doctor who told me I had patellofemoral pain syndrome and to get back in the gym.

I never had pain squatting or lunging with weights, it was only the act of load bearing with my knee over my foot where I got the sharp pain. Similarly to a few previous comments I have read on your blog, the pain when I work out seemed to disappear and even after prolonged weights I found improvements in my knee and could run up the stairs no problem! Well I think all of this was not allowing it to heal properly as the pain always came back when I didn’t work out for some time.

I think the strength on the other areas were maybe masking the knee problem short term, who knows! But I certainly didn’t do it any favours getting back lifting weights. Pain started to feel a little more prominent this past year. I can walk totally fine. Hiking is my passion and something I haven’t been able to give up. But this causes me a lot of pain the next day and is hard on the joint coming down.

All of this led me to pay for an MRI to see what was going on. It showed I have a ‘punched out lesion within the cartilage of the patella in a central position. There is thinning of the trochlear cartilage in association with this. No reactionary oedema but evidence of a dominant lateral trochlear facet which is slightly dysplastic. Grade 3 chondromalacia’

The specialist said I could require arthroplasty in the distant future, but I should focus on swimming and cycling to manage it and avoid impact activities. He said there is no way to treat it and it will continue to get worse with age. Sure enough I left feeling very upset, hopeless and frustrated.

My strength PT said we should be still focusing on strengthening quads, glutes, calves core and hips etc but he has me still load bearing with some weight which I don’t feel is the best option for healing after reading through the blog! Would you agree? I have a lot of range of motion and don’t get any pain walking but when bent with pressure I’m getting the sharp pain. I have only just recently the past two weeks started to feel a burning sensation in that knee after movement. Is this a worrying sign that it is getting worse?

Desperate to find a way to combat the pain and make sure I am not doing further damage. I am due to go traveling to Canada (I’m from the UK) in a matter of months, a trip I have planned for a long time when my knee wasn’t causing me these problems) to do a lot of hiking which is so important to the trip. I don’t want to miss out on life because of this, but also do you think I could progress my grade 3 into grade 4 if I hike?

The magic question I suppose is, do you think it is possible to turn grade 3 chondromalacia around and live pain free!? I have an unbelievably healthy lifestyle, my passion is fruits and veg and I am 5ft8 and 51kg so I have this in my favour!

For starters, congrats on the healthy lifestyle and the ideal weight! You're young, eating well, and not carrying around a lot of extra pounds (or kilos). That seems like a good way to start a healing journey.

Next, I avoid giving advice. I'm not a medical professional, and even if I were, I've never seen you (or your knees). But I will share some things to think about.

I half-like the specialist. He said to focus on swimming and cycling and avoid impact activities. That strikes me as quite sensible, at least early on. Once your knees are in better shape, maybe you can do impact activities. For now, swimming and cycling, as long as your knees tolerate the activities well and you are careful not to push too hard, are two of my favorite "knee rehab" exercises (along with slow walking).

But I only half-like him. He also said there is no way to treat your condition and it will continue to get worse with age. Boy, he's a real cheery fellow, huh? I know nothing about your knee, but I think his dire prognosis is probably crap. One of the best things I read, early on during my struggle, was from Doug Kelsey, who was responding in his head to a doctor who had just told a patient that he'd never get better. And Kelsey's reaction was terrific, along the lines of: That's ridiculous, absolutely ridiculous.

Hope is so, so, so important. Orthopedic doctors should be smart enough to know that at least some knees do heal, without surgery. Mine did!

I'm not crazy about the strength physical therapist. I see the word "strength" and I wince. One thing I've come to realize about many physical therapists: they're young, frightfully fit, and haven't had any personal experience of whatever they're giving you advice about treating.

And they love strengthening muscles: because their playbook is full of strengthening exercises (and stretches). Stronger quads are great, but not if the effort to strengthen the muscle is greater than what the knee can tolerate. Unfortunately, you don't always realize that until the next day.

You might think, "Well, working out with weights helped my knees before, didn't it?" Okay, maybe it did. But maybe your knees aren't in the same place anymore. They could be worse, or more sensitive to the heavy loads and the bending.

