Knee Pain Recovery: When to Return to the Sport You Loved?

Someone left this question recently (edited for brevity):

My side question to you is, how/when did you decide cycling was reasonable to try again? It has been 2+ years since I have been on the bike. My knee pain/symptoms have improved. I can now go on 2 mile walks, use a rowing machine for 15 min, even do gardening & housework. Of course if I overdo it, my knees will remind me and I can have a setback. So day to day life is so much better than two years ago, so I don't want to risk losing that. ... What was your indication that gave you confidence to try cycling again?

Viewed narrowly, this is a question about cycling. When can someone return to cycling after a bout with knee pain? But I think it’s a question that could be asked more broadly: During your recovery from knee pain, when is it appropriate to return to your favorite sport, “x”? (Here’s more musing on that question by the way.)

Answering this should force you to confront an unpleasant question: Was sport x somehow involved in your developing knee pain? Chances are it was. And when that’s the case, you might have to be even more careful about returning to that activity.

For me, cycling was something I really loved. I loved the intensity of the workouts, climbing hills and pushing myself to the limit, trying to set personal records on courses. I also knew I was a pretty good rider – nowhere near good enough to ride with the best, but competitive on a local level.

After developing knee pain, I had a tough time giving up riding my bike. A few times, when my knees felt a little better, I would get back on the bike, thinking, “Maybe, just maybe, they’re fine now.” Of course they weren’t, and a few minutes later I would get off the bicycle, miserable, wondering if my knees would ever heal.

Finally, I reluctantly gave up cycling. I said, “I just can’t do this and get better.”

For me, getting better was partly about accepting a grim truth: I might never be able to ride my bike again. In fact, I think it’s almost easier if you manage to convince yourself that that part of your life is history. When you accept that, you’re not always trying to climb back on your bike on the first day you have pain-free knees.

But at some point, I did of course.

It was after I returned to America from Hong Kong. I knew my recovery was well in hand, and I felt confident it was just a matter of time before my knees were normal again.

I can’t tell you I reached this decision about returning to cycling after x weeks of no pain from my knees, or after two months of being able to do x. Heck, I don’t even remember now.

What I do recall about the decision: As I said, I had pretty much given up on cycling, after failing on multiple occasions to ride without triggering the burning in my knees. Instead, I was just focusing on getting better. And, at some point, when I felt like my knees were really stronger, and that I wasn’t at risk of backsliding, I rolled the bike out, took a deep breath, and went on a very, very slow ride. And my knees were fine.

Open Comment Forum: What Was the Biggest Mistake You Made?

Of course the normal open comment forum rules apply: Feel free to ignore my suggested topic, and talk among yourselves about whatever you'd like.

But for anyone who wants to go along:

What was the biggest mistake you made when it comes to managing or dealing with your knee pain?

This is probably a moderately hard question. I pondered it myself. I couldn't think of a single event.

As in, I can't really say, "The biggest mistake I made was seeing Doctor X and taking his advice to do Y."

Rather, I think the biggest mistake I made was not taking my knee pain seriously for months, and assuming it would go away, because I was healthy and had always recovered well from minor injuries.

By the time I did take it seriously, I was in a really deep hole. And then, at that point, unfortunately I kept digging that hole. I knew I had a problem with knee pain. I knew it wasn't going to magically resolve itself. But still, I tried to keep semi-active. I stressed my knees more than they could handle.

Then, finally, I hit that low point where I conceded how bad things were, and with that knowledge, I could chart a path to recovery.

What about you? What was the biggest mistake you made?

Anyone Want to Talk About Using a Walking Desk?

I got this comment recently. Lately I have been trying not to sound like a broken record (it feels like I've written about so many topics already on this blog), so I've been sifting through the comment section for ideas for new posts.

Richard - Thank you for publishing your experience and being a resource for us. I've been dealing with pfp for 2 years and it's when I'm sitting at my desk that it's worst. Recently I fashioned a DIY cycling desk at my apartment, which has been effective but nothing helps as much as walking. Curious if you, or others, have invested in a walking desk?

Anyone want to share their experience with a "walking desk"?

I was curious about walking desks -- no, I've never used one -- so I did a quick Google search. They look like a treadmill married to a small, simple table at the proper height. See here for an example.

