The Knee Thing

Teamster boss Jimmy Hoffa is either under a Jersey City landfill, a barn in the Detroit suburbs, the turf of the Giants old football stadium in East Redford or the 9th hole of a golf course on Wilmington Island. Nobody really knows (1).

We do know, however, where Hoffa’s fat pad is buried. Named after Albert Hoffa, a German surgeon who may have been Jimmy’s paternal great-uncle, the pad is located behind the patella and inside the knee joint capsule. It is part of the shock-absorbing structure of the knee joint (2). And because it extends into the space between the patella and the upper anterior joint capsule, it is uniquely vulnerable to being pinched by hyper-extension of the tibia.

When this happens the pad becomes damaged and inflamed, particularly if you eat the modern pro-inflammatory diet. Now the fun starts, because there are two more vulnerabilities; Hoffa’s pad is intensively vascularised (3), and it is intensively innervated (4). This means that after the initial trauma, swelling of the pad pushes it further up into the femoral/patellar space where it will almost certainly be traumatised again; and it will be very painful.

Now you don’t have to over-extend the knee to trigger that pain. It will come even after normal extension. Unless the problem is treated, you become progressively more immobilised. Getting up from a kneeling position becomes torture, and your exercise program is now on hold.

Treatment options include taping, tissue manipulation, orthotics, cortisone injections and in the last resort, surgery. None of these are particularly effective, and athletes and sports persons may require many months of therapy, even years, before they can regain peak performance.

I first encountered Hoffa’s fat pad at med school in 1968, and had forgotten it completely until half a century later, I developed hoffitis. 30 miles a week of hard walking on soft sand, with over-extension, did the trick.

A sports therapist told me I would need at least 8 months of expensive treatment, and 18 or more if I did not stop walking the beach, so I hit the bottle (of fish oil and amphiphilic polyphenols). I used the Balance test to bring my 6:3 ratio down to 1.5, and by 14 weeks the pain had largely gone.

This is not serious medicine, but it was a reminder of the effectiveness of the pharmaco-nutritional approach, and it allowed me to go back to the exercise I love and advocate. And there is, as always, a larger point. Hoffa’s fat pad is not unique. It one of many intra-articular fat pads (5, 6), whose role and importance is just starting to be understood.

Under the microscope these look like the kind of white fat that people accumulate in many tissues as they gain weight, but they behave very differently. They do not wax and wane with weight gain and weight loss, even at the extremes such as cachexia. They are not involved with calorie storage but play a role in joint health and maintenance by providing adipokines, local growth factors (7, 8), and progenitor stem cells (8, 9), all of which play a key role in replacing worn / damaged cartilage.

Cartilage is avascular, and receives nutrients from the synovial fluid and capillaries that lie under the cartilage plates.  During exercise, joint loading temporarily obliterates those capillaries, causing reactive hyperaemia, oxidative stress and microscopic cartilage damage. Intra-articular adipose tissue is probably involved in sensing this, and initiating a set of responses which impact on cartilage economics by down-regulating MMP expression, thereby reducing inflammation; and up-regulating chondrocyte and chondroblast activity (10), thereby increasing cartilage formation.

Regular exercise, via cyclic loading on the cartilage plate, also’pumps’ at least some nutrients into the ground substance (10), and instructs the cartilage to produce more local growth factors (11). This is why ‘normal’ levels of activity maintain healthy joints, whereas over- and under-use both lead to cartilage loss (12).

Nutrition comes in here too. The anti-inflammatory polyphenols, for example, inhibit MMP activity, slow cartilage loss and delay the progression of osteoarthritis (13). So do the omega 3 HUFA’s, although given that most fish oil products are badly mis-formulated, the evidence is not very clear (14).

These beautiful feed-back loops constitute a homeostatic system whereby joint structure and function is maintained within limitsappropriate to the levels of physical activity being undertaken.Our weight-bearing joints are naturally self-regulating, self-lubricating and self-repairing. In subjects taking regular but not excessive exercise, and with good nutrition, those joints will not tend towards cartilage loss and osteoarthritis.

In this brave new world, however, joints often do fail. Too many are in pain, bound up in canes and knee braces and the anti-inflammatory drugs which kill as many as 100,000 a year (15). Joints are forced into failure because the modern diet and lifestyle overcome all the homeostatic mechanisms we inherited from the evolutionary process.

Today’s combination of overweight, chronic inflammation and lack of exercise causes excess cartilage breakdown. In addition, our nutritional status is deeply compromised by the ultra-processed diet.

We are depleted not only in the anti-inflammatory polyphenols and omega 3 HUFA’s, but in most or all the micronutrients required to build cartilage.

Cartilage regeneration is therefore impaired; and with breakdown now outstripping regeneration, our cartilage plates inevitably degrade over time.

We then commit the profound error of thinking that this is an entropic and unavoidable problem caused by ageing. But it is not. It is just another symptom of cumulative damage driven by catabolic dominance, caused by chronic intoxication and an increasingly unnatural lifestyle. This is why the numbers of years lived with disability due to osteoarthritis more than doubled between 1990 and 2019 (16); and is driving the plagues of NCD’s currently overwhelming our healthcare systems.

Today’s plague doctors are taught only to bleed and purge their patients with pharmaceuticals. Natural pharmacology provides therapeutic tools (aka pharmaconutrition) which are cheaper, safer and far more effective. When today’s medical teamsters finally understand this they will move their focus from the treatment of symptoms, to prevention and cure. Only then will they be able to remove the handle from the pump (17), and stem the rising tides of disease at source.

Next week: Math trauma, and how to become unbreakable.

References: