Hey, What's Your New Year Resolution?

Happy holidays everyone!

Some of you have been frequent visitors, and frequent commenters, and I thank you for your involvement.

Others of you drop by for a while, ask a few questions, then fade into the background. That's fine, I know what you're going through. I spent many afternoons of my recovery ricocheting around the internet like a pinball, seeking bits of insight that might help explain what I was going through and how I could get better.

Sometimes, someone buys one of my books from Amazon or Smashwords. And every so often, someone returns a book (it's so much easier to return an electronic book!) And -- this will probably sound weird -- I think that's great. It's great Amazon has a policy that, if you don't like something, you can get a no-questions-asked refund. I love that. When I wrote "Saving My Knees," I really, really believed in the message. Still, I realized later after reading a few reviews that it wasn't for everyone.

Now, on to the new year! I hope that this will be a year of steady, gradual improvement for thousands of knees out there. I know that sounds boring, but sometimes slow and boring is the way to win the race.

So let's talk! Do you have a resolution for your knees, or for your recovery program? If so, share it below. I'd love to hear what's on everyone's mind.

Cheers, and best wishes.

Richard

Don’t Take That Meniscus in Your Knee for Granted

I just read an article about the meniscus, that rubbery, crescent-shaped piece of cartilage that helps absorb impact between the long leg bones that meet in your knee.

Decades ago, the common medical wisdom was that the meniscus wasn’t all that important, and when it was torn, surgeons simply took it out.

Of course common medical wisdom was wrong.

Patients who had their meniscus removed often developed arthritis in their knee later. That suggested the meniscus actually played a critical role.

Now we have new, and quite sobering, details about what happens when the meniscus is extracted from the knee.

According to a new study, “extensive cell death occurs within hours during vigorous exercise.”

Researchers used a powerful microscope to observe what was happening, minute by minute, as the vigorous activity was occurring. The article says that half of the cells that create new knee cartilage were dead within four hours (I assume these cells were chondrocytes?).

Whoa. That’s really grim.

Now, an intriguing question (that the article doesn’t pose, but that occurred to me): Are people who have an injured/torn meniscus also susceptible to a certain amount of cartilage cell death? Because their meniscus isn’t working as well as it should?

For me, the bottom line is that I don’t find this study surprising. What I find more surprising is that medical savants of 40 years ago could have looked at a rubbery cushion in the knee joint and decided that it really wasn’t that significant.

Medical hubris at its finest.

One Reason Bad Knees Don’t Heal

So I found out that my brother, he of the torn meniscus, decided against surgery for now. He learned that his health insurance would leave him exposed on thousands of dollars of the cost and decided to take a pass. But his doctor told him he should expect to have a knee replacement in ten years.

How’s that for a future? Ugh.

Now, if I were him, I would not accept that. I can imagine a doctor saying the same thing to me about ten years ago, and today my knees are fine. But I also know that a lot of bad knees never heal. For us active types, there’s a very good reason for that.

Quite simply, it’s because we can’t give up what we love doing most. For me, it was cycling. For him, I think it’s hiking and weightlifting.

With knee pain, I think there has to be a sort of “come to Jesus” moment. Your knees have to get so bad, your misery so complete, that you resign yourself to the fact that everything must change.

Everything. And that means that sport that you love has to go.

I know I clung to cycling for as long as I could. I convinced myself I’d pedal differently, or stop going up mountains, and gradually the pain would go away. It did not. But I labored under this delusion for as long as possible, unwilling to face the truth.

Unwilling to have that “come to Jesus” moment.

I believe one key turning point in my recovery was fully, and unconditionally, accepting this statement:

I will stop riding my bicycle, and I may never ride it again, and I’m okay with that.

That was both a depressing and liberating realization. The sweaty physical activity I took part in, those wonderful, heart-pumping, intense workouts, involved cycling. Losing that seemed terrible.

But it was necessary.

I switched over to easy, high-repetition motion. For some people, that can be cycling. For me, it wasn’t. I found my body liked slow walking the best. I structured a program around that.

And, over the course of many months (as I detail in my book), I healed.

I’m not sure if my brother is at that point yet, where he can say, “I may never go hiking again, and I don’t care.” I don’t think so. But I think that’s the beaten-down point you have to reach, and in some odd way, embrace, before you can begin the journey up and out of a pit of despair.

What about those of you out there who are active? How have you dealt with this problem of resisting facing the reality of your limitations?

