What to Do About Intermittent Knee Pain/Swelling?

 Dipping into the mailbag (well, "comment bag"):

What would you do about intermittent and unpredictable pain? Mine started after a mild injury last winter. I got a clean bill of health from a doctor and got on with physio, which helped enough.

But recently I've been getting bouts of pain and swelling, which your blog has helped me to recognize are probably delayed onset pain from activities. I like walking and swimming anyway so I decided to follow your methods. The issue I'm having is that a walk of, say 5km, can be fine one week and agonizing the next. I'm struggling to develop and keep to any plan because it all just feels so unpredictable.

This is a great question, because it's a hard one, and also so common (especially for people who are desperately seeking to remain active).

So, in a nutshell, if you're an active person struggling to overcome knee pain, the situation can look something like this:

One day, you notice you have knee pain. Over the next few weeks, you try to ignore it. But it doesn't go away. Frustrated, you finally decide to curtail your activities. You settle on something like "I'll walk 5,000 steps a day. That's nothing! I'm used to doing so, so much more! But I'll just do the 5,000 steps for a while, build up my knees and maybe leg muscles too, then increase my walking. And then, after some months, I'll be healed!"

But then: Ugh. You do your 5,000 steps each day and the results are decidedly mixed. You have some good days. But there are bad days mixed in, and you're not quite sure why. You flounder about, growing more frustrated. What's going on? You know you're fit enough. You should be able to walk 10,000 steps a day, no problem. Gradually, you start to lose hope ...

In this case, "Intermittent Pain" is getting "pain and swelling" ... and the results of walking some distance can be fine one week and "agonizing the next."

So here are some thoughts (and again, not advice, but things to consider):

1. A couple of scary words in Intermittent Pain's account are "swelling" and "agonizing." This sounds like what would be expected from someone with a weak joint who is doing too much.

Even though some weeks are "fine," my inclination would be to worry I'm playing around a little too close to the edge of what my knee can tolerate. This reminds me of when I got a leave from my job in Hong Kong because of my bad knees and, convinced that they really needed movement, proceeded to drown them in easy movement. And I got worse.

My real "ah hah" moment came on realizing my knees were a lot weaker than I initially thought. That's when I scaled way, way back on my walking. This can be very, very hard to do for active people who are used to biking or running or hiking for hours and hours every week. But when I scaled way, way back, I was able to find a new baseline, then start to improve from that.

2. Another thing that can be useful is trying to keep notes on what's happening on the bad knee days. Do they typically fall on days when you have to sit a lot the day before? Do they come after you eat certain foods? In certain weather? I would hoover up details, jot them down, and see if I can detect patterns. 

3. I don't know what the mild injury you sustained was, but might it be worth going back to the doctor (or seeing another doctor) to make sure there's no lingering issue (or new issue) that could be causing problems? There always could be something structurally wrong that needs attention.

4. You mention you like swimming. That's wonderful (and typically a great activity for bad knees). If I were you, I might think about spending as much time in the pool as I can, and as little time walking about on land as possible, when it comes to getting my exercise in.

That's all from me! Readers of this blog may have other thoughts. Good luck! 

On Crepitus, 'Normal'-Looking Cartilage, and 'Real Pain'

I've received a few good questions in the comment section, and am a bit dry on blog posting material, so I thought: why not use these? The first one (edited lightly): 

I noticed crepitus in one knee about two years ago, but brushed it off. I had no other symptoms until I pulled my calf during running, and after that developed a baker's cyst. I rehabbed the cyst, but I was asking the physical therapist about the crepitus, and he said the same thing: unless there is pain, just ignore it.

I returned to life as normal without pain, but when I started training for a half and working on my squats I noticed the same posterior knee pain, but now on both knees. I took it easy for a while since it seemed everything I was doing was causing pain. Once I got back to running, I noticed tightness in the front of the knees although still only crepitus on one side.

I went back to the PT, who did an ultrasound and found no issues. I asked if he could examine the cartilage with other methods and he said that with just the ultrasound it's showing the cartilage is thick and healthy, so there is no need for other exams. I am trying to get a second opinion, but now I am in the trap of, "What am I really feeling? Do I feel real knee pain or is it only mental/psychological?"

