A Story About Vitamin D and Knee Pain

This isn't the story you might think it is, from that title.

Rather, it's about how the medical community gets stuff wrong—and I’m not talking about two or three hundred years ago. It’s a much more recent story. It’s a story about how medical knowledge is always evolving, and like most things that are complex and unsettled, how mistakes are made and perpetuated, and how wrong information can assume a life of its own.

Twenty or so years ago, a new measure popped up on my annual blood test: “vitamin D.” The lab was now checking whether I had enough vitamin D circulating in my blood. It turned out that my level, while apparently not alarming, was nonetheless deemed “insufficient.” I should be taking vitamin D supplements, I was told. That seemed fine—vitamin D is relatively cheap and comes in small, easy-to-swallow capsules, and I didn’t think much of it.

I’m not sure how long it took before I discovered, to my surprise, that a lot of people I knew also had a vitamin D insufficiency. That of course set my skepticism gland tingling—especially as, at that time, I was living in sun-splashed South Florida, a place where the sun provides a plethora of free vitamin D. How were all these seemingly healthy people lacking in vitamin D?

Well, they weren’t.

An interesting story appeared in Scientific American a couple of years ago about how the medical community fatefully misinterpreted a vitamin D meta-study. I encourage you to read the full article. Again, this is Scientific American, a publication long known for rigorous, fact-based judgment, and not the National Enquirer.

Vitamin D supplements took on an other-worldly super pill aura in the early 2000s when, as the article tells us, “researchers began amassing a pile of studies suggesting that low vitamin D levels could be a factor in cancer, cardiovascular disease, dementia, depression, diabetes, autoimmune diseases, fractures, respiratory illnesses and Parkinson’s disease.”

One problem: the supposed benefits of taking extra vitamin D came from “observational” studies. Observational studies do not purport to show cause and effect. The author gives an example of say owning a Porsche and being wealthy. A lot of wealthy people own Porsches, but if I go out and buy one, that doesn’t mean it will make me wealthy.

In any event, a later study of 26,000 basically healthy adults, who took a hefty dose of vitamin D or a placebo for more than five years, showed vitamin D takers demonstrated none of the myriad benefits that had been touted. The vitamin didn’t help with cancer or heart disease, or “prevent falls, improve cognitive function, reduce atrial fibrillation, change body composition, reduce migraine frequency … reduce knee pain or even the risk of bone fractures.”

No Benefit Above 20 ng/ml

But the utterly fascinating part of the article, to me, concerns the birth of vitamin D-ism:

The belief that so many of us are deficient in vitamin D came from a misinterpretation of normal levels that the Institute of Medicine determined a decade and a half ago. Here’s what happened:

The institute had experts examine multiple studies of vitamin D and health. The committee concluded that the bone-strengthening benefits of vitamin D top out at 12 to 16 nanograms per milliliter, and there is no benefit to having a blood level above 20 ng/ml.

They noted that most people are just fine at 16 ng/ml!!!!

So how did we get to this point? Most of the population exceeds 20 ng/ml, and so should be in a “sufficient zone”—but instead is flagged with the “insufficiency” label between 21-29 ng/ml.

Well, 20 ng/ml was “erroneously interpreted by some health-care workers as the bare minimum, instead of a level marking good amounts for most people.” Then came a second set of guidelines, put out by another medical group, the Endocrine Society, which was looking at much of the same evidence that the institute used. But the Endocrine Society’s advice was “aimed at clinicians, particularly those caring for patients at risk for vitamin D deficiency.”

Plus, there was another interesting, um, wrinkle we’ll get to soon.

The Endocrine Society categorized anything under 20 ng/ml as “deficiency,” and 21 to 29 was “insufficiency.” Its guidelines were largely taken to mean that everyone needs a vitamin D level of at least 30 ng/ml.

But the Institute of Medicine pretty much said: “Whoa, not so fast.” It pushed back against the endocrine group’s conclusions. For example, the Endocrine Society used a study of only 34 people to claim that people with vitamin D levels above 30 ng/ml absorb calcium better. But it ignored a study of more than 300 people that “found that calcium absorption pretty much maxes out at vitamin D levels of 8 ng/ml.”

Hmm. Why?

