What if there is one thing in your body that is silently working against you whenever you try to get rid of knee pain?
And as long as this one part is holding you back, not even the very best exercises and treatments may work.
Research has identified this problem as a “barrier to recovery”[1] that has a “strong correlation with pain and function”[2]. They also found that it’s one of the reasons for a person not returning to their pre-injury activity level.[3] And that removing this problem was the “strongest predictor” of rehab success.[4]
Let’s see if this applies to you and if so, what you can do about it.
What Is It?
If you look through the research on knee pain, you’ll of course come across strengthening exercises, stretches, or trials that examined adjunct treatments such as hyaluronic acid or shockwave therapy.
What I didn’t except though, were papers on the connection between a person’s beliefs about pain and their odds of rehab success.
We know that people react differently to pain. Some have an exceptionally high pain tolerance and can just push through, others, like me, will be more, shall we say, careful with their reaction to pain.
When it comes to rehab success, it’s not pain tolerance that matters but your beliefs about pain and how those beliefs change your behavior. This can start with something as innocent as pain avoidance.
Pain Avoidance
Pain is a signal the body uses to tell us that something is wrong. Maybe you sprained your ankle, got stung by a bee, or cut yourself preparing dinner. The response usually is to rest the injured body part until it has healed to the point where it can be loaded again.
But what if you’re dealing with a chronic injury and you’ve somehow convinced yourself that every time you feel pain, you’re making it worse by causing more damage in the joint?
This belief, combined with the pain, can cause fear of movement, or kinesiophobia, and this fear of movement has been linked to
– altered gait[5]
– higher pain levels[6]
– reduced function[7]
– reduced physical activity[8]
– lower quality of life[9]
The irony is that fear of movement due to pain can lead to a self-reinforcing cycle by reducing strength, function, and load tolerance, which eventually leads to more pain.
You can see how a person may get stuck in this loop. It hurts, so they do less and then it hurts more because the body has gotten weaker. It’s another example for why complete rest is rarely a good idea.
We’ll cover what you can do about kinesiophobia in a moment, but first I need to introduce to you to its ugly sibling: pain catastrophizing.
Pain Catastrophizing
Dealing with knee pain can be a super frustrating process. Imagine having pain, getting examined, paying $1,000 or more for an MRI, only to be sent home with no certain diagnosis or worse, something like “the structures in your knee look age-appropriate.”
In a situation like that, with pain that has lasted for a while, it’s easy to understand that a person may not be in the best of spirits. What you have to be very careful with though, is hyper-focusing on the pain and letting your current situation influence your thinking about the future.
That’s when you can slip into pain catastrophizing. Its three components are rumination, magnification, and helplessness. Here’s how to check for them.
Rumination is present if you constantly think about the pain and can’t seem to get it out of your mind. You may keep thinking about how much it hurts and how badly you want the pain to stop. You may also be anxious to find a solution that makes the pain go away.
The key features of magnification are fear that the pain may get worse, thinking about other painful experiences, and wondering whether something much more serious may happen.
Finally, the worst of the three, helplessness. This is about feeling overwhelmed, like you can’t go on, thinking that there’s nothing you can do, and that the problem will never get better.
Oof.
You can see how the combination of pain avoidance and pain catastrophizing can stir up a perfect storm to make knee pain last ages. A person with all those thoughts swirling around in their head may even give up without a fight.
Here’s an example from my life to show how this may play out.
About three months ago, I did some exercises and heard a noise in my knee you never want to hear during training. *SNAP*
A few days later I noticed significant swelling around my kneecap. One visit to an orthopedist and an MRI later I found out that I had a grade IV lesion in the posterior horn of my medial meniscus.
In days that followed, I found myself thinking about the injury all around the clock from the moment I woke up in the morning to when I went to bed. I started digging into research about these types of meniscus tears, which is where I was confronted with all sorts of bad news.
The papers said symptoms may last up to 6 months, maybe even a year, and that in those that have it, risk of osteoarthritis of the knee increases significantly. These thoughts got stuck on repeat in my head and I already saw myself cancelling the family vacation we had planned for the following month and instead getting surgery.
So basically, I ticked a lot of those boxes. I avoided movement for fear of causing longer rehab time, I thought about the injury constantly, I was afraid that it would get much worse, and given that the meniscus is a structure with little to no self-healing capacity, I didn’t see anything I could do to make it better.
That’s a dangerous place to be in mentally. Here are six solutions you can use to get out.
Six Solutions
Solution #1 is to get help. This may seem obvious, but you’d be surprised how many people try to find all the answers on their own. So go talk to your doctor and get physical therapy if necessary. Beyond this, get support from your friends and family or look online to get in touch with other people that have dealt with your problem.
