Dreaded Runner’s Knee

Dreaded runner’s knee. That feeling when you notice a vague soreness in the front of your knee that you can’t pinpoint. Then you start to notice more localized pain with going up the stairs or coming down a hill. The pain sometimes gets more severe around the top of your kneecap (patella) or along the rubber band that attaches the kneecap to your leg (patellar tendon.). Then it progresses to a sharp pain with bending or a crunchy sound in your knee (crepitus.) Sometimes, you may even have pain with sleeping or sitting in chair for too long. When it gets severe, it will even feel like your knee gives out on you. Then one day it happens when you are on a long run… You are halfway through your run, and you feel your knee give out on you. It feels that the top of your knee is now separated from the bottom. You are left looking for the imaginary person who obviously ran into your knee causing it to feel unstable. The next obvious question is how you will continue with your training. Will this happen again on your next long run? Will it happen on race day? Can you keep running? 

What is runner’s knee? It is irritation related to the tracking of your patella. If your patella shifts when you run, it will often cause irritation of the soft cartilage on the back of your patella. This will often cause pain and swelling in your knee. Bending and squatting can exaggerate the movement of your patella and worsen symptoms. Once the swelling and irritation starts, it often continues to get more irritated. As the cycle continues, the first thing you go to is rest. After a little bit of rest, you try to return to your running. Unfortunately, you then notice with rest that the pain returns as soon as you start to run again.  

So what’s going on? The cartilage on the back of your patella is soft and is easily irritated. When your patella moves more as it is tracking, it can hit that soft cartilage causing the irritation in the form of inflammation. Once the swelling starts, your knee becomes painful and this can affect your gait. The more you run, the more the muscles fatigue and your patella moves continuing the cycle. The problem with resting is that it doesn’t help to strengthen your muscles to help decrease the movement in your patella with your gait. It doesn’t mean resting from running can help with pain and decrease the swelling in your knee.  It is better to find a balance of decrease your mileage while working on strengthening. 

While you are rehabbing and running, make sure to check in with yourself. If you start to feel more pain in your knee on a run, think about your gait. Do you feel like your stride looks strong or would you look like a sloppy mess? If it is more of the latter, I recommend stopping and walking to get a restart on your gait. You may want to slow your speed and really focus on maintaining your level pelvis while you are running.  

Until your pain is significantly improved, you will want to keep your mileage and speed down to a level that does not fatigue your pelvis. For many this will be about a mile before you hit your “wall” at your long run pace. This will help you to not exacerbate the weakness of your pelvis. While doing this, you want to add some exercises to help strengthen your legs, core and pelvis. Be careful as you will often worsen your pain before it gets better. Remember you are strengthening the muscles that help your patella track better, but until they are strong, they can also exacerbate the movement of your patella. A rule of thumb, if your pain is increased around 2 points on the pain scale after you do your exercises you are ok to continue. If it is more than that, time to cut back and take a few days rest.  I recommend doing a combination of these exercises daily until you are pain free at rest and do not have significant pain with running. What is significant pain? Pain that is affecting how you are running? Are you running with a limp? If so, you are in significant pain and should rest. Once your pain improves, you can start to decrease the frequency to 3 times a week.  

For anyone with a history of runner’s knee, I recommend a simple exercise to check in to make sure your strength is where it needs to be before you increase intensity, speed or duration. Watch yourself in a mirror doing a single leg squat with the other leg bent behind you. This way you cannot cheat and use it for balance. When you are looking at this, you want to look at two areas – your knee that is performing the squat and your pelvis. When you bend your knee, does your patella shake? Does it stay in line with your big toe or is it looking/feeling like it is going to collapse inward? Do your pelvis/hips stay level or do they shake? Do you start to bend forward at your pelvis instead getting deeper in your squat at your knee? If you answer yes, it is time to work on those strengthening exercises before you progress further. If you answer no, go ahead with progressing forward with your training plan.  

If you recognize these exercises from a prior tip from me, don’t be surprised. Many of the pains runners suffer are related to similar weakness and often have overlap in the treatment recommendations.  

• Walking lunges: you will do these like normal lunges but slow and take your time. At each point in your lunge, stop and gain control if you wobble at all. Once you complete a lunge on one side, step through with your other leg and lunge on that side. Again, slow and controlled.  
• Planks: Work up to a goal of 3 minutes for your plank. 
• Single leg squats: just like I described above. Slow and controlled is key. You can increase intensity by doing this off a step. 
• Clamshells: definitely focus on slow controlled closure. You want to feel a burn in the middle of your gluteal area. That’s how you know you are doing it correctly. 
• Hip 4 way: using a band either around your lower legs or attaching to one leg and to a door. Standing on one leg, use the leg attached to band if not using a circular one and move it all 4 directions. Each direction will be a set of 10. Start with forward (flexion), then inward (adduction), outward (abduction) and backward (extension). Take a break between each direction. Remember your support leg should be still and not loosing your balance. If you are, stop and rest. 
• Wall squats: use a Pilates ball or towel behind your back to start. Slowly squat down until your knees are bent to 90 degrees. Then slowly go back up. If you want to make it a little harder, you can try holding a ball between your knees as you squat. 
• Calf Raises: for these, you want to focus on lowering your heels slowly. I often recommend instead of counting, do these for a certain amount of time like when you are brushing your teeth. You can also add a set with your heels turned in, turned out and in the middle (normal stance.) 

Dr. Jennell Kopp
– Medical Director of Athletics and Head Team Physician, University of Denver
– Sports Medicine Physician at Common Spirit
– Colfax Marathon Medical Director