Why I Don’t Try to Convince Others of What (I Think) I Know

I thought I’d heard about every question under the sun about chronic knee pain, my experience with it, and what I learned. Then I got this question, which I found intriguing. It got me thinking:

I'd be curious to hear if you or any readers have successfully convinced their doctors/therapists that anterior knee pain is mostly mistreated. I've begun to introduce ideas like envelope of function and how a joint first approach trumps addressing biomechanic irregularities. All of my therapists entertain the discussion and do not dismiss me, which I greatly appreciate. However, none have embraced those ideas. Frankly, I understand why. It feels like the height of arrogance for a patient to tell a doctor they are mistreating people. I feel like the crazy patient sometimes. Still, I feel compelled to convince medical professionals they are treating the most common type of knee pain incorrectly. Has anyone successfully convinced their doctors? Richard, do your doctors in Asia know you wrote a popular book on the subject?

A lot to unpack here.

First, I’m not surprised your therapists “entertain the discussion” and “do not dismiss” you. This sounds much like my physical therapist in Hong Kong, as I mused about various ways to treat my pain. But I reached the point where I think I could’ve told him that aliens were beaming me messages from deep space, and he would’ve murmured with a similar understanding.

So I would counsel against mistaking superficial “understanding” with an openness to changing deeply held beliefs.

And, as for whether my doctors know I wrote a popular book on the subject: Sadly, it’s only been sort of popular (sales are a pale fraction of what Stephen King’s next novel will do). And I assume, no, they don’t know. I have made no attempt to tell them. I don’t think it would matter much if I did.

So, to get to the real question: Why not try to spread the word to doctors and therapists that there are some serious problems with their approach to knee pain?

* I don’t proselytize about knee pain. It’s a waste of time, really. When people in the real world ask me about my experience, and they seem genuinely interested and open-minded, I’m happy to share.

Also, I wrote a book, and that’s my rather long argument about knee pain. Naively, I wrote the book thinking that everyone who suffered the same kind of lingering, hard-to-treat pain would find the book a nugget of gold in a slag pile of outdated thinking.

Of course they didn’t (check out my one-star reviews on Amazon – fortunately, not too many, but there are some). I made a kind of solipsistic error, I suppose, in thinking that most people would be like me and would approach the problem the same way, with the same kind of “I’ll beat this if it takes 20 years” determination, and willingness to entertain theories that deviated from the mainstream.  

* Can you really tell doctors anything? I’m only being a bit facetious. You, the patient – the one supposedly seeking advice from them – are trying to tell them they’re wrong? Because you saw something on the “internet” and Googled a few research articles? And meanwhile, they see knee pain patients day in and day out; they took the med school courses; they cut open the cadavers; they did the grueling residency.

I do believe the smarter doctors – and I think there are a good number – do realize the human body is maddeningly complex, that they don’t know perhaps as much as they wish they did, that they can learn from patients as well as pass on learning to them. I’ve had people on this blog say that they’ve shared some of my ideas with doctors, who say something like, “That makes sense.” That’s at least with regard to high repetition, low load exercises like walking.

* But they often aren’t willing to go much farther. Well, why not? Why not wonder if they don’t have an accurate picture of knee pain, and how damaged cartilage can be made healthier, or even restored?

Well, in part because I think this demands an exceptional individual, honestly. It demands a kind of radical curiosity, along with a sh*tkicker willingness to discard an accepted orthodoxy. And that’s hard. That’s very, very hard. How many people do you know who are willing to jettison a whole knowledge base – you know, put it up for intense examination, then toss it out the window if it seems flawed?

As a species, we’re invested in our narratives, our beliefs, our received knowledge.

I think stretching is a great example. My sister-in-law is a personal trainer. I think she’s a smart woman. She’s asked me about my knee pain before, and I’ve told her my story. I’ve also said that I think stretching is probably a waste of time (though, again, by all means, if you like to stretch, and it feels good and you’re not doing any contortionist stretching, it could well be fine for you or at least not harmful).

At that point, I can see her shutting me down. Stretching a waste of time? This is a heterodoxy of a high order indeed. So I could point her to studies that I’ve read, but why bother? On this point, she’s basically signaling, “Whatever you say on stretching, I’m not going to believe it.”

