Saturday, February 28, 2015

Corrective Exercises: A Waste of Time?

I found a very interesting article not long ago. It very much reminded me of my “awakening” during my struggle with knee pain.

First, start with the entrenched thinking (flawed) on what causes “patellofemoral pain syndrome.”
American Family Physician describes the cause of PFPS as an imbalance of the forces that keep the kneecap in alignment during knee extension and flexion. This imbalance can increase the risk of muscle dysfunction, poor quadriceps flexibility, overuse, trauma and a host of other musculoskeletal problems. In other words, during PFPS, the kneecap does not glide back easily on its “track” to the femur. ... Some health professionals, such as physical therapists and athletic trainers, recommend corrective exercise as a self-care method for patients.
Sounds simple, straightforward, reasonable. Except:
Despite the prevalence of corrective exercise prescriptions, current evidence shows that this intervention may not always effectively treat knee pain and could be a waste of time.
The problem is, the idea behind corrective exercise is that you’re crooked (your kneecap is mistracking) or that various muscles or tissues are too tight or too loose. But “studies have shown that PFPS may not always be a biomechanical problem.”

A 2006 Swedish study is then described, one that I was previously unaware of. Eighty patients with PFPS were examined. Of those, 29 had no identifiable cause of their PFPS (the others either had “slow bone turnover disease” or a type of pathology of the knee, and a small number dropped out.) For the 29 who didn't have a clear cause for their pain, “researchers could not differentiate between [them and] the control group that had no knee pain and were not diagnosed with PFPS.” So they weren’t identifiably crooked or imbalanced in a way that the control group was not.

Of course there is evidence that exercise can reduce knee pain, but as Paul Ingraham says in the article, that’s “probably not because it’s ‘correcting’ anything.”

I’ve linked to Paul’s website a few times over the years, such as to this essay where he examines the obsession that physical therapy has with crookedness/imbalances. I like his thinking and he’s a good writer. In the article above he is quoted saying, regarding the misalignment theory (the underlining is mine):
Exercises are prescribed in the hope that such things can be corrected, usually by strengthening and stretching.  Unfortunately, a lot of exercising for these goals is often out of tune with how exercise actually does help patients.
I couldn’t agree more with that. And, finally, he does well to note that knee pain comes in many stripes, with many possible causes. So, he notes:
Exercise is no kind of magic bullet. Patellofemoral pain has many faces, many possible causes and complications, and some cases do not respond to any kind of exercise, ‘corrective’ or otherwise.


  1. My adventures with knee pain have been going on for 3.5 years now. My first three physiotherapists prescribed single leg squats to strengthen my VMO. I was totally in the dark as to what was going on. For a long time, I thought I had fat pad impingement. Another common theme was the need to tape my knee to correct misalignment. It always struck me as very strange that I, a person with no expertise, should try force my knee cap into an alternative "good" track. I continue to walk around grinning inanely and repeating the " motion is lotion" mantra plus " take a walk & feed your knees" .

  2. Yeah, I got the single leg squat thing from at least 4 medicos/physios/PTs. And then I went to one of the top Sports Drs in Sydney who actually videoed my leg muscles in action jumping off a box plus some other tests and concluded quad muscle weakness (including the VMO) was not the problem. Who'd have thought it, given I cycled about 200kms a week for 5 years (insert sarcasm emoticon)?

    He concluded it was hip/glute weakness (which was true - they were relatively weak compared to the quads/hamstrings - but I'm convinced they were not causing my knee pain).

    Anyway, I strengthened my hip and glute muscles considerably, but it did nothing for the knee pain - in fact the exercises (single leg deadlifts using a small dumbell in each hand, walking sideways with a band around ankles, hip hitches etc) actually aggravated my knees further - particularly the deadlifts.

    Like most people on here, I can categorically say the only 'exercise' that does not make them worse, and may make them better (if done in moderation) is..........drumroll................walking!

    And yet not one of the medical geniuses I saw recommended walking. Almost all had some kind of strengthening recipe which they trot out as standard fare.....with the exception of one Sports Dr who suggested PRP injections (which I eventually had, and they definitely helped), or drilling holes in the back of the kneecaps to stimulate cartilage growth (which I avoided like the plague as it is knee surgery which got me where I am in the first place).

