Another Study That Says ACI Isn’t as Good as Advertised

Autologous chondrocyte implantation, as I described in Saving My Knees, is an extensive procedure: harvest good chondrocytes from your knee, grow hundreds of thousands more of them in a lab, then fill the holes in your cartilage with the cultured tissue.

A while ago, I came across a study of the surgery suggesting that its benefits may fall short of what’s advertised. (More than a year ago, some of you may recall, I looked at ACI vs. microfracture, and which is better.)

Here’s the study if you want to peruse it yourself. If you’re thinking of undergoing ACI, take a look at the graphic color photos. This isn’t “keyhole” type surgery. ACI is a major operation.

This particular study followed 19 patients, average age 32, who were professional soldiers and athletes -- and who thus put high physical demands on their knee joints. This was a hard-luck group to begin with: all but two had had either a microfracture or a “clean up” of their ragged cartilage.

After having the ACI performed, 11 of the 19 (more than half) underwent “second-look arthroscopy” because of “persistent pain, decreased range of movements, and mechanical symptoms.” (Which tends to support my belief that, unfortunately, surgery often begets surgery.)

The results? Well, the authors of the research note that previous studies have found ACI to have a success rate of up to 90 percent -- pretty impressive. In this study, however, only 31%, or 1 in 3 subjects, “returned to prior levels of athletic performance.”

The conclusion was that “in high-demand patients who have a longstanding disability, large defects, and failed previous cartilage techniques, the results of autologous chondrocyte implantation may not be as good as those reported or expected.”

That should give those pondering ACI, or even a lesser surgery, something to mull over.

Surgery is sometimes very successful. You’ll find people who come out the other side of the operating room wishing they had done it earlier.

But it’s never a slam dunk of a decision. It’s not to be taken lightly. In particular, listen to your doctor when he says after assessing your bad knee, “I wouldn’t advise surgery for you right now.” Because this is someone who has an economic incentive for performing surgeries -- if he opposes it, that should tell you something.

I’d never advise anyone to have surgery or not to have surgery. However, I would say it’s never a bad idea to think twice about it, and to make sure you’ve exhausted other options.

Celebrating “Take Knee Pain Seriously Day"

Today is “Take Knee Pain Seriously Day.”

If you’re puzzled because you’ve never heard of this special day, that’s understandable. I just invented it myself a few moments ago -- but for a good reason.

One thing I learned, after overcoming chronic knee pain, was that early on I wasted months thrashing about, unsure of what to do. While this may sound bad, I’m convinced that most people with similar knee pain waste years.

One mistake I made (and that I bet many others make too) is that I didn’t take the pain seriously enough, especially during those first few months. Acting early is the best, easiest way to escape being stuck with a long-term condition that just worsens and worsens.

Here are some signs you may not be taking your knee pain as seriously as you should:

You’re willing to modify your physical workouts/lifestyle ... but not by much.

You decide not to run for a week. Or you shave a few miles off your run. Or, in my case, I resolved to keep cycling over the same challenging routes, and the same steep climbs as before, only “taking it easier” (which I sometimes did and sometimes didn’t). The radical step of abandoning the bike completely didn’t come until later.

You tell yourself “I’ll just give the knee a few weeks to get better, no problem.”

This is a typical early-stage reaction to knee trouble. But most knee issues don’t occur overnight -- and the cure certainly doesn’t either.

So if you’re serious about getting better, you need to give yourself enough time (and have a long-range plan too by the way).

You don’t bother to educate yourself about your condition.

In my eyes, this is another sign of a lack of seriousness, especially after doctors tell you they can’t help -- or what help they do suggest (short of surgery) just doesn’t prove that satisfying.

In that case, you absolutely have to make every effort to help yourself. You have to try to understand better what you’re suffering from and the various explanations of and treatments for it.

Finally, in closing, here’s the irony of “Take Knee Pain Seriously Day.”

