Episode 47: What Type of Knee Pain Do I Have?

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• Joe Gambino
• Joe LaVacca

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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, focusing on patellofemoral pain and meniscus injuries. They discuss the importance of understanding symptoms, the role of patient history in diagnosis, and the considerations surrounding surgical options. The conversation emphasizes the need for effective communication between patients and providers, and reassures listeners that many knee injuries can be managed conservatively without surgery. 

 Takeaways

Understanding the signs and symptoms of knee pain is crucial.

Patellofemoral pain affects about 20% of the population.

Many cases of knee pain do not resolve quickly.

Patient history is vital for accurate diagnosis.

Special tests in physical therapy have variable effectiveness.

Meniscus injuries can vary significantly by age and mechanism of injury.

Swelling is a key indicator of potential meniscus issues.

Surgery should be considered based on individual circumstances.

Diagnoses should not be seen as a death sentence.

Effective communication with healthcare providers is essential.

Transcript

Joe Gambino (00:00.542)
Welcome back into the Beyond Pain podcast. am one half of this show Joe Gambino and Mr. Joe LaVacca over there. Dr. Joe LaVacca over there is the other half of the show. This podcast you can find on YouTube cups of Joe underscore PT on Instagram Beyond Pain podcast. And we are most active on Instagram LaVacca over there at strength and motion underscore PT and myself at Joe Gambino DPT. And if you do want to work with this, you could find an application form in the show notes.

Feel free to fill that out and one of us will get back to you. Welcome back, my friend.

Joe LaVacca (00:32.73)
Good to be back. I'm excited to continue our knee pain conversation, especially with some of the things that we brought up in our previous episode. for those listening, if you did not check out our previous episode on anterior knee pain, go back, click on that, listen for some context. Because I think what we're going to be spending most of our time on today is maybe trying to delineate a little bit more about all these anterior knee pain signs and symptoms and well,

Joe Gambino (00:34.188)
Yes.

Joe Gambino (00:40.845)
Mm-hmm.

Joe Gambino (00:57.464)
Okay.

Joe LaVacca (00:59.776)
Hey, you guys spoke about patellofemoral pain and meniscus pain and this type of pain. How do I know I have that? So I'll run you through some lists. We'll run you through some ideas that we always do and help maybe clarify some treatments or ideas or just set expectations for you and your providers because I really think that that's important part of the process.

Joe Gambino (01:18.53)
Yeah, I like this topic because I really wanted to make it where you're hearing some of these things that you're, you should have like, okay, maybe this is what's going on. If it sounds like you, because just a quick aside, cause you know, like in a clinic talk in a sense, but when we were in PT school and when I had students, when I was a perfect stride, the number one thing that people say is that the stuff that you learned in school is not the stuff that makes you a good practitioner.

Right. But then I sit here and I'm like, well, probably the thing that you learn from PT school that is probably the most important thing is the typical signs and symptoms for any sort of diagnosis. That's out there. The age range, how it occurs, whatever it is. Right. Because then when you're starting to talk to somebody and then all of a sudden you're like, well, they fit this age group. They are, you know, sometimes it's male or female. Right. That that's more prone to something.

Joe LaVacca (02:15.032)
Mm-hmm.

Joe Gambino (02:15.278)
the story starts to tell you that these, it's like, oh, well, all of sudden now I can start to think, oh yeah, you may have a meniscus tear. And now when I assess you, I can confirm that or dispute that. And then I can start to do, you know, we'll talk about, you know, what differential diagnosis is as far as is there other stuff that can kind of mimic this, that it might actually be a set of maybe a meniscus or something like that and how we can kind of figure out is it this tissue versus that tissue. So I think this is a great topic because even if you're not a provider,

and you're listening to this and hope to have some answers for your knee pain. If you start to see these stories line up with you, then you might be able to say, OK, I might have this. And then you can go get a look at by somebody to confirm or deny it. Right. So you can if you have thoughts, you're more than welcome to do that. But I don't know if there are someplace specific that you were looking to start as far as this conversation was.

Joe LaVacca (02:58.851)
That's right.

Joe LaVacca (03:10.082)
Yeah, no, think the most important thing is having a good conversation with your provider. And in a busy clinic, when time is of the essence or potentially even lack of confidence of your provider is a factor depending on how long they've been in the field, I think it's really worth noting that your history along with the likelihood of the diagnosis, so let's just start maybe with patellofemoral pain right?

