Saturday, March 14, 2015

Three Reasons Why “Mistracking Kneecaps” Probably Isn’t the Reason for Your Pain

Last time I mentioned in passing an interesting Swedish study. It found clinical tests perceived no significant differences between subjects who had knee pain of unclear origin and a control group. So, in other words, the knee pain sufferers weren’t crooked or imbalanced in some way the control group was not.

Intrigued, I managed to locate the study (most are behind paywalls, but luckily, this one was not). It begins with a fairly broad discussion of patellofemoral pain syndrome that won me over with these two lines:
Some practitioners who find no identifiable cause to the pain use both the term PFPS as well as the term AKP (anterior knee pain), but the terms are best reserved to describe the patient who has yet to be evaluated. If no causative explanation for the pain is found, despite a thorough investigation, the term idiopathic anterior knee pain (IAKP) seems reasonable.
Yes, yes, yes! Let’s stop pretending PFPS is a real diagnosis. “Idiopathic anterior knee pain” is more honest and useful. Basically, it means “you have pain in the front of your knee and we don’t know why.”

There is another discussion section, at the report’s end, that is well worth perusing too. The researchers’ skepticism about catchall explanations for PFPS that cite mechanical abnormalities is virtually palpable.

Here are three big problems with the “oh, you’re crooked/imbalanced” line of thinking.

(1) There’s no accepted definition of what constitutes crooked in the first place -- or more precisely “meaningfully crooked” if you will, because I’m sure very small discrepancies in the length of someone's legs (or in whatever) wouldn’t be considered important even by diehard structuralists.

To make this more concrete: Say you believe patellar maltracking causes most cases of PFPS. Well, if a kneecap doesn’t track perfectly by 1/100th of a millimeter (the width of a thin hair), that’s not enough to be significant. But then, what is? 2 millimeters? 6? 10, 20? The fact is, no one has set forth an assertion on this that’s supported by clinical evidence. So we don’t even know what crooked is.

(2) Also we can’t measure it well anyway (a related, overlapping issue). The Swedish researchers report:
“Fitzgerald and McClure (1995) studied four different manual clinical tests for patellofemoral alignment where measurement reliability ranged from poor to fair ... they were unable to find a reliable clinical method for assessing alignment.”
So there’s no accepted definition of malalignment and no good way of measuring it anyway. But wait, it gets worse:

(3) “Fairbank, Pynsent, van Poortvliet and Phillips (1984) reported that in pain-free subjects, between 60% and 80% of the population fall into what is generally classed as lower extremity malalignment.”

So, even when someone does take a stab at defining malalignment, it turns out -- surprise -- that most of us who are pain-free share this “problem.” In that case, if almost everyone is crooked/imbalanced, what’s so special about it?

And the answer just may be: not much at all.


  1. This article Makes me glad not to be fiddling round with expensive tape anymore. I'm in my 3rd month of afternoon stiffness & soreness having been lulled into a false sense of security by a symptom free couple of weeks last year. I strayed way over my Goldilocks zone last November being on my feet far too much each day on a family holiday. Now, to make friends with my knee again, I'm street walking in the morning before the soreness & stiffness sets in. Then I walk in chest deep water at the pool to ease the afternoon discomfort. . Just wondering if anyone has any ideas about the risk of iadding to inflammation by sitting in a spa i(113 degrees f. 44 degrees c). In general is heat application a good idea for IAKP.?

  2. Yes, afternoons are the worst. I'm interested in how you people coping with everyday life. Richard quit his job, I am suffering every day at work in my chair, and the people around me do not understand anything. Social life sucks, and what little is left of it is in the haze of pain killers... I'm currently going through minor setback probably caused by long standing at the funeral. It was very cold and I immediately knew I was going to pay... That was five days ago.