I have also started having back pain, which I never really had before. I keep pretty active with cycling almost every day to work, but I have dropped running. I am afraid everything I am doing is destroying my joints, but am also afraid doing nothing is destroying my joints. Did you have issues of navigating this in terms of knowing what is real pain versus normal sensations your body is interpreting as pain? How do you navigate that? Also, how does one get your book if they live in a country where the Amazon site there does not offer it?

First, on finding my book if you live in a country where they don't offer it: it is also available on Smashwords. If you can't get it through Smashwords, no big deal. What I say in the book is scattered all over this blog. It's not like I'm holding anything back with the promise, "This secret is in the book!"

Lots of things to react to in this story (and readers may wish to chime in with their own thoughts). A few things to think about:

* Once I got back to running, I noticed tightness in the front of the knees although still only crepitus on one side.

"Tightness" can be swelling. As Doug Kelsey once observed, it doesn't take much swelling at all for the joint to tighten up. And swelling means you're pushing the knee too hard. What happened? I know very little about your situation but I can almost imagine:

Baker's cyst diagnosis. Stop/reduce running, focus on rehab, then when the "all clear" signal is given, ramp up running, perhaps too quickly. Problems then ensue.

* I went back to the PT, who did an ultrasound and found no issues at all with the knees. I asked if he could examine the cartilage with other methods and he said that with just the ultrasound it's showing that the cartilage is thick and healthy ...

Um, color me a little skeptical here. I think ultrasound might show the cartilage is of normal thickness. But I'm not sure how it can see whether it's "healthy" exactly. Also, remember: people with normal-looking cartilage can have lots of knee pain. Or people with rough-looking cartilage can have no knee pain. I do think there is a correlation between the amount of knee pain and how much cartilage you have and how it appears on an imaging test, but that's not a perfect correlation at all.

Further, crepitus can be a sign of early cartilage damage and thin synovial fluid. I had a lot of crepitus, but a relatively clean MRI.

* I have also started having back pain, which I never really had before.

Yup, sounds familiar. It could be a compensation injury (i.e., you're using your back in ways you never did before, to compensate somehow for the knee injury). Or, it could be what I call the ol' "poltergeist loose in the house, that keeps popping up in random rooms." Chronic inflammation can cause strange joint problems all over the body -- at least that's what I believe.

* I am afraid everything I am doing is destroying my joints, but also afraid doing nothing is destroying my joints. Did you have issues of navigating this in terms of knowing what is real pain versus normal sensations your body is interpreting as pain?

Doing nothing is definitely bad, but you may also need to scale back your activity somewhat. This can be a hard balance to achieve. Does the biking bother you? If not, then maybe become a casual cyclist for a few years (ramping up intensity over time if you can). Forget about running. Shove it right out of your mind. Maybe someday you can return to it; maybe not. Make your peace with that.

As for knowing what is real pain versus what are normal sensations masquerading as pain ... my default would be to assume it's all real pain of some kind, and to treat it carefully. Personally, I aimed for the least amount of pain possible. Even if it was all in my head, it felt real enough, and when I ignored the pain, it seemed to come back with greater force, so my approach worked for me.

However, TriAgain (who fought and overcome knee pain and often visits here) might have a somewhat different perspective. He took medication for a while to get on top of inflammation that was limiting him severely, and doing so was key to his recovery, so he might have thoughts on the mental aspect.

Best of luck and hang in there!

Saving My Knees: the Elevator Pitch

Recently I was thinking about the "elevator pitch" for my book (which is basically what I learned about healing bad knees). The elevator pitch, as most people know, is the 30-second speech encapsulating something that can be fairly complex. It's supposed to be an idea condensed to the amount of time one might spend riding an elevator in a high-rise.

What put me in mind of elevator speeches was a conversation I had a few weeks ago with someone about what I did to heal my knees. Generally, I try to avoid the subject. There's so much that could be said; I feel sort of talked out on the matter; many people don't respond well to the book's core message anyway.