When I went back to my orthopedist and told him about my concerns, he calmly explained to me that while he loved performing surgeries, I had no clinical symptoms indicating a need for one and that with a few weeks of taking it easy, the knee would likely be okay.
This 10-minute conversation made me feel infinitely better and optimistic about the future.
Next up, try to learn as much as you can about the injury. The less it is veiled in mystery, the less intimidating it will be. For example, research has repeatedly proven that just because an MRI shows a pathology, doesn’t mean it will cause pain.[10]
Plus, if there is pain, it rarely means you’re causing tissue damage unless you’re loading the joint explosively or doing other high load movements. In contrast, walking and slow training with adequate resistance are safe forms of exercise in almost all situations.
Aside from learning about the injury you also have to foster a positive outlook.
If you find it difficult to get rid of negative thoughts, realize that just because your brain presents you with a thought, doesn’t mean you have to accept it as true. For example, in optical illusions the brain the brain will tell you outright lies that are difficult to expose even if you know the truth.
One way to disarm negative thoughts is to put them into the same category as optical illusions: They’re not the truth, but mistakes made by the brain.
The truth is that the human body is crazy resilient and bounce back from all sorts of injuries and illnesses. So have faith in your body’s ability to heal. Yes, your current situation may suck, but it will get better.
Also, it’s probably not the first time in your life something bad has happened to you, but guess what? You’re still here. And just like you managed to get through those bad situations in the past, you’re going to get through this as well.
To make this happen, you have to take control of your situation in whatever shape or form you can. Don’t be passive. Stop telling yourself “There is nothing I can do” and instead focus your attention on finding answers to the problems you’re facing. A wise man once said, “Your focus determines your reality” and it’s true. If you focus on the problems, they will appear bigger. If you focus on finding answers, you will find those too.
Also, just because life is pushing you into a certain direction, doesn’t mean you can’t push back.
If you get frustrated during this process, instead of giving up, divert your attention away from the problem for a while. Distract yourself. Watch a new show, read a book, hang out with friends, do whatever you can to shift your focus away from the problem. Find a way to have some fun. Your body will relax, which as it turns out is much better for healing than being stressed and upset.
Finally, the last and probably most effective solution is to move in whatever way you can. If you can’t yet jump, find a way to enjoy sports without jumping. If you can’t yet run, walk, or cycle. It doesn’t matter if you walk slowly, as long as you move. Don’t focus on what you CANNOT do but find things you can do. This will also help you gain more confidence in your body.
I used those exact methods to deal with my little meniscus issue. Here’s what happened. Three weeks after my last talk with the doctor I was already playing beach volleyball again, albeit without jumping and without explosive movements. So pretty much just standing around and gentle walking. But it was still fun!
Another 4 weeks later and I was back to light jumping and easy running. Here are some shots of my 8-year-old son and I playing against my dad and my uncle. Think about this.
In March I was stressing myself out by worrying about surgery and arthritis. Fast forward two months and I’m back on the court playing almost normally again. In fact, this whole thing may help me become an even better player by forcing me to focus on technique instead mostly relying on athleticism.
Now of course your story is different but based on everything I know I’m convinced that once you find the right strengthening approach for your situation, you will get better and if you haven’t found it yet, you have to keep looking.
The alternative is giving up and that’s really no alternative at all.
Footnotes
[1] Maclachlan et al. 2017, p. 732
[2] Selhorst et al. 2021, p. 1268
[3] Slagers et al. 2021, p. 148
[4] Piva, SR et al. 2009
[5] de Oliveira Silva, Danilo et al. 2019
[6] Piva, SR et al. 2009, Selhorst et al. 2020, p. 24
[7] Piva, SR et al. 2009
[8] Bäck et al. 2020
[9] Luque-Suarez et al. 2019
[10] Khan et al. 2003, Draper et al. 2009, p. 574, Pappas et al. 2016, p. 486, King et al. 2019, p. 71, Khoury et al. 2021, p. 25, Malmgaard‐Clausen et al. 2021, p. 837
Bibliography
Bäck, Maria; Caldenius, Victoria; Svensson, Leif; Lundberg, Mari (2020): Perceptions of Kinesiophobia in Relation to Physical Activity and Exercise After Myocardial Infarction: A Qualitative Study. In Physical Therapy 100 (12), pp. 2110–2119. DOI: 10.1093/ptj/pzaa159.
de Oliveira Silva, Danilo; Barton, Christian John; Briani, Ronaldo Valdir; Taborda, Bianca; Ferreira, Amanda Schenatto; Pazzinatto, Marcella Ferraz; Azevedo, Fábio Mícolis de (2019): Kinesiophobia, but not strength is associated with altered movement in women with patellofemoral pain. In Gait & Posture 68 (2016), pp. 1–5. DOI: 10.1016/j.gaitpost.2018.10.033.
