GUEST BLOG: How should we explain patellofemoral pain to patients?

On a daily basis we face the challenge of explaining a patient’s pain to them. When this goes well it can reassure them, help them manage their condition and be a key starting point for treatment. Unfortunately, however, it doesn’t always go well and sometimes our words can have a negative impact if not chosen carefully. Patellofemoral pain can be particularly challenging issue to explain, so how should we approach it?

What are we trying to achieve?

First of all it’s worth considering what are our goals with this explanation? Broadly speaking our goals might be;

• Reassure that pain doesn’t mean damage
• Provide an explanation that the patient can understand and apply to their rehab
• Be clear that movement is helpful not harmful
• Help the patient find the right level of exercise to start with
• Discuss a graded return to activity based on their goals
• Change their attitude towards their joint and its response to exercise
• Address any specific concerns and worries
• Aim for physcological and physical resilience

So, not much then! Where do we start?..

…Before we talk, we listen! A good place to start is to ask the patient what they think is wrong with their knee. This can help highlight unhelpful beliefs that we might be able to change and identify specific concerns.

It’s also good to know what not to say! We know that our words can have a nocebo effect and certain words may be recieved more negatively than others by patients. Research in arthritis has suggested the terms, “wear and tear” and “degenerative changes” have an especially negative impact (see table below). How often have we said to patients, “it’s just a bit of wear and tear!”? Although I’m not aware of evidence on it I suspect the term, “mal-tracking” can be interpretted negatively too.

By contrast no negative impact was reported for the word, “inflammation”. The terms “irritated”, “sensitive” and “overworked” seem to be received quite well too. These might be good options to consider in our explanation. Pain specialist Mike Stewart also suggests talking about the distress that can accompany pain, thinking beyond the ‘ow factor’ and considering the broader impact pain has on people’s lives.

Source: Barker et al. (2014)

Changing perceptions

When you’re in pain it’s easy to see your body as damaged and fragile. We might hope to change this view and help people see that their bodies are amazing things that can adapt and strengthen in response to exercise. Combining this with the thoughts above we may try something like this,

“We know that when we exercise muscles they strengthen. Did you know that a joint can strengthen in response to exercise too? It just needs the right amount of exercise and enough time. If we work it too hard or don’t give it the time to strengthen it can become a bit overworked and irritated. When this happens, everyday activities can become painful because the knee becomes sensitive. In time this sensitivity reduces and we can build back up to where you want to be. This usually needs to be done gradually though to give the joint enough time to adapt and strengthen.”

It can help to use a positive anecdote here for some patients. I talk about one particular, wonderful patient who could only manage 1 minute on a bike before his pain become too severe. He started with just under a minute and gradually built up… 6 months later he cycled London to Brighton! While we, as scientists, don’t put much stock in anecdotes as evidence, patients can find them helpful to illustrate a point.

Some patients might want a more detailed explanation. Where I’m based, for example, we sit between two universities and treat a lot of lecturers and students who may be interested in research. For them I talk about this amazing study which suggests some joints are able to adapt even in the middle of a multi-day ultra-marathon event! This helps to challenge the view that a joint is simple hinge that get’s ‘wear and tear’ and instead shows it’s an amazing, living tissue that constantly tries to adapt to the stresses placed upon it.

Goldilocks theory

A barrier to our idea that exercise is helpful is that, for many with patellofemoral pain, exercise hurts! The challenge is trying to find the right type of exercise at the right volume, intensity and frequency. Like Goldilocks’ stolen porridge we want exercise that’s not too hot, or too cold, but just right. Ideally we can achieve this without having to burgle bears!

In more scientific terms we don’t want to underload the tissues and create deconditioning, or overload the tissues and cause lasting symptom aggravation. We want to find the right level to improve load tolerance and reduce pain. It’s important to use the patient’s own experience as examples with this to help make it relevant to them. For example, if a runner tells you they can run 3 miles but 4 causes lasting irritation we can suggest that 3 sits at the right level but more might be overloading the tissues a little at the moment. In time we can build up to 4 (and beyond potentially) but we would start at around 3 miles and progress from there. This links in nicely with recent recommendations from the excellent work of Barton et al. (2015) who highlight that activity modification is a key component of managing patellofemoral pain.

Normalise pain

It’s unlikely for many for patellofemoral pain that their rehab is going to be completely painfree. We usually need to load sensitive tissue in order to help it to strengthen and adapt so it’s likely, at times, that this may hurt. We need to be clear that this pain isn’t creating damage and it’s a normal part of the process. A pain monitoring system can be a useful way to ensure that we aren’t creating lasting tissue irritation;

We also want to try to keep exercise as comfortable as we can for the patient. Pain can be a significant barrier to adherence to rehab (Jack et al. 2010) and may cause a level of quads inhibition (Rice and McNair 2010).

Message received?

Image source

Providing the right explanation is, in a way, only half of the process. We also need to see if the patient understands the message and is happy to apply it. A good question to ask is, “how would you explain your knee to a friend?” Or, “can you explain back to me what you’ll take from today’s session?”

Psycosocial factors like stress, anxiety or depression may influence how someone interprets your explanation and whether it provides sufficient ressurance for them. Fear is a very powerful emotion and not one that can always be talked away,

“I must say a word about fear. It is life’s only true opponent. Only fear can defeat life. It is a clever, treacherous adversary, how well I know. It has no decency, respects no law or convention, shows no mercy. It goes for your weakest spot, which it finds with unerring ease. It begins in your mind, always.” Life of Pi, Yann Martel

On the flip side, low levels of fear and positive perception of return to sport are associated with a greater likelihood of returning to pre-injury level (Ardern et al. 2013). Hopefully our explanation fosters a positive perception of return to activity as something that strengthens our bodies rather than damages it!

We should consider the impact of mental health on rehab and seek appropriate help for those need it. It can also be very helpful to try to assess the patient’s outlook towards they pain. A Pain Catastrophizing Scale can be a good way of doing this and might help us prioritise our treatment more towards education in those with an especially negative view of their pain.

Building ‘resilience’

A careful consideration of the key messages delivered in the right way can be a very powerful part of our treatment process and empower the patients to make informed decisions about their rehab. Considering the impact of mental health and providing a comprehensive rehab programme can help a patient with patellofemoral pain build both physical and psychological resilience. There are no recipes though! This will always need to be taylored to the individual and their specific goals.

Tom Goom is a Running Specialist and Clinical Lead at the Physio Rooms in Brighton. His website, running-physio.com has become a popular source of evidence-based information for runners and clinicians and he teaches around the UK on his Running Repairs Course. You can follow Tom on Twitter via @TomGoom.