Sunday, January 29, 2023

One More Time: Running Isn’t a Death Sentence for Your Knees

I think I’ve been in the forefront of voices trying to spread the message that no, running isn’t inherently bad for your knees, and in fact can even help strengthen them.

Just search this blog. Here I am back in 2010:

Keep Running Past the Age of 40 and Your Knees Will Fall Apart! True or False?

The answer, incidentally, was a resounding “false.”

In October of last year, an article in the Washington Post highlighted more good news for runners. Studies are increasingly showing that not just running, but its extreme form, distance running, is actually beneficial for your knees:

… distance running does not wreck most runners’ knees and, instead, fortifies them, leaving joints sturdier and less damaged than if someone had never taken up the sport.

A recent 2019 study is cited, where the researchers rounded up 82 middle-aged first-time racers who had signed up for the 2017 London Marathon. Few had done much if any running. None had knee pain.

By conventional wisdom, this group should have been prime for lots of damaged knees. They were middle-aged, didn’t have a history of running, and were training for a 26.2 mile grueling endurance race!

But what the researchers observed: most of the pre-training knee scans showed signs that the runners did have signs of joint injuries setting up, such as cartilage tears and bone-marrow lesions. But two weeks after their first marathon, most of the lesions had shrunk, and so had much of the areas of bad cartilage.

Still, there were signs of fresh (though slight) damage in the bones and cartilage around their kneecaps. That was understandably concerning. So new scans were taken later, six months after the race and:

Many of the lesions and tears that had begun shrinking during training were smaller and the fresh damage seen around some kneecaps had largely dissipated, with few remaining signs of lesions and tears.

But the more important, more broadly relevant message in this article (after all, not all of you are runners or want to be) comes from Jean-Francois Esculier, a clinical professor of physical therapy at the University of British Columbia in Kelowna. This is one of the BIG messages in my book (emphasis below is mine):

“For a long time, we thought that cartilage could not adapt” to running or other activities, he said, because it lacks blood supply and nerves. “But in fact, cartilage does adapt,” he said, “by becoming stronger and more tolerant to compression.”

Yes, yes, yes. Knee cartilage is not an inert material, like the rubber on your car tires, fated to eventually wear out. But the difficulty we face in recovering, with bad knees, is dialing back our level of activity enough so that we don’t continue to do further damage to our weak knees.

I’m happy that these messages are gaining wider acceptance. But the battle is not yet won, for as the article noted:

An online survey conducted by Esculier and his colleagues, its results published this year in the Orthopaedic Journal of Sports Medicine, found more than half of the 2,514 respondents believed distance running damages knees.

So don’t be surprised if your doctor isn’t on the side of the enlightened yet. But opinion in the orthopedic doctor/therapist community is finally swinging around. And that’s a very, very good thing for people with knee pain.

Sunday, January 1, 2023

A Success Story to Start the New Year!

Why not start 2023 with a story of someone overcoming knee pain? Hoisted from comments and lightly edited (with emphasis mine): 

Your book "Saving My Knees" was an inspiration. It gave me hope that I could overcome the limitations of osteoarthritis (Stage 3 according to an orthopedist who interpreted my MRI results). Three years ago, I couldn't walk the length of my house without pain so bad that it even interrupted my sleep at night.

After reading your book, I decided to chuck the orthopedist and the NSAID he recommended, and embark on a program of my own design after reading everything I could about osteoarthritis.

I soon learned that inflammation played a major role in both the pain that people with osteoarthritis endured and the progression of the disease. In addition to daily walks and yoga, I adopted an anti-inflammatory diet consisting mostly of plant-based whole foods. Currently, I eat seven to ten fruit and vegetable servings per day as well as legumes, whole-grains, and soy. I also lost 20 lbs. of excess weight, which I'm sure has contributed much to my improvement.

This morning I walked [four miles in an hour] with no pain. Most days I walk 6,000 to 9,000 steps daily during my walks and about another 1,200 to 1,500 steps as I do my daily chores at home. Not bad for a man in his seventies!

I love reading stories like this.

First of all, note that this person's knee pain was hardly mild: "stage 3 according to an orthopedist" (I suspect that refers to the extent of deterioration in his cartilage, where stage 4 is bone on bone) and "I couldn't walk the length of my house without pain so bad that it even interrupted my sleep at night."

Can you imagine that? Just walking from one end of your house to the other, and then having intense knee pain at night as a result? I'm sure some of you can, but this is definitely at the more extreme end of the knee pain spectrum.

After that, he did a few smart things, maybe the smartest being this: "I also lost 20 lbs. of excess weight ..."

