Humans, Salamanders, and the Ability of Cartilage to Heal

Get a load of this: a scientific study is confirming that cartilage does have the capacity to regrow. Hooray!

Of course some of us have believed that for a while.

The reporting on this discovery has a kind of breathless tone of disbelief. The researchers who did the study call this ability we possess a “salamander-like” regenerative capacity. Salamanders, of course, can regrow limbs and parts of major organs.

As I’ve said a number of times, at least two studies done a decade or so ago have discovered that deep holes in cartilage can fill in naturally, at least part of the way, over a few years.  (For more, see here and here.) That doesn’t surprise me at all.

From an evolutionary biology standpoint, it just makes sense.

The cartilage in our knees takes a banging over the course of decades. It’s hard to believe that it would be designed so that it just wears out, like the tread on an overused car tire. Cartilage should have some natural regenerative capacity. Indeed, evidence has been found that, when damaged, it does try to repair itself.

The problem is, cartilage changes slowly. Defects in the tissue can easily get worse if too much pressure is applied to the knee joint. So getting better isn’t quick, or easy.

Anyway, more details on the study:

Researchers at Duke Health found that molecules called microRNA oversee the regeneration process. These molecules are more active in animals that are known to efficiently mend their own damaged limbs or fins, such as salamanders or zebrafish.

The research team thinks the microRNA could be used in treatments that could possibly reverse arthritis.

By the way, the researchers also looked at the age of cartilage in different locations in the body. It happens to be “young” in the ankle, “middle-aged” in the knee, and “old” in the hip. That, they suggest, could be why arthritis occurs more often in hips and knees.

So there you go. As you focus on gentle, low-load movement to heal your knees, you may be awakening your inner salamander!

The Dangerous Shift by Orthopedists to 'Symptom Control'

I’m feeling a bit sour. This kind of irked me:

A new review of how specialists and primary care doctors treat knee osteoarthritis (OA) finds that the use of pain-relieving prescriptions has risen dramatically, while lifestyle recommendations and physical therapy (PT) referrals have dropped.

The next sentence provided needed context: doctors appear to be increasingly concerned with “symptom control” rather than treating the underlying issue. The analysis was based on data collected from national surveys conducted by the Centers for Disease Control and Prevention.

The lead author on the study, which was published last month in Arthritis Care & Research, rightly says we need to shift our thinking away from taking care of the immediate pain and toward preventing a further decline in physical health.

Well, yeah. Short-term fixes for hard-to-solve, long-term problems aren’t a good idea. It’s like using zip ties to hold your car’s battery cables together (I’d link to the YouTube video where I saw this “fix,” if I could only remember where – I discovered the video when I had to replace my own battery cables.) Short-term fixes are sometimes necessary of course because you need some way to get your car home, or in the case of your knees, to manage pain that's reached unbearable levels.

But, once the pain abates, you should start thinking of a long-term plan to take care of the problem.

Below are more details from the study, which I found mildly horrifying. The researchers discovered that:

* In the 2007-2009 period, orthopedic doctors referred patients to physical therapy 15.8% of the time. Less than a decade later, in 2013-2015, that figure dropped almost by half, to 8.6%.

* Many of these doctors also abandoned “lifestyle counseling” (e.g., exercise recommendations, advice about managing weight). Specifically, lifestyle counseling fell from 18.4% of all visits to less than half of that, or 8.8%.

So what were these poor patients leaving with, if not referrals to physical therapy or good advice about the importance of controlling their weight? You guessed it: little pieces of paper for their local pharmacy.

The number of prescriptions written by orthopedic specialists for nonsteroidal anti-inflammatory drugs (NSAIDs) more than doubled, from 132 per 1,000 visits to 278 per 1,000, and tripled for narcotics, going from 77 per 1,000 to 236 per 1,000.

Personally, I think what many of these orthopedic doctors are doing is shameful. I’m not sure how much of it is because of the long-legged twentysomething drug reps showing up every few weeks with new pills and free goodies to shower on power prescribers, but I think there’s a better way.

True, it’s a harder way, a longer way. Still, if you minimize the pills, and stick to a careful regimen, you can actually improve the health of your bad knees. This isn’t just my story anymore, but the story of a fair number of other people who are regular visitors to this blog!

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.