As I said here, I'm not at all convinced that issues of physical misalignment (the patella incorrectly tracking) usually explain knee pain. However, another kind of misalignment can be a big obstacle to getting better.
This kind of "misalignment" I came face to face with on one of the message boards I now frequent, where knee pain sufferers gather to share stories, advice, and from time to time, a little encouragement. Someone recently posted asking to hear from others who had "end-stage chondromalacia."
That phrasing intrigued me. Think about it for a moment. If you have "end-stage" anything, you're pretty much finished, right? If I came to you and said, "I have end-stage skin cancer," your reaction would probably be to clutch my hand, quietly murmur "I'm so sorry," then wait for me to disclose how much time I had left on this earth.
Well, it turns out there is no such thing as "end-stage chondromalacia." Or at least I've never heard of it, or read of it. I Google'd the phrase as well. Not a single hit. I doubt that a physician ever said to anyone, "You have end-stage chondromalacia."
However, I don't doubt that this person is in a lot of pain and missing a lot of knee cartilage. He or she is thinking: "My cartilage will just keep wearing down. It's not coming back. I'll just have to wait for a total knee replacement. Things won't get better."
Once you're convinced you have an end-stage condition, what does your life become? Answer: a matter of dreading the inevitable. Forget about hope. Negative thoughts dominate. Bad days are expected. Good days (or good moments) are explained away as flukes; they don't really matter because you're on a one-way street called Misery Lane.
I've been there. Early on, I was determined to beat knee pain. But I couldn't, even following my physical therapist's advice to the letter. A doctor told me my knees would never get better. And, not unexpectedly, my attitude -- little by little -- reset on me. Eventually I became an intensely negative ball of energy.
Part of healing meant doing an attitude re-alignment. It's not easy. It's hard as hell. Especially for someone like me -- I'm not by nature anything resembling a blithe optimist. But I realized my mind was working against me, and that wasn't good, so I began meditating. I just wanted to find some quiet interior space where I didn't hurt and wasn't angry all the time.
Of course meditating alone doesn't do it. You also need a plan -- a really good one if you've got "end-stage chondromalacia." You have a small margin of error.
What would I do if I were in that position?
I would seriously think about getting on crutches for a while and getting access to a continuous passive motion machine. Robert B. Salter did an incredible experiment in the early 1980s that showed an astounding rate of healing of full-thickness cartilage defects (yup, that's right down to the bone) among rabbits that were hooked up to a continuous passive motion device.
But here's the rub: at the same time, you'd probably have to go non-weight-bearing on those knees for a while, then gently introduce weight-bearing activities. I don't know exactly how this plan would be carried out. Right now this is just me musing aloud, trying to find a solution. Because trying to find a solution is positive at least.
I hope this knee pain sufferer can connect with a really smart physical therapist, someone like Doug Kelsey at Sports Center. If I were this person, I would even consider moving to Austin, Texas (where the clinic is). As I say in my book, a good physical therapist is worth his (or her) weight in gold.
That's because the best way to kill a negative attitude is with a plan that shows there is a path to getting better. Who cares if it's a long one? As long as you can see the light, and see the way to move toward it, you have some hope. And that's really important.
Saturday, December 18, 2010
Saturday, December 11, 2010
What Are You Doing for Your Knees the Other 98% of the Time?
Anyone who reads my book (to be available the first week in January, it appears) will see me, in chapter eight, engaging in a bit of "medical study deconstruction" -- namely, taking apart a large study that was done about the effect of physical exercise on knees and showing how it comes up short in a number of ways.
It was a fun and illuminating exercise (fun because, to my wife's dismay, I spend a lot of time with my brow furrowed, thinking about things). To those who wonder what insight a layman could possibly have into a formal medical study, well, you might be surprised. The application of basic logic will get you far in analyzing complex subjects, even without specialized knowledge. For instance, judging the truth of the statement "the green disarticulation contours were green" doesn't require an understanding of what disarticulation contours are, why they are drawn, how they are drawn, whether they should or should not have been drawn in this specific instance. To recognize the sentence is true, you just need to identify an identity: "green equals green."
Okay, that example may seem a bit trite, but my advice is not to let the "experts" scare you away from examining their work, cloaked in all its jargon and statistical raiments. At the very least, after a thoughtful examination, you'll be in a position to ask some good questions.
And one question I asked, regarding this study, was "What were somebody's knees doing the other 98 percent of the time?"
Let me explain: The study looked at people who exercised, to see if they were less likely to develop osteoarthritis of the knee later in life. One category of exercise, fittingly enough, was walking. They were asked if they walked for exercise, and if they did, if they went less than, or more than, six miles a week.
Through how the categories were constructed, the researchers made it sound as though six miles a week was a lot of walking. So I decided to do a little math.
Let's say Joe Smith walks six miles a week for exercise. How long does it take to walk a mile? Well, I've walked one in 13 minutes before, but the average is probably closer to 20 minutes. So that equals two hours a week total. How many hours is Joe awake each week? Let's say Joe gets a full eight hours of sleep a night -- an optimistic assumption, but we'll go with it. That means Joe is awake 112 hours (16 hours x 7 days).
Divide 2 by 112 and you get 1.8 percent: That's right, Joe spends less than 2 percent of his waking hours on walking for exercise. Why does that matter? I hope you can see now where I'm going with this. What's happening with his knees the other 98 percent of the time? That's HUGE. (And the study in question makes no mention of this as a potential issue.) After all, his knees don't just magically detach from his body whenever he happens not to be exercising.
