Updated: Sep 28
Do you have a recurrent dull ache in the front of your knee that is limiting your running?
Is your knee tender to the touch on or around your knee cap?
Does your knee hurt after you’ve been sitting for too long or maybe first thing in the morning?
Does your knee feel like it pops or clicks more frequently?
These are all typical complaints that characterize “Runner’s knee," clinically known as Patellofemoral Pain Syndrome (PFS). Runner's Knee/ PFS pain is mostly caused by overuse rather than a traumatic injury.
Runners with this injury can often continue to run without having to completely stop. Stopping all activity may stop the pain from getting worse (though not always,) but it's more important to address the underlying issues so that the pain does not return or just hang around.
Knee pain isn't something runners should just accept as a part of what it means to be a runner or assume that injections or surgery are the only or best option.
Although this condition of knee pain can seem fairly straightforward, PFS pain can come from a variety of different structures such as the knee cap, patella tendon, fat pad, surrounding muscles, and ligaments. Though it can be easy to categorize the pain as PFS, it is harder to identify what structure is the actual source of pain.
At 901PT, we take a closer look at the symptoms during a thorough examination to pinpoint the exact cause. We also examine above and below the knee because weakness and tightness in these areas (especially the hip and ankle) can have a significant effect on the stress being placed on the knee and be key contributors to PFS.
Keep reading because this article will help to shed light on a few of these issues and what to do about them.
***One key point before moving on: Despite what is the actual source of pain, the overall goal is to assess if the painful tissue in the knee is able to cope with the load placed on it, and then form a plan to help the body heal and regain it’s resiliency to a load of running (or squatting, etc). Too many times we find people are overly focused on the actual source of pain and feel paralyzed or frustrated by this.
However, it is our experience that by focusing on the environment around the painful knee and addressing the excess load being placed on it, we can achieve a successful outcome and keep our runners running without having to take a prolonged break or need an x-ray or MRI that can, honestly, lead people down an unnecessary pathway.
Now back to the knee-
1. One way we can assess the patella’s ability to handle compression (to see if this is causing pain) is to perform the PATELLAR GRIND TEST.
This test is just one piece of the puzzle because there is no one test that has perfect validity or reliability to say exactly what is going on. But using this test coupled with a series of other tests can help us know exactly how to treat it.
In the below video, the test is demonstrated so that you can perform this on yourself. This can be done with the knee straight (as seen in the video) or you can do the same test with the knee bent to about 20-30 degrees.
*** IF you have pain with this test, it can indicate that your knee has become sensitive at the patellofemoral joint due to too much compression of this joint from either over-training or potentially from other surrounding issues.
2. One such issue can be from having too much tightness or tone in your quad muscles.
The quads play a crucial role in how your knee cap functions, so they're a great place to start self-treatment when you have pain in the front of your knee. This can be done by correctly using a foam roller on the quad muscle to help relieve the tension or even trigger points (knots) that can develop in this muscle and be a major source of the pain. See the below video for how to do this.
3. Next is an assessment (and exercise) on how much motion you truly have in your knee.
This simple test (and treatment) can be super helpful if you have pain or tightness with bending or straightening your knee. You MUST address this because we find that people can have a long history of PFS yet have never addressed the fact they lack FULL motion of either flexion or extension.
To perform this motion, start with lying on a slick surface while wearing a sock. Keep your opposite knee bent for support. Then take your time as you bend and straighten your knee by sliding your heel back and forth. Pay attention to how far your knee goes in each direction and compare it to the opposite side.
IF your knee is stiff in one direction, you NEED to work on this. Do this by holding for 3-5 seconds at the end of your limited range. You can even grab your ankle as you bend the knee and add overpressure to this movement to ensure you have full motion.
When you straighten your knee, make sure your knee can fully extend (again compare to your other knee). Do this by squeezing/tightening the muscles of your thigh at the end of your range (this is called a “quad set.”)
You may feel some discomfort as you straighten and bend your knee, but this is safe to proceed as long as the more you do, the easier it becomes. But don’t be surprised if this is sore at first! Perform 20 heel slides 3-4 times a day.
These might be uncomfortable but should be tolerable, and the goal is to help normalize your knee range of motion.
