The Beyond Pain Podcast

Episode 46: How to Diagnose and Manage Anterior Knee Pain

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 Summary

In this episode of the Beyond Pain podcast, hosts Joe Gambino and Joe LaVacca delve into the complexities of knee pain, particularly focusing on anterior knee pain. They discuss the importance of understanding both mechanical and psychosocial factors in treatment, the significance of accurate diagnosis, and the need for patients to be informed consumers in their rehabilitation journey. The conversation emphasizes the importance of setting clear goals and being aware of the nuances in pain management and recovery. 

 Takeaways

Anterior knee pain can stem from various causes, including patellofemoral pain and meniscal injuries.

A mechanical approach to knee pain often yields better rehabilitation outcomes.

Knee pain can linger for months or even years, requiring patience in treatment.

Understanding the patient's environment and psychosocial factors is crucial in treatment.

Accurate diagnosis is essential for effective treatment of knee pain.

Patients should be proactive consumers in their rehabilitation process.

Not all knee pain is related to soft tissue; many issues are joint-related.

Setting clear goals is vital for tracking progress in rehabilitation.

Pain management should focus on improving function rather than just alleviating pain.

Rehabilitation is a non-linear process, and setbacks are normal.

Joe Gambino (00:00.793)
Welcome back into the Beyond Pain podcast. am one of your hosts, Joe Gambino, and I am here with Joe LaVacca The other half of the show, you can find this on Instagram. That's where we are most active at strength and motion underscore PT for Lavaca over there at Joe Gambino DPT for myself. This podcast is on YouTube cups of Joe underscore PT and on Instagram as well, beyond pain podcast. And if you do want to work with us, you can find the application form right in the show notes. Just click it.

fill out some questions and then either Joe or myself will get back to you. Welcome back, Joe boy.

Joe LaVacca (00:36.322)
Welcome back. I know this is the second week we've really been dropping, maybe the third, dropping superlatives and adjectives for me. And I just want to, again, say how much smoother, how much greater that opening transition was. So as much as, again, it still pains me. Because I was kind of like, I was like, maybe he'll bring it back. Maybe there'll be a surprise adjective today. We just kept it rolling. I'm doing good, man. We're in Colorado again. I am one week.

Joe Gambino (00:54.491)
Ha

Joe Gambino (00:59.193)
Mm-hmm. Just kept it rolling.

Joe LaVacca (01:06.286)
from the move, so I'm leaving a little bit early to get things done. But yeah, there's still endless things to do for the move and I didn't realize how much of a pain in the ass it is because I haven't moved in five, six years and you just sort of forget. I mean, every credit card, the driver's license, the emails, the auto pays, the bank accounts, the forwarding of the mail and I'm like,

Joe Gambino (01:08.741)
Right.

Joe Gambino (01:24.08)
boy.

Joe LaVacca (01:36.398)
You know what the hardest thing for me to change was? And I actually still haven't gotten the figure. No, that's one. Disney is giving me the most difficult time updating my account. I can't even log into it. All it just brings me into is the app. like, I know I have the app. I need to see where the billing address is, where this is, because I need to change my internet, I need to change all this stuff. And I'm like...

Joe Gambino (01:40.037)
your bar stools.

Ha

Joe Gambino (01:50.743)
Of course, no mix.

Joe LaVacca (02:04.788)
still cannot log into Disney. So Disney, if you're listening, help me out. Help a brother out. Yeah, that'd be cool. Hey, look, all we need is one for the tipping point, right?

