Knee pain in runners: the 2 most common causes

Knee pain running is common. With the marathons in London and Brighton we’ve seen an increase in people coming into our clinics with knee pain associated with running. The 2 most common causes of knee pain in runners are “Runners knee” and ITB syndrome. In this posting we’ll talk about runners knee pain, what it is and how to treat it. Next we’ll do the same for ITB syndrome.

Runners knee

“Runners knee pain” is more correctly termed patella femoral syndrome and can affect as many as 1 in 4 runners. The symptoms are typically pain under the knee cap and around the front of the knee and used to be called chondromalacia patella.

Anything where the leg is bending and straightening can become painful, particularly when weight bearing, and there may be creaking or cracking under the knee cap, a symptom termed crepitus. Of course running, particularly once milage when training for a longer distance event is increased is a common cause. Aggravating factors also include going up and down stairs, running, in particular up or down hill, leg extensions/quad strengthening in the gym, often sitting for a prolonged times at work or in the car for instance.

Cause of Runners Knee Pain

The causes of runners knee are related to the anatomy of the area. The underside of the patella (kneecap) has a ridge which slides along a narrow groove in the femur (thigh bone). Every time you bend and straighten your knee the patella slides up and down the groove. Trouble can start when your kneecap moves out of its track or groove and rubs up against its sides causing friction. This is called patella misalignment or maltracking. That it becomes painful when you run is not surprising when you realise that there are on average nearly 1000 steps per mile.

Common things that can cause misalignment and how to fix them are:

  • Quadriceps imbalance: This is perhaps the most common cause of runner’s knee. The quadriceps muscle on the front of the thigh is made up of four parts and running strengthens the outer part more than the middle part, thus the patella is pulled out of alignment. This usually resolved with some specific rebalancing exercises for the muscle group.
  • Foot instability: Often your feet imbalanced every time they hit the ground, and you’re feeling the constant pounding and repetition of this mistake in your knee. Over pronating, which means your foot is rolling in too much when you run, is the most common type of this, something that is often associated with fallen foot arches. A combination of orthotics (these are special insoles; at Sundial we use Superfeet orthotics) for your running shoe and exercises is usually enough to rebalance and stabilise the foot. You should also have your running analysed to make sure your shoe is the suitable for you. For more on orthotics and running go here.
  • Tight muscles at the back of the calf or thigh: If the calf muscles are tight the foot will have to pronate further when running or walking causing an increase in rotation at the lower leg bones, if the hamstrings are tight when running or walking the knee is not fully straightened, this also means the foot has to roll more into pronation. Both of these can cause patella misalignment and are treated with specific stretches and rebalancing exercises.
  • Gluteus medius weakness: One of the muscles that make up the buttock, it often relatively weak in runners. If the gluteus medius is not strong enough the upper leg rotates inwards and causes an unequal pull of the patella over its groove. Again, some specific strengthening and stretching exercises usually resolve this.

In addition to the specific treatments for each cause there are a few other things which also help resolve runners knee.

  • Ice: Wrap a cold packs around each knee, with the pack at the front for about ten minutes, a few times a day to bring down the swelling. Make sure the cold pack is wrapped in a thin cover to avoid cold burns!
  • Rest: Not what a runner wants to hear close to an event, but where possible, stopping or decreasing your running will help then problem settle whilst treatment takes effect.
  • Laser treatment: This is useful in reducing the inflammation around the patella and encouraging faster healing
  • Taping: Specific taping techniques, particularly kinesio or Rock taping, something our physio Quentin specialises in, can help straighten the pull of the patella
  • Running/gait analysis: Many running shoe shops offer this and it’s a good way of screening your running for problems and also seeing if your shoes are suitable for you

If you would like a check to see if you have runners knee then call us for our free Runners MOT with our physios or chiropractors.

Do orthotic insoles help with knee pain in runners? Leading Brighton Chiropractor answers

Knee pain is common in runners and a common cause is the patella or knee cap. Pain caused by the patella is often called patello-femoral syndrome or PFS for short. The pain can be severe enough to stop runners going out but also occurs in other sports people and non-sports people alike.

Chiropractor and physio treatment in Brighton

The research on PFS treatment is poor. The studies that have been done are often of poor quality and come up with conflicting results for all sorts of treatment and this can be confusing not only if you are a runner looking for something to help but also if you are a physio or a chiropractor treating these common knee problems.

One of the recent reviews (1) looking at all the evidence for orthotics in the treatment of PFS, sometimes called Runners Knee, found little difference between the groups given orthotics and those given flat insoles which were supposed to do nothing. The other trial which met the criteria compared physio exercises and orthotics. Again not much difference was found between the 2 groups. Delving deeper into the 2 trials reveals why the orthotics groups did not do so well as groups in other trials – but more of that below.

Another study (2) into patello-femoral pain found that orthotics may indeed help. In fact more than three quarters of the runners involved improved. The authors concluded that orthotic or orthoses as they called them may have had a significant effect. This study was excluded from the larger review because it did not meet all the inclusion and exclusion criteria. For example some of the patients were only 12 years old and the study was not a randomised controlled trial.

The difference with this small study and the previous review is that the runners were analysed much more carefully. Their feet, ankles and knees were measured and an orthotic prescribed if they had the right sort of problem.

Chiropractic treatment may help

There are many different causes of PFS. One cause is thought to be over-pronation or excessive flattening of the arch after the heel strikes the ground. If you have over-pronation and it is contributing to PFS then you may respond well to the correct orthotic. If you have PFS from another cause, a weak thigh muscle for instance an orthotic will be a waste of time. In this case a pelvic joint manipulation by a chiropractor may help as in this study (3).

A correct diagnosis of the knee pain is essential for the correct treatment to be applied. A thorough examination should reveal the cause of the problem so that the right treatment can be applied. Too often clinicians use a one size fits all approach that is doomed to fail. This may well also explain why some studies don’t show an improvement whereas others do.

Orthotic buying advice

You can spend a fortune on a custom made orthotic and except in rare cases it is completely un-necessary. Other trials comparing custom made orthotics, often costing several hundred pounds, with much cheaper off-the-peg versions fail to show a difference in the outcome of symptoms.

We have found Superfeet insoles an effective and cost-effective option. They cost between £25-32 and are available on an unconditional money back guarantee from the manufacturer. So even if you don’t have faith that they might work for you it is worth giving them a try but only if you over-pronate. Many running and hiking shops as well as clinics sell them.

For more information you might like to look at a presentation given in June 2011 to the European Chiropractors Conference in Zurich here

Matthew Bennett DC

Sundial chiropractor working with Brighton and Hove Albion and previously with the British Alpine Ski Team.

References

1.Hossain M, Alexander P, Burls A, Jobanputra P. Foot orthoses for patellofemoral pain in adults. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD008402. DOI: 10.1002/14651858.CD008402.pub2.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008402.pub2/full

2.The Lower Extremity 5(2): 95-102, 1998. Copyright © 1998. Reprinted with permission from Elsevier and the American College of Foot and Ankle Orthopedics and Medicine. Journal of the American Podiatric Medical Association http://www.japmaonline.org/content/93/4/264.abstract

3. Journal of Manipulative and Physiological Therapeutics Volume 22, Issue 3, March-April 1999, Pages 149-153

http://www.jmptonline.org/article/S0161-4754(99)70128-4/abstract

4. A comparison of rearfoot motion control and comfort between custom and semicustom foot orthotic devices. Davis IS; Zifchock RA; DeLeo AT. Journal – American Podiatric Ass, Sep 1, 2008; 98(5): 394-403