Runner’s Knee: Arriving Right On Time
Although they’re not acknowledged in the mainstream media, when it comes to running injuries, there are a couple of constants that ring true.
Before I cover those constants, I’d like to cover the half-truths that come out of what I call first layer knowledge.
More specifically, the half-truths that the experts go to on a regular basis.
To be clear, I’m not blaming you or anyone else for believing these stories. Because in theory, they all sound good. And that is more than likely why they’ve been repeated for so long. But just because they continue to be repeated doesn’t make them any more true.
It’s also important to consider the old saying, “Out with the old, in with the new”. Because there’s science to show that our brains tend to gravitate towards whatever the *new* thing is. Which makes me think of all the experts that come out of their first weekend-long certification and tell everybody and their uncle that they have adhesions.
A few years ago, I remember reading through an article where an expert had come up with a new stretch for a person who was struggling with plantar fasciitis. Which sounds really good. But then again, second layer knowledge allows us to see that the “new” stretch isn’t any better than the old stretch.
Once you’ve determined that the expert’s recommendation doesn’t in some way, shape or form resemble a band-aid or something you could read in a magazine or even a linear path that resembles a one-size-fits-all model; a very simple way to sort through all of the things that the experts recommend is to ask yourself this question: If I’m beginning with the end in mind right now, is this technique, and/or thought process throwing me farther in the direction of being fragile (read: weaker)?
And then follow that question up with, Or am I moving in a direction that is going to allow me to be anti-fragile (read: stronger)?
In order to get an accurate answer to either question, you first have to have a way of measuring for an outcome. And in doing this, it’s extremely helpful to measure the right metrics.
And then ask yourself, Do the results transfer to a place where my muscles are capable of tolerating more force on a day-to-day basis?
After coming out of rehab, it’s possible that you no longer have pain.
So the question is, are you performing better than you were before the pain and/or injury?
[Sidebar: Just the other day, I noticed a young lady who had a few strips of fluorescent green kinesiology tape strategically placed around her right kneecap (or patella).
She was wearing those strips of tape like they were a badge of honor.
Are those colorful pieces of tape doing anything that an old-school neoprene brace with a hole cut out for the kneecap isn’t capable of doing?
Answer: I think we could agree that the flashy tape provides less support than the old-school brace does. And because of its elastic qualities, it’s also going to allow for more range of motion at her knee joint.
But if she doesn’t have an optimal range of motion throughout her ankle, second layer knowledge tells us that there’s going to be less range of motion at her knee with or without that brightly colored tape.
Note: According to all of the research that I’ve seen on the value of kinesiology tape, it’s more of a placebo than anything else.
If she didn’t buy the story on the supposed therapeutic benefits herself, the expert who stuck it there did. Ouch.]
I don’t have a crystal ball right in front of me. Nor have I gone for a walk in your shoes. But even still, when it comes to dealing with something as complex as runner’s knee (a.k.a., patellofemoral pain syndrome), I’ve been working with the musculoskeletal system long enough to know that an expert has told you at least one of these half-truths that come straight out of first layer knowledge:
- One of the muscles that make up your quadriceps is tight, and it’s pulling your patella (read: kneecap) to the outside. Meanwhile, the muscle on the opposite side of your thigh is weak. And between the two, they’re throwing the tracking of your patella off. The way in which they are determining what is weak from what is strong has to be called into question here. (Again, it’s extremely helpful to measure the right metrics.) More than likely, the expert isn’t doing any measuring. Instead, they are just repeating what they heard their college professor say many years earlier. And even though that thought process hasn’t allowed for phenomenal results for all of these years, they continue to parrot the same thing.
- You have a substantial imbalance in the strength of your thigh musculature. They forgot to mention that you’re not alone on this one. Everybody has an imbalance in their thigh musculature. You just happen to have a kneecap that doesn’t want to stay on its track. But your kneecap’s inability to stay on track is not about the strength ratio between your quadriceps and hamstrings. This is due to the fact that, in more ways than one, your quadriceps are going to be stronger than your hamstrings. Just in terms of mechanics alone, when everything is intact, it’s impossible for anybody to have hamstrings that are as strong as their quadriceps.