Joe Gambino (02:08.629)
Yeah, CEO is just tuning in one of our 20 subscribers on YouTube That's it right that's it that's it all right You should share your stool story since I dropped an inside joke on the podcast and no one knows what the hell we're talking about a wife on that funny

Joe LaVacca (02:28.278)
very, very quickly then, because I can go on. This could actually be a whole episode with my frustration. I bought some stools that Courtney and her mom actually have both in their homes. Just clear. They were just kind of cool. They're unassuming, know, nice enough. I didn't know quite what I wanted to do, but I know I needed chairs for the island. First ones I order are too tall from the seat, from the seating, the seat height, because I just looked at the picture online. It was just measuring from the floor.

the backing. Okay, fine. Have to return those. That's going to cost me almost as much as the chairs cost me to buy. So I've been on Amazon talking to representatives every single day. I've ordered things from Amazon since I was probably, what, when I graduated college. Actually, I would say the people I've been talking to have actually been very helpful. So Amazon, if you're listening, thanks for all the customer service. I really appreciate it. Anyway.

Joe Gambino (03:14.779)
There, customer service sucks.

Joe LaVacca (03:27.374)
I finally got them to work that out. Then I get four new chairs with the appropriate seat height. One's cracked. One doesn't quite sit the way that it should. So the backing pushes forward instead of pushing back. So now I have to throw out those two chairs. Two more chairs are coming. So by the time I get home, I will have I'll have 10 bar stools.

Joe Gambino (03:37.146)
Mm-hmm.

Joe LaVacca (03:52.866)
that I do not know what to do with and I have to end up either returning them or throwing them away. So if you're listening also and you're in the market for barstools, give us a shout or give me a shout, especially if you're in New York, you can come pick them up. You can actually take them for free if you want at this point. That's how frustrated I am. I I know, know. Facebook marketplace sometimes though, I don't know, maybe it's almost too convenient. I feel like there's people trying to steal your identity and

Joe Gambino (04:11.003)
Just Facebook marketplace him, my friend. No, you'll get him out there like that.

Joe LaVacca (04:22.924)
maybe slash half murder you. So I'm a little hesitant to do that. And like I said, I mean, for the most part, it seems like everything will work. I'm sure once I pay for the shipping of like $300 to send these chairs back, there'll be some error that does not refund me. And that's gonna be a whole other thing. Then we'll really have an episode about it, because then I'll need to vent. I'll need to go into a good old fashioned Seinfeld rant. Yeah.

Joe Gambino (04:23.483)
I'm sure there's a lot of that going out there. Yeah.

Joe Gambino (04:38.117)
Yeah.

Joe Gambino (04:45.339)
Yes.

Yeah, we'll call them Seinfeld episodes. They just talk about nothing. Yeah, yeah, I those probably do better than these ones.

Joe LaVacca (04:52.386)
The episode's about nothing,

Joe LaVacca (04:56.814)
Well, judging from Instagram stories, if it's any indication of that, I mean, I'll post some random, you know, water bottle that's on my desk and it'll get like five thousand views. And then I post something actually relevant to our field. And there's 82 people that see it. And even they didn't quite see it because then they'll message me about like a course or if I have a post about this or a reference, I'm like, yeah, didn't you see this? And they're like, no, no, no, no. So.

Joe Gambino (05:14.426)
Yeah.

Joe Gambino (05:18.081)
Yeah.

Joe Gambino (05:23.373)
Nope. Nope, not at all.

Joe LaVacca (05:25.398)
Still trying to figure out that algorithm, but we'll get there.

Joe Gambino (05:27.323)
Yeah, that's it. We'll get there. We'll get there one day. Anyway, let's digress. Let's get in. are talking about we're talking about knee pain today. So I'm I'm excited. I think this would be a good one. And I will throw the ball on your court. And why don't we start the conversation around just in general, what kind of themes are you seeing when people come with knee pain? And we'll go from there.

Joe LaVacca (05:31.502)
Yeah, we'll dive in, we'll dive in.

Joe LaVacca (05:56.834)
Yeah, well think the most common things I see are anterior knee pain. And anterior knee pain can cover a broad spectrum of things. Again, the probably most common anterior knee pain culprits that I would come back to are patellofemoral pain or meniscal type injuries. The other thing I would say kind of globally is I probably attack

knee stuff a little bit more mechanical than anywhere else in the body, just because I think it just lends itself to have so many different variations in terms of how we load it, where we can load it, whether that's open chain or closed chain. So whenever I've taken a quote unquote more mechanical or biological approach with the knee, it always does seem to push me a little bit further in the rehab progress with people.