Hmm. Looks interesting. Prolonged sitting is poison after all, right? I really do believe that.

So here are a couple of quick thoughts from me about "walking desks," and I warn you again: this is coming from someone who has never tried one:

* They look like an interesting idea for people who are already fit. I noticed that in the images that Google brought up, most everyone pictured looked like they could go out and run about 5 miles, no problem.

* For people with bad knees, I'm not so sure, but I guess it depends on how bad your knees are. They remind me too much of my early failed experiment with walking constantly, after I realized that the key to rehabbing bad knees was motion. But I overdid the walking. In a big way.

* So with a walking desk, what happens when you need to take a break? After a while you will get tired. Your muscles will be tired. Your feet will be tired. Maybe your knees will be tired too. Do you shift over to your non-walking desk nearby? Or are you supposed to be walking for an entire eight-hour day? Not sure I'd be keen about that.

Who out there has tried a walking desk, or a similar setup? Want to share what you learned?

When Your Doctor/MRI Speaks a Foreign Language

I got this comment recently:

Hi Richard, not sure if you have any suggestions or experience on exercises or treatments regarding diagnoses of focal chondrosis, narrowing of the patellofemoral joint, subluxed patellas or joint effusion?

Well, that's a mouthful certainly. What's all this clinical jargon mean? (And why do medical technicians and professionals always speak in some baffling foreign language?)

Anyway, here's my take. If I'm wrong, someone feel free to correct me, but I think I'm in the ballpark:

"Focal chondrosis" appears to be simply a loss of articular cartilage. "Focal" suggests a particular location (or locations).

"Narrowing of the patellofemoral" joint is what it sounds like, and was perhaps seen on an X-ray. If there's loss of your protective cartilage, an X-ray will simply detect that the joint space has narrowed. That's because the cushioning cartilage has thinned, showing the bones closer together. Remember: an X-ray can't actually see the tissues, so basically someone infers what's going on based on how far apart the bones are.

"Subluxed patella" seems to be a patella that's mistracking or becoming partially dislocated. On this point, I'd be curious. Is this something that's just been "clinically observed"? Or what exactly is the evidence of this?

There are plenty of reasons to be skeptical when it comes to the role of patella mistracking when it comes to knee pain. See here, here and here, for instance.

And finally we have "joint effusion." "Effusion" is just swelling. So you've got swelling in your joint. D'oh! No big revelation there, I'm guessing.

At this point, what exercises might be suitable?

Well, "effusion" suggests that the joint is being stressed beyond what it can handle. That means that, whatever exercise regimen you choose, it should probably be fairly easy, at least in the beginning.

As for the cartilage loss, this bears repeating: cartilage loss, by itself, doesn't have to be a sentence of knee pain and misery. It does often correlate with knee pain and misery, true. But someone can have knees that feel healthy while having pockmarked cartilage.

What exercises are good for these conditions? You might want to consider activities that slowly build the strength of the remaining cartilage. They could be low-load, high-repetition. And, of course, you want them to be easy (see "joint effusion" above).

Finally, what about the "subluxed patella"? Hmm. A couple of quick thoughts:

(1) It's not really medically significant, even though some misguided doctor/physical therapist thinks it is. In that case, you might want to just try the light-load, high-repetition, and see how it goes ...

(2) It is medically significant. In that case, honestly, you might not get any satisfactory results apart from surgery. "Muscle strengthening" programs probably won't do the trick.

So those are a few thoughts. Others are welcome to comment below. And, of course, remember: none of us has seen your knees. We're just throwing out things to consider. Your best advice, in the end, is really to see another doctor and get that second opinion.

What Footwear Should a Knee Pain Sufferer Look for?

A short post today, drawn once again from the comment section.

Someone threw out the question: What’s the best footwear for someone with knee pain?

Ah yes. This is familiar territory. In Hong Kong, one of my experiments was with a pair of fancy $100 shoes that promised to lessen my knee pain by some impressive percentage.

I was really eager to try these out, thinking they might even shorten my time to healing. So I put them on and ... it was a disaster. They didn’t help at all. $100 down the toilet.

Now, sometimes I suppose that your physical therapist might advise special footwear to correct some “imbalance” in your step or stride.

I would be rather skeptical about this. That’s me anyway. Physical therapists all too often like to put forth theories of pain resulting from crookedness and imbalances.

