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Save Yourself from Patellofemoral Pain Syndrome!

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

Paul Ingraham, updated

Photo of many runners disappearing into the mist. A caption superimposed on the image reads: patellofemoral pain is a common and often chronic injury in runners (many non-runners too), causing pain mainly on the front of the knee.

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. It’s also common in teens. Almost 40% of pro cyclists will get anterior knee pain in any given year,1 but runners are by far the most numerous victims, and PFPS is the most common of all runners’ knee injuries.2

Most people recover from PFPS with a little rest and then slowly working their way back to normal activity, but not everyone. This kind of runners’ knee can be extremely treatment resistant, and sometimes becomes a seriously style-cramping chronic pain problem.

This deep-dive tutorial is for patients with serious and stubborn patellofemoral pain, and the professionals trying to help them.

I survived a brain tumor. Knee rehab has been worse.

~ a reader

A quick overview of patellofemoral pain

Diagram illustrating the difference between patellofemoral pain syndrome and iliotibial band syndrome, showing how the former causes pain primarily on the front of the knee, while the latter causes pain primarily on the outside of the knee.

PFPS affects the kneecap & surrounding area. Don’t confuse it with iliotibial band syndrome (ITBS) which definitely affects primarily the outside of the knee (the lateral or outward-facing side of the knee). This picture is of a right knee.

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.[Wikipedia] 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.3 “Basic physical therapy” probably isn’t actually effective, but recovery proceeds anyway simply because the body is pretty good at healing.4 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 pain 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.

Getting good care for patellofemoral pain is a challenge

Knee pain may be common, but it’s surprisingly hard to find good self-help information for it. Patellofemoral pain is one of the most misunderstood of all knee pain problems. There are countless shallow webpages about it, but most just repeat the same points of oversimplified conventional wisdom.5 And not many doctors and therapists are prepared to treat tough cases. Sports medicine in general is amazingly primitive considering how much potential funding it has. You’d think anything affecting elite athletes with huge audiences would be getting more attention! The situation is improving, but only recently and it still has a long way to go.6

And so, many popular treatments for PFPS are of dubious value:

You should try to find good professional help, but it’s a great idea to be as well informed as possible 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.

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 with an even broader meaning, and it’s a little more direct and honest: it’s pain, and it’s on the front of your knee, ‘nuff said.

A humourous graphical definition of patellofemoral pain syndrome, showing the meaning of the root “patello” means “kneecap,” the word “pain” means “ow,” and “syndrome” means “kinda mysterious.”]

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 roughly on the front of the knee, which may have any of several possible causes, none of which are particularly clear. Technically, it’s a diagnosis of exclusion[Wikipedia] — what’s left when everything else has been eliminated.12 The problem gets “syndrome” status because of this lack of clarity, and the fact that this particular kind of joint pain is so common.

Photo of a woman in a chair. Chair workers often suffer from patellofemoral pain syndrome.

Do you live in a chair?

“Chair warriors” who spend more than 4–6 hours per day suffer as much from knee pain as many runners. Woe to you if you both run and work in a chair …

“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!

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.

About patellofemoral pain in teens

Patellofemoral pain in teens isn’t specifically covered in this book. However, the book is still useful for young patients.

The incidence of patellofemoral pain in adolescents is only a little bit higher than it is in the general population, and it is generally less serious and stubborn. It is mostly a temporary condition: they recover from or grow out of more easily than adults do. Although serious cases certainly can and do occur in teenagers, their age is not particularly relevant to those cases. A serious case in a teenager has to be handled in pretty much the same way that you would handle a serious case in an adult. So although age is a factor I haven’t focused on, everything that I have focused on should be of interest to teens with persistent knee pain.

Part 2

Nature of the Beast

The (many) possible causes of 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:

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 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. (That’s sarcasm.) In a tutorial for physicians published in 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 S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician. 2007;75:194–202. PubMed #17263215.  PainSci #56699. 

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.

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.

The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).

~ Teaching people about pain — why do we keep beating around the bush?, by Lorimer Moseley, 2–3

Assault on the conventional wisdom about patellofemoral pain syndrome

Joints wear out, right? Comedian Louis CK:16

The doctor shows me an x-ray of my ankle and he’s like, “Yeah, your ankle’s just, uh … worn out.”

“What do you mean? I injured my ankle?”

He’s like, “No, it’s just shitty now.”

And yet! Pain in the patellofemoral joint mostly does not appear to be associated with any identifiable tissue degeneration or damage, dysfunction or malfunction, asymmetry or weakness.1718 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…

END OF FREE INTRODUCTION

Purchase full access to this tutorial for USD$1995. Continue reading this page immediately after purchase. See a complete table of contents below. Most content on PainScience.com is free.?


