Recently, I've been asked a few times about Patellofemoral Pain Syndrome (PFPS) as well as a few clients walk into my office with complaints of knee pain so I thought I'd put together some information to try to clarify some of the issues related to this common ailment.

A quick Google search of 'Patellofemoral Pain Syndrome' provides you with almost 350,000 results and after this post, you'll be able to add another one to that list.  Try many of the other iterations like PFPS, patellofemoral pain, patellofemoral syndrome, runner's knee, chondromalacia patella, movie-goers knee, etc. and you'll come up with thousands more.  So what does this all mean?  Well it means there is a ton of information (and misinformation) about one of, if not, the most common knee injuries to plague athletes, weekend warriors, office workers, young, old...just about anyone.

The first goal is to define what it is.  The simple version is pain around and/or behind the kneecap (patella) as it articulates or touches the femur.  That sounds pretty straightforward but it can present itself in a variety of ways which is why you will find so many definitions/results with a Google search and among healthcare practitioners.  It is also part of the reason why it has been given the vague designation of a 'syndrome'.  The truth of the matter is nobody knows exactly what causes it or what is happening at the patellofemoral joint when PFPS shows up to the party.  All we know is that the end result is pain.  Since there is no consensus on what is actually happening, that makes finding a solution more challenging than say a broken bone or muscle strain.  Add other knee injuries that can be confused with PFPS like iliotibial band syndrome (ITBS, yet another syndrome and another post), patellar tendonitis and bursitis and one can see how a 'simple' definition can become a complicated issue to diagnose and resolve.

Though quite varied from person to person, there are some hallmark symptoms, however, that can help narrow down the differential diagnosis.  These commonly include, but are not limited to, pain with squatting, ascending/descending stairs, running and prolonged sitting.  Sometimes joint effusion or swelling will be present but again, this is quite variable also.  Granted, these are common complaints among other knee injuries as well so PFPS often becomes a diagnosis of exclusion due to signs, tests and subjective complaints that can help distinguish between issues like meniscus pathology, tendonitis, bursitis, ITBS, etc.

Now this is where physical therapists make the 'big bucks' (I can dream, right?).  It is nice to have someone walk into my office with cookie cutter complaints so that the solution is easy but honestly, that situation doesn't happen very often.  Instead, I am able to use my training and knowledge in anatomy, kinesiology and biomechanics, muscle physiology, neuroscience and psychology to assess the incredibly dynamic system that is the human body and brain to formulate a conclusion as to why someone is experiencing pain, in this case patellofemoral pain.  Through careful observation, specific tests and measures, and most importantly, listening to my clients, I can deduce the driving factors of someone's patellofemoral pain and customize a plan to resolve his/her pain and limitations.  Quite often, there are multiple factors involved and it is my job to determine the best way to address them and sequence the plan to get my clients back to moving better, feeling better and living better.

Stay tuned for my next post to learn about some of the ways patellofemoral pain syndrome can be resolved.

Knowledge = Power; Share the Power:

Recently, I saw a picture of my friend's dog, Sammy, in a ridiculous position (one of many at this point) and my first reaction was to laugh as usual and shake my head.  I'm pretty sure we've all seen something like this at one time or another.  Immediately my next reaction was "How is that comfortable?"  As you can see above, most of the time he is lounging on big fluffy pillows but it still looks like an awkward position.  But then it got me thinking, maybe it isn't so awkward after all.  Maybe this kind of variety is a good thing to do.  Clearly it doesn't seem to faze him as he's good to go after he gets up and stretches it out a little bit just like every other dog you've ever seen.  Maybe we can learn something here.  Granted, humans are not dogs and dogs are not humans (even though we treat them like that sometimes).  However, we are made of the same stuff like bone, muscle, nerves, ligaments, etc. so maybe it isn't such a bad comparison in this instance.

How many times are you told some position or posture is bad for you?  Doctors, physical therapists, chiropractors, yogis, the internet are constantly telling you what you should and shouldn't do.  There are obviously some basic guidelines that are worth practicing but they may not have to be so strict.  I will be the first to say that I am guilty of saying something similar to my clients over the years but more recently I've added a caveat and I think Sammy does a great job of illustrating my caveat.  It goes something like this: "Just don't do it 100% of the time."  None of Sammy's positions are the same so he is most definitely not doing the same thing 100% of the time.

