Runner’s Knee Treatment: A Whole Body Approach

What Is Runner’s Knee?

Let’s get some Latin in. As you probably know us Sports Therapists and Physiotherapists like a good label. Runner’s knee is a lay term for something that is categorised as patella femoral pain syndrome (PFPS).

As with all medical conditions that end in syndrome the text book says the condition is ‘not fully’ understood. The label is used to describe pain either around or behind the knee cap. Patella femoral pain syndrome can affect anyone but particularly affects runners.

Many years ago as an impressionable freshly qualified Sports Therapist I was always mortified to read ‘not fully’ understood. Now I just enjoy the challenge of trying to work out an individual solution for every person I see. Thankfully, having seen so many knee conditions, there are consistent patterns we see and that’s what we’ll share with you here.

What Causes Runner’s Knee

Let’s start with the official stuff before we get into my experience of what works and what doesn’t. This review of the research cites the following potential causative factors:

• Imbalances in patellar (knee cap) tracking
• Overuse
• Trauma
• Muscle dysfunction
• Tight muscles on the outside of the knee
• Limited or excessive mobility of the patella
• Poor quadriceps flexibility

This piece from the British Journal Of Sports Medicine cites:

• Larger angle between your thigh bone and shin bone
• Patellar (knee cap) tilt
• Lack of strength taking leg away from the other when then standing (hip abduction)
• Lower strength when straightening the knee (knee extension)
• Less strength in the muscles that rotate your hip outwards (lateral rotation)
• Foot arch was not considered a risk factor

Firstly I was surprised to see that foot arch was not considered to be an important factor. For me foot position can be a contributing factor in many of the causes mentioned. Furthermore, one of the groups of muscles that affect foot position, the muscles at the front of the shin (the anterior compartment – tibialis anterior, extensor hallucis longus and extensor digitorum longus) are entirely continuous with the knee cap and quadriceps as shown below:

We often find that fascial or muscular release of these muscles immediately changes the pain around the knee cap.

Aside from overuse and trauma I’d group all of the other findings here into a catch all biomechanics category. These will be unique for all of us.

I completely agree that patellar tracking and tilt can be contributory factors in the symptoms. Locally the biomechanics of tracking and tilt issues will involve the muscles that act directly across the knee – quadriceps, hamstrings, adductors and iliotibial fascia.

Simply releasing these muscles and associated fascia off my be enough to sort the symptoms out. But not always. Why would that be? Well that’s the next step back in the biomechanical chain. Why are the quadriceps tight and dysfunctional? Why is there tension on the outside structures of the knee that affects patellar tracking?

For us this is where the fun begins! That’s our job to work out how to address the true cause one, two or however many steps back it takes. Let’s take an example of what we mean by this. Let’s say we identify that the quadriceps are tight and / or weak.

The cause of quad tightness and weakness can be manyfold. But things we might consider include hip flexor tension or dysfunction, glute weakness, breathing limitations, tension in the neck, tension in your six pack (rectus abdominus)… the list goes on. The previous picture of the superficial front line shows the connection of the quadriceps into the superficial stomach muscles (rectus abdominus) and then onto the neck. The following picture better explains how tension in the hip flexors can affect the nerve which not only gives sensation into the knee but also makes the quadriceps work:

How you stand and how you move gives us insight into which are most likely to be at fault here. But there are many factors to consider. This is not a straight forward process.

As another example of tracing back from the causative factors identified in the research let’s consider tight structures on the outside of the knee. Most likely to be the tight lateral fascia as in the iliotibial tract (ITB) and / or the outermost quadricep (vastus lateralis) which sits underneath the ITB.

This can be held tight by what we call the lateral line as show below. But then it’s another case why? Most commonly this will be from one side of our pelvis being higher than the other. This can be on the same side or the opposite. If you look at yourself in the mirror in your underwear with your feet together you should be able to see if one side of your pelvis is higher than the other.

None of these ideas are absolute. These are features we need to check, treat and test to establish which is the most important factor, or realistically, factors, of you.

Finally, before moving onto what you can do, I’d like to consider overuse and trauma. Oddly enough I feel we can group these two together. To grossly simplify both overuse and trauma lead to excess muscle tension which leads to dysfunction and it’s effectively the same process we describe above.

Of course treating overuse and trauma is very different. Although both involve paying more attention to the signals the body is giving us and working at ways to reduce the levels of sensitisation.

Runner’s Knee Stretches

With so much talk above of tension leading to dysfunction which leads to symptoms Runner’s Knee or patellofemoral pain syndrome I thought it would be good to give some stretches that we commonly find help the muscles mentioned above.

Before you give them a try please be aware that these are ideas only and in no way replace guidance by a professional in person. Performed correctly they are very safe but please be aware that you try these at you own risk, no matter how minimal that might be. In other words, if you break yourself doing them it’s your own fault not ours!

Now the way we make stretching extra safe and extra effective is to not go too far. Stretching should always be pain free. If we feel pain you’ve gone too far. Back off to the point that it feels like a nice stretch. If that is not possible then the stretch is not right for you just yet and we would recommend you seek professional advice to better understand why.

