A Cautionary Tale From the Big Medical Business of Knee Pain

Knee pain is a big, big business, not surprisingly.

Here’s an alert from Seeking Alpha, a website covering news on publicly traded companies, that shows starkly what small companies have at stake with cartilage restoration technologies.

In this case, Histogenics apparently developed a treatment called NeoCart. It’s described as a “cell-therapy based implant designed to help restore and heal knee cartilage through the use of a patient's own cells.”

I’ve written here and here about autologous chondrocyte implantation. I’m not sure how NeoCart works exactly, but it sounds a lot like ACI.

Alas, the NeoCart story may have a sour ending. I’ve been skeptical about ACI; I’m doubtful that it will lead to a result better than an old-fashioned microfracture. And sure enough, here are the findings of a study that sent the shares of Histogenics into a nosedive:

NeoCart, when compared to microfracture, was unable to demonstrate a statistically significant improvement in function and pain.

When the news came out, back in September, the stock abruptly plunged more than 75%, to about 60 cents a share. Think of that. If you had invested $100,000 in this company, overnight you wound up with less than $25,000.

Back in September, the CEO of the company hastened to assure investors that the results weren’t as bad as they looked.

If you believed that, if you held on to your stock, thinking “It’s going to rebound now” – and investor psychology shows people do tend to cling to their losers, hoping they’ll recover at least somewhat – you’re in even worse shape now.

Its latest stock price is 11 cents, or about one-fifth of its value in September. Right now it’s trading in the basement of the penny stock dungeon, jerking up and down on vapors and wisps of news.

What’s the upshot here?

Well, if you’ve got money to blow out your, um, ears, you should realize that investing in small companies whose fortunes are riding on unproven medical technologies is always going to be high risk. So caveat investor.

But for me, it’s at least as significant to ponder that maybe surgeons like Scott Dye have it right when they espouse a belief in doing as little surgically to heal bad knees as possible. If you can mend your bad knees without any kind of surgery, so much the better.

But if you’re going to do something to restore lost cartilage, maybe the simpler, less-invasive microfracture, which aims to stimulate your body to heal itself, beats this fancy, complex technology where your cartilage cells are grown in a lab then sutured back into your joints.

Something to ponder.

Pro Tip: How to Navigate This Site

So, some news first: I had an interview recently with a freelance writer for the Washington Post. Her topic (a very good one) was how to avoid knee replacement surgery. Well, that’s something I’m not bashful about talking about. If my knees had continued going downhill, I have little doubt that right now I’d be sitting in an orthopedist’s office, and the subject of knee replacement would be front and center.

She asked me how my knees were. That was the icebreaker question. I told her they weren’t normal. I think her breath caught slightly on the other end of the line. I could almost hear her thinking, “A relapse? Did I pick the wrong person to talk to?”

Then I explained that my knees are much better than normal. That’s the crazy thing. I emerged from this knee pain saga with knees that are probably in the top 5% for my age. Honestly, I do not have knee pain, and can chase my kids through the snow without problems, and so I feel very, very fortunate!

I will let you all know once the story runs, assuming she lets me know (or if she doesn’t, one of you can let me know, and I’ll provide a link to it). Of course there’s no guarantee my voice will be in the final story – I’m in the journalism business, and I know a good journalist leaves a lot of material on the cutting room floor – but I think there’s a decent chance.

Now for today’s subject: pro tips on searching this blog.

I realize I’ve been posting here now since June 14, 2010. Wow. Almost nine years.

Since then I’ve covered a lot of territory. So here’s how you can find some things if you’re new and are seeking help:

* If you search the blog for “success story,” you’ll find some detailed stories from people who have overcome knee pain (or are making great progress in overcoming it). I love success stories. Some of these stories you may relate to better than my own.

* If you search the blog for “Scott Dye,” you’ll find more about Scott F. Dye and his concept of the “envelope of function,” which for my money is the smartest framework for understanding and devising a plan to heal from knee pain.

* If you search on “glucosamine,” you’ll find plenty of material on why I think the supplement is basically a waste. But of course, if you think it works, go for it. The only damaged party will be your wallet (unless you’re diabetic).

