The "Paperless billing was requested" (minor) scam -- AT&T edition

I got this AT&T text message the other day...

Except, of course, I never requested paperless billing. I suppose I should have for purely ecological reasons, but Emily prefers the paper copy. It’s her workflow — and modern email is unreliable for many people (flow control is the big issue).

I suspect this was a side-effect of some minor service agreement, like accepting AT&T’s recent (unexpected) increase in our mobile share data allowance. AT&T is showing a bit of its old dirty tricks here (they are generally much reformed), especially the requirement to correct this by (ugh) making an (ugh) phone call.

I will probably accept this one — it feels like a battle not worth fighting. AT&T isn’t alone in this sort of thing, corporations have become quite clever at tricking customers into accepting paperless billing — without, say, offering to share the savings.

The eBook is dying. I'm the only person on earth who blames the DRM.

My main workaround for eBook misery has been to buy from Google Play, strip the Adobe DRM, and store the ePub (really should be written EPUB but nobody does that) files in folders in Google Drive.

I do this because Apple is incompetent and, among other things, can’t produce a workable iOS eBook reader (Wait, audiobooks are now worse). A set of folders and descriptive file names is the most scalable solution we can manage across iOS and OS X. Yeah, I could leave Apple — if I cut off my right arm. Apple and Google live and breathe customer lock-in, and i’m well locked.

Since iOS 9 and some Google Drive update this no longer works. It still works for dropbox, so this is probably Google’s fault.

Nonetheless, it makes eBooks suck even more. 

Which brings me to those recent articles pointing out that people now buy paper books, not eBooks. I’ve read explanations ranging from mystical beauties of paper to the high cost of digital books. Nobody mentions the DRM (FairPlay, Adobe, etc) and the data lock, including proprietary file formats, that block development of decent cross-platform eBook solutions.

I feel like a raving loon. Or like the sighted man in the country of the blind ranting about the approaching lava flow.

Damnit Jim, it’s the DRM. 

How data lock destroys the customer experience - Apple edition.

But for FairPlay, I would not use iOS 9 audiobooks. I wouldn’t swear every time it loses its place. I wouldn’t be pissed at Apple.

But for proprietary data formats I would not use Apple Aperture. I wouldn’t be pissed at Apple.

And so on.

Rheumatic syndromes remind me of pre-quark particle physics

This mornings board review included looking at the evolution of “inflammatory osteoarthritis” from 1970 to 2015. What was once described as an acute “inflammatory” (suddenly red and painful) form of osteoarthritis was later reformulated as “erosive osteoarthritis”, “psoriatic arthritis” and some vaguely described disorder that gradually morphs from osteoarthritis to rheumatoid arthritis — not to be confused with seronegative arthritis.

Bah. Humbug. It’s as bad as our mushy and obsolete classifications of neuropsychiatric disorders.

Unlike the neuropsychiatric disorders (autism, schizophrenia, etc) though, the rheumatic syndromes remind me of pre-quark partial physics. Lots and lots of fermions (neutrons, protons, etc etc) with mysterious distinctions; understanding the composing quarks brought a sort of sense to the world. Perhaps one day we’ll learn that seemingly distinct rheumatic syndromes are combinations of underlying simpler pathologies that in different contexts (microbiome, immune system etc) seem to make up different disorders...

Ok, not a great analogy. Just a thought. Classifications are powerful though, and that means they can be misleading — and harmful.

Update: On a quick literature scan it looks like psoriatic arthritis treatments (TNF inhibitors) haven’t worked that well for erosive osteoarthritis, which does suggest that inflammatory arthritis split is clinically meaningful...

Fixing a painful wrist with high frequency weightlifting and wrist hyperextension. WTF.

In the spirit of my medical anecdotes, I present my left wrist.

Late Monday afternoon, while typing, I developed sharp pains in my left wrist. It hurt! I couldn’t type, though changing wrist position with a gel pad helped. Maybe, I thought, it was something with some recent mountain biking. Or maybe it was the high intensity CrossFit cleans I was doing. Whatever, it was obnoxious.

