Saturday, October 16, 2010

How Traditional Physical Therapy Almost Ruined My Knees

This is the story that I figured, one of these weekends, I'd get around to telling.

It's the story that explains why, in preceding posts, I may sound a tad bitter when I disparage those who believe in "quad-strengthening" to relieve chronic knee pain.

Yeah, I'm a little bitter -- a little angry even -- because of a bad personal experience, which showed me in convincing fashion why this "strengthen the quads" focus is pretty dumb.

Here's what happened:

I had just returned from a two-week vacation with my fiance in Tibet. Beautiful countryside, and we ambled about at a slow pace (Lhasa, where we spent most of our time, is a two-mile-high-plus city, which left us gasping for oxygen much of the time). At that point, I'd been battling knee pain for about five months. So it was still early days for my condition, you might say.

When I flew back from Tibet, my knees felt pretty decent. I even started to wonder: "Could I be cured?" (Of course now I know joint problems don't mysteriously resolve in two weeks, but in Tibet I did manage to find, by accident, a sweet spot of motion interspersed with non-stressful resting positions.)

Soon after my return, I marched into my physical therapy appointment with a big grin: "I feel pretty good," I said. My therapist responded with a broad smile and said, "It's time to hit the weights!"

Of course, I thought. This is the perfect opportunity to build up my quads, at last! For months I had been thwarted in my efforts to do so -- my knees reacted badly to the exercises that my PT prescribed. He had modified my daily exercise regimen, ad nauseam, to no avail. But my joints feel better now, I thought triumphantly.

He showed me a "safe range" for doing leg presses and seated leg lifts. For example, with leg presses, he told me to push the chair on the machine as far back as possible and to focus on doing the exercise at a nearly full extension, so as not to put pressure on the kneecap. He also showed me a "safe range" for the leg lifts.

I began visiting a gym during my lunch hour. During the exercises, my knees felt fine. My muscles would burn a little and I thought, "This is great, I'm finally getting my quad strength back." But I soon noticed something rather odd. The next morning after my little workout, I would wake up with a small, focused, intense burning in my knee joints -- a symptom I'd never had before.

My PT didn't seem worried by this, so I kept doing the exercises. Unfortunately I began noticing more of the next-day symptoms, and what's more, the overall condition of my knees took a dip for the worse. It soon became obvious that my problems were roaring back. So I stopped doing the leg presses, thinking they might be too stressful. Then, after a while, I noticed for the first time my knees were becoming uncomfortable DURING the seated leg lifts. I took this as a bad sign. Plus, I had developed a small amount of swelling in the joints.

But you know what I was thinking, in the back of my mind, this whole time? I can't give up; I need to strengthen my quads ... once my quads are strong enough, this swelling and pain and discomfort will go away ... my physical therapist must be right about this; after all he studied anatomy and went to school to help people like me and besides everywhere you look online, the advice for cases like mine is "strengthen your quads!"

Then one day I stopped kidding myself. I wasn't getting better. I was getting worse -- a lot worse. Whatever hole I had been in before had become about twice as deep. Occasionally I would leave my desk during the workday and slowly shuffle around nearby streets, just to try to relieve, a little bit, the awful burning in my joints. And that's when I began to realize that the traditional approach of physical therapy to treating bad knees -- those with chondromalacia, PFPS -- was badly flawed.

Now if there's a PT reading this, I bet that person is thinking, "Well, the problem was that your physical therapist had you doing too much! You were lifting too much weight, or lifting weights too often."

To which I would reply: I could have done less weight, and probably it would've taken longer for the symptoms to arise. But why not face the real issue: my knees were still weak. Strengthening muscles requires a lot of force (relative to strengthening joints), and one thing that weak knees can't tolerate, is a lot of force.

About that time, I began to drift away from physical therapy (until then, I had been the perfect patient, doing my stretches and exercises every morning). I began crafting my own program to save my knees, a program that took almost a couple of years, but that gave me back my knees and the physically active lifestyle that I missed so badly.

