Contents

Foreword

Introduction

1 ... An Active Lifestyle

2 ... Prelude to a Fall

3 ... The First Ring of Hell

4 ... Doctors

5 ... Physical Therapists

6 ... The Puzzle

7 ... Inside Knee Cartilage

8 ... The Experiment

9 ... Trying to Heal

10 ... A Rocky Start

11 ... Recovering

12 ... My Four Golden Rules for Bad Knees

13 ... An Orientation Toward Healing

14 ... The Road Not Taken: Surgery

15 ... Final Thoughts

Appendix: My Year of Recovery

Select Bibliography

~~~~~~~~~~~~~~~~~~~~~~~~

SAVING MY KNEES

How I Proved My Doctors Wrong and Beat Chronic Knee Pain

By Richard Bedard

FRESH VISIONS PRESS : NEW YORK

The greatest obstacle to discovery is not ignorance; it is the illusion of knowledge.

—Daniel J. Boorstin

Copyright 2011 by Richard Bedard. All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means including information storage and retrieval systems without permission from the publisher, except by a reviewer, who may quote brief passages in a review.

Foreword

Sometimes it’s good to know the story behind the story. That’s certainly true for this book.

I wrote the first draft of Saving My Knees in a white heat of passion, my mind brimming with ideas. Afterwards I spent too many hours to count in researching, revising, fixing style. Every single line was scrupulously fact-checked; that took the better part of a month and left me exhausted. I hired four readers, from Arizona to New Hampshire, to go over each page with a critical eye, then made changes based on their suggestions.

As a veteran journalist, I was convinced the story of how I saved my aching knees was fresh and different and could help millions of others. There are lots of “heal your bad knees” books, but they follow the same tired formula. They feature the same information, the same dull, pedantic writing style, the same types of illustrated exercises, the same detached clinical viewpoint.

Feeling confident, I began to approach literary agents with my polished manuscript. And I quickly slammed into a brick wall. It soon became clear no agent would ever agree to represent Saving My Knees, nor would any major publisher ever offer to buy it.

Why not, considering I had a compelling first-person story not only of beating the odds to recover, but also of making surprising discoveries along the way? After all, I learned why standard physical therapy so often fails patients and how damaged knee cartilage has been shown to heal and grow back. These weren’t opinions either; my findings were backed by extensive research.

All fine, an agent told me, except for one problem: I’m not a doctor.

That created a maddening Catch-22. A book that isn’t prescriptive at all would be easier to sell to publishers since I lack the authority conferred by a medical degree. At the same time, it would be harder to sell to the public, since knee pain sufferers want tips on how to get relief and heal.

I was on the horns of a dilemma. To get through a publisher’s door, I needed a book that contained no advice, which the publisher would then reject, realizing it contained no advice. Crazy, huh?

After spotting this intrinsic absurdity, I had a soul-searching moment while mulling what to do next. What did I want Saving My Knees to be? Of course I liked the thought of creating a tangible book that a talk show host could thrust in front of a TV camera, or that a Barnes & Noble clerk could stack near the store entrance in tall, imposing piles.

But failing that, I just felt a strong compulsion to share what I had learned. I wanted this story to spread far and wide. I wanted this book to be accessible to anyone from Birmingham, Alabama, to Bangalore, India. Because, in my heart and mind, I believe the message on these pages represents the cutting edge of what will be a revolution in rethinking how to treat chronic knee pain.

So I decided to bypass the corporate publishing conglomerates and make Saving My Knees widely available, though only in electronic form. The year 2011 seemed like the perfect moment for such a move. Amazon.com has begun selling millions of Kindles a year; much of the world now has personal computers and Internet connections.

Now that you know the story behind the story, you may be curious about what kind of book this is. I guarantee it’s unlike any other you’ll read about beating knee pain.

I don’t include twenty pages of illustrated exercises, with precise details on how far your heels should be away from the wall or where your hands should be placed while doing single leg wall slides. This isn’t a “Be Like Mike” book either: I don’t claim that doing exactly what I did to get better is what you should do.

My preference would be to call Saving My Knees broadly prescriptive. I lay out what I tried, how I succeeded, and what I learned. My goal is to show how knee pain sufferers have to start thinking about their knees and what’s important for those ailing joints to heal.

There is no manual to your knees. Sure, there are textbook chapters on knees in general, and it’s good to know how cartilage inside a joint works (chapter 7), but if you want to heal your particular knees, you have to become much better acquainted with them. You also have to stop throwing up your hands and writing off pain as “just another bad knee day.” Take charge of your plan to get better!

When you finish, and find your mind, too, spilling over with ideas, come visit my blog and join the conversation.

savingmyknees.blogspot.com

(Also, my home page is www.savingmyknees.com.)

IMPORTANT NOTE: If you have knee pain, start by seeing a trained medical professional. Reading a book (this one or any other) is no substitute for a comprehensive in-person examination and tests that may illuminate what’s going on. Also, obviously, I’m not a doctor or physical therapist—though I did achieve something that they said I couldn’t.

Richard Bedard (rb4096@yahoo.com)

Introduction

In 2006, the National Center for Health Statistics released a wide-ranging study on pain. Among the findings: almost one in five adult Americans complained of knee pain.

A year later, I joined that unhappy cohort.

Until then, what I knew about knees wouldn’t have filled the front of a Post-it note. Mine had always worked great. I was like the owner of a smoothly running car. Why bother to look under the hood when it always started right up?

In early 2007, that all changed. I had just begun doing some serious training on my bicycle. On weekends, my workouts included repeatedly pedaling up a steep 1.9-mile section of road.

That August, I planned to ride the Mount Washington Hill Climb. The gentle-sounding name is a misnomer; the “hill climb” consists of a brutal ascent to New Hampshire’s highest point at 6,288 feet above sea level. Hundreds of riders mash up the mountain’s slopes and try to reach the top first.

The event attracts top cyclists of all ages. One winner went on to glory in the Tour de France, the most famous endurance cycling contest in the world. In my mid-forties, I knew that I lacked the youth and talent to even place in the top ten. Still, I was fiercely competitive and vowed to train hard and do my best.

Then, while sitting at work one day, I noticed an uncomfortable burning around both of my kneecaps. I tried to ignore the sensation, thinking it would go away. Instead, over the following weeks, it got steadily worse.

What I didn’t know was that my knee joints were in deep trouble. Hard uphill cycling had damaged the shock-absorbing cartilage that pads the bone endings (for months before my training officially began, I was riding vigorously in the low mountains). I later learned that bad cartilage is a common culprit in knee pain. Many sufferers head down a one-way street to osteoarthritis.

So I dropped out of the Hill Climb and called in the cavalry. Over the course of a year, I visited four doctors and sought help from two physical therapists. I was determined to beat this problem (it went by a grab bag of names: patellofemoral pain syndrome, chondromalacia patella, runner’s knee). No one could help me. My confidence began to crumble.

My knees kept getting worse. Eventually it wasn’t only sitting that hurt. Sometimes it also hurt to walk. I couldn’t stand comfortably in one place for more than a few seconds, so riding in elevators became an agony. My knees burned constantly while at my desk, forcing me to contort my body into strange positions to get through the workday. I began to struggle with bouts of depression.

The doctors were pessimistic. My physical therapist, who initially advised against surgery, finally threw in the towel as well. He suggested that for me, maybe going under the knife wasn’t a bad option after all.

When everyone gave up on me, I got mad enough to do something radical. I quit my job and decided to live off my savings for one year. Those twelve months would be devoted to my own scientific experiment of sorts. Could the health of my knees improve at all? If so, how? Was the answer a certain dietary supplement or kind of exercise or what?

Every day I jotted down detailed notes about my knees, from how they felt to how many steps I walked. I researched with a passion to understand how knee cartilage functions, right down to the cellular factories called chondrocytes that churn out this incredible tissue. I read scientific studies about how cartilage defects change over time.

My most serendipitous online discovery was the Web site of a physical therapy clinic in Austin, Texas, by the name of Sports Center. In lucid, compelling prose, Chief Therapist Doug Kelsey broke with some of the most cherished orthodoxies of his profession. He helped me understand why the standard physical therapy regimen had been hurting, not healing me.

Those orthodoxies can be deeply ingrained. I casually mentioned my knee problems once to a physical therapist treating me for something else. She replied without hesitation, like the smart kid at the head of the class, “Stretch the IT (iliotibial) band, strengthen the quads.”

Inside I cringed. My former therapist believed that too; he prescribed exercises to build up my quadriceps muscles that left me hobbling for weeks. Must the village be destroyed in order to save it?

At some point during my recovery, during long sessions of deep thinking, the seed of the idea that became this book took root in my mind, and began to grow. Early on, I remember hunting high and low for a thoughtful, inspiring first-person account of overcoming chronic knee pain. My doctors had robbed me of the most precious commodity any patient has: hope. I needed someone to restore that, but sensibly.

There are many pessimists when it comes to aching, burning, grumbling knees. Cartilage deteriorates and that’s a fact of life, they say, shaking their heads. Trying to arrest this process is as futile as King Canute commanding the incoming tide to bend to his will and recede. Bad knees don’t improve. They may feel better if you strengthen the nearby muscles, but a damaged joint can’t repair itself.

I now know that’s dead wrong.

You can nurse bad knees back to good health. Broadly, my successful effort required three things:

1. A plan.

At first that sounds trite, or even misplaced. Recovering from a bruised shin or sprained ligament doesn’t require a plan. Injured knees, however, present a much trickier proposition. They heal on a much slower timeline. It’s often easy to lose track of where you are on that timeline. And it’s all too easy to reset that timeline—in a bad way—when you carelessly walk too far, or carry a few heavy bags of groceries (or a backpack full of books) before you’re strong enough.

When the journey is long, yet the goal is clear, a plan is indispensable. If you embarked on a two-week European vacation, hoping to see Buckingham Palace in London, the Eiffel Tower in Paris, and a half dozen other landmarks, you would sketch out a plan first. Saving my knees required a much better plan. For this journey, I was traveling between two amorphous states: feeling not very good and feeling good. Going from New York to Berlin is a cinch compared to this trip.

At times the plan may change. Flexibility is a virtue.

Just never lose sight of where you’re going.

2. A commitment to motion.

I once read a comic book that featured a tale about an Eastern emperor upon whom was laid a deadly curse. He can escape it only by building monuments and palaces, one after another, never ceasing. No sooner is one completed than he commissions the next. Then, while inspecting a work site, he slips and falls. Days later he awakes in bed, his head bandaged, horrified to discover that all the building has stopped because of his injury. The long shadow of the curse he tried to outrun at last catches and kills him.

This idea of perpetual motion to ward off evil resonated with me. Too much inactivity can be deadly for knees. Understanding how motion helps the joints adapt and heal turned out to be a major breakthrough for me. Of course that was only a start. What kind of motion? How often? And the classic dilemma: how do you exercise knees that hurt almost all the time?

3. A readiness to learn the language of “hurt knee.”

Bad knees send out a flurry of signals, all the time. Many may not reach the pain threshhold, but they’re still significant. Decoding this language obsessed me. Mastering it was essential to getting better; I was saved repeatedly from stupid behaviors because I knew how my hurt knees communicated and what the different sensations meant.

Many people think they listen to their aching knees because they follow the well-worn advice, “If it hurts, don’t do it.” That, I learned, was sort of like saying you speak German because you know how to say “Where is the train station?” and “Can I have a glass of water?” If I had remained stuck on that very simple level—allowing “if it hurts, don’t do it” to guide my activity—I never would have healed.

I finally did recover. It took the better part of two years.

How did I save a pair of bad knees that my doctors said would never get better?

Well, that’s a long story.

1   An Active Lifestyle

The orthopedic doctor instructed me to squat from a standing position, as if I were sitting down on an invisible chair. I hesitated, knowing what would happen next. He had finished an examination of my knees that showed a normal range of motion. Now he was about to find out how bad the cartilage really was.

I lowered myself carefully. My knees made a thick, wet crunching noise as they bent. The ugly sound embarrassed me. He didn’t say anything.

A few minutes later, I was seated beside his desk, passionately telling him about my commitment to healing. He listened without comment, then bluntly delivered his opinion: “Your knees will never get better.” My best hope was to arrest their decline to avoid full-blown arthritis in a few years.

That took my breath away. “Never” sounded like a death sentence. My life had become thoroughly miserable. Every day my knees hurt. They burned so badly that I sometimes fantasized about hacking off my kneecaps with a butcher knife. I ducked social events after work, fearful of the pain from sitting or standing too long.

It was too depressing to imagine that they would never improve, no matter what I did.

After that doctor’s visit, I struggled to put the whole nightmare in perspective. Nothing had prepared me for the onset of chronic knee pain. The experience was like falling through a trap door in slow motion. Would I lose forever the active lifestyle that had come to mean so much to me? How had I arrived at this misery?

For decades, I took my good health and my body’s resiliency for granted. As a child, I was always the fortunate one who never broke a bone, pulled a muscle, or sprained an ankle. Casts were bulky white objects covered with signatures and scribblings that other kids wore.

Luck was surely on my side, considering how active I was. I grew up in a white clapboard farmhouse in rural Downeast Maine amid deep pine forests and strong, clear rivers. I enjoyed traipsing through the woods around our home. And I loved sports: everything from schoolyard kickball to winter pickup games of touch football on an ice-covered field.

The schools in Washington County, Maine, didn’t offer much in the way of athletics. The area is poor and hardscrabble; there isn’t room in pinched budgets for track and field or football programs. They did have basketball gyms though, and fans packed the bleachers even on frigid December nights.

So it wasn’t surprising which team sport I fell in love with first. Basketball seemed appropriate anyway for a gangly youngster with long arms. In shootarounds, I would sometimes imagine myself playing for the legendary Boston Celtics.

My enthusiasm for basketball eventually waned as I realized my shortcomings on the court. I stood only a few inches taller than average and lacked quickness and aggressive instincts. My modest talent usually sufficed for making the squad, but not much more.

After reaching high school, I decided to try something different. On a whim, I signed up for the cross-country team.

Distance running should have fit me well. I was a slender six-footer who possessed more endurance than speed. Also my bookish nature gave me a high tolerance for being alone. I was the kind of teenager who, on a warm summer day, would disappear with a novel by Vonnegut or Dostoyevsky and hide away under a nearby bridge, reading intently as the water swept past.

Despite that, in my mid-teens, I couldn’t get too excited about setting out on training runs on quiet, dusty roads that never seemed to end. Running long distances—basically, anything more than a mile—strikes most high school students as boring and pointless. Besides, being on the cross-country team wasn’t considered cool. We were the athletic versions of the chess club nerds.

In high school, I was a joyless runner. In college, my attitude changed completely. I was at Harvard in Cambridge, Massachusetts, majoring in government. Jogging along the broad Charles River helped relieve stress. Gradually my legs became leaner and stronger. Sometimes it felt as if I was flying over the ground, swallowing chunks of the paved riverside trail with each stride. Running became fun.

On vacations I began to clock my times on a 4.5-mile hilly loop of road in my hometown. The route swept along blueberry barrens, through stands of evergreen woods, and over a rushing river. My mother, who took up running too, entered us in local races. I was never fast enough to win, but kept improving. At the age of twenty-five, I finished a 10K in 36:34.

In my twenties, running happened to be an ideal way to keep fit. It was cheap (just the price of an occasional pair of Asics or New Balance shoes), and I could lace up and take off anywhere in the world. That proved especially convenient. In the six years after graduating from college, I lived everywhere from Switzerland and Paris to California, Kentucky, Pennsylvania, and New York City. For a while I taught high school students computer science, then got a journalism degree and became a newspaper reporter.

Then, in my thirties, running lost its appeal. I wasn’t doing it regularly and nagging injuries started to bother me. Even though they were minor ailments such as shin splints and sore foot arches, the magic feeling of effortlessness vanished. I began to feel sluggish and plodding.

I didn’t realize it then, but my changing weight surely affected me. I went from 172 pounds in college to 185 pounds in my mid-thirties. That doesn’t seem like much of a difference, but there’s a multiplier effect at work during the act of running. For each extra pound you carry, as much as six more pounds of force are transmitted into the knee joint.

In the fall of 2000, seeking a less stressful activity, I made a fateful decision. A year earlier I’d moved to Fort Lauderdale to become an assistant business editor at the Sun-Sentinel newspaper. Sun-drenched Florida, where almost all the beachgoers look fit and tan, was terrific for year-round sports. I had done some cycling alone in the mid ‘90s, while living in Oklahoma and writing a book about tornadoes. So I joined a biking club.

For months I stuck out like a sore thumb. In cycling, unlike running, equipment and style matter. Riders bragged about their lightweight, fast bikes that cost up to $5,000. They debated brands of headsets, cassettes, pedals, forks, seats. Meanwhile I couldn’t even get the basics right. My socks were wrong, my helmet was too large and clunky, and my solid-blue jersey looked like a plain Jane at the ball compared with their busily and brightly patterned ones.

So I upgraded my sporting wardrobe while also learning group-cycling skills and etiquette. Organized riders travel in long “pacelines.” Only a few inches separate their wheels as they accelerate to speeds up to thirty miles an hour. The rider in front does the “pulling” by taking the brunt of the wind.

Our outings were usually courteous and orderly until we reached the designated sprint zones. Then all hell broke loose. After a few rides you became familiar with the finish lines: the speed limit sign, the highway turnoff—whatever arbitrary marker worked best at that spot. As we got closer, the speed rose and the paceline splintered.

The last hundred yards were the most intense. You had to dig down deep inside for that last bit of strength. Your legs pistoned crazily. Your thigh muscles burned. Your lungs felt raw; your heart slammed impossibly fast. For a brief moment, your heart rate monitor might even flash its maximum, confirming that you had reached your physical limit, that you couldn’t wring out one more watt of energy.

I loved it. Distance cycling was my true athletic calling, at long last. It was an aerobic, endurance sport. Anatomically, I was suited for it, with naturally large thigh muscles and a long femur, the upper leg bone that acts as a big lever with each pedal stroke. Though I didn’t possess a lot of raw talent, my body often managed to push beyond its own fatigue. Near the end of a three-hour ride in the subtropical heat, I would get out in front of the tired pack and just hammer for miles.

The group rides usually turned into punishing, extreme workouts. Still, an even more exquisite form of torture awaited me: time trials. These races pit individual riders against the clock. The best time trial series in South Florida was held out in west Palm Beach County, at a remote site where alligators slid in and out of nearby canals. For miles, all you could see were sugar cane fields, acres of swamp, and electrical transmission towers.

To gain a racing edge, I would bring aerodynamic equipment to fight air resistance and trim precious seconds. My rear wheel was a smooth disk that made a hollow whooshing sound as I brought the bicycle up to speed. My time-trial helmet looked like a backward-flowing teardrop. Rubber booties covered my shoes, to smooth out irregularities that would disrupt air flow. I even shaved my legs (a savings of five seconds on a forty-kilometer course, one online site claimed!).

Once a time trial begins, you find out why it’s known as cycling’s “race of truth.” There is no one to hide behind and no letting up until it’s over. One time, I wore my heart-rate monitor. My absolute maximum was 183 beats per minute; during the race it constantly flickered between 173 and 174. Gradually I learned how hard to push myself without burning out. It’s like an art, keeping the needle for your internal engine constantly on the edge of the red zone.

I rode fast enough to place second among the men aged 35-44 in the 2005 time-trial series. My best time in the 15k (9.3 miles) was twenty-two minutes flat. That averages out to 25.4 miles an hour. Plenty of South Florida’s elite riders could top that. A few even smashed the twenty-minute barrier. But that never mattered to me because cycling meant so much more than winning a race or sprint. It was about embracing an active lifestyle that lifted me to a new level of feeling good.

It was about stumbling with wobbly legs off the bicycle after a long ride, exhausted in a wonderful way. It was about waking up each morning in my early forties with the energy of a twenty-five-year-old. It was about feeling strong and confident, taking long strides across the newsroom or bounding up a flight of stairs. It was about being healthy and not getting sick—not even a head cold—for almost five years.

My only health scare came in April of 2003. I began to experience irregular heartbeats while sitting quietly or trying to sleep at night. My heart would noticeably skip a beat, then follow with a hard beat as if to catch up. The pattern would keep repeating, affecting every eighth beat or so. The episodes would last for hours at a time over several days.

The onset of irregular heartbeats can be terrifying. Usually your heart expands and contracts silently in the background; you notice its presence only by pressing your hand against your rib cage. Odd heartbeats alert you to the possible frailty of this organ. Sometimes I found myself pounding my chest, alarmed and frustrated, as if I could manually bump it back into a proper rhythm, like a bad case of hiccups.

At the time I was cycling 140 miles a week. I would have cut back, except the abnormal heartbeats always smoothed out with aerobic activity. When my pulse cleared 130, there was never a problem. Also I never had dangerous symptoms of dizziness, faintness, or weakness. Still, not knowing what was going on unsettled me. I sought out a cardiologist.

Before the appointment, I chugged twenty ounces of caffeine-rich Mountain Dew to try to induce the strange beats. It worked. During my electrocardiogram test, they showed up perfectly. The doctor, at first surprised to see someone looking relatively young and fit, questioned me about my cycling and placed his stethoscope against my chest. “Strong heart,” he said simply. He also checked my ankles and didn’t find any swelling.

A few minutes later, after studying the EKG printout, he allayed my fears. I had nothing to worry about, he said. The unusual reading was what you might expect in an endurance athlete. All the hard exercise forced my heart to adapt and pump blood more efficiently. My resting pulse in the morning was usually forty to forty-two; the average unconditioned heart beats sixty to eighty times a minute.

Once I stopped training, the problem would probably go away, he said. He turned out to be correct.

After escaping that brush with mortality, I felt stronger than ever. I had faith in my body’s ability to recover from any kind of illness or injury. One day while cycling in a small park, I ventured onto the road’s sandy shoulder to pass a slow-moving groundskeeping vehicle. When I tried to hop back up onto the pavement, my front tire twisted. I went down hard, like a sack of cement, and cracked or bruised a rib. For days it hurt to sneeze or breathe deeply. That slowed me down on my bike, but for no more than a month.

Then came a very nasty collision on a windy fall day. I was among half a dozen cyclists sprinting on State Road A1A, the slender route that snakes down the eastern Florida coast beside the beaches. Hurricane Wilma had recently raked the neighborhood and knocked down a flashing-light warning sign for a drawbridge. I blew past everyone on the sprint and tucked my head to take a breath. I looked up to see the red-and-white safety arm for the drawbridge lowering directly in front of me.

There was no time to react. I slammed into it at twenty-five miles an hour. The arm, made out of what seemed to be heavy aluminum, caught me across the upper chest and arms. I was thrown to the ground as my bike skidded out from under me. It was a stunning, violent crash.

Without hesitating, I sprang to my feet. The drawbridge arm was dented in the shape of a rooftop profile. Supporting cables lay about on the road like strands of spaghetti.

I grabbed my bicycle and tried to straighten the handlebars. The other riders rolled up. They seemed amazed to find me upright with nothing broken, only bruises. One gave me an incredulous look and said, “That’s the most amazing thing I’ve seen.” Later it occurred to me that, had that drawbridge arm been ten inches higher, I would have been decapitated.

But bruises didn’t bother me. They would heal. I always healed well.

I didn’t know the day would soon come when that confidence would be thoroughly shattered.

2   Prelude to a Fall

My problems all started because of a change of scenery.

In January of 2006, to quell an itch for new adventures, I quit my job at the Sun-Sentinel in Fort Lauderdale to join Bloomberg News as a finance editor in Hong Kong. The two locales had virtually nothing in common, except for being at roughly the same steamy latitude on the map.

Little did I suspect, my life would change completely during three years in the former British colony. For one, I would get married, to a smart Chinese woman with a good heart and a beautiful smile. I would also suffer through what physically was my worst time ever. My knees were about to break down, leaving me confused and deeply scared.

Deciding to move to Asia wasn’t easy. I liked the Sun-Sentinel, my cycling buddies, and my bandmates from a group we named Bone. The three of us, all in our forties, did a few small gigs for kicks and even cut a CD. The trouble was, rock guitarist was a hobby and my real career path appeared uncertain. The newspaper industry looked shaky. All across the United States, circulation kept eroding as advertising dollars dried up. Profit margins shrank.

It seemed to me that newspaper companies were paying the price for being asleep at the switch during the great migration into cyberspace. They squandered a huge opportunity to leverage their main resource—bright, creative people who develop high-value content—into control over profitable swaths of the Internet. And my employer, Tribune, seemed too bureaucratic and hidebound to adapt anytime soon to the revolution.

Bloomberg struck me as a company with much stronger prospects. Michael Bloomberg, now the mayor of New York, built a globe-spanning organization around an information-rich electronic terminal. The “Bloomberg” (the man and machine have become synonymous) sliced and diced financial data. It was a real-time window on markets as they moved: stocks, bonds, credit-default swaps, currencies, you name it. Having that information at their fingertips made Wall Street’s traders and investment bankers smarter—and richer.

Unlike the hapless newspaper chains, Bloomberg had found a way to mine gold in the knowledge industry. It didn’t take long for me to accept an offer to join Bloomberg’s worldwide team of top journalists. I would specialize in China affairs, helping to shape stories on everything from public stock sales to mergers and acquisitions. My salary shot up by half, barely eclipsing six figures. It was a career achievement in a profession known for its low pay.

The year 2006 was a thrilling time to be a business journalist covering China. The sleeping giant had fully awoken after its decades-long spell under the cult of Mao. The government was unshackling more pieces of the once state-controlled economy. A new generation of entrepreneurs and wealthy capitalists was on the rise.

And China, a behemoth of 1.3 billion people, began to roar. Its economy was exploding, growing more than ten percent a year. The country’s statisticians could barely keep up. They ended up revising the 2004 growth figures upwards by seventeen percent. That was like misplacing an economy the size of Denmark’s.

For a Westerner, so many things about China were fascinating: The newspaper photo of a seven-year-old boy, exhaling a thick cloud of cigarette smoke, above a caption that said China has 350 million smokers—more than the U.S. has people. The pre-Olympic campaign in Beijing to clean up embarrassing translations of English, such as the local restaurant menus that featured “Pock-faced Lady’s Tofu” and “Fry the Cow River.” The homogeneity of China’s leadership: a New York Times photo showed nine old men, each with a full head of hair dyed black, wearing dark blue suits and white shirts and red neckties (except for one maverick in a blue one). The sobering food scares, such as when a factory manager sold edible lard made from swill, sewage, and recycled industrial oil. The rampant intellectual piracy (fake Harry Potter books included Harry Potter and the Chinese Porcelain Doll).

Hong Kong had its own distinct image as a hive of international commerce and finance. That changed little even after the British returned the city to China in 1997. Hulking container ships constantly plied the waters around the main island, where the skyline near the waterfront stands out against an escarpment draped in verdant green.