So I sort of splinted it with my weightlifting wrist wraps and then I waited to see what it would do.

It kept hurting, but another mountain bike ride didn't make it worse.

Maybe, I think, it’s an inflammatory arthritis of some kind. I’ve a family history and some intermittent personal history to worry about. Who knows.

I go to my morning CrossFit anyway. (Hmm. I wrote that one at 54. Now I’m 56…) Today the workout is muscle cleans and push press — about 180 of em. Great. That’s gonna hurt. I do the first 80-90 with a straight wrist, which is extra work. Then, between sets, I realize my wrist isn’t hurting any more. I do the next 90 with the usual wrist extension.

There’s some mild aching as the endorphins fade, but then nothing. Twelve hours later it’s slightly sore with unusual motions. [1]

If a patient came into my office with wrist pain back in the 90s I might have recommended ice, a splint at night, and some gentle range of motion exercises. Today somebody smarter might suggest something like the Dynaflex Pro. I don’t think anyone would recommend high intensity high repetition wrist extension weightlifting.

That’s what helped though.

I do not understand my increasingly aged body, and I don’t think I’m the only mystery. I suspect nobody really understands joints and backs. Once upon a time we recommended bed rest for sore backs, then we recommended activity and exercise;  I personally did well with relatively intense weight and flexibility training. More recently, mountain biking made my anterior knee syndrome slightly worse, but deep squats seemed to have no effect and conventional rehab seems to have helped. Today there’s the wrist.

Pity the poor physician who has to make a recommendation for someone’s sore wrist. It doesn’t work to say “I really have no idea”. It would be nice to know what’s going on though.

[1] I can make up a theory. I have reason to suspect I’m prone to dumping calcium into sore tendons and tissues — a counter-productive response that promotes inflammation. Bad genes I guess. Maybe the vigorous activity promoted clearance of some local calcium deposits. Maybe a stuck tendon sheath loosened up. Maybe the gods had mercy...

Update 5/1/2023: Almost 8 years later I can see this was probably the start of wrist involvement in my mixed-type arthritis. It became an on and off problem over the next 8 years. I'm on HCQ to slow progression and the symptoms seem to be dose responsive. It's annoying but not bad. When it's more bothersome I do "true pushups" or ring pushups or more reps at lower weights.

No, Apple News.app is not necessarily evil. Why do you ask?

[When first wrote this I chose an article, that, by chance, didn’t have a redirect to the original site. Which means I got things a wee bit wrong. Sirshannon gently corrected me. So now a bit of a rewrite …]

Viewing what I thought was a NYT article in News.app (turns out to be an Apple article that showed up on NYT page, which is kind of interesting) I can use Pinner.app 4.0 to create a Pinboard: Bookmark. That bookmark includes a URL like this:

https://apple.news/ABLDsKpUXSOafJmAr1FFtNg

From Pinboard app.net pourover and IFTTT (still around) share that link and my comment to app.net, twitter and my kateva.org/sh personal archive.

So far, so open. But what happens next?

If you access the particular link on an iOS device Apple launches News.app and you can view it there — both Safari.app and Chrome.app do the same thing.

If you access the link anywhere else you get this:

However, that’s not the end of the story (thought I thought it was). This link, opened in a web browser, redirects to a web page:

https://alpha.app.net/sirshannon/post/65149315#65148990

Apple does not redirect to the web version of the article. With NYT and other sources I chose one can open the News page in Safari.

This isn’t is surprising for two reasons. The first is that, even more than Google, Apple is all about Roach Motel class lock-in. The second is that, unlike the RSS of old, News.app has a viable ad-funded business model. Links to the open (perennially dying) web don’t fit that model.

