#34: Patello-femoral pain syndrome with Professor Bill Vicenzino

[Music] Welcome to the Shoulder Physio podcast, a podcast dedicated to exploring meaningful topics in Musculoskeletal healthcare. I'm your host, Jared Powell. Before we begin, the primary purpose of this podcast is to educate and inform. The views expressed in this podcast by myself and any guests are information only. Do not constitute professional advice and that general in nature. If you act on the basis of any podcast episode, you should obtain specific advice from a qualified health professional before proceeding. Today's guest is Bill Vichenzino. Bill is a professor of physiotherapy at the University of Queensland. Bill has had a spectacular research and clinical career in physiotherapy and remains a world leader in several Musculoskeletal conditions, including the topic of today, Patel FMRal Pain. Patel FMRal Pain is a common condition of the knee affecting both adolescents and adults. However, there is still some uncertainty about how this condition comes about and how best to treat it. Thus, I've invited the master himself to come on the show and school us on the interesting clinical presentation, that is Patel FMRal Pain. Without any further delay, I bring to you my conversation with Bill Vichenzino. Bill, Vichenzino, welcome to the show, mate. Oh, well done. Thank you very much. Pronunciation, good. We're always off to a good start when you get my surname right. Well done. Thank you very much. I'm a home work. I'm a home work. Bill, I'm like others. Thanks for inviting me on for a chat over this interesting condition. Hopefully there's something for the audience in it for them. And yeah, thanks very much for that. It's a very interesting topic. I think we've had this chat offline. They were both kind of pretty excited about having a bit of a naturopher. We both got experiences from treating people with it. Let's go. Yeah, so the condition of interest is Patel FMRal Pain. But before we get into it, Bill, who are you, mate? For all the three people that don't know who you are, who are you? And what do you do, Bill? I'm an old physiotherapy professor who's about to retire. So entering my 65th year. So I graduated as a physio at the University of Queensland in 1980. A lot of you weren't born then. And over the next 10 years, I worked in private practice, bit in hospital, mainly in private practice and did my sports and musculoskeletal postgraduate degrees at Curtin and Perth, which was a very, very good experience when I'd recommend to other people. That was about 10 years of that. We had two children over there and had a practice. And then we decided to come back with FMRal and Brisbane where I worked some locoms. And then, yeah, I started off as a clinical tutor down in the clinic at UQ, seeing patients, teaching students, did some lectures. And before long, I was, well, it's to me in Curtin, what did my appetite for research? And then Tony Wright, who became my supervisor and Gwen Jell, we're really keen to progress the HDs and research. And so I always want to, one of their PhD students, Tony Wright's PhD student, did that while I worked. And then I basically promoted through the ranks in 2000. I got my PhD not long after that. I had a rapid promotion, because I was very lucky. And fortunate that I could win grants successfully, one of the grants that I got was an individual grant of telepharynx, footerfossis, which we'll talk about. And I've got interest in tennis elbow and or lateral epicondylulgia. But 10 in octogenery, there's a lot of my papers in that area. I would have never dreamed. I was talking to students that started up with the Master's program the other day. We were talking about where we're going to, where we've come from. And I reflected that I would never have dreamed I was in that position in that classroom, talking to my last class for semester, as a professor of physiotherapy, having had such wonderful collaborations with many, many of our leading experts in our field. So yeah, my message to anyone is, is, yeah, have you five, 10 year plan, but it can go many, many places you wouldn't dream of. So I'm rambling on a bit. I'm sorry about that. So I find myself now as a professor of Swartz Physiotherapy at the University of Queensland. I'm a director of the Master's Physiotherapy program. And I have PhD students research programs, et cetera, et cetera, which you'd expect for an academic. Not unfortunately last decade or so, less and less clinical contact as other administrative duties take over. I just get to old and I need a bit more sleep. Yeah, relatable, mate. No, if I can speak for a lot of people when I say that, you know, we've all come through reading your work and congratulations on the career that you've had Bill. You've been a wonderful contributor to the profession. So I'll have a drink on behalf of you. What is it? First day today, tomorrow night, Bill, I can't drink till Friday. I'll have a little sip of beer tomorrow night in, in toast to, to your marvelous career, mate. Oh, thank you very much. Thank you very much. Yes. It is, it is a, it has been a privilege and it's also a great learning experience at work with a lot of physiotherapists, physiotherapy students and graduates. So all very bright people. Yeah, I've probably learned more than I've taught. So yeah, thanks. That's how you want to be, yet. You always want to be in a room where you're not the smartest person, I think. So you've always got something to learn. I'm not saying you're not the smartest person in the room. No, no, no, no, no, I know exactly what. Well, some of the people I've collaborated with, I've just got the smartest person that's good. That's the point. But the voice learning and yeah, and it doesn't matter how smart you are, I think reflection and learnings are a lot more than being smart. And anyway, that's probably another podcast we're going to swacks on and everyone can go to sleep. Let's get to the point here. So the point is you're the number three expert according to expert scope on patellar femoral pain and you're the number two expert according to expert scope on tennis elbow, lateral epicondalalgia, whatever you want to call it. And you've got a H index of a ridiculous 93, which is absurd, really, to be nearing the triple figures. So I'm congratulations made again. Yeah, I don't follow my H index or a lot of that stuff. But so thanks for that. I haven't looked that up for ages. I haven't had to put in for a promotion document or anything. We don't need that shit. And you forgot to mention in tendon opathy, I think I'm number three. I was number one for tennis elbow, but Luke heels up at up the coast there near you. He's taking that mental off me. We collaborate a lot. So I don't know how he sneaked to head. The good thing to the good thing probably for your audience is that the number one and two in patellar femoral pain, microathlete for thanks number one, we we collaborate. It's still collaborate quite a lot about on this condition. And I think Christian, probably the other person up there, he's also someone we collaborate with. So I've kind of got an insight into their mind. So hopefully we can we can give some hopefully it's top level. It will be. It will be. Don't worry. So on patellar femoral pain, let's let's go right to the start in terms of diagnostic label. What do we call this thing? Is it patellar femoral pain? Is it anterior knee pain kneecap pain? Patellar femoral pain syndrome? What do we call the thing? Is syndrome a banished word these days? What's the what's the preferred label? What is in a name, eh? When I graduated, it was a condromylation patellar, but we've pretty much moved away from that because you couldn't visualize, well, condromylation patellar just