By Louise Rafkin

Like many baby boomers, I live a sporting life. I grew up swimming, biking, and playing soccer, and for the last 20 years, I’ve been studying and teaching martial arts. The particular style I practice—Poekoelan Tjimindie Tulen—is from Indonesia and, because it’s based on the movements of animals, can be quite acrobatic. Often when I’m teaching a group of young kids, I’ll find myself dipping into a cartwheel or scampering across the floor on all fours like a monkey. At 46, I’m still asking a lot of my body.

In general, I haven’t slowed down, except when I’ve had to. And when I’ve had to, it’s usually been because of knee pain. Sometimes searing, sometimes throbbing, sometimes pinching or even twitching, recurring knee pain has been my Achilles’ heel. Though I’ve kept gray hair at bay and wrinkles mostly under wraps, my knees seem to be the part of my body delivering me into middle age. Several times a year I have knee pain that lasts days, sometimes weeks, and occasionally even longer.

I’m not alone, of course. Knee pain is often the first sign of osteoarthritis, a fancy name for the joint degeneration that accounts for nearly 11 million doctor visits each year. According to the Arthritis Foundation, half of us will develop some level of arthritis in at least one knee by age 65, and women over 50 are twice as likely to get it as men. And for a growing number of people, the pain of arthritis will hit well before retirement age. It’s even turned up in people as young as 20.

The ranks of orthopedic surgeons specializing in sports medicine are burgeoning, with aging athletes such as myself boosting their practices. Kamikaze snowboarders, avid distance runners, and weekend hoops players crowd waiting rooms in the hope that something, anything, will alleviate their pain and get them back to doing whatever it was that brought them—no pun intended—to their knees. Alongside us active folks are several other groups of arthritis candidates, including people who’ve had previous knee injuries and those to whom genetics have dealt a sorry hand: Many who suffer from knee degeneration simply have joint cartilage that is easily worn down.

Unfortunately, curing knee pain is no easy matter, and conventional medicine is often woefully inadequate to the task. No one has figured out how to replace cartilage, so traditional treatment often involves arthroscopic surgery to remove loose cartilage or smooth out any that’s jagged and battered. However, a 2002 study in the New England Journal of Medicine reported that patients who underwent this surgery fared no better than others who had a sham operation.

And those who address knee pain with a daily dose of anti-inflammatories (called NSAIDs, or nonsteroidal anti-inflammatory drugs) may be in for trouble down the line. Early this year the FDA launched an educational campaign about the risks associated with the long-term use of common painkillers such as aspirin, ibuprofen, naproxen, and ketoprofen, including stomach bleeding and kidney problems. Even some of the newer prescription pain inhibitors like Celebrex and Vioxx, which researchers thought would sidestep the stomach problems of traditional NSAIDS, turn out to have other gastrointestinal risks, especially if taken long term. A recent study even suggests a strong connection between Vioxx and an increased chance of heart trouble.

Luckily, alternative medicine has plenty to offer in this area, both to ease pain and to bolster the health of cartilage. Even some traditional orthopedic surgeons, a group not known for their endorsement of holistic practices, have begun to see the light. Before even considering surgery, Lesley Anderson, a top orthopedic surgeon in San Francisco, asks all of her knee patients to follow what’s now become the gold standard of alternative treatment for arthritis: a three-month-long program of targeted exercise, weight loss if needed, and supplements.

“Patients often see an improvement in a matter of weeks,” she tells me when I seek treatment in her office one day. And many have been able to put off surgery for quite a while.

In my own case, a series of small ligament tears over the years led to instability in the joint, which caused the cartilage to get both roughed up and worn down. I also blew out my anterior cruciate ligament (ACL) a few years ago and had it replaced. Though the surgery went swimmingly, Anderson tells me the scar tissue it left me with, plus my ragged cartilage, is what’s causing my occasional pain. With a grimace, she says the arthritis indicators on my X-rays rank me right up there among those who will face knee problems in the future.

