The x-ray

From time to time, I recognize instantly when I have taken the first step on a journey. Or, in this case, the first limp.

I was sitting at home when I received a phone notification that a new test result was available for me to review on the patient portal for the electronic medical record system used by my healthcare providers. I clicked the link, logged in, and there it was: my knee x-ray images and the radiologist’s report.

For those who don’t speak defensive medicalese, the report said I have moderate to severe osteoarthritis in my right knee, with bone-on-bone contact in the medial compartment (the inside part of the knee). There were also bone spurs and some mild degenerative changes in the lateral compartment (the outside part of the knee) and the patellofemoral compartment (the kneecap area).

After the radiology technician shot and had a chance to view the first xray, the tone of my interactions with her changed. It was remarkable. As I came in she was cold, businesslike, barely looked me in the eye. Now her voice softened, she moved at a more deliberate pace, and I swear I felt the warmth of her concern as she put her hand on my forearm to help me hold the cartridge for the “sunrise” view of my knee.

She knew after seeing the first picture that my knee f*cking hurt.

When I viewed this little defensive blurb of an xray interpretation later I winced. I suspected this was the issue, but there were other possibilities to explain my sudden episode of severe pain around and above this knee. I could have been ridden with gout. Or had a torn meniscus. Or a ligament injury. Or an infection. Or cancer. The list goes on.

But no. It was the osteoarthritis rearing its ugly head. The degenerative changes that had been creeping up on me for years, silently stealing away my knee’s cartilage and cushioning, had finally reached a tipping point. The bone-on-bone contact was causing inflammation, swelling, and pain. This ain’t getting better.

That was limp one.

For those who don’t know, I lived for three decades of my life, from about age 29 to 59, morbidly obese. I weighed more than 400 pounds that entire time, and for a stretch of about six years I was over 500 pounds. I had a 66 inch waist. At the end of the second of those three decades I moved to New York City and began commuting in the NYC subway system. I walked a lot, and I climbed a lot of stairs. My knees took a beating.

Fifteen years ago, I had a vertical “sleeve” gastrectomy. The left-hand two thirds of my stomach was removed. What’s left resembles a shirt-sleeve on x-ray, hence the name. I lost 150 pounds in six months. Don’t let anyone kid you about weight loss feeling good. It doesn’t. Remember, there aren’t any obesity problems in Gaza. But, that’s another story.

In the first year after the surgery, chondromalacia patella emerged in this knee. The culprit then was musclular wasting after surgery. It had weakened the leg muscles that held my kneecap in place. The kneecap started to track laterally (to the outside of the leg) instead of straight up and down in its groove on the femur. This caused pain and inflammation behind the kneecap, especially when going up and down stairs. Physical training strengthened the muscles, and I was able to manage the pain with NSAIDs until I recovered enough muscle to stablize the kneecap to once again walk pain-free. That was 13 years ago.

My weight loss is probably mostly responsible for the fact that I have lived without significant knee pain for the last 13 years. But, the damage done during those three decades of morbid obesity was already in place. The cartilage in my knees had been slowly wearing away for years. The bone spurs had been growing. The degenerative changes were happening.

Chicken, meet roost. You’re home.

So, my doctor hasn’t even seen this film but I know what we’re going to do. I met a knee surgeon on match.com just after recovering from the chondromalacia patella episode in 2012. When our romance fizzled I went to see her to get an opinion about the knee. She told me basically I was headed to where I find myself today, and she predicted it would roughly be about when I qualified for Medicare, which is good news, because they cover the knee replacement.

F*ck. She was so right on I am considering going back to see her again. I hope her sports medicine practice still gets behind-the-home-bench seats for the Knicks.

People who act as their own doctors have a disturbed narcissist for a patient. I don’t do that. I will talk with my providers and specialists about all this and we will come to a consensus about what to do next, and when. Anyone’s first thought is going to be let’s try shooting you up with steroids and adding NSAIDs to your pain management for six months. Just like putting a sudden financial windfall in savings for six months so you can think about it, that’s a nicely conservative approach, but conservatism is not always the best approach. Maybe buying NVIDIA stock, or maybe just the S&P 500, is a better approach right now….

Because of rigorous self-honesty I know that I am coming into all this wanting to proceed thoughtfully but without futile delay to knee replacement. My other knee, the left, isn’t in great shape either. It has the same disease, it just seems to be lagging with respect to the right.

Because I have to do this in a health care system that had me wait two and a half hours to get a knee x-ray on the day before a holiday, nothing is going to happen in a hurry. Also, the foot thing I have been whining about since mid-September isn’t over, it has just faded into the background. That wound is healing, slowly, and there’s more diagnosting testing ahead of me to get to the root cause of that problem.

So, I limp on. I know many of you are facing similar challenges. Perhaps witnessing a care management professional struggling with managing their own care will bring you some comfort. This ain’t easy, even when one is fully steeped in the US medical finance and care coordination culture, as I am.

Thanks for being here.