On Quads Sets and Easy Passive Motion

Okay,  so here’s a comment I received (lightly edited):

I am a little worried right now, as unfortunately, I experience pain when walking. I also experienced it while biking. I am not sure yet what low-rep activities to pursue at this point, and I can't take off work to devote my time to laying with my legs up. Sometimes the pain comes on directly during physical activity, and other times will just appear as I'm resting, even laying down, usually at night. I also have an adorable 20-lb. daughter that I have to carry around quite a bit... unfortunately I think it is causing a toll.

Question: Some studies you mention say isometric quad sets improve, thicken viscosity of the synovial fluid. So I'm thinking about keeping some of those exercises and abandoning the wall sits, one-legged squats my PT had me do. Any thoughts? Also wondering how this works, as it doesn't seem like there is any motion involved with these exercises. 

Another question: it appears that bearing appropriately light load and motion is the best combo. In the study with the rabbits, did it seem that they were bearing load when they were attached to the passive motion machine? It seemed to indicate that motion, no load, allowed regrowth of cartilage only when a hole had reached the cartilage. I am considering whether or not bicycling in the air, while laying on my back, would be a smart way to get more motion without overloading and damaging the cartilage.

First, on this: “I'm thinking about keeping some of those exercises and abandoning the wall sits, one-legged squats my PT had me do.”

This sounds like you have a real muscle-first kind of guy. In other words, a typical physical therapist. As I see it, the trouble with “wall sits” (put your back against the wall and slide down, until it looks like you’re sitting on an invisible chair) and “one-legged squats” (squat down on one leg, then straighten up) is that they’re great for people with good knees (or knees that aren’t too bad) but can be disastrous for people with tender, easily upset joints.

When I had chronic knee pain, both of those activities bothered my knees. Eventually I simply said, “no more.”

Now, as for the isometric quad sets: Right, a study showed subjects who did them had thicker viscosity of their synovial fluid. How does that work, when there’s no motion? You know, that’s a good question. I’ve wondered it myself. How the hell does that work?

In any event, I have to confess: I’m not a huge fan of isometric quad sets. I guess they could be a useful way to build up your quads without irritating the joint (though sometimes they do irritate it, oddly enough). I have wondered if perhaps the thicker synovial fluid that researchers found was due to something else.

Then again, maybe quad sets are a good idea, which is my way of saying, “You might want to try them and see if they’re useful for you.” In any event, the bottom line for me is they didn’t factor in my recovery.

On the rabbits and passive motion: Yeah, no load. That’s my understanding. Like when your physical therapist grabs your leg, and moves it through a range of motion, and you just lie there on your back and watch.

So would lying on your back and pedaling in the air be the equivalent? Uh, I’m not sure about that. I just got on my back and went through some “air pedaling” motions, and it was harder than I expected. It certainly wasn’t easy peasy passive motion. However, you can always try it – I’m usually quick to point out that I don’t have advice or answers necessarily, but just like to share my thoughts on things.

I think it’s easier to replicate near-passive motion on a stationary bike. Set the resistance to zero, for instance. Or try to pedal backwards. Still, if your knees get cranky doing that, maybe this isn’t the best activity for you. One other option, if you really think you need to go back to square one, are what Doug Kelsey calls “sliders.” You basically put your feet on something like a dolly, and move your legs back and forth using its smooth rolling motion (I think).

I would definitely find out how Doug advises the exercises be done.

You might think about starting there, and build up to something harder later: easy cycling, or walking, or whatever.

One last note for everyone out there: I talked to the Washington Post reporter again, and she says that the article that she’s writing got delayed, but it’s planned now for early November. I’ll keep you all posted!

Any More Success Stories Out There?

From time to time, I like to encourage people to send in their success stories, or even updates about what they're doing that's working well.

The small community that we have here benefits greatly from hearing voices other than mine talking about what works (and what doesn't) when it comes to knee pain.

So consider the comment section open to success stories or updates! Some of you have been visiting this blog for years, and have years of struggling with knee pain before that. You have long stories to tell that make mine seem quite short by comparison.

Anyway, that's all from me! Not a lot to report on my end ... I don't really think about my knees too much anymore, and that's kind of a nice place to be.

Cheers!

We're Losing One of the Good People ...

Sadly, it appears Dr. Scott F. Dye is retiring. "Silvertongued" posted this in the comment section the other day:

I've been seeing Dr. Dye since last year. I'm lucky enough to live driving distance to his office. He's been instrumental to my recovery. He's a great doctor and very compassionate, as we have been sharing over the years in this forum. He told me last visit that he'll be retiring at the end of this year.

As some of you know, I discovered Dye rather late, during my post-recovery. True, during my recovery, I did happen to come across his name in a magazine article. He seemed a bit odd though. What stuck in my mind from the article was a certain incident, when he wanted to better understand the source of patellofemoral pain:

He noted that many patients who had arthroscopic surgery for other reasons had fibrillated cartilage in their patellofemoral joint, but did not have patellofemoral pain. Meanwhile, patients with presumed patellofemoral pain might have pristine cartilage in their knee at the time of arthroscopy. This led him to ask the question, “What anatomic structures in the knee can really feel pain?”

