What Does "Knee Strengthening" Mean Exactly?

My belief is that, to heal bad knees, you need to focus on strengthening the joint -- that's what's causing you trouble after all -- and forget about obsessing over your leg muscles. (You can build up your quads all you want, until they're as thick as tree trunks, after you fix your knees!)

That's how I succeeded in my recovery, which I describe in my just released book, Saving My Knees.

But what does it mean to "strengthen" a joint? In my case, I had to contend with bad cartilage. An MRI revealed I had "mild" chondromalacia (though I had not-so-mild pain symptoms, so I suspect that the problems lay deeper than the MRI could see). So my mission became to restore that cartilage to better health, to make it stronger. But how?

I began digging around in the world of articular knee cartilage. What constitutes weak or poorly functioning cartilage anyway? Obviously, if it's worn down or damaged structurally, the tissue won't work as well. But then I learned something curious: bad cartilage is generally too soft.

Now here's where things can get confusing. If you cruise the Net long enough, you'll find at least one instance of a doctor pooh-poohing the diagnosis of "chondromalacia," saying that the term makes no sense because it means "soft cartilage," and cartilage is supposed to be soft. That's a rather disingenuous thing to say though.

Because chondromalacia means an "abnormal softening of cartilage." Cartilage is somewhat soft because it must act as a rubbery shock absorber, compressing and then bouncing back to its original shape. Cartilage-as-a-brick wouldn't function too well; a brick has no ability to deform to absorb shock, then recover to its original state.

The issue arises with a kind of excessive and unhealthy softness that (at its extreme) is captured in this delightful bit of imagery from the book Heal Your Knees: "If a man in his eighties tears a meniscus, it wouldn't make sense to try to repair it, because that would be like trying to put stitches in a Boston cream pie."

You don't want Boston-cream-pie cartilage, certainly, that can't hold a stitch -- or bear the burden of a walk up a hill. To better understand why, consider this excerpt from Disorders of the Patellofemoral Joint, by John Pryor Fulkerson (my bold):

Closed chondromalacia is common and may or may not be symptomatic ... it consists of simple softening of articular cartilage, which begins in a very localized area and then extends progressively in all directions ... softening, which may at times appear fluctuant, may be present in varying degrees of severity, from simple softening to a more advanced form in which a type of "pitting edema" can be observed after digital or blunt instrument pressure. This loss of elasticity, which this softening represents, decreases the function capacity of cartilage and explains the reaction of adjacent subchondral bone to which the compression forces are transferred abnormally.

There we go. That supplies the needed clarity. Soft = loss of elasticity. Loss of elasticity = not very good shock absorber. Since cartilage's key role is to lessen shocks/forces transmitted through the knee joint, too much softness means lots of problems. Plus there's this to consider: soft tissue is more prone to flaking, fraying and tearing. Flaking off bits of cartilage can be a source of pain, as they migrate through the synovial fluid to the nerve-rich synovium. And I hardly need to belabor the point that you really want to avoid tearing your cartilage.

So my calculus was simple: I didn't want to prematurely have Boston cream pie (or anything resembling it) in my joints. That meant I needed to strengthen and stiffen my knee cartilage (here I'm talking about indentation stiffness, and not brittle stiffness), through a long program of high-repetition "exercise" that gradually increased in intensity.

I knew that approach could work, from a Swedish study ("Positive Effects of Moderate Exercise on Glycosaminoglycan Content in Knee Cartilage"). Moderate physical activity boosted the content of glycosaminoglycans (GAGs) in the cartilage of participating subjects. Having more GAGs in your cartilage is great; they contribute to making the tissue healthier and more resilient.

So for anyone trying to understand how I healed, that was one important, basic insight. I knew my cartilage was weak/damaged/soft. And I knew I had to make it stronger.

And I did, and by doing so, strengthened my knees.

"What Should I Do If I Have 'Weak' Knees?"

As I promised a while back, occasionally I'll lift a "story" from the comment section and turn it into a blog post. Today is the first installment of that occasional series. For the umpteenth time, I'm not a doctor or physical therapist, so I'll just offer "things to think about" and "observations from my own experience beating knee pain and researching knee injuries." Other readers with insights (which may be much better than mine) are welcome to chime in (my comments section is completely open).