* If you like reading me being philosophical, puzzling over unusual things, try these:

Of Breakdown Points and Discontinuities in Healing, Part I

Of Breakdown Points and Discontinuities in Healing, Part II

* If you want to read about debunking bad structuralism, go here:

The Odd Tale of the HQ Ratio

* And, last, one reason I’m so optimistic about the ability of cartilage to heal:

Why I’m So Optimistic About Cartilage Healing

Why I’m So Optimistic About Cartilage Healing, Take 2

The World Needs More 60-Year-Old Physical Therapists

Seriously.

I was thinking yesterday about why physical therapy latched on to its muscle fixation, when it comes to treating bad knee joints. You know the tired old song: Strengthen the quads to overcome the pain from ailing, balky knees!

Of course (as so many here can testify), the quad exercises end up further hurting the knee, which isn’t healthy enough to tolerate the force needed to strengthen the muscles. I had this frustrating experience myself and only started getting better when I rejected such catastrophic advice.

But where did the advice come from in the first place, and why did it prove so popular?

I can’t testify to its origins, but one thing I have noticed about physical therapists: they tend to be young, perky, athletic people. They like to stretch too. They eagerly acquire new stretches.

And it seems none of them have had the chronic knee pain that they are advising you on.

Is experience of a thing a necessary condition for advising on that thing? We don’t require a medical doctor to have lived through every problem he’s giving recommendations on, certainly. Nor should we.

But a certain humility and awareness of mortality and open-mindedness to alternative solutions comes with age, at least in the realm of physical ailments. This, I think, is a good thing when faced with the intractable problem of chronic knee pain. As a patient, I wouldn’t mind a little genuine empathy – if not with my knee pain, then perhaps with the fact that the body does betray its owner sometimes in mysterious ways, and can bring any of us low with pain that has no clear source and no clear solution.

That’s why I’d welcome more 60-year-old physical therapists who have had bad knees, bad elbows, bad feet – who have fought the good fight for months with a condition only to have it recur, then to subdue it, again and again, and finally win in the end. I’m not saying all physical therapists have to be mature adults, with hair shot with steely gray, but wouldn’t it be nice if a few more of them were?

Open Comment Forum: What Does Your Knee Like Best?

I'm going to keep this short, as I'm really tired this weekend. The usual rules apply: you can choose to answer the question I pose, or you can talk about whatever you want to.

It's an open comment forum. All of you are driving the bus.

Anyway, I thought it might be useful to start with this question: What does your knee like the most? Is it half an hour in the sauna, a short and slow walk, a massage, a meditation session, or what?

By sharing what personally works and what doesn't, I think we can all help each other.

All fine with my knees by the way (no, I don't say that to gloat, but rather as a perfunctory update, as sometimes people do ask how much knee pain I still have). Both knees feel good. It's like a rebirth!

Cheers.

How Long Will It Take for You to Heal?

I received a comment recently, the first part of which went:

So if we continue to walk for 2-3 miles a day and bicycle 20-30 minutes every day, are we going to heal in 2-3 years?

First of all, if I could answer this question, I would not be wasting my time with a blog. I would be making billions of dollars trading stocks and futures contracts.

The truth is, I can’t answer this question. Neither can anyone else.

If you are in the presence of someone who tells you, with great conviction and vehemence, that he can answer this question, I would advise you (and God knows, I try not to give advice) to check to make sure that your wallet is still on your person, and intact, then to make your way quickly toward the closest exit.

Knee pain can be a terrible place of fear and uncertainty. And part of that uncertainty, sadly, revolves around how long it will take to get better. Honestly, I can’t even tell you for sure that if you do all the right things, you will emerge from this nightmare with pain-free knees.

I have a large, abiding faith that many bad knees can be healed, over a time period that can vary greatly by individual. I base this partly on my own experience – my knees that a doctor told me sternly would never get better (what I’m sure he thought was a necessary bit of truth-telling) did in fact improve – so much so that today they feel normal or even better than normal, considering my age.

I also base my optimism on much research that I did, which I detail in Saving My Knees.

But to offer blanket reassurance that anyone can heal within a tight time frame by doing a fixed amount of walking and cycling? You may get better in 12 months on that regimen. Or it may take nine or 10 years. Or you may never get better, because that program is too much for your particular knees.