And I think the other big thing that's been helpful with me is realizing how long knee pain actually does linger, even when it is something like a patellofemoral pain syndrome or a meniscus type pain. And, you know, for some people we're talking months to maybe a year or more. So I think when I kind of picture the body and my biases, and we've talked about our biases many times on the show,

It is, hey, that bio-psycho-social, it's understanding the patient's environment and, what's their relationships like in their sleep and all these other complicated factors. And then with the knee, I'm just sort of like, it hurts when you step down off six inches? Why don't we just step down off three inches until that doesn't hurt anymore? it hurts with your five mile run? Can we just do five one mile runs instead? Can we alter a position with, instead of having you do a two legged squat, just do a one legged squat?

And combining that just with the education of, this is going to potentially linger, I think has really been helpful. And funny enough, I think a couple of people I've been thinking about recently with their knee pain, it's almost like I inherit people because people have been looking at their knee pain a little bit more like psychosocially, like, your x-ray is fine. You're okay to keep going. And I'm like, wow, this is like,

Joe LaVacca (08:23.714)
just such a seesaw because I'm usually battling the other way with all these diagnoses. And then I inherit more people where it's like, yeah, well, my previous provider just said I was okay. There was nothing really to do and just to like live my life and get sleep and, you know, change my shoes. And I was like, wow, this is where I actually disagree that there could be more things mechanically driven. So is that at all similar to how you're approaching it?

Do you still stick with that whole BPS concept here that we've talked about so many times before, or do you feel like it has been more mechanical in nature for you?

Joe Gambino (08:50.587)
Thank

Joe Gambino (08:57.051)
Yeah, well, I have some questions. Well, maybe we'll do this first and then I'll give my thought process just for listeners sake. When you say, you look at things more mechanical and how you're attacking things from a knee pain, can you kind of break that down as like maybe what that means specifically if you weren't a clinician and what kind of things does that include?

Joe LaVacca (09:18.092)
Yeah, so sort of what we just hinted at. So let's say for instance, you're squatting and we're looking at your knee or the lower half of your bone and the top half of your bone. So we'll say your shin bone and your thigh bone. Where does that angle push forward to the side? Does it go in? Does that correlate with your symptoms? And in which case I'd probably say to a client,

Hey, your knee's driving forward a lot more here. You think we can kind of pull it back? Does that alleviate your symptoms? Hey, your knee seems to be diving in on our gait assessment on this, on this. Do you think you can try to slow that down for us? So taking more angles and forces into consideration, maybe even a little bit more so than, hey, are you sleeping okay? What's your relationships like?

Is there any other stresses involved in your life right now? Do you carry all your stress in your knee sort of thing where maybe that's a little bit more of a conversation around spines and necks and low backs. So I think that's where I'm always surprising myself as much as I'm the, hey, know, great at exposure, as long as we're ruling things out, you're probably safe to keep loading on a good plan. I do find that knees can get pretty irritable if we just

give people the keys with let pain be your guide. So I almost then say from the mechanical perspective, hey, let's reduce the amount of pain in that knee as much as possible because then once the knee swells, it could take a few days or it could take even like a week for that swelling to go away. And then usually we're losing time from getting our movements in. So I would say that's how I would think more mechanical versus psychological or like social.

