Of Breakdown Points and Discontinuities in Healing, Part I

Now for something completely different.

During the many months when I had no job, when my sole focus was on fixing a pair of bad knees -- could it really be done? -- I did a lot of thinking. Not surprisingly, much of it was about damaged knees. My internal dialogues became more interesting when I realized my personal experiment was succeeding -- I was getting better -- even after a doctor (and not any doctor, but the best of the four I had seen) told me my knees were a lost cause.

At that point I could stand back (in a metaphorical sense) and survey the long timeline of my recovery. And one thing that struck me as curious was how incredibly lumpy it was, even though I was steadfast, meticulous, careful, diligent.

There were ups. And downs. All over the place.

So I began pondering more deeply what was going on with wear-and-tear injuries, and the long-term healing process, and I had the following thoughts:

STRUCTURAL BREAKDOWN POINTS

Say there's an old country bridge over a river with a five-ton weight limit, and the limit is absolutely, precisely real. And say a dedication ceremony for a park on the river's north bank is held on the bridge, because of the astonishing scenic view from there. Dignitaries and various paraphernalia are packed onto the structure.

Soon the bridge is supporting 9,999 pounds, but no one appears worried. Indeed, it seems stable. Then someone remembers a two-pound cake he forgot and rushes off, then returns with it.

And the bridge collapses.

Or consider a ceramic cup that's held x inches off the ground. If you drop it, you've got a dirty cup -- but nothing worse. Hold the same cup x + 4 inches off the ground, drop it, and you've got pieces of a cup.

So there's a point at which an object or structure breaks. When it does, it undergoes a significant change of state -- in the case of the cup, from "whole" to "pieces."

What's happening at the pre-breakdown point? What's the bridge like, a few pounds shy of its weight limit, or what's the condition of the cup on impact when dropped from x inches, not x + 4? Outwardly, either appears fine. However, both may be very stressed internally. Further, the unseen stresses may contribute to an overall weakening of either (next time you drop the cup at x inches, it may break instead of just getting dirty).

SO WHAT DOES ALL THIS MEAN?

What I think is a fascinating paradox lies at the heart of these observations:

(1) Small factors can have huge consequences (a two-pound cake causes a bridge to collapse).

(2) Small factors don't really have huge consequences (that two-pound cake becomes a problem only if you've unwisely loaded the bridge with 9,999 pounds of other stuff).

Our knees are structures, of a biological sort (the distinction is important, because they're not brittle, in the same way a concrete bridge is, and they have a capacity for self-repair, but I still think the analogy broadly holds).

If you have a wear-and-tear or overuse injury that results in knee pain (as opposed to having knee pain from a sudden, traumatic accident), there is probably a crossover point where your joint goes from being extremely stressed with no pain to being extremely stressed with pain. It could be a slender crossover point, that is covered quickly, leaving you suddenly wondering, "Why do my knees hurt today? What did I do wrong? What should I do now?"

EARLY DELUSIONS WITH KNEE PAIN

Okay, here's the point of these musings:

To me the idea of breakdown points, and the central paradox of them (outlined above), suggests that many of us suffer two delusions early on with knee pain.

(1) Delusion #1: "I must be in pain because of that hike (or whatever) yesterday, so I'll just take it easy for a week or two, and I'll feel better."

So you blame a proximate cause for the breakdown. But that's like saying the two-pound cake brought down the bridge. It did, but it really didn't when you look at the larger picture.

Based on this delusion, you reason that a week or two will suffice to fix a sore knee. This is a short-term fix to a long-term problem. It usually doesn't work.

The problem is, you've deluded yourself into thinking the problem is smaller than it is. Why? Because, during the preceding months, when your joint was being quietly stressed and damaged in small ways, you still hadn't hit that breakdown point and crossed the pain threshhold, so you never realized how close to trouble you were.

(2) Delusion #2: If you're lucky enough that your knees do feel better in a few weeks, you think, "Phew! They healed. Glad that's over!"