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You can also keep reading more without buying. Here are some other free samples from the book, and other closely related articles on PainScience.com:

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I guarantee only education, not “results”

This book does not spell out a treatment plan. There is no secret cure that will be revealed when you pay the fee. The entire reason the book exists is that there is not a good, reliable treatment for patellofemoral pain syndrome. It’s very 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.

However, there are good reasons for optimism.

What I can do is 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.

Mostly what’s for sale here is simply a deep understanding of the subject and your options. For some people, it’s worth $20 just to feel like they aren’t overlooking something. In general, if it’s not in this tutorial, it probably doesn’t matter.

And $20 is lot cheaper than even a single appointment with most healthcare professionals. And you might just get more out of it.

Part 2.3

Appendices

Reader feedback … good and bad

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here’s some highlights from the kind words I’ve received over the years … plus some of the common criticisms I receive, at the end. These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details.

Thanks for a well written, humorous and informative piece. Your book helped me understand what I did to my knee running and how to treat (and not treat!) stubborn injury. Might see you jogging through Stanley Park or water front, on one of our visits to daughter, love Vancouver.

~Matt Randlett


I wanted to write a short thank you email for all the help you have brought me. Im a recently graduated medicine student from Argentina, and i have been getting knee pain for almost 8 months. I have been to the best traumatologists in the country, none who could explain correctly what was going on with my knee. They did exactly the kind of mistakes you constantly mention all along your book.By reading the tutorial i have at last fully understood what im up against, how to correctly fight it, and hopefully beat the crap out of this horrible pain.Just wanted to write this short thank you email, you should know your amazing work helps people all around the globe.

~Petra Fellows


My name is Lexy, I’m a 23-year-old with patellofemoral syndrome. For the past six months. I don’t have any questions really, but I wanted to reach out and let you know how valuable your writing has been to me. I’m just an occasional visitor of painscience.com, but when I get those mental waves of dread that tell me my injury is going to last forever, your writing style has been super helpful in putting things in perspective, and helping me be realistic, yet hopeful about my recovery. I’ve seen PTs, acupuncturists, orthopedic surgeons and doctors, many of which have given me shit advice and left me feeling upset and angry, or like my pain wasn’t being taken seriously. I thank you for creating a forum where I feel a sense of solidarity with other humans/athletes, and most importantly where I don’t feel like I have to pay a ridiculous amount of money to feel like a factory-line patient. I really appreciate that.

~Shakil Irvine


I wanted to send you a quick email to deeply thank you for all your work. I grappled for 18-months with horrible knee pain that threw my life into a tailspin. Your books were critical for getting me on the path to healing. I have spent much of my career in health research and policy and really admire your ability to distill evidence and then present it clearly and accurately to a general audience. Thank you.

~Franco Sargent


Your tutorial on patellarfemoral syndrome really cut through a lot of misinformation I’ve received from MDs and PTs.

~Alastair Rosario


Given what I have learned about patellofemoral pain syndrome over the last two years through personal experience, your tutorial is probably the best summary of everything I have seen.

~anonymous


This has already served as a massive eye opener for me. It makes a huge amount of sense where previously there was only confusion.

~Greg Bruce, “struggling masters athlete”


Just reading tutorial has already given me hope that I can finally get some relief from my chronic patellofemoral pain syndrome. Why didn’t I find this 2 years ago?! It has been so frustrating, both physically and emotionally, as I’m sure you already know from your patients. Your eBook is very enlightening and well written. Please feel free to use my comments as a testimonial. I was glad to see other testimonials, too — it’s nice to know that I’m not the only one who is struggling with this.

~Melanie Caldwell, Yonkers, NY


Finding this information was a huge relief for me. I really did think I had “tried everything.” But I found pages and pages of stuff in your article that no other doctor or therapist had ever even mentioned.

~Jared Foster, long-distance runner


I’m reading your patellofemoral pain tutorial slowly to absorb your wisdom and expertise. It’s also very pleasurable reading. As I learn, it seems almost comical to me that I have consistently pushed beyond the “envelope of function” into the “zone of overload.”  I see just exactly the mistakes I have made going into my marathon. It just seems so obvious now! Thank you so much. You have helped me in a great way that goes way beyond $20 …

~David Greenman, distance runner, Harrison, New York

This is pretty much exactly the sort of revelation that I hope my readers have!  “Gosh, it’s so simple, really ...” ~ Paul

One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

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

What about criticism and complaints?

Oh, I get those too! I do not host public comments on PainScience.com for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most disatisfied customers have strong themes:

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.

Extra special thanks to Tony Ingram, for substantial contributions of expertise and writing to this book in 2014 — the book is much better for it.

Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is actually a much bigger project than a book. PainScience.com was originally created in my so-called “spare time” with a lot of assistance from family and friends (see the origin story). Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.

I work “alone,” but not really, thanks to all these people.

I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.

About the 2nd Edition

The 2nd “edition” of the PFPS tutorial was launched on July 28, 2014, after months of collaboration with Tony Ingram, a Physical Therapist who did his Masters thesis on anterior knee pain. Tony was officially a co-author for a while, but retreated to focus on pursuing a PhD and a career in science.

Like all my books, this one was updated many times over the years, but changes were too small and spread out to constitute an “edition”: that had to wait for this, by far the largest ever major change to the book. It has several new sections, a lot of new science, and a strong (and overdue) new emphasis on the evidence-based value of exercise — reversing my grumpy anti-exercise position. It’s also much less exclusively about a single theory of knee pain than it was.

A new position on exercise

Exercise for patellofemoral pain syndrome is a good example of a treatment that works, but probably doesn’t work how most people think it works. I was anti-exercise before because the evidence just wasn’t there for it yet, and too many professionals fancied that they were prescribing exercise to change biomechanical parameters (e.g. patellar tracking) that correlated poorly with the condition. Such prescriptions tended to be overzealous: too much exercise, too soon for patients suffering from what is fundamentally an overuse condition.

Now there is good evidence that exercise is effective — hallelujah, some much-needed good news — but dosage and timing are key, and the biomechanical rationale still needs to be taken out with the trash.

Not just one guy’s theory any more

The previous version of the book had a significant weakness, a major idea about the nature of the beast (basically the whole “it’s the homeostasis, stupid,” ). The idea was plausible and elegant, but lacked adequate scientific support for an important basic point of the book. One advanced reader complained:

I didn’t buy your book so I could get one guy’s theory about how patellofemoral pain syndrome works.

Fair enough. She went on to say that it was probably a pretty good idea, just painfully unsupported. Simple as it is, that’s one of the best single constructive criticisms I’ve ever received. On the one hand, I unapologetically offer my take on these complex subjects. They are my books, and this is not a medical journal. On the other hand, I don’t want my take to be based solely on private speculation — if my opinion is to have much value, it should be clearly based on a diversity of expert and scientific sources. And so this is one of the major repairs in the 2nd edition. My basic point was sound, but badly needed some scientific and more diverse expert support — and now it has that.

Further Reading

A few more articles about patellofemoral pain syndrome and related topics:

What’s new in this tutorial?

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

Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document 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 95 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

NovemberExpansion: Previously this chapter was just about massage in general and foam rolling in particular. I’ve widened the scope to address the underlying assumption that there’s a need to “loosen” the quads, and now cover both stretch and massage. [Section: Loosening the quads with massage and/or stretch.]

JulyMinor addition: Added a brief discussion of an important principle: exercise is a pain-killer! Sometimes. [Section: 2. Common Resting Pitfall No. 2: Being fooled by delayed pain.]

JulyNew section: No notes. Just a new section. [Section: The science of resting.]

MayNew section: No notes. Just a new section. [Section: The noise, noise, noise! The significance of knee snaps, crackles, and pops.]

MarchNew section: No notes. Just a new section. [Section: Is it possible to exercise to recovery while still in some pain?]

MarchEdited: Just cleaned it up, clarified, made it less about runners exclusively. [Section: What happens if you “run through” patellofemoral pain syndrome? What if you push it?]

JanuaryNew section: No notes. Just a new section. [Section: “Patella release technique” from a popular YouTube video.]

JanuaryScience update: Added brief discussion of the poor state of evidence for stem cell therapy, citing Pas et al. [Section: Regenerative medicine? Platelet-rich plasma injections and stem cell therapy.]

JanuaryMinor addition: Added sidebar about crutches and canes. [Section: Jan’s Phase II: Total rest (September).]

JanuaryAdditions: After long neglect, I finally added some new points to this section, regarding tendinitis and infrapatellar fat pad impingement fat pad syndrome. [Section: Other possible diagnoses and sources of diagnostic confusion.]

2018Editing: Just making the same points a bit more clearly. [Section: How do you exercise without pissing off your knees?]

2018Expanded: Added discussion of plica syndrome. [Section: Eliminate other concerns.]

2018Additions: More detailed summary of the troubles with meniscectomy. [Section: Surgery is only a last resort.]

2018New section: A new standard chapter for most PainScience.com tutorials summarizing several key concepts about placebo. [Section: Some important things to keep in mind about placebos.]

2017Science update: Cited and discussed Schandelmaier et al on low intensity pulse ultrasound for fracture/osteotomy healing. [Section: Ultrasound is not a strong option.]

