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.)