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 the point that we're at today? 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 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!

Why to Be Optimistic About Recovering from Knee Pain

Right now I can't ride my bike. I'm frustrated.

But all this has absolutely 0% to do with my knees. Rather, the weak link in the biomechanical chain for the past month has been a sore left foot. Why is it hurting? I don't know. Part of me thinks that it's the dreaded PF: plantar fasciitis.

Of course because exercising becomes addictive, I was slow to walk away from the bike and my active lifestyle (sound familiar? welcome to how Type A people deal with sports injuries). I don't have easy access to a pool (and am a poor swimmer), so I'm casting about for some other cardio activities. I am toying with the idea of buying a rowing machine.

Anyway ...

That's just a quick update of me, and where I'm at currently: great knees, lousy left foot. During this self-imposed period of being on the sidelines, I've had more time to reflect. I don't contribute much to this blog anymore, but then I see a little spurt of book sales (kind of amazing that the book still sells, even in modest numbers), and I think of the "knee journey."

I know occasionally I post about it, the Big Picture Overview, for people who may have just stumbled onto this blog. I know how they feel, and how they're struggling with trying to digest so much advice, some of it conflicting. I know that in a fresh way too (with my left foot, I'm seeing "walking barefoot is good" and at the same time "don't walk barefoot," e.g.).

Today I just want to talk about one uplifting, inspiring part of my journey: realizing that the old doc's line that "bad knees can't heal; they'll just get worse and wear out over time" was a load of crap.

The thing is, the more I thought about it, the less sense it made. Our bodies are designed to heal. Even brains adapt after horrible traumatic brain injuries. How can a knee joint -- a joint that has evolved to take a lot of pounding force, day after day -- not have any capacity to improve?

But what happens is bad knees have a much smaller "envelope of function." They can't tolerate as much stress. So when you subject them to the normal forces that normal knees can withstand, yes, they do get worse. And yes, if you continue to do that, you won't get better.

The first problem is, most of us are great at digging holes, and not the good kind. We feel twinges of pain and we think, "Oh, I'll exercise through it" or "It'll go away soon." We don't try to modify whatever behavior is contributing to that pain for a while, and sometimes a long while. We dig a giant hole for ourselves, where we unhappily find ourselves at some later time, desperate for the solution to our nagging knee pain.

It can require radical changes to get your knees back within that "envelope of function" that will allow healing to begin, very slowly. Most people, I'm now convinced, lack the patience and determination and sheer willpower to heal their bad knees.

But even before you set out on the journey, you have to start with that little seed of optimism: that it's possible. I did it. Someone who posts here under the name "Knee Pain," she did it. And "TriAgain," who also posts here, he did it. I have more respect for these people than for myself, and my journey, because theirs took longer and seemed to me to be more difficult.

But it all starts with a simple premise: bad knees can get better. You have to believe that. I did, not because I'm some kind of starry-eyed optimist, but because the rational part of my brain told me that this was the only viewpoint that really made sense.

How the Idea of 'Sunk Cost' Relates to Recovering From Knee Pain

I was thinking of the idea of "sunk cost" a few days ago while trying to fix the vent for my dryer.

The vent is a four-inch wide tube, made of thin metal, through which the dryer's hot air whooshes outside. Ours is old (like everything in this old house) and I had to replace the cracked cover. Among other things, the cover keeps small animals (and insects) from entering your house through the vent.

I bought a replacement cover at Home Depot for five or six bucks. But when I got home, I immediately noticed problems: It wouldn't fit over the existing, slightly crumpled end of the vent. Also, the screw holes to hold the cover in place weren't aligned with the existing holes.

I started thinking about how I'd have to drill new holes through the siding and into the house. I'd have to get a smaller vent pipe, that would fit my new cover. I went to a hardware store in that frame of mind ... and then ...

Voila! There was a vent tube for sale with an already attached cover. At first I passed it by -- after all, I already had a cover. But then I realized: No, wait a minute. This might be exactly what I need. So I bought it, took it home, and it fit just about perfectly, no new holes needing to be drilled.

The vent cover I had just bought? I realized it was a "sunk cost" (I couldn't really return it by then, because it had been scratched up after my attempts to jam it onto the existing vent). I had to write it off and move on.

