What Does Your Doctor or Physical Therapist Really Believe About Bad Knees?

I thought I’d try something different today -- a very basic, bird’s-eye view of beliefs about chronic knee pain and the appropriate treatment.

Hopefully, this will help clarify why I succeeded in my long battle to overcome burning and aching in my knee joints, after a doctor -- the best of the four I saw -- told me in a grave voice that I would never get better. He was very much wrong.

First, take a look at this simple diagram, what I call the distilled matrix of beliefs both about the proper treatment for bad knees and about their capacity to heal:

That first line represents treatment. Let’s start there.

To treat bad knees, you will believe in an approach that's either “Joint Focused” or “Not Joint Focused.” (True, you may adopt a blend of the two, so you may want to think of these as endpoints on a spectrum).

“Not Joint Focused” largely equates to “Muscle Focused.” Every time you hear a doctor or physical therapist say that, to overcome your pain, “you must strengthen your quads, your hips, your glutes” -- you’re receiving “Muscle Focused” advice. (Also, the advice to stretch belongs in the “Not Joint Focused” box -- you can’t stretch a joint, but you can stretch muscles, for example).

So that’s the box on the upper right.

One of my huge revelations was that I needed to be in the upper left quadrant. That is, I needed a “Joint Focused” treatment regimen.

So for months, while trying to heal my bad knees, I didn’t worry about my weakening quadriceps muscles. I didn’t care if my quads turned to butter. I walked very slowly, often for short distances (too short to be of much benefit to muscles). I knew that if I fixed the joints first, I could strengthen the muscles later.

Now here’s the weird thing: Most of the current thinking about how best to fix aching, grumbling knees fits in the upper righthand box. But, if your knee joints hurt, common sense dictates that you focus on fixing them, not some nearby (or not so nearby) structure in your body. So this should make you wonder why that box on the upper right is so darn crowded.

(Of course part of the reason has to do with a preponderant structuralist view that seeks reasons for knee pain outside the joint, in imbalances and misalignments, instead of from injury or normal wear-and-tear inside the joint. I don’t want to get sidelined into a long discussion of structuralism today; there’s more on what I think of structuralism here and here.)

Now move down to the second line. This stands for beliefs about the capacity of bad joints to heal. (Be careful here -- this doesn’t mean “the capacity of bad joints to hurt less.” Someone in the upper right corner may argue that strengthening quads results in “less pain,” because stronger leg muscles better protect the weak joint. At the same time, that same person may argue that the joint itself hasn’t improved because it can’t.).

Now, for this line, two states of the world again exist. You’re either optimistic that knee joints can get better, or you’re pessimistic (or, once more, you may be somewhere in between).

Now here’s an interesting thing: You may think it makes more sense for the second line (beliefs about the joint’s capacity to heal) to be swapped with the first line (beliefs about the appropriate treatment regimen) -- because which logically comes first? But I used this order for a reason. The second line goes a long way to explaining where you find yourself on the first line.

It helps explain the mystery of why that “Not Joint Focused” treatment box in the upper right is so darn crowded. “Not Joint Focused” seems irrational until you drop down one box to the south, into “Joint Pessimistic” territory. Ahah! If you believe knee joints can’t improve (“Joint Pessimistic”), why would you advocate “Joint Focused” treatment? That’s just banging your head against the wall!

“Joint Pessimistic” shows up in many forms. Doctor to patient: “Your knees eventually just wear out and that’s life” or “You’re getting old and your knees won’t get any better.” Scientific literature (and popular medical thinking): “Cartilage has a very limited ability to heal” or “Damaged cartilage can’t heal.” The physical therapy profession (speaking to its members): "Patients should be told that treatment is aimed at structures surrounding the joint, rather than the joint itself" (which is presumably beyond hope).

On the bottom half of this matrix, I lodged myself squarely in the leftside quadrant, “Joint Optimistic.” I did so not from a sense of wild, hopeful desperation. Rather, I did so after a lot of reading, partly of new medical studies from the past decade. I found evidence that damaged cartilage apparently did heal, more frequently and more dramatically (even over bare bone!) than anyone had ever suspected.

Once you’re “Joint Optimistic,” it makes sense to target the joint in your recovery efforts. That’s what I did, and it worked extremely well in the end (though very slowly, and my healing occurred in a lumpy, nonlinear fashion -- but joints are just tough to rehab).