This bustling Asian hub possessed a surprising amount of natural beauty. Miles of fairly remote, high-quality hiking trails threaded through mountains and parks. The city hosted Chinese banyans dripping with ropy roots, a dizzying number of dragonflies, and a nightmarish lineup of snakes, from muscular pythons to swaying cobras and highly poisonous banded kraits.

I loved much about my new home, but hated the pollution. The Associated Press said the makers of The Dark Knight scotched plans to film Batman dropping into Hong Kong’s harbor after a water test turned up tuberculosis and salmonella. Household trash bearded the waterlines of small beaches.

At least you could avoid contact with the water, unlike the air. The skies are almost three times as filthy as New York City’s. Winters were the worst. The north wind blew smokestack emissions from China’s heavily industrialized Guangdong province overhead, creating a gray miasma. The first time I visited The Peak, a famous tourist lookout, I was horrified to see the sharp separation between blue sky and the brownish-gray haze that shrouded the city.

Sometimes the air had a smoky, chemical smell, but usually the pollution didn’t bother me when I resumed my cycling abroad. I lived on sparsely populated Lantau Island (the largest of Hong Kong’s scattered islands) in an isolated community called Discovery Bay. The development lay sandwiched between a wall of hills and the South China Sea. A 25-minute ride on a giant catamaran ferry connected us to the central island.

Discovery Bay was a little cramped for cycling: the main drag stretched only two miles end to end. Still, the pavement was smooth and the traffic light. (Private cars were basically prohibited, so golf carts, costing more than $100,000 each, were everywhere.) While exploring on my bike, I noticed that hardly any vehicles found their way onto a 1.9-mile-long hill road that ascended to a reservoir, then higher still to a golf course on a plateau.

The long climb presented the kind of challenge that stirred my competitive nature. In pancake-flat South Florida, I had never developed any ability as a climber. There, cyclists did their hill training at a local park, on the sides of a paved-over landfill. In Hong Kong, that hill to the golf course became my obsession. The first mile angled upwards as harshly as the Tour de France’s legendary Mount Ventoux. During my two-hour Saturday morning rides, I would fight my way to the top three times. Then Sunday morning I’d do it all over again.

On a long climb up a steep hill, you don’t move fast enough to generate any cooling wind. The intense summer sun would bore into the small of my back and make me feel like an ant trapped under a magnifying glass. By then the day’s ride would be almost over, and the bladder of my Camelbak hydration pack empty. Without water, it was a hot, painful slog to the top.

At first I struggled to reach six miles an hour on the ascent. As time passed, I lost a little weight and continued to stubbornly throw myself back onto the slopes. At the end of my first year in Discovery Bay, on a cool, windless day, I flew up the road to the reservoir, averaging better than 8.3 miles an hour. My grit must have showed as I muscled my way higher, all alone. A man out for a stroll watched me for a few moments. Then he called out with wry amusement, “I think you won.”

My intense weekend workouts left me completely drained. I welcomed that feeling of utter fatigue, believing that my suffering would only make me stronger. Actually I was sowing the seeds for disaster.

On each climb, the cartilage lining my kneecaps had to withstand tremendous pressure. For starters, my Florida bicycle lacked easy gears for climbing and it took months for me to fix that. To make matters worse, I foolishly marked out my own “sprint zone.” Every time up, I made a short, furious uphill push over one stretch of road. The effort left me gasping—and, considering the high forces generated, probably began to damage my knee cartilage. Then there was the fact that all my climbing came at the end of long rides, when my body was tired and dehydrated.

Sometimes I even went cycling while recovering from a recent illness, and getting sick turned out to be a frequent problem. My terrific immune system seemed to be missing in action. I came down with a nasty case of food poisoning in Beijing that laid me flat and shivering and nauseated. I battled a flu in Tokyo during my Bloomberg News training. A head cold in Xi’an. And there was more: another flu, several more colds, and a few severe stomach upsets.

In early 2007, while pedaling up the twisting road to the golf course, I noticed an uncomfortable feeling in my right knee. The sensation was more annoying than painful—a slight fullness or soreness. I eased up a little and tried to push harder with my left leg to compensate. A minute later the knee seemed better.

That discomfort in my right knee occasionally returned while cycling uphill. One day after riding and showering, I crouched to pick up something and heard a rippling crunch from inside both knees. It sounded sort of like someone sitting on a bag of potato chips. However, there was no pain. Knees pop and crack a lot anyway, so I wasn’t alarmed.

What did worry me were the problems I was having at work, sitting with legs bent. As an editor, I had a classic desk job. Moreover, Bloomberg demanded ten-hour days, eight a.m. to six p.m. At first my knees would be fine up until midweek, then a general burning sensation would settle in around the kneecaps and persist through Friday. As time passed, the burning feeling began arriving earlier in the workweek. Soon I was coming in Monday, sitting down, and waiting with dread for it to begin.

Questions raced through my mind: What was wrong? Where did it start? When would it go away?

3   The First Ring of Hell

What causes an injury usually isn’t a mystery. A vast miles-long network of nerves tells you with all the subtlety of a foghorn. You jump for that basketball rebound, then come down on a twisted ankle and let out a pained gasp. Or you sling in that softball from center field and feel a twinge in your shoulder and rub it, wincing.

Unfortunately, early damage to knee cartilage usually doesn’t announce itself. That made it challenging for me to sleuth out the origins of my injury. But as I learned more about my condition, I was able to construct a pretty good narrative of what probably occurred:

Almost two months after I arrrived in Hong Kong, so did my titanium Litespeed road bike, aboard a freighter. I wasted no time in unpacking the bicycle and, in late March of 2006, began riding up the hills of Discovery Bay.

Every weekend, without fail (unless the rain was too hard), I struggled up that weaving road to the golf course a total of six times. My knees felt fine. I suspect though that the cartilage was already beginning to deteriorate under the strain from my spirited climbing.

By January I felt pretty strong. Eager to test myself in competition, I made a blunder that pushed my knees over the tipping point: I decided to start training for the Mount Washington Hill Climb in August. I planned to fly home and be among the six hundred cyclists that ascend to the New Hampshire mountain’s peak, a grueling 7.6 miles. Some exhausted competitors even topple over on the final steep rise, only yards from the finish line.

The hill leading to Discovery Bay’s golf course wasn’t tough enough or long enough to train well for such an arduous event. The other end of Lantau Island featured a harder climb that ended at a tourist attraction, a towering bronze Buddha.

So one day in mid-February I found myself on the remote, forested hill, on a brand-new Cannondale with a lightweight aluminum frame. As I grunted and drove the bicycle forward, my front tire lifted off the pavement a few times. My gears weren’t adequate for a climb that steep; my front chainrings were too large. Near the top, my speed sank to 4.5 miles an hour. I felt a twinge of discomfort in my right knee.

The knockout blow for my knees came two days later, on February 19, during an attempt at cross-training. I went for a marathon hike along the spine of the island. A small ramshackle ferry deposited me at sea level at the village of Mui Wo, then I began climbing. I later estimated that I walked straight up more than 4,500 feet, or close to a mile.

Low clouds enveloped the mountain peaks and high plateaus, making the scene sort of surreal. Despite the cool weather, I walked for long stretches in denim shorts with bare knees. The last stretch of the hike was a long descent. The outline of the 100-foot-high Buddha loomed in the distance. I was exhausted. My legs slammed down, again and again.

The next morning, my thigh and calf muscles felt like ground hamburger. They were accustomed to cycling, but not hiking. They recovered slowly over the next two weeks. Once they did, a new problem attracted my attention. Something seemed to be amiss in both knees. The joints had stopped giving me gentle hints that trouble was brewing. Now the red warning light was flashing hard. I had burning discomfort around my kneecaps while sitting for long periods.

That symptom puzzled me initially. I knew virtually nothing about knees. It seemed that resting should help them heal. And what better way to rest than to sit quietly at a desk? Strangely though, the symptoms abated when I walked about. I began trying to figure out what was going on by poking about online.

It didn’t take long to make a match: chondromalacia patella. The term is just a fancy way of saying the cartilage lining the kneecap is going bad. The condition sometimes afflicts cyclists who do a lot of hill work. Eventually doctors diagnosed me with patellofemoral pain syndrome, also known as runner’s knee. Not all my symptoms lined up. I didn’t really have trouble climbing or descending stairs, but my knees did hate sitting.

“Patellofemoral pain syndrome” is quite a mouthful. It sounds impressive. Months later, when I became weary of shuttling between doctors and physical therapists, I asked an orthopedist straight out, “What does that mean?” He bristled at my impudence, sidestepped the question, and our session soon came to an awkward end. I had come in complaining of knee pain. As I left, he pointed to the diagnosis section on his patient form and said, without apparent irony, “I’m going to write down that you have knee pain.”

Well, what does the term mean? “Patellofemoral” simply refers to the joint area where the kneecap (patella) and thighbone (femur) meet. The “pain” part is kind of obvious—that’s why you’re sitting in the doctor’s office. Then you have the magical word “syndrome.” During my research about this condition, I came across an online wag who opined that when they say you have a syndrome, you know you’re screwed.

As best I can tell, this medical term is sort of lawyerly and self-referential. It boils down to something like this: patellofemoral pain syndrome is the condition of having the constellation of symptoms that constitute patellofemoral pain syndrome. The definition begs the obvious question: “What’s causing the symptoms?” It may be bad cartilage, true. Or it may be a really tiny green man in your knee tapping on the nerves with a really tiny pickaxe.

So if your knee pain is caused by a really tiny green man—or something other than bad cartilage—you can’t complain about being misdiagnosed. The doctor who examined you can in good conscience lift his hands and protest, “I just said you have patellofemoral pain syndrome.” In reality, defective cartilage is often somehow to blame. The terms “patellofemoral pain syndrome” and “chondromalacia patella” are frequently, if mistakenly, used interchangeably.

At this point, a knee pain sufferer may be wondering why all this matters. The last few paragraphs may seem like an odd semantic digression, or an amusing exercise in picking nits. Except there’s a critical point buried in there.

During my long struggle to recover, I learned a lot of things. Foremost was this, my first axiom of healing if you will: Before devising a plan to heal, you need to know what’s wrong and what’s causing it to be wrong. “Patellofemoral pain syndrome” simply says you have knee pain with certain characteristics. It feels like a copout, a halfway diagnosis that doesn’t try hard enough to pinpoint exactly “what’s wrong.” You have to know what’s wrong to figure out how to fix it.

Whatever the proper name for my condition, one thing became clear during the spring of 2007, as I tried to sort out the problems myself: my knees were getting worse. Cycling began to bother them more and more. On May 20, I stepped off my bicycle and vowed not to get back on until I felt better. With a heavy heart, I abandoned the Mount Washington Hill Climb. All my energy had to be devoted to healing.

Still, I couldn’t halt the downward slide. At first my knees tolerated walking very well. Each workday morning, the Discovery Bay ferry dropped me off at Pier 3. I then clopped in my dress shoes about three-quarters of a mile to the business district, passing through the glitzy IFC Mall, then over an elevated pedestrian walkway, and finally reaching the Cheung Kong Center, where Bloomberg’s offices were.

Eventually I began to experience discomfort during that walk. After that came problems standing in one spot. The packed elevators at day’s end were the worst. Bloomberg occupied the top floor for our elevator bank, so the trip down usually made several stops. The company on the twenty-third floor seemed to employ a small city’s worth of workers. As they wedged themselves onto the full elevator, I would stand still and grimace. My knees would heat up as if a cigarette lighter flame was flickering inside the joint.

I avoided lines in fast-food restaurants or stores. Whenever stuck in one, I would bounce back and forth, alternately shifting my weight from one leg to the other. I wanted to keep moving to prevent my knees from lighting up. At night my final pre-bedtime ritual was brushing my teeth. It took only several minutes, but I couldn’t stand in one place that long. The awful burning would set in, and I’d have to do my back-and-forth shuffle again.

My social life outside of work dried up. I declined invitations to go out for drinks or for group dinners with the finance team. The prospect of having to sit for another hour or two was too daunting. My knees were too weak.

As I struggled with my physical limitations, my personality changed. At work, I was increasingly unpleasant. I became the kind of boss I would never want to work for. I lost my temper once in the newsroom, subjecting a reporter to a loud and profane outburst that many co-workers overheard. The incident left me deeply embarrassed and ashamed. This wasn’t the kind of manager I wanted to be.

At times I broke down, all alone in a small inner room in my apartment, the door shut tightly so no one else would hear. My knees hurt so often: sitting, standing, walking. Was this agony going to define the rest of my life? In my darkest moments, I thought about ways to kill myself. My suicide plans grew more vivid and detailed. Then I would think of my mother and fiancee, and how devastated they would be, and realize I couldn’t give up.

This sounds so dramatic now, as I look back. After all, there are quadriplegics helpless within their own skin, their bodies a useless shell, their minds still keen—a cruel fate. But chronic pain is a terrible burden. It saps your will to live. It’s easy for healthy, well-meaning sympathizers to pat you on the shoulder and smile and say, “Everything will be okay.” I don’t trust them. For them, chronic pain is theoretical, not real.

Seeking relief, I desperately tried many things. I think that’s a common response to recurring knee pain, especially among fallen athletes. You’re terrified about losing the health and well-being you’ve gained through an active lifestyle.

I popped aspirin and over-the-counter painkillers to quiet the inflammation. They lost their effectiveness after a while. Also, after swallowing six aspirin one day, I spent the night waking up burping. The aspirin was chewing up my stomach. It didn’t matter. Becoming dependent on painkillers and anti-inflammatories was taking the wrong path anyway; they weren’t treating the underlying problem.

Before giving up cycling, I tried swapping out my pedals for a pair that allowed my feet and ankles to rotate more freely and naturally. I experimented with pedaling differently, to take pressure off my knees. I switched to gentler gears that quickened my rate of spin when climbing uphill. Those solutions came too late to do any good, however.

I used ice on my knees. Heating pads. I rubbed them. Gently moved the kneecaps before exercise. I bought a child’s kick ball with Superman’s image on the front and squeezed it between my legs while sitting. That provided relief for one online sufferer; his chondromalacia was caused by mistracking kneecaps, he wrote on a message board. It didn’t work for me. Knee injuries, I discovered, were sort of like snowflakes: they came in many different varieties.

Then there were the $250 MBT shoes that came with their own CD. They were black with freakishly fat soles. The engineers took their inspiration from an East African, barefoot tribe that supposedly had great posture and few joint and back problems. The design tried to reproduce the natural instability of walking barefoot over soft ground. The strange-looking and tippy shoes proved tricky to walk in, but the makers claimed they reduced stress on knee joints by nineteen percent. I gamely set out in my MBT shoes and half an hour later was back in my room, moaning over my painful knees.

After trying so many things, when relief still didn’t come, I adopted coping strategies. These can be very dangerous, I would learn later, but at the time my thinking was simple: I needed some way to reduce the pain enough to get through the workday. My knees couldn’t tolerate long periods of sitting in a normal position.

Elevating my legs and keeping them straight usually made the burning sensation go away. So I brought in a pair of gray trousers from home and crawled under my desk. A sturdy wire basket bolted to the underside held a rat’s nest of electrical and communications cables. I knotted the trousers to the basket, making a sling, and secured the setup with plastic cable ties. I managed to slice my thumb open with a pair of scissors, but otherwise, the operation was a success. I could slip off my shoes and thrust my stocking feet into the sling to keep my legs extended.

Coping strategies are probably common among people with nagging injuries. Later I realized what I disliked about them: you avoid facing and dealing with the problem. When you’re sleeping with a light shining in your eyes, do you get up to turn it off or roll over? Pretending the problem isn’t there doesn’t get rid of it. I couldn’t sit normally. That was a problem, a big one. I couldn’t spend the rest of my life with my legs propped up on boxes or makeshift slings.

Clearly I was in trouble and needed help. I began to seek out orthopedic doctors, looking for answers and options. It would turn out to be a frustrating and demoralizing experience.

4   Doctors

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.

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.

5   Physical Therapists

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.

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.

6   The Puzzle

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.

When I moved on to his writings on bad knees, my jaw dropped. He perfectly described my failed experience in physical therapy. It was uncanny.

The problem, he said, is that standard physical therapy targets quadriceps muscles, but the force required to strengthen the muscle often exceeds what the joint can tolerate. That results in aching and swelling. The missing ingredient: an exercise program aimed at improving the soft joint surface. Weak muscles are not the main problem.

It seemed like a stunningly obvious application of common sense. Why not direct your energy toward fixing the part of your body that actually hurts? Once you accept this, you start to see why regular physical therapy often fails in treating bad knees.

A muscle-first approach generally emphasizes lower repetitions, higher loads. Tim prescribed many quadriceps exercises for me that included sets of ten—a good number of repetitions for bulking up a muscle. The trouble was, the force needed to strengthen my quads overwhelmed my weak joints.

A joint-first approach emphasizes higher repetitions, lower loads. Cartilage, the soft tissue in need of attention, requires a lot of repetitions (Kelsey says in the thousands) with a much gentler load in order to biologically adapt.

Kelsey believed bad knees could get better, when you undertake a program that subjects them to the proper amounts of load and motion. That lifted my spirits. Here at last someone was offering to restore the hope that my doctors had snatched away.

I badly wanted to seize that hope, but I wasn’t convinced yet. It was time to put on my geek hat and dive into the mystery of knee cartilage and what the latest scientific research revealed about its inner workings.

7   Inside Knee Cartilage

One popular line of thinking maintains that God was asleep at the switch when it came time to design the human knee.

Just look at how it’s rather exposed; no big muscles protect the knee as with the shoulder and hip. Or consider how the simple act of descending a staircase appears to court disaster. Our body weight shifts from bending leg to bending leg. View this process through an X-ray machine and you’ll be left marvelling that, with each step, the thighbone doesn’t thrust over the top of the shinbone, causing the limb to collapse in two pieces.

I first heard a version of the “crummy design” view of knees while in college. A Tufts University freshman who had a car (unlike me) gave me a ride home from the Boston area to Maine for Christmas vacation. She was studying anatomy and went off on a long rant about how poorly engineered knees are. I pretty much accepted this at face value for the next two decades.

When I hurt my own knees, I found myself thinking again about whether the joints were intrinsically, and hopelessly, flawed. This was now more than a matter of passing interest. I wanted to understand what my chances of recovery were. If the pessimists were right, and knees were the anatomical equivalent of an April Fool’s joke, my prospects didn’t look good.

I soon learned that, contrary to what an X-ray may suggest, bent knees are fairly stable. They’re held together by a nest of tissues, most prominently ligaments, which connect bone to bone and act as stabilizers. The hamstrings, quadriceps, and large calf muscle all cross the joint too. These muscles and ligaments help preserve the integrity of your skeleton, so you don’t have to reassemble your legs like a cartoon character after you go down a couple of stairs.

If the design of knees had stopped after throwing in a bunch of supporting tissues to stabilize the area, we would be in very bad shape indeed. Any time we tried to walk, the end of the femur would grind into the end of the tibia, or shinbone. Bones are well-supplied with nerves, so the end result would probably involve a lot of screaming.

Understanding why this doesn’t occur requires a journey inside the joint itself, where things get really rough, where heavy loads must be withstood daily without structural damage occurring. This is where the fascinating story lies.

Bones don’t clumsily crunch into each other because a special tissue known as hyaline articular cartilage pads their endings. This cartilage—normally pearly white, smooth and spongy—measures about one-tenth of an inch thick (almost the height of a couple of stacked quarters).

Articular cartilage lives in an unusual environment. Prick your finger with a needle and out comes blood. Prick a joint capsule (the fibrous sac that encloses the knee joint) and out comes synovial fluid. The thick, straw-yellow liquid has a consistency similar to that of egg whites. Its viscosity keeps our constantly moving knees well-lubricated. It bathes the cartilage in the absence of blood.

In the absence of blood.

That simple phrase turned out to be a revelation of the first order for me.

It deserves special attention, like words on a banner trailing a prop plane in the sky.

THIS CARTILAGE HAS NO BLOOD SUPPLY.

This matters hugely when you’re trying to heal aching knees. Remember how the blood rushes in troops to tidy up and repair damaged tissue, such as with a sprained ligament. When you hurt your articular cartilage, all these MASH units are effectively sidelined, impotent. They can’t get to the accident site.

Unfortunately, it gets worse.

THIS CARTILAGE HAS NO NERVE SUPPLY EITHER.

Predictably, this creates the makings of a real mess. If the tissue had nerves, you could immediately sense damage being done. You’d no doubt respond by modifying your activity, knowing the cartilage can’t heal the same way as muscles and ligaments.

The lack of both blood and nerves seems like powerful support for the “knees suffer from lousy design” argument. My investigation had just begun though. As I delved deeper, a very different picture emerged.

It turns out that knees have adapted beautifully to what’s demanded of them. Their job isn’t easy. We sporting types in particular put them through a hellish obstacle course over a lifetime: jumping, stop-and-go sprinting, squatting while balancing heavy weights, running 26.2 miles straight in a marathon. In fact, the environment inside the joint capsule might be thought of as “Mechano World,” a harsh place of constant mechanical stresses.

Knees successfully handle a lot of abuse, and articular cartilage deserves a lot of the credit. It may not heal well, but its other qualities happen to be outstanding. It’s a Superman among our various body tissues.

Cartilage’s amazing properties begin with its crazy slipperiness. Two wet ice cubes rub together with practically no friction. Cartilage would be incredible if it were two or three times as slippery as ice, but actually, it’s up to eight times more. When healthy, it glides freely. All the hard surfaces that meet in the knee joint that could become irritated by rubbing together—the underside of the knee cap, the ends of the thighbone and shinbone—are capped with this slick tissue.

It’s also a super-resilient cushion that spreads load. Without this property the sport of running wouldn’t exist. A runner’s knees absorb force equal to up to six times his body weight. That’s like a 150-pound person supporting a 750-pound friend on his back.

How cartilage absorbs shock is quite ingenious. It’s not a dry cushion, like the one on the couch. It’s wet, like a sponge. When your knees don’t have to support any load, such as when you lie down, cartilage fills with synovial fluid and water. When you stand up, the pressure of your weight squeezes out the fluids. So when you go for a walk, fluid is constantly being pressed out and absorbed back into the tissue.

If you’re worried that when the water and synovial fluid are pushed out, the cartilage might collapse too much, don’t be. Another design trick prevents it from deflating like a beach ball someone just sat on. To see why, you first need to appreciate how cartilage is structured. You need to understand the “matrix.”

Cartilage is as much as four-fifths water—about what you’d expect for a really wet sponge—but the other chief ingredients are pretty important. It also consists of a tough, ropy protein called collagen. On the surface, knee cartilage has a higher proportion of collagen than in the middle, keeping the tissue tear-resistant where it most matters.

The other big element in the matrix is—big word alert—proteoglycans. They weave all around the collagen skeleton. They give it body and form cartilage’s spongy scaffolding.

A proteoglycan is a large molecule that combines a protein core with many long-chain sugar molecules. Easy visualization: a bottle brush. The spine of the brush represents the protein; the individual bristles the sugar chains called—bigger word alert—glycosaminoglycans.

(Does that word look familiar? That’s no coincidence. Glucosamine is one of the sugars that link together to form a single glycosaminoglycan. When my doctor advised me to take glucosamine tablets, he was hoping the amino sugar would wind up in my knees after its voyage through my body.)

Now it’s time to answer that “beach ball” question: why doesn’t this watery, tenth-of-an-inch thick layer of cartilage go flat when you step down hard and it must support your entire body weight?

Thank the glycosaminoglycans. On the atomic level, they carry a negative charge. That means they repel each other, in the same manner that the like poles of two magnets resist being pushed together. So your cartilage does begin to compress when the water and synovial fluid are expelled, but the glycosaminoglycans in the tissue push back. The closer they are squeezed toward each other, the more they resist.

All these properties of articular cartilage combine to make for an impressive substance well-suited to surviving the rigors of Mechano World. It excels at absorbing shock and minimizing friction. However, it’s still living tissue. It needs to be nourished. It needs to dispose of waste. That’s a problem without a blood supply.

How the cartilage meets this challenge is enormously significant. In Mechano World, logically enough, it resorts to a mechanical solution. Its answer to the basic problem of eating and excreting, if you will, is wonderfully simple and elegant: motion.

Yes, take a walk and feed your knees! When your foot lifts, pressure comes off the knee and synovial fluid hurries into the cartilage, bearing nutrients. When your foot strikes the ground, the fluid is pressed out, bearing waste products.

As living tissue though, cartilage requires more than the ability to obtain nutrients. It would wear down pretty quickly without some capacity to rebuild over time. So there are special cells scattered throughout the articular cartilage in our knees. These tiny factories churn out more matrix. They’re called chondrocytes.

Remember from biology class that cells are fairly sophisticated. They are the smallest structural units of any organism capable of independent functioning. So chondrocytes are like the smart guys in the control room. They have to figure out how much new matrix to make. They take their cues from the daily forces they must withstand.

Not surprisingly, chondrocytes figure heavily into theories of why good knees go bad. Sometimes it all starts with an initial trauma, such as from repeated high loads. Maybe that paunchy, out-of-shape cubicle dweller starts playing pickup basketball during lunch breaks. He leaps and lands on hard pavement, again and again. After a while, the high compressive forces damage the structure of his knee cartilage and kill chondrocytes too.

A common view of osteoarthritis is that chondrocytes can’t pump out enough matrix as cartilage deteriorates and thins. The delicate balance between removing old tissue and making new is upset. Inflammation of the joint worsens the situation. A pro-inflammatory protein called interleukin-1 delivers a double whammy. It stimulates the production of enzymes that strip away cartilage. At the same time it inhibits chondrocytes from making replacement tissue.

Most people with achy knees don’t realize what’s happening on a cellular level. They just know their knees hurt worse and worse. They fall into what I call the death spiral. It happened to me and I fought to escape it.

The death spiral is simple yet deadly. Because your knees hurt, you move them less. Inactivity weakens the joints and supporting muscles, leading to even less movement and more pain. Then repeat the cycle: Because your knees hurt, you move them less. Inactivity weakens the joints and supporting muscles . . . and on and on, until climbing one flight of stairs becomes an ordeal.

What you’re doing to protect your grumbling knees makes sense intuitively. Rest them so they’ll get better. That’s what I thought initially. But too much inactivity is poison for joints; they need movement. The cartilage starves without it. From my research, I knew this in an academic sense. Now I sought concrete proof.

I began spelunking through medical journals. The publications sported unsexy names like Arthritis Care and Research and Archives of Internal Medicine. The dry, technical articles inside contained phrases like “the volumes of individual cartilage plates (medial tibial, lateral tibial and patella) were isolated from the total volume by manually drawing disarticulation contours.”