4. Another key factor in treating Runner's Knee is to address the imbalances that often occur in the hip muscles above the knee.
Having well-functioning hip musculature will help offset the stress placed on the knee, not just because of the strength these muscles provide, but because the hip muscles (including the gluteus medius, piriformis, deep hip rotator muscles) play a critical role in the “neuromuscular control” of the pelvis and hips. Lacking control in these muscles can lead to increased torque and stress to the knee causing problems.
One way you can address this with the “Bridge Series” exercise to help activate and improve the control of your hips. (See video below)
The beauty of this exercise is that first it can be done even if you’re having a fair amount of knee pain because you are lying on your back and therefore not overloading the knee. Also, by doing a combination of movements, you are training the hip muscles in multiple ways (in multiple planes) that are needed for running. A simple glute bridge exercise will not accomplish those needs, this is why we recommend this series!
Note: For all three of the bridging exercises make sure to NOT allow your lower back to arch, but instead keep your core activated. When done correctly, you should feel your butt muscles burning, not your lower back muscles. Also, you should feel your hamstring and quad muscles working too, but this cannot be to the exclusion of your butt! So be sure you squeeze the butt muscles throughout this series.
1. Glute bridge: While keeping your knees apart, squeeze your butt muscles as you raise and lower your hips. Do not arch your back. Do 2-3 sets of 10 reps.
2. Bridge with Hip Abduction: Squeeze your butt muscles as you raise your hips. While keeping your pelvis/hips still and NOT shifting (by keeping your butt and abs tight), move your knees in and out. Do not arch your back. Do 5-10 reps before lowering your hips back down. Do 5 sets.
3. Bridge with Marching: Raise back up to the bridged position. While keeping your pelvis/hips still and NOT shifting (by keeping your butt and abs tight), march your knees back and forth, performing 3-5 marches each knee before coming back down. Do 5 sets. Be sure to adjust your range and reps for a good butt burn and make sure there is no knee pain with this exercise.
5. Lastly, a great way to help address the problems associated with knee pain is to work on your squat!
Squatting helps in multiple ways, mainly in developing good movement patterns of the lower body as well as strengthening your quads, glutes, and hamstrings, all of which are needed for running (especially those quads!) Every runner needs to include these in their weekly cross-training program!
However, many people are fearful of squatting and wonder if it will make their knee pain worse. So what we recommend here is to start with performing mini squats. This is a great place to start if you are fearful of pain with squatting all the way because you simply adjust your squat depth to keep your squat as painless as possible and to focus on form. Then as you improve, you can work on squatting deeper working towards a parallel squat, and then adding weight.
To perform the squat while minimizing stress to the patellofemoral joint, start with hinging at your hips and sticking your butt out as you bend your knees. You should feel your body weight primarily through your heels, but don’t let your toes come off the ground (keep your big toe pressed into the floor).
As you descend and ascent out of the squat, keep your knees in a neutral position by not allowing them to point inward (or too far outward). You can focus on your kneecaps staying in line with your 2nd toe. As you focus on controlling your squat, monitor how your knee feels.
If it’s painful, we recommend 2 things:
1. First, simply do not squat so low that it causes pain.
2. Second, really accentuate the hip hinge and do not allow the knee to go over your toe.
*Disclaimer*: It's not wrong or bad for your knees to go over your toes during squats. That is a very normal motion and your patella and knee joint is fully able to handle this stress.
HOWEVER, with this condition, allowing your knees to go over your toes may increase your pain and can be counterproductive. So you may need to first bias the exercise by sticking your butt further back to reduce your knee from going over your toes. As your knee pain calms down and eventually goes away, feel free to start allowing your knees to naturally track over your toes for a more normal and deeper squat.
The goal here is to master good form, work on feeling the muscles in your leg activate and improve in strength, and then eventually increase in squat depth.
In conclusion, patellofemoral pain can be tricky due to the many structures surrounding the knee.
The above advice can be helpful to start figuring out the specific cause of your particular knee pain.
Ultimately, your recovery will be much more successful under the guidance of a specialist.
We're knee and running experts at 901PT and can diagnose what's going on with your knee and walk you through a strategic plan on how to get back to 100%.