Everything was going well until late February. That’s when I first noticed pain in my right knee. The pain started at the top of, or directly above, my kneecap. I assumed it was just tendonitis and decided I just needed to do a better job warming up before and stretching after my runs. But soon the pain spread to the outer edge of my right kneecap. Was it iliotobial band syndrome? I spent most of the spring experimenting with various bands and braces, trying to ease what I thought was simply a tendon or ligament issue. But the pain kept getting worse, and it spread to my left knee as well. It got to the point where my knees didn’t just hurt, but they burned with every step for the first mile-and-a-half of my runs. Going up and down stairs, or even trying to stand from a sitting position, became a painful chore. And anytime something hit either of my kneecaps, even something as innocuous as a belt buckle bouncing against them while getting dressed, sent pain shooting through my legs.
So after months of trying on my own to manage the issue with stretching, braces, and lots of Ibuprofen, I finally went to see an orthopedist. He took X-rays of my knees and promptly diagnosed my with patellar-femoral syndrome (PFS) — basically my kneecap was rubbing against the bottom of the femur in both of my legs. In his opinion, the issue was caused by too much tightness in my hamstrings, and what I needed was some physical therapy to stretch my hamstrings and strengthen my quadriceps. So at the end of May, I started PT. I spent an hour twice a week in the PT’s office, and I spent time at home several nights a week working on my PT “homework”.
Earlier in the spring, when I could no longer tolerate running three days a week, I started participating in a deep water running class at our community swim center. The instructor was a remarkable woman in her late 70’s who participated in numerous endurance runs (24-hour type events) throughout the year. She was also a long-time member and coach at our local Road Runners club. Shortly after I received my diagnosis, I shared with her that I wasn’t convinced of the doctor’s opinion. I had been doing my own research, and I was convinced that what I was experiencing was PFS caused by chondromalacia — basically a deterioration of the cartilage between the kneecap and the femur. I really wanted a second opinion from an orthopedist who really understood running, ideally one that was a runner him/herself. She was able to provide me some names, and I made my appointment with a highly ranked, marathon runner of an orthopedist.
On my first visit to his office, I was...not prepared. Whatever his actual level of competence was, he clearly had a high opinion of himself. We didn’t accomplish much during that first appointment, but he did prescribe me a regimen of meloxicam, and that did help the pain significantly. I was more prepared for my second appointment, and we had a good discussion about my condition, courses of treatment, and outcomes. The discussion was “good” in that we were able to communicate openly, without the overwhelming pretense of the previous appointment. But the actual discussion of outcomes was not so good. If it wasn’t something that would clear up after a couple months of anti-inflammatory meds, and maybe a cortisone shot or two, it was probably something I was just going to have to live with. So yes, my self-diagnosis was correct, and the cartilage was not going to re-grow itself. I walked out of that appointment after receiving a cortisone shot in my right knee. I figured it was worth investigating how effective the shot would be.
The cortisone shot made a modest difference, and by the beginning of July I was starting to feel pretty good. I was hopeful that the regimen of PT and meds was making a difference. So I decided in the middle of July to try life without taking a meloxicam every day, and the first day without meds went pretty well. I was a bit more achy on Day 2, but it wasn’t too bad. Unfortunately by Day 5 I was feeling miserable again. I stopped running. It was back to the meds, and back to the orthopedist — now with an MRI in-hand — to discuss the next plan of action.
It was during this appointment that the doctor discussed hyaluronic acid (HA) injections with me. The idea was that he would inject the HA formula into my knees, and that would help lubricate the joint, thereby reducing the inflammation and pain. The doctor handed me some material on HA injections and said he would be submitting paperwork with my insurance company to get my injections approved. He expected it would be a month or so before he had approval.
Given I had a month or so, I decided to do some research on my own. So I started with the requisite Googling and poring over the results for research that appeared legitimate. How effective was the treatment? What were the side-effects and risks? Was there anything specific to be concerned about with regards to my hypertension? From what I could tell, the HA itself seemed rather benign. HA is a compound found naturally in the human body. Like most things, the body produces less of it as we age. I couldn’t find any good long-term research (10+ years) on potential negative effects, but it seemed that the compound was generally considered safe.
What I found particularly interesting was that the research I found seemed to indicate that the results from HA injections were mixed. There weren’t any negative outcomes, but the research didn’t point to consistent positive outcomes either. In fact, the more I read, the more it seemed that a long-lasting regimen of HA taken orally had better outcomes than the injections. Of particular impact was a study I found on the NIH website. This particular study was an analysis of other studies that looked to determine the effectiveness of HA taken orally. And it seemed to indicate that on oral HA regimen could be effective in helping knee pain.
So at the beginning of August I decided to start taking HA pills, 150mg every morning. Why, I figured, should I let the doctor stick needles in my already-aching knees if I could get the same or better results from a pill? I was still taking the meloxicam as well, and I decided I would continue taking the meloxicam throughout the month, as we had our family vacation planned for the middle of the month. I didn’t feel any immediate change, and in factI felt pretty miserable after our first night on vacation. We had set sail on the Disney Fantasy for a week-long cruise, and my youngest son spent the first evening racing all over the ship (and up and down the stairs) playing their interactive scavenger hunt. He had me in-tow, and my knees definitely paid the price for following him. But by the beginning of September, I started feeling better. Much better. So I stopped taking the meloxicam again, sure that I’d be miserable by Day 5, just like last time. But this time, I wasn’t miserable. Yes, I felt a little more pain being off the anti-inflammatory that when I was taking it, but it was manageable.
I had been keeping up with my PT all summer, and I decided I would try to start running again. I did my first 5k on Labor Day morning, and I survived. I spent a couple of weeks running 5k’s on Monday and Friday (while resuming deep water running on Wednesdays as well), and I was feeling pretty good. So on September 20, I tried 4 miles. I was definitely sore for a couple of days afterward, but again, it was manageable without any other meds. And honestly, some of the soreness was probably from working muscles harder than I had worked them in a few months. On September 27, I did 5 miles. And to my surprise, I recovered from that run even easier than the 4 mile run the week before. I hadn’t run 5 miles all summer!
While I was doing my research, I found out that my mother was getting “injections” in her knees as well. Turns out she’s getting HA injections, a course of 5 over several months. We’re comparing notes, and it seems we’re both seeing benefits right now. But our experience raises an interesting question. Between the two of us, we’ve visited three different orthopedists. All three of them have suggested HA injections. Not one has suggested oral HA. Why? My parents doctor told them the uninsured cost of each shot is $1500, though their insurance covers the full cost. Meanwhile, a 30-day supply of HA capsules runs about $30. So would you prefer $7500 a year for someone to stick a needle into your knee every few weeks, or less than $400 of oral meds? If there’s a good reason, I haven’t heard it yet. In the meantime, I’ll continue with the stretching and strengthening, mixing the running on land and in water, and taking an HA capsule a day. It’s not a miracle cure by any means, but it has reduced the pain in my knees considerably. And being able to run again has definitely improved both my physical and mental state.
