Saving My Knees: How I Proved My Doctors Wrong and Beat Chronic Knee Pain (5 page)

Dr. Simpson didn’t support doing an MRI, so that brought me to Dr. Song. My first impression of his practice was that he appeared to have adapted well to the age of managed care. His waiting area was full of patients who briskly moved in and out of his office. When my turn came, I entered the cramped quarters and sat next to his desk. He struck me as a rather nervous and edgy man. He didn’t maintain eye contact well, and when he did look at you, it was a bit askance, as if you weren’t to be trusted.

Dr. Song didn’t do much of a knee exam at all. He listened as I recounted my history and explained my reasons for wanting an MRI, then approved it without objection. On September 6, 2007, I underwent the procedure. The hardest thing was simply keeping each knee perfectly still during the long scans. When the results came back, they finally supplied me with some answers.

The MRI revealed chondromalacia, mainly of the patellae, but no other issues. So I did have bad cartilage, though the report described my condition as “mild.” That puzzled me. Of course without an invasive procedure known as an arthroscopy, it was impossible to know how bad the tissue really was. From the constant pain signals, I surmised that something traumatic had happened to create such problems.

I would return to Dr. Song later, when my difficulty sitting at work became too severe to ignore. He even agreed to support my first experiment to save my knees. He signed off on my plan to work half-time for three months to try to strengthen the joints. I will always be grateful for that; many other doctors would have refused.

But he was clearly uncomfortable. At one point he said, “I don’t want to get between you and your company.” That remark threw me off balance. Wasn’t his main responsibility to heal his patient? If he thought my plan made sense, he should support it. If not, he shouldn’t. Then later, I wondered if he was reacting to the pressures of being in a managed care network that tries to control costs while keeping its clients (companies like mine) happy.

Orthopedist number four, my last-ditch effort, was Dr. Lin. By then I was at the end of my rope. I’m not quite sure what I expected entering his office on a Friday at mid-afternoon. I clutched a typed-up summary sheet that listed my symptoms and history. By then I carried a lot of baggage and wanted to be efficient. It was probably good that my expectations were low.

An empty waiting room greeted me (it was also empty when I left). A wariness began tingling in my frontal lobes. As I settled into a well-cushioned seat, his secretary pleasantly informed me that the cost of the appointment included five days of free pills. At that point, the prescription itself seemed like a mere formality. It was coming. The handwriting was on the wall.

Dr. Lin was a bluff, hearty Asian with a bushy mustache. He had a garrulous manner, as if we were two guys having a beer after work. I handed him my summary, babbled for a while, then told him I was dedicated to getting better. He inquired about my age. He never asked to see the MRI or X-ray images I brought. He never examined my knees. He never so much as asked me to hike up my pant legs so he could take a gander from across the room, just to make sure there wasn’t a rod sticking out of them sideways.

After five minutes during which I did most of the talking, he proclaimed loudly, “You have arthritis!” I frowned, confused. Old people who had a lot of joint stiffness and problems moving about had arthritis. That wasn’t me, not yet. He waved aside all my points, including the chondromalacia discovered by the MRI.

His assessment came down to this: “You’re forty-six, your body is going to go downhill, you just need to accept that, and you have arthritis.”

Dr. Lin didn’t have pills for chondromalacia, but he sure did for arthritis. I left with ten pink tablets and ten white tablets to counteract the effect on my stomach of the pink ones. He no doubt made a mental note to expect me back in another week or so, looking for another fix.

Curious, I returned to Dr. Chiu the following week. He actually did look at my knees. In response to my question, he said flatly, “No, you don’t have arthritis.” He did leave open the possibility that I would in several years if my joints kept deteriorating.

The conflicting diagnoses left me pondering the word “arthritis.” True, it literally does mean joint inflammation. Such a simple definition misses a lot though. If a seventeen-year-old complains of inflamed knees because he stupidly trained too little then ran a marathon, it’s doubtful a doctor will call the condition arthritis.

A better definition (for osteoarthritis anyway) is “a degenerative joint disease that includes structural changes, such as bone spurs.” Osteoarthritis appeared to be the relevant variety for me, as my joints weren’t tender or swollen, as they normally would be for other forms such as rheumatoid arthritis. Dr. Lin had no idea whether I had bone spurs or swelling even; after all, he never looked at my knees.

What he probably did was put me in a box. He asked my age, then in his mind he went down a decision tree—chronic joint inflammation, over forty—and he arrived at the conclusion “arthritis.”

I would encounter that box again and again. It’s a small, bleak box with no windows. You’re often put in that box when you’re older. If you’re young, you’ll heal. You have hope. If you’re older, you’ll never get better and should bear your pain with stoicism and quiet despair. In other words, start shopping for the lining of your coffin.

