I first felt it when I was walking up the stairs. Then, a few months later, walking down the stairs. Then I felt it when I went anywhere. I'm not that old. How were my knees betraying me already?
I went to a local orthopedic specialist and he told me it was arthritis. Surely, he was mistaken. That was something that old—like early-bird dinners and AARP old—people got. After a quick examination, "lose weight and get a Fitbit," was pretty much his advice. I hadn't gained enough weight to warrant knee pain, though. I hobbled around for a full year. Carb-free and limping, I was distraught. What more experts confirmed was barely any consolation. “Over the age of 30, everybody has some imaging evidence of arthritis,” says Lillie Rosenthal, a New York City-based integrative physician with a focus on physical medicine and rehabilitation.
Eventually, the pain became unbearable. Another year later, I met with a different orthopedic specialist who thought my discomfort was caused by a torn meniscus. This, I could handle. A sports injury is respectable. (A recent fall, also respectable.) That doctor immediately sent me for an MRI and rushed the results. I limped my way back to his office. He wanted me to have surgery within days. “You’ve been in enough pain,” he told me. I would have gone through with it, but coincidentally that week a New York Times article popped up in my feed about how doctors falsely diagnose torn meniscus. So, I held off. I was at a crossroads. The pain wasn’t going away but I was skeptical about surgery. My MRI results said “may have tear to lateral meniscus.” May?
How accurate are MRIs to begin with? “I have rarely seen a 'normal' knee MRI because it never really comes back normal. [MRI] is exquisitely sensitive; it picks up so much,” Rosenthal says. “But it’s not necessarily specific for explaining what the problem is.”
Many doctors suggest physical therapy at least twice a week prior to considering surgery to see if the pain can heal on its own to strengthen muscles. I know: It’s hard to imagine exercise when you are in so much pain. Still, I wanted to avoid the knife if I could, so I found an encouraging, patient therapist to help me along. I wondered, along the way, if PT would be nearly as effective as that other doctor imagined surgery would be.
“Most physicians recommend a course of conservative management before surgery,” says Alicia Filley, a Houston-based physical therapist who regularly reviews research on knee injuries in her role as editor of Sports Injury Bulletin. “However, physical therapy requires work, perhaps a change in lifestyle, and consistent effort. Some may think that surgery is a ‘quick fix,’ not realizing that the recovery from surgery is sometimes more difficult than the initial therapy would have been.”
The PT helped, but I was still in pain and not sure what to do so I tried a third and final orthopedist upon recommendation from a friend. He asked a series of questions and took another X-ray. I brought a copy of my MRI with me to have him reassure me. I just needed him to tell me that it was okay to have surgery and that it would swiftly return me to my youthful self.
But of course, he did not. He said that my meniscus was not torn at all, and that the pain was simply a symptom of a problem with my cartilage. Instead of cutting open my knee, he prescribed a gel (hyaluronic acid) shot which almost instantly began to work. It was even covered by my insurance.
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Gel shots, or viscosupplementation injections, can provide relief of knee pain originating from cartilage wear and tear, says Craig Capeci, an NYC-based orthopedist and clinical assistant professor at NYU Langone Orthopedic Hospital. The wear and tear he refers to is "cartilage damage that can be a precursor to arthritis, which is global loss of cartilage in the joint," he adds. "Gel injections can work in any cartilage-wear situation in by putting a naturally occurring substance back into the knee in a gel form that also acts as a cushion or lubricant."
When I got them—the shots were administered once a week for three weeks consecutively—the doctor numbed the area around my knee and then slowly injected the gel. It was a little different from a regular injection since I felt the release of what was in the syringe in a more pronounced way; it was uncomfortable for a few seconds and then mildly so thereafter. The gel is meant, I’m told, to serve as a lubricant to the joints, which are isolated in this case as the source of the problem. For me, the pain didn't completely go away, but I was able to tackle more active tasks with less pain after my first set of shots.
There is a range of shots and treatments available for people in my situation. In addition to gel injections they include steroids, as well as emerging biologic injections like stem cell and platelet-rich plasma shots. All are said to “temporarily relieve pain in some patients, “ Rosenthal tells me. My doctor thought the gel shots were my best option, though, based on how I described my condition. Success is hard to predict, Capeci says about the gel shots. "I usually tell patients there’s about an 80 percent chance of a positive response, but it's hard to predict the duration and level of the response."
Should I have gone under the knife? Seems like no. “Surgery can fix the knee by replacing it [or repairing it] but it doesn't identify and address the cause,” says Rachel Tavel, a Brooklyn-based physical therapist and certified strength and conditioning specialist. “Why did one knee get worn down over time more than the other, leading to osteoarthritis? Maybe it's because of chronic weakness in that hip. If you replace the knee joint, you don't solve the problem area, which is actually the hip.” Her point is, surgery isn’t promised to fix pain; you can tend to a knee thoroughly but the problem might not be coming from the knee.
After the gel shots and months of PT, stairs were still problematic, but I was now able to go on hikes, long walks in the park and a variety of other activities. My knee still couldn’t withstand the impact of running, though. I returned for my next gel shot six months later only to learn that insurance no longer covered the procedure, so if I wanted the fluid I would have to pay around $750. This was disappointing; I paid out of pocket the second round, but now I'm not sure I can afford to continue with them. With the escalating price of shots, I am once again looking into other ways to relieve my knee pain.
For now, I’m going to try spending more time on the causes of the pain rather than the numbing of it. I will change my diet. I will look into root causes. I will continue PT. And maybe one day I’ll run again. The intricacies of the knee world are complicated, more so than I realized when I went to my first doctor for advice. “The gold standard for knee pain is history-taking and physical examination, [which means] the doctor putting their hands on the body to examine it. Ninety percent of all diagnosis can be made like that,” Rosenthal says, perhaps suggesting that an MRI followed by surgery is not the holy grail of relief.
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