When you look at what Paul has laid out in terms of the longer term solution for patellofemoral pain, it seems like exercise is the number one component that people need to be engaging in. The thing that's worth highlighting is that exercise is probably the best solution, but not for the reasons that we previously thought, so not for biomechanical reasons only.
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SPEAKER_01:Today we have a super exciting episode for you as not only will we be getting five top tips on treating patellofemoral pain with Luke Murray but we will also be giving you the listeners an amazing opportunity to get your hands on an amazing free giveaway. But you will have to be quick as this offer will only be available to you for a very short time. Luke Murray is a specialist MSK physiotherapist who has previously worked with Arsenal Football Club, London Irish Rugby Club and in the NHS. Luke was a strength and condition We'll be right back. Luke, thank you so much for coming on to the podcast. It's been a year since you and I spoke, glass in hand. It's almost Christmas time. We're going to chat today about one of your favourite subjects, which is patella femoral pain, and you've been doing a bit of digging into a great resource. So tell us a bit more about that, Luke. Yeah, thanks for having me on, James. Good to see you again one year on. So yeah, I've been having a look at the e-book by Paul Ingram on painscience.com. It's called The Complete Guide to Patellofemoral Pain Syndrome. It's really, really, really good. I'm actually surprised at the amount and the volume of detail that he's got in there and the amount of research as well. The amount of references in it is unbelievable. So today, I think the focus that I'd like to chat about would be the exercise specifically for patellofemoral pain. All things to do with exercising and patellofemoral pain that might be useful for general population or for physios working with people that have knee pain, given how common it is and all the different lovely labels that it has between runner's knee, chondromalacia patella, iliotibial band syndrome, all that good stuff. Yeah, it's a topic that we spoke off air. I'm really interested in the moment. I've been also doing a little bit of digging around as well in terms of the masterclasses that are on the physio network available to members as well that Claire Robertson's done. So signpost to those as well. But yeah, really interesting subject, big subject. We're going to cram into the 15 minutes that we've got. Just before we dive into the topic, I'd love to let the listeners know that really excited to say we as Physio Network are running a Christmas special right now. So you can get this ebook for free. That's right, for free. If you sign up to our brilliant practicals, I can safely say they are fantastic as well. I've done several of them now and they are a real eye opener into seeing the X and how they assess and manage patients in true time. They're a fantastic service that we have started this year, actually. So do get on on those, get signed up and you get a free copy of this ebook. So it's fantastic. The link is in the show notes to claim the offer. I'm sure you're interested. I'm not even going to say if you're interested. So Luke, let's get straight on. I'm going to take a drink of my red wine and you're going to dive into tip number one for exercise around patella femoral pain. Very short and sweet. But when you look at what Paul has laid out in terms of the longer term solution for patellofemoral pain, it seems like exercise is the number one component that people need to be engaging in. The thing that's worth highlighting is that exercise is probably the best solution, but not for the reasons that we previously thought. So not for biomechanical reasons only. So I think over the years, you can see the whole understanding of patellofemoral pain developing among the evidence-based community. And I think we've gone from maybe not completely, but there has been an element of change recently where we've stopped sort of talking about the realigning of the knees or the stretching of tight muscles, maybe even just purely strengthening or weak muscles as all major components to patellofemoral pain. Now, a program might involve elements of all those things, but it's not because the weak muscle is causing the pain. It may not because of the tight muscle causing the pain, or it may not be because of a misalignment of the knees that's contributing or causing the pain, I should say, as opposed to contributing. So we know that exercise works in terms of what it does for people that are in pain. And like if somebody has been in pain for a long time, their whole life envelope of function has reduced because of that pain in the knee. And then it's a case of trying to find a way in to get them exercising again without irritating the knee and build things back up so that we're improving that envelope of function and restoring an element of normality that would have been there pre-pain or pre-atellofemoral pain. Why does exercise work is probably a bit of a mystery. And I really like that is that Paul highlights how it's not very clear cut. It's not a case of We do this, and this is the outcome, and that's because of the tight muscles, the realignment of the knees. Actually, it's probably far more complicated and far more mysterious as to why somebody improves when they exercise. So you can look at that in a few ways. You can say, well, okay, that gives me nothing because I don't know where to start. But it also, from a different perspective, gives you everything because... There are so many options. It opens up the menu of all the different types of exercise that is open to you that you can tailor to the person that's in front of you that has their anterior knee pain, their chondromalacia patella, whatever term that they've been given prior to seeing you that they bring to the table. So to get into the nitty gritty of that, we can go through in a few more of the points.