Swallowing a sunk cost can be very, very hard to do. It's in human nature not to want to give up on something that we're invested in. I know five or six bucks isn't much at all, but my thinking had completely swung around to, "How do I make this work because I've already bought it?"

Similarly, with knee pain, if you're experimenting with ways to heal, you will sometimes have to accept the harsh reality of a sunk cost. As readers of my book know, I followed a very structured plan to get better.

But sometimes that plan just wasn't working, for whatever reason.

In the book, I described going to Tibet, doing some very slow walking with my wife (fiancee at the time), and feeling like my knees had been reborn. I was getting better! So when I returned to Hong Kong, I vowed to strengthen my leg muscles, as my physical therapist had been urging, to make sure my knee pain didn't come back.

But instead of the gym exercises pushing me beyond knee pain, they pushed me back into knee pain. My old problems returned. I stubbornly persisted with the exercises until it became impossible to ignore: they were hurting me. I couldn't continue that way.

In essence, I was staring at a sunk cost of sorts. I had invested heavily in this "strengthen your quads" approach. I was religiously going to the gym, lifting leg weights, trying to get stronger. Meanwhile, my knees were getting worse. To continue doing the same thing would be insanity.

I did walk away from that approach, but it was hard. It felt like I was giving up in a way. I had sunk my time and faith into something that didn't work. It's difficult to accept that, first of all, then summon the strength to move on.

Still, there will be moments in the journey to recover from knee pain where I think we do have to write off an approach, a belief, or whatever -- as a "sunk cost." We invested in it, sometimes to an extreme degree. But if it's not paying dividends, then the smart thing to do: go ahead and write it off and accept the loss (of money, time, or whatever).

Then find a new way forward.

'Your Knees Will Never Get Better'

No, no. A thousand times no. If your doctor is saying this, you need to find another doctor. This is the one thing I am convinced of, after a months-long personal struggle with knee pain that I won.

I thought that today -- a day when I honestly wasn't sure whether to write a blog entry, or just disappear into the basement and do an hour or two of easy cycling -- I would make a short post on this subject.

It is really the "raison d'etre" of this blog, and of my book. I wanted to counter the pessimism because I heard the same "your knees will never get better." And they most emphatically did.

I know that some doctors say "your knees will never get better" because they don't want to sugarcoat the reality of knee pain, because they truly believe they are speaking the truth. Maybe that's the saddest part, that they just aren't aware of how aching knees can heal.

It's not easy, but it can be done.

Here are some posts I've written on the subject:

How I Saved My Knees (in Dialogue Format)

What I Did to Save My Knees

Plus, as a bonus, for anyone who has an aching back ... 

How I Saved My Back

All free posts! (The blog is always free!)

And: anyone with a success story they want to share? (I always love to get those stories out there.)

A Success Story: Gradual Strengthening and a 'Reconditioned Brain'!

It's a new year, so what better way to start than with a success story? This one I got in the comment section. I edited it lightly:

I'm a long time reader. I first had knee pain in 2018 and lived with it through lockdown. It was agony. For much of it, I was ready to just chop my leg off.

Through walking, and cycling, and following your advice I healed about 70% in 2022. However, my wife and I learnt that we would have a second child in 2023 and I was desperate to fix it even more.

I visited my 5th physio. The others hadn't helped at all, but this physio had been highly recommended and seemed, well, enlightened.

So we began a very, very gradual strengthening program, always playing it safe and being careful. The physio was convinced I'd been badly advised by a doctor (who said I had very cracked cartilage and was basically a lost cause). This time, my physio reassured me that they were wrong, and that nearly everyone my age (45) has wear and tear, but that lots don't feel pain.

The physio based her treatment around the concept that the pain I felt was a memory - something stuck in my nervous system.

By slowly strengthening, I both made my leg stronger, but also reconditioned my brain, telling myself that the knee was good now and the pain had gone.

After 6 months of this, I was able to return to light jogging in summer 2023. Jogging now is helping - my knee feels strong, pain free and functions so much better.

My physio now feels that it wasn't cracked cartilage that caused my agony, but patella tendonitis .. My tendon certainly feels stronger now, and doesn't complain when I kneel on hard floors.

I would never have believed I could get back to running and cycling. One physio told me that I'd been stuck with it for four years so it was 'chronic'. I hope my story gives hope to others, as yours did for me.

Great to hear! I don't know as I really have much to add. Very, very gradual strengthening? Great idea. Pain as a memory, stuck in someone's nervous system? Hmm ...

