I Think I have Runner’s Knee: What do I do Now?
Runner’s knee is very common in runners, but can occur in non-runners as well. “Runner’s knee ” is the layman’s term for patellofemoral pain syndrome, or PFPS.
PFPS actually has quite a few different causes. Two people can have the same diagnosis but need slightly different exercises or treatment, depending on their individual presentations. Highlighted here are the most common and general treatments for runner’s knee.
If you are unsure of your symptoms and potential diagnosis, see your physician and ask for a referral to physical therapy. A PT will be able to do a thorough exam and prescribe exercises that are designed for you personally.
Disclaimer: Although I am a physical therapist by profession, I am not YOUR physical therapist. This article is for informational and educational purposes only, does not constitute medical advice and does not establish any kind of therapist-patient relationship with me. I am not liable or responsible for any damages resulting from or related to your use of this information.
Relevant Anatomy of the Knee
The knee is comprised of two joints: the tibiofemoral joint and the patellofemoral joint.
The tibiofemoral joint is between the tibia, or shin bone, and the femur, or thigh bone. This is the larger of the two joints where all your ligaments–think ACL and PCL–and cartilage sit. This is the joint at which flexion and extension, or bending and straightening, occur.
The patellofemoral joint is made up of the patella, or knee cap, and the trochlear groove of the femur. When you flex and extend your knee, the patella has to be able to slide up and down smoothly in the groove. When it doesn’t, this is when pain and problems arise.
Causes of Runner’s Knee:
This can be a recent change in activity, whether that be in frequency or intensity.
This can mean a couple things:
First, if you’re wearing running sneakers that are “dead” or have reached the end of their lifespan in miles worn, you’re putting your joints at risk for injury. Because your shoes no longer have sufficient cushioning, your joints are absorbing much more force with each stride.
Second, if you’re wearing the wrong size or the wrong type of support for your foot structure, this could lead to problems. It’s recommended that you get fitted properly at a running shop on a regular basis. Our shoe size can change with age, increased miles, and for women, pregnancy.
Lastly, non-running related: If you went for an impromptu hike or walk in anything but sneakers or hikers (i.e. sandals, flip flops, dress or fashion shoes–think: anything that is NOT an athletic shoe or hiker), this can lead to knee pain as well as foot pain, such as plantar fasciitis.
Some people have a patella that sits high in the trochlear groove, also known as patella alta. Others might have a tilt or a rotation in the knee cap relative to neutral. These differences in alignment will cause the patella to track abnormally in the groove, thus causing increased friction between the underside of the patella and the femur. Differences in patellar alignment can be a problem if they cause pain.
Abnormal patellar tracking.
As mentioned above, this can be due to a difference in resting alignment which can cause abnormal tracking. Additionally, having imbalances in muscle strength and/or muscle flexibility can also cause abnormal tracking. Tight muscles can pull the patella out of the trochlear groove and weak muscles may prevent the knee cap from tracking properly as well.
Hip Abductors: Typically weakness in the hips, especially the hip abductors, which are located on the outside of the hip, will contribute to knee pain. Every person with knee pain should be addressing hip strength. And in all honesty, all runners should be doing some sort of hip abductor strengthening to address or prevent injury.
Quads: Weak quadriceps, and more specifically, the medial portion, or VMO, will allow the patella to track more laterally within the trochlear groove. A strong quad will keep the patella centered where it needs to be.
Glutes: The glutes are part of your core. The glutes are a hip extensor. If the glutes are weak, your knee will have to compensate, and this will lead to pain.
Abdominals: Yes, this is also a contributor. In running, your power and your forward momentum comes from your central core, not just your legs. If your abs are weak, guess what needs to compensate–your legs, which can lead to knee pain, or even hip pain.
Hamstrings: Because the hamstrings cross the knee joint, if they are tight, they will cause undue pressure at the back of the knee. This pressure then translates to pain at the patella.
Quads: If the quads are tight, they can contribute to a change in resting patellar alignment (see #3: patella alta above) and thus a change in patellar tracking.
ITB: The iliotibial band, located along the outside or lateral hip, has fibers that connect directly to the patella. If it’s tight, it can pull the patella laterally, again causing changes in tracking within the groove.
Common Symptoms of Runner’s Knee:
Gradual onset, worsening over time.
Typically runner’s knee symptoms begin gradually. You may only notice them with activity at first. If symptoms are left untreated, they will only worsen with time. You may begin to notice symptoms at rest or after a brief period of rest. Some runners experience no pain while running but have pain after finishing their run. This does not mean that running “through” it is a good idea!!
Funny noises coming from your knee.
Common symptoms include clicking, popping, or grinding under or in front of the knee cap. This can either be due to the patella not sitting in the trochlear groove properly during motion of the knee. Or, it can be due to the cartilaginous under surface of the patella rubbing, or grinding, on the femur (as with poor tracking).
Pain with activities that load or bend the knee.
Activities that are often painful include squatting, lunging, and doing the stairs. Most of the time it’s more painful when descending the stairs than it is ascending.
Start up pain.
You may not have pain at rest, however after sitting for a while, especially with the knee in a bent position, you might have pain for the first several steps upon rising.