Healing Your Knees With ‘Virtual Reality’ Cycling

Okay, a confession up front: I know this won’t be the most popular post of all time, or even in the top 20. Still, I have been to other (virtual) worlds on my bike, and I want to share what I have discovered, and how it may apply to people recovering from knee pain.

The backstory: On Aug. 11, I crashed on my bike in the rain and broke the fifth metacarpal in my right hand, badly (I also broke the tip of my ring finger, but the orthopedist pointed out that was essentially small potatoes compared to the oblique displaced fracture of the metacarpal).

I was very, very morose about this turn of events, as this apparently meant I would miss the best cycling month in the New York City area: September (as well as August naturally). And I did miss it. I wasn’t cleared to ride my road bike outside until last month.

But I was determined to do something, even while wearing a cast. While encasted, I was advised not to sweat excessively (bacteria flourish on dirty, sweaty skin), but I couldn’t see myself spending Saturday mornings taking leisurely walks to Main Street. I evaluated some options (believe it or not, I had my eye on a fast recumbent bike, and was getting close to pulling the trigger on the purchase, then I found out that basically everyone would drop me on climbs.)

I ended up buying a smart trainer instead and joining the community of “Zwifters” and riding in my basement. The Zwift subscription costs $15 a month. The Zwift setup can range from a few hundred dollars to a few thousand; you can find the breakdown on YouTube videos.

What is Zwift? It’s a virtual world where you pedal on your bike, which is attached to a trainer, which in turn communicates your level of effort to the Zwift software. The software may be on an iPad or a PC (and if you want to add another layer of complexity, that device may in turn be hooked up to a smart TV that shows you cyling in the Zwift world.)

The harder you pedal in real life, the faster your bike-riding avatar goes.

The native Zwift world (called Watopia, which is probably meant to sound like a utopia for cyclists as all the roads are bereft of cars) has a variety of geographical features. There are underwater roads that travel through transparent tunnels, a volcano that can be climbed to the summit, and a rather daunting “hors category” Alpe mountain climb.

The cool thing about using a smart trainer is that Zwift tells the trainer if you’re going uphill or downhill, and how steep that grade is, and the trainer adjusts accordingly. So it’s quite hard to push up a 13 percent incline, but of course you’ll pedal down that grade with no effort at all.

Now for the quick bullet points, to get to the heart of the matter: How well does virtual reality cycling (like Zwift) work for knee rehab?

* First, virtual cycling keeps you engaged. Unlike a stationary bike, where you better bring something to read or have a fertile imagination, the Zwift landscape is always changing. And other cyclists, from all over the world, are passing by (sometimes Zwift feels like a geography test of “name the country that flag next to that person’s name belongs to”).

Also, there are group rides segregated by level. The riders “virtual chat” back and forth (you can see their messages come up on the Zwift screen, even when you’re not part of the dialogue).

* But Zwift worlds are not flat. I’ve noticed that the default route choices in the software never send you up a mountain, but they can still send you up some steep hills. This isn’t optimal for someone healing from knee pain. You do have the choice of making a U turn anywhere to avoid an ugly ascent, and I suppose you could make an effort to stick with flattish roads.

Or, if you’re not on a smart trainer, I guess you could just stick with easy pedaling, even though it’ll take a while to get up that hill.

* One negative is that Zwift tends to bring out your inner competitor. It’s very much geared to more-intense athletes who like to monitor their personal records, and want to see if they can beat their last record on a timed hill climb, or if they can pass that guy four seconds in front of them.

* Another possible negative: A lot of these Zwift athletes are pretty damn good. Example: I began climbing a big Zwift mountain in August, trying to hold 230 watts or so. Then I got better. Recently I was trying to hold 280 or 290 watts on the climb, and I broke my previous record and passed a lot of people on my way up.

Intrigued, I checked my personal record for the Zwift climb, to see how I compared with the others. I felt pretty good about myself until I found out I was about 25,000 out of 176,000. Ugh. Are the others really that fast? Or are some of them “digital doping” (i.e. lying about how much they weigh to go faster). I suspect it’s some of both.

* Another Zwift negative: The software forces you to ride in a certain world anytime you log in. Zwift controls which world everyone will ride in on a given day. I’m surprised that riders have no choice, as Zwift just created a “New York City” world that’s frankly awful.

Anyway, my feeling on Zwift as a rehab tool is it could be helpful, but more for people who are at a more advanced stage of their recovery. It is an interesting world to ride in. I know that I’ve gotten noticeably stronger on climbs. But I wouldn’t want to tempt the Knee Gods with some of those efforts unless I felt pretty good about how my joints felt.