But what if you just crossed that threshhold from pain to no pain in a small way, and the truth is the accumulated defects and stresses in the joints are just waiting to cause more problems? Two months later, you feel pain and say, "Darn, my knees again."

But it's not again. It's the same problem as before. Instead of trying to fix it with a long-term plan, you hoped it would go away. And now it's back.

Part II (in a few weeks -- I'm off to Florida on vacation next week ;)) will look at the mirror image of this concept. If there are such things as breakdown points with our knees, might there also be "mending points"? If so, what implication does that have for the healing process?

On Getting Comfortable With the Time Frame for Healing Bad Knees

The New Yorker recently ran a short piece in the front of the magazine entitled "Countdown." The theme was unpredictability, but I took away a different message.

In 1927, we are told, a physics professor in Australia by the name of Thomas Parnell set up an experiment to demonstrate how viscous a fluid can be. "He poured hot pitch into a glass funnel, let it cool, then waited."

And waited.

And waited.

Eight years later, a drop fell. Nine more years passed before the second drop. All in all, there have been eight drops at an average interval of ten years. It takes very little time for a drop to descend: about one-tenth of a second. No one has actually seen one falling.

Sometime in 2013, the ninth drop of pitch is expected. Then, after it falls, there will be a good decade of waiting until the next one.

How's that for slow?

Still, what I found most interesting about the experiment wasn't how long it takes for a drop of pitch to separate out from the mass it's a part of. Rather, it was the idea that pitch -- like a pair of bad knees -- has its own scale of time on which it changes. Someone who failed to appreciate this might have packed up the pitch experiment after five or six years, deeming it a failure.

Similarly, in nursing my knees back to health, I realized the importance of "cartilage time." Some readers of Saving My Knees may naively interpret this term simply as advice to "be patient." The truth is, "cartilage time" is something more subtle.

It's a recognition that your treatment plan must be based on the right time scale -- the time scale for what you're trying to heal. How long is that, for cartilage and soft tissues inside a joint? What I found: Not days. Not weeks. But many months, or even years.

What happens when your expectations aren't "in sync" with this reality? For one, you get frustrated. For example, suppose you go to a physical therapist and are told, to heal your grumbling knees, you must strengthen your quadriceps and other muscles. So you embark on a muscle-strengthening program.

Many frustrations may follow (partly because you're focused on strengthening the wrong thing). But one reason you'll be unhappy after a couple of months (when your knees feel no better) is because you mistakenly expect to improve on a muscle-strengthening schedule (which is over weeks, or a few months). Actually you need to adjust your expectations to a much longer time frame.

Getting the time scale wrong can be an incredible source of frustration. Early on in my struggle, my knees would feel a little better one week, a little worse the next. That proved maddening. I felt lost. Was there never going to be an end to this misery?

But when I realized I wasn't going to recover in a few weeks -- or even a few months -- my outlook changed. I made my peace with the fact it was going to take a while. I became more patient. My program to heal became more gradual. And that was a good thing.

Arthritic Knees Are in Constant State of Repair, Study Finds

Just call this "Good News February."

A couple of weeks ago, I ran a success story from Ron, who credited his recovery to the same approach that helped me heal.

Of course, much of the medical profession still seems to doubt that bad knees can repair themselves. This pessimism, not surprisingly, has resulted in a prevailing treatment regimen that emphasizes stretching and strengthening muscles, to prevent bad knees from getting worse. Oddly absent from the protocol: activities designed specifically to strengthen the knee.

But what if bad knees can repair themselves? Ah, then the game changes completely (as I've said many times). Then you probably need a plan that, at least broadly, resembles what I did to heal.

Well, check this out, hot off the press (my bold):

Researchers at Duke University Medical Center used new tools they developed to analyze knees and hips and discovered that osteoarthritic knee joints are in a constant state of repair, while hip joints are not.

"This suggests the knee has capacity for repair we didn't know about and the main treatment strategy probably would need to focus on turning off the breakdown of knee tissue," said Virginia Kraus, MD, PhD, professor of Rheumatology and Immunology at Duke. "I was hugely surprised to find this."