It wasn’t exactly beach reading. Yet my fascination with the subject matter propelled me through the statistical and clinical jargon. What I ended up discovering was incredible.

For example, in a 1980 article in the Journal of Bone and Joint Surgery, researchers described how they operated on 147 New Zealand White rabbits and created small holes in their knee cartilage. They wanted to see whether the rabbits’ limbs healed best when put in a cast or when moved freely soon after surgery, either actively or passively.

The procedure went like this: The sedated rabbits had the knees of their right hind limbs shaved, then cut open. A dentist drill was used to sink four holes in the cartilage. Each hole spanned one millimeter in diameter (the thickness of eight sheets of copier paper) and penetrated to the bone.

After surgery, the rabbits were split into three groups. One group was set loose to move about a large cage as they wished (and they did so, gingerly at first). The second bunch had their knees immobilized in a plaster-of-Paris cast. The rest found themselves hooked up to a strange-looking apparatus.

As their bodies rested comfortably in a padded half-shell, their operated-on knees continuously flexed back and forth. The rabbits didn’t do anything; a small electric motor powered the contraption. The motor drove a vertical rod attached to a plastic cup that securely held the animal’s foot. The rod moved up and down, straightening and bending the rabbit’s knee through continuous passive motion.

At selected weekly intervals, the 120 adolescent rabbits and 27 adults were killed. Their knees were sliced open for examination. What the researchers found was stunning.

It didn’t matter much whether the rabbits had their operated-on knee encased in a cast or whether they wandered freely about their cages. Among the younger animals who were immobile, only eight percent of the drilled holes healed. The rate barely improved to nine percent for those allowed to move about at will (they tended to be hopping around after one week). However, a whopping fifty-two percent of the defects mended among the rabbits hooked up to the device that repeatedly flexed their joints.

The adults saw a similar breakdown, though skewed lower. The healing rate was three percent for those immobilized, five percent for the older rabbits that roamed their cages, and forty-four percent for those who underwent continuous passive motion.

The winner by a country mile: continuous passive motion. Anyone doubting the numbers only had to look at the photos included in the article. They made the point as dramatically as those anti-smoking ads that contrast a healthy, pink pair of lungs with a black, tarry set that belongs to a longtime smoker.

One photo shows a close-up of knee cartilage that seems magically restored to perfect health, no evidence of any drilled holes. That rabbit spent three weeks on the continuous passive motion machine. Above that is a startling image of a knee joint that has decayed horribly. The scar tissue resembles a glue-like jelly. It surrounds small islands of normal-looking cartilage. That rabbit spent ten weeks with its leg in a cast.

During the investigation, the authors of the report, led by Robert B. Salter, made a couple of curious observations about how cartilage healed. Initially the replacement tissue was immature, fibrous, and not as durable as the original. Over several weeks though, the newly formed tissue took on the characteristics of normal articular cartilage. Chondrocyte factories appeared, ready to start spewing out matrix.

Also the holes didn’t heal from the sides. In other words, the surrounding healthy tissue didn’t branch across the hole, plugging it. Rather, the defects seemed to heal from the underlying bone upwards. That turned out to have one not-so-good implication. Further research by Salter’s team didn’t find continuous passive motion to be effective for cartilage lesions that weren’t deep enough to reach the bone.

Salter’s rabbit study, though impressive, does warrant a few caveats. First, a one-millimeter hole is very small (though to be fair, for a 6-pound rabbit, it’s proportionately much bigger than for a 160-pound human). Also the rest of the rabbit’s joint is presumably in fine shape—he doesn’t have pre-existing bone spurs, bad synovial fluid, or cartilage lesions. And obviously this is a rabbit, not a person.

Still, other scientific trials have examined the effects of immobility on knee cartilage. Some looked at animals, others humans. They reached a similar conclusion: joints start to go bad when they don’t get any movement.

United States, 1981: An article in Arthritis and Rheumatism reviews what happened after seven mongrel dogs had their right rear limbs placed in casts for six weeks. None had any surgery beforehand. Conclusion: “Immobilization of the knee of a normal dog by casting results in rapid degeneration of articular cartilage.”

Finland, 2000: Researchers write that they observed “significant softening” of the cartilage of beagles that had their knees immobilized for eleven weeks. Conclusion: “Immobilization of the joint of a young individual may cause long-term, if not permanent, alterations of cartilage biomechanical properties. This may predispose the joint to degenerative changes later in life.”

Switzerland, 2003: A published study looks at changes that occurred in the knee cartilage of patients after they suffered traumatic accidents involving the spinal cord. Conclusion: “Human cartilage atrophies in the absence of normal joint loading and movement after spinal cord injuries.”

The Switzerland study shows that inactive knees actually suffer a couple of related problems. One, the cartilage is deprived of the movement needed to nourish itself. Two, it isn’t called upon to bear any weight, and so begins to thin out and get soft.

That would seem to argue against a sedentary lifestyle. After all, cartilage responds to expectations, as signaled by how active you are. If you want to be a couch potato, your cartilage gets the message and weakens. If being inactive is bad, might exercise have a salutary effect? Indeed, that appears to be true.

Healthy adults between twenty-one and seventy-nine years of age lost knee cartilage more slowly as they became more physically active, Australian researchers found. Beagles that ran regularly on an uphill treadmill boasted up to twenty-three percent thicker cartilage in their knees, a Finnish study claimed. Also the dogs’ glycosaminoglycans jumped by almost a third. Remember, those long, negatively charged sugar chains contribute a lot to the tissue’s strength and elasticity.

While exercise seems to benefit the cartilage of healthy people, what about those with damaged joints? Swedish researchers Ewa M. Roos and Leif Dahlberg assembled thirty people whose knees had already been operated on once. Members of this group stood a high chance of developing osteoarthritis. Most of the patients, ages thirty-five to fifty, complained of painful, stiff knees.

The participants were split up. Half received no special intervention. The others attended hour-long exercise sessions, three times a week. Under close supervision, they cycled on stationary bikes, jogged on trampolines, performed knee bends with light weights. An enhanced MRI test evaluated their knees at the beginning of the trial and four months later.

The results: exercisers saw a significant increase in glycosaminoglycan content in their knee cartilage, according to a 2005 medical journal article. The findings suggest, the authors wrote, that “human cartilage responds to physiologic loading in a way similar to that exhibited by muscle and bone.” What’s more, they went on, the improvement in the tissue may explain why osteoarthritis patients report benefits from exercise.

All these studies were eye-opening and exhilarating for me. For months, I had felt as if I was in the fight of my life with one arm tied behind my back. My doctors kept insisting I couldn’t get better. They were the experts. They went through medical school, served grueling residencies in their specialty, examined hundreds of problem knees every year.

Their pessimism left me wrestling with self-doubt. My family rallied to support me, but behind their expressions of sympathy, I sensed their doubt too. They assumed that the medical professionals must be right. To them, I was like the terminal cancer patient who stubbornly refuses to believe half a dozen doctors who make the same diagnosis.

Now I possessed evidence that exercise could improve the quality of cartilage. But what about the quantity? Does damaged tissue ever thicken on its own? Or does cartilage that is blistered, or pocked by a shallow hole or deep hole, just continue to wear away? The question has wide relevance beyond problem knees. A 2005 study found that three-fifths of healthy, middle-aged adults had defective cartilage on the inner half of their dominant knee alone.

My doctors gave me the impression that bad cartilage recovered rarely if ever. Fortunately, in 2000, researchers in the Australian state of Tasmania decided to look at how defects in the tissue changed over time. In all, 325 subjects completed a two-year study. An MRI exam was used to grade the quality of the cartilage at various locations in their knee joints.

The scoring system went like this: Zero represented normal, while four stood for the other extreme, worn to the bone. The other grades accounted for intermediate levels of cartilage damage and loss: one (blistering), two (irregularities and less than fifty percent loss of thickness), three (deep ulceration with at least half the tissue gone).

So for example, a subject might start out with good cartilage at a certain location, say under the patella. It would be scored a “zero.” Two years later, if almost half the tissue was found to be gone, it would be downgraded to a “two.” I expected to find evidence of good cartilage going bad. The more tantalizing question was, did bad cartilage ever become good—or at least better?

Surprisingly it did, and with an astounding frequency. The figures appeared in a March 2006 edition of Archives of Internal Medicine, in an article bearing the rather clunky title, “Natural History of Knee Cartilage Defects and Factors Affecting Change.”

A full thirty-seven percent of the subjects had a cartilage defect improve in one of their knee compartments! That even exceeded the thirty-three percent that were found to have a worsening somewhere. The report included an MRI image showing a case of clear thickening. A sizable hole had filled in, going from a “three” to a “one.” The researchers wrote, “The decrease in cartilage defects may represent cartilage repair and healing.”

Intrigued, I scanned the top of the article to learn more about the subject population. If perfectly healthy, perhaps these people just healed better. But it turned out that one-third suffered from chronic knee pain. Despite that, their defects improved at about the same rate as those of their pain-free counterparts.

The authors did identify factors that led to an increase in cartilage defects over time. Being overweight or female boosted your risk. Being over forty did too. But there was also good news buried in the age-related statistics. Subjects over forty and under shared roughly the same chance of having faulty cartilage improve somewhere in their knee. That suggests the ability of the tissue to heal doesn’t flip off, like a toggle switch, once you reach a certain age.

A huge risk factor for worsening cartilage was having bone spurs, outgrowths that form when the body tries to restore stability to a decaying joint. The bony protrusions often restrict normal leg movement and damage or interfere with the remaining cartilage. From that revelation, I took the message that knee pain sufferers should take early action, before the joint undergoes significant structural changes.

Overall, the study seemed to support much more hope than despair. Those subjects whose cartilage got better didn’t even follow any knee-friendly exercise regimen, as with the Swedish experiment.

At this point, a skeptical reader might protest. There’s an unacknowledged elephant in the room: measurement error. MRI technology isn’t perfectly accurate. Also the resulting images are literally black-and-white, but their interpretation isn’t. Opinions can vary among those reading the same MRI.

The Australian researchers took pains to address the potential for human error at least. The same person graded all the MRIs at the beginning and end of the study. Also he evaluated the final set of MRIs without knowing any of the initial scores, to avoid prejudicing him.

Even so, some errors probably crept in. Say the human grader initially scores a cartilage lesion a “three,” but it’s actually a “two.” Two years later, he rechecks it. The defect is still a “two.” He correctly marks it as such but incorrectly records the lesion as having improved. The problem lies with his early mismeasurement.

Of course committing such errors can skew the figures both ways. He also may incorrectly measure and fail to capture an improvement.

It’s unclear how eliminating measurement error would have affected the results. That’s not so for a related issue: the problem of how precise the measuring tool is. Once you factor this in, it becomes clear that the study probably undercounted the number of defects that improved—perhaps by a lot.

That’s because the precision of a measuring tool can matter a good deal when quantifying change. This is an important point to grasp. Here’s a simple illustration of what I mean:

Imagine you’re monitoring the growth of teenagers, year to year. There’s only one catch: you’re using a very crude ruler. Whereas normal rulers display not only inches, but also eighths or sixteenths of an inch, this ruler measures only in feet. So for example, anyone who is more than four feet tall, but no more than five, is considered five feet in height.

Say Carol is five-three, Bill five-eight, and Jim five-eleven. They’re all marked down as six feet tall (more than five feet, less than six). Now let’s suppose the purpose of this experiment is to quantify the percentage of teenagers that grow from year to year.

If, one year later, Carol has spurted three inches, Bill has gained two, and Jim one and a half, what will our statistics show, after we’ve measured everyone with our foot-long rulers? That’s right: only one-third of our subjects have grown. Carol and Bill are still six feet tall. Jim is now seven feet.

The problem: our measuring device lacks sufficient precision.

Now apply that idea to the cartilage defect study.

The researchers employed a commonly used zero-to-four scale to grade the quality and thickness of cartilage. What if they could have been more precise than that five “slice” measurement (zero, one, two, three, four)? Instead of rating a location a “three,” for instance, what if they could measure the equivalent of inches in our height example above?

If so, a 3.3 defect that changed to a 3.1 would count as an improvement, whereas under the old scale, both 3.3 and 3.1 were considered “3.” Simply because of this greater measurement precision, and for no other reason, the number of observed subjects whose cartilage got better somewhere in their knee joint will rise. (Of course we also must accept the corollary: more of them will be found to have a worsening at some area in the joint too.)

All this may seem a bit arcane or tangential. However, it’s very significant. A five-point scoring system isn’t that precise at all. Had the researchers possessed better technology and more confidence, they might have expanded their scale to accommodate fifteen different grades, fifty, or even one hundred.

The implication is worth pondering. Knee cartilage may conform to a very dynamic model, constantly changing both for worse and for better. I found that very heartening. It struck me as a cutting-edge view.

Advances in high-tech imaging will be critical to settling the matter. It’s risky and unethical to slice open living knees just to satisfy scientific curiosity, so we depend on machines to peer inside the joints. At this point, it appears the heavy lifting will fall to the MRI scanner, a relatively recent invention.

The first X-ray image dates all the way back to 1895; the first MRI scan of a human subject didn’t occur until 1977. Three years later, the first commercial MRI machine was manufactured. A couple of decades after that, the technology became widely used in clinical studies of cartilage and osteoarthritic joints.

Further refinements in magnetic-imaging technology may reveal surprises in how knee cartilage changes over time. At least two studies using MRIs have already spotted one puzzling trend: the worst cartilage defects stand the best chance of getting better!

In one study, published in 2006, Australian researchers tracked changes in the knees of eighty-four healthy people. Various locations in the joints were graded using the standard zero-to-four scale. The subjects started out with a total of nineteen spots of really bad cartilage that scored either a “three” or “four” (meaning that the tissue was at least half worn away, or even gone altogether).

Amazingly, over a two-year period, these sites recovered the best. More than half of them improved—one went from bare bone to full thickness. About a fifth stayed the same, and about a quarter got worse.

That blew me away. In fact, there was a lot of information I uncovered that really buoyed my hopes. Cartilage could become stronger. It could also thicken over time. And if it was completely worn away at a certain location, it could even regrow again and often did.

Later, it occurred to me that I shouldn’t have been so astonished. Why shouldn’t cartilage be able to heal and adapt? The rest of the body does. I play guitar, so the skin on my fingertips thickens into calluses to withstand the pressure of the thin metal strings. Astronauts in outer space rapidly lose bone density from living in a weightless environment.

With my newly gained knowledge about how knees work and how cartilage can improve, I felt more confident about charting a path to recovery. At last it was time to devise my own experiment to get better.

8   The Experiment

It wouldn’t be easy to develop a plan to heal my knees. For one, I would have to make a realistic appraisal of my condition and think deeply about what I reasonably could and couldn’t achieve. Also I’d have to find some suitable exercise to put in motion a pair of knees that didn’t like doing much of anything.

But first, there was one nagging, unresolved matter to confront: after reading a mound of scientific studies, did I really know what I thought I did?

All along, I had been wary about the inclination, especially in a field as fertile as knee research, to cherry-pick the studies I happened to agree with. It seemed intellectually dishonest. If one researcher says bad knees benefit from exercise and another says they don’t, what do you have at the end of the day?

I had already reviewed a Swedish study that claimed exercise helps bad knees. That left the contrary position to consider: that exercise either was harmful or didn’t matter either way. Any well-conducted investigation that reached either conclusion would send me spinning back to square one. I would have to re-examine a lot of my assumptions before creating a program to get better.

I found the perfect foil in a study whose impressive size gave its conclusions more heft. That’s because too-small sample sizes can skew results, as any good statistician knows. For instance, it’s premature to run full-page magazine ads claiming that a drug cures sixty-seven percent of subjects based on a trial consisting of three people, two of whom got better. Maybe in a second set of three, no one will benefit.

The Framingham Study, which looked at the relationship between activity and knee osteoarthritis, didn’t have a problem at all with sample size. It boasted 1,279 subjects, far more than any other study I’d looked at. That alone ensured its results would receive widespread notice. A major finding: “Walking for exercise and other recreational activities in older persons without knee OA (osteoarthritis) do not affect these individuals’ risk of developing OA, even if they are overweight.”

In other words, older Americans, whether skinny or fat, don’t have to worry that those tennis matches or weekend strolls along the beach boost their risk of developing arthritis in their knees. The Framingham Study attracted plenty of attention; I heard it mentioned while listening to a Hong Kong radio station one day. A doctor, whose syndicated health segment aired daily, cited the research to reassure listeners that exercise was safe for their joints.

After examining the article by the Framingham researchers, published in 2007 in Arthritis Care and Research, I viewed their conclusion differently. Sure, you could put a positive spin on the investigation, but you could just as easily highlight the negative. Namely, if exercise doesn’t affect the risk one way or the other, that means physical activity isn’t bad, but isn’t good either. Indeed, researchers said their evidence suggests that “exercise does not protect” against the onset of osteoarthritis.

That struck me as peculiar. Cartilage loss contributes to the progession of the disease. Exercise should help buffer the tissue against breaking down by making it stronger and more elastic. It became clear I needed to delve into the methods of the Framingham Study to understand how the researchers found what they did.

Their methodology seemed straightforward enough. The subjects, who were older and largely overweight, had their knees X-rayed. At some point, they filled out a survey about their level of activity and the intensity. Then about nine years after an initial exam, their knees were X-rayed again to scan for signs of osteoarthritis. They also answered questions to determine if they had common symptoms of the disease, such as stiff joints.

After collecting the data, the researchers spun off the results into several complex-looking tables with numerous categories. You could trace along columns and rows to locate, for example, the number of heavy people who walked at least six miles a week who wound up with symptoms of knee osteoarthritis. Or you could find the number of thinner people who did sweat-inducing exercise less than three times weekly and whose X-rays indicated they developed the disease. There was a lot of information to wade through.

The longer I stared at the figures, the more puzzled I grew. In places they resembled a bunch of one-way signs that a tipped-over truck had dumped in the middle of the highway. They pointed this way and that. Take for instance the subjects’ level of activity, as compared with peers’. One table suggested that being active was good for heavy people: it may protect them from symptoms of osteoarthritis. At the same time the results paradoxically suggested that being inactive was good for them too: it may prevent joint-space narrowing, a hallmark of the disease.

While the conclusions indicated by the numbers never quite achieved statistical significance, there was enough oddness to inspire me to look deeper. The Framingham Study, after all, didn’t really discover any relationships between anything, except for the obvious one, that fatter people got knee osteoarthritis more often. If no relationships exist in the first place, that makes sense. However, I began pursuing an alternative explanation: that the study had serious limitations.

The researchers did concede a shortcoming in their choice of a measuring tool. Their investigation began in 1993, more than a decade earlier. They used an X-ray machine to assess the knee joints instead of the much more revealing and precise MRI scanner. That meant they couldn’t see the state of the soft tissues.

A bigger problem seemed evident in the study’s methodology. The subjects filled out a one-time survey about how active they were: Did they walk for exercise at all? If so, less than six miles a week? More than that? Did they work up a sweat through intense physical activity? If so, less then three times a week? More than that?

Their answers determined which categories they landed in. And that’s where they remained, no matter what else happened between X-rays. If their exams were six months apart, or a year, or even two years, it wouldn’t seem like a big deal. But on average they weren’t examined a second time until nine years later.

So let’s say Bill discloses on his survey that he breaks a sweat at least three times a week because he recently started running. Suppose he abandons the sport after only six months. For the other eight and a half years between checkups, he mostly lies around watching ESPN and eating donuts. Then the X-ray finds osteoarthritis in his knees.

In the Framingham Study, Bill’s case would be used to support the thesis that breaking a sweat at least three times a week may contribute to developing arthritis in the knee. That’s simply because the researchers sampled his activities at a misrepresentative point during that long time span.

Of course the counterargument is that, deep enough into adulthood, athletes tend to remain athletes, and non-athletes tend to remain non-athletes. That’s a fair point. But even so, lives change a lot over nine years. People marry. They divorce. They move to new homes. Their schedules change: the new job perhaps leaves less time for the daily walk. Their bodies change too: they may substitute easy hiking (no sweat) for running (lots of sweat).

It wouldn’t be surprising if most of those Framingham Study subjects actually skipped through several different categories between their original and final X-rays. Over the nine years before my chronic knee pain began, I would have hopscotched through at least three. During that time I had periods of inactivity, mild activity, and lots of activity.

Surveying variable habits only once during a nine-year study seems problematic. Still, an even more fundamental issue overshadows that, I realized. The inescapable truth is, it’s almost impossible to design a good long-term study involving people that answers the question, “Does exercise help prevent knee osteoarthritis?”

A well-designed and well-executed investigation would allow a clean line to be drawn between cause and effect. In the real world, where human knees are attached to living, breathing people, that’s hard to do. To see why, start by considering a fictional experiment that successfully proves a certain (unexpected) cause and effect.

The experiment involves two groups of four rats in identical cages. They’re all young, healthy, and bright-eyed. The thesis: a brand-new reddish-colored food called “Randy’s Rat Vittles” promotes long, healthy lives. The rats in cage one are fed a standard brown rat chow. The rats in cage two receive Randy’s Rat Vittles.

The rats in the first cage gobble up their grub and ten seconds later are sniffing about normally. The rats in the second cage chomp down the red food and ten seconds later keel over dead.

Various scenarios could explain the sudden die-off in cage two. Perhaps all four rats had hidden heart defects and, in one of those strange coincidences, happened to expire at once. The most likely explanation though hits us with the force of a mallet landing squarely on the crown of the head: there’s something bad in Randy’s Rat Vittles that killed them.

Reasonable people don’t dispute what occurred or why. That’s because this experiment features two critical things: a well-controlled environment and clear, easy-to-measure results.

When the entire second set of rats dies, that’s a clear outcome. Death is the ultimate adverse reaction to a drug or food. Also the rodents lived exactly ten seconds after eating the rat vittles. That’s an easy-to-measure and significant shortening, not lengthening, of their lives.

What’s more, the well-controlled environment allows the key variable to be isolated. Both groups of rats occupy identical cages. Further, the little drama unfolds so quickly that the rats in the second cage don’t have time to disappear into different habitats, mingle with others, munch on other things. The only significant variable is what they just ate.

This hypothetical experiment produces a slam-dunk conclusion, that Randy’s Rat Vittles radically cut short the lives of rodents that consumed it. (The product would be more fittingly marketed as Randy’s Rat Poison.) Researchers would love to design a human study on exercise and knees that could provide such indisputable clarity. But this turns out to be fiendishly tricky.

For starters, measuring outcomes isn’t as simple. To determine how exercise affects knees, ideally a researcher should examine the joint and tissues firsthand. Salter’s team did so for its continuous passive motion study that used rabbits. The published report included wonderful images of the animals’ knee cartilage. The tissue was dried, sliced, stained, and inspected under a microscope. This yielded valuable information about the quality of the cartilage that filled in the holes that had been drilled.

The rabbits didn’t mind: they were dead. They all got an intravenous overdose of pentobarbital. Of course, in human trials, subjects wouldn’t have to be killed; surgery could be performed instead to inspect joints and harvest samples. Still, that carries its own dangers and crosses ethical boundaries, so it isn’t generally done.

That leaves medical imaging technology to do the measuring. Devices such as MRI scanners will continue to improve. They will supply increasingly accurate and comprehensive details—though, to be honest, studying a computer-derived picture of a thing is never as good as studying the thing itself.

What if this weren’t an issue? What if changes in knee joints could be measured perfectly? A bigger headache awaits the determined researcher: it’s practically impossible to ensure a well-controlled environment for long-term experiments with people.

Human subjects aren’t like Salter’s rabbits, who either received the same kind of cast or moved about in the same kind of cage or were hooked up to identical continuous passive motion machines. They enroll in a study, then are promptly set free in the world, to do basically whatever they want to.

In the course of going about their lives, you can bet on one thing: they’ll use those knee joints. A lot. In a lot of different ways too. Some of them will end up walking fifty yards to get to work, others a quarter of a mile (or even a mile, as I did in Hong Kong). Their jobs will affect how much movement their knees get, from data entry clerks (inactive) to warehouse laborers (active). So will their leisure activities, from roaming the mall to reading magazines on the backyard hammock.

A large portion of their movement doesn’t qualify as “exercise” though, creating a rather ticklish problem. As a researcher, how do you successfully isolate the variable of “exercise” when it’s such a relatively small input into the equation of how we use our knees? Someone who exercises by walking six miles a week spends less than two percent of his waking hours on “exercise.” Shouldn’t it matter what his knee joints are doing the other ninety-eight percent of the time?

Just look at two hypothetical people, Mary and Ted. Mary reports doing no walking for exercise and appears inactive. However, she typically averages 7,000 steps daily as a young mother, chasing her toddler about, running errands, visiting friends. Ted walks a mile a day to exercise and thus seems active. Yet he works a desk job and averages only 6,000 steps a day. Is Ted more active just because he “exercises”?

Suppose researchers could overcome this obstacle and capture the exact number of steps that subjects take every day. Even that may not be enough detail. One footfall doesn’t necessarily transmit the same force into knee joints as another. The impact of sixty steps can differ widely, depending on whether they occur during a leisurely amble to the mailbox or an ill-advised sprint to catch a public transit bus that’s about to pull away.

Now for the kicker. Say the researchers could basically wave a magic wand and make all these complexities go away. Say they attached a super-sensitive device to everyone in the study. It measured each step taken, how much force the knee joint absorbed each time the foot struck the ground, and even whether the subject was sweating at the time. This astounding gadget makes the argument about an uncontrolled environment irrelevant.

Believe it or not, they may still be wasting their time trying to find out, “Does exercise help prevent knee osteoarthritis?” Because they may be asking the wrong question to begin with.