With that swell news, and the occasional swollen left knee, I need no further convincing. My diet begins immediately, I hunt down the right supplements, and my on-again off-again relationship with my trainer moves into a serious “on” phase. Like many arthritis sufferers, I want to stave off going under the knife again and prolong the pain-free periods between flare-ups as long as I can. In the meantime, here’s a more detailed look at the strategy that is giving new hope to other gimpy-kneed athletes like me.

LOSE POUNDS TO LOSE PAIN
The problem with carrying extra weight is one of sheer mechanics. The more pounds on your frame, the more work the knee joint has to do to support you and move you around. Anderson says even a 5 percent weight reduction can unload 40 percent of arthritic symptoms.

“Ten or 12 pounds make a big difference,” she says, managing to note the exact poundage I’ve apparently not-so-secretly packed on in the past few years. But if losing ten can have a significant impact, just listen to what shedding 50 pounds did for Mary Mihaly, a 53-year-old knee patient who had much more to lose.

Three years ago, Mihaly, who lives in Cleveland, Ohio, was taking up to eight tablets of ibuprofen each day just to function normally. Some days she had to hold on to a railing simply to go down a single step. Osteoarthritis runs in her family; her mother and two of her sisters have already undergone knee replacements, though none of those were successful. All the women still suffer from pain and limited
mobility.

Hoping to avoid the fate of her siblings, Mihaly decided once and for all to lose weight. (Over the past three years, she had quietly put on a hefty 75 pounds.) She began her regimen by walking, first putting in a mile a day and then slowly working up to three. With a little attention to her diet, and some time at Weight Watchers, she’s now 50 pounds lighter.

“I knew my knee pain would probably ease if I took the weight off,” she says, “but I didn’t think the effect would be so drastic.” After years of feeling pain with every step she took, Milhaly is now doing much better. “I climb stairs and can even carry laundry baskets up from the basement,” she says. She’s also able to hike up some hills on her daily walks, something she never thought she’d be able to do again.

But what really allowed Mihaly to turn her back on her pain was a daily dose of glucosamine and chondroitin supplements.

BUILD CARTILAGE WITH PILLS
“I am absolutely convinced these supplements have kept me mobile,” Mihaly says. “If I stop taking them for even a short while, the pain and inflammation are unbelievable.”

Indeed, many people swear by these supplements to relieve pain. But their added advantage, say experts, is that they can actually help repair—and possibly even rebuild—cartilage itself. Both glucosamine and chondroitin—singly and in combination—have been shown to slow and even prevent cartilage degeneration, says Jason Theodosakis, a physician in Tucson, Arizona, and author of The Arthritis Cure. A few studies suggest they can spur the growth of new cartilage.

Given the unregulated supplement market, Theodosakis stresses the importance of taking the right pill. When he tested more than 100 products, only three passed his tough screening: Osteo Bi-Flex (Rexall), Cosamin DS (Nutramax Laboratories), and TripleFlex (Nature Made). He recommends 1,500 milligrams of glucosamine HCl or 1,900 mg of glucosamine sulfate once a day. For chondroitin, he suggests 800 to 1,200 mg a day. If you’re taking a combo pill, the dosages of each supplement stay the same.

For those willing to spend a little more money, Theodosakis’s top pick these days is a pill that combines glucosamine and chondroitin with the newcomer avocado-soybean unsaponifiables (ASU), a vegetarian supplement made from avocado and soybean oil. (Glucosamine comes from lobster and crab shells; chondroitin is made from cow and shark cartilage.) ASU seems to work better in those with severe cartilage loss, and may provide relief faster—within a few weeks, even—than glucosamine and chondroitin. But since all three of these ingredients work slightly differently, Theodosakis says it’s worth covering your bases in one pill. The key is to stay on it even if your pain doesn’t lift. Most people get some relief within a few months, but it can sometimes take up to six. For now, the combo pill, called Avosoy, is only available from Theodosakis’s website (drtheo.com), and the usual daily dose is 300 mg. (More companies are expected to market it soon.)

Another supplement with positive buzz is SAMe (short for s-adenosylmethionine), a naturally occurring biochemical that has been prescribed in Europe for decades. SAMe is the number-one choice of Richard Brown, an associate professor of clinical psychiatry at Columbia College of Physicans and Surgeons who has studied the supplement extensively.

