Kneecap Pain and Running

Understanding Kneecap Pain for Runners

Patellofemoral pain syndrome (PFPS) typically presents with a dull pain just beneath the kneecap and lower front part of the thigh just above the knee joint.  It is very common injury for runners. Hence, patellofemoral pain syndrome is sometimes referred to as “runner’s knee” or misalignment of the patella.

The patella pain can be elicited during walking, running, going up/down stairs, squatting and even during long periods of rest, without moving the joint. One or both knees can be affected simultaneously and it is more common with women than it is with men.  The reason for the gender issue is based on the fact that women tend to have wider hips, which results in a significantly greater “Q angle” at the patellofemoral joint of the knee.

A number of risk factors for Runners knee have been identified and linked with the onset of patellofemoral pain syndrome in runners. Athletes who log excessive repetitive stress on their knee joint are the most predisposed population to develop patellofemoral pain with an overuse injury.  Other factors include knocked knees, wide hips, flat feet and excessive foot pronation.

The perceived kneecap pain is a result of abnormal forces associated with the patellofemoral joint such as abnormal muscle pulling on the painful patella, weak quadriceps muscles, tight hamstrings, subluxations, dislocations, arthritis, stiff Achilles tendon, tendonitis, and degenerating knee cartilages losing their cushioning effects.

This results in an inflammatory response that unleashes a cascade of protective patella pain.  Interestingly, this area is more often not swollen.

Signs & Symptoms of Patella Pain for Runners

  • Dull aching pain around the kneecap.
  • An increase in symptoms during and/or after lower extremity activities such as walking, running, squatting as well after long periods of rest with the joint in a fixed position.
  • Pain may also be perceived behind the knee.
  • Patella tenderness but not necessarily swelling around the knee.
  • Knee joint catching or locking.
  • Difficulties attaining full range of movement with popping or snapping sensations noted with active movement.

Professional Treatment for Runners Knee

  • Rest, elevate and ice the area for 15-30 minutes, up to 4 times a day.
  • Stretching of the quadriceps, hamstrings, hips, ankles and Achilles is a must.
  • Significantly limit or postpone your running for now.
  • Utilize the latest physical therapy modalities and rehab devices to reduce swelling and decrease pain.
  • Avoid excessive weight bearing activities.
  • Utilize a self myofascial roller to be used regularly on the quads, lateral thigh, hamstrings and calves.
  • Utilize a knee compression sleeve or patella brace as needed.  They can either decrease or increase the symptoms, depending upon the athlete.
  • Avoid making sharp movements on the knee joint, changing direction with the foot fixed to the ground, bending the knee back and forth.

Asking the Right Questions like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. What type of tissue around my knee is the source of my pain?
  2. Is there any arthritis in my knee and if so, where is it located?
  3. What type of exercise or physical therapy can I do to minimize or eliminate this pain?
  4. Do you recommend I take glucosamine?
  5. Are there any long term complications I should be concerned about?
  6. Do you recommend the use of orthotics for my injury?

Elite Sports Medicine Tips from Mike Ryan

  • Healthy Mind & Body – A healthy body and mind makes for a quicker recovery. Stay positive.
  • AM Stretches – Stretch the muscles around your knee joint before you begin your day.  A proper warm up is always smart if reducing kneecap pain is your goal.
  • Keep Rollin – Lower extremity rolling to increase the blood flow and mobility of the muscles associated with the knee is a must.
  • Gear Up the Right Way – Make sure your equipment from your shoes to your exercise equipment is right for you and not contriputing to the problem.
  • Level Hipped & Level Head – Make sure you don’t have a leg length discrepancy or alignment problem.  When it comes to eliminating kneecap pain, correcting this is priority #1.

Chondromalacia of the Patella Tendon

Chondromalacia - Dreaded Runner's Knee

Chondromalacia, known as “Runner’s Knee”, is one of the most common sources of knee pain for athletes over 20 years old.  The patella injury involves the patellofemoral joint, where the patella (kneecap) and the femur (thigh bone) interact.

Chondromalacia is the pathology that takes place when the articular cartilage on the back of the kneecap becomes irregular and damaged.  Because the back of the patella is now not the smooth and firm surface it usually is, it can damage the distal femur articular cartilage surface.  Much like a damaged pulley, the stresses that are placed on the moving surfaces being loaded become a source of patella pain.

Healthy articulating surfaces in the human body, including the patellofemoral joint, have 3 times less resistance than a wet ice cube on ice!  Think about that for a minute. This simple yet amazingly efficient system of transferring forces over joint surfaces allows 400 pound men to run and jump with minimal damage to the joint…..until that articular cartilage becomes damaged.

The back of the patella has a medial (inner) facet and the lateral (outer) facet that both come into contact with the medial and lateral condyles on the distal femur bone.