As symptoms worsen, you may have less and less tolerance for sitting for prolonged periods. Many report that they are unable to sit through a movie or take long car rides. If left untreated, your sitting tolerance time may decrease over time.
How to treat Runner’s Knee and Get back to Running:
First and foremost, REST!! Stop the aggravating activity or activities. If running is causing you knee soreness, you need to stop. If long walks or doing the stairs multiple times a day is increasing your pain, you need to decrease these as much as possible.
Icing can help with decreasing pain and inflammation. If you also have some swelling about the knee, elevate the leg when resting and icing to help the swelling go down.
Wear good shoes.
Make sure that you are wearing good fitting and supportive footwear. This doesn’t mean just for running. This is for all the time. You may even need to wear shoes in the house (if you don’t normally) temporarily to give your knee the support it needs to heal and feel better. Go get fitted at a shop for everyday shoes and go to a running store to get properly fitted for your running sneakers. Get rid of any sneakers that you have worn for more than 500 miles or 6 months, whichever came first.
It’s important to strengthen the four main muscle groups of the legs/core that we identified previously as possible contributors to runner’s knee: hip abductors, quads, glutes and abs.
Here are exercises to target each group specifically:
- Hip Abductors
Perform side lying clamshells and side lying leg lifts.
While lying on your back, perform straight leg lifts with the toes pointed toward the ceiling.
Then perform straight leg lifts with the toes pointed outward at about 45 degrees. With this amount of hip external rotation, this will target more of the VMO.
Perform a glute bridge with a ball, yoga block or small pillow between the knees. Make sure that the knees are in line with the hips. Squeeze the knees in gently as you contract the glutes and lift the hips up off the ground. Slight activation of the hip adductors in this exercise will also help activate the VMO.
Planks are an easy way to get your abs as well as many of your other postural muscles firing and in shape for running. Start with a modified plank on your knees and work up to a full plank.
Incorporate side planks as you are able. Pay attention to your form. When you start to lose form, stop your plank. Don’t force the amount of time for the sake of time. Make sure you’re doing it properly! Quality over quantity!
It’s important to stretch the three main muscle groups of the legs that we identified previously as possible contributors to runner’s knee: the hamstrings, quads and ITB.
Here are stretches to target each muscle group specifically:
A forward bend toward the floor will stretch your hamstrings but it will also get your low back and shoulders. This means it’s not a great stretch for isolating the hamstrings in particular. A better stretch is to place your foot up on the bottom step of a staircase or a low stool and to hinge forward from the hips, keeping the back flat. You shouldn’t need to lean forward very far to feel a stretch, maybe just 1-2”.
You can do the traditional standing quad stretch by bending your knee and holding onto your foot behind you. Just make sure that your thighs remain parallel and that your knee doesn’t swing out to the side. Keep both knees together, no more an inch or two apart.
The best stretch to isolate the ITB is the cross body strap stretch. Lie on your back, attach a strap or belt to the foot. Bring the foot up to the ceiling then across the body toward the opposite side. Use your arms to hold up the weight of the leg with the strap so you can really relax the leg into it.
It’s really important that you perform these strength and stretching exercises at least 3x/week. There is variation in the recommended frequency under each description as you should be doing them more often in the beginning, especially if you’re not running! You can begin to taper the frequency as you feel better.
Return to Running Gradually.
You should be symptom free all day, for at least a week before even thinking about returning to running. If you can’t get through a normal day without pain, then you’re not ready to add increased load/stress/demand to the knee with higher level activity. That higher level activity being running.
Once you are symptom free for all regular day-to-day activities, then you can gradually begin to get back to running. Start with short bouts, consider walk-run intervals, and go at a conversational pace. Speed can come later. Begin on flat and even terrain before considering hills or uneven surfaces, like trail.
If you’re feeling good, and want more guidance on return to run, check out The Running (Re)Start Training Plan!
Additionally, make sure that you perform a gentle warm up before heading out. Getting into a run with cold muscles is never a good idea.
As long as your knee remains pain free, you can keep increasing your running back to your normal, whatever that means for you.
Try not to get overzealous and do too much too soon; you may end up setting yourself back. If you do develop pain again, stop your run, take a few days off, focus on your exercises and then only begin again when you’re symptom free again.
See a Physical Therapist.
If you’ve tried to self diagnose and treat with some of the suggestions above and things don’t seem to be improving, you may need to go see a PT. A PT can do a full evaluation of your alignment as well as identify any strength or flexibility deficits you have and prescribe appropriate exercises. Additionally, a PT can perform some taping techniques for alignment and patellar tracking when necessary.
Prevent the Recurrence of Runner’s Knee:
Continue your stretching and strengthening exercises 2 to 3x/week, even when you are back to running.
Get a good shoe fitting for everyday and athletic shoes. Get fit every so often to make sure that your size or foot needs haven’t changed.
Keep track of how old your running shoes are or how many miles your shoes have on them. You should never wear them more than 6 months or 500 miles, whichever occurs sooner.
Be smart about changes or increases in your training, whether that’s in intensity, frequency or duration.
Runner’s knee is treatable and preventable. This article and the recommendations here are by no means exhaustive. The exercises listed are only suggestions. There are MANY, many exercises that can be done for stretching or strengthening involved structures. If you’re unsure if an exercise is right for you, check with your physician or physical therapist before proceeding.
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