In medical terminology, “runners knee” is called patellofemoral pain syndrome (PFPS). It is a problem that responds very well to physiotherapy treatment and there is a reasonable amount of research evidence behind what we do.

What is it?

The pain arises from around or under the patella (knee-cap) and can be as a result of it not tracking properly in its groove. There are some common risk factors that can affect how the patella tracks.

• The resting position of the patella: some people are predisposed to problems because of the position of their patella. It may sit too far to the outside of the groove, or be tilted or rotated, which may increase contact within the groove. Physiotherapy can treat the muscles around the knee to alter biomechanics to optimise this tracking even with patellae that are malpositioned.

• The muscles around the knee: namely the quadriceps or thigh muscles. If the inside quads muscle does not activate well it can cause tracking issues, and people with patellofemoral pain tend to develop weaker quads. If the iliotibial (IT) band, which runs down the outside of the thigh, is tight, it can pull the knee cap more towards the outside of the knee.

• Hip and pelvis control: if your pelvis drops on the opposite side as you bend your knee this can cause strain through the knee and affect the angle of pull through the muscles, causing tracking issues. A simple way to test how you move is to do a single leg squat in front of the mirror; if your belt line drops down as you bend and your knee does not move over your foot then you do not have optimal mechanics. But the good news is that this too can be improved.

• Foot position: if your feet roll in a lot then your knee will have a tendency to twist in and this can cause tracking issues as well.

What causes it?

Like most running injuries, runner’s knee is an overuse rather than a traumatic injury.

• Changes in load can be one of the biggest factors. So this could be related to the volume or intensity of your training. Insufficient recovery can also be a factor. This is why it is important to keep a record of what you have done and only change your training parameters gradually. I normally tell my patients that it is best to avoid changing both speed and duration in the same session as they are building up mileage. You should also factor in a lighter week every four weeks to allow for some recovery in your training.

• Biomechanics, relating to the way you move, can also affect the relative load through the patellofemoral joint. The risk factors listed above can increase the chances of developing problems. This is something a physiotherapist should assess in detail in terms of muscle length, activation and how you move, with functional tasks as well as walking and running.

• Footwear can also be a risk factor. It is important that you wear appropriate footwear. Some people may require motion-control trainers, while others may need more cushioning. The easiest way to check what footwear you need is to get an assessment at one of the many specialist running stores. It is also important to replace your trainers regularly. It is quite difficult to give an accurate time frame or maximum mileage as it depends on many factors such as weight, running style, if they are ever used for anything else except running and the style of trainer. Although it is quite a large range, 300-500 miles is often quoted. Racing flats or “barefoot” style trainers will wear more quickly. A lot of runners can tell by the feel of the shoes – the trainers feel dead and the spring has gone. It is important not to just go by the external appearance as this will not give you a gauge of what is happening in the sole, which is where the shock absorption and control takes place. It is also worth pointing out that even if trainers are left in the cupboard the shock absorption component will degrade.

• Training surface: if you change where you train this can also sometimes put you at risk of injury. For example, if you do not normally do hills or run off-road then a sudden change to this surface will increase the demand on your legs significantly. Your body needs time to adapt to the surface you train on. So don’t be tempted to just go out and do a really hard hill session out of the blue, or you may end up in a physio’s room seeking help.
  

How to treat it?

There are a lot of treatment options for patellofemoral pain and it normally responds well to physiotherapy. The treatment is not prescriptive and will depend on where you are in your training and why you have developed symptoms. The main treatment options are as follows :

• Education: understanding why you came to have this injury will help to avoid recurrence. This is a key part of the treatment. It is important to look back and see if you have made any training errors related to load or training surface.

• Rest or reduction in activity: mostly there will need to be some alteration in your running activity. If you are lucky, it might just be cutting this back a little but if the pain is too severe, you will need to rest to allow the irritation to settle. If you are training for a particular event then it is important that you keep up cardiovascular training where possible but using an alternative method that does not aggravate the symptoms until you are back to running.

• Taping: there is evidence to suggest that taping the knee can help in the short term to relieve pain and may allow you to continue running and start exercising the muscles in the thigh earlier. Some patients also find it helpful to use a knee brace.

• Correcting any biomechanical issues: this will involve assessing how you move, and using mirrors and videos to help to teach you new movement patterns. It is likely to involve improving glutes and quads strength and activation, and sometimes muscle stimulators may also be used to make changes more quickly if you are very weak. There are a number of different exercises that target these muscles, including squats, single leg squats and lunges. However, pain is a big inhibitor to muscle function so it is important that the exercises are comfortable. It is worth understanding that doing these exercises without appropriate instruction and supervision may worsen the condition.
  

• Soft-tissue release and stretching: each person will present differently. Some people have tightness in their calves, quads and hamstrings, and therefore soft-tissue release and stretching may be appropriate. Mobilisations to the ankle and around the kneecap may also be used. However, issues in flexibility as a primary factor are probably less common than strength and control issues with patellofemoral pain. This means that stretching/rollering alone is unlikely to resolve your symptoms.

• Orthotics: if you do roll your feet in excessively then you may need an orthotic device – an insole you insert into your shoe to help support your arch. This can be bought off the shelf or custom-made by a podiatrist. If your feet only roll in a little then you may be able to improve the position of the foot enough with the correct pair of trainers.

• Anti-inflammatories: if you are unable to carry out normal functional activities without significant pain, then a course of anti-inflammatories may be appropriate. If you are in training and have a race coming up, then – with the advice of a medical professional – it may be appropriate to run with some pain and use anti-inflammatories to reduce the symptoms. This course of action obviously risks masking the pain and should therefore be discussed with your doctor or therapist. If you choose to continue to train, despite pain, to compete in a race, it is important that you allow yourself time post-race to address thoroughly the issues surrounding why you developed the pain in the first place.
  

Rebecca Christenson is a physiotherapist at Pure Sports Medicine. Contact her at puresportsmed.com or follow her on @rebchristenson.