I strongly believe in patients becoming smarter about their knees and pain symptoms so that they are equipped to ask good, incisive, challenging questions of the medical professionals that examine them. That's what I'd like to help people with: getting smart enough to ask some good questions.

So without further ado, here is Anonymous complaining of "weak knees":

Have you or anyone had just "weak knees?" For over 7 years, I have had this issue and have seen a variety of doctors, multitude of tests, physical therapy and still...same old..same old thing. I was wearing a rocker type shoe from Kmart for about 6 months and my weakness went away, but...then my feet started to tingle and get sore from them. It became too much...so...I tried the Sketcher brand and the weakness came back. So now, I am back to a good pair of running shoes with good support wit weak knees. I am considering on seeking out another orthopedic surgeon's thoughts, but...because I am not in pain they feel nothing is wrong. If I wear knee supports the feeling goes away, but in several days, I get tingling in my feet. One doctor thought that since my knees are OK with supports that by realigning and tightening the knee cap, the problem would be solved. I should be happy that I don't have pain...but...a weakness all day can be just as brutal. No medication works on weakness...so...I manage through the day. When I relax at home on the couch, the feeling will go away in about an hour and then the problem starts all over again the next day.

I found this case interesting mainly because of the vagueness of the complaint: "weak" knees. Notice as well the comment "because I am not in pain they (doctors) feel nothing is wrong."

First, I'm going to go out on a limb here and say that, even though nothing is currently wrong, I bet Weak Knees (Anonymous, this is your moniker for the rest of this post :)) isn't that far away from having problems. The fact that something in your body feels amiss is often a softly blinking red warning light. Before my knee issues flared up, I was having twinges in my right knee while cycling uphill. I would adjust my stroke briefly, easing up, then the sensation would go away. So I continued to ride as hard as before, thinking (wrongly) that the problem would eventually just fix itself.

Second, I'm going to put on my swami hat and surmise a few things about Weak Knees. I could be wrong about all three speculations, but let me list them and explain my thinking:

1. There is a good chance Weak Knees is overweight.
2. There is a good chance Weak Knees leads an inactive lifestyle.
3. The physical therapy that Weak Knees did was directed at muscle-strengthening and not at improving aerobic capacity.

Again, I could be completely wrong about all three points, especially because there is so little information given about what "weak knees" means exactly. Do the knees feel like they are about to give way? Do the knees feel like they offer poor support for ordinary daily activities, such as squatting or kneeling? Do they ache at all? Or after climbing a few flights of stairs, does Weak Knees just not feel that good?

The vagueness of this self-diagnosis intrigues me, however. Much of my life I have enjoyed a sporting lifestyle. That means I have spent a lot of time with people who enjoy a similar lifestyle.

And when they have pain in one of their joints, such as the knee or spine, they describe it in a variety of manners, but "weak" is generally not one of them.

Symptoms of diffuse weakness I associate with people who tend to be overweight and out of shape. Excess weight is probably the worst thing I can think of for someone seeking to recover from knee pain or avoid it in the future. That extra fat means your knees have to work much harder to move your body around. That weight discourages you from moving in general. And, I think on some level, being overweight makes people more susceptible to "general malaise" type of disorders.

The best kind of exercise, I'm convinced at the grand age of 49, is something that gets your heart beating without your body taking a beating. That isn't meant to dismiss the benefits of running. I don't believe the myths that knees just wear out from all the pounding of running and inevitably become arthritic, though that may be true for runners who don't watch their weight or who run carelessly (e.g., who take off four months, then try to resume at the level they were at previously without building up their training). But if you've got knee joint issues, cycling (or swimming, or walking) may be a more suitable activity.

If I were Weak Knees, knowing that my joints were just weak and not hurting, I'd first drop onto my weak knees and praise the Lord I've got some time to sort out any issues before the curtain of pain descends :). Then I would talk to my doctor about what aerobic activity might be good for me that would help strengthen the knee joint and improve my cardiovascular fitness. You'd have to start slow, if you've been inactive, but exercise -- SWEATING exercise -- does a body much, much good. It's like acquiring a protective invisible force field against future knee damage (and I have yet to meet a cyclist who's complained of weak knees). I wouldn't waste a minute looking into this.

