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 stories. 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.

One more special comment. In the Spring of 2009, I received an incredible endorsement from Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:

I'm writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

High praise indeed! Thank you, Dr. Tomlinson — testimonials just don’t get much better than that.

• “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.

The original publication date of this tutorial has been lost, but I think it was in 2004. It remained quite rudimentary until 2007, when significant upgrades began. This change log was started in May ’07, along with many major improvements. As you can see, the tutorial has been updated many times since, and remains a live document.

A major feature of my tutorials is that I actively update them as new science and information becomes available. Unlike regular books, and even ebooks — which can be obsolete by the time they are published, and can go years between editions — this tutorial is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 39 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

Minor update (May 2 '13, section #2.2) — Apt aging joints humour added, via comedian Louis CK. See section #2.2, Assault on the conventional wisdom about patellofemoral pain syndrome.

Minor update (Mar 29 '13, section #7.6) — Upgraded risk and safety information about Voltaren Gel. See section #7.6, You and “vitamin I”: anti-inflammatory meds, especially Voltaren® Gel.

Science update (Dec 18 '12, section #7.19) — The writing was on the wall, but a new comprehensive review of knee lube jobs has confirmed that knee lube jobs are all washed. The section now reflects that. See section #7.19, Should you get a lube job? Artifical synovial fluid injections.

Science update (Dec 5 '12, section #2.13) — Two new studies of the connection between knee pain and the inner thigh muscles, showing … modest correlations of dubious significance. See section #2.13, Weak and uncoordinated muscles, perhaps?

Science update (Nov 20 '12, section #7.11) — Weak but interesting new evidence on natural running and injury prevention. See section #7.11, Should you run naked? On faddish running styles and running shoes (or the lack thereof).

New section (Nov 16 '12, section #7.1) — New standard section I’m introducing to most of the tutorials to “manage expectations.” Too many readers assume there’s going to be a specific miracle treatment plan. See section #7.1, So what’s the plan?

Major update (Nov 16 '12, section #7) — Greatly expanded. Now offers a comprehensive summary of all treatment options: the good, the bad and the ugly. See section #7, Other Treatments: What else can you do about PFPS?

New section (Nov 15 '12, section #8) — An important new section created as a direct response to reader demand. See section #8, Now what?: An action-oriented summary of recommendations.

Medium update (Nov 13 '12, section #7.14) — Added a few paragraphs about foam rolling and trying to “elongate” the IT band. See section #7.14, Quadriceps massage.

Science update (Oct 28 '12, section #7.10) — A minor but interesting new item about high heels. See section #7.10, Orthotics and shoes.

Product upgrade (Jul 30 '12) — PDF versions of all SaveYourself.ca tutorials are now available. They are ideal for printing and offline reading on e-readers. The online version will always be the “real” version (guaranteed current) and the best way to read the books, but fresh PDF copies will always be available to customers. Announcement on my blog: Finally! PDF versions of my books, and the “technologically interesting” story of how they were made.

Minor update (May 14 '12, section #6.1) — Another nice swimming update: I added some excellent perspective from an experienced competitive swimmer. See section #6.1, The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.

Minor update (May 4 '12, section #6.1) — Very simple swimming tip added. Hat tip to reader Eric C. See section #6.1, The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.

Updated (Mar 8 '12, section #6.8) — Answered some common reader concerns about planning. See section #6.8, Jan’s Phase I: Preparation (July and August).

Updated (Feb 23 '12, section #4.4) — Bone scans and the reason for getting them are now described much more thoroughly. Added some new science confirming that many PFPS knees are “hot.” See section #4.4, Hot kneecaps! Should you get an x-ray, MRI, or bone scan?

Major update (Feb 23 '12, section #4.1) — Expanded and heavily edited. In particular, the concept of a “diagnosis of exclusion” is now explained thoroughly. See section #4.1, Eliminate other concerns.

New section (Dec 30 '11, section #7.23) — No notes. Just a new section. See section #7.23, What can a runner with knee pain do at the gym?

New section (Dec 13 '11, section #7.8) — Not a beefy update: just a few quick thoughts about heat. See section #7.8, Heat (very briefly).

Minor update (Dec 13 '11, section #6.3) — Addressed some common fears about the threat of getting out of shape while resting. See section #6.3, 1. Common Resting Pitfall No. 1: The runner’s natural stubbornness.

Minor update (Sep 28 '11, section #7.10) — Added reference to Kong et al, about the effect of shoe wear. See section #7.10, Orthotics and shoes.

New section (Aug 22 '11, section #7.10) — Expanded the section so much that it’s effectively new. It was just a single paragraph about orthotics. Now it is a much more thorough discussion of orthotics, shoes, and impact reduction. In particular, it features a fairly enthusiastic endorsement of Oesh shoes. See section #7.10, Orthotics and shoes.

Minor update (Jul 29 '11, section #1) — Added a reference about the poor overall quality of online information about common injuries. See Starman. See section #1, Introduction.

Minor update (Jul 8 '11, section #6.1) — Added an item about swimming to the “activities that may strain the knee” chart. See section #6.1, The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.

Major update (Jun 21 '11) — Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really be cleaned up in general, paving the way for efficient conversion to other formats (Kindle, Apple’s iBookstore, etc). Best of all, it is now significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

New section (Mar 20 '11, section #7.11) — Finally, long overdue, a new section on this topic (for all the running injury tutorials, in fact). See section #7.11, Should you run naked? On faddish running styles and running shoes (or the lack thereof).

