Recently I’ve been thinking more carefully about what we know and don’t know and how to live an ordinary life even with the not knowing parts arising. Why now? A debilitating knee injury that surprised me on Thursday, October 2nd.
I got up to go to the bathroom about 3:30 am. As I started walking back to my bedroom, my right knee buckled under me, and I fell to the floor. I gingerly got myself to bed and awoke around 6 am.
For a while I navigated breakfast, morning coffee and my recumbent exercycle, limping around, afraid of falling again, but telling myself everything would be okay if I were careful. By nine o’clock, though, I started worrying. What if this was a bigger deal than I thought?
I contacted my health care provider, Kaiser Permanente, and within about 45 minutes had a phone conversation with a doctor. I described what happened and how my knee felt insecure, and that I saw some bulging on the inside. He gave me two options. He could order me a knee brace, which I would need to drive to the pharmacy to pick up. With the brace on my knee, I could wait for 5 days and see if I needed more care. Or I could go to urgent care right away.
Without seeing me in person, he couldn’t say for sure which one I should do. Either one might work out just fine, he said, and left the decision up to me. I sat there, mulling the choices in my mind. What came up most strongly for me was my sense of uncertainty. I couldn’t tell which, from just the facts I knew in that moment, was the right thing to do.
He waited as I sat in silence, until I decided to go to urgent care. In retrospect I can see there may have been any of several reasons behind my decision.
Maybe I just wanted to opt for more certainty in the moment.
Or maybe it was an abundance of caution, which reflects an aspect of my personality at a higher level.
Or maybe it’s because I’m 81 years old and recently had a mild heart attack from a covid infection, one I didn’t know happened until it was diagnosed in urgent care. A reflection on a recent past experience causing me to worry.
Or maybe an old sense of practicality prompted the thought, “Why not? If getting the knee brace means driving to the same place where I’d go for urgent care anyway.”
Or maybe it was some mixture of all the above ways of reasoning.
Luckily, I live a 5-minute drive from the Mt. Talbert primary care building where they host urgent care. I limped carefully into the building and checked in at the front desk at 10:15 am. At 10:45 a nurse called me over, did blood pressure and temperature readings and asked what brought me in. After I explained what happened, she sent me to get X-rays done. By 11:25 I was back in urgent care, and at 12:10 I was called in and seen by a nurse practitioner.
She asked me to sit and roll up my pant leg. She touched different parts of my knee, asking if I felt any pain or discomfort. Then had me stand up and lift each leg in turn while leaning against the wall. After all this she said I probably had a tear in the meniscus cartilage that cushions the knee joints. That it was likely a minor tear.
She said the X-rays see only the bones, not cartilage or muscles, but they definitely showed I had arthritis, and the bones in my right knee were likely hitting each other directly on the inner side. She ordered both a knee brace and crutches so I could walk about safely and said I should put ice on the knee 3-4 times a day until the swelling went away.
She gave me a handout with some exercises to start doing after the pain goes down. In the meantime, she asked me to set up an appointment on kp dot org for a visit to osteopathy and for physical therapy. Happily, she said the tear didn’t seem big enough to require surgery.
Notice that, aside from the X-ray, the nurse practitioner was using three methods to measure my injury. What her own hands told her as she touched my knee and what she saw, combined with how I answered her questions. Not anything near the precision of the calipers I used to measure metal in my career as a machinist.
After that first visit, I felt more positive, and the next day got on my exercycle and did a bit of walking every hour, stopping when it seemed the most recent step or cycling turn felt a little painful. The next day I awoke and almost couldn’t walk to the bathroom even with the crutches. Had I overdone it? And how to adapt? This, and the need, in particular, to take a shower and eat food, started me thinking.
I live alone, prepare my own meals, take a shower without help and exercise daily. The injury changed what I can do and how I think about it. I figured out that being self-reliant while walking around on two crutches was out of the question. How do you carry your food from the kitchen to the dining room table when both hands are holding the crutches? Okay, hobble around on one crutch while carrying just one dish at a time. So that means multiple trips back and forth from kitchen to table rather than one.
Two days after going to urgent care, I learned to lean one crutch against the back wall in the bathtub and one on the wall behind my towel. That way I always had one crutch handy to support my knees, and keep from collapsing, as I entered and left the shower. In reaction to how I felt the morning after increased exercise efforts, I definitely had become more conservative in what I did.
A week later, on October 8th, I saw another Physician’s Assistant in the osteopathy clinic where they take care of knees. She did an even better job of enlarging the X-ray and explaining how, when your knee bones touch, it can lead to small tears in the meniscus, which is cartilage that absorbs shock and stabilizes your knee as you walk. The tear is also part of why you feel pain.
The official after visit report from the osteopath says, “X-ray shows severe osteoarthritis with bone-on-bone contact, loose bodies, and bone spurs. Meniscal degeneration likely contributes to instability and flexion contracture.” In other words, I can’t bend my knee as well as before and will more easily fall if I’m not careful.
The X-ray was quite clear. I could see the knee bones on the inside literally in contact with each other, but with space still left on the outer edges where the meniscus may be largely intact.