And why should she? Imagine you’re a personal trainer. You learn all these cool stretches. You share them with your clients. You trade stretches with other personal trainers. You are an expert in stretching! This has worth in your world. And then someone has the audacity to come along and suggest it may not be valuable after all! Why would you think about abandoning this thing you are so deeply invested in?

* I do sometimes wonder how money might be distorting all this, at least a little.

Think about it: If cartilage can heal (if slowly), why would anyone but the impatient (I suppose there are plenty of those), get a cartilage replacement? So all the surgeons trained to do those operations, all the companies that culture cartilage cells for implantation – how are they going to support themselves and be profitable?

I realize this has a deeply cynical, even conspiratorial ring to it. I don’t mean it to sound that way. But honestly, who’s looking into natural cartilage restoration? Where’s the money in that? There are financial incentives in this world, and they can at least subtly flavor how orthopedic surgeons view things.

Anyway, goodness, this has gotten much longer than expected. For me the bottom-line answer to the question posed above, I suppose, is I wrote a book. I’m immensely proud it has helped some people.

I don’t feel the need to convince anyone at this point. For a while, I did, and I was passionate (almost to the point of tears) about my story. But now, I guess my story is receding into the long narrative of my own life, as my knees have been fine for over a decade. I don’t want to get into a debate with people who swear by glucosamine, or who don’t think cartilage can get better.

Heck, just last week I saw my wife had bought some knee joint pills. If I were a zealot, I guess I’d go in and give her a long explanation why I think she’s wasting our money, and why I doubt she’ll find relief. But there’s no need to. If she wants my opinion, she knows where to find me (under the same roof). Hah!

A Few Thoughts on Knee Surgery

I got this comment recently:

I have been struggling with knee swelling/pain sporadically over the past 7 years and got frustrated with the Ortho's recommendation of RICE... I finally got an MRI and found out it is a real problem - stage IV Chondromalacia, no cartilage in part of my knee joint. I found your book on google and then Doug Kelsey's book and now I'm starting online therapy with the PT he recommends - I'm so grateful. What I'm curious about is if you've known much success of people in their mid 30s in surgery. I seem to see pretty low success rates so I'm not seeing the point of paying a ton in surgery... any thoughts?

Ah, surgery. That's a big topic. 

I considered it once myself. I'm so, so, so glad I didn't go through with it. However, I don't mean to imply it's the wrong course of action for you. I wouldn't try to judge what's best for you.

First, I guess it depends on what kind of surgery. There's a kind of "I'm going in to have a look around and clean up the joint" surgery that I, personally, would run like hell from. Studies have shown this surgery isn't any more effective than conservative treatment of the bad joint.

But if the surgeon wants to perform a microfracture, where he creates holes in the bone to spur bleeding and prompt cartilage regrowth in an area where there's no cartilage, that's different. Is that worth it? Well, I guess it depends. Cartilage, it appears, can grow naturally even where there's bare bone -- just consider this study.

Still, is the replacement cartilage that regrew in this study fibrocartilage? Would a microfracture get you better cartilage, and faster? That's something for you to discuss with your doctor certainly, but I'm just letting you know what I know.

Notice I haven't said anything about your age. I honestly don't think there's much difference in your chances for a successful outcome between mid-twenties, mid-thirties, or mid-fifties, if you're healthy and committed to doing the right things to aid in your recovery.

Also, this person wanted to know whether I had an MRI and what did it show?

I've written about this extensively, as the question comes up frequently. So I'll just send you here for that answer.

One final observation on surgery: if you do have surgery, my personal observation is that the biggest mistake people make post-surgery is doing too much, too quickly (shamefully, I think their physical therapists are partly culpable in this).

So, if I did have surgery, I would go very, very, very slowly in my recovery, even if my knees felt great.

The Times Helps Repudiate the Belief in Muscle Strengthening for Bad Knees

It’s great to see another news article, this one in the New York Times, ratifying the central message of my book, which of course is drawn from my personal experience beating knee pain.

