Saving My Knees: How I Proved My Doctors Wrong and Beat Chronic Knee Pain (6 page)

Finally the truth became impossible to ignore when my knees began to swell a little. They also started feeling uncomfortable during the exercises themselves, even while working out in the “safe range.” Both were bad signs. Following Tim’s advice was trashing my joints. Discouraged, I abandoned the weights.

That was a particularly low period. In one month, I went from feeling okay to terrible. I hurt worse than ever. A bitter hopelessness set in.

At work, I sometimes sat with my legs propped on the desktop for relief. Other times I sent the other Asia finance editors an e-mail, excusing myself. I would leave the building and shuffle around nearby streets like an old man, just trying to quiet my burning joints.

Months later, after leaving my physical therapist for good, I began to re-examine exactly what he told me to do and why. In my mind, I asked some hard questions.

For example, Tim loved stretching. At first, it did seem like a magic answer to my problems. Take a standard stretch for the quadriceps. Stand up straight and bend one leg back. Grab the ankle and pull your heel toward your butt. You feel a tug as the stretching lengthens the muscle in the front of your thigh. That translates to reduced pressure between the kneecap and thighbone when you sit back down. I noticed immediate, remarkable relief.

But a stretched muscle contracts again. My strategy to use frequent stretching to endure the agony of sitting soon washed out. My knees were better for a few minutes, then the burning sensation returned. Stretching seemed flawed for a bigger reason too. How does temporarily lengthening muscles that lie around a joint help repair problems inside that joint? If your garage leaks, you don’t go out and replace the roof over the adjoining shed. 

Fans of stretching (and they are legion!) might reply that I was seeking the wrong benefits in the first place. You need to stretch to warm up, reduce post-exercise soreness, prevent injury, or become more flexible, they might say. The “preventing injury” rationale certainly intrigued me. I didn’t want my knees to become any crankier.

So I began reading and thinking about stretching to understand why it works. What I uncovered surprised me. There’s a lively ongoing debate over its usefulness. Scientific studies suggest that the value of stretching has been greatly oversold.

In Australia, a year-long study of 2,600 soldiers found that those who stretched their leg muscles before exercise got injured at the same rate as those who didn’t. The Centers for Disease Control and Prevention sounded a similarly dubious note. It conducted a mass review of more than 350 stretching studies, spanning four decades. Its conclusion, published in 2004: there’s no evidence that proves stretching prevents injuries.

What about to stave off muscle soreness? It doesn’t appear to do much good there either. Whether you stretch before exercise or after has little or no effect on how sore your muscles feel in the days following a workout. That’s according to an analysis of ten randomized trials that appeared in the
Cochrane Database of Systematic Reviews
.

What about using stretches to warm up? This doesn’t even pass the common sense test, when you think about it. As Paul Ingraham, a registered massage therapist in Canada, says in an online article, “That’s like trying to cook a steak by pulling on it.” The best warmup may be simply doing a less-strenuous version of the intended activity (slow jogging to prepare for a road race, or lifting light weights before doing intense bench presses).

What about to become more flexibile? Maybe if you’re a gymnast. But for most others, you have to ask: what’s inherently good about being more flexible, especially if it’s not helping prevent injuries? Effortlessly achieving the lotus position may be a neat parlor trick, but flexibility outside of a normal range doesn’t seem to be a virtue in and of itself. In fact, it’s been shown that, after stretching, sprinters run more slowly.

My mounting doubts led me to re-examine one hoary chestnut for treating patellofemoral pain syndrome: stretch the IT band. After all, I did faithfully stretch it (or tried to) every single day for months, with little to show for my exertions.

My preferred IT band stretch was one that Tim showed me. It was supposedly effective, though difficult. You lie on your side, positioning a tennis ball between your outer thigh and the exercise mat. You then roll back and forth over the tennis ball, so that it presses hard into the iliotibial band, from your knee to your hip.

I scavenged some stray balls from a crawlspace beside the Discovery Bay tennis courts. I also bought a padded blue yoga mat to lie on. The padding helped, but rolling the side of your leg back and forth over a tennis ball isn’t much fun. After several weeks, the procedure became tolerable. Still, it didn’t relieve my knee pain.

On my weekly visits, Tim sometimes performed a vigorous massage of the tissue that appeared to work better. He really kneaded the tendon hard, and thoroughly, using his fingers and knuckles. My knee pain would lessen immediately afterwards, but only for an hour or two, and I’m not even convinced that the massage was the reason.

