Non-specific knee pain is a good enough diagnosis
You click bait jerk. I know. But hear me out.
Apologies for the length of the post. It was meant to be a microblog but it morphed into pre-course reading for those taking Reconciling Biomechanics with Pain Science.
I know many people hate the term non-specific low back pain. The assumption being that if you know the anatomical source of pain you can give tailored treatment to your patients. But not only do I think that doesn’t matter much in the spine (there are exceptions and I wrote about that here) but it also doesn’t matter much at other joints. Let’s talk about the knee for example.
You could have knee cap pain (more formally known as Patellofemoral pain - as if that tells you anything), ITB pathology (we hear its not a friction syndrome but a compressive pathology - and again that doesn’t tell us anything - 11 year old blog here), knee OA (pick a joint - it doesn’t matter either), patellar tendinopathy or even an ACL reconstruction.
Main Points of this Polemic!
1. The diagnosis does not dictate what you do
2. For the same person with different diagnoses their care would look very similar (i.e you follow a framework or gasp, a “recipe”).
3. The diagnosis might nudge you in the direction of some things being more important (e.g you have to build strength or change tissue quality).
What does the basic recipe always look like?
Resuming and dosing the goal activity (e.g Running is Rehab)
Modifying Life stressors
Addressing unhelpful beliefs
Local Exercise (what hurts)
Regional Exercise (the joints around what hurts)
Global Exercise (Halo exercise - exercise at distance)
Get Healthy
Symptom Modification
1. Resuming and Dosing the Goal Activity - Load Management of the Goal Task
Well, d’uh. For every pathology here the person’s goal task will be something you will manipulate - classic load management. If you work with a runner then you will probably be managing how much they can run. But running or the whatever the goal task is MUST be part of the intervention. It is THE stimulus to catalyze adaption. It is the THING that most people want to return to. If we think movement preparation (or capacity) is important than the specific task might be the best thing to prepare someone for it. Read Running is Rehab for more on this.
So, what guides treatment? Solution Focused Questions
Expose or Protect? This is the biggest challenge for me and where a lot of people would disagree. Its sometimes argued that a lot of specific exercises are needed FIRST before you start doing the goal task. Meaning you should do heavy resistance training or plyometric work BEFORE you return to running. Others might say you can do those exercises but you can also dose running appropriately. Others might say just run and that is the best stimulus to adapt. But, this debate occurs irrespective of the diagnosis.
It’s not the diagnosis that guides a return to activity or sport. It could be how sensitive the person is, how they respond to pain, next day sensitivity levels or relevant impairments (e.g strength). I admit that some diagnoses here (e.g ACL repair) will certainly hedge your bets into want to addressing strength before a return to sport. Like all general frameworks we want to find exceptions (more at the bottom).
2. Modifying or Addressing Life Stressors - “Load” Management of the Person
Pain and injury are multidimensional. You want to know what is going on someone’s life. You need to know what their life stressors are as these can influence what you do and could be things you modifiy For example, if someone has elevated levels of life stressors (work stress, emotional stressors) then this might influence how much “rehab” stress you put on someone. Again, the diagnosis is not going to influence this.
3. Addressing unhelpful beliefs and Making Sense of Pain
We need optimistic views about our pain problem. We need to make sense of our pain. We need to know it’s safe to move, to exercise and to live. We need to know that physical stress is a force for good in painful and injured tissues. That the knee is allowed to go into valgus and that we should prepare for that. All of these positive messages would apply to every single diagnosis here.
So what guides treatment?
The person, of course. The beliefs that people have and that might need a discussion.
4. Local Exercise (where it hurts)
Yes, I know. I’m a revolutionary. If the knee hurts you should probably load it. You are going to do this for all of the conditions regardless of the diagnosis
So what guides treatment?
This is where we all quibble and can depend on your philosophy. I believe in movement preparation and comprehensive capacity (example here). This means three things help me here:
1. What are the things someone wants to do (OK, lets build them up to do that)
2. What are the things people have trouble doing - aka. Train what you suck at (OK, lets do that)
3. Belts and Suspenders - I can’t be sure what is needed so I will develop a robust system (strength, power, mobility, elasticity).
How does the diagnosis help a little bit here?
