Injury: Patellofemoral pain syndrome (runner’s knee)

Gavin Burt is a registered osteopath specialising in running related injuries. He graduated from the British College of Osteopathic Medicine with a first class honours degree in Osteopathic Medicine in 1998. He is a veteran long distance runner and managing director of Backs & Beyond Ltd (www.backsandbeyond.co.uk) in North London.

Here are his top tips on diagnosing and treating PFPS - 

By far the most common running injury that darkens my door, and i’m sure the doors of most osteopaths and physiotherapists, is Patellofemoral Pain Syndrome.

Also known as Runner’s Knee, PFPS is when the cartilage between the kneecap and the knee becomes irritated and inflamed, resulting in pain at the front of the knee while running.

As well as being a really common injury, if left to its own devices and not treated promptly and properly, it can end up creating knock on effects to other joints (remember the knee bone’s connected to the leg bone etc etc….!). It can even lead to something altogether more serious, Chondromalacia Patella, a condition where the cartilage behind the kneecap actually becomes frayed and damaged.

It all sounds rather depressing, but there is lots of good news. You should be able to identify it, effectively treat it, and take constructive steps to avoid it happening again.

How to identify it - Page 2

Identifying PFPS

Identifying PFPS

You should suspect that you may have PFPS if you feel the following….. :

1) A dull and aching pain around the area of the kneecap.

2) Pain that worsens when walking up or down stairs, kneeling, or squatting. Basically any movement that puts a heavy load through the knee while it is bent. This includes doing lunges, burpees, and explosive ‘plyometric’ training.

3) Interestingly the pain can come on from sitting with your knee bent for a long time (often called the ‘theatre sign’)

5) You may be able to see some swelling around the sides of your kneecap

The Causes - Page 3

The Causes of PFPS

Like most running injuries, PFPS is an overuse problem, which occurs for two main reasons, which often happen together…...

1) The kneecap is being forced against the knee with unreasonable pressure. The kneecap acts as a pulley, redirecting the force of the pull of the quadriceps (thigh) muscles into a direction that induces straightening of the knee. By its very nature then, the forces clamping the kneecap to the knee can be substantial and damaging.

2) The kneecap is not ‘tracking’ properly. In an ideal world the patella sits comfortably in a bony channel and doesn't shift left or right much when you bend your knee, but if there is an imbalance in the strength or flexibility of your quadriceps muscles, it will cause the kneecap to migrate to the left or the right, and the friction that is produced from this migration irritates the cartilage behind the kneecap.

How to treat PFPS - Next Page

How to treat PFPS

Where to go from here

If you think you have developed PFPS, it’s useful to ask yourself some questions - 

a) Have I increased the intensity, length or duration of my running by too much in too short a space of time?   I dont think i need to say too much about this as everyone harps on about the 10% rule! And for good reason. Every run will create a little irritation in all joints, which the body then heals and is stronger for it. If you increase training too quickly, your body simply has no time to heal the irritation before the next time you run. If this happens a few times you will start to hurt.

b) Are my running shoes giving enough support or cushioning to my foot (are they right for me?) or indeed are they worn out?  The cushioning of good new running shoes helps reduce the shock of foot impact reaching the knee. Of course, its even better to ensure you include grass or other softer surfaces in your training runs, rather than always pounding the tarmac.

c) Could I be doing too much jumping, plyometrics, squats or lunges in my cross training schedule?   These types of exercises really make you feel stronger, but can be so detrimental to our kneecaps if not done carefully or correctly. You’ll know if this is the main cause of your PFPS if simply removing any of these types of exercise reduces your symptoms..

d) Have I had in the last year or so a previous injury that was never treated that may have led to my body adjusting the way it works, resulting in PFPS?   The only real way of finding out the answer to this question is to go and see an osteopath or physiotherapist who is experienced in running biomechanics, and they can tell you by assessing the mechanical working of your body. However, you don’t need to be a rocket scientist or a brain surgeon to realise that one injury can lead to another. For PFPS this is particularly true if you have had a back problem, or if you have had any type of foot pain that causes you to adjust the way you run.

e) Could my style of running be putting too much pressure through my knee?   People who develop PFPS are often what I call ‘thigh runners’; when they run they bounce up and down a lot, with the shock being absorbed by the quadriceps (remember the ‘pulley’ analogy i mentioned?), and their centre of gravity is often just on top of their feet or behind their feet, running as if they have a rope around their waist and are being pulled forward by someone. PFPS is just one condition as a result of this type of running (others include groin pain, ITB syndrome, achilles tendonitis and shin splints).

The type of style change that can help improve or prevent PFPS is fairly simple to apply. Imagine that you have a rope tied around your waist, and the rope is tied onto a sledge behind you (I thought the winter analogy might be appropriate!), and that you are trying to run while pulling the sledge. Imagining running this way changes where you place your centre of gravity, so that you can start to activate the muscles at the back of your legs (your hamstrings and glutes) which will take the strain off your quadriceps and kneecap. A word of warning however, beware that leaning further forward does give one the tendency to run on the toes, making us more susceptible to shin splints and achilles problems. To avoid this, just imagine that you are landing and taking off from your heels, and not pushing off with the ball of your foot.. You know when you’ve got this right if when you toe off, you should not feel much pressure against the ball of your foot.

f) Could I be running asymmetrically due to some of my muscles being tighter on one side?   Now this is my all time most important running bugbear, and one that i bore my patients with day in and day out. So listen carefully, as i will say this only thousands of times! Everyone’s muscles are tighter on one side compared with the other. So why is it that when we stretch, we spend the same amount of time stretching for example both calf muscles?? Surely that just perpetuates the difference in flexibility that is already there? And surely that means that we would run asymmetrically, creating potential for all manner of running injuries?

Balance and symmetry is so important to healthy and pain free running, so when you stretch I would recommend doing the following - Starting with the calves, test which calf feels tighter by simply testing a stretch on each side. Identify the tighter muscle. Stretch the tighter side for 50% longer than the more flexible side. Do this protocol for every muscle that you stretch on a regular basis.

Dos and Don'ts - Next Page

Some Dos And Don'ts

Don’t stretch the quads as the stretch itself tends to increase the pressure of the patella against the knee. Instead try foam rolling or using a wooden spoon or rolling pin to massage up and down the quadriceps muscles. This will give a similar result as stretching.

Do Stretch your hamstrings, calves and hip flexors on a regular basis.

Do try sports taping to help keep the patella in line (or a sports ‘open patella’ knee support may help), and strengthening exercises to encourage the kneecap to track properly.

Do strengthen your hamstrings and glutes, as you will need their support as you change your running style to be more efficient.

Do try ‘retrorunning’, which is essentially running backwards. Most safely done on a treadmill with side bars, retrorunning takes pressure off all the usual muscles that are used when running forwards. A 5 minute session three to four times per week is a good start.

Do visit an osteopath or physiotherapist who specialises in running injuries, not just one who deals with sports injuries in general (after all they may only be experienced in swimming injuries of the shoulder!). A good running injury therapist will check lots of things, one of the most important (especially for runners who regularly run over 5k) being whether or not you have one leg shorter than the other, which is often due to a pelvic imbalance that can be corrected on the spot.