With the advice of the Physician’s Assistant in mind, I prepared myself for weeks of recovery. The next day, October 9th, I drove to the monthly United Airlines retirees’ luncheon and enjoyed myself as always. October 10th my knee was extra painful in the morning again.
This caused me to experiment with different levels of exercise and walking. Should I start with two minutes per hour on the exercycle and then increase slowly? But then some days I felt better and pumped the pedals for 3 to 5 minutes.
October 14th to the 17th I attended a healthcare conference in downtown Portland. It was organized by The Camden Coalition, and the theme was “Putting Care at The Center.” Four days of hour-and-a-half- or two-hour meetings on everything from strengthening Patient Advisory Councils to redefining and managing care for people with complex health conditions and avoiding doctor burnout.
I registered for this conference months before the injury and already paid almost $700 just to participate. I didn’t know if I could get a refund at such a late date. I also knew I would learn a lot at this conference and believed it would be a valuable experience for my podcasts. So, I decided to attend in spite of the knee injury. But how to get to the hotel where the conference was happening and home again?
I could have saved money by taking the Max train downtown at less than $5 a day. But that would have meant a long walk in the morning and evening getting to and from the Max station near my home. And it meant an hour ride each way instead of half an hour by car.
I could have driven, but that would have meant finding a parking garage and walking from there to the hotel and back every day. They cost $12-$14 a day. I worried about how long the walk would be, especially after a day at the conference.
I ended up taking an Uber every day. Even though the daily cost was about 60 dollars, they delivered me right to the front door of the conference hotel. I would be doing plenty of walking during the conference itself.
The conference was engaging. I’m glad I made the effort to attend. But after sitting down for hour-and-a-half meetings, even on relatively comfortable chairs, it was as hard on my knees and leg muscles as over-enthusiastic exercising. I tried to sit in a place where I felt comfortable getting up and bending my knees every hour, but I got so engaged in the content and the conversations with other attendees that I often didn’t think about exercising.
For the next four weeks I navigated through the sitting, standing, walking and riding of my exercycle. It was challenging, trying to figure out how much to do each thing each hour of each day.
Some mornings the pain and wobbliness seemed worse and I couldn’t always guess to what extent increased exercise of this or that type was the cause. Some mornings, after going to an evening event where I sat for an hour and a half or more without getting up to move, the pain and sense that my knees may buckle again seemed worse for a couple or three hours. Because of this I decided to not go out in the evening two days in a row.
On November 10th I had an appointment with a physical therapist. He talked with me at first to understand, from my perspective, what happened and how I was doing, then looked at the knee itself, then printed out a regimen of six exercises he wanted me to do. He did them himself first as I watched, then watched me do them.
The after-visit email I got also connected me to an app provided by an external company that Kaiser Permanente uses. There are videos of how to do the specific exercises the therapist gave me and a way to keep track of when I do them. I am supposed to contact him by email in two weeks so he can check in with how I’m doing and to decide whether any changes to my exercise routine are needed.
I left feeling very confident in managing the exercises. We will see how it goes. But there was one thing I’ve noticed after these three office visits. It is clear that there is no magical scientific instrument that can tell me how the original fall happened when it did, how I am doing with the exercises, when to increase their frequency or intensity or when I will reach some end point.
Especially in the conversation with the physical therapist, it became clear that the number one way to measure my progress and to decide when and how much to increase exercise intensity is based on how my body feels as I am doing the exercises. I am the measuring instrument, if you will. And my sense of the messages I get from my body are not as clear or precise as I would prefer them to be.
As the physical therapist said, sometimes I’ll only know I went too far because of how I feel the next morning. “Listening to your body is the number one way to measure how things are going,” he said. OOOkay, I thought. This will be an adventure.
Each day, as I pay attention to the changes in my legs and how they respond to treatment and the decisions I make, I notice how sometimes I don’t listen to my body. Instead, I get caught up in the complex role my smart watch plays in my everyday life.
When I got the watch, I was prompted to set three minimum goals. How many hours a day do I get up and move for a minute or so? I set the watch for nine hours. How many minutes a day do I exercise vigorously enough to get my heartrate up 25 or more beats a minute above the resting rate? I set it for a minimum of 15 minutes a day. And I set it so I burn at least 400 calories a day.
To give me this information, the watch measures my heart rate and respiration. I’m not sure exactly how this happens, but it takes the measurements from things it senses happening in my body while being next to my wrist. Doing this, it tells me when I reach each of my three daily goals.
But it also offers or suggests “medallions” to celebrate doing more. Exercise more times per day or reach higher goals for minutes walking at high intensity or number of calories burned and get a visual reward.
I’ve had a love/hate relationship with my watch. I like the reminders to get up and move every hour because I know my body feels better when I do. And there is this study published in JAMA, the Journal of the American Medical Association, that supports it.
But I’ve also noticed in the past that I could easily overdo the exercising or let it get in the way of other important things in my life. Before my knee injury I regularly moved around 14 to 16 hours, exercised vigorously 55 to 60 minutes, and at times burned well over 500 calories. My body felt healthy doing this, but some days I went way over even these numbers, and I realized it was because I was paying attention to the motivational algorithms, not to my body. I made the effort to reset my attention and focus on how many minutes of vigorous exercise I did between the exercycle and walking around outside.