At least 90 percent of people reading this blog post, I’m willing to bet, are taking their knee pain seriously. They know they’re in trouble, and they’re willing to be patient about achieving a solution.

The irony is that the people who most need to hear this message don’t even know it yet.

A Story About Healing Naturally

At some point, when you have chronic knee pain, you consider surgery or medication to help you through the ordeal. I know I did. I badly wanted my knees to be fixed, or at least, for the pain and discomfort to go away.

Luckily I figured out a natural way to heal (which took a lot longer than an hour-long surgery, but worked better, and didn’t leave me with scars or side effects). Partly I put faith in my body to “figure out” how to get better, if given enough time and gentle coaxing in the right direction (which for me translated into lots of slow, careful walking, with a very gradual build in intensity).

The virtue of a “natural approach” to healing was underscored for me by a recent article in the New Yorker entitled “Germs Are Us.” The tease: “Bacteria make us sick. Do they also keep us alive?”

The article considers the beneficial role played by the thousands of microbes that inhabit our bodies. Buried toward the end is a neat anecdote that serves as a reminder that sometimes a cure doesn’t come at the end of a scalpel or in a bottle of medication.

The story is about, of all things, earwax.

A man was suffering from a chronic infection in his left ear. His doctors were stymied. They tried different antibiotics, antifungal drops. Nothing worked.

Then one day the man showed up at the clinic, smiling. He was fine. “Do you want to know what I did?” he said. His doctors assumed that one of the drugs had finally found its mark.

But no.

The ear pain sufferer had taken a piece of earwax from his good ear and inserted it into his bad one. Apparently the bad ear lacked certain good bacteria that arrived on the transplanted earwax, and these microbes promptly went to work (doing whatever they do) and cured him!

Pretty cool, huh?

I’ll admit there can be a mysterious aspect to healing naturally. Something works, but why? Now, I’m a hyper-rational guy, always on the hunt for cause and effect, but maybe there are times you just have to allow that there are things we don’t fully understand yet, and trust that your body can work out problems if given the right conditions.

When my knee pain was at its worst, I remember a few times dropping defiantly into a deep crouch (“Ah screw it, who cares,” I was usually thinking). From the uncomfortable squat, I pushed upward into a standing position. And you would not believe the hideous sound something in or around my knees made. It was like someone ripping a wet sheet of canvas.

I never focused on eliminating that sound. I never even focused on figuring out what it was. Rather, when I was pretty sure I had discovered the right way to heal my knees, I threw myself entirely into that effort and more or less trusted that my problems -- the inflammation, the noisy cartilage, that godawful ripping noise -- would get better, all together.

And they did.

That's pretty cool too.

Is Vigorous Physical Activity Bad for Your Knees?

I have Google scrape the Web for me each day for news about knee pain. Lately articles reporting on this study have been filling up my news alerts.

Very high and very low levels of physical activity can both accelerate the degeneration of knee cartilage in middle-aged adults, according to a new study.

Researchers Thomas M. Link and colleagues tracked changes in the knees of 205 adults (45-60 years of age, with no knee pain reported at outset), using MRI exams over a four-year period. The result: Subjects who participated more frequently in high-impact activities (such as running or playing tennis) or who were sedentary had their knee cartilage degenerate more than those who were moderately active physically.

Before we go further, I have to include a disclaimer: Once again, I couldn’t access the full study. So, for instance, I don’t know exactly what “moderate activity” means, which is annoying. But from context I’m going to guess it translates into lower-impact exercise, such as swimming or walking.

What I like most about this study:

* It shows (yet again) that being sedentary is bad for knee joints.

* It underscores my belief that there are joint-friendly exercises (assuming I’ve interpreted “moderate activity” correctly), such as walking. They combine high-repetition and low impact, and subjects in the "moderate activity" group saw little change in their knee cartilage over four years.

* The study looked at subjects with a BMI of 19-27, thus excluding overweight to obese knee pain sufferers. This makes the results cleaner to analyze.