Here’s an illustration that will make clear why that’s so:

Suppose I tell you about a scientific investigation into whether exercise helps or hurts knee joints. I describe the methodology: Researchers rounded up one hundred people who were asked to run three miles, three times a week. MRI exams were done at the beginning and end of a two-year period.

Then I break the bad news. More than ninety-five percent of the subjects experienced a disastrous thinning of cartilage with many more defects present. Faced with that set of facts, you would probably conclude that running must be harmful for knees.

Now I spring a surprise on you: the subjects were all at least 150 pounds overweight. At this point you’d probably start laughing and revise your conclusion. In fact, you’d probably end up arguing that the study doesn’t really show anything at all about the link between exercise and knee health. It stands to reason that the morbidly obese shouldn’t suddenly take up running nine miles a week; that’s too much stress on their joints. Perhaps a program of light walking would suit them better.

In other words, exercise isn’t some pure good, where more is always better. We know that on a gut level: if running three miles a day makes you fit, running thirty miles a day doesn’t make you ten times as fit (in fact it would almost certainly start to wear down your body fast). So the right question when it comes to the link between exercise and the health of knee joints may be something more subtle like this: “Will the proper amount of appropriate exercise help prevent osteoarthritis?”

To further appreciate why framing the question this way matters, let’s invent two people for the Framingham Study and call them June and Jim. They both have achy knees and are at risk of developing osteoarthritis. June appears inactive from her survey: she doesn’t do any “exercise,” even walking. She moves as much on her bad knees as is comfortable. She sometimes goes outside to a nearby field to pick wildflowers, or takes a short stroll to visit a neighbor.

By contrast Jim is a dynamo. He was a track star in his younger days and doesn’t want to abandon an active lifestyle. He runs five miles four times a week. A hardened ex-soldier, he has a “damn the torpedoes” attitude. He wears supportive sleeves over his knees and ices them after workouts to reduce swelling. He accepts the pain with no more than a slight wince.

If Jim develops osteoarthritis but June doesn’t, they become statistics to bolster the argument “exercise contributes to knee osteoarthritis.” But someone might also conclude that Jim is simply pushing his bad knees too hard. Meanwhile June appears to be inactive, but perhaps the movement she gets is ideal for what her joints can support. She sometimes pushes herself a little, and that’s just enough for the cartilage to get the right signals to rebuild a little more. Maybe she even starts to feel better.

If researchers did want to set up a sophisticated study—one that looks at whether the proper amount of appropriate exercise helps knees—they might want to consult someone like Doug Kelsey. Patients at his Sports Center clinic in Austin routinely have their bad knees precisely tested. They do repeated squats to determine their “load tolerance.” That refers to the level of force that they can withstand, pain-free, without a breakdown in form. That’s important, Kelsey says, because a 200-pound man who has a load tolerance of 120 pounds overloads his knees by 80 pounds with each step up a flight of stairs.

Acquiring such data strikes me as critically important. The numbers establish a baseline on which to build. They guide a physical therapist in tailoring a workout program to a patient’s capabilities. Exercise should be seen as a qualified good, rather like medicine that’s beneficial in the right dose.

After coming to terms with the Framingham Study, I was ready to move forward on my own plan. My confidence was high that my bad knees could become better. That seemed like a nebulous goal though, the more I thought about it. I began grappling with the question of what exactly I expected to achieve. Objectively, what qualified as “getting better”?

After some thinking, I laid out three levels of improvement. The first would be simply feeling better. The bad cartilage would be unchanged, but I’d no longer have knee pain. The next level would be not only feeling better, but also having stronger cartilage. Still, the tissue would look the same as before (if anyone were to examine it), and my knees would remain just as crunchy.

Level three would be the Holy Grail of healing: to have the tissue actually repair itself and thicken. It would incorporate the benefits of the previous levels: no pain plus improved properties of the tissue itself. Even then the cartilage would not be restored to its original state, I was pretty sure, but that was okay. Most healthy individuals have some defects anyway.

Doing this assessment comforted me. Escaping my misery required only reaching level one. The bar to clear was low. Plenty of scientific evidence suggested that I could go further, perhaps all the way to level three. But to be happy, I didn’t need to.

That matter aside, I then had to confront who I was: a scared, unhappy guy who chafed to get back on his bike but whose knees hurt most of the time. This guy feared losing all his hard-won aerobic conditioning and leg strength. The problem was, he was deceiving himself. For months he kept saying, “Another week or two, and I’ll be cycling again, and all this will be behind me.”

That was unrealistic. I had to accept that.

In my mind, that wasn’t the same as accepting defeat. I drew a clear, bright line between the two. Congyu once said, “You should accept your knees are bad,” but her tone suggested that they would always be bad and that was my fate. I rejected that as a self-fulfilling prophecy of failure.

Instead, I accepted that my bad knees would not get better overnight. Adopting a longer-term perspective for healing changed my mindset in a good way. I stopped riding an emotional yo-yo. The entries in my personal journal no longer resembled the writings of a manic depressive: one week gloom and cursing, two weeks later optimism that “I think I’m pulling out of this at last,” then a week later more despair. That mirage of false hope that repeatedly appears and vanishes can be as cruel as anything.

Expanding my timeframe for healing was smart for another reason. Bad knees aren’t very forgiving of mistakes; they swell and ache in protest. I needed to build in time for them to recover from the many small mistakes I would make.

A fitting metaphor for this challenge occurred to me one day, after a brunch with Congyu. We went to an all-day breakfast nook off Discovery Bay’s central plaza. Outside, children raced over the sun-splashed cobbled stones under the watchful eyes of their nearby mothers. We both ordered hearty breakfasts.

While waiting for the food, I spied a Chutes and Ladders game in a box of toys the restaurant kept on hand to divert squirming youngsters. I had never before played this old classic. So Congyu and I, both of us well over thirty years old, decided to give it a whirl. The game turned out to be quite simple. You roll a die and advance the indicated number of spaces. You weave back and forth across the board, climbing higher. The first player to the top wins.

On the way you encounter many chutes and ladders scattered across the board. Whenever your playing piece lands at the foot of a ladder, you “climb it” vertically to a higher-numbered square. Anytime you land on the upper end of a chute though, you slide down to a lower-numbered square. So the thrill of the game consists of constantly being bumped up and down the board by the many chutes and ladders.

We must have played for the better part of half an hour. Sometime afterwards, I realized that this basic board game held significance for my struggle to save my knees. You could say, in real life, I was playing a game called simply Chutes.

It was Chutes and Ladders without the ladders. It worked like this: I did all the right things for a week or two, progressing up that long path to getting better. Then I made a mistake, doing something that overstressed my knees. At the time it could seem as innocuous as a short hike up a steep hill. My knees wouldn’t bother me at that moment, leading me to think, “Great, I must be okay now.” Then the next morning they would feel sore. I had just tumbled down a chute.

Chutes, I realized, is a cruel game. Chutes throw you down fast, but there are no ladders to lift you up as quickly. Instead, you must climb back up that path slowly, step by painstaking step. If you continue to make mistakes, you keep falling down chutes. For knee pain sufferers, they can be everywhere. A chute can be as simple as a weekend shopping expedition where, without realizing it, you walk a few thousand steps too far. After a while, you don’t even recognize that you’re trapped in this game. You give up.

To win at Chutes, I needed to be determined, as well as clever enough to exploit whatever advantages I possessed. My leg strength, for example, seemed like an asset. My thighs were still thick and muscular from my years of intense cycling workouts. However, that also could count as a disadvantage. My tremendous leg strength may have masked the extent of my joint problems for a while and may have caused me to do even more damage. Now that I couldn’t exercise, I risked losing power in my thighs fast, exposing how bad my knees really were.

Fortunately, I possessed a disadvantage that, on closer examination, could be spun into an advantage of sorts. I had pain in both knees. That fact doesn’t appear to contain any upside, only twice the misery. Yet I recognized that, thanks to the lovely property of bilateral symmetry, it could be useful to have two equally bad knees. Bilateral symmetry of course describes how the left and right sides of our bodies essentially mirror each other. Because of that, I could test a certain exercise on one knee at a time, using the other as a “control.” If the first knee responded well, then I’d try it on both.

All this thinking in the abstract about my knees was fine, but I also had to choose some kind of suitable exercise. It would have to agree with a joint-first approach to improving my knees. If my bad cartilage could adapt best under the load of thousands of light repetitions, I needed a low-stress activity. My knees didn’t tolerate even gentle cycling; that was out. I walked fairly well though. An easy stroll of a mile and a half would give me about three thousand steps.

And so walking became my exercise of choice. I went out and bought my first-ever pedometer, a basic ten-dollar model. Until then I had no clue about how a pedometer worked. It just seemed like a convenient device that attached to a belt and somehow managed to calculate how far someone walked.

Mine had an electric-blue casing and was a little larger than the head of a wristwatch. I unwrapped and studied it. My bottom-of-the-line version was simple. It had only a small display screen and a pair of identical buttons that reset the step counter to zero.

A little research revealed what lay inside the unit. A motion sensor that can be as simple as a swing arm records each step. The sensors turn out to be fairly accurate because the act of walking is actually rather jarring. During a normal step (by tiptoeing you can fool the pedometer), your foot smoothly descends then abruptly strikes the ground. The delicate sensor registers the jolt.

At first I was disappointed by how it worked. My pedometer counted steps, not distance. But then, after some thought, I realized that the device suited my needs perfectly. The amount of force on my knee joints mattered much more than how far I went. My pedometer indirectly tracked the variable of force by ticking one digit higher each time my foot struck the ground.

Using my pedometer, I began keeping records of my daily walks. I jotted down how many steps and what kind, noting whether the terrain was flat, hilly or something in between. I observed whether the steps came in bunches, such as during a trip by ferry to Tsim Sha Tsui to buy a portable CD player, or all at once, such as on a long walk.

The details went into my knee journal. I created the journal to have a place to put down daily observations about how my knees felt and how I used them. I hoped the journal would wind up charting my progress over months. More importantly, I believed it could help me see patterns and isolate cause and effect along the way. For me, a bad knee day wasn’t a waste unless I failed to learn something about why it occurred.

That philosophy seemed to put me at odds with Dr. Chiu, who once said in an offhand way, “You’ll have good days and you’ll have bad days.” That statement makes knee pain sound like colors on a roulette wheel. Sometimes the ball of chance rolls to a stop on black (no pain), sometimes red (pain). That seemed too arbitrary to me. I wanted to explore what contributes to making days good or bad.

Take the weather. People with bad knees complain about being human barometers, able to feel the approach of storm fronts by the discomfort in their joints. On several occasions, my knees worsened when typhoons swirled closer and the air pressure plunged. So I kept notes on air pressure in my journal. Gradually a pattern emerged. When my knees were in poor shape they could predict bad weather, but once they improved enough, they (happily) lost that ability.

I also broadly tracked temperature. Was the day warm, cool, cold? This eventually turned up an interesting tidbit: my knees preferred cold days to warm. (My wife’s bad knee, on the other hand, liked warm days better.) That knowledge became important when I almost hurt myself by pushing too hard one January. After that, I tried to guard against over-exercising in cold weather because my knees would send signals that they felt stronger than they really were.

Early on, I realized the journal needed one more feature. While I did include daily observations about my knees, that alone wouldn’t allow me to easily identify trends over time. If my joints were “sort of achy” one week and “achy” the next, how much worse was that? Using words as measuring sticks seemed sloppy and imprecise. Instead I created what I call a knee score.

This was my attempt to give quantitative weight to the qualitative evaluation of how the joints felt. The scale ran from one to twenty. “One” was the worst and indicated that my knees were burning or aching constantly and bothering me a lot. At “eight” the discomfort was moderate. “Thirteen” signified some symptoms, but manageable. Anytime I reached “seventeen,” I was fine for periods of an hour or two. “Twenty” I would reserve only for times when my knees felt great for the entire day.

After settling on this system, I still had to figure out when to determine the score. This wasn’t a trivial issue. Most mornings, it was like I woke up with a brand-new set of knees that wore out at some point: by early evening, late afternoon, or even sometimes mid-morning. It wouldn’t be fair to compare a knee score from Tuesday at 7 a.m. to one at Wednesday at 4 p.m.

My solution was to sample two points daily: one at about 7:30 at night, the other half an hour after waking. I chose to wait half an hour because of my morning routine, where I always poured a bowl of cereal then sat at my computer to eat and surf the Internet. Because my knees didn’t like sitting, this activity served as a mini “stress test.” It gave me good insight into how weak my joints were that day.

The morning score turned out to be particularly useful for another reason. It often served as a delayed verdict on the previous day’s activities. Realizing this was an epiphany of the first order. I could do damage to my knees and not know it until a day later!

The experience of delayed symptoms wasn’t my imagination. After returning from Tibet, whenever I did weightlifting sessions, my knees would suffer the next day. They also hurt on mornings after Tim had me do one-legged dips to examine my leg strength and alignment. My limbs were strong enough to do the weight room exercises and the dips, but my injured joints couldn’t handle the load and always complained later.

With the journal for my knees, a scoring system for how they felt, and my trusty pedometer, I was ready. My plan for getting better would involve gentle movement, and a lot of it. Ideally, I would also avoid long sessions of sitting, a prime irritant for my weak knees. That forced me to grapple with a hard truth: working at a desk ten hours each day was a roadblock to recovery.

I had to get some time off from work. There was no way around it. I put together a case to present to my bosses in the news department. They had so far impressed me with their sympathy for my situation. When I talked to them, they nodded in understanding, but said they couldn’t make the final decision on my request.

That responsibility rested with the human resources department. That didn’t worry me at first; everyone I knew in human resources seemed reasonable and concerned about my welfare. So I arranged a sit-down meeting with a pleasantly earnest HR representative. Indeed, the company did want to help, she assured me. But getting that help wouldn’t be so simple.

9   Trying to Heal

Before hurting my knees, I’d never had much to do with human resources people. I knew they were involved in the hiring paperwork when you first joined a company, then sort of faded into the background. They resurfaced occasionally to lead sessions that alerted employees to such things as the career perils of sexual harassment. At one place I worked, they redesigned the yearly evaluations: a several-page form grew to about ten pages, requiring numbers and comments for a seemingly endless series of little boxes.

Now that I needed them to approve my plan to heal, I was eager to open a dialogue. I wanted to share what I had discovered about bad knees that my doctors apparently didn’t know yet. Their unflagging smiles were inscrutable though. It was impossible to figure out what they really thought about anything because their point of view seemed to have become one with the corporate hive mind. Their expressed “thoughts” sounded like iterations of policies.

To capture the essence of my frustration with human resources, in an inspired moment I thought up the parable of Grog and Nog:

During prehistoric times, Grog and Nog worked for Painted Rocks ‘R Us. They painted small decorative boulders that they carried to caves and arranged in the interior to maximum aesthetic effect. The company they belonged to was small but growing fast.

One weekend Grog hurt his foot in the woolly mammoth hunt. He went to work, limping noticeably. His job required lugging heavy rocks all day long, and he couldn’t do it comfortably. Finally he went to the company owner, Borg, and pleaded for a month off so his injury could heal.

“I like you,” Borg said, clapping him on the back. “You’re a really good worker. Take a month off. See you in September.” A month later, refreshed and healed, Grog returned to Painted Rocks ‘R Us.

Meanwhile, the company’s explosive growth continued. Large colored rocks became the must-have cave accessory for the troglodyte with taste. Revenue and profits spiked higher. More workers were added to keep pace with demand. Eventually a new company executive drew Borg aside.

“This operation is much, much too informal,” the executive said, shaking his head. “You let people take off a month or two when they hurt their feet, you’ve got no written guidelines for sickness or pregnancy or the accrual of vacation time, and that’s just for starters.”

“If someone doesn’t feel good, I just tell him to stay home until he feels better,” Borg said, blinking in puzzlement.

“Well, that’s all wrong. Some of your workers take one day, others a week or two. How can you be sure someone isn’t taking advantage of you? Besides, you’re not treating everyone fairly. You need rules, policies, and procedures.”

Chastened, Borg said, “Okay.” And so, over the next few months, a special team spent many hours discussing and debating and then writing down pages of rules, policies, and procedures.

Soon afterwards, Nog was out late one weekend vigorously flinging spears at a pterodactyl. He showed up at work Monday, moaning. Whenever he tried to move a rock, pain shot through his elbow. So he went to Borg and said, “Can I get a month off, like Grog did, so my elbow can heal?”

Borg replied, “You’ve got to see HR.”

“Huh?” Nog replied, scratching his head. “HR? What’s that?”

“They’re in charge of medical leave.”

So Nog trudged off to visit the newly formed HR department, where a smiling woman explained the company couldn’t do anything yet. He must see a doctor first.

Unfortunately, in prehistoric times the medical thinking on sore elbows wasn’t very advanced. After examining Nog, the doctor said: “This thingamajiggy in your elbow hurts when you move rocks, and that’s your job, and you’ve got to be able to do your job, so let me prescribe this pill here,” he said, reaching for a small, flat stone. “Your health plan will pay for it.”

“A stone?” Nog said.

“Yes, whenever you feel pain, just pound the pill ten times against your forehead.”

Nog returned to work, immediately felt pain on doing some lifting, and whacked himself in the head repeatedly with the stone. That made him dizzy. He noticed that when he felt dizzy, his elbow didn’t hurt as much. But once his head cleared, his elbow hurt even more. After several weeks he returned to the doctor, frustrated.

“Doc, I don’t think it’s healing.”

The doctor shrugged. There wasn’t much optimism in the prehistoric medical community about the ability of chronically sore elbows to heal. So he advised, “Keep using the pill for a few more weeks. If that doesn’t work, we’ve only got one more option. But it’s guaranteed to take care of your arm for good.”

“Great,” Nog said, excited. “What’s that?”

“Amputate.”

The point of this story really isn’t that HR departments are bad or bureaucratic. They do serve a valuable purpose, especially in an age of litigation. We do need codes of behavior, standards to evaluate performance, policies to govern absences for health reasons. For critical judgments on medical leave, it does make sense to go outside the company and seek an expert opinion. Naturally that means a qualified physician.

But what happens when the prevailing knowledge in the medical community about a certain condition turns out to be faulty? What happens when it’s more valuable for a human resources person to be able to think outside the box than follow rigid policies to the letter?

Because, the fact is, medical beliefs do change. Doctors once used bloodletting to treat everything from acne to asthma. Two centuries ago, if I had pneumonia and my human resources department ordered me to see a physician, he might have treated me by draining a few pints of my blood into a bowl.

On its face, that seems like a ridiculous parallel. Medical science today is far beyond that level of ignorance, busily plumbing the secrets of the human genome. Yet the inner workings of human cartilage remain somewhat mysterious.

Not so long ago, doctors believed the tissue had no capacity to heal. That has been proven false, leading to a more nuanced appraisal: “Cartilage has a limited capacity to heal.” In another decade, the thinking may evolve further, to something like, “Cartilage has a good capacity to heal, very slowly, under the right conditions.” That’s what I believed.

So I wanted to try an experiment: working half-time for three months to cut back on the extended periods of sitting. My ideal workday would consist of a morning and afternoon shift at my desk, with five hours of light exercise sandwiched in between.

Of course human resources wouldn’t approve my plan without a doctor’s consent. On this point they wouldn’t budge. I thought about which orthopedist to try to recruit, then settled on Dr. Song. Even though he seemed rather curt and unfriendly before, he might be an open thinker. He had agreed to my having an MRI.

On a fall day in 2007, I found myself back in his office. The appointment began with me talking in a fervent blue streak for the better part of ten minutes: sitting at work bothered my knees a lot, I had tried a million things without success, and on and on and on. He gave me his sideways look of suspicion, as if I were trying to sell him a beachfront lot on some island he’d never heard of.

Finally he said, still eyeing me warily, “What do you want me to do?”

“I know I can get better,” I insisted, “if I’m given a chance.”

Then I outlined my idea to work half-time. During the five hours in the middle of the day, I would immerse myself in motion that didn’t put much strain on my knees, such as moving about in a pool or walking slowly around the city. As the weeks passed, the weak joints would get stronger and allow me to exercise more vigorously. I promised to work with a physical therapist during the three months, though to be honest, I didn’t expect much help from Tim. He was a muscle-first guy; I needed a joint-first guy.

Dr. Song never offered a specific critique of my plan. He would support it, he did say, and anyone at Bloomberg who had questions about his decision could telephone him. I was elated. The experiment would soon begin.

I was quickly proved wrong. The news department’s liaison in human resources, after listening to my account of the doctor’s visit, informed me, “We need to have something in writing.” I shrugged, thinking that wouldn’t be a problem, and confidently returned to see Dr. Song.

Inexplicably, he balked at this new request. He seemed uneasy. He told me rather brusquely that he didn’t have time to put anything in writing. I was silent but stunned. How long could that take? Five, ten minutes?

Arguing with him would be futile; I didn’t have much leverage. The path of least resistance became clear: I would write up something myself that sounded reasonable, then ask Dr. Song to sign it.

The wording would be tricky. There had to be some details about my rehabilitation activities, but including too many would risk having Dr. Song say, “I don’t agree with this and won’t sign.” It also would be dishonest, as well as flirting with his rejection, to use the phrase “I recommend that . . .” He had recommended nothing, but supported my proposal. One final landmine: Dr. Song might belong to the Church of the Almighty Quadriceps too. That meant I had to tread lightly when it came to this idea of improving my joints. So I made a few subtle shifts in phrasing to emphasize the benefits for my leg muscles.

I presented him with the following statement:

Richard Bedard has chondromalacia in both knees, a condition that benefits from regular exercise to strengthen leg muscles around the knee. He has expressed concern that he is unable to exercise as vigorously as he needs to because the cartilage in the knee joints remains weak.

I support a plan under which he would take two to three months to try to improve the health of the cartilage through frequent motion (such as light walking and moving his legs in the swimming pool), then attempt to strengthen the leg muscles. Under this plan, he would work a half-day shift, with a break in the middle to focus on movement and exercise.

He reviewed, then signed it, adding his official stamp for good measure. I then submitted the document to Bloomberg’s HR department and held my breath. Would they wonder why it wasn’t on office stationery? Was there enough detail? Had they asked me any questions, I was prepared to tell them the full story, crazy as it might seem. I had nothing to hide.

But no questions came, or requests for further paperwork.

I remember that giddy moment when I realized there were no more obstacles. I was actually going to do this. I had spent hours dissecting the Tibet vacation in my mind, trying to figure out what exactly helped my knees start to heal. It seemed to be motion, motion, motion. Instead of being stuck behind a desk, I was strolling through outdoor markets and wandering the grounds of Tibetan monasteries with Congyu.

My first day working half time, I took the subway to Kowloon and bought a neoprene wetsuit top at a hole-in-the-wall specialty shop for thirty-six dollars. I envisioned myself splashing in the health club pool for hours on end. It was late October, and the insulated top would help keep me warm in the water.

By then, the club’s pool was already a familiar part of my therapy. For a few months I had been swimming there. It wasn’t pretty. I was a lousy swimmer, never having learned to coordinate my breathing properly. At Phillips Andover Academy I passed the high school swim test, a requirement to graduate, by doing a determined dog paddle.

In Hong Kong, I solved the breathing problem. Namely, while swimming in the water, I didn’t breathe. I filled my lungs with air and did a face-down overhead crawl, surfacing with a gasp on touching the other end. That worked fine, except my knees didn’t like the kicking motion associated with the stroke. I fixed that by buying a pair of inflatable armbands for young children and rolling them over my feet onto my ankles. The armbands kept my legs effortlessly afloat. Overall I looked a bit ridiculous making my way through the water, so I just stayed in the slow lane and tried to avoid busy times.

On the first day of my experiment in healing through motion, I lowered myself into the pool, feeling excited. The bright-blue wetsuit top was zipped all the way up to my neck. I was hopeful about what could be achieved through water exercise. The fluid provides a unique, buoyant environment that can be ideal for rehabilitating bad joints. Your body moves against constant, gentle resistance.

It didn’t take long for the flaws in my plan to become evident. The neoprene didn’t insulate very well. That turned out to be a big problem; I have low body fat and the water felt chilly. Once I warmed up things improved somewhat, though a different issue emerged: it’s really boring to kick your legs back and forth again and again, especially when you don’t feel too comfortable.

After an hour of swimming and easy underwater kicking, I gave up for the day and got dressed. It was time to walk. And walk I did: around a small park outside the Citigroup Tower, through the upscale Pacific Place mall, down into the hubbub of the Wanchai district. I took slow, shuffling steps to try to protect my joints. Periodically I sat and rested for a few minutes. That first week, I drowned my knees in movement.

The result: The burning and pain in my knees didn’t get better. It got worse. That mystified and irritated me. I felt like a fraud, having fought so hard for this half-time work schedule. And for what? My thoughts turned again to the Tibet vacation, and this time, I forced myself to recollect in more detail what Congyu and I did. I even wrote down notes, trying to reconstruct the events of each day. And I discovered something surprising. We weren’t moving all the time at all.

We took a long trip to Qinghai Lake that involved several hours sitting on a train and then more sitting in a hired car. After that came the real test of stamina, the thirty-hour railway passage to Lhasa. We moved very little over that day; the train was too crowded. We also took a half-day jeep ride to Namtso Lake. Of course on other days we did often walk, whether in search of another cultural attraction or just a sidewalk vendor selling crisp red apples.

The Tibet experience wasn’t about an orgy of motion leading to the first signs of healing for my knees. I had drawn the wrong lesson. A more subtle truth appeared more likely, that my knees had responded well to the right amount of movement: not too much, not too little. In Tibet I fortuitously landed in that “sweet spot” by accident. But finding that sweet spot again wouldn’t be easy. My disastrous weightlifting adventures in the gym had further damaged my knee joints and set me way back.

Over the next month, I tried to find the right balance between movement and rest. Weekday mornings, I would first go to Bloomberg to help update the headline screens that displayed our top stories worldwide, confer with the China reporters, and do some editing for the Asia finance team. At 10:30 I would leave and faithfully do my walking and pool exercises. I would return to work at 3:30 and finish my day at six.

Despite my best efforts, that whole time I floundered about. No matter how hard I tried, my knees didn’t improve at all. It was exasperating.

Early on, I had vowed to be flexible during this experiment. Inflexibility cost me dearly once, when I persisted lifting weights with my legs even though my knees kept feeling worse. So with no progress to show after three weeks, I changed course. I scrapped my regular routine of light exercise to try something different.

