Knee Caps, Knee Pain and Bending the Narrative

Several years ago, a friend of mine said to me, “I’m really concerned about you.”

“Yeah? Why is that? What are you concerned about?” I replied.

“Because you have hair in your ears,” she said.

I paused, tilted my head, and said, “Why would that concern you?”

Without hesitation she said, “Because men with hair in their ears have heart attacks.”

“Really? How do you know that? Where did you learn that?” I asked.

“Because my father had hair in his ears and he had a heart attack and I know other men like that too,” she said with care woven into her voice.

I explained  that I didn’t think she had anything to be concerned about. Whatever hair was there was normal, served a good purpose and until I could braid it, I believed I was okay. She remained convinced of her position though (interestingly, in 1984, a couple of doctors in New York proclaimed that men with ear hair were more susceptible to heart disease. The next year, having been accused of misinterpreting the data in a major way, they recanted).

We all bend the narrative, from time to time, to fit our perspective; to make sense of things that don’t make sense to us.

Knee Caps and Knee Pain

If you have knee pain, especially around the front of your knee, there’s a good chance that someone along the way has suggested that your pain is caused by a poorly positioned patella (knee cap). It’s either tilted, rotated, tipped, or too far to one side or the other.

Because certain muscles (quadriceps) attach your knee cap to your thigh bone (femur), clinicians logically conclude that these muscles must be weak; that the muscles are unable to keep your knee cap where it’s supposed to be so when you do something like climb stairs, your knee cap ends up in the wrong position, tissues get stretched, squished or twisted too much and the result is you hurt.

Treatments may include strengthening exercises for the muscles or taping of the knee cap (in an attempt to reposition it), knee braces, stretching of tissues that seem tight around the knee cap or electrical stimulation of the thigh muscles, or stretching of the IT Band. Sometimes these things help; sometimes they don’t.

And even if these types of treatments help, what I’ve found, more often than not, was that people felt better for a day or so but very few could really do much on their leg. As soon as they started climbing stairs or had to squat down to pick up something or tried to jog, the symptoms returned.

This belief, that your knee pain comes from a poorly positioned knee cap, is very firmly entrenched in the medical community even though the assessment process, how you figure out that the patella isn’t where it should be, is a completely unreliable one. For something to be reliable, from a scientific perspective, it means that the results are consistent upon repeated measurements. So, if your assessment process isn’t reliable, it means that one time you get one result and another time you get a different result. If you plan a course of action based on unreliable information, you often end up with at least a poor result and sometimes, a disaster (think weapons of mass destruction in Iraq).

Ok, so now what? I think of it like this. The problem of anterior knee pain (patellofemoral pain syndrome, chondromalacia) is not primarily the result of an abnormally positioned knee cap but the result of poorly conditioned tissues which is then exacerbated by patellar mechanics.

Injured tissue is weak tissue. When you climb stairs, the force that goes into your knee cap is about two times your body weight. If you weigh 150 lbs, that’s 300 lbs. of force.  If your knee cap tissues (tendon, bone, synovium, ligament, muscle) cannot withstand that level of force, you’ll hurt. It’s about that simple. So, the answer is to somehow increase the strength of your knee joint tissues and not just your muscles while encouraging as normal movement as possible of the knee cap or patella.

What I tried first though, back in 1984-85, was conventional muscle strengthening. The logic I used, because this is what I was taught in PT school, was that if I could make the quadriceps muscles stronger, the muscles would take up more of the force sort of like biological shock absorbers and they would pull the knee cap back over or at least act like a super strong bungee cord and keep it from sliding around. It seemed to make sense at the time.

But, in practice, it was a disaster. In order to increase my client’s muscle strength, I had to increase the amount of weight used in the exercise because otherwise, she didn’t feel any fatigue or effect from the exercise. But, when I increased the weight, her knee hurt. Decrease the weight, knee pain was ok but the muscles never really got tired.

To make things worse, the knee pain showed up with weight bearing activity so exercises ike squats were out. And, this is when I would pull out whatever else I had in the tool box, like heat or cold or massage or some other exercise, something, anything, to buy me some time to figure out what to do.

I was bending the narrative; trying to make a joint based problem fit into a muscle weakness paradigm.

So, this went on for a while, a few years, stumbling around trying to fix the knee pain, strengthen the muscles, blah, blah, blah, until I wandered into a fitness equipment store and discovered something called a Total Gym.