One last note: if my analysis above is anywhere close to correct, I would NOT have surgery to try to correct this condition. Surgery is generally best considered a last resort for non-specific knee pain. But again, Anonymous, talk to a qualified doctor about this.

Thinking About Knees: On the Lighter Side, for a Sunday Morning

I couldn't resist blogging this.

I was paging through the New Yorker on an exercise bike at the gym yesterday and came across the following cartoon that brought a smile to my face:

A man has propped open the hood of his car, which is probably broken down on the side of the road, and is staring into the engine space. Staring back at him is a needle-nosed, spiky-haired imp. The tiny imp is saying, "I'm your problem."

Wow. Wouldn't that be nice if figuring out what was wrong was that simple?

You go to the doctor, complaining of knee pain. He taps your knee with a rubber hammer, and a little spiky-haired imp sticks his head out the side, his mouth full of your chewed-up cartilage, and says, "I'm your problem." The doctor wrestles the imp out of the joint, and into a pocket of his lab coat, then smothers him, and you walk out of the clinic with pain-free knees.

Well, we can always dream. :)

Here Are My "Radical" Beliefs About Healing Bad Knees

I had a funny little moment of awareness this morning.

I was thinking about "Saving My Knees," my story of how I did what my doctors said I couldn't: heal my bad knees. I was thinking about how finding a big, mainstream publisher for the book turned into a hopeless quest.

Because, well, I lack a medical degree and my ideas about how to fix bad knees are presumably too "radical," too far outside what's accepted and what makes sense.

That's when I had that funny little pop of an epiphany. Basically, I said to myself: Am I really the radical here? Am I the one whose ideas about healing bad knees fail to meet the common sense test? Just how wild and outlandish are the things I believe in?

So I decided to do a compare-and-contrast exercise. The list below spells out, in simple form, what I believe in. It will show you what allowed me to save my knees and encouraged me to write a book about my experience of discovery and recovery. To counterbalance my "radical" perspective, I also include the received wisdom of traditional physical therapy and doctors.

Me: Focus on directly fixing the problem (bad knees).
Traditional Physical Therapy and Doctor's Advice: Focus on fixing something adjacent to the problem (the muscles that lie around the joint, which you are told to strengthen).

Me: Taking a pill (glucosamine) every day won't help your knees (especially when two separate medical studies have shown that pill is torn apart by the liver and the contents never reach your joints in meaningful amounts).
Traditional Physical Therapy and Doctor's Advice: Glucosamine can help your body mend bad knee cartilage (two of my doctors prescribed it).

Me: Lengthening muscles around your knees (stretching) may briefly make you feel good, but won't have a significant long-term effect on healing your bad joints.
Traditional Physical Therapy and Doctor's Advice: If you have bad knees, you should stretch various leg muscles.

Me: Trying to stretch a tendon (iliotibial band) that has the tensile strength of soft steel is most likely a complete waste of time.
Traditional Physical Therapy and Doctor's Advice: You should stretch the iliotibial band.

Me: Healing bad knees will probably take a year or two -- if you're lucky.
Traditional Physical Therapy and Doctor's Advice: Healing bad knees should take a few months (note: this is implied -- if you believe stronger quads are the key to escaping knee pain -- see point number one on the list -- this follows, as muscles can be strengthened in a matter of weeks or months at most.)

Me: Bad knees are not usually caused by a mistracking patella, especially if you're say 40 years old and this "mistracking patella" never bothered you much in the 39 preceding years after you learned how to walk.
Traditional Physical Therapy and Doctor's Advice: Bad knees are usually caused by a mistracking patella.

Me: Cartilage has a very good capacity to heal under the right conditions. A cut in your skin heals, a broken bone heals. Would humans really be created with a substance in their knee joint that must take continual pounding and abuse and has either no or very little capacity to heal?
Traditional Physical Therapy and Doctor's Advice: Cartilage can't heal (or has a very limited capacity to).