Draper, Christine E.; Besier, Thor F.; Santos, Juan M.; Jennings, Fabio; Fredericson, Michael; Gold, Garry E. et al. (2009): Using real-time MRI to quantify altered joint kinematics in subjects with patellofemoral pain and to evaluate the effects of a patellar brace or sleeve on joint motion. In J. Orthop. Res. 27 (5), pp. 571–577. DOI: 10.1002/jor.20790.
Khan, K. M.; Forster, B. B.; Robinson, J.; Cheong, Y.; Louis, L.; Maclean, L.; Taunton, J. E. (2003): Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. In British Journal of Sports Medicine 37 (2), pp. 149–153.
Khoury, Miguel A.; Chamari, Karim; Tabben, Montassar; Alkhelaifi, Khalid; Ricardo, Trueba; Damián, Couto; D’hooghe, Pieter (2021): Expanded adipose derived mesenchymal stromal cells are effective in treating chronic insertional patellar tendinopathy: clinical and MRI evaluations of a pilot study. In J EXP ORTOP 8 (1), p. 18. DOI: 10.1186/s40634-021-00358-7.
King, Dominic; Yakubek, George; Chughtai, Morad; Khlopas, Anton; Saluan, Paul; Mont, Michael A.; Genin, Jason (2019): Quadriceps tendinopathy: a review—part 1: epidemiology and diagnosis. In Ann. Transl. Med 7 (4), p. 71. DOI: 10.21037/atm.2019.01.58.
Luque-Suarez, Alejandro; Martinez-Calderon, Javier; Falla, Deborah (2019): Role of kinesiophobia on pain, disability and quality of life in people suffering from chronic musculoskeletal pain: a systematic review. In Br J Sports Med 53 (9), pp. 554–559. DOI: 10.1136/bjsports-2017-098673.
Maclachlan, Liam R.; Collins, Natalie J.; Matthews, Mark L.G.; Hodges, Paul W.; Vicenzino, Bill (2017): The psychological features of patellofemoral pain: a systematic review. In Br J Sports Med 51 (9), pp. 732–742. DOI: 10.1136/bjsports-2016-096705.
Malmgaard‐Clausen, Nikolaj M.; Tran, Peter; Svensson, Rene B.; Hansen, Philip; Nybing, Janus D.; Magnusson, Stig Peter; Kjær, Michael (2021): Magnetic Resonance T 2 * Is Increased in Patients With Early‐Stage Achilles and Patellar Tendinopathy. In Magnetic Resonance Imaging 54 (3), pp. 832–839. DOI: 10.1002/jmri.27600.
Pappas, George P.; Vogelsong, Melissa A.; Staroswiecki, Ernesto; Gold, Garry E.; Safran, Marc R. (2016): Magnetic Resonance Imaging of Asymptomatic Knees in Collegiate Basketball Players: The Effect of One Season of Play. In Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 26 (6), pp. 483–489. DOI: 10.1097/JSM.0000000000000283.
Piva, SR; Fitzgerald, G. K.; Wisniewski, S.; Delitto, A. (2009): Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome. In J Rehabil Med 41 (8), pp. 604–612. DOI: 10.2340/16501977-0372.
Selhorst, Mitchell; Fernandez-Fernandez, Alicia; Schmitt, Laura; Hoehn, Jessica (2021): Effect of a Psychologically Informed Intervention to Treat Adolescents With Patellofemoral Pain: A Randomized Controlled Trial. In Archives of Physical Medicine and Rehabilitation 102 (7), pp. 1267–1273. DOI: 10.1016/j.apmr.2021.03.016.
Selhorst, Mitchell; Hoehn, Jessica; Degenhart, Todd; Schmitt, Laura; Fernandez-Fernandez, Alicia (2020): Psychologically-informed video reduces maladaptive beliefs in adolescents with patellofemoral pain. In Physical Therapy in Sport 41 (2018), pp. 23–28. DOI: 10.1016/j.ptsp.2019.10.009.
Slagers, Anton J.; van Veen, Esther; Zwerver, Johannes; Geertzen, Jan H.B.; Reininga, Inge H.F.; van den Akker-Scheek, Inge (2021): Psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy: a cross-sectional study. In Physical Therapy in Sport 50, pp. 145–152. DOI: 10.1016/j.ptsp.2021.04.010.