If You Take Painkillers, Opioids May Be a Poor Choice

I spotted this article about a pain medication study a while back (underlining is mine):

A yearlong study offers rigorous new evidence against using prescription opioids for chronic pain. In patients with stubborn back aches or hip or knee arthritis, opioids worked no better than over-the-counter drugs or other nonopioids at reducing problems with walking or sleeping. And they provided slightly less pain relief.

The opioids that were tested included the generic version of Vicodin. The nonopioids they were up against included generic Tylenol and ibuprofen.

So, basically, Tylenol beat Vicodin. Sounds like a good reason to chuck the Vicodin in the trash. After all, as a doctor quoted in the article says, if opioids don’t work better, there’s no reason to use them considering “"their really nasty side effects -- death and addiction.”

In case you’re wondering, the study randomly put patients in either the opioid taker or non-opioid taker groups. Further details:

Patients reported changes in function or pain on questionnaires. Function scores improved in each group by about two points on an 11-point scale, where higher scores meant worse function. Both groups started out with average pain and function scores of about 5.5 points. Pain intensity dropped about two points in the nonopioid group and slightly less in the opioid patients.

Many of you already know my position on medication for chronic knee pain. Personally, I took as little as I could. I wasn’t worried about becoming a drug addict, but rather the fact that the drugs muted the signals from my knees that I was trying to listen to in order to figure out how to get better.

Is a Knee Replacement Worth It?

This was the subject of a recent New York Times column. I like the Times columns on health topics; they’re generally smart and well-balanced and backed up by good studies.

The author of this one was no less than Jane Brody – former (and presumably reformed) glucosamine enthusiast – who had both knees replaced. She has no regrets, though is quick to note that there are some limitations with artificial knees.

The upshot of the article is that more people are undergoing this major surgery, and at a younger age – and it’s not always medically justified:

One recent study conducted by Daniel L. Riddle, a physical therapist at Virginia Commonwealth University, and two medical colleagues, for example, examined information from 205 patients who underwent total knee replacements. Fewer than half — 44 percent — fulfilled the criteria for “appropriate,” and 34.3 percent were considered “inappropriate,” with the rest classified as “inconclusive.”

A knee replacement is definitely major surgery. If you don’t believe me, Google it and check out some images. And that new knee doesn’t come with a lifetime warranty. On average, artificial knees apparently last only from 10 to 15 years.

But for some people, it will make sense. I think though, like much surgery, it should be looked upon as a last resort. That's my opinion. I’d be interested in hearing below from people who have had the surgery, and finding out whether the experience was good or bad.   

(By the way, thanks for all the good thoughts in the comments section regarding my hand. I still have a splint on my ring finger, which was turning into a mallet finger – ugh – so I’m not a full-fingered typist yet. Hopefully I’ll get there in a few weeks. Patience! Not as much needed as when healing from knee pain, but still, a displaced fracture is no picnic.)

How Would You Treat a Torn Meniscus?

I’m still in a hand cast (with my right thumb, index finger and thumb wriggling free, but my pinky encased and my ring finger barely visible, like a pig in a blanket). So I’m going to keep this short.

I figured I’d try something different. Often you ask me questions, which I spin into blog entries. This time I’m going to ask all of you a question.

My brother, who loves to hike and work out at the gym, has a torn meniscus. Apparently he injured it when shoveling snow. He turned to pitch a load of snow, and the torque on his knee and weight of the loaded shovel must have combined in a bad way to tear his meniscus.

In the immediate aftermath of the injury, he had difficulty walking for a couple of weeks. Since this happened, the knee has never been the same.

He has scheduled surgery for November. Now you probably know where I stand on that. In the world of knee studies, you can throw a stone and hit three or four clinical trials that say surgery for a torn meniscus is no better than physical therapy.

However, that’s fine in the abstract, but when you’ve got the torn meniscus, and PT hasn’t done you a lot of good, surgery starts to look very tempting.

So here’s my question for all of you out there: Anyone have a torn meniscus that they recovered from? What kind of rehabilitation program worked for you?

Okay, all from me for now. This cast (fingers crossed) should be history next week, as long as the bone healed properly. Because of the nature of the break, that’s not a given. Still, my doctor seemed fairly confident.

(Oh, I’m still riding my bike, only indoors. If any of you are on Zwift, that’s me in the blue-and-white jersey, trying to hold 240 watts going up that giant mountain in Watopia.)

Cheers!