Joe Gambino (11:06.649)
Yeah, no, I, I agree with that. think the way that to answer your question and the way I kind of go about it is. So, and as pain, you know, if we're going to the concept of someone having, you know, increased swelling, when they kind of push it a little bit, then it's, know, in that case, yes, you're, you're going to want to modify, right. To let the swelling come down and let pain come down. And then you're going to find that entry point, so to speak. and that can be changing the way that they're loading it, or that could just be a lower step up or whatever it is. but then it's that gradual progressive.

overloading of tissue and that's kind of where my mind has always come. It's, you look at the way I kind of simplified it for any joint, the way that I look at it as well. We'll look at movement. We'll see where you're limited. We'll see what the movement patterns look like. We'll try to clean up any mobility or whatever that may need to be addressed. We'll clean up any movement patterns with some coaching that needs to be addressed. We're going to find an entry point into pain free movement or if we need to with some low level discomfort.

as long as that's all going well, then we're going to just progressively load those tissues until it can tolerate a whole lot more. And usually that in my experience leads to, you know, things going in a pretty good direction, obviously a little up and down, right? mean, rehab is never linear. I that's what people should always expect is that, especially as you're feeling better, that I think the increase of a flare up is more likely because you're going to end up pushing it more. We've talked about that a bunch of times, but for me it's

You know, sure, you know, if we need to, if squatting with your knees going forward is an issue, can we do it more of a Spanish style squat, or, know, with the bands behind the knees and get the knees way behind the toes. And that allows you to squat and that helps things feel better than that's what we're going to do. And then how can we start to load that and eventually get those knees more and more forward if the goal is to get back to squatting traditionally for whatever that looks like for that person.

Joe LaVacca (12:57.794)
Right, and I was thinking, even listening to you talk about the joint swelling and the tendency for me to treat knees a little bit more of that mechanical approach. Could it be, or do you agree that maybe most of the knee pains that we're seeing are probably more joint or capsule related as opposed to a muscle, a tendon?

something soft tissue. Now know there's tons of anatomy everywhere, but for the most part, even your body type aside, I can still find the bones around your knee, right? Whereas palpating your back, depending on your body type, your muscular morphology, I might not be able to even find anything structurally to poke and prod on on your back or your hip.

You know, people's feet, you know, maybe can correlate here too, maybe more so around the ankle. I know the foot's a very complicated structure. But again, when you think of the knee, there's a lot of just connective tissue there, not a lot of muscle crossing that knee joint. So maybe that's one of those things to keep in mind that when we see swelling, we can maybe more accurately say, hey, this is probably coming from the joint.

the patellofemoral contacting surfaces, the cartilage or the meniscus, as opposed to something more broad like a shoulder, a hip and a back, because we don't see, quote unquote, swelling in those areas like we do at a knee or an ankle. So I don't know, maybe I never really thought of it like that until we just had our little stream of consciousness here, but what do you think about that? Do you think if you sit down and really think about diagnoses around the knee?

Joe Gambino (14:51.043)
Mm-hmm.

Joe LaVacca (14:51.266)
They do tend to be more joint related than soft tissue related.

Joe Gambino (14:56.699)
Especially if we're looking at the concept of swelling, I would put that in as kind of like a joint issue, so to speak. If you had just like a tendon or muscle related issue, it's not gonna drive tons of swelling into the space, right? So that I would probably categorize as more of a joint related issue. Many sort of, almost even like miniscule.

high pain or things like that. I would probably classify as more of like, yeah, sure. It's a tissue, right. But it's inside the joint. It's part of the joint space. I would probably categorize that as, as, as joint issue as well. and then anytime like, you know, sure. If we're talking about the patella and having some, some pain around there, if we're getting some sort of pinching or deep joint pain with, with flexion, and I'm probably going to start to consider that a joint related issue unless it

you know, I can like rub a quad and the pain goes away, right? then that's not going to, you know, that's going to indicate more probably either the tendons irritated that attack, you know, like the quad tendon or something like that is irritating, maybe patella tendon or something like that. So if I can rub a tissue and it makes the pain better, then I'm going to probably say it's going to be more soft tissue. Otherwise I'm going to probably say, okay, there's probably something going on within either the joint, either the tendons, the ligament around there, whatever that might be.

