Date: 2018-06-15
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Miles today: 0.0

The Amtrak Vermonter actually arrived in Essex Junction near Burlington on-time Tuesday evening. Perhaps that was an omen.  I do believe in omens and portents; I just wish I knew what they mean. I met with a nurse practitioner at the University of Vermont Medical Center yesterday morning. Her job was to triage my condition and make referrals, and that she did. I am to take high doses of naproxen (Aleve) for the next five to seven days. Without the Aleve, my pain level was pretty high. With it, I can function and sleep. The first opening at UVM Orthopedics is in about a month, but I started physical therapy this morning. As far as pain goes, this was my most severe episode of patella-femoral pain. I was told from the first diagnosis of osteoarthritis in 1997 that episodes would increase in frequency and severity. The new name of degenerative joint disease for osteoarthritis is quite descriptive. It doesn¢t get better. The goals of treatment are management of pain and inflammation. As is usually the case with diseases that have no cure, DJD attracts scads of proprietary remedies and well-intended treatment protocols largely based on wishful thinking and anecdotal reports. Dare I say financially motivated quackery? Treatment recommendations with a strong evidence base are harder to find.  The 2nd Edition of Treatment of Osteoarthritis of the Knee, Evidence-Based Guidelines, adopted by the American Academy of Orthopaedic Surgeons in 2013 offers a good summary: https://www.aaos.org/cc_files/aaosorg/research/guidelines/treatmentofosteoarthritisofthekneeguideline.pdf. Recommendations with moderate to strong evidence include strengthening, low-impact aerobic exercise and physical activity, weight loss, and the use of non steroidal anti-inflammatory drugs. There are moderate to strong recommendations against acupuncture, lateral wedge insoles, glucosamine and chondroitin, hyaluronic acid injections, needle lavage, and arthroscopy with lavage and/or debridement. The jury is still out on the really cool treatment alternatives like PRP (Platelet-Rich Plasma) and stem cells. The American College of Rheumatology has issued similar guidelines. When the recommended nonsurgical treatments are insufficient, then joint replacements should be considered.Over the years, I have tried various compounds of glucosamine and chondroitin, proteolytic enzymes, various straps and braces including full off-loading braces, cortisone injections, and arthroscopic bilateral release of the patellae. The latter procedure performed in 2010 gave me three really good years, culminating in my failed thru-hike attempt in 2013. None of the others have been even temporarily effective. I haven¢t tried the injection of hyaluronic acid, but there is so little evidence of its effectiveness for the patella-femoral knee compartment that it isn¢t even covered by insurance.  I nearly had bilateral total knee replacements in 2013. We had gotten as far as selecting the joint and discussing my preference for anesthesia (femoral blocks with light sedation), but the surgeon was scheduled to attend an international conference first. He came back convinced that stem cell treatment would be the standard protocol within five years and that he would be viewed as a barbarian for having done joint replacement surgery. Guess what? A standard stem cell protocol remains five years away, and there are real doubts about the quality of the regenerated cartilage. I am tempted to return to Sarasota for a reevaluation and to proceed with the total knee replacements.Things move slower up here in Burlington. Perhaps that¢s a good thing. The orthopedic surgeons affiliated with the UVM Medical Center don¢t have a direct financial stake in each replacement surgery. Physical therapy went well this morning, and I¢ve scheduled three weekly appointments. Today was mostly an evaluation, but they gave me a couple of exercises to add to the ones I¢m already doing. I¢ll start the PT exercises, stretching and foam rolling tomorrow and return to the Y on Monday. They have little doubt that the current arthritic flare will subside and that I can get myself back to where I was before this episode, able to do virtually anything except deep knee bends or squats without pain.  They encouraged me to avoid activities that cause pain. Unfortunately, those are the activities that I want to do. I¢ve tried long-distance cycling and don¢t enjoy it, and find that any intensity causes the same knee pain that I¢m experiencing now. I loathe swimming.I anticipate that in a couple of months I¢ll find myself in a quandary. Do I limit my activities to the equivalent of sitting and rocking, what some would term acting my age, and gradually descend into senescence, or do I risk total knee replacements now, while I¢m in peak physical condition? The latest joint replacements have a thirty-year life expectancy. Will the UVM surgeons even the consider replacement if I¢m capable of the activities of daily living? Obviously, I¢m unhappy not to have completed my thru-hike. Obviously, I¢m frustrated with the way things have ended. Could I have recognized the onset of the arthritic flare episode and gotten off the trail for a few days for it to have subsided? Possibly, but I don¢t know how to distinguish between early arthritic pain and the usual pains that accompany all backpacking. Why, after surviving the foot- and knee-destroying terrain of Pennsylvania and the New York trail west of the Hudson River, did my knees suddenly act up on comparatively gentle terrain? Is this God¢s way of laughing at me? Or is it simply that stuff happens? Fate or chance?So that¢s how I¢ll end this journal, with a great big question mark. Thanks to all of you who have followed me, and especially to those who signed my guest book! Your encouragement and your book recommendations really meant a lot to me along the way. If I find any answers or decide on new knees, I¢ll let you know.