I'm not sure how much an anti-inflammatory diet contributes to alleviating knee pain -- it didn't seem to make a huge difference for me, but my dietary changes weren't really radical -- but I've read so many medical studies about how being overweight contributes to knee pain that I'm quite confident that shedding pounds will make some kind of difference, if you're patient.

I also sense a kindred spirit in these words: "I decided to chuck the orthopedist and the NSAID he recommended and embark on a program of my own design" ... which is exactly what I did. Again, I'm not trying to denigrate doctors, and some are very, very good, and they are important to help diagnose what might be plaguing you. But ultimately, a lot of healing chronic knee pain will depend on you and your individual efforts and plan to heal.

But of course he healed, you may have thought after reading the first few paragraphs -- he was probably in his twenties or thirties, at an age when healing is still possible ... nope! He was in his seventies!

In some ways, it may be easier to heal in your seventies instead of your twenties or thirties. Why?

When you are young, that illusion of immortality, of being unbreakable (at least in a permanent way), is still very much with you. And that can be a dangerous illusion. It will cause you to pronounce yourself prematurely healed; you will tend to think that all healing must be on a two- to four-week (or at most a four- to six-week) timeline.

When you are older (in your forties, fifties, sixties, or beyond), you have two advantages: (1) the knowledge that good health shouldn't be taken for granted, that it can be a fragile and easily lost thing if one is reckless or ignores the body's warning signals (2) patience.

Yes, healing takes longer in someone older, but that older person is more likely to possess the wisdom and patience to be able to handle that fact.

There you are: a success story to start 2023.

How are you all doing out there? This year, my posting will probably become less frequent, as book sales have kind of tapered off, and that has led to a corresponding dip in traffic to this blog. But I'll still be here, at least occasionally.

Best wishes, and to all, good knee health in 2023!

Saturday, December 3, 2022

Conquering Knee Inflammation: What Doesn't Seem to Work

If you have chronic knee pain, you have almost certainly struggled with inflammation and wondered how best to suppress it.

You may have tried two things that I’m not a big fan of: anti-inflammatory over-the-counter pain relievers and steroid injections into the joint.

Well, there’s more evidence now that they’re both probably not good ideas.

(1) Anti-inflammatory pain relievers

A writeup of a study tells us that:

Taking anti-inflammatory pain relievers like ibuprofen and naproxen for osteoarthritis may worsen inflammation in the knee joint over time.

This study included more than 1,000 people from something called the “Osteoarthritis Initiative.” 277 people had moderate to severe osteoarthritis and underwent “sustained” treatment with anti-inflammatories; 793 others made up the control group.

Everyone had an MRI initially, then later after four years.

Joint inflammation and cartilage quality were worse at baseline in the participants taking [non-steroidal anti-inflammatory drugs], compared to the control group, and worsened at four-year follow-up.

Why would this be? Now this is an interesting explanation, from the study’s lead author, though maybe not for the reasons she intended:

The anti-inflammatory effect that normally comes from [non-steroidal anti-inflammatory drugs] may not effectively prevent synovitis, with progressive degenerative change resulting in worsening of synovitis over time,” she said. “On the other hand, patients who have synovitis and are taking pain-relieving medications may be physically more active due to pain relief, which could potentially lead to worsening of synovitis, although we adjusted for physical activity in our model.

This first part reads a bit strangely. It’s an explanation that parses as no explanation at all. Listen carefully to what she’s saying. I’m going to translate it to simple English (synovitis is important, by the way, as it’s expected to have an effect on the progression of knee osteoarthritis):

The anti-inflammatories don’t prevent synovitis, so the knee continues to degenerate and that results in worsening synovitis. Huh? That’s a fine explanation if anti-inflammatories are no more effective than a placebo (or not taking these drugs at all, as with the control group). But that’s a lousy “no explanation” considering these knees were worse than those in the control group.

So that means that, not only do the anti-inflammatories not prevent synovitis, but they either make it worse, or worsen the degenerative processes in the knee, than if you do nothing at all. Pretty damning stuff there, though the author makes us do too much work to get to this point.

Then look at the second part of the explanation. The author manages to kind of screw this up as well. Here’s my gentle translation:

Patients taking anti-inflammatories may engage in more physical activity because of the pain relief, and that could lead to worse synovitis, though we adjusted for physical activity in our model.

Again: huh? I fully agree with the basic point on the front end of the sentence, typified by the macho man runner with bad knees who says, “Eh, I can still run four or five miles, I just pop a couple of Advil after I’m done.” He’s probably beating back the pain with the Advil and doing more damage to his knees.