- The musculature on the outside of your hip is weak. And that weakness is impacting your body’s ability to accelerate motion, i.e., supination. But they didn’t think to mention that prior to accelerating your chain in one direction, those same muscles were responsible for decelerating your chain in the opposite direction, i.e., pronation. And in order for your chain to achieve all of that motion, your brain has to sense stability.
- There is an imbalance in your structure. Somewhere (?). This one makes me think that they are looking at your body like it is a house. And since they don’t understand how your feet take advantage of motion from the ground up and the top down, it’s very difficult for me to see how they could say that your feet are weak or even out of balance. Your feet are your foundation. But the way in which they take advantage of motion determines how everything above them moves. Said another way, when the expert throws off the foot’s ability to move, they’ve also driven your knee in an abnormal way. And if they have driven your knee in an abnormal way, that will have a negative impact on how your hip moves. The bottom line is, it’s impossible to change motion of your foot without also changing motion at the knee and hip. Since this mindset doesn’t improve your muscle’s ability to stabilize the joints, your kneecap will continue to slide off its track. If we continue to think along the lines of your body resembling a house, we should also touch on the whole chiropractic adjustment mentality. Meaning, it’s not the chiropractic adjustment that got you out of pain. It’s that your brain figured out a different way for you to adapt (i.e., compensate). So you may or may not be out of pain, but you still aren’t performing to the best of your ability. In more ways than one, a chiropractic adjustment is like stretching. Which is a negative input! But yet the person on the other end of that rapid force bought the story. Which means they will continue to scratch the itch. Meanwhile, the muscles continue to hang on for dear life.
- Your running form is inadequate. I think there is value to working with a running coach. That being said, by consciously changing your running form, you’re in turn allowing for a conscious compensation throughout your chain. Meaning, your brain is either going to figure out how to adapt or it’s not. I’m not saying it’s the only reason, but the brain’s ability to adapt is one of the reasons why some people were capable of running in the Vibram Five Fingers.
At this point you might not be ready to hear this, but then again maybe you are, so consider this: If you buy into any of the things on that list, you and your patellofemoral pain syndrome (PFPS) have in turn entered into a race down a rabbit hole that can’t be won. At least not over the long haul.
Does that mean you aren’t capable of coming out the other side with a knee that no longer feels painful when you go down the stairs or even run in the next marathon?
Answer: No, it doesn’t. And that’s what makes the science of pain so intriguing. When it comes right down to it, pain is deceptive. And so are the stories that have continued to lead you and many others on the confusing journey down that very narrow rabbit hole.
Only to cross the finish line, with little to no pain. But more often than people care to believe, that journey didn’t leave you performing any better than you were when you were standing at the starting line.
So if the journey didn’t leave you performing better, where did it leave you?
Answer: The mindset behind all of those things that I listed is driven by the worn-out need to only chase the pain or address the symptoms.
“The Pain. The Pain. The Pain. What’s your phone number? The Pain.” – Hugh MacLeod, author of Ignore Everybody
Pain is a driver. And that driver lends itself to your brain wanting to hear a story that it can believe in. (One that you’re ready to hear.)
Along the same lines, your mind gravitates towards an expert who allows for a certain level of certainty. And that level of certainty allows you to feel like you’re in good hands.
But by chasing the pain and only addressing the symptoms, the expert is more often than not only relying on the next best guess.
Having heard that side of the story, your brain might feel differently.
I think it’s safe to say that all of the experts have had varying experiences throughout their years of practice. And I feel like it’s important to acknowledge that even though they are in the one field of study, they more than likely have entered into their current field with backgrounds that differ in more ways than one.
But yet, they tend to hang out among minds that have a similar worldview. Otherwise known as their comfort zone.
Which is extremely limiting! (emphasis added)
Whether we choose to acknowledge these things or not, it’s difficult to deny that when the overriding goal is figuring out the best approach for dealing with your patella femoral syndrome (PFS), all of these variables come into play.