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SPEAKER_01:hit some nails on the head there in terms of what we're now seeing with exercise improving function, but actually not necessarily the primary source of improving pain, some of the other functions there. So let's dive straight in. Number two, what are we going with next, Luke? Yeah, so leading in from the very broad overview that it's probably not all about biomechanics, number two would be about pain itself and what's the cause of that pain. Is it a pain problem or is it a weakness problem? So what I found most interesting was that Paul highlighted this being a sort of a chicken and egg scenario with pain versus weakness. So we don't really know if it's something that like you've banged your knee or you've done so much in the gym or you've gone for a very long run and that's caused a knee pain itself or it's caused some element of damage. We don't really know if it's that or if it's a case that for whatever reason, your knee is weak and that weakness then contributes to the pain. So Paul sort of suggests that it's potentially a pain problem, first of all, maybe because of overdoing it. Like I said, if you were doing excessive squats in the gym or excessive running, that you just completely exceeded what your knee can cope with and then you start to develop pain. And what was interesting from that point of view is that you view it as a pain problem initially and that the actual symptom then is the weakness. So the symptom really isn't the pain. The pain is the cause of the overall problem. And the weakness is the consequence of that, not the cause of it. So I suppose from a practical perspective, does it really matter? Do we care if it's a pain problem or a weakness problem? Because regardless, our tools that we have at our disposal are going to be exercise. So I don't think from the people that I've worked with that have had anterior knee pain, they don't really, not really too concerned about why they've got all the pain. They just want to find out what can be done to get them back to what they want to do, you know, from a very purely a practical perspective. So I think a combination then, like I was saying earlier on, of different methods can help. So if somebody has a desire to do just general exercise where they don't want to engage in a specific structured, I need to do these specific exercises for these sets of reps, like very regimental across the week, that it gives you a bit of freedom that you can actually just get them exercising in a way that they enjoy, and get them exercising in a way that just suits the person that's in front of you. So that if somebody has pain, we don't necessarily have to go in all guns blazing with the strength in an exercise to improve their quad strength. They may not be able to do that because of so much pain in the knee. In actual fact, they may want to actually go for a swim. They may want to be able to jump on the bike or the cross trainer or something that they can exert themselves in a slightly different way without irritating the knee itself. So you don't have to pigeonhole yourself to doing all squats, all leg press, leg extensions. Actually, you can go from doing something that doesn't seem like an actual specific treatment. You can keep things quite general and just get people moving again. And that might address the pain. And then when pain comes down, you can start to explore more things like getting people stronger within a range that may have previously been too uncomfortable for them. As you said there, it leads into the first thing there in terms of that option. All the options are open to us in terms of what exercise we give, depending on the person, because we don't have to necessarily give a specific thing, which is great. So number three, diving straight in, Luke. Yeah, so the next one is another hot one, the VMO and its importance for patellofemoral pain. So similar to what I was saying again earlier on, there was that type of narrative around patellofemoral pain that there was a poor... activation of the VMO or timing problem with the VMO where it wasn't necessarily doing what it was meant to do. So that the vastus lateralis was pulling the kneecap laterally, which was causing misalignment or just not having the patella in the trochlear groove in the way that it should be there. So then by strengthening the VMO, you can then pull the patella more medial and that might improve symptoms. So that was a big narrative around patellofemoral pain. And I think we still see that quite a bit. I know myself, I've seen it on different referrals from other clinicians that want to hammer the VMO and get the VMO as strong as they possibly can, as if that is even possible. And what I really liked about Paul is that he sort of challenged his own bias. So he highlights where his belief was, say, 10 years ago or so, around 2010, 2011, where he thought that it was absolutely impossible to isolate the VMO. And that, myself, was a position that I held. But actually, he would then reference his six studies that show that you can sort of preferentially engage VMO relative to the rest of the quads, but is that of any relevance? So, off the top of my head, a few of the exercises I did was like a squat with a ball between the knees to emphasize the hip adduction, and that for some reason, seemed to activate VMO more in comparison to other parts of the quads. Same with very deep squats, that seems to activate VMO a small bit more as well. And there were a number of other exercises that Paul referred to in the book. But it