But occasionally I find myself engaged again in a dialogue on the topic, and my thoughts skip through a whole bunch of things and I get kind of excited until in the end I figure I've either made a convert to my way of thinking or my interlocutor thinks I'm crazy.

So I started thinking, once again, about the essence of my message. I guess it would go something like this:

You can heal your bad knees. The pessimistic doctors are wrong: knees don't just "wear out." But be careful: many physical therapists urge strengthening muscles around the joint, and that can further damage your knees. Broadly, the best way to heal involves lots of easy movement and very, very slow progress that can be maddening, with disheartening setbacks. More narrowly, you'll have to experiment some to find out what works best for your particular knees.

I think that's the essence of what I have to say. My particular story is what the book is all about. But, once again, no one needs to buy the book. The message is here on the website ... look around for a while and see whether or not what I'm saying makes sense to you. Everything I learned is here. Plus, on the website you benefit from getting to read some cool success stories about how others conquered their knee pain!

Don't Discount the Placebo Effect

This was a strange story. A 60-year-old man, who lives out in the country, is suffering from knee pain. He consults with a neighbor, who advises him to try ...

WD-40.

As most of you probably know, WD-40 is a lubricant. I own some myself. It's good for freeing rusted machinery parts, stuck bolts, that kind of thing.

What happens when you apply it to your knee, repeatedly? Well, this man showed up at his doctor's office, complaining of his knee pain. The doctor noticed that the skin around his knees was "rough, reddish." It turns out he had been using the spray for months at that point.

You might think this is just a titillating story about something that a reasonable person would have the common sense not to do. But there's more to it than that.

The doctor told the man, of course, to stop spraying WD-40 on his knees, immediately. But what's interesting is that the patient reports that, when he first tried the lubricant, he "felt some relief," so he continued using it.

Felt some relief? From a smelly, petroleum-based chemical that's meant for things like lawnmower parts, not human skin (and what lies underneath)?

To me, this strongly suggests some kind of placebo effect. What's more, I'm convinced that there are a lot of suggested solutions for knee pain that involve the placebo effect.

I've never been convinced of the efficacy of glucosamine or chondroitin. Yet people swear by them. The placebo effect? I think that there's a high chance that's involved here.

I'm not sure the placebo effect is necessarily bad. If someone said to me, "On days, when I wake up and rub the belly of my lucky Buddha statuette, I have less knee pain," my response would be, "Keep rubbing the belly of your lucky Buddha."

Why not? A certain amount of pain is what we perceive on a subjective level. If we can somehow "trick" our brains into thinking there is less pain there, that doesn't seem like such a bad thing. But of course, the placebo effect works better on some than others. Sadly, I don't think it would help me much because of the way I am.

For others though, if something helps with your knee pain, and it's not doing harm to your body (or to your pocketbook, or at least not excessively), why not keep doing it?

Just don't spray WD-40 on your knees. Please.

Exercise, the Anti-Aging Drug

The Wall Street Journal ran a good article last week. The premise was a simple one that I heartily agree with:

Longevity researchers have spent decades hunting for a magic pill to slow the aging process. But the best solution--at least for now--may be the simplest one: Move more.

The author points out that exercise stimulates muscle and bone growth that helps lessen fatigue and, for older adults, protect against bad falls. It can reduce the risk of certain diseases, such as cancer, diabetes and heart disease.

In addition, exercise improves memory. It helps us learn better. It reduces inflammation.

And on and on and on.

All this talk of exercise may seem frustrating on a blog devoted to people with damaged knees. But it's good to know why it's so important to get better: because living a long, happy, healthy life involves being able to do things like play a game of tennis, walk up a mountain or even toss a frisbee back and forth.

What I like most about the opening to this article is that it doesn't say, "Go out and run a half marathon." Rather, the advice is much more basic: "Move more."

People suffering from knee pain won't be able to do the ambitious activities that others engage in. But, no matter how much your knees hurt, there are usually ways to move more without making your condition worse.