So, to sum up, in this matrix the right-side quadrants go together logically, as do those on the left side.

Now, within the “Joint Optimistic” believers and “Joint Focused” treatments, there can be differences. For example, Doug Kelsey of Sports Clinic was a huge inspiration to me. But he thinks nutritional supplements such as glucosamine are beneficial for joints; I’m a lot more skeptical that they do much good, if any.

Anyway, the point of this matrix is to give you a fuller understanding of the belief system of your doctor or physical therapist, and what it means. You should feel free to ask that person: Are you optimistic about bad joints healing, or pessimistic? (Hardly anyone will say, “Oh, I’m pessimistic,” so you’ll have to read their body language, or carefully parse their answer.) Also, from the exercises you’re given to do, figure out whether you’ve been assigned a “Joint Focused” treatment regimen or a “Not Joint Focused” one.

All this really, really does matter. For me, the first step to beating my chronic knee pain was realizing I needed to be on the left side of this matrix -- and I needed to stop listening to people who were on the other side.

What’s the One Piece of Advice That All Knee Pain Doctors and Experts Agree On? (Part II)

Last week I revealed (to a chorus of groans, I’m sure) that the one, simple thing that everyone agrees on for reducing knee pain is:

Lose weight.

This week, I’m going to provide more evidence (I say “more” because I’ve already visited this topic, here and here, bearing lots of evidence.) But the “lose weight” message is important enough to merit periodic revisits.

So here you have yet more proof, in round-up fashion:

* A report published in the August 2009 issue of the periodical Radiology linked obesity with the rapid progression of knee osteoarthritis and cartilage loss.

All 336 subjects, though overweight, started out with minimal or no loss of knee cartilage. During the 30 months they were monitored, one-fifth of the patients lost cartilage slowly and 5.8 percent lost it rapidly. For every 1 point increase in body mass index, the risk of rapid cartilage loss jumped by 11 percent.

* A 16-week diet that included protein shakes and soups helped people lose weight, lessening joint pain, according to findings published in the December 21, 2011, issue of the European Journal of Clinical Nutrition.

The 175 obese people in the study lost an average of 26 lbs. in the first eight weeks. Dropping all that weight had a significant impact; it “helped more than 60 percent of the participants reduce their knee pain and improved their ability to walk.”

* Another study looked at morbidly obese patients who underwent surgery (such as bariatric) to spur weight loss. A year later, they had lost almost 51 lbs. on average and reported significant improvement in knee function and less pain.

* A higher BMI means more knee pain among women -- whether or not they have osteoarthritis -- according to a study published July 7, 2011, in Arthritis Care & Research.

The 594 women who took part were examined over 14 years. “Significant predictors” of pain were found to be greater initial weight and weight gain. (Curiously, the relationship applied only to patients with pain in both knees, not just one.)

* A study of 20 morbidly obese youngsters, average age 14.2 years old, showed that each had a cartilage lesion in at least one knee region, as indicated by MRI.

The defects (surprising in adolescent children) were similar to those found in victims of “various accidents” or in older people.

It was unclear, at least at the time of this 2005 report, whether the cartilage damage was due simply to mechanical overload or whether metabolic factors might also be to blame.

* And, just in, published December 27 in Arthritis Care & Research:

196 subjects (from 25 to 60 years old) were split into three groups: those who lost 5 percent or more weight during two years, those who gained 5 percent or more and those whose weight remained stable (everyone in between).

Those who put on extra pounds reported stiffer, more painful, worse-functioning knees, whereas those shed weight boasted of the opposite.

So there you have it.

Evidence -- pretty much overwhelming at that -- that losing weight is one of the smartest things you can do to beat knee pain.

What’s the One Piece of Advice That All Knee Pain Doctors and Experts Agree On? (Part I)

Occasionally, as I’ve noted before, I get a taste of how confusing it must be for a new knee pain sufferer seeking relief. Chase a few helpful-looking links on the Internet and your head will be set awhirl.

Stretching should be part of a program to beat knee pain! Stretching is useless! Take glucosamine for proven relief! Glucosamine is a placebo! Ice your knees to subdue inflammation! Inflammation is good; it’s a necessary part of the healing process! Strengthen your quads! Don’t worry about strengthening your quads!