The time frame for healing is not a really knowable thing at the beginning. I know: more fear, more uncertainty, more doubt. Not what anyone wants. But the alternative is dishonesty.

I think the best thing is to think of this as a purposeful journey. You are not wandering, lost, in the desert. You have an objective. You are experimenting. Your aim is, at the end of each year, to have knees that are at least a little improved from where they were at the year’s beginning.

And think about it: if your knees never get back to 100%, but they get a little better each year, and you have a positive outlook, because you’re actually executing a plan, and you have some control over your future,  isn’t that something good? Isn’t that a victory of sorts?

Part of the reason my initial experience with bad knees was so miserable was the helplessness, the belief that nothing could be done. There is at least a solution to that. Keep in mind that others have healed, that all is not lost, and push forward with purpose. There’s an excellent chance that good things will happen.

Could I Have Healed My Knees Without Quitting My Job? (And Other Questions Answered)

I recently came across a comment loaded with questions and thought, “Why not just do a post answering these?” They came from someone in his late twenties who hurt himself skiing last February and is now struggling with knee pain. He’s tried a number of things to fix the problem, has many questions, and I invite all of you out there to help me with the answers if you’d like.

Q: Do you believe you could have still recovered in the office setting (which, I assume, means had I not quit my job and continued to work sitting at a desk)?

A: I honestly don’t know with certainty. I know it would have been harder, for sure. The act of sitting was causing me problems, and I had a job that required a lot of sitting (a standing desk would not have helped either, because at that point I couldn’t stand in one place for very long either).

Q: Your story somewhat ends abruptly, in the second year of recovery. Did you slowly increase your activities on the same rigid scientific approach? At some point did it feel like you came out of the rehab stage?

A: Yes, others have made the same complaint about the book, so that’s probably my fault for moving too quickly through the narrative of the latter stages of my recovery. But to me, it simply wasn’t as interesting. That’s because I began making steadier progress, suffering fewer setbacks. Yes, I was still careful about how fast I increased my step counts, etc.

Apart from that, I’m not sure that there was a clear line of demarcation where I “came out of the rehab stage.” I was pretty much healed when I rejoined Bloomberg in the last part of December 2009. Still, I had days at Bloomberg where my knees felt a little cranky. That minor discomfort did go away eventually, but that just goes to show healing is long and gradual.

Q: Does research suggest a cortisone shot prevents cartilage from healing?

A: I’m not a fan. And yes, the research on cortisone shots is not good. Just do a search on this blog for “steroid.” You’ll see.

Q: How did you explain your injury to outsiders?

A: I don’t recall this being a big issue. I mostly just said I had knee pain. If you come up with a short spiel that goes, “I have knee pain and I’m working to resolve it,” that seems to satisfy most people. They don’t particularly want to hear that much about your injuries anyway.

Q: Does research suggest age playing a factor in the speed of cartilage recovery?

A: I’ve seen at least one that shows an age-related effect, yes. But it’s significantly smaller than most people would guess. So you probably do have an edge, being in your late twenties, but I don’t think it’s a huge edge.

Q: I’ve seen your comments on diet, that you think it did not play a significant part in your recovery but losing weight is one of your 4 keys to rehab. Have you done any research on the claims that low carb/keto type diets can help arthritis patients?

A: Unloading the knee by shedding a few pounds is always a good idea for pudgy people; for thinner people the benefits may be much smaller (because there’s less fat to lose). I’m ignorant and agnostic on the effect of special diets on knee pain. Usually, diet didn’t affect my knee pain.

However, when I loaded up on fatty foods, I did seem to feel a bit worse. So it’s probably smart to try to eat as healthy as possible, and look for anti-inflammatory foods. (One other important note on diet: my experience is by no means representative; if you comb through comments on this blog, you’ll find a number of people who say changing their diet was absolutely important in getting their knee pain under control.)
 
Q: Do you think weightlifting, upper body type workouts, are safe to resume?

A: I would think so, but I would still carefully monitor my knees. This seems minor, but some of those exercises cause unrelated muscles to tense up, and that could cause irritation for bad knees. Also, be prepared: if you have knee pain long enough, you may find other mysterious joint issues popping up, such as with your elbows or shoulders, when you’re lifting weights.

Generally though, I think it’s good to engage in activities that get your heart pumping and get you perspiring.