Although the experts might not be able to come to an agreement on everything that I have listed as a factor as to why you’re dealing with patella femoral syndrome, they do all share one thing in common: they all have blind spots that drive them to approach the human chain in the same ways that they always have.
Since those ways don’t include a way for you to see or even to feel an improvement in your ability to perform better, it’s easy to sweep those things under the rug. As if they’re not even possible. When in reality, they are. But to go there would mean they’d have to step out of their circle of comfort.
And how are you supposed to know what you don’t know?
Here are the two constants that I mentioned at the beginning:
- Stability (throughout all of the motions that you and everybody else has available to them)
(1) Timing: Just because you have all of the same body parts that everybody else does, doesn’t mean that you have muscles that are contracting (read: pulling) at the right time, in the right direction or even at the right joint. And when there are muscles that are under-performing, there will also be tight muscles that are responsible for limiting motion in a specific direction.
Which tells us that the tight muscles are the symptom.
Going back to the list of half-truths that I mentioned earlier: (#1) One of the muscles that make up your quadriceps is tight, and it’s pulling your patella (read: kneecap) to the outside. Meanwhile, the muscle on the opposite side of your thigh is weak. And between the two, they’re throwing the tracking of your patella off.
That theory has been around for a VERY long time. And even though it has been repeated for many years now, second layer knowledge allows us to see that there are HUGE gaping holes in that theory. The most glaring hole is that it’s not about the kneecap. Because until the brain senses stability throughout the joints that are called into question, that kneecap is going to continue to come off of its track.
Said another way, until the foot, leg, thigh, pelvis, and trunk can move at the right time, that kneecap is going to track improperly.
As I was in the process of writing this post, I got into a brief conversation with a lady who had runner’s knee or patellofemoral pain syndrome . At the beginning of the conversation, she told me that her first surgeon didn’t do a lateral release. And according to her, that is why she ended up needing another surgery a few years later.
[Note: Just in case you’re not familiar with what a lateral release entails, it’s a procedure in which the surgeon snips the most lateral quadricep muscle that just so happens to go from the front of your femur to the back of the same long bone. From there, the muscle attaches to the outside of your kneecap and the shin bone (i.e., tibia).]
She went on to say, “When I went in for the second surgery, the new doctor did perform a lateral release. Looking back on it now, I feel like if the first doctor had performed a lateral release, I wouldn’t have needed to go through a second surgery.”
In theory, a lateral release sounds good. Doesn’t it?
But if we circle back to second layer knowledge, that muscle was tight for a very good reason (i.e., protection).
Or then again, maybe it wasn’t.
Before we go all in on the whole lateral quadricep being tight and pulling the kneecap laterally theory, I think it’s imperative that we take a good hard look at how an expert determines whether or not a muscle is tight to begin with.
Because truth be told, that alone has to be called into question.
More often than not, that lateral quadricep is under-performing. Meaning, there is a crimp in the hose that supplies the input. And no matter how hard they try to stretch or strengthen that muscle, the connection from the brain to the muscle is not going to be any better.
Second layer knowledge also tells us that since the lateral quadricep muscle lies deep to the iliotibial band, and it is no longer intact, it’s not going to be capable of playing its role in the same way that it once was. Ever.
And because the hip musculature that makes up the iliotibial band is responsible for the same roles at the knee, those muscles will be forced to take on more. This is the way in which her brain will figure out how to recruit other muscles to pick up the slack.
Which will also have a significant impact on how her foot interacts with the ground.
Said another way, that quadricep muscle will never be capable of lengthening to decelerate motion in one direction (i.e., pronation).
Since the chain can’t take advantage of all of the motions in that direction, it won’t be capable of storing all of the elastic energy that allows the muscles to pull everything against gravity in the opposite direction (i.e., supination).
In other words, when it comes to timing and her ability to perform better, that surgical procedure was no better than the fluorescent green kinesiology tape that was strategically placed around that other young lady’s kneecap. And since there’s no going back, it only makes sense that a lateral release is the worst band-aid of them all.