Maybe Kraus was hugely surprised. I'm not at all. This is the driving idea behind Saving My Knees -- your knees stand a good chance of healing if you do the right things and are very patient -- and there are medical studies over the last decade that show why (which Kraus may be unfamiliar with, but others of us know about).

The article on the Duke University web site goes on to note:

Perhaps the natural repair response would be sufficient to lead to a reversal or halting of the disease process in the knee if the joint breakdown could be halted, Kraus said.

Note the language is carefully couched -- "perhaps ... would be sufficient ... reversal or halting of the disease process." But I can assure you, from having parsed plenty of medical studies, that all researchers speak with this same abundance of caution. My own experience was that "the natural repair response is sufficient to lead to a reversal of the disease process in the knee" -- because my conviction is that I was in the early stages of a bad disease process that I managed to turn around.

All in all, I was happy with this article, except for this part:

The knee is very accessible for injections, so it would make sense to inject the knee with agents that could turn off the degradative processes, and these could be delivered periodically with close monitoring, Kraus said. "That seems like a very viable strategy."

Argh. (That sound you hear is me banging my head against a wall.)

Somehow we've gone from "the knee has a naturally robust repair response" to "what artificial agents can we inject into the joint?" What's frightening is I don't think Kraus even realizes the irony. Maybe, on a deeper level, her strategy of choice just reflects the times we live in -- when there's a problem, we immediately seek to harness our superior technological knowledge in service of a solution.

But do we really need to inject foreign substances into our knees to "turn off the degradative processes," as if these processes are biochemical toggle switches waiting for the right substance to float by to trigger a shutdown?

I really don't think so (and to explain in depth why I think this is a flawed approach would take another blog-length entry). Let me just observe: I had destructive chronic inflammation in both my knees. I managed to turn it off without jabbing a needle into the joint capsule.

How? The simple version: I focused on stopping activities that my knees didn't like, and weren't strong enough for (such as periods of bent-leg sitting) and starting activities that my joints craved (lots of gentle motion), and on strengthening my knees over time.

And guess what? My body apparently figured out how to flip that biochemical toggle switch on its own. Which is really the best way to go, if you ask me.

My "Radical" Discovery About How to Beat Knee Pain

Sometimes I imagine what this blog must look like to someone who has stumbled upon it by accident, maybe after a long afternoon chasing hyperlinks, trying to figure out: Why do my knees hurt? How do I fix them?

And occasionally, I like to write something specifically for this first-time visitor whose head is spinning from all the advice and information he/she has been absorbing.

So this visitor arrives at a blog called "Saving My Knees" and wants to know: What does this guy believe in? What makes him different from everyone else out there, with all their theories and ideas and suggestions? What's his magic prescription for healing?

Well, at heart I believe in something so simple it's practically radical:

When you have knee pain, the problem you should focus on -- believe it or not -- is your knees.

Not your quads. Or your hips. Or your glutes.

Not the fact that your hamstrings aren't too flexible, so might they need to be stretched? Not your VMO muscle, which you think may be too weak. Not your iliotibial band, which seems tight.

If you want to heal bad knees, you need a plan that puts those knees front and center.

I'm not sure at what point in history doctors and physical therapists began going down the other path, of trying to heal bad knees by focusing on things that are non-knee -- or things that are knee (slightly mistracking patella) that usually don't matter much.

That philosophy is known as structuralism. While the idea that misalignment is the root of all evil has a superficial, intuitive appeal, I'm skeptical that it applies for most knee pain sufferers. In many cases, I'm convinced, knees go bad just because of injury or good old-fashioned wear and tear or some combination of the two, seasoned with time and inactivity (or foolish activity).

In which case the million-dollar question becomes: How do you treat knees as opposed to the many surrounding muscles that you've been told to stretch and strengthen and massage and whatever?

My experience: Low load, high repetition. Making very, very slow gains -- and building on those. Monitoring your knees very closely. Resigning yourself to what is probably a multi-year healing process.

