Last updated: 31-Oct-18
By Karina Teahan, Chartered Physiotherapist
Runner’s knee! Anterior Knee Pain! Patellofemoral Pain Syndrome (PFPS) or Chondromalacia Patella*! Take your pick as all refer to an injury behind or around our kneecap (patella) that can linger for quite a while. (*Sometimes referred to as Chondromalacia Patella but care needed with this term as it can really only be diagnosed with MRI or arthroscopy).
In this article we will refer to it as PFPS.
It not only stops our running but can affect simple day to day activities such as descending stairs, driving, squatting down & kneeling. 25% of people will have PFPS at some stage in their lives so it is quite a common condition.
An MRI or x-ray usually isn’t required to diagnose PFPS. There is a “shopping basket” of potential risk factors/symptoms associated with this condition so have a look below as to which may be applicable to you:
- Your knee bends backwards a bit too far (knee hyperextension).
- Abnormal knee cap (patella) position is when your knee cap may be too high (patella alta) or pulled too far to the side. Even a small discrepancy will cause changes in how the joint is loaded, and resulting pain, if not corrected. The outer part of your quads (Vastus Lateralis or VL) can pull the knee cap too far to the side if they are overly active, or if other parts of the quad muscles aren’t doing their job properly.
- Foot position: excessive pronation.
- If you have sprained your ankle in the past, beware, this this can actually lead to weakness in the muscles around your hip and indirectly cause knee pain.
- If you have low back pain your glute muscles sometimes do not fire properly leaving you more prone to knee pain.
- Do you have pain over the knee cap in sitting? If you do, it may suggest you have tight hip flexors or quads.
- Do you have pain going up hills/stairs? If you do, it may suggest you have tight calf muscles or weak glut muscles.
- Do you have pain coming down stairs? Again this may suggest tight calf muscles or weak quad muscles. However, in particular, it suggests quad weakness if you feel it in the downward phase of a squat (eccentric load).
- Perhaps you have had inward twisting of the thigh bone (femoral anteversion) since you were a child. This may leave you prone to altered patella joint loading.
Any of the impairments noted above can alter the mechanics and loading on the under-surface of your knee cap and irritate the bone underneath the cartilage (cartilage doesn’t have nerves hence won’t be the source of your pain), or the soft tissue structures surrounding it.
Puffiness below your kneecap, which is worsened by standing or going barefoot, may suggest that a little structure, we all have, called a “fat pad” which lies below your kneecap, is being pinched. It has lots of nerve endings in it and so can be quite painful.
It is essential to get on top of your pain before trying to get back running. Your muscles may be stopped from doing their work properly because of pain and swelling, and if you try to run in this phase, you will cause more joint injury. Exercises are shown in the video.
- Ice massage over any swollen area on oiled skin 3 mins x 3 daily in acute phase.
- Deep dry needling over the outer part of quads as trigger points commonly build up here
- Straight leg lifts while lying down, to activate and strengthen the quads. If your knee is acutely painful and this exercise is sore then you can start with doing the exercises with the knee a little bent, push the lower part of your leg up against your other leg and hold 10 seconds x 10 reps (isometric quads exercise)on alternate days and progress to longer holds as able.
- When going down stairs lean slightly forward at the hips and you will note your knee feels more comfortable.
- Taping. There is no amazing evidence behind taping but for some people it feels really nice. You will know if the taping has a role in your situation if you feel benefits straight away. It should not increase your pain!
- Foot assessment & footwear: high heels over-load the knee cap, barefoot/pumps/flip-flops offer no hind-foot support. Tight calves/hamstrings may indirectly cause over-pronation and knee pain by resulting in excessive rotation of your tibia as you walk/run so stretch out these muscles.
- Tight hip flexors will compress the kneecap excessively and can easily be stretched or foam rolled.
- Glut exercises are a must for this condition. I have given a glut circuit in my recent article on “Top Tips for runners 2018” but here are some very useful ones to start on for this condition (check out the video):
- Hip drops: start at 10 reps and aim to progress to 3×20 with a light ankle weight if possible.
- Side bridge.
- Lateral (sideway) walking progress to Monster Walking with Theraband.
- Sitting static/eccentric external rotation (Theraband).
- Bridging with external rotation (Theraband tied around thighs).
- Clam at 20 and 90 degree hip flexion.
- As your knee pain settles and your muscle function improves you will be able to start adding squats and leg presses. Start with a wall squat before full squatting. Avoid lunges in the early stages and when you do start, begin with reverse lunges.
- Cross training: I find rowing on an ergometer is great for quads muscle activation & strength without overloading the knee. For others, it may be the cross trainer, elliptical trainer or exercise bike using a high cadence and low resistance as long as it is not causing your pain to flare.
As with all running injuries try avoid doing too much, too fast or too soon, without adequate recovery/rest. Make sure you consistently include mobility/stretching and strength and conditioning in your training schedule.
Wear good runners, and consider house trainers in the early symptomatic stages. If you have a desk job and drive to work, remember to get up as often as you reasonably can, and perhaps fit in a lunchtime walk – even 5 minutes to come out of the flexed position.
Also, when sitting, try not to cross your legs as this can, indirectly, draw your knee cap sideways via the ITB. When running, try to increase your step rate and reduce your stride length slightly to reduce load on your kneecap.
When running, try to lean forward slightly (Chi running style!) to reduce kneecap contact pressures. A really useful website is: www.clairepatella.com this lady is a genius on knee pain and how best to manage it. Every little helps!