Joe LaVacca (16:19.372)
Okay, and it reminds me of a call I had this week. Someone gave us a buzz and they've been dealing with anterior knee pain for the better part of two or three years. Doesn't seem like it's getting better. And the diagnosis that he was given was jumper's knee or patella tendonitis, right? So typically when I'm thinking of a jumper's knee,

The reason why it's coined that is it's almost exclusively with younger jumping athletes, right? So let's even just like stereotype even further and just say basketball, right? If you're not younger jumping, playing basketball, I'm not thinking that you probably have patellar tendonitis when you present with anterior knee pain. And I think why that's important for people listening is with tendons, you you and I are taught

or it seems to be the accepted theory, that we load these tendons into pain. They need heavy load, they need loads of different speeds, of different times, depending on how irritable they are. But now if you have a meniscal pain or a driver of, let's say, the sensitivity, or a patellofemoral driver of pain or sensitivity, well then now loading the anterior joint is just going to become

more and more and more painful. And lo and behold, just a couple of questions with this guy. He doesn't jump. He's never played sports. He just sort of got his quote unquote patellar tendonitis just from lifting at the gym. And I was like, that doesn't seem like the mechanism for knee. So I think that's a good message for people listening. If you are struggling with knee pain, again, we we've talked about diagnoses and prognoses before and

which one we thought was more or less important. And maybe this is one of those times where having a good diagnosis for your anterior knee pain is really important because I'm not gonna wanna push patella femoral pain into four fives and sixes out of 10. I'm not gonna wanna push a meniscal pain into that entire number, but I would feel comfortable pushing a tendon if you are comfortable doing so. So big piece of advice, he had never even considered.

Joe LaVacca (18:41.678)
of self-moral pain, like not one of his providers had thought of it. So, you know, I think he was in a little bit of disbelief that we were just kind of chatting about that over the phone. And then I asked him a couple of other questions about symptoms and he was like, yeah, this is all right on. This is exactly how I feel. I think, I hope I didn't upset him too much in terms of like making him feel like he wasted time over the last two, three years. But I also think it's important for you and I then to also have expectations around

you what we're treating, you know, is function improving, are symptoms becoming a little bit more tolerable? Do you find that you can walk or run or sit for longer periods of time while you're doing either a strength and conditioning program or something else? So again, I think the diagnosis stuff, I'll admit it, I'm kind of like the first one to sort of be like, eh, it probably doesn't really matter.

until it matters and I do think this might be one of those cases that where it might really matter.

Joe Gambino (19:41.743)
Yeah, no, I agree with that. And what I would just do things I want to mention based off of what you said. One, you know, this person got this diagnosis, you know, jumper's knee or whatever it is. I feel like there I've seen this. There are like blanket diagnoses that when you can't find an answer, people will give you this as an answer. Arthritis, you know, like a tendinopathy, you know.

in the shoulder, I like some people like, you have limited mobility. You just have frozen shoulder. Like when people tell me that frozen shoulder and describe to me what it is that they don't have frozen shoulder. Right. so if you're listening, I would always question what people like, I think just be a good consumer, right? Like physical therapy, movement, things like this, like you're consuming the help, right? Like you should, the same way you'd find a person trainer. Hopefully you don't just pick the first person you get.

Joe LaVacca (20:15.554)
Yeah.

Joe Gambino (20:38.361)
You go buy a car, hopefully not just buying the first car that you see, right? You should be questioning what people tell you and hope that it makes sense. Not just rely on their expertise because sometimes if, especially if someone says nothing's popping up here, I don't see anything wrong. I think you have this right. Like they just think you have that right. Like if someone's telling me and I go through an assessment and nothing is coming up that tells me you have a specific.

this, right? I'm not going to tell them that I think you have this because of, don't know, whatever reason. I'm to say, well, everything's looking pretty good, but you have pain with this. These movements are painful. Well, there's nothing necessarily wrong here. You have an elevated pain response. We're dealing around pain more so. So this is how we're going to attack it, right? I'm not going to give you a diagnosis just to give you a diagnosis, right? I'm going to explain your findings when I'm seeing how I think everything correlates, but I'm not going to tell you you have arthritis just because

I don't really know what the exact issue is that that's being irritated. Right. I think that's, you know, again, going back to nocevic language and some of the other episodes we've done, I think that can do more harm for somebody than good by doing so. So be a good consumer. And if, especially in these cases where they're saying we don't really see something that's going on here, don't just take a blanket diagnosis or a blanket program from them. Maybe do a little bit more research or get a second opinion.