    1. I can't help thinking that a common cause of much of the knee pain discussed on here is sitting in a chair. I'm certain mine is worse when sitting (I've now got a stand up desk platform to see if that helps). When I'm on holidays, doing more walking/standing, things seem to improve.
      I'd love to know how many of the other regular posters on here spend a lot of the day sitting, and have done so for several decades.
      It seemed to me from Richards book that getting away from sitting at a desk was a key part of his healing - perhaps as important as regular walks?
      But I'm not sure what comes first. Does an injury or surgery or overuse (in Richards case) trigger the knee pain and sitting then exacerbates the problem. Or is the underlying problem brought on by decades of sitting, just waiting for some type of trauma event to tip things over the edge into constant pain?

    2. I think the problem starts before the pain. The pain comes later. I'm sure it is sitting to blame for my bad knees. Before the pain started I had a six-month period of extreme inactivity. In the morning I was sitting at work, and in the afternoon I returned to my old hobby - playing guitar (like a Richard I play guitar). Trauma event was a minor injury with barely noticable pain in left knee which I earned during one squat five years ago,
      MInor trauma + too much sitting equals constant knee pain.


    3. And Goran, did the minor trauma in one knee lead to pain in BOTH knees?

    4. YES!!!!!! At first left knee, two months later right one, as a result of overload!!!

    5. Hi, same with me. I suffered pretty bad groin strain more than two years ago. After that I could not move much for half a year and somewhere around that time knees started to hurt. Just a little bit at first. My theory is that the inacitivity and possible change in posture after the injury contributed to this. When I recovered from the strain, I wanted to get back into sports and I think this made the knees worse. They were not quite ready for that.
      I also work as a programmer and have always been weekend warrior. Quite bad combination for the knees :(


  3. In my case I also quit my job, at home I take breaks from sitting every 30 min ( I walk around my apartment for 5 min ).
    I'm happy with my progress so far, as I mentioned before I'm on PT since 2 months ago with one of Kelsey's coach. My right knee has improved a lot, left one still not that good but getting there. I can squat with my right knee and have no pain.
    I have some symptoms here and there but for being only 2 months exercising it's pretty amazing.

    1. Athenea, apart from the exercising, is there anything else the Kelsey coach has you doing? For example do you have to avoid certain activities like crouching down? Was it the coaches suggestion to avoid prolonged sitting?

    2. Hi!
      Basically I'm following her advice for any activity. I'm avoiding deep squatting so far but I'm doing some easy bilateral squats with the help of a light resistance band attached to the top of the door.
      Regarding prolonged sitting, yes it was her advice to take breaks every 30 min.
      It depends on which stage of your recovery you are, for example 2 months ago I was really bad (by that I mean I couldn't even put my leg straight) so I wasn't walking much for example, but now I'm in much better shape so I'm going for a walk 4 times a week for like about an hour or so with a small break in between. I've been edging the walks meaning I started walking only 20 min, then 25, 30 etc...
      Another thing I have tight IT band and quads so she suggested to do some dry needling to release those knots in the muscle as they are putting pressure on the knee.
      Also her advice was to follow a diet high in protein and take supplements.
      That's all I do apart from the exercises for lower limb, core and balance.


    3. Athenea, this sounds a lot like what my physio has been advising. I see her every couple of weeks for myofascial release (tight quads and a very s****y ITB that keeps playing tricks on me!) and dry needling. And every week for one hour of water therapy. This has been the best thing. I don't think I could have plucked the courage to walk without the stick if I hadn't done hydrotherapy first. I too started walking 20 min at first, I can now walk for almost one hour non stop (albeit very slow and paying attention to how I position my feet).

      Re. the sitting, I can't think of anyone who cannot go for a one minute break every 20-30 minutes? It's all it takes to do 100 steps and 'oil' your joints, and it makes a huge difference to your knees. Go to the water cooler, the bathroom, the copy machine. Get up and ask a colleague instead of sending them an email. And if anything, taking regular short breaks is best for productivity. I also walk for at least 30mn (slooooooowly) at lunch time, and 15min morning and evening during my commute. Then another 30mn in the evening.

    4. Hi Deloupy! How is the dry needling going? Do you feel any improvements at all? I've tried today for the first time, the physio just used 3 needles and said that in the next session she'll do more... is that normal? I was hoping she will put needles all over my leg but in 15 minutes I was done.

    5. Same for me. Sometimes, she only uses 2 needles. If she hits a very tight spot, I can feel the effect straight away. It travels along the nerve to my toe, and all of the sudden, I feel my muscles relax and within minutes I'm in less pain.
      It is not acupuncture, so the needles only stay for a short time and they won't be used all over the leg. A friend of mine does acupuncture on my legs sometimes, and she will use at least 10 needles, but she will hit points that are sometimes quite remote from the source of pain: in my feet, or my shin for example.

  4. Awesome, thanks! Good to know this is how it works! Actually I feel less pressure on my knee now! I have my next appointment on Monday, I'll see how it goes.

  5. Hi Richard,

    I discovered and read through your book a week ago, and then read through all your blog entries back to 2010. I plan to pick up Doug Kelsey's Runner's bible next and will read that as well. Thank you for choosing to share your detailed research, experiments, and successes in reclaiming your knees. Your book was a great read and it gave me the glimmer of hope and stubbornness that I really needed.

    After 6+ months of steadily worsening knee pain, an MRI recently diagnosed me with Grade 4 chondromalacia patella. I am/was a long distance trail runner, and my goal for 2015 was to complete my first 100 mile race. Instead, it now looks like I'll be spending 2015 on a much more difficult goal to retrain and rehabilitate my knees. I don't know if I can regrow/fix my cartilage, but I'm sure going to try.

    Months of prescribed and dedicated strengthening and foam-rolling exercises have not helped. I do think I have some structural problems (I know you're not a fan of this), given that my hips internally rotate to such an extreme degree that I can make people shriek in horror. But without fixing my knees first, I think the rest of my issues, whether they helped cause my knee pain to begin with or not, are moot at this point.

    My knee decline was self-inflicted, I have no one to blame but myself. Over the course of one summer, I won a peak-bagging challenge and lost my knees in the process. I would pop ibuprofen just to be able to hike downhill towards the end. As an ultrarunner I'm also unfortunately pretty good at pushing through pain. Eventually I could no longer run downhill, then I could no longer run on flat roads, then I had to stop cycling up hills, and most recently I can no longer sit without a burning sensation in my knees. Even walking and light cycling make my knees unhappy.

    So now there's almost nothing left to lose. I stumbled upon your book and your approach just seems to make common sense to me, so I will put it into practice. I picked up a pedometer, found a used bicycle trainer, and started up my own diary/log book for my knees. Losing what little weight I can is also on the daily menu. I'm not sure yet how to find the right baseline to keep my knees moving, since despite slowly dropping more and more activities off my list over time, my knees kept worsening. For now, I plan to spend a week or two simply keeping track of pain and activity levels to evaluate if I should do less or more the following week.Hopefully a pattern will emerge.

    I refuse to give up on my knees and I'm very grateful to have your success story to look to, as well as the successes of others captured in your blog. I know it's going to be a very long process, but I wanted to say thank you for your help now, because no matter how it ends, at least I now have enough hope to begin.

    All the best,

    1. Your story sounds very similar to mine Doris. I'm almost 3 years into the knee pain journey. I'd say my pain has reduced about 50% by dropping all my previous triathlon activities, and just doing easy walks, non-kicking swims and upper body strength work. Like you, even light spinning on a bike is no good. I still have regular good and bad periods.