One of my complaints about physical therapy stems from this 2/98 problem. My therapist laid out a program of exercises and stretches that took me ... about two hours total, each week. Yet he didn't seem concerned about what my knees were doing the rest of the time! He never asked me questions that I would ask any knee patient, knowing what I know now. (Do you lug things to work? Do you often carry a loaded backpack? If so, about how much does it weigh? Do you often carry a child around the house? If so, how big is the child? Do you navigate a lot of steps during a typical day? Do you run for a bus? Do you run at all during a typical day? If so, for what distance and how often? Do you squat a lot at work? Do you stand a lot at work? Etc., etc.)
These questions are important because they are the other 98 percent! If your PT isn't asking about the other 98 percent, I believe you need to do the asking and thinking yourself. Because your job/house/lifestyle/whatever greatly affects how you use your knees. And how you use your knees -- over 100 percent of your waking hours, not just 2 percent -- is a big determinant of how your knees feel (and heal), I learned during my recovery.
It was a fun and illuminating exercise (fun because, to my wife's dismay, I spend a lot of time with my brow furrowed, thinking about things). To those who wonder what insight a layman could possibly have into a formal medical study, well, you might be surprised. The application of basic logic will get you far in analyzing complex subjects, even without specialized knowledge. For instance, judging the truth of the statement "the green disarticulation contours were green" doesn't require an understanding of what disarticulation contours are, why they are drawn, how they are drawn, whether they should or should not have been drawn in this specific instance. To recognize the sentence is true, you just need to identify an identity: "green equals green."
Okay, that example may seem a bit trite, but my advice is not to let the "experts" scare you away from examining their work, cloaked in all its jargon and statistical raiments. At the very least, after a thoughtful examination, you'll be in a position to ask some good questions.
And one question I asked, regarding this study, was "What were somebody's knees doing the other 98 percent of the time?"
Let me explain: The study looked at people who exercised, to see if they were less likely to develop osteoarthritis of the knee later in life. One category of exercise, fittingly enough, was walking. They were asked if they walked for exercise, and if they did, if they went less than, or more than, six miles a week.
Through how the categories were constructed, the researchers made it sound as though six miles a week was a lot of walking. So I decided to do a little math.
Let's say Joe Smith walks six miles a week for exercise. How long does it take to walk a mile? Well, I've walked one in 13 minutes before, but the average is probably closer to 20 minutes. So that equals two hours a week total. How many hours is Joe awake each week? Let's say Joe gets a full eight hours of sleep a night -- an optimistic assumption, but we'll go with it. That means Joe is awake 112 hours (16 hours x 7 days).
Divide 2 by 112 and you get 1.8 percent: That's right, Joe spends less than 2 percent of his waking hours on walking for exercise. Why does that matter? I hope you can see now where I'm going with this. What's happening with his knees the other 98 percent of the time? That's HUGE. (And the study in question makes no mention of this as a potential issue.) After all, his knees don't just magically detach from his body whenever he happens not to be exercising.
One of my complaints about physical therapy stems from this 2/98 problem. My therapist laid out a program of exercises and stretches that took me ... about two hours total, each week. Yet he didn't seem concerned about what my knees were doing the rest of the time! He never asked me questions that I would ask any knee patient, knowing what I know now. (Do you lug things to work? Do you often carry a loaded backpack? If so, about how much does it weigh? Do you often carry a child around the house? If so, how big is the child? Do you navigate a lot of steps during a typical day? Do you run for a bus? Do you run at all during a typical day? If so, for what distance and how often? Do you squat a lot at work? Do you stand a lot at work? Etc., etc.)
These questions are important because they are the other 98 percent! If your PT isn't asking about the other 98 percent, I believe you need to do the asking and thinking yourself. Because your job/house/lifestyle/whatever greatly affects how you use your knees. And how you use your knees -- over 100 percent of your waking hours, not just 2 percent -- is a big determinant of how your knees feel (and heal), I learned during my recovery.
Saturday, December 4, 2010
I Followed Your Advice, So Why Aren't My Knees Getting Better?
Sometimes I imagine this question, in a slightly querulous tone, coming from someone who has read either my entry here about what I did to save my knees, or this loonnnggg thread here, on Knee Guru's bulletin boards, that also reveals how I got better. (Quick disclaimer: I steer away from giving advice, so I took some poetic license with the title of this post.)
At Knee Guru, several smart people greeted me by peppering me with questions, curious about my "exercise regimen." How did I do this, how did I do that, what did I mean by this, what did I mean by that? And then, I have no doubt, they tried what worked for me: lots of easy, joint-friendly motion (for example, I did "walkarounds" in my apartment, where a wind-up timer would go off every 15 minutes, to alert me I needed to get up and walk a little, about 70 steps. Cleaving to that routine kept dosing my knees with movement).
After a few days of copying everything I did, I'm guessing many of them gave up in frustration, because their knees felt about the same.
So let me take a moment to make a few more in-depth observations about how I healed.
First, and it's hard to overstate the importance of this: recovering from a slow-healing injury isn't linear. What that means: you don't feel 15 units of healthy today, 16 units of healthy tomorrow, 17 units the day after that, and so on until you're at 100 percent again. If only healing were like a smoothly ascending straight line on a sheet of graph paper! Because then, as soon as you discovered the proper solution to getting better, you would know immediately that you'd found it because you would begin feeling an improvement every day forward.
Unfortunately, on the long road to saving my knees, there were ups and downs. Over a single month, I might happen to feel worse on the 22nd than on the 5th -- even though I was getting better over the entire month. So I learned that what I really needed to focus on was the trend line of healing. I had to be patient and squint hard to see that line. It only becomes clear over the course of some time.