I’m doubtful that malalignment is a significant problem for most knee pain patients, as I’ve said repeatedly before. Dr. Scott Dye, who I respect greatly, is also skeptical that it lies at the root of as much knee pain as the therapeutic community would have us believe.

So back to footwear: Does it matter at all?

Yes, I think it does, and maybe a lot. But my requirements would be simple: comfortable and well-cushioned shoes, such as for running. Running shoes are designed to lessen impacts on the joints, absorbing some shocks before they reach your knees.

To me, that’s a pretty good match for what I’d want.

The person who wrote the comment also asked about going barefoot around an apartment or wearing slippers. Hmm. Not sure there’s a big difference there, but thoughts from others are welcome.

Stay safe all!

Could I Have Healed My Knees Without Quitting My Job?

This question occasionally comes up. It was in the comments section recently, and since I’ve decided to try to flip as many comments into posts as possible, I thought, “Why not?”

So, could I have gotten better without quitting my job?

The honest answer, really, is I just don’t know. I’m doubtful. But maybe I could have. It would have been much harder certainly.

But let’s unpack this one for a moment. Because, partly what I was doing by leaving my job to try to heal my knees, was establishing “proof of concept.”

Remember: the only doctor I had faith in, while living in Hong Kong, had told me flat out that my knees would never get better. “Never” is a big, final-sounding, devastating word. I’m sure he saw himself as a truth teller, trying to dissuade a naive patient of notions he could still heal.

But I took this as a challenge, because I’m that kind of guy. Could my knees heal under the most optimal conditions – if I quit my job, devoted my life to what I was convinced it would take to get better? If I succeeded, it would show that at least some of those dire verdicts that doctors deliver to patients are unwarranted.

In the end, it was a great feeling of vindication when I realized I was right, and I was going to heal all the way. I felt as if I had won my life back.

But what about you? That’s really what you want to know, even though you’re asking about my knees. Can you heal without quitting your job?

And, my wishy-washy answer is, it probably depends. On how bad your knees are. On what you do at work to try to alleviate the stress of sitting. On your own inner fortitude and will to beat this thing.

I’m not advocating that everyone quit their job to fix their knees. It may work, but it may not. First, I’d try everything possible to heal my knees while staying employed (ahem, especially right now). Then, if you have to confront that hard decision, give it a lot of thought.

I also got this question:

Light flat gradual building up walking is the way to go. My question to Richard is how do you know what’s too much? As long as there is no pain during and after is that ok?

Well, no pain during and immediately after is, I would say, the minimum. But you also have to monitor for delayed onset symptoms, which can pop up a couple of days later. So this can be a very, very frustrating exercise, determining “how much is too much?”

So I would think of starting at a low base. What’s the easiest walking that doesn’t bother your knees at all? Then maybe cut that in half. One of the hardest lessons I learned early on was that my knees were much weaker than I thought, and I had to go more slowly than I expected.

Okay, that’s it for now. Take care everyone, and be careful. I know the warm weather is tempting all of us into going outside, but the world is not a completely safe place yet.

Simple Guidelines for Walking With Bad Knees

I thought I’d do something short on some things that I learned about walking with bad knees. A few simple rules (or since “rules” seems a bit strong, let’s say “guidelines,” with the caveat that this is what worked for me personally).

1. Movement is very, very important, so walking is often a good idea for people trying to recover from knee pain. But if you walk too far, and too fast, your knees will just get worse.

2. In the beginning, when you decide to “walk your knees back to good health,” you will almost invariably walk too much. This is partly because you will have forgotten that you now have a pair of bad knees and that walking can be a very stressful activity for them.

3. Go flat for a while. Choose a walking path that has no inclines, no declines. Avoid steps. That will lessen the impact on your joints.

4. Walking downhill is more dangerous than going uphill. Your body weight tends to drop harder on your vulnerable knee joints. I used to pretend, when going downhill, I was stepping on eggs and trying not to break them.

5. Walking is a great idea! It’s one of those functional knee exercises that’s perfectly suited to something you’ll have to do, again and again, for the rest of your life. Sure, you can do all sorts of odd exercises intended to strengthen your knees, and the muscles around them. But it’s hard to beat walking for something practical that you need to master to be able to live a normal life!