Running, Knee Pain, and Hyaluronic Acid

I have been a running enthusiast for most of my adult life.  I started running in my early 20’s as a way to shed a few extra pounds one summer, but I realized once I started that running had a significant impact on my mood and clarity of thought as well.  Once I figured that out, I was hooked.  Fast-forward some 25 years, and I decided that 2019 would be the year I’d run my first half-marathon.  I’d done 10-milers before, but never had I gone further.  I felt really good in the fall of 2018, so that was my New Year’s resolution: I would spend 2019 getting in shape to run the Montgomery County Parks Half-Marathon in September.

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. 

Avengers: Endgame Musings

This is not really likely to be how Endgame plays out, based on everything that’s been dropped in the media over the past 10 days or so. (No, I haven't seen, or even looked for, the leaked material. So please #Don'tSpoilTheEndgame for me or anyone else.) But with only a week or so to go before the film's release, I'll offer than maybe this is how the plot should have unfolded, based on the story presented by the 22 films leading up to Endgame.

The short answer: It was all Loki, all along.

Loki has always been among my favorite Marvel characters. The God of Mischief, for sure. But also someone who is treacherous, cunning, one to run a complex game, and certainly one to manipulate others into doing his bidding. But the MCU version of Loki, though brought to life on screen wonderfully by Tom Hiddleston, has been noticeably underpowered. Maybe that’s just a byproduct of the story telling in the MCU, or maybe that’s all been part of Loki’s long con.

Limiting the analysis to just what we’ve seen in the MCU, here’s what we know about Loki. Odin raised him as his son, and Loki clearly believed he had a shot at succeeding Odin as the ruler of Asgard and the Nine Realms. That is, of course until he finds out in Thor that he’s an adopted Frost Giant, and that Odin has been planning for Thor to succeed him for years. But Loki has ambition, and he’s not going to let his oafish brother take the throne that easy. With his brother banished to Earth in mortal human form, Loki concocts a plan to sneak the Frost Giants into Asgard to kill Odin during his Odin-sleep, betray the Frost Giants by killing Lauffey as he murders Odin, thereby starting war between Asgard and Jotunheim. Let the plotting begin.

Of course we’re also introduced to both the Tesseract and the Infinity Gauntlet in Thor. Whether truly a fake or just a retcon, the implication here is that at one point in his reign, Odin was actively pursuing the Infinity stones. Thor may not understand everything (or anything) about the stones at this point in his life, but it’s very likely Loki does. Thor is the warrior, the jock, the party boy. Loki is the kid who survived by maxing out his mind -- magic, lore, strategy, etc. We know from the opening of Captain America that Odin once possessed the Space stone in the form of the Tesseract and sent it to (left it in?) Norway a millennium ago. We also know from Thor: The Dark World, that Odin's father, Bor, once took the Reality stone (in the form of the Aether) from the Dark Elves and hid it away.  Knowing the family history with at least two of the stones, and knowing that Odin’s vault includes a relic for controlling the Infinity stones, you can bet Loki has studied them.

"Someone has been playing an intricate game, and has made pawns of us."

And that leads us to the first Avengers movie. Loki has successfully escaped justice on Asgard. He still craves the throne, but he’s also learned that Thanos already has the Mind stone in his possession, and he’s looking for more. Now Thanos would never attack Asgard, and Odin, directly without the stones. But with Odin getting on in years, and needing to enter Odin-sleep more often, a powered-up Thanos and his Black Order would be a severe threat to Loki’s plans for rule.

So how do you take an Infinity stone from Thanos? Just as one does not simply walk into Mordor, one does not simply take an Infinity stone from Thanos. But, he might be convinced to give someone the stone -- someone who, perhaps, knew the location of another stone, and offered to lead an invasion to take it and return it to Thanos. Of course, Loki had no intent to ever make Thanos more powerful. And he never had any intention of taking the stones for himself, not yet anyway. Further, if he were to take the Mind stone from Thanos -- and the Space stone from Earth -- and then not hand them back to Thanos, he’d be on the run for the rest of his days. So what better plan than to lose the Battle of New York on purpose? If that were to happen, then Thanos would lose control of both the Mind stone and the Space stone, and in theory each would probably be better protected than before.

Great plan so far. But now assume that when Loki commandeers the minds of several SHIELD agents with the sceptre at the beginning of Avengers, he realizes that SHIELD has been infiltrated by Hydra? Maybe now there’s a chance to help Hydra sow chaos on Earth (thereby keeping the Avengers occupied) by making sure that when he loses the battle, the sceptre falls into the hands of compromised SHIELD agents. Now he’s starting to clear the field ahead of him, and he’s done it by simply losing the battle on purpose!