‘A Religiosity Around Vitamin D’

Well, here’s that interesting wrinkle I just promised: the lead author of the society guidelines was an endocrinologist who has received at least $100,000 from companies that make vitamin D supplements and tests, journalists discovered. He is also a vitamin D promoter who wrote a book, “The Vitamin D Solution: A 3-Step Strategy to Cure Our Most Common Health Problems.” To be fair, he did deny to the magazine that he had conflicts of interest and said most of the money he received from the industry had nothing to do with vitamin D.

All that all may be true, but Upton Sinclair’s wise observation comes to mind: “It is difficult to get a man to understand something, when his salary depends upon his not understanding it.” Money—even small amounts—tends to influence us in subtle and not-so-subtle ways.

Now, a coda to the vitamin D story. My two children, 13 and 16, recently had blood tests. They both came back perfectly normal—except for one thing, the doctor said. Can you guess what?

“Insufficient level of vitamin D.”

I laughed when my wife told me this. Not much has changed, apparently. My healthy son and daughter are deemed to have insufficient levels of vitamin D, most likely because of a misinterpretation of an old study that, oddly, lives on and on.

Indeed, Scientific American informs us that more than 10 million vitamin D tests are done yearly in the United States, despite the fact that major medical organizations don’t recommend this mass-screening of the population. Why does it continue? There’s a telling quote in the article:

“There’s a religiosity around vitamin D.”

Ah. That I understand. As I’ve written about stretching and knee pain, it’s very hard to talk a stretching adherent out of this conviction that stretching is helpful for injured tissues, no matter the evidence. At some point a rational person has to realize, when talking to someone who belongs to the Church of Stretching: I’m not dealing with science-based people. I’m dealing with belief-based people.

With knee pain though, it’s often not a religiosity that you’ll be fighting against, but wrongheaded, entrenched thinking. It’ll be comments like these:

“Your knees just wear out and there's nothing you can do about it.” “Cartilage can’t heal.” “Your bad knees will just get worse.” “If you run long enough, your knees will fall apart.”

Wrong, wrong, wrong, wrong.

So if you get discouraged by your doctor’s pessimistic message about your knee pain, don’t feel bad. Remember, it looks like they got vitamin D wrong too.

Guess What? Others Are Also Figuring Out Cartilage Can Heal.

TriAgain, an Australian triathlete who has spent long years rehabbing his knees, left a link behind to a post that I found amusing.

Amusing, I guess, because it does sound a lot like what I’ve been preaching for the last 15 or so years (and what Doug Kelsey was preaching before me) about the ability of knee cartilage to strengthen and heal. It’s by a fitness coach called Julien Raby.

Right near the top, he says:

Cartilage is a living tissue with active cells that respond to movement — and certain types of movement can actively help it rebuild.

Yes, yes, exactly. He then goes on to helpfully explain:

Cartilage consists of living cells called chondrocytes, which produce collagen and matrix—two components responsible for the tissue’s ability to absorb shock and allow for smooth joint movement.

These chondrocytes respond to specific types of physical load by increasing anabolic (building) activity. In other words, move right, and the tissue gets stronger. Move wrong, and degradation accelerates.

That’s pretty much the formula, in a nutshell. Of course finding that sweet spot of exactly the right amount of movement, that builds up the tissue instead of tearing it down further, generally involves a lot of exasperating trial and error. Or at least it did for me.

But the underlying optimism is correct, I’m convinced (cartilage can heal). And so is the broad prescription (movement, of the right kind, and in the right dose).

I’m not sure I agree with all he has to say. He thinks leg presses are a suitable high-repetition activity for knee pain. I’d be rather doubtful, but maybe if the weight is very light and the motion is smooth and easy? Also, he mentions glucosamine as a “promising” nutritional supplement — I tend to doubt that, for reasons explained elsewhere (on this blog, in my book), but your mileage may vary.

Still, it’s great to see someone out there proclaiming cartilage can heal, so confidently and so openly. When I published “Saving My Knees,” fifteen years ago, I hoped and thought that the day would come that the thinking about knee pain would evolve. The old model, that knees simply wore out like a pair of old tires on a car, never made sense. It amazed me that so many people bought into that line of dismal thinking, and not because I’m a pie-eyed optimist (if anything, I’m a pie-eyed pessimist).

