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Save Yourself from
Patellofemoral Pain Syndrome!

AN ADVANCED TUTORIAL FOR PATIENTS AND PROFESSIONALS

Patellofemoral pain syndrome (aka runner’s knee) explained and discussed in great detail, including every imaginable self-treatment option and all the available scientific evidence

by Paul Ingraham, Vancouver, Canada MORE

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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

illustrations by Paul Ingraham, Lindsay McGee

Welcome to the most detailed guide to patellofemoral pain syndrome available. This is not just a web page — it’s a full-length e-book for patients and professionals. Every anterior knee pain base is covered: what it is and how it works, the myths and controversies, diagnostic help, worst case scenarios, analysis of every possible treatment method. I have yet to meet the patient who has actually “tried everything.”

Patellofemoral pain syndrome (PFPS), also known as runner’s knee, is the most common of all kinds of knee pain, causing pain around and under the kneecap. Almost anyone can get it, but it particularly affects runners, cyclists and hikers, and also office workers or anyone else who sits for a living. Runners are the usual victims, however, and often the most frustrated ones — PFPS is the most common of all knee injuries in runners.1

Knee pain may be common, but it’s tricky to find good information about it. Patellofemoral pain also seems to be one of the most misunderstood of all knee pain problems. There are countless brief descriptions and definitions of it online, but most just repeat the same points of oversimplified conventional wisdom. And while every doctor and therapist has basic knowledge of the condition, few are prepared for a tough case.

Getting good care for patellofemoral pain is a challenge

Many popular treatments for PFPS are of dubious value:

• Quadriceps strengthening is by far the most common prescription for PFPS. The idea is to teach them to pull more evenly on your kneecap — which good science has shown to be difficult at best, possibly impossible, and quite likely irrelevant.2

pro Attention physicians & therapists

Although addressed to patients, this tutorial is also for professionals and covers advanced concepts and recent research. It is easy reading, but it is not simple. Many footnotes contain extra, advanced information.

Yes, I do criticize common practices and conventional wisdom! Let me know if you disagree — I often make changes based on feedback. See my professional reading guide.

• Hip strengthening is a new treatment — almost fashionable — but it is far from proven and has been over-hyped since about 2005. It may have some value, but few people will still be enthusiastic about it after reading through the full story.
• Quadriceps massage is a popular alternative treatment, but massage — while good medicine for many painful conditions — is really not very helpful for kneecap pain, which is a very “jointy” problem.
• “Stay active” is one of the most common recommendations — but it may be the worst therapy of all for patellofemoral pain. It’s just knee jerk advice, given by professionals unfamiliar with the nature of PFPS.
• Treating PFPS like arthritis is a basic misunderstanding of the condition. Family doctors usually do this, but they are generally poorly informed about PFPS.3 It’s an understandable mistake — the distinction between PFPS and arthritis is quite complicated — but it’s bad news for the patient with serious chronic pain!
• Knee surgery is rarely a good option and often prescribed prematurely. Specialists4 and orthopaedic surgeons cannot be counted upon to provide good advice for PFPS.5 I believe that surgery is quite risky, and so do other experts.6

You should try to find good professional help, but you’ll need to be informed when you do it or you can easily waste a lot of time and money on dubious therapies — even if this tutorial can’t give you “the answer,” I hope it can at least help you avoid ineffective treatment.

Is there a miracle cure for anterior knee pain?

Is there a miracle cure for patellofemoral pain? Of course not! It’s important to state this clearly. Wouldn’t it be great if there were a proven treatment with minimal cost, inconvenience, or side effects? But medical science is nowhere close to this for most chronic pain conditions, and especially for patellofemoral pain.7

However, there are good reasons for optimism.

I can explain all the options, help you to confirm your diagnosis, and debunk bad ideas. It may or may not lead to a “cure,” but it will get you as close as you can get. Some readers will finally break free of their patellar pain. Others will make progress after ditching a counter-productive therapy, or trying an option they didn’t know about before. And maybe that is kind of miraculous!

With some effort and inconvenience, some people will achieve results that are sort of like a miracle.

How can you trust this information about patellofemoral pain syndrome?

I’m inspired by the MythBusters approach: I question everything and I have fun doing it. (No explosions, alas.) I assume that anything that sounds too good to be true probably is. I make no big promises, I do not claim to know the one true cause of anything, and I am not selling a treatment system or my own services. When I don’t know something, I admit it. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 130 footnotes), and I link to the original sources so you can check them yourself.

A quick overview of patellofemoral pain

Patellofemoral pain syndrome (PFPS) is a problem with pain that feels like it is mainly on the front of the knee, specifically on the underside of or somewhere around the edges of the kneecap. One or both knees can be affected. The pain is usually worse when climbing stairs or hills, or after sitting for a long time.