needs to be highlighted, is that even relevant? It wasn't shown to be better for pain. It just showed that it did target the VMO slightly more than other parts of the quadriceps. So, It's something that maybe could be used, but just because you do those exercises and you get an improvement in pain doesn't mean that the VMO was the problem in the first place. So it comes back to the overarching theme in the book that the specifics of the plan are less relevant and general exercise is more relevant. So if you give somebody that is a type A personality, likes structure, likes routine, likes attention to detail, you might give that person the specific exercises outlined in the book and you might get an improvement in their symptoms because you're giving them that sense of autonomy over their symptoms. They're able to do something that's not irritating their knee. They can build momentum, they can see progress, and they get a reduction in their pain as they address whatever you've given them. In terms of some of the evidence that Paul references, there was a study by Peeler et al. where they just found that there was no significant correlation between the VMO And like the insertion length of the BMO, the fiber angle, the limb alignment and patellofemoral joint dysfunction. In another study, I think it was by Bal Krek or something like that, they said that the BMO was identical in people with and without patellofemoral joint, sorry, instability of the patellofemoral joint. So to the naked eye, there is no identifiable difference in people that have a stable or unstable patellofemoral joint. So it's food for thought in terms of how you want to go about targeting the VMO. And it may or may not be relevant. And I'd say pick it for certain people that you feel may respond better to that sort of structured approach. Time isn't on our side. So we're going to dive straight into the last couple of tips, Luke. Fire away with number four. So number four is how do you actually exercise without irritating the patellofemoral joint? And this comes back to the basic principles of rehab and the person that's in front of you. Some people, you'll want to work around the pain as opposed to walking through the pain. And Paul talks an awful lot about relative rest. So taking a period of time off as being actual rehab itself, that's a prescription that we may need to let it calm down for a period of time. So that means reducing the things that are irritating us. That could be something like reducing your running volume, reducing your frequency of running and avoiding things like deep squats or avoiding leg press. because they're the things that put a large amount of stress through the patellofemoral joint and will irritate the joint potentially beyond what it should be so that you can pick other exercises that still give the person a really good workout, but don't irritate the knee joint itself. A quote that I really liked was, rehabilitation is a careful balancing act between exercising enough to stimulate recovery, but not so much as to aggravate the symptoms. So instead of going all guns blazing when they're in discomfort at the front of their knee, you would instead do knee curls, You might do hip abductions. You might do the dreaded clamshell that physios seem to hate. Exercises like that where you can still get a pretty good workout without putting too much load weight bearing through a bent knee is probably the best solution for patellofemoral pain to get somebody going. Definitely. And there's some nuances there. Picking out from one of the masterclasses that Claire Robertson has done for us is She really highlights actually some of those key things that you can look at outside those exercises that really doesn't aggravate the knee, that does do some good things in terms of our external rotators and other side of things as well. So another reason to check out the masterclasses we've got on that. Number five, Luke, we're going right into the end, crossing the finishing line with number five. This is the best one to finish on. This is like the psychological aspect of pain. I think most people, when they have knee pain, are always thinking, Do I need to be pain free to actually return to my activities? And the short and simple answer is absolutely. You can return to exercise without having to get rid of all of your pain. Paul says that rehab involves deliberately provoking discomfort while being smart about your loading. So recovery is completely compatible with discomfort and you don't need to wait for pain to go before you return to all of your activities that you love and enjoy. I think as clinicians, that's something that we need to hammer home so that we set our expectations appropriately going forward for that patient as well. Perfect. Luke, five great tips for the listeners there treating patients with patella femoral pain. As you've alluded to, there's a hell of a lot of information in the e-book from Paul Ingram. So for listeners, head into the show notes down below. As I said before, you can get a free copy of this book if you sign up to the brilliant Practicals by Physio Network. It's a Brilliant way to learn from some of the best clinicians around the world and learn a lot quicker. This offer does end in a few days. So make sure you do grab it now. The link is in the show notes right below. So take this opportunity to grab a free copy of this ebook. And as Luke says, it is jam packed with lots of information. So Luke, thank you very much. Raise a glass. Thank you to another great year. We shall no doubt see you very shortly in 2024.