Last, will going on this planned hike cause your knees to worsen? Maybe yes, maybe no. It depends on a lot of variables. How many miles a day? How many miles a day can your knees tolerate? How fast? How much climbing and descending? How many breaks? And you have to ask yourself: If this hiking trip isn't working out, is there a Plan B that you're confident enough to execute? Or do you just plan to suffer through?

Some thoughts. And one parting thought: If you bought Doug Kelsey's book, then you made a smart move. His book should be an invaluable guide on your journey. Doug really, really knows his stuff.

Anyone Out There Want to Share a Prolotherapy Experience?

A very short post today.

I got this comment:

Richard, and others here: I am curious what you think about pro treatments. I am grade 4 chondromalacia patella in left knee and grade 3/4 in right knee since a car accident 15 months ago. According to x-rays the fracture in the left knee has finally healed but my pain has not decreased dramatically. I am constantly taking off from my teaching job and have had 4 doctors and 2 physical therapists and am still like this. The prp is not covered by insurance. I had one treatment 2 mos ago and it may have helped the fracture heal the rest of the way but I'm still suffering immensely.

First, to be clear: I know very little about prolotherapy, or platelet-rich plasma therapy (I understand that they are somewhat different). Doug Kelsey, whom I have great respect for, has written about PRP here.

So what I think of prolotherapy, or platelet-rich plasma injections, is probably not that valuable.

But a lot of people with knee pain are regular (or semi-regular, or occasional) visitors to this blog. Anyone out there have an experience with prolotheraphy they want to share? I'd be very interested to learn whether it's been helpful, and what the pluses and minuses are.

Why I Don’t Try to Convince Others of What (I Think) I Know

I thought I’d heard about every question under the sun about chronic knee pain, my experience with it, and what I learned. Then I got this question, which I found intriguing. It got me thinking:

I'd be curious to hear if you or any readers have successfully convinced their doctors/therapists that anterior knee pain is mostly mistreated. I've begun to introduce ideas like envelope of function and how a joint first approach trumps addressing biomechanic irregularities. All of my therapists entertain the discussion and do not dismiss me, which I greatly appreciate. However, none have embraced those ideas. Frankly, I understand why. It feels like the height of arrogance for a patient to tell a doctor they are mistreating people. I feel like the crazy patient sometimes. Still, I feel compelled to convince medical professionals they are treating the most common type of knee pain incorrectly. Has anyone successfully convinced their doctors? Richard, do your doctors in Asia know you wrote a popular book on the subject?

A lot to unpack here.

First, I’m not surprised your therapists “entertain the discussion” and “do not dismiss” you. This sounds much like my physical therapist in Hong Kong, as I mused about various ways to treat my pain. But I reached the point where I think I could’ve told him that aliens were beaming me messages from deep space, and he would’ve murmured with a similar understanding.

So I would counsel against mistaking superficial “understanding” with an openness to changing deeply held beliefs.

And, as for whether my doctors know I wrote a popular book on the subject: Sadly, it’s only been sort of popular (sales are a pale fraction of what Stephen King’s next novel will do). And I assume, no, they don’t know. I have made no attempt to tell them. I don’t think it would matter much if I did.

So, to get to the real question: Why not try to spread the word to doctors and therapists that there are some serious problems with their approach to knee pain?

* I don’t proselytize about knee pain. It’s a waste of time, really. When people in the real world ask me about my experience, and they seem genuinely interested and open-minded, I’m happy to share.

Also, I wrote a book, and that’s my rather long argument about knee pain. Naively, I wrote the book thinking that everyone who suffered the same kind of lingering, hard-to-treat pain would find the book a nugget of gold in a slag pile of outdated thinking.

Of course they didn’t (check out my one-star reviews on Amazon – fortunately, not too many, but there are some). I made a kind of solipsistic error, I suppose, in thinking that most people would be like me and would approach the problem the same way, with the same kind of “I’ll beat this if it takes 20 years” determination, and willingness to entertain theories that deviated from the mainstream.  

* Can you really tell doctors anything? I’m only being a bit facetious. You, the patient – the one supposedly seeking advice from them – are trying to tell them they’re wrong? Because you saw something on the “internet” and Googled a few research articles? And meanwhile, they see knee pain patients day in and day out; they took the med school courses; they cut open the cadavers; they did the grueling residency.