Here's a little more about how I did it:

What I Did to Save My Knees

Another Success Story to Brighten Your Day

Fishing through the blog's comment section each week, I never know what I'll find. Usually it's a complaint about balky knees or a plea for advice. But sometimes it's a jewel -- a success story -- and one recently got me excited enough to burst in upon my wife and 2-year-old daughter, while they were taking a bath, to tell Congyu, "Honey, listen to this."

Here's the longish story -- in full -- from someone named Ron. I'll return at the end to comment on a few things:

I wanted to let you know that I have runners knee and I am 56 years old. I have had the signs of it for about 5 years. In the beginning I can remember the movie goer stiffness. I did not know at the time what it was. I had to stop running over 2 years ago do to the pain in my left knee that seemed to come out of no where at the time. After I stopped running I figured out what I had, self diagnosis, Runners Knee.

So I did the exercises, foam roller and stretching. Sources were youtube and others on the internet. I was thinking I was getting better so I went for a run about 6 month's later. I ran about 1 1/2 miles and limped/walked for the last 1/2 mile. I was nearly on crunches the next day and it took about a week to walk normal.

At this time I decided to see a doctor and get the knee fixed. I was not getting any where. The doctor took x-rays and said the cartilage looks remarkably well and conferred with me on the runners knee diagnosis. He gave me a prescription for physical therapy. I'm thinking wow the professionals are going to fit it. They looked at the knee and did not see anything unusual. Next they iced, massaged, stretched, exercised and ultra sounded it. After 2 months of this and no improvement I got a second opinion from a orthopedic surgeon with great recommendations.

He looked at my knee and the X-Ray of it. He then had me do a couple of things and felt around and told me I had runners knee and told me to take Ibuprofen for the pain if I wanted to run. He spent about 5-10 minutes on me.

Afterwards I decided I to quit the therapy after 2 months of it. I worked on the exercises the therapist had me doing and iced a lot. Guess what after another 2-3 months no help. My knee was no better off. IT would swell if I did to much on it or had a sudden jolt like slipping on the ice or tripping and catching my self on the bad leg. I was getting bummed.

I started looking for the magic bullet on the internet, hours and hours. I finally ran across the Runners Bible, I think I paid $70.00 for it. I was desperate. I started doing the exercises, total gym mainly. Thousands of repetitions. I also gave up all the recommend exercises from the therapist. No help in first month.

I seen your kindle book. I was on the see saw about buying it. Finally I bought it. As I read the book I'm waiting for your magic bullet to fix the knee. When I finished and there was no magic bullet! I was disappointed. But the more I thought about the studies you presented and how you cured yours, eureka the light bulb went off. Its up to me to get well. I needed to move and monitor and be in the Goldie locks zone(runners bible)to heal.

Well I am a over achiever when it comes to exercising. I must have set my self back a dozen or times by over doing it. I did not keep a dairy, but had to remember several times at what I did to cause the pain a day after it happened. The pain is delayed like you said.

Walking has done the most for me. I walk our dog 2 miles every night. I have a desk job, but I will get up and walk around if I sit for a long period. I also ride my bicycle some. I have pushed to hard in the knee strengthening areas and set myself back many times. I finally got it through my thick head to back off and gradually increase the weight and volume. Slower than paint drying like you said in you book, I would say much slower than that even.

I am not cured but I am starting to run a little and am really working both legs out hard with no pain or swelling. I'm expecting to enter a 5 K in June. 2 1/2 years after I had to stop running. I have to give your book and also the Runners bible credit for my healing. I Gotta thank GOD too. I prayed a lot...:)

If I had to give anyone advice I would say create a knee dairy(I did not),get a pedometer and walk a lot also be perceptive about what causes pain and gradually increase or maintain exercise level. When in pain rest but keep the knee moving some, Know your limits and don't be a man to the point it sets you back in your progress.

(1) The first impression an unknowing reader takes from this is: "Wow, this guy really went through the mill." But if that reader has sought treatment for Runner's Knee (or chondromalacia, or patellofemoral pain syndrome), that initial reaction is probably closer to, "That sounds about right."

