Knee Surgery and the Iatrogenic Problem

I recently happened to be thinking of what it takes to beat knee pain, and things that often don't work.

Surgery came to mind.

Now, to be clear right from the outset: Surgery may be a good idea for you. In fact, it may be a great idea. It all depends on what's causing your knee pain, and whether a surgical solution fixes that.

What worries me: I think there are too many people in the situation I was once in, when I had chronic, diffuse knee pain that had no clear cause. After a while, their thinking goes like this:

I've tried everything they've told me to do. I don't seem to be getting better. I have nowhere else to turn. Should I have surgery?

Surgery as a last resort, when the doctor plans to look around your knee and "clean up" some areas of damage, seems like a potentially risky proposition.

This isn't like someone popping the hood on your car, spotting a loose battery cable, then tightening it down and then -- voila! -- the car works great again.

I suppose a surgeon can look for loose bodies and remove them. Fine. But when it comes to trimming and shaving the existing cartilage, how does a surgeon know exactly how much cartilage to remove? This knee joint you'll be using thousands of times a day, probably, and a screwup could leave you in even worse shape.

Which brings me to the word of the day: iatrogenic. It's an interesting word that I was unaware of before I began my knee pain journey. It refers to new injuries that are created by surgical intervention.

That's a sobering thought. You go under the knife to get better. What you may not realize: there's a not insignificant chance you'll emerge worse off.

I do think most surgeons are pretty good, and they certainly have your best interests in mind. But what they do is very, very hard, and they're not trying to fix a machine, but a human being. That's a task of a much higher order.

Again: I'm not trying to imply that surgery is never a good idea. It sometimes is. But before you commit, you should have a good idea of what the surgery is trying to do and what the chances of success are.

  

'Static Stretching’ Falls Out of Favor

I know my views on stretching don’t align with those of many other people, including some frequent visitors to this blog.

I’m a skeptic about whether stretching helps with knee pain, but if it feels good and isn’t causing further damage, well, what’s the harm?

But avid stretchers do have to be careful. I came across this article that summed up reasons not to engage in “static stretching”—that is, stretching before physical activity.  

A growing body of research is showing how our views of pre-exercise “static” stretching are changing in real time—while revealing many of the ugly truths about stretching when your body is “cold.”

The dangers include a risk of injury to cold muscles and a possible decrease in performance, which of course would be ironic, considering stretching is supposed to help someone achieve a higher level of performance.

No. 3 on the list actually made me laugh:

You should warm up before you stretch.

Hmm. If I need to “warm up” before I stretch, why do I need to stretch then? It seems that the warming up has probably achieved what the stretching was supposed to.

But then again, it’s true that stretching never made a lot of sense as a “warm-up.” My favorite line here comes from Paul Ingraham, a much smarter stretching skeptic than I am: “That’s like trying to cook a steak by pulling on it.”

Generally though, most stretching is probably harmless if it’s done gently.

I think the only stretch for knee pain sufferers that I’ve reacted violently to is the one pictured in this blog post.

A hard pass on this ugly-looking stretch! I dubbed it the “Just Asking for Trouble Stretch.” 😉

How to Sit at a Work Desk With Chronic Knee Pain

Fishing in the comment section ...

Richard, thank you so much for your book which I have just come across. Your symptoms and journey are very similar to mine and I have switched from treating my knee pain as a muscular-skeletal imbalance to treating it as a chronic cartilage injury.

I work very long hours at a desk and I was wondering if you had any thoughts on the ideal sitting position that allows the knee cartilage to heal. In your book, you mention that you spent a lot of time sitting on the floor. I am giving this a go - legs straight out in front with my knees slightly supported at the back with a pillow so that they aren't over-extended. But as you rightly point out, modern offices aren't set up this way! And there doesn't seem to be anything online about how to work long periods at a floor desk - there aren't even any floor desks.

I exercised my editorial prerogative and cleaned up a few small spelling errors in the above, so as not to detract from the main message: how do you sit at work with a pair of knees that ache and burn when bent?