In average cases, the pain is not severe and the problem often goes away with basic physical therapy.8 “Basic physical therapy” probably isn’t actually effective, but recovery proceeds anyway simply because the body is pretty good at healing.9 But many cases get worse instead of better. For the unluckiest patients, “basic therapy” completely fails and patellar pain becomes permanent and almost crippling.

Honest professionals know that the causes and cures for patellofemoral syndrome are unknown. But most doctors and therapists buy into the conventional wisdom: that the problem is essentially “mechanical.” Unfortunately, those theories have serious errors that are rarely discussed. Fortunately, a few medical experts suggest good alternatives, which will be explained in detail in this tutorial.

What’s in a name? The many labels of patellofemoral pain

“Patellofemoral pain syndrome” is a surprisingly meaningless name. It basically means “strange kneecap pain,” but in Latin. “Anterior knee pain syndrome” is another common name, and it’s a little more direct and honest: it’s pain, and it’s on the front of your knee, ‘nuff said.

Sometimes the “pain” part is dropped and it is just called “patellofemoral syndrome” or PFS.

The words “patellofemoral pain syndrome” are often used as a catch-all diagnosis in practice, without any diagnostic certainty — they may refer to nearly any pain on the front of the knee, which may have any of several possible causes, none of which are particularly clear. The problem gets “syndrome” status because of this lack of clarity, and the fact that this particular kind of joint pain is so common.

“Runner’s knee” is a popular description among runners, of course, and they do get it more often than anyone else. But it is not a good term to use, because there are at least a half dozen other conditions that could be meant by it, especially iliotibial band syndrome. And of course it excludes other people who get the condition — all those people with cyclist’s knees and hiker’s knees, for instance!

Runners get anterior knee pain more often than anyone else.

Calling it “runner’s knee” particularly leaves out people whose knees hurt while sitting and because of sitting. Office workers and other chair-bound workers really do suffer from PFPS in droves. In fact, another name for this condition is moviegoer’s knee because of the tendency of the condition to cause pain after sitting for a long time. This also explains the use of the term “theatre sign” among professionals, as in, “He’s got theatre sign — must be a case of movie-goer’s knee.” In my professional experience, however, you could just as well say, “He’s got desk job sign — must be a case of office worker’s knee.”

One more naming note: occasionally you’ll hear therapists or doctors call this condition “patellofemoral tracking syndrome” (PFTS) or even chondromalacia patellae (definitions coming soon), but these are blatantly in error: these are things that might be causes of the condition, but they are not the condition itself.

What causes patellofemoral syndrome?

Officially, no one knows what causes it. Here is an entertaining selection of typical disclaimers from some scientific papers dating back to 1988:

• Back in 1988 Potter et al. summed it up: “Ironically, as simple as its presentation is, lack of consensus on the fundamental factors associated with PFS remains. No agreement exists on the exact pathophysiology ….”
• In 1993, the Clinical Journal of Sports Medicine published an editorial called “The myth, mystic and frustration of anterior knee pain,”10 a title that certainly reveals a degree of medical uncertainty on the subject!
• You would hope for progress over the next few years, but in 1998 Journal of Orthopaedic & Sports Physical Therapy published the opinion that “there is no consensus on the most effective method of treatment … the indications and contraindications of each approach have not been well established … [and] there is no generally accepted classification scheme for patellofemoral disorders.”11
• Not long after, in 1999, the journal American Family Physician, in one of its excellent physician tutorials, said that “Managing patellofemoral pain syndrome is a challenge, in part because of lack of consensus regarding its cause and treatment,” and “no single biomechanical factor has been identified as a primary cause of patellofemoral pain.”12
• And things are no better as recently as 2006. With resounding negativity, Naslund concluded that “no consensus on the definition, classification, assessment, diagnosis, or management has been reached.” Wow. That’s really a lack of consensus!

That’s the official, reasonable position. Any honest doctor or therapist should be happy to admit that almost everything about PFPS is basically a mystery. But in practice, most doctors and therapists think that they know: they think and act like the conventional wisdom is adequate.

The conventional wisdom

I’m pleased to say that American Family Physician came around. They say that the mystery of PFPS has been solved. (It hasn’t really, of course. I’m being sarcastic.) In a new tutorial for physicians published last year (2007), they confidently declared the cause of PFPS:

[Patellofemoral pain syndrome] is caused by imbalances in the forces controlling patellar tracking during knee flexion and extension, particularly with overloading of the joint.

Dixit.

Well, thank goodness! That’s nice and clear, isn’t it? The conventional wisdom says that patellofemoral pain syndrome is painful degeneration of the cartilage on the underside of the kneecap, caused by a “mechanical” failure of that joint. What kind of failure? A “tracking” problem, in which the patella doesn’t slide evenly in its groove or “track” on the femur. For this condition, we need yet another multisyllabic name: “patellofemoral tracking syndrome.”

