Knee Pain: The Dirty Little Secret

You have knee pain.

You got to a knee doctor. He examines you thoroughly, shrugs, and says, "I'm sorry, but you're not a candidate for surgery. I advise you to see a physical therapist."

So you go to a physical therapist, who prescribes some mixture of exercises and stretching. You dutifully follow the recommendations. You stretch quads. You stretch hamstrings. You even stretch something called an iliotibial band, which you didn't even know you had.

And of course you strengthen. You work on your quads. Maybe your hips and glutes too.

And you don't get better.

"Wow," you think. "I must be one of those really bad cases, one of the hopeless ones that can't be saved." You get kind of depressed. But then you cheer up a little. "Well, at least there's good pain relief medication nowadays," you think, chuckling blackly to yourself.

What can be done? After all, you've tried everything?

Right?

The only thing you haven't done is ask one simple question: "Why the hell am I doing all these things to fix my knees that don't seem to have anything to do with my knees?"

So you read some more, trying to make sense of a treatment protocol that never seems to try to repair what it should be trying to. Gradually, you gain an understanding of the model for knee pain: If you have knee pain, your body's out of whack! Your gait is wrong. Your patella doesn't track correctly. Certain muscles and tendons are too tight, or too loose, or too weak.

This explains all that advice to stretch and strengthen. Of course.

But then, you read and think some more. Are you really structurally out of whack -- or at least in a significant way that would cause problems? You find out a medical study discovered no link between mistracking kneecaps and knee pain. And why has following the recommendations of "structuralists" brought no relief?

Frustrated, you feel that you're right back at square one. Again you wonder: "If my knee hurts, why is my whole treatment regimen aimed at things that are not-knee?"

That's when you realize something. There are two good reasons for someone not trying to fix something that's a problem. (1) That person doesn't know how. (2) That person doesn't believe it can be fixed. And the second reason will reinforce the first. After all, why bother trying to find a way to repair bad knees naturally if you don't think such a thing can be done anyway?

Now you've discovered the dirty little secret in the world of knee pain. The prevailing school of thought is deeply pessimistic. Your knees aren't targeted directly because most doctors and physical therapists don't think that anything can be done to save them after the first signs of osteoarthritis appear.

Just listen to this guy:

Once [osteoarthritic] changes have started, there is no turning back unless there is a reconstruction of the bone surface with total joint implants, according to [Gregory Masiko, MSPT, Cert. ART, center manager at Excel Physical Therapy and Fitness in Glen Mills, Penn.] A treating [physical therapist] must tell patients that they are not affecting the arthritic changes within the knee directly, but instead are focusing on the tissue that both supports and governs motion at the joint, he stated.

It is true that bone spurs can't be exercised away. But the belief that nothing can be done for any arthritic changes, such as runaway inflammation or a deterioration in cartilage -- that simply isn't. Studies show that cartilage can heal, and that exercise induces positive changes inside the joint.

But the practicing medical profession appears to be a few decades behind researchers in the profession, who have made their hopeful discoveries since 2000.

Now you know.

How Real Is the Placebo Effect?

Did anyone happen to see the article "The Power of Nothing" in last month's New Yorker? (Here's a link to the abstract, but the full story is paywalled unfortunately.)

Very, very interesting -- and I'll return to its possible relevance for knee pain in a bit.

But first: what are placebos? Well, when we think of them, what usually comes to mind are sugar pills, or dummy pills of some sort, that contain no active medicinal ingredients. So in a clinical trial of Lipitor, researchers would test the actual Lipitor against a dummy pill, with subjects not knowing which they got -- real Lipitor or fake Lipitor. If there's a significant improvement in the Lipitor group versus the takers of the dummy pill, the drug company knows it's got a winner.

But what if you gave 100 people sugar pills that looked like Lipitor, told them they were Lipitor, and their cholesterol improved as much as if they were taking the real thing? Then you'd have a placebo effect at work.

Here are some interesting takeaways from the article:

* Some people respond better to placebos than others (and it may be for genetic reasons). Also some illnesses and afflictions are more amenable to the placebo response than others.

