The Beyond Pain Podcast

Episode 21: "Knee" to Know Basis

• Par Four Performance • Episode 21

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Summary
In this episode, Joe Gambino and Joe LaVacca discuss patellofemoral pain, also known as anterior knee pain. They compare it to low back pain in terms of its complexity and the need for a management approach rather than a fix. They explore the importance of ruling out other diagnoses and focusing on allowing the knee to load better. They also discuss strategies for managing pain during running and other activities, including cadence adjustments and modifying workouts.

Takeaways
Patellofemoral pain is similar to low back pain in terms of its complexity and the need for a management approach.

It is important to rule out other diagnoses before diagnosing patellofemoral pain.

Allowing the knee to load better is a key aspect of treatment.

Pain management during running and other activities can involve adjusting cadence and modifying workouts.

The goal is to give the body the tools to reduce the likelihood of pain and re-injury, rather than aiming for a complete fix.

Joe Gambino (00:00.953)
Welcome back into the Beyond Pain podcast. I am your host, Joe Gambino and I'm with the lovely Joe Lavaca. You can find us on Instagram. I am, I am. was trying to think about something. You know, need it. need it. We are recording these back to back. need it. I need a couple of days to recharge my adjectives. You can find us on Instagram at johgambino .dpt for myself and at strength and motion underscore PT for Dr. Lavaca over there.

Joe LaVacca (00:10.504)
You're running out of adjectives.

Joe Gambino (00:31.161)
And this podcast is on YouTube, cups of joe underscore PT. And you can find it also at the Beyond Pain podcast, actually just Beyond Pain podcast on Instagram. And there is an application form in the show notes. If you do feel like working with us, please reach out. more than happy to have a conversation and connect. And that's it, Joe. Here we are.

Joe LaVacca (00:55.704)
All right, welcome back. We're here.

Joe Gambino (00:56.899)
Welcome back where we're about to talk about the knee today, some patella femoral stuff, some anterior knee pain stuff. I will, I will let you start us off.

Joe LaVacca (01:07.064)
well, think the, I also just want to say something. If you're struggling with patellofemoral pain or anterior knee pain, I just want to start by saying, I'm sorry. I realized recently, probably over the last few years that patellofemoral pain is sort of like a low back pain of the knee. And I never really treated it like that. You know, I'm thinking like, anterior knee pain. no problem. we'll just, you know, straighten up your quads, but not a lot of people can tolerate direct.

quad strengthening when they have patellofemoral pain. well, we'll just do your hip strength and your clam shells, your abduction, all that other stuff. And it's like, well, yeah, sometimes there'd be a weakness there. But a lot of times these clients are already coming in and crushing clam shells and crushing hip strength and doing all the different things. So it required me to increase my knowledge base of it a little bit. And the more that I kept listening to some other podcasts for clinicians about the topic and reading a little bit more about it,

it did start to seem a lot like low back pain and I just never made that connection before. So if we're talking about patellofemoral pain, I guess let's just start with where it is, right? Anterior part of the knee. Do you see it more medial, lateral, or is just like anterior as like a global sort of approach good enough for our conversation right now?

Joe Gambino (02:32.643)
I think a global approach is actually interesting. This is actually what you just said is interesting to me. And I was actually reading something this morning before the podcast and preparation for it. And on specific low back pain and patellofemoral syndrome sound very much alike as far as, ooh, I get balloons. If you're watching on YouTube, that's going to be fun. So.

Joe LaVacca (02:53.138)
yeah. Way to make the connections.

Joe Gambino (03:02.339)
The definition that they had here when I was reading it is refers to anterior knee pain usually occurring during activities, we're running, squatting, walking up and down stairs. So anterior pain, I think is perfect for our conversation today. And it's a diagnosis of exclusion. So you look for everything else. And then basically if nothing else pops up, then patellofemoral syndrome is likely to be the case if have anterior knee pain. there's, especially because as I was going further, the diagnostic testing is absolutely terrible.

So there is nothing as far as diagnostic testing that we can say with full certainty that you would have patellofemoral syndrome, even if you have anterior knee pain. And interesting enough, the biggest correlation to patellofemoral syndrome is just painless squatting, which I found interesting. And that's also not enough for us to tell, it's a particular diagnosis, right?

Joe LaVacca (03:32.141)
Yes.

Joe LaVacca (03:59.138)
Sure.