“Not only will SAMe help with swelling, stiffness, and joint lubrication,” he says, “it can repair cartilage.” In a 2003 study at the University of California, Irvine, SAMe proved as effective as Celebrex in reducing knee pain and swelling—without stomach problems. Brown recommends 600 mg a day of a high-quality SAMe supplement (Nature Made and LifeExtension are his picks) and stresses that the tablets must be enteric-coated to ensure that they’ll maintain potency and release at the right place in the intestines. At about $3 per day, SAMe is more costly than many supplements, but gaining in popularity because of its good results.

WORK THOSE QUADS
It’s hard to believe people with arthritis used to be told not to work out. Now it seems that taking it easy is the worst thing a knee-pain sufferer can do. Experts have found that the right kind of exercise is key to maintaining mobility and limiting pain.

I learned this firsthand after visiting Chris Chorak, a San Francisco physical therapist and competitive triathlete. She says the job of the thigh muscles, or quadriceps, is to take the pressure off the knee joint. Strong quads function much like a good bra, she says, lifting the knee and giving it support. Chorak specializes in knee injuries, and a large percentage of her clientele are baby boomers who came to their sports late in life and don’t have the muscles to support their newfound zeal for running marathons, playing hoops, or sprinting down the field in weekend games of soccer.

One of the first things Chorak tells them is to take up biking. A great way to build leg muscles, cycling is non-impact and puts very little stress on the joint. She also assigns single and double leg squats—starting with 15 and working upward from there—as well as leg lifts and weight workouts. (If your knee pain is relatively mild, ask a trainer at the gym to set you up with the appropriate quad-building exercises; otherwise, you might want to see a physical therapist so you don’t make things worse by overdoing it or choosing the wrong routine.)

Water exercise—including shallow-pool exercises for building strength and deep-water “running” for a cardiovascular workout—is important too, both for increasing muscle strength and as a way to continue working out through periods of injury. (Some people actually have the opposite problem—they can’t bring themselves to cut back on exercise—but it’s important not to hammer away at a sport if it’s causing you pain.)

The beauty of exercise goes beyond its muscle-building potential. It also increases flexibility and range of motion. Moderate tai chi and yoga workouts have been shown to greatly improve mobility—and that can prevent further damage, says James Dillard, New York City physician, acupuncturist, and author of The Chronic Pain Solution. “Without a wide range of movement, the joint simply pounds down the cartilage in one spot,” he explains. “More wiggle room in the joint enhances the ability of the cartilage to heal.”

Under Chorak’s tutelage, my quads, which had been deflating post- ACL surgery, soon puffed back up into their former splendor. Back in the martial arts studio, my tiger movements—tucked-in hands and feet with knees and elbows bent—which had me looking more like gimpy tiger than crouching tiger, once again became effortless.

Not that it’s been easy. The hardest thing about this whole alternative approach to aging knees, including the leg lifts, dieting, and remembering to take those pills every day, is sticking with it. But my own experience has been amazingly successful. For several months now I’ve strictly adhered to Anderson’s prescription, and so far so good. I’m stronger, I feel better (when I’m not fantasizing about pasta and ice cream), and though I’m only five pounds lighter, I can actually tell the difference—especially when I’m midair in a jump kick.

“Take that!” I whisper to my aging knees as I tumble into a cartwheel, offering a silent prayer of thanks to the doctors and therapists—and even lobsters—who have sacrificed their time (or shells) to keep me aloft.

What to Do When It Just Plain Hurts
While you’re waiting for all that exercise, dieting, and supplement-taking to kick in—or if your pain just doesn’t seem to let up—one of these innovative methods might bring relief.

• THE POWER OF THE PULSE Seventy-three-year-old Mary Olmsted, in San Diego, California, uses an FDA-approved knee brace that sends pulsed electrical stimulation directly into her knee joint. Wearing the brace for up to ten hours a day has allowed Olmsted to keep a total knee replacement at bay. Manufacturers of the brace (BioniCare) say the electrical waves not only ease pain but actually stimulate cartilage growth (though there’s no independent research to prove this).