* A lieutenant colonel made an intriguing discovery during the Second World War, when 75% of gravely wounded soldiers -- men who, by all rights, should have been begging for pain relief -- declined morphine. He was astounded and concluded that expectations explained their seeming stoicism: because they had survived terrible attacks, they had positive outlooks. And so, our expectations can have a profound impact on how we heal.

* Why do placebos work? One explanation: the brain "produces its own pharmacy," secreting substances called endorphins that are chemically similar to opiates, like morphine. (In fact, in one study, patients who were told they would receive a painkiller -- whether they actually did or not -- experienced the same relief as those who secretly got between 6 and 8 milligrams of morphine.)

* The appearance of a placebo pill can matter: Larger pills produce stronger effects. Capsules work better than pills. Colored pills are more likely to relieve pain than white ones.

* The concept of "placebo" is a bit slippery: "For many people a placebo is just a sugar pill. For others, the definition includes the entire ritual of treatment, the complete interaction between doctor and patient."

One more thing: you'll be interested to know that one meta-study -- a study of many other studies -- found no evidence of a placebo effect with a couple of notable exceptions, such as "trials involving the treatment of pain."

Okay, what's all this have to do with lousy knees?

A few things, I'd submit:

(1) Certain knee pain treatments are considered effective by certain people probably because of the placebo effect.

To me, glucosamine is a prime example. As I explain in Saving My Knees, there's no reason it should work because the supplement you swallow gets ripped apart by your liver and little of it remains to circulate in the bloodstream. Yet I wish I had a dime for every comment I've read from a knee pain sufferer that goes like this: "Boy, when I don't take my glucosamine, I really feel it." To me this sounds like a classic placebo effect at work.

(2) Placebos have their limits.

They don't magically cure cancer. They don't even work for some people. Their efficacy seems to be highest for certain kinds of subjective ailments (and perception of pain is very subjective), and for a certain subset of the population.

(3) Expectations really matter!

While I'm not a believer exactly in "you create your own reality" (a certain amount of reality just happens, and you have to deal with it), the mind can be a powerful force. The placebo effect, in cases where it does work, shows that the mind can aid in healing or make pain more tolerable.

So instead of coming up with three reasons why your knees will never get better, come up with four reasons why they will. Instead of dwelling on what you can't do, figure out what you can -- celebrate it -- then figure out how you might be able to get from "can't do" to "can do" for what matters most to you, and sketch out a long-term plan to make it happen.

Put your brain's pharmacy to work -- for you.

Are Your Knees So Bad They’re Beyond Hope?

The idea for this post comes from a recent comment that went like this: “My doctor is negative about my knees, talking about bone on bone and osteoarthritis. Can I still benefit from your experience and methods and heal my knees?”

In other words, is there realistically any hope for knees that feel lousy pretty much all the time, that are missing a lot of cartilage, that are already osteoarthritic?

OPPORTUNITIES WASTED

First, a quick rant (some of you know this one by now).

I doubt that terrible, crippling knee pain (short of that caused by a traumatic accident) just steals into your joints in the middle of the night. It’s generally preceded by annoying, persistent knee pain. That in turn is preceded by occasional, nagging knee pain. And so on.

That means that, with knee pain that has steadily worsened over many years, opportunities have been squandered. Why do people waste good chances to get better early on? For many reasons, I suspect, but partly because of a grim fatalism that nothing can be done, that knees “just wear out.”

Of course that’s not true. You can reclaim a pair of bad knees (as I did), but it helps to act sooner, not later. You may have to swim upstream against the prevailing advice (with its focus on strengthening your quads, stretching your ITB, etc.). But you can do it.

Still, if you didn’t seize that optimal window to heal early on, are you doomed? I don’t think so.

THINKING OUTSIDE THE BOX

While struggling with my own recovery, I thought a lot about knees (way more than any human being should), and about how the body heals, and grappled with tough questions. For example: If damaged knees can heal (I firmly believe they can, after mine did), why don’t people who have really bad knees ever seem to get better?

Hmm.

If you believe that knees “just wear out,” it’s no mystery. The really bad knees never get better because that’s the immutable law of the universe, for them to get worse and worse, just as gravity exerts a pull that can’t be denied, no matter what your belief system. Case closed!