Which brings me to point two: whatever path you choose to heal, it will probably take many months to bring you to your destination. For me, it took the better part of two years. This too has enormous implications, because early on (if you're like I was), you're casting about in frustration and desperation for a solution, any solution. So you try different things, in the same manner that a clotheshorse swaps out hats -- okay this guy says if I eat asparagus, that's good for the joints, I'll do that, wait this guy says I need to squeeze a beach ball between my knees, okay let's see if that works, now this guy says ...
Essentially you're a butterfly in the garden of healing, flitting from flower to flower, never committing to anything. Will you get better this way? I doubt it. You need to find a path, stick with it for a while (to verify that it's the right one), and then persist to the end.
Last observation on healing: the worse off you are, the longer it will take to make a few small gains. This too is critical to know. If your knees are really bad, it could take five or six months to make them just a little better. During this time, sadly, you may be tempted to just give up, thinking, "If it takes this long to go a little way, it will take me 20 years to get better!"
But what I observed about healing: it starts going faster as your knees get stronger.
I quit my job right at the end of April 2008. I had to; I couldn't sit in one place, with my knees bent normally, without a lot of uncomfortable burning, and my joints were going downhill fast. As soon as I quit, I devoted myself to a program of gentle motion, in amounts that my knees could tolerate. I focused like a laser on my goal.
Four and a half months later, I felt a little better, but not much. I began to have serious doubts. Would I really be able to beat this thing? What I didn't know was that my dedication to slow and steady motion was already helping my knees prepare for the next level of my program -- that November, I started walking on hilly trails, very carefully at first. Had I not spent the summer building up my knees, I don't think they could have withstood the rigor of that kind of exercise.
So if you're wondering why you're not getting better, even though you think you're doing what you should be, just consider these points above. Healing isn't linear. It's not swift. And, early on, it can be really, really slow. This is all important to know to win the battle.
At Knee Guru, several smart people greeted me by peppering me with questions, curious about my "exercise regimen." How did I do this, how did I do that, what did I mean by this, what did I mean by that? And then, I have no doubt, they tried what worked for me: lots of easy, joint-friendly motion (for example, I did "walkarounds" in my apartment, where a wind-up timer would go off every 15 minutes, to alert me I needed to get up and walk a little, about 70 steps. Cleaving to that routine kept dosing my knees with movement).
After a few days of copying everything I did, I'm guessing many of them gave up in frustration, because their knees felt about the same.
So let me take a moment to make a few more in-depth observations about how I healed.
First, and it's hard to overstate the importance of this: recovering from a slow-healing injury isn't linear. What that means: you don't feel 15 units of healthy today, 16 units of healthy tomorrow, 17 units the day after that, and so on until you're at 100 percent again. If only healing were like a smoothly ascending straight line on a sheet of graph paper! Because then, as soon as you discovered the proper solution to getting better, you would know immediately that you'd found it because you would begin feeling an improvement every day forward.
Unfortunately, on the long road to saving my knees, there were ups and downs. Over a single month, I might happen to feel worse on the 22nd than on the 5th -- even though I was getting better over the entire month. So I learned that what I really needed to focus on was the trend line of healing. I had to be patient and squint hard to see that line. It only becomes clear over the course of some time.
Which brings me to point two: whatever path you choose to heal, it will probably take many months to bring you to your destination. For me, it took the better part of two years. This too has enormous implications, because early on (if you're like I was), you're casting about in frustration and desperation for a solution, any solution. So you try different things, in the same manner that a clotheshorse swaps out hats -- okay this guy says if I eat asparagus, that's good for the joints, I'll do that, wait this guy says I need to squeeze a beach ball between my knees, okay let's see if that works, now this guy says ...
Essentially you're a butterfly in the garden of healing, flitting from flower to flower, never committing to anything. Will you get better this way? I doubt it. You need to find a path, stick with it for a while (to verify that it's the right one), and then persist to the end.
Last observation on healing: the worse off you are, the longer it will take to make a few small gains. This too is critical to know. If your knees are really bad, it could take five or six months to make them just a little better. During this time, sadly, you may be tempted to just give up, thinking, "If it takes this long to go a little way, it will take me 20 years to get better!"
But what I observed about healing: it starts going faster as your knees get stronger.
I quit my job right at the end of April 2008. I had to; I couldn't sit in one place, with my knees bent normally, without a lot of uncomfortable burning, and my joints were going downhill fast. As soon as I quit, I devoted myself to a program of gentle motion, in amounts that my knees could tolerate. I focused like a laser on my goal.
Four and a half months later, I felt a little better, but not much. I began to have serious doubts. Would I really be able to beat this thing? What I didn't know was that my dedication to slow and steady motion was already helping my knees prepare for the next level of my program -- that November, I started walking on hilly trails, very carefully at first. Had I not spent the summer building up my knees, I don't think they could have withstood the rigor of that kind of exercise.
So if you're wondering why you're not getting better, even though you think you're doing what you should be, just consider these points above. Healing isn't linear. It's not swift. And, early on, it can be really, really slow. This is all important to know to win the battle.
Friday, November 26, 2010
Keep Running Past the Age of 40 and Your Knees Will Fall Apart! True or False?
I'm an enemy of received wisdom, especially on the subject of what constitutes proper care of one's knees, because there are so many mistaken beliefs out there.
For example, you often hear: Keep running long enough and you'll wreck your knees.
After all, how can all that pounding be good for joints where bones meet, their endings protected only by thin pads of cartilage? And if your knees naturally wear out over time, why hasten the inevitable by subjecting them repeatedly to the high-force activity of distance running?
That's the received wisdom on knees and running. The truth appears to be quite different.
While assembling a bibliography for my book about recovering from chronic knee pain, and sorting through my many files, I came across an article by Gretchen Reynolds that I saved a while ago. Dated Aug. 11, 2009, it appears online at the New York Times Well blog. The provocative title: "Can Running Actually Help Your Knees?"