And here we are, a decade and a half later, and there are more voices emerging, saying, “Hey, cartilage can get better. Your knee pain today doesn’t have to be your knee pain forever.”

That’s a great message to have at your side if you’re trying to recover from knee pain.

A Brief Q&A on Knee Pain-Related Issues

It's been a while since my last posting, and yes, it was in a decidedly political vein. What is happening in America is still alarming. It is deeply puzzling and saddening, and I often wonder how so many good people of conscience can remain silent. The subversion of America's institutions rises above the divisive politics of our times; this is not a Republican vs. Democrat issue. Personally, I don't care much for either party.

But enough on that ... these days political commentary abounds, and I have made my contribution. It's time to get back to knees. I thought I'd highlight today a few questions and comments that came up on this blog during the last four months (I'm going to label them all questions, though some obviously are not). I have done a little light editing.

Q: I find it fascinating that cycling can be beneficial for bad knees despite being a repetitive motion.

A: Welcome to Joint Land! Seriously, joints benefit from movement. Repetitive motion (when gentle enough) is often exactly what is needed. Remember too, that it is through being squeezed by movement that cartilage is nourished and disposes of waste products.

However, getting the balance right (enough movement, but not too much, with the right amount of force on the joints) is tricky, which leads us to ...

Q: For me it would be very important to understand if you walked on pain and what you felt during the day. I walk even 8,000 steps a day, a maximum 1,500 consecutively. The sensations improve, but my knees feel a little weak. And, if I don't feel burning while walking, at rest (both sitting and lying down), it gets worse. If I overdo it, my knees feel "full," my kneecaps a little blocked and unstable, even when walking in the pool. Always feeling burning doesn't give confidence in the therapeutic program.

A: It's hard to figure out exactly the right type of exercise, and the right amount. However, knees that feel full could indicate swelling, which suggests you might be overdoing it. However, again, I'm not a doctor or even a physical therapist. If I were you, I'd think about working closely with one and trying to get these symptoms under better control.

How much "pain" should someone be expected to tolerate on a recovery program? This may not be all that helpful, but my personal feeling: as little as possible. That's why I dialed back my own movement program quite radically at one point in Hong Kong, after coming to a rather shocking realization: my knees were a lot weaker than I thought. Going back to square one in my attempt to heal was depressing, but in the end, the adjustment worked well for me.

Will it for you? Or might you need something else? I don't know. I'd look for a good physical therapist, someone whose approach you can trust, and try working with that person. Failing that, Doug Kelsey has written on excellent book on healing knees; it can be bought on Amazon here.

Q: Recently my life changed completely. Doctor's appointment turned out to be completely unexpected and hit me hard, but at the same time it might have saved me. Ended up having surgery in both knees: medial plica removal in both, left knee required autologous chondrocyte transplant. My ortho (the best in Austria, doctor for the Austrian Ski Association) discovered that my hole is actually 1 cm wide and on the weight-bearing area. I will just say sometimes surgery is the only way, so make sure to get a proper doctor.

A: Sometimes people assume I'm anti-surgery. To be clear, I'm a surgery skeptic -- I think it's probably overdone. Yet there are surgery success stories, and I'm delighted when someone comes forward with one. It's fine to try healing your bad knees on your own, giving it your best effort, but then if that doesn't work, there's nothing wrong with considering surgery.

There are people who bitterly regret their surgery. There are people who wonder why they waited so long to have their surgery. To better ensure you fall into the second category, do your research first, and if there's a reasonable chance that your knees can heal naturally, think about giving them that chance.

All for now! Hope you all had a good summer, and yes, my knees are still fine! 

Why Facts and Truth Are So Important

Today I want to talk about facts and truth. Some of you may not like what you’re about to read. I’ve tried to keep certain polarizing subjects out of this blog, but as an American who cares deeply about the basic democratic principles this country was founded on, I think it’s time for more of us to speak out.

Over the past decade, we have seen big, bold lies being peddled to the American people. That would have been unthinkable 30 or 40 years ago. They include:

(1) Ukraine invaded Russia (the exact opposite of what occurred).

(2) The current president was overwhelmingly elected in 2024 by the biggest majority in history; in truth he won by a narrow margin of the popular vote.