Scan that list. Think about it. And ask yourself: Who's the "radical" here?

Am I Really Some Crazy Guy Who Doesn't Believe in Strong Quads?

Okay, the book is out, so it's time to get back to the regular business of the blog ...

One thing I realized recently: someone not familiar with the story of my recovery might stumble upon bits of my writing, specifically my dismissal of quadriceps strengthening to heal bad knees, and say, "Well, this idiot clearly doesn't know anything."

EVERYBODY says that to cure patellofemoral pain syndrome (a.k.a. runner's knee, chondromalacia patella), you have to focus on strengthening the quads, or those large muscles in the front of your thigh. By everybody, I mean doctors, physical therapists, your grandma from Dubuque ...

And I think this advice is wrong -- sometimes dangerously so, as when following it leads you to injure yourself even further.

So does this mean I don't think quad strength matters? Strong quads, weak quads ... whatever.

Not at all.

Having strong quads is GREAT. They do help preserve your knees. My quads are quite strong right now. I spent the summer chasing aerobically fit, young (mostly) cyclists along flats and up hills in western Long Island. Some Saturdays I was in the saddle for almost 70 miles. The rides were intense. We would start with 40 to 50 cyclists. At the finish, there might be five or six of us.

But my own recovery taught me that, when your knees hurt, it's absolutely wrong to FOCUS on strengthening your quads first. Ironically, this conclusion turns out to be simple common sense and "strengthen your quads to beat knee pain" turns out to be baffling advice -- when you stop to really think about it.

Because: Your focus should be on what hurts, on the weak link in the chain. When you have bad knees and walk half a mile, or climb two flights of steps, and then have pain -- it's not your quads that are grumbling, but your knee joints. Your quads may be weak, average, or even strong (I happened to have fairly strong quads at the time I developed chronic knee pain). But one thing is certain: your knees are weak.

So you gotta strengthen your knees first. And what I discovered works best for that, as I outline in my book, is a program that focuses on easy motion that over time increases in intensity and duration. And by "over time," I mean months, not days. I fashioned a plan to heal that centered on walking and pretty much walked my way to stronger, healthier knees. THEN I got back on my bike and really started building up my quads.

I know I've blogged on this subject before. But it's so important I wanted to hit it fresh, with a new year upon us. That quad-strengthening approach is hardly ever questioned ... which is what I find truly crazy, because it really doesn't make sense. The cart has been put before the horse. Why don't physical therapists see this?

Well, one does. I'm going to cite Doug Kelsey again. If you put the two of us in a room, we might not agree on absolutely everything about healing knees (he once advocated taking glucosamine; my research led me to believe it's probably worthless), but Doug is the smartest PT, by a long shot, that I've come across anywhere.

Here he answers a reader's question about a program to heal patellofemoral pain syndrome (abbreviated below as PFS). The bold is mine:

Almost every exercise program that you find for PFS targets muscle (quadriceps strengthening, stretching of the hamstrings, etc.) and having stronger muscles is helpful but weak muscles are not the primary problem. The muscular weakness is in response to the changes in the joint. Some clinicians argue that cartilage does not respond to exercise; that it is biologically inert. However, there is ample scientific evidence proving that cartilage does respond like other biologic tissues of the body (muscle, tendon, ligament, bone) as long as the motion-force combination is within a certain range.

So you need to strengthen the joints. And you can. I'm living proof.

P.S. I'm going to start a new (occasional) feature where I lift some of the cases from the comments section and devote posts to them. One thing I know (from my own experience): people with hurt knees have an insatiable desire for knowledge, and they're eager to tell their stories, hoping someone can provide a glimmer of insight. As I've made clear (I hope), I'm NOT a physical therapist or a doctor, just someone who did a lot of reading and experimenting who saved a pair of bad knees that doctors said would never get better. So I won't offer any advice, more like "things to think about and discuss with a medical professional." We'll see how it goes.

If You're Having Problems of Any Kind Buying/Reading "Saving My Knees," Read This

"Saving My Knees: How I Proved My Doctors Wrong and Beat Chronic Knee Pain" is now on Amazon.com as an electronic Kindle book. I'm still waiting for the product description to be added, but the book is ready to be ordered and downloaded.