Very, very different.

A casual observer might have assumed I had thrown up the white flag and surrendered: No swimming. No long walking. In fact, it didn’t look like I was doing much of anything, except lying on my back beside an indoor swimming pool and reading novels.

Actually, my new program was more complicated than that. When elevated, my knees burned less, so I would lie backwards on a chaise longue. My feet were propped up on the back rest. Every nine minutes, I got up and walked for a minute around the swimming pool, exactly 101 steps. Then I repeated the sequence. Again and again, for three or four hours at a time. Short bursts of motion interspersed with a knee-friendly resting position.

Over the next two weeks, my knees began to feel noticeably better.

When I visited my physical therapist and told him about this “exercise,” and how well it worked, his reaction was unforgettable. Tim looked as if someone had just slapped him hard. He didn’t know what to say. By Tim’s physical therapy playbook, I should have been doing quad-building exercises in repetitions of ten to thirty. Or at least something more strenuous than strolling once around a pool, then resting.

Meanwhile, the fact that something that stressed my knees so little worked so well alerted me to a dark reality: I was in pretty bad shape. My weak joints became irritated very easily. But a paradox puzzled me. I walked fairly normally. My knees moved normally. An MRI had indicated no more than “mild” chondromalacia. Why did I hurt so much if the problem wasn’t so bad?

That prompted me to investigate what causes the pain that accompanies cartilage disorders. My research led to the discovery of an odd disconnect. You may have severe chondromalacia and no knee pain. Or you may have mild chondromalacia and lots of pain. You can’t always correlate how much you hurt with how much cartilage you have left.

That seems counterintuitive at first—a man with a scratch on his arm should suffer less than someone who has a gaping flesh wound. But that easy analogy overlooks a key fact about hyaline articular cartilage: it has no nerve endings. So when the tissue weakens and fissures, it doesn’t relay any pain signals itself. Instead two nearby structures are mainly to blame for the discomfort.

The first culprit: the bone lying under the cartilage (for example, the femur or tibia). It happens to be nerve rich. Normally cartilage protects the bone from excess pressure, such as from long periods of bent-knee sitting. When healthy, the rubbery tissue transfers load agreeably. When not healthy, look out. The adjacent bone is exposed to more stress and responds by firing off pain sensations.

The second culprit: something called the “synovium.” It’s a membrane that lines the knee’s joint capsule and seals in the synovial fluid. For a knee pain sufferer, the synovium can become irritated through a multi-step process that may begin with something as simple as a brisk trot across the parking lot.

Inside the joint, the force from that act of running shears off fragments of soft cartilage. Along with related debris, they float about in the synovial fluid. (Doug Kelsey colorfully likens the fluid at this point to a snow globe.) Eventually they reach the synovium (which, like bone, has plenty of nerves unfortunately). It absorbs the cartilage remnants and the assorted cellular detritus and becomes inflamed and possibly swollen, communicating a dull aching to your brain.

The role of the synovium in knee pain especially intrigued me. I wondered if it could help explain why my “mild” chondromalacia caused so many difficulties. Could there be profound changes to the structure of my cartilage, undetected by MRI, along with widespread superficial damage? And could that superficial damage be more painful than a few deep lesions? A large area of roughened tissue could create a field of loose fibers, susceptible to being sheared off.

I wondered if cycling hard uphill predisposed me to this kind of trauma. The circular smoothness of pedaling implied a certain kind of pressure—fairly steady, intense, and evenly distributed. The breakdown of the tissue may have taken place over a broad area because the cycling motion doesn’t produce the same focused, striking force as jumping or running. Also the location of maximum damage would most likely reflect the contact points when my knee was pushing hardest on the pedals. That would be an almost ninety-degree angle: the same as for sitting in an office chair.

My thoughts were only armchair musings, I admit. I was groping about for some way to explain the misery of my condition and figure out what to do next, as my experiment neared the halfway mark. The simple pool walkarounds certainly helped my joints, but they weren’t vigorous enough. I had to make faster progress.

My mother mailed me a book from the United States on healing knees that suggested a solution: aquatic exercises. I had splashed around in the pool some, swimming and kicking softly, but hadn’t yet tried formal exercises. The authors raved about the miraculous effects of immersing yourself in water. They laid out a ten-minute pool program designed to put knee pain sufferers like me on the comeback trail. It consisted of short, minute-long exercises. None appeared very stressful.

I typed them into my computer and printed out the sheet of paper. I bought a waterproof sports watch for sixty-five dollars to time each exercise interval. Then, on a December day, I slid into the pool, looking forward to the promised benefits of water therapy. Following instructions, I walked over the bottom of the pool, then did some kicking, curls, and squats.

I had no pain at the time, and my knees felt fine immediately afterwards. Then a familiar ache began to set in. Back at work, my knees felt increasingly uncomfortable. By evening it was clear to me what had happened: I had backslid because of ten minutes of mild pool exercises. It was an astonishing failure that depressed me for days.

Part of me flatly refused to believe it. On January 4, I mustered up enough courage to try again. This time, I decided to walk across the bottom of the pool for six minutes, and do nothing more. If that went okay, I could build on that base. Once again, I felt fine in the water. Later though, my knees got a bit stiff. The next morning, I woke to the dreaded burning sensation in my joints.

That day’s knee journal entry practically screams out my frustration: “I feel like I’m going to hurl myself off a bridge.” I couldn’t even walk over the bottom of a swimming pool for six minutes without suffering problems!

It seemed ridiculous. My knees couldn’t be that terrible. It was impossible. So I decided to try an experiment that drew on one of my dubious “advantages,” that of bilateral joint pain.

I returned to the weight room, to the machine for seated leg lifts. My left knee would be the guinea pig, my right the “control.” I inserted the pin under the five-kilogram plate (eleven pounds). That wouldn’t put much strain on the joint. Using my left leg, I lifted the weight a little, held it briefly, then lowered it. I did that only five times.

The next day, the difference was clear. My left knee felt “full,” a symptom of mild swelling, and noticeably worse than my right.

Two weeks later, I tried a similar test. The exercise: straight leg raises. While lying down, I lifted my left leg only, held it for ten seconds, then lowered it. I did only ten repetitions. The next day, my left knee felt warm and tingly compared with the right.

That was an unbelievably frustrating time. Still, it forced me to accept unpleasant truths and move on. For instance, one key to improving your knees is simply finding out what they like to do. Mine didn’t like working out in water, even gently. That was okay, I consoled myself. I didn’t live in the water. At some point, my knees would have to adjust to the stresses they would endure on dry land.

As the end of January loomed, I made a final spirited push to get stronger, mainly through my walking regimen. My three months of working half time were almost over. Dr. Song resisted supporting an extension. The gains I made had taken longer than expected and seemed fragile, I confessed to my boss.

Bloomberg had been very supportive of me during this time. It bothered me that the company insisted on paying me full wages for working half as many hours. To clear my conscience, I returned almost $4,000 to Bloomberg (that was then donated to a good cause, I learned). By rights, even after adjusting for taxes, I should have given back more. My boss convinced me to keep the rest in case unexpected expenses arose related to my knee problems.

On January 28, 2008, I returned to work full-time with fingers crossed, hoping for the best. To counter the long spells of sitting, I walked around the perimeter of the floor every half hour. The 170 steps took me past the copier nook, the TV studio, the glass-walled conference rooms, the long rows of data workers. I also used my lunch break to swim at the health club pool.

The first few weeks my condition was stable. I felt a good deal better than in the fall of 2007, but at the same time, my knees occasionally became inflamed while sitting. That worried me. How much better was I, really? It felt like I was living in a house that, while structurally sound to the casual observer, might be perched on quicksand.

Then, in mid-February, the downward slide began. My knees started to worsen. My initial reaction was disbelief, then my moods swung between gloom and a directionless rage. Finally I made myself face the facts. I hadn’t come that far over the three months of half-time work. Starting out, my expectations were high, of getting strong enough to ride my bicycle again for hours at a time. But my knees were just too bad.

A fellow finance editor heard of my renewed woes and recommended a product called Tiger Balm. He used it once successfully for a knee injury. I found it easily at a local pharmacy. Tiger Balm looked like an Asian version of Ben Gay. The orange-brown, camphor-rich ointment came in a small, six-sided bottle bearing a crude image of a leaping tiger. A slip of paper inside the box claimed the product derived from “a secret herbal formulation that dates back to the times of the Chinese emperors.” Tiger Balm supposedly treated everything from headaches and stuffy noses to muscle aches and flatulence.

Despite my natural skepticism, whenever I tried something new, I always wanted to believe it could work. I rubbed the Tiger Balm thoroughly on my knees before retiring at night. The flow of blood in the region definitely seemed to increase for a while, judging by how hot my knees got. The skin would feel prickly; my legs would sweat. After a couple of weeks though, I had to accept that Tiger Balm may be effective for muscles but not for cartilage, lying deep inside the joint.

I continued to struggle to get through the long workdays. I wore my soft-soled New Balance running shoes around the office, though they didn’t help much. The human resources department ordered a special ergonomic device, a footrest with a tilting top. That let me elevate my knees somewhat and move my legs a little while sitting. When that failed to offer enough relief, I propped my feet (and knees) on top of my desk.

A simple bit of math began to obsess and discourage me. My knees hated sitting. At work alone, I occupied a chair for ten hours. That constituted more than half of my waking day. Getting better under those conditions seemed impossible. It was like having a large abrasion on my forearm that, instead of letting heal, I scratched anew every day. I was doomed if I didn’t get out from behind that desk for a while.

I tried to work with Bloomberg to design a plan to take a period of unpaid medical leave. But HR departments, as I knew all too well by then, have policies that constrict their flexibility. Complicating matters, the Hong Kong office was only one arm of the global company based in New York. A thicket of bureaucracy lay before me.

At least my boss was on my side. During that trying period, I gained a deep respect for him. He was fairly young to be leading the finance team. That may have explained the frown stamped onto his features; he must have always felt the pressure from Bloomberg to succeed. At times he could seem a bit cold and brusquely efficient, but he tried his hardest to do the right thing by me. He supported the idea of medical leave.

If a doctor had agreed, that would have cinched things. But Dr. Chiu examined my knees again, listened to them crunch when I dropped into a squatting position, and told me they would never get better. I disagreed, saying they stood a chance of healing if I could eliminate the constant burning. Did he know of a special chair that would raise my legs and also keep them straight? I offered to pay for it out of my own pocket.

“Unfortunately there’s no good chair in the world,” he said. His matter-of-fact tone left no doubt. He couldn’t—or wouldn’t—assist me.

Finally, I pushed the company to make a decision. By staying behind a desk, I was just digging myself a deeper hole. One afternoon, an editor from London called to break the news: I should resign, then reapply after I got better.

That outcome wasn’t unexpected, but I still recall feeling a bit shocked. My mouth went dry. It was late April. Congyu and I were to be married on August 8, less than four months away. And I would be unemployed, facing a grim future if my doctors proved correct and my knees didn’t heal.

At least I had a plan. I had recently signed a new lease on my apartment, in order to stay in Hong Kong for twelve more months. That would allow Congyu and I to get married in China, near her family, and give her time to see if her fledgling startup business might take off (she and her best friend ran a consulting firm that offered management and sales training for Chinese companies). Meanwhile, in Hong Kong I would focus like a laser on saving my knees. Every day would be a knee day.

Just before leaving Bloomberg, I had a vivid, disturbing dream. I was sitting in the rear of a bus, traveling through the countryside. The bus stopped at a store and all the riders got out. I wandered over to an establishment next door and began chatting with a few locals, telling them tornado stories from a book that I’d written. Then at some moment I realized, with a feeling of panic, that I’d lost track of time. The bus, with Congyu aboard, was gone. I remember an awful feeling of abandonment.

The meaning of the dream was clear. Only one other time in my adult life had I so precipitously left a full-time job. In the early 1990s, I abruptly quit as a reporter for a small daily in southeastern Pennsylvania, packed my worldly goods in my Toyota Corolla, and relocated to Oklahoma to realize an ambition, to write a book about living in the heart of Tornado Alley.

It turned out to be a terrific educational experience, though later I vowed not to throw caution to the winds like that again. Then the situation with my knees left me no choice. This time, I was better fortified financially. Still, no matter how much you soothe yourself that everything will be all right, taking the plunge—leaving your job, your tether to financial security and social respectability—is frightening.

Later, I wondered if the anxiety permeating my missed-bus dream was actually an omen. I was about to go through the worst summer of my life.

10   A Rocky Start

For me, 2008 will always be the Year Of The Lost Summer. Over the course of three months, a confluence of bad luck and bad decisions caused my life to keep getting worse. By the end of August, if I had woken one morning to find hordes of locusts swarming in off the balcony, it wouldn’t have surprised me.

What should have been a summer of slow, steady gains for my ailing knees became a nightmare.

One reason everything fell apart over that wet, then sultry summer: I unwittingly had done something that proved foolish. You might say I had grabbed a snake by the tail. The snake masqueraded as a friend, but finally snapped up to bite me. This treacherous serpent was my good old buddy, the coping strategy.

For injuries that heal in a few weeks or a month or two, coping strategies are often benign. We all know what they look like and may hardly notice them. Someone leans heavily on the banister when descending stairs to take pressure off that hurt foot. Or swivels his entire upper body when looking to the side, waiting for that painful crick in his neck to go away.

A chronic injury can reveal the evil face of coping strategies. They allow us to work around a problem without fixing it. When we do that, we may start using our bodies in ways that quietly shift stress elsewhere, creating new problems.

My main coping strategy revolved around the uncomfortable act of sitting. My legs wanted to be extended and elevated. At work, I hung a sling under my desk to prop them up. That left me casting about for a solution at home. It wasn’t long before I bought my first “chondro” chair—short for “chondromalacia” of course.

I found it in Causeway Bay, the glittery shopping mecca of Hong Kong. An underground furniture store tucked off the beaten track stocked a cornucopia of chairs. One low-slung leisure model put my butt close to the ground and my knees inches higher. The geometry looked perfect. Plus the tube-metal frame was light and the price cheap, at twenty-six bucks. I had nothing to lose.

After lugging the box home, I quickly assembled the pieces and sank down into the lime-green, napped fabric. The burning in my knees lessened appreciably. So much for my doctor’s claim that no chair in the world would alleviate my symptoms! I shoved my expensive office swivel seat into a corner. For months my chondro chair was the place where I worked at my computer and played my guitar.

The chair worked so well that I sought a more upscale version for work. One Saturday I paid a visit to Hong Kong’s “furniture capital,” Ap Lei Chau. This islet hangs off the southern coast of the main island; I remember taking a long taxi ride to get there. The driver deposited me at a tall, drab building that contained an eclectic mix of furniture stores on its many floors. I picked out chondro chair number two among a display of items for boats. The attractive, sturdy deck chair had eggshell-white canvas cushions. It would have looked perfectly at home on a luxury sailboat.

Two days later, there I was at Bloomberg’s offices, maneuvering a cherry-wood deck chair down the twisting glass staircase to my work station. My cargo was heavy, but I had fashioned a makeshift carrying strap from an old belt. My co-workers made the expected quips. “It sure feels relaxed around here now,” one reporter said. The joshing was all good-natured. They knew I was struggling to find a way to keep working.

My chondro chairs and underdesk sling were blatant examples of coping strategies. When I told Tim about the sling, he warned me that I would develop back problems. Keeping my legs raised and straight, while bending over a keyboard, put constant pressure on my spine. I had a nagging suspicion he was right. But what else could I do?

A month before I quit Bloomberg, the back problems began. For three-quarters of a year, I had been sitting every day at a stressful job in an unnatural position. Finally my spine could no longer tolerate the strain. My back tightened and seized up while I sat. I would rise from my seat, grimacing, and walk around to try to manage the pain. The deck chair proved to be a wash: better for my knees but worse for my back. I had to abandon it.

Next came a nasty case of tendinitis. A week before leaving my job, I noticed a spot of soreness on my left inner forearm, near the elbow. The tendon had gotten sore a few times before that, while I noodled about on the guitar. My green chondro chair put me in awkward ergonomic positions, whether for strumming the instrument or typing at the computer (my wireless keyboard often balanced on my knees). Sometimes my burning joints forced me to strum songs more or less lying on my back. I contorted my body into strange positions to try to keep doing the things I loved.

Post-Bloomberg, the tendon became chronically inflamed. Then the same tendon on the right side grew tender and painful as well. It soon became clear this wasn’t a garden-variety ailment. Brushing my teeth hurt. Clapping my hands together to kill a fly hurt. Lifting headphones off my ears hurt. Carrying a bag that held no more than a foot-long Subway sandwich hurt. One night I probed the tendons and listened to them slide around. They were like hot, dry, creaky sticks. It was as if, had I moved the wrong way, they would’ve snapped like frail dowels.

So I was jobless, ready to embark on a year-long crusade dedicated to healing, and had a bad back, two bad knees and two bad forearms.

An appointment with a general physician confirmed that I had medial epicondylitis, also known as golfer’s elbow. “Medial” in this context refers to inner; the bad tendons lay near the inside knob of the elbows. He recommended physical therapy. Fortunately, my departure from Bloomberg at the end of April didn’t immediately terminate my company-sponsored health insurance. So I made the acquaintance of my third physical therapist. I’ll call her Patty.

She was a young, peppy Asian of small build who got right down to business. My first appointment, I received two kinds of treatment. Patty used ultrasound to warm the injured area and to speed healing. She also attached stick-on pads to my forearms, then turned on a machine that directed a soft flow of electrical current through the pads to relax the muscles in the area.

Patty then handed me three photocopied pages of almost a dozen exercises and stretches. Each was accompanied by a simple diagram. She skimmed down the list, one by one, as though ordering from a Chinese menu. She crossed out a few and checked others. She wrote down how many repetitions and how many sets.

What she failed to do became obvious after the exercises overstressed my left elbow, the weaker of the two, and the joint developed the bulbous swelling of bursitis. She hadn’t made any attempt to find out how strong my forearms were before blithely prescribing ten of this, fifteen of the other. One exercise involved sitting with my palms behind me and flat to the floor, then leaning back and bending, then straightening, my arms. She prescribed fifteen of these a day. But she didn’t know if I could do even one comfortably.

The inflammation continued to ravage my tendons and make them extremely weak. They even reacted badly to activities of light stress, such as typing and writing longhand. The severity and persistence of the condition alarmed me. I was no expert on tendinitis, but began to wonder if something else was going on.

So I return to a favorite theme: Before devising a plan to heal, you need to know what’s wrong and what’s causing it to be wrong. In this case, diagnosing medial epicondylitis seemed like the easy part. More difficult was precisely determining the cause.

The reason for nagging tendinitis isn’t always obvious, I knew from an experience in South Florida. At the time I was doing a lot of cycling, and an adductor tendon on the inside of my right thigh started to bother me. At first glance, it seemed related to my riding more than one hundred miles a week. A doctor advised doing five to fifteen minutes of adductor and hip muscle stretches before and after cycling. I followed his advice, but couldn’t shake the injury. I was baffled and annoyed. Why had this sprung up so suddenly? I had been putting in long miles on my bike for years.

Then I started doing a little detective work on my own and realized something. Not long before, I had moved my bicycle seat forward a few inches to build up my quadriceps muscles more, to make me a better sprinter. The change wasn’t much at all, but the new position altered how I used my muscles when pedaling. I remember immediately being struck by how remarkable the difference was.

After deducing that my seat might be at fault, I slid it back to a normal position. After some weeks, the tendinitis faded away.

Still, that battle with sore tendons was nothing compared with what I suffered in Hong Kong. During the summer of 2008, my forearms would ache, a deep, dull sensation that felt ten times worse than sharp pain. Sometimes nausea swept over me and I fought the urge to throw up. By itself, even a chondro chair that caused me to adopt terrible ergonomic positions couldn’t cause a condition that extreme, I thought.

Then, while idling away another evening at home, I decided to watch the old Hitchcock classic Notorious on DVD. The Ingrid Bergman character is a spy who’s been found out. Instead of being exposed, she’s surreptitiously given small doses of a poison that keep her weak and bedridden. After the movie ended, something clicked in my head. Could anything in my environment be “poisoning” me and contributing to my problem?

Medications couldn’t be to blame, it seemed. I didn’t take any. Upon further reflection, I realized that wasn’t quite true: there was the Rogaine.

It was kind of silly, my attempt in middle age to grow back some hair that genetics had robbed me of. The product hadn’t done much either, from a casual inspection of my pate. There might be a dozen or so hairs that Rogaine could take credit for. I rubbed it onto my scalp once daily, just before going to bed.

Then I thought about the symptoms of my tendinitis: they were always worse in the morning and improved as the day progressed.

Curious, I went online and did a search on “minoxidil,” the active ingredient in the hair-restoration product. A few clicks brought me to a Web page about the drug, maintained by the University of Maryland Medical Center, a well-known teaching hospital. Among the listed side effects: tendinitis. Elsewhere I learned about the maker of Rogaine’s own clinical trials. Patients suffered a number of adverse reactions. These included tendinitis.

That the Rogaine might be involved in my epicondylitis spurred me to action. I wasted no time tossing it out. After that, the worst episodes of pain went away.

Even so, the tendons were already badly damaged. Chronic inflammation had swept through them like a forest fire that crackles through a stand of trees on a dry summer day, leaving behind charred remains. They continued to be sore and weak all summer long.

At least my medical mystery was solved. Or was it? As I struggled with multiple health problems, a disquieting thought crossed my mind. What if everything happened to be connected? It didn’t take long to pinpoint a common denominator: joints. Knees . . . tendons . . . spine.

My research branched off in an unpleasant direction. I began to look at autoimmune diseases, such as rheumatoid arthritis and reactive arthritis. The former seemed the bleakest. In rheumatoid arthritis, for reasons unclear, your immune system attacks your joints. It’s as though the troops designed to protect your body get confused and go beserk, trying to destroy the very organism they are supposed to defend. Joints swell. Cartilage breaks down. Bone erodes. This form of arthritis usually strikes between the ages of thirty-five and fifty.

During a long-distance phone call, my father urged me to have a blood test. The symmetry of my joint pain matched well the classic pattern of rheumatoid arthritis. I wondered whether other perplexing symptoms might fit too. My knees suffered from what seemed like an unusual amount of inflammation. Also, while I was under emotional stress, the burning sensation would worsen or even appear out of nowhere. Was that significant? Or simply a reflection of how weak my knees were?

The possibility of having rheumatoid arthritis scared me a lot. If my own body was sabotaging my attempts to heal, I feared becoming an impotent bystander, forced to helplessly watch a terrible process beyond my control. Nonetheless, I wanted to settle the matter and so arranged to see a rheumatologist.

After making the appointment, I began to have second thoughts. Many of my symptoms didn’t line up with those of rheumatoid arthritis. My joints were painful, but not swollen. I didn’t have morning stiffness. I didn’t feel fatigued or feverish.

From the outset, the rheumatologist who examined me seemed doubtful as well. He checked the strength of my hands and their mobility and found them to be perfectly normal. He didn’t see any evidence of rheumatoid arthritis, though he ordered an X-ray of my hands and a blood test to be more certain.

My next visit, he shared the results with a shrug. The thin finger bones of my hand looked fine, according to the X-ray images. The blood test didn’t spot anything strange in measurements of two markers of inflammation. My sedimentation rate, or the speed at which red blood cells settle out in a test tube, was reported to be within a normal range. If there was inflammation, the cells would clump together and fall out faster. The other marker, the level of C-reactive protein in my blood, came in low—a very good finding.

More hopeful news followed when the bursitis lump on my left elbow was drained. A lab test was negative for the presence of bacteria. The swelling didn’t appear to be related to any kind of infection.

I heaved a huge sigh of relief after getting all the good test results. I had dodged a nasty bullet. I would have celebrated, except my arms were still almost useless. The aching tendons became sore easily. They made it impossible for me to do many of the activities that I had planned for those twelve months away from the workplace, such as learning Photoshop and doing some composing on my guitar. Odd as it sounds for someone living in an international city, I started to worry about going stir crazy.

In the end, only my writing remained. I parceled this activity out in small two-hour daily chunks. When typing hurt too much, I tried writing in longhand. When writing in longhand hurt too much, I tried grasping the pen lightly and making soft, whispery strokes. I repeatedly asked my physical therapist whether it was okay to continue writing. She assured me it was, as long as I used proper form. I wish I hadn’t listened to her. My right forearm kept getting worse while my left began to improve a little.

In August, Congyu and I got married in a quiet civil ceremony in Shenzhen. She looked absolutely beautiful, wearing a lovely white dress and strappy shoes with high heels. As for me, I looked fine but wasn’t.

The next day, while lounging around Cong’s apartment, I drew a picture of a ceramic owl that sat next to her TV set. I used her charcoal artist’s pencil and applied hardly any pressure while sketching. The image was small and simple. Yet the tendon near my right elbow became inflamed and pained me for several days afterwards. When I told her what happened, her eyes widened with surprise. She knew I was having trouble with my arms, but never realized how severe it was.

Even while the problems with my back and forearms made my life unpleasant, I vowed not to be distracted from my main goal that summer: saving my knees. I had a detailed plan of action that I began executing immediately after leaving Bloomberg.

At my request, my mother mailed a large box containing twenty pounds of protein powder; she shipped it over because the supplement costs one-third as much in the United States as in Hong Kong. Many diets lack sufficient protein, an organic compound that supplies the building blocks for the repair of damaged tissues. Every day, I consumed a high-protein drink, along with one and a half liters of water to stay properly hydrated.

My mother also sent me a wind-up timer, again at my request. She never questioned what it was for or why I needed it; moms are wonderfully and unconditionally supportive. Had she asked, I would have told her that the timer was to keep me on a schedule of “dosed motion.” I like that phrase; it suggests that movement can be administered with the precision of a pharmaceutical.

Here’s how my “dosed motion” worked: In addition to my short daily walks, I periodically moved around my apartment. Every fifteen minutes, the timer rang and I got up and walked. The distance covered was only sixty or seventy steps at a time: from the kitchen to the bedroom, back and forth. I was trying to copy the success I had with the simple pool walkarounds. The lesson I had learned before: bad knees need to move frequently, but not too much at once.

