If You’re Resolved to Have Surgery or Medical Treatments, Here Are Options to Consider

I’m not a big fan of surgery for chronic knee pain, to put it mildly. Some procedures absolutely make me shudder (“lateral release,” e.g.). Others I imagine could be useful, in certain circumstances.

If I were desperate enough to seek a medical intervention, I’d favor something as natural as possible. That means a procedure that encourages my own body to turbocharge the healing process.

With that in mind, here are treatments worth looking at (Note: that’s not an endorsement of any of these, and anyone with knowledge of, or experience with, any of the following, please add your thoughts below). Also, important caveat: These procedures are more for problems with tendons and ligaments than cartilage, as far as I can tell.

(1) Prolotherapy

I was first introduced to this on Doug Kelsey’s (now defunct) blog, The View. As many of you know, I have tremendous respect for Kelsey, whose thinking about chronic knee pain greatly influenced me during my recovery.

Kelsey’s genius on matters of physical therapy probably derives in part, unfortunately, from his own misfortune -- he has a number of ailments, including a knee problem of his own. Anyway, he underwent prolotherapy.

My understanding is that the treatment involves a series of shots that cause an inflammatory response in the body’s tissues that spurs healing. It is painful, apparently! (Inflammation often is.)

(2) Injections of platelet-rich plasma

Scientific American took a look at this treatment almost three years ago (not the freshest information, but a decent place to start). A small vial of your blood is spun in a centrifuge to separate out the platelet-rich plasma, which is then injected into the injured tissue.

The theory behind why this should work: The injured areas, such as tendons, have a poor blood supply, so healing sometimes becomes difficult. The concentrated platelets in the plasma bolster the nutrients and growth factors at the site, aiding healing.

Notice the word “theory.” “PRP” has its skeptics. Still, the doctor in the Scientific American article said that, of his patients who have undergone it, maybe 60 percent have gotten better.

(3) Whatever Kobe Bryant had done

Bryant, of course, is the NBA superstar who plays for the Los Angeles Lakers. His right knee, under the kneecap, is missing so much cartilage that it’s practically bone on bone, he has said. He flew to Germany for treatments that apparently worked wonders, leading other athletes to make the pilgrimage to the same doctor, hoping for similar results.

What’s the procedure? Apparently it’s a more vampiric undertaking than PRP (“as much blood as they took the first day, I didn’t think I’d have any left,” said this patient). Again, the blood is centrifuged, but heated first, because the objective is to capture anti-inflammatory proteins, rather than platelets. The resulting orange serum is then injected into the ailing joint.

So there you have it. Three novel treatments worth a look (if you’re resolved to have some kind of treatment anyway). Anyone familiar with any of them, feel free to share your thoughts below.

The Importance of Setting Realistic Goals

Not long ago, a colleague at work turned to me and said, “I’m going to lose 20 pounds by July.”

I had a pretty good idea what was going on.

Most of us employees had signed up for free, company-provided health screenings. These consisted of a finger-prick blood test for cholesterol and glucose levels, a blood pressure check, and a weighing.

His weighing showed that a sedentary desk job and a fondness for pistachios had caught up with him. (Note: If you want to gain weight, just eat in front of your computer while working. You’ll enjoy the food less and eat more. I guarantee it.)

Losing a few pounds is certainly a laudable goal, especially when you find yourself on the wrong side of your ideal weight. But in his case, he had given himself two months to achieve something that most people would find extremely difficult to accomplish in six.

I remember expressing skepticism that he could lose so much weight so fast. Inside though, I was thinking something more like, “If you do lose 20 pounds in two months, I’ll eat my keyboard.”

About a week later, it was clear my keyboad would remain intact. I spied him gobbling pistachios again, the weight-loss resolution apparently a dim memory already.

When you set an unrealistic goal, I think you’re basically setting yourself up for failure. Further, failing at something is no fun, and just erodes your self-confidence.

With overcoming knee pain, this issue is particularly acute. That’s because the key bit of traditional advice for beating knee pain -- “strengthen your quads” -- mentally conditions you to expect a recovery on the wrong time scale.

Muscles strengthen relatively quickly. Knee joints don’t.

So, not knowing any better, you think: “I have chronic knee pain. If I strengthen my quad muscles, I can escape it. I’ll devote myself to a two- to three-month quad-strengthening routine. Then I’ll feel fine again!”

My bet is you won’t though. My bet is (if you really have chronic knee pain that’s been troublesome for a while), you’ll need six months. 9 months. 12 months. A year and a half. Two years.