Just because asymmetrical motion is always going to be present to some extent doesn’t mean it is normal.
This is due to the fact that when a bunch of muscles that cross the same joint(s) is capable of stabilizing the asymmetrical motion in question, there will be a new normal.
Then it’s just a matter of building on that success. Only to progress to the next new normal. Which is much better than the previous old normal ever was.
When the brain finds itself in a place where it can no longer figure out how to adapt, history has shown that there will be pain and/or an injury.
Rather than hiding behind a title, and using tools and techniques that only address the symptoms; an expert could choose a different response. A response that involves asking a question that allows for more insight.
In the case of runner’s knee or any other running injury for that matter; the ankle is a direct extension of the knee. So whether it’s a positive or a negative input, it’s impossible to address one without having an impact on the other.
That is also the case for the hip and the knee. Whether it’s a positive or a negative input, it’s impossible to work on one without having an impact on the other.
Therefore, the input matters!
This might be hard for you to hear, but the reality is, rolling out your hip musculature with a lacrosse ball isn’t improving the connection between your brain and the muscle any more than a lateral release or kinesiology tape is.
When the tool or technique is not capable of improving that very real connection between the brain and the muscle, there is going to be much more mobility back at the joint. Not only at the hip, but also at the knee joint.
At this point, you’re probably thinking about all of that first layer knowledge that you’ve been bombarded with throughout the years. Which is to say, contrary to what you have heard, mobility and flexibility by themselves are not the goal.
They were never the goal. At least not when it comes to an improvement in performance.
The goal is to have stability throughout the *new* available range of motion. Only then will the muscles not tighten up within minutes.
[Side bar: I recently had a chiropractic student tell me a story about one of my colleagues at the university. After an orthotic company did a presentation for her class, she told me that approximately half of her classmates were in favor of recommending orthotics to their future patients. Just to get a feel for where his students stand, the professor asked all of the future chiropractors who were sitting in front of him that day a question, “Raise your hand if you’re currently using an orthotic from the same company that did the presentation weeks earlier.” After taking in the show of hands, the professor informed them that they were all using the very same orthotic in their shoes.
The moral of the story: Orthotics aren’t as custom as people are led to believe.
But just based on the very nature of what an orthotic is, it’s going to throw off the timing of the foot, leg, thigh and pelvis from the bottom up.
Since it’s throwing off the timing from the bottom up, it’s impossible to have all of those moving parts move at the right time from the top down.]
Like I mentioned before, you don’t know what you don’t know. So with all due respect, the things that were on that list end up being the blind (read: the expert) leading the blind (the consumer).
(2) Stability: That is the term that we need to dust off and bring back into the conversation. And while we’re at it, instead of telling a story that sells a whole category of running shoes, or an over-priced orthotic that isn’t any more custom than the one that you can get over the counter; let’s be honest about what it means to have stability at a joint that allows for motion in the first place.
Going back to the list of half-truths that come straight out of first layer knowledge that I mentioned earlier: (#4) There is an imbalance in your structure. Somewhere (?).
In order for all of the moving parts throughout your chain to arrive at the right time, your brain has to sense stability.
Then, and only then, will your kneecap stay on its track!
And where does your brain find stability?
Answer: Through your muscular system. Otherwise known as your first line of defense.
For some reason, the experts continue to address your muscular system in the same way that they always have. Which is to focus on improving joint mobility and flexibility.
And then your brain does what it always does. It figures out a new movement strategy that allows you to adapt.
So I think you can see that at the end of the day, the expert isn’t the only one who has a circle of comfort. Your brain prefers to spend time there as well.
If you enjoyed this post, I would greatly appreciate it if you would help share my message on patellofemoral syndrome or runner’s knee. You can do this by emailing it to a friend, family member, colleague or feel free to share it on Facebook.
A BIG thanks in advance. (:D
— Rick Merriam (@rickmerriam) October 19, 2015
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