The article begins simply enough, with a familiar bit of received knee pain "wisdom":

The idea made so much sense that it was rarely questioned: exercise to strengthen muscles around the knee helps patients with osteoarthritis, making it easier and less painful to move the inflamed joint.

So a professor of biomechanics, Stephen Messier, decided to test this belief. He ran an 18-month clinical trial with 377 people. One group lifted heavy weights three times a week, while another did moderate strength training, and the third was simply counseled on “healthy living.”

If strengthening muscles around the knee joint is the solution to chronic knee pain, the group lifting the heavy weights should have seen the most improvement. It did not. Instead, the knees for all three groups got slightly better.

I find it kind of humorous, seeing learned experts scratching their heads in utter bafflement over something that, if they thought about it on a common sense level, would make perfect sense:

Lifting heavy weights can be an utter disaster for weak joints. Personally, I’ve been there. And a lot of other people who read this blog have been too.

At the end of this article, we learn that Messier may still be, uh, dispensing dangerous advice:  

Despite the new, unexpected results, Dr. Messier still urges patients to exercise, saying it can stave off an inevitable decline in muscle strength and mobility. But now it seems clear there is no particular advantage to strength training with heavy weights instead of a moderate-intensity routine with more repetitions and lighter weights.

He's right to advocate "movement" (not sure I'd promote "exercise" per se, as that usually connotes people jumping about). But he's still hung up on weight training (sigh). At least he’s getting nudged closer to the truth. Maybe after another 10 years, two or three more studies? :)

Low intensity, high rep. Not a hard formula ... it worked well for me, and for many others.

Some Thoughts About the Delayed Onset of Knee Pain

There was an interesting story posted on the latest open comment forum. I want to focus on one piece of it (bolded). I've edited the entire story down for space:

I have been dealing with a knee issue since mid 2017 when I felt something "tweak" while doing "sissy squats" as part of a strength training program. Since this incident this knee has bothered me off and on and several orthos have diagnosed it as patellofemoral syndrome or PFS.

Running and cycling both aggravate it. I've tried the following methods for relief/cure:

- Rest from running/cycling. I had a 4-5 month period of rest from running/biking when I had a minor hip surgery. As soon as I got back to running/biking the pain came right back.

- Strength training, particularly those described as targeted for relieving PFS (quad strengthening). Step ups, and wall sits can really aggravate it although after a few reps the pain lessens during the activity (just as it does with running/biking), it comes back after as if I've damaged something.

- Robin Mckenzie "treat your own knee" regimen - Mostly the isometric holds that he recommends. I've gotten relief from this, but not a cure.

- Stretching and tissue work that supposedly helps PFS - Mostly foam rolling the quads and IT band and similarly stretching these areas. Similar to Mckenzie's regimen, this helps but does not cure.

- Treating my symptoms as Dr Sarno's "TMS". While this treatment has worked with other chronic pain I've experienced, this knee pain has not responded to that methodology at all.

- NSAIDs/Anti-inflammatories - Naproxen/Ibuprofen will knock the pain out altogether after a few days of steady use, but this isn't a long-term solution.

This part in bold sounded so familiar I had to separate it out. I remember, during my disastrous attempt at weightlifting to strengthen my quads (because that was what the physical therapist said I was supposed to do, once my knees were strong enough!), there would initially be a little discomfort that would then become more tolerable after a few repetitions.

But -- and here's that giant, ten-foot "but" -- later my knees would become more uncomfortable. At first I chose to ignore what was obvious after a week or so of this weightlifting program: my knees were getting worse. I was backsliding. When I realized that, I got upset and briefly depressed.

Even so, this terrible experiment turned out to be valuable: it got me thinking more deeply about the whole phenomenon of "delayed onset" knee pain.

I don't think it's unusual at all for a pair of bad knees to "warm into" an activity. This is why I hate that glib line from doctors about how to treat knee pain: "If it hurts your knees, don't do it." That's far too simplistic. Your knees may feel okay during the activity, after a little initial discomfort.

The key is how they feel later. "Later" can be immediately afterwards. But I discovered "later" can also be a day or even two after the offending activity. That makes it undeniably difficult to sort out cause and effect with bad knees. Still, it's very important to know about delayed pain, I think.