But if you’re an optimist on the subject, like me, the answer turns out to be more complex. I think people with really bad knees don’t heal for a variety of reasons: They become mired in pessimism. Their knees have changed permanently (bone spurs, for example) in ways that complicate or thwart healing. Or they’re not patient enough, radical enough, or creative enough.

The third reason (by the way -- that list above is not meant to be exhaustive, just a sampling of reasons) is the one I want to explore (the meaning of the other two, after all, is kind of obvious).

ON BEING PATIENT, RADICAL AND CREATIVE

Patient enough means girding yourself for a long process to heal. It took me the better part of two years. For someone with severe chondromalacia, I’m guessing it may take 4, 5, 6 years. And the hardest part would be the first year or two, I would bet.

That’s because the worse your knees are, the slower your gains. That was my experience. Early on, there were weeks, even months, when I wasn’t convinced I was really making significant progress. After about seven or eight months though, I could tell my plan was definitely working, and my rate of improvement was faster too.

Radical enough means you may have to make big life changes. I quit my job -- I know, not many people can afford to do that -- but sitting at my desk was contributing to the chronic inflammation that kept my knees weak. I couldn’t convince my doctors of that, but by then it was okay: I had done the research and felt confident that I was right. For other people, radical enough may mean giving up that second-floor bedroom for a while if your knees aren’t strong enough to climb and descend stairs.

Finally, creative enough is all about finding innovative solutions to vexing problems. You want to find a way to lighten the load on your knees? One commenter recently described how, for a while, he decided to use crutches. And he used a Bosu Ball at work to get in regular flexing of his bad knee. That’s creative!

When I wanted to move my knees a lot, but couldn’t do so without discomfort, I thought of making a poor man’s continuous passive motion machine (and went so far as to sketch out designs on paper). I never did try to construct it, but did create a rock-climbing-harness-and-bungee-cord setup in my mother’s garage that allowed me to do hundreds of deep-knee bends at a time, with little strain on my recovering joints.

PARTING THOUGHTS

Finally, if your knees are really bad, I would develop a long-term plan -- you’ll need it, because there aren’t any short-term fixes (short of surgery, which may or may not work). And I’d seek out a good physical therapist, someone who believes what Doug Kelsey and others at Sports Center in Austin believe -- that you can get better -- and knows the right path to take too.

For some more thoughts, check out this blog post. It’s my most popular ever, so it must’ve struck a chord with a few people. It will give you hope about cartilage repairing itself, even when you’re down to the bone.

One last observation: Even for the very worst knees, I’d be surprised if some improvements couldn’t be made. Even if your ceiling isn’t full healing, but rather living with 50 percent less pain, that’s an improvement!

How Worried Should You Be About That Creaking From Your Knees?

The crackling noise -- which in Saving My Knees I likened to that of someone sitting on a bag of potato chips -- is called "crepitus." This medical term means a "grinding, crackling or grating sensation or sound," so says this arthritis Web site.

The site also declares, incorrectly I think, "If it occurs without any pain, it is unlikely to be caused by arthritis or any medical condition, and is usually meaningless." A popular "save your knees" book on the market also asserts that that noise from your knees, unaccompanied by pain, isn't significant. I think that's wrong thinking, and dangerous.

What if you were a ship's captain and spotted a strong beam of light through the fog? If you continued on your way without incident, you might conclude that the light was meaningless. However, if you strayed too close to the light's source -- and wrecked your ship on the rocky shores that this lighthouse was trying to warn you of -- I think you'd argue the opposite: that the light was quite meaningful indeed.

Similarly, crepitus of the knee (note: I'm talking about a certain kind of noise here, not the airy pops or harmless cracks that all joints make from time to time) is a warning that something is amiss. Before I developed knee problems, I heard (and ignored) crepitus in my joints because there was no pain (so I figured, as the writer above tells us, that it was meaningless).

Big mistake. A few months later, I was in the fight of my life to rescue a pair of burning, aching knees.

So then am I advocating that knee crepitus become an obsession as you try to recover? Nope, not that extreme either. For two big reasons:

(1) You don't have to eliminate all crepitus to have happy joints again.