2017Science update: Cited Siemieniuk — the British Medical Journal strongly denouncing the common athroscopic surgeries. [Section: Surgery is only a last resort.]

2017Revision: Clarifications about the value of treating inflammation in principle. [Section: Treating for inflammation: is there any point?]

2017Science update: Significant science upgrade based on McAlindon et al. [Section: Steroid injections are powerful, but where would you put the needle?]

2017Upgrade: Shoes now have a section to themselves (orthotics discussed separately), and I made several improvements at the same time, mostly about spring-based shoes as a generic concept. [Section: Hitting the road: shoes, surfaces, impact, and the spring in your step.]

2017Major upgrade: Much more detail and modernized references. The entire section is now dedicated to orthotics (and shoes have their own section, also upgraded). [Section: Orthotics.]

2017Major science update: I have reversed my position on vastus medialis isolation on the basis of new evidence. [Section: Is one part of the quadriceps — the vastus medialis — more important?]

2016Science update: More information and citations about ineffective knee surgeries for context. [Section: Surgery is only a last resort.]

2016Minor update: Cited van Gent 2007 on training volume and the “fine balance.” [Section: Prevention for runners and other athletes.]

2016Minor update: Cited van Gent 2007 for perspective. [Section: Misc other possible biomechanical bogeymen.]

2016Major update: Fully modernized risk and safety information about all over-the-counter analgesics. [Section: You and “vitamin I”: anti-inflammatory meds, especially Voltaren® Gel.]

2016Science update: Significant revision in light of (finally!) good new evidence about natural running and injury prevention. [Section: Should you run naked? On faddish running styles and running shoes (or the lack thereof).]

2016Science update: Added a strong (and interesting) reference about surgical lavage and debridement. [Section: Surgery is only a last resort.]

2015Science update: Added citations to shore up efficacy, and evidence that taping tinkers with knee sensation. [Section: Taping and strapping.]

Older updates — Many older updates are listed in a separate document, for anyone who cares to take a look.

Notes

  1. Clarsen B, Krosshaug T, Bahr R. Overuse Injuries in Professional Road Cyclists. Am J Sports Med. 2010 Sep. PubMed #20847225.  BACK TO TEXT
  2. Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95–101.

    This report on two year’s worth of injuries among Vancouver runners — many of whom I probably run with every day on Vancouver’s sea wall — found 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. Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician. 2007;75:194–202. PubMed #17263215.  PainSci #56699.  “ … 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
  4. As we’ll discuss in detail below, most “basic” physical therapy for PFPS consists of minor interventions of dubious value — mostly corrective exercises, stretching, ultrasound, taping and strapping — 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
  5. 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
  6. Grant HM, Tjoumakaris FP, Maltenfort MG, Freedman KB. Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time? Am J Sports Med. 2014 Apr;42(7):1738–1742. PubMed #24758781. 

    Things may be getting better: “The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.” Fantastic news, if true! On the other hand, maybe I should be careful what I wish for, since my entire career is based on making some sense out of the hopeless mess that is sports and musculoskeletal medicine …

    BACK TO TEXT
  7. The science of this controversial claim will be discussed in great detail below. BACK TO TEXT
  8. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best 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, Pains, and Injuries: Most doctors are unqualified to care for many common pain and injury problems. Especially the stubborn ones.
    Cartoon of a man sitting in a doctor’s office. The doctor is holding a clipboard with a checklist with just two items on it: stress related and age related. The caption reads: “An extremely general practitioner.”

    Cartoon by Loren Fishman, HumoresqueCartoons.com

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  9. 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
  10. 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
  11. 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 — surgical debridement doesn’t work! 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 DC. The myth, mystic and frustration of anterior knee pain. Clin J Sport Med. 1993;3:139–43. PainSci #56702.  BACK TO TEXT
  14. Wilk KE, Davies GJ, Mangine RE, Malone TR. Patellofemoral disorders: a classification system and clinical guidelines for nonoperative rehabilitation. Journal of Orthopaedic & Sports Physical Therapy. 1998;28(5):307–322. BACK TO TEXT
  15. Juhn MS. Patellofemoral pain syndrome: a review and guidelines for treatment. Am Fam Physician. 1999;60(7):2012–2022. PainSci #56687.  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 J, Näslund UB, Odenbring S, Lundeberg T. Comparison of symptoms and clinical findings in subgroups of individuals with patellofemoral pain. Physiotherapy Theory and Practice. 2006 Jun;22(3):105–18. 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 SR, Fitzgerald GK, Irrgang JJ, et al. Associates of physical function and pain in patients with patellofemoral pain syndrome. Arch Phys Med Rehabil. 2009 Feb;90(2):285–95. 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.”

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There are 261 more footnotes in the full version of the book. I really like footnotes (and I try to have fun with them).


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