What I like least about this study:

Basically, one thing: the insinuation that hard exercise will ruin your knees. I just don’t think this is true. Earlier, I wrote about a study that showed that longtime marathon runners -- a group that, if any, should have creaky, decaying knees if high-impact sports are bad -- were found to have better joints than non-runners.

Then, there’s this article, saying that “recent research finds jogging might be good for your knee cartilage and joints.”

It cites a Swedish study that discovered that the biochemistry of cartilage improved in the knees of runners vs. non-runners (the belief is that the high impact occurring when your feet strike the ground increases the production of proteins that make cartilage stronger). Other studies (one of Massachusetts residents, and one by Stanford University) concluded that runners were no more likely to develop arthritis than non-runners.

So does this mean there’s no objective, found truth on whether vigorous exercise helps or hurts or does neither? Where does the truth lie?

This is what I think:

If you are older (say between 45 and 60, which was the age range for the subjects in Link’s study), you must exercise smarter if you’re going to do high-impact sports. If you’re going to do low-impact, lower-intensity activities (such as walking), you can afford to be dumber about your approach.

What do I mean by “exercise smarter”? Well, (1) maintain a healthy weight (2) warm up before working out (3) be fairly consistent in your routine.

Number 3 is very important, in my estimation. It means don’t start running twice your normal distance, for example, without giving your body a period of time to adjust. It means don’t think you can hike uphill six miles without problems just because you play a lot of tennis and you’re fit.

That’s because:

Yes, your knees can adapt to more stressful demands put upon them. (The reason marathoners don’t have knee problems, it has been hypothesized, is that the joints get into a “motion groove” where they acclimate to the rigors of long-distance running.) But the adaptation is best when gradual and consistent (don’t run as if you’re training for a race in June, vegetate for July and August, then in September try to resume where you left off in June).

Maybe I’m a dumb optimist, but I think you can be a 60-year-old marathoner with perfectly healthy knees. You just have to be smarter about it than the guy who enjoys walking for exercise.

Reflections on Turning 50

Earlier this year, I reached one of those dreaded milestones. I turned 50 years old.

Five decades. Half a century. Wow.

When you turn 30, you’re jokingly referred to as “over the hill.” But it’s only joking.

At 40, the joking has a hollow ring. You have the uncomfortable feeling that you've probably lived half your life already. The sense of a midlife crisis can become intense.

Then, there’s 50. All of a sudden, you qualify for your first AARP card. And the minor aches and pains you felt before can become lingering, even chronic issues if you’re not careful.

I’ve thought a lot about age and healing, especially after an orthopedist in Hong Kong cheerily told me about five years ago, after I described my knee pain symptoms, that I was over 40, my body was just going to go downhill, and I should accept that.

Fortunately, I didn’t accept that. I was convinced that there wasn’t some “ability to heal” switch that toggled to the off position when I reached a certain age. And, sure enough, after much perseverance, I managed to get better.

That’s not to suggest though that I believe in the saying “Age is just a number.” A realist has to concede age does indeed matter. Senescence is a real phenomenon. Older muscles, for example, don’t recover from hard exercise as quickly and are more prone to injury.

But that doesn’t mean age is a defining number. People can forestall and mitigate the effects of aging -- and it’s not that hard to do.

Vigorous exercise is a good way to slow the advance of the calendar. But, as you get older, it’s good to get smarter about how you exercise.

For example, in the weightroom, I warm up by doing 50 repetitions of an easy weight that’s one-half to one-quarter of the maximum I lift. When I bike in cold weather, besides warming up, I take care to keep my knees comfortable (unlike some cyclists I go out with, who wear jackets and arm warmers while leaving their knees bare!)

Also I’m more careful about taking part in impact sports or activities that involve a lot of jumping or running. It’s not that I can’t do them; it’s just I try to do them smarter (in my younger days, playing softball, I sometimes made leaping catches where I landed on my head -- these days, I’d let the ball drop :)).

