Captain Scott, pilot, athlete, all around good reader, asked about knee pain when the kneecap (patella) "slides to the outside due to tightness in the tendons and muscles on the outside of the knee." His physician recommended surgery to cut the tight area. Is this needed?

Poor tracking is not a disease or a syndrome, or that you are doomed to arthritis. Usually it is a simple injury process that can be stopped. Tracking problems are often given several names: Lateral Facet Syndrome, Chondromalacia, Anterior Patello-Femoral Pain Syndrome, Lateral Pressure Syndrome, Malalignment Syndrome, Maltracking Syndrome, Patello-femoral Degenerative Arthritis, and other scary names. Not all of these are due to poor tracking. Calling something tracking when it is not often leads to much time trying tracking "cures" when you need other things.

Instead of surgery, you can stretch the tight side areas and retrain the weak ones, so the kneecap slides normally instead of grinding sideways in its channel. Stopping causes stops need for surgery, or even bracing and pain pills. The knees heal and you go back to all you want to do, using the new healthy mechanics.

What can you do when pain continues after physical retraining? Captain Scott wrote that he had been to physical therapy for his knees "for a few months without much success." He had previously endured ongoing treatments for back pain, then discovered Fitness Fixer methods and resolved the pain. He came back to see if he could do the same for his knees.

Kneecap tracking should begin normalizing within days of stopping causes - far sooner than "a few months." If not, one obvious thing to check is if you have the right re-tracking stretches, exercises, and functional retraining. After that, here are four common reasons when PT does not "work."

  1. Tracking Exercises That Don't Fix Tracking. A common PT scenario is doing 10 (or however many) repetitions of straightening the knee against resistance of a stretchy band, called "terminal extensions," "setting" exercises such as squeezing things between the knees, stretching the lateral (side structures), and small leg lifts with ankle weights to strengthen inner thigh muscles (VMO)s. Without retraining gait and knee use during real life movement, the person often gets up from the PT session and walks away and goes back to their activities with the same poor tracking. PT needs to look at and fix specific use during real life activity - do you turn your knee inward or your feet outward, do you let your foot flatten, do you let your upper leg bone rotate, do you walk with your feet turned outward (duckfooted) or inward (pigeon toe). Weight or resistance used is often far less than what the knee encounters when the person stands up and uses their knees to walk away from their exercise session. Tracking angles should monitored during rehab. Not just during standing or during leg lifts, but during the patient's customary activities. If they are not changing, and they are the confirmed cause, then you may not be changing tracking.

  2. Are You Sure It's a Tracking Problem. Knees can hurt for other reasons. Not all patello-femoral pain is from tracking. You can go for the best re-tracking programs, but if your knee does not have an actual tracking problem, it is no mystery when tracking exercises do not help. You have not spent time fixing the cause. Make sure that tracking is the reason before treating for tracking. Tracking can be identified with specific patellar x-rays or other scans that can clearly include position during several points of motion. Tracking also can be visualized - look at kneecap path during quadriceps use during several kinds of movement. The kneecap slides up and down obviously under the skin at the knee during use. There is a variable degree of normal angle at the knee. Human legs are not straight from upper to lower leg. That angle at the knee allows us to walk upright on two legs in a smooth gait. The angled knee is one of many markers that tell forensic scientists and anatomists if the leg bones they are looking at are human. Sometimes a normally tilted kneecap slide is misidentified as a tracking problem when it is a normal angle in line with the joint.

  3. Multiple Causes. Sometimes tracking mal-alignment is confirmed and rehab done. The patella tracks normally and stops wearing the area, but pain continues from other causes. No mystery. Check for other poor knee mechanics that cause injury. Check if your shoes are too hard. Many people paying for "good supportive shoes" get knee pain from the hard shoe. Often the pain from bad shoes is sharply outlined around the kneecap with deeper aching. Check your bending. If you have pain with knee bending (squatting), fix that. Check your stretches. Some twist the knee joint, such as lotus and hero poses in yoga, hurdler's stretch and others. Stretches should stretch muscles, not cartilage in joints. Fitness Fixer articles summarize and my books detail more.

  4. Medicines that Cause Pain. Whether you have tracking problems or not, common prescription medicines cause pain that does not respond to PT. Look into stopping reasons you need the medicines in the first place, and save yourself time, money and pain.

My idea of health care is a quick, straightforward assessment of causes and intelligently addressing them. That beats having someone stick a knife in your knee and charging you for it.

Related Knee Fitness Fixer:

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Books To Fix Knee Pain:

  • Fix Your Pain Without Drugs or Surgery
  • Health&Fitness in Plain English THIRD edition - How to Be Healthy, Happy, and Fit for the Rest of Your Life. Both available from www.DrBookspan.com/books.