When is loading contraindicated with knee pain?

A big thank you again to you doctors for dispelling myths about pain and training. Just read Dr. Baraki’s article on patellar tendonopathy and wish I had had that knowledge years ago.

Have a history of “PFS” as diagnosed by docs years back. Spent a lot of time kneeling for work the last few months and had some discomfort in what felt like the tendons at the back of the knee which was slightly exacerbated by squatting and biking but not deadlifting, which went away (have had similar from prolonged sitting with a lot of flexion). A few repeats of kneeling and feeling pain in the patellar tendon region, and then sort of the same symptoms of pain in the back of the knee, going away after a few days. Have mostly tried to stay away from full flexion on the ground.

Fast forward: long day of being on the ground about 2 weeks ago, same sort of soreness. Went away, and nothing major of note happening since other than occasional kneeling on harder floors with some discomfort. A few days ago the pain was more notable with some pain in the patellar tendon region, as well as medial and lateral side of front knee (some more prominent popping on the lateral side, though this is somewhat present in the other knee). Pain also present behind the knee at deeper flexion and is worse than before. Some minor puffyness posterior and around the patellar area as well, and some stiffness in the front around the quad.

Not precisely sure what the issue is and am trying to stay away from kneeling for the time being. Anything worth being cautious of, or proceed as normal as per BBM protocol?

Thanks in advance!

The most common “red flag”-type symptoms that would typically require a change in management for acute knee pain would include things like signs or symptoms of acute joint inflammation (suddenly giant, red, hot, swollen, tender, as can be seen in conditions like joint infections or crystalline diseases), or a significant traumatic injury, particularly if followed by objective instability (as can be seen in cruciate ligament injuries, for example).

What you are describing does not sound like a situation where loading would be contraindicated. The normal recommendations likely apply; although if you would prefer a more individualized assessment/recommendations, our rehab team can help.

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Thanks doc. So some degree of inflammation/puffyness – occasionally warm and slightly puffy/stiff (i.e. after a long day) but not hot or red and not immediately obviously swollen – is generally an acceptable threshold for typical managed training? There’s no concern with exacerbating bursitis or similar with moderate load?

I should note that knee pain absent the other symptoms (typically under the patella) is a common thing in both knees that I try to avoid making worse but otherwise work around and ignore.

Thanks again!

[quote=“RVR, post:3, topic:13115, username:RVR”]
Thanks doc. So some degree of inflammation/puffyness – occasionally warm and slightly puffy/stiff (i.e. after a long day) but not hot or red and not immediately obviously swollen – is generally an acceptable threshold for typical managed training? There’s no concern with exacerbating bursitis or similar with moderate load?
[/quote]​

Yes, although I would not even categorize that as an acutely inflamed knee in the same sense as knee affected by gout/pseudogout or a bacterial infection (septic joint). I mainly described those “red flag” type situations as an example of how I’d think about new-onset knee pain clinically, not because I was concerned about a true inflammatory arthritis in your case.

I would manage bursitis the same as tendinopathy, the same as “patellofemoral pain syndrome”, the same as other non-specific knee pain.

Gotcha! Good to know, thanks for the clarification.

Glad to hear it, will keep going then. The PFS “diagnosis” was frustrating years back as I didn’t know enough to know it was code for “yeah it hurts for some reason”.

Thanks again for the work you guys do and for your time.

Follow up question: it seems “conventional” to suggest that tendons can be “permanently damaged” if someone “hurts” or pushes too far during the early phase of recovery. Is there any merit to this in the situation of non-complete tendon tears and tendonopathy in general, or should one take a similar angle as with back pain?

Curious about this as some musicians or similar seem to struggle with smaller joint tendonopathies for many months or even years, but I’m unsure if that is a protective mechanism more than anything.