Baz Luhrman’s 'Sunscreen Song', while not really a song, contains a few genuine pearls of wisdom. One of these is a one-liner that resonates with those of us who have struggled with joint problems, be it due to disease or injury:
'Be kind to your knees; you’ll miss them when they’re gone.'
I was lucky enough to ride out my first 13 years living with rheumatoid arthritis (RA) without experiencing any major problems with my knees. There was an incident in grade 9 where, during a school trip overseas, a rather large friend tackled me to try and get me to join in in a group photo… I came crashing down on my knees on a tiled floor and thereafter one of my knees did swell up, but a once-off cortisone shot into the joint sorted me right out.
I first experienced a more serious change in my knees when I was finishing up my vet studies at Onderstepoort in 2013/2014. Clinical year can be quite an unsettling experience: your schedule changes every two to four weeks when you change from one rotation to another; you are sometimes on call overnight; the work is physically demanding (from farm animal work to nursing small animals in hospital cages at floor level); you are squeezing in studying and reading up on cases in between; and you’re learning to deal with emotional pet owners for the first time. Being a veterinarian is not all about cuddling puppies…
When my left knee swelled a little, I didn’t immediately think RA. I had been crouching a lot in the clinic and I assumed I had injured it somehow, so I slapped on a Transact plaster or two and figured it would come right. Only when the joint effusion became so pronounced that I could barely walk up a flight of five stairs did I realise something was up. My rheumatologist in Pretoria, Prof. Christa Janse Van Rensburg, first tried to control the acute flare-up with an intra-articular cortisone shot and a course of oral prednisone. I also went for regular physiotherapy with Colin Hill. (By the way, I highly recommend both of these wonderful healthcare professionals!) This worked, but the effect was short-lived.
During an elective rotation where I was doing some rather exciting stuff, helping perform necropsies on by-caught dolphins and turtles (for disease surveillance purposes and to better understand the species we are trying to conserve), I climbed into the back of a bakkie (or 'pick-up') to help retrieve a large turtle, and I re-injured my knee. In hindsight, I assume I tweaked or crushed a portion of already overactive synovial membrane, which then caused another cycle of inflammation, overproduction of synovial fluid, and swelling in that knee. It was time to treat more aggressively.
Dr Daan du Plessis performed a partial synovectomy and debridement procedure on my affected left knee in November 2014, at the end of my clinical year. During the December holidays, I rehabilitated the knee, was able to cycle for short distances over gentle terrain, and felt 'reset' and back to normal by the time I started my first job in January 2015.
Unfortunately, my knees (yes, both of them this time) flared again just a few weeks later. With the multifactorial nature of this disease, it’s difficult to say what exactly triggered this flare. My first job was extremely physically demanding and stressful with poor routine, rest, and an unhealthy diet while living and working on the move, so there is that aspect; but in hindsight, perhaps another contributing factor was my biologic drug no longer working as it should have been.
The next step in treatment was to try three days in hospital on intravenous cortisone, using my C-reactive protein (CRP) level as a marker for whether the flare-up was under control or not. This happened to come at a time when my boyfriend (well, now ex-) and I were meant to attend a family wedding. I could, in theory, have very easily gotten dressed up and been disconnected from the drip for a few hours, but I was too self-conscious to attend a wedding with an obvious catheter stuck to my hand. To my ex’s credit, he did come and visit me in hospital numerous times over that weekend, but I skipped the wedding. Silly me – there was no good reason for me to lie in that hospital bed feeling sorry for myself!
Prof. Christa’s approach was slightly different to many other rheumatologists: with additional expertise in sports medicine, she encouraged me to remain active and didn’t limit me to the usual cycling and swimming only regimen. A common question is, 'How do I know when I am overdoing it?' and I asked this. Her response was: discomfort is okay; pain is not. I continued to struggle on and off for most of that year, but I used to cycle on occasion, played action hockey weekly albeit wearing two knee guards, took Zumba classes, and used to swim in my boss’s pool during my lunch break.
You don’t realise how important your knees are until you struggle with them. Think about it: • Crouching becomes a problem, even just to pick up something you’ve dropped • Even a few stairs can be tough because your knees can’t bend the way they need to • Being unable to bend your knees to crouch causes you to compensate by bending and straining your back more… Which is the lesser of these two evils? • The small bumps, like when you accidentally walk into furniture, become more painful • Driving a manual car in traffic or up steep hills becomes a challenge • You can’t cross your legs when you sit • Impact sports of any sort, even just running, are painful and potentially harmful • You feel discomfort or pain every time you sit down in a chair or stand up again • Horse-riding can hurt your knees, depending on your leg strength and the stirrup set-up • Sitting as a passenger on a motorbike can be extremely uncomfortable • Even just a soul-nurturing walk on the beach can be strenuous
One particular experience regarding the effect of the above struggles on my mental well-being stands out in my memory… I went on the most amazing road trip through Namibia in 2016. I’ll write about this trip in detail at a later stage, but just know it was an amazing adventure! We visited Etosha, went 4x4ing along the Kunene river (the border between Angola and Namibia), and came back down south via the coast. We visited Sossusvlei, a well-known salt pan in southern Namibia, and climbed the tallest sand dune next to the pan. Walking up a sand dune with questionable knees is tough… I did make it in the end, but I remember struggling and becoming quite emotional. I even shed a few tears while trudging up that dune. Struggling with seemingly mundane things that able-bodied others take for granted brings up thoughts like, 'If I’m struggling with this small obstacle, what hope is there for me for the rest of my life and larger obstacles?' That may sound dramatic, but it’s important to be aware of and address the mental health challenges that often go hand-in-hand with chronic pain and chronic illness. (More on this later.)
I am very thankful to have found a better equilibrium: I now work in a practice with a good routine and significantly less emotional strain; my rheumatologist in Cape Town, Dr Ingrid Louw, changed my biologic from Humira to Enbrel; I found a personal trainer who has helped me push through the initial discomfort of training on rehabilitated knees and with a funky elbow to a place where I am among the strongest ladies at the gym; and I have been flare-up free for two and a half years now. I’ve even done a few trail runs and obstacle course races!
For those still nursing problematic knees, here are a few tips:
• Sports massage and physiotherapist strapping can be very helpful.
• Be mindful of your back: maintain your legs’ muscular strength through appropriate exercise.
• Wear knee guards if needed. I preferred the ones with the circular hole at the knee cap to allow for release of pressure, instead of a solid one where your knee would effectively be compressed.
• Choose cleats for cycling: the circular motion of both push and pull that you need to use when cycling with cleats is much more beneficial than the push of normal pedals. Also, never stand up and pedal up a hill; rather gear down and remain seated.
• Regarding crouching for a bush wee while camping, see my blog post titled 'Planning a camping trip'.
• Swimming IS good for you, for the low impact exercise, the movement against resistance, and the massage effect of the water. Better still if the pool is heated.
• Consider investing in an automatic transmission car, especially if you have to spend a large proportion of your time driving in traffic or up hills.
Useful Links:
• Prof. Christa Janse van Rensburg
• Colin Hill Physiotherapist
• Dr Ingrid Louw
• C-reactive protein
• Humira
• Enbrel
• Sossusvlei, Namibia
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