That I wasn’t getting better seemed to warrant pessimism. But the doctors consistently ignored a point I made repeatedly, until it felt like I was shouting at the deaf. My job required ten hours a day at a desk, but I couldn’t sit! That position caused my knees to burn, which probably meant inflammation, which in turn kept my joints weak. How did I stand any chance of healing without being able to conquer this endless burning?

My exasperation led me to formulate a thought experiment for doctors. Here it is:

You’re a physician practicing medicine on another planet. A patient shows up. “Doc,” he says, “I have knee pain. My daily activity consists of standing next to four different kinds of pods: green, red, blue, yellow. When I stand next to the green pod, my knees feel fine. I also have no problems with the red and blue pods. But when I stand next to the yellow pods, my knees burn and hurt.”

What’s logical to advise? I bet most doctors taking part in this thought experiment would say, “Avoid standing near the yellow pods.”

What happens though when you substitute “sitting for long periods at work” for “yellow pods”? My guess is that these same doctors would start to backpedal, suddenly unsure of their footing. If you order a white-collar worker to “assume the position,” he sits down. And if he can’t, what then do you have? I had become a contradiction in terms.

It certainly didn’t help that bad knees heal slowly, if at all. Any doctor who agreed that prolonged sitting was bad for me would wind up in an unenviable spot. He would have to support paid medical leave or some other measure that could disrupt my employer’s workplace. He would have to sign off on paperwork and speculate how long my recovery would take. Even if he believes bad knees can get better, is he willing to stick his neck out and say mine will, and when?

Instead the doctors tried to skirt the seriousness of my problem with sitting. They recommended small things, like stretching out my legs from time to time or periodically walking around the newsroom. But walking for a minute each hour wasn’t enough to counteract the effects of sitting during the other fifty-nine.

The orthopedists couldn’t help me further. In the binary world of surgeons, where patients are either candidates for the knife or not, I was a “no cut.” This gave me scant comfort. It seemed certain that eventually I’d need an operation because my joints were continuing to fall apart.

They did suggest physical therapy. Today, knowing what I know, I couldn’t agree more. Good physical therapists are worth their weight in gold. Unfortunately, I soon discovered that the standard treatment for grumbling, aching knees rests on some dangerous thinking. My physical therapist’s advice left me hurting worse than ever.

Later it became clear to me that, despite what they may want you to think, many physical therapists share a dark secret. They are no more optimistic about improving the health of your knee joint than are doctors.

My main physical therapist was a fellow I’ll call Tim Chang. I briefly consulted with another early on, whose approach was quite similar to Tim’s. My treatment seemed to be the standard fare for bad knees suffering from patellofemoral pain syndrome.

I met Tim soon after my first visit to an orthopedist. He was handsome and fresh-faced, apparently in his mid-twenties. His vigor and cheerfulness seemed appropriate to his profession. Whenever he demonstrated leg exercises, his muscular thighs bulged through his gray slacks. Here was someone who prided himself on keeping fit, I thought.

In me, he acquired a patient who was scared, frustrated, and desperately searching for a way forward. My strengths included tremendous discipline and willpower: sticking to an exercise regimen wouldn’t be an issue. I also was still trying to understand my condition and soaking up new information like a sponge.

While I sat and listened, Tim started out by manipulating an anatomical model of a knee joint to show how the bones normally interfaced and moved. He clarified why sitting bothered me. It’s a simple mechanical issue. Bending my legs to a ninety-degree angle increased pressure between the kneecap, where the damage was, and the end of the thighbone.

He had me change into shorts and examined both of my quadriceps, the set of four large muscles that travel down the front of the thigh that control knee extension. Mine were still very strong, he noted approvingly. That strength would help cushion the impact of weight-bearing activities on my tender joints. He studied my gait as I walked in stocking feet, checking the alignment of my hips, legs, knees, and feet.

He instructed me to do one-legged dips as he monitored my posture. The cartilage crackled brightly as I bent each leg in turn while trying to keep my balance. He asked me to do those dips on several separate occasions. It never caused pain at the time, but invariably I would suffer the next day. This remained a mystery to me until months later, when I started investigating cartilage injuries more deeply.

Later it also struck me as curious the questions that never came up. He inquired about my pain symptoms of course. He asked about my exercising—what kind, how long (though there wasn’t much to say since I had given up cycling). But he never seemed interested in how I used my knees over the course of a day, apart from exercise. Did I walk a hundred yards to work or a mile? Did I lug a heavy backpack, a light backpack? Did I go home and carry a three-year-old around on my shoulders?

Still, I wasn’t thinking critically in the beginning. I sought solutions. Any suggestions he offered, I seized eagerly.