So, despite my dire expectations, Apple, for now, is providing redirects to the web source. This doesn’t mean Apple will never interfere with the distribution of information that would hurt Apple’s business or offend its executives, and my confusion between NYT and Apple content is a bit weird (user error?), but for now News.app isn’t necessarily evil. I’ll be staying with Reeder and the lost mist-enshrouded all but forgotten Shangri La of RSS, Feedbin and Reeder until the last link dies  I’ll be experimenting with sharing News.app articles from it via RSS, Feedbin and Reeder ...

History: the printer has passed

First they came for the photo printer.

Then they came for the ink jet.

Now they’ve come for the rest.

Amazon return package label printing now includes ‘email to a friend’ and ‘request label by mail'

Yes, mail. Handled by people.

End an era, yes, but which era? 

Thirty years back — when we all had dot matrix printers?

One hundred and fifty years back, when typewriters became common?

Or do we go back to when paper became common in homes ...

Making of the modern pop song - fusion of the corporate and the anonymous individual

Bruce Springsteen and the E Street Band was the apex of my popular music connection. In a weird adventure of late childhood I attended Winterland's (San Francisco) last-but-one performance — featuring Springsteen.

These days my kids control the radio. So I hear a lot of country-pop and pop-pop. I assumed that music was made more or less the same way that Bruce did his work 30 years ago.

I couldn’t be more wrong. This month’s Atlantic Magazine included a short article that was the most surprising thing I’ve read in years [emphases mine]. It’s a review of John Seabrook’s book ‘The Song Machine’...

Karl Martin Sandberg, Mikkel Eriksen, Tor Hermansen and Other Songwriters Behind the Hits of Katy Perry and Taylor Swift - Nathaniel Rich, The Atlantic

The biggest pop star in America today is a man named Karl Martin Sandberg. The lead singer of an obscure ’80s glam-metal band, Sandberg grew up in a remote suburb of Stockholm and is now 44. Sandberg is the George Lucas, the LeBron James, the Serena Williams of American pop. He is responsible for more hits than Phil Spector, Michael Jackson, or the Beatles.

After Sandberg come the bald Norwegians, Mikkel Eriksen and Tor Hermansen, 43 and 44; Lukasz Gottwald, 42, a Sandberg protégé and collaborator who spent a decade languishing in Saturday Night Live’s house band; and another Sandberg collaborator named Esther Dean, 33, a former nurse’s aide from Oklahoma who was discovered in the audience of a Gap Band concert, singing along to “Oops Upside Your Head.” They use pseudonyms professionally, but most Americans wouldn’t recognize those, either: Max Martin, Stargate, Dr. Luke, and Ester Dean.

Most Americans will recognize their songs, however. As I write this, at the height of summer, the No. 1 position on the Billboard pop chart is occupied by a Max Martin creation, “Bad Blood” (performed by Taylor Swift featuring Kendrick Lamar). No. 3, “Hey Mama” (David Guetta featuring Nicki Minaj), is an Ester Dean production; No. 5, “Worth It” (Fifth Harmony featuring Kid Ink), was written by Stargate; No. 7, “Can’t Feel My Face” (The Weeknd), is Martin again; No. 16, “The Night Is Still Young” (Minaj), is Dr. Luke and Ester Dean….

… The illusion of creative control is maintained by the fig leaf of a songwriting credit. The performer’s name will often appear in the list of songwriters, even if his or her contribution is negligible. (There’s a saying for this in the music industry: “Change a word, get a third.”) But almost no pop celebrities write their own hits. Too much is on the line for that, and being a global celebrity is a full-time job. It would be like Will Smith writing the next Independence Day.

… We have come to expect this type of consolidation from our banking, oil-and-gas, and health-care industries. But the same practices they rely on—ruthless digitization, outsourcing, focus-group brand testing, brute-force marketing—have been applied with tremendous success in pop, creating such profitable multinationals as Rihanna, Katy Perry, and Taylor Swift...