(3) The current president didn’t really lose the 2020 election, but was the victim of widespread voting fraud. Dozens of court cases were filed alleging as much, and were thrown out for lack of evidence.

Now, to be clear, politicians and others in their orbit lie with some regularity. But these lies I just cited are not little white lies, or fibs, or truth-stretching lies. These are blatant, easily provable falsehoods. These are lies akin to insisting, “the sky is green,” when anyone can clearly see it is blue.

Why do lies matter? Why should we care if politicians, or others, blatantly lie to us? Obviously, one reason: there are gullible people who will believe the lies. Big Lie No. 3 prompted a storming of the U.S. Capitol building by an angry mob.

But beyond that, we will find ourselves in a truly bad place if we are unable, or unwilling, to parse out obvious untruths. Truth is not something that is just a matter of opinion. “Well, you may think that, but I don’t agree” is fine for certain things, like whether strawberry or chocolate ice cream is better, but not for two plus two equals four.

Using the Veneer of Science to Serve a Personal Agenda

When I tried so hard to heal my knees, I looked to scientific studies. I wanted results that had been tested in the crucible of the scientific method, objectively, without partiality to any particular thesis about healing. I wanted researchers whose papers were untainted by support from any drugmakers or glucosamine sellers.

These studies inspired me, gave me purpose, and allowed me to heal by pointing me toward a path grounded in facts and truth, not unfounded hope.

Contrast that with what we see today: a top-ranking U.S. government official just promised to reveal the cause of autism by September. This is someone who has a controversial (and minority) viewpoint on this subject. Do we really trust that a flurry of full and impartial studies will be conducted in less than six months, on this matter of significant debate, and the truth will come to light?

Or is this just a cynical attempt to pass off as “truth” someone’s opinion or agenda?

Now I want to introduce you to Hannah Arendt.

I read her while at Harvard. Arendt, who was Jewish, fled Germany in 1933, escaping before the Nazi horror truly began. She later wrote an authoritative and seminal work on totalitarianism; the power of her writing derives not only from her formidable intellectual prowess, but also (one suspects) from her analyzing a phenomenon that was unfortunately too close to home.

She said this (my emphasis added):

The ideal subject of totalitarian rule is not the convinced Nazi or the convinced Communist, but people for whom the distinction between fact and fiction and the distinction between the true and the false no longer exist.

So all those malleable people, who can no longer tell the difference between what is true and what is false—whether from ignorance, indifference, or willful blindness—are an authoritarian’s best friend. That’s something worth pondering.

That so many of us are willing to swallow Big Lies should be alarming all by itself. But there is much, much more that we should be wrestling with now. Do we really believe in Constitution-enshrined free speech, even if it might be personally distasteful or repulsive? How willing are we to defend that? Do we really believe in the system of checks and balances that our founders created?

If I Wanted to Be an Authoritarian, This Would Be My Game Plan

On Jan. 25, I tweeted a musing about how (if I were a wannabe authoritarian), I would try to take control of America.

(1) First, I said, I’d mass-fire people in the government bureaucracy and install as many loyalists as possible. This is the easiest part for the chief executive to do, as the president does have wide latitude to appoint and hire and fire workers in federal agencies. By itself, this would be quite empowering—imagine having the IRS, SEC, Justice Department, etc., under your thumb.

(2) Next, and this is harder: I’d have to bring the courts to heel. Courts are dangerous, because they deal heavily in fact and law and precedent. They will not bow to my fictions. They are often slow-moving as well, so if I aspired to be an authoritarian, their meddling and demands for evidence would slow me down. However, their slowness could be an asset: I could just move quickly, before they have a chance to respond. Another strategy: at some point, I could just ignore them. What can the courts do? It’s not like they have an army.    

(3) With the courts subdued, I would then be freer to move on to media/critics. If I have a loyalist installed at the Federal Communications Commission, I would have him investigate media outlets I don’t like and threaten to take away their license. Note that the head of the FCC said recently: “Federal law requires (Comcast’s) licensed operations to serve the public interest. News distortion doesn’t cut it.” But then who defines “news distortion”? Ah, well that would be me, the would-be authoritarian, using my own version of what qualifies as “truth.”

You may have noticed that I have left Congress out of this mock “game plan.” Sadly, our Congress is basically impotent today, and this is one reason I think many Americans are drawn to a strong ruler.

