Mastering the "Goldilocks" Problem With Bad Knees

I found this recent comment interesting, as one of the most frustrating aspects of healing bad knees is getting the "Goldilocks principle" right: You don't want to move too much. But you don't want to move too little either.

I find your book useful as you say that during your initial months, you were not sure if you were improving or not and it was by month 7 that you knew your plan was working.

So you need to move your knees. To me, that's like a First Principle, not open for debate. Knees that don't move at all will only get worse.

But then how much do you move them if they hurt all the time/most of the time/some of the time? And how can you tell you're on the right track with your program?

This is very, very hard to do. It's where many people fail, I'm sure. There is no "Just do this" blueprint. Just imagine how easy healing would be if the prescription was something like, "Take 800 steps a day for the first four weeks, then increase that by 200 steps a day for the next four weeks, etc."

The problem is, that may be just right for your knees. Or too much. Or too little. Or your best approach to healing may not be through walking at all.

There can be a lot of experimentation during those first few months that feels more like flailing around. It's important not to push your knees too hard. But you do have to push them at least a little.

So what does that mean?

What helped me the most was when I decided to err on the conservative side, in a big way. I started slow, very slow, then chose to build from there. That's not always an easy path to follow, especially for a Type A personality, when you feel you should be doing more.

But the unfortunate reality is that, yes, there can be entire months where you can't tell if you're getting better, backsliding, or simply moving in place. It's frustrating. But you can take some solace in knowing that many others go through the same thing. You're not alone!

Will Quad Sets Help Your Knees?

This came up recently in the comment section.

I remember doing quad sets during my recovery, and my knees didn't like them much. So I stopped doing them and got better anyway. Because of my personal experience, I never really looked that closely at quad sets.

Doug Kelsey does so here, though, in "The Ultimate Guide to the Most Misunderstood Exercise for Knee Pain." He makes some interesting observations:

(1) That quad sets are sometimes prescribed for a mistracking patella. And he dashes some cold water on doing quad sets for this reason.

(2) That quad sets are sometimes recommended to strengthen the thigh muscles. But, alas, they're not really great at this, because they generally don't stress the muscle enough.

(3) That quad sets are definitely useful for something else: thickening the synovial fluid that helps cushion impacts in the knee joint and just makes movement easier in general.

For this use, he advises 100 repetitions a day, in sets of 10. Patience is helpful too: beneficial effects probably won't appear for two months.

What is the science behind this? I'm always curious about that. It appears that the seminal study, which Kelsey himself cites, goes back to 2003. The sample size was a bit small (20 subjects, with a total of 28 bad knees), which isn't optimal, but what they found was without a doubt impressive.

The subjects did an isometric exercise that involved keeping their leg straight and raising it. Patients were told to do the exercise 90 times a day. Joint fluid was taken from their knees at the beginning of the trial and after 12 weeks.

What researchers discovered:

Joint fluid viscosity increased from 45.8±7.6 to 59.8±8.6 mPas (P<0.05). In contrast, there were no significant changes between at baseline and after 12 weeks in the patients without any treatment.

A roughly 33% improvement is really good. Note that these aren't exactly quad sets that the patients did, but I have to assume the benefits are similar.

Anyone out there who has a story to share about quad sets, good or bad?

'I'm Not Dead Yet,' as Monty Python Once Said

Reading all the comments come in after I announced an easing away from the blog was almost like having a ringside seat at my own funeral. Part of me wanted to shout, "Hold on, hold on! I'm still here!"

Yes, my posting from now on will be more sporadic. The blog might go dark for months at a time, or maybe for good at some point. But we're not at that point yet.

If you want to keep the blog alive in some form, go ahead and post questions you have, and I'll answer them (and invite others to help me do so).

Finally, I did want to post this comment from Knee Pain. I realize to many of you reading this, "Knee Pain" is just another online moniker. But she's been with me almost as long as this blog's been around.

She is one of the original hard-luck cases. Look up her success story and you'll be amazed. Her comeback is much more inspiring than mine.