But look at the back end of that sentence: “... we adjusted for physical activity in our model.” So, in other words, that should have eliminated physical activity as a factor. That's because the researchers presumably made adjustments so they were basically comparing people from the two groups (control vs. steroids) who were doing the same amount of activity, like jogging or playing tennis.

That leaves us with a frightening implication: that had this variable not been adjusted for, the people taking anti-inflammatories might have had even worse knees. Yikes.

(2) Steroid injections

Check out the findings described in this article:  

Steroid injections, which are often used to treat pain in knee osteoarthritis, may actually make arthritis worse, according to two new studies.

Again, the researchers used some participants in this Osteoarthritis Initiative, which apparently includes almost 5,000 people.

44 were injected with steroids, 26 with hyaluronic acid (which is supposed to lubricate the joint), and the other 140 didn’t get either treatment.

Those who had a steroid injection had significantly more osteoarthritis progression, including medial joint space narrowing, a hallmark of knee osteoarthritis.

Not that hyaluronic acid is necessarily a good treatment either. An osteoarthritis researcher who was quoted in the article said that there’s conclusive evidence that injections of this substance aren’t better than a placebo, and at the same time, there’s “strong evidence” that they’re associated with “serious adverse events.”

Getting on top of chronic inflammation is important. But be careful if you’re doing it through drugs. Research what you’re popping into your mouth or getting injected into your knees.

Sunday, November 6, 2022

If You Want to Discuss Knees, This Is the Place to Do It!

My alternative title for this post: "Why I'm Very Rarely on Facebook, and Why You Shouldn't Bother to Try to Friend Me There."

I was going to write about something different today, but will save it for the future. Instead, I want to talk about my frustration with Facebook (aka "Scam Central"), because a lot of people undoubtedly read my book and think, "This is cool, I like this guy, I'll friend him on Facebook!"

I would rather that you not. Instead come here, join this community, and post a comment and join our ongoing dialogue. I'm increasingly distrustful of Facebook. Here is the latest reason why:

An old colleague of mine recently sent me a "friend" request. It was his name, his profile picture. I went ahead and confirmed him as a friend. This is the exchange I then had with my "friend," who I worked with on the business desk at the Sun-Sentinel newspaper in South Florida:

Him: "Hello (hand-waving icon) ... how are you doing today (heart-covered smiley face icon)?"

My suspicions were somewhat aroused. The message was short, contained nothing of a personal nature (e.g., "Hey, I drove by the Sun-Sentinel building yesterday and thought of you"), and contained those weird icons. But maybe he had found Jesus? Maybe he had started selling life insurance and was mass e-mailing a bunch of his friends, just trying to break the ice and seeing who might respond?

So I sent back a short reply, just to see what would come next, and this is what I got in return:

Him: "Good to heard from you am also doing pretty good and enjoying life at this moment, have you heard about the community development block grant?"

Whoa. My scam radar went into high alert (notice the misspelling of "hear" that a foreign speaker would be more likely to let pass undetected). There still is no reference to anything in this email that proves this is the real person I worked with.

Also, there's that "community development block grant" reference. Hmm, I wondered, what's that? Well, it turns out this block grant is the "fraud du jour."

I immediately "unfriended" this impostor and my resolution stiffened to have as little to do with Facebook as possible (a company that seems less than diligent about rooting out the flourishing scams and disinformation on its platform).

You may be thinking: well, that's only one incident. Except it's not.

Last year I got a Facebook email from an old colleague along the lines of "Is that you in the video?" with a link. Intrigued, and not thinking smartly, I clicked the link.

It was a virus. I was immediately infected and spread it to my network of friends, which I felt bad about. Plus, I had to waste time changing my account password, etc.

So if you have questions about knees, comments about knees, or want to share your impressions about my book, please do it here! Yes, I'm on Facebook. And yes, there are plenty of times when I wish I wasn't.

Speaking of knees, how is everyone out there doing? Anyone with updates to report?

My love and best wishes to you all (except for you scammers, who can ... well, I won't go there).

Sunday, October 9, 2022

Knee Surgery and the Iatrogenic Problem

I recently happened to be thinking of what it takes to beat knee pain, and things that often don't work.

Surgery came to mind.

Now, to be clear right from the outset: Surgery may be a good idea for you. In fact, it may be a great idea. It all depends on what's causing your knee pain, and whether a surgical solution fixes that.

What worries me: I think there are too many people in the situation I was once in, when I had chronic, diffuse knee pain that had no clear cause. After a while, their thinking goes like this:

I've tried everything they've told me to do. I don't seem to be getting better. I have nowhere else to turn. Should I have surgery?