That's my story. Anyone else want to share?


  1. Sure, I'll share. I first went to the doctor for my knees around 2006. I was 33. I had been a runner, but slowly I started to notice slight pain when running. Eventually I had sharp pain going up and down stairs, and noticed that my knees felt generally weak. I felt I was young for such a problem, so I put off going to the doctor for about a year and a half.

    The first doctor I went to diagnosed me with patellofemoral syndrome. Looking at my x-rays he said that my kneecap was not optimally shaped… something about it not being symmetrical. He spent about 8 minutes with me, talking a mile a minute, and then left me with this nurse who proceeded to give me these huge leg/knee braces that were supposed to help me. They were the most ridiculous things—they would not fit under pants, and worn with shorts, I couldn’t imagine going out of the house with them on. I never wore them.

    He sent me to a physical therapist who gave me exercises for the inside of my quad muscles and quads in general. I did notice some improvement as I did these exercises. My knees were not all that bad yet—not as bad as they are now.

    I slowed down on the exercises and eventually the pain returned. I did not like the rush job I got from the first doctor, so I went to a second doctor. He spent a lot more time with me, talking about q angle. He said mine was too large. It made sense to me. So he sent me to a different PT, who definitely had different ideas. His focuses were stretching, hip exercises, core and hamstring exercises, and massaging over the IT band (not to loosen it, but to loosen the adhesions). The other thing he did was to tell me to stay active (biking and walking). Over time, those activities had produced not pain but a sort of instable feeling afterward, and being more prone to pain. He said not to worry about that. So I kept going (big mistake). Also, I did not feel his exercises were helping very much.

    I think I hit a new low when I took a trip to San Francisco this summer, where I had to walk up and down steep hills (about 3.5 miles) every single day. My knees got worse each day. It was awful. When I came home I was pretty worried about it. They did feel better as I stopped using them so much, but they definitely seemed to have turned a new corner. A few weeks later I was biking and had pain in one knee—this was a first. I went home and started reading more about chondromalacia online. All I seemed to be reading was either stuff that had not worked for me, or stories of surgery and chronic pain. I spiraled downward into a depression. I cried every day. I had always been active and figured that I would always be. I did not know what to do other than wait for the inevitable.

    Then I found this blog, and Doug Kelsey’s website. And I had a smidgeon of hope where I had none before. I am trying some exercises that DK suggests in his book, the Runner’s Knee Bible… some seem to be good, though something is aggravating my knees, so I’m trying to figure out which is which. My knees feel pretty bad right now. But hopefully in a year or so, I will be able to say that they feel better!

  2. What a story! Thanks for sharing -- I used to be a runner and grew to love it, so I know that's a hard sport to give up.

    I noticed that the first doctor said something about your kneecap "not being symmetrical." But the second doctor didn't mention this? Now maybe if you went to a third doctor he would not mention the "Q angle." Which would probably confuse the heck out of you as a patient.

    I haven't looked into the Q angle much but it's very much a structuralist approach. Now maybe it is the Q angle that's causing your problem. Or maybe you can find a woman in your running club with an even worse Q angle who has no knee problems. Or maybe it's your Q angle coupled with the fact you sustained a minor injury and didn't know it. Or something else. I don't know. What I do know is with the dreaded and vague "pfps" it behooves a patient to get multiple opinions.

    San Francisco sounds like it was a bad experience. Going downhill is VERY hard on your knee joints (if you read my book, you'll see I had very strong legs and I pushed my knees over the edge with a long mountain hike). Your trip sounds like it put you in a deeper hole.

    It's important to have hope though and a plan going forward that makes sense. Doug is the guy as far as physical therapy goes -- hands down, no question about it. At one point I even thought about moving to Austin, Texas, for a year so I could benefit from Kelsey's approach. It turned out that I did have many of the answers though, so I never did ... it just took me a while to get better. My story is a story -- meant to be inspiring because I figured out a lot through my research (and reading people like Doug) and in the end I beat this thing, thank God.