She left a very kind comment, and a great update on how she's doing.   

Hurrah for 10 year anniversary!! I'm very grateful that I found your book.

I remember I practically read it in one sitting. It was very encouraging and great to find someone who could RELATE to this tricky problem of finding just the right amount of movement BUT not too much that would cause a flare up

I remember stories that you shared that I could relate to like the one where you carried something kinda heavy around Hong Kong (maybe it was a fan?) and that caused a flare up. I carried a computer monitor down several flights of stairs and that caused a flare up and I also remember pulling a suitcase on a leash and somehow even that caused a flare up (I think because the act of pulling something heavy with just arm changed my weight distribution on my legs?) Argh.

I was just reflecting recently that my bad knee now seems totally reliable. I'm doing lots of walking and hiking and biking and even backpacking and.... I've stopped worrying that it is going to have a flare up. It doesn't even send me little grumpy warning signals anymore.

That said, I feel it's important to stay vigilant and keep moving and exercising and not get complacent. I don't want a relapse.

Excellent! That's the kind of comment that brightens my Sunday!

Have a good knee day, everyone. 

An Update On the Blog (and a Few Basic Rules)

I'm heading off on a weeklong vacation, so I thought I'd do a quick update on the blog.

I always planned to keep this blog going for a few years, then let it quietly fade away. Part of the idea was to continue the blog while the knee books were selling, as a way to support readers who had questions. At long last, knee book sales are tapering off, so I'll soon transition to a much more occasional blog.

I never thought sales would continue for this long! It's been a pleasant surprise. The message of Saving My Knees isn't probably for everyone, but some people have apparently found it valuable. But now that sales are dropping off, and I find myself increasingly pressed for time to devote to other projects, I will soon transition to spottier posting.

Also, there are few rules here. But these are a couple:

(1) I have a lot of people reach out to me. I don't really want to become anyone's knee counselor. I'm not qualified for one, and two, I barely have enough time (with two young kids and an old house) to take care of everything in my life as it is!

So the best way to ask questions is right here, on the blog. There are several advantages to that: (1) The answers to your questions may help other people who have a similar problem. (2) If I don't know how to answer your questions, I bet someone else here will.

(2) Please don't post spam comments. I just delete them. I don't mind people posting links, in the context of a comment that's related to a post (or an issue someone has), but there are comment spammers that I delete quickly. They post "thin" comments that don't really directly engage with anything on the site.

They often look something like:

Great info! I loved what you said. If you want to take care of your knee pain, try the Magic Sleeve (with a link to the bogus Magic Sleeve).

One last thing: If anyone does have questions related to knee pain, please drop them in the comments. I'm at the point where I'm mostly foraging in there to find things to post, as I get closer to this blog going semi-dark.

(Not fully dark! I want to be able to jump back in here from time to time, especially as studies pop up that validate the message of Saving My Knees!) 

The 10-Year Anniversary of 'Saving My Knees'!

I'm actually a bit late on this but:

January was the 10-year publication anniversary of "Saving My Knees," my account of beating chronic knee pain. That whole unhappy time feels so distant now, like a long-ago bad dream that I've finally managed to shake off.

Today, for example, I went on a 64-mile bike ride ... a hard 64-mile bike ride. I felt fine during the ride, and I feel fine now afterwards. No Advil. No ice packs. No anything (well, my quads did grumble this afternoon when I walked down the stairs from the second floor).

I realized that, even if my knees fell apart tomorrow (which I very much doubt), I will have had 10 great years that my old orthopedic doctors would never have guessed lay in my future. What's more, my knees have gotten stronger over the years.

For example, in the several years following the publication of the book, I did have some minor issues from time to time. Sometimes I would have a little burning sensation around the kneecaps, the same as when I was suffering from chronic knee pain. These episodes would be rare, and last only a few weeks, but I took the symptoms very seriously.

But in the last several years -- maybe even four? or five? -- I haven't had that burning sensation at all. In the future, I realize, it may come back. But for now, I take this as a sign that my knees have healed, and adapted to the intense stresses I regularly put on them.