But suppose you proceed with this unrealistic goal of healing in two or three months. After a month, when you realize you’re nowhere near being halfway healed, you may despair and think, “That’s it. There’s no way my bad knees can be fixed.”

So you give up, having decided you can’t reach a goal that was never realistic to begin with.

Of course your problems are really twofold. Your larger problem is arguably that you’re following the wrong path (focusing on strengthening muscles instead of the joint). Still, even if you get on the right path, chances are good you’ll flub your recovery if you begin with the promise of unrealistic expectations.

Why Many Knee Studies Are Seriously Flawed

I’ve cited many knee studies on this blog, usually to buttress some point I’m making.

But I’ve also come to the conclusion that a certain kind of knee study has to be approached with much caution. That’s because it suffers from serious and intrinsic flaws.

First, let me be clear what I’m not talking about: so-called “natural” studies that, instead of testing a hypothesis, look at say how knee cartilage changes over a two-year period, and how characteristics of subjects such as age and BMI influence those changes. (Fortunately, one of my favorite studies falls in this category: the two-year study by Australian researchers showing that, in a whopping 37 percent of subjects, a cartilage defect actually improved somewhere in their knee.)

The kind of study I'm talking about is more ambitious. It attempts to prove a link between some activity X and the health of your knees. And it suffers from serious limitations.

To see the issues, let’s create a fictitious study that has a sensible premise: it sets out to prove that walking benefits bad knees.

Researchers round up 600 subjects with knee pain and split them into three groups. Group A doesn’t walk at all for exercise, Group B walks 1-7 miles a week (as much as a mile a day), Group C walks more than 7 miles. And, to better capture long-term changes, the researchers decide to observe the subjects’ knee joints at the beginning and end of a 10-year period.

Okay, why is this study already in trouble, just by design?

(1) There’s no way to account for “category drift.”

Lives can change a lot over 10 years. A moderate walker may become a super walker -- or a nonwalker. Or someone may jump back and forth between these three categories quite a bit.

What if a moderate walker for nine years becomes a nonwalker in year 10 -- which happens to be the same year he’s surveyed by our researchers about his level of physical activity? If his joint health turns out to have improved, the results would be recorded under “Being a nonwalker is good for your knees.”

That makes no sense, because for 90 percent of the study’s duration he was a moderate walker!

(2) The big problem: Exercise is only a small part of how someone uses their knees in daily activities.

Consider this math: Let’s say you’re awake 16 hours a day. Let’s say you walk a mile a day for exercise and that takes 20 minutes (that’s a three-mile-an-hour pace -- not too demanding). So if you do the math, how much of each waking day are you exercising by walking?

Barely 2 percent.

Which raises the question -- what are your knees doing the other 98 percent of the time? This matters hugely! Because if "walking for exercise" is the variable that is being studied, then what's going on during the other 98 percent of the day is going to contribute to “variable pollution," contaminating the findings.

(Question to ponder: If subject A has a job where he walks several miles at work, but doesn’t walk for exercise, while subject B is deskbound but walks a mile a day for exercise -- who’s really doing more walking?)

(3) The study never makes adjustments for what level of activity (and type of activity) is appropriate for each particular subject.

Say Mary walks one mile a day, which puts her in the “moderate activity” category. At the end of the 10-year period, an MRI reveals her knees have gotten worse. So should her example be used to support the thesis that “moderate walking is harmful for people with bad knees”?

Not necessarily.

Maybe Mary’s joints are so bad that she needs less walking, or shorter bursts of walking, until she can strengthen them. Maybe, had she been in a group that walked only one-quarter mile daily, while taking 60 steps around her room every half hour, her knees would have gotten better.

It’s sort of useless to create a study to draw conclusions about how much of activity X is beneficial when you have no idea how much of activity X each particular subject should be doing (which depends on the strength of their particular joints).

Okay, those are some reasons why I consider many knee studies badly flawed.

Now it’s time for a visit from my imaginary critic:

Great, so researchers shouldn’t undertake a study unless it’s perfect? Subjects’ environments must be totally controlled for all variables? That’s ridiculous. You can’t find any study that meets those high standards. Basically, you’re throwing a lot of good science out the window.

My response: Yes, the perfect is the enemy of the good.

But showing how the good can be flawed -- and sometimes, not be very good at all -- isn’t meant to be an exercise in nihilistic nit-picking. Recognizing that serious flaws exist for many knee studies, and knowing what they are, means you can better evaluate to what degree the study you’re looking at may have escaped those problems.