.... “It’s not enough to have one hook anymore,” Jay Brown, a co-founder of Jay Z’s Roc Nation label, tells Seabrook. “You’ve got to have a hook in the intro, a hook in the pre, a hook in the chorus, and a hook in the bridge, too.”

Sonically, the template has remained remarkably consistent since the Backstreet Boys, whose sound was created by Max Martin and his mentor, Denniz PoP, at PoP’s Cheiron Studios, in Stockholm. It was at Cheiron in the late ’90s that they developed the modern hit formula, … Seabrook describes the pop sound this way: “ABBA’s pop chords and textures, Denniz PoP’s song structure and dynamics, ’80s arena rock’s big choruses, and early ’90s American R&B grooves.” ... music is manufactured to fill not headphones and home stereo systems but malls and football stadiums. … Session musicians have gone extinct, and studio mixing boards remain only as retro, semi-ironic furniture.

The songs are written industrially as well, often by committee and in bulk. Anything short of a likely hit is discarded. The constant iteration of tracks, all produced by the same formula, can result in accidental imitation—or, depending on the jury, purposeful replication….

… Hits are shopped like scripts in Hollywood, first to the A-list, then to the B-list, then to the aspirants. “. The most-successful songwriters, like Max Martin and Dr. Luke, occasionally employ a potentially more lucrative tactic: They prospect for unknowns whom they can turn into stars. This allows them to exert greater control over the recording of the songs and to take a bigger cut of royalties by securing production rights that a more established performer would not sign away...

… K-pop, a phenomenon that gives new meaning to the term song machine. Lee codified Pearlman’s tactics in a step-by-step manual that guides the creation of Asian pop groups, dictating “when to import foreign composers, producers, and choreographers; what chord progressions to use in particular countries; the precise color of eye shadow a performer should wear in different Asian regions, as well as the hand gestures he or she should make.”

In K-pop there is no pretension to creative independence. Performers unabashedly embrace the corporate strategy that stars in the United States are at great pains to disguise. Recruits are trained in label-run pop academies for as long as seven years before debuting in a new girl or boy group—though only one in 10 trainees makes it that far...

Of course it’s hardly surprising that pop songs have evolved to match the most common interests of the biggest audience. What fascinates here is the fusion of the modern corporate model with the peculiar talents of three Scandinavians and one American, and the purity of “star power” required of the modern pop performer.

I wonder when the nsAIs (non-sentient AIs) will displace those Scandinavians. Apple is famously vertical and AI-pop is the obvious next step after K-pop.

I’d love to read a Madonna essay on the topic, she seems now a bridge between the old world of Springsteen and the new world of Katy Perry. 

Vanguard voice biometric enrollment: the wrong way to do security

This showed up in my email. What’s wrong with it?

It tells me to click on a link to get started. How do I know this is really a Vanguard email? 

For something involving account security at this level it should give me instructions on how to proceed after I’ve logged in to my Vanguard account.

I believe this is a legitimate email, but I can’t trust it.

If you want to take a nonagenarian for a six hour flight to San Francisco...

If you want to take a mildly demented barely ambulatory nonagenarian out of his nursing home bed for a six hour flight to San Francisco you may be insane or murderous. Or perhaps your 93 yo WW II vet is in better shape than mine.

Or maybe you’re prepared.

I did this. Actually, my brother and I did this together, except for the plane flights where I went solo with Dad. We did it because my 93yo father had one request left in his life — to see his younger sister in San Francisco. And, thanks to an accident of Quebec’s healthcare and his disabled vet status, he had money to pay for the trip. 

Of course when I agreed to fulfill his wish he was 3 months younger than when we actually went — and significantly stronger. Old old age is like that.

Stil, we went. And because my brother joined us in San Francisco it went pretty well. Luck helped — we had perfect flights and transportation.

I don’t know anyone else who has done this, but I’m sure hundreds have. Somebody gets those old vets out for Normandy ceremonies.  On the other hand, I suspect those guys are in better shape than Dad (some of ‘em probably run foot races and jump hurdles).