"You faked your own death. You stole the throne, stripped Odin of his power, stranded him on Earth -- to die -- releasing the Goddess of Death."

With Odin weakening, Thanos de-stoned, and the Avengers battling Hydra and each other, it’s time to worry about Hela. He knows that when Odin goes, she’s coming back, and she was a handful for Odin even at his full strength. So he speeds Odin towards his end with magic (our first hint at how powerful Loki really is), takes the throne disguised as Odin, and basically waits for things to get so bad that Thor rushes back to Asgard. In the meantime, he’s learned that Hulk is on Sakaar and hatched a plan to use Thor and Hulk to take out Hela. So he travels to Earth with Thor just in time to see Odin pass, Hela arrive, and then he “foolishly” opens the bifrost. And how is it that Loki and Thor just happen to land on the same planet where Hulk has been hanging out, bashing heads for two years? There's really no reason to assume this was pure chance. Thor and Loki crash off the rainbow bridge at different points in both time and space, and yet both arrive on the same planet in a far-off star system. And whatever Loki's story about arriving "weeks ago", it's just as likely he's visited Sakaar before via one of the secret pathways between worlds that he found on Asgard.

Oh yeah, and Loki knows the Ragnarok prophecy too. That’s his wild card. With Hulk, Thor, Hela, and Surtur all battling on Asgard, he’s sure that one of them (and probably more) aren’t going to make it out. The most important thing for Loki is to make sure he survives the fracas with the Space stone in his possession. And sure enough, he does. So by the end of Thor: Ragnarok, Odin is dead. Hela seems to be lost in Surtur’s destruction of Asgard. Surtur’s job is done, and he’s off to whatever demons of prophecy do once they’ve completed their fated tasks. The Avengers are broken. Thanos has none of the Infinity stones. Things are looking up for the God of Mischief.

But Thanos and Thor still sit between Loki and his goal of ruling the Nine Realms (and Asgard, wherever it’s people land). So there’s still some thinning that needs to be done. Thanos isn’t going to stop trying to collect the stones, and none of the Avengers — Thor included — understand the danger like Loki does. So given the choice of backing Thanos or the Avengers, Loki puts his money on Thanos. Loki cuts a deal with Thanos to survive the snap in exchange for the Space stone -- and a little bit of theatre ensues to sell the con. He’s betting that Thanos will power up, defeat the Avengers, and then retire with his task accomplished. After all, Thanos’s goal is not intergalactic rule. It’s “saving” the universe from itself. With that task complete, Thanos doesn’t really care who rules over whom. That takes us to the end of Infinity War. Thanos is successful and looking to retire to the sunsets on a nice planet that feels like Titan once did. Half of the Avengers have been decimated. All that’s left is to take care of Thor, and then it’s on to ruling the Nine Realms.

“If we can’t protect the Earth, you can be damned-well sure we’ll avenge it.”

So that brings us to Endgame. As Tony Stark told Loki in The Avengers, “if we can’t protect the Earth, you can be damned-well sure we’ll avenge it!” And that’s where we are. In my version of Endgame, the remaining Avengers defeat a tired, wounded, unprepared Thanos; undo the snap; then then come face-to-face with Loki and…? That raises an important question. How do you create a situation where all of the now-restored Avengers and Guardians can be thrown into battle, in a way that creates drama in the outcome? Maybe Galactus, but that's challenging both from the standpoint of licensing (IIRC, Galactus was part of the Fantastic Four property licensed to Fox at the time of writing and filming) and the trap of ever-escalating baddies. So then what? Here’s a clue: we saw his head and gleaming-red eyes in Spider-Man: Homecoming. That’s right, Loki resurrects Ultron (remember, he never does the heavy lifting himself), and with Loki's help, Ultron creates a new drone army to battle Team Good at the grand finale. The Avengers and the Guardians prevail, of course. But also of course, Loki escapes in the end, left to fight another day.

That's how I'd play the story out. It provides a nice story arc for Loki, and it brings him more in line with the character we've seen in print. It also provides the "Marvel twist" on the villain. We've been lead to believe that Thanos was the bad guy from the original Avengers on -- that he was controlling and manipulating Loki, Hydra, and Ultron to advance his own agenda -- while in reality it was Loki pulling all the strings. I see it as a nice way to wrap up the character arcs of heroes and villain alike.