For instance, category drift will be a bigger issue with a longer term study that samples a subject’s activities at only one point in time. So that may argue for the superiority of a shorter term study (which has its own drawbacks, true).

My message here, once again, is about thinking critically. There’s so much bad and suspect information about healing chronic knee pain that we’re foolish if we don’t think critically.

Handling Setbacks on the Long Road to Healing

The question of how to deal with setbacks came up recently in the comments section. It’s a great question because I doubt even the smartest, most patient person can navigate a healing process that spans many months without a single setback.

First, why are setbacks so bad, when it comes to overcoming chronic knee pain?

They’re depressing. Really depressing. It’s not like you were healing that fast to begin with, right? So you feel a little better after two months of doing all the right things, then do something wrong -- you may not even be sure what -- and suddenly you hurt as much as you did before.

Argh. Bad knees are forever, you start thinking to yourself. At this point, you’re particularly prone to negativity, self-pity, and a bunch of other bad feelings.

Also, at this point, you’re prone to abandoning what works. After all, you tried to improve your joints very, very slowly, you were feeling somewhat better, then an ill-advised hike/long walk/sprint to catch the bus set you back.

Maybe you start thinking: “This program can’t be working -- it’s too slow and if my joints are getting stronger, how can a little x (whatever the offending activity was) cause such problems? Ah, forget it. It’s time for surgery/pain medication/a life of doing whatever I want because it doesn’t matter anyway.”

You feel lost, not knowing how far you were set back. To me, this is a big issue, especially when you’re measuring hard-fought gains in inches, figuratively speaking.

Obviously, you want to get back on track. But do you take a few easy days? An easy week? Should you return to your program of three weeks before, when you were taking 20 percent fewer steps each day? Or do you need to hit the reset button more dramatically, and go back three months, maybe to when you weren’t even taking long walks yet?

These are frustrating, demoralizing questions to deal with. You’ll want to downplay the significance of the setback. You’ll want to act as if you were less affected than you really were -- which raises the risk of doing more damage to your joints.

Okay, that’s why setbacks are bad, in my opinion. Now, how to deal with them?

Make sure they don’t happen.

No, that’s not meant to be a “d’oh” statement. Because I believe you really need to be thinking hard about not pushing your knees too much.

So this means (1) Err on the conservative side with activity. (2) Monitor your knees very closely. (3) Learn as much as you can from whatever setbacks you do have. Failures are never wasted when they’re recycled into knowledge (that in turn prevents future similar failures).

Recognize and accept the setback.

The worst thing, I think, is pretending it never happened and just merrily going on with your existing program, not changing a thing, not reflecting on how and why you screwed up. Because then your knees may just get worse and you’ll be no smarter for what you just went through.

Instead, my advice is to face it head on. You may be lucky -- maybe you just need to take an easy day or two and you’re right back on track. If not, you’ll probably have to experiment a little to figure out what level/type of activity your suffering knees are now happy with.

Know you’re in good company.

I had setbacks. And I bet that almost everyone whose knees healed over a 12-month-plus timeframe had at least one setback. They happen. So it’s good to be philosophical about something that’s practically inevitable.

Some years ago, I remember getting very angry at myself for losing/misplacing something. How could I be so stupid? Then I decided to take a larger view of the situation, and it relaxed me somewhat. The larger view was this: Over the course of anyone’s life, that person will lose or misplace a certain number of things. So, unless I lose personal items at an extraordinarily high rate (suggesting say Alzheimer’s), the occasional object that goes missing is just me filling my cosmic quota. :) No big whoop.

Cry if you need to.

Throw something across the room. Curse the unforgiving God of Bad Knees for not cutting you a break.

After all that, figure out how to get back on that slow path going forward. Because that’s the only way to go, isn’t it, if you want to win back your old life?

Healing Knees and Closed Chain Vs. Open Chain Exercises

This is a continuation of last week’s post, a success story with a twist near the end. Pat, who was suffering from knee pain, met a physical therapist who, upon hearing of how she improved by “walking small steps” around her apartment, approvingly said, “closed chain.”

So what are “closed chain” exercises, and are they the key to chasing away knee pain?

I had come across the closed/open chain terminology before, but never bothered to really look into it. Generally, I distrust geeks bearing jargon. I’m an Occam’s Razor kind of guy. When simple reasons explain phenomena as well as complex, why not keep it simple?