My knees still crackle some, though certainly less than before. Perhaps they always will. That's okay by me, if I'm not in pain. I do, however, make a point of listening closely to the crepitus occasionally, because when it starts getting louder, I know my knees are probably going in the wrong direction.

Remember, over the age of 30, most people have cartilage defects in their knees, and probably a lot have some kind of related crepitus. (You can hear minor crepitus if you bend over a subject's knee, so your ear is just above the joint, and have that person do a leg extension.) Back when I was thinking about doing a rugged mountain climbing event on my bicycle, someone who did the climb every year (and so trained a lot on hills) reported on a forum that his knees were very noisy. But he had no pain.

(2) Monitoring crepitus smartly is really, really hard.

Readers of my book will recall that knee noise was one of the variables I tracked and scored. In retrospect though, I'm not sure how useful that was.

Why?

Because the condition of damaged cartilage changes very, very slowly, so you're not likely to find significant differences, day to day. Because the noise appears to be a function of a variety of things (such as the quality of the synovial fluid at a given instant). From my experience, these other things are quite variable over the short term in ways that aren't easy to understand.

For example, even after an easy cycling session, my knees sound crunchier than usual. If my primary objective were to eliminate all noise from my knees at all times, maybe I'd stop cycling -- which would be a bad thing.

So, in conclusion, I think crepitus associated with cartilage damage is absolutely meaningful, even if you're pain-free. Ignore it at your own peril. But should getting rid of crepitus be the be-all, end-all of a program to heal bad knees? Absolutely not, in my opinion. I would focus on getting rid of pain. Strengthening my knees. Engaging in lots of knee-friendly movement and exercise.

And, in the end, after doing all the right things and getting better, I bet you'll find the crepitus has improved along with the rest of the joint.

Merry Christmas to All!

Yes, I know ... I'm a week early with the holiday wishes.

But let me explain.

My life has become very time-starved, with a 10-hour-a-day job and a sometimes difficult two-year-old now living with me (Joelle is the most beautiful little creature on earth, but when she does NOT want to do something, she summons the strength of a dozen grown men and lets loose a wail to wake the dead).

Not having enough time has encouraged me to be efficient. I try to maximize every minute of the day. During my half-hour lunch break at Bloomberg, I usually find a spot on a bench at the officer tower and write out blog entries, longhand.

I actually rather enjoy it, so no need to feel sorry for me (if anyone was). I start a post on Monday, scribble and revise and scribble some more until I finish, usually by Wednesday or Thursday. Then I tear the pages out of my notebook, tuck them into my backpack, and bring them home for typing up (and posting on the blog) over the weekend.

At least I usually do. This week I goofed. My entire mini-essay on crepitus is, as I write this, sitting in a desk drawer on the empty 25th floor of 731 Lexington Avenue. It never made the trip home because I got distracted right after lunch and forgot it.

So I decided to flip things around. Next week I was going to do the "Ho, ho, Merry Christmas, and may all your knees stop complaining for one weekend!" Instead, I'll do that now -- consider it done -- and next week, I'll let you know what I think about crepitus.

One last thing: a huge thank you to all who have dropped by this site over the past year, and who have taken the time to review Saving My Knees on Amazon. Even if a single copy of the book never sells again, its popularity has exceeded my expectations.

And, finally: Does anyone out there have an uplifting story they want to share? I'd love to hear from others who have had success with their knees. How? What did you do? Please let me know below. I'd love to do a blog post on this. Let's share our knowledge of what works!

The Last Ride of the Season

On Dec. 4, at quarter to noon, I unclipped from my bicycle for the last time in 2011.

November turned out to be a better month than expected. I managed to ride every weekend. I stretched my rule of thumb on weather a little ("never go out on a day when the temperature is below 40 degrees"), as I found that through smart layering of the right clothing and diligently keeping extremities (toes, fingers, head) as warm as possible, the cold didn't bother me as much as last year.

Still -- there reaches a point when all the bundling gets to be a bit much, and the quality of the ride deteriorates anyway (I was out in front Sunday, doing no more than 22 to 24 miles an hour for a stretch, and looked back to see the group had lazily drifted off my back wheel -- that never happens on a July ride).