Another syndrome? I’m afraid so. It even has almost the same acronym: PFTS instead of PFPS. The conventional wisdom is so entrenched that many professionals consider the “tracking” syndrome to be virtually synonymous with PFPS itself.

The conventional wisdom is so entrenched that patellar “tracking” syndrome is virtually synonymous with patellofemoral pain itself.

But the idea that tracking problems cause patellar pain has not been proven beyond a reasonable doubt. In fact, as I will show in the sections ahead, it’s incredibly difficult to even prove that these problems even coexist, let alone how much they have anything to do with each other … if anything at all. Even stranger, it turns out that tracking problems are extremely difficult to even identify, let alone blame for anything. And as if this wasn’t enough trouble for the conventional wisdom, it turns out that even the “degeneration” of the kneecap’s cartilage is a scientific myth … a myth that probably has little or nothing to do with patellofemoral pain syndrome!

Wow. That’s a lot of myths.

Assault on the conventional wisdom about patellofemoral pain syndrome

Pain in the patellofemoral joint mostly does not appear to be associated with any identifiable tissue degeneration or damage, dysfunction or malfunction, assymetry or weakness.1314 Sometimes it just hurts, even though the knee — indeed, the whole leg — seem to be healthy in every way that we can measure knee health. And if that seems a bit odd, you ain’t seen nothing yet!

Even when the joint is degenerating …

Acknowledgements

Thanks to Dr. Scott Dye for helping me to understand and believe in my own unconventional ideas about patellofemoral pain syndrome, and by extension every other joint problem.

This document and all of SaveYourself.ca was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stores. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Steven Novella, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

Further Reading

• “The pathophysiology of patellofemoral pain: a tissue homeostasis perspective,” an article in Clinical Orthopaedics & Related Research, 2005.. This article by Scott F. Dye, MD, an orthopaedic surgeon from San Francisco, was by far the most influential source for this article. I do not normally recommend scientific articles to my readers, most of whom are ordinary people with knee pain, and not especially interested in slogging through medical jargon. However, in this case, I have to make an exception: although Dr. Dye’s writing is certainly intended for a professional audience, patients should still be able to get something out of it. It’s clear (for a scientific paper) and sensible, and even somewhat visionary in tone. Despite the fact that it’s certainly harder reading than this article, and despite the cost — the article will set you back US$10 to access — I still think it’s worth it. If you really want a good depth of understanding of PFPS, it’s required reading.
• This article, Massage Therapy for Your Quads, will add to your understanding of the quadriceps muscle group and its relationship to the kneecap.
• There are other kinds of knee pain, and it’s not always easy to tell which kind you’ve got. For the scoop on another common knee problem, see SY Save Yourself from IT Band Syndrome! — All your treatment options for Iliotibial Band Syndrome reviewed in great detail, with clear explanations of recent scientific research supporting every key point. Not sure what kind of knee pain you’ve got? See The Runner’s Knee Diagnostic Stand-Off.
• The journal American Family Physician publishes free tutorials for doctors which may also be useful for patients. I have come to trust those tutorials as one of the best sources available when I am trying to understand conventional medical opinion. They are usually well-written and beautifully illustrated, and determined patients can often get plenty of value out of them despite the jargon. See “Patellofemoral pain syndrome: a review and guidelines for treatment” for a 1999 tutorial for doctors, and “Management of patellofemoral pain syndrome” for their 2007 article on the subject. Bear in mind that these articles present only the conventional wisdom, however, and primarily discuss structural explanations for knee pain. As such, I do not think that they are useful to my patients and readers except as the best available representation of conventional wisdom.

Notes

1. Taunton et al. British Journal of Sports Medicine. 2002. This study of a year’s worth of injuries among Vancouver runners — many of whom I probably run with every day on Vancouver’s sea wall — reported that “Patellofemoral pain syndrome was the most common injury, followed by iliotibial band friction syndrome, plantar fasciitis, meniscal injuries of the knee, and tibial stress syndrome.” Return to text.
2. The science of this controversial claim will be discussed in great detail below. Return to text.

3. Most doctors are well aware that there are serious shortcomings in the medical management of most musculoskeletal problems, especially chronic pain cases. Dr. Jonathon Tomlinson, an instructor at St. Leonards Hospital in Hoxton, explains that “undergraduate training is focused on hospital orthopedics (broken bones and anything else that’s amenable to surgery) or rheumatology (nasty inflammatory diseases) which comprise a minority of the aches/pains/strains and injuries that people actually suffer from.”

