Sunday, October 25, 2015

Old Bad Beliefs Die Hard: The Story of the Q Angle

Recently I found it curious that my Google search net snared a knee pain article from a physical therapist urging people to correct their “Q angle.”

It was like coming upon one of those stories about Japanese soldiers being discovered in the jungle decades after World War II ended, skulking about in camouflage, believing that they were still actively fighting the United States.

“Q angle” certainly has an air of mystery and mathematically infused importance, just by the very term. It ought to mean something. Something really important.

Anyway, this is one of those terms that you can spend 1,000 words defining and still fail to make clear. Or you can simply borrow an image and voila:

This physical therapist blogger -- whose clients include “numerous pro athletes from the NFL, NBA, MLS, and the WNBA” -- tells us:
When I see a Q angle that is off, I also see an excessive amount of rotational force absorbed by the knee. Furthermore, the meniscus and other internal structures of the knee are compromised more when the Q angle is increased.
Let me cut to the chase here, because the author doesn’t clearly state the “issue”: He’s basically saying a Q angle that is too large is probably the source of your knee problems. Women tend to have larger Q angles, due to natural anatomical differences, such as wider hips.

A few decades ago, the Q angle was the hot go-to theory among structuralists looking for causes for your aching knee. The thing is though, there’s evidence a bad Q angle is not the boogeyman it’s been made out to be.

If you recall my blog post about the study called “Hip Strength and Hip and Knee Pain Kinematics During Stair Descent in Females With and Without Patellofemoral Pain Syndrome,” perhaps you recall this line I quoted from the researchers’ report:
Many studies have not supported the relationship between an increased Q angle and PFPS [patellofemoral pain syndrome].
Paul Ingraham, who I often cite here, delves into the Q angle more deeply and also bashes the idea that it’s some kind of “aha” measurement for discerning and fixing knee pain. He asks the big question: Does the size of the Q angle reliably measure how the quadriceps is pulling on the kneecap?

He cites a study that looks into this question, and ends up concluding, “Clinicians are cautioned against using the Q-angle to infer patellofemoral kinematics.”

So among researchers, the Q angle theory of knee pain has been discredited. But old theories die hard. That’s a good thing to keep in mind if someone starts in about how your knee problems are due to your Q angle. They may be fighting some long-ago war.


  1. So these comments have nothing to do about the Q Angle.. but I am hoping for a response from you Richard or others on this blog... It has been about 6 weeks since I started my "long term program" (I have had a bad knee for 7 years now) Basically I started trying to walk (gentle action) and do some leg slides with a band (DK's excercise) What I am finding is that I seem to have a set amount of steps I can take in a given day or week. For example if I walk 1.4 miles (one loop at the local park trail) two or three times in a week.. I get so much pain eventually that I have to rest for 2-3 days before doing any more walking... Now sometimes I can walk the loop no problem, once or twice I have even walked it twice (abt 3miles) with only slight pain afterwards.. So my question is.. how much pain is normal or to be expected as part of the long term program...? Should there be pain?

    Please understand.. for the last 7 years I have walked rarely (usually when travelling only and that was always OK) basically in the past I pretended "it wasn't so bad" so every couple week or sometimes more often I would do something like bike riding or bouncing on a rebounder for excercise or even a very slow jog.. only to have extreme pain the following 1-2 days... (but at least I got some sweat in.. I would tell myself)

    Well now with this "program" the pain is not concentrated after a strenuous activity but more spread out.. and often right after the walk I feel some discomfort sometimes more than others..

    So how much pain is ok with a long term program... is my question.. and if it seems like I am able to walk less rather than more overall...

    (I did read the post below about being patient and long term recovery... which was helpful but I am still wondering if what I am doing is right.. because of the pain after walking which is not nearly as bad as the pain after I would do a strenuous activity in the past.. but it is still troublesome and makes me fear I will run out of "steps" when I need to take a walk for work or something...)

    Thanks for any feedback... I have also bought a total trainer.. a cheap one.. but not put it together or tried any excercises on it...