fent away of saying soft cartilage at the patellar. We moved away from that saying, well, if you don't visualize it, you can't say that we almost come full circle and recognize that probably the sub-condral bone is anything out of the patellar going to be sensitive. It's going to be underneath the cartilage surface and for it to be provoked, it probably needs to have softening of the cartilage. But we call it, I think quite fairly patellar femoral pain. I mean, if you've done a scope and you've poked the cartilage in it, softened, you can see the fishering while you're probably okay to call it condromylation patellar. That's a surgical thing, but telepharmal pain syndrome, we use syndrome for a long time because I don't know, maybe it just makes it sound like a medical term and important, but I'm not never too sure why we call it a syndrome or why we call a lot of things syndrome. So we elected to call it patellar femoral pain. That's a consensus type thing. It takes away any ambiguity, you know, diagnostically. There's nothing fancy about it. It's pain at the anterior part of your knee. Around the kneecap, it's provoked by things that load your patellar femoral joints. So squatting steers up and down, sustained sitting, may in later stages. But essentially, it's activities that load the patellar femoral joint and this pain, that pain is that anterior knee joint. Now, you need to have some, you need to be a bit careful on examining to make sure that it's, you know, that it's not the patellar tendon, the fat ad and, and you know, you've got to mirror it. Other things down at the patellar tendon at the tubular osteo as well. So you need to differentiate the diagnosis. You need to knock out those things that are probably more obvious. So acute injuries, it's generally, we consider it as a non-acute injury, you know, an overused type injury. So there's no acute inciting event. So you rule out ligamentous instability, meniscal issues, if you came clinically, and I guess meniscal issues come with a different presentation. I like to think of it just dipping back at it. So that's the telephone pain, the consensus statement is pain around there, kneecap, loading the patella formal joint, creates the pain, and you've excluded it, you've excluded other potential sources for knee pain. That's kind of how we'd go about it. I like to think of it as a, um, probably a knee extensor disorder, and so there's a myriad of those. And when you come to managing them, they probably not manage that much differently. There's some nuances, but you pick them up on testing patient's ability to manage that extensor mechanism so of the knee. So anyway, digressing a bit, but we'll probably come back to that to treatment, but yeah, patella formal pain, pretty simple clinical diagnosis. There's none of the things that have been, you know, the special tests that have come about the grinding and the, have you even forgot the name of it now, but um, Clark Clark's test. Yeah, Clark's test. Yes, that's it. Yeah, those are, those are non-helpful at all. People have studied their capacity. Barric too, Bill, do that. Yeah. Yeah. Well, Danny, you know, damn right, hit in the face, and I fully backed them in to do that. And if you wanted to overdog dose the condition, because that's the condition you can treat well, go ahead. I saw a, um, I just, just on sort of clinical test there. I saw it just in preparing. I left on my homework, pretty late, Bill. I had a look at Michael Rathsless, Rathsless work today, and he's got this nice little modified single leg squat for 45 seconds that you hold in 60 degrees knee flexion. And if you get pain within that in 45 seconds, it's a pretty good diagnostic test for anterior knee pain, not so much telephemeral pain specifically. So really easy to sort of do in clinic. Yeah. His population, he did a great voice PhD. He just, um, got a group of students, adolescents, quite a few, and follow them. And so because it was done by distance, couldn't examine all of them, some of them got examined when they got into your knee pain. But yeah, they referred to anterior knee pain into this group. It can be a number of different things that are that are going on there. But telephemeral pain, when they did the diagnostics on subgroups, telephemeral pain seems to be the one that's most common in that. Yeah. It's a really great way of provoking the extensive mechanism. And yes, that test, I think they use that more as an outcome measure. Like to see whether you've improved, but it does. Yeah. And it does, it does differentiate well. I think you found between people with them without anterior knee pain. But it's just a, for me, it just seems a lot more real world test versus compressing someone's battella in soupine and saying, does that hurt? Because why would I write now? Well, when they taught it in undergraduate, because we did it way back then, everyone's knee cap hurt. And there's one people who are gone. Oh, I don't have the telephemeral pain or con-revalation patellar. Yeah, back then. Yeah. Yeah, the specificity must be written out on that. Anyway, so telephemeral pain, we're happy with that. Critical testing. There's a bunch of things we can do, but it's mainly affected by a squat or any load to the patellar femoral joint. What about pathophysiology? Actually, before we get into patellar fears, Bill, I want to talk about natural course of the condition or natural history of the condition. If we were to leave someone who comes in with patellar femoral pain and we just say, just don't worry about it. Continue on doing what you want to do. Do, do, avoid things that hurt, do things that feel good. Will they get better in time or will they, will they suffer with pain for years? Yeah, it's unfortunate on a nice natural history. There's a number of studies, some old ones and some more recent ones that you can expect one in four people that have had this pain as an adolescent to have significant problems. A lot more have ongoing issues that they can manage, but significant problems in about 25% of people. So it's probably not fair for the GP or the Physio or any healthcare practitioner to say it's self-limiting. It can come as part of this growing pain scenario in a young child, but it's probably not wise to say it's naturally going to resolve by itself because there's a high probability it won't. So something needs to be done about. We do know that the longer you've had it, the more severe it is. The prognostic factors, poor prognostic factors that it's going to be around for a lot longer and it's going to be a lot more severe than those that haven't had a severe pain for shorter durations. Yeah. Hey guys, Jared here. I'm stealing you away from the pod for exactly 30 seconds. I want to inform you about my online course on shoulder pain. It is a comprehensive 16-hour course that is broken up into digestible chunks that you can complete at your own pace. You also have access to the course forever, all for as long as the internet exists. Thousands of clinicians have graduated from the course from 50 unique countries around the world. If you want more info, check out the show notes, all my website, shoulderphysio.com and I'll see you in the lectures. Yeah, the troubling study that I am aware of was that if you're an adolescent and if your diagnosed with patellar femoral pain is a strong chance, you're still going to have pain two years later. As you mentioned, as you alluded to, the strong chance they're going to have pain one in four people into their 40s as well. That's a really troubling conversation to have with a teenager. Yes, well, it's something that you want to navigate pretty carefully because unfortunately there are a lot of things that we can get onto knee extension as an exercise