If Standard Physical Therapy Doesn't Work for PFPS, Why Does It Sometimes Work?

I'm not a believer in standard physical therapy, with its muscle-oriented approach, to treat PFPS (patellofemoral pain syndrome). So if I'm right, and it doesn't work, why then does it sometimes work? (Thus the paradoxical title of this entry.)

I think the easiest way to understand what's going on is through what I call the "socket wrench analogy."

Let's say you're trying to remove a nut from the end of a bolt. You're up on a ladder and you've spotted the bolt, attached to a brace that helps hold in place the rain gutter, which you're trying to rehang in a different location.

As any casual weekend handyman (or woman!) knows, removing the nut can be accomplished several ways. You can get a pair of pliers, squeeze the jaws around the sides of the hexagonal nut, and try to loosen it. Or you can use a socket wrench, a tool that has various snap-on pieces that fit various-sized nuts. A socket wrench is expressly designed to loosen and tighten nuts.

Here's what will happen if you reach for the pliers: In a certain number of cases, you'll succeed just fine. Pliers aren't designed to remove nuts from bolts, but they'll do the trick in a pinch. But then sometimes you'll come across that hard case, where the nut is stubbornly frozen. Using the pliers, you stand a good chance of not only failing but stripping the sides of the nut, thus making it almost impossible to remove some other way.

Now, with the socket wrench, you stand a much better chance of achieving your goal. Because this tool is specifically designed for the task.

So if your success rate with pliers is 55 to 65 percent, then your success rate with the socket wrench would be higher, maybe 90 to 95 percent.

With PFPS, if the success rate with standard physical therapy is 55 to 65 percent, then I would estimate that with a joint-focused approach, it would be significantly higher.

Standard physical therapy tries to save your knees through your leg muscles. I think it does work sometimes, and I suspect it works best for the milder cases of PFPS (just as that pair of pliers will remove the nuts that aren't too stuck). Strong legs do protect weak knees, so it's not as though having stronger muscles is a bad thing. Quad-strengthening exercises may overtax a weak knee, but if the joint isn't too weak (as with mild PFPS), perhaps no damage will be done.

Once you get a hard case of PFPS though, I bet that standard physical therapy often fails. Why? It's the wrong tool to fix the problem. Your problem isn't your leg muscles; it's your joints. So why not apply the right tool (joint-friendly exercises) in the first place to fix what ails you?

What I Did to Save My Knees

That's an ambitious title for a post -- too ambitious really (that's why I wrote a book) -- but I just realized that, through several months of entries, I haven't been very clear about how I saved a pair of knees that my doctors said would never get better. At the time I was in my 40s with chronic pain that one doc even diagnosed as arthritis.

Here's my short answer: Joint-friendly motion. A lot of it.

When I realized my hurting knees had to move, and had to move a lot, the first thing I did was jettison all the advice of my physical therapist. Because he wanted to improve my knees by strengthening the muscles around the joint. Anyone who's done exercises to build up muscles knows that they respond best to low repetitions of high force.

For a while, I struggled with my physical therapist's recommended exercise program, wondering why I wasn't getting better. My muscles weren't getting stronger; my weak joints sabotaged my attempts to bulk them up. Then, as I researched the science of joints more deeply, I realized: damn, this guy has been giving me lousy advice.

Strengthen the quads is the wrong prescription. Strengthen the joints is the right one.

My first invaluable insight into restoring bad knee joints came via Doug Kelsey, who is by far the smartest guy I've read on rehabbing injuries. He suggested that a soft tissue like cartilage (which is often implicated in knee joint pain and mine was definitely damaged) responds best, in a positive, adaptive way, to high repetitions of low force. High repetitions = thousands of times.

So that got me thinking. Hmm. What exercise gets you high repetition, low force? You may think: well, there's lifting a really light weight. Unh unh. Tried that. You'd be surprised how heavy a five-lb. weight becomes after you extend it with your bent leg 100 times. There really aren't many activities that are high repetition, low force. Two however came to mind: flat-stage, easy walking (for me, 2,000 steps equals about a mile) and gentle cycling.

Cycling was out. I hurt my knees cycling hard up mountains, and my knees got irritated and inflamed with even easy cycling on a stationary bike. I suspect this was because of the peculiar cartilage damage pattern (it was worst under the kneecaps and I think mirrored the contact points of my cartilage for the pedal stroke). Walking though was different: I had retained a decent ability to walk.

So I kept a knee journal as I began walking and increased my step counts, from week to week. It was slow. There were setbacks. But eventually I could hike for five miles in the mountains. Then a full thirteen months after I seriously began my rehabilitation, I climbed back on a bicycle. My back felt stiff and I was wobbly, like an old man, not like the guy who took second place in his age category two years running in a time trial series in South Florida just five years previous.

That return to the bike came 15 months ago. Now, finally, I'm back cycling at full intensity. My knees feel really good. They also make less-crunchy noises (indicating the cartilage has probably healed somewhat).

So why was I convinced that motion was so important for knees (I think it is the single most important thing, by far, to effect healing)? I did much, much research -- which is what I'll get into in future entries. And what do you do when your knees hurt too much to walk a few miles a day? Ah, I've been there. There are answers. When my joints were really weak, I used to walk around a pool, 101 steps, every 10 minutes, just to give them periodic "dosed" motion.

