Saturday, November 2, 2013

What’s Your ‘Viewing Frame’ for Understanding Knee Pain?

I came across a cool story not long ago in a New Yorker article. The larger article was called “Giving Voice,” about how a surgeon pioneered methods to help singers regain the richness of their voices.

The story concerns the surgeon, Dr. Steven Zeitels, and a surgical laryngoscope -- a device that holds the throat open during operations -- that he designed.

The typical scope had an oval viewing area, even though the vocal cords (when viewed down the throat) form a triangle. His laryngoscope had a triangular opening. That meant he could see areas that were obscured before.

Using the old equipment, surgeons had concluded that cancers in the front of the vocal cords were especially deadly.

“The reason was, they didn’t see them in the first place,” Zeitel says. “They attributed a biologic process to the fact they never saw them!”

A beautiful story, for what it says about how we can unknowingly misinterpret the world because of the limitations of our viewing frame.

It’s true literally -- as with a piece of medical equipment -- and figuratively -- as with a set of beliefs that leads to restricted vision.

What does this have to do with knee pain?

In brief: everything.

One thing I discovered during my own odyssey with bad knees:

What your doctor or physical therapist believes about chronic knee pain -- what causes it, what are the chances of a bad joint healing -- matters a whole heck of a lot, because such beliefs directly influence what that person will advise you to do about the pain.

But, what I came to realize, is that they often see the problem through a certain view-restricted frame, sort of like that oval laryngoscope. That’s the frame of imbalance/crookedness. E.g., your knee pain is being caused by hip muscles that are too weak, or a hamstrings-quadriceps strength ratio that’s out of whack.

If you’re a doctor or rehabber, and you view knee pain this way, chances are very good for example you’ll believe that the origins of knee pain are a mistracking patella. But the important thing for patients to know (when your doctor or physical therapist presents this analysis as fact), is that this is just a theory.

Mistracking kneecaps may cause most patellofemoral pain. Or not.

Here’s a study (that I’ve cited a few times before) that provides evidence contradicting that theory. Researchers carefully observed a group of subjects and found no correlation between the degree of kneecap mistracking and knee pain. (Sure, it’s a small study. But the results are intriguing, certainly.)

The trouble is, if you believe that crookedness/imbalances are basically the source of knee pain (and that constricts your viewing frame), you’re going to waste a lot of time with subjects like me, who don’t have mistracking kneecaps, or other structural issues.

Of course, you might just conclude “patellofemoral pain syndrome cases that don’t have a clear cause related to muscle or structural imbalances are very hard to treat” (aping the language of our oval laryngoscope users). You might even venture that my condition is “unfixable” (I felt that my physical therapist, after a while, basically gave up on me).

And that would be a shame, because you would’ve given up on someone who eventually healed his knees.

(So what is the correct way to view knee pain with the aim of overcoming it? I would argue a perspective such as “envelope of function” makes much more sense. For more, see here and here.)


  1. Just finished reading your book in two sessions it would have been one sessions, but aching knees forced me into motion. Thank you, thank you I had a full reconstruction on my knee coming up to three years ago from a basketball game and still struggling with random swelling, sleepless nights, pain and stiffness etc.

    I am forty, I trained everyday in fitness and strength and was just starting a new career in personal training which I was starting to give up on. I love strength training and found it so hard to go easy. Your story was like listen to my own, yours seemed a lot worse!!

    It just makes so much sense what you have said. I now know my pain is not random. I know deep down what you are saying in your book is true. But everyone was saying strengthen your leg muscle etc.

    I look back on my own story while reading your book; my knee would feel good, so I push a bit more, then a bit of swelling, then rest, couple of days later sleepless night from pain, then start again endless cycle. I am now going on cartilage time and a knee journal with renewed hope!

    Thank you Richard

    Matthew from down under

  2. Matthew, have you been assessed for CRPS?

    cheers, TriAgain.

    1. What does it means “TriAgain”? From where is coming “Tri”? Thanks!

    2. CRPS = Complex Regional Pain Syndrome. Often triggered by knee surgery.

      If that's the question you're asking?


    3. My pain is not constant it only happens about once or twice a month, then slowly gets better with over a week. CPRS sounds like it goes on for months. Also when I do wake in pain I feel it in another joint such as hip or shoulder as well and always on one side of the body. Perhaps this sounds like arthritis I had rheumatoid blood test come up negative, doctor didn't seem interested after that. I can handle the pain every so often its losing the athletic ability to do things like jumping and squatting that's frustrating. Thanks for asking


    4. Hi Matthew

      Agree, that does not sound like CRPS. CRPS pain is fairly constant, often is a burning/stinging and I also got skin temp changes (hot, then cold) and knee cap discolouration (purple with red blotches). I too asked my Dr could I have rheumatoid arthritis, but he dismissed the notion, said that was not the problem. My knee x-rays also came back looking very good - minimal oesteoarthritis, which the O/S said is fairly rare for a 49yo. But I do know the cartilage on the back of my kneecaps is damaged.

      I fully get the loss of athletic ability. As my username suggests, I was heavily into triathlon before my knees went bung. The past month, I was improving a lot, my hope was rising, then started cycling again and have gone backwards again. I've just got to let it go and get my knees better!


    5. I had a Mri about 6 mths after my reconstruction and it showed up cysts on my kneecap cartilage. The surgeon didn't want to do surgery because he said you will end up with no cartilage left. Which I am glad I didn't! I have a lot of pain and stiffness in my lower leg around shin bone and calf muscle do you have that as well? This is two and half years after surgery!

    6. Matthew, I has surgery about 18mths ago to remove 1/3rd of my medial meniscus which was torn in my L knee. My problems started about a month or so after that in BOTH knees (hence my eventual suspicion of CRPS). I did get burning pain down in my ankle and up in the muscles above the knee - but not stiffness.

      My MRIs since 2008 have shown high grade chondromalacia to my R kneecap cartilage, but not much in the L kneecap cartilage.

      My medicos have assumed my pain is due to that kneecap cartilage damage, bit I think there is something else going on (namely CRPS which is the nervous system sending erroneous pain signals). My medicos now agree this is possible/likely. If it is, and having been diagnosed so late, I'm in trouble!

  3. I often adopt and misadopt views. By adopting the view I start seeing everything from that perspective and then I disadopt it (often) after discovering it's imperfections. In the end, I synthesize a bunch of different views or alternative theories, under a meta-theory umbrella. I'm not saying this is the answer, but it's all scientific reasoning. A lot of it is trial and error. Cool post.