Saving My Knees: How I Proved My Doctors Wrong and Beat Chronic Knee Pain (4 page)

I grew up with an unquestioned faith in the wisdom of medical doctors. It never occurred to me that they could amputate the wrong limb or leave a surgical sponge inside a patient. The doctors of my imagination never made mistakes. When they offered their considered judgment, the right response was simply to nod and say, “What should I do?” Their advice served me well through years of mostly minor ailments.

During my frustrating battle with knee pain, I began to look at them differently. For one, doctors weren’t omniscient. Also their level of competence varied widely. And they seemed to like patients who were smart, but in a suitably agreeable and deferential way (this last observation isn’t meant to be a slur against doctors; it strikes me as true of many other professionals who have acquired a specialized body of knowledge).

Their fallibility shouldn’t have come as a surprise. Doctors apply their problem-solving skills to the most complex machine on the planet: the human body. They have a hard job. To understand why, just contrast their diagnostic challenges with those of an auto mechanic.

The mechanic may start a troublesome car to hear the engine knock, or try the sluggish shifting lever for himself. But the doctor working with a new patient may have to settle for, “Sometimes after I eat, I feel . . .” or “I’ve got this stabbing pain that comes and goes in my upper arm, right about here . . .”

And then communication issues arise. An inarticulate patient may not be able to describe symptoms well. A more articulate patient may possess an adequate vocabulary, but consider his sharp pain to be what the doctor would define as dull pain. And what is, say, severe pain? That depends on who you are: a tough guy like Clint Eastwood or a softie like the fairytale princess whose sleep was disturbed by a lone pea lying under a mound of mattresses.

Some communication failures are even intentional. Human beings often lie, mislead, and evade. Sometimes they do so out of shame. An embarrassed patient avoids mentioning a risky sexual encounter, wrongly thinking it’s unrelated to his condition.

Other times, a liar pursues a hidden agenda. For example, complaints of soft-tissue knee pain are common in workers’ compensation fraud cases. So doctors must be careful not to be hoodwinked. An auto mechanic, on the other hand, doesn’t have to worry that the reported piston misfiring may be because the Chrysler Sebring wants to take a month-long rest in the garage.

Even if a patient’s communication is honest, clear, and thorough, an accurate diagnosis may remain elusive for other reasons. A problem may not be where it appears to be; pain can be “referred.” An ailing spine may cause feelings of discomfort in the hip or groin.

Further complicating matters, certain symptoms trace back to a confounding number of possible culprits. Consider inflamed knees. The blame may fall upon the common “wear and tear” disease of osteoarthritis. Or the patient may have a more pernicious form of arthritis known as rheumatoid. Or rogue bacteria may set off inflammation. Reactive arthritis can start with salmonella food poisoning!

What happens when the first diagnosis proves faulty? A mechanic may take a closer look at a malfunctioning car: removing the radiator cap, popping off a tire to inspect the brakes. Or he may try swapping out new parts for old.

These approaches don’t work as well with people. Invasive surgery to inspect a problem carries its own risks, including infection. As for replacement parts, man-made substitutes exist for knees and hearts for example, but are costly and vastly inferior to the originals.

Understanding the many challenges that doctors face was important, especially as I became a chronic pain patient. As this kind of patient, you drag around a long history of symptoms, a pile of test results, and a considerable amount of exasperation. Appreciating the doctor’s perspective would help me communicate effectively to get the assistance I needed.

My first orthopedist was Dr. Chiu (for this account, I’ve changed the names of all my doctors and physical therapists). A co-worker recommended him. He practiced in a suite of offices near my workplace. He was slight of frame and blandly good-looking, with a remarkably limp handshake.

I described to him how my knees burned so much that it was impossible to sit comfortably. He listened quietly, then had me hop up on the examining table. He checked the tracking of my kneecaps. He bent my legs and manipulated each knee in turn, to make sure the joints weren’t loose and moved normally. He probed with his fingers, trying to find tender spots. He asked me to extend my legs to ensure my range of motion was good. He seemed satisfied by the results. Then he led me into a small room and took X-rays from several angles.