So patella femoral pain on average is gonna affect maybe like 20 % of the population. So it's a pretty high number, but it's probably not gonna account for every bit of anterior knee pain we see. The thing that we mentioned briefly in the previous episode is that a lot of these cases though, don't resolve in six to eight weeks. I know more than half linger for months at a time. So it is really important that you and your provider have those conversations. They understand your history.

because with the special tests that you and I can do, whether it's virtual or in person, and I was reading a lot about special tests this week, two thirds are weak or have unknown value in terms of them giving a diagnosis. So if you have been a PT patient, your PT might have like wiggled your knee a little bit, twisted it, done some sort of slide or glide, and these are all called special tests that are helpful for ruling in

or ruling out a diagnosis. But the only way they really work is by understanding the prevalence of what we're trying to rule in or out and your history coupled with it. So from a patellofemoral pain standpoint, that's where I'm going to always be asking people activity levels. Did we jump up too much too soon? However, it is also

kind of correlated with a lot of just sedentary populations too. They'll start to tell me how they have what we would say is a movie goer sign. Hey, I might sit down for 20, 30 minutes. My knee really aches. I have to get up, move around. People who commute a lot or fly a lot in New York City, that's another sort of like big one. Maybe there will be some mild swelling, but it'll be around the knee joint complex, not maybe like interdispersed.

Joe LaVacca (05:35.662)
around the joint line, at least from my experience with it. And then typically we might find a little bit of limitation where that kneecap doesn't move around. It is called a floating joint. So it should be that you take your kneecap and you can move it along the face of the clock, 12, six, nine, three big circles. And if it's moving freely, great. We know we have good mobility there. But those would be kind of like right off the bat, like sort of things.

Sensitivity to load, sensitivity with more anterior load, and I think you pointed that out for our listeners in the last episode. When that knee goes more and more over the toe, maybe when we drop a little bit more into flexion or bending of the knee, that's gonna become more sensitive. And then I kind of pair that with the quote unquote movie goers sign, which is usually a nice way to kind of rule in or out patellofemoral pain.

Joe LaVacca (06:34.734)
You got yourself muted.

Joe Gambino (06:36.856)
Yeah, my little colorful mic here if you're on YouTube. I look over here and I wasn't muted. So anyway, I agree with that. I think that was well said. One other thing, if we're ruling out, is that anterior load stuff. If I can alter positions and all of a it feels better than all of a sudden I'm like, okay, yeah, this is all. Again, think it's also easier to rule things out if I remember correctly, than to rule something in.

If I, my goal is to just kind of like roll things out as quickly as possible and then kind of move on. But again, I always go back to movement. What's painful and what's not painful where, know, like the assessment, right? Movement, diagnosis over, over a particular diagnosis really kind of resonates in my head. But if I hear all these things, I'm definitely going to be starting to think about the tele joint and everything else that's kind of going on there. And I'm to just let you keep the run, running with this. you can, you can go right into meniscus and she's doing such a great job.

Joe LaVacca (07:35.884)
man, I appreciate that. Meniscus, just my mindset shifts a little bit with meniscus. I knew it was coming, man. I knew it was coming. Meniscus, think this is where age comes into factor for me as well as mechanism. So with age, we'll start with older than 40, and that's not to hurt anybody's feelings. I will be approaching 40 as will Joe in the next year and a half so we know what the struggle feels like.

Joe Gambino (07:40.12)
There's your compliment.

Joe LaVacca (08:05.582)
But if you're over 40 without a specific mechanism of injury and you're maybe getting some locking or catching around the joint, maybe we have some loss of range of motion, particularly in extension and end range flexion. So usually moving the knee in those middle ranges feels pretty good. And then when we try to lock out the knee, it kind of hurts if it's more maybe anteriorly involved or like on the front side.

and as we start to push the knee backwards, if you get that end range pain bending the knee, maybe it's more of a posterior side implication around the joint. But if you're younger, and let's just kind of throw younger into this category of less than 40, then you might, might, not all the time, you might have a mechanism that involves some sort of pivot and shift.

that involve a contact, know, someone might be rolled up on you in your sport. Maybe you fell. So if you're younger, the mechanism is gonna really ring true and then probably help me out, rule out that patellofemoral pain idea, you know, because there was a specific moment in time, not a gradual buildup. It's gonna probably take away tendonitis for me, right, because you had a mechanism, right, you

The tendon of the knee, like we said, is mostly going to get irritated with repetitive loads, particularly with jumping. And then it's going to bring me to, well, what's left? mean, really the big picture stuff, looking at the joint itself, the integrity of it itself. And then to couple old and young together, I would typically look for swelling after activity. And that's going to be another hallmark, in my opinion, of these meniscal type injuries.

So you can feel good, hey, know what, knee's looking good, I go on a bike ride, I go on run, I go to the gym. I was fine the whole time, and then six, 12, 24 hours later, I look down, knee feels really icky, I lost some motion, it maybe is a little warm, but there's definitely signs of swelling, and then that's your sign to say whatever you did in the gym, even though it did not hurt, might be a good time to pull.

Joe Gambino (10:29.006)
Yeah, I like that breakdown. And maybe here's my, here's a question for you that I think might be on a listener's minds, uh, because meniscus is one of those things that's very, very common to go under under the knife for. So at what point, um, in time would you say, these are the findings that pop up that maybe we should consider that as an option.