   Medical researchers have done many studies showing that most doctors do not understand aches and pains or heed expert recommendations. A good recent example is a paper in the Archives of Internal Medicine showing that family doctors frequently ignore guidelines for the care of low back pain — see Williams et al.

   More generally, the Journal of Bone and Joint Surgery, and the Journal of the American Osteopathic Association, have both published papers recently showing that physicians simply do not have an adequate understanding of musculoskeletal medicine. In 2002, Freedman et al felt that “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” Then again in 2005 in JBJS, Matzkin et al concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” Most recently, in 2006, Stockard et al wrote “82% of allopathic graduates ... failed to demonstrate basic competency in musculoskeletal medicine.”

   Return to text.
4. Sports medicine specialists are probably the least of all evils — although no professional category seems generally well-informed about PFPS, you probably stand a somewhat better chance of getting competent help from a sports medicine doctor than from any other kind of health care professional. Although they are more or less as prone to the toeing the line of conventional wisdom as any other health care professional, at least their expertise is directly concerned with non-surgical management of conditions like PFPS — and so there is at least some respectable chance that a doctor in this speciality will have paid some attention to the scientific controversies. Return to text.
5. Orthopaedic surgeons are surgeons — not only do surgeons strongly tend to perceive musculoskeletal problems only in terms of surgical solutions, but they are (quite correctly) professionally preoccupied with their surgical expertise and professional development, which means that they are typically not knowledgeable about conservative physical therapy methods for relatively minor overuse injuries like PFPS. Many of them certainly try to make a professional point of avoiding the overprescription of surgery, but that doesn’t necessarily make them experts in what to do instead of surgery. And PFPS is a particularly bad problem to take to a surgeon for the simple reason that, among knee injuries, PFPS is just about the last one that you’d want to operate on. This will be fully explained as we continue with the tutorial. Return to text.
6. Surgeons often oversimplify patellofemoral pain syndrome as simply a case of “arthritis” of that joint, and recommend a debridement (filing or smoothing) of the knee cartilage, either of the patellofemoral joint, or of the main joint between the tibia and femur (which is particularly irrelevant to patellofemoral pain). However, debridement has been proven to be ineffective even for arthritis (let alone PFPS, which isn’t arthritis), originally and most spectacularly by Moseley in 2002, then most authoritatively by The Cochrane Collaboration in early 2008 (see Laupattarakasem), and most recently by New England Journal of Medicine in September 2008 (see Kirkley). This is one of the most straightforward scientific slam dunks in surgery research in recent history — debridement doesn’t work! For more details, see Knee Surgery Sure is Useless! Return to text.
7. There isn’t even a reasonably reliable surgical Plan B for patellar pain, as there are with several other common joint problems. Return to text.
8. Dixit et al. American Family Physician. 2007. “ …although management can be challenging, a well-designed, non-operative treatment program usually allows patients to return to recreational and competitive activities.” Return to text.
9. As we’ll discuss in detail below, most “basic” physical therapy for PFPS consists of minor interventions of highly questionable value, yet the clinical impression of most professionals is that mild patellofemoral pain does go away with conservative advice. The most likely explanation for this — and it’s a common “problem” in physical therapy — is simply that most of those cases would have gotten better regardless of the therapy. Of course, in some cases, some good advice may be mixed in with bad advice, and that may help. And there may be some placebo effect: being therapized really does help a lot of people to feel better, regardless of whether or not the therapy makes any sense, and yes this phenomenon can occur even with something as seemingly un-psychological as knee pain! See Moseley. Return to text.
10. Reid. Clinical Journal of Sports Medicine. 1993. Return to text.
11. Wilk et al. Journal of Orthopaedic & Sports Physical Therapy. 1998. Return to text.
12. Juhan. Job’s Body. 1998. Return to text.
13. Naslund et al. Physiother Theory Pract. 2006. In this study of 80 patients with a diagnosis of PFPS, signs of pathology could be found in only 15 of 80 patients, and the authors conclude that even these “cannot be detected from ... commonly used clinical tests.” Return to text.
14. Piva et al. Archives of Physical Medicine & Rehabilitation. 2009. Researchers tested 74 patients diagnosed with patellofemoral pain syndrome for the presence of several factor that are commonly suspected to be associated with that condition, the “usual biomechanical suspects”: muscle weakness and tightness, coordination, and postural and anatomical abnormalities. They also considered psychological factors, which is quite unusual for a study of knee pain.
    
    They found no correlation at all with between the biomechanical factors and chronic anterior knee pain.
    
    (Interestingly, the researchers did find that “psychologic factors [anxiety and fear-avoidance beliefs about work and physical activity] were the only associates of function and pain in patients with PFPS.”) Return to text.

There are 109 more footnotes in the full version of the patellofemoral pain syndrome tutorial. See above for details, or click the “buy” button to buy it now.

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