Category Archives: Knee Pain

A MedPage Today article indicates that chronic stress may precipitate or aggravate arthritis. Even childhood stress. The link is not as strong for rheumatoid arthritis as it is for more common types of arthritis. Most for the reviewed studies “categorized stress as stemming from adverse life events … or adverse childhood experiences …. Most studies … suggested a relationship between exposure to chronic stressors and arthritis development.”

Would stress reduction improve the quality of life of arthritis patients? The study at hand doesn’t address that but I’d wager that it would.

Steve Parker, M.D.

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Photo credit: Steven Paul Parker II

Dr Ken Berry published at YouTube a 4-minute video on a diet he believes will lessen the effects and incidence of knee osteoarthritis. For men, the lifetime risk of developing knee osteoarthritis is 40%. For women, 47%. The effects of arthritis are pain and impaired functional status. The title of the video even mentions reversing arthritis. I suppose improved pain and functional ability would be at least a partial reversal.

In short, Dr Berry suggests a diet free of all sugar (no mention of fruits), all grains, and all vegetable oils.

Dr Berry refers to a study done at University of Alabama at Birmingham.  The research was published in Pain Medicine.

Dr Berry also referred to a study of cadavers that found a doubling of knee osteoarthritis from around 1850 to 2000. The researchers don’t think aging and obesity are related to the increase. Maybe diet has some thing to do with it.

How was the UAB study done?

The twenty-one study participants were folks with knee osteoarthritis between 65 and 75-years-old. Nine men, 12 women. Average baseline weight was 194 lb (88 kg). The 21 participants were randomly assigned to one of three diets they would follow for 12 weeks:

1. L0w-carb diet group (8 participants). Restricted daily total carbohydrates (not net carbs) to 20 grams or less for the first three weeks. Then could go up to 40 grams “if required” (not explained). No fat or protein or calorie restriction. Limited amount of vegetables were OK (e.g., 2 cups/day of leafy greens, 1 cup of non-starchy vegetables). Carb-free sweeteners (stevia, sucralose) were allowed but maltodextrin-containing sweeteners were limited (stevia, sucralose, aspartame, saccharin). This group had no drop-outs.
2. Low-fat diet group (6 participants). 800–1,200 calories/day. It looks like the men were put on reduced calorie diets—500 cals under estimated baseline or maintenance calories. Women’s calories were reduced by 250-300/day from baseline. Calories were reduced mainly through reduction of fats. They ate veggies, fruit, low-fat foods, whole grains, low-fat dairy, and limited cholesterol and saturated fats. Macronutrient distribution: 60% of calories from carb, 20% from protein, 20% from fat. (Yet Table 1 indicates 50–67 g of fat/day. Twenty percent of 1,200 of calories is only 27 g of fat. So misprint in table 1?) This group had one drop-out.
3. Control group (N=7), eating as per their usual routine although given documents on portion control. Two drop-outs.

The authors indicate that groups 1 and 2 ate about 100 g of protein/day.

All participants filled out surveys documenting knee pain levels and were put through periodic supervised tests like a timed walk and repeatedly arising from a chair with their hands placed on opposite shoulders.

Results

The low-carb diet group is the only one that demonstrated decreased pain intensity and unpleasantness in some functional pain tasks. In other words, improved quality of life.

The low-carb group lost an average of 20 lb (9 kg) compared to the low-fat weight loss of 14 lb (6.5 kg), not a statistically significant difference. Even the control group lost 4 lb (1.8 kg).

A blood test—thiobarbituric acid reactive substances or TBARS—indicated reduced oxidative stress in the low-carb dieters.

The authors hypothesize that the improvement in arthritis pain in the low-carb group was related to the reduction in oxidative stress, which reduces pain and inflammation.

Will these old knees make it up Humprheys Peak one more time?

Implications

With so few participants, you know this was a pilot study that ultimately may not be entirely valid or replicable. But it’s promising. Next, we need a study with 150 participants.

Dr Berry is getting a bit ahead the the science here. He gives a powerful personal testimony in his video. And perhaps he’s seen many of his patients improve their arthritis with a very low-carb diet.

The carb consumption of the low-carb dieters would be ketogenic in most folks. Yet I didn’t even see “ketogenic” in their report. Perhaps because they didn’t measure ketone levels?

