Arguments With My Knees
My personal journey towards coming to terms with my altered physical ability and strength
Long before personal GPS devices existed, teenage me sprinted down the country road outside my parents' house, then ran to the cemetery, into town, and out again, completing a 6-mile loop.
I continued to run (5 miles daily, then every other day) until a bicycle accident caused a slight meniscus tear in my left knee. Initially, I ignored it, expecting it to heal as injuries before. But my left knee, which had always been occasionally whiney, became downright argumentative.
When I finally saw an orthopedic doctor, I learned about the tear and that I had mild osteoarthritis (OA). This was when I realized that I would never be able to run as I used to, flying over uneven terrain without a care in the world. I was devastated.
This was when I realized that I would never be able to run as I used to, flying over uneven terrain without a care in the world. I was devastated.
According to the Center for Disease Control, osteoarthritis affects about 32.5 million adults; nearly 12.5 million are 65 or older. At 53, my osteoarthritis is considered "early" onset, Dr. Brett Hayden, orthopedic doctor and surgeon at Mount Sinai Hospital, told me. Risk factors that can lead to this include an ACL or meniscal tear.
There's also a genetic component. Osteoarthritis is the gradual degradation of cartilage in any given joint, Hayden explained. With this degradation comes inflammation. As it progresses, bone spurs or degenerative tears on the meniscus (different from the tear I have resulting from an accident) can form.
Eventually, the cartilage becomes completely worn out. Bone rubs against bone. While my OA remains "mild," my knees swell if I do something foolish like hike nine miles with 6000 feet of elevation, which, because I wanted to, I recently did while on Reunion Island, a French island in the Indian Ocean.
Adjusting My Expectations
I've adjusted my expectations about what my body can and can't do, precisely how "fast" I can do certain activities. On that trail on Reunion, everybody zoomed past me as I trudged, my knees whispering complaints with each step. Though my extremely slow hiking pace embarrassed me, I never considered stopping.
I worry I might further damage my knees by refusing to sideline myself. And I wonder if my 30-plus years of running caused the early decline of my cartilage.
I worry I might further damage my knees by refusing to sideline myself. And I wonder if my 30-plus years of running caused the early decline of my cartilage. Doctors used to think osteoarthritis was caused by overuse.
In recent years, though, evidence shows an inflammatory component, Maura Daly Iversen, physical therapist and chair of the Physical Therapy, Movement and Rehabilitation Sciences department at Northeastern University, told me.
It is not the same as rheumatoid arthritis, but an inflammatory component nonetheless. Doctors don't entirely know why yet. They know that inflammation is actively involved in the disease's progression (as opposed to wear and tear). Immune cells and inflammatory mediators (regulatory molecules) in connective joint tissue prompt the production of degrading enzymes.
Iverson said new methods of treating and slowing down osteoarthritis will emerge. In the meantime, my insistence on remaining active isn't necessarily causing harm.
"If you have mild arthritis and continue to pound on the knees, you could aggravate your symptoms, but it's unlikely you're really going to make the true condition or the natural history of the condition significantly worse - unless you have a real injury," said Hayden.
Signs of Overdoing It
Of course, you shouldn't completely ignore your body's protests, either.
"A little bit of soreness is okay, but if you're doing activities to severe pain on a consistent basis such that it affects the rest of your life outside of those recreational activities, you may want to dial it back a little bit," said Hayden. Something that, for me, is easier said than done.
Osteoarthritis symptoms ebb and flow without anything necessarily changing on a micro or macroscopic scale. During that hike, my joints became inflamed, likely because of bone rubbing against bone.
Osteoarthritis symptoms ebb and flow without anything necessarily changing on a micro or macroscopic scale.
"Inflammatory mediators and cytokines rush to the site," explained Hayden. This causes an "effusion" of fluid inside the knee, which creates stiffness and pain. In general, exercise shouldn't cause increased swelling. "Sometimes," said Iverson, "You can't tell right away. I'm sure if you were hiking and noticed your knees getting bigger, you'd stop."
I did notice. I had no choice but to keep going, though. I half limped, half dragged myself with trekking poles through the village of Hell-Bourg to a hotel. The lovely young man at reception brought me dinner to my room, apologizing for the stairs. I must have looked frightful. I'd skidded and fallen more than a few times on the steep, rocky descent to the village and was covered in dirt.
