Terrance Heath

The Pain Update

Filed By Terrance Heath | August 07, 2011 1:30 PM | comments

Filed in: Living
Tags: chondrolamacia patella, knee injury, pain

I was walking around the office yesterday when one of my coworkers asked me why she’d seen me walking the halls so often. I told her why, and then it occurred to me that I hadn’t told that story here.

I’ve been remiss. I received so many supportive comments when I posted about my chronic knee pain and my frustration with it. I thought I should post some kind of update.

Be kind to your knees. You'll miss them when they're gone.

- Mary Schmich

I used to wonder what the phrase above -- from Chicago Tribune columnist Mary Schmich's now famous column meant. I no longer have to wonder.

The knees were not the first to go, in my case. It was the eyes. But the knees now appear to be on their way out. And they are not going quietly.

Actually, it started a while back. Far enough, in fact, that I can't pinpoint when it started. For a while, the various methods I turned to to treat it worked pretty well. If I took an over-the-counter pain reliever, and wore a knee brace or a less obtrusive band below the kneecaps, it subsided somewhat.

By "it" I mean pain; burning, searing pain around and behind my left and right kneecaps. In my case, it starts when I'm sitting down, especially if I've been sitting down for an extended period. Standing up usually relieves it. Putting my feet up also works. But now the various methods I've tried have stopped working. Even standing up doesn't offer as much relief as it used to. Once the pain starts, it's there for the duration of the day.

That was in April. Three months later, I can definitely say that things have gotten better. Things have changed. I’ve had to make some changes, but all in all things have gotten better. The news is good.

First, like I said before, the diagnosis was exactly what my own research suggested: chondrolamacia patella.

Chondromalacia patellae (also known as CMP) is a term that goes back eighty years. It originally meant "soft cartilage under the knee cap," a presumed cause of pain at the front of the knee. This condition often affects young, otherwise healthy athletes.

Chondromalacia is due to an irritation of the undersurface of the kneecap. The undersurface of the kneecap, or patella, is covered with a layer of smooth cartilage. This cartilage normally glides effortlessly across the knee during bending of the joint. However, in some individuals, the kneecap tends to rub against one side of the knee joint, and the cartilage surface become irritated, and knee pain is the result.

The term "chondromalacia" sometimes is used to describe abnormal-appearing cartilage anywhere in the body. For example, a radiologist might note chondromalacia on an MRI of an ankle.

Pain at the front of the knee is common in young adults, especially soccer players, gymnasts, cyclists, rowers, tennis players, ballet dancers, horseback riders, volleyball players, and runners. The pain of chondromalacia patellae is typically felt after prolonged sitting, like for a movie, and so is also called "movie sign" or "theater sign". Snowboarders and skateboarders are prone to this injury, particularly those specializing in jumps where the knees are under great stress. Skateboarders most commonly receive this injury in their non-dominant foot due to the constant kicking and twisting that is required of it during skateboarding

I’d already been to my orthopedist when I published that first post, had scheduled another appointment to talk to him about pain relievers, because I was starting to think that I’d lose it. At that point, I was even willing to consider opioids, despite my concerns about recovery. I was that desperate, and already starting hear myself say things like “I can’t live like this.”

It was beginning to dawn on me that I was one of 100 million Americans who have chronic pain.

More than 100 million Americans suffer from chronic pain at a cost of around $600 billion a year in medical treatments and lost productivity, according to a report from the Institute of Medicine (IOM).

An IOM committee commissioned by Congress concluded that pain is not optimally managed in the U.S. and that effective treatment of chronic pain will require a coordinated national effort to transform how the public, policy makers, and health care providers view the condition.

The report included recommendations for achieving what the committee referred to as a “cultural transformation” in how Americans understand and approach pain management and prevention.

“We see that for many patients chronic pain becomes a disease in its own right,” committee chair Phillip Pizzo, MD, of Stanford University School of Medicine, said at a Wednesday news briefing. “We need to address this in a more comprehensive and interdisciplinary way and include prevention as a very important goal.”

The shortage of pain specialists in the U.S. and a poor understanding of pain by general practitioners remains a major barrier to effective pain management, Pizzo said.

What hadn’t dawned on me was that I was starting to experience the depression that goes along with chronic pain. I didn’t have it as bad as others. Depression related to chronic pain can lead some to consider suicide. That wasn’t the case for me, but I was beginning to wonder how I was going manage to live with the pain.

Austin Box
Living with the pain has its perils, too, including accidental death. Twenty-two year old Oklahoma linebacker Austin Box died this May, after being found unresponsive and rushed to the hospital. A toxicology report revealed that pain killers killed Box, who had suffered multiple injuries, including some that required surgery on his elbow and back. The report noted that five were in Box’s system when he died — oxymorphone, morphine, hydrocodone, hydromorphone and alprazolam — and ruled his was an accidental death, caused by “pulmonary edema and aspiration pneumonia.”

Derek BoogaardSuicide wasn’t a factor in the death of New York Rangers “enforcer” Derek Boogaard either. But chronic pain was. Boogaard, 28, was found dead in his Minneapolis apartment. The toxicology report of Boogaard’s death revealed that he died from a mix of oxycodone and alcohol. Boogaard struggled with addiction and chronic pain as a result of hockey-related injuries.