This changed drastically after my knee injury. I’ve narrowed my focus to seeing if I can do more like 20 minutes a day, and only to the extent my heart rate increase is measurable to the watch. Not the 115 to 120 beats a minute when I felt healthy.
Still, I realized the urges from the watch felt attractive to my mind at times. It showed up strongly a couple of times and the next morning I woke up with more felt pain than before, and either or both knees almost buckled under me in the morning. I had let the watch influence me to “do more.”
After a few of these experiences, I made a commitment to myself to be okay with it if I didn’t reach any of the goals on a particular day. As I write this podcast episode, two weeks after seeing the physical therapist, my knees are feeling better. Doing the exercises the therapist gave me seems to be working.
My knees feel stronger now, in a way I can’t exactly explain, and I feel confident I’ll get better in a way that will allow me to go back to my pre-incident life. I’m leaving it open as to the details of what that will mean, but I am training myself to treat exercise, in the long run, as one of many ways to live a healthy and vibrant life. Not as an area where I strive to do more in competition with myself or to please an algorithm. But the fact is, it will take time and effort to let go of unconsciously letting the algorithms affect me.
None of us can completely escape the role that our personal experiences play in how we approach life, or in how we think about things. But what does that mean as I learn and grow? What does it take to get closer to a more accurate sense of what is true beyond my own experiences?
My journey through this meniscus tear and the knee arthritis it showed in uncomfortable detail is very personal. What life experiences contributed to my knees becoming arthritic can only be understood if you know way more details than even I or the doctors know. I remember some things from the recent and distant past that likely played a role, but I didn’t spend my life recording every life event that could have been involved.
And we are a long way from knowing to what extent my biology interacted with the environments I’ve moved through in the last 80 plus years. Whether from when my parents’ gametes were created, to how I became a fetus that grew into a baby born 81 and a half years ago, to jobs, recreational activities, nutrition and exercise to name just a few examples. There are more things than my doctors or I can know that ended up with my knee buckling out from under me at 3:30 on a random morning.
There are many ways to make measurements. Some are very precise and some are not. When I started working at United Airlines machining aircraft engine and landing gear parts, there were some materials I’d had experience in my prior 18 or so years. But some, like nickel plating, I hadn’t.
It didn’t take long to learn the types of tooling or the feeds and speeds to use, but nickel plate can be tricky. More than other metals it can vary in its quality in ways that affect how you finish machine it. Like machinists, those who did the nickel plating followed high quality processes.
But no process is perfect, and there is an acceptable range within which the plating process can be done and still meet aircraft repair requirements. Occasionally, I had to adjust the way I machined the nickel plate on a specific part.
I learned that there is a look, feel and even the sound of the cutting tool, and the nickel itself, as the tool spins and the cutting edge works its way down the part. While our micrometers and dial bore gages were very accurate, they didn’t help us know if the actual machining of the metal was going well. Even in this world, where accurate measurement of the final size of machined parts was critical, there were some things like this where success depended in part on how the process looked or felt in the midst of its’ happening.
With all the uncertainties in measurement I’ve listed I still had good enough information to make high quality repairs of airplane parts and still have good enough information today to be on a healing path for my knee. I will be able to get better, to walk more like I did in the past, and to make it less likely that a similar incident will happen in the future.
I think this is an example of combining my personal measurements, my data points, with those of many other humans. After all, the experience of lots of doctors with lots of patients are where the testing and advice I got came from. I am moving between the individual, the scientific data gathering, and the medical organization levels of knowledge.
For the rest of my life, I will live with arthritis in my hands and knees, and I hope to still live a healthy and vibrant life even given those physical limitations.
There are things in our own lives, our personal data points, that offer a window to larger truths. That’s why, in writing for my podcasts, I constantly go to resources that bring in other humans’ lives, others who are each a data point in the way I am. And resources that try to accurately measure what happens in the lives of larger numbers of humans.
It is easier to get full, rich details in individual stories. But large-scale studies can sort out what is most relevant for the purpose of generalizing and can be accurate when done well.
This is humbling. What I know is part of the truth but will never be THE truth in some larger way. What studies of a larger number of human experiences show can bring us closer to that larger truth in a statistical way. And history shows that we humans at times draw generalities from population studies that in some ways ignore parts of the truth demonstrated by the lives of minority sections of larger populations.
I learn a lot by moving back and forth among different levels of research. They all have a different part of the truth. And we can’t get closer to the truth unless we take in evidence and experience from all the different levels.
A complicated way of saying I’ve learned some important things about my own life as I deal with this meniscus tear. I will be better off if I am aware of and act in accordance with the messages I get from my own body. I can follow the advice of the good folks in the medical system to get better and maybe stay healthier. I can use learnings from medical system studies to check the validity of my data and the expertise of the medical professionals.
I hope this rumination prompts you to find ways stay healthier in your own life as well.
In the meantime, thank you for listening. You can follow links I refer to in my podcasts by going to the written format on Substack and clicking on the bolded text.
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