Joe LaVacca (10:40.558)
Mm-hmm.

Joe LaVacca (10:50.06)
think the biggest thing from my understanding is this swelling response. So if you have a mechanism, particularly, right, like something you fell, you got twisted, you got rolled up on, and you're having a lot of swelling, then you might be one of those people that responds to surgery early on. And maybe that swelling is just a sign that there was a little bit more involvement of the joint tissues, the cartilage, the meniscus, you name it. Maybe that tear is kind of quote unquote

you know, more complex than some simple tears, quote unquote. But when we just look at the idea of like, well, I got an MRI, you know, I have this tear. Well, the outcomes kind of fall apart just because your tear might be a little bit bigger or more complicated. Doesn't necessarily mean you fit the bill for surgery. Just because your pain's been around for a little bit longer doesn't mean you necessarily fit the bill for surgery.

And the cool thing about a lot of those meniscal surgeries is when we compare them to placebos, meaning you fall asleep, they drill, not drill, but they cut kind of two holes in your knee. And then they basically look around with a camera and then sew you back up versus putting two holes in your knee, looking around with the camera, doing the debridement, doing the cleanup, doing the repair, do whatever they need to do. Well, just the look around surgery and the real surgery.

a year later have very similar outcomes. So does that mean that surgery does not work? No, I don't want people to leave with that message that, well then why would I ever get surgery? Surgery is a very personal decision. So if you have a knee injury and you have a lot of the swelling and you and me and all the PTs out there are like, no, don't get surgery. We know it's no better than placebo. But now you're talking to a single dad or a single mom.

or someone who works three, four jobs, or someone who just doesn't have the time, doesn't have the motivation, doesn't have the desire to do a rehab program, then surgery is perfect for that person. They don't need to live in agony. They don't need to live with constant catching or locking of their knee if they are not gonna be able to commit to a rehab process. So I think that's what I would look for. Swelling number one.

Joe LaVacca (13:12.034)
The mechanical symptoms even are a little bit inconsistent, because I used to guide people on if you're getting catching, locking, instability, you should probably consider the surgery. But now I'm really more about the swelling, swelling response, your mechanism, and what's your life going to look like as you commit to a process of healing and recovery.

Joe Gambino (13:32.204)
Yeah, I like that. The other thing I would add is like, know, activity level, you know, if you're playing college sports, you're playing or, know, whatever, you know, you just enjoy being active and this is going to slow you down for a period of time. You know, something again, right. I do think it's a very personal decision. I always tell people you have to weigh the risk reward of anything that you do. Right. I mean, I am always someone who's going to say, you know, if it was my body, I'm to try and try to delay anything as long as possible. if it was a huge impediment to my life and

Joe LaVacca (13:36.018)
sure.

Joe Gambino (14:02.304)
I knew that I can potentially feel better sooner with the surgery or something like that, then it's something that I'd have to consider right away, weigh my options. So I think that you should always consider. And if you're someone who's adamant about not getting surgery and you do get a doctor says you should get a second opinion, right? You should weigh all of your options and figure out what is the best thing for you, right?

That's really all I have to say on that. think we did a pretty good job there as far as these two symptoms go or diagnoses go as far as what you would feel there when you should look for surgery, things with that nature. Is there anything else that you'd like to add or bring up here? I know this was a little quickie here.

Joe LaVacca (14:42.444)
No, think, you know, again, that's a lot of information in a pretty short period of time when it comes to assessment or even things to look at for yourself. So I would just encourage people, if you have more questions around your condition, that's a perfect time to fill out that form. Send us a DM on Instagram or comment on YouTube and we can maybe add a little bit more context to your case, work with you, help you out, and hopefully get you back on the path to recovery.

Joe Gambino (14:58.583)
Mm-hmm.

Joe Gambino (15:07.586)
Yeah. And the last thing I'll say here before you could take us home is, you know, again, with all these diagnoses, you know, they're diagnoses, right? They're not labels. They're not a death sentence. You have a meniscus tear. Many, many people do very, very well. Conservative care surgery, get back to everything they want. Same thing with telephamoral pain. Same thing with a lot of diagnoses out there. So discuss you. You fit into one. Does it mean that you're destined for lifelong pain or anything like that? You just need to find the.

right approach or you just kind of need to go about finding ways to work on that in a way that suits you.

Joe LaVacca (15:43.404)
Yep, absolutely man. All right. Well, Joe, thank you. I love you. let's do the thing. I feel like I just don't do it right. Am I sure? Okay. Yeah, all right. I'm kind of getting, but I feel like I turned too much. I just have to keep it straight, straight on for those watching on YouTube. My hearts are getting better. Anyway, Joe, thank you. We love you. Listeners, we love you. Thank you for making it this far into the episode. And don't forget to tune in next week for another episode of the Beyond Pain podcast.

Joe Gambino (15:52.408)
You did a great job, that looks just like a heart. Yeah.