If you want to do something like this, and before I dump all my trip memories (we aren’t doing this again), here’s what I learned:

• Airlines don’t make this super clear, but if you press a bit you can schedule wheelchair pickup from the front desk to the airplane seat. Do this. Do not do what I did, which was to make use of my father's transport wheelchair, walker, and my own strength. We might still be walking from the plane to the car rental office if a Montreal (YUL) security officer didn’t volunteer to push my father’s chair while i juggled luggage and walker. There’s no fee for checking a wheelchair or walker and you can also do plane side check with either. If you have the airlines doing wheelchair transport you’d check the transport chair and the walker in oversize baggage.
• During flights you want your 90+ yo in an aisle seat. They can’t necessarily get out of a window seat, especially when (in our case) the armrest divider was fixed. Inside passengers can typically squeeze buy ‘em - 90+ yo men tend to be small. Assume 2-3 bathroom trips a flight unless your guest has a catheter or is used to using a diaper. Bathroom trips require a physically strong companion — assuming your guest has some ambulatory ability. The seats need to be near the bathroom. We were in “business class seats” (not worth the money) and too far forward to use the assigned toilets, but the flight crew had us used first class which we could reach.
• You typically get to do special lines for customs and security. That helps. Carry food and snacks and water.
• You want two people for travel and care — at least one of whom should be strong (I’m strong, and my brother is stronger). At least one should be either a hospital or nursing home nurse (best) or a physician (not bad). If you’re using the airline wheelchair transport service you can make do with one person for that operation. Parenting experience is a plus.
• Get a “handicap” hotel room and an adjoining room with twin beds. My father needed an attendant for every bathroom visit — typically 2-5 a night. He slept in one of the twin beds and my brother and I took turns in the other. On our off night we slept in the handicapped room bed (king sized, one bed, which is weird hotel choice for a “handicapped” room but there you go). We used the handicapped bathroom with him.
• Whatever laxative routine is used at the care facility kick it up a notch. If warmed packed prunes are part of the routine bring those with you. Do not assume you’ll be able to buy them. Bring your dulcolax - both oral and suppository and glycerine suppository. Not ready to deal with poo? Don’t do the trip.
• Bring a waterproof bed sheet cover — as used with child travel.
• Wet wipes. Lots.
• Bibs - robust.
• Shirts: Purchase lightweight long sleeve travel shirts for summer travel. My father wears golf shirts at the Vets residence because he can take them on and off himself, but you need long sleeve shirts for sun protection and to reduce skin scrapes.
• Laundry: Assume you’ll do laundry 1-2 times, not least because you don’t want a lot of extra luggage. That still requires rolls of quarters at most hotels.
• If your nonagenarian uses pull-ups bring lots. If s/he doesn’t bring some.
• Assume most of the tourist stuff will be drive-by car touring. In our case I used Google and my own knowledge to construct a route made up of waypoints, then we used Google Maps on my iPhone to navigate from one waypoint to the next. Worked terribly well.  a handicapped parking card is a huge help (my aunt was with us and we could use hers) but with two people one can manage the 93yo and the other can drive around until pickup.
• Very limited alcohol - messes up sleep.
• Assume one social meal and 4 hours of drive by touring per day max. Every hour (at least) schedule a walkabout/transfer to keep bodies moving.
• Four days is a good visit length: one to travel/recover, one to prep/travel, two to visit and tour.
• Bring comfortable OTA headphones for your 90+ yo to listen to audio on long trips — something like Bose noise canceling headphones. But buy a set of the cheap airline phones in case he doesn’t like ‘em. (My Apple buds didn’t work with the airplane audio mini-jacks.)

There’s more but that’s enough for now — and probably the most I can remember since most of the traumatic memories are already fading. The good memories, because this trip actually, amazingly, worked, are getting stronger.

It could have gone quite badly though. This isn’t for the faint of heart.