To an onlooker, my first month out of work would have seemed pretty dull. I spent a lot of time sitting on the floor with my legs out straight or lying on my back with my knees propped up on the couch cushions, all the while waiting for a cheap department store timer to jingle. My objective was simple at that stage: to reduce the frequent burning sensations in my knee joints. I made good progress.

Then even that small victory was snatched away, shortly after record-breaking rains doused Hong Kong in June. The city turned unbelievably soggy and sodden. Almost every day dawned gray and depressing. Weeping rain, sheets of rain, typhoon rain, we had it all. The monthly total was almost four and a half feet of water. That easily shattered a hundred-year-old record.

In the subtropics, rain and heat and humidity combine to spawn outbreaks of mold and mildew. Six years in South Florida, another hot, moist climate, never prepared me for the infestation I faced in Hong Kong. White mold sprouted in a clothing cabinet. Green mold coated the backside of my bookcase and bearded both my pairs of Oxford dress shoes. Mildew ran riot in a large clothing closet. And black fungus spread widely over the ceiling throughout my apartment.

The more dark corners I explored, the more fungus I found flourishing. That led to an eradication attempt that spanned a few weeks. I washed, rewashed, and thoroughly dried loads upon loads of clothes. I spent a few days climbing up and down a chair, painting the ceiling with antifungal chemicals. Then, when that failed to control the mold, I would occasionally get back up on the chair to spray spots on the ceiling with a bleach solution.

All the stepping up and down, and the cleaning and scrubbing and kneeling, took its toll on my weak knees. They slipped backwards. They began to bother me more.

With my health increasingly fragile, I then had a run of incredibly bad luck with the physical world around me. First, my computer broke down, in the most annoying way: in stages. To begin with, the hard drive crashed. After it was replaced, the motherboard died. After a new motherboard was installed, the monitor stopped working.

Without a PC, which was my chief source of entertainment (I had no TV), I turned to my photography hobby to fill the long, empty days. I considered organizing my own photo-taking expeditions to nearby islands. While testing out my camera, a digital Canon 20D, I snapped a few photos at night and noticed something bizarre on the long-exposure images. Spidery threads radiated in one corner, like a branching network of nerves.

One by one, I held my expensive lenses up to the light. On most, the tiny threads traced over the glass. A Canon repair center in Tsim Sha Tsui confirmed what I suspected: my camera body and several lenses were riddled with the fungus that had overrun my apartment. They would have to be carefully cleaned. That took several weeks and cost more than $700.

Casting about for a new diversion, I turned to books. Mass-market English paperbacks in Hong Kong cost $15 apiece, so I got a library card. A bookmobile rolled into Discovery Bay every Tuesday. Of course something was bound to go wrong. Sure enough, the bookmobile missed a week because of a typhoon. After that it failed to show up a few times because of unspecified maintenance issues.

Failures and frustrations kept piling higher and higher. In mid-summer, I had reluctantly given up almost all typing and writing longhand to let my sore tendons heal. Then I realized that voice-recognition software might be a good way to work around my infirmity. So I went to a computer shop to buy a program called Dragon NaturallySpeaking.

Of course the computer shop I visited didn’t happen to have any copies on hand. A day-long intensive search of the city revealed that neither did anyone else. In fact, it turned out the U.S. makers of the software were between versions—what were the odds? It wouldn’t be in stock for a week, a clerk told me. That week turned into a month.

I hated my life that summer. The weather was uncomfortable. My body felt like it was falling apart. My confidence evaporated in my ability to heal from anything. Everything big that could go wrong did: the problems with my computer and camera, the unavailable software that I needed to get my life back on track. My anger constantly simmered just below the surface.

During that summer, I began to seriously meditate for the first time ever. It was an attempt to relax and control the pain and dissipate some of the pessimistic funk I had fallen into. I was an intensely negative ball of energy. My mother sent me a sort of idiot’s guide to meditation that I read, but didn’t follow too closely. The standard cross-legged posture would have caused my knees to complain and didn’t seem important anyway. I also never focused on a word or sound or scene.

The way I practiced meditation was simple. I tried to unknot my muscles, as much as possible, while letting my mind go blank. I sought to unburden myself of all kinds of tension, whether physical or mental. It surprised me how feverishly active my mind was. At the beginning of a meditation session, it seemed like I was trying to restore order to the trading floor of the New York Stock Exchange going full tilt. That was the background cacophony I lived with.

Sometimes, after a period of focused silence and relaxation, I slipped into a trance-like state. The physical pain would go away. A pleasant sensation would spread through my mind like the bloom of firecrackers lighting up the night sky. It’s hard to describe this state; I recall experiencing a sort of warm tingling on reaching an interior space where everything was peaceful and simple and clear.

Coming from an ardent rationalist, I realize all this sounds rather warm and mushy. But when healing is hard, you need to marshal all available resources. You need your mind to be working with, not against you. You need to be able to shed the anxiety and bitterness and negativity weighing you down. These things levy a very real physical tax that impairs your ability to get better.

Meditation turned out to be a good strategy for surviving a bad time. I was grateful when the summer of 2008 began to recede in the rearview mirror. At the end of September I took stock of my gains over my first five months away from Bloomberg.

My progress looked scant. My knees tolerated better my daily walk of a couple of miles, but that still wasn’t far. I could sit normally at a desk without problems, but only for a few hours at a time. My knee joints seemed stronger, but only a little.

It seemed like a good time to make an aggressive push forward. Winter was fast approaching. That meant cool, dry days and lots of sunshine. The weather would be perfect for hiking.

Up until then, I did all my walking on level ground. The problem was, I couldn’t work up a sweat and get my heart pumping. The hills and mountains of Hong Kong held out the promise of a grueling workout. I decided to accept the challenge. It was time to do some climbing.

11   Recovering

On my quest to save my knees, the theme of adaptation often preoccupied me. I strongly believe that our bodies, when subject to the proper stresses, have an amazing ability to change to meet the new demands put on them.

For months I had done easy walks along the Discovery Bay beach and around a nearby cove where small, creaky ferries picked up passengers bound for Mui Wo and the island of Peng Chau. As the end of the year approached, I was looking for opportunities to push my joints harder, little by little.

In October, I tried light cycling again. After two ten-minute sessions on my indoor trainer,  days apart, with a careful monitoring of symptoms in between, I had to accept that my knees just weren’t ready. Biking would have to wait.

That left hiking on hilly trails, a program I had resolved to begin as summer waned and the fierce heat abated. Doctors often advise patients with bad knees to avoid steep terrain. That didn’t make sense to me. If you always avoid it, how can your knees ever adapt to it?

At the same time, I knew enough not to start dashing recklessly up and down mountains. Hiking sensibly was important. When walking in the cold, I took care to keep my knees covered and warm. Also I went down slopes and stairs carefully.

Going downhill seemed to pose a much bigger risk to my damaged cartilage than going uphill. Gravity acts as a brake of sorts when you climb higher, slowing you down. But it has the opposite effect when you descend, hurrying you along and causing your weight to slam down with more force than normal. So when the terrain sloped lower, I made a conscious effort to take softer, more controlled steps, pushing back against gravity.

In November, I started hitting the hiking trails. They led me away from the dull safety of Discovery Bay toward a raw, natural part of Lantau Island. One route in particular was a favorite. Rambling down it was like passing through a portal into an earlier, rural Chinese society. On a lazy summer day, you could hear the loud thrum of crickets and the slow scrape of hoes in small gardens.

The path begins by taking you south, away from Discovery Bay’s modern apartment towers and sidewalks of pastel-colored brick. It hugs the shoreline and wends through small scatterings of squatter huts, even crossing through the middle of one. The crude huts are cobbled together from scrap sheet metal and discarded wood. Bricks anchor tarps that cover rusted tin roofs. One squatter sold vegetables from a garden that sprawled over a steep hillside.

After three-quarters of a mile of relatively easy walking, the trail angles upwards. It rises past an abandoned shell of an old British jeep in the middle of nowhere, a Land Rover open to the elements with dried vines curling around a windshield post. A little farther on, a narrow paved road leads to the tree-sheltered Trappist Haven Monastery, where the chapel bell tolls at five minutes before the hour.

Then you make your way farther inland, away from the sea. A footbridge spans a small stream shrouded in shadows. As the path becomes quieter and more remote, you can’t tell what you’ll stumble upon. A half dozen wandering feral cattle sometimes take up a spot alongside the trail to graze for a while. Red-necked keelback snakes slide through the grass.

Soon the climbing begins in earnest again. The trail tilts up and winds back and forth as the tree cover thins. Finally, a long set of stairs ascends to a small pagoda with concrete benches for the weary. From this perch, on a clear day you can glimpse the main island of Hong Kong some six miles away.

It took me a while to reach the highest point, the pagoda rest station. I tried to pace myself. Every week or two I hiked a little farther on the trail until on December 13, I reached the summit. It was a terrific feeling. Sweat rolled down my brow and my heart drummed hard and strong in my chest.

Breaking the sweat barrier was so important for me in getting better. It’s hard to overstate how much it mattered. For so long my knees protested at any exercise hard enough to produce a sweat. Then, one day, I was striding up that trail to the monastery, feeling my body perspiring because it was really working, and I never wanted to stop moving.

The “sweat effect” went deep. Certainly sweating during vigorous exercise did me good psychologically. It represented a tangible milestone of progress and revealed as well how much I missed that happy, tired feeling after a good workout. But beyond that, something magical seemed to happen in my knee joints. Immediately afterwards, they felt much better.

Wondering what was going on, I looked into how exercise affects synovial fluid. This normally thick fluid is vitally important, helping to protect knee cartilage. In a badly diseased joint, it becomes thin and watery.

A Japanese study from 2003 supplied some insight. For three months, patients with osteoarthritic knees did “isometric” quadriceps exercises; the term refers to a type of exercise where muscles are tensed without movement. The results were quite impressive: the viscosity, or thickness, of the patients’ joint fluid jumped by almost a third.

Not only my joints, but my whole body started improving noticeably that winter. Aerobically, I felt more fit. Also the up-and-down hiking caused my leg muscles to get sore, then stronger. Soon I noticed that, when puttering around the apartment, my knees were simply more functional. I no longer avoided bending them when I had to reach down for something. They flexed easily and I could even hold a crouched position for a few seconds with no discomfort.

Amid all these changes came an even bigger life change. On January 7, almost a week before my forty-seventh birthday, Congyu called in the morning. I was at my desk, absorbed in a bit of writing, but quickly perked up on hearing her voice. It had a strange, subdued quality. I thought of her elderly father, whose remaining kidney was bad; a surgeon removed the first because of cancer. Had his health taken an abrupt turn for the worse?

Then she spoke in a small voice full of wonder: “I’m going to have a baby.” That news surprised me. Before marrying we talked about having children, and time was running short—she was thirty-seven, I was forty-six. But I assumed it would take a few years of trying, not four months. We were both over thirty-five, and in my mid-twenties, I was rejected as a sperm donor because of low fertility. We talked for a while; I remember being at a loss for words and saying “wow” a lot. A great new adventure lay before us.

When we traced backwards to figure out the date of conception, I realized with a smile that it was early December. That seemed appropriate. Late November and early December marked a turning point for me. About then, my walking on the monastery trail started paying big dividends. For the first time in many months, I felt very hopeful and optimistic.

The prospect of becoming a father certainly lent a new urgency to my program to heal. I vowed to push myself even harder and almost blundered into a trap. December and January were such good months that I wrongly assumed that my knee issues were almost behind me. What I didn’t account for was the cold weather effect. The chilly temperatures that my knees preferred were masking some problems.

The joints became crunchier than before, even though my muscles felt good. When Hong Kong had a few agreeably mild days, my knee scores dipped a little. Then I got some unpleasant feedback on a hike: tingling under my left kneecap. The message hit me loud and clear. I was doing too much by walking at least three miles up and down, nearly every day.

I realized then that my Type A tendencies sometimes cloud my better judgment. My nature is to exercise hard and always perform my best. That kind of thinking can be destructive in trying to recover from an injury that mends slowly and poorly. So I made adjustments. I began to build in regular off days of easier, shorter walks over flat ground. Also, during the months of February through April, I decided not to keep increasing my step counts. Instead I worked on improving my form while walking, especially downhill, and letting my knees grow into my new regimen.

As they continued to recover well, I took aim at another trouble spot: the forearm tendons that attached to my inner elbows. My arms as a whole had become terribly weak. Congyu had taken photos of me during Christmas, opening gifts from my mother. It shocked me to see how thin and flabby my upper arms were. The muscles had wasted away.

By the end of 2008, I had become resigned to the idea of having surgery. The damaged tendons weren’t getting better after more than half a year. My last visit with Patty, she grimly observed that patients with chronic tendon pain regain only about seventy percent of their original strength. At first that discouraged me. Later I wondered if that figure was just the equivalent of an old wives’ tale.

Certainly I did struggle to heal. Patty suggested exercises that I did daily, but without success. Periodically, I stopped doing them for a week or two, thinking the problem could be that the muscles and tendons were being overtaxed. But taking a break didn’t seem to do much good either. During December and January, I felt despondent about my bad forearms. They even got sore after continuously curling 3.3 pounds (about the same weight as a few cans of soup) for three or four minutes. I needed help.

Once again it came from Doug Kelsey, half a world away. On his blog he described how to fix a bad Achilles tendon on the back of the heel. At the same time, he made a common-sense observation that contained a profound truth: a tendon is a tendon, no matter where it is. The tissue fulfills the same function, has the same characteristics, and needs the same approach to repair.

His treatment for the damaged Achilles tendon consisted of a thrice-weekly workout that combined low-repetition “eccentric” exercises (in which a contracting muscle is forcibly lengthened) with high-repetition movements (to stoke the injured tissue’s metabolism). The objective: push the tendon hard enough to make it sore the next day, coaxing it to rebuild itself.

I designed my own version of this program for my forearms, using dumbbell weights. The small 3.3-pound plates fit into my palm and were light enough to do 150 quick repetitions. For the low-repetition exercises, I started doing bicep curls with an eleven-pound weight (that showed how weak I was; in Florida I regularly did thirty-five-pound curls without a problem).

To make the exercise eccentric, I simply shifted the emphasis. Normal curls are about lifting; mine were about lowering. I would bring the dumbbell up to my shoulder, then focus on slowly controlling the descent to the start position.

My first session, in late January, I had poor form. On each curl with the eleven-pound dumbbell, the weight dropped rather quickly. My skinny arms and weak tendons couldn’t provide any push-back resistance. The dumbbell felt as heavy as a burlap sack filled with rocks. I grunted and grit my teeth. The next day I achieved one desired effect: my tendons were sore.

Over the following weeks, the damaged tendons repeatedly endured the same cycle: get sore, get a little stronger. Gradually I added more plates to the bars, at last reaching twenty-two pounds. My form improved too. I went from doing twenty awkward repetitions with eleven pounds to doing thirty, nice and slow, with twice the weight.

In early April I was happily surprised to find I could type for a few minutes at a time, no symptoms. Near the end of April, three months after beginning the exercise regimen, I was typing almost normally.

At long last, everything was coming together. My knees were better. My arms were better. My back had even begun to improve, through special exercises to strengthen muscles around the spine.

At that point, my time in Hong Kong was nearing an end, but I had one more goal to achieve. It had been kicking around in the back of my mind for months. Before flying back to America on April 30, I wanted to walk to Mui Wo along the familiar monastery trail. Until then, I always stopped at the pagoda on the hill, roughly the halfway point, then turned around. Going all the way, at least once, felt right as a symbolic act of completion.

I set out on a late April day under cool, dreary, low-hanging skies. A whisper of wind rustled the foliage. Through the stillness, I heard the trilling of birds and the calls of other hikers on the trail. First I climbed up to the pagoda way station. Once there, I rested and gazed out toward Hong Kong Island. All I could see was thick mist shrouding a small island in the near distance.

After a ten-minute break, I began a slow descent to Mui Wo. The drone of a ferry engine drifted over the green hills as my feet crunched over loose soil. I tried to listen hard and see hard too, to freeze in my memory these last impressions of Hong Kong. I had gone through the worst period of my life here. But along the way I discovered a stirring message underneath all the despair: that things do get better, when you believe in yourself and have a rational plan for progress and don’t give up.

In the end, I became convinced that we always have to keep in mind our natural resilience, instead of becoming obsessed with what seem like the inevitable breakdowns that come with the aging process. Our bodies do change with time; that’s an undeniable fact. We grow a little slower, a little more fragile. But that’s not the whole story.

Even into old age, our bodies are remarkable in what they can do. It’s important to appreciate that. Over the course of our long lives, they respond to millions of physical insults and find a way to heal. They don’t suddenly forget how to do that when a certain page on the calendar flips over.

I quit my job to prove that my bad knees could get better. After twelve months, my journey wasn’t over, but I had accomplished a lot. My knees were stronger and more mobile. They rarely ached or pained me. And I was convinced that even better days lay ahead.

12   My Four Golden Rules for Bad Knees

After my long struggle to fix a pair of achy knees with bad cartilage, I spent some time reflecting. What had I learned that might transcend my own experience and help someone else? If my knowledge were distilled into a few simple guidelines, what would they be?

I came up with four golden rules that helped me greatly in my recovery. Superficially, they’re all rather obvious and about as controversial as vanilla ice cream or Mother’s Day. But they turn out to be more complex than meets the eye. I bet you’ll find a few surprises in here.

Use it or lose it.

Knee cartilage has a thankless job. Owners of knees do stupid things all the time. Over time, damage can occur to the cartilage, the shock absorber that helps the joints function properly. But once the cartilage is damaged, and a knee begins to hurt, the answer isn’t to stop moving. It seems paradoxical at first, but immobility only feeds the process of decay. Joints starve when they spend too much time at rest.

My personal experience convinced me that a program to mend bad knee cartilage needs to be based on motion. It’s not the high-force motion of exercises designed mainly to build up your quadriceps. That approach risks trashing your joints as you try to save them. Gentler, high-repetition activity does much better at nourishing the injured soft tissues.

As for what kind of motion, this probably depends on what your knees tolerate well and what you want to achieve. For some, walking may be best. For others, it may be cycling—or doing easy leg kicks in a swimming pool.

“Unloaded” exercises may help you return to your desired sport. I know that Doug Kelsey has invented a device that enables unloaded running. The user hangs from a harness that creates a sort of anti-gravity effect. The setup allows running over a treadmill at less than full body weight.

I created my own unloaded exercise, a “bungee squat.” I draped thick bungee cords over a two-by-four that ran overhead in a garage, then attached the hook ends to a rock-climbing harness I wore. With my bungee support in place, I repeatedly lowered myself from a standing to seated position for five to ten minutes at a time. I easily did four or five hundred repetitions with little stress on my knees. Plus it was kind of fun!

Of course, whatever exercise you settle on, it’s always going to be challenging to figure out how much sustained movement your bad knees can handle, and at what force. That leads to rule number two:

Listen to your knees.

This seems like a real Homer Simpson “D’oh!” statement, obvious in a forehead-slapping kind of way. Actually nothing could be further from the truth. I suspect there’s an epidemic of people who don’t know how to listen well to the signals from their recurring knee pain. That’s because I used to be one of them.

I thought I knew how to listen to my knees. If an activity hurt, I didn’t do it. If it didn’t hurt initially, I would do it until my knees told me to stop. That was my superficial way of listening. Had I remained at that level, I never would have gotten better.

My problem: I wasn’t listening smart enough or hard enough. Once again, cartilage has no nerve supply. If a quarter-inch-high imp crept into your knee joint and slashed the surface of the articular cartilage a thousand times with a tiny razor blade, you wouldn’t notice a thing at first. The pain signals never come from the tissue itself, but rather from surrounding structures, such as a synovium that becomes inflamed after absorbing free-floating cartilage fragments.

The lack of nerves has huge and unfortunate implications. It confounds your ability to draw straight lines between cause and effect. What would happen if you banged your thumb with a hammer on Monday, felt no pain at that moment or the next day, but then sometime Wednesday morning you yelped “Ouch!” That would be strange. You would be inclined to reason, “It couldn’t have been that accident with the hammer on Monday, because I didn’t feel anything then.”

In fact, because of the delay in receiving the pain signals, you might unwittingly do further damage to your thumb. After a while, as it occasionally became sore for no clear reason, you might conclude that you just had a bad thumb and that nothing could be done to fix it.

That sounds scary. That also describes how bad cartilage often behaves. When you screw up and further damage the tissue, your knees may not let you know until the next morning, or even two days later. My knee journal was littered with examples of this “delayed symptom” phenomenon.

On one occasion, for instance, I decided to buy an electric fan as another long, brutal Hong Kong summer approached. The small models in the stores looked underpowered and overpriced, so I found a big pedestal fan through an online flea market. I walked over to the owner’s apartment to test it and found that the blades blew a nice, strong breeze. There was only one issue that made me hesitate: the fan was heavy. Carrying it home would strain my knees too much. They were very weak then.

The seller graciously agreed to drive me back in the family golf cart. So I only had to lug the fan down a few flights of stairs to the waiting vehicle, then after a short ride, carry it into my building to the elevator bank, then down the hall to my apartment. It didn’t seem far. My knees felt okay the whole time, but I knew the cartilage was soft and vulnerable.

This all took place on a Saturday. On Monday, my right knee got very sore and stayed that way for a few days.

At first I refused to believe that moving the fan was to blame. I pored over my knee journal and studied all the other possible variables between Saturday and Monday: the weather, my daily step counts, other activities. No other likely culprit emerged. I’m almost certain that the weight of that fan, coupled with the act of descending the stairs, caused my fragile knee to blow up. If that were an isolated incident, I might be skeptical. But the delayed onset of symptoms occurred too often to be denied.

So it became clear that listening to my knees involved much more than monitoring symptoms during an activity and immediately afterwards. I had to listen smarter, over a couple of days. Otherwise, I stood no chance of drawing the correct conclusions about what my knees could and couldn’t do. Had I not connected the dots between toting that heavy fan and suffering soreness two whole days later, I might have just sunk into despair and chalked up my pain to a random bad knee day. Instead I gleaned valuable information about the poor ability of my joints to support extra weight.

Listening harder is somewhat different. It became important because my knees often behaved like a mumbler, or like that low talker on an episode of the Seinfeld sitcom that no one can seem to understand. I would frequently have strange sensations that didn’t express clearly what was wrong—or even if anything was wrong. They might be little twinges, or tiny spots of soreness, or maybe a small touch of achiness. I consider them sub-pain signals. They don’t really hurt. If my knees were great, I would ignore them without thinking twice.

With bad knees, I didn’t have that luxury. Failing to heed a subtle warning can have painful repercussions. So when someone is a mumbler or a low talker, but what they’re saying is critically important, what do you do? Listen harder. If you listen hard enough, you can start to decode the language. You can figure out whether to be concerned about that twinge at the outset of your walk. You can judge whether it’s a normal part of warming up or a sign of trouble ahead.

Listening to my knees properly meant reacting to what they were saying and being willing to break with my exercise program, and very quickly at that. Had I understood what my knees were telling me, I never would have continued so long with the weightlifting that my physical therapist advised. My knees were screaming that it wasn’t working. And they were protesting in their peculiar, complex way: they felt fine during the workout, but the next morning the burning in my joints told me they weren’t happy.

The “listen to your knees” rule matters so much that I cringed on seeing an activity scale for bad knees in a book. Here’s how the scale works: You have a certain amount of points you can “spend,” if you will, on physical activity each week. The younger, healthier, and thinner you are, the more points you get. So for instance, a forty-six-year-old with current knee problems who is twenty pounds overweight may have enough points to walk up and down hills for five hours a week.

This strikes me as a really bad idea, tailoring your activities to a crude point system. It’s like trying to fine-slice prosciutto with a dull ax. Perhaps that overweight forty-six-year-old with painful knees shouldn’t be walking five minutes a week on hills. Maybe he can’t tolerate a stationary bike either (when I figured out my allotment of weekly points, the total indicated that I should be able to cycle over hills for more than ten hours a week; in reality I couldn’t tolerate ten minutes).

Listening to your knees also involves trying to distinguish between sounds that are meaningful and those that aren’t. Normal knees make a lot of noise: airy pops and clicks and even scary-sounding cracks. Experts say knee noises unaccompanied by pain can be safely ignored.

I don’t think that’s quite true because damaged cartilage makes a telltale sound. When you bend your knees, it may remind you of a soft wet ripping, or the grinding of bits of gravel, or the crackling of potato chips breaking. That noise deserves attention, even when no pain is associated. You need to make changes, and fast, to whatever stressful knee activities you engage in. Trouble may be lurking on the horizon. I wish I had known this.

Finally, to really listen to your knees, you need to be able to hear them. That’s a big reason I eventually threw out my painkillers and anti-inflammatories. While I’d be the last person to snatch pills out of the hands of a chronic pain sufferer, just think of what these medications do. They mask the very symptoms that are crying out, “don’t do this” and “stop doing that.”

I discovered as much after taking an arthritis drug once. It allowed me to sit normally at work with only background sensations of pain. The next morning though, I paid the price. While sitting, my discomfort was twice as severe. Obviously one response is to simply pop another pill to make the next round of pain go away.

Then an epiphany hit me: isn’t the pain itself an important message? You can stifle that message. You can drown out what your knees are saying with the pleasant white noise of a little red or yellow or pink pill. But does that really help you get better?

Once I learned how to listen to my knees, I was ready to apply my third rule:

Get on cartilage time.

I once saw a cartoon where a frightened mayfly blurts out something like, “My life flashed before my eyes: all twenty-four hours.” The joke makes us laugh because we realize everything has a different scale of time. For an igneous rock, a decade is the human equivalent of an eyeblink. Meanwhile a mayfly born at the crack of dawn is passing through middle-age by sunset.

Parts of our body heal on different time scales too. Muscles are bathed in blood; they recover more rapidly from injuries. Cartilage has no blood supply and its cells are isolated within the larger matrix; it improves very slowly. I used to quip that healing my knees was like watching paint dry—except paint dries much faster.

Getting on cartilage time requires adjusting expectations. Healing bad knees may take six months, a year, several years. It’s one thing to say, “Okay, I’m willing to get on cartilage time and devote a few years to fixing my knees” and another to fully understand what that implies. For me it meant telling myself to stop being impatient and to stop fixating on short-term results.

