Home Blog Who “Kneeds” Normal Knees?

Who “Kneeds” Normal Knees?

Written on June 24, 2010 at 7:00 am, by Eric Cressey

Okay, this subject line was undoubtedly the worst of all time, but I promise that the information that follows will be worth reading.

A lot of you were probably hoping that you were out of the woods after I told you how bad your lower backs and shoulders look on diagnostic imaging such as MRIs.  I’m sorry to say that these “normal” structural disasters also apply to the knees.

A 2010 review from Flanigan et al. looked at studies that collectively examined the (1,862) knees of 931 athletes (40% of whom were professional athletes) using MRI and arthroscopy.  They found that 36% of these knees had full-thickness chondral defects, but 14% of these subjects had no symptoms when diagnosed.  The researchers concluded that “Over one-half of asymptomatic athletes have a full-thickness defect.”


Years earlier, Cook et al. screened 134 elite junior basketball players (268 total knees) for patellar tendinopathy.  At the time, only 19 (7%) of the 268 tendons presented with symptoms (pain) of tendinopathy.  Interestingly, though, under diagnosis with ultrasound, researchers actually found that 26% of all the tendons could be labeled tendinopathy based on the degenerative changes observed.  In other words, for every one that actually presents clinically with symptoms, more than three more go undiagnosed because people either haven’t reached threshold, or they move well enough to keep symptoms at bay.  Or they are Kurt Rambis and can just look so awkward that nobody even pays attention to their knee sleeve.


On the “move well enough” side of things, check out this study from Edwards et al.  They showed that these athletes with asymptomatic patellar tendinopathy actually land differently – both in terms of muscle recruitment and sequencing – than asymptomatic athletes without tendinopathy.  Fix that movement pattern neurally and strengthen the right muscles, and those issues never reach threshold.  Leave it alone, and they’ll be presenting with knee pain sooner than later.  Mike Robertson does a great job of outlining ways to improve knee health via movement retraining in his Bulletproof Knees Manual.


This is just the tip of the iceberg.  You’ll see loads of chronic ACL and meniscus tears that folks never realize they have.  I could go on and on. The take-home messages?  Yet again, diagnostic imaging is just one piece of the puzzle, and how you move is far more important.

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5 Responses to “Who “Kneeds” Normal Knees?”

  1. Mike Robertson Says:

    Great points, Eric.

    I’ve seen some knees that on a x-ray/MRI look horrible, but there’s almost zero pain associated with them.

    On the other hand, I’ve seen some of the cleanest MRI’s ever, and these people are in constant knee pain.

    I’ve said this numerous times, but one of the best thing you can do whether you’re 100% pain-free or in chronic pain is to clean up your mechanics.

    Get your alignment right, turn on and strengthen the right muscles, and it’s amazing how much better you’ll move and feel.

    Great post!


  2. Carson Boddicker Says:


    Excellent comments and thoughts. It blows my mind how easily professionals are willing to rely upon imaging to make the calls. Now, I certainly recognize value in imaging, especially to rule out worst case scenarios, but it seems that there is too much variability to be entirely confident in decision making.

    Carson Boddicker

  3. bob gorinski Says:

    Excellent post. Your previous one on this topic inspired me to get into the issues with the pathoanatomical model of diagnoses.

    “The Problem is a Verb”

    at www[dot]bobgpt[dot]blogspot[dot]com

  4. Dom Says:

    Another great newletter by Eric Cressey – thanks Eric!

    I’m 41 now, but still think and act like I’m 25, and play a lot of tennis. Starting to feel a few minor aches in the knees (medial mainly).

    To take as much stress as possible away from the knee joint, I’m focusing much more on good movement, to be lighter on my feet. It makes a huge difference. And of course gym work to strengthen the muscles round the knee joint.

  5. Manny Katz Says:

    There are snippets of info here which raise further questions. Are MRIs a better diagnostic tool for tendon problems than U/S? My medical facility (Kaiser) does not do U/S for knee or shoulder problems anyway.

    I am not a trainer and neither need nor understand all the technical anatomy and physiology. Isn’t there something simpler I can access about how to strengthen these parts that have tendon problems or other anomalies?


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