The opening is attention-grabbing:
To be fair, a skeptic might say, "Not so fast! Perhaps the marathoners were relatively young and thus better able to withstand the stresses (just wait til they get older!). Or they may have been the equivalent of professional athletes, with efficient and streamlined bodies. Who else could run so far, so often?"
Yes, good points, but what about this second study that Reynolds cites:
Stanford University followed middle-aged, longtime distance runners (they didn't have to be marathoners). They were largely in their 50s and 60s (no spring chickens there). The trial went from 1984 to 2002. At the end, the knees of the runners were compared with those of a control group, about the same age, who didn't run.
At the time of their first exams, 6.7 percent of the distance runners had mild arthritis in their knees, as opposed to none of the control group subjects. Which seems to be an argument for inactivity.
Except, by the end of the study, the results reversed. Only one in five runners showed signs of arthritic changes in their knee joints; that contrasted with one in three non-runners. Severe arthritis hobbled almost one in ten non-runners, but only one in fifty runners.
What could explain this?
The article suggests that the knee may develop a "motion groove" (those who read my book will discover me discovering that movement is the magic ticket to knee health). Cartilage adapts to the load of running. I would add further: the tissue gets stronger and stiffer and better able to cope with ordinary daily activities without complaining and becoming sore.
Reynolds tosses in a caveat at the end of her article. Once a runner becomes injured, the "exquisite balance" implied by that "motion groove" can become disrupted, leading to a "degenerative pathway" that causes cartilage to wear down and fall apart -- and then comes pain and arthritis. (I've purposefully put some of these phrases in quotations because I'm not totally on board with the author's analysis here -- I smell a Structuralist lurking -- but that's for another time.)
Injury risks do abound for runners and must be guarded against at every turn. Gaining too much weight is a no-no. Being an inconstant runner -- someone who takes off a few months, then tries to pick up at his old level of intensity -- could lead to problems. Ambition can get you in trouble (for example, suddenly going from running three miles twice a week to ten miles three times a week as you begin training for a race). Stubbornly running through early pain signals is stupid.
But running sensibly doesn't appear to be a knee killer. It may help your joints, in fact (though my exercise of choice is cycling, which is easier to do within knee-safe bounds).
SKEPTIC'S CORNER: If you read the comments after the Reynolds article (299 of them!), you will see skeptics weighing in with arguments that can be summarized along these lines: (1) there is selection bias at work, as the runners were all healthy individuals (2) the runners weighed less than the subjects in the control group (3) anyone who is in their 50s or 60s and still running long distances has, through genetics and anatomy, superior knees and cartilage to begin with.
My thoughts, point by point: (1) The study's authors did recognize the possibility of selection bias, as the runners were indeed all healthy, but two things should be noted. First, could running be part of the reason for that good overall health (exercise has been proven to boost the immune system)? Second, osteoarthritis of the knee isn't considered systemic (unlike, say, rheumatoid arthritis), and so how much effect does good health have on one's knees, if any?
(2) The runners had only a "slightly lower BMI," according to the authors. Yet that difference at the outset is a BMI of 22.3 for runners vs. 24 for non-runners (the gap is maintained through the study), according to a table included with the report. For two six-foot men, that translates into a 164.5 lb. runner and a 177-lb. non-runner. That is significant, unfortunately, and I would say is the biggest flaw in the methodology because of the well-established relationship between excess weight and arthritis.
(3) This, to me, is the least convincing argument. Remember, at the outset, 6.7 percent of the runners had mild arthritis, while none of the non-runners did. If the runners really benefited from superior cartilage/knees, then why did they have worse knees at the beginning and better knees at the end? Also, if you drill down into the results, 44.4 percent of the runners complained of a previous knee injury versus 35.9 percent of the non-runners. So why was that injury figure 20 percent higher for the runners if they started out with superior knees and cartilage?
For example, you often hear: Keep running long enough and you'll wreck your knees.
After all, how can all that pounding be good for joints where bones meet, their endings protected only by thin pads of cartilage? And if your knees naturally wear out over time, why hasten the inevitable by subjecting them repeatedly to the high-force activity of distance running?
That's the received wisdom on knees and running. The truth appears to be quite different.
While assembling a bibliography for my book about recovering from chronic knee pain, and sorting through my many files, I came across an article by Gretchen Reynolds that I saved a while ago. Dated Aug. 11, 2009, it appears online at the New York Times Well blog. The provocative title: "Can Running Actually Help Your Knees?"
The opening is attention-grabbing:
An article in Skeletal Radiology, a well-respected journal, created something of a sensation in Europe last year. It reported that researchers from Danube Hospital in Austria examined the knees of marathon runners using M.R.I. imaging, before and after the 1997 Vienna marathon. Ten years later, they scanned the same runners’ knees again. The results were striking. “No major new internal damage in the knee joints of marathon runners was found after a 10-year interval,” the researchers reported.At first blush, this seems incredible. Of all classes of runners, marathoners train the longest; the race itself of course covers 26.2 miles. Over many years of running, their cartilage should be pounded to dust, right?
To be fair, a skeptic might say, "Not so fast! Perhaps the marathoners were relatively young and thus better able to withstand the stresses (just wait til they get older!). Or they may have been the equivalent of professional athletes, with efficient and streamlined bodies. Who else could run so far, so often?"
Yes, good points, but what about this second study that Reynolds cites:
Stanford University followed middle-aged, longtime distance runners (they didn't have to be marathoners). They were largely in their 50s and 60s (no spring chickens there). The trial went from 1984 to 2002. At the end, the knees of the runners were compared with those of a control group, about the same age, who didn't run.