I do believe the smarter doctors – and I think there are a good number – do realize the human body is maddeningly complex, that they don’t know perhaps as much as they wish they did, that they can learn from patients as well as pass on learning to them. I’ve had people on this blog say that they’ve shared some of my ideas with doctors, who say something like, “That makes sense.” That’s at least with regard to high repetition, low load exercises like walking.

* But they often aren’t willing to go much farther. Well, why not? Why not wonder if they don’t have an accurate picture of knee pain, and how damaged cartilage can be made healthier, or even restored?

Well, in part because I think this demands an exceptional individual, honestly. It demands a kind of radical curiosity, along with a sh*tkicker willingness to discard an accepted orthodoxy. And that’s hard. That’s very, very hard. How many people do you know who are willing to jettison a whole knowledge base – you know, put it up for intense examination, then toss it out the window if it seems flawed?

As a species, we’re invested in our narratives, our beliefs, our received knowledge.

I think stretching is a great example. My sister-in-law is a personal trainer. I think she’s a smart woman. She’s asked me about my knee pain before, and I’ve told her my story. I’ve also said that I think stretching is probably a waste of time (though, again, by all means, if you like to stretch, and it feels good and you’re not doing any contortionist stretching, it could well be fine for you or at least not harmful).

At that point, I can see her shutting me down. Stretching a waste of time? This is a heterodoxy of a high order indeed. So I could point her to studies that I’ve read, but why bother? On this point, she’s basically signaling, “Whatever you say on stretching, I’m not going to believe it.”

And why should she? Imagine you’re a personal trainer. You learn all these cool stretches. You share them with your clients. You trade stretches with other personal trainers. You are an expert in stretching! This has worth in your world. And then someone has the audacity to come along and suggest it may not be valuable after all! Why would you think about abandoning this thing you are so deeply invested in?

* I do sometimes wonder how money might be distorting all this, at least a little.

Think about it: If cartilage can heal (if slowly), why would anyone but the impatient (I suppose there are plenty of those), get a cartilage replacement? So all the surgeons trained to do those operations, all the companies that culture cartilage cells for implantation – how are they going to support themselves and be profitable?

I realize this has a deeply cynical, even conspiratorial ring to it. I don’t mean it to sound that way. But honestly, who’s looking into natural cartilage restoration? Where’s the money in that? There are financial incentives in this world, and they can at least subtly flavor how orthopedic surgeons view things.

Anyway, goodness, this has gotten much longer than expected. For me the bottom-line answer to the question posed above, I suppose, is I wrote a book. I’m immensely proud it has helped some people.

I don’t feel the need to convince anyone at this point. For a while, I did, and I was passionate (almost to the point of tears) about my story. But now, I guess my story is receding into the long narrative of my own life, as my knees have been fine for over a decade. I don’t want to get into a debate with people who swear by glucosamine, or who don’t think cartilage can get better.

Heck, just last week I saw my wife had bought some knee joint pills. If I were a zealot, I guess I’d go in and give her a long explanation why I think she’s wasting our money, and why I doubt she’ll find relief. But there’s no need to. If she wants my opinion, she knows where to find me (under the same roof). Hah!

A Few Thoughts on Knee Surgery

I got this comment recently:

I have been struggling with knee swelling/pain sporadically over the past 7 years and got frustrated with the Ortho's recommendation of RICE... I finally got an MRI and found out it is a real problem - stage IV Chondromalacia, no cartilage in part of my knee joint. I found your book on google and then Doug Kelsey's book and now I'm starting online therapy with the PT he recommends - I'm so grateful. What I'm curious about is if you've known much success of people in their mid 30s in surgery. I seem to see pretty low success rates so I'm not seeing the point of paying a ton in surgery... any thoughts?

Ah, surgery. That's a big topic. 

I considered it once myself. I'm so, so, so glad I didn't go through with it. However, I don't mean to imply it's the wrong course of action for you. I wouldn't try to judge what's best for you.

First, I guess it depends on what kind of surgery. There's a kind of "I'm going in to have a look around and clean up the joint" surgery that I, personally, would run like hell from. Studies have shown this surgery isn't any more effective than conservative treatment of the bad joint.

But if the surgeon wants to perform a microfracture, where he creates holes in the bone to spur bleeding and prompt cartilage regrowth in an area where there's no cartilage, that's different. Is that worth it? Well, I guess it depends. Cartilage, it appears, can grow naturally even where there's bare bone -- just consider this study.