Joe Gambino (03:59.585)
Very interesting. A lot of people will struggle with it. I think there's a lot of other diagnoses that it could be. So I think it's a great thing to kind of rule out those things. And then from there, it's to me personally, right? It's how can we just start to allow that area to start to load better and how can we give it the tools? It's not just about strengthening at that point, especially if it's been something they've done in the past. So I'll be interested to hear what you think on that. If that's similar to what you've been thinking and reading and where you are from a treatment perspective.

Joe LaVacca (04:27.168)
Yeah, so I kind of typically think of like patella position, right? Not to talk about like maltracking and all that other stuff. I think that's getting into the weeds and I don't think a lot of that stuff is kind of holding up to a lot of scrutiny, at least at the moment. So patella position, right? When I'm in a deep squat or I'm starting to squat, that knee hurts, but it doesn't hurt the whole time through the squat. There's usually like a little bit of a painful arc or a painful position.

Same thing with steps, like it doesn't hurt the whole time up or down. It's usually at a very specific moment and then people usually kind of clear that pain or kind of clear that hurdle. The other one that is very, very commonly talked about, at least by patients, I see it didn't come up over here, is the moviegoer sign, where now you're just sitting in a bent knee position or you're traveling on a plane ride or an Uber ride and that knee starts to ache. So when I hear people talk about

prolonged position or specific position, I'm gonna kind of jump into this idea that it's probably gonna be a patellofemoral pain. If it's activity, right, jumping, skipping, hopping, right, anything that ends in ing, particularly that, just for people listening, like you said, exclude tendon, right? If it's not hurting when you're jumping, it's probably not going to be your tendon, right? So we're going back to this position idea.

If it's not giving out on you, maybe we don't have to think about ligament or maybe instability. And when I was asking you before if you noticed it or if it came up in your reading, if it was more anterior medial, more anterior lateral, usually your joint line stuff or your meniscal stuff will be very specific. It'll be kind of pinpoint either on the medial or lateral side. So I think that's maybe helpful for some people just to sort of navigate, should I load through something? Should I not? Should I go get this looked at?

And then having realistic expectations going forward in care. Because like you were saying, sounding very similar to low back pain syndrome, I think expectation with this rehab is really, really important. Because one of the things that I highlighted this week was we are looking to manage it, not fix it. And I know that that could be a somewhat difficult conversation.

Joe LaVacca (06:49.368)
So when you are seeing this, because it is so common, think 90 % of runners deal with knee pain. think it's one of the most common things that unite runners, aside from the insanity of liking to run. We talked about that this past weekend when we were together. How do you kind go about helping people understand this idea of management versus fixing?

Joe Gambino (07:12.365)
Yeah, I think anytime, I with it, with how pain is in general, with it being as complicated as it is, I don't think there's, I don't think we look at, I don't look at the human body in general and an injury and say, I'm going to fix this injury. Right? Like this is not the way I look at pain and movement and things like that. It's how can I give the tools, we can look at it from a management perspective in essence, but how can I give it the tools to have less of a likelihood for pain or re -injury to happen?

Right. And, know, that may start on the rehab side of things, and then eventually they'll look like more performance out of things, but there's no way to ever 100 % guarantee that pain is going to never show up again. Right. We're just trying to mitigate the chance of injury versus completely say it's never going to happen. So everything that we do, it's all management of our bodies. And that's kind of how I look at things in a whole. I guess, and I think, that's how my education.

comes off. I don't think, you know, I'm not sitting here like, well, if we do X, Y, and Z, you know, it's going to like, magically make you better. Right. But it's, it's, it's more of having a conversation about, well, this is what's missing from a mobility perspective. This is what's missing from a strength perspective. This is what's missing from a movement perspective. This is what running or whatever your activity looks like. And this is the limit, right? Like this is what you can do successfully, but this is what you can't do successfully. Like there's, there's that.

I could run a mile fine, but a mile and a quarter causes pain. and I take all of those pieces and now we're just trying to work on those pieces, right? Plus what the person's goals are. So it's, it's, it's, it's kind of like creating a, a plan. Hey, I know you want to go run a full marathon in September. We have nine months to do it right now. You can run a mile without pain. Well, how can we start running a mile and work maybe on some.

some running fitness components with success, how can we start to build that tolerance up to running further? And then how can we reduce pain and create more strength or mobility or whatever that person wants? So that's kind of how I look at everything as a whole and creating that structure to where they need to go.

