Knee Pain - Patellar Tendon Pulls Laterally and Meniscus Tear

Hello! I’m posting here after being asked by Michael Ray to describe a particular knee issue I have after commenting on a post regarding the new knee rehab program on Instagram. I was wondering if the program may be a good fit for me?

I’m 31 years old, 6’6”, 220 lbs and over the last 3 years or so have made my health a priority, losing 60 lbs. I navigated that journey without many injuries, thankfully, until about a year ago when I started having issues with my right knee. For a while, I’ve always had issues with my knees constantly popping (when standing, walking, or… really, any sort of movement) but never any pain lifting.

At some point, I started to get pain in my right knee, when putting too much weight on it. More often than not, it occurred during squats. I held off from doing much weight training that caused strain on my knee while seeking medical opinions. Some tests showed that my patellar tendon “pulls laterally” when I bend my knee. The way it was described to me was that the tendon is supposed to sit in a groove on your knee cap when your knee bends. Mine, however, pulls pretty drastically to the outside of my knee. Tests also identified a small meniscus tear. It’s worth noting that I have a similar patellar tendon issue in my left knee, but not as severe.

I did Physical Therapy for a while which primarily focused on increasing flexibility in my knee and strengthening my IT band. The PT did help a bit but after a while, they cut me loose, and I am still having issues with the knee when trying to do heavier weight.

Before training legs, I start every workout with a warm-up on the stationary bike and a 4-5 different stretches they had me do in PT. I also occasionally do bosu ball squats because I was told that those can help strengthen my knee as well.

I am currently doing a program that has two lower body days a week. Those days include a low bar squat and deadlifts with some additional, very standard, isolation exercises.

Some days the knee responds fine to squats and other days I can’t do it for fear of pushing through pain and causing additional injury.

I’m just wondering if this new program may be something that could help me as well as looking for general opinions and input.

Thank you in advance for any feedback.

Thanks for the additional information. The knee template would likely be beneficial to you but we need to address some of the narratives you’ve been provided.

When you state tests were performed on the knee, what tests? Given you mentioned a meniscus tear, my assumption is an MRI?

I also think it would be beneficial for you to listen to this pain podcast I did to help reframe the meaning of pain: https://www.spreaker.com/user/philweightliftingpodcast/episode-74-with-michael-ray and this podcast we just released via BBM on injury: https://www.youtube.com/watch?v=V43mSQEjZY8&t=2457s.

If you do buy the knee rehab template, I recommend a consultation with us so we can help you implement it and discuss the topics of pain and exercise: Contact Us | Barbell Medicine.

Overall, the info you were likely provided in PT isn’t well supported in the research evidence and may have instilled some false narratives and behaviors. Bosu ball squats aren’t necessary and the narrative of “strengthening your knee” isn’t relevant if you’ve been externally loading your knee with squats and deadlifts. Either way, bosu ball squats isn’t an exercise I would recommend.

Regarding your tendons pulling a direction, I’m skeptical of this narrative. We can find patella subluxation that occurs with the knee during flexion and extension but this in itself isn’t necessarily a cause for concern nor is it well correlated to symptoms.

Mike, may I interrupt here for a second?
(I don’t know if this is only a therapist / asker sub-forum or if other members may contribute; if it is the former, feel free to remove my post. I would like to provide some comfort to the OP as I am in a somewhat similar situation).

@Ender Not to write a whole essay again, here is my discussion with Mike which may be insightful. Long story short: 12 years ago I broke my knee, which got fixed but mechanically it’s not really in pristine condition. Some patellar subluxation there, also torn meniscus and a couple of other issues.

Ad the “PT issue

At some point earlier this year, I decided I was fed up with constant aches and pains and went to see a “good” PT. What they had me do is a very conservative routine of isometric quad contractions lying on the floor on my back, progressing to pilates rubber band abductions / adductions, light knee extensions. Finally, the time came for silly wobble board squats and, here’s the kick, a thing called a “Roller bone:rage:. Now, lying isometric quad contractions and pilates rubber bands might provide some useful stimulation in someone who just got out of surgery or something similar, but these other silly contraptions… Serve no other purpose than to produce circus acts, if you ask me. All they did was induce pain in my low back and waste a bunch of time which could have been used elswhere.

We are training balance and knee stability here…”?! What will restore / teach you better balance than squatting down with a loaded barbell on your back, trying not to fall on your nose/ass while at it? :slight_smile:Yes, but your core…” Don’t even get me started on this one.

Getting fed up with these stupid routines, I took up barbell training and went the SSLP route. About a month and a half into it and the knee feels much, much better. I still struggle with issues from time to time, there still is some pain sometimes but as I progress with training it is getting better by the day. Currently, I am at my max weights (85kgx3x3 squat, I know, nothing to write home about) so some degree of pain is present → which means I should pay more attention to load management, probably.

### Ad the “Fear of causing additional injury

I totally understand how you feel! You have this link in your mind, between the “hurt” and the underlying “tissue damage”, there may be some crepitation sounds, clicks and pops… and it all “sounds” pretty horrible. BUT. It would be excellent if you could at least for a while, try to put this thought aside. Some three weeks ago I squatted 60kg, had what I thought was severe pain (“man, some damage must have been done”) but two weeks later I squatted 85 and almost no pain at all. What do I make of this?