    How can I adjust my program to make it better and less painful

    1. Hi, Tom. If you have no history of walking, and you're only six weeks into your long-term program, I'd think about erring on the conservative side. Athenea makes some good points. One is walk a little, rest five (or ten minutes), walk a little, rest. In Hong Kong, that is how my walking went. I always rested at the halfway point (you may want to rest more often). The total trainer is also a great suggestion. It will unload bad knees; walking may be at the limits of what you can comfortably handle right now. How much pain is too much pain is a tough question to answer. I always tried to minimize pain as much as I could. But at the same time, you're in a place right now, unfortunately, where your knees are going to send out a lot of signals. Some are definitely "back off" signals. Others may not be so significant. How to tell which is which? It takes time and listening to your knees to know ...

  2. Hey Tom,
    From my experience I'd say that as soon as you start using the total trainer (respecting your load tolerance) things will start to get easier for you.
    Find your load tolerance (check how to do it on DK blog) and do bilateral squats (with 2 legs) every day, 5 min in the morning, 5 min in the evening.
    As for walking, what you can do is to walk every day, but just a little bit.
    For example:
    Week 1: Walk 10 min (slowly), rest for 5 (sit down somewhere), walk for another 5 min.
    Week 2: Walk 15 min, rest for 5, walk for 10.
    And so on.

    This is something that worked for me, which it doesn't mean it will work for you...But try it out and see.
    Bilateral squats are very important as they serve as "nutrition" for your knee. You need to know your load tolerance to know in which level you should start (in your total trainer).

    I hope this helps,

    1. Hi Athenea,

      Quick question: how long were you dealing with your pain before starting with your coach?

      I'm sending in my info and will be doing an initial consultation very soon. I'm hoping it helps and that she can help guide me to coax my body to heal a little better. Been dealing with mine for about 6 months now. It's improved a little, but I don't really attribute a whole lot of it to the physical therapy I was doing. I think my biggest gains have been from walking, light bicycling, getting up moving around frequently, and my body naturally healing.


  3. Thank you Athenea! I was in quite a bit of pain when I wrote that post last night.. but today it has been much much better.. I know what I need to do as for adjusting my walking (I just don't like it!) I will proceed with the total trainer and give it a try... and I am reading some of the older posts on here as well.. It is a LOT to think about and work on the knee when I am also a busy professional and have little time.. but this blog and the posts have given me some hope... Thanks again for the encouraging word!

  4. I've got a question for anyone who is willing to give their input, but first I just wanted to share what I'm currently being assigned by my PT for exercises, as a frame of reference:

    -Quad sets
    -Leg raises (Forward, Backward, Adduction, Abduction) - 2x10 each way, 2lb ankle weights
    -Band walking - square pattern and diamond pattern, each pattern in both left/right directions, 10reps/direction
    -Lateral stepping on 4 inch steps 1x10
    -Mini-squat, against wall, feet out 45degrees (for VMO...ugh) 1x10
    -Stationary bike, 3 days a week (I usually got around 25-30 rpms on lowest resistance, so very slow), 10 minutes

    I typically do things in about that order as well. Anyway on to the question...

    When you try to move around, exercise, etc. how much ache/pain are you willing to tolerate? So we're all on the same page with this (as much as possible) I'd like to use a 1-10 scale, where 1 is you're perfectly normal, and 10 is you don't even want to move or think about moving.

    Why I'm asking:
    My symptoms throughout the day really aren't too bad. However I do things like keep my feet up on a nice, big, beanbag style footrest at work, and generally avoid the things I'm recommended to avoid by my PT - squatting, kneeling, running, jumping, basically everything but most people on here, I'd imagine. Even though I have trouble buying in to what she's having me do, I try to be a good patient and do it, simply filing it under "well, ya gotta try something". When I do my PT exercises occasionally some aches/pains crop up (nothing immediately intolerable usually, except when they try to have me do mini-squats, and if it happens I stop immediately). I move pretty frequently at work, and in the evenings I've been going for longer walks (last night I did 1.25 miles, albeit slowly - took about 40 minutes).

    In much is too much, and how were you able to tell?

    Ultimately I'm trying to dial it in so I'm within my "envelope of function" and not doing too much, but not doing too little either. Is it as black and white as "no pain/ache whatsoever, no matter how minor" for most of you? Is it "it's normal to have some aches, soreness, even a twinge of pain here and there, but any more than that, you need to stop and back off"? Or is it somewhere in between, or possibly neither?

    I'd love to here as many opinions as possible, especially by those who have made some serious progress with their individual knee issues thus far.