In general, consistency, repetition and overuse are what tend to get people in trouble more than a specific position or posture itself.  They end up sitting the same, standing the same, laying on the same side to watch television often for prolonged periods of time.  As you can see above, Sammy doesn't subscribe to doing the same thing over and over again.  He's living the dream of variety in his life (at least in sleeping positions).  Maybe all of these different positions stimulate his nervous system (his brain) and the tissues of his body since nothing is ever the same.  Maybe it is important to take advantage of the full range of motion of each joint at some point during the day.  Maybe it is important to stretch muscles in a variety of positions throughout the day.  The living body, dog or human, is extremely adaptable and can handle all kinds of positions and postures.  Think break dancers and Cirque du Soleil performers.  They can do all types of "crazy" and "awkward" things with their bodies and they make it out alive just fine.  Just don't do the same thing 100% of the time.  Chances are your body welcomes the change and variety and will be better in the long run.

So don't beat yourself up if you find yourself in a "bad" position on a super soft sofa that was really comfortable.  Don't beat yourself up if you find yourself slouching as I just was until writing this sentence.  Just don't do it 100% of the time and you will be ok.  When you do catch yourself doing something all of the time, take some advice from Sammy: Change things up and add some variety to your life...or napping position at the very least.  Your body will thank you for it.

If you read Parts I, II, and III, this topic got into some heavy material which is important to be aware of but there is also some good news out there which was touched upon in each post.  That good news can really be summarized in one word: MOVE.  Something I find myself sharing with my clients is a very simple analogy I wish I could take credit for but Sir Isaac Newton beat me to it with his first law of motion: A body at rest stays at rest and a body in motion stays in motion.  Granted he was talking about physical objects but it is amazing how much this relates to the dynamic organisms human beings are and their overall health, well being and mobility.  And based on the current body of research, if you move more, you tend to live longer.  That is pretty darn good news!

Avoiding sitting for prolonged periods of time and/or adding movement into your daily routine can be accomplished in any number of ways.  You are truly only limited by your imagination.  It could be simple things like taking 1-2 minute walking breaks each hour at work, taking the stairs instead of the elevator/escalator, parking farther from your destination, etc.  Each of these ideas often seems trivial in isolation but it is amazing what happens cumulatively over weeks, months and years, and they can become normal routines you don't even have to actively think to do.  (Your car will probably have less dings in it too from car doors and grocery carts...you're welcome.)

The more challenging change is actually engaging in more sustained activities instead of sitting because that involves time and we all know time is precious.  However, if you take an honest look at your schedule you can probably find at least 30 minutes during the day to engage in some type of activity.  You may have to tweak your schedule and routines a bit at first but again, sticking with good habits becomes a new routine.  Instead of passively watching television, actively watch your favorite shows by incorporating some simple bodyweight exercises (pushups, squats, lunges, etc.), stretching or matwork style routines (Pilates), or if you really want to get your heart rate up, shadowboxing (one of my favorites).  Or better yet, trade an hour of television altogether for an activity you like to do.

The easiest thing you can do and a great starting point is highlighted in this short video which addresses a few different things but relates very well to this topic.

The moral of this story is not to cause a panic or to suggest strict rules to live by because that would be unnecessarily extreme.  Instead it is meant to be food for thought so that you can take advantage of this information and incorporate it into your life as you see fit.  You know your schedule, you know your life and how you want to live it.  Hopefully this information can help you optimize the ways in which you live your life so that you can be a happy, healthy and mobile person for a long time coming.

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In this latest installment, I will summarize a couple of studies that address sitting time and associated health risks.  You can catch up on Parts I & II if you missed those the first time around here and here.

At this point there is a growing body of literature studying different outcomes, disease progressions and chronic conditions as they relate to sitting and they all have the same conclusions.  Prolonged sitting essentially has a dose response outcome: the more sitting you do, the more likely you are to suffer from chronic health issues and a shortened life span.  In many studies, these results are independent of other factors like diet and activity level which is even more concerning.  Even if you get your 5 mile run in everyday but you sit for 8 hours, it turns out there is still an increased risk for chronic health issues.  That being said, things like diet, exercise and sleep have profoundly positive effects in other ways so be sure to keep those good habits in your life.