My headlamp was crooked to my forehead under tangled hair and a dirty baseball cap. And my knees. They were huge. He must have heard them screaming.
Managing a Flare-Up
Iverson recommends ice every four to six hours, resting, and nonsteroidal (NSAIDS) pain relievers (ibuprofen and similar) for flare-ups. There's also manual therapy, during which a physical therapist provides traction or compression to the joint with their hands. This improves blood flow, increases the range of motion and reduces swelling.
The only one of those things I had on me was ibuprofen. I lay down with my knees elevated, hoping that I would be able to sleep. If your knee becomes crazily swollen (as mine was), Iverson says that sometimes it's worthwhile to use compression bandages to help keep the swelling down. It does not, though, she emphasized, strengthen the knee.
"Sometimes I think about the person when I suggest that because some people think if they have a compression bandage on their knee, they can do anything," she said. I am, obviously, one of those people she'd probably not recommend use a compression bandage.
Medications and Injections
Hayden suggests taking NSAIDs for two or three weeks to manage a flare, though patients who have or are at risk for chronic kidney disease should consult with their primary doctors before doing so. As should people with a history of GI bleeds.
Your orthopedic doctor can also give corticosteroid injections to manage inflammation. These usually have a mixture of numbing medication, either lidocaine, bupivacaine, or ropivacaine.
"This doesn't change the overall condition; it doesn't generate cells or cure cartilage wear, but they are potent anti-inflammatory medications that can really alleviate your symptoms," said Hayden. For me, they're beneficial.
"Over time, multiple injections can lead to degradation of the joint. We generally don't recommend more than three in a year," said Hayden. Nor do doctors give them within three months of knee replacement surgery because of the increased risk of infection. It's essential to consider the big picture.
Another type of injection is hyaluronic acid, a gel injection that provides mechanical lubrication. These require insurance pre-authorization. Hayden (as well as my orthopedic doctor) recommends starting with cortisone because there's more of a consistent response to it.
"When you look at the recommendations from the American Academy of Orthopedic Surgeons (even though many studies show patients get relief with gel injections), they're generally not recommended for routine use," said Hayden, mainly because of the variable response from people who have tried it.
There are things you can do to slow the roll of osteoarthritis, one of the most important being a consistent regime of physical therapy exercises.
While they can be extremely helpful for some (I have a few friends who had them that call them 'life changing'), for some people, they may not work at all. I've also heard that cortisone shots become less effective the more you get. Hayden says this may have more to do with the progressive nature of OA than with the shots.
The Progressive Nature of Osteoarthritis
"You don't stay in the mild arthritis category forever. We don't know exactly how quickly for any individual patient it will progress, but it's a dynamic condition. So, as the knee arthritis gets worse, the cortisone injections usually stop working as well," explained Hayden.
While it's challenging to predict the progression, it's not inevitable that you will end up in the severe category. "Some may go from mild arthritis to complete bone on bone in a year while others may take 20 years, if ever, to get to that severe category," Hayden assured me.
And there are things you can do to slow the roll of osteoarthritis, one of the most important being a consistent regime of physical therapy exercises.
About Physical Therapy
When managing osteoarthritis, conservative, non-surgical physical therapy is your best friend. The weaker your muscles get, the more pressure your knee feels. While staying physically active is often counterintuitive for people with knee issues, it's vital, said Iverson.
"Think of your muscles as supporting a suspension bridge," she said, "Even though the bridge [your knee] may sway, if you let the suspension weaken, you're going to have more problems."
Physical therapists work on pain management, improving range of motion and developing muscle strength. They will provide you with a suggested set of exercises and show you how to do them properly so you can perform them at home. While there are online resources to get you started, make an in-person appointment if possible.
Insurance often covers physical therapy, especially if you get a prescription from your orthopedic doctor. While I will never wholly stop my knees from complaining, doing physical therapy 2 or 3 times a week minimizes the violent arguments.
The morning after my Reunion hike, the swelling had subsided somewhat. I walked to a bus stop and up a steep hill to my next overnight destination. My knees grumbled, but they did not fail me. They were still runner's knees, after all, and I (albeit a much slower one) was a runner and hiker.