The last thought I want to leave with you: if you are an American—conservative, liberal, it doesn’t matter—who is troubled by what has been happening, speak up. Say something. Alaska Senator Lisa Murkowski said recently, “We are all afraid.”

That’s sobering, coming from a legislator who is in a position of influence, who could be a real force for change if she had the courage. But we shouldn’t be afraid. People of conscience, who care about America’s ideals, can speak with a unified voice that will not be easily silenced. Make them hear us.

Make them understand that we the people do have the ultimate power.

A Few (Hopefully) Final Thoughts on Structuralism and Knee Pain

I didn’t originally envision my recent thoughts on structuralism as a two-parter, but hey, I’m at the point now where I go with the material I get …

This blog of course is in semi-retirement, now that “Saving My Knees” is nearing its 15th birthday, and reader interest has understandably begun to wane. However, for some reason, over the last couple of months there has been a little upsurge in book orders, which always gets me thinking about the blog again.

I received a comment about my last post’s musings on structuralism. To recap, structuralism has been described as a school of thought that attributes the origin of musculoskeletal complaints to one or more biomechanical abnormalities. For instance, a structuralist may blame your mistracking patella for your knee pain (even though there are lots of people with mistracking patellas who have no knee pain).

I got a comment that raised some good, thoughtful points. Here it is, edited and notated, with some responses at the end: 

I agree with your point about structuralism. But the functional PT exercises get at something slightly different. Don't you think that the *way* we use our bodies should matter?(1) Let's say I sit at a desk all day for work. My movement patterns will probably be pretty damn different from a hunter-gatherer's. My muscle tone and activations will be different. This idea isn't about fixed (or mostly-fixed) anatomical differences, but about what muscles we use and how we use them.(2)

For example, my right knee has had issues on and off for many years. My right achilles, hamstring, and hip also have had mild injuries. It's possible it's a coincidence that everything is on the right side, but I think my body has been compensating for injuries, throwing off the whole system.(3)

In running, there are different types of running gait, some of which put more strain on the calves, others on the quads. Why do different people run in different ways?(4) There's going to be some fixed anatomical reason, but the muscle tone and activation will also influence running form. Tight ankles means someone is more likely to turn their feet outwards, for example. That can cause problems in the knee.(5)

(1) Does the way we use our bodies matter? Of course. It would be hard to find anyone sensible who would dispute that. If my favorite hobby is jumping out a 15-foot-high barn window, onto hard ground below, I’ll probably develop knee pain before long. Or, as a less extreme example, if I’m a sedentary desk warrior living in a snowy climate, and only get winter exercise from shoveling snow, I stand a good chance of developing back pain, during the cold months, from overusing flabby muscles.

(2) At least some of the ideas of functional physical therapy make sense to me. I wouldn’t argue with doing exercises that enable us to better handle everyday activities. I probably qualify as doing these myself. On workday mornings, for example, I do a few minutes of the “bird dog” yoga pose to keep my back strong. I tell people that I do exercises like this to prepare for sitting behind a desk for eight to ten hours. And I’m 100% serious.

(3) Could a body compensating for injuries cause more injuries? Absolutely. Use your body repeatedly in unnatural ways and pay the price. In the book I call these “compensation injuries.” I developed back pain in Hong Kong from sitting at work with my legs straight out, supported by an under-desk sling, in order to relieve my knee pain. That put too much stress on my back.

(4) Running form is a fascinating subject by itself. I ran cross country in high school. And the guy on the team with the weirdest running form – I can still see his arms swinging from side to side – was the fastest guy on the team. Anatomy, muscles, soft tissues, I’m sure there’s an interplay between them all that explains why someone runs the way they do.

(5) So, when it comes to running, I’m sure some of my own issues stem from being a pronator. That has implications beyond wear marks on the outer edge of my shoes.

Anyway, this may come as a surprise, but part of a structural analysis makes sense to me. For instance, as noted above, I used to be a runner.

Even though I have a good body for running, it’s probably not ideal. I’ve watched the truly elite runners. Even if I had their conditioning, their weight, their ability to process oxygen, I still probably wouldn’t be able to do what they do. And it’s probably for structural reasons.