The authors of the report mention other studies finding improvement of osteoarthritis  pain and inflammation by the Mediterranean diet. The Mediterranean diet even helps rheumatoid arthritis.

How about combining a very low-carb and Mediterranean diet? As in my Ketogenic Mediterranean Diet. If you have the funds to run the study, I can probably get you a nice discount on books. Have your people contact my people.

Given the safety of very low-carb diets, I can’t argue against a 12-week trial if you have bothersome knee osteoarthritis. Get your doctor’s clearance first.

Steve Parker, M.D.

References:

Strath LJ, et al. The effect of low-carbohydrate and low-fat diets in individuals with knee osteoarthritis. Pain Medicine, 21(1), 2020, pp 150-160.

Oliviero, F, et al. How the Mediterranean diet and some of its components modulate inflammatory pathways in arthritis. Swiss Med Wkly, 2015; 145; w14190.

Veronese, N, et al. Adherence to the Mediterranean diet is associated with better quality of life: Data from the Osteoarthritis Initiative. American Journal of Clinical Nutrition 2016: 104(5): 1403-9.

McKellar, G. et al. A pilot study of a Mediterranean-like diet intervention in female patients with rheumatoid arthritis living in areas of social deprivation in Glasgow. Ann Rheum Dis 2007;66(9):1239-43.

Slöldstam, LB, et al. Weight reduction is not a major reason for improvement in rheumatoid arthritis from lacto-vegetarian, vegan or Mediterranean diets. Nutr J 2005;4(15).

Paul Ingraham cured my PFPS. He’s not a physician or physical therapist. But he’s a smart guy, writer, and former massage therapist. I don’t care about your credentials as long as you can help me with your intelligence, integrity, and the scientific method.  Click for his article on patello-femoral pain syndrome if interested. I paid about $20 USD for the full article, and it was well worth it. Full disclosure: I don’t know Paul and earn no commission or other compensation for this endorsement.

Photo credit: Steven Paul Parker II

The key to my cure was probably radical rest, or what Paul calls profound rest.

If you have PFPS, I hope you find something useful here.

Regular readers here know I’m a huge proponent of exercise. Unfortunately, exercise can be risky. You can injure yourself. I did that a few years ago when I was getting in shape to climb Humphreys Peak. I accelerated my training program too rapidly and developed patell0-femoral pain syndrome (PFPS).

This is how my right knee felt in 2017:

I’ve developed over the last month some bothersome pain in my right knee. It’s not interfered much with my actual hiking, but I pay for it over the subsequent day or two. I’m starting to think this may put the kibosh on my Humphries Peak trek next month.

The pain is mostly anterior (front part of the knee) and is most noticeable after I’ve been sitting for a while with the bent knee, then get up to walk. The pain improves greatly after walking for a minute or less. It also hurts a bit when I step up on something using my right leg. If I sit with my knee straight (in full extension), it doesn’t hurt when I get up. The joint is neither unusually warm nor swollen. Ibuprofen doesn’t seem to help it.

That episode resolved after I stopped hiking for 3–4 months. But in 2018 I had recurrence of similar pains in my left knee, with no clear precipitant this time. I continued my usual weight-training program and expected another spontaneous resolution. Six months passed…no improvement. That’s when I found Paul Ingraham’s article.

By the way, I’m the one who diagnosed my PFPS. It’s been said that a doctor who diagnoses and treats himself has a fool for a patient. He can’t be adequately objective.

Alternative diagnoses would include patello-femoral osteoarthritis and degenerative meniscus, due to my age (over 60). Diagnosis of the osteoarthritis could be facilitated by knee X-rays: weight-bearing posterior-anterior imaging, weight-bearing lateral view, and sunrise view.

This was my treatment plan for PFPS in early Feb 2019, based on Paul Ingraham’s recommendations. Paul explains how to do various specific exercises below in his article.