      What didn't work for me:
      - meniscus surgery - fixed the locking left knee but seems to have triggered chronic pain in both knees
      - any quad/calf/hip/glute strengthening exercises (made it worse)
      - stretching (sometimes temporary relief but that is all)
      - bouncing on a mini-tramp
      - easy cycling
      - squatting/crouching/kneeling
      - many dietary supplements I tried (I can't name one which really made a difference, except perhaps fish oils, but not sure)
      - ice (I actually wonder if lots if icing triggered my patella cartilage meltdown?)
      - applied kinesiology (= witchcraft)
      - ignoring the pain and pushing on
      - sitting at a desk

      What may be helping me:
      - PRP injections
      - heat (hot bath - relaxes muscles & nerves)
      - walking
      - accupuncture (too early to tell)
      - nerve pain medications (but they are a bit nasty so I stopped taking)
      - lying down
      - anti-inflammatories (but not a long term option IMO)
      - emu oil and Lawang oil (relief, but not a cure?)
      - mediatation/mindfullness exercises (but I'm lazy at doing it)
      - walking around slowly fishing and standing lots in cool water in NZ (the fishing and scenery in NZ will take your mind off anything!)
      - getting away from a desk
      - beer (but not a long term solution!)
      - change of mindset; forgetting about triathlon

      Good luck with it.

    2. Thanks for your reply, TriAgain. Looks like you've been through the ringer and tried just about everything. Sorry to hear that you've given up on triathlons. I'm not ready to give up on my running future yet, but after 3 years of battling knee pain I probably would too. Have you tried following the exercises prescribed by Doug Kelsey at all? I just finished reading his Runner's Bible book and it seems to be a bit contrary to Richard's approach, despite the the fact that Richard highly recommends him. It seems to emphasize lots of drills and exercises, and doesn't emphasize easy walking the way Richard does. For me, the simplest approach would be my preference - if I can heal by doing easy walking, progressing to easy cycling, then hiking, and eventually running, that would be ideal. Besides, just doing quad sets, what Kelsey recommends as the first step, already makes my knees uncomfortable and a little angry.

    3. Yes runnerD. I got an E-book by Doug Kelsey called The 90 Day Knee Arthritis Remedy and tried his exercises. They did not work for me. Anything that involves repetitive loaded knee bending seems to be a problem - except the minimal knee bending involved with walking.

    4. You sound a little like me, runnerD. I also did crazy stuff to push my body to the limits. I was sprinting up mountains on my bike in Hong Kong while dehydrated, at the end of training rides! Nuts.

      It is definitely a long journey, recovering your knee health. I think athletes may be better suited for it in some ways, because they already have a mental toughness, high levels of self-motivation, an ability to laser-focus on goals, and the dedication to stick to a regimen. The tough part is that all the beautiful leg strength you have gained vanishes, and that can exacerbate the knee pain cycle. So there's a bit of a severe, frightening drop, to a feeling of helplessness (in my case I went from being able to bike up mountains powerfully to being unable to spin bike pedals for two minutes at no resistance without irritation and burning). I'd try to keep moving, but the movement may have to be very light and easy for a while, with frequent rests. Lots of luck.