American economy 2015: Ta-Nehisi Coates and Donald Trump lead to the same conclusion.

Donald Trump as the voice of the non-college 50%. TNC on the mass (black) incarceration society - and reparations. Hundreds of colleges produce no earnings boost (but lots of debt).

There is a common thread. America needs 40 million non-college jobs that pay $30 an hour.

That is our 21st century “Manhattan project” class challenge.

Get creative.

Google Trends: Across my interests some confirmation and some big surprises.

I knew Google Trends was “a thing”, but it had fallen off my radar. Until I wondered if Craigslist was going the way of Rich Text Format. That’s when I started playing with the 10 year trend lines.

I began with Craigslist and Wikipedia...

• Craigslist is looking post-peak
• Wikipedia looks ill, but given how embedded it is in iOS I wonder if that’s misleading.

Then I started looking at topics of special relevance to my life or interests. First I created a set of baselines to correct for decliniing interest in web search. I didn’t see any decline

• Cancer: rock steady, slight dip in 2009, slight trend since, may reflect demographics
• Angina: downward trend, but slight. This could reflect lessening interest in search, but it may also reflect recent data on lipid lowering agents and heart disease.
• Exercise: pretty steady
• Uber: just to show what something hot looks like. (Another: Bernie Sanders)

Things look pretty steady over the past 10 years, so I decided I could assume a flat baseline for my favorite topics.That’s when it got fascinating. 

• Inline skating (I do this) is dead and so is skateboarding
• Microsoft Excel is stable, but Google Sheets is way way up. Apple Numbers is doing a lot better than I expected.
• Special Needs has a slight downwards trend but Downs Syndrome has plummeted - perhaps due to America's eugenics program. I wonder if the fading of Downs syndrome is responsible for the modest decline in special needs searches.
• Cycling for exercise is somewhat down, with a nice seasonal spike pattern. Mountain biking has declined significantly.
• Cross Country Skiing varies (bet it’s snow depth) but seems constant at a low level
• CrossFit has probably peaked but is still popular.
• AI (artificial intelligence), much to my surprise, is way down.
• Growing use of searches on “Apple Quality” — probably not in a happy way (I’m betting this is Apple corp, not Apple fruit).
• Dementia is a slowly growing concern
• Backpacking is in a gentle decline
• Google seems to have flatlined and even Android is trending down, but Facebook has fallen off a cliff (hard to interpret, it’s so ubiquitous), Apple has slow growth but iPhone is only holding steady. Weirdly, Twitter looks rather like Facebook - not healthy at all.
• RSS. Sob.
• Health Informatics, my professional discipline, has had a big decline since 2004. It feels that way. SNOMED CT is in a lesser decline. On the other hand, family medicine is pretty stable (one weird 2011 peak) even as Geriatrics is in decline (WTF?)
• Carbon tax is off the radar and interest in global warming is way down. Be afraid.
• eBooks are post-peak - a failure to takeoff (I blame the DRM).

Some of these findings line up with my own expectations, but there were quite a few surprises. It’s illuminating to compare Excel to Google Sheets. The Downs Syndrome collapse is a marker for a dramatic social change — the world’s biggest eugenics program — that has gotten very little public comment. I didn’t think interest in AI would be in decline, and the Facebook/Twitter curves are quite surprising.

Suddenly I feel like Hari Seldon.

I’ll be back ...

See also:

• Research the past 200 years of memetic propagation: Google Books ngram viewer 12/2010

Repairing a 2010 RockShox Monarch RT3 - good luck getting parts

My 2010 RockShox Monarch RT3 rear shock is on its deathbed. It needs a rebuild or replacement (much more expensive), but it’s hard to know if parts are available. It’s easy to find parts for the 2012 model — but are they compatible?

The net was little help — until now. Buried in a footnote in the 2012 Rockshox spare parts manual: "2011-2012 Monarch parts are not compatible with pre-2011 Monarch rear shocks."