The key thing is to get on the right path to healing. That path, I'm convinced, involves just the right amount (and right kind) of motion. Moving is how you win the battle.

What's Your Knee Pain Personality?

While writing my book about recovering from chronic knee pain, I had a flash of insight: There are two dominant "knee pain personalities," if you will. They are both extreme, in their own fashion. Each personality type presented an obstacle to healing.

I call them the "Humpty Dumpty" and the "Warrior" (other colorful nicknames can be devised; these are the two that I happened to like best).

Humpty Dumpty types manage the long-running knee pain battle by being ultra-conscious of their fragility. These people have suffered enough setbacks to adopt caution as a byword. If they make a dash for the bus, and their knee swells/aches that day or the next, the lesson they take away is not to run for any more buses. Which at first seems sensible.

Notice though that they don't think, "How can I strengthen my knees so that they can tolerate an occasional sprint to catch a bus?" Instead they pencil "running for bus" on their mental list of "things that people with knee pain like mine shouldn't do." Over time it becomes a long list. A Humpty Dumpty is, in fact, prone to falling into the "bad knee death spiral":

Do less physical activity and --> your knees become weaker and --> your weak knees hurt more and --> because your knees are weak and hurt you do less physical activity and --> your kness become weaker and --> on and on and on ... until you've got a pair of really bad knees.

A Humpty Dumpty probably believes that knees are sort of like that brand-new car that, once rolled out of the showroom, has only so many miles on it. After time, knees simply wear out, as that car does, and there's not really anything that can be done about it. So a Humpty Dumpty is an interesting mix of prudence and resigned pessimism.

Ah, you may think: I'm not one of those! I know I have bad knees, but I'm still running/playing volleyball/hiking mountains/participating in the weekend touch football tournaments.

You may be the other extreme: a Warrior. That probably described my personality early in my battle with chronic knee pain.

Warriors have sporting lives full of props, and I'm not talking about running shoes or tennis raquets. Ice, that's a prop they like. (Over time, my bags of ice melted to the inverse shape of my knees as I stubbornly tried to continue my cycling-in-the-mountains routine.) Ice will quiet inflamed joints (until you remove it, I discovered). Or aspirin, or Advil -- those are good props that let you exercise through the pain (or help you through the post-exercise pain). Knee braces: yet another prop.

They accept their knee pain. They're tough.

And their knees don't get better either. Just as Humpty Dumpty's don't.

When I finally recovered, it was by cleaving to the middle path. I looked for ways to be active, but through gentle motion, and not too much at once. That was anathema to the Warrior in me -- I remember laughing scornfully at my doctor the first time he suggested that I cut back my cycling to ten minutes a session for a while, because my body was conditioned to going out hard for up to two and a half hours.

But later, when I began to learn more about what I needed to do to get better, in a real and lasting way, I realized I couldn't be a Humpty Dumpty and sit back and rest and do nothing and hope my knees would somehow improve on their own. And I knew that Warrior behavior was destructive too. By working out through knee pain, all I'd ever get would be a life sentence of more knee pain.

Those are big realizations to make. If you've got problem knees and are trying to chart a way forward, figure out your knee pain personality. Then ask yourself: Is my personality working against my long-term goal to get better?

Good (Knee) Habits

After a punishing, fast bike ride on Saturday morning (about 63 miles), I had just dropped onto my bed for a moment, post-shower, when everything I wanted to do that afternoon started clicking through my mind, like a slideshow at high speed. First, I was going grocery shopping -- that's a 1.5-mile trek to the nearest Trader Joe's and the same distance back, except the return leg includes carrying 10 to 15 lbs. of groceries in a backpack. Then I had to buy energy gels at the bike shop. Then there was the check to deposit at the bank.

And yet, I lounged around my Forest Hills apartment for a full hour before setting out for the grocery store. Why was I dawdling? I'm usually quite driven, with a fairly structured life.

Why? Good knee habits.

Three years ago, I couldn't have ridden 10 minutes on my bicycle, even at a ridiculously slow pace, without my knees burning. Cartilage under my kneecaps was damaged, seriously enough that it transformed my life. I couldn't endure bent-leg sitting. At home, I would have my legs extended and propped up on boxes. At work, I had them straight out too, hanging in a sling on the underside of my desk.

I did a lot of things to engineer a long, slow comeback. One thing I realized was important at the outset: good knee habits.

For example: When the temperature is below 60 degrees, I cover my knees when cycling (I own both knee warmers and leg warmers). During my recovery, whenever I went for long walks, I would stop halfway through and rest for ten minutes -- not because my knees hurt, but simply because I wanted to ensure they didn't start to hurt. Saving your knees is about being proactive, and smarter than simply following the adage, "If it hurts, don't do it." Once it hurts, you've already screwed up (a little secret that doctors and physical therapists don't tell you).

When I finally got back into shape cycling -- when my joints were strong enough to tolerate the 50-, 60-mile rides at high intensity that I loved so much -- I acquired a new habit. After a hard ride, once I dismount, I take at least one hour of down time before asking my knees to go for a long walk or do anything strenuous. So that means I return from cycling, exhausted, and lie on my bed for a little while or tap away at the computer or read a book. I give my knees a chance to take a breather.

Not because they hurt.

But because I don't want them to hurt again.