Joe LaVacca (09:23.094)
Yeah, I really like that. give, you know, the big picture thing because a lot of people, think when they come and they find me, and I had a guy recently who was so intelligent, you know, I forgot his actual job, but it had something to do with like economic science and he, his whole life was about finding answers to problems. And he came in struggling with pain, probably

maybe almost a year at that point, not getting better. Sharpness was almost like increasing and he was really concerned because he'd been to PT. He'd done the hip strengthening. He'd done the quad strengthening. He went as far as getting blood work done. He changed his diet. He changed his sleep schedule. He changed his shoes. mean, talk about a guy that did his own research and then did not stop when the answer wasn't given to him or he wasn't satisfied with his previous care.

So when we came in, the first thing I said to him was, hey man, we gotta accept the fact that at least right now in the medical field, pain doesn't have an answer. So I don't think that I can give you that. So let's just be forthright, let's be honest. I know enough about this to tell you that this is going to be a process. And maybe this is also where I'm gonna probably maybe challenge my own pain rules just a little bit.

Because I've seen the patellofemoral pain get so finicky and get so irritated with people Initially even though maybe the first eight weeks were together. I'm gonna probably just tell people work away from pain, right? Let's just completely avoid pain as much as we can with this thing and let's try to figure out What are the things that you can tolerate? So you already brought up a whole bunch, right? Mainly with squatting and walking up and down stairs and things like that. Okay, so

I'll actually encourage them, hey, maybe when we're going upstairs, can we do like a quick, just go up with your good one and can we do just to go down with your bad one? And I actually mimic it like almost like you have crutches, right? Or you just had surgery on that knee. If we are training and we're talking about squatting, I'll start them on box squats. I might start them on partial range of motion, knee extension or knee flexion type of loads. So those types of things have been kind of helpful at least to work away from the pain.

Joe LaVacca (11:46.316)
But when you are kind of approaching that and he was at least willing to try this because of how many times he had failed already, is that something similar that you do with this? Because I do feel like patellofemoral pain, there's always these outliers like we were talking about in our previous episode with pain. And I've always found patellofemoral pain to be one of those things that set people off. And then they really don't want to do the run, the squat or that exercise again.

Joe Gambino (12:15.715)
Yeah, I will let pain and symptoms and how they flare up dictate those things. That's probably not the first thing I'm going to do unless they tell me like every time I'd like even try running, even like a walk, run my knees, like the pain really skyrockets and I'm like, I can't do anything for weeks. Then sure, I'm to be like very cautious upfront. But if we're talking about, Hey, you know, this has been going on for quite a while. I haven't had any success.

I'm gonna get that information. Okay, hey, I could run a mile and I am but a mile and a quarter I can't do I'm gonna I'm gonna give them some freedom I'm gonna keep the things they like in because that's I think part of you know, we talked about therapeutic alliance and and being able to like I always think we should be giving people what they enjoy doing as much as we can and only taking it away when absolutely necessary so if like it's hindering I have somebody Recently that I'm working through with this stuff. I'm like, hey

You know, the questions are always like, can I still do this or can I still do that? My answer is always yes. Do it. You know, let's find out, you know, if, all of a sudden you're, you're doing X, Y, and Z, and then the, the pain is going up and it's preventing you from actually recovering, then we need to take those things away and we'll know quickly. It's not like we're going to be doing this for six months and find out, well, maybe it really is that you kept squatting, you know, and you know, now we need these next six months to remove that and get you better.

Joe LaVacca (13:37.982)
Yeah

Joe Gambino (13:43.417)
know within a week or two, right, we're gonna know, hey, you know, I think what people don't realize with pain is that, and this is not for everybody because there are slow responders and some people where it's harder to get those changes to happen. But for most people, as we start the rehab process in a week or two or within the first month, I mean, there's noticeable changes in symptoms. So those are some of the things that you look for, right? Like is symptoms coming down? Are they able to do a little bit more? I'm a big fan of having one or two.

