What is Runner’s Knee? All about Patellofemoral Pain Syndrome
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If you’re an avid runner or someone who enjoys an active lifestyle, you might have experienced a dull ache in your knee, especially after a run or a long walk. This common condition, known as Runner’s Knee or Patellofemoral Pain Syndrome (PFPS), can be quite painful, and can take some time to get over.
Understanding the causes of a chronic pain condition is always important to get the treatment right, but it's even more so with Runner's Knee. The key to managing Runner's Knee effectively is in breaking the vicious cycle of pain, muscle switch-off, and kneecap malalignment.
Let's dive into how the mechanisms of Runner's Knee inform our treatment approach with the Runner's Knee Essentials.
Runner’s Knee is surprisingly common. Research shows that approximately 20% of adults develop Runner’s Knee at some point in their lives. Its prevalence has increased by 65% over the last 20 years. As the name suggests, the condition is particularly common among runners, affecting up to 30% of female runners and 20% of male runners.
Runner’s Knee develops over time, often triggered by a change in activity or an increase in intensity. If you notice inner knee pain from running, there's a high chance that's Runner's Knee.
It often starts as a dull pain inside the knee or behind the kneecap, which can escalate to a sharp pain when bending the knee beyond 30 degrees or compressing it. This pain is not pinpoint but more of a low-grade ache that becomes sharper under certain conditions.
One telltale sign of Runner’s Knee is the so-called "moviegoer’s sign" – experiencing pain after sitting for about 30 minutes, which often eases after taking 10-20 steps. Additionally, descending stairs and going downhill usually feels worse than going up due to the increased pressure on the knee.
Runner's Knee is tricky to diagnose, even for expert physical therapists. It's a diagnosis by exclusion. There are a handful of tests that physical therapists use to diagnose Runner's Knee. Of those, we favor three: the small knee bend, heel-on squat, and heel-off squat.
The Small Knee Bend test has the most research supporting its utility for diagnosing Runner’s Knee, and it's the first test we like to use for people with Runner's Knee-like symptoms.
In contrast, the Patella Compression Test, though some physical therapists use it, is neither particularly sensitive nor specific (meaning it has too many false negatives and false positives). Even worse, the Patella Compression Test can be quite painful, so we never recommend this test for Runner's Knee - causing unnecessary pain for an unreliable test is not what we do at Alleviate!
Here's how to perform the three Runner's Knee tests yourself:
1. Small Knee Bend: Stand on one leg on the affected side and bend your knee to 30 degrees (or as much as you can). Hold onto a chair or a doorway to keep yourself stable. If you feel pain inside your knee, it could be Runner’s Knee.
2. Heel-on Squat: Perform a squat with your heels on the ground. This is not a balance test, so you can hold onto something stable for balance. Pain inside the knee during this movement suggests Runner’s Knee.
3. Heel-off Squat: Perform a squat with your heels off the ground. If this test causes pain inside the knee, it’s another indication of Runner’s Knee.
The primary cause of Runner’s Knee is repetitive stress, often from overuse during activities like running. However, several other factors can contribute, including malalignment of the kneecap, muscle imbalances between the inner and outer thighs, foot mechanics such as overpronation or flat arches, and weaknesses anywhere in the kinetic chain, from the hips to the feet. These factors can all lead to improper tracking of the kneecap, causing pain and inflammation.
One of the key mechanisms behind Runner’s Knee is that pain causes the VMO (vastus medialis oblique) muscle to switch off, worsening the malalignment of the kneecap. This exacerbates the pain, which further discourage the VMO to do its job, which worsens the kneecap tracking... It's a vicious cycle.
Several risk factors can increase the likelihood of developing Runner’s Knee.
Breaking the negative feedback cycle of patella pain causing the VMO muscles to switch off is crucial. Because of that, with Runner's Knee, pain relief is the first step in the overall treatment strategy.
Pain relief focuses on reducing pain while maintaining activity to prevent the loss of capacity. Load management, such as wearing a knee brace or using taping, can help correct knee alignment and reduce pain during activities.
Soft tissue mobilization techniques help activate the VMO muscle, which helps proper kneecap alignment and pain reduction. Massaging the inner and outer thigh muscles after activities or when you are in pain reduces tension, facilitates smooth movements, and relieves pain.
Finally, following a progressive strengthening exercise program for Runner's Knee stabilizes and strengthens the entire kinetic chain, from the hips to the feet. With stronger muscles working together, less of the load and impact of your activities goes through the kneecap.
ITB (iliotibial band) is the long tendon on the outside of your thigh, from the top of your hip bone to the knee. ITB stretches are often recommended for knee pain, but they don’t work for Runner’s Knee specifically.
The ITB is made of collagen, which just doesn’t stretch. Massaging painful tissue actually strengthens the pain signal, and it makes the negative feedback cycle worse - exactly the opposite of what we want in Runner's Knee treatment.
With active treatment using the Alleviate Method, you should start seeing significant improvements within 10-14 days, with noticeable pain reduction and improved function. Runner's Knee is a notoriously difficult condition to completely recover from, but a well-designed course of physical therapy can significantly reduce pain over 6-8 weeks, depending on the severity of your condition.
By gradually increasing your capacity to tolerate load and strengthening the whole kinetic chain, you should be able to resume your favorite activities.
As we've seen, the key to managing Runner’s Knee is pain reduction first, followed by active treatment. The Alleviate Method first focuses on breaking the vicious cycle of pain and malalignment, and applies the three pillars of physical therapy treatment for long-term recovery:
By massaging the VMO (Vastus Medialis Oblique) muscle before running or starting your day, you can “wake up” this key muscle that pulls the kneecap inward and upward, reducing pain and improving range of motion.
The Alleviate Massage Blade (included in our Runner's Knee Essentials) replicates the shape and strength of a seasoned physical therapist's hand, so you can activate your VMO with ease.
After activities or at the end of the day, give it another round of soft tissue massage to release tension and transform the tissue so it can take on more load, without pain.
Taping or using a purpose-built knee brace can help correct the kneecap alignment. This reduces the stress