Joe LaVacca (21:47.906)
Yeah.

Joe Gambino (22:03.419)
whatever that might look like. And the other thing that you mentioned was being goal-oriented. We're always looking at function and making sure that's improving. And one of the struggles I see a lot of people when I'm conversation with them for the first time, like, yeah, things are getting better. And then when I ask them about their goals, they're not really moving towards their goals, right? There's just like, oh yeah, I feel a little bit better. And what does that really mean in the grand scheme of things if you're not?

being able to get back to playing with your kids or going for a run or playing golf, whatever your goal is, right? So like when I'm looking at something with somebody, right? And if you're listening and you know, like your goals are the North star and your starting point is like our ground floor where we're going. And you should always be moving towards that North star, even if there's pain still, even if there's mobility issues, even if you're not feeling like you're whatever is going on, right? Like this is

If you feel like you're getting closer to doing this again with more ease, pain free at whatever level that you want, that is what really matters. It doesn't matter what the diagnosis is, what the plan is, what you were doing in the past. It's only thing that matters that you're going from here to here at whatever level that is.

Joe LaVacca (23:14.936)
Mm-hmm.

Joe LaVacca (23:18.86)
Right, right, yeah, totally. And then that brings us right back to that whole tolerance and capacity conversation. You know, as long as both are moving up, then you're probably on a good track. Give yourself a little bit more time. If it's only your tolerance that's moving in a poor direction, then it's time to revisit things. Because if your tolerance is getting more more sensitive to certain motions, then

in so facto, the capacity or function of that knee is just gonna follow suit, because you're just gonna naturally do less and less with it. So yeah, really good points there.

Joe Gambino (23:56.571)
Perfect. All right, anything else you want to talk about as far as knee pain and a vacuum goes?

Joe LaVacca (24:02.126)
I think generally, no, think generic, the generic, that's a new one. Generically, no, I think we can always dive into a little bit more, maybe get into a little bit of nitty gritty of patella femora and meniscus just because we brought those up today and how we can go about like maybe ruling those out a little bit more clearly. But no, think that's covered. I think the big takeaway was if you're having anterior knee pain that's not progressing, then I think it's some

Joe Gambino (24:06.758)
New words.

Joe LaVacca (24:31.584)
it's very much time to reconsider maybe your diagnosis, maybe getting into that idea of not pushing into pain so much, because there's just so many endless varieties for that. And I think that would be my big takeaways from our episode today.

Joe Gambino (24:45.755)
And I just make a mention of that because there are there, know, definitely people that push it, but there are definitely people who baby it. And if you're on the opposite end of that spectrum and nothing, you know, you don't feel like you're moving and you're not loading it and you're trying to shy away from pain, then it's probably going to be a hint in your mind that you may want to go the opposite way and explore a little bit of discomfort and see, see where that gets you. And then I think just keep in mind the things that we talked about, about, you know,

You know, being a good consumer as far as rehab goes and you know, understanding that there are blanket diagnoses and then not every person who you're relying on for their expertise is going to give you good expertise in a sense and make sure you're goal oriented as far as rehab and movement goes to make sure that you are moving in the right direction, your goals, that North Star is gonna really let you know if something is actually working for you or not.

Joe LaVacca (25:38.542)
Yeah, for sure. All right, man. All right, well, Joe, I love you. Thank you for sharing some advice with us today. Oh, yeah. Listeners, we love you. Thank you for making it this far. And don't forget to tune in next week for another exciting episode of The Beyond Pain.

Joe Gambino (25:40.069)
Take us home, Joe boy.

Joe Gambino (25:57.915)
Boom.