When I took a closer look at what the IT band is, I found out why stretching this tendon proved so tough. It’s like trying to stretch a brick, says Doug Kelsey, the chief physical therapist for the Sports Center clinic in Austin. The IT band doesn’t want to lengthen, like say a rugged bungee cord. Rather, its tensile strength compares to that of soft steel.

Even if I could stretch this tendon like silly putty, did I need to? Stretching it might make sense if my kneecap were being pulled off center, toward the outer edge of the trochlear groove. Loosening a tight iliotibial band would then allow the floating patella to slide back into a more normal position.

No doctor, however, ever asserted that my kneecaps weren’t tracking correctly. On my X-rays, they both appeared to be sitting pretty normally in the joint space. Though Tim did try taping my kneecaps (along with almost everything else he could think of), he never identified mistracking as an issue either. 

Later I began to wonder if misalignment/imbalance was just the default paradigm for understanding and treating patellofemoral pain, whether this framework made sense or not. There must be many instances when the patient’s body mechanics check out as fairly normal. Even when they don’t, were unusual biomechanics really to blame, barring a severe condition such as a very poorly tracking kneecap or a leg-length discrepancy?

My skepticism was validated when I came across a study, published in 2006 in the
Journal of Bone and Joint Surgery
, that explored the link between abnormal tracking of the patella and patellofemoral pain syndrome. Some of the subjects had knee pain; those in a control group didn’t. They all had MRI images taken as they flexed their knees at different angles.

After studying the raw data, the Canadian researchers concluded, “It is clear from the data that an individual with patellofemoral pain syndrome cannot be distinguished from a control subject by examining patterns of spin, tilt, or lateral translation of the patella.” In other words, you may have a badly tracking patella and no knee pain. Or you may have a perfectly tracking patella and lots of pain. So the paradigm foisted on me, and millions of others, didn’t really make any sense.     

Tim couldn’t seem to accept though that there wasn’t some issue relating to how I was configured, how I moved, how my muscles were balanced. He always appeared very interested in sniffing out a hidden glitch in my alignment. Periodically he would check this, as if I was a recklessly driven car that may have been crashed into a telephone pole while he wasn’t looking.

His fixation put me in mind of a woodpecker drilling a sterile chunk of dead tree. It keeps hammering away, following an ingrained behavior. I wonder if many of us are like that woodpecker. We are taught things in our professional training that become like second nature. We are grilled and tested until the knowledge becomes reflexively available, to the point where it crowds out independent thought.  

Tim’s other obsession was with my muscles. Strong legs protect weak knees! The line has a sort of catchy bumper sticker appeal, but it frustrated me that he devoted all his problem-solving skills to figuring out how to build up my muscles. That approach seemed like trying to fix a bad automobile carburetor by replacing the vehicle’s shock absorbers, so the carburetor wouldn’t jiggle as much and might run better.

At one point I wanted to scream, “What are you doing to help my joints?” The conclusion I reached: nothing at all. I had stumbled onto the dirty secret that many physical therapists share with medical doctors. They too are pessimistic that cartilage can heal and that knee joints can truly get better.

This became clear to me after perusing an article in the December 2008  issue of
Advance for Physical Therapists and PT Assistants
, a periodical for industry professionals. It looked at a study that showed physical therapy to be as effective as arthroscopic surgery for osteoarthritic knees.

I was edging toward osteoarthritis, so the subject matter caught my eye. What I read didn’t inspire me. Two quoted experts said physical therapy can only strengthen muscles around the knees and correct abnormalities in someone’s gait, but can’t turn back the ravages of the disease. One of them advised telling patients that the treatment will not affect arthritic changes in the joint directly, but instead focus on the surrounding tissue.

That sounded depressing. Unfortunately, it’s probably a common belief, and one that Tim would agree with. I asked him once about exercises to target my joints, not muscles. His face went blank. He didn’t speak for a long moment, then gave me a throwaway line about just continuing to walk slowly.

Over the course of nine months, I ended up visiting him nineteen times. During the late summer of 2007, and into the fall, I went weekly. At some point, as my condition failed to improve, I realized our time together was coming to an end.

