As I sat there on the edge of the examination table, idly swinging my feet and staring at my right knee, I felt slightly nauseous thinking about what kind of news I would shortly get from the doctor once he returned. Earlier in the month, I had suffered through an hour of a surprisingly loud MRI assessment, and now the orthopedic surgeon was in another room surveying the results. I heard a knock and the surgeon walked slowly into the room with a foreboding look on his face.
I initially injured my knee in high school during my senior year, 17 long years ago. During a basketball game midway through the season, I ran into an opponent while I was chasing down a rebound. I twisted at a funny angle as I was falling and I knew immediately I had done something serious. My knee swelled up to the size of a grapefruit immediately and I couldn’t put any weight on it. After an x-ray and removal of fluid, I learned that I had slightly torn my meniscus, but would not need surgery if I took it easy and let it heal. Of course, as a high school boy, there was no way I was going to follow the doctor’s orders. I was back on the court within a month, followed by a full season of baseball before graduating in the spring.
For years after high school, I played pickup basketball several times a week, slowly working my way up from a simple knee sleeve, to a fully loaded professional level knee brace for my bum knee. By the time I hit my late 20’s it would take me a day or so to get over an evening of pickup. During this stage of life, I got married and we had our first kid. Like most dads, I put on some baby weight just like my wife. Unlike my wife, I kept it on while she lost hers. My diet and exercise routine started to fluctuate as our lives became more complex. I would go through periods of laziness and weight gain, then guilt about being fat would motivate me to exercise and get back into shape. I probably repeated this cycle a dozen times over the course of 5 years.
By 2014, I started realizing that my knee was breaking down. Where once I could participate in as many sports as I could fit in my schedule, now a single hour of basketball resulted in days of limping in pain. But being a dad of three young children, basketball remained one of my few outlets where I could hang out with my friends and escape the stress of crying babies and dirty diapers once a week, so I chose to overlook the degradation of my knee. With increasing frequency, my knee would randomly lock up. I would be unable to bend it until I literally shook my lower leg around. There were days where my kids would want to race and I would have to graciously concede because there was too much pain. As my condition grew worse, I finally listened to my wife and went to a doctor to get it checked out.
Which brings me back to the doctor’s appointment.
He sat down in a chair in front of me and told me very bluntly that the inside of my knee looked like ground hamburger.
Apparently, I had the knee of someone 20 years older.
To be more specific, my lateral meniscus was completely gone, there were shards of cartilage floating around the knee joint, and my bones, which would normally have a smooth surface, were jagged and showing signs of osteoarthritis.
It was like getting punched in the gut.
For some background, let me explain the diagnosis. In a typical knee joint, there are two pads that cushion the space between your upper leg bone, the femur, and the two lower legs bones, the tibia, and fibula. These are known as meniscus. The lateral meniscus is located on the outside half of the knee and is responsible for absorbing much of the force generated from turning and changing directions.
Because my lateral meniscus had disintegrated over the years after being injured in high school, I now had nothing between my bones. Meaning that every time I stopped suddenly or changed directions quickly, my bones would rub against each other. So instead of smooth bones that would glide along the knee joint fluidly, I now had jagged bones that were grinding on each other and the surrounding cartilage.
Obviously, I asked the doctor what that meant for me. In the short term, he calmly stated that he could clear out the shards of cartilage and remove that last fragments of my lateral meniscus. If all went well, my leg wouldn’t lock up anymore and I probably wouldn’t have as much swelling following physical activity. But he made it clear, now that there was no cushion on the outside of my knee, my bones would continue to degrade and I would probably need a full knee replacement within 10 or 15 years.
When asked what I could do to improve the situation, he told me that losing weight and staying hydrated would give me the best chance of avoiding a full knee replacement. In the meantime, surgery was scheduled for the next month.
One month. 30 days.
I wanted the surgery to be as successful as possible, and I wanted recovery time to be as short as possible. Fortunately for me, I work in a research laboratory and have access to most of the world’s leading research journals. Part of my daily job includes exploring scientific literature, then applying it to issues of health. It was a no brainer to put this skill to good use in preparing for my upcoming knee surgery.
In research, the key to getting an effective answer is to start with a specific question. The question I decided on was: What is involved in the development and repair of the knee joint?
It turns out that while the knee joint is a tremendously complex body part, it is made up of three main components:
Because most of the issues with my knee were due to the degradation of cartilage, I focused on that area. Cartilage is deposited on the ends of bones by a combination of cells called fibroblasts and chondroblasts. The components of knee cartilage consist mainly of collagen and chondroitin sulfate. Collagen is formed when fibroblasts lay down layers of elastic fibers. Collagen gives tissues like skin, tendons, ligaments, and cartilage their flexibility. Chondroitin sulfate is a substance interspersed throughout cartilage, and while it has many different functions, it’s best known for being an anti-inflammatory signal to surrounding cells.