So if your knees are bad, and not getting better, don’t blame your age. Blame your weight. Blame your job. Blame the fact that you don’t have a recovery plan, or if you do, it’s not the right one or you’re not following it closely enough.

Because age doesn’t matter nearly as much as others will tell you it does. Trust me here. This is something I happen to know firsthand.

Do You Train for Work?

I remember mentioning this concept to a colleague once. We were talking about our tiring 10-hour-a-day desk jobs. So I said that I “trained for work.” He gave me a sideways smirk, as if to say, “Yeah right. Like there’s a workout routine designed for someone who sits like a rock in a chair all day.”

But I was actually serious.

It’s not that you have to train to be able to do nothing but wiggle your fingers over a keyboard. It’s that you have to train to counteract the deleterious effects of doing nothing, for such long periods, but wiggling your fingers over a keyboard.

Sitting can be poisonous for our bodies, which were designed for movement. Doug Kelsey at Sports Center in Austin once wrote that an old teacher said something to the effect that sitting does for your spine what putting a plastic bag over your head does for your breathing.

So I actually do train for work. Every workday morning I do this “bird dog” exercise for three and a half minutes, to keep my back muscles strong. I also do this “rock ‘n roll” exercise (another great recommendation by Kelsey) for five minutes, for my neck, which is a little crackly and has given me minor problems in the past.

What about my knees?

Actually, what I do for my knees probably benefits my neck and back too. First, on the way to work, I walk a good three-quarters of a mile to my subway stop (bypassing two closer stops, just so I can get in some beneficial movement). During daily snack breaks (Bloomberg has lots of free food on the premises), I eat while slowly strolling the floor. And at lunch, after a quick, light meal, I head for the exits and walk the streets for a good 10 or 15 minutes.

So, in sum: I move as much as possible during work breaks, to try to negate the effect of all the toxic sitting. And early in the morning, I do various exercises to help prepare me to withstand all that sitting without discomfort.

Our bodies need movement. Our 21st-century jobs often don’t accommodate that need so well. So a little special effort is required to keep all our body parts running smoothly.

What Causes Patellofemoral Pain Syndrome and Chondromalacia, Part II

Last week I shared a “unified theory of chronic knee pain” -- basically, that bad cartilage was involved much of the time.

Let me be clear what we’re talking about: diffuse, achy pain generally. There are other, more specific pains when a doctor pokes something and you go “ouch.” Different structures are probably involved there (e.g., I wouldn’t consider “patellar tendinitis” to be PFPS -- I could be wrong here -- because patellar tendinitis diagnoses a clear, identifiable problem).

Now what are some objections to this “unified theory”?

An MRI shows that my cartilage is fine but I have knee pain! So how can the source of pain be the cartilage?

Remember, a typical MRI takes a picture that is imperfect. (Two wood-frame houses may look identical in a photograph, but if the beams of one have been hollowed out by termites, they will not perform the same structurally.)

Initial cartilage damage associated with chondromalacia starts deep within the tissue -- and so, it appears, would not be detectable by a standard MRI.

In chondromalacia of the patella, the initial lesion is a change in the ground substance and collagen fibers at the deep levels of the cartilage. It is a disorder of the deep layers of the cartilage that involves the surface layer only late in its development. (Weinstein, Stuart L. and Buckwalter, Joseph A., eds. Turek’s Orthopaedics: Principles and Their Application.)

Some people with cartilage lesions have no pain, and others with lesions have pain -- if that’s the case, how can bad cartilage be to blame?

Partly the answer appears to be that thin cartilage becomes a problem at some point, despite a knee pain sufferer having a number of initially non-painful lesions:

A recent study proved that one can have as much as Grade III wearing without pain. So, pain is variable. The source of chondromalacia pain is not the articular cartilage itself, but the thinning of it, which transfers loads onto the underlying subchondral bone, which is pain-sensitive. (UCSF School of Medicine, Physical Therapy and Rehabilitation, on patellofemoral pain)

Another important thing to consider here, it seems, is the quality of the remaining cartilage. Recall that chondromalacia literally is an abnormal softening of cartilage. It may have minor wear and be soft (and hurt more), or may have more wear but be fairly stiff (in a good way) and resilient (and hurt less).