Why is it only electronic? That answer's here.

How can you read it? Or buy it if you live abroad? That answer's here.

Now, what if, after following the instructions given on the link above, you still don't have a way to buy or read the book?

Welcome to the trouble-shooting post. I'll fix problems here, best I can. Explain your issue in the comment section below and I promise to periodically update this post with possible solutions.

How Can You Read "Saving My Knees," an Electronic-Only Book, If You're Kindle-less?

Q: Argh ... I didn't find an Amazon Kindle under my Christmas tree this year, so how can I read your book "Saving My Knees"?

Another made-up question ... but I wanted to do three blog posts, addressing three important matters. One: Why is the book electronic only? Two: How can I read it then? Three: What if I still don't have any way to read it?

Today's installment: "How can I read it then?"

Amazon should be processing the book in the next 24 hours, at which point I'll add a link here to where the book can be found online. If you own a Kindle or Kindle DX, you can download "Saving My Knees" and you're off to the races ... you'll be virtual-paging through almost 55,000 words that will get you thinking about your knees in new ways and challenge some of your beliefs about how to heal.

But what if you don't have a Kindle? Here are some solutions, all of them absolutely free.

If you own an iPad, you can download "Kindle for iPad," which should enable you to read any of Amazon's electronic books on your iPad.

If you own an iPhone, you can download "Kindle for iPhone."

If you own a BlackBerry or Mac, or a device that uses either the Android or Windows Phone 7 operating systems, go here for your solution.

I saved the best for last, because most of us own ordinary ol' PCs and not any of this other fancy gadgetry. That's no problem at all, as "Kindle for PC" will set you up nicely to peruse e-books all day long.

I've been using Kindle for PC for a few weeks now (partly to preview "Saving My Knees," to see how it will look as an e-book). I usually refrain from being a software cheerleader, but Kindle for PC is very, very neat, even if, like my good friend Molly, you hate technology and belong to the Lead Pencil Club.

First, the feature set: If you've just finished the Evelyn Wood speedreading course, you can display the book in newspaper-like columns, to whiz through the content faster. If you like your book to fill the computer screen, that's an option. If you want to change font size, font display, or how many words are crammed onto a line, you can tweak any of that, easily. And it goes without saying that you can quickly jump anywhere you want to in the book.

Kindle for PC does other things too, but here's what I think is coolest: it opens up a whole new world of free books. Access to free, quality content always elevates a good piece of software to great. For example, old books in the public domain (whose copyright protection has expired) can be downloaded from Amazon ... at no cost (I'm a huge Lewis Carroll fan so my first selection was "Alice in Wonderland"). Also there are some modern books that cost absolutely nothing too, such as a rather good thriller I downloaded for kicks.

Okay, you may be thinking: I've got a device to read the book on. But I live abroad. What about payment? (You'll pay $9.99 at most for "Saving My Knees", depending on the size of Amazon's discount.)

As I understand, Amazon's U.S. e-books are available through the U.K. site (with the payment automatically converted to pounds). My guess is that Amazon will expand this option this year to other countries ... we'll see.

So what about the rest of you, who don't live in the U.S. or the U.K.?

I'll admit I haven't done a lot of research into this yet. But I did find a Web page that shows how to buy a Kindle book from Amazon.com without a U.S. billing address, by using a gift certificate purchased with an international credit card.

Note: I can't vouch for this method, as the site is not Amazon-sanctioned, but anyone who gives this option a try, share your experience in the comments section and I'll be sure to update this post.

So there you have it! If this still doesn't help you, the last of these three posts will throw the floor open to the truly hard-luck cases to describe their problems, and we'll figure out solutions.

I want this book to be distributed as widely as possible because I think the message is very important and this kind of inspiring, fact-based story isn't available anywhere (and, amazingly, I've yet to find the scientific studies that I cite in "Saving My Knees" in any other "heal your knees" books). My hobby is troubleshooting and thinking around corners (that was part of the secret to my success in recovering), so I'm sure we'll find a way for everyone who wants to read this book to have that opportunity.