Important new info (Feb 8 '11) — Where’s the fire? Recently I published a major new article about repetitive strain injuries (like patellar pain), in which I explain that these injuries are rarely actually inflamed. Instead of being “on fire,” excessively stressed tissues tend to break down without inflammation — a kind of rot. This significant fact of biology is not yet given proper attention in this tutorial, and it should be. I learned the science of this myself only just recently, and it is going to take me a while to revise all of the tutorials and articles that are affected by it. Meanwhile the new RSI article is available, free to all, and I have also mentioned and linked to it where necessary throughout all tutorials. For the full scoop on inflammation and repetitive strain injuries, see: Repetitive Strain Injuries Tutorial: Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome.

New section (Dec 2 '10, section #4.7) — New short section for both this book and the iliotibial band syndrome book covering potentially confusing alternative diagnoses, such as politeal artery entrapment syndrome (PAES). See section #4.7, Other possible diagnoses and sources of diagnostic confusion.

New section (Nov 27 '10, section #1.6) — Brief new section — just a note, really, but quite important to some readers. See section #1.6, About patellofemoral pain in teens.

Minor update (Sep 29 '10, section #7.5) — Added some data on the incidence of PFPS in cyclists. See section #7.5, Treating for inflammation: is there any point?

New cover (Aug 6 '10) — At last! This e-book finally has a “cover.” SHOW

New section (Jul 27 '10, section #7.20) — No notes. Just a new section. See section #7.20, Glucosamine, chondroitin sulphate and other “nutraceuticals” have failed every large, fair test.

Major improvements (Jul 8 '10, section #3) — Substantial changes related to new science summarized in Am I wrong? An update on the conventional wisdom. See section #3, A Modern Perspective: Patellofemoral pain as “the itch you can’t scratch”.

Major improvements (Jul 8 '10, section #2.13) — Substantial changes related to new science summarized in Am I wrong? An update on the conventional wisdom. See section #2.13, Weak and uncoordinated muscles, perhaps?

Major improvements (Jul 8 '10, section #2.12) — Substantial changes related to new science summarized in Am I wrong? An update on the conventional wisdom. See section #2.12, Misc other possible biomechanical bogeymen.

New section (Jul 8 '10, section #2.3) — A flurry of substantive updates and re-writing today inspired by some new scientific papers. See section #2.3, Am I wrong? An update on the conventional wisdom.

New section (Jun 29 '10, section #7.9) — No notes. Just a new section. See section #7.9, Steroid injections are powerful, but where would you put the needle?

New section (Jun 14 '10, section #7.22) — No notes. Just a new section. See section #7.22, Prolotherapy is not relevant to patellofemoral pain syndrome.

Minor update (Apr 2 '10, section #7) — Miscellaneous upgrades, and a nice anecdote from a reader about a “boot cure.” See section #7, Other Treatments: What else can you do about PFPS?

Minor update (Apr 2 '10, section #6.1) — Added thoughts about the effect of elliptical machines on PFPS and some other minor updates. See section #6.1, The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.

Older updates — Listed in a separate document, for anyone who cares to take a look.

1. Clarsen et al. Overuse Injuries in Professional Road Cyclists. American Journal of Sports Medicine. 2010. PubMed #20847225. BACK TO TEXT
2. Taunton et al. A retrospective case-control analysis of 2002 running injuries. 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.”

   BACK TO TEXT
3. In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics,” such as knee pain and low back pain — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. BACK TO TEXT
4. The science of this controversial claim will be discussed in great detail below. BACK TO TEXT
5. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and they are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches and Pains. BACK TO TEXT
6. 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. BACK TO TEXT
7. 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. BACK TO TEXT
8. 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! BACK TO TEXT
9. There isn’t even a reasonably reliable surgical Plan B for patellar pain, as there are with several other common joint problems. BACK TO TEXT
10. Dixit et al. Management of patellofemoral pain syndrome. American Family Physician. 2007. PubMed #17263215. “ …although management can be challenging, a well-designed, non-operative treatment program usually allows patients to return to recreational and competitive activities.” BACK TO TEXT
11. 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. BACK TO TEXT
12. In practice the diagnosis is more inclusive — as is this book, much of which is useful even for the patient who turns out in the end to have something a little better defined. BACK TO TEXT
13. Reid. The myth, mystic and frustration of anterior knee pain. Clinical Journal of Sports Medicine. 1993. BACK TO TEXT
14. Wilk et al. Patellofemoral disorders: a classification system and clinical guidelines for nonoperative rehabilitation. Journal of Orthopaedic & Sports Physical Therapy. 1998. BACK TO TEXT
15. Juhan. Job’s Body. 1998. amazon.com BACK TO TEXT
16. A one-minute excerpt from his 2008 stand-up show Chewed Up is embedded below, but you can also watch the full segment (2:30) on YouTube. Funny stuff! BACK TO TEXT
17. Näslund et al. Comparison of symptoms and clinical findings in subgroups of individuals with patellofemoral pain. Physiotherapy Theory and Practice. 2006. PubMed #16848349. In this study of 80 patients with a diagnosis of PFPS, with all other likely diagnoses already eliminated from consideration, signs of pathology were found in only 17 of 75 patients, and the authors conclude that even these “cannot be detected from ... commonly used clinical tests.” That’s quite a few mysteriously painful knees. BACK TO TEXT
18. Piva et al. Associates of physical function and pain in patients with patellofemoral pain syndrome. Archives of Physical Medicine & Rehabilitation. 2009. PubMed #19236982.

    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.”)

    BACK TO TEXT

There are 129 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.

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