    5. RunnerD and TriAgain, my name is Jeremy and I live in Austin, TX. Just thought I would share my knee story. For 40 years, I had no knee issues in my life. I am now 41. I started avid backpacking 3 years ago, and I would go on quarterly trips around the country. In April of 2014, I went for a weeklong backpack trip on the Appalachian Trail. At the end of the second day (after hiking 17 miles), I started getting a pain at the outer upper edge of my left kneecap on the downhill portion of the hike. The next morning, the pain was still there, but I continued to push. The next evening I got in wifi range and researched what it could be. IT band syndrome, PFPS, etc came up on my search and said there would be no permanent damage with 4 to 6 week recovery times. So I decided to push through the pain for the next 4 days/50 miles. By the end of the trip, it hurt to walk on flat surfaces, downhill was impossible, and uphill majorly hurt. I went home broken, but ready to start my 4 to 6 week recovery. Of course, it is almost 52 weeks later and I am still in recovery. The xrays were normal, the MRIs showed thinning cartilage at the inferior patella, but that's not even where my pain was. I went to PT and every exercise we did would set me back days at a time. We were doing way to much load on the joint. I then went to Phil Davis in Austin, and he eased me in with ART therapy, ultrasound, e-stim/heat, and very low motions. Going to all these medical providers would also hurt since they all wanted to push, pull, and squeeze the very place I was injured. I ended up seeing Phil 32 visits in the span of 5 months. He got me from not being able to go up a single step, to doing a lot of steps, and squats and leg presses. He eventually had me doing strength and distance, although I was still in pain at some point every day. I eventually relented on this therapy since the continued pushing in the gym combined with all the walking was still causing me daily pain. I just wanted to get out of pain!! I eased off the weight training over the last few months and tried working on more endurance stuff like light hiking, swimming, etc. The pesky knee pain still would not subside. I am currently in a mode where I'm still walking and going up and down steps, but I stopped weight training, and for the time being stopped exercising. I still have daily pain even after trying to remove all the daily irritants to my knee. It's funny that during my rehab I could do some pretty major things pain free (walk 40 min, squat 180 lbs, go down steps), but then I still have pain driving home from the office. There is almost always a delay in my pain as well, usually between 8 and 36 hours. After reading this blog, I may start introducing walking again to my routine and ramp that up. It's a fine line since I have hurt my knee doing almost everything over the course of the last 12 months. I will try this motion-based treatment going forward to see if it can get me over the peak with my knee pain. Here is my list of things that helped/hurt in the last 12 months. So many other things are convoluted, meaning I can't tell if they helped or hurt:

      - Sleep, ice, vacations, light stretching, baths, mental therapy
      - weight training, sitting in car, sitting in office, biking (with resistance)
      Can't tell:
      - Swimming doesn't seem to hurt unless it's already in an irritated state
      - Biking at low resistance may be ok
      - Walking may be ok, but too much is not. Need goldilock's on this one.

      I'm approaching the 1 year mark, but I still don't have a line of sight to a full recovery. I also developed to a much lower degree the same symptoms in my right knee (even though it was totally fine a year ago on the fateful trip). As an engineer with a very strong will and very stubborn personality, I will keep a focus on this recovery and apply as scientific principles as possible until I'm fixed. Jeremy.

  6. Hi Jeremy, thanks for sharing your story. It's nice to hear from others who are also going through the long recovery process. One thing you wrote definately resonated with me:
    "Going to all these medical providers would also hurt since they all wanted to push, pull, and squeeze the very place I was injured."
    This is exactly why I've stopped seeing my physio and am even worried to follow up with my sport doc. My knees always feel worse after an appointment. My physio always asked me to do a one-legged squat at the beginning of every appointment and the last time I saw him, I finally just refused, knowing that even if I'm able to do one without pain, it will come back to bite me within the next couple days. I've gotten to the point where I'm pretty sure I know better than my physio what is good for my knee. Unfortunately, I haven't found any physio in town (I'm in Vancouver, Canada), who will focus on joint rehabilitation without focusing on building muscle strength.
    I decided to just create my own rehab program based on all the info gathered from the Saving My Knees book and blog, and the Runner's Bible but I'm only one month into it, so don't have much progress to share so far. I've spent the last month trying to puzzle out just how much my knees are able to tolerate - got a spreadsheet going logging daily steps, pain level and charting progress (or lack thereof). Of course, I started out trying to do too much and my pain levels were all over the map. For the last 5 days, I've scaled it way back to just doing three 15 minute walks per day (about 1650 steps), with my watch otherwise set to alert me to walk around the house for 2 minutes every 20 minutes. So far, this is the most consistently happy that my knees have been over consecutive days, so I'm going to try this for another week or two before trying to 'edge' any further. Luckily (and well, unluckily) I'm currently unemployed, so I have a bit of freedom in trying out knee rehab schedules. It also means I can thankfully avoid sitting with bent legs in a desk chair all day long, which really aggravates my knees.
    I'm also trying my best to lose some weight for the sake of my knees (trying to get down to at least 50kg - started at 54kg, now around 52kg but fluctuating). I'm finding it pretty hard to shed pounds without being active, and while still maintaining a nutritious diet without feeling hungry all the time.
    It's interesting that you were able to make progress in increasing your knee function and activity level, even through consistent pain. Do you think you were just increasing your tolerance of pain instead of actually increasing function in your knee? I'm now avoiding anything at all that causes actual sharp pain, immediate or delayed. I've gotten fairly clear feedback from my knees that anything causing sharp pain beyond a mild burning sensation sets back my recovery by at least a week. At this point, if I saw a small child run out into the middle of the street, I'm pretty sure I wouldn't run to save it...
    Anyways, I wish you the best in your recovery. Please keep us posted on your progress. Hopefully your stubbornness (and mine) will triumph in the end :)