First, he said, I needed to start stretching to redress any issues of tightness. Throughout my life, I had never done much stretching and rarely suffered injuries. Even so, I accepted that now things had changed. I had to be careful and would stretch.

Several stretches became part of my daily routine. I learned ways to stretch the quadriceps, the hamstrings (the large muscles on the back of the upper leg), and the iliotibial band. The IT band is a thick tendon that starts at the hip and runs in a flared shape along the outer thigh. It joins the body’s network of bones just below the knee. Tim told me a tight IT band could pull my kneecap off center.

A mistracking kneecap can be bad news. It can wear through cartilage much like a misaligned car chews up tires. The kneecap ordinarily slides smoothly through the trochlear groove, a curved notch at the end of the femur shaped like the space between a couple of large knuckles on your hand. It’s not hard to visualize how a bellied piece of bone could pass back and forth through such a channel with ease. But shift the bone a little right or left, and it starts to rub on the sides. The cartilage on the underside begins to fray.

Why do kneecaps mistrack? Possible reasons abound. Some put the blame on muscles: Your inner quad muscle is weaker than the outer quad. Your hamstrings are too tight. Muscles in your buttocks aren’t strong enough. Or anatomy may be at fault: Your trochlear groove is too shallow. You have flat feet. You have wide hips.

Besides stretching, Tim also told me to do exercises to strengthen key leg muscles. Mainly I tried to build up my quads. The exercises run together in a blur now: Sliding up and down sideways against a wall, letting one leg at a time support my weight. Leaning back against a wall, as if sitting in an invisible chair, and holding that position. Extending my leg, while seated, against the tension of a blue Theraband elastic loop.

Tim supported getting me back on the bicycle. I missed riding very much and embraced that idea. For $310, I bought an indoor trainer and climbing block to support the front tire. The setup allowed me to convert my Litespeed to a stationary bicycle. A smooth cylinder pressed against the rear tire, providing light resistance and allowing me to cycle at a relaxed pace. Tim suggested no more than ten minutes a day at first.

I followed his advice with much hopefulness. I never lacked dedication or desire. Every morning, without fail, I performed my stretching and exercises. But as the weeks passed, my knees didn’t seem to be improving. Sometimes they felt a little better, sometimes a little worse. This wasn’t at all what I envisioned.

The problem was, my easily irritated knees couldn’t tolerate that much. Even gently riding the bicycle for ten minutes caused discomfort. So Tim experimented. Instead of leg presses on a gym machine, he had me lie in a stationary position and push with my feet against a wall. He substituted other isometric exercises too, where I could tighten the muscles without moving the joints.

He kept modifying my workout, making it less stressful, until we reached the point of absurdity. My hurting knees protested at anything but the easiest of exercises. But these didn’t tax my muscles enough to produce the kind of satisfying burn that would indicate they were getting stronger. My bad joints sabotaged his plan to bulk up my legs.

Tim tried to cheer me on our weekly visits. I mentioned surgery a few times, having become aware of a procedure called an arthroscopy that could trim away bad cartilage and clean up the joints. Tim persuaded me to give physical therapy a few months at least. I wasn’t seeing any progress though. He just seemed to be throwing things against the wall to see what would stick.

A colleague once asked why I never changed physical therapists. This good question had no simple answer. I compared my experience with Tim to a bad marriage. You think you should leave, but then again, your partner knows you so well and you’d have to start fresh with someone new. The bigger reason though was probably the same one that unhappy couples cite. You’re not sure there’s anybody better out there. I was doing a lot of reading about patellofemoral pain syndrome. Most experts advocated the same approach as Tim did.

Tim also had come to fill a role that required very little skill. Whereas my co-workers darted down side hallways when they saw me coming, afraid of being buttonholed for a long-winded talk by the Boring Knee Guy, Tim was the friendly listener I needed. He would do a deep massage of my IT band and nod sympathetically while I went on about my symptoms and mused about what to do next.

Together we bumbled along during the summer of 2007, awkwardly trying to find a path to healing. Tim tried an ultrasound treatment that applied heat deep in the joints. He tried taping my kneecaps to place them in a less stressful position. Taping seemed to work on a few occasions, but on others it just made my knees feel worse.

Then in September something wonderful and strange happened. It occurred during a two-week vacation to Tibet. My then-fiancée, Congyu, suggested the trip. We had been seriously dating for more than a year; she once worked for China’s largest bank and lived in Shenzhen, just across Hong Kong’s border with the mainland. She loved to travel and had long desired to visit the rugged, mountainous region at China’s western edge.  

To prepare for the trip to Tibet’s capital, which sits more than two miles above sea level, we spent a few days in the mile-high Chinese city of Lanzhou. From there we went thirty hours by rail to Lhasa. The vistas we glimpsed from the train windows compensated for having to endure the crowded cars and reeking squat toilets. The land was pristine and beautiful, though desolate.

