Managing and Preventing Runner's Knee (Patellar Femoral Pain Syndrome)

Runner's knee, or Patellar Femoral Pain Syndrome (PFPS), is one of the five most common running injuries. The other four are: iliotibial band syndrome, plantar fasciitis, tibial bone strains, and Achilles tendinosis. According to some data, it is in fact the most common running injury. As such, it is one of the fastest routes for any and all interest or enthusiasm around running to come to an emphatic end.

This type of injury is pain under and around the knee cap. It is usually mild pain experienced during running only. If it continues it can become painful to walk and eventually become as serious as any other running injury. As always, I recommend that you stop running and go see a doctor if the condition becomes more painful.

But perhaps contrary to what many seem to think, this is usually a very manageable and preventable injury. So with that in mind, let's take a closer look at what runner's knee is and what we can do about it.

The first thing I always explain to my “coachees” is that knee pain is rarely due to the knee itself. Most often, knee injuries are due to forces stressing it from above and below. Some muscles and fascia get too tight and pull at the knee uncomfortably while other muscles and fascia are too loose, weak, and underused to provide the crucial balancing of forces the knee requires in order to function effectively.

To help you diagnose knee pain origin for yourself, here is a rough guide to the most common reasons for different types of knee pain:

• Pain on the outside or inside of the knee: Likely caused by tight and overused IT band and outside hip flexors. This is often accompanied by weak hip abductors and external rotators. Most likely PFPS.
• Pain on the tendon directly underneath the kneecap: This is not PFPS, it is actually known as patellar tendonitis. Related to tendon degradation, weak/tight quads and hamstrings, and poor explosive leg strength.

John Davis also provides some great insight into the cause of runner's knee as well:

“Historically, research on PFPS focused on factors that affected the motion of the kneecap, particularly how the quadriceps control how the patella “tracks” in the femoral groove.
Indeed, scientific research has showed that people with poor quadriceps and calf flexibility, poor vertical jumping ability (which is highly dependent on your quads),  and weak quadriceps are all risk factors for PFPS.

Blame was often ascribed to a small muscle on the outside of your thigh, called the VMO, which seems to fire differently in people with PFPS. And runners who did exercises that were designed to target the VMO often recovered!

Interestingly: Recent research has demonstrated that these gains were probably from improvement in general quad strength, not VMO activation. And unfortunately, many runners don’t find relief from doing only quad strength, more exercises are needed.”

According to Chris Tucker and Matt Fitzgerald in The Runner's Body, there are several key treatment and rehabilitation options for PFPS:

• Ibuprofen or another nonsteroidal anti-inflammatory medication in conjunction with placing an ice pack on your knee for ten minutes up to three times a day to reduce inflammation
• Strengthen and activate the hip abductors and hip external rotator. Balancing exercises are also helpful. Check out this Hip Strengthening Routine for an example of this. Doing these right before your run can be particularly helpful to activate underused muscles, which you can then consciously continue to use as you run to help with knee pain
• Pronounced heel striking is sometimes an issue. Shorten your stride and focus on landing softer if you do this
• If your shoes are uncomfortable or lack sufficient cushioning, try to find the most comfortable running shoes you can. Comfort remains the best guide to shoes that are the best fit for any individual.

Additionally, I would make some other recommendations. Tape around the knee just underneath the knee cap has been found to be helpful. n stretch routine (here's the one I've created as a good start) should be done after every run and perhaps every day if you are facing knee issues. Extra attention should be placed on stretches targeting the hips, IT Band, quads, and hamstrings, as well as any areas that feel like they are tight or in need of stretching.

Another great supplemental activity is foam rolling. Contrary to its name, foam rolling is more about finding the spots that need it the most and remaining stationary in a position that gets that spot. Those spots are anywhere that feels particularly tight, but the outside hip flexors and IT band are great starting places for foam rolling.

While all these strategies work their magic, it is likely you can continue to run. I would recommend running until the pain starts and then ending your run immediately at that point. Many find that they can run a certain amount and no more, such as 2 miles. For some, it may be safe to run/walk through several cycles of pain free running followed by stopping instantly at the onset of any knee pain. Over time, especially in conjunction with the above recommendations, the amount of pain free running you can do will likely increase.

So don't despair! Runner's knee is a manageable injury, and need not ruin running for you.
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