Tick bite causing meat allergy? (alpha-gal oligosaccharide allergy)

When Emily saw repeated comments online about a tick bite causing allergies to red meat we first assumed it was a mass medical delusion.

Turns out the belief comes from a Vanderbilt University allergy researchers claims and a 2009 WaPo article.

… Scott Commins, an assistant professor of medicine and lead author of the U-Va. study published in the Journal of Allergy and Clinical Immunology, said that in susceptible people such as Newell, a tick bite that causes a significant skin reaction seems to trigger the production of an antibody that binds to a sugar present on meat called alpha-galactosidase, also known as alpha-gal. When a person who has the antibody eats meat, it triggers the release of histamine, which causes the allergic symptoms: hives, itching and, in the worst case, anaphylaxis.

But many questions remain unanswered, said Platts-Mills, whose research is continuing. His lab has collected data on more than 300 patients from across the country and abroad.

"We're sure ticks can do this," he said. "We're not sure they're the only cause." Nor do researchers know why anaphylaxis is so delayed or why only some people develop a problem after tick bites. They do know that the allergic reaction is dose-related: Eating a tiny amount of meat probably won't cause a serious reaction. A large steak will….

The University of Virginia’s Thomas Platts-Mills is pushing the tick theory — though a recent abstract (article is $40) equivocates (emphasis mine) ...

The alpha-gal story: Lessons learned from connecting the dots

Our recent work has identified a novel IgE antibody response to a mammalian oligosaccharide epitope, galactose-alpha-1,3-galactose (alpha-gal). IgE to alpha-gal has been associated with 2 distinct forms of anaphylaxis: (1) immediate-onset anaphylaxis during first exposure to intravenous cetuximab and (2) delayed-onset anaphylaxis 3 to 6 hours after ingestion of mammalian food products (eg, beef and pork). Results of our studies and those of others strongly suggest that tick bites are a cause, if not the only significant cause, of IgE antibody responses to alpha-gal in the southern, eastern, and central United States; Europe; Australia; and parts of Asia. 

So the belief that a tick bite is causing a meat allergy has a basis in at least newspaper reporting and at least one team’s publications.

From my literature search it’s not clear anyone but Plats-Mills and his collaborators are making the strong connection to tick bites, much less to the Lone Star tick. I’d file this one under “suspect”. Of course that means that if Plats-Mills is right about the tick connection he will be well rewarded.

I’d bet he isn’t.

On knee pain and the state of medical knowledge (updated)

One of the interesting things about being old (45+, sorry to tell you that) and active and is that we develop conditions that we then get to read about.

That's typical. But if you're old and active and a physician there’s a twist. You get to compare the medical textbooks (and web references to your personal experience, and because of the old-part this reading is further informed by a finely tuned bullshit detector.

The bullshit detector is first developed in medical school. No, it’s not when we learn that following the exam preparation advice of professors is suicide — that’s the betrayal and pit-of-knives detector. For me it was the illuminating moment when I realized my 1986 renal physiology professors really had no idea how the kidney really worked. In their hearts they knew this, but there were exams to write and textbooks to teach to — so they faked it.

Later we run into seemingly erudite residents and medical students who we sooner or later realize are just spinning during medical rounds. Attendings varied in their response, I think some were hapless while others found it amusing. Or not amusing.

Much later, sometime after the first few years of practice, we realize that most journal articles are rather like those residents. (More recently reproducibility studies have made this rather more apparent.) We begin to spot the handwaving in textbooks — and to treasure the few that are relatively honest about ignorance.

Which brings me to my the pain below my left patella (knee cap). It could be related to the patellar tendon, to the “fluid-filled sacs” (bursa) that are usually said to be [1] under and around various tendons and neighboring bones, or the knee joint (cartilage/arthritis).