People with less severe knee problems might consider a TEN (transcutaneous electrical nerve stimulation) unit, which works similarly. It pumps a mild electrical pulse into the knee, stimulating nerves and blocking pain messages from reaching the brain. A small portable box with tentacles of electrodes that attach directly to the knee, the TENS unit has been used for decades to lift pain (it does nothing for cartilage). You can get both types of devices at a pain management clinic or from a physical therapist.

• THAT NEEDLING FEELING Acupuncture has been proven to work against all types of pain, including the aches of arthritis. New York City physician and acupuncturist James Dillard says not a day goes by that he doesn’t use needles on one of his arthritis patients. “Brand-new research shows that acupuncture is extremely effective in dealing with knee pain,” he says. In one study, acupuncture was shown to be even more effective than TENS for decreasing pain—and therefore increasing flexibility—in arthritis patients.

• RUB IT OUT Topical creams made with ibuprofen, naproxen, and other nonsteroidal anti-inflamma-tories (NSAIDS) have recently been shown to relieve soft tissue pain without causing the stomach problems of their oral counterparts. In a study of 32 men at the University of California at San Diego, creams applied to the skin eased pain for up to 48 hours after use. Currently NSAID creams are available only with a doctor’s prescription and must be purchased from a compounding pharmacy—one that mixes drug formulations to order—though several of the creams can be ordered online (you’ll still need a prescription to get these).

Another possible source of relief are the topical gels and creams made from capsaicin, the stuff that gives chili peppers their zing. Apply a good-quality cream (.025 percent strength) four times daily. Tiger balm and menthol-based creams may also be helpful.

• JUICE IT UP Many knee patients respond well to prolotherapy, especially those with severe arthritis who are too young for knee replacements, says Christopher Centeno, physician and director of the Centeno Clinic in Westminster, Colorado. The treatment involves injecting the joint with a mixture of concentrated sugar water and an anesthetic. The body first responds to the injection with inflammation, then sends specific cells to the site to repair the damaged tissues. In a 2000 double-blind placebo-controlled study, prolotherapy decreased pain and increased flexibility in knee patients. The typical regimen is three to four injections, spaced at three- to four-week intervals, Centeno says.

• RELAX AWAY THE PAIN When you relax the body, you quiet the nervous system’s response to pain, says Dillard, who claims many patients get as much relief from a massage as they do from acupuncture. He also recommends relaxation tapes, meditation, and deep breathing. In fact, every patient he sees gets a brief lesson in proper breathing techniques for pain relief: Count to four on the inhale, six on the exhale. “Deep breathing is a universal treatment for taking the edge off pain,” Dillard says. “Every single day I see it work successfully.”

• NATURAL ANTI-INFLAMMA-TORIES If cartilage supplements don’t relieve your pain fast enough, try adding a natural anti-inflammatory. Fish oil is a good one—aim for 3 to 5 grams a day. (More than that can thin the blood, so check with your doctor if you regularly take other anticoagulants such as Saint- John’s-wort, aspirin, or warfarin.) Vegetarians may prefer flaxseed oil, a vegetable-based source of omega-3s; again, take 3 to 5 grams a day.

Several herbal anti-inflammatories are also available, though arthritis expert Jason Theodosakis says none are supported by enough evidence to be worth recommending. “There are probably some that work, but we have to be cautious,” he says. “Just because it’s natural doesn’t mean it’s harmless. One study showed that a ginger product had just as many side effects as prescription anti-inflammatories.

Get Back in Line!
Simple structural problems—knees turned in or out, pronating feet—can contribute to the breakdown of cartilage. If you have either of these conditions (consulting a physical therapist or podiatrist is a good way to find out), you may benefit from customized orthotics, inserts that fit inside your shoes and realign your feet. (Insurance sometimes covers the cost, which can be anywhere from $300 to $600.) Melina Linder, a serious hiker and biker in her mid-forties, says she doesn’t even go to the bathroom at night without her orthotics. But it’s well worth it. Linder, who used to be unable to walk down a hill without pain, recently hiked all 33 miles of the demanding Milford Track in New Zealand.