Over the winter, for instance, I rode my bike indoors, in the basement, in virtual worlds created by Zwift. I rode with groups that were stronger than me; I would spend three hours, without stopping, pedaling like mad to stay with the "B" group. Sometimes I averaged about 230 watts over that period.

And ... the knees were fine, even though I pushed them harder than I probably should have.

Ten years after publishing the book, I've gotten smarter about a few things. For one, my story doesn't resonate with everyone (in the latest foreword to the book, I even tried to scare off people who I didn't think would care for it very much).

But I think the message is a powerful one. I don't pretend at all that it originated with me; Dr. Scott Dye and Doug Kelsey figured this out first, and I took liberally from Kelsey when trying to put together a program to heal.

In the book, I just wanted to tell my own story, hoping it would inspire others and, most of all, give them optimism. I suppose I took a chance; what if I had published the book and my knees had fallen apart two years later? I would've felt like a fraud.

Instead, everything worked out great for me, and I'm certainly grateful. If you have knee pain, you can beat it. Remember that. You can beat it. I did. And if you look for "success story" on the search bar for this blog, you'll find plenty of other people who did too. 

Of Magic Pills and Surgery

A brief post today about magic pills and surgery.

I saw this yesterday:

When it comes to battling with joint pain in a natural way, certain remedies like the use of methylsulfonylmethane (MSM) may be helpful.

That word is certainly an impressive concatenation of chemical prefixes, and gave me flashbacks to high school chemistry. I will add that I know nothing about methylsulfonylmethane.

(I have written extensively about glucosamine and chondroitin, which rigorous scientific studies have turned against as solutions to knee pain. They are most likely placebos, it appears.)

So why am I down on something that I know nothing about?

It's more like this: we want things to be easy. Take a pill. Or schedule a surgery. And whatever ails us is fixed.

Essentially, you hand over control of your knee pain to a surgeon, or to the researchers who came up with the formulation for the pill.

But I don't think it usually works out well with knee pain. My experience is that YOU have to get involved with YOUR knee pain. You can't outsource the problem to some nutraceutical company, or orthopedic surgeon.

You have to focus on beneficial movement, monitor symptoms closely, and not lose sight of the end goal, day after day after day.

But you may be thinking: What's wrong with taking a pill? Maybe it will help.

Maybe. But it may also lull you into thinking that you can be less vigilant in your own efforts to fix the problem.

Anyway, for the record, I took a number of different joint pills. I don't think any of them helped in the least. I also followed a strict program of movement that gradually increased in intensity, and that worked.

That's how I think knee pain suffers get better, not by popping something out of a bottle. (Note: there are times of course when surgery makes sense, but there are far too many knee surgeries for problems that can't easily be fixed by that kind of intervention.)

A Bad Knee, a Pessimistic Doctor, and a Muscle-Obsessed Physical Therapist

I got this comment -- a story really -- and it's a long one, so I've edited it down. You can find the full comment here. I've underlined some parts that I found interesting.

I am a 28 year old female, very active, but unfortunately twisted my knee 3 years ago getting ready to take off for a run on wet grass. The sharp pain was horrendous, as my leg twisted my knee tensed and it felt like I had torn everything in there. I carried on stupidly as I was in a bootcamp and embarrassed to highlight myself as injured!! As a 25 year old healthy girl at the time, I assumed it would fix itself and carried on about my life ignoring the niggle up the stairs and when hiking. I initially went to a doctor who told me I had patellofemoral pain syndrome and to get back in the gym.

I never had pain squatting or lunging with weights, it was only the act of load bearing with my knee over my foot where I got the sharp pain. Similarly to a few previous comments I have read on your blog, the pain when I work out seemed to disappear and even after prolonged weights I found improvements in my knee and could run up the stairs no problem! Well I think all of this was not allowing it to heal properly as the pain always came back when I didn’t work out for some time.

I think the strength on the other areas were maybe masking the knee problem short term, who knows! But I certainly didn’t do it any favours getting back lifting weights. Pain started to feel a little more prominent this past year. I can walk totally fine. Hiking is my passion and something I haven’t been able to give up. But this causes me a lot of pain the next day and is hard on the joint coming down.