We’re not all designed to run marathons, or even 10k’s sometimes. Even with proper training, certain body types may never be able to run 60 miles a week without problems, while others can. I recall the time I ran a half-marathon in Switzerland, and all the training, and the niggling pains, and thinking, “I probably don’t want to push myself into a race beyond this distance.”

So I think that, while healthy, we do operate within some kind of overall structural limitations. But where the structuralist story falls apart for me is when a runner develops knee pain, and a structuralist physical therapist discovers tight ankles, and exclaims, Ah hah! We need to stretch out those ankles, because that’s the problem!

I think this fails because:

(1) It can be easy to confuse cause and effect. To take a different example: you may have a weak right hip along with your right knee pain. But the answer isn’t just “strengthen the hip to fix the knee pain.” As Kelsey notes, “People with knee pain will almost always have weakness of the hip on the same side as the knee pain.” What he proposes: Fix the entire hip-knee-ankle chain together, using reduced loads, instead of trying to cure the right hip “imbalance” by strengthening it in isolation.

(2) But going back to the tight ankle: it’s virtually impossible to prove that the tight ankles caused the knee injury in the first place. Lots of things could have caused or somehow contributed to that knee pain; there are many forces feeding into the knee joint. Just because a therapist finds a tight ankle doesn’t mean that that was a prime mover for the resulting pain.

(3) But let’s suppose it was. Suppose the therapist has “God’s Diagnostic Tool.” And God’s Diagnostic Tool indicates that a tight ankle, over time, basically led to this problem. Then what do you do?

I think you’re still best served by an “envelope of function” approach to treatment. You need to back off your running and keep that knee within the acceptable envelope, moving it but not pushing it too hard, until it heals. And maybe you have to accept that you need to train more carefully, or you’re not built for say marathons.

I know, at this point, the structuralist would probably jump in to say, “And stretch that tight ankle!” But personally I’m a skeptic of stretching (but a big proponent of warming up). The fact is, people run for years with their tight ankles and other little muscular and tissue imbalances and they do okay, as long as they stay within their “envelope of function” ranges and don’t overtrain.

(4) Sometimes it’s just impossible to “redress” the imbalances that are found anyway. What if the PT thinks that the imbalance to fix is a too-weak vastus medialis oblique (VMO) muscle that needs to be stronger to stabilize the patella? So he prescribes VMO-strengthening exercises.

That sounds great except … they happen to be useless, as Doug Kelsey explains here:

People with knee pain, especially patellofemoral pain, are often told by clinicians to strengthen their VMO to improve the alignment and tracking of the patella ... But, since the VMO doesn’t have its own nerve supply, you can’t isolate the muscle from the rest of the quadriceps … this isn’t just my opinion. Cerny examined this in 1995 and found no difference between the VMO activity and the rest of the quadriceps for a variety of common exercises used to target the VMO.

Anyway, at the end of the day, I’m not saying that structure, imbalances and crookedness are always irrelevant. I’m just saying that, if I’m trying to heal from an injury, I think the idea of staying within an envelope of function and slowly increasing load, while getting enough movement, is generally going to be a more successful (and logical) way to treat the problem.

There will always be exceptions, naturally. But they don’t prove the rule.

The Knee Bone, the Thigh Bone, and Adventures in Structuralism

After my last post, I got this comment:

Hi Richard, what do you think of the hip (especially abductor) strengthening exercises that are now being commonly prescribed for chondromalacia/PFPS? Seems like the dominant advice is shifting away from quad strengthening and towards hip strengthening. Have you tried it or done any research on it?

After reading this, that children’s song, “Dem Bones,” began running through my head:

The leg bone's connected to the knee bone,

The knee bone's connected to the thigh bone,

The thigh bone's connected to the hip bone …

Truly, we are all biological marvels. The way locomotion has evolved is astounding. I don’t profess to have much of an understanding of how, exactly, we walk and how this process can be both fluid and stable, but I know that it’s complex. Walking, running, jumping … our bodies have to recruit a bunch of different muscles and rely on certain supportive tissues to accomplish these activities.

Unsurprisingly, there appear to be some physical therapists who are fascinated by the biomechanical interplay that lies behind the movement of our lower limbs. They are fascinated by the connections, by how one thing seemingly remote from our knees (our butt muscles, e.g.) can influence a joint that is a couple of feet away.