So now I plan to take at least four months off, to focus on easy spinning in the gym, on a stationary bike. It gives my knees a bit of a breather. Because here's the dirty secret: the kind of intense once-a-week riding that I do is not the best thing for a pair of knees fresh off recovery from chronic pain.

I do it because I love it so much -- and I love the super feeling that comes from this high level of conditioning. I do it because I'm confident I can recognize the danger signs, if my knees start to get in trouble again. This year, I was heartened by the fact that, when the season ended, my knees felt better than a year ago at the same time.

And yet -- a couple of weeks ago, I happened to bend down after a cycling session and heard some extra crunchiness from my right knee. That got my attention.

Which brings us to:

What is that crunchy noise from your bad knees? How concerned should you be about it? How important is it to monitor that crunch, as you try to heal? What's it trying to tell you?

Next week, I'll give you answers based on my own experience.

What's Going on With Chronic Inflammation?

Sometimes you ask a question rhetorically, to make a point. Other times you ask out of legitimate curiosity, like today.

When I had constant knee pain, I was pretty certain that chronic inflammation had set in, from the burning sensations that plagued me so much of the time. And I was quite curious about what that implied for my prospects for healing.

Nothing good, I concluded after doing some reading about inflammation. There are a couple of types, almost like cholesterol. There's the good inflammation, that occurs in the aftermath of an injury and signals the body to speed "troops" to the area to spur healing. Then there's the bad kind that spirals out of control and leads to further problems (arthritis pain research has shown that a pro-inflammatory molecule called Interleukin-1 stimulates the synovial cells to produce more of the enzymes that degrade cartilage, and also inhibits the creation of new tissue).

My research into inflammation never went very deep though. I did learn enough to know that there are plenty of mysteries about chronic inflammatory processes. Battling bad knees, I became preoccupied with two questions. They are below, and anyone with insights (or other questions), please feel free to chime in.

1. Can chronic inflammation in the knee joint spread to other parts of the body and even become systemic on some level?

I once mentioned this to a general physician, who quickly pooh-pooh'ed the idea. But I still wonder. The internal plumbing of our bodies is all connected, after all. The knee -- or any other part of the body -- isn't "firewalled" off from any other part.

Readers of Saving My Knees will understand why I'm asking this. The book describes my battle with problems in multiple joints -- elbow tendons, back, knees. Were they all really completely unrelated? Or did the chronic inflammation in my knees, after a long enough period of time (about a year) make me more susceptible to other joint issues?

At one point I thought I had rheumatoid arthritis! So did my father, frankly (a blood test ruled it out). While writing the book, I was a bit worried that the multiple joint problems would somehow undermine the authenticity of my story, or lead people to think, "Oh, he didn't have chondromalacia, he had something else." Then, months later, when discussing the book online, I found lots of other knee pain sufferers who thought they too might have had rheumatoid arthritis (but didn't). My story become more authentic, not less.

2. If chronic inflammation is bad, then shouldn't anti-inflammatory medication be good, if you want to heal?

I began by asking doctors a variation of this question. I wasn't interested in anti-inflammatories for their ability to mute pain signals (which is why most people like them). I knew they did that. I wanted to find out if they'd help my injured knees to heal. On this, the doctors seemed uncertain.

The more I thought about it, the more I saw evidence of a tradeoff. Perhaps anti-inflammatories would slow the degradation of cartilage, all else being equal. But all else wouldn't be equal. Anti-inflammatories would trick my knees into thinking they felt better than they really did, and thus might encourage me to do stupid things (walk too far, sit too long) that I otherwise wouldn't. These activities might cause further damage inside the joints.

I did take a prescription anti-inflammatory once, an experience I mention in the book. It allowed me to sit at work with less discomfort, but the next day my knees felt a little worse. Had I taken enough of the pills, I probably could have run a road race, but what price would I have paid afterwards?

Still, I think an intriguing question remains: If it were possible to take anti-inflammatories that didn't dull the important signaling to "not do this and not do that" that's coming from your knees (of course this would be medicine that didn't offer pain relief, so who'd take it?), would the medicine then help slow the rate of tissue breakdown, or help you heal?

Maybe yes, maybe no. I'm not sure.