Don't Let Knee Pain Ruin Your Gain

Pain beneath the kneecap is one of the most common maladies runners suffer. Often it begins during the run but can sometimes get even worse after you finish. Going up or down stairs increases the pain in many cases, though usually there isn't observable swelling. “Runner's knee” is perhaps most common during or after runs lasting an hour or more, when your quads begin to tire. We are of course talking about patellofemoral syndrome, and here we look at solutions and prevention strategies as our injury article series continues moving “up the leg” (see Keep Achilles Pain from Nipping at Your Heels in Jan/Feb 2014).

The patella is the bone that protects the front of the knee joint, and it is the largest sesamoid bone in the body—meaning it is the largest of the bones that sit completely within tendons. Because the patella sits inside the patellar and quadriceps tendons, it connects to the most powerful muscle group in the body, the quadriceps muscle group. The patella must withstand tremendous amounts of force, and that force is directly related to the forces that come from the quads.

Sometimes these quad forces play out undesirably; for example, if a runner has a strong lateral (outer) quad, the patella can be pulled too far to the lateral side. How well-aligned the patella tracks up and down along the front of the femur also has to do with the thin layer of cartilage lining the back of it, the articular cartilage. Poor alignment or injury to the articular cartilage are frequent causes of patellofemoral pain. Weak or tight muscles contribute because they will compromise running or biking form. If your glutes, core muscles, hips and/or quads are poorly conditioned, this can lead to pelvic instability, another major cause.

Think of your pelvis ideally remaining in a steady, level state as you run. If your muscles are underconditioned, your pelvis may wobble—which is very much like the wobbling of a car with bad wheel alignment. This puts stress directly on the knees, often leading to patellofemoral syndrome. Overpronation, the excessive inward roll of the foot upon footstrike, is sometimes rooted in this unwanted hip motion, explaining in part why orthotics can help remedy knee pain.

Indeed, patellofemoral pain is often quite preventable and almost always very treatable. If you cannot run without pain and the pain is intense enough to alter your form, you should employ dynamic rest. This means cease running, but perform regular pool workouts such as deep water running, and maintain vigorous upper body weight training. Bicycle if you can do so pain-free.

Additionally, slowly begin to build up strength in your knees, quadriceps and hips. Weak or inflexible quads are a major culprit of knee pain, since evenly built-up, strong quadriceps surround and lend stability to the knee. And targeting knees and hips in addition to the quads is the most effective strategy of all, because improved form will result, helping to prevent the injury from returning in the future. The following plyometric exercises will help with lower body strength and flexibility.


Quads-Hip Flexors Roll
Lying facedown in “plank position”with a foam roller under you just above your left knee, cross your right leg over your left ankle. Roll your body backward until the roller reaches the top of your left thigh. Roll back and forth several times, and repeat with the other leg.


Power Squat
Standing with your hands behind your head and feet shoulder-width, pull your elbows back and stick out your chest. Lower your body as far as you can, pause, and slowly push yourself back up. Repeat 10 to 12 times.


Split Squat
With medium-to-heavy dumbbells in your hands, and standing staggered (one foot in front of the other two to three feet apart) with the instep of your back foot on a bench or chair, brace your core and lower your body as far down as you can. Pause, then return to the starting position, repeating for 10 to 12 reps on each leg.


Mountain Climbers
Using a bench or secure chair, get in pushup position with arms straight. Lift your right foot and raise your knee as close to your chest as you can. Going as fast as possible, touch the ground with your right foot and repeat from the starting position with your left leg. Perform at least 10 reps for each leg.


Walking Lunge
Instead of pushing your body backward to the starting position after completing an ordinary lunge, raise up and bring your back foot forward and past your front leg so that you move forward one step with each rep. Alternating legs, complete 10 to 20 reps, then perform backward walking lunges to return to the starting point.

Improve Biomechanics
As noted, poor running form all too often lies at the heart of knee troubles. Consider having a friend shoot video of you on a treadmill so you can look at what aspects of your form may be hindering the smooth, straight, forward motion we need to keep excessive pulling forces from overtaxing our knees. Hip wobble and overpronation are certainly not the only issues that can undermine pain-free training; you may realize that you are landing with your foot out too far in front of your body, for example. A good way to ease landing forces on the knees is to shorten your stride while increasing turnover. Aim for a cadence of 85 to 90 footstrikes on one leg for each minute of running.
If patellofemoral pain persists after more than two months of disciplined, home-based treatment, it's probably time to call the doctor. You may have a different problem after all, and an MRI is usually recommended. Patients over age 50, in particular, may have some form of patellofemoral arthritis—a wearing down of the articular cartilage that warrants professional medical attention, diagnosis and advice.


The Athlete's Book of Home Remedies by Jordan D. Metzl, MD, 2012, Rodale, New York, NY, pp. 31-35 

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