I have a client with advanced knee arthritis who has seen dramatic improvement in her symptoms after including body weight squats in her routine. She is even considering delaying the knee replacement that she has been planning. What she finds baffling about all of this is how a knee that clearly shows significant pathology can be feeling good at all?
Pain And Pathology Often Don’t Add Up
The short answer here is that structural issues in the body often do not translate into any kind of predictable pain, or even any pain at all. This review by Terence & David (2018) discusses the fact that many of the structural issues that are correlated to pain, like tears, lesions, synovitis, and others often produce pain only half the time or less. Culvenor et al. (2019) found similarly that after the age of forty 19% – 43% of people without symptoms showed some kind of pathology in the knee on scans. Most eye-catchingly, Webster et al. (2013) showed that scans done on people with non-specific low back pain were actually associated with worse outcomes. This, they suspect, may be due to the fact that a scan will likely find something but, for the aforementioned reasons, there may be no way of knowing if what has been found is really causing any pain. That being the case, trying to fix it could end up being worse.
Why Is It So Hard To Believe?
I think one of the reasons this can be so hard to believe is that we are well conditioned in the mechanistic model of the world. The mechanistic model is a worldview formulated by thinkers like René Descartes (“I think, therefore I am”), and others, that said that humans are like machines. We are a collection of parts that can be deconstructed. Like a car, when something breaks we figure we just replace or repair it and then the machine will function again.This view has done some amazing things for us, particularly in medicine, but, it’s not totally accurate and so the model doesn’t always hold up. (If you’d like to know more about why, check out these posts here and here.)
Another possible reason we have trouble wrapping our minds around the inconsistencies of the human body is that human beings have a negativity bias. As Vaish, Grossmann, & Woodward (2008) put it:
“There is ample empirical evidence for an asymmetry in the way that adults use positive versus negative information to make sense of their world; specifically, across an array of psychological situations and tasks, adults display a negativity bias, or the propensity to attend to, learn from, and use negative information far more than positive information.”
I think that means that when something is broken and it needs to be repaired to work properly again, we’re more likely to take note of that and learn from it. We remember finding the problem and going through to the solution. When something is broken but there is no issue, we tend not to think about it again. We all have broken windows that we prop up with boards, or janky machines held together with wire and so long as that works, the damaged pieces don’t bother us. Our bodies are sometimes like that too. We have many imperfections and broken parts. Sometimes, the part needs to be fixed, but other times, it is just there and doesn’t bother us.
What To Do?
There is no real easy answer to this question, but the above discussion has a piece of the answer in it. Basically, things are often not straightforward, simple equations like “you have arthritis so you need a new knee.” They are nuanced, like “you have arthritis, and you probably will need a new knee at some point, but you might be able to push that back or maybe even get around it entirely with some exercise, although you may not want to push it back so far that you are too old to have it done.” My best advice is to look for conversations that feel nuanced and thoughtful like that. If you are thinking things through, then you are doing the best you can to find the answer.