'I'm Only 18. I Have Knee Pain. What Now?'

Recently, an 18-year old suffering from knee pain left some questions in the comment section.

A brief synopsis of this case:

I have been experiencing patellofemoral pain (as well as achy quads and calves, and some sharp medial pain that comes and goes a bit too much for me to fully attribute to a meniscus tear) for 7 weeks now. ... I am only 18 years old, was previously fairly active on a day-to-day basis, and a runner and casual player of many sports. I can work out why my pain (probably) started - a sudden fitness obsession after months of a mainly sedentary lifestyle brought on by the pandemic and moving from a relatively flat area to a rather hilly one.

Then, the person asked:

After reading your book and Paul Ingraham's, I have some questions. Firstly, I know that both of you encourage rest and many doses of light exercise to slowly build up joint strength. This seems reasonable. But what did you do (or what do you recommend) when you were *not* able to rest and *had* to push that envelope of function? Does this mean constant setbacks, or is it possible to push it a bit and then rest/light exercise for a longer period of time?

This reminds me of something that of course should be quite obvious: We live imperfect lives in an imperfect world when it comes to developing programs to heal. We have to sit too long at desks at work. We have to climb hills sometimes to get to the commuter train station. We have small children who insist on being carried around.

What's the answer to all these knee-unfriendly obstacles that are part of everyday living?

I wish I knew. Luckily, when I lived in Hong Kong, I was largely able to control my healing program. But I quit my job and had no family at the time! This enabled me to conduct a scientific-like experiment, and not many have that luxury.

My best thoughts on this are that people should control what they can, closely monitor what they can't, and try to learn from mistakes. So for instance, if I know that I have to walk up a couple of hills just to get to my train station (which I can't control), then maybe I don't take a long walk at lunch and instead do something less intense (which I can control).

Also, if I'm doing something that turns out to really bother my knee (in other words, I made a mistake), I should try to learn from that. But what if it's something I can't control, like walking up those hills? Well, humans are quite ingenious and can often solve difficult-seeming problems.

So maybe I try walking up the hills much more slowly. Or I hitch a ride with someone. Or?  

And then this question:

Secondly, do I have a chance of this not lasting as long as your pain and the pain of some others in this blog, as I am starting my attempt at recovery (hopefully) early and because of my age?

I think your age is definitely a positive factor, being only 18. And if you've only had your knee pain for seven weeks, and you're already serious about fixing it, you should be in very good shape indeed.

Try to be positive! Which leads us to:

Thirdly and finally, what advice do you have about the emotional side of pain? I was very depressed and anxious for over a week after one of the remissions and I am now grimly aware that this recovery may be a long, non-linear process and I may never get back to running or competitive sport again.

Well, heck, that sounds grim! I already sense a lot of negativity here. So I would tell myself:

I'm only 18. I haven't had knee pain that long. I have a great chance of beating this, and I will.

What I might do, if I were you, as you seem to like to be very active: Figure out a new knee-friendly sport to throw yourself into (well, ease yourself into may be a better phrasing). I think cycling, if you can tolerate it, can do wonders for bad knees. Some people like swimming, or exercising in the pool.

Again, try to be positive! I've read a lot of very tough, hard-luck cases in the years doing this blog. And yours, be thankful, isn't one of them. You seem like a great candidate for figuring this out and being able to do a lot of the activities that you did before this pain crept into your life.

Good luck!

If anyone else has any thoughts, please chime in below, thanks. 

When Knee Pain Comes With Golfer's Elbow

 I got this comment recently:

Hey Richard, funnily enough I have now developed that elbow pain you were talking about in your book. Has yours healed now? Any tips?

That "elbow pain," for me anyway, was "medial epicondylitis," also known as golfer's elbow.

Some context: I had had the knee pain for a while. The golfer's elbow just came out of the blue. There were no identifiable triggers for it. None at all.

Of course, as many of you know, this led to a lot of musing on my part about the ghost of inflammation loose in the haunted mansion of the body (if you want to ladle on those Halloween metaphors).

In other words, once inflammation takes up shop somewhere, in a matter of time you can develop other weird, seemingly unrelated problems in distant areas of your body. And I think the problems may be connected.

I have not seen a lot of science on this, so I could easily be wrong here. But I find it very odd that, as my knee pain deepened and persisted, various other ailments began to plague me, from the golfer's elbow to back pain (though that had a proximate cause, because I was sitting in an unnatural position).

Anyway, to the question: what to do?

I had terrific success with eccentric bicep curls (look them up on YouTube; you'll find lots of videos).

We're all accustomed to regular bicep curls, where the effort is expended in curling the weight up. For the eccentric version, the emphasis is on slowly releasing the raised weight back down to the starting position.

Over time, I really think this rebuilt the chaotic tendon fibers. My tendons went from being painful and dry and crackly feeling (they were almost like parched sticks, it seemed) to normal. I have no problems today and there's no reduced tendon strength as far as I can tell.

Be patient though. It does take time.

That's my experience, at least. Anyone else with any other ideas?