Still, is the replacement cartilage that regrew in this study fibrocartilage? Would a microfracture get you better cartilage, and faster? That's something for you to discuss with your doctor certainly, but I'm just letting you know what I know.

Notice I haven't said anything about your age. I honestly don't think there's much difference in your chances for a successful outcome between mid-twenties, mid-thirties, or mid-fifties, if you're healthy and committed to doing the right things to aid in your recovery.

Also, this person wanted to know whether I had an MRI and what did it show?

I've written about this extensively, as the question comes up frequently. So I'll just send you here for that answer.

One final observation on surgery: if you do have surgery, my personal observation is that the biggest mistake people make post-surgery is doing too much, too quickly (shamefully, I think their physical therapists are partly culpable in this).

So, if I did have surgery, I would go very, very, very slowly in my recovery, even if my knees felt great.

The Times Helps Repudiate the Belief in Muscle Strengthening for Bad Knees

It’s great to see another news article, this one in the New York Times, ratifying the central message of my book, which of course is drawn from my personal experience beating knee pain.

The article begins simply enough, with a familiar bit of received knee pain "wisdom":

The idea made so much sense that it was rarely questioned: exercise to strengthen muscles around the knee helps patients with osteoarthritis, making it easier and less painful to move the inflamed joint.

So a professor of biomechanics, Stephen Messier, decided to test this belief. He ran an 18-month clinical trial with 377 people. One group lifted heavy weights three times a week, while another did moderate strength training, and the third was simply counseled on “healthy living.”

If strengthening muscles around the knee joint is the solution to chronic knee pain, the group lifting the heavy weights should have seen the most improvement. It did not. Instead, the knees for all three groups got slightly better.

I find it kind of humorous, seeing learned experts scratching their heads in utter bafflement over something that, if they thought about it on a common sense level, would make perfect sense:

Lifting heavy weights can be an utter disaster for weak joints. Personally, I’ve been there. And a lot of other people who read this blog have been too.

At the end of this article, we learn that Messier may still be, uh, dispensing dangerous advice:  

Despite the new, unexpected results, Dr. Messier still urges patients to exercise, saying it can stave off an inevitable decline in muscle strength and mobility. But now it seems clear there is no particular advantage to strength training with heavy weights instead of a moderate-intensity routine with more repetitions and lighter weights.

He's right to advocate "movement" (not sure I'd promote "exercise" per se, as that usually connotes people jumping about). But he's still hung up on weight training (sigh). At least he’s getting nudged closer to the truth. Maybe after another 10 years, two or three more studies? :)

Low intensity, high rep. Not a hard formula ... it worked well for me, and for many others.

Some Thoughts About the Delayed Onset of Knee Pain

There was an interesting story posted on the latest open comment forum. I want to focus on one piece of it (bolded). I've edited the entire story down for space:

I have been dealing with a knee issue since mid 2017 when I felt something "tweak" while doing "sissy squats" as part of a strength training program. Since this incident this knee has bothered me off and on and several orthos have diagnosed it as patellofemoral syndrome or PFS.

Running and cycling both aggravate it. I've tried the following methods for relief/cure:

- Rest from running/cycling. I had a 4-5 month period of rest from running/biking when I had a minor hip surgery. As soon as I got back to running/biking the pain came right back.

- Strength training, particularly those described as targeted for relieving PFS (quad strengthening). Step ups, and wall sits can really aggravate it although after a few reps the pain lessens during the activity (just as it does with running/biking), it comes back after as if I've damaged something.

- Robin Mckenzie "treat your own knee" regimen - Mostly the isometric holds that he recommends. I've gotten relief from this, but not a cure.

- Stretching and tissue work that supposedly helps PFS - Mostly foam rolling the quads and IT band and similarly stretching these areas. Similar to Mckenzie's regimen, this helps but does not cure.

- Treating my symptoms as Dr Sarno's "TMS". While this treatment has worked with other chronic pain I've experienced, this knee pain has not responded to that methodology at all.

- NSAIDs/Anti-inflammatories - Naproxen/Ibuprofen will knock the pain out altogether after a few days of steady use, but this isn't a long-term solution.