At the time of their first exams, 6.7 percent of the distance runners had mild arthritis in their knees, as opposed to none of the control group subjects. Which seems to be an argument for inactivity.
Except, by the end of the study, the results reversed. Only one in five runners showed signs of arthritic changes in their knee joints; that contrasted with one in three non-runners. Severe arthritis hobbled almost one in ten non-runners, but only one in fifty runners.
What could explain this?
The article suggests that the knee may develop a "motion groove" (those who read my book will discover me discovering that movement is the magic ticket to knee health). Cartilage adapts to the load of running. I would add further: the tissue gets stronger and stiffer and better able to cope with ordinary daily activities without complaining and becoming sore.
Reynolds tosses in a caveat at the end of her article. Once a runner becomes injured, the "exquisite balance" implied by that "motion groove" can become disrupted, leading to a "degenerative pathway" that causes cartilage to wear down and fall apart -- and then comes pain and arthritis. (I've purposefully put some of these phrases in quotations because I'm not totally on board with the author's analysis here -- I smell a Structuralist lurking -- but that's for another time.)
Injury risks do abound for runners and must be guarded against at every turn. Gaining too much weight is a no-no. Being an inconstant runner -- someone who takes off a few months, then tries to pick up at his old level of intensity -- could lead to problems. Ambition can get you in trouble (for example, suddenly going from running three miles twice a week to ten miles three times a week as you begin training for a race). Stubbornly running through early pain signals is stupid.
But running sensibly doesn't appear to be a knee killer. It may help your joints, in fact (though my exercise of choice is cycling, which is easier to do within knee-safe bounds).
SKEPTIC'S CORNER: If you read the comments after the Reynolds article (299 of them!), you will see skeptics weighing in with arguments that can be summarized along these lines: (1) there is selection bias at work, as the runners were all healthy individuals (2) the runners weighed less than the subjects in the control group (3) anyone who is in their 50s or 60s and still running long distances has, through genetics and anatomy, superior knees and cartilage to begin with.
My thoughts, point by point: (1) The study's authors did recognize the possibility of selection bias, as the runners were indeed all healthy, but two things should be noted. First, could running be part of the reason for that good overall health (exercise has been proven to boost the immune system)? Second, osteoarthritis of the knee isn't considered systemic (unlike, say, rheumatoid arthritis), and so how much effect does good health have on one's knees, if any?
(2) The runners had only a "slightly lower BMI," according to the authors. Yet that difference at the outset is a BMI of 22.3 for runners vs. 24 for non-runners (the gap is maintained through the study), according to a table included with the report. For two six-foot men, that translates into a 164.5 lb. runner and a 177-lb. non-runner. That is significant, unfortunately, and I would say is the biggest flaw in the methodology because of the well-established relationship between excess weight and arthritis.
(3) This, to me, is the least convincing argument. Remember, at the outset, 6.7 percent of the runners had mild arthritis, while none of the non-runners did. If the runners really benefited from superior cartilage/knees, then why did they have worse knees at the beginning and better knees at the end? Also, if you drill down into the results, 44.4 percent of the runners complained of a previous knee injury versus 35.9 percent of the non-runners. So why was that injury figure 20 percent higher for the runners if they started out with superior knees and cartilage?
Saturday, November 20, 2010
Is Your Knee Doctor (or Physical Therapist) a Structuralist?
And why should you care?
Doug Kelsey, chief therapist at Sports Center, defines structuralism as "a school of thought that believes the genesis of musculoskeletal complaints is from one or more biomechanical abnormalities."
Further, he says:
So if your doctor (or physical therapist) says your problems are caused by a poorly tracking patella -- or that you must strengthen hip/butt/quad/whatever muscles and stretch the IT band/quads/hamstrings/whatever in order to redress your body's imbalances -- chances are excellent you have a Structuralist.
But does Structuralism make sense as a model to analyze and treat the majority of people who suffer from chondromalacia or patellofemoral pain syndrome? Logically (and instinctively), the answer is no for several reasons.
(1) Can stretching, one of the solutions in the Structuralist toolkit, really correct biomechanical abnormalities? Stretching temporarily lengthens muscle fibers. Then they contract again. How long must you stretch to achieve a lasting, beneficial effect? Answer: it's unclear. Paul Ingraham, massage therapist and stretching skeptic, does quote this therapy-exercise textbook (in his comprehensive online essay looking at how stretching fails to deliver what it promises):
(2) If the Structuralists are right -- if your biomechanics are at fault -- why do chondromalacia and PFPS usually strike at older ages: 30, 40, 50? Let's look at the commonly blamed factor of kneecap mistracking. If that's to blame for knee pain, wouldn't it become a problem soon after you learn to walk? Why aren't there more three-year-olds with PFPS?
Okay, that seems a bit silly. Let's take a charitable view of Structuralism. Let's say patella mistracking doesn't manifest until the skeleton has finished growing, in the mid to late teens for most people. Fine. Then why isn't there an onslaught of cases of PFPS when people reach their early twenties, as their adult frame finishes growing and their badly tracking patella dooms them to a life of pain?
(3) Finally, here's the big problem with Structuralism, as Kelsey observes: Nobody has perfect biomechanics in the first place. Yet most of us do fine anyway.
Those are three reasons that logically (and instinctively) Structuralism doesn't make sense. But in the world of evidentiary medicine, musings and common sense alone don't constitute grounds for overturning a prevailing paradigm. In the medical world, physicians turn to clinical studies. So let's look at one.