What Happens When You Have Chondromalacia

In between the two facets is the intrafacet ridge which glides in the trohclea groove located between the medial and lateral condyles of the femur or thigh bone.  Patella injury can result in damage to any combination of these articular contacts or the patella tendon itself.

With activity, the patella may not glide or track in the proper manner with knee flexion and extension.  With abnormal motion, damage to the surrounding tissues and/or the cartilage on the underside of the patella or distal thigh bone can take place.

The vastus medialis muscle, the most distal and medial of the quad muscles, will usually become weak with any patella injury.  With this inner quad weakness and resulting tightening of the outer knee structures, the patella tends to shift too far laterally or to the outside.

Younger Athletes and Osgood Schlatters

With younger athletes who have not physically matured enough to close their growth plates, they are susceptible to Osgood Schlatter disease.  Osgood Schlatters is a condition where the insertion of the distal patella tendon is elevated.  It significantly changes the tracking and movements of the kneecap.  Because of the alterations with the wear patterns of the backside of the patella, excessive articular cartilage damage occurs and patella tendon quickly becomes symptomatic.

Signs and Symptoms of Patellofemoral Pain Syndrome

  • A visible (atrophy) and functional quadriceps weakness when compared bilateral.
  • May have discomfort/pain in the anywhere around the patella with prolonged sitting and activities involving resistive knee extension such as running and jumping.
  • May have a history of Osgood Schlatters disease or patella injury.
  • Swelling sometimes occurs after activity.
  • A palpable grinding/clicking sensation from behind the kneecap with leg extension that may or may not be accompanied by pain.
  • A Q-angle greater than 20 degrees.

Professional Treatment for Chondromalacia & Osgood Schlatters

  • A product like the Trigger Point Quadballer is a great therapy option to relax the quad and increase the knee range of motion
  • Biomechanical analysis to assess the lower extremities bilaterally to determine if there are specific mechanical issues that are contributing to the Chondromalacia.  Common factors are:
    • Leg length discrepancy
    • Poor flexibility
    • Excessive pronation or supination
    • Quad weakness
    • Weak abdominal musculature
  • Consistent use of rollers and massage to the entire thigh area including the lateral thigh, groin and hamstring muscles.
  • Implementing aggressive quad strengthening exercises that are pain-free with minimal patella crackling or noise present.  To accomplish this, the types of exercises, the specific range of motion and the amount of resistance must be closely monitored to safely improve strength without increasing the symptoms.
  • Full flexibility of the lower extremity and low back.  The hip flexors, the IT band, the calves and, believe it or not, the big toe are the most overlooked areas for athletes who are not successful in overcoming this patella injury.
  • Warming up the knees are often overlooked but it is priceless with this injury.
  • Aggressive manual therapy and modalities to decrease the pain while increasing the mobility of the soft tissue associated with the patella.
  • Ice, ice, ice….immediately after any activity.

Questions a Pro Athlete Would Ask about Chondromalacia

To ensure you are treated like a smart professional athlete with a patella injury or Chondromalacia who wants to safely return to his/her sport, you’ll want to ask your sports medicine specialist the following questions:

  1. Are you certain of the diagnosis?
  2. Do I need any other tests to determine the extent of this injury?
  3. How badly damaged is the cartilage on the back of my kneecap and are there any activities that I need to avoid as I rehab this injury?
  4. What are my options with treating this injury?
  5. What factors do you consider to be the main reasons for my injury and, more importantly, need to be addressed with my rehab?
  6. Quad Weakness
  7. Poor Flexibility
  8. My Sport(s)
    1. Who do you consider to be the expert patella rehab specialist in this area?
    2. Do you have a detailed rehabilitation protocol to direct my rehab for both my therapist and me?

Tips To Help You Heal And Reduce Knee Pain

  • Be Farsighted – Chondromalacia is often the result of a biomechanical problem that needs to be corrected.  Look above, below, behind and in front of the kneecap to find the source(s) for the pain..
  • Change Now & Stay the Course – Most factors for patella injuries don’t just go away.  Plan on finding the problem, making the necessary changes and then maintain those changes for the long haul.
  • Be Honest With Yourself – Look closely at your workouts for the past 3 months and ask:  “Did I change too much too soon?”  Increasing the workload too fast is a common problem with athletes suffering from acute patella injuries.
  • Ice is Your Friend – Here we go again…….Ice hurts but it’s exactly what you need for this injury.  The Pro’s will tell you that ice is their best teammate. You’ve heard me say this many times throughout MRF, however I can’t stress the importance enough. You need ICE and lots of it. Also, if you have a child with Osgood Schlatters, make sure he/she is icing properly.
  • Father Time Has a Bum Knee – As we age our flexibility naturally decreases unless we work at it.  Consistently maintaining out flexibility is the key while joining a yoga or Pilates class is the ideal solution.  Start stretching NOW and take a lot of stress off your knees, patellas and low back so you can make this patella pain a thing of the past.