Q: Any other exercising activities you came across that don’t overload the knee joints? I think my knee is responding OK to low-watt biking.

A: My favorite ideas remain walking slowly, pool exercises, and easy cycling. If your knee does well with low-watt biking, congratulations. That may be your ticket out of this mess.

A Success Story of Overcoming Knee Pain After Devastating Setbacks

As I’ve said, I love success stories. Mine, of course, is one. But someone who can't relate to mine may be able to relate to someone else’s, so the more success stories I can share the better.

In the early days of this blog (that takes me back!), a frequent visitor was a woman who went by the simple moniker “Knee Pain.” She was one of the people I was rooting especially hard for, as I could feel her complete determination to beat this curse of knee pain in virtually everything she wrote.

Well, she checked in late last year and told her story in the comment section. And she had made some very good progress, I was pleased to learn. Because I love success stories, I kept meaning to pull out all the bits and give them a proper home inside one of these posts.

Finally I’m getting around to that.

Here’s her story, with my editing as usual. If you want to see her full comments, go here.

Also, Knee Pain, if you're out there reading this, you're welcome to update us on your progress and field questions in the comment section below. I know it's been four months since you posted the story below. 

"I was diagnosed with chondromalacia patella in 1993. In later years, it's also been diagnosed as PFPS (patellofemoral pain syndrome). Doctors say that the kneecap is not tracking properly and the cartilage has worn down too much. There's no signs of knee arthritis.

My pain is in my right knee. My bad knee doesn't swell or turn red or other colors. It seems to look exactly like my good knee -- even when it's at its most painful.

I don't have the "burning and aching.” Instead, when my knee is irritated/flared up, I get stabbing pain when I bend my knee. The severity of the pain can range from a just a dull stab to a gut-wrenching pain. (It feels like a flying elf is hovering over my knee with a long knife and gleefully plunges it into my knee.) I only get these stabs when I move my knee. Not at rest.

I didn't quit my job. As long as I am sitting perfectly still, it doesn't hurt while I'm sitting. My type of work uses a computer, so I can still type with my fingers without moving my knee. I went on 2 business trips with the help of a wheelchair when the pain was just too bad and I couldn't walk very far. I've also used a cane.

I've trained myself to never run or jump. Ever. That would cause a flare up. I don't even move quickly. Stairs are a constant nemesis (especially walking down stairs), but I can conquer them one at a time, making my good knee take on all the burden. As for household chores, kneeling or squatting are not a possibility. I sit on the floor or in a chair.

I've had soooo many ups and downs since 1993.

For the most part my doctors recommended physical therapy in the form of strengthening the quads and the vastus medialis. I really don't think that worked for me. Even before reading Richard’s book, I had the gut-feeling sense that trying to strengthen the quads flares up the knee joint itself, sooooo.... instead of helping me, it kind of sets me back. It was only after reading Richard's book (in 2012) that I felt like my gut-feeling was validated!

In 2010, I had the synvisc injection. That made it worse. My knee got a brand-new symptom which was that it would catch and lock up, which was horribly painful.

In 2010, I had arthroscopic surgery to smooth out the cartilage in the knee. The result was that it definitely helped with the knee locking problem! But I kept having irritation and flare-ups.

I asked my doctor if she thought I should next try the total knee replacement? She felt very confident that I should be able to get well with just physical therapy. So I kept trying to use natural methods to get better. But .... not very successfully ....until I tried water therapy starting in March 2012. More on that later. :)

My knees are doing very well right now and I'm grateful every day.

Currently I can swim, bike (up to 10 miles with small slopes), and play a court sport (running around after a ball on a court -- including jumping!!) I can walk up and down stairs without pain.

I'm still scared I could have a setback, but I keep trying to move cautiously forward.

This is the THIRD TIME I've gotten to this "happy golden knee health level" with my knee. I think that the thing that seems consistent with how I've achieved the "happy golden knee health level" is the low-load/high rep that Richard talks about in his book.

The first "happy golden era of knee health" was approximately 2000-Sept. 2006. This started by me taping my kneecap into the "correct spot" (what I learned from a physical therapist) and then gently biking. I started off with just very short and easy. Flat. I would walk my bike up any slopes. Over time, I built up and was able to bike further and with tiny slopes. Then, over the course of months and years, I built up more and more and I could bike really tough routes. I danced. I learned the Lindyhop. I hiked. I learned to windsurf!