This study ("Patellofemoral Joint Kinematics in Individuals with and without Patellofemoral Pain Syndrome", published in 2006) included three groups: 1. 20 people with PFPS who had clinical signs of patellar malalignment (as evidenced by tests performed during a physical exam) 2. 20 people with PFPS who had no clinical evidence of malalignment 3. 20 people with no knee problems.
An MRI captured images of their knees in various stages of being flexed, to note "patellar motion" as a function of the particular angle their knees were bent. So the MRI could see, for example, whether the kneecap was perfectly centered in the trochlear groove or sliding out to the right or to the left.
If Structuralism was the correct paradigm for understanding PFPS, what would we expect to find? Easy: that the patients with knee pain tended to have kneecaps with the worst tracking.
What the researchers actually found:
In other words, if you just look at MRIs of how someone's patella tracks, you'll have no idea whether they have PFPS. Someone with a kneecap that tracks perfectly may have PFPS. Someone with no knee pain may have a patella that mistracks. The authors make the point more bluntly in a follow-up letter to the journal where the study was published: "Our findings add to the evidence that patellar mistracking is not a clinically significant factor for most individuals with patellofemoral joint pain."
So there you have it, a crumbling edifice called Structuralism, that your doctor and physical therapist are probably using right now to analyze why you have knee pain and how you should fix it. And is it any wonder that more people aren't healing? And is it any wonder that, in order for me to heal, I didn't need a visit from the angels from above, but rather a cold-eyed rejection of this whole Structuralist approach (I got better through a simple, long process: I strengthened my knees).
So when I ask, "Is your doctor (or physical therapist) a Structuralist?", it's not an idle question. The fate of your knees may hang in the balance.
Doug Kelsey, chief therapist at Sports Center, defines structuralism as "a school of thought that believes the genesis of musculoskeletal complaints is from one or more biomechanical abnormalities."
Further, he says:
For patella pain, the biomechanical abnormalities include a laterally tracking patella, weak medial quadriceps, tight hamstrings, tight iliotibial band, tight calf muscles, weak or tight hip rotator muscles and over pronation of the foot. A Structuralist view would then be to set the mechanics "right" and symptoms would subside.Sound familiar? Pay close attention to that first one: "a laterally tracking patella." That is, in layman's terms, a kneecap that isn't perfectly centered in the trochlea, or the groove that it's supposed to slide through with the greatest of ease. We'll return shortly to that mistracking patella.
So if your doctor (or physical therapist) says your problems are caused by a poorly tracking patella -- or that you must strengthen hip/butt/quad/whatever muscles and stretch the IT band/quads/hamstrings/whatever in order to redress your body's imbalances -- chances are excellent you have a Structuralist.
But does Structuralism make sense as a model to analyze and treat the majority of people who suffer from chondromalacia or patellofemoral pain syndrome? Logically (and instinctively), the answer is no for several reasons.
(1) Can stretching, one of the solutions in the Structuralist toolkit, really correct biomechanical abnormalities? Stretching temporarily lengthens muscle fibers. Then they contract again. How long must you stretch to achieve a lasting, beneficial effect? Answer: it's unclear. Paul Ingraham, massage therapist and stretching skeptic, does quote this therapy-exercise textbook (in his comprehensive online essay looking at how stretching fails to deliver what it promises):
Several authors have suggested that a period of 20 minutes or longer is necessary for a stretch to be effective and increase range of motion when a low-intensity prolonged mechanical stretch is used.That's a lot of time to devote to a single stretch, for a single muscle, as he notes. Then how often would you have to stretch like that? Once a day? Once every ten hours? Six hours? And, even supposing that stretching can change your biomechanics, how are you supposed to be able to tell when you've reached the sweet spot, of just the right amount of change, and not too much (after all, you don't want to have your patella start tracking to the left because you overcorrected for its tracking to the right, and too much flexibility does lead to unstable joints)?
(2) If the Structuralists are right -- if your biomechanics are at fault -- why do chondromalacia and PFPS usually strike at older ages: 30, 40, 50? Let's look at the commonly blamed factor of kneecap mistracking. If that's to blame for knee pain, wouldn't it become a problem soon after you learn to walk? Why aren't there more three-year-olds with PFPS?
Okay, that seems a bit silly. Let's take a charitable view of Structuralism. Let's say patella mistracking doesn't manifest until the skeleton has finished growing, in the mid to late teens for most people. Fine. Then why isn't there an onslaught of cases of PFPS when people reach their early twenties, as their adult frame finishes growing and their badly tracking patella dooms them to a life of pain?
(3) Finally, here's the big problem with Structuralism, as Kelsey observes: Nobody has perfect biomechanics in the first place. Yet most of us do fine anyway.
Those are three reasons that logically (and instinctively) Structuralism doesn't make sense. But in the world of evidentiary medicine, musings and common sense alone don't constitute grounds for overturning a prevailing paradigm. In the medical world, physicians turn to clinical studies. So let's look at one.
This study ("Patellofemoral Joint Kinematics in Individuals with and without Patellofemoral Pain Syndrome", published in 2006) included three groups: 1. 20 people with PFPS who had clinical signs of patellar malalignment (as evidenced by tests performed during a physical exam) 2. 20 people with PFPS who had no clinical evidence of malalignment 3. 20 people with no knee problems.
An MRI captured images of their knees in various stages of being flexed, to note "patellar motion" as a function of the particular angle their knees were bent. So the MRI could see, for example, whether the kneecap was perfectly centered in the trochlear groove or sliding out to the right or to the left.
If Structuralism was the correct paradigm for understanding PFPS, what would we expect to find? Easy: that the patients with knee pain tended to have kneecaps with the worst tracking.