later on, but there are a lot of things that are propagated by general population and I'll tell you an experience I had in a gym in a Wanakau New Zealand late last year, but there's a lot propagated. So you've got to be careful how you bring that up. I'd recommend bringing up in light of this is something that, learning how to manage this is going to be very good for you in the long term because it's going to be that kind of an adventure for people that have this rather than talking about cures or not cures. Yeah, we do know when we get to treatment that there are some good treatments over three months, I can get quite good success rates in that shortish midterm. Yeah, you're far from each other, femoral pain, I've had it as well. I've had it on and off for 15 years and it afflicts me for six weeks. Back things off, stops squatting, do some of this, some of that, stop running, do more bike, and then six weeks later, I'm usually better again. So whilst it may be recurrent in nature, it doesn't seem to be getting worse to me each episode seems to pass without too much fuss and so you can manage it. It's one of the classic, it's a bit like tendons in middle age, this boom bus type thing, we're all busy and so you get excised in when you can and then you don't, and then all of a sudden you have time and you learn to moderate it, you learn to identify so you don't really hurt yourself badly and then you go again. Yeah, so what's underpinning it all Bill? What's causing the pain? What are the mechanisms that play? Is it a classic, no-susceptive type of pain? Is there a no-sie plastic element? Is there something structural that we need to be aware of? Are there psychological factors that roll in terms of moderating outcomes or perpetuating the course of the condition? Where are we at? Do we know? Do we not know? Tell me, mate, tell me you're the oracle, you're the sage. It's a easy answer, easy question to answer, yes, to all we've got. To all we've got. Yeah, okay, so no-sieceptively there are some very pain sensitive structures. Scott died, brought his brother to orthopedic surgeons, got his brother to probe with anaesthetic through an arthroscope. Robies need no pain at all at the patellar surface, maybe a little bit of sensation on the femoral condyle, sonovium, yeah, that's starting to get discomfort, but the fat pad, yeah, he was swearing, he was saying apparently there's a video of it at a conference that I got told about there where he was quite unhappy about being probed there. So locally there are tissues around the patellar femoral joint. And don't forget, we talk about the patellar, but the femoral surface, the femoral condyle is not uncommonly the one that's got degenerative or osteothermic changes in it. And so the tissues around the sonovium and the fat pad tend to be the ones that get sensitized. Yeah, and then the subcontrial bone, which they didn't probe, but we do know through imaging that you do get that bone bruising, you get that hyper-signal in that area, which denotes that there's increased activity, likely increased brochure and no-sieceptive stimulates. So there are reasons why you can have, there are no-sieceptive reasons, there are pain-sensitive structures that could be signaling a lot pain. Probably if I look back and look at all the literature and there's been, and we're doing a scoping review on this, we're looking at all the qualitative data as well, I'd say I'm going to go way to the other side of things and the social context, which not surprisingly because we're looking at adolescent to the early adulthood, the social context comes up a lot when we start asking people about this problem, this condition and how to fix them from having to care for others and they've got the problem so they can't do exercises and they can't bend or go up and downstairs to the child that wants to be part of the peer group and do the sport and can't keep up and things like that. That comes up so many times that I think, so we talk about psycho-social but I think we should be talking so-show psycho, the social aspects of it are something that comes up time and time again to these. qualitative interviews or these focus groups that you read about in the papers and the ones we've done ourselves. So you've got local, no-sceptive drivers for sure. And we know almost all these conditions are brought on by a bout of overload. But why so long? Well, we've got to look at the social context within which they exist, which is not uncommon for a lot of other conditions like back pain. You know, we're all thinking like that now. In terms of pain mechanisms, you know, we do have some studies that show there's local sensitization mechanically and some that show there are remote and so therefore widespread sensitization. But that's not uniform. I mean, we've done some studies where we were unable to find it when we blinded the examiner, we were unable to actually find remote sensitization. So I'm wary of saying that it's, you know, that central nervous system processing has gone awry as a statement for telephimal pain patients. So I, and a lot more work needs to be done on that. We did a consensus statement where I think the, the research has decided more research needs to be done on that. We're not too sure what it means clinically. So patients didn't think much of it at all. Actually, they didn't, they didn't, the patients we interviewed you or did they do surveys. They didn't think much of that. They are more interested in clinically things like pain self efficacy from their memory can is if over, you know, those kind of psychological construct that we are becoming more aware of in in musculoskeletal conditions that tend to be perpetuated. Like the quick answer would have been for me to say, oh, we don't know and I don't give you a long answer said that we might know some little insights for some patients, but I don't think anyone could stand up and say we know exactly why this problem exists. Well, why it exists may not be as difficult in the first little while, maybe six months of the year, but as it progresses out, it's more complicated. So yeah, that's, that's my impression to the social stuff that you mentioned is, is fascinating. That seemed to be important and that seems to be the best thing or the, the thing that we seem to neglect the most in healthcare, which is, which is something that I've found that the context, the environment, the social aspects and the psychological all of it. Let's say psychosocial or sociosocial sociological it's, yeah, I know it's fashionable to say that it's important and I sort of I feel like I'm making a bit of a meme out of myself when I do say it, but it does seem to come up every single time you dig into the literature. And I fully grant that there's probably a nosy septic process going on there certainly initially, but it may be it turns into a nosy plastic type condition when there's some aberrant firing of of no seeception even in the absence of any structural damage, but there's got to be some sort of psychological social moderating role there. Yeah, yeah, yeah, that has to be, yeah, we did a lot better than I did in an shorter time. Yes, I don't think you're too far off the off the point there. I think a lot more work needs to be done to understand fully and when it comes to management, you know, you look at the local, but you really do have to consider, like when you prescribe exercise, you need to know the context. I mean, when we were looking at a, a futures workshop where we had some patients in the room that were mums had kids and we had vignettes, which they talked about and we gave some of the vignettes, you know, child and they had to work and they had to look after the house and does not have two jobs, etc, etc. It comes up