A lot of them are structuralists (not my word, rather, the writings of Doug Kelsey first introduced me to the concept). Structuralism is the subject of this rather long post. Kelsey defines it as "a school of thought that believes the genesis of musculoskeletal complaints is from one or more biomechanical abnormalities."

And, for a structuralist trying to diagnose the source of patellar pain, abnormalities of interest include “a laterally tracking patella, weak medial quadriceps, tight hamstrings, tight iliotibial band, tight calf muscles, weak or tight hip rotator muscles and over pronation of the foot,” he informs us. (There’s our hip!)

One glaring problem with the structuralist story of knee pain, though, is that nobody has ideal biomechanics, yet most of us do just fine anyway. For example, I’m pretty sure I have a mild leg-length discrepancy. Yet it didn’t bother me for decades. Then, in my forties, I wound up with serious, chronic knee pain.

So was it because of my leg-length discrepancy? Or because I had been cycling recklessly up small mountains in Hong Kong, then piled on a long endurance hike on top of that one day, and that pushed my knees over the tipping point?

I think you’ve figured out where I stand on this. I’m not a fan of structuralism. There could be cases where it makes sense, but I would expect them to be a small minority. If your knee hurts – d’oh – why not start with where the pain is coming from? The knee? That’s more logical to my brain anyway.

I urge you to read that earlier post I linked to about structuralism, and especially take note of a study cited that looked at knee cap mistracking. Hell, that’s an instance of structuralism that even seems to make sense. A mistracking kneecap should cause issues, right?

But a study was done. And it found, basically, that whether a kneecap tracked improperly was no predictor of knee pain. You could have knee pain and a perfectly tracking kneecap, or no pain and a mistracking kneecap.

Physical therapists, in my experience, have been the biggest fans of structuralism. I had one who liked to have me do one-legged dips to check my alignment. I don’t think he ever figured out anything about my alignment. However, by putting so much force on what were bad knees at the time, he did manage to set me back in my healing.

Fighting Through That Hopeless Feeling

I got this comment from my latest blog post, and I imagine a lot of people here can relate:

I’ve been suffering from knee pain for 8 weeks now. I fell into the trap of “resting” and immobilizing because I was scared of pain, and because I couldn’t get free of the pain. Along the way I found your blog, and decided to try your methods. I finally got free from the pain 2 weeks ago. I walked 1,500 steps in the course of a day. Doing 50 to 100 steps every hour. And I woke up the next day with a return of pain. I’m so crushed and in disbelief. How did I go from walking 6 miles a day to unable to walk barely half a mile without pain? I feel so hopeless. I’m only 25.

Setbacks. They are ugly and so, so depressing. This fact has come into greater focus for me now, as I try to recover from whatever is ailing my left foot (maybe plantar fasciitis?). Twice, I thought I had this foot problem licked. And twice, I have had setbacks. Ugh.

So what should be said to someone who is only 25 and is unable to walk barely half a mile without pain? And who feels like everything is hopeless?

Well, first, I guess I'd say: look on the bright side. You're 25. That may be seen as a curse (what 25-year-old is cursed with chronic knee pain?). But it can also be viewed as a blessing. Younger bodies generally heal better. I would not write off being able to heal at any age, but it gets harder as a 65-year-old.

Then: have you seen a doctor or therapist? It might be time, if not. Sure, a doctor might leave you frustrated and confused. But it's possible that this doctor -- or an imaging test that's done -- may discover something going on in your knee that, in the end, will put you on a smoother glide path to healing. It always helps to have a professional examine your bad knees and question you about them and offer an opinion about what's going on.

And then, on your setback: I know how this feels. I remember trying to heal my knees, and the times when I pushed them a little too hard and suffered a setback. It was always crushing. That's a reason why, to this day, I say that healing my knees was by far the hardest thing I did in my life (and, as a result, the thing that I'm most proud of).

If walking bothers you now, you might think of trying gentle cycling (a stationary bike is generally better, as it's easier to control the force applied) or gentle movement in the water (is there a pool nearby?). And, if it makes you feel better, make yourself a big "I've Fought Through a Setback" badge and wear it proudly. You'll have more. That's typical of healing through knee pain.

Lots of luck, and don't give up!