The experience of living with Patella Femoral Knee Pain; loss, confusion and fear avoidance
This is the title of an excellent paper that I read recently (Smith, B et. al. 2018). It highlights an issue with Patella Femoral Pain (PFP) that I see on a weekly basis in the clinic, so well, that I couldn’t see a more apt title for my blog!
PFP is pain around or behind the patella (knee cap). It is one of the most common forms of knee pain and is commonly aggravated by climbing or descending stairs, squatting and running. A study has shown that long-term prognosis is poor with only one-third pain free one year after diagnosis (Collins, NJ et al, 2013) and another study (Stathopulu, E et al, 2003) finding that 91% still reported pain and dysfunction four years after diagnosis.
The authors undertook in-depth, open-ended interviews with participants who had a diagnosis of PFP for an average of six years (range three months to sixteen years). This allowed the researchers to collect and categorise some great insights into the experiences of those with Patella Femoral Knee Pain and in turn help us to refine our management of this problem.
The five major themes that emerged from the interviews were:
1. Impact on self
2. Uncertainty, confusion and sense-making
3. Exercise and activity beliefs
4. Behavioral coping strategies
5. Expectations of the future
Impact on self
• Anxiety from an inability to continue with significant and meaningful activities
• Persistent pain interrupting a person’s behavior and a person’s sense of who they are and what they might become, e.g. whether they can play with kids on the floor, go with their friends on an adventure holiday, or become a carpenter
Uncertainty, confusion and sense-making
• The cause of the pain is unknown and troubling
• Not being able to predict or control the pain intensity
• Individuals were trying to reason their symptoms through a confusing biomedical model often because this was how their symptoms were explained in the past
• Confusion by the noises in the joint even though this is common in normal joints,
• Participants attributed their pain to structural changes despite their being very little link between imaging findings and Patella Femoral Knee Pain
• Because people were not able to make sense of the pain they put their ‘lives on hold’ which likely lead to more catastrophising
Exercise and activity beliefs
• Uncertain diagnosis contributed to people not knowing if activity could make their problem worse
• Cultural beliefs, e.g. if something hurts your body is telling you if you do that you’re going to cause more harm
• That past exercise or sport was the cause of pain despite no mechanism of injury
• Individuals who stop exercising through advice from therapists, e.g. therapist advises to stop exercise until they are pain free while they are doing their passive treatment
Behavioural coping strategies
• People associated rest and avoidance of activity with the idea that time was necessary for the healing process
• Sitting in a particular way to limit bending the knee
• Using knee braces
Expectations of the future
• People mainly focused on being pain free over any functional improvements
• Most had a negative view of the future, e.g. thoughts like if it hurts doing stairs now, how bad will it be when I’m older, will I need a chair lift?
• I will probably not be able to join the police force now
• Central to their negative beliefs were that they felt they had very little control over their symptoms
• They felt physiotherapy would not work
• They perceived that there was not much they could do to control their future in relation to their PFP
How this study supports how I manage those with Patella Femoral Knee Pain
The findings of this study is consistent with what I hear from patients with PFP all the time. However, it is the first time PFP has been scrutinized formally and it highlights how further study is needed to gain consensus on how we apply this knowledge to the treatment of the condition. In the meantime, here are ways I consider my approach to PFP to be consistent with the findings of this study:
• I gain an understanding on how exactly PFP is impacting on the individual. This will allow me to create and address functional goals that will help you to recommence your significant and meaningful activities rather than to let pain limit meaningful activities and its associated anxieties.
• This will be facilitated by gaining an appreciation of your pain through a thorough history and physical examination so that I can help give you an understanding of your pain and to put it in context.
• We will then be in a position to focus on your functional goals in an informed and safe way so that your life is no longer on hold.
• Based on our assessment I will help guide you to what exercise will be helpful and where other types of exercise sit in regard to your PFP.
• I will help clarify if and when, rest can be helpful and when it is not.
• We will develop strategies that you can use to manage your symptoms and achieve your functional goals on a day to day, month to month basis. This will mean you have a greater degree of control over your problem. This may involve how to positively load your knee and how to identify when a pacing strategy may be beneficial.
• We will also discuss your future and focus on setting your goals. I will help you follow a realistic and achievable route to your goals. This way you will not have to feel apprehensive about your future. You will have a greater degree of control over your future.
There is no one solution or magic exercise or massage technique that will be the answer to every person dealing with PFP. I have highlighted that there are many common issues which occur in people with PFP. However, they manifest in infinite different ways because we are all so unique. For this reason, it is important to tell us your whole story and allow us to assess your knee so that we can commence a treatment approach specific to you.
By Anthony Sheridan, myPhysioSA Associate Physiotherapist
Collins, NJ et al. Prognostic factors for patellofemoral pain: a multicenter observational analysis. British Journal Of Sports Medicine 2013, 47, 227-233
Smith, BE et al. The experience of living with patella femoral pain; loss, confusion and fear avoidance. BMJ open, January 2018
Stathopulu, E and Baildam, E. Anterior Knee pain: a long term follow-up. Rheumatology 2003, 42, 380-382