I had lost faith in him. It became worse when I began learning more about how knees work. One day, he idly remarked that he was surprised I didn’t have pain during weightlifting, only afterwards. I looked at him in disbelief. By then I had discovered that cartilage has no nerve supply and so damage often isn’t perceived immediately. When I mentioned this, he looked down and didn’t reply.

In my eyes, his greater fault was a simple lack of curiosity. He was good at coming up with less-stressful variations on exercises to build up my leg muscles, but had little interest in alternative approaches that didn’t come out of his playbook. He couldn’t help me construct a program of light walking; he didn’t understand (or care to) why that worked better than anything he proposed. He never bothered to explore why two weeks in Tibet brought me some success when everything else failed.

Among his greater and lesser shortcomings, one thing I couldn’t forgive him for: giving up on me. For months he counseled against surgery and urged me to be patient. Then, one day, he caved in. He had tried to help me but couldn’t, so he dropped his opposition to arthroscopic surgery. The operation would snip away frayed cartilage and flush out any tissue fragments floating around the joints.

Fortunately, I was enlightened enough at that point to realize that surgery wasn’t the answer. I wasn’t finding many happy stories online from patients who had undergone arthroscopies.

Leaving my physical therapist felt like the right move, but I faced an enormous problem. Four doctors couldn’t help me. Two physical therapists didn’t have any good answers either. How was I going to get better?

My options were running out. It seemed that there was only one person with the motivation and desire to think deeply about what was going on with my knees and try to figure a way out of this maze of pain and frustration. Like it or not, that was me.

There is a story about how the prolific American humorist James Thurber, unable to leave his work behind, would get lost in thought at inappropriate times. His wife would spy him across the room at a party, wearing a familiar distracted expression. She would go up and admonish him: “Dammit, Thurber, stop writing.”

My wife’s line to me would probably be, “Stop thinking.” I tend to ponder and analyze things to an irritating degree. Congyu is more intuitive and spiritual. She’s Chinese and places more faith in the vicissitudes of good fortune and in lucky numbers, such as “eight.” She chose the date for our marriage: 8/8/08.

It didn’t take long for us to clash when I began trying to solve the puzzle of my hurting knees. She empathized: a left knee had bothered her since the age of nineteen. (Her doctors too appraised the joint as “normal.” I carefully listened to her bend it and, sure enough, heard the telltale crackling of rough cartilage.) Her way of coping involved a mixture of resigned acceptance and experiments with Chinese medicine. One day she presented me with a bag of what looked like candies and the argument soon followed.

“Where did these come from?” I said. They turned out to be pieces of chewable medicine, individually wrapped in silver foil, that were supposed to help me heal.

“Taiwan,” she replied cautiously, sensing my resistance.

“What’s in them?”

“I don’t know,” she huffed, as if my question were prima facie absurd.

“How do you know if they’re any good then?”

“This medicine has been around for many, many generations,” she said.

After a few more minutes, it became clear we were sliding out onto that dangerous ledge where one false step would plunge us over the edge into a nasty spat. Finally I shrugged and offered to try the stuff. It was actually tasty, with a molasses flavor. Over the next few weeks I polished off the entire bag. My knees felt the same though.

So I added Chinese medicine to the long list of things that didn’t work for me. It didn’t matter. The inescapable truth was that figuring out how to save my knees would be hard. That meant I needed to be open-minded and flexible. Even though I wasn’t always the smartest guy in the room, flexible thinking was fortunately one of my strengths.

I started out by turning to the Internet, that noisy bazaar of ideas. I knew that the Net, when used wisely, can empower patients. A discriminating consumer can sample from a smorgasbord of high-quality information. For instance, a standard Google search now includes published books. A Google Scholar search homes in on the latest peer-reviewed articles in medical journals.

I knew too that useful ideas on the Net sometimes pop up in unexpected places. The reason I knew this was because a rather unusual Web site helped me once during a long battle with a plantar wart.

The name sounds nasty, but plantar warts are often small and benign looking. One took up residence on the side of my right foot while I was living in South Florida. I ignored it, hoping it would go away. Instead the wart got bigger.

I had a bad premonition that getting rid of it wouldn’t be fun. A podiatrist gave me a foretaste of things to come when he blithely said, “I’m going to burn a hole in your foot.” He used a scalpel to whittle away dead skin in the area, going as deep as I could tolerate. Then he packed a chemical called Cantharone into the hole, as if it was slow-fuse dynamite.