That part reminds me of a post I wrote last year, Rethinking Osteoarthritis Pain (a Recent Presentation Now on Video). The speaker in the video talked about how bad knees are about more than the knee, and more specifically, as I wrote then:

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.

Interesting, and if that does happen, it wouldn't surprise me at all. I think the longer that someone lives with chronic inflammation, the more mischief it stirs up in the body.

And not in a good way.

What I've Learned About My Knees This Year

It's December, another year drawing to a close, and I'm grateful to be the owner of two well-functioning knees. I now know the danger of taking them for granted, of exercising through the warning signs of injury.

At this point I have normal, or probably better than normal, knees. But that doesn't mean there aren't some issues that pop up here and there.

I am a bit fanatical about getting in my exercise, and I like to do it intensely. That's great for my cardiovascular system, but as I get older, it can be a bit taxing on my joints.

I can give you an example that involves my favorite indoor cycling activity, "Zwifting." Zwift is a "game" where a stationary bike on a smart trainer is connected to, say, an iPad and the cyclist can see himself (or herself) on the screen, riding through video game-like courses alongside other riders.

The faster you pedal in real life, the faster you go in the game.

The only trouble with Zwift is, unlike cycling in the real world, you never have to stop. No red lights. No crashes. No flat tires. No pulling over to the side of the road so someone can photograph a sunset.

It's just pedal, pedal, pedal, pedal, and this can be rather intense for long rides. I started riding 100-mile centuries in Zwift. I did one yesterday: 4 hours, 20 minutes. Phew!

However, I've noticed my left knee bothers me sometimes after these long rides. I can't tell if it's because of the bike fit on the trainer, or just pushing so hard for so long, without a break. I never have a similar pain riding in the real world.

So I've tried to troubleshoot this, and this year I'm experimenting with ramping up more slowly to the long, really hard rides. Not sure how well it's working, as I always have to fight my natural inclination to zoom off with the fast riders; it's hard to hang back and take it easy in the beginning.

Other than that, my knees are good. I walk half a mile to catch the train when I commute to work; when I work from home, I take two breaks during the day and walk almost 40 minutes during each. Motion is good. Sitting too long is bad.

What I've learned about my knees this year, I suppose, is that taking good care of them is a lifelong project. I don't need the same constant focus as when I lived in Hong Kong and battled chronic knee pain, but I am still alert to little aches, or feelings of instability, and I try to modify my behavior a bit before things get worse.

What about all of you out there? Anyone have any good lessons from this year to share?

In the meantime, happy holidays to all, and if I were a drinker (which I'm really not), I would make a toast to your good knee health in 2024!

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.

 

Calling All Readers! Any Questions Out There?

I'm throwing this post wide open, inviting any of you to contribute. I know I usually run these posts with the heading "Open Comment Forum," but in this case, I want to see how many readers are left out there (I know some have drifted to the exits over the years, hopefully as their knees have gotten better).

For years, I've talked about stepping back from this blog (I'm kind of talked out, and my knees aren't a problem anymore, so "Saving My Knees" is becoming more like a receding bad memory). I have cut down on the frequency of posts, but every time I'm ready to take a hiatus, it seems, there's a little flurry of book orders, and I think to myself, "Maybe those people will come here, looking for a place to turn, and find an abandoned storefront! That wouldn't be good!"

At this point I'm mainly interested in posting about three things:

(1) Success stories. If you have one, and haven't shared it yet and would like to, please post it below! It doesn't have to be, "Your book changed my life!" I'm not fishing for plaudits. Rather, I think everyone out there with hurting knees benefits from reading success stories. They're all a little different, and I think that's good, because knee pain, and the best ways to treat it, are all a little different. I like to turn success stories into posts.

(2) Questions from readers. People are often struggling with things, and I like to post the questions, as people who follow this blog may have answers. Of course I don't always. For example, if the question is "Has anyone had a bad experience with hyaluronic acid injections?" I'm not going to be much help, because I've never had the procedure. But others can chime in.

(3) New science/medical studies/research. I'm always watching to see if something new and interesting crosses the wire, as we say in the news business. So far, most of what I've seen over the last few years just reinforces the findings and the message in "Saving My Knees." And that's a good feeling.

So how about it? Any questions or untold success stories out there?