    1. Brandon, in terms of how much was too much and how was I able to tell, it was basically 3+ years of trial and error. And even then (and still now) some things leave me with more pain/discomfort than I'd like for no obvious reason. For example, last week I spent 7.5hrs in a car as a passenger and that gave me more trouble than my gym circuit which includes deadlifts and kettle-bell swings which put a lot of force through the legs/knees! Go figure?

      What your PT has you doing does not seem excessive, though at my worst, my walks were only 15mins and still mostly top out at 30mins.

      I always had some pain/not right sensations and still do, but the intensity is less. And if I do stir things up, it only lasts a day or so, not weeks. So for me it is normal to have some aches/burning/stiffness and has been throughout the journey which is still not over. If I'd stopped when I had ANY discomfort, I'd have done nothing and that was not an option for me.

      So I think the answer is somewhere inbetween - finding a level of activity where the pain etc is not clearly getting worse, but don't expect zero pain. And finding that level, and when to start to increase it is tricky.

      Strangely, I seemed to make real gains once I started by 25-30min gym circuits which were both upper & lower body & quite intense. The lower body stuff consisted of sideways band walks/deadlifts - I'm now using 40kg barbell/kettlebell swings now up to 20kg. How much of this was due to gaining strength and how much was due to re-training my CNS to overcome pain sensitisation (which I think is a large component of my problem) I don't know. But my thought processes started to change from thinking my knees were very fragile and could not handle much to realising I could do quite robust things on them and they would not collapse - though they could get sorer. Finding exercises which re-trained my CNS without making my knees too sore is the key. Not sure if that logic applies to you or not?

  5. TriAgain,

    Thanks for the response! It does certainly provide some insight. I'm trying to take charge of my recovery but feel so up and down about it. I'm likely going to try the total trainer/doug kelsey route, but i have a hard time believing anything will work. I've consudered ciaching as well, but it's fairly expensive. I read your write up that you posted on another site earlier today actually, and had some questions if you don't mind.

    You mentioned Doug Kelsey's approach was too much for you at the time you tried it. Does that mean you bought a total trainer and all that and just couldn't do the exercises? I was thinking about trying The Runner's Knee bible program on my own and if that didn't work or I got confused trying a coach. My concern is that many of those tests and exercises seem pretty hard on a knee (deep knee bends, kneeling, etc). Was that what you encountered?

    1. Triagain: What sort of things did you do to tackle CNS?

    2. Brandon

      I also had a hard time believing anything would work. As an impatient A-type triathlete, I just wanted to be over this sh*t and back racing again. It wasn't until I let go of that desire a lot, that I really started to make some headway.

      I bought Kelseys 90 Day Knee Arthritis Remedy book, but nev er got a Total Trainer. I simulated the TT by proping a rowing machine up on boxes of various sizes in the gym, and doing single and double leg squats at various angles (= various %'s of bodyweight), but it did not seem to work for me - it definitely worked my leg muscles, but the pain did not abate. I could do most of his other exercises, but it did not seem to be getting me anywhere - perhaps I just did not persist long enough.

      It is really difficult to know if it wasn;t just time (a bloody long time) that started to heal me, but if I had to pinpoint things that probably helped they would be:

      - mentally losing the triathlon obsession;
      - moderate walking but no more than 30mins @ 100-120 steps/min;
      - PRP injections x3;
      - my gym circuit which would appear like a huge risk with the leg work I did, but the small number of reps higher load seemed to work better than low load high reps (like Kelseys TT is)
      - we moved office = no stairs (even though there were only 20)
      - driving an auto car instead of a manual
      - accepting a much lower level of physical performance, at least for the present
      - neuroplasticity exercises to try and turn off the pain centres in my brain

      There were times when I was absolutely convinced I'd never have any reduction in pain, I just couldn't see how it would get better after 3yrs. But then I had some rapid improvement over a few months.

    3. Anonymous re tackling CNS sensitivity.

      I tried drugs (Lyrica) but they messed with my head a fair bit.
      It was a change of mental attitude and brain training that really helped - see these:

      Also I think getting into some fairly heavy leg/knee loading exercises in the gym helped as they convinced my brain my knees were not about to snap! But this is a fine line as if your knees have lost tissue homeostasis (as mine surely had) you could get outside your envelope of function and get worse. For some reason, my envelope of function was more sensitive to high reps/low load than low reps/high load (which is probably why I struggled with the Kelsey TT work).