Because the exasperating experience above, I'm willing to bet, closely tracks what millions of other have gone through. In some significant ways it mirrors my own frustrations (they tried ultrasound on me too and one of my doctors also thought my cartilage looked good, according to an X-ray -- but a regular X-ray can't even see cartilage; the tissue's presence (or absence) is simply implied by the distance between bones!)

(2) Finally Ron gets on the right path (with Doug Kelsey's The Runner's Knee Bible, and I'm proud to say, an assist from Saving My Knees). And he's getting ready to run a 5K in June. Which is how long after he had to stop running? A few weeks? A few months?

Nope. Two and a half years.

Which is why I think it's so important for people to rethink their time horizon for healing. Get on cartilage time, as I say. If you expect to be back competing in your favorite sport after a few months, you're setting yourself up for disappointment.

(3) Setbacks, setbacks, setbacks.

Healing is not smooth. Healing is not linear. Every week will not necessarily be better than the preceding one. You will screw up -- I guarantee it -- and your knees will let you know when you do.

If you're smart, you'll learn from the setbacks. If you're not, you'll shrug and say to yourself, "I guess my knees will never get better." And if that's your approach, guess what? They won't.

It's very hard to stay within what Doug Kelsey calls "The Goldilocks Zone" (I refer to the same thing as the "sweet spot" of movement -- not too much and not too little -- and have seen it referred to more technically as the "functional envelope.") Nobody hands you a manual that says, "Right now your knees can do x steps daily, then you should increase that by 1,000 steps every two weeks." You have to figure that out.

(4) Why do you have to work so hard?

Well, look at Ron's experience with the orthopedic surgeon who came with "great recommendations." He spent 5 to 10 minutes on Ron and recommended Ibuprofen (an over-the-counter anti-inflammatory) to combat the pain from running. First, setting aside whether trying to run through pain by using medication makes sense (I would say no, no, and no again), look at that number -- 10 minutes -- and really think that over.

How much time is 10 minutes? That's about the length of a coffee break or a water cooler chat about the Super Bowl.

Now, I don't mean to denigrate surgeons. They have hard jobs and see a lot of patients. But in 10 minutes even the most brilliant surgeon can't extract enough information to understand the complexities of what's going on with your knees -- and these complexities hold the key to your getting better.

What a good surgeon will do: inspect the joint, bend your knee, and ask you "Does this hurt? What about this?" as he probes. But once he determines there isn't an obvious overlooked problem, and you really do have the kind of nagging knee pain common to cartilage damage, he's gonna kind of shrug.

What else can he do?

Once the damage is bad enough, and you need some kind of surgery just to make life tolerable, he figures he'll see you again.

Again: this isn't meant to be an indictment of surgeons. Because at this point, a surgeon isn't who you need anyway. You really need two people on your case. One is a smart physical therapist who believes that knees can heal (not just that muscles can get stronger), and knows how. The other -- more important -- is yourself.

P.S. I'll throw open the comment section below to Ron and others who want to ask him questions (assuming Ron checks in regularly, and I think he does). People always want to know more about success stories. All yours, Ron!

"What to do About Weak Knees?" Revisited

This was a popular blog post. A commenter had complained of “weak knees” -- no pain, no instability -- just general weakness. I went out on a limb and surmised that this person was overweight and inactive. Showing that I have no future as a carnival weight guesser, the commenter wrote again to say that he/she was five-ten and 135 pounds (which may qualify as underweight, if anything) and likes to ride a bicycle and ski cross-country. Okay, zero for two -- hey, it happens ... :)

Today I thought I’d return to this odd case once more, seeing if any readers have insights or suggestions. First I’ll give you all three comments this anonymous person has left (settle in, because they're long):