What the researchers actually found:
No differences in the overall pattern of patellar motion were observed among the groups ... It is clear from the data that an individual with patellofemoral pain syndrome cannot be distinguished from a control subject by examining patterns of spin, tilt, or lateral translation of the patella.(If you're a Structuralist, that sound you just heard is the floor collapsing beneath you.)
In other words, if you just look at MRIs of how someone's patella tracks, you'll have no idea whether they have PFPS. Someone with a kneecap that tracks perfectly may have PFPS. Someone with no knee pain may have a patella that mistracks. The authors make the point more bluntly in a follow-up letter to the journal where the study was published: "Our findings add to the evidence that patellar mistracking is not a clinically significant factor for most individuals with patellofemoral joint pain."
So there you have it, a crumbling edifice called Structuralism, that your doctor and physical therapist are probably using right now to analyze why you have knee pain and how you should fix it. And is it any wonder that more people aren't healing? And is it any wonder that, in order for me to heal, I didn't need a visit from the angels from above, but rather a cold-eyed rejection of this whole Structuralist approach (I got better through a simple, long process: I strengthened my knees).
So when I ask, "Is your doctor (or physical therapist) a Structuralist?", it's not an idle question. The fate of your knees may hang in the balance.
Sunday, November 14, 2010
So What Exactly Is Knee Cartilage Anyway?
In my last blog post, I dropped a rather long, important-sounding word: glycosaminoglycans.
These polysaccharides help to keep cartilage elastic and resilient. And, according to a Swedish study, their content increased in the knee joints of people who exercised.
Now I want to take a whirlwind tour through the make-up of cartilage, which I studied when I was battling knee pain, to put that fifty-cent word in some meaningful context.
First, hyaline articular cartilage (that’s the kind we're looking at, because it pads the ends of the bones that meet in the knee joint) is like a tough, rubbery, wet sponge. It’s four-fifths water (showing you why it’s important to stay hydrated).
Take out the water and what do you have left? There’s a tough, ropy protein called collagen that is found in higher concentrations on the surface than deeper in the tissue (to keep your cartilage tear-resistant where it matters most). Then you have molecules that weave around that collagen skeleton that are called proteoglycans.
Let’s look up close at those proteoglycans. They’re large molecules that consist of a protein core and many long-chain sugar molecules (if you want to visualize a proteoglycan, the easiest way is to imagine a bottle brush -- the spine of the brush is the protein core, and the many bristles are the sugar chains).
What are the sugar chains called? Go to the head of the class if you've already figured this out: glycosaminoglycans. (A quick aside: if you were to tear apart a glycosaminoglycan in your molecular toolshed, you would find it's composed of sugars such as glucosamine. Ah, so you now you know where that glucosamine you’re swallowing for your joint pain is supposed to be going! But unfortunately it never gets there, making glucosamine supplements useless -- more on that some other time).
So why should you give two hoots if your cartilage has a low content of glycosaminoglycans or a high content?
Well, when you subject your knee to load, that tough, rubbery tissue that is cartilage gets compressed. Remember, it’s not like a plate of metal, but rather a tough sponge with a high proportion of water. It needs some way to protect itself from intense forces being transmitted through the knee joint during everyday activities. Otherwise, your cartilage could get chewed up pretty fast.
Of course, there is that tough collagen, which helps. But the glycosaminoglycans also play a key role. On the atomic level, they carry a negative charge. So they repel each other when pushed closer together.
So let’s say you jump in the air to grab a Frisbee. When you land, knee cartilage has to absorb that load of your body hitting the ground. The pressure will expel water and synovial fluid from the tissue and push the glycosaminoglycans closer together. But as they’re pushed closer, that negative charge causes them to repel each other more strongly (you know how intense this pushback can be if you've ever tried to place the like poles on a pair of magnets in contact with each other).
So having plenty of glycosaminoglycans is critical for keeping the tissue resilient.
Knee cartilage 101! Important stuff to know.
These polysaccharides help to keep cartilage elastic and resilient. And, according to a Swedish study, their content increased in the knee joints of people who exercised.
Now I want to take a whirlwind tour through the make-up of cartilage, which I studied when I was battling knee pain, to put that fifty-cent word in some meaningful context.
First, hyaline articular cartilage (that’s the kind we're looking at, because it pads the ends of the bones that meet in the knee joint) is like a tough, rubbery, wet sponge. It’s four-fifths water (showing you why it’s important to stay hydrated).
Take out the water and what do you have left? There’s a tough, ropy protein called collagen that is found in higher concentrations on the surface than deeper in the tissue (to keep your cartilage tear-resistant where it matters most). Then you have molecules that weave around that collagen skeleton that are called proteoglycans.
Let’s look up close at those proteoglycans. They’re large molecules that consist of a protein core and many long-chain sugar molecules (if you want to visualize a proteoglycan, the easiest way is to imagine a bottle brush -- the spine of the brush is the protein core, and the many bristles are the sugar chains).
What are the sugar chains called? Go to the head of the class if you've already figured this out: glycosaminoglycans. (A quick aside: if you were to tear apart a glycosaminoglycan in your molecular toolshed, you would find it's composed of sugars such as glucosamine. Ah, so you now you know where that glucosamine you’re swallowing for your joint pain is supposed to be going! But unfortunately it never gets there, making glucosamine supplements useless -- more on that some other time).
So why should you give two hoots if your cartilage has a low content of glycosaminoglycans or a high content?
Well, when you subject your knee to load, that tough, rubbery tissue that is cartilage gets compressed. Remember, it’s not like a plate of metal, but rather a tough sponge with a high proportion of water. It needs some way to protect itself from intense forces being transmitted through the knee joint during everyday activities. Otherwise, your cartilage could get chewed up pretty fast.