And so (it would have been interesting to be a fly on the wall during this experiment):

Dye asked a colleague to perform knee arthroscopy on his knee without anesthetic. During the arthroscopy, the surgeon would probe different anatomic structures, and Dye would report what he felt. ... He discovered that he had almost no pain with palpation of the patellofemoral joint, while probing of the anterior fat pad and anterior joint capsule was exquisitely painful.

I can just about hear him scream when that probe touched his synovium. All in the name of science, I suppose, but at the time I remember thinking he was a bit eccentric.

Years later though, I came across his "envelope of function" framework for how to understand and recover from knee pain. This was something completely new for me. Intrigued, I read a few of his scholarly articles. It soon become clear that he belonged to the smart set when it comes to knee pain: he made a lot of common sense suggestions, debunked some myths, and analyzed diffuse, chronic knee pain in a way that was completely logical.

I then looked up some of his videos on YouTube. He is an, um, refreshingly direct and original speaker, not shy about his disdain for certain wrongheaded beliefs. I urge you to look him up on YouTube, as he really is entertaining.

So in honor of the retiring Dr. Dye, I am listing below some of my posts about him and his beliefs. If you're a new visitor, still trying to figure out your knee pain, I urge you to take a look. It's good stuff.

Why You Need to Know About the “Envelope of Function”

What Implications Does “Envelope of Function” Have for Designing a Plan to Beat Knee Pain?

Scott F. Dye on Why Your Knee Pain Diagnosis Stinks (And Why You’re Not Getting Better)

Update: A commenter below actually says Dye is not retiring, just "limiting future office visits to once a month." So if you're interested in seeing him, it would be worth placing a call, it appears.

A Musing on My Occasional Knee Recklessness

I may not be the best role model for someone trying to figure out how to manage the post-recovery period after beating knee pain.

This occurred to me a couple of months ago. I was struggling with a little pain at the side of my left knee.

What happened: As some of you may remember, I broke my hand in two places while cycling on Aug. 11 of last year. That left me in the basement, racking up miles cycling in the virtual reality world of Zwift, and sometimes badly disobeying my doctor’s orders to minimize sweating under my cast.

Eventually the cast came off and I was cleared for cycling again, but by then it was late in the season and I figured I’d just stay inside, logging miles on Zwift, until April.

Now normally, I take off a month or two during the winter and only do easy stationary bike cycling. I figure it’s good to give my knees a little break. Not this year though. Frustrated about the broken hand, and trying to preserve some semblance of conditioning, I did long rides and races on Zwift, pushing myself hard. My best ride, I averaged 251 watts for 51 minutes, which I thought was respectable.

But, during a race on Zwift, I pushed down hard with my left leg to go up a sudden steep climb and got a sharp pain on the inside (medial) of my left knee. It kind of lingered for months. Every time I thought it was gone, I’d move my leg/knee a certain way – and bam – there it was again.

I think it was a ligament sprain. In any event, intense cycling wasn’t helping any. So early in July, I finally went into knee conservation mode. I began cheating on pedaling, putting more stress on my right leg. I backed off sprints. I went out on more rides alone.

It took about a month, but the knee got better and I’m fine now.

But the experience did make me think: Wow, I managed to heal my knees and then dove right back into the kind of crazy cycling I’ve always loved to do. Which is great on one level: I did succeed in returning to doing exactly the same intense physical activity I had grown to love.

However: a more sensible me might have toned things down a bit. I probably could have avoided some of the little burning-under-the-kneecap episodes I’ve had since 2011, when I published the book. I’ve talked about those before, and they never lasted more than a few weeks or a month, but I think they came about because, well, I like to ride my bike really damn hard.

If I had just wanted the most trouble-free knees, I would have adopted a moderate riding program, not the cycle-til-you-want-to-collapse riding that I often do. So maybe this isn’t the most sensible way to handle your post recovery. Still, I will say that I’m always careful now to monitor symptoms. When I feel as if a knee-related problem is starting to spiral out of control, I modify my behavior and nip it in the bud.

The takeaway here is that I’m not encouraging anyone to do what I’m doing. It’s rather hardcore. But I’m also saying with my example that, if you bring your knees back from a painful state, and do it carefully, that there’s a good chance you can return to doing whatever you want. Just take small steps to get there. :)

Are You Mentally Ready to Beat Knee Pain?

I was pondering this question recently, because it occurred to me that beating knee pain depends first of all on being in the right mental state. Specifically, there are four traits you need.

(1) You need to be receptive to the right message.

I’m not even saying, arrogantly, that it’s necessarily my message. I’d like to think that my message makes a lot of sense. But maybe you disagree. Or maybe you like parts of what I have to say about understanding and healing from knee pain and dislike others.