So I delved a little into the book, Closed Kinetic Chain Exercise: A Comprehensive Guide to Multiple Joint Exercise. I was far from an expert on the subject, but the same surely couldn’t be said of authors Todd Ellenbecker and George Davies.

Open-chain exercises, they tell us, isolate joint and muscle movements. Further, the movement pattern is “often nonfunctional.” And the “distal end of the extremity is free in space.”

To understand these points better, consider a pure open-chain exercise -- the seated leg extension (that’s the one in the gym where you straighten your bent leg forward, against the resistance of weights). The “distal end” of the limb (that would be your foot) is out there in open space, not fixed to anything. The exercise recruits only a few muscles and joints. And functionally, well, it’s pretty much useless, unless your daily activities entail punting a football repeatedly.

So that brings us back to closed-chain exercises (such as squats). Are they then superior? Sure sounds like it.

However, it turns out that things aren’t that clear. Here I’m just going to step back and let the authors of the book explain.

First, the functional vs. nonfunctional distinction doesn’t exactly hold up after all:

One of the common arguments against the primary use of open kinetic chain exercises in the lower extremity is that they are not functional. For example, there are limited instances in the lower extremity where an individual functions in a seated position bending and strengthening the leg ... Closed kinetic chain exercises are considered to be more functional, because they closely simulate the actual movement patterns encountered in both sport and daily activities.

Analysis of most functional activities reveals that they are, in fact, a series of successive open kinetic chain and closed kinetic chain motions. An example is the normal gait cycle. During walking, approximately 65% of the gait cycle is weight bearing (closed kinetic chain) and 35% is non-weight bearing (open kinetic chain). Interestingly, during running, the percentages of closed and open kinetic chain motions essentially reverse.

Further complicating matters:

Activities progress along a continuum from closed to open kinetic chain, with many activities of daily living and sport activities incorporating components of both. For example, during the gait cycle, the stance phase is a closed kinetic chain pattern, whereas the swing phase is an open kinetic chain pattern. Another example that shows the interplay between these two movement patterns is riding a bike, during which the foot is fixed on the pedal in a closed kinetic chain pattern, yet the pedal and foot freely move in space. Another example is skiing, where the feet are fixed to the skis (closed kinetic chain), but the skis move on the snow and are not fixed to an object (open kinetic chain).

What’s more, some purported benefits of closed-chain exercises may not actually exist:

Many clinicians have assumed that in the closed kinetic chain position of the lower extremity there is automatically a resultant co-contraction of the muscles that should dynamically stabilize the knee joint. Although some studies did demonstrate this phenomenon, several recent studies actually refuted that significant co-contractions occur with some closed kinetic chain exercises.

Finally, in conclusion, I found this quoted comment (my bold) from other researchers (cited as Snyder and Mackler; sorry I didn't get the full footnote) quite interesting. It refers to rehabbing after surgery to repair the anterior cruciate ligament, but I think the phrase “after reconstruction of the anterior cruciate ligament” could easily be replaced by lots of other phrases, such as “for patients with chronic knee pain.”

Rehabiliation after reconstruction of the anterior cruciate ligament continues to be guided more by myth and fad than by science ... The present study ... suggests that closed kinetic chain exercise alone does not provide an adequate stimulus to the quadriceps femoris to permit more normal function of the knee in stance phase in most patients in the early period after reconstruction of the anterior cruciate ligament.

Now if all this “open chain” vs. “closed chain” stuff sounds a bit faddish, well, the physical therapy trends (according to the authors) looked like this:

1970s Functional rehabiliation
1980s Open kinetic chain exercises (with emphasis on isokinetics)
1990s Closed kinetic chain exercises

How’s that for inducing whiplash? The same physical therapist you saw in 1985 who was saying, “You gotta do open chain, open chain, open chain,” ten years later was probably saying, “You gotta do closed chain, closed chain, closed chain.”

My personal take is that you need to do gentle, high-repetition activities (and if they’re functional, so much the better) to heal bad knees, giving yourself lots of time to achieve results. I wouldn’t worry too much about where my activities lie on the open-closed chain continuum.

Full disclosure: I own a bike chain. I like it. It gets me places. :)

A Quick Note About Drive-By Comment Spam

Happily, the pageviews have been rising for this blog.

Unhappily, that has drawn some opportunist spammers. They leave what I consider "drive-by" spam. It usually goes like this: "I found this article informative and useful for knee osteoarthritis," with an embedded link on "knee osteoarthritis" that leads to some surgeon's website.