  7. RunnerD, it sounds like you and I have some similarities and some differences. A couple questions for you...Where does it hurt on your kneecap? Mine is on the outside of knee on the top. You hurt yours over 6 months, where I hurt mine over 5 days. Your MRI showed something, but mine is somewhat inconclusive. I pondered going in for another MRI as a follow up after 9 months, but insurance probably wouldn't cover it again. I did notice that a hot bath really helps my knee pain, and I think it makes the muscles completely loose. I will do one every night :)

    Going back to your question, I don't think I was increasing my tolerance for pain, since the pain was the worst right after the injury. I never did lifting or walking through the pain, and it would always creep in later in the evening or the next day. Part of me thinks I should go back to pushing it on the rehab, but the other part says to lay low, let it heal more, and just increase light activity as is promoted on this website. I'm going to start taking a multi-vitamin/calcium/fish oil pills just to see if it helps, but it sounds like that is not bad stuff anyway to be taking daily. I may start PT again where I don't have to bend the knee as much. My PT guy (at the end of my stint with him) had me doing jumps and clean/jerks. While I could do it, I think it was too much stress on my knee. Good luck to both of us...I will keep you posted, and hopefully you will do the same. Jeremy

    1. Very interesting comments, Jeremy. Bent-leg sitting is very stressful for bad knee joints; it doesn't appear so, but the reality is quite different. Anything that loosens (lengthens) your quad muscles -- light stretching, a hot bath -- is likely to provide temporary relief, as the kneecap isn't being pressed as tightly against the injured area. Conversely, anything that tightens the muscles, such as stress, will probably compound symptoms. At least this is my understanding of things -- my standard disclaimer, as I'm not a doctor of course. Good luck!

    2. The pain in my kneecaps is pretty diffuse. In can be anywhere around the edge and behind the kneecap, the whole area tends to have a burning feeling. If I get any sharp pain, it is generally directly behind my kneecap. I definitely can't push it at all with my knees anymore, or it goes right back to square one and it feels like I start the recovery process from scratch all over again. It's hard to tell so far though, whether I'm actually making slow progress and then regressing, or whether my knee just constantly fluctuates between feeling a little better and then a little worse, from week to week, and nothing is really changing. My previous physio had a term called VOMIT, which he said stands for Victims of Medical Imaging Technology - basically what you see or don't see in an MRI or other medical image doesn't always relate directly to your level of pain or function, so it's not all that useful as a diagnosing tool, but people still put a lot of stock in it anyway. I understand the need for some sort of answer though, because I really wanted that MRI myself, even if it ultimately doesn't help or change my recovery process. Maybe it's because it feels like other people are more inclined to believe you actually have knee problems (as opposed to just being whiny about your knees) if you have the MRI 'proof'.

    3. Mine too, the pain moves about from around & under the kneecap to on the joint line and over thee patella tendon. I agree, MRI is not a great diagnostic tool, other than convincing most OS's they need to open your knee up, which really should be last resort. Being guided by pain level and function is a much better guide to going under the knife or not. My GP suggested as much, but foolishly I ignored him.