But in 2006 I had a catastrophic relapse. Why? I'm not totally sure, but I SUSPECT it's because i had a lifestyle change in which I wasn't as physically active. I stopped biking as much. More sitting. Less moving. And then, after a night of very intense waltzing ... boom. That was it. Back to all the pain. It was devastating.

In March 2012-October 2012 I had my second happy golden era of knee health.

I got the idea of doing water therapy! I got a book called "the complete waterpower workout book" because it has suggestions for people with bad knees (and all sorts of other injuries). I wore my neoprene knee brace to start.

Some exercises involved standing in chest high water and doing movement like moving my leg in a circle. Some involved wearing a floatation waist belt in deep water and moving my legs in different ways.

I also learned I have to listen to my knee because it didn't like all the leg exercises -- even the ones to help with "bad knees." For example .... swinging my leg forward with a straight leg -- as I recall -- was too intense for my knee initially.

After about a month I took off my knee brace. I did have a little trouble. But I was able to work through that by just going slower and more carefully.

In July 2012, I got Richard's Saving My Knees book and read it in one sitting.

I learned about high-rep/low load.

I learned about delayed onset pain.

I started posting on this blog about how I was improving.

Then after my knees were starting to feel better I started gently biking again. And I could go up and down stairs without hurting. Amazing!! And then I started biking more and I started biking more.

I thought I was CURED!!

But no!!!

I "overdid it" on one of my bike rides and BOOM that was it. Another catastrophic relapse.

My big takeaways from Happy Golden Era #2 in combo with what I learned from Richard's book were:

1) I'm a believer in low-load/high-rep, thicken the synovial fluid. I saw it work two times for myself -- even though I didn't know it was called that or that the biking and the water therapy were essentially doing the same thing.

2) I definitely agree with the idea of not even attempting to strengthen the quad muscles until after I've got the knee joint itself feeling calm and stable.

3) I was so glad to learn that Delayed Pain Onset is a real thing. Not my imagination. It helped give me the courage to believe in my own hypothesis that maybe when I'm doing something, only days later I will feel the negative result. So I need to be patient and "let the dust settle" after doing knee activities and make sure I'm OK.

4) Patience. Patience patience patience patience. I promised myself 100 times that if I ever got the chance to get to another "happy golden era" again, then I would be a lot more patient.

Starting 2016, I used all this knowledge to try to make another big (but slow and gentle) push for a third "happy golden knee era."

It worked!! (So far!)

-- I can go up and down stairs without pain.
-- I've walked without knee pain for up to 5 miles
-- I can bike up to about 10 miles with small slopes
-- I can swim for up to 90 minutes
-- I'm playing a court sport (running around a court after a ball -- including occasional jumping)

How I got to this point was once again using the water activity.

However, this time I did my water activities in cold water. (BTW: I was learning on another post that maybe being in cold water helped reduce inflammation and that might've helped with my success this time.)

I did once again start with essentially wearing a thick knee brace. Once again, not "swimming" but more like gentle leg motions. (When I did opt for "swimming" then I just dragged my legs.)

By July 2017 I built up to swimming a mile! But still, I wasn't supplementing this with land activities.

Then in 2018 I really realized wow my knees are feeling pretty great.

So then I started experimenting with land activities such as walking up to 5 miles.

And I was doing really well so I invested in buying a road bike in April 2018. I started super cautiously riding short easy distance on flat. 4-5 miles. Then wait at least 72 hours. See how my knees feel. Bike another 4-5 miles on flat. Then wait at least 72 hours. See how my knees feel.

Then I decided to try a court sport running around after a ball. The court sport did stress my knees some. I did get a few SMALL sharp stabbing pains within the 72 hour waiting period. So that was kind of scary. I decided to try again and just be cautious. After a couple sessions, the small stabbing pains went away. Now it's been two months of trying the court sport and I'm not having any stabbing pains anymore.

Anyway!

This is where I am now.

But.

I know I have to remain cautious.

I need to remain patient.

And it's really hard to be careful and patient because I'm feeling very excited that I can once again do all these different kinds of activities!! I feel like my life possibilities are opening up again!"