Nevertheless, you can’t shut yourself off from being receptive that the right message will come along. If regular physical therapy doesn’t work for you (as it didn’t for me), giving up shouldn’t be the default option. The default option should be to study other types of treatments and thoughtfully evaluate them, and keep pushing forward.

(2) You can’t be consumed with negativity.

This seems obvious, but it’s easier said than done. Most people who have tried a lot of things to overcome knee pain, failing many times along the way, become deeply discouraged. That’s not surprising. When something new is suggested, they might think, “Might as well try it, because everything else has failed.”

That heavy negativity weighs you down and prevents you from giving a new treatment a fair chance. Negative people tend to flit from one cure to the next, in manic depressive style, and never stick long enough with something to learn anything useful from it. How many successes do “I can’t do it” people have versus those who embark on new programs with hopefulness, even when things seem bleak?

(3) You have to be prepared to think “outside the box.”

Thinking “inside the box” has failed a lot of knee pain patients over the last few decades. The conventional prescription of muscle strengthening around the joint doesn’t work well for those with really weak knees. It just trashes your joints. And you figure that out quickly, unfortunately.

So what do you replace it with? You should be ready to look at creative, sensible alternatives that maybe aren’t part of a typical physical therapist’s playbook. Discoveries aren’t made by people entranced by the status quo; they’re made by those who dare to think differently.

(4) You need to possess a certain stubbornness, patience and will to persevere.

Healing from knee pain can take a long, long, long time. That’s what I learned. Luckily for me, when I set my sights on a goal, I pursue it with a steady, single-minded determination. And there are other people whose stories appear on this blog, who have shown an even greater singularity of purpose along with complete devotion to doing whatever it takes to get better. And they make the time it took for my recovery, over more than a year, seem downright fast.

Sure, even if you have these four traits, there's a lot of other things you need to do. But I think being in the right frame of mind is where you have to start.

Once More: Proper Exercise Won’t Damage Your Knees

One thing that exasperates me is the all-too-common belief that, once you develop chronic knee pain, you have to stop exercising completely or else the condition will get worse.

So I’m always happy to hold up a study (or in this case even better: many studies) that disprove this wrongheaded attitude.

Here is the opening paragraph of a summary of the research:

A study by scientists has discovered that therapeutic exercise does not harm articular cartilage of the knee in people with osteoarthritis, a leading cause of disability worldwide associated with pain, impaired mobility and quality of life. It may, in fact, benefit articular cartilage.

It turns out that this conclusion was reached by a research fellow at the University of Aberdeen's Institute of Medical Sciences. He didn’t examine a single study either, but rather 21 of them that were conducted in countries from China and Holland to Turkey.

The two main findings: (1) Therapeutic exercise doesn’t damage the articular cartilage in the knee joint. (2) Also, that kind of exercise doesn’t increase inflammation.

All great results, and they should give knee pain suffers confidence to embark on an exercise program.

Now, what’s important to remember though: therapeutic exercise is good. Any old exercise may not be. Even if you think you've found the perfect exercise that's not too stressful on the knee, you have to be careful and monitor any symptoms closely.

On Stretching and Knee Pain

I was thinking about stretching recently. My mother was in town for a few weeks. She’s edging toward her late 70s, is in great shape, and was talking about her yoga class.

She mentioned all the stretching she does for class, and I just kind of nodded absently.

It’s no secret I’m not a big fan of stretching. Most of my life, I never bothered to stretch, and I was fine. Then, when I developed knee pain, a physical therapist advised that I stretch, and at that point, hell, I was willing to try anything. I even thought to myself, “Of course. Stretching. Never did it and look where I am now. Stretching is what I need to do!”

I learned a stretch for my quads that brought me some temporary relief, but the knee pain would soon come back. What’s more, I never got the sense that my knees were really getting better on account of the stretching. So I started to look into stretching, and what I found went into Saving My Knees and also became this five-part series below:

To Stretch or Not to Stretch, Part I
Can Stretching Really Help Fix What Ails Your Knee?
Stretching, Part III: A Critical Look at the Biggest Pro-Stretching Claims
On the Real Benefits of Stretching If You Have Knee Pain
Why Is Stretching So Darn Popular, If Its Benefits Have Been Greatly Oversold?

Still, a lot of people love stretching. It’s like this unquestioned, ingrained thing, and the belief in stretching is really hard to dislodge. Frankly, I doubt it’s worth arguing about. I think you could cite clinical studies that disprove the benefits of stretching until you’re blue in the face, and any diehard stretcher would listen impassively, then go off and start doing some stretches.

I think it’s almost reached the level of religious belief. But that’s not necessarily a bad thing. It’s good to take a benign view on such matters. I’m sure some of the things I do now, that I think are helping me in some way, actually aren’t making any difference at all.

My thinking now is, if stretching helps with your knee pain, great, keep doing it. I’d say the same about taking glucosamine (unless you’re diabetic of course).

I’m not sure stretching does any good. But most stretching – if done gently enough, without any strange, hard, twisting forces being put on joints – seems harmless enough.

So if you want to stretch, go for it. Me, I just prefer to warm up. I think that works better.