Thursday, May 26, 2011

Comment Corner: Structuralists Run Amok?

I harvested this comment from my last post. It intrigued me for several reasons. I have edited it down a fair deal. Take particular note of the bolded points, which are discussed later:
I have knee/leg problems including chrondromalacia patella, weak VMO, tight ITB. I used to run in college but since then have spent most of my life sitting down. I attribute my problems to the sitting, not the running.

After having no improvement with PT (leg lifts, quad strengthening, stretching, partial squats, balancing, patellar taping) I got synvisc in one knee in January. Wow, it worked!
Since I felt much better (down to 2-4 extra strength ibuprofen a day) I figured I had a window to get my legs stronger before the synvisc wears off. So I did bodyweight squats and 20 pound goblet squats, one-sided calf raises, lots of stretching, and some very light jogging. I also tried walking around in vibram "5 fingers" barefoot shoes to give my feet and ankles exercise.

Now my leg muscles are all noticeably bigger and stronger - but my knee joints themselves HURT much more!

My guess is I made my quads and calves too strong and now they are yanking more on my patella causing cartilage damage. I also have some muscle soreness on my anterior thighs right above where VMO meets my knee joint. I don't know if that means my VMO is weak compared to my other quads or too tight or what. I also get ankle pain now!

My question is - how can I get my legs back into alignment? Should I avoid strength exercises and let the quads weaken? I have been taking it easy but still have joint and muscle pain.

I saw you recommend low load high rep for knees, does that advice apply even when I have pretty strong legs that might be causing the problem?
Before we walk through this, my standard disclaimer: I'm not a doctor, of course. I don't even play one on TV. Nor am I a physical therapist. I did, however, heal my own knees -- which both my doctors and physical therapists had given up on -- after much research and experimentation (the full story of which I recount in Saving My Knees).

So consider the following just "interesting things to think about and discuss face to face with a medical professional."

Now, here are the bolded parts of the anonymous commenter's story that caught my eye:

1. weak VMO, tight ITB

Who said you had a weak VMO (a physical therapist, I bet)? Do you really believe that building up your VMO vis-a-vis the other muscles in your quadriceps is possible? Because that's the trap you find yourself in -- if you think you need to strengthen only the VMO, then you have to believe that you can successfully strengthen this muscle in isolation. But here's the problem, according to Doug Kelsey, chief therapist at Sports Center:
This is the number one myth of knee rehabilitation ... isolated strengthening of the vastus medialis oblique (VMO) ... The VMO is one of four muscles which all share the same nerve: the femoral nerve. Muscles contract when nerves tell them to contract. Since the VMO has the same nerve as the other three thigh muscles, it will contract along with the others ... there is no anatomical support for the idea you can isolate and strengthen the VMO ...
As for the tight iliotibial band: what was causing it to be tight? After all, maybe you were told to stretch it (which is a waste of time, for starters), but my first rule of healing is that you not only have to find out what's wrong, but also what's causing it to be wrong. Here's Kelsey on a big reason for a tight ITB:
... pain felt on the outside of [the] knee may be due to swelling from inside the knee. The fluid accumulates in the small pocket under the IT Band. The tendon then rubs on the swollen tissue causing pain. The solution is to improve the health of the joint and reduce the swelling instead of stretching the IT Band.
So if you can't build up the VMO in isolation -- and if your tight ITB is caused by a bad joint -- then the solution isn't to improve your body mechanics (which is probably what a "structuralist" physical therapist would advise). The key is to get that knee joint healthier. However, here's what I bet your PT prescribed: exercises to build up your VMO and stretches for your tight ITB. If so, you were already probably heading down the wrong path ...

2. but since then have spent most of my life sitting down

Ah. There's an interesting clue.

Here's what I'm guessing: you got a Synvisc injection into a joint where the cartilage had significantly softened/degraded. After the injection, instead of thin, watery synovial fluid passing over and into damaged/soft cartilage, you had thicker but synthetic "synovial fluid" passing over and into damaged/soft cartilage. Notice the one unfortunate constant in both before and after: "damaged/soft cartilage."

3. I felt much better (down to 2-4 extra strength ibuprofen a day)

Whoa! To me, having to take 2-4 extra strength ibuprofen a day isn't a sign that I'm feeling great. Sounds more like I'm soldiering through pain. You may be a tough guy. That can be good sometimes. But it can also lead you to push too hard -- that's a common tough guy mistake with bad knees.

4. I figured I had a window to get my legs stronger before the synvisc wears off

Uh oh. Now I'm getting a bad feeling. You know, you sort of sound like I once did -- because that was precisely my thinking once upon a time, when I considered getting a Synvisc injection. The trouble is Synvisc doesn't last all that long: generally five weeks at least, and up to six months. So here's the situation: you're someone who, since his running days, has spent "most of my life sitting down," you're about to embark on an ambitious muscle strengthening program (for someone who hasn't done much for the preceding x years, full-body squats and goblet squats certainly strike me as ambitious), and you want to acquire that muscle strength before the Synvisc wears off, in as little as five weeks ...

Now here's the tragedy. If traditional physical therapy were correct -- if the key to beating chronic knee pain lay in muscle strengthening -- you'd be golden. Your analysis would be dead on. But, if your knee joints are too weak, muscle strengthening is yet another kind of trap, and a frustrating one at that. And even with a Synvisc injection -- it will help, but remember you still have some bad/soft cartilage in your joints, most likely -- you can still plunge headfirst into that trap.

If muscle strengthening is the correct approach, then congrats! You've just escaped knee pain. But if it's not, and your joints are weak, then you've probably exacerbated the knee pain you're trying to overcome. And you do admit that, while you now have strong thighs, your knees hurt much more.

5. My guess is I made my quads and calves too strong and now they are yanking more on my patella causing cartilage damage.

Hmmm. That's not my guess. That's certainly a structuralist sort of guess -- that you've strengthened yourself out of alignment. I find another theory much more likely: you seized a window of opportunity (granted by the Synvisc), as you should have. Good move. But you seized it by going full-tilt on muscle strengthening when you should have dialed back a bit and instead gone full-tilt on joint-strengthening. Synvisc, along with some handy ibuprofen, pushed you to greater levels of leg strength. Meanwhile though, you were doing more damage to your joints.

Again, I simply present these as things to ponder. I could be right, I could be wrong. But I found that joint-first was the way to go in my recovery. It's slow, admittedly -- you're not going to get all the way to where you want to be in two to three months -- but you certainly can make good headway and get on the right path.


  1. Thanks for responding.

    I do think getting legs stronger is a good approach but I went too fast. Muscles get stronger much faster than cartilage does! As you wrote, this is the major failure with the tradition PT approach to knee problems. Also a major failure of western lifestyle of sitting down all week then being a 'weekend warrior' which leads to injuries.

    I can tell my VMO is weak because that area gets tired and sore after I do a lot of walking, and the rest of my quads are fine. I saw online some people use electric stim on the VMO. My PT did not. However, if it's the same nerve then I guess stim on the VMO would also contract the other quads.

    I am also curious if you got pain and soreness right below the patella. Not behind it where the cartilage is, but the soft area just below the kneecap. A tendon maybe?


  2. My pain was mainly diffuse pain in the area of the kneecaps. I didn't really have a problem with localized, recurring pain in a specific place (though, over the course of many months, I had little pains in various spots).

  3. Hi Richard,

    I'm writing a comment, because I couldn't locate an email for you.

    I work for Doug Kelsey and I'd like to speak with you. We appreciate your support of Doug and his philosophies!

    Please contact me at