This part in bold sounded so familiar I had to separate it out. I remember, during my disastrous attempt at weightlifting to strengthen my quads (because that was what the physical therapist said I was supposed to do, once my knees were strong enough!), there would initially be a little discomfort that would then become more tolerable after a few repetitions.

But -- and here's that giant, ten-foot "but" -- later my knees would become more uncomfortable. At first I chose to ignore what was obvious after a week or so of this weightlifting program: my knees were getting worse. I was backsliding. When I realized that, I got upset and briefly depressed.

Even so, this terrible experiment turned out to be valuable: it got me thinking more deeply about the whole phenomenon of "delayed onset" knee pain.

I don't think it's unusual at all for a pair of bad knees to "warm into" an activity. This is why I hate that glib line from doctors about how to treat knee pain: "If it hurts your knees, don't do it." That's far too simplistic. Your knees may feel okay during the activity, after a little initial discomfort.

The key is how they feel later. "Later" can be immediately afterwards. But I discovered "later" can also be a day or even two after the offending activity. That makes it undeniably difficult to sort out cause and effect with bad knees. Still, it's very important to know about delayed pain, I think.

Recognizing this gets you to a higher, more sophisticated level of being able to "listen to your knee pain." And that's where I think you have to be to heal effectively.

Open Comment Forum: Anyone Want to Share a Problem?

It's been a super busy weekend for me, so I'm just getting around to this blog post now.

I thought I'd keep this short today and ask if anyone out there is struggling with a particular problem when it comes to their knee pain.

Want to share? Someone here (either me or one of the regular blog visitors) might have some ideas about what you could try next.

Or, if you'd prefer to discuss something else, that's fine too. The comment section is wide open.

Meanwhile, I hope you're all staying safe. In America, the vaccines are becoming more widely available. I haven't been able to get one myself, but my mother has, and my father is getting close.

We just have to hang in for a few more months, then hopefully life starts to return to normal.

Best wishes to all, and keep moving those knees! 

When You're in Pain, It's Good to Try to Figure Out What's Wrong

Seems obvious, right?

I mean, who would dispute that?

I was thinking about this recently though because of my mother. She told me she has plantar fasciitis.

Now I don't know much about plantar fasciitis. But I do half-remember a post that Doug Kelsey, whom I respect very much, wrote about the problem.

I tried finding his post -- unsuccessfully, sadly. I wanted to send it to my mother. Because right now she's in that early stage of: I have this condition. It hurts. What do I do?

I caution that I'm imperfectly remembering what Doug wrote, but I recall the part that resonated with me went something like this:

People often do the wrong thing to recover from plantar fasciitis. They do the wrong thing because they don't understand what it is. It's actually a slight tear in the ligament near the ball of the foot. Some people recommend stretching, but this doesn't make sense. Why are you stretching a torn ligament? You need to let it heal, then slowly strengthen it.

Anyway, I wish I could find that post, because that really struck me as very logical, even though plenty of people don't do it. In fact, my sister-in-law had plantar fasciitis. She's a personal trainer, and she loves to stretch. So what did she do? It felt tight, so she stretched. I guess eventually it healed, but probably not thanks to the stretching.

What does all this have to do with bad knees?

Chronic knee pain can be a maddening puzzle. Early on though, I think it's good to try to figure out what exactly is going on in the joint. The most sensible treatment for your knee pain will differ, depending on what's wrong.

In the end, if there is no clear cause -- if you basically get a shrug from your doctor(s) -- then I would think about adopting the high-repetition, low-load method of trying to heal slowly, but steadily. That's what worked for me. And that's at the heart of other success stories you'll find on this blog.

 

What’s the Relationship Between Knee Pain and Cartilage Damage?

Ah, what an interesting question. Early on, I tended to think that, where there was chronic knee pain, you’d find damaged cartilage in the joint.

Of course, not in all cases. But in very many.

However, after I learned more (and heard more personal stories from all of you), I modified that belief. People who have knee cartilage that appears perfectly fine get terrible knee pain sometimes. And people with potholed cartilage can have pain-free knees.

But – here’s the but – I definitely think there’s a high correlation between knee pain and bad cartilage. One does not necessarily imply the other. But there is a good likelihood that if you have persistent knee pain of difficult-to-determine origin, you have issues with the cartilage in the joint, or vice versa.