There probably is no great solution here (well, the best solution is not to have to sit at a desk for eight or nine hours a day, but I realize, most of us don't have the luxury of walking away from our white-collar jobs).

So the first thing I would warn about: Be careful about contraptions that you rig to help alleviate your knee pain. Make sure they don't put a strain elsewhere on your body. I wrote about my underdesk sling that I thought was fairly clever ... until I developed back pain that just wouldn't seem to go away.

Don't trade one problem for another.

The idea of a "floor desk" is interesting, but then: what's your "floor chair" look like? If it's not properly designed, then once again, you could wind up with back pain.

What I would think about trying, if I had it all to do over: an underdesk "pedal exerciser" that I could pedal occasionally, to give my knees very light movement. I even bought one of these for use during my recovery, when my knees every so often would burn a little. It may even have been this one here.

In the end, I never used this exerciser much. The short periods of discomfort just went away, and they're all history now. But if I had more serious chronic knee pain, and I was stuck in an office, I might try it. You have to try something! Don't suffer in silence.

Anyone else with suggestions?

On Keeping Up Hope When All Is Dark

When it's pitch black all around, and there is no light source within reach, it can be rather terrifying to say the least.

One impression I got reading recent comments: a lot of people out there are struggling, and they're scared about what an uncertain future holds for them and their hurting knees. They see darkness all around and don't know where the light will come from.

What do you tell people in that situation? Well, first, I must admit to a weakness of mine: I'm not really a rah-rah kind of guy. I'm a poor cheerleader. I'm naturally skeptical and scrutinize and think about claims of knowledge and rightness carefully.

But, in a way, I suppose that makes me a better "cheerleader." I'm not falsely pushing some snake oil. I stand behind things I believe in (but am open to the fact that my beliefs may be wrong, though you have to prove that to me, too).

So what is it important for people to remember when they feel like their life is being ruled by the misery of knee pain, and their plight will never improve?

First, it can get better. Not that it will. You have to work hard at healing knees. There's a lot of sliding around, going forwards and backwards, and sometimes not knowing why, and it becomes hard to resist that temptation to throw your arms up in the air and say, "None of this makes sense; I'll never get better."

Second, the amount of patience you need is truly Job-ian. There are people on this forum who have spent years (and not one or two years either, but a lot more than that) figuring out this puzzle of their knee pain, only to finally triumph (more or less) over it. I'm grateful they're part of this community.

Third, you have to commit to doing something. And that something is movement, of some kind. I really believe that inactive joints are soon-to-be-dead joints. You have to move, but it has to be the right kind, and the right amount. I don't like the gung ho, never-been-injured therapists exhorting patients to push, push, push, and suck up the pain.

Fourth, you need to nurture hope, optimism, belief, like a fragile sprout sunk into a hostile soil. One way to help do this is not to become knee obsessive (says the man who was definitely knee obsessive!). If your mind is in a good place, that will help in healing. Laugh at a comedy. Enjoy a friendship. Tell someone you love them. Get out of your own skin, your own worried mind, for a little while.

Anyway, just a few simple thoughts today. Remember the saying, "it is better to light a candle than curse the darkness." That's what we're trying to do here, light candles. Happy wishes to all!

Open Comment Forum: What's Everyone Want to Talk About?

I'm throwing things wide, wide open because, for one, there isn't much for me to post about that relates to my own knees.

They continue to be great (knock on wood), especially considering I hit the dreaded milestone that begins with the number "6" this year (believe me, when you get there, you'll stare at yourself in the mirror for a while, saying, "Nah, can't be, really? Seriously? Am I?")

By the way, this winter, after I had a bad Zwift ride on my bike, I decided to do something a bit different for me: training. My idea of "training" has typically been: ride as hard as you can one day, then the next day, take it "easy" by riding not quite as hard but still pretty hard.

This led to the predictable results. I rode hard a lot, in an unstructured fashion, and sometimes was close to that overtrained, burned-out feeling.