that well, when do you do exercises and etc, etc. How do you still have to run around up and down the stairs in the house and etc. etc. So even if we're dealing with the local muscle and whatever you want to do locally, you do have to consider the rest of it because it's not an isolation, isolation at all. And invariably you'll probably give these people exercises. If you're aiming to do a decent job, like I said, it's an extensive mechanism, just mechanism disorder, the extension mechanism will not be good. It'll be, it'll be a need of some work exercise or do that. Well, you need to structure a program so that people can do it. So when and where and how. Yeah, it speaks to exercise burden and that's another big big interest that I have where we have this preconceived bias to think that sort of more is better and we just there's this dose response relationship between all right, if I just give you 10 exercises, you'll get stronger, quick and you'll get better quicker. Kind of not as simple as that. Look, we're getting to treatment in a minute. I'm going to I'm going to shelve that for just for one second because we're going to get side track bill, but I want to try and anchor us to these talking points because they're very, very important that I pick your brain on every single topic. Pathophysiology. So I want to talk about the old school, I'm saying this in inverted commas, old school, lateral tracking of the patella, the weak VMO, the tight ITB. And stuff. What I say old school, this was still current and in vogue when I graduated 13 years ago, which is a while ago, but it's not, you know, it's not the 1980s bill like someone else here. So where are we at with lateral tracking of the patella, is it a plausible pathophysiological mechanism of injury or has it completely been thrown in the bin. Where we are. Okay, where are we at? So probably for the audience in British and sports, and 2017, Chris powers and a group from the patella, federal international consensus group, look together over a number of retreats, a flow chart on the pathobymechanical aspects of this condition. Now, almost all the literature is cross sectional. So very little of this is longitude and so we don't know whether it's causative or just something that's there anyway. And the other thing is that, in joined in that is that we don't quite have that last link between elevated patella formal joint loading, which could be due due to increased telepharmus joint reaction force and or decreased patella formal joint contact area. Those two things seem to be at play with patella for all pain when you look at cross sectional studies that elevator patella formal joint loading in the cartage and bone stress that goes with that. But then the leap to pain is is a leap. It's like because we've done cross sectional studies, you know, we can say they're different on that elevator patella formal joint loading. We go down deeper into the patella formal joint loading that's the decrease patella formal joint contact area, Chris put together what's kind of a nice way of looking at it. So the contact areas where you think about those things like in a male tracking due to muscle imbalance, excessive rotations of the femur and tibia, you know, red, macular tightness or looseness, you know, abnormal patella formal joint and enemies, shallow grooves, etc. They may lead to male tracking or male alignment, but in any event, it's possible they lead to, you know, a reduced contact area compared to those that don't have patella formal pain. Then if you go to react joint reaction force as well. In adults, there seems to be some differences in hip kinematics. I don't follow this research, but they do. There is a spec review that says there are some foot changes that are different in those patella formal pain than not. And then you got reaction forces measured through kinematics studies and all those in for increased patella formal joint reaction forces. And so, you know, it's kind of, if you look at the model, he's got this kind of nicely laid out the biggest and we had, we had quite an argument over this. The biggest contentious issue is at the top. It's an arrow to patella formal pain. And I argue it should not be that it's kind of like should be this elevated patella formal joint loading is different in these people and these people, which, which is different to saying it. It links to patella formal pain to, yeah. So, I mean, around about way, I, it's, it's, it's not impossible. It is impossible to measure muscle imbalance in the clinic. You know, you can't feel it. The MG like in a lab measuring in the lab, you need to have really high skills, do it properly and to pick it up. So, you know, you can see a lot of the issues. Well, we're not talking of unstable joints. We're not talking about a dislocating patella, which is a different thing. We're talking about people got patella formal pain, the stable joints. You know, being able to quantify that the patella is out of place, whether it's tight on one side or not. You know, if anyone, yeah, you just couldn't give credence that it's plausible that they would be reliable and valid markers clinically. If it does exist, we can't measure it. So, I tend to sit on the fence, you know, I mean, if you had a measure that you knew, who'd measure it even in a laboratory and you could show that it was causative. And that's one thing you've got the measure that can do that, but I'm not convinced we got the measure to do it. So, we can't say that it doesn't happen, because we don't have the measure that's valid enough to show that it might happen. So, it's probably not wise to think of it as maltraking malalignment. And the interesting thing is when we talk to patients of the telephone pain, we asked them to we had a. a draft for Mark Matthews study, a draft advice brochure and ask them to give us feedback on it. We had such nocy-sebic information on that like, you know, we talked about male tracking, we talked about increased pressures and that. And the patients just said, "Oh, do you really think so?" We stepped back and go, "Oh shit, we didn't have that written in there." We'd basically just take it to the best of everyone else's, right? As a draft, to where do you go? You look at whatever else's published and you say, "Well, we'll fashion this up into this two-sided A4 fold up brochure that we're going to give everyone." That's a bit of education so they know about their condition. So, yeah, you need to be a bit careful about how you present this material to people because they hook on, yeah, we want to hook onto something. We want to hook onto, you know, we want to hook onto, you know, this little part of my body is not right. And so we need to fix that because that gives you a focus that gives you some, yeah, some focus, some reason. And that's okay if you can validly say that, but if you don't, if you can't validly say it, then you're giving someone some really false ideas, which there is no solution. So you've already set them up to fail. So very cautious about after my experiences and focus groups and and in my own experience of my, taking my daughter's off to a specialist and myself, very careful about how you say stuff to people and therefore, yeah. So, do we know that it's there or not? It's very hard to say whether it's there or not, maltraking that is, lateral deviation. And maybe we shouldn't say that. We shouldn't accept it as a fact. Yeah, more work to be done, a lot more work by the hands of it. So it does seem to afflict, but other femoral phoenix, afflicts females more than males. So it's not beyond the realms of possibility to think that there is some anatomical underpinning, you know, the cue angle of females is famously greater than in males, which might lead to some