On Crepitus, 'Normal'-Looking Cartilage, and 'Real Pain'

I've received a few good questions in the comment section, and am a bit dry on blog posting material, so I thought: why not use these? The first one (edited lightly): 

I noticed crepitus in one knee about two years ago, but brushed it off. I had no other symptoms until I pulled my calf during running, and after that developed a baker's cyst. I rehabbed the cyst, but I was asking the physical therapist about the crepitus, and he said the same thing: unless there is pain, just ignore it.

I returned to life as normal without pain, but when I started training for a half and working on my squats I noticed the same posterior knee pain, but now on both knees. I took it easy for a while since it seemed everything I was doing was causing pain. Once I got back to running, I noticed tightness in the front of the knees although still only crepitus on one side.

I went back to the PT, who did an ultrasound and found no issues. I asked if he could examine the cartilage with other methods and he said that with just the ultrasound it's showing the cartilage is thick and healthy, so there is no need for other exams. I am trying to get a second opinion, but now I am in the trap of, "What am I really feeling? Do I feel real knee pain or is it only mental/psychological?"

I have also started having back pain, which I never really had before. I keep pretty active with cycling almost every day to work, but I have dropped running. I am afraid everything I am doing is destroying my joints, but am also afraid doing nothing is destroying my joints. Did you have issues of navigating this in terms of knowing what is real pain versus normal sensations your body is interpreting as pain? How do you navigate that? Also, how does one get your book if they live in a country where the Amazon site there does not offer it?

First, on finding my book if you live in a country where they don't offer it: it is also available on Smashwords. If you can't get it through Smashwords, no big deal. What I say in the book is scattered all over this blog. It's not like I'm holding anything back with the promise, "This secret is in the book!"

Lots of things to react to in this story (and readers may wish to chime in with their own thoughts). A few things to think about:

* Once I got back to running, I noticed tightness in the front of the knees although still only crepitus on one side.

"Tightness" can be swelling. As Doug Kelsey once observed, it doesn't take much swelling at all for the joint to tighten up. And swelling means you're pushing the knee too hard. What happened? I know very little about your situation but I can almost imagine:

Baker's cyst diagnosis. Stop/reduce running, focus on rehab, then when the "all clear" signal is given, ramp up running, perhaps too quickly. Problems then ensue.

* I went back to the PT, who did an ultrasound and found no issues at all with the knees. I asked if he could examine the cartilage with other methods and he said that with just the ultrasound it's showing that the cartilage is thick and healthy ...

Um, color me a little skeptical here. I think ultrasound might show the cartilage is of normal thickness. But I'm not sure how it can see whether it's "healthy" exactly. Also, remember: people with normal-looking cartilage can have lots of knee pain. Or people with rough-looking cartilage can have no knee pain. I do think there is a correlation between the amount of knee pain and how much cartilage you have and how it appears on an imaging test, but that's not a perfect correlation at all.

Further, crepitus can be a sign of early cartilage damage and thin synovial fluid. I had a lot of crepitus, but a relatively clean MRI.

* I have also started having back pain, which I never really had before.

Yup, sounds familiar. It could be a compensation injury (i.e., you're using your back in ways you never did before, to compensate somehow for the knee injury). Or, it could be what I call the ol' "poltergeist loose in the house, that keeps popping up in random rooms." Chronic inflammation can cause strange joint problems all over the body -- at least that's what I believe.

* I am afraid everything I am doing is destroying my joints, but also afraid doing nothing is destroying my joints. Did you have issues of navigating this in terms of knowing what is real pain versus normal sensations your body is interpreting as pain?

Doing nothing is definitely bad, but you may also need to scale back your activity somewhat. This can be a hard balance to achieve. Does the biking bother you? If not, then maybe become a casual cyclist for a few years (ramping up intensity over time if you can). Forget about running. Shove it right out of your mind. Maybe someday you can return to it; maybe not. Make your peace with that.

As for knowing what is real pain versus what are normal sensations masquerading as pain ... my default would be to assume it's all real pain of some kind, and to treat it carefully. Personally, I aimed for the least amount of pain possible. Even if it was all in my head, it felt real enough, and when I ignored the pain, it seemed to come back with greater force, so my approach worked for me.

However, TriAgain (who fought and overcome knee pain and often visits here) might have a somewhat different perspective. He took medication for a while to get on top of inflammation that was limiting him severely, and doing so was key to his recovery, so he might have thoughts on the mental aspect.

Best of luck and hang in there!