So light stretching it is. We recommend holding the stretching for a minimum of a minute. Ideally longer but start with shorter duration while you get the hang of it. Take that initial stretch just to the point of where you start to feel the stretch. When there focus on your breathing. Take extra long out breaths and look to relax the whole body, particularly the muscle you are stretching, as you breathe out. If you feel that there is no stretch left increase the stretch a little and repeat the breathing. At no point force this process.

Stretches which will affect the muscles that act directly across the knee are:

If you found your pelvis was higher on one side than the other then this might be a useful additional stretch for you to address that next step back in the biomechanical chain:

Exercises For Runners Knee

Getting the legs stronger, particularly the quadriceps can help runners knee. But we have seen many cases where doing strength training has actually made things worse not better. The key is to get the ‘dosage’ of the amount of exercise just right. Even better is to improve the quality of the movement pattern whilst we’re at it.

In our experience people who don’t benefit from strengthening exercises fall into two distinct categories. The first is those that continue to do too much. That can be too much exercise as it’s important for the their mental well-being or they try too hard to fix themselves and do too much rehab.

The second category are those for whom the condition has just got too sensitive to be able to do much. This can come from ignoring the problem for too long or simply being very anxious. Either in life generally or specifically about the knee. In these cases we find it best to calm the nervous system as a whole, correct any faulty or damaging beliefs and fears about the condition, reduce the sensitivity of the condition with our hands on work and then start building in strength and confidence from there.

This excellent research piece here suggests that general quadricep strengthening reduces pain in patients with patellofemoral pain syndrome. Interestingly it also concludes that research into taping, bracing, or foot orthotics is inconclusive.

This piece here reviewing lots of papers researching the benefits of exercise therapy to help runners knee or patellofemoral pain syndrome concluded any evidence was very low in quality. Which might explain why response to strength training alone can be so varied. It also ties in with our experience in that you need to understand the individual biomechanics and individual situation to get a lasting solution rather than looking for a one size fits all.

That said, I know many people are out there trying to find solutions to solve their knee problems, many of whom simply can’t afford to come to a private practice like ours. With that in mind here are our 3 favourite strength exercise that we find most consistently help most people.

As with stretching never to pain. Less is more to start. Make sure your body is ready for them first and the gradually increase the amount of repetitions. As a guide perhaps start with 3 sets of 10 every other day and then add 1 rep each time you do it – so long as the pain has not increased that is.

Quadricep Contractions

A great way to get the confidence in the muscles that makes the knees work. The exercise is simply tensing your quadricep muscles. To do so sit on the floor with your legs straight out in front of you. Tense the muscles at the front of your thigh so that they pull the knee cap upwards. Do this on the better knee to start with. Notice how it feels. Then try this on the problematic side.

Most likely the muscle contraction will feel different from one side to the other. It may even look different. Can you make the problematic side feel more like the good side? Try squeezing a bit quicker more confidently and see if that helps. Make sure you’re not holding your breath in anticipation of pain on the problematic side. If this exercise does give you pain of course don’t continue. But if you don’t feel pain and you keep at it both sides will feel more and more similar.

So this is a very specific entry level rehab exercise. So long as that doesn’t hurt progress onto the next two very functional exercises:

Squats

Bridge

Always work in a pain free range. That range will get slowly better as will endurance in your legs importantly using a better movement pattern which will become more and more natural.

These exercises can be used to improve a movement pattern whilst you continue to run or as a pre-cursor to your running comeback to improve the movement pattern whilst the sensitivity of the knee recovers.

For a first run back you can try a 10 minute walking warmup, 1 minute run then 1 minute walk 5 times through, then a 10 minute walk to finish. 30 minutes in total. The couch to 5k programme is a great guide for a return to running also. These ideas may be a bit basic for experienced runners but the same principles apply. Start small and build gradually and listen to your body as you go. Experienced runners idea of small will just be bigger!

Runner’s Knee Recovery Time

Of course the question everyone wants to know the answer to. And the question that has no answer! It’s individual. Sometimes it takes us no time at all. A couple of sessions of treatment, some stretches and some tweaks to your lifestyle and training plan and away you go.

Sometimes it takes longer. It’s more likely to take longer if you have on going stress in life. This literally makes us more sensitive. Not just emotionally, but physically too. We simply feel more pain. In instances like this we find putting a greater emphasis on healthy wellbeing practices helps reduce the sensitivity of the condition and makes it so much easier to address the physical symptoms.

Runner’s Knee Not Going Away?

So what do you do if your runner’s knee or patellofemoral pain syndrome is not going away? Our first choice would be to come and see us so we can work out what is going on for you and get you moving more freely and with less pain as soon as possible.

Our second choice would be to go see any other therapists to do their equivalent of what we do. Our third choice would be for you to simply follow the ideas that we’ve presented here and see if you can get them to work for yourself.

Our least favourite option would be for you to do nothing. Either carry on pushing through the pain. Or carry on avoiding doing the things you love doing for fear of how bad it might get or making it worse. Pain is there for a reason. It’s telling is that we need to do something different. We just need to work out what those somethings are.

If you’d like to understand more about how we might be able to help you with your specific set of circumstances then click here and fill out the form to arrange a call back and we can talk you through how we might be able to help.