    4. Thanks Triagain!

      I too first strugged with DK's TT work when I first tried it on my own because I overestimated how "strong" my knees were, and I had a few other muscular issues at play. Now that I'm working with one of his coaches we started at a level below what I was doing and I've advanced quickly. She also prescribed a lot of core/balance exercises, etc.

      Thanks! :)

  6. Brandon,

    I work with one of DK's coaches (worth every single penny) and this is a rule I follow...

    Pain on a scale of 1-10.
    I try to stay within the 1-3 mark, 4 is a warning, 5 is time to back off. Since working with my coach my constant burning/ache has really calmed down and I only add additional exercises/weight/duration/etc when I can do exercises with NO knee symptoms. Then, I very gently nudge it to the next level.

    For example:
    2 sets of singe leg squats on the total trainer at level 3 - I add a third set when I can do the first 2 with no symptoms.
    Once I can do 3 sets with no knee symptoms (no pain whatsoever, and no achiness hours later), I increase the angle of the total trainer.

    DK's coaches can carefully and accurately measure all of this. A year of standard PT absolutely destroyed my knees to the point where I could not walk; and cost the same as one of DK's coaches, at least with a coach I'm getting something out of it.

    I wish I dumped my PT a long time ago, quad/vmo strengthening is absolutely detrimental to knee cartilage when you can not tolerate at or above body weight force in your knees.

    Best of luck,

    1. Great to know! Thanks Alex! I'm definitely picking up a total trainer at this point. It's good to hear from another source (Athenea on this forum is another) that DK's coaches are the real deal. It's reassuring that my money likely wouldn't be wasted.

      Thanks also for your insights into my question as well! I appreciate it!


    2. Couple more questions for you, Alex:

      1. How long have you been with your coach?
      2. How much do you feel you have improved in that tineframe?
      3. Are the exercises she gives you enough to break a sweat, at least a little?
      4. If you had MRI/xrays, did she look at them or did you just discuss the results?

      There was one other but I'm spacing it out at the moment.


  7. I'll answer your questions in the order you present them:
    1) 5months
    2) Significant improvement but I can't quantify it. My knees were really, REALLY bad... I could barely walk, couldn't sleep, I couldn't step on/off a curb without knee pain, stairs were out of the question, couldn't sit in a chair, couldn't get out of the chair without pain...etc. My knees used to ache deeply every second of the day; that has really calmed down and my knees are slowly starting to feel more resilient. The key is that knees heal slowly...really slow, slower than what you can imagine. I still have a long ways to go but I have a program that is working.
    3) No, I don't break a sweat but we are working to get me able to sweat via exercises without knee symptoms, I'm just not there yet. I used to do Crossfit so I really miss the endorphins from exercise but getting there.
    4) I had an MRI which I emailed my coach the report that she read and we discussed.

    I understand that the coaching is quite costly but so is standard PT, for me, I wasn't improving, I was only getting worse and my knees were ruining every aspect of my life so I've been pleased with the results and will continue. I tried doing DK's program in his book on my own but it was too much for my knees, then when I enlisted the help of a coach she was able to measure exactly how much load my knees could tolerate and she devised an accurate knee program that matches my needs. Not everyone requires a coach; Richard for example healed without one, but for me it was the right call.

    Best of luck,

    1. Yeah, definitely sounds like the right call for you. That sounds really rough, man. Glad you're starting to feel better!

      The primary reason I'm considering coaching is just to have a little better direction. Maybe they can provide some answers to things that normally would take me a long time and lot of trial and error to figure out. I think my time is worth quite a bit to me, and if they can help me heal sooner with their guidance than doing it on my own that's a huge plus in my book, and like you said, worth every penny. Plus I'm hoping they may provide some insight into other things that are cropping up too, like elbow, hip, and back pain.

      Again, I really appreciate your responses. Thanks a ton!


    2. Brandon - I also got elbow/hip/back pain & still do to an extent. Which is why I started looking into CNS issues, things like fibromyalgia, allodynia etc. While I'm sure I had some knee damage/loss of tissue homeostasis, I think CNS issues were making it (and other aches and pains) worse. One way to deal with CNS sensitisation is moderate exercise - hence one of the reasons the Kelsey approach works for some people, and why I think the quite intense gym routine I devised has helped (endporhins & re-training my CNS).