I'm reminded of the simple exercise where someone can sit in a chair, place their feet on a low, rolling platform, then just roll it back and forth. This shows that if it hurts to walk, it's possible to start with something really, really easy. I think everyone can find some way to move more.

So that's what's on my mind today. How's everyone doing out there? Any success stories to share?

Rethinking Osteoarthritis Pain (a Recent Presentation Now on Video)

Here is a video that a reader found quite valuable. The title apparently was "Rethinking Osteoarthritis – Is It More Than Just The Joint?"

The speaker has that kind of irrepressible, smart-sounding Ted Talk energy, paired with a collection of visuals that are meant to be accessible, not intimidating. Even when some of the terminology gets technical, the talk is fairly easy to follow.

I'd say the speaker's thinking pretty much lines up with mine (and that of Doug Kelsey, and of course Dr. Scott Dye, who are really the people who deserve the credit for first bucking conventional wisdom on this subject, or should I say, conventional pessimism).

Some key points she makes that are terrific:

(1) Let's get away from the gloomy "wear and tear" language when it comes to bad knees. We should prefer "wear and repair." We can all heal, no matter our age.

(2) Bad knees are about more than the knee. Chronic inflammation kicks off a process where pain signals being sent to the brain are intensified, and at the same time the ability of the brain to repress such signals is damped.

(3) Cartilage loves loading and can adapt. Amen! That's the "Saving My Knees" message in a nutshell.

(4) Just because your knees looks bad on an MRI/X-ray, that doesn't mean you have knee pain.

Excellent points. So why would I be reluctant to wholeheartedly endorse her message?

(1) She makes a point about "weight doesn't matter the way you think it does" that I think is kind of trivial and possibly dangerous, because I think weight does matter a lot, and a careless listener might be prone to interpreting her statements as "weight doesn't matter that much." It is certainly true that there are different kinds of weight (fat vs. muscle e.g.) and that excess bad weight brings inflammation.

(2) It worries me when people stray a bit too much down that road of "it's not just the joint," even though this is undeniably true. One problem can be that, if you think it's just the "pain signal," you can take drugs to reduce that, and you could do further damage to the joint while exercising. So I think you have to be careful not to focus too much on the pain signal and lose track of the joint, which is presumably in some state of disequilibrium.

(3) It's true that knees pockmarked with cartilage lesions can be pain free, and knees with no signs of damage can hurt. But this is another argument I would be hesitant to take too far because of correlation. If MRIs of 100 knees show multiple grade 4 lesions, and MRIs of 100 other knees look fine, I am willing to bet with high confidence there are more knee pain sufferers in the first group than the second, even if a few people in the first group have no pain and a few in the second group have a lot of pain.

I suppose I'm not quite as skeptical about the usefulness of these tests as she is.

Still, this is a really good, and watchable presentation, that was only posted on YouTube 7 months ago, so it seems fresh. Enjoy!

Anyone Have Thoughts About Going Barefoot?

I'm lifting this straight from the comments on my last post.

hello, what do you think about barefoot? I find it easier for my very damaged knees compare to Nike carbon (Alphafly) which are better when it comes to cushioning but foot and knee feels unstable

I never tried going barefoot to see if that would put less stress on my knees (well, except around my Hong Kong apartment, I suppose).

As I recall, I tended to look for as much cushioning in a sneaker as I could find. That was basically my footwear strategy.

In the book, I do mention a special pair of shoes I bought that were supposed to reduce stress on my knee joints. The manual in the box sounded very promising. I was very excited about trying them out.

But once I started walking around in these new (and rather expensive) shoes, I soon discovered they were a disaster. My knees felt worse. I quickly abandoned that experiment.

Still, healing knees is like running a series of experiments where you try things and toss aside what doesn't work, and keep trying. There's no magic one-size-fits-all formula. What works for me may not work for you, and that includes our choice of footwear.

Since I broached the subject, if anyone has experience with going barefoot, please weigh in below. Did it help or hurt your knees? I wonder sometimes about activities such as walking barefoot in loose sand, for someone who has knee pain, as that would seem to risk exacerbating instability in the joint.