I finally got mad at myself after a particularly miserable Zwift group ride that I should've done well on. And I said to myself: "Hey, you were disciplined enough to beat knee pain. You can be disciplined enough to keep to a training schedule that lets your muscles recover, then grow stronger."

My goal was to finish a flat-stage century with the "B" level riders on Zwift. This is no easy thing. They crank out from 2.8-3.2 w/kg for almost four hours. I kind of wondered if my chance to reach this goal had passed, considering I wasn't getting any younger, you know.

But training made a difference: I finished not one, not two, not three, but seven centuries with the Zwift B riders this winter. I'm not dumb enough to think I'm as good as them (sometimes I'd sneak a peek around the pack and most of them had lower heartrates than mine by 10, 15 beats per minute).

You can attain your goals, no matter your age! That includes vanquishing knee pain from your life.

So: How is everyone doing out there? What's the problem you have right now that you need help solving? This is a wonderful little community of problem solvers, I will say, and I've enjoyed browsing through the comment section recently.

Please drop a comment below; I would love to hear from everyone, cheers.

A Lesson I Hope You Don’t Take Away From My Book

Sometimes I worry that people might take the wrong lessons from my story of overcoming knee pain.

For example, in the book, I discuss my travails with doctors. My experience taught me that doctors are only human, that they sometimes get things wrong, and that you shouldn’t depend entirely on them to pull you through knee pain.

In short, you need to get involved in your own recovery.

I can see though how someone could read about my experience and conclude, “Doctors aren’t that important; you’ll have more success treating your knee pain yourself and not relying on a doctor, who perhaps believes the wrong things anyway.”

I know I’ve said this before, but I’ll say it again: Someone with knee pain should always start by seeing a good doctor and listening carefully to what that person advises.

This article that I read recently drove home why that’s so important.

The woman was a 28-year-old nurse who started having pain in her knee. She figured it was a torn meniscus. For a torn meniscus, often surgery isn’t advised, and someone does as well by undertaking a smart program of physical therapy.

She could’ve designed her own recovery program. But first, she went in for an MRI to confirm her suspicions.

It turned out that it wasn’t a torn meniscus. The imaging test found a tumor in her leg that was bigger than a peach. She had osteosarcoma, a type of bone cancer.

I’ll bet she was stunned. There’s quite a big difference between “torn meniscus” and “bone cancer.”

But had she accepted her own diagnosis, and simply Googled around for a while and found some good exercises for a damaged meniscus, she could’ve delayed her cancer treatment by valuable days.

So if you have knee pain, seeing a doctor should be step one. You might diagnose yourself correctly. But if you don’t, the consequences can be life-threatening.

When You Find Yourself in a Hole ...

I found myself thinking recently about that piece of advice: If you find yourself in a hole, stop digging.

What brought that to mind is knee pain among Type A personalities, with whom I share some traits. They tend to be organized, competitive, ambitious.

In cases where they take part in some sport or form of exercise, they do so with more dedication and energy, and that can get them into trouble.

When they find themselves with knee pain, I imagine that many try to do what I did: work around it, deny it, assume it will just go away with a little time and with only minor changes to their workout routine.

Essentially, they've found themselves in a hole, then they keep digging it deeper. At some point, if they're self-aware enough, they realize what's happening and they modify their behavior.

To beat knee pain, Type A and more laidback Type B personalities may need wildly different approaches.

For Type B people with knee pain, the best course of action may be get moving and do more. For Type A people, it may be to do less, to ease up, and that can be a harder prescription to follow for those who are accustomed to putting out maximum effort.

I remember in Hong Kong, trying again and again to ride my bike without getting that awful burning in my knees, and I could never do it. So finally I just told myself: That's it. I am through cycling for now, and maybe forever.

That was really, really tough. But sometimes I think that, to overcome chronic knee pain, the only way you can return to doing what you love is by being willing to abandon it forever.

It's a hard lesson that a lot of Type A people with knee pain learn: A lot of furious, motivated digging just leaves you at the bottom of a bigger hole.