Then you have the many unorthodox methods for overcoming knee pain, from acupuncture to squeezing an inflatable ball between your knees while sitting. And, even when a piece of advice seems to be consistent across practically all web sites (you need to move!), there’s much disagreement on how to interpret this in practice (what kind of movement? how much?)

So, considering the welter of conflicting, confusing signals about how to treat your bad knees, when there’s a bit of simple advice that’s easy to interpret that everyone agrees upon, shouldn’t we sit up and take special notice?

I would certainly think so.

At this point, I hope I’ve piqued your curiosity. The idea behind the buildup of suspense is to engage you the reader in really thinking about, “What can this be? And why doesn’t everyone do it?”

Because, once I draw back the curtain, you’ll probably react with a deflated, “Oh, he means that.”

So here goes.

100 percent of everyone out there agrees, for relief from knee pain ...

Lose weight.

Okay. I’m imagining the hue and cry already. Some of you are probably protesting: But I’m not overweight! Doesn’t apply to me!

My guess, however, is that it does. As I’ve said before, I think more than 90 percent of knee pain sufferers (and maybe more than 99 percent) could benefit from losing at least a little weight. I was skinny when I battled knee pain. Still, I forced myself to shed about three pounds. And I think it helped.

Knees are extraordinary in many ways, but one of the most remarkable has to be how knee cartilage has evolved so many mechanisms for surviving and thriving based on mechanical feedback, i.e., based on forces and pressures exerted on it. And that’s going to be influenced by how much you weigh. That’s not a conjecture on my part. That’s simple physics.

Here’s a quote I recently came across from orthopedic surgeon Ronan Banim that starkly (and effectively) summarizes the problem:

In clinics we are seeing knees that are literally being crushed by excess weight.

How's that for graphic imagery?

Next week, it’s time for the evidence. I’ll provide a roundup that further illustrates why losing weight = a smart way to start addressing that knee pain that’s been bothering you for so long.

For Happier Knees, Avoid Soda, Cigarettes

When we’re young and ridiculously healthy and generally pain-free, we beat up our bodies a lot. That abuse partly comes in the form of junk we stuff into our mouths (as a college freshman, I liked to go into an “all nighter” with a full box of Entenmann’s soft chocolate-chip cookies by my side -- a box that would be depleted well before sunrise).

Some of us drink too much. Some of us take up smoking, with little thought to the long-term consequences.

When we get older, we usually get smarter about the self-abuse. When we get older and injured, it’s wise to be especially careful about bad diets and bad habits.

Take something as seemingly innocuous as soda. A study by researchers at Harvard Medical School showed that drinking soda may worsen knee pain -- and not because the sugary beverage tends to pack on excess weight. Rather, according to this short article, “one theory is that ... chemicals in soda may affect bone health in joints.”

Or consider an activity that we all know is definitely harmful: smoking. Indulging in this habit has been shown to be bad for your knees.

The January 2007 issue of Annals of the Rheumatic Diseases included results of a study of 159 men (12 percent of whom started out as smokers) that looked at the relationship. The men who had knee osteoarthritis who also smoked  sustained “greater cartilage loss” with “more severe knee pain.”

The researchers wrote that the harmful effect of smoking on articular cartilage “may be greatest when cartilage is already damaged by other mechanisms.”

So what’s going on here, on a cellular level?

The authors note that investigations into smoking and back pain have found that “components of tobacco smoke have a deleterious effect on chondrocyte function in discs, inhibiting cell proliferation and extracellular matrix synthesis.” Remember, chondrocytes play a critically important role as the cellular factories that produce more cartilage.

In their discussion section, they expand further. A study on smoke-exposed rats showed “disordered chondrocytes” in their intervertebral discs. In a separate study, on bovines, nicotine inhibited the proliferation of chondrocyte cells and impaired their ability to make new cartilage.

What causes such problems?

For one, smoking increases oxidant stress, and “oxidant stress may contribute to cartilage loss.” Then there’s this: “Cigarette smoking also increases carbon monoxide levels in arterial blood, contributing to tissue hypoxia, which may, in turn, impair cartilage repair in smokers.”

What this all adds up to is clear. What you put into your mouth (or suck into your lungs) can matter a great deal if you have chronic knee pain.

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.