Some Good News About Cartilage's Ability to Rebuild Itself

I’ve said before that there won’t be a third edition of Saving My Knees because I expect that what lies between the covers will eventually no longer seem that radical and will become widely accepted.

And, happily, along comes a New York Times article to underscore that very point.

To recap, what I’ve said (in the book and on this blog):

The cartilage in your knees doesn’t simply “wear out.” It’s not like the tires on your car. It has an underappreciated ability to adapt and even repair itself (though very slowly).

To be clear, these insights don’t originate with me.

Doug Kelsey, an Austin physical therapist and author, was the first person to really awaken hope in me when I was struggling with a pair of bad knees while living in Hong Kong.

The gist of what he said: Don’t believe pessimistic doctors who say bad knees never get better. They certainly can.

I also uncovered scientific studies showing natural changes in cartilage that indicated the tissue, over a period of several years, showed signs of getting worse, yes, but also of healing. Places in the knee joint that were bone-on-bone often had cartilage filling in the holes when examined by MRI a few years later.

Okay, that’s a bit of a long windup for this New York Times article. The Times was looking at  running and the hoary myth that running is bad for your knees (to be clear, it can be, if you run when injured or don’t train properly).

Ross Miller, an associate professor of kinesiology at the University of Maryland, was involved in a study to try to figure out a puzzle: why, if running pounds knees so hard, don’t more runners develop conditions like osteoarthritis?

He knew that some recent studies with animals intimated that cartilage might be more resilient than researchers previously had believed ... animals that ran tended to have thicker, healthier knee cartilage than comparable tissues from sedentary animals.

The study looked at what would theoretically happen to the healthy knee cartilage of two groups: one would walk six kilometers (roughly 3.7 miles) a day for years, the other instead would walk for three kilometers and run for three.

It’s admittedly a bit confusing to follow what was going on: volunteers were going around a track that had embedded force plates, which measured the impact of running and walking. The collected data was fed into complex computer simulations, that drew on lots of other data too.

Now, here’s the really interesting part, and the Times explanation is a bit confusing, so I'm going to simplify.

There are three possible scenarios for cartilage and how it responds to running:

(1) The cartilage can’t change to adapt to the harsh forces (and therefore would be expected to deteriorate over time).

(2) The cartilage can slightly repair itself after repeated minor damage.

(3) The cartilage can remodel itself and adapt to the intense forces, growing thicker and stronger, just as exercise builds up muscles.

If you were to poll most orthopedists, I bet their beliefs would fall mainly into scenario (1) and (2), but certainly not (3).

Surprise.

If you assume (1) is true, runners have a 98% chance of developing arthritis in their knee joints, the study found. Even if you assume (2), the slight repair taking place isn’t enough to counter the frequent running, and their chances of arthritis decline only a bit, to 95%.

But if you assume (3), they have a 13% chance of eventually suffering from arthritis, which is the same as for the people who were walkers only. This does seem to match up with evidence that the incidence of arthritis among dedicated runners isn’t higher, and may be lower, than for the rest of the population.

The article concludes:

What these results suggest is that cartilage is malleable, Dr. Ross says. It must be able to sense the strains and slight damage from running and rebuild itself, becoming stronger. In this scenario, running bolsters cartilage health.

I can’t say this would surprise me.

I just hope orthopedic doctors see this article too.

Could Turmeric Be Useful for Muting Knee Pain?

The latest study making the rounds is about the possible health benefits of turmeric for knee arthritis sufferers.

Turmeric, a yellow spice with a bitter taste that most people probably know as the flavoring for curry, is believed to be an anti-inflammatory.

The study took 70 people with knee pain and gave half of them a capsule full of an extract from turmeric every day for three months. The other group received a placebo.

After the trial concluded, the people taking the turmeric extract had more improvement in pain than the placebo group. The typical benefit was described as “modest.”

One red flag with this study: a supplement maker supplied the pills for the study and some of the funding. Knowing the history of glucosamine, and the early poor-quality and conflicted studies that were done looking into its efficacy, I would urge an appropriate dose of caution because of that.

Someone involved in the study does acknowledge that more research needs to be done.

That leaves me curious: Has anyone out there had success with using turmeric?

I suppose I should share my own experience. When I was in Hong Kong seeking to heal from my chronic knee pain, my mother sent me a bottle of pills, and I remember that turmeric was touted as one of the main ingredients.

I took all the pills. I noticed no difference in how my knees felt.

But that’s just my own experience. Anyone else out there have a story about turmeric, good or bad?

Does Thinner Cartilage Cause More Knee Pain?

Here’s a study that could be of interest, as it casts doubt on the relationship between cartilage loss and knee pain.

The researchers found that a thinning of cartilage was associated with only a modest increase in knee pain. The writeup was published in the Annals of the Rheumatic Diseases.

There were 600 subjects who either had, or were at risk of, osteoarthritis of the knee. MRIs were taken of their knees at the outset, after one year, and after two years, then the images were compared.

Loss of cartilage thickness was significantly associated with a small degree of worsening knee pain over 24 months.