Early on, I always compared one day to the previous, looking for signs of healing. An especially good weekend made me feel giddy, thinking my pain would soon be gone. Then a bad day would follow and send me into black despair. The up-and-down cycles left me depressed and sapped my energy. It felt like I was flailing about. At one point, realizing how deadly my short-term thinking was, I stopped recording my knee scores for a while. They seemed to put constant daily pressure on me to improve.

Once you get on cartilage time, you can focus more on the trend line of healing, not the noisy data points that jump around a lot. After all, no matter where you find yourself on that trend line, there will be good days and bad, relatively speaking. But are the bad days better than they were a few months before and less frequent? To settle such questions, I would track long-term trends by noting in my knee journal the “good” and “bad” from each week.

This feature occasionally turned out to be useful for moral support. Nine months after leaving Bloomberg, for example, I got discouraged after a couple of bad days. I browsed through old knee journal entries and they lifted my spirits, showing how far I had come. At the two-week mark, I was in such poor shape that I had to sit with my legs draped over a box and considered good my ability to stand in one spot and brush my teeth at night without too much burning in my knees. At nine months, neither of these problems had been an issue for a while.

When you give yourself more time to heal, something beautiful happens. Time becomes your friend, instead of the enemy that’s constantly draining out of the hourglass. You make peace with taking baby steps toward your goal. You allow yourself to proceed more slowly and carefully, without self-recrimination. That may sound easy, but for hard-driving, competitive people, it’s not. I knew that firsthand.

Before my knee injury, I trained intensely and constantly tested the limits of my endurance. When Dr. Chiu told me during our first appointment that I should reduce my cycling, perhaps to ten minutes a session at first, I almost burst out laughing. My body was conditioned to go two to three hours, hard. In ten minutes, I would barely break a sweat. But then, a few months later, my knees were unable to handle even five minutes of gentle biking.

While “get on cartilage time” put me on the appropriate time scale for healing, my last rule put me in the best position to succeed. True, it wasn’t as relevant for me because of my slight frame. Still, adhering to this simple rule can lead to a lot of knee pain relief.

Lose weight.

I never thought much about the relationship between body weight and knee pain until a trip to Mui Wo that turned into a book-buying orgy.

I’ve always loved secondhand bookstores. I like the thrill of the unexpected find, the possibility of snaring a bargain, and on a more visceral level, just the heavy, dusty scent of old books that fills the air. So one December day when Congyu and I took a Saturday ferry to Mui Wo, I was delighted to find a sundries shop with thousands of used books tucked away on the second floor. Congyu waited patiently while I selected a bunch of paperbacks. After paying for them, I found another secondhand bookstore down the street and bought a few more.

All the books went tumbling into my backpack. We then strolled around. Mui Wo has a lot of charm and feels like a blend of old Hong Kong village and hideaway resort. A white elephantine hotel overlooks the long beach. Away from the shoreline, paths wind toward the hills in delightful and unexpected ways, past small temples and homes that seem impossible to find again on future visits.

I should have realized that my book-filled backpack would cause trouble later. The next day I noticed a light burning in my knee joints while standing. Well, I thought to myself, it’s no wonder. My backpack must have weighed twenty-five or thirty pounds. To verify this, I reloaded it with the books and stepped on my bathroom scale. I was astounded to find that it was only eleven pounds. But it felt so heavy! I couldn’t imagine having bad knees and lugging around that much extra weight all the time.

An afternoon of carrying a full backpack taught me a real-life lesson about why doctors tell heavy patients with knee pain to lose weight. Unfortunately, the advice is all too often ignored. It’s simply hard for someone to imagine the effect of shedding ten pounds. If so, I heartily recommend the “backpack test.” Fill one with ten pounds, then wear it on a long walk. That should convince anyone. It convinced me.

For a knee pain sufferer, losing weight makes sense for so many reasons. First, you just feel healthier after shucking that excess fat. Then you have the mechanical benefit. Cartilage that thins or becomes damaged is a less effective shock absorber. Dropping pounds lightens the burden it must bear. There’s yet another advantage, if you believe motion is good for your joints. The lighter you are, the more you’ll be able to move without stressing them too much.

Any remaining doubters should look at the scientific evidence. Studies consistently show a strong link between weighing too much and developing knee problems. In one group of women, the risk of developing osteoarthritis in the joint soared by more than a third with every eleven pounds of weight gain.

That didn’t surprise me at all. Knee joints are sort of like the body’s rugged stevedores, dockworkers who muscle around heavy loads all day long. And for the human body, what’s a more direct input into the load equation than how much you weigh?

I was already rather thin when I developed knee pain, so there was no spare tire for me to work off. I did drop five pounds, from 175 to 170. Early in 2009, I went for broke and tried to reach 165; I last maintained that weight in high school. My battle to shed pounds proved revealing. As I seesawed higher and lower, I would notice small differences in how my knees felt, even between weighing 171 and 168.

You may not immediately sense those extra two or three pounds. But your knees know they’re there.

13   An Orientation Toward Healing

As far as I know, no one has ever done before what I did: conduct a twelve-month experiment, both tightly controlled and well-documented, into what affects and improves a pair of knees with damaged cartilage. That statement isn’t meant to sound boastful. You have to become rather boring and an obsessive note taker to accomplish such a thing. I turned into a guinea pig of my own making.

My life was dull and repetitive to an almost embarrassing degree. Many days I went for walks on similar paths at similar times. Each evening, I sat on a dark-brown couch and watched a full-length movie DVD for entertainment. Even my meals remained basically the same, week after week. I was Mr. Predictability.

Which was exactly perfect for this experiment.

My dull, structured existence allowed me to zero in on any significant day-to-day changes. They became factors to monitor to determine their effect on my knees. I purposefully tweaked certain variables, one at a time. One week I might try doing a new exercise, or walking on hills, or cutting my step count by one-third. Another week I might try a nutritional supplement.

It wasn’t an exciting life by any means, but the insights I gained were tremendous. By the end of the year, my head was swimming with thoughts and observations. Some of what I learned fit into my four golden rules. Much of it resisted easy classification. If a common theme described the leftover bits and pieces, I would say it’s “orienting both mind and body toward healing.”

First, orienting my body required figuring out, on a physical level, what my knees needed to get better.

To determine this, I constantly drew lines between how my knees felt and what probably caused that feeling, good or bad. What I discovered was fascinating. The hands-down winner for what influenced how happy my joints were: movement.

Sometimes the link wasn’t obvious. Early in the summer of 2008, I spent a lot of time scrubbing outbreaks of fungus off my apartment ceiling and cleaning in general. Meanwhile, my knees worsened. I became frustrated and went for shorter daily walks, thinking that might help. It didn’t.

That left me looking for something else to blame for my deteriorating condition. Then one day I decided to wear my pedometer while cleaning. That led to a revelation. In one day, I racked up a whopping 8,258 steps without leaving my apartment—the same as for more than four miles of walking.

Other times, the influence of motion on my troubled knees was quite clear and indisputable. The joints reacted to how much they moved (three thousand steps? five thousand?), in what fashion (walking? cycling?), and with what load (nothing? backpack? heavy fan?).

During my recovery, I also made sure my body had the nutrients it needed. I ate regular meals of brown rice and garlic (the spice is touted as a natural anti-inflammatory, among its many good properties). I topped off my day with a protein powder drink, to make sure my body had an ample supply of the raw materials needed to mend injured tissue. And I drank plenty of water, the liquid that accounts for up to four-fifths of cartilage, in order to stay well-hydrated.

I also took a number of supplements that target injured joints. My experience with these smartly packaged products was like a series of blind dates that all end badly. At first I would get excited by the label: one promised to end inflammation, depicted by a red flaring spot of pain on a man’s knee. The product contained rosemary, turmeric, and ginger. Another boasted of assisting the body in tissue repair using proteolytic enzymes. Not one had any perceivable effect.

Orienting my mind toward healing required a different emphasis. To begin with, I had to lose my gloomy perspective and come to grips with my fears. Negativity had taken over my life. Whenever I looked in the mirror, the face that gazed back was anxious and unhappy.

When you live sad and discouraged in a world of hurt, your outlook begins to change and turn against you. Doubt robbed me of the ability to enjoy small victories. Instead of celebrating a good day for my knees, I would think, “What if this is an illusion, or an aberration?”

Countering this negative mental energy required a certain inner fortitude. It also helped tremendously having an exercise program that allowed me to make continuous progress, even if in tiny increments. When unsure about how much exercise to do, I tried to err on the conservative side.

That helped me avoid setbacks, which are bad for many reasons. They’re demoralizing, for one. They chip away at your resolve and darken your mood. They may cause you to abandon your exercise program for a while, as you succumb to feelings of hopelessness.

Setbacks are also wasteful and confusing. They erase gains and send you rolling down another “chute.” Once you get up and brush yourself off, you then have to try to figure out how far you have fallen. If the activity that brought on pain symptoms was too hard, and perhaps damaged your knee further, what now? Do you return to the exercise regimen of a week before, a month before, two months before?

Avoiding setbacks isn’t easy. Sometimes I seemed lost in a game of Pin the Tail on the Donkey, trying to hit a target while blindfolded. I lurched around quite a bit, trying to find that sweet spot between doing too little exercise and doing too much. During one winter, I walked too far too fast; luckily my knees sent out warning signals to slow down. By contrast, that previous August and September I probably did too little, scared that my joints would quickly worsen as they did earlier in the summer.

This tendency to settle into one of two extremes—being too active or not active enough—constitutes its own kind of mind trap. I even came up with a shorthand for the people who get stuck in these two behaviors: the “Warrior” and the “Humpty Dumpty.”

During the early months of my struggle, I was definitely a Warrior. I didn’t want to accept the reality of my hurting knees. I persisted with my same level of activity. Gradually I made a few concessions, such as cycling more slowly uphill and tinkering with my pedal stroke, but I still rode hard.

After working out and showering, I would go straight to the freezer. The bags of ice had melted to the inverse shape of my knees. Twenty minutes of extreme cold numbed the joints, which felt good—at least until they warmed up again.

Even after swearing off cycling to give myself a chance to heal, sometimes I would revert to this Warrior behavior against my better judgment. I would throw up my hands and say to myself, “Why not work out? I have to do something. My knees can’t get any worse, right?” Of course they could and sometimes did.

You can find Warrior types without looking hard. Sometimes they’re wearing big, bulky knee braces that they put on quickly, from having had so much experience. They may look normal on the volleyball court or on the running track, but their lives are propped up with pills and ice. After exercising, they hurt. But they have courage and a commitment to an active lifestyle. They will be lowered into their graves wearing a defiant snarl.

The Warrior types believe in motion (good), but to an excessive, harmful degree. They remind me of a curious finding from an animal experiment where dogs had one leg encased in a cast for six weeks, then after that, ran heavily on a treadmill. They were killed, and then the immobilized joint was studied. The good news: the dogs’ cartilage responded to the demanding treadmill activity by cranking out more proteoglycans, making the tissue more elastic. The bad news: the cartilage was thinner.

By contrast to the Warrior, the Humpty Dumpty appears to be the very picture of caution and good sense. These types are acutely aware of the limits their bad knees place on them. They find it prudent to avoid anything that stresses their knees. Their problem: if they’re not careful they finally reach the point where they don’t do much of anything at all.

I went through a brief Humpty Dumpty phase. I took a lazy week-long vacation to rest my knees, hoping they would improve. No walking, no biking, just a lot of lying about. They did start to feel better. Then I returned to work and found myself in the same place as before, or perhaps worse. Knee cartilage softens when not used enough. Soft cartilage is more susceptible to tearing or fraying and doesn’t function as well.

It’s easy to imagine how a Humpty Dumpty is created. I had to look no further than my wife.

When she first had problems with her left knee, in her early twenties, I don’t think she was a Humpty Dumpty. She waited for it to get better and tried to live her life as before. But then, from time to time, something would send her spilling down one of those familiar knee-pain chutes.

A few years ago, for instance, she felt okay and ran a short distance to catch a bus. The next day a painful swelling stiffened the joint. Her response to that incident: she had acted rashly, she got burned, and she wouldn’t do that again.

Instead of trying to strengthen a bad knee enough to withstand a short dash, Humpty Dumpties retreat into a defensive crouch. They become fearful of re-injuring their knee. So they may baby it a little. They may also try not to use it as much. They become prone to falling into the debilitating spiral where less activity weakens the knee, causing it to hurt more, leading to less activity, and so on.

Humpty Dumpties buy into the bleak pessimism that bad knees never get better. Knees to them are like cars. They just wear out, as your car eventually does after being driven out of the showroom. Treating the joint better delays the breakdown, just as changing a car’s oil periodically and performing regular maintenance will prolong its life. Still, deterioration is seen as an inevitable, one-way process.

When I oriented my mind toward healing, I rejected this kind of thinking. I believed that my knees could get better and stronger, not out of some misplaced romantic notion, but because that made the most sense. Cartilage is living, biological tissue. In anyone’s knees, old cartilage is constantly stripped out and new is laid down. This process gets out of whack when the joint goes bad. But who says the imbalance can’t be corrected? I found that you can restore ailing knees to good health, though very, very slowly.

I’m hopeful that the next generation of physical therapists will realize this too. I’m hopeful that they will abandon their muscle-centric approach and focus first on fixing bad knee joints.

That will require a much more precise and smarter approach. For one, it will mean no longer sending patients out the door with recommendations to do ten of exercise A, twenty of exercise B, and to stop of course if you feel pain. That’s frightfully imprecise. Legions of knee pain sufferers deserve better.

If my vision comes to pass, smarter physical therapy will be the wave of the future. Programs will be “bespoke,” or highly tailored to the individual, like a custom-made suit that drapes smoothly over one’s frame. Therapists will become more scientific-minded, to better measure progress over the long arc of healing. They will collect exact measurements to establish baseline capabilities for bad joints, with the aim of improving those over time. They will update their measurements frequently, take more-detailed notes, ask more questions about the full range of a patient’s weight-bearing activities.

If all this comes true, physical therapy will solve many more cases of hard-to-treat knee pain and help patients avoid one unpleasant option: surgery.

14   The Road Not Taken: Surgery

In the fall of 1995, patients were recruited for an unusual medical trial.

The site: the 118-acre campus of the Veterans Affairs Medical Center in Houston, one of the country’s largest hospitals dedicated to caring for war veterans. The subjects: people aged seventy-five or younger who had at least moderate knee pain and osteoarthritis. The question: for sufferers of the disease, how useful was arthroscopic surgery?

Seven years later, the findings landed on the pages of the prestigious New England Journal of Medicine with the impact of a bombshell.

The arthroscopy is a big procedure in the world of knee pain. As the study’s authors noted in their report published on July 11, 2002, more than 650,000 of the operations were being performed in the United States yearly. At a cost of roughly $5,000 each, that totaled $3.25 billion dollars.

The procedure aims to clean up bad cartilage. The surgeon first makes several small, quarter-inch incisions in the knee. He inserts through one opening a pencil-shaped device that includes, at the tip, a tiny television camera and fiber-optic light. Through another hole he slides in a cutting instrument. In this manner, he accesses the inside of the joint without having to slice the knee wide open.

Commonly the surgeon performs both “debridement” and “lavage.” For debridement, irregular cartilage is shaved smooth. For lavage, the joint is flushed with a large amount of liquid to wash away cartilage fragments floating in the synovial fluid.

Subjects in the Houston study were randomly assigned to one of three groups. One-third had an arthroscopy performed that included both debridement and ten liters, or more than two and a half gallons, of lavage. One-third underwent the operation with only lavage. The last batch of patients became the placebo group.

When conducting drug trials, manufacturers whip up placebo pills that look like the genuine medication, but lack the active ingredient. Subjects don’t know which they are getting: the real pills or the fake ones. This allows researchers to establish a control group of placebo takers to measure results against. It’s not hard to create a dummy pill. But how do you convincingly fake surgery?

One way is to engage in a bit of artful deception. Placebo patients at the veterans medical center received a tranquilizer. Their knees were prepped and three small incisions made, as if they were having surgery. They heard the splash of saline solution, as if lavage were taking place. The surgeon even moved their joints exactly as he would in an arthroscopy. Afterwards, they received the same postoperative care.

That sufficed for the problem of how to do “pretend” surgeries. The actual operations, however, posed a different kind of issue. Namely, who would be selected to perform them? A surgeon who possessed poor skills could be blamed personally if the trial showed arthroscopic surgery in a bad light. So someone with strong qualifications was chosen. He had ten years of practice at an academic medical center. He also served as orthopedic surgeon for a professional basketball team.

After the operations, both real and simulated, researchers periodically checked in with the subjects. The monitoring checkpoints included after two weeks, six weeks, six months, and finally two years. What the study found, as reported in their article “A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee,” was shocking.

At no time did either of the two surgery groups report less pain or better functioning than the placebo group. In fact, at some points, the patients who had debridement (the most aggressive of the interventions) had more trouble walking and climbing stairs than those who had nothing done at all.

The implications were enormous. The U.S. health care system was running up a yearly multibillion-dollar tab for an operation that was useless much of the time.

In 2008, a Canadian study underscored that conclusion. Its findings: patients with knee osteoarthritis who had arthroscopic surgery fared no better than a group that didn’t. Still, some outside experts argued that the procedure remains useful for other knee problems, such as for tears in ligaments or in a disc-shaped cushion known as the meniscus.

The more I thought about it, the less surprised I was. Look at what needs fixing, and what surgery does about it. If you have soft, decaying cartilage, that’s tissue prone to ripping and flaking. You want it to be stiffer and stronger. Also you want the cartilage to be thicker wherever it has worn down. If either goal could be achieved through an arthroscopic procedure, that would be wonderful.

But neither can. If anything, what occurs post-surgery is the opposite of what you want. Soft cartilage grows softer during the post-operative period of less mobility and reduced load, when you’re hobbling about on crutches. As for the thickness, if a surgeon slices away some tissue, that doesn’t leave you with more, but less.

As for smoothing out the cartilage surface and flushing out floating bits from the synovial fluid, that seems good. However, if the remaining tissue is soft and vulnerable, it may simply start breaking up again, putting you right back where you started. What’s worse, you may emerge from surgery thinking that you’ve been “fixed.” That puts you at even greater risk of trying to do too much, too soon, and causing new damage.

Something else bothered me too. An arthroscopy isn’t a black-and-white process. The surgeon isn’t removing pieces of a foreign object, such as embedded glass that clearly doesn’t belong there; he’s making his best guess about where to shave a tissue that is vitally important for the proper functioning of knees. What if he makes a mistake and slices too deeply at a location? Or inadvertently creates a tear where there was none before?

My knee cartilage had molded itself to my body over decades of time and millions of footfalls. In its way, the tissue had retained the memory of steps I’ve taken, of the peculiarities of my sort of stiff-legged gait, of the way I bent my legs and jumped. Even though damaged, it was still dynamically changing and adapting. And I would be placing my faith in the ability of a surgeon to shave and shape it perfectly, in less than an hour, working in cramped quarters through a few small incisions.

For so many reasons, I decided not to pursue having an arthroscopy. The operation probably would have left me in no better shape physically, though worse off financially.

Of course my surgical options didn’t have to stop there. People with knee pain who are willing to surrender to the scalpel have plenty of choices to consider.

If your kneecap pulls to one side, wearing down the cartilage, you can have a “lateral release” to cut a certain fibrous tissue that supports the patella and that may be too tight. Or, if the synovial fluid is thin and diseased, you can have a thick synthetic replacement such as Synvisc injected. If you’re missing a big chunk of cartilage, you can have a microfracture at that location: the bare bone is pricked to prompt bleeding that regenerates the tissue. If your knees are really bad, the entire joint can be replaced with a plastic and metal implant.

On the cutting edge of science, cartilage is even being regrown outside the body and then implanted. This piqued my curiosity. Under one method, healthy cartilage is harvested from your joint, then sent to a laboratory to be cultured. The initial sample grows to about twelve million cells in a month. A surgeon then goes back into your knee and cleans out the damaged area. He sutures a flap of tough membrane from your shinbone over the hole. He then injects the new, sensitive cartilage under the protective patch.

This particular technique, called Carticel, is a means of “autologous chondrocyte implantation” (in other words, “autologous” means derived from your own tissue, and of course “chondrocytes” are the matrix-producing cells in cartilage). A division of Genzyme Corp. that holds the license for Carticel conducted a review of its effectiveness. Among 126 patients who underwent the treatment, average knee scores rose from 3.26 (in the “poor” to “fair” range) to 6.39 (a little better than “good”) over four years.

Those encouraging results demand a few words of caution. First, the study wasn’t independent; it was run by the very people who have a financial interest in seeing Carticel succeed. Also the technique is recommended only for cartilage defects at the end of the thighbone (not for damage under the kneecaps). And another big exclusion: Carticel isn’t advised for anyone with osteoarthritis.

The treatment also happens to be more expensive (about $35,000) and extensive than the minimally invasive arthroscopy. A surgeon must perform two operations, first to snip out some good cartilage to be cultured and then to implant the lab-grown tissue. The second procedure involves peeling the knee wide open. Even after the new cartilage is sewn into place, half of the subjects in the Genzyme-sponsored study had to return within four years for more surgery.

Not surprisingly, there’s a significant risk of side effects, most commonly the formation of excess tissue and scars throughout the joint. In one review of the treatment, one of five Swedish patients experienced various other problems. They included everything from superficial infection of the surgical wound to a condition known as frozen knee, where the joint resists bending normally.

Other companies are busy developing products to challenge Carticel. Regenerating knee cartilage is an exciting new frontier in biotechnology. The viability of this field, though, rests on a premise that I’m suspicious of: that cartilage can’t heal significantly on its own. The evidence suggests otherwise.

In an Australian study, researchers set out to examine how cartilage changes over time. Using an MRI, they found in their initial exams that the tissue had worn to the bone at five different sites among 84 subjects. Two years later, they re-examined the five sites. At four of them they found cartilage where there was none before—at one location, it even looked almost normal.

My skepticism about surgery only deepened after cruising online message boards where knee pain sufferers congregated to share tales of woe. Many of those who went under the knife sounded disillusioned. Some were pleased with the results, but at least as many were unhappy.

What’s more, surgery seemed to beget more surgery. The hardest-luck cases on the message boards posted with signature lines that included their various medical procedures. It was like looking at the list of war medals from decorated combat soldiers.

I can’t vouch for the character or truthfulness of anonymous people online. I also can’t offer an opinion that’s based on my personal experience when it comes to knee surgery. I never had an operation done. But I know someone who did.

“Jim” had a microfracture at the end of one of his leg bones to stimulate new cartilage growth. We bumped into each other in the Hong Kong community where I lived, shortly after the procedure. His spirits seemed high. He was like the new kid on the block when it came to conquering knee pain. He excitedly shared a tip with me: glucosamine. He had just begun taking the supplement and his doctor said it would regrow cartilage. I nodded, making no comment. Glucosamine had done nothing for me.

I silently sized Jim up. He was an ex-Marine with a muscular but definitely large build. He appeared to be carrying an extra twenty-five or thirty pounds. He was walking around normally, even though a microfracture creates only a weak form of cartilage that would still be soft.

Inside I winced. Jim was overweight, coming off a microfracture, and seemed to be going about his ordinary life. If he didn’t get into a smart physical therapy program, and hopefully lose a little weight, that brand-new cartilage could get chewed up in no time. And the thing is, because the tissue has no nerve endings, he might not even notice the damage for a while.

Over the following months, I cleaved to my boring walking routine and occasionally crossed paths with Jim. I enjoyed chatting with him: he was gregarious and passionate about understanding arcane corners of economics and history. He always seemed to be lifting an arm in greeting to a passerby. I could picture him late nights in the local bars, pontificating and tossing down beers.

After a while, Jim mentioned that he wasn’t happy with the microfracture and was still hurting. He started pondering other options. At one point he had a series of Synvisc injections to lubricate the joint better and help reduce his knee pain. Those didn’t seem to do much good either.

One day it surprised me to see how badly he was walking. The word “walk” may be a euphemism. He looked like a limping dog, dragging a useless broken limb behind.

We freely talked about knees at some length. I made a remark about the importance of motion. The next time we met, he said his knee was better. He was trying to move the joint more, instead of holding it still and protecting it. His walking looked slow, but more normal.

I congratulated him, while thinking that he still had a very arduous journey before him. His knee was in bad shape. He needed to be under the care of a very good physical therapist.

It’s hard to say what will happen to Jim. In the worst-case scenario, he could be looking at a total knee replacement before the age of fifty-five. Surgery may be the only answer if things get too bad.

Or, if he does everything right, he may avoid the scalpel. There’s always hope.

15   Final Thoughts

In this closing chapter, I’d like to reach out and speak more directly to you, the reader.

I hope you somehow benefited from my story. From the beginning, I wanted Saving My Knees to be the kind of book I failed to find on bookstore shelves while trying to escape the misery of chronic knee pain.

At the time, I wanted to read about someone like me who had to endure a hellish struggle, but who in the end won. But I wanted much more than that. The greater your adversary, the more you need to know to beat him. I wanted to read about the inner workings of cartilage, about what the latest scientific studies showed about how the tissue changed over time. And I wanted a book that was fairly clear-eyed and lucid, not cloaked in mysticism or based on some wonder herb I had never heard of.

As shown on these pages, I discovered that bad knees that are considered hopeless can be coaxed back to good health. My story isn’t one of exceptionalism either. I’m not that one-in-a-million guy who, through tremendous grit and luck and maybe a visit from the angels above, banished his knee pain. My joints didn’t miraculously strengthen; I applied myself diligently to a long, slow program that in the end had impressive results.