    After almost 3 years of research, I'm pretty sure what happened to me is that surgery to remove a torn piece of meniscus in one knee (which seemed unavoidable given the tear was locking the joint) caused the spontaneous meltdown of the patella cartilage in both knees. I bet the OS's would say that's not possible though.

  3. I note that the article by Paul Ingraham does not generalise. He uses 'may, often, sometimes, not always', etc. This is important, because not everyone respond to corrective exercises, but some people do.
    After 18 months, I think I have nailed where and how my knee hurts, and what I can do. I don't think my weak hips were a cause of my painful knees. In fact, I think the knees made my hips weaker and more painful, because I started walking with very stiff legs and hips. However, eventhough this wasn't present at first, there is now a correlation between my hips, glutes, ITB and knee pain. I know that when my ITB starts acting up, the pain that I feel on the side of the knee eventually propagate to the front and the burning resumes. I know that when I slack on my pilates exercises, my knees are somehow more painful. That's not to say that strengthening my hips will cure my knee pain, but it stops it from getting worse. If I have a stiff hip, and stiff ITB and side knee pain, I know I can't walk well and my knee eventually will not get better.
    Bottom line is: everyone is different, has specific issues, your knee pain is not my knee pain (a friend has cartilage damage that shows on the MRI but she can run, walk, cycle. I don't have visible cartilage damage and can't do these things). So experiment, and find what's working for you. If the PT suggests strengthening exercises (NOT the one leg squats, squatting on weak knees is mental), try them, they may work. If not, try a different approach

    1. Quote: "In fact, I think the knees made my hips weaker and more painful, because I started walking with very stiff legs and hips. However, eventhough this wasn't present at first, there is now a correlation between my hips, glutes, ITB and knee pain."
      The same with me! As I wrote it.
      The truth is that no one knows the cause and cure does not exist!!!!


  4. My knees seem to be improving. And the magic seems to be: walking. I started by just walking on flat. Now I've incorporated slopes. Today I tried walking two miles slowly incorporating slopes. Then. Had a nice long seated chat and a coffee. Then two more miles on flat. Trying not to "over tire" my knees. I do still aspire to get back into water therapy, but..... walking is so much more convenient and simple. Whereas water therapy requires more planning and also is just not as enjoyable because I don't enjoy being in the indoor public pool. I'd rather be outdoors walking in nature. :)

    I should clarify that I've been building up my walking abilities slowly. First just short distances on flat. Then. A bit longer distances. Then. A bit longer. Then. Incorporated some slopes. Then. A few more slopes. I'm really delighted that I was able to walk 4 miles today and I'm pretty confident that I will not suffer a delayed-pain-onset setback. Due to the mildness of my walking. I mean. I feel confident that my walk was within the Goldilocks zone. No daring attempts at steep hills nor long staircases. No pushing the envelope to 5,6 miles. Nope. Stay comfortable with my slow progress and be happy that there IS progress -- and not pain.

    - K Star (formerly known as "knee pain")

    1. That's wonderful to hear -- fingers crossed that it all goes well, and am excited that you've managed to make that much progress. It's been one step at a time ... literally! Keep us updated.

  5. PS! In addition to walking, my ability to deal with stairs has improved. I can go upstairs, slowly, like a regular Person. Going down stairs is much improved. But. Seriously it's been so long since i've been able to go down stairs like a regular person that I've literally forgotten how to walk down stairs properly. But anyway, I'm not experiencing pain in my stair descents. I do still avoid stairs as much as possible. But. Sometimes stairs are unavoidable. So. It's a relief and a celebration to be able to start navigating stairs in a relatively normal yet pain free way. :)

    ~ K Star

    1. Hi K Star,

      May I ask when did you start your walking program to heal your knees? I've been at it for about 3 months + prolotherapy. (I've had 2 years of awful knee pain). I was making my way towards 7000 steps/day and unexpectedly had to go up/down 1 set of stairs. Shooting pain went through both knees, I can barely walk now and that was 3 days ago; so I'm currently fighting a major set back. I find stairs to be my biggest struggle! And as you said - sometimes they are unavoidable.