Minimising inflammation is key to reducing recovery time after surgery.
For one, any energy your cells expend keeping an area of injury inflamed takes away energy that could be directed toward the repair. In addition, inflammation typically sets off a series of events that involve the attraction and infiltration of immune cells to the site of inflammation. This is bad because immune cells are known more as destroyers than builders within the body, and for recovery purposes, one needs to promote as much energy to rebuilding as possible.
These facts led to some interesting discoveries. In addition to searching through the scientific literature, I also delved into several fitness and nutrition podcasts. I found that podcasts were an excellent resource to gain insight from top-level athletes and sports physicians. My theory was that anything considered beneficial for an Olympic or professional athlete should be great for me. Some of the podcasts I learned the most from included Tim Ferriss, Ben Greenfield, and Abel James (Fat Burning Man Show). I should note that while many of the guests I listened to used legitimate scientific literature for most of their claims, there were definitely some guests that promoted topics that I would consider very questionable in terms of scientific evidence (structured water and essential oils come to mind).
In several interviews, including ones with Dr. Peter Attia M.D. and Dr. Dom D’Agostino Ph.D., I learned how low-carbohydrate diets can both help reduce inflammation and increase the rate of recovery following surgery. I felt like I had stumbled upon a gold mine.
After doing some more in-depth reading, I became convinced that there were many reasons why a low carbohydrate meal plan could potentially reduce recovery time, while the disadvantages appeared to be minimal.
Before mentioning the potential benefits, let me give a brief explanation of a typical diet, then what your body goes through when you start restricting the number of carbohydrates. Here’s what I learned from my research:
First, an average U.S. citizen typically eats a diet consisting of red meat, processed and refined grains, potatoes, sugary sweets, and caloric drinks. This kind of diet and one that I participated in can lead to type II diabetes, obesity, and high blood pressure. It also wrecks many beneficial hormones like insulin, testosterone, human growth hormone, and thyroid hormone. There are many reasons why this type of diet is so damaging, but some of the most important ones are:
So why is limiting carbohydrates the answer to fixing these problems? Well, in simple terms, it’s not. Changing the composition of macronutrients (protein, fat, carbohydrate) does not necessarily improve the quality of your diet, but it can serve as a simple and effective framework for nutrition. But when you restrict the carbohydrates in your diet enough, some interesting effects occur. Human bodies preferentially use carbohydrates as fuel, as opposed to protein or fats, because they are more easily converted into sugars that can be converted to energy. When little to no carbohydrates are present, the body must transition into a state called ketosis, in which fatty acids, instead of sugars, are used for energy. The largest and most accessible source of fatty acids in a body is - you guessed it - body fat. This ketogenic diet has been shown to:
This all sounds great, but the reality of maintaining a ketogenic diet is not for the faint of heart. Through reviewing scientific literature and personal experimentation, I found that inducing ketosis (switching to fat burning mode) required me to eat less than 50 grams of carbohydrates per day for about 3 days. During my research, I had come across the term “keto flu” several times, and on my 3rd day of limiting carbs, I fully experienced this “flu”. The reason this term exists is that your body has to make some drastic changes to hormone and blood sugar levels to switch from sugar-burning to fat-burning. The symptoms of these changes, of which I have experienced all consistently when transitioning into ketosis include:
For me, the symptoms occurred mainly on Day 3 and went away quickly thereafter. I could usually minimize the headaches by taking Panadol or turmeric (Indian herb that has shown to be pain relieving).
So back to my knee surgery.
I probably researched ketogenic diets about a week before implementing one, leaving me about 3 weeks of preparation time before my surgery. My personal ketogenic diet consisted of eating less than 50 carbohydrates per day (tracked using the Myfitnesspal app), cutting out processed deli meat, eating several servings of broccoli and/or cauliflower, increasing protein consumption of chicken, beef, and pork, and increasing fat consumption using grapeseed oil (for cooking) and mayonnaise. I would eat absolutely no fruit, bread, pasta, or rice.