He bandaged the end of my foot and told me not to wash out the Cantharone (a blistering solution) for a few days, unless the pain became intolerable. After that I returned to the newspaper office where I worked and the intense burning began. I gritted my teeth and hobbled about for several days, then off came the bandages. After a series of Cantharone applications, the podiatrist wished me luck and gradually the area healed up.

Then the wart came back. He repeated the treatment. And it came back again.

At this point I asked the logical question: what next? He somberly informed me that the options didn’t look good. Surgery wasn’t desirable because scar tissue might form on the bottom of my foot. Walking then might become uncomfortable with each step I took. Also the surgery might not get rid of the wart for good anyway.

Desperate, I began chasing hyperlinks through cyberspace, trying to find an alternative. When it comes to warts, it seems as if everybody has some kind of home remedy. Most didn’t make much sense to me.

Then I stumbled across a very interesting Web page. Some guy left detailed instructions on how he vanquished a plantar wart using sulfur soap, sulfur powder, and generous strips of duct tape. What’s more, he posted before-and-after photos that showed his skin looking perfectly healed.

That intrigued me. Sulfur soap wasn’t readily available in my neighborhood. I did have an over-the-counter medication called DuoFilm. By itself, it proved pretty useless against the wart. But what about in combination with duct tape?

I remember feeling incredibly foolish the first morning of the experiment. I dabbed some DuoFilm on my foot, stuck on a piece of duct tape from the local hardware store, then put on my dress shoes and went to work. Afterwards I replaced the tape daily.

After a few days, the wart appeared to be shrinking. At first I thought it was only my imagination. Over several weeks, however, the improvement became impossible to deny. The wart was really going away. Then, one day, it was gone entirely.

I got rid of it with duct tape
! My amazement spurred me to write a first-person account for the
Sun-Sentinel
. My podiatrist failed to root out the wart with painful applications of Cantharone. I beat it with a painless procedure that required no more than a sticky gray tape a handyman might use to mend a broken broom.

The Internet helped me banish a pesky wart. I felt confident that it could shed some light on what to do about my knee problem. I visited many Web sites, discussion forums, and blogs. I looked for respectable sources, such as doctors and physical therapists.

In my online browsing, once again I noticed an oddity. Some medical professionals use “chondromalacia patella” as a synonym for “patellofemoral pain syndrome,” while others clearly distinguish between the two. This time, instead of ignoring the confusion, I began to muse about what it signified.

Remember that “patellofemoral pain syndrome” applies to a bucket of symptoms. You have the condition if you have enough of the symptoms (I had only half of them, but had diffuse pain around my kneecaps, so I got the diagnosis). The main cause could be “chondromalacia,” meaning an abnormal softening of cartilage. Or it could be some unspecified other thing.

In short, as I’ve noted before, “patellofemoral pain syndrome” doesn’t explain a heck of a lot. It’s like a half-solved math problem. That, I thought, may be why so many Web sites equated “patellofemoral pain syndrome” with “chondromalacia patella.” The two weren’t the same, but at least the word “chondromalacia” has some explanatory power, and bad cartilage is often involved when a patient suffers from chronic, low-grade knee pain.

This brings me back to my first axiom of healing, which bears repeating:
Before devising a plan to heal, you need to know what’s wrong and what’s causing it to be wrong
. My doctors preferred the grandiose vagueness of “patellofemoral pain syndrome,” but that term didn’t tell me what’s wrong. It simply repeated what I already knew: I had knee pain with certain features.

(A quick aside: I’m not the only one who thinks this diagnosis comes up woefully short. In 2006, Ronald Grelsamer—an M.D. and author of
What Your Doctor May Not Tell You About Hip and Knee Replacement Surgery
—wrote that there’s
no such thing
as patellofemoral pain syndrome! The syndrome “has never existed though the term has been commonly used,” according to Grelsamer. He added: “A medical syndrome is associated with a well-defined set of signs, symptoms, laboratory values, imaging studies and so forth. There is no such set of parameters associated with the ‘patellofemoral syndrome.’”) 

Fortunately, I insisted on getting more information to help determine what was wrong. An MRI gave me much-needed clarity, that I had deteriorating cartilage, and ruled out damage to other soft tissues. As for “what’s causing it to be wrong,” that was almost certainly the hard cycling up hills that I no longer did.

That left me with the hard part, figuring out whether a plan could be devised to fix bad cartilage. The enormous puzzle still hadn’t been solved.  