Surgery as a last resort, when the doctor plans to look around your knee and "clean up" some areas of damage, seems like a potentially risky proposition.

This isn't like someone popping the hood on your car, spotting a loose battery cable, then tightening it down and then -- voila! -- the car works great again.

I suppose a surgeon can look for loose bodies and remove them. Fine. But when it comes to trimming and shaving the existing cartilage, how does a surgeon know exactly how much cartilage to remove? This knee joint you'll be using thousands of times a day, probably, and a screwup could leave you in even worse shape.

Which brings me to the word of the day: iatrogenic. It's an interesting word that I was unaware of before I began my knee pain journey. It refers to new injuries that are created by surgical intervention.

That's a sobering thought. You go under the knife to get better. What you may not realize: there's a not insignificant chance you'll emerge worse off.

I do think most surgeons are pretty good, and they certainly have your best interests in mind. But what they do is very, very hard, and they're not trying to fix a machine, but a human being. That's a task of a much higher order.

Again: I'm not trying to imply that surgery is never a good idea. It sometimes is. But before you commit, you should have a good idea of what the surgery is trying to do and what the chances of success are.

Sunday, September 11, 2022

'Static Stretching’ Falls Out of Favor

I know my views on stretching don’t align with those of many other people, including some frequent visitors to this blog.

I’m a skeptic about whether stretching helps with knee pain, but if it feels good and isn’t causing further damage, well, what’s the harm?

But avid stretchers do have to be careful. I came across this article that summed up reasons not to engage in “static stretching”—that is, stretching before physical activity.  

A growing body of research is showing how our views of pre-exercise “static” stretching are changing in real time—while revealing many of the ugly truths about stretching when your body is “cold.”

The dangers include a risk of injury to cold muscles and a possible decrease in performance, which of course would be ironic, considering stretching is supposed to help someone achieve a higher level of performance.

No. 3 on the list actually made me laugh:

You should warm up before you stretch.

Hmm. If I need to “warm up” before I stretch, why do I need to stretch then? It seems that the warming up has probably achieved what the stretching was supposed to.

But then again, it’s true that stretching never made a lot of sense as a “warm-up.” My favorite line here comes from Paul Ingraham, a much smarter stretching skeptic than I am: “That’s like trying to cook a steak by pulling on it.”

Generally though, most stretching is probably harmless if it’s done gently.

I think the only stretch for knee pain sufferers that I’ve reacted violently to is the one pictured in this blog post.

A hard pass on this ugly-looking stretch! I dubbed it the “Just Asking for Trouble Stretch.” 😉

Sunday, July 17, 2022

How to Sit at a Work Desk With Chronic Knee Pain

Fishing in the comment section ...

Richard, thank you so much for your book which I have just come across. Your symptoms and journey are very similar to mine and I have switched from treating my knee pain as a muscular-skeletal imbalance to treating it as a chronic cartilage injury.

I work very long hours at a desk and I was wondering if you had any thoughts on the ideal sitting position that allows the knee cartilage to heal. In your book, you mention that you spent a lot of time sitting on the floor. I am giving this a go - legs straight out in front with my knees slightly supported at the back with a pillow so that they aren't over-extended. But as you rightly point out, modern offices aren't set up this way! And there doesn't seem to be anything online about how to work long periods at a floor desk - there aren't even any floor desks.

I exercised my editorial prerogative and cleaned up a few small spelling errors in the above, so as not to detract from the main message: how do you sit at work with a pair of knees that ache and burn when bent?

There probably is no great solution here (well, the best solution is not to have to sit at a desk for eight or nine hours a day, but I realize, most of us don't have the luxury of walking away from our white-collar jobs).

So the first thing I would warn about: Be careful about contraptions that you rig to help alleviate your knee pain. Make sure they don't put a strain elsewhere on your body. I wrote about my underdesk sling that I thought was fairly clever ... until I developed back pain that just wouldn't seem to go away.

Don't trade one problem for another.

The idea of a "floor desk" is interesting, but then: what's your "floor chair" look like? If it's not properly designed, then once again, you could wind up with back pain.

What I would think about trying, if I had it all to do over: an underdesk "pedal exerciser" that I could pedal occasionally, to give my knees very light movement. I even bought one of these for use during my recovery, when my knees every so often would burn a little. It may even have been this one here.

In the end, I never used this exerciser much. The short periods of discomfort just went away, and they're all history now. But if I had more serious chronic knee pain, and I was stuck in an office, I might try it. You have to try something! Don't suffer in silence.

Anyone else with suggestions?