I started my diet on Monday, following a doozy of a Sunday in which I ate most of a large pizza and a pint of ice cream by myself. The first and second day of the diet was exciting. My energy level was at least as good if not better than normal, and I was motivated by many thoughts of having six-pack abs and ripped biceps. The third day, on the other hand, started with a headache early in the morning (which I initially attributed to a lack of coffee) and ended with me exhausted and trying to take a nap on the couch in the evening as my kids ran around trying to get me to wrestle them. By the end of the first week, I was running on fumes. The good news was that I had lost five pounds already. Research would suggest this was due mostly to water loss based on the amount of water sugar and glycogen sequestered in your body, but it was still exciting. However, the excitement of unlimited meat and cheese had hit its apex and I started to look upon simple saltine crackers as if they were the nectar of the gods. Also, I wasn’t even sure if the diet was working. To help keep my motivation up, I went to the local grocery store and bought ketosis testing strips. You urinate on these little strips of paper in the morning and they change colour if you have excess ketones in your urine, a sure sign that you have entered ketosis. 7 days after beginning the diet I used one of these strips, and when the colour change, while subtle, was visible I experience the joy akin to hitting a game-winning shot in a playoff game. It was incredible.
Over time I found that consistently checking my ketones levels every morning served to maintain my enthusiasm because when I was tempted to cheat I thought about how disappointing it would be to see no change in color of the test strip.
Another improvement I found to maintain a ketogenic diet was to incorporate more spices into my meals. Initially, I added simply salt and butter to my entrees, but after the monotony started to weigh on me, I explored some recipes that expanded my palate. This was essential in keeping enough variety to keep me interested.
As the scheduled surgery neared, I was feeling better about my situation but still nervous. I had lost almost 10 pounds, my energy levels had improved, and my sugar cravings had disappeared. It was much easier for me to avoid overeating since the increased fat and protein consumption quickly left me feeling full.
The surgery was scheduled for a Thursday morning. It was to be a laparoscopic procedure, meaning two small holes in the sides of my knee would be used to gain access to the interior of the joint.
When I woke up a little after lunchtime the doctor assured me that everything went according to plan, that there would be some significant pain for the next few days and I was to stay off of my feet if at all possible. He gave me a prescription for a full two weeks-worth of hydrocodone (pain medication), then the nurse wheeled me to my wife’s car.
I took a pill that night to ensure that I got a good night’s rest.
When I woke in the morning, I was very nervous to get out of bed. My wife had taken the kids to daycare, so I was home alone for the day. I slowly rotated to the side of the bed and then gingerly shifted my weight to my feet. My bum leg was wrapped all the way from my ankle to my hip in an athletic bandage (probably to reduce the chance of blood clots). As I grabbed my crutches and prepared to travel to the living room couch I was astonished. What I thought would be excruciating pain turned out to be very slight considering the situation. While my range of motion was limited by swelling and being bandaged tightly, there was no wincing or fear that I had made a horrible decision of going under the knife.
By the end of the weekend, three days after surgery, I no longer needed crutches to get around. It was exhilarating. On Monday I went back to work, and hardly anybody realized that I had knee surgery the week before. The lack of sympathy I received was slightly disappointing.
I started rehabilitation with a physical therapist a week after the surgery. The first session was mainly an assessment of my range of motion and muscle strength. While there was a noticeable amount of muscle atrophy, the therapist was very impressed that I was already near the full range of motion of my healthy knee and most of the swelling had dissipated.
Initially, my doctor had prescribed 8 weeks of rehab and told me there was a chance I would only need 6. But 3 weeks into the rehabilitation program it was very apparent that I was way ahead of schedule. The range of motion of my surgically repaired knee was over 95% of my healthy knee, and the strength of my hurt leg was almost back to normal. I was cleared to discontinue rehab within 30 days of beginning, a full month ahead of schedule. All the while maintaining a ketogenic diet.
The surgeon was pleasantly surprised at the speed of my recovery, and I made it a point to tell him that I thought being ketosis was instrumental in my recovery. My knee felt great, better than it had in several years. At 8 weeks post-surgery the surgeon cleared me to resume all physical activity, including basketball. I was to invest in a knee brace that limited stress on the lateral side of my knee, but there were no other constraints. I could not have been more satisfied with how everything turned out.
I am writing this article almost exactly a year after my surgery, and I assure you that implementing a ketogenic diet was the right decision for me. I have continued to maintain a ketogenic state for most of the year, but I have started incorporating cheat days intermittently. My total weight loss is currently at 17 pounds. Most importantly, the flexibility and health of my knee feel like it was over a decade ago. It no longer locks up and there is no swelling after my weekly night of basketball. Slowly but surely I have gained confidence as my leg has gained strength, and on most nights I forget that I’ve had serious knee surgery. In fact, I signed up to race a marathon at the end of the year. Overall, the prospects for my knee look great, and there’s a chance I might not need a replacement at all in the future.