When the X-ray film came back later, it didn’t help much. The images looked fine. No erosions of the bone. No fractures. No bone spurs. Furthermore, the joint space wasn’t narrowed. That meant my cartilage wasn’t dangerously worn to the point where the bones might start rubbing painfully against each other. My knees appeared normal.

The trouble is, X-rays only imply the presence of cartilage by noting how much distance lies between bones. They can’t really “see” soft tissues. Thus they can’t convey any information about what cartilage looks like. My X-rays couldn’t tell whether mine was perfectly smooth, badly blistered, or even pocked by holes.

Dr. Chiu suggested that I cut back on my exercising for a while. He recommended straightening and moving my legs every ten minutes or so while sitting at work. I remember being skeptical this would be sufficient. It wasn’t. Months later, on reconsidering his advice, I realized it was like flinging cups of water on a raging house fire.

He did prescribe something: glucosamine sulfate. This dietary supplement was supposed to alleviate pain and help my damaged cartilage rebuild itself. I walked out clutching a large box of red capsules and feeling hopeful. Of course I knew nothing about glucosamine sulfate.

I took 1,500 milligrams a day for almost eleven months. When the red pills ran out, I found a cheaper generic brand through a reputable online drugstore. The new pills were white, big, and hard to swallow, so I made a double plastic sleeve from the triangular corners of a Ziploc bag. Each night I tucked the day’s dosage inside the inner pouch and pounded up the pills with a claw hammer, then swallowed the powder with orange juice.

The results: absolutely nothing. I perceived no benefit at all. Gradually I became curious about what this glucosamine sulfate was, and why so many doctors prescribe it for joint pain.

It turns out the sulfate part of the name doesn’t matter much: the sulfur molecule is simply the carrier, the van if you will, to deliver the payload. And that’s the glucosamine. This amino sugar contributes to firmness and elasticity in cartilage and other connective tissue.

Glucosamine’s benefits don’t end there. Lab studies have examined its effects up close, on the nitty-gritty level of cells and molecules. They found that it helps suppress inflammation and cartilage-destroying enzymes.   

No one denies this substance is pretty important. Now you may wonder where it comes from, apart from bottles labeled “glucosamine” something or other, sitting on a drugstore shelf. Answer: your body makes it from glucose and glutamine. This in turn prompts an obvious follow-up question: what are glucose and glutamine and, more to the point, how common are they? Are they rare and often deficient in the human body? If so, it certainly makes sense to add pills to a daily diet to spur cartilage healing.

Unfortunately, that’s not the case. Glucose happens to be the main form of sugar that our bodies store for energy; glutamine is the most abundant amino acid in the bloodstream and is found in a wide variety of foods from meats to milk and spinach. The two components that make up glucosamine are about as rare as rats and cockroaches in the world at large.

Of course someone could rightly argue that having pieces of a thing aren’t the same as having the thing itself. In fact, the sophisticated take on why we need to add this amino sugar to our diet goes like this: Our bodies don’t make as much glucosamine as we age. Production lines are especially taxed, unable to keep up, when injured cartilage needs repair. A supplemental dose of glucosamine means our bodies don’t have to make it from scratch. They can just grab some that’s already preformed, sort of like being able to throw up a neighborhood of prefab homes in a fraction of the normally required time.

Sounds pretty good. There’s only one problem. The “prefab sections of home” get torn apart en route.

When you swallow a glucosamine pill, it doesn’t make a beeline for your knee joints. Rather it heads off to the liver, an organ whose many functions include metabolism. The liver then rapidly breaks it down. After the industrious wrecking crew finishes, only a minuscule amount of glucosamine reaches the blood to wend its way to the joints. That’s what researchers discovered in a 2005 medical study where osteoarthritic patients took the recommended dose of 1,500 milligrams of the supplement, then had their blood tested.