Whenever I find this kind of comment, I delete it immediately.

Here are the ground rules:

I have a high tolerance for many different kinds of negative and critical comments. You can even call me an idiot (I'd rather you didn't, but if you feel that strongly ...). As long as you're not offensively profane, I won't delete your comment.

And I don't mind if you make a remark relevant to the blog post and mention a book that helped you heal. Or even if you mention you wrote a book that might help others heal. Or even if you know a doctor who might help others, and include a link to his (or her) Web site.

I'm more interested in whether you're contributing in some way to the dialogue. But when someone writes a throwaway line like "Great post! I like it a lot." and scatters similar comments across multiple posts, with links to a Web site, it's clear they're not interested in participating in a dialogue. They've just been paid to hawk someone's product.


That, to me, is spam. I report it as such. So spammers be forewarned.

Yet Another Success Story

I love success stories. I especially love it, of course, when they validate my own thinking ;), but any good story will do. Let’s share what works!

Here’s a gem from “Pat” that I recently discovered among the comments. I’ve edited it a bit, mainly for length.

I had a Synvisc shot (3 in 1) November 30 and had virtually no relief. Regular PT of the quad strengthening type did not help. End of April of this year, I was certain I needed a total knee replacement (4 surgeons concurred I have patellofemoral arthritis of my left knee). 

By chance, I found your little ebook on Amazon at that time and read it in a couple of hours. I scoffed at the idea that I could recover as you had done because I couldn't really walk at all on hard ground without excessive pain. I had a limp. I had almost fainted from the pain at the market the week before. But I said what do I have to lose -- nothing else had worked -- so I started padding around my apt. wood floors in my bare feet, since barefoot had always felt better than shoes. 

At that time I was so close to scheduling TKR surgery that I had grab bars put in my shower in the beginning of May. Believe it or not, within a couple of days of starting to walk 60 steps every hour or so around my apartment, I started to feel much better -- almost right away, really. 

Then within a week or so by a great stroke of luck I met a woman who had been scheduled for TKR with my same surgeon (coincidence), and she had found a physical trainer very near where I live in Santa Monica, CA, at a place called Drive Cardio. This guy she said had virtually cured her -- she was leaving the next day on a 3-week hiking trip in Turkey. 

I started seeing him and told him that walking small steps had started to help me. He said "closed chain" (I don't know this stuff) and I have continued to see him once a week. He does different things every time -- uses a bosu ball, a stability ball (small "micropushes" with it against a wall), etc. Every week is usually a new series of movements in different order and different intensity. He says what's important is increasing "vascularity." 

I am doing more strengthening stuff each week but it's been very gradual. Certainly not the kind of quad strengthening I had been doing before. I continue to walk around my apt. but I can also walk outside now without pain and use cardio machines which I couldn't use before. 

My recovery was so fast after reading your book, maybe because I didn't have a long history of pain -- only since Nov. 2011. Last week I went on a short trip to Vegas and walked pretty much all day for 3 days. I still have a tiny bit of pain in my knee here and there but it's more like a 1/10 versus 6/10. Am even feeling well enough to plan a trip to Europe this fall. 

I feel so grateful for having chanced upon your book. I've recommended it to others. By the way, I'm a 66-year-old woman. I should say I was quite flexible and athletic for my age before my knee pain.

Hooray!

Okay, a few comments:

I’m glad that walking around the apartment in short bursts provided such rapid, positive results. Sounds like that therapy fit Pat perfectly! However, other knee pain sufferers won’t see benefits that are that fast or remarkable -- so keep that in mind, everyone. All bad knees are different.

My favorite part of the story: She’s 66! And considering a total knee replacement! This is someone at the age where I’m sure many doctors would wag their heads sorrowfully and say, “I’m sorry, you’re just too old, your knees will never get better.”

But they did.

Let me be clear. It’s not that I think age doesn’t matter. It’s that I think age matters much less than the medical community currently thinks it does. You don’t suddenly lose the ability to heal when you reach 40, or 50, or 60. Maybe you heal more slowly. But you can still heal.

Congrats to Pat on finding a physical therapist whose approach suits her (and her bad knee). The description that struck me the most about his program was “very gradual.” The proper way to heal knees, I’m convinced, is very, very slowly and very, very patiently.  

I was intrigued when she said he counseled “closed chain” exercises. I had heard some about these, but had never looked into them. So I did. Next week, I’ll tell you what I found.

Cheers!