1. Avoid all activities that stress the patella-femoral joint or aggravate pain for at least two weeks, if not longer (2–3 months). Paul calls it “profound rest.” I started this Feb 17. No knee-loading exercise (e.g., leg presses, any kind of squat, deep knee bends) until pain is truly in remission from rest. I quit my usual squats, Bulgarian split-squats, and single-leg Romanian deadlifts.
2. Consider Motrin (ibuprofen) 400-600 mg three times daily for two weeks (I did 600 mg 3x/day) but usually no help
3. Consider cold-packs (10–20 mins) when it flares up but usually no help. (I never did this because I couldn’t find my WalMart cold-pack.)
4. Find a substitute for the squats? E.g., stationary bike? No bike for now: too much stress on patello-femoral joint at this time
5. Paul’s not big on stretching (quadriceps and hamstring stretches routinely recommended by others). I didn’t stretch.
6. While recovering, keep leg straight most of the time, even when sitting. Sit less. (I didn’t sit less but did make a huge effort to keep my  affected led fully extended, or at least not bent more that 20 degrees at any time. This necessitated sitting on the edge of my seat at work, and/or lowering the height of the seat. At home relaxing, I’d keep my leg fully extended. I think this was extremely important for my healing. I considered getting a standing desk for home or work but didn’t.)
7. Start with exercises that keep knees straight. Exercise both lower extremities. As condition improves, can start to add other exercises, very slowly, that allow bent knees. Single-leg RDLs may be a good start (started in Sept 2019). Restart squats, deep knee bends, and leg presses (cycling?) only very late into recovery. Rehab must progress VERY SLOWLY. If an exercise causes more knee pain, back off and work the hips first. Exercise 2–3 times/week. Walking on the flat in moderation is usually OK. Strengthening hip abductors may be helpful.
8. Hamstring curls via machine or therabands. Curl to 60 degrees, not 120. (I curled to 90 degrees using therabands).
9. Quadricep setting. (I didn’t do this. Straight-leg raises on your back seem to be similar, which I did.)
10. Straight-leg raises, on back and side-lying. (Done: 3 sets of 10 reps each side.)
11. Clam shells. (Done: 3 sets of 10 reps each side.)
12. Knee lifts? (don’t know what that is; not done).
13. Consider the following although not from Paul: Hip abductor strengthening: “monster walks” (lateral steps with elastic band around (just proximal to) knees: 1 min x 3 sets. Hip hikes (what’s this?): 2 sets of 20 reps each side.
14. Consider the following although not from Paul: Quad strengthening: terminal knee extensions with elastic band, 3 sets of 15 reps; leg presses?; semi squat, 3 sets of 10 reps (also recumbent bike?). Also consider stork stance TKE (terminal knee extensions) as alternative to standard TKE.
15. Paul likes trekking poles for hikers. (I’ve been using these for years; Leki brand.)
16. Not from Paul: Home physical therapy for six weeks
17. Not from Paul: Turkish get-ups now or later? Much further into recovery!

Update of Progress on April 4, 2019:

Knee definitely feeling better, probably due to profound rest as above.  On Feb 23, I aggravated knee mildly by sledding in snow with Paul in Care Free – no regrets! Around Feb 26, Sunny got me started on Platinum’s Ortho-Chon Plus, 3 caps twice daily. Per 3 caps: glucosamine sulfate 800 mg, turmeric 380 mg, methylsulfonylmethane 350 mg, berberine HCL 145 mg, Boswellia serrata extract 140 mg, hyaluronic acid 50 mg, cat’s claw 10 mg, total cetylated fatty acids 3 mg. Not sure if these did any good at all; I’m skeptical. Started feeling less pain around Feb 29.

I am not healed or in remission yet. Doing hip exercises twice or once/wk with Therabands: clamshells, straight leg raises, side-lying straight leg raises, hamstring curls.

I had to put hip exercises on hold temporarily on March 28 due to a right low back muscle strain either from the exercises or weed pulling.

Update on Nov 25, 2019:

The PFPS is in remission and has been since July or so. For the last couple months I’ve been doing single-leg Romanian deadlifts and “walking” on elliptical-type aerobic machines at Anytime Fitness—some machines also work the upper limbs, others don’t—which are very easy on my knees. Avoiding treadmill since I have a palpable click in one knee, and treadmill aggravates my degenerative joint disease (DJD in both knees but predominantly left knee).

Both offending knees

Next step is to slowly re-introduce exercises that load the knees (particularly the patell0-femoral joint). This is scary but must be done. My quads have atrophied somewhat. Squats? Lunges? Bulgarian split squats?

Steve Parker, M.D.

PS: Most types of knee pain will improve if you lose excess fat weight.

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