    3. I THINK my aches and pains I'm getting are more related to compensation and coping mechanisms. For example I tend to push myself straight up out of my chair at work so I don't have to bend my knees or push up my body weight with them. My pains are above my elbow, in the lower triceps area, and also right around the bony spot on the inside elbow. Deeply bending the elbow for extended periods can bug them. Last night i was installing a microwave in ny kitchen and when i was done they were on fire, i think from turning the screwdriver.

      My lower back has ached off and on for a long time.

      My hips ached before my knees, but really only started when I'd wake up in our new bed about a year or so ago (a super expensive tempurpedic...go figure).

      I'm also getting light muscle spasms in my thighs and knee areas. As i type this my right hamstring is ever so slightly spasming. Not painful by any stretch but concerning in how often it's been happening lately.

      What were some of the specific issues you experienced that you feel are/were CNS related?


    4. Honestly I think a lot of my pain issues right now are from not taking proper care of myself (diet and in particular lack of exercise). At least that's what I'm hoping.

      Right now my arms feel weak and tired (I'm actually tired and mildly sore from installing that microwave too), but I'm extremely stressed and worried right now, especially when I think about if I would have CNS issues (they seemed ok earlier).

      I have some other concerns as well, in particular about CNS related issues. For about 4 years I was on testosterone replacement therapy, and in May I was pulled off of it because a)my wife and I wanted to start trying to have children and TRT makes you infertile while you're on it, and b)the new endocrinologist I was seeing thought that my low-T was likely from sleep apnea (which I now know I DO indeed have, although only mild). I have not been on it since.

      I believe the knee pain was caused/reached it's tipping point (although I had not noticed any symptoms prior so tipping point it probably a poor description) from refinishing my deck - sanding/powerwashing/staining...a lot of up and down ladders and work on hands/knees) because it all seemed to start around then. Plus I was about 25-30 pounds heavier than I am now. My fear though is maybe pulling me off of the testosterone is messing with more than the well known stuff - emotions, cognitive ability, etc.

      So here's a question for anyone - do any of you get little muscle spasms in your knees, thighs, etc? Nothing painful, just basically some very light muscle twitching? Just seeing if this is even slightly normal.

    5. Sorry...long winded me coming out.

      Ultimately I feel like I can attribute my aches/pains to specific factors. Lower back, for example: The ultimate, original cause I have no idea (probably weak core/lack of exercise/being overweight for years), but I can tell you sitting on a hard floor doing quad sets will make it stiff, or sitting for too long in a car, stuff like that. In fact when I'm moving around it typically feels totally normal, although it has a rare moment here and there. If I sleep on my back, feels fine in the morning.

      Hips - typically don't bother me too much nowadays but there was a stretch in September where it was rough. I got out of a chair that I was leaning back in (the whole chair leaned, now just the) yet trying to keep my legs as straight as possible. I think the seat of the chair was wrenching on my left leg weird (my right foot was higher, left was basically on the ground), and when I stood up my left hip ached for three days or more.

      That's another thing...keeping your legs up at work kills your lower back too, I think (unless your job is sitting in a LazyBoy). It seems to focus a lot of pressure on that tailbone area.

      My only real concern when at the moment when it comes to CNS related stuff is if the aforementioned TRT and subsequent stoppage of it affected anything.

      I get odd little feelings, like when my car keys tap the top of my kneecap sometimes in the car while they dangle in the ignition. I wouldn't call it painful, but it's not totally painless either. When it happens you know something's not right. Doesn't happen all the time, either. I've just always figured it was sensitivity from my knee pain making me a little hyper sensitive when maybe my knees were having a bad day or something. I get similar feelings when my jeans rub on my knees or get pulled too tight on my legs. However my knees are the only place I get this stuff, the rest is just the aforementioned aches/pains.

  8. Brandon, I think you are moving in the right direction with diet/losing weight/figuring out what exercises you can tolerate etc. Don't stress about the CNS possibility, just keep moving forward. A positive mindset and exercise are the key to beating CNS-related pain sensitivity anyway, so you are doing the right things. Expect ups and downs & setbacks, but remain pro-active.