At first glance I — a 5ft. 7in., 150 lb., nonathletic 42-year-old — don’t have much in common with a 6ft. 7in., 258 lb., 28-year-old hockey player, or a 6ft. 1in., 228 lb., 22-year-old football player. Except pain, that is. And while theirs came from injuries sustained in their athletic careers, and mine came from prolonged sitting in the course of my own blogging career (thus, perhaps, making it all due to occupational hazards), pain is pain is pain.

And pain is often invisible. Box’s parents didn’t know how much pain he was in, and they had seen their son with days of his death. No one seemed to know the extend of Boogaard’s pain either. And until I started talking it, no one in my family or my office knew what kind of pain I was in every day.

That is, until I started talking about it. Talk led to action. If I wasn’t going to just go on living with a high level of pain on an almost daily basis, then I was going to have to find out what to do about it.

My next visit to my orthopedist was initially frustrating. I was pretty aggressive in asking about surgery, and pushing for stronger pain relievers. My orthopedist dissuaded on both fronts.

He was reluctant to do surgery. My husband, a doctor, later told me that an orthopedist is really an orthopedic surgeon. And if a surgeon doesn’t recommend surgery — thus turning down a chance to perform surgery — then maybe surgery wasn’t warranted. I was frustrated at first, but then my own research revealed two studies which showed arthroscopic surgery doesn’t work for knee pain and is no better than medical and physical therapy.

My general care doc had suggested to me earlier that opioid pain relievers were ineffective in treating joint pain. My orthopedist thought they might even make the pain worse. He turned out to be right about that too.

Opiate-induced hyperalgesia is what doctors call a “paradoxical phenomenon," a drug having the reverse effect than intended. After decades of heroin abuse topped off by a medical course of OxyContin and other prescription opiates for pain, the accumulated damage caused certain receptors in Shawn's central nervous system leading to certain pathways in his brain to hit critical mass. His pain wiring went haywire.

The condition is actually not uncommon (albeit blessedly temporary) in non-addicts even on short-term high-dose prescription opiates. "Any individual can develop hyperalgesia after 30 days and maybe 75 to 100 morphine units a day," says Dr. Michael Hooten, director of the Pain Rehabilitation Center at Mayo Clinic. But for addicts, the condition tends to be not only more prevalent but more acute, complex and long-lasting. According to Hooten, 20 to 30 percent of the general population struggles with chronic pain, but among addicts the proportion is 45 percent or more.

Hyperalgesia typically has a gradual onset, with pain increasing incrementally. The all-too-frequent response is for doctor and patient to assume the painkiller is losing its effect because of the swift development of tolerance and therefore to increase the dose. But as more narcotic floods the nervous system and brain, the hyperalgesia intensifies. The remedy has become the enemy. For that reason, all addicts on prescription opiates--and their doctors--should be vigilant from the start that hyperalgesia is as much of a risk as addiction.

So, my orthopedist sent me back to physical therapy, and gave me steroid injections in both knees to relieve the pain long enough for physical therapy to work.

It turned out he was right again. Physical therapy turned out to be the best thing for me. I had a wonderful physical therapist. He was always pleasant to work with, and really seemed to know what he was doing. After assessing me, he told me I was luckier than I thought. I didn’t suffer any lack of mobility, for starters. Plus, I had not issues with the tracking or alignment of my kneecap. The culprit was muscle strength, or lack thereof, that led to my kneecap being poorly supported, and thus causing pressure that ultimately damaged the cartilage under my kneecap.

After eight weeks of physical therapy, I was stronger, and in a lot less pain. There were other things that contributed. I made some changes at home and at work. As my orthopedist recommended, I placed footstools under my desks at home and at work, so that I could sit with out having my knees bent. I stand up during my commute to and from work, now. If I sit, I’m careful to sit with my legs extended, rather than with my knees bent. At home, I either sit with feet up or my legs extended.

I also have a program on my computer at work, that reminds me to take a 10 minute break every hour. I use that break to walk around my office, usually reading something on my Kindle. And I’ve gotten into a routine of using non-steroidal anti-inflammatory drugs (NSAIDs) to help manage the pain, taking care adhere to the recommended period of time between doses. I’ve even experimented with binaural beats to relieve chronic pain, via a few iPhone apps. I don’t know how much it helps, but it doesn’t hurt, and I think it even relaxes me a bit more.

The result is the good news that I mentioned earlier. The pain that was daily about a 7 or 8, on a scale of 1 to 10, now rarely gets above a 2 or 3. On days when I’m particularly active and spend very little time sitting, it gets down to a 2 or 1.

At this point, I’m starting to realize that I may never be pain free again — at least not in my knees — but I have far less pain than before, at manageable level that doesn’t disrupt my life

That’s a very good thing.

(Cross-posted at The Republic of T)

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Jay Kallio | August 8, 2011 3:35 AM

Really happy to hear your update! Chronic pain is often life changing, so it's awesome that you have found some ways to minimize your knee pain. You are not alone living with pain, I'm sure you know you have plenty of good company there. Thanks for getting back to us with your good news!