Therapists cannot agree on the location of people’s kneecaps!

Assessing kneecap alignment is a reflex for most manual therapists — a staple of knee pain diagnosis, as inevitable as a doctor asking you to say “ah.” Kneecap alignment is almost universally regarded as a sign of patellofemoral pain syndrome and patellar instability and accurate assessment of kneecap position is essential for meaningful taping (a popular treatment method). Obviously you can’t use tape to align a kneecap if you don’t know how it’s misaligned to begin with.

But is assessment of patellar alignment actually reliable? Turns out probably not. As with so many other eyeballings of biomechanics, the same patient is likely to get different diagnoses from different professionals.

A 2009 paper in Manual Therapy reviewed nine reliability studies of 306 knees. (They noted that this is not much evidence, and more is needed. No kidding! We’re talking about one of the most common of all testing procedures for knee pain, and we’ve only properly studied its accuracy on 306 knees, ever? Think about how many bazillions of dollars of therapy money are spent on knee alignment issues!)

As with so many other eyeballings of biomechanics, the same patient is likely to get different diagnoses from different professionals.

What evidence there is showed that assessment of patellar position was “variable” from one therapist to the next — if you get a bunch of clinicians to all assess the same kneecap, they will come up with a variety of diagnoses.

Of course it’s possible that there is a way to accurately assess patellar alignment, and maybe someday we’ll know that and all manual therapists will be properly trained in it. Maybe. But that doesn’t matter to patients now. These scientific tests of existing methods with competent practitioners should have produced clear agreement and strong reliability — not “variable” results. That’s pretty discouraging for patients.

Despite these problems, a “wonky patella” diagnosis is commonly used to dubiously shore up a diagnosis of patellofemoral pain syndrome or iliotibial band syndrome (which is usually unnecessary, because we can diagnose those conditions just fine without even asking the patellar alignment question), and then used as a justification for a bunch of time-wasting and money-wasting therapy and therapeutic exercises. Elaborate and tedious exercises to try to “align” kneecaps are almost as common as the testing procedure itself. Take your hurtin’ knees to a manual therapist, and odds are excellent that they will not only conclude that you have an alignment problem, but that you need therapy and exercise to fix it. Imagine that. But it’s all based on a diagnosis that is proven to be unreliable.

If you’re doing a bunch of therapy based on the idea of patellar misalignment — and I mean both patients and professional — you should seriously reconsider it.