Wilmot et al performed an analysis and summary of 18 moderate to high quality studies in 2012 all related to sedentary lifestyle and risk of diabetes, cardiovascular disease, and cardiovascular and all-cause mortality. (1)  In order to avoid discrepancies in analysis because of differing methods in each study, they compared highest sedentary times to lowest.  It is possible that this could skew their results by using the extremes but even taking that into consideration their results are striking:
112% increased risk of type II diabetes
147% increased risk of cardiovascular disease
90% increased risk of death by cardiovascular disease
49% increased risk of all-cause mortality

In 2010, Alpa et al looked at leisure time spent sitting and all-cause mortality rate. (2)  They compared sitting more than 6 hours vs. sitting less than 3 hours during leisure time and did not include occupational sitting time over the course of 14 years for over 120,000 people participating in the study.  Independent of physical activity women who sat for more than 6 hours had a 40% higher death rate than those who sat for less than 3 hours and men had an almost 20% higher death rate.  When combining sitting time with low physical activity, those numbers jump to 94% and 48% respectively!  Now you can imagine what happens if you add sitting time at work to these leisure numbers.  Conversely, those that sat less than 3 hours for leisure and were physically active had lower death rates.

I could continue to highlight other studies like the amount of time watching television and cardiovascular disease or the risk of obesity and prolonged sitting but I think it is quite clear already what the overall conclusion is.  Whether someone has to sit for work or chooses to sit for many hours during his/her leisure time (or both), that alone is a risk factor for his/her health and well being.

By pure coincidence, I came across an infographic basically addressing the same issues.  It is a bit sensationalized but even so it sheds some light on this important issue.  You can check it out here.

Wishing you many more healthy years before Mr. Reaper knocks on your door!  Then again, you may have some knocking on your door with much more reasonable requests of tricks or treats in the near future!

References:

1. E. G. Wilmot, C. L. Edwardson, F. A. Achana, M. J. Davies, T. Gorely, L. J. Gray, K. Khunti, T. Yates, S. J. H. Biddle. Sedentary time in adults and the association with diabetes, cardiovascular disease and death: systematic review and meta-analysis. Diabetologia. November 2012, Volume 55, Issue 11, pp 2895-2905.

2. Alpa V. Patel, Leslie Bernstein, Anusila Deka, Heather Spencer Feigelson, Peter T. Campbell, Susan M. Gapstur, Graham A. Colditz, Michael J. Thun. Leisure Time Spent Sitting in Relation to Total Mortality in a Prospective Cohort of US Adults. American Journal of Epidemiology. Volume 172, Issue 4, pp. 419-429.

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In the second installment of my sitting series, I will touch upon metabolic issues but if you missed Part I, you can catch up and read that here.

It is not rocket science to understand that your metabolism is directly related to your energy expenditure.  The more active you are, the higher your metabolism is to meet your energy needs.  Therefore the opposite is also true: the less active you are, the lower your metabolism is to meet your energy needs.  In our modern society, we have traded active lives out of necessity for sedentary lives by way of convenience.  Many of these conveniences involve sitting.  You sit in your car to do your errands, you take in information and entertainment when you sit to watch television and so many of us sit at a desk with a computer now to work for 8-10 hours each day.  That adds up to a lot of sitting every day of our lives which makes for a relatively sedentary lifestyle.

To illustrate this, I will briefly highlight a study performed in 2011 by Swartz et al (1) that looked at energy expenditure in four 30 minute situations.  The first involved sitting for 30 minutes without a break as the baseline measurement.  The second, third and fourth bouts of sitting were interrupted by periods of walking for 1, 2 and 5 minutes, respectively.  It should come as no surprise that each person expended more energy when they interrupted their sitting time with a period of walking and as expected walking for 5 minutes expended the most.  To put this into perspective you would burn an extra 24 calories on average over the course of an 8 hour work day if you walked for 1 minute every hour.  Do it every half hour and that number would double.  For a week that would be 120 calories (or 240).  660 calories would be burned per week if you walked for 5 minutes every hour but this may not be as realistic as 1 or 2 minute walking breaks.  Extrapolate these numbers over a year and you get the picture.

The obvious implication of this small study is for weight maintenance, and for many people that means weight loss.  Granted this particular regimen may not be possible on the hour, every hour, every day for every person but it does shine light on incredibly simple lifestyle and work style changes that can add up to very beneficial results.  Now it should be noted that the exact numbers will be different for everyone but the idea remains the same.  Simple changes in position and activity will lead to a positive change in your metabolism.  Even alternating periods of sitting and standing at your desk will boost your metabolism rather than sitting the whole day.  The ultimate would be those fancy treadmill desks but most offices aren't really equipped for that just yet.

Beyond the direct impact sitting has on metabolic rate and calories burned (or not burned), prolonged periods of sitting have been linked to a long list of chronic diseases and conditions associated with metabolic changes detrimental to a person's health.  These include but are not limited to Type II Diabetes, Cardiovascular Disease, Metabolic Syndrome, Atherosclerosis, Obesity and Breast and Colon Cancers.  At best, you may be inconvenienced by not fitting into a pair of jeans or having to go to your physician more often for tests to keep track of any signs or symptoms.  At worst, your life becomes more challenging as you get sick more often, suffer major health setbacks like amputations and risk premature death from largely preventative health issues.