Again, is someone has an ACLR we are definitely leaning toward building up their strength (but, is it the ACLR that guides this or the fact that someone is returning to high levels of activity?). If someone has knee OA then we might also want to lean towards building strength as strength increases might be a mediator for recovery (but is it the diagnosis or the fact that someone has difficulty performing their activities of daily living?). If someone has patellar tendiopathy then maybe heavy resistance training is important because we want to challenge the tendon to adapt (although to be honest the research is so weird and mixed here). I personally hedge my bets with ITB issues just like tendinopathy. I tend to think its very similar and the ITB might also benefit from some heavy loading to catalyze adaptation. Because in these two cases I think the tissue MIGHT need a specific stimulus to catalyze repair.
Pulling a principle from the research here we might infer that the more you think there is a “tissue issue” in terms of “damage” then the more likely it is that we should apply heavy loads to catalyze some tissue adaptation).
5. Regional Exercise
We consistently see that if someone has some knee problem then they should also train around the knee. For decades it was advised to do outside the hip work even though the research was really saying just do ANY hip work. And that idea is being fleshed out with more work suggesting that if your knee hurts you should train something at the hip and even something at the foot.
So what guides treatment here?
This is great. We let the person guide our treatment. It again seems like we are just creating a robust system (e.g Movement Preparation). So, we train above and below the painful area choosing exercises based on:
person’s goal tasks help us choose exercises,
the person’s preferences help us choose exercises or
even other health goals help us choose exercises (e.g choose hopping or heavy resistance training to build bone density)
6.Global Exercise
Pain problems are not just local issues. A lot of local “dysfunctions” can be viewed as the local manifestation of global problem. This is probably why sham exercise is potentially helpful for Greater Trochanteric Pain. Or why arm exercises help with knee OA. Adding Global exercise could be part of all our programs and again the diagnosis doesn’t help you choose
So what guides treatment then?
Patient preference, giddy up
7. Get Healthy
A bit of a catch-all and not always an easy sell but this again recognizes that pain is multifactorial and we don’t fully* understand it. But, we do know that emotional health, metabolic syndrome, psychological traits (catastrophizing, ruminating), loneliness, uncertainty, high BMI etc can all influence what we feel. All of these fall under a broad umbrella of Health.
So what guides treatment?
Patient preference (what are people interested in addressing) again but this takes time and understanding. It is a weird sell to tell someone that their knee pain can be exacerbated by their general health. And a lot of people don’t have the emotional energy to address everything and we should not expect them to. This is where using the cup analogy for pain can be helpful. We want to introduce the concept the pain is influenced by so many health related things and note that not all of those things need to change. We can work on small steps. Small changes can add up.
8. Symptom Modification (A catchall to calm stuff down)
My symptom modification tends involve movement modifications and graded exposure. Calm things down, build things back up. For others, it might involve manual therapy, taping or orthotics. Whatever. It probably doesn’t matter. They are just some ways to change pain. Some thoughts on when to do what below.
Clinical Decision Making and Wrapping Up - Where do we need more information/knowledge
With a framework like this for knee pain it doesn’t mean we do identical things for each patient or that our treatment is not tailored. It simple means that our tailoring is not determined by the diagnosis but rather by the person. What are the questions we need answers to:
1. When do we need to be specific?
When must someone get stronger? When must a tendon get stiffer? I’d suggest that its not the tissue pathology that determines this but rather the things people want to do (e.g sport and activity). These questions are important because they dictate your exercise prescription. If you a tendon’s material properties must change to achieve recovery than you have fewer options in exercise prescription. You will have train heavy-ish (e.g >70%max load).
2. Movement Preparation trumps quality but…
There has been shift we have been advocating for for more than a decade that the key to rehab is to build people to tolerate their life demands instead of the classic kinesiopathological model that suggested how you moved was a very important factor (details in this old blog here).
Now our debate is what is the best way to prepare someone to get back to doing the things they love. I’ve advocated in this blog that local and regional exercise is helpful for knee pain. We have pragmatic research that suggests that it’s associated with recovery. However, when is the goal task sufficient? When can we just walk, hike, run, sprint or trampoline with the right dosage to get better. This is related to “when do we need to be specific”. I don’t have all the answers here (lots of hunches) and that is why I advocate the comprehensive capacity approach. But, it sure would be nice to see some research that compares “load management/doing the task you love” with specific exercise. And want to know something funny which is slightly against the thesis of this piece? I think that with some diagnoses (ACLR) coupled with specific goals (high level sport) the goal task won’t be enough :). Ha, thought I’d end with a twist