Point of my post - BBL training is the way to go but with better / smarter programming. Would highly recomment a consult with Mike as I am way underqualiffied to give any recommendations.

Stay strong! :wink:
Alex

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Thanks for the response, Michael.

I had an MRI on my knee done. The findings are below:

Menisci: Instrasubstance degeneration of the anterior root of the lateral meniscus without discrete tear identified. The medial meniscus in intact.
Ligaments: The ACL, PCL, MCL and LCL are intact.
Bones: No fracture or dislocation. Lateral subluxation of the patella.
Cartilage: Within normal limits
Extensor Mechanism: Intact
Muscle and Soft Tissues: Trace joint effusion. No poplineal cyst

I will definitely check out those podcasts as well as fill out the consultation form to see what that looks like.

It’s a bummer to hear that maybe what I was being taught in PT isn’t well supported… Considering I did it for so long… And put a fair amount of money into it.

I’m also seeing a chiropractor who seconded the patella subluxation diagnosis. Can you elaborate on your belief that it isn’t necessarily a cause for concern? Or related to my pain?

Thanks for the response @alex.starbuck . Maybe once I listen to those couple podcasts I’ll feel a little better about dealing with the pain.

I know the feeling of feeling like a “circus act” at PT, haha. It took me a while to get good at those bosu ball squats. I almost feel like I HAVE to do them now, haha. I’m going to dive into your other post a little bit later. Thanks again for the response.

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Thanks for the information. I wouldn’t focus too much on what you’ve done previously in PT because we can’t change that. Rather, it would be appropriate to assess the narratives you’ve been provided and then learned behaviors (given you still feel the need to complete the exercises you were given in PT). What is the chiropractor doing for you?
Did you ever have a trauma to the knee joint previously?
When you are squatting - are you noticing instability of the patellofemoral joint (meaning the patella shifts about - possibly medially and then pops laterally)?

Typically conservative management is recommended for patella subluxation (barring it’s a trauma situation and there are defects necessitating surgery). Given you’ve already tried conservative management and are still having symptoms then it is likely there may be some prior held beliefs that are ongoing perpetuating the situation but if you are consistently subluxating during knee flexion and extension this might be a different discussion about management. Happy to help.

Edit: I wouldn’t get too concerned about the meniscus. I wrote a detailed blog about management of the meniscus HERE.

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Sorry for the late response, Michael. I appreciate you taking the time to help.

It sucks to hear that maybe what I was taught in PT may have not been helpful but agree that there’s no point in holding on to it.

As far as what the chiropractor is doing, I will ask for specifics on my next visit because, honestly, I’m not really sure, He kind of has me lay on my back and bends my knee, pushing on my shin towards my hamstring? I know that is awful description but I guess this is a wake up call that I need to be more informed about what specifically he’s doing.

I’ve never had any sort of knee trauma. And I don’t notice any instability when doing squats.

I’m going to purchase the knee template (probably next month) and see how that helps. Question in the meantime: Is their a warm-up regiment you’d recommend pre-squatting (or pre-lower body) to get my knee adequately warmed up? I’m wondering if what I’m doing now, as suggested by the PT, is maybe not the best information as well.

Also, in the future, I may consider private consultation. I’ve already filled out the form and gotten additional information.

Thanks again!

Edit: I also listened to one of the podcasts you linked to a while back and, after listening, definitely think some of it is possibly mental. There is no denying that I definitely have pain during flexion (even non-weighted) about I think I’ve built it up in my head some too and have used it as an excuse to not push myself squatting. I’m going to work on that.

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There is one very important point you mentioned here - the realization that medical practitioners (be it a doctor of western medicine, chiropractor, PT or whoever) may not know what they are doing and may not be the best person to help you. In a world of ever increasing complexity it seems as if people are relying more and more on the titles: “Oh, he’s a doctor, I’m sure he knows what he is talking about. He told me to rest a lot and never ever to squat because that is bad for my knees. I should instead do the press leg (Da fuq, “Press leg”!? The proper name is actually a LEG PRESS)”.

It is ultimately upon yourself to learn as much as you possibly can so that you may make wise and informed choices.

It is funny how nowdays people who like cars know a lot about cars so they can easily choose a “good” mechanic and understand what needs to be done to the car but at the same time, so few people know or are interested in the workings of a human body and are GROSSLY ill equipped for choosing a medical “mechanic”.

Keep learning and of course, lifting ;).

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Hey Ender,

I wouldn’t worry yourself with what treatments you sought out in the past to help with this issue and their validity. Nothing can be done now, other than make more informed decisions moving forward. I strongly suggest inquiring what the chiropractor thinks he/she is doing to help with your issue, how is it helping, and what evidence they are using to make those claims.

Regarding warm-ups, no, I don’t typically recommend specific warm-ups for any issue outside of go and do the movement you are training at lower intensity.

Keep us posted.

@alex.starbuck , well said.