The Insanity of Running Medicine

Bruce,
I want to challenge you to read Patellofemoral Pain Syndrome: Proximal, Distal and Local Factors in the March 2010 edition of JOSPT. This article has several keynotes and inter-articles from an international research retreat from the leading experts on PFPS and its occurance/treatment. That stated, Im not sure all of your statements or critical thinking here is valid. While all runners with knee pain may not have PFPS, its been documented with good evidence to support, that it does occur alot (2.5 million runners/year). We all need to do a good job at not rushing to dx anything too quickly and look at all of the biomechanical errors that are occuring with each patient. Although a patient may be given a dx, we must treat all of the factors that led us to give a patient that dx.

@JosephBrence- I don’t think Bruce was arguing about the fact that there is PFPS in runners. I thnk he is simply stating that PFPS is a precursor to chondromalacia, more severe chondromalacia is considered to be OA; however, this condradicts much of the evidence we have stating that there is no OA in runners. He’s simply saying that there are inconsistencies within our evidence/ literature, and medical professionals often make the PFPS diagnosis too quickly without really examining the pt. It sounds like you are both on the same page when stating “We all need to do a good job at not rushing to dx anything too quickly and look at all of the biomechanical errors that are occuring with each patient.”

* edit: … evidence we have stating there is no increase in OA in runners vs nonrunners

My only comment on this topic without going in to a diatribe is that I was once diagnosed with PFPS and was told that I would never run again. Two words…WRONG DIAGNOSIS. In hindsight, what I was really dealing with was a patellar tendinosis involving the inferior-inferolateral pole of the patella. Thankfully, the PT who finally helped me, never even knew the original diagnosis but fortunately understood the sport of running, its associated demands, and my body.

Joseph
How was that reference helpful for understanding this topic? I did not see it after reviewing it.

I think there may be a bit of mixing up apples and oranges here.

I have reviewed fairly extensively the literature supporting the notion that running does not result in a higher incidence of knee OA (or hip OA for that matter) and, to the best of my recollection, every one of these studies is referring specifically to the tibiofemoral — not patellofemoral — joint.

Consequently, I don’t believe you can draw the conclusion that this therefore means PFPS cannot be the #1 running injury.

My studies show no increase OA in the lower quarter in runners to the general population except in elite runner’s hips.

PFPS is a precursor to chondromalacia that then progresses to grade 4 OA? Wow, is that some old school thinking, and I think the error is in Bruce making the connection that when clinicians use the term PFPS they are in fact inferring the chondromalacia/arthritis precursor. I for one, do not agree. Anything that ends in “syndrome” is, by definition a collection of signs of symptoms…it is not an anatomical/medical diagnosis. We know from the in vivo work of Scott Dye (Op Tech Sp Med 1994, AJSM 1998) that the articular cartilage is not the usual pain generator even when chondral damage on the patella is present. PFPS encompasses many extensor mechanism dysfunctions, often with etiology in poor hip rotational and frontal plane control… the whole idea that PFPS is caused by lateral tracking is a largely disproven tenet (Souza and Powers, JOSPT 2009). So call it “Anterior Knee Pain”, “PFPS”, or whatever else gets the runner to your door, but it is our job as PT’s to find out what tissue is at fault and what the etiological factors are, and that requires “thinking outside the box”….i.e. stop the “insanity” of blaming the patellar articular surface, since most of the rest of us already understand that.

Brian, if PFPS is anterior knee pain due to any knee extension dysfunction then OK. I do not think we have gotten to PFPS as the number one running injury dx because of thoughtful, enlightened diagnosticians. I would not include patella tendonosis as PFPS but would “Anterior Knee Pain”. That dx is about as helpful as cervicalgia for neck pain!!!!!!!!!!

It all depends on the definition of PFPS. If it is synonymous with all anterior knee pain, then no… PFPS it is not necessarily a precursor to chondromalacia. However, that is a poor- ill defined diagnosis and should not be “the #1 running injury” because it encompasses multiple, specific diagnoses.

If you define PFPS as a dysfunction within the patellofemoral joint, then the two articles that Brian mentioned support the fact that knee pain is seldom caused by actual patello femoral cartilage or tracking problems. The problems often do not originate in the patellofemoral joint itself, and are much better defined with a more tissue/joint specific diagnosis. Again, supporting the fact that PFPS is a poor diagnosis for runners with anterior knee pain.

Either way you define it, PFPS is not a clear diagnosis. As medical professionals we should make our diagnosis on more than just signs and symptoms. It is up to the PT to find the specific impairments associated with the injury.

It’s unfortunate that in nearly all the literature on PFPS that no one aside from a few researchers (Tyler et al., and Nicholas et al.,) highlight the role of hip flexor strength in addressing PFPS. Lets not forget it’s a hip external rotator too. I’d encourage people to start working their way up to the upper quarter too. There is more to PFPS than the trunk, hip, and foot/ankle and the research will prove this in time. In closing, I think it’s always helpful to think of the patellofemoral articulation as a train on a railroad…if the tracks are not aligned then the train will not move properly on the rails. I really enjoyed hearing everyones comments on this topic. Happy holidays

Onward!

Let’s not effect the role of arm swing to balance the runner straight to keep the knee from twisting.

I would like to say before this post is archived that PFPS is misdiagnosed as the most common running injury because we have no good database for running injuries. Runner’s World is not a good journal for medical research. The military doses a good job but not exactly our typical running pts. Sports Medicine leaves running out. APTA Sports Section is starting a special interest group just this year.

What is the incidence of OA in retired runners/ People with knee OA that have run recreationally or competitively in the past? Breakdown by age starting in the 20’s…… Many people stop running all together due to pain and would thus be classified as “nonrunner.”

Chris- agree that hip flexor strength and control is so important and can be overlooked!

The evidence shows no increase knee OA in runners vs none.

Shirley Saarhman, not sure if I spelled her last name correctly, is an excellent source for mm imbalance.

The diagnosis of PFPS is what it says…a syndrome. YES can’t blame the train. just heard that comparison on Gary Gray DVD on the patella.

with experience, furthering my education, gathering research, gathering others’ experience, of course it isn’t the patella’s fault.

Two great educators above to look into

How does this relate to this being the top running injury diagnosed? Shirley did not spend much of her teaching on running!

Joseph,

I am interested in reading the article you posted-Patellofemoral Pain Syndrome: Proximal, Distal and Local Factors in the March 2010 edition of JOSPT, however I do not subscribe to the journal. Would you be able to attach it as a PDF? Thank you.