Of course, there is that tough collagen, which helps. But the glycosaminoglycans also play a key role. On the atomic level, they carry a negative charge. So they repel each other when pushed closer together.
So let’s say you jump in the air to grab a Frisbee. When you land, knee cartilage has to absorb that load of your body hitting the ground. The pressure will expel water and synovial fluid from the tissue and push the glycosaminoglycans closer together. But as they’re pushed closer, that negative charge causes them to repel each other more strongly (you know how intense this pushback can be if you've ever tried to place the like poles on a pair of magnets in contact with each other).
So having plenty of glycosaminoglycans is critical for keeping the tissue resilient.
Knee cartilage 101! Important stuff to know.
Saturday, November 6, 2010
You Can Strengthen Knee Joints: Scientific Proof
Check out this hard-luck group of 30 people:
They're all between 35 and 50 years old. They've all undergone surgery to repair a torn meniscus (a disk of cartilage in the knee joint). 87 percent of the group are aware of their knee problems at least monthly, and most have pain, stiffness and functional limitations.
Not a happy bunch.
They were subjects in a Swedish study to gauge the effect of exercise on something called "glycosaminoglycans" in knee cartilage. Big word, but important stuff: these polysaccharides are critical for keeping cartilage elastic and resilient.
The subjects were split into a control group (whose level of activity didn't increase over the course of the study) and a group that exercised. Each week, the exercisers were expected to go to at least three group classes, supervised by trained physical therapists.
The classes consisted of warm-ups, such as cycling, rope skipping and jogging on a trampoline. After that the subjects did "individually progressed weight-bearing strengthening exercises." These included such activities as repeatedly sitting down and standing up while holding a barbell bar (with no weight on it) and doing lunges while holding dumbbells.
After four months, researchers used a special enhanced MRI to peer into the joints of all the subjects.
The exercisers were found to have a significantly higher content of glycosaminoglycans than members of the control group. Also, they had improved scores on a special scale designed to assess pain, joint function and quality of life for people with troubled knees.
In Arthritis & Rheumatism (the November 2005 issue), the study's researchers, Ewa M. Roos and Leif Dahlberg, wrote that:
So what the heck are glycosaminoglycans, and why do they sound so suspiciously like "glucosamine"? Ah, not a coincidence at all. I'll look at that next time, because answering the question properly requires a bit of a "fantastic voyage" into cartilage, on a cellular level.
(Note: observant readers will wonder about the exercises prescribed in the Swedish story. Aren't some of them "quad strengthening" -- which I've made no secret of disliking? Yes, but a few things: 1. They were done after a period of supervised warm up. 2. They were done under the supervision of physical therapists, who were monitoring each individual's form (a breakdown in form signals someone is doing an exercise beyond his or her capability). 3. They were specifically tailored to individual patients. 4. I'm not saying I endorse these particular exercises for knee pain sufferers; I'm just saying knees benefit from movement -- and here's evidence.)
They're all between 35 and 50 years old. They've all undergone surgery to repair a torn meniscus (a disk of cartilage in the knee joint). 87 percent of the group are aware of their knee problems at least monthly, and most have pain, stiffness and functional limitations.
Not a happy bunch.
They were subjects in a Swedish study to gauge the effect of exercise on something called "glycosaminoglycans" in knee cartilage. Big word, but important stuff: these polysaccharides are critical for keeping cartilage elastic and resilient.
The subjects were split into a control group (whose level of activity didn't increase over the course of the study) and a group that exercised. Each week, the exercisers were expected to go to at least three group classes, supervised by trained physical therapists.
The classes consisted of warm-ups, such as cycling, rope skipping and jogging on a trampoline. After that the subjects did "individually progressed weight-bearing strengthening exercises." These included such activities as repeatedly sitting down and standing up while holding a barbell bar (with no weight on it) and doing lunges while holding dumbbells.
After four months, researchers used a special enhanced MRI to peer into the joints of all the subjects.
The exercisers were found to have a significantly higher content of glycosaminoglycans than members of the control group. Also, they had improved scores on a special scale designed to assess pain, joint function and quality of life for people with troubled knees.
In Arthritis & Rheumatism (the November 2005 issue), the study's researchers, Ewa M. Roos and Leif Dahlberg, wrote that:
The changes imply that human cartilage responds to physiologic loading in a way similar to that exhibited by muscle and bone.So weak or damaged cartilage can change, and for the better. Furthermore:
In a cartilage matrix with low [glycosaminoglycan] content, as in cartilage disease, insufficient viscoelasticity may cause cause progressive denaturation of collagen molecules, collagen loss, and subsequent development of [osteoarthritis].Is having more glycosaminoglycans all that matters in beating knee pain? Of course not. But if you want robust knees that can withstand the rigors of daily living -- and that includes the "rigor" of sitting -- you need good, healthy shock absorbers, or cartilage. And good cartilage needs plenty of glycosaminoglycans to keep it stiff and functioning well.
So what the heck are glycosaminoglycans, and why do they sound so suspiciously like "glucosamine"? Ah, not a coincidence at all. I'll look at that next time, because answering the question properly requires a bit of a "fantastic voyage" into cartilage, on a cellular level.
(Note: observant readers will wonder about the exercises prescribed in the Swedish story. Aren't some of them "quad strengthening" -- which I've made no secret of disliking? Yes, but a few things: 1. They were done after a period of supervised warm up. 2. They were done under the supervision of physical therapists, who were monitoring each individual's form (a breakdown in form signals someone is doing an exercise beyond his or her capability). 3. They were specifically tailored to individual patients. 4. I'm not saying I endorse these particular exercises for knee pain sufferers; I'm just saying knees benefit from movement -- and here's evidence.)
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