Recognizing this gets you to a higher, more sophisticated level of being able to "listen to your knee pain." And that's where I think you have to be to heal effectively.

Open Comment Forum: Anyone Want to Share a Problem?

It's been a super busy weekend for me, so I'm just getting around to this blog post now.

I thought I'd keep this short today and ask if anyone out there is struggling with a particular problem when it comes to their knee pain.

Want to share? Someone here (either me or one of the regular blog visitors) might have some ideas about what you could try next.

Or, if you'd prefer to discuss something else, that's fine too. The comment section is wide open.

Meanwhile, I hope you're all staying safe. In America, the vaccines are becoming more widely available. I haven't been able to get one myself, but my mother has, and my father is getting close.

We just have to hang in for a few more months, then hopefully life starts to return to normal.

Best wishes to all, and keep moving those knees! 

When You're in Pain, It's Good to Try to Figure Out What's Wrong

Seems obvious, right?

I mean, who would dispute that?

I was thinking about this recently though because of my mother. She told me she has plantar fasciitis.

Now I don't know much about plantar fasciitis. But I do half-remember a post that Doug Kelsey, whom I respect very much, wrote about the problem.

I tried finding his post -- unsuccessfully, sadly. I wanted to send it to my mother. Because right now she's in that early stage of: I have this condition. It hurts. What do I do?

I caution that I'm imperfectly remembering what Doug wrote, but I recall the part that resonated with me went something like this:

People often do the wrong thing to recover from plantar fasciitis. They do the wrong thing because they don't understand what it is. It's actually a slight tear in the ligament near the ball of the foot. Some people recommend stretching, but this doesn't make sense. Why are you stretching a torn ligament? You need to let it heal, then slowly strengthen it.

Anyway, I wish I could find that post, because that really struck me as very logical, even though plenty of people don't do it. In fact, my sister-in-law had plantar fasciitis. She's a personal trainer, and she loves to stretch. So what did she do? It felt tight, so she stretched. I guess eventually it healed, but probably not thanks to the stretching.

What does all this have to do with bad knees?

Chronic knee pain can be a maddening puzzle. Early on though, I think it's good to try to figure out what exactly is going on in the joint. The most sensible treatment for your knee pain will differ, depending on what's wrong.

In the end, if there is no clear cause -- if you basically get a shrug from your doctor(s) -- then I would think about adopting the high-repetition, low-load method of trying to heal slowly, but steadily. That's what worked for me. And that's at the heart of other success stories you'll find on this blog.

 

What’s the Relationship Between Knee Pain and Cartilage Damage?

Ah, what an interesting question. Early on, I tended to think that, where there was chronic knee pain, you’d find damaged cartilage in the joint.

Of course, not in all cases. But in very many.

However, after I learned more (and heard more personal stories from all of you), I modified that belief. People who have knee cartilage that appears perfectly fine get terrible knee pain sometimes. And people with potholed cartilage can have pain-free knees.

But – here’s the but – I definitely think there’s a high correlation between knee pain and bad cartilage. One does not necessarily imply the other. But there is a good likelihood that if you have persistent knee pain of difficult-to-determine origin, you have issues with the cartilage in the joint, or vice versa.

In fact a recent study, looking at 565 people who had a knee arthroscopy, supports this:

Published results showed a strong association between patient-reported knee symptoms and the burden and severity of underlying cartilage damage rather than with specific meniscal pathology ... researchers intraoperatively confirmed and classified the diagnosis of meniscal pathology and concomitant cartilage damage.

The researchers found that “the mean average symptom score increased with the severity of cartilage damage.” Also, there was a relationship between the number of compartments where damage was found and the intensity of symptoms reported.

When there was damage in three knee compartments, there was more frequent catching and locking of the joint, as well as grinding and clicking symptoms. Women and heavier people (a BMI of more than 25) were more likely to have more widespread cartilage damage.

The good news is that cartilage doesn’t have to be restored to a pristine state to get rid of bad knee pain, I believe. So, in the end, “damaged cartilage” shouldn’t mean you’re stuck with those bad knees forever!