Movements which I've talked about this on how many podcast episodes but like movements that are goals for them. Hey if Squatting is painful You know, maybe that's person's test writer. Maybe if it's like kneeling we're working to build back kneeling Maybe that's the person's test and we want to see this kind of change happen between this session and next session Well, that's there. Those are some signs that things are moving in the right direction So if we're seeing the objective stuff getting better, even if pain doesn't change to me, that's that's a that's a win so I think that you have to look at it that way and

and the management of things. it's not just pain is very tricky for people. And I feel like when they are, as your client was smart, where they know things, it's even harder because sometimes, I mean, they have their own biases on what they think they need. have their own, you know, I mean, they're constantly doing research and the education sometimes if they don't, they may not buy into it. I've had it before where they're like, no, I believe this. And then my viewpoint is different. I'm not gonna be able to help that person.

because our viewpoints are too different, they're not gonna trust what we're doing together.

Joe LaVacca (15:13.462)
Yeah. Luckily he was, he was so willing to sort of accept something a little bit different. we did have a lot of conversations around reframing pain, but he had such a long history of these flares and some fear around it that really our first step was, Hey, know, isometrics became our best friend, you know, wall sits, split stance squats, single leg, like step down just with like a partial range hold. And it was just doubt dosies do these as often as we can. And.

for many of clients who tend to be irritable, not even around knee, but everywhere else. And I think we've mentioned this probably a few times already, like having those isometric options for people that they can change and tweak and modify angles and change your trunk position. I think those are really, really powerful and something low cost and people can do at home. You don't really need any equipment to do an isometric. It's just usually setting your body up in a position and then trying to hold it.

You know, being that he was a runner and I think probably I'll go out on a limb here and say that most of the people I see now with persistent issues are runners who are trying to do too much too soon because they feel better and I just want to kind of get after it. So do you have any tactics for running for clients? Like you said, hey, my runners love running.

they don't typically always love this idea of, you know, a mile run and then that's it. That's their workout. So do you have ways of approaching that to still get people to love running run, but then also be respectful of their rehab process.

Joe Gambino (16:55.489)
Yeah, that's a harder one. I think it's always for me, it's expectation management. If they can't run more than a mile, then the mile is going to be in or around the limit, right? Because otherwise you're to be flaring things up. You might be able to do double sessions in a day if that's tolerable, that rest period is okay. But what I tell people is, because I'm big on the pain guidelines,

If you go for a mile run and there's no soreness, no discomfort, no nothing afterwards, then the next day it doesn't need to be like three days later because you don't need to recover from that. You can add 10, 10 % more. So you can just add a little bit more to that next run. Don't change speed. Don't change the route. Just add a little bit more distance. If that's good. The next day you run the same thing, go a little bit further and a little bit further until you hit that point of, okay, now my knee is just a little sore. Now we're going to maintain this.

until this harness is gone. And then we're going to progress again and then we're going to progress again. And then when you had another shelf, another plateau, we're going to stay there and just let the tissues adapt. I think that's what people don't remember or think about is like, they're just like, well, this is a task. This is what I'm going to do. I can go do it. And then it's painful. And then they have to reset it. Let's find those areas of struggle and then let's the tissues have to adapt. You use the and I tell them, like, listen, you need to realize they're running right now for the mile and a quarter.

is not fitness for you. This is tissue training. This is an extension of rehab. Unfortunately, fortunately enough for you, can still run, but we can't go more than that right now. I know like, you know, and it's harder if someone has a race coming up soon, then it's the risk reward conversation comes up. We can go further. We can do our best to manage how important is this race to you to go run. Some people are very important. I need to go run this race. Okay.

Joe LaVacca (18:23.894)
Yeah, that's great.

Joe Gambino (18:46.051)
Let's manage this. Let's do the best that we can. You're going to train minimal just enough to get you to the race. And then we're going to run the race and have fun. And then after that, we're going to, you know, maybe take a step back from running and things like that. So, you know, those are all conversations to have and you just, the person needs to be ready to take it, take it back. Right. but I've had many times where the person comes in and they're a month out from a race and they're trying to get to that race and you can't take away running from that person in that moment.

Unless you're really confident that like two weeks off is not really, you know, they can maybe do something else to keep up to energy systems and that is really not going to, you know, two weeks off maybe might be enough for them to really enjoy that race and really perform at that race. But it's hard to, to really have that correlation. But that's kind of how I look at it.

Joe LaVacca (19:25.517)
Yeah.

Joe LaVacca (19:31.416)
Yeah, I love splitting up those sessions. That's a big piece of advice that I give to clients. Like, hey, if we can run a mile and then maybe walk for five or 10 minutes, is that enough of a recovery or a factory period for you where now maybe you can try another mile? Or like you said, try another mile in the afternoon or that evening, right? If they're working out in the gym, I also just tell them, hey, if you're planning on being there for 45 minutes, an hour or whatever, run your mile on the treadmill.

