Saturday, August 13, 2011

My Personal Experience With Structuralism

I've had a few negative things to say about structuralism, the view that muscular imbalances and biomechanical flaws are the root causes of chronic pain.

That's not to say that structure never matters at all. But an obsession with it isn't justified by the scientific evidence.

I encountered structuralism before even knowing what it was. My first orthopedist, whom I sought out because of my burning knees, initially said my problem was related to mistracking kneecaps. (Later, during our discussion, he either backed away from this diagnosis or forgot it -- I can't tell which -- because he didn't mention badly tracking kneecaps again.)

What was curious, he offered this diagnosis even before he saw my X-rays (which showed normally seated kneecaps that didn't appear at all prone to mistracking). I suspect now that he diagnosed me reflexively. Structuralist thinking is prevalent when analyzing causes of knee pain, and "mistracking kneecap" is high on their list of explanations of what's wrong.

My physical therapist also seemed to be a structuralist. He would occasionally take a few minutes of our session to study my gait and alignment, trying to find evidence my leg mechanics were out of whack. He never found anything, that I could tell. Later I realized my case probably frustrated him because I didn't fit the structuralist model.

My mechanics were fine. I just had bad knees.

In a previous post on this blog, I summarized a study that found no relationship between patella mistracking and the knee pain of patellofemoral pain syndrome. This is how I explained the study's conclusions (my bold):

… if you just look at MRIs of how someone's patella tracks, you'll have no idea whether they have PFPS. Someone with a kneecap that tracks perfectly may have PFPS. Someone with no knee pain may have a patella that mistracks. The authors make the point more bluntly in a follow-up letter to the journal where the study was published: "Our findings add to the evidence that patellar mistracking is not a clinically significant factor for most individuals with patellofemoral joint pain."

Since then, I've found an essay well worth reading by Paul Ingraham (a massage therapist, very bright guy, and voracious reader of medical literature). He wrote a long piece subtitled, "The story of the obsession with crookedness in the physical therapies."

He says:

In my opinion, most biomechanical problems are much less important than is generally supposed … Not only are structural explanations for pain generally unsupported by any scientific evidence, the last 25 years of research results mostly undermines them.

Read the whole piece. Ingraham hauls out a bounty of evidence that includes: a 1984 study in Lancet showing that leg-length discrepancies don't contribute to back pain, a European Spine Journal study that abnormal neck curvatures aren't connected to neck pain, and a British Journal of Sports Medicine article that major muscle imbalances in elite Australian-rules football players aren't related to the number of injuries they suffer.

The takeaway here is that, if you have bad knees that aren't getting better, you need to take control of your future and educate yourself in lots of ways. That includes understanding the framework for analysis that your doctor is using (which may not make sense). So learn to spot structuralist thinking (strengthen your VMO!), and when you hear it, ask some hard questions.

Certainly the road to recovery is long. But first, you need to be on the right road.


  1. Just saw a doc last week that gave me the mistracking diagnosis again (big q-angle, etc). I can really barely even notice the mistracking. I'm not sure it's really there. He only tested my left knee. Funny thing is, he did not test my right knee. Well, maybe he did for a milisecond, but he focused completely on the left. The left is worse, but I have chondromalacia in both knees. So... wonder how he'd explain that.

  2. Yes, women often get the Q angle diagnosis because of the wider pelvis. I haven't looked into Q angle much, but it does sound very structuralist. My mother has a wide pelvis and was a jogger for years without problems. Which means???