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 am the one with this strange condition. I could type you a long story...but I will be brief. Prior to this condition, I have been physically active (road by bicycle, cross-county skiing and such. I am 5'10 and weigh about 130 lbs. This weak knee condition slowing emerged about 10 years ago. Initially I was instructed to do circuit training at my gym and such. It seemed to help...but...as the months/years crept up, this weakness was more constant. The feeling in the knees are exactly that...a weakness within the knee area. They never feel like they are going to give out...just a darn feeling of weakness. I could be sitting at work and have that annoyance. Have tried pain meds, but..it's not pain, so nothing helps. And, I am not overweight, was physically active and have mystified doctors. As these years have transpired, I noticed that the rocker shoe removed this condition. I did have tingling in the feet with these shoes and was told that my shoe size 8 1/2 or 9 which was the wrong size, thus creating a tight foot-bed. Once I went up to a size 10 1/2 with an orthotic, the tingling subsided. Would bore you with more details, but had to resort to a normal shoe style. Recently, I had to adjust my new orthotics with my shoes due to smaller toe box and foot soreness. So,they reduced the arch material so my foot would not hit the seems within the shoe. Two days after the adjustments, the weakness in my knees came back. Two days ago, I purchased a shoe with a wider foot-bed and they built up the arch support and fingers crossed in day 2, the weakness in my knees are dissipating. So as you can see, their is a connection between the angle/alignment of the foot and my knees. I believe that my knees are slightly misaligned, thus creating the condition. Several summers ago, I rode my bicycle to and from work. It seemed to keep things in check, but as soon as the weather changed and I had to resort to driving...the weakness reappeared. In the past, the 3 P.T.'s were always mystified during the sessions and how my weakness would disappear and reappear. From all the orthopedic surgeons I have visited, only 1 suggested that I wear knee supports. During this 1 month trial, my weakness went away. Due to this, he had a plan of operating on the knees that would essential tighten the knee cap and properly re-align them for support. It's difficult to reach that decision, since other doctors said my knees are fine, but...the weak knee symptoms are quite debilitating. Through these years of experimentation, I now know there is a link between the alignment of my feet and my knees. So...I hope this addresses your logic. If anyone know of a good knee specialist in Ohio that has dealt with this condition I would appreciate a response.

I am that person with weak knees. I am 5'10' and weigh about 135 lbs. I was always been active...riding my bicycle, cross-country ski, enjoyed working out in the yard...and 8 or so years ago, I started to feel a weakness in both knees. Started to workout and it seemed to help a bit. But...as time transpired, nothing seemed to work. As the day progresses, my knees start to feel weak. Through these years, I have seen 3 different P.T.'s and they are uncertain about my condition. When I work Kmart rocker shoes, by weakness went away..but still had tingling in the feet. Went to a shoe store and was told that my 8 1/2 shoes should be 11 B. So....I went that direction and tingling went away, but...they had me wear their shoe orthotic over the insole to take up room. I started to supinate and ended up with nerve pain. So...I had to get orthotics and scrap the rocker shoes. I have tried several orthotics and have not found one yet that has helped me. While I was being fitted with one...they were trying to fit the orthotic with the shoe vs. my foot. And, during that course, I first had no weak knees, but by the time the removed much of the original support, the weakness returned in my knees. If I go home and crash out for an hour or so, the weakness will go away. When I wake up, I am OK..but..then the day starts all over again.

Here are a few of my thoughts, in no particular order:

(1) Someone who has weak knees and accompanying pain might say there’s a word for people like Anonymous: lucky. :) I too had weak knees. But I also had burning, aching, and even some swelling in the joints.

Have other people out there had “just weak knees” that don’t seem unstable (remember, they don’t feel as if they are “going to give out”)? If so, what exactly do they feel like? Because my second observation is:

(2) You say to-may-to, I say to-mah-to.

What does “weak” mean in this context? “Weak”, by itself, can be a hard descriptor to parse. For example: You’re sitting. Your knees feel weak. What exactly is that sensation? When I’m sitting nowadays, I either (a) don’t feel any sensation from my knees or (b) feel a slight sensation, such as an occasional tingle.

