Runner's Knee: Prevention Is the Best Treatment

Runner’s Knee: Prevention Is the Best Treatment 4/9/13

Written by Stacy Ciarleglio, a licensed athletic trainer and ultra runner. 

“I have bad knees.” It’s a common phrase in the world of running. A lot of people complain that they have bad knees or their knees always hurt so that’s why that can’t run or don’t run as much as they would like to. The knee gets a bad reputation, but really, a lot of the blame can be placed on the foot and the hip! Since the knee joint is located between these two, pain that actually is caused by an insufficiency in the foot or hip often presents itself as knee pain. 

The term, “runner’s knee” is a catch all phrase for pain around the knee. Typically, there is no major event that causes the onset of the pain. It may come on after a run, during the day after sitting for a while with the knee bent, or while going up and down stairs. Often, the pain isn’t bad enough that people stop running or working out, but it’s an annoying presence. Continuing to push through symptoms of runner’s knee without addressing the cause can lead to pain that is so bad that you will have to stop running.

The technical term for runner’s knee is patellofemoral pain syndrome, which means that there is pain in the general area of the patella (kneecap) and femur (leg bone). Whenever the word “syndrome” is used, it means that there are many different contributing factors to the pain. Since there are so many factors that can contribute to the pain, it is important to identify the underlying cause of the pain and address that.

The best treatment for runner’s knee is preventing it from ever happening in the first place! Preventing and treating runner’s knee can be broken down into a few categories; strengthening, stretching, footwear, stride, and training plan/ surface.  

When we look at strengthening, it helps if we compare the knee to a train. You’re probably thinking, “what?” right now, but hold on.  Let’s think of the patella as a train and the femur and tibia (shin bone) as the tracks. When we bend and straighten our knee, the patella moves within grooves on the femur and tibia, so, the train moves on tracks. If there is something throwing off either the train or the tracks, pain develops in the general area of the knee. One of the best ways to stabilize the upper train track (femur) is to strengthen the hip. When we run, 3 – 5 times our body weight comes down on a single leg, if there is weakness in the hip, over time, it can present itself as pain in the knee. In a previous Sports Medicine Corner article titled “Gluteus Medius: rotational stability of the hip,” I discuss some exercises that are helpful for stabilizing the hip. Another culprit in runner’s knee can be weak hamstrings. Many runners are quad dominant, meaning they have strong, overdeveloped quadriceps and weak, tight, underdeveloped hamstrings. When we run, we run forwards, and the muscles in the front of the body (quadriceps) get strong, while the muscles in the back (hamstrings and glutes) become weakened. Since most of us are not going to go run backwards, strengthening the hamstrings should be a regular part of your training. Correcting the muscle imbalance can not only help to prevent runner’s knee, it can also help improve your running performance.

Stretching is the next thing that should be a regular part of your routine. While there are many different stretches for the quads, hamstrings, and hips that are all good to do, I want to focus on stretching of the Iliotibial Band (IT Band). The IT Band starts in a muscle up in the hip (Tensor Fascia Lata), runs along the outside of the thigh, and inserts on the side of the kneecap. Going back to the train on the tracks, a tight IT Band will pull the train a little off its track, causing pain typically along the outside of the knee. Most people don’t even realize their IT Bands are tight until they develop a twinge of knee pain, and at that point, it’s usually a little too late. Make IT Band stretching part of your regular routine. How do you stretch the IT Band? Before I answer that, let’s look at what the IT Band is made of. The IT Band is made of a band of thick, tough fibers of fascia (connective tissue). This type of tissue reacts differently to stretching than a muscle or a tendon. In that case, simply holding a stretch for a certain amount of time is sufficient. With the IT Band, one of the most effective ways to stretch and elongate the fascia, is to use your own body weight to break up the adhesions (scar tissue or “knots”) that form within the band. This is accomplished by using a foam roller or other device (Orb, Trigger Point ball, quadballer) for self myofascial release. This process will be uncomfortable at first, but with regular use, it should get more comfortable. Those painful adhesions that you are breaking up are the culprits that lay dormant, until one day they decide to cause you knee pain. Break them up! 

Moving down the kinetic chain to the foot, let’s briefly discuss footwear. Keeping in mind that there are many contributing factors to knee pain, improperly supported feet can play a part in the injury process. Both people that overpronate (their foot and ankle roll in too much) and underpronate (their foot and ankle don’t roll in enough) can be susceptible to knee pain. Making sure that you are in the proper footwear for your foot type is important. Overpronators should be well supported and underpronators need to be cushioned. Typically, overpronation pain will present itself as pain along the inside and / or bottom of the knee. Underpronation pain generally presents itself on the outside of the knee, near the attachment of the IT Band.

Even if you are keeping up with strengthening, stretching, and proper footwear, there still is a chance your knee may give you some problems. At this point, you need to take into consideration your running stride as well as your training plan and surface. Overstriding can be a cause of knee pain despite good strength and flexibility. You have to put your body into a good, efficient position to be able to use the strength and flexibility that you have worked hard to obtain. Proper progression of training is important as well. The body needs time to adapt to the stresses of running. Running, and other exercise, causes a breakdown of the tissues in the body. Those tissues need time to repair themselves and become stronger, otherwise, injury occurs. Strength that you have developed in the gym, on the bike, elliptical, or in the pool is good, but running will still stress your body differently and you need to gradually increase mileage, frequency, and intensity of your runs. A good rule of the thumb is to not increase your mileage by more than 10% per week. If you are not running on a regular basis, take a day off between runs until your body has adapted to running more regularly, even then, a rest day per week is good and necessary for recovery. Lastly, don’t increase the intensity of your runs too soon. Get your body used to running before you start stressing it more with speed work and hills.

Many people ask if there is something they can put on their knee while they run to help them. I like to say “yes” and “no.” There are devices such as the Tendon Trak, patella tendon strap, KT Tape, and knee sleeves that can be worn during activity to help decrease the pain and symptoms of runner’s knee. However, these devices do not address or correct the underlying causes of the pain. I will suggest the use of these devices only if other measures are being taken to treat the condition and the runner wants something that will help them feel better on their runs so they can continue training. 

I know all of this strengthening, stretching, footwear, etc is a lot to think about. Runners want to run! However, taking a few minutes each day to address these things can help prevent injury and keep you running longer and stronger!