sort of issue at the Patelophemeral joint. So I think it's plausible to think that there may be some sort of Patelophemeral force type issue that's underpinning the development of pain. But as you said, we don't, we don't, they're all speculative, right? It's all conjectural knowledge at this point. We don't have anything to say whether it is definitively this that's causing the pain or is causing the pain. Yeah, you're raised a good point. I mean, I think back to my early days in clinic in the mid 80s and there's a different, different phenotype. There's a definite like it's generally females, generally adolescent. It generally comes with the knock knees or the flat feet. It's a perception in my brain that's very kind of unsolidated because that was my experience. And I don't think it's an unusual experience. I think the issue becomes when we then take that phenotype and then try to make some theories about why they're manifesting pain. I think that is where we run into strife in the business. It's okay to say you've got that phenotype. So I'm going to predict you might have this kind of presentation pain wise. And that might help us now, you know, making some hypotheses when you first see the person start asking some questions. But we've got to be a bit careful not to jump, you know, to wanting to correct them as the sole way in which we're going to address this before, you know, doing further examination and being careful about going down a slippery slope. Do you have any theories bill of why females are more afflicted? No. And as you mentioned this, I should have looked up some of the research somewhere in the back of my mind. I think females tend to be weaker at the hips than males. But correcting that doesn't correlate with correcting the patellar ferroplane from memory. Don't quote me on that. No, I don't have a theory why it's more on females and males. It's just an observation. Maybe it is because of the the alignment issue, you know, the low limb and pelvis. One thing, oh, wonder though, there is this thing though, generally speaking, women like in the 80s, even, women were not and young girls were not, were not given the same, they weren't, they weren't as active physically and that, you know, come to menstruation and that and development. They kind of withdrew a lot more and didn't keep on active participation as a group, you know, there was some that did. But and so I wonder whether, you know, now with the equal opportunity or increasing opportunity to stay active and be active and be strong and and all that stuff and and being less of a gender bias in that. I wonder if it's, I wonder if that in the end shows us something, you know, decades to come, whether things get worse or better due to just physical conditioning and exposure at graduated levels as you're growing and developing. So I that's an interesting question I hadn't really given that much thought I should have. But it's an observation and it's held up in the literature that women, especially females that listen to more prone to this. You recruit for studies and it's easily you're going to get higher proportions of females or women in in in your cohort. Yeah, it's I think it's four to one in terms of the the prevalence, which is which is high, you know, well, we're both hyperchalifabral patients, like it doesn't affect males as well. But it is interesting and it's something to think about in terms of what is there, underpinning that that development of the telephone role. It's interesting because I I've got a clear memory in my mind of a couple of families I treated early on in my clinic. I don't know why, but I can remember the mother sitting there, the child that I was consulting there and and the other younger child over there. And the mother's gone, she's got my problem and I don't want her to have it. The mother's around 40. She's got the knock knees, that I've got the doctor, and she's starting to get it. What can we do about it? And you know, she goes, the interesting thing was this example that I remember is at that stage, I was giving everyone footerthoses if they even hinted like they're pronating and I got the pediatrist down the road to make them because at that stage, I wasn't doing them myself. And you know, these people would get better. We can talk about some of the procedures we used to get to that decision of using them. But these patients have come back and bring up and you know, they check up. Yeah, we're going good. It's better, a lot less plane, etc. Then one day we'll get a phone call, the mother's panicking, just seeing the surgeon and the surgeon just told them it's all bullshit. They're not better. And they're world crashes around them and yet they'd been up to that point, feeling a lot better. And the surgeon says it's not to do with that. And then they get shaken. So it's kind of like it's mum, child, child, I went off the trail a bit. But basically, it's almost like that social context. You have a young female patient in front of you. Maybe it's a good idea to ask if the mother isn't there. Maybe it is a good idea to ask mum about her and her mother. And to just get a sense of the thinking in that little bubble, that family grouping of what they make of this, how much of an imposter is it on life, what can't they do? Parents want to help their kids. So mum felt like you don't do those running up and down hills. You back off and do something else. Well, you know, she's going to sport the child and not doing it as well. Because and so the context, I think that's why I meant that's one of the things I've meant about context before. It probably do need to understand in the young female more of the family context in terms of the lineage, the family history. Generational, Patel FM, real pain. Yeah, well, I don't know if you had it, but used to be a pretty common thing in our practice at Mannington Perth. Yeah, yeah, right. There you go. Let's go. Something just come to me, Bill, and just tell me if you don't want to speak to this, but Crepitas. So lots of people come in, they're really worried about the Crepitas, the sound that their their knee makes when they flex and extend it or whatever and they're often terrified by my knees, make a lot of noises when I squat, I'm sure yours do. Bill, the problem, maybe they don't, I've seen what your squat mate, you're a machine, but what do we say about Crepitas? Do we just say don't worry about it? I think Claire, Claire Patella on Twitter has done a lot of work or X has done a lot of work on this. What do we say about Crepitas? We're all Claire Patella. She's got a real name. But it's going to add conferences and I thought it's Claire Patella. Well, she's in she's like Madonna, she's in Stantia just into her handle. Yep, yep, yep. Yeah, I look, I think if you've got someone in front of you that's an older person, then yeah, they've got evidence that they might have osteoarthritis. That's one kind of Crepitas, and that's for those that haven't felt a joint that is like Crepitas, like bumping over a gravel road kind of Crepitas, you could feel it, you could hear it. The Patellar Firmal pain ones are really like that. They're generally cracks and stuff out of a joint and you get a bit of, you know, point of range, you go through a point of range and it does that. I've never ever thought that was a major issue. I know I've worked with some colleagues that make a big deal about that, but you know, that's the antecedent to Articular Cartridge, the generation. There's no evidence of that, no evidence of all that, and I think I think Natalie Collins did a, I think some study that we did, she did a second analysis presented at a conference and I'd have to look it up. But I think this some work done which essentially shows that it really is not