In Lhasa, we did a lot of strolling at a moderate pace, trying to adjust to having less oxygen to breathe. We visited several monasteries. We went to the majestic Potala Palace, the former home of the Dalai Lama. We also ambled past stalls where yak meat ripened in the heat, and I bought a Tibetan prayer wheel as a souvenir.

A two-day sidetrip took us three thousand feet higher, to the scenic salt lake of Namtso, which was surrounded by snow-capped mountains. Despite the breathtaking scenery, only a few hardy souls lived in the nearby rough encampment of tents and primitive shelters. Congyu and I joined two Chinese travelers in taking a simple, unheated room with four beds. We all retired early, burying ourselves underneath mounds of blankets.

My indelible memory of Namtso came around 11 p.m., when I awoke needing to use the outdoor toilet. I groped about and dressed in the darkness. The electrical generator for our “hotel” was already shut down, so I had to stumble through the large unlit common area. I finally stepped outside and shivered against the cold, then looked up. The sky was clear and ablaze with night light. The half moon and stars looked so brilliant and close. It was what I imagined outer space to be like.

The first day at Namtso, I struggled with a severe headache while trying to take photos. Headaches and nausea were symptoms of the altitude sickness that occasionally afflicted me in Tibet. But what didn’t bother me was more surprising. Midway through the vacation, my knees stopped burning all the time. They felt pretty much okay. Was I finally getting better? Was there something special in the pure yet thin air, in the mild September weather, in the blue skies dotted with fair-weather cumulus?

The sudden change especially amazed me because of what I wasn’t doing. In Tibet, I didn’t do any stretching or exercises for my quadriceps. I didn’t take any glucosamine either.

(Such rapid healing seems too good to be true, and in retrospect, I’m sure it was. Here’s what I think really happened: My knees were enormously relieved not to have to sit ten hours a day. Away from my office desk, the chronic inflammation managed to quiet down. That was a significant breakthrough. Inflammation helped keep the joints weak and caused discomfort and pain. Still, the underlying problem hadn’t gone anywhere. Damage to cartilage and joints can’t be repaired in a few weeks.)

The improvement in my condition left me feeling nothing short of ecstatic. After returning to Hong Kong, I could hardly wait to see Tim again. All along, he had wanted me to lift weights to build up my leg muscles. I never could before without having symptoms. That no longer appeared to be a problem. At our next appointment, he listened to my good news with a broad smile, then told me, “It’s time to hit the weights.”

I was ready. I badly wanted to win back my fitness.

He carefully showed me a “safe range” for doing seated leg presses—an exercise that requires straightening bent legs to move a weight. I should restrict my effort to the last part of the extension, he said, to lessen the pressure under the kneecap. He also demonstrated a “safe range” for seated leg lifts, which I planned to do to strengthen my vastus medialis oblique. A weak VMO, a muscle near the inside of the knee, is sometimes blamed for a mistracking patella.

I was energized. During my worktime lunch break, I began going to a health club in an office tower across the street. Each workout session, I rotated between a couple of leg machines and did sets of twenty to thirty repetitions, low enough to build up the muscle. My knees felt good. Tim never told me how much weight to lift—why bother? My joints would be protected as long as I stayed in that safe zone, I figured.

It was fun being back in a weight room. I liked the atmosphere: the grunting of athletes pushing themselves to their limits, the determined padding of feet on treadmills, even the strutting of the muscle-bound gym rats. My legs possessed a surprising amount of strength, even though I hadn’t done any cycling for four months.

After a few days, the first problems surfaced. Upon rising in the morning and standing up, I would feel a hot, focused burning in my knees. It was disconcerting. The burning in my joints had never been so intense and concentrated before. Also, until then, my knees were usually pretty good on waking, then worsened over the course of the day. When I mentioned all this to Tim, he didn’t seem concerned, leading me to believe the problem was only temporary.

The trouble was, my knees felt worse in general. Over the few weeks after my return from Tibet, they took an alarming and steep decline. I considered stopping the weight room workouts, but I still believed in Tim’s basic philosophy:
Build up the quadriceps, because strong legs protect weak knees
.

That thinking seems practically ubiquitous. Everywhere I turned online, that same advice was dispensed. In fact, if you dropped a quarter in a gumball-type machine labeled “PT Advice: Bad Knees,” it would probably spit out a hollow plastic ball with a strip of paper inside that said, “Strengthen the quadriceps!”

Self-doubt nagged at me. My impatience must be the real problem, I thought. My knees felt fine during the actual weightlifting; wasn’t that a good sign? The discomfort that bothered me at other times would surely pass, once my quads gained enough power. I continued my weight routine though quit doing the leg presses.