At this point I met someone, thousands of miles away, who literally changed my life. I use “met” loosely; he wouldn’t know me from the mailman if I strolled into his clinic. I came to know many things about him from afar, by reading his essays and blog entries online.

He had a Dalmatian named Spencer. He lived in Texas. He too suffered from bad knees. His photo made him look unprepossessing: a middle-aged man with a goatee, genial face, and a shiny bald head.

He was the founder of Sports Center, a physical therapy clinic in Austin. His writing revealed him to be perceptive and clear-thinking and unafraid to break with convention. He held two patents on “anti-gravity technology” that helped patients exercise when they were recovering from injuries. His name was Doug Kelsey.

He wrote a blog about injuries and healing called
The View from Sports Center
. I began sifting through the archives, looking for advice about knees. One of his first lines to resonate with me was this one below. He responds (in bold) to an imaginary comment by a doctor to a patient:

“Well, you have arthritis. Your knees are just wearing out and there’s really not much you can do about it.”

Hogwash. Hooey. Balderdash. It’s just nonsense.

At the time I wanted to clap my hands in delight. This physical therapy director from Texas dared to boldly give a raspberry to the pessimistic knee doctors. Still, my natural wariness also kicked in. Kelsey’s deceptively easy style lulled you into agreeing with him. While reading one of his essays, you would scratch your head and say, “Of course that makes sense.” But did it?

As a seasoned journalist, I automatically squint a bit harder when I encounter prose that seems too fluid, too effortless. It can be the hallmark of the con artist. We’ve all seen those text-heavy magazine ads. The writing sets out to prove that this product—this memory aid, this extract from algae—is fantastic and a bargain at $39.99! The writing is straightforward and seductive.

I spent some time scrutinizing Kelsey’s blog. The more I did, the clearer it became that he didn’t have a secret agenda and wasn’t trying to sell some product hidden behind the curtain. He just had a desire to share his knowledge and insights. He also was confident enough in what he believed that he didn’t have to hide behind a wall of jargon.

Finding such people is a wonderful kind of serendipity. They are very intelligent and rare individuals. They possess a gift for reducing hard concepts to simple English. They are people like Paul Krugman and Richard Feynman, for example. Both have won Nobel prizes, a testament to their formidable acumen.

Krugman is an academic economist and columnist for the
New York Times
. His peers love to get lost in bewildering thickets of formulas and models. Krugman hacks through the jungle to explain, in terms my mother could understand, what an economic issue means and why it matters.

Feynman was a bongo-playing physicist who mischievously titled one of his books,
Surely You’re Joking, Mr. Feynman
! Testifying at a public hearing on the explosion of the space shuttle Challenger, he revealed a defect in the rocket booster’s O-rings by dipping one of the rubber seals in a glass of ice water, to show it wasn’t resilient in cold temperatures. He tweaked the noses of NASA’s powerful managers with a science experiment so basic that a young child could understand it.

Like Krugman and Feynman, Kelsey had a talent for making complex matters easy to comprehend. He sometimes used his clear, compelling style of writing to contrarian ends, breaking with the conventional wisdom of his profession. His blog post, “The Cold Truth of Ice,” questions why we reach for the ice pack when injured. I started to read it, thinking, “How can a physical therapist not believe in ice? Is he nuts?”

But Kelsey says, in essence, hold off for a moment. Let’s look at what’s going on here:

Suppose you sprain your ankle ligaments. A couple of things happen at that point. The tissue swells as ruptured cell membranes leak proteins and other contents. The area also becomes inflamed.

Acute inflammation is a normal part of healing from an injury though. It signals the body to send in troops from the immune system to clean up damaged tissue and begin the repair process. The troops hitch a ride on our body’s fantastic liquid transport system: the blood. Now what does ice do? It reduces inflammation and blood flow, both of which play a crucial role in healing.

That still leaves the problem of uncontrolled swelling. Too much pressure at the injury site isn’t good and will cause further tissue damage. However, Kelsey notes, swelling can also be reduced by compression, elevation and, when your body is ready, the right amount of movement. These methods won’t cut back on the number of immune system troops streaming to the injured site either.

The more I thought about it, the more sense it made. Furthermore, ice is dangerous because it acts like a painkiller. It masks symptoms, encouraging injured athletes to push too hard. If the only way you can run two miles or play a tennis match is by packing your knees in ice afterwards, your body is trying to tell you something.