Runner's knee…who dis?

“Hmm my knee feels a little weird…”

“Ok, stairs were not fun this morning…”

“That run killed my knee, I had to walk the last mile to the car…”

“I’ll just lay off a few days, and then do the long run that I had planned for today then…”

(A few days later) “Well, that didn’t work.”

What is it?

The term “runner’s knee” can be used to refer to several different diagnoses for knee pain, but technically runner’s knee is referring to patellofemoral pain. That is a fancy way to say that the space between the knee cap and the thigh bone has become irritated or sensitive.

If you have a general vague knee pain that came on gradually with increased activity, feels like it’s behind or around the knee cap, and running, jumping, squatting, stairs or prolonged sitting seems to irritate it. Then chances are you may have runner’s knee, so keep reading. Before we dig in, this is not medical advice and it’s always important to work with your health care professional to come to an accurate diagnosis and treatment plan.

Ok so, now what?

First off, your knee cap isn’t out of place even though it can certainly feel “off”. This also isn’t about damage to the knee, think of it more as irritation or sensitivity from doing too much.

Key #1: Don’t stop being active, find a level of activity that causes minimal to no pain (0-3-4/10), that settles quickly and, over time starts to trend better. This may mean pulling back mileage, interjecting walk breaks in runs, or if things are really sensitive use walking or cross-training for a bit to let things calm down.

Key #2: Start loading the knee joint progressively, this means to strengthen it, and then make things harder, and then add weight. I’ll show you what this can look like below.

“But I’m pretty strong so why do I need to strengthen?”

When this joint becomes sensitive its tolerance for load through that joint goes down. So you have to meet it where it’s at and then progressively bump up the loads. That can be accomplished with strengthening exercises.

Key #3 Work on your movement control. Learning to control your knee position and pelvic position with exercise and drills can help minimize the stress the knee joint has to tolerate. If you think of your knee as a hinge, learning to control the knee via the foot or the hip can take the rotational stress off of that hinge.

*Remember appropriate rehab is progressive and challenging so the goal is to find a set and reps sequence that challenges you but keeps pain low level, settling quickly, and progressing in the right direction. Ok, so here we go…

Phase 1: Play nice

• For a cranky patellofemoral joint, exercises that don’t require much knee over toe motion and have a shallow knee bend help calm things down and allow you to start loading the joint. We also want to choose a movement control exercise that does’’t involve a ton of knee bend or knee over toes position.

Loading Exercise: Shallow Wall Sit: 4 sets of 45-60 seconds, full rest in between.

Movement Control: Dynamic Marching Foot Focus: 3 sets of 30 seconds progressing to 60 seconds. focus on stable foot and ankle, but relaxed little toes

Phase 2: Hello quad and glutes

• Time to up the intensity after things have calmed down a bit. Increase the depth of the wall sit and add some load to make things harder. For the movement control exercise, we want to hone our control of the knee via the hip and the foot. This exercise is also a quasi single-leg exercise which is important to be able to tolerate before moving to complete single leg work.

Loading Exercise: Wall sit +/- weights: 4-5 sets of 30-45 seconds, you should be getting some leg shake going towards the end of these sets.

Movement Control: Lateral toe-tap progression with thera loop: 4 sets of 10-12 reps each variation/side. Don’t rotate the knee so far out that the big toe comes off of the ground.

Phase 3: Knees over toes is ok (that’s running)

• When symptoms have calmed down we want to start loading the patellofemoral joint in ranges that it has to tolerate with running. So that means letting the knee travel over the toes.

Loading Exercise: Tempo goblet squat (the serious face is required to make the gainz.) 4 sets of 6-8 reps 3 seconds up, 3 seconds down with moderate to heavy load.

Movement Control: Basic step up: 4 sets of 10-12 reps. A taller step isn’t necessarily better, keep the step height 6-8 inches.

Phase 4: Split squats r hard…

• Most people that are tolerating these exercises are able to tolerate some running at this point or potentially even the previous stage. It may not be 100% yet and like the exercises, running would need to be progressive. Run/walk progressions are helpful to accomplish this and to keep you from getting antsy and pushing it too quickly.

Loading Exercise: Rear foot elevated split squat: 4 sets of 6-8 reps progressing to 10-12 reps. 3 seconds down, 3 seconds up.

Movement Control: Fluid step up: 4 sets of 10-12 reps. The main difference from previous version of step ups is now you never unload the stance leg, this demands more control.

Other things that might be important…

Ankle mobility: if you have stiffness in the ankle/foot that limits your dorsiflexion (the ability for the lower leg to go straight over the foot) this could be playing a role in your runner’s knee. This may be a specific situation to work with a PT with to improve this movement strategy. One simple test is to perform a single leg mini squat on level ground and then with your heel elevated 2-3 inches (on a half foam roll, bumper plate, etc). If you notice much more control and smooth movement with the latter then ankle mobility might be something you need to work on.

Cadence or step rate: increasing one’s step rate can help reduce force at the knee. A 5% increase in cadence with the speed kept constant can decrease 20% of the energy absorbed at the knee. As a general rule, if you are below 165 steps per minute at paces faster 10 min per mile, or below 155 steps per minute at paces slower than 10min per mile you may want to increase your cadence 5-10%. This may just be a temporary change or if you find it advantageous for you then keep it.

Slope: incline or decline can add stress to the knee, depending on how sensitive your knee is you may want to run on level ground and slowly phase back in hills as you can.

Trunk lean: leaning forward at the trunk puts less stress on the knee joint so this may be a temporary cue that may help. But once things start to settle in terms of pain time to “un-cue” and run tall. That’s going to be more economical.

Working other key muscle groups: bridge variations, side planks, and calf work can also be helpful for this injury. I have plenty of these exercises on my youtube channel that you could add to the above phases.

FINAL NOTE:

Rehab is not a linear process. It can have setbacks and plateaus along the way, but if you stay patient and consistent you will get to the other side of it and back to consistent healthy training. If you have questions about runner’s knee I’m happy to troubleshoot them with you.

Thanks for reading!

-Steve White, PT, DPT, OCS, CSCS