Still, if you have a lot of deep lesions, chances are good you have more pain than someone with less damage.

The severity of cartilage lesions detected at arthroscopy highly correlates with incident pain (Aaron, Roy K. and Ciombor, Deborah M. “Pain in Osteoarthritis.” Medicine and Health Rhode Island, July 2004) 

How can damaged cartilage cause pain if the tissue has no nerves?

The key thing to remember here: the source of the pain sensation isn’t the cartilage itself.

Because there are no nerves in cartilage itself, the pain must emanate from subchondral bone, which is experiencing deficient conduction of stress through mechanically inadequate cartilage. ... Fibrillation of articular cartilage usually follows fissuring with progression to ulceration in some cases. When fibrillation progresses to a larger area of the patella, bone may begin to experience abnormal pressure increases or irritation from flaps of cartilage that are placed under pressure. (Fulkerson, John Pryor. Disorders of the Patellofemoral Joint.)

Or, here are some other ways bad cartilage triggers pain sensations:

The articular cartilage is not sensitive to stimulation, but ... the adjacent synovium is the primary pain source [fragments of cartilage can migrate through the synovial fluid to the synovium, irritating it]. The subchondral bone ... is another likely source of pain from excessive load on an unprotected bone surface. Finally, the resulting effusion [swelling] caused by articular breakdown may itself be a source of pain. (Johnson, Donald H. and Pedowitz, Robert A., eds. Practical Orthopaedic Sports Medicine and Arthroscopy)

And as for inflammation:

... Cartilage debris and sulfated polysaccharides liberated from cartilage breakdown have been shown to be inflammatory in joints and to stimulate the release of proinflammatory cytokines. (Aaron, Roy K. et al. “Pain in Osteoarthritis.” Medicine and Health Rhode Island, July 2004)

Then, if you happen to believe that where there’s smoke there’s fire, well, osteoarthritis and cartilage damage go hand in hand:

This loss or damage of articular cartilage is an early finding in osteoarthritis. Chondromacia patella is thus an arthritis involvement of the patella. (MDGuidelines, entry on patella chondromalacia)

But there are other things going on inside bad knees. How can you blame poor cartilage for everything? For example:

The association of bone marrow edema with pain in osteoarthritis of the knee has recently been emphasized. Bone marrow edema was found in 78% of patients with pain compared to 30% of patients without knee pain. The presence of bone marrow edema is associated with progression of cartilage degradation. (Aaron, Roy K. et al. “Pain in Osteoarthritis.” Medicine and Health Rhode Island, July 2004)

Here’s where a careful person has to admit, “Yeah, there's plenty going on that we don’t fully comprehend.”

But consider for a moment swelling of the bone marrow. The first matter to ponder: Does this contribute to cartilage degeneration or is this caused by cartilage degeneration? To me, the latter sounds more plausible. Still, let’s posit the former: that the bone marrow swelling is responsible for cartilage damage -- or that a third, even larger unknown force causes both the cartilage degeneration and the bone marrow swelling.

Okay then, where does that leave us, in terms of finding a path toward healing?

If your main problem is bone marrow swelling (or intraosseous hypertension, or focal osteonecrosis, or bone marrow lesions), then it seems you’d want a more bone-oriented treatment regimen. Now, I am way out on a limb here (I’ve done very little reading on this subject), but bone resembles cartilage a lot more than muscle. So I would think a gentle, joint-friendly program of high-repetition movement would be a smarter way to go than a “strengthen your quads” approach.

So even if the “unified theory” is wrong -- even if cartilage isn’t involved in much of all chronic knee pain -- I think the same activities that would strengthen and help repair this tissue would probably also benefit the joint overall.