In fact a recent study, looking at 565 people who had a knee arthroscopy, supports this:

Published results showed a strong association between patient-reported knee symptoms and the burden and severity of underlying cartilage damage rather than with specific meniscal pathology ... researchers intraoperatively confirmed and classified the diagnosis of meniscal pathology and concomitant cartilage damage.

The researchers found that “the mean average symptom score increased with the severity of cartilage damage.” Also, there was a relationship between the number of compartments where damage was found and the intensity of symptoms reported.

When there was damage in three knee compartments, there was more frequent catching and locking of the joint, as well as grinding and clicking symptoms. Women and heavier people (a BMI of more than 25) were more likely to have more widespread cartilage damage.

The good news is that cartilage doesn’t have to be restored to a pristine state to get rid of bad knee pain, I believe. So, in the end, “damaged cartilage” shouldn’t mean you’re stuck with those bad knees forever!

I Love Success Stories! Here Are Some You Should Read.

It's easy to get discouraged when trying to heal your knees from chronic pain. One step forward, one step back ... when will it ever end?

It's comforting and uplifting to hear occasionally from people who have beaten stubborn cases of knee pain.

In my last post, I wrote about a triathlete who posts here as TriAgain, and his success story. I thought that today, for ease of reference, I'd do a short post that provides an overview to the success stories that have been published on this site.

* The most useful post of TriAgain's success story was probably this one, on lessons learned. It's worth a close read.

* Here's a success story I found on Yahoo's chondromalacia forum. This person had left knee cap pain that was getting worse, and exercise aggravated his knee.

* I was delighted to find out that my book had found its way into the hands of a couple apparently from South America. The husband, Luis, wrote about his wife, a professional runner, and how she beat knee pain. It was a success story in two parts: here and here.

* This one is from "Ron," and one of my first success stories. I was so excited that I went in and shared it with my wife and daughter, who was two at the time (and is now 11!).

* You're never too old to heal! "Pat" told me the story of how she did, and she was 66!

* One of my favorite commenters over the years was "Knee Pain." She seemed to be the epitome of a "can do, never say die" attitude. She got discouraged, I could tell, but vowed not to give up. So I was particularly pleased to be able to offer her success story.

* This was a "train through the pain" success story. I shared it, but with a caveat that the approach taken wasn't one I would endorse. But still: it's good to be open-minded about ways to heal.

* "Karen" shared a success story that involved my favorite sport: cycling. But she had a clever way of dealing with the sometimes too-heavy joint strain of pedaling.

I hope you enjoy these and are able to learn something from them!

Another Success Story to Celebrate!

I love success stories. They lift the spirits of people struggling to stick to what can be a years-long process to rehabilitate their bad knees.

I was pleasantly surprised last month to learn that TriAgain, an Australian triathlete who was one of the first people to post comments on this blog, has announced that he has completely healed.

"I'm declaring my knees 100% fixed now," he wrote in a comment. And how long did it take?

Only ... eight years and six months! How's that for dedication to a cause? It makes my own experience seem like a walk in the park.

Congratulations to TriAgain! There's more on his story here; I wrote about his battle back in September 2015. And his latest comments are here.

One thing I have come to realize is that we all don't heal in quite the same way, or hold quite the same beliefs. For instance, I'm quite skeptical of the value of stretching. Meanwhile, there are some who have healed from knee pain who swear stretching really helped.

But I think we agree on the important stuff. To me that's:

That bad, cranky knees can get better. If you choose to give up on your knees, that's your choice, but it's not as if they must inevitably stay the same or get worse.

That the road to recovery is often not easy, and there aren't any gimmicks or magic pills. I suspect that a number of people bought my book looking for some "secret" on page 159 or some such. I truly learned a lot from having knee pain and healing, but there's no magic juice or exercise that does the trick for all.

That healing requires a certain fortitude, optimism (but very much grounded in the possible), tenacity, determination, and stubbornness not to give up the fight, even when you seem to be losing (and there will be plenty of those times).

That, in a world where facts sometimes don't seem to matter, facts and science really do matter if you are serious about healing, because a knee pain sufferer is running an experiment of sorts, trying to unlock the combination that leads to steady, slow improvement (per Scott Dye).   

That patience is a key virtue, because it can take months (or even eight years) to get better.