My hunch is that 10 people who had the same sensation in their knees as Anonymous would find different ways to describe it besides “weak.” It’s not that I distrust Anonymous, it’s just that (to get philosophical for a moment) words are imperfect vessels to contain our thoughts and impressions, and I suspect that this feeling of weakness is a bit more complex or nuanced.

(3) Could this be a neural issue? Or something systemic? I’m just throwing out ideas here, because of the odd and strangely asymptomatic nature of the problem. Or perhaps it is an imbalance issue, though I tend to be skeptical of misalignment as a cause of knee pain, as I think this reason is cited too frequently and doesn't answer the question of "Why now?" In other words, why does alignment suddenly become a problem -- unless you were say in a car crash and your body got knocked out of alignment?

(4) Has Anonymous tried building up to intense physical activity of the sweating variety? By that I mean really working out aerobically (I can’t tell how intense the bike riding and cross country skiing were). I’m a believer in vigorous physical activity banishing all sorts of strange little aches (if it’s the right joint-friendly activity -- say swimming or cycling). And the intensity should be increased gradually.

(5) At one point in the narrative, Anonymous claims to have been wearing size 8 1/2 shoes on size 11 feet. Hmm. I can usually tell immediately if I’m off by only one shoe size. So Anonymous, this leads me to a final thought:

(6) The power of self-awareness, creativity and a commitment to problem solving.

The power of self-awareness, if you’re Anonymous, is to pay special attention to your environment and what may be causing issues. Keep a knee journal. It's not just shoes that can contribute to the onset of symptoms.

Creativity is using the ol’ noodle to solve problems -- biking was helping Anonymous with the weak knees, then the weather got cold, and that was that. ??? Gyms have stationary bikes. Buying a bike roller or a trainer allows you to ride indoors. Heck, with under-the-desk pedal exercisers, you can ride at work! So a change of seasons doesn’t qualify as a reason to stop doing what your knees like.

And the commitment to problem-solving is the determination to get this right yourself, if need be. The docs don’t know what’s wrong and can’t help. Now you need to help yourself.

Experiment. See what works. And, if you're Anonymous, say a little prayer of thanks that at least you’re not in pain yet. :)

P.S. One other thing I would be remiss not to note. The observation by Anonymous that "When I wake up, I am OK..but..then the day starts all over again" could have just as easily been made by me a few years ago. Each morning, when I awoke, it was like I started the day with a set of brand new knees, that gradually wore out as the day went on -- by mid-morning on a bad day, by mid-afternoon on a good day. This I believe is a classic symptom of knees that aren't strong enough to endure what is required of them -- i.e., the normal sitting and walking and standing that we do, day to day.

So Anonymous, you may not be as alone as you think.

Buying "Saving My Knees": the Value Proposition

It’s been a year since Saving My Knees became available on Amazon.com. Sales have exceeded my expectations. I’ve gotten a great, heartening response from readers. Life is good.

Yet ...

There’s a criticism of the book that I’ve heard a few times that goes like this:

This book is overpriced. The message can be boiled down to “move a lot and listen to your knees.” And who knows if you can get better doing what the author did anyway? Every knee problem is different. Don’t waste your money.

So I thought I’d try something different this week, on the book’s (more or less) one-year anniversary. I thought I’d give you the “value proposition,” if you will, for shelling out $9.99 for an electronic book that you can’t even resell at Sam’s Secondhand Bookstore.

Because Saving My Knees contains information that I would’ve paid $100 for when I had knee pain and was thrashing about, frightened and helpless, trying to figure out why healing was so difficult.

Yes, it’s my story, but I think many people suffer from basically what I did. True, they may be a little worse or better than I was, may have cartilage flaws in different places that throw off different symptoms, may be sedentary instead of weekend athletes.

But I don’t think those differences matter so much, because what I advocate isn’t a one-size-fits-all solution to knee pain. Rather, it’s an approach or framework that can be tailored to someone’s specific needs, with a little imagination.

But ah, I’m starting to wander! So without further digression, here are a baker’s dozen of reasons (as opposed to a banker’s dozen ;)) for buying Saving My Knees.