My doubts grew about the value of taking glucosamine. It turned out I had plenty of company. In 1999, an editorial in the British medical journal
Lancet
bore the rather blunt title, “Hype about Glucosamine.” Scientists revisited positive trials from the 1980s and 1990s, only to discover that most were small and of poor quality. Many were sponsored by a company that made and sold a brand of the supplement, suggesting a serious conflict of interest.

Better designed studies were needed. Around the world, in the first decade of this century, researchers responded by setting up more rigorous experiments. What followed were findings that dashed a lot of hopes.

More than 200 Netherlands patients with hip osteoarthritis derived no advantage from taking glucosamine, according to a 2008 article in the
Annals of Internal Medicine
. Those who consumed the suggested daily dose had the same amount of pain, restrictions on mobility, and joint space narrowing as those who didn’t.

That same year,
Arthritis and Rheumatism
magazine reported that glucosamine and another widely touted supplement, chondroitin sulfate, didn’t slow cartilage loss in arthritic knees any more than a dummy placebo. A two-year multicenter study in the United States reached that conclusion.

The United States also hosted the lollapalooza of glucosamine studies, which included 1,600 patients. Researchers looked at the subjective marker of pain relief. Did patients with knee osteoarthritis who took glucosamine or chondroitin sulfate feel better, regardless of what happened inside their joints? That’s a good question: many glucosamine advocates boast about how their pain has subsided.

Both of the dietary supplements, however, proved no more effective than a placebo.

Fans of glucosamine found little to celebrate in the five-year, $12.5 million study, except for one odd result. Patients with more severe osteoarthritis pain experienced more relief than expected after taking a combination of glucosamine and chondroitin sulfate. This may just be a statistical anomaly though. In a different study, patients who popped a glucosamine-chondroitin combo fared the worst. They lost more knee joint space than all four other groups being compared, including placebo takers.

I never jumped aboard the glucosamine bandwagon because of my personal experience. Still, other joint pain sufferers claim to be unable to function properly without the supplement. The debate over its usefulness will probably rage for years. Maybe someday researchers will find a solid reason why it brings relief to some people. Then again, if the benefit just turns out to be the “placebo effect,” that may not be so bad either. The mind can be a very powerful force in healing.

A month after seeing Dr. Chiu, as the daily glucosamine pills failed to alleviate my pain, I decided to get a second opinion about my knees, in case Chiu had overlooked something. That’s how I came to pick Dr. Simpson more or less randomly from a directory of orthopedists in Bloomberg’s managed care network.

Before our meeting, I mused about my chances of getting a good doctor. Optimistically, Simpson could be a young guy, full of verve, schooled in the latest thinking on knee injuries. He could be bright, open-minded, and dynamic. He could be a budding superstar, using this network as a stepping stone to launch his own practice. Pessimistically, Simpson could be a tired hack.

Within minutes of entering his office, I realized with a sinking heart I had Simpson number two. He had the dull, bored look of a bureaucrat who just happened to be wearing a lab coat. He examined my knees, much as Dr. Chiu did, but found nothing abnormal. His response to my complaint of knee pain was basically a shrug. He had no good advice or insights to share. I wasn’t a candidate for surgery—at least not yet.

Dr. Simpson was the one who stiffened when I challenged his diagnosis of patellofemoral pain syndrome. He must have sensed my frustration. Two doctors had now told me my knees were basically normal. So why did they hurt so much? They felt far from normal. I left feeling despondent.

Meanwhile, I was becoming weary of the nebulous “patellofemoral pain syndrome” verdict. I wanted some hard information on what my knee joints looked like. Was bad cartilage really my problem or could it be something else? Standard X-rays don’t depict soft tissue, but magnetic resonance imaging does. An MRI employs a powerful magnetic field to draw a picture in black and white and shades of gray. It can identify fluid inside a joint, tears in a ligament, or torn or thinning cartilage.