Make no mistake about it: healing injured knees is long and slow. That’s why I believe so strongly in getting on cartilage time. If you don’t, after a while, little setbacks will overwhelm you. What would happen if you tried to hard-boil an egg, but never gave the process enough time? What if you always removed the egg from the water after thirty seconds, one minute, or two minutes, then cracked the shell to find the insides all runny? You might conclude after wasting a hundred eggs it was flat-out impossible to hard-boil an egg.

While I hope readers find Saving My Knees an uplifting and edifying story, I realize there are skeptics who may still have doubts. The main criticisms, which I’ve heard before, deserve an airing. In the spirit of open and honest inquiry, I think that it’s best to address these reservations head-on—and that this is a good way to end.

Below are the imaginary critics speaking, in italics, followed by my responses.

Your story is good—as far as it goes. But as Tolstoy wrote, “happy families are all alike; every unhappy family is unhappy in its own way.” Similarly, unhappy knees differ greatly in their symptoms and what they best respond to. What works well for one may not work at all for another. So how much relevance does your story really have for some other knee pain patient?

First of all, I didn’t suffer from a rare disorder. Quite the contrary. Knees that ache and groan are common. Call the condition patellofemoral pain syndrome, chondromalacia, runner’s knee. Whatever the name, the tissue that badly needs attention and repair is often the same: cartilage.

My wife’s hurting knee, proclaimed “normal” by her doctors, made a familiar crackling noise. A surgeon who cuts into a knee with bone spurs, or abnormal looseness, frequently finds significant cartilage damage. Certainly knee joints are complex, and many things can go wrong with them apart from cartilage defects. Still, if the critical shock absorber that’s called on constantly to withstand loads doesn’t work well, a joint doesn’t stand much of a chance.

That means a lot of us knee pain sufferers face the same questions: Is it possible for damaged cartilage to get better? If so, how? Those are the big issues I grappled with.

The exact details of what I did to get better may not be relevant to others. I walked a lot to bathe my joints in gentle, high-repetition movement. That may not make sense for someone who struggles to walk, but who rides a stationary bicycle with ease.

But somewhere above the level of fine detail, larger lessons became clear. “Knee joints need motion” is one. This doesn’t immediately apply to a joint swollen to the size of a soccer ball, but to become healthy, knees ultimately need to move more, not less. “Listen to your knees” is another. That means so much more than “If it hurts, don’t do it.” If you wait until it hurts, chances are you’ve already screwed up.

You don’t have much good to say about the standard physical therapy program for bad knees that emphasizes building up leg muscles. So that just means it didn’t work for you. Meanwhile, why not acknowledge that it does work for eighty to ninety percent of patellofemoral pain syndrome patients.

If this were true—if the standard treatment worked for that many patients suffering from patellofemoral pain syndrome—it would be impressive for sure. (Experts do give rates in that range.) Such a level of success would help validate the “muscle-first” approach and suggest that the medical community has a good understanding of the condition and how to treat it.

That’s not the case, however. The medical community doesn’t understand patellofemoral pain syndrome well at all. Just listen to a few informed voices:

“Despite its prevalence, there is no clear consensus in the literature regarding terminology, the aetiology or treatment for [patellofemoral pain syndrome].” That’s from a July 2006 article in the New Zealand Journal of Physiotherapy. “It is a difficult syndrome to treat,” the Canadian Physiotherapy Association notes on a Web page. “Managing patellofemoral pain syndrome is a challenge,” observes the American Family Physician journal.

Granted, standard physical therapy does sometimes succeed, if not eighty to ninety percent of the time. If it’s a failed approach, why does it work at all?

The answer can be best appreciated, I think, by comparing the two main philosophies I’ve outlined in this book for treating bad knees.

A “muscle-first” approach represents standard physical therapy. When physical therapists design a program that focuses on exercises in repetitions of 20 or 30, not 1,000 or 2,000, they’re “muscle-first’ers.” As I’ve noted before, their favorite maxim is “Strengthen the quads.” A “joint-first” approach emphasizes strengthening the knee first and foremost, and the muscles later, as the joint becomes able to tolerate higher stresses.

(A quick aside: I’ve often wondered if the dominance of “muscle-first” thinking stems from a human bias to prefer solutions that draw on knowledge that we have the most confidence in, regardless of its direct relevance. Joints are somewhat mysterious and complex; it’s not immediately apparent how to improve the functioning of one. Comparatively speaking, muscles are simple and responsive. We know how to make them stronger. We know how to stretch them too.)

Now what happens when these different philosophies are applied to actual treatment of someone with hurting knees?

To begin with, a physical therapist in either camp will do some good by steering an athletic patient away from whatever activity prompts symptoms: running, playing basketball, tromping up the sides of mountains. The bad knee is being overworked. Lighten its daily load for relief. Modifying activity alone may account for a certain number of patients getting better.

So score that a win for either side.

Next comes a recommendation for some kind of exercise program. Here the two schools of thought diverge in a significant way. A “muscle-first” therapist may prescribe such low-repetition exercises as leg presses and wall slides, along with cycling. A “joint-first” advocate may agree on the cycling, a high-repetition activity, though not the others.

Now here’s the interesting thing: for patients whose knee joints aren’t too weak, either “joint-first” or “muscle-first” therapy may lead to similar rates of success. While doing twenty leg presses may not be joint friendly, if your knee is strong enough, it may not be joint unfriendly either. So standard physical therapy may work just fine for mild patellofemoral pain syndrome.

This leaves the more difficult, even chronic cases, where a weak knee joint becomes easily irritated or inflamed. This is where, in my experience, “muscle-first” treatment reveals its flaws and unravels. In fact, it can even be counter-productive and result in further damage, as happened to me.

A “muscle-first” program does sometimes work, but it can be very dangerous when it doesn’t. The patient pays a high price in pain and frustration.

Now for a final blast of powerful skepticism:

You are very optimistic that knee joints can get better, that cartilage can improve. But so often, knee pain turns into a life sentence of misery. People don’t escape it. So why aren’t there more good stories to be told? Why do so many people fail?

I think the reason is fairly complex.

Let me start with a baseball analogy.

Imagine a pinch hitter going into a baseball game in a do-or-die situation. It’s the last out of the last inning. His team trails by one run. He needs a hit to knock in the runners on second and third. He squares off against the opponent’s ace pitcher, then looks up at the scoreboard. His jaw drops. It shows he already has two strikes and he hasn’t even swung the bat. One more strike and he’s out, then it’s game over!

During my recovery, I realized how apt this analogy was for knee pain sufferers like me. It’s as if, like that pinch hitter, we’re on the verge of striking out because of circumstances beyond our control. Articular cartilage has no blood supply to aid in healing: strike one. It has no nerves to send signals when damage is being done: strike two.

A batter can still succeed when he’s in the hole, down two strikes. The key is, he needs to be smarter. He can’t just swing away with abandon. Victims of knee pain need to be smarter too. Specifically, they need to devise a long-term plan to get better.

That rarely happens though, I suspect. After they first experience pain symptoms, they often waste a lot of time, just as I did. They flounder around. They try different pills and exercises. Sometimes the bad knee feels better, lulling them into a false sense of security. Maybe they shrug on a backpack and join that Saturday afternoon hike, or jog a few miles with a friend. Their knee swells that day or aches the next. Over time, if they suffer enough setbacks, their knee grows much worse.

At this point a good plan becomes a necessity, not a luxury. Really bad knees don’t handle mistakes too well. They require a lot more patience and determination.

Unfortunately, by this time, these owners of painful knees have lost hope. Instead of a plan, they possess only a glum desire to forestall a total knee replacement for as long as possible. They cling to props that allow them to live as normal a lifestyle as possible. If their knee swells after they walk down the stairs, they don’t choose to live on the first floor until they can strengthen the joint enough to handle steps. Instead they pop a few Advil and try to ignore the pain.

Abuse a knee joint long enough, and it will change in ways that throw up further hurdles to getting better. Bone spurs form and inhibit a normal range of motion. The tibia broadens to help the overwhelmed cartilage support everyday loads, also restricting motion eventually.

Such structural changes can greatly reduce the likelihood of healing. In one Australian study, only a couple of subjects who had bone spurs also had fewer cartilage defects after two years. Seven times that number had more defects.

Then there are disease processes in the joint that wreak their own havoc. Doing the right thing for cartilage may not always be enough to arrest these harmful changes. Biochemically, what’s going on inside bad joints is complicated. Still, my own experience left me heartened on this point. The proper amount of exercise appears to have many benefits for knees well beyond what it does for the cartilage.

Finally, what I think is the biggest reason that bad knees often don’t improve: an epidemic of wrong thinking. Faced with cases of stubborn knee pain, many doctors opine, “Your bad knees will never get better.” That negative verdict firmly puts a ceiling in place. After that, experience not so surprisingly corroborates expectation.

I spent a long time pondering why so many orthopedic doctors snuff out hope, when there is a good, uplifting story to be told about the ability of cartilage to adapt and even thicken. Maybe they aren’t aware of the studies that I read, many published in the last five years. Maybe they’re trapped in a hammer-looking-for-a-nail mindset: they see patients as either candidates for surgery that they can help, or everyone else. Maybe, on some level, they’re influenced by billion-dollar drug companies that have a dog in the fight, in all that lucrative arthritis medication. Maybe they do think that patients can get better, but they lack confidence in how this occurs, and so keep silent, so as not to raise anyone’s hopes too much.

Or maybe they honestly do believe that bad knees don’t get better. I can understand why. Achieving real, lasting gains is hard. It’s not hard in the way that pushing a boulder to the top of a mountain is hard. It’s hard because of the patience required.

Still, when “hard” becomes a synonym for “impossible,” that’s a tragic error. In one year, I made great progress in healing my knees. Here’s a comparison:

When I started, I couldn’t stand comfortably in one spot for more than a few seconds without my knees burning. I usually had to sit with my legs extended and elevated. My walking was slow, and with each step, I was conscious of my bad knees. I tried to avoid bending them when picking up something. The way my knees felt would usually worsen, sometimes by a lot, over the course of each day.

When I finished, I could sit normally in a chair for hours without a problem. My walking was stronger and faster; I could hike five miles through hills without symptoms. My knees no longer weakened as the day went on. My leg muscles felt stronger, and more important than that, the joints themselves felt stronger.

Best of all, I got my life back.

That’s not hyperbole. I still recall the moment, during my recovery, when I spontaneously began to laugh at something. The sound from my mouth seemed strange, and I suddenly realized why. For months I had been thoroughly miserable and depressed. For months I hadn’t freely laughed at anything.

Now I look to the future with optimism.

As I write these closing words, in what should be my last revision to this book, it’s now more than two years after my experiment to save my knees began. I’m cycling every week again, as intensely as ever, and my knees feel good. No, I’ll risk jinxing myself by telling the truth: they feel great.

It all starts by getting your hope back. Hope drove me forward; it was the only miracle drug I ever found during my long ordeal. This wasn’t a cheap, thin hope either, like that of a lottery player that maybe, just maybe, he holds the winning ticket against fifty-million-to-one odds. It was a hope that rested on the most solid of foundations: knowledge and experience.

August 2010

Appendix: My Year of Recovery

My knee journal traced the long arc of my recovery and the many highs and lows. Some entries appear below, in all their prosaic glory, with annotations in italics. They are included to show, in more detail, exactly what I was doing—and how I was constantly being proactive, thinking about my next move.

May 4, 2008, Sunday (Day six after leaving Bloomberg; the journey is just beginning!)

1008.6, 29.8 (Air pressure, followed by temperature in Celsius. Tracking these numbers may seem crazy, but again, it reflects my scientific-minded approach. To know how my exercise program was working, I wanted to be able to adjust for any other effects that could influence my knee scores, such as changes in weather.)

Morning: 7 (Once again, the scores are on a 1-20 scale. A “3” signals a good deal of misery; a “7” indicates moderate discomfort; a “13” stands for some discomfort that’s pretty much manageable; “18” means fleeting and only mild discomfort; “20” is for a knee that feels basically normal.)

Evening: 12

Woke up with right knee feeling a bit sore and full (“Full” is generally code for some degree of swelling. One thing I learned early: Avoid anything that causes swelling because the joint is screaming that it can’t handle the stress. Any swelling, even mild, became one of my most-heeded “back off” signs. I would immediately reduce my exercise intensity, or even take a few easy days.) Maybe walking in Tung Chung yesterday after Friday’s long walking is to blame. Discouraging. (I constantly played medical Sherlock Holmes. Why am I having a bad morning? Well, what did I do yesterday? And the day before? In this case, a boat show outing with Cong the previous Friday racked up 9,552 steps (about four and three-quarter miles, though not all at once), which was followed by a day trip to Tung Chung on Saturday that involved more walking. Too much!)

End-of-day wrap: Good bounceback during day. Only one flat-stage walk, 3,415 steps, pretty short. (Reacting to the bad morning, I reduce my walking to one and three-quarter miles.)

May 25, 2008, Sunday (Now I’m four weeks into my recovery program.)

1007, 29.1

Morning: 11

Evening: 8  (This may seem confusing. Three weeks after the preceding entry, my morning score has improved, but my evening score has dropped! The lesson: don’t get too hung up on the numbers for each day. Healing bad knees is a long process. The scores really should be averaged over longer periods to be put in better perspective.)

Rain, sticky heat. Knees warm on waking (“warm” and “hot” usually implied various degrees of inflammation), but that sensation went away after 10, 15 minutes of sitting. Three walks: 2,061 steps, 2,070 steps, 1,272 steps. Some crampiness in evening in both knees. (I developed my own odd terminology to describe various knee states. “Crampiness” was a sensation I could quickly identify, though would be hard pressed to describe beyond saying it felt like the joint equivalent of muscle crampiness.)

Weekly plan and summary for week 5. (I started doing a “plan and summary” at week’s end to put more structure into my program. Where was I at that moment? What was good about my condition, what was bad, and what was I going to try the following week? It was important to guard against the sense of just drifting along; I wanted to be moving forward purposefully.)

Plan: Still haven’t achieved goal #1, to do three daily walks of 2,000 steps. (I was trying to build up to walking one mile, over flat, easy terrain, three times a day, without experiencing any symptoms—but I wasn’t strong enough yet.) The plan for week five: 1. Three daily walks of about 2,000 steps each. 2. Basic stretching every day: four quad stretches each leg, one hamstring stretch each leg. (Having healed now, I think stretching did nothing to help me. However, old habits die hard—my physical therapist believed in stretching—and so, early in my recovery, I made sure to cover all the bases. Gradually, as stretching’s ineffectiveness became clear, I phased it out.) 3. Crabwalks on Monday, Wednesday, Friday. (I don’t talk about “crabwalks” elsewhere because I think their contribution to my healing was minimal. However, they were one of the few low-repetition exercises that my knees tolerated pretty well. How to do one? Knot a rubber resistance band (such as a Thera-Band) in a loop. Pull the loop over your ankles. Then walk with slightly bent knees side to side like a crab, back and forth, pushing outward against the band with each step. This strengthens your quads and butt muscles.) Will continue with calf rises, 30 each morning. (These are simple calf exercises done by standing flat-footed, then rising onto tiptoes, then dropping back to the flat-footed position, then repeating. I began doing them because my calf muscle, for no apparent reason, began aching. One thing I discovered: when your body doesn’t feel good, lots of things can go wrong!)

Summary:

Good: Crunch got a little lower. (That is, my knees sounded less crunchy.) Able to sit for a few hours at a stretch in a normal chair. (This sounds trivial, but it represented a real victory! It meant that, for a little while, I could sit with my knees bent like a normal person’s, without pain or discomfort.) Knees felt better during the day in the apartment and while doing walkarounds. (“Walkarounds” was my shorthand for the periodic “dosed” motion I got walking around my apartment. Every fifteen minutes or so, my wind-up timer would ring, prompting me to get up and move around, taking about seventy steps each time.)

Bad: Got severe cramp in right calf one morning. Also bad that I’m not able to build up distance yet. Will be patient for another week at least.

June 28, 2008, Saturday (Two months have passed.)

1005.7, 28.4

Morning: 14

Evening: 14

Knees a touch warm and full when I woke up. Why? Can think of only three reasons: 1. Walked too fast yesterday. 2. Did almost 10,000 steps Thursday. 3. Cleaned yesterday, including a lot of standing, and briefly was kneeling on knees. Of the three, I think #3 is most likely. Bad sign last night: had some burning while standing and brushing teeth—been a while since I had that symptom. One other interesting possibility: have been wearing old sneakers a lot in past couple of days because of heavy rain. Been wearing them since Wednesday. It’s possible that my feet land differently and that stresses cartilage differently. Will switch back to running shoes today. (This entry is notable because I’m playing detective at full intensity here, trying to figure out why I woke up a bit off. The larger point: if you want to win back your knee health, you have to pay much more attention to the joints to figure out what they like and don’t like, and how fast they can be nudged along in an exercise program. You have to stop being a passive owner of your knees and take an active interest in their welfare, all the time.)

Cut back on walking: 2,558 steps at noon and 3,020 steps at 6 p.m. Trying to let knees bounce back. Knees felt raw in the morning, but came back in afternoon.

September 28, 2008, Sunday (Five months in! The problem is, summer has been uneven, with a number of setbacks, so I want to try something new . . . which fails, as can be seen by the dropoff in my scores over the course of the day.)

Morning: 16

Evening: 10

Sunny, warm. Air pressure about 1008. Walks of 2,100 and 2,640 steps. Ten minutes of cycling in morning. Knees a little stiff at night. (This signaled that my knees couldn’t tolerate cycling that well yet.)

November 20, 2008, Thursday (I’m closing in on the seven-month mark and am starting to do some vigorous walking, but challenges remain.)

Morning: 15

Evening: 14

Air pressure about 1023. Still dry, very cool. About 1,000 steps to plaza in morning, then 4,620 steps on monastery trail. (This was the up-and-down path that allowed me to do some climbing, though at this point, I’m mostly traversing the flat stretches of the trail.) Ended trail hike early because of right knee soreness. (Here I’m reacting in an early, pre-emptive way, and not for the first time. I could have continued the hike with a little soreness, but the next morning I would’ve suffered a little, pushing me backwards in my attempt to heal.) Knees bounced back over rest of the day though.

January 21, 2009, Wednesday (Almost nine months have passed and I’m definitely feeling better, but I have to guard against overconfidence.)

1016.9, 24.5

Morning: 18

Evening: 18

Warm, sunny. 10,218 steps on monastery trail. Some left kneecap tingling during hike; will monitor. (I was always alert to unusual sensations from my knees and tried to categorize each. Was the sensation benign? A harbinger of trouble lurking? A sign to take the intensity down a notch?)

February 1, 2009, Sunday (I’ve entered month ten of my recovery and this day stood out as a particularly good one. A rare 19!)

1020.2, 20.3

Morning: 18

Evening: 19

Cloudy, cool. 1020 air pressure. 7,881 steps on flat stage. Knees really good at night. (I began alternating walks on flat and hilly courses, so as not to push myself hard on consecutive days. Also, whenever I went more than four or five thousand steps, I sat down and rested for ten minutes at the midway point to let my knees recover a little. This is important though: my knees weren’t hurting and telling me to take a break; I began doing this simply because it made sense to me.)

March 9, 2009, Saturday (By now, month eleven, the nice thing is that there are many positive things showing up in my journal—many reasons to celebrate.)

1016.9, 18.8

Morning: 17

Evening: 18

Cool, overcast. 10,145 steps on monastery trail, with a little walk around Discovery Bay mixed in. Note: knees very good on trail going up and down, no twinges at all for first time ever. Also knees generally very, very good over the last three days—good sitting, walking. Is it cool weather or? (Again, I’m considering what other factors may be influencing how I feel.)

April 5, 2008, Sunday (I’m in month twelve, generally feeling strong enough to try things—such as riding my bike again.)

1014.6, 26.5

Morning: 18

Evening: 17

Sunny, warm. 30 minutes cycling, 6,609 steps on flat stage. (Because of the cycling, I cut back on my walking this day. Getting back on my Litespeed felt good! I still didn’t feel ready to ride regularly. On June 1, after returning to the United States, I began going out on the bike every couple of days. I did only forty minutes at first, spinning the pedals a lot, pushing them fast but not too hard. Rehabbing bad knees is all about patience!)

Select Bibliography

In writing this book, I consulted a wide variety of sources, from blogs to textbooks to leading medical journals. Instead of cluttering the main text with footnotes, or even notations for endnotes, I decided to include a select bibliography at the end. For readers wishing to delve more deeply into the subjects discussed on the preceding pages, below are some of my sources.

Aaron, Roy K. and Ciombor, Deborah M. “Pain in Osteoarthritis.” Medicine and Health Rhode Island, July 2004.

Arokoski, Jari P.A., et al. “Normal and Pathological Adaptations of Articular Cartilage to Joint Loading.” Scandinavian Journal of Medicine and Science in Sports, August 2000.

Beckett, James R.J., et al. “Effects of Static Stretching on Repeated Sprint and Change of Direction Performance.” Medicine and Science in Sports and Exercise, February 2009.

Biggee, B.A., et al. “Low Levels of Human Serum Glucosamine after Ingestion of Glucosamine Sulphate Relative to Capability for Peripheral Effectiveness.” Annals of the Rheumatic Diseases, February 2006.

Bohndorf, Klaus, et al. Musculoskeletal Imaging: A Concise Multimodality Approach. New York: Thieme, 2001.

Bray, George A. and Bouchard, Claude. Handbook of Obesity: Etiology and Pathophysiology. London: Informa Healthcare, 2003.

Callaghan, John J., et al. The Adult Knee. Philadelphia: Lippincott Williams & Wilkins, 2002.

Chard, Jiri and Dieppe, Paul. “Glucosamine for Osteoarthritis: Magic, Hype, or Confusion?” BMJ, June 16, 2001.

Cicuttini, Flavia, et al. “Association of Cartilage Defects with Loss of Knee Cartilage in Healthy, Middle-Age Adults: A Prospective Study.” Arthritis and Rheumatism, July 2005.

———, et al. “Compartment Differences in Knee Cartilage Volume in Healthy Adults.” The Journal of Rheumatology, March 2002.

Clegg, Daniel O., et al. “Glucosamine, Chondroitin Sulfate, and the Two in Combination for Painful Knee Osteoarthritis.” The New England Journal of Medicine, February 23, 2006.

Cooper, Grant. The Arthritis Handbook: Improve Your Health and Manage the Pain of Osteoarthritis. New York: DiaMedica, 2008.

Ding, Changhai, et al. “A Longitudinal Study of the Effect of Sex and Age on Rate of Change in Knee Cartilage Volume in Adults.” Rheumatology, February 2007.

———, et al. “Natural History of Knee Cartilage Defects and Factors Affecting Change.” Archives of Internal Medicine, March 27, 2006.

Dixit, Sameer, et al. “Management of Patellofemoral Pain Syndrome.” American Family Physician, January 15, 2007.

Dutton, Mark. Orthopaedic Examination, Evaluation, and Intervention. New York: McGraw-Hill Medical, 2004.

Felson, David T., et al. “Effect of Recreational Physical Activities on the Development of Knee Osteoarthritis in Older Adults of Different Weights: The Framingham Study.” Arthritis Care and Research, February 15, 2007.

Fulkerson, John Pryor. Disorders of the Patellofemoral Joint. Philadelphia: Lippincott Williams & Wilkins, 2004.

Haapala, J., et al. “Incomplete Restoration of Immobilization Induced Softening of Young Beagle Knee Articular Cartilage after 50-Week Remobilization.” International Journal of Sports Medicine, January 2000.

Heintjes, Edith M., et al. “Exercise Therapy for Patellofemoral Pain Syndrome.” Cochrane Database of Systematic Reviews, 2003, Issue 4.

Herbert, R.D. and de Noronha, M. “Stretching to Prevent or Reduce Muscle Soreness After Exercise.” Cochrane Database of Systematic Reviews, 2007, Issue 4.

Imboden, John B., et al. Current Rheumatology: Diagnosis and Treatment. New York: McGraw-Hill Professional, 2006.

Ingraham, Paul. “Quite a Stretch.” http://saveyourself.ca/articles/stretching.php, last modified October 5, 2010.

Johnson, Donald H. and Pedowitz, Robert A., eds. Practical Orthopaedic Sports Medicine and Arthroscopy. Philadelphia: Lippincott Williams & Wilkins, 2006.

Jones, G., et al. “Early Radiographic Osteoarthritis Is Associated with Substantial Changes in Cartilage Volume and Tibial Bone Surface Area in Both Males and Females.” Osteoarthritis and Cartilage, February 2004.

———, et al. “Sex and Site Differences in Cartilage Development: A Possible Explanation for Variations in Knee Osteoarthritis in Later Life.” Arthritis and Rheumatism, November 2000.

Kirkley, Alexandra, et al. “A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.” The New England Journal of Medicine, September 11, 2008.

Kiviranta, Ilkka, et al. “Moderate Running Exercise Augments Glycosaminoglycans and Thickness of Articular Cartilage in the Knee Joint of Young Beagle Dogs.” Journal of Orthopaedic Research, March 1988.

Klapper, Robert and Huey, Lynda. Heal Your Knees. New York: M. Evans and Company, 2004.

MacIntyre, N.J., et al. “Patellofemoral Joint Kinematics in Individuals With and Without Patellofemoral Pain Syndrome.” The Journal of Bone and Joint Surgery, December 2006.

Manske, Robert C. Postsurgical Orthopedic Sports Rehabilitation: Knee and Shoulder. Philadelphia: Mosby, 2006.

Martin, James A., et al. “Post-Traumatic Osteoarthritis: The Role of Accelerated Chondrocyte Senescence.” Biorheology, 2004.

McKeon, Brian P., ed. Knee Arthroscopy. New York: Springer Publishing, 2009.

Miyaguchi, Masatsugu, “Biochemical Change in Joint Fluid After Isometric Quadriceps Exercise for Patients with Osteoarthritis of the Knee.” Osteoarthritis and Cartilage, July 2003.

Moseley, J. Bruce, et al. “A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.” The New England Journal of Medicine, July 11, 2002.

Overington, Mark, et al. “A Critical Appraisal and Literature Critique on the Effect of Patellar Taping: Is Patellar Taping Effective in the Treatment of Patellofemoral Pain Syndrome?” New Zealand Journal of Physiotherapy, July 2006.

Palmoski, Marshall J. and Brandt, Kenneth D. “Running Inhibits the Reversal of Atrophic Changes in Canine Knee Cartilage after Removal of a Leg Cast.” Arthritis and Rheumatism, November 1981.

Puliti, Beth. “No More Knee Pain.” Advance for Physical Therapists and PT Assistants, December 15, 2008.

Roos, Ewa M. and Dahlberg, Leif. “Positive Effects of Moderate Exercise on Glycosaminoglycan Content in Knee Cartilage.” Arthritis and Rheumatism, November 2005.

Rozendaal, R.M., et al. “Effect of Glucosamine Sulfate on Hip Osteoarthritis: a Randomized Trial.” Annals of Internal Medicine, February 19, 2008.

Salter, Robert B., et al. “The Biological Effect of Continuous Passive Motion on the Healing of Full-Thickness Defects in Articular Cartilage. An Experimental Investigation in the Rabbit.” The Journal of Bone and Joint Surgery, December 1980.

———. Textbook of Disorders and Injuries of the Musculoskeletal System. Philadelphia: Lippincott Williams & Wilkins, 1999.

Sawitzke, Allen D. “The Effect of Glucosamine and/or Chondroitin Sulfate on the Progression of Knee Osteoarthritis: A Report from the Glucosamine/Chondroitin Arthritis Intervention Trial.” Arthritis and Rheumatism, October 2008.

Skinner, Harry B. Current Diagnosis and Treatment in Orthopedics. Norwalk, Conn.: Appleton & Lange, 1995.

Silbert, Jeremiah. “Dietary Glucosamine under Question.” Glycobiology, June 2009.

Theodosakis, Jason and Buff, Sheila. The Arthritis Cure: The Medical Miracle That Can Halt, Reverse, and May Even Cure Osteoarthritis. New York: St. Martin’s Press, 2004.

Towheed, Tanveer E. “Current Status of Glucosamine Therapy in Osteoarthritis.” Arthritis and Rheumatism, August 15, 2003.

Vanwanseele, B., et al. “Knee Cartilage of Spinal Cord-Injured Patients Displays Progressive Thinning in the Absence of Normal Joint Loading and Movement.” Arthritis and Rheumatism, August 2002.

———, et al. “Longitudinal Analysis of Cartilage Atrophy in the Knees of Patients with Spinal Cord Injury.” Arthritis and Rheumatism, December 2003.

Vigorita, Vincent J. Orthopaedic Pathology. Philadelphia: Lippincott Williams & Wilkins, 2007.

Wang, Y., et al. “Factors Affecting Progression of Knee Cartilage Defects in Normal Subjects over Two Years.” Rheumatology, January 2006.

Weinstein, Stuart L. and Buckwalter, Joseph A., eds. Turek’s Orthopaedics: Principles and Their Application. Philadelphia: Lippincott Williams & Wilkins, 2005.

Wnek, Gary E. and Bowlin, Gary L., eds. Encyclopedia of Biomaterials and Biomedical Engineering. London: Informa Healthcare, 2008.

Table of Contents

Foreword

Introduction

1 ... An Active Lifestyle

2 ... Prelude to a Fall

3 ... The First Ring of Hell

4 ... Doctors

5 ... Physical Therapists

6 ... The Puzzle

7 ... Inside Knee Cartilage

8 ... The Experiment

9 ... Trying to Heal

10 ... A Rocky Start

11 ... Recovering

12 ... My Four Golden Rules for Bad Knees

13 ... An Orientation Toward Healing

14 ... The Road Not Taken: Surgery

15 ... Final Thoughts

Appendix: My Year of Recovery

Select Bibliography