The knee is the most commonly injured body part in distance runners. Patellofemoral pain(PFP), or commonly named “Runner’s Knee,” represents as much as 13%-30% of medical consultations for running-related injuries. PFP is defined as pain around or behind the patella (knee cap) that is aggravated by at lease 1 activity that loads the patellofemoral joint. In this Blog, I would like to discuss the comprehensive management of PFP.
As stated above, PFP can occur with activities that load the PFJ. If you are a runner with pain in the front of the knee, you obviously know that running loads the PFJ. It is also common to experience pain with other PFJ loading activities such as squatting, going down stairs, lunging, and even sitting with your knee bent. In this Blog I am going to summarize a paper written in the Journal of Athletic Training which outlines a comprehensive, evidence-based approach to managing “runner’s knee.”
The appropriate management of PFP is multifaceted and takes into account all factors that can contribute to an onset of pain in the front of your knee. There are 4 main categories that need to be addressed help get you back to running pain free:
1. Education on Training Modifications
Like most running-related injuries, training error is a big contributor. For running, this has been shown to account for upward of 70% of injuries. Basically, the runner does too much too soon. This is the easiest to example-increasing mileage too fast, speed, adding more difficult terrain can all increase the load through your body and contribute to pain. You are in effect increasing the load to where it is higher than your body can handle (it’s capacity). See picture on right.
But what if you didn’t do any of these things? Then we have to consider factors that may have decreased your capacity during your recent training period (see right side of picture above). As seen, there are other “life factors” that could have predisposed you to a pain onset and these have to be considered and managed.
Either way, the goal is to keep you running and the first and maybe most important step is to help you to modify your running so that you can continue running while at the same time, decrease the sensitivity of the tissues around your knee cap region. There are multiple studies that have shown that this education alone, can help runners get back to running pain free.
2. Strengthening Exercises
Contrary to popular belief, there is no strong evidence that your pain came on because you were weak. However, there is a lot of research that shows that strengthening exercises are beneficial for PFP. Exercises that target both the hip muscles and the quadriceps (thigh) are recommended to optimize outcomes. What and how you do this will depend on your symptoms and need to be individualized for each runner and their pain presentation. If you need assistance in getting started in this the right way, please let me know.
3. Gait/footwear Modifications
The evidence for managing PFP shows that for pain symptoms that have been around longer, making gait modifications that shift forces away from the PFJ can be helpful. These changes can be temporary to help decrease pain and keep you running. Some modification examples may be changing your stride length by changing your cadence, changing foot strike pattern, and minimizing hip drop (see picture to right). Also, even something as simple as focusing on “running softer” i.e. making less noise with foot strike, has been found to be very beneficial.
In regard to foot wear, there is a lot of research about the “right” kind and how this may or may not relate to running injuries. In general, if you want to reduce your chance of experiencing a running-related injury, pick a show that is comfortable to you you right from the beginning. No need to get hung up on a certain type of shoe for your foot shape (i.e. pronation or supination)-just get one that is comfortable.
For a runner who is experiencing knee cap pain, the evidence might surprise us. Your first instinct if you are having pain with running might be to get a shoe with more cushion. However, this may not be the way to go. Research looking at forces placed through the PFJ has shown an increase in PFJ when cushioning was increased (moving toward a more maximalist shoe). Conversely, moving toward a minimalist shoe (less cushioning) decreased the forces through the PFJ. Therefore, minimalist footwear represents one of the many options available in the treatment approach for runners with PFP, although a gradual transition period must be considered to allow for adaptation of the foot, ankle and calf muscle, and Achilles tendon unit.
4. Addressing Non-mechanical Factors
Like pain in other body regions, the influence of psychosocial factors on running injuries has been investigated. More research in this area is showing that non-mechanical factors can be a contributor to a new pain onset in runners. What are non-mechanical or psychosocial factors? These can include stress, anxiety, overall lower mental health-related quality of life, more negative emotions, perfectionism, and lack of sleep quantity. These factors are actually more influential than several factors that were classically believed to cause PFP, such as flexibility, lower extremity alignment, arch height, rearfoot motion, strength, and footwear. All of these factors have the potential to decrease the body’s capacity to recover and decrease the overall tissue capacity as discussed in the first section of this blog. How much these are a factor in a runner’s pain presentation, and how much they should be addressed, varies with each individual, but without considering these as a contributor and taking steps to change these things, the rehabilitation of PFP may be incomplete.
In summary, there are many reasons for developing PFP and multiple factors that can be addressed to help you get out of pain. Which treatment strategy is best for you can only be determined by a detailed assessment of your training, physical function, and consideration of psychosocial influences. Education in the concept of the overall balance of external loads and internal capacity should represent the main component of the clinical approach, supplemented by exercise and gait or footwear (or both) modifications and addressing psychosocial factors when judged necessary.
Don’t let knee pain stop you from doing the running that you enjoy and keeps you healthy. I would be happy to start your path to recovery with a phone call. Just click on the button below and we will find a time to chat about what can be done to help you.
Bob