predictive of severity or anything. So I wouldn't get the creptosis is interesting. But I would differentiate it like there's real prepidus where you get the clunking in the gravel road, bumpy, corrugation type thing and you can hear it, you can feel it as opposed to the patellar final pain ones, even my knee and probably yours, you get my snaps more than it kind of snaps cracks and then couple of rips and it's all good to go and no sequily afterwards. I wouldn't recommend people get that worried about that. I'd be more worried that you aren't able to develop good force generation in your quadriceps muscle. I mean if it's impeding your ability to generate good force well then maybe I'd be concerned about it then. So how relevant is it to the things that are important to keep the knee healthy? Well said mate, well said even though I caught you off guard well done. So let's go Bill, I knew we'd wander off track here mate but we're going to talk about treatment here. So every single clinical practice guideline that you read on Patella Phenrols pain it says do hip and knee strengthening exercises. So that's usually gluteal exercises at the hip and quadricep strengthening exercises at the knee. Do we address both? Do we address one or the other? Is the knee more important? Is the hip more important? Or neither? Do we just sit around and foam roll the ITB? What's the value of strengthening exercises these days? I'm going to I'm going to address a little bit. I turn up to a Michael Rathliffe had some award for getting some experts together in a room and Copenhagen a few years ago. I was luckily to be invited and I was introduced to this fellow that said here the the largest RCT my Patella Phenrol pain and again that's interesting so you've got more more than 218 subjects in your group. You guys will know I've kind of got many I get okay good so I still have the long of the largest RCT in the world but you know I say that just because I do stuff like that but basically his study was to look at quads versus hamstrings and to his credit it is the biggest study that's done that and there's no difference no no difference and you can't predict who's going to benefit from either doing hips or quadricep so same same result and that's kind of come out in the literature that you can exercise either raw which which I guess brings us to the question so are you going to do both are you going to do one so my approach to that is you do get some people that are really pain averse and sensitized either sensitized to pain averse anyway they don't like the idea of really waking a lot of weight through their knee so in those instances why not really get the butt going abduction abduction external rotation particularly extension really work them hard to get them you know comfortable with heavy load well it's relative to them and then gradually build in some knee work and you could start as easy as isometric with most people as long as you get a point in range which isn't painful you can load up in on a knee extension machine or a wall squat or whatever and then gradually you know start to get them in tisatonics and higher loads so how could you decide if they're too sensitive at the knee perhaps go to the to the hip otherwise there's no real guidance I think I do believe I have a feeling that it is a knee extensive disorder I teach my students for the last five to ten years when I teach knees teach well when I leave the sessions the learning sessions activities for the knee I urge them to think of it as a knee extensive disorder it is going to be painful and inhibited so how can we load this knee extensive so that we can get maximum force generation and eventually you know the endurance of power whatever's needed for the activity that I want to do well without pissing the patient off essentially bring him along in the journey and so yeah Chris power to do a nice little biomechanical analysis study in physical therapy or just general for the general for the physical therapy where he shows that you know if you load the knee on a knee extensive machine up to about 40 degrees you're less likely to generate joint reaction forces which are provocative in terms of just the load and if you do your squats down to about 60 degrees so really small squats with heavy loads you're unlikely to to bring I think that's the right way right you're unlikely to bring the the kneecap into much loading that creates pain that is painful so you can load people that's a nice little biomechanical modeling study he did and he bases it a bit on some of his FMRI studies he did on a couple of cases so it's a nice little research to work like I've just said then I hope I've got that the right way around I would look at a patient's ability to extend the knee if it's painful in certain ranges I would just limit their one's extension exercise around those ranges you'll still and if need be if that range is quite substantial isometrics generally are quite well tolerated and if not well go to the hip so stepping back a bit the exercise you're doing yes it's for the patellar phrom pain condition but ideally I would think you've asked the patient what is it that this kneecap pain this knee problem is preventing you from doing or really compromising what you're wanting to do and then focus on what that sport of that sport that activity is it may well just be you know they've got to walk a lot of stairs work or they've got to squat a lot at work or whatever it is break that down and then exercise the muscles which are you need to build conditioning in to get them to the stage where they can do those activities with a lot in reserve so therefore you know they can do those activities before they really load the joint excessively so what is it that you want to do with these patients and we do know that either all is going to be beneficial in the groups so you've got you got ability to play around with that and justifiably say to the patient that this has been shown to work yeah exactly there's there's quantitative evidence that this this is an effective intervention although we don't know how and why so so before before we go there let me just let me just step back a bit I know you're keen to ask about that so we won't forget that we did a network met her and also as well I'm on the ortho group Maris Winters is the lead author and he's the mathematical whiz on it Bayesian statistics and you know Smoky Mirrors and all that stuff but basically education comes up so you take all the studies as a systematic review and then you compare them and essentially education comes up yeah better than doing nothing exercise a bit better than education education a foot of thoses a bit better than exercise or educational alone if you then start adding in you know patella stuff you get a better result but if you do everything education exercise patella taping and foot of thoses you'll get the best effect over three months we couldn't find enough data out to 12 months and the data we did find nothing really is any better than than what would be a natural history or wait and see so everything we know works well it's quantifiable at three months outcomes so after that it's not as good it may well be and so before I go away from that we'll probably come back to the foot of thoses afterwards so we'll go on to where you wanted to go Jared sorry just on strengthening so hip exercises work knee exercises work both in isolation and together how do they work Bill do are they getting you stronger and is that a valid mediator of recovery so they do get you stronger so if we look at Mark Matthews Fox study where he did 220 or something something like that did I mention was the largest study down in patella phrompaine physical therapy sorry I'm going to leave that in an capital letters bill so basically his study looked at hip exercises which were given in a clinic three days a week for four weeks four six weeks four weeks and thing was by a therapist to meet it out they all rubber band exercise are really strong exercise we all as authors and viscated tried a session and it was categorically hard work with doms later on so it was kind of like and I'm familiar with the claims in there oh no no that real like we didn't use police we use rubber bands because we wanted to easily get it out to a lot of clinics to use and we wanted to use them in Denmark and in in in in a in our ball Denmark and brism Australia so we had two two things so basically one group did that another group got given our thoses and the group they got a thoses got some foot exercises as well so we had hip exercises were versus a foot intervention and we showed that there's really no difference between those two that study of marks was trying to see whether or not those that got better in the foot of thoses compared to the hip exercise was that because they had something in their foot that was different and we had some ability measures in there some postural measures in there and no we didn't we could not find any foot measures that would predict Those are got better. most improvement with footer foces. So the next thing was, that was our primary aim, but we always had in mind, we've got this like 100 a lot people doing exercise. You know, can we predict who benefits from exercise? Was we've taken, you know, a range of measures at the beginning, we take isometric abduction, abduction, abduction, external rotation on us, also on fixed handheld ion of monitors. So we did good structural measurement, abduction, abduction, external rotation on the hip, at baseline, and we did that at six weeks as well. We also talk, because we know nowadays, we're getting a lot more aware of psychological factors. We ask them the anxiety, anxiety, and depression scales, pain catastrophizing scale and temposcale of canary zephyria. Now, the one thing we didn't do, which I really think was a mistake, but we had a shitload of measures, and we had to go with something, with pain self-efficacy, but we'll park that for now, because in tendon opether, we find in gluteal tendinopathy, pain self-efficacy is probably one of the mediators, one of the mechanisms for which education next size might work. So to develop the story a bit more, so Shunade Holden did the analysis for us on Marx data set. So she was independent, and we're wanting to know whether those, any changes in strength with exercise compared to a focease, any changes in strength, or any changes in psychological characteristics, that mediated, that were responsible for the differences we saw between hip exercises and foot-of-focies. And we looked at cuse, and we looked at, as an outcome, we looked at cuse and pain-free squat. So we picked really specific patellopheral pain activities. These were not the primary outcomes from our fox trial. Our fox trial, our primary outcome, was a global rating of change. In other words, are you better, same or worse, which I believe is probably the best outcome. That's a story for another podcast. Anyway, for this study, we measured the telephemeral specific, a physical test, pain-free squat and the cuse, the telephemeral scale and the cuse. So we found that the exercises actually did improve the strength. We also found that hip abduction, our induction was improved with the foot-of-focies as well. So the isometric strength improved for both groups. External rotation, though, was a little bit better, significantly so, in the hip exercise group. So the hip exercise group was a little bit stronger. And then, from memory, I just pulled it up, and so I did open it up, because I never can remember these things. On the treatment effect, external rotation and anxiety were better with the exercises, done on why anxiety was better. But none of the other measures we took, differentiate were better on hip exercises versus foot-of-focies. So that's one of the first things you want to see in a mediation analysis that your mediator is different between treatments. So we got rotation. So then we also do another part of the study, which then shows that any of these changes that occurred due to these treatments. So now looking at the effect, does that make any difference on the outcomes on, not the effects at three months, but the outcomes at three months. And basically, pain catastrophizing, tempered, a tap of scale, were the two only ones that were kind of, were the only two outcomes that were different from baseline to the end. So it's probably a complicated way to come to what the mediation analysis is. And in essence, we really were unable to show that those strength changes, all those psychological changes. None of those were responsible for mediating. In other words, they're not the mechanism by which we observed improvement in these patients or differences between the groups in these patients. So we have a bit of a conundrum we do. We can improve. We can improve. So you give someone hip exercises, the ones we gave and a footer-thosis, if you say in this person we can do both simultaneously, we know that external rotation will be stronger at six weeks and three months. We know that's going to happen. But that increase in strength is not, well, what we've shown is not responsible for the changes in CUSP and being able to do more sit-to-stands or squats or whatever, a step-ups or whatever I said it was before, as the outcome measure, pain-free squats. Yeah. So we're at a bit of a quandary, and that's where I come back to the pain self-efficacy because pain self-efficacy is a bit different to anxiety, it's a bit different to catastrophization and canesia phobia. It's more about being able to do more, being more efficacious in the face of pain. So being able to get on with things, pain self-efficacy scale. Whereas, you know, canesia phobias more about with drawing from it or care with it, catastrophize and make more of it than what it is, and anxiety's just, you know, not knowing what the shit's happening and being anxiously about it. So basically, maybe would have been nice at pain self-efficacy. Like I said, and I'm not too sure there's that much difference between a lot of these muscular, skeletal conditions that are overuse in nature, these grumbly long-term ones. We did show pain self-efficacy as one mediator or hip strengthening and education in, in a glutesal tendinopthitrile. So, yeah, I guess you can tell a patient, we know these things will end up being better than doing nothing or just education and nothing, but we're not quite sure why this happens. And I'm not too sure a patient needs to know that, but I think the clinician needs to be, when they reflect on it, think carefully about what has changed. And yeah, we don't know currently is my answer, which is a bit of a null response, but it's better than what we had before when we didn't know. - Well, exactly, that's just the current state of play, Bill, and it's not just at Patelophameraport, pain, it's every muscular skeletal condition. We really don't know how and why exercise works. Well, there's one, Aiden Cashin down at Sydney Uni, did a mediation analysis on their low back pain intervention sensory motor training, and they found that I think it was back pain beliefs mediated almost the entire effect of this sensory motor training intervention for low back pain. So, physical biomechanical variables, such as strength, kinematics, all these kinds of things are rarely shown to be mediators of recovery. And it's an interesting thing because two things, the study I talked about before in Denmark, they also did some mediation analysis and weren't able to show strength mediated improvements. But also, we're starting to find out, there's a study recently that show that you don't need to, is this foster arthritis? As long as you don't even have to adhere to them, as long as you do some exercise, it doesn't matter the volume, the intensity, it's just as long as you do some. And so, you know, I wonder about pain self efficacy, because I think that's definitely an at tendon opathy trial. We did a lot of education trying to explain to people what the condition is. We had an MRI that showed it was a tendon opathy, so that's anxiety relieving already. So you kind of got a diagnosis, and they told us when we reviewed, when we did some follow-up qualitative stuff, they told us that was a really good thing, even if they got a weight in C group, they felt at least they got a diagnosis, and they could be reassured on that. So you reassure them, nothing's really wrong. You then teach them ways in which they can move with less pain, and they often tend to frequently feel less pain frequently. And so that's the other mediator that we found in that study, is pain frequency, it seemed to be a mediator, and also the ability, the patients, specific function score, those three things were the mediators. So the ability, I read that, is if we've reassured them, it's okay to move, and they've been able to do more PSFS, and so hopefully C went up, and they had less frequent pain. And our education's about that. Our education, all these is, look, you need to keep moving. We know musculoskeletal tissues, you don't move your rest, and you're going to deteriorate. That's just a given. So you need to keep moving. Now we also know that if you really flog yourself, you're gonna get boom bus cycles, and it's painful, and you don't, then you don't like to do the exercise. So just be sensible about it. Right, realize what things hurt you. Just get a walk around them, like we give them tips. So if you tell a federal pain, you, in the education, you give them the tips, okay, they'll probably tell you, it hurts when I go for hikes up and downhill. It's okay, let's get you walking on, on flats. Let's increase your speed on flats. Now let's just try gentler slopes, and let's just do it within your capacity and gradually spread it out. So patients will generally give you the insights you need to meet around where along the load spectrum you need to set them off for those things. And, you know, I do wonder whether it's all about less frequent pain, and then being able to do, will be efficacious, do more, or do the same, or do more with less pain, or do the same with less pain, that kind of thing. They're moving in pain. I wonder whether that's what we're doing. I love it Bill, education, manipulating load. It's sort of all what it's about, isn't it? And yeah. At all times, trying to empower and promote optimism and movement is going to be good for you. We just have to find the right dose and the right type and not sort of getting into that hole. It hurts when you never, never scoff below 90 degrees again or never bloody sit with your legs for us or never, you know, all these things which we sort of, we can say, you forget that you say in a concert or that that creaky need that you've got is not good, you know, just get away from all that crap and empower the person. I have, can I tell you a story? I don't want to drag this out, but I was in that in one occur last year, I went for 10 days or so and I found a gym that 24, seven hour gym and like I end up going almost every day or every other day and this is gentleman there who's, I can't remember his age, well into his 70s, if not 80s, big tall, strapping guy. And I've noticed him and I said get a do it because he is really whacking at his, doing the hit and he's doing all the weights like this, though tomorrow I'm going, good on you, but I don't want to be like you when I grow up. And I'm sitting down, ripping out some quads like I've just done some squats, I've gone over to the quad extension machine. I'm really, no grunting trying to force our eight sets, each individually comes over to me and goes, oh mate, you shouldn't be doing that. You're going to really, that really stuffs up your cartilage and that I'm going. So then I started talking to him, he's an all black, he's one of the famous all blacks from my back and you know, he's had reconstruction surgery and total knee and all kinds of stuff. And you know, he said, oh the surgeon, that's obviously their God surgeon for rugby over in Q, he said you'll never do that. And I'm going, oh mate, that's not true. I mean, my knee's never been better and I've loaded like, or, but Jesus, and so it's quite interesting like you've got an EO would imagine, you know, he's an elderly gentleman, everyone knew him right in the gym, everyone say good item, I've chat to him. So he's you know, he's going around telling people in that gym, how back off that son. And so this, this issue I think is, and there's your social context, you know, we really do need to think carefully how we relate these things, especially when we don't have the evidence for it. It'd be a different thing if we had evidence for it, but I don't think we do or we don't. Yeah, agree. So in that case, you are on the side of optimism, bro. I think so. I think so. And be sensible, right? If you're finding like it's really hurting and it hurts the next day, well, you've just done too much. Yeah, work around it. So for international listeners, and all Black is someone who's played for the New Zealand Rugby Union team, which is actually the greatest sporting team of all time in terms of winning percentage, which is phenomenal. And anyway, so those guys are heroes over in New Zealand as they should be. Who doesn't know? Who doesn't know the all Blacks? Surely it's iconic here exactly, but just, you know, you got to include everyone, Bill. Yes, I'm sorry. I've taken enough of your time, Bill. Thank you so much, mate. Thank you for today. And also thank you for your years of service. I think you've got to still stay active in the research sphere. Is that right for a bit? Yes, I stopped turning up for classes in the middle of the year. Then after that, I've got some great collaborations in research and PhD students that I'd like to still keep active with because I'm not that old, but old enough to hand over the teaching and stuff to younger's. Yes, I'm still going to be, you're not going to get rid of me. I'm still going to be around for a few years. God willing. Yes. Nonetheless, I'm still going to raise a glass for you tomorrow, mate. Thanks. Thanks very much for your time, Bill. Can we find you on Twitter? Where are you active? Oh, yeah, I'm, yeah. Twitter, I, when I get busy at teaching, not so much, but at Bill, I'm school, which is, you know, I think, we just got to make sure you spell which and Zena right, it doesn't come up. And I'm on Instagram. I like Instagram, which is your pictures. And I guess I tend to be the, look at the pictures in the paper rather than read. So Instagram's one, which I'm probably more on. I'll probably dare say, be more on Twitter once I hang up the duster and chalk. Look forward to it, Bill. Thanks for your time, mate. You're welcome, mate. Thank you for listening to this episode of the Shoulder Physio podcast with Bill Vichensino. If you want more information about today's episode, check out our show notes at www.shoulderphisio.com. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio podcast would like to acknowledge that this episode was recorded from the lands of the terrible land people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning and working from every day. I pay my respects to elders past, present and emerging and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.