David Felson, one of the researchers, did note that an “indirect path” exists between cartilage loss and knee pain. The relationship could be through nerve-rich structures, such as the synovium and bone marrow.

Good news, right?

My first inclination is to say: sort of.

I wonder if the condition of the cartilage is more significant than the thickness. If the cartilage is thinner, but is stiff enough to absorb shocks well, it seems logical that someone would not feel pain.

But, to be fair, there is good news here. The welcome implication is that you don’t have to restore your knee cartilage to normal for your pain to go away.

Finding the Numbers to Your Combination Lock

I went on a 103-mile bike ride yesterday -- phew! Some say it's not the heat ... but yes, it's the heat! It's hard to stay properly hydrated when the temps climb into the upper 80s. This morning I'll be in the basement, riding the stationary bike, trying to make up for the fact that yesterday's ride burned up most of my day.

Now then, here's a reader comment that put me in mind of something Dr. Scott Dye once said:

I have no idea what is the matter with my knees, have had no diagnosis and have kind of given up on that front, though I'm convinced it started mentally as i was suffering from chronic stress at the time, I also have a raised vein or nerve in leg so could be that WHO KNOWS. They do improve a lot with motion though, and lately on my walks ive just had the urge to start gently jogging, its like my body wants to take off, whats your advise on that? I havent jogged but i really want to.

Here's what Dr. Dye said that I found to be very true, though curious coming from a physician. It concerns the difficulty of finding the right program to heal a person's bad knees:

“It is not unlike trying to find the numbers to a combination lock.”

We tend to naturally attribute shaman-like qualities to our doctors, believing they have an almost magical power to heal us. How strange it is, then, to hear a doctor compare what he's doing to cracking a safe. It's perhaps a bit unsettling. Aren't doctors supposed to be supremely confident in their diagnoses?

But I think Dye's observation is quite perspicacious. He nails it. The fact is, there is no manual on healing knees that will work equally well on all knees. A certain amount of experimentation is in order.

Partly I have come to that realization from listening to all of you while writing this blog. As I've said before, I wrote my book naively assuming that what I did would be useful to the same degree for everyone. I still think the book has enormous value, and broadly the approach is the correct one, but I've also tempered my position somewhat, so that now I'm closer to Dye's thinking:

Healing your knees will involve finding a solution that will probably be, to some degree, unique to your particular knees.

So why does this reader comment put me in mind of Dr. Dye?

Because here's someone who has bad knees, it appears, but who wants to "start gently jogging." How could that be a good idea?

But suppose this person is right: that stress contributed to the knee issue in the first place. Maybe a little gentle jogging, getting the heart pumping and the body sweating, would help lower his stress levels -- and it might not be harmful to his knees too.

Maybe?

I am opposed to giving advice, but if I were this person, I might try an experiment: maybe try a short jog, very slow, maybe up a hill as that's less stress on the joints, and then monitor my knees for a couple of days. Do they feel better or worse?

If they feel better, maybe try it again, for a little longer, being careful of course and not pounding down hills.

Do I think this would have helped with my own knee pain? No, not really. But then again, if we are all trying to find the numbers to our personal combination locks, when it comes to beating knee pain, we have to be open to trying different things.    

A Goldilocks Theory of Cartilage Damage

Here’s a study I can’t access (without paying for), but I found the main conclusions interesting. The researchers decided to look at the following:

Knee cartilage damage is often linked to mechanical overloading. However, cartilage requires mechanical load to remain healthy, suggesting that underloading may be detrimental.

So there you have it. Essentially, they’re testing what we’ve talked about repeatedly here: trying to find a motion “sweet spot,” if you will. If you subject your knees to too much load, they will get worse. If you don’t subject your knees to any load, they will get worse too.

The key is finding that elusive “sweet spot” where they can handle the proper amount of load, which can be gradually increased over time. However, of course, this is no simple thing.

So what did the study consist of?

The researchers looked at how the load on a person’s knees correlated with worsening cartilage damage over a two-year period. There were 964 subjects, including 62% women. The average age was 66.9 years old, and the average BMI 29.7 (this borders on obese and roughly equates to weighing 220 lbs. for someone who is six feet tall).

People who walked a moderate or high number of steps each day (at least 6,000) and who had a high BMI (more than 31) had a greater risk of worsening damage of the cartilage in the medial part of their tibiofemoral joint, compared with those who were thinner.

But people who walked less than 6,000 steps a day and who had a low BMI were at higher risk of worse damage in both the medial part of the tibiofemoral joint and lateral (outside) part of their patellofemoral joint (where the kneecap meets the femur). They were compared to a group that also had a low BMI but walked more steps.

Clearly, one takeaway is that weight has a big influence on how much walking you can safely do.

But the results also do suggest that there is an optimal level of motion: too much will cause further damage, and not enough is harmful too.

The trick is finding that proper balance. What’s scary for people with bad knees is that finding that balance becomes a really hard task when your knees don’t seem to like to move much at all.

It will frustrate you endlessly, I guarantee. But when you do figure out the right balance, you are suddenly in a position to get better, slowly but surely.

And that's a great feeling, when you realize you're starting to make progress toward healing.