1. You’ll find a dynamic explanation of how cartilage works inside a knee joint, in a way that I’ve never read before. It’s not the dry textbook “this is this and this is the other and blah blah blah.” It’s as detailed as it needs to be (if you’re going to understand medical studies that reference glycosaminoglycans, you need to know what they are), while not bogging down in pointless details. I tried to write the science so it doesn’t read like science.

2. You’ll read about my one-year scientific experiment into saving a pair of knees -- that worked. I didn’t get lucky. And I was carefully tracking variables throughout this whole time, so this is a high-quality study. Now, what about the fact that I’m a one-man sample size? I’d argue that that may not be exactly the case, as the Sports Center clinic in Austin has helped many knee pain sufferers, and its approach appears to be similar to mine (no surprise there -- the writings of its founder greatly inspired me!).

3. You’ll find out about the weaknesses inherent in certain knee studies. You may have heard of a famous study that claimed, “Exercise doesn’t improve bad knees.” That may have discouraged you from an exercise program. In this book, you’ll learn exactly how such a study can be flawed in serious ways. This will help you analyze the worth of similar studies yourself.

4. You’ll read about hard evidence that cartilage can heal! I’ve NEVER read about these clinical studies in any book about healing knees (if a reader knows otherwise, please point out the book and I’ll give due credit). Once cartilage can heal, that changes the whole ballgame. That makes what I did not only possible, but the most sensible approach!

5. You’ll discover why glucosamine most likely doesn’t work, and so can save money on pills that won’t rebuild your cartilage after all. How much is that worth? According to the online CVS site, a two-month supply of glucosamine is $8.99. So the book pays for itself in less than three months. ;)

6. You’ll see how to play medical detective. This is a great skill to have. The human body is a tremendously complex machine. You want to be able to help figure out what’s wrong with you, and what makes it worse, and what makes it better -- whether it’s knee pain or some other ailment. This is a very useful skill that I draw upon today.

7. You’ll learn about how to keep a knee journal. This is a super way to navigate a long-term recovery. You can’t just bump along, week to week, hoping you’ll get better. You need to be aggressive about taking matters into your own hands. The knee journal helps you figure out what’s working and what isn’t -- and helps you transition to successively harder stages of your recovery program.

8. You’ll get access to a valuable bibliography that lists a wide-ranging sampling of technical books and articles I used. If you like doing your own research, dig right in. There are a lot of sources here, enough to keep you busy for weeks.

9. You’ll meet Doug Kelsey (if you haven’t already at his Web site), who was a terrific inspiration to me. Doug has refreshingly original insights into knee pain and believes you can escape it if you follow the right plan (and are patient). If you’re serious about healing, you definitely need to know what he says about nagging knee pain.

10. You’ll get a reasoned debunking of some of the common myths for treating knee pain: that your focus should be on strengthening your quadriceps, that your problems are caused by a mistracking patella, that stretching your iliotibial band is important.

11. You’ll get, as an added bonus, an example of how to heal a stubborn case of tendinitis (thanks again to Doug Kelsey). I healed bad tendons in my forearms that I thought would end up sending me into surgery.

12. You’ll find out why “just listen to your knees” and “move a lot” aren’t really the solutions to beating knee pain -- at least not as you properly understand both to mean right now. I moved a lot and my knees got worse. I listened to my knees and they got worse too. Yes, I eventually succeeded by doing both, but in a more sophisticated way, which I explain in the book.

13. You’ll learn about the “delayed symptom effect” with knees. Without understanding how this works, your prospects of figuring out how to heal are rather slim, because “bad knee days” will just seem like random events to you, rather than the logical outcome of something you did.

Of course, now that I’ve done my pitch for the book, a reminder: it’s not for everyone. If you want an other-directed solution (surgery, meds), or a very specific solution handed to you on a plate (“do this many repetitions of this exercise x times a week), please don’t buy Saving My Knees. It will just make you cranky.

And, if you’re interested in the message, but counting your pennies, as I’ve said many times before, the blog’s always free. :)