And then let's go with something else aerobic, be it the rower, be it the elliptical, be it the arm bike, be it whatever, just to now capture what you put so well that I'm going to steal this idea of like performance versus tissue, right? Cause all we need is your heart to pump. I just need you to get that aerobic signal to your body, especially if you're leading up to a race. So how else could we get it? If you don't like elliptical row or whatever, can we look at your program and then maybe start to give you more?

higher rep training with shorter duration breaks with your squats, your kettlebell swings, know, partial range squats, of course, but can we modify that to some degree? I think the biggest thing I usually tap into with runners who want to continue to run, cadence. Not a lot of them know their cadence offhand and that's for those listening, just steps per minute. So you hit a timer for 60 seconds, you count how many times your right foot and your left foot hit the floor.

that's your cadence, and just by bumping up cadence, bumping it up, not slowing it down, five or 10%, that has been shown to mitigate or change forces and pain around the knee. So if we have a knee that's mechanically sensitive, bump up that cadence, then they maybe do a minute on, minute off with that, because it is a little bit of a change, and they can play with it. It could be 5%, 6%, 7%, they can go back to 7%, find something that works for them.

Try that and then the other thing that has seemingly helped is get on that treadmill Jack up the incline and maybe we start just doing like 10 20 second uphill sprints and then by the time they're done with you know 10 rounds of that they're Smoked anyway, and now we don't have knee pain We've had a high intensity workout session and then they kind of feel like they're working on something Even though they still quote -unquote have patella from oral pain syndrome. So I think

Joe LaVacca (21:57.404)
With runners, those are the biggest things I'll try to tweak with them. If you want to try an orthotic, go for it. I think your foot posture and position hasn't really been well correlated, but you slap an orthotic in someone's foot, their knee feels better. Hey, maybe that's again, one of those things of like, I only have two weeks. What can I do here? I'll teach them how to tape then. If we're up against the gun, let's tape your knee. A lot of runners like that idea.

So I think again, there's always case by case. I'm never gonna tell them not to do something like you said, especially if they love it and especially if it can break that pain cycle.

Joe Gambino (22:35.247)
Yeah, I love that. I was going to say before you even, kind of my one sentence I would have had you summarize real nice is do fun, have fun with what you can do. you know, so like I had somebody who was preparing for a marathon. we've been working for, for quite some time and, he's like, yeah, I want to, I want to, you know, buy this date. You know, this is, this is the half marathon. want to be able to run at that time. You could run about a mile or so. and really all we did was cadence work, speed work.

Joe LaVacca (22:44.61)
Hmm.

Joe Gambino (23:04.933)
That was what we started with within that mile time. Like have some fun. Let's push it. How can you start to increase your mile time? Let's do some speed work and we'll feed you out. I want literally your mile to be like you can't run another 10th of a mile. That's what we're working for here. And then we worked on cadence. We built it up 10 % jumps at a time. Get used to it.

Joe LaVacca (23:14.72)
Yeah, exactly.

Joe Gambino (23:28.799)
And we got to the point for that marathon. And he was like, we was running like five miles at a clip at that time, maintaining his cadence and hitting some PRs. And then he, heard his tail and he was like, you know what? I don't want to mess up my toes. So I'm not going to do the race. I think he dropped it. He dropped, he dropped the weight on his tail or something like that. So he, so he bowed out of it, but he's, he's ready for his next one. He's he hasn't been running because the summer got really hot.

Joe LaVacca (23:41.816)
Yeah, I gotta worry about all those other body parts too.

Joe Gambino (23:54.989)
what we've been doing, finding other ways we've been adding more hit stuff into his program. Like you could find other ways to get the heart rate up, have a little bit of fun. I think that's really the point there is right. Like what can you do with what you have and how can you have some fun while we work towards getting you back to the things that you want to do and where that's running, whether it's squatting, whether whatever it is, right? Like that's how we need to start to approach it. Have some fun. You want to do the things that you can do and then slowly work your way back to the things that you really enjoy that maybe you have some trouble with.

Joe LaVacca (24:23.224)
Absolutely. Well said.

Joe Gambino (24:25.45)
Thank you, Well, Joe, love you. Listeners, we love you. And if you made it this far into the episode, extra love for you.

Joe LaVacca (24:29.25)
I love you.