The cause is important to treatment. There’s nothing much to do for arthritis except rest and general muscle strengthening. Patellar tendonosis is treated with knee extension exercise starting at 90 degrees, but something (I’ll get to that) called “patellar-femoral syndrome” is treated with knee extension exercise starting close to full extension. So it’s good to differentiate those two.

The differentiation turns out to be relatively simple. If pain hurts coming down stairs (down > up) it’s likely “patella-femoral syndrome”; you won’t be able to do resisted extension at 90 degrees of flexion but you’ll be fine doing it at at 10 degrees of flexion. Also, “patello-femoral syndrome” is much more common than patellar tendonpathy. A related characteristic is that discomfort is maximal between 15 and 35 degrees (stair descent) — so I have no discomfort extended or in a deep squat.

The medical knowledge/bullshit detector bit comes with reading about "patello-femoral syndrome”. As far back as 1990 one of our texts, “Practical Orthopedics” by Lonnie Mercier, refreshingly admitted that this might as well be called something like “sore knee syndrome”. It’s probably a bunch of things involving some degree of irritation of the bursae and tendons (patellar, iliotibial) beneath and below the patella along the course of the patellar tendon. We used to think it had something to do with the cartilage below the patella, but as far back as 1990 Mercier’s text suggested that “chondromalacia patellae" was relatively infrequent, not clearly related to symptoms, and ought to be carved out as a separate diagnosis.

Reviewing a 2007 AAFP article it looks like nothing fundamental has changed [2]. So points to Mercier.

I wasn’t able to find a persuasive evidence-based treatment program for “sore knee syndrome”; I liked Dr Lee Cohen’s PDF for its guide to resuming exercise [3]. Basically I’m avoiding what hurts (flexing knee on stair descent), doing what doesn’t hurt (high rep, low pressure cycling and swimming), doing near-full-extension quad cybex-style weight. I'll increase extension range as the knee improves, and I’ll try some of Dr. Cohen’s routines. I don’t like NSAIDs because of repeated studies showing they delay tendon healing, so not doing those.

Once I can do squats with 50 lbs or so (very light) and run a mile or so without discomfort I’ll go back to CrossFit...

- fn -

[1] human anatomy is more variable than the diagrams suggests

[2] I don’t particularly recommend that article btw. It reminded me a bit of 1986 renal physiology.

[3] Low intensity mountain and road biking feels fine, so I’m doing that. I’m “on leave” from CrossFit until I can do squats without pain or swelling — one of the great things about contract-free CrossFit at our gym is they’ll stop fees if we’re out for 2 weeks or more.

Update 9/12/2015: Occurred to me that I should change to flats on my mountain bike until the knee is done healing (it’s improving well). Normally SPD cleats allow a lot of lateral mention, but sometimes my mountain pedals get jammed with sand. That’s a formula for worsening my knee problem. So flats for now (which, these days, work pretty well anyway).

Update 11/24/2015: I learned a few more things, which really ought to be in a textbook. 

My own knee did get better after a few weeks of CrossFit abstention, a bit less mountain biking (week off), and quad strengthening. Subsequently, however, I found CrossFit didn’t bother it much at all, but heavy mountain biking could be annoying. Since mountain biking season ended I have been mostly doing CrossFit and ice hockey — and it is now better. I ended up thinking the mountain biking was probably the greater aggravating factor.

Ahh, but there’s a twist as well. I have since learned that what mountain biking and stairway descent have in common is 15 degrees of flexion, which is when the patella is most in contact with the femur. At greater degrees of flexion strong quadriceps pull the patellar undersurface away from the femur — which is why my strong quadriceps limited the pain. Alas, the clinical presentation cannot distinguish inflammatory arthritis (idiopathic, as in OA involving primarily the synovium), from psoriatic arthritis (less idiopathic, with tendon involvement). In my case other clinical findings point to more chronic conditions - psoriatic arthritis or idiopathic inflammatory arthritis (aka, erosive osteoarthritis). So I’ll write a bit more about that sort of thing over time.