When It Comes to Knee Pain, What’s Your Religion?

When I read an expert’s answer to how to deal with knee pain, the question above is always forefront of mind. What is their belief framework for analyzing and treating the underlying condition?

Mostly I find experts are structuralists of some stripe. In other words, they believe “your knee cap is mistracking and that’s why you have pain and that’s what you have to fix.” Some are more hard-core than others.

Take “Running Doc,” for instance, who tries to help Laura G. here who has been told she has “Runner’s Knee.” But her only exercise consists of shopping expeditions at the mall!

Well, the doc describes her problem instead as “Maller’s Knee” (for anyone curious about who the great physician “Maller” is, I think this is just an attempt to be clever). He then goes on to equate “patellofemoral syndrome” with “chondromalacia patella” (as I note in my book, they’re not technically the same, but it’s a revealing confusion).

He does promise the reader that “understanding the real cause makes treatment easy and pain relief possible in a short period of time.” To me, after hearing so many stories from knee pain sufferers engaged in a frustrating battle to beat their problem, this phrasing sounds a bit glib, to say the least.

The underlying cause, he tells us, is your ....

Feet.

And your parents stuck you with those feet, so your pain is -- well, sorry bub -- your biological structuralist destiny, you might say.

How does he get from your feet to your knees?

Here’s one example he gives:

Your foot rolls in (pronates), leading to your kneecap mistracking and scraping along one side of the patellar groove, leading to the cartilage under your kneecap getting eroded away, leading to ... pain.

So what’s the solution? Interestingly, one would assume -- after such a bleak kind of structuralist analysis -- that nothing short of surgery to fix the cursed defect would do much good.

But actually, he states that arthroscopic surgery helps maybe one out of 100,000 sufferers (a bit hyperbolic I’d say, and I’m no fan of surgery either). No, the real solution: orthotics.

His apostolic faith in orthotics made me smile. Here is the New York Times telling us that a longtime researcher into orthotics has found they don’t really work and when they do, it’s not clear why. And so, “The idea that they are supposed to correct mechanical-alignment problems does not hold up.” (After reading the article I bravely gave up the shoe orthotics I thought I couldn’t live without, and I’m perfectly fine today without them).

As for Running Doc’s “first mover” in his chain of events resulting in knee pain misery -- that maltracking patella -- that too may not be the problem for a large number of cases of knee pain. (See this study I’ve linked to about a kajillion times.)

So at this point you may be thinking, “Okay smarty pants who isn’t a doctor, what’s your religion?” And I’d have to say my thinking aligns best with that of Dr. Scott F. Dye and his thinking on “envelope of function” (see here). Basically, when you exceed that envelope over a period of time, you’ll get knee discomfort then pain. If I were talking to Laura G. about her problem, I’d be more curious about the following than what her feet are doing:

What’s your weight? Is it where it needs to be? Has it changed recently? By how much?

Did your amount of non-exercise movement change before the onset of knee pain?

Were there any traumatic knee events you suffered in the year or two preceding the knee pain?

Can you describe how you use your knees, 24/7, during a typical week?

Of course I could be off base with this line of inquiry in Laura G.’s particular case. It’s always possible that she was born with crappy feet and is now paying the price for it. But somehow I doubt that’s the real problem.