In medical terminology ‘Runner’s Knee’ is called patellofemoral pain syndrome (PFPS). It is a condition that responds very well with Physiotherapy treatment, which we can say with confidence from both experience and there is a reasonable amount of research and evidence behind what we do.
A common sign of runner’s knee is that the pain comes from around or under the knee-cap, or patella, and can be as a result of it not moving as it should around it’s neighbouring bones and muscles, which we call ‘structures’. In this case the knee-cap moves in a ‘groove’ in the knee and the risks of injury arise when the knee-cap doesn’t properly ‘track’ that groove.
Unfortunately some people are predisposed to runner’s knee because of the position of their knee-cap. It may sit too far to the outside of the groove, or be tilted or rotated which may increase contact within the groove.
Even with knee-caps that have poor positioning, Physiotherapy can treat and strengthen the muscles around the knee which can then change the movement, or biomechanics, of the knee to improve the way the knee-cap tracks the groove.
Also if the inside thigh muscles, or quadriceps, don’t activate well it can also cause these knee-cap tracking issues and people with pain at the front of the knee (also known as patella-femoral pain) tend to develop weaker quads. If the ITB (a band that runs down the outside of the thigh) is tight, it can pull the knee cap towards the outside of the knee.
If your pelvis drops on the opposite side as you bend your knee this can cause strain through the knee and affect the angle of pull through the muscles, also causing knee-cap tracking issues.
A simple way to test how you move is to do a single leg squat in front of the mirror; if your belt line drops down as you bend and your knee does not move over your foot then your hips and pelvis may be dropping lower. But the good news is that this can be improved with personalised physiotherapy treatment.
Finally, foot position. If your feet roll in a lot then your knee will have a tendency to twist in at the knee and this can also cause tracking issues.
Like most running injuries it is an overuse injury, rather than a traumatic injury.
One of the biggest factors is changes in load, or weight, that is put through the knee. This could be related to the volume or intensity of your training and insufficient recovery time will also play a part here.
This is why it is important to keep a record of what you have done and make sure to change your training parameters gradually. I normally say to my patients that its best to avoid changing speed and duration both on the same session as the need to be built up separately and you should also factor in a lighter training week every four weeks to allow for recovery in your training.
Another factor is your biomechanics – the way your body moves and its individual functionality. The risk factors I mention above can increase the chances of developing problems at the knee joint, and depending on how you move and how much weight you send through your knee can have an impact on your chance of developing runner’s knee.
This is something we assess in detail in terms of muscle length, activation and how you move with functional tasks as well as walking and running. These kinds of tests are included when a Podiatrist assesses your movements during walking and running — also known as a gait analysis — and our running assessment, which also looks at your movements during running.
The shoes you wear affects your foot’s position and this can be a risk factor. It is important that your footwear is appropriate for your feet, your movements and your sport.
Some people may require a motion control trainer while others may need more cushioning. The easiest way to check what you need is by seeing a Podiatrist to be assessed. They will not only check the way you walk and run, but the shoes you wear themselves as they can tell you a lot by the wear and tear, in face often the older the shoes the better! But it is of course important to replace your trainers regularly, especially when you can feel they are no longer supporting you.
For example, racing flats or barefoot trainers will wear more quickly than regular trainers, and a lot of runners can tell by the feel of the shoes – the trainers feel dead and the ‘spring’ has gone.
It is important not to just go by the external appearance as this will not give you a gauge of what is happening in the sole and this is where the shock absorption and control takes place. It is also worth pointing out that even if trainers are left in the cupboard the shock absorption component will degrade.
If you change where you run or train this can also sometimes put you at risk of injury. For example if you don’t normally do hills or run off road then a sudden change to this surface will increase the demand on your legs.
Your body needs time to adapt to the surface you train on, so don’t be tempted to just go out and do a really hard hill session out of the blue otherwise you may end up in a physio’s room seeking help for rehab rather than prehab!
There are a lot of treatment options for Knee-cap pain and, as I mentioned, it is something that normally responds well to physiotherapy treatment. But the key to the success of the treatment will be depend on finding out where you are in your training and why you have developed symptoms.
This is a key part of treatment, because understanding why you came to have this injury will help to avoid it happening again in the future. It is important to look back and see if you have made any training errors related I mentioned above.
Mostly there will need to be some alteration in how much running you do. If you are lucky it might just be cutting back a little but if the pain is too severe you will need to rest to allow the irritation to settle. If you are training for a particular event then it is important that you keep up cardiovascular training where possible but use an alternative method that does not aggravate the symptoms until you are back to running.
There is evidence to suggest taping can help in the short term to relieve pain and may allow you to continue running and start exercising the muscles in the thigh earlier. Some patients I’ve seen have also found bracing helpful when they have experienced runner’s knee.
Correcting any biomechanical issues will involve assessing how you move and making small, gradual changes to your movement to improve how you run. Normally it requires the use of mirrors and videos to help to teach new movement patterns, and it’s likely to improve your gluteal (buttocks) and quadricep muscles’ strength levels and ability to activate.
Exercises which target the glutes and quads including squats, single leg squats and lunges are likely to be included in your rehab program. Sometimes muscle stimulators may also be used to make changes more quickly if there are significant weaknesses in these muscles, but your Physiotherapist will advice when and if these are necessary.
Pain is a big inhibitor to muscle function so it is important that the exercises are comfortable. The way you execute the prescribed exercises, and the specific point in your rehab that they should be introduced, is a crucial part of the success of the treatment.
This is why we always advise seeing a healthcare professional to help, support and guide you through the recovery process, because without appropriate instruction and supervision it could make things worse.
As with any injury, each person can present differing symptoms, pain or signs of runner’s knee. For example, some people may have tightness in their calves, quads and hamstrings that can affect the way they move and, although Physiotherapy is a great first point of call, in these cases soft tissue release and stretching can help.
This is likely when your clinician will refer you on to a member of the Soft Tissue Therapy team, as they can work to mobilise the ankle and around the knee cap to support and enhance your recovery.
But it’s unlikely that flexibility issues are a main cause of runner’s knee compared to strength and control issues, so stretching, foam rolling and soft tissue treatment alone is unlikely to resolve your symptoms. It’s important to use these two sports medicine services alongside one another.
If you do roll your feet in excessively then you may need an orthotic which is an insole you put in your shoe that helps to support your arch. This can be bought off the shelf or custom made by a Podiatrist. If your feet only roll in a little then you may be able to improve the position of the foot enough with the correct pair of trainers.
If you are unable to carry out normal functional activities without significant pain then a course of anti-inflammatories may be appropriate. If you are in training and have a race coming up then, with the advice of a medical professional, it may be appropriate to run with some pain and use anti-inflammatories to reduce the symptoms.
This obviously risks masking the pain and should be discussed in depth with your doctor or therapist.
If you chose to continue to train, despite pain, to compete in a race it is important you allow yourself time post-race to thoroughly address the issues surrounding why you developed the pain in the first place, which is where we come in.