I had never seen it. Remember, this was over 20 years ago and Total Gym was not known at all as it is now (thanks to Chuck Norris and Christie Brinkley). I had one of those “ah-hah” moments. Squats with a low load and the ability to adjust the load. Perfect. So, I asked the sales guy how much it cost.

“Oh, you don’t want that. It’s a lousy work out. Just a gimmick,” he said.

“Yeah, well, I do want it. How much do you want for it?” I asked.

And this discussion went on for a couple of minutes. He finally said, “I’ll sell it to you for $250.00 but don’t come back here complaining about it. You can’t return it.”

I bought the Total Gym and it became a staple in our practice.

By experimenting with the Total Gym, I discovered that I could test your leg and determine the amount of pain free force you could produce for a single leg squat. By raising or lowering the machine, I could increase or decrease the force going through the leg (and the force is always some percentage of your body weight). I decided to call this a Load Tolerance Test. You can think of it as a strength test though. It’s the amount of pain free force you can produce for a specific movement and still control the movement. If during the test, the movement hurts or you lose control of the motion, the test stops.

So let’s go back to the earlier example. You weigh 150 lbs and climbing stairs and squatting hurts your knee. I test you on the Total Gym (doing a single leg squat to about a 70 degree knee angle) and discover that at 110 lbs., your knee feels fine. Any more force than 110 lbs. though, you hurt.

Most people, when they hear something like this, immediately think, “So, you’re saying I need to lose 40 lbs.?” No. Not at all. What the test results mean is that your leg “strength” is less than your body weight. Think about this for a minute. Why do joints hurt? Physical demand exceeds physical capability. So, climbing stairs is way too hard for your leg (specifically your knee). Every time you go up a stair or squat down to the floor, you exceed your leg strength by 40 lbs.

If you start exercising at this new load though, your muscles still won’t get tired. The reason is that the test reveals the amount of force your leg can withstand not the amount of force your muscles can produce. In most cases, the test stops at the onset of pain; not muscle fatigue. Now, it seems as if I’m right back where I started. I know your leg strength, which is great, but I still can’t make your muscles fatigue. And, if my goal is to increase the strength of your quadriceps, I have to figure out a way to tire out your muscles. Right?

Increasing your muscle strength is important but to do that, you have to increase your joint strength first. But, at the time, when I first bought the Total Gym, I hadn’t quite figured all of that out. I was close, was experimenting, reading, but I was missing some key components until I read an article by Robert Salter, MD and realized I was behind in understanding joint healing.

Dr. Salter had discovered that injured joints healed better, more completely, if those joints were not immobilized but were allowed to move. However, he also discovered that the joints not only had to move but had to be protected from too much force. The injured tissues were fragile. At the time of his discovery, injured joints were usually placed in a cast or immobilization brace. Salter was encouraging his colleagues to get people out of the casts and get their joints moving but the medical community couldn’t understand how that would work nor how to do it so they refused and for the next twenty years, all but ignored his work.

Salter didn’t give up and now his ideas are considered the gold standard following practically any type of knee surgery. Injured joints are rarely casted or immobilized anymore and if they are, it is for as a short of a time as possible.

So, while the idea of moving injured joints is now much more common, the other half of the equation failed to make it across the chasm: controlling the force into the joints. Sometimes patients will be told to use crutches for a while after surgery and encouraged to progress easily or slowly with their exercises or weight bearing. But, “easily” or “slowly” are vague and about the last thing you want when it comes to rebuilding joint strength is to be vague.

Most knee joint pain is caused by tissues that cannot withstand the force they are exposed to. The patellar mechanics can make that worse but keep in mind that there are plenty of people walking and running around with less than optimal mechanics who have no symptoms (Of course, there are situations, such as arthrofibrosis, adhesions of the patella to the tendon, patella fracture , subluxation, dislocation, among others that can create knee pain).

The complete answer is a new narrative; one that combines tissue healing and strengthening with respect for biomechanics. You need good control of the hip, flexibility in the ankle, and knee joint tissues that can withstand the force (If you want to learn more about rebuilding the strength of the knee joint, I explain the process in detail in my book, “The Runner’s Knee Bible“: Load Tolerance, dosage, specific exercises and a tailored regimen).


The Runner’s Knee Bible: How You Can Keep Running Strong and Avoid the Condition that Sidelines 65% of All Runners.

“I wished my doctor’s would have told me the things I discovered reading the Runner’s Knee Bible – Paivi T.”

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