All of this led me to pay for an MRI to see what was going on. It showed I have a ‘punched out lesion within the cartilage of the patella in a central position. There is thinning of the trochlear cartilage in association with this. No reactionary oedema but evidence of a dominant lateral trochlear facet which is slightly dysplastic. Grade 3 chondromalacia’

The specialist said I could require arthroplasty in the distant future, but I should focus on swimming and cycling to manage it and avoid impact activities. He said there is no way to treat it and it will continue to get worse with age. Sure enough I left feeling very upset, hopeless and frustrated.

My strength PT said we should be still focusing on strengthening quads, glutes, calves core and hips etc but he has me still load bearing with some weight which I don’t feel is the best option for healing after reading through the blog! Would you agree? I have a lot of range of motion and don’t get any pain walking but when bent with pressure I’m getting the sharp pain. I have only just recently the past two weeks started to feel a burning sensation in that knee after movement. Is this a worrying sign that it is getting worse?

Desperate to find a way to combat the pain and make sure I am not doing further damage. I am due to go traveling to Canada (I’m from the UK) in a matter of months, a trip I have planned for a long time when my knee wasn’t causing me these problems) to do a lot of hiking which is so important to the trip. I don’t want to miss out on life because of this, but also do you think I could progress my grade 3 into grade 4 if I hike?

The magic question I suppose is, do you think it is possible to turn grade 3 chondromalacia around and live pain free!? I have an unbelievably healthy lifestyle, my passion is fruits and veg and I am 5ft8 and 51kg so I have this in my favour!

For starters, congrats on the healthy lifestyle and the ideal weight! You're young, eating well, and not carrying around a lot of extra pounds (or kilos). That seems like a good way to start a healing journey.

Next, I avoid giving advice. I'm not a medical professional, and even if I were, I've never seen you (or your knees). But I will share some things to think about.

I half-like the specialist. He said to focus on swimming and cycling and avoid impact activities. That strikes me as quite sensible, at least early on. Once your knees are in better shape, maybe you can do impact activities. For now, swimming and cycling, as long as your knees tolerate the activities well and you are careful not to push too hard, are two of my favorite "knee rehab" exercises (along with slow walking).

But I only half-like him. He also said there is no way to treat your condition and it will continue to get worse with age. Boy, he's a real cheery fellow, huh? I know nothing about your knee, but I think his dire prognosis is probably crap. One of the best things I read, early on during my struggle, was from Doug Kelsey, who was responding in his head to a doctor who had just told a patient that he'd never get better. And Kelsey's reaction was terrific, along the lines of: That's ridiculous, absolutely ridiculous.

Hope is so, so, so important. Orthopedic doctors should be smart enough to know that at least some knees do heal, without surgery. Mine did!

I'm not crazy about the strength physical therapist. I see the word "strength" and I wince. One thing I've come to realize about many physical therapists: they're young, frightfully fit, and haven't had any personal experience of whatever they're giving you advice about treating.

And they love strengthening muscles: because their playbook is full of strengthening exercises (and stretches). Stronger quads are great, but not if the effort to strengthen the muscle is greater than what the knee can tolerate. Unfortunately, you don't always realize that until the next day.

You might think, "Well, working out with weights helped my knees before, didn't it?" Okay, maybe it did. But maybe your knees aren't in the same place anymore. They could be worse, or more sensitive to the heavy loads and the bending.

Last, will going on this planned hike cause your knees to worsen? Maybe yes, maybe no. It depends on a lot of variables. How many miles a day? How many miles a day can your knees tolerate? How fast? How much climbing and descending? How many breaks? And you have to ask yourself: If this hiking trip isn't working out, is there a Plan B that you're confident enough to execute? Or do you just plan to suffer through?

Some thoughts. And one parting thought: If you bought Doug Kelsey's book, then you made a smart move. His book should be an invaluable guide on your journey. Doug really, really knows his stuff.