On that note, start a good habit by getting up wherever you're sitting to read this and walk around for a minute or two.  Next time I will discuss some of the long term health risks in more detail.

References:

1. Ann M Swartz, Leah Squires, Scott J Strath. Energy expenditure of interruptions to sedentary behavior. Int J Behav Nutr Phys Act. 2011; 8: 69.

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Sitting.  It didn't take long before I remembered why I don't like sitting for prolonged periods of time.  It is only recently that I have spent more time parked on my posterior between marketing, blogging, (I am currently standing for this one), and reviewing new research along with many other administrative items as owner of my practice.  Prior to my leap as a business owner, I was on my feet and moving more during the day as a staff physical therapist in several different clinics.  Sitting was something to be cherished when I had the chance.

Now under normal circumstances when you are sitting for a while, that soreness sensation, generally in your lower back/sacroiliac region, is the brain and body's gentle way of telling you to MOVE!  ANYWHERE!  JUST MOVE!  It's quite an ingenious alarm system because it works really well....as long as you listen to it.  Unfortunately I failed to listen to that initial alarm system recently and that soreness turned into a more constant and very annoying pain to the point where any static position was uncomfortable.  It was even a bit challenging to fall asleep and my sleep is not something to be messed with.  However, the solution was still an easy one....all I had to do was start moving more.  Walking, running, (even a 10 mile trail race), and changing positions all felt great so it is no surprise that my constant pain has decreased almost back to its baseline of normal soreness if I sit for too long.

With this experience in mind, I wanted to share some issues related to sitting beginning with a basic understanding of the biomechanics involved and soft tissue considerations.  There are different classifications of sitting but for the purpose of this discussion, I will focus on the very technical version that we all succumb to at some point during the day with or without knowing it: the slumped sitting position. 

Before going any further, it is important to have a reference point, which would be standing in this case.  In stance, the spine is naturally curved when looking at it from the side.  More specifically, the lumbar spine, roughly the bottom third of the spine, has a lordotic curve which changes when we sit.  Using the L1 vertebrae to the top of the sacrum, Lord et al measured the average decrease in lumbar lordosis angle from standing to an upright sitting position, (90 degree angle at the hips and knees).  It was 49 degrees in stance and decreased to 34 degrees in sitting. (1)  When the body gets lazy, gives in to gravity and slumps, this change is even more dramatic further decreasing the lordosis and sometimes eliminating it altogether.  This by itself is not a cause for concern as it happens normally with many activities like putting your socks on or bending over to tie your shoes.

Something else also happens as a result of this position: stretching of posterior structures and tissues of the lumbosacral region.  These can include muscles, tendons, ligaments, fascia, etc.  In order to accommodate the decrease in lordosis, tissues must lengthen and stretch compared to their length in stance, which is a more neutral position for the spine and pelvis.  It should be noted that this by itself is also not a cause for concern because tissues are stretched all of the time throughout the body as we move during the day.  Time, on the other hand, is the enemy.  When tissues are stretched, they trigger mechanoreceptors which are responding to the mechanical deformation of being lengthened.  Initially the messages sent from the mechanoreceptors to the brain are not enough to trigger any type of soreness or pain response but the longer the time being stretched, slumped sitting in this case, the more frequent and "louder" those messages become.  If it is long enough without a change, the brain processes the increasing messages and begins to perceive this as a potentially "dangerous" or "threatening" situation, and the output is sensations of soreness first followed by pain.  This is the ingenious alarm system mentioned above as the expectation is that you will move so those tissues are not being stretched, (or not in "danger"), anymore allowing the mechanoreceptors, (and your brain), to chill out.  This can obviously be overridden, as I did for too long and over several days, since most of the time you know that you are not actually in any danger, just uncomfortable.  As I described above, any kind of movement, especially if you get on your feet for a bit to return the normal lordotic curve to your lumbar spine, usually relieves this type of soreness and discomfort.  Unfortunately, many of us are stuck sitting, often slumping, for prolonged periods of time for work or in that super soft sofa you love.  So do the easy thing: listen to that alarm system, get up and move a little bit.  Your body, (and brain), will thank you for it.

Stay tuned for Part II as I discuss some of the metabolic issues associated with prolonged sitting.


References:

1. MJ Lord, JM Small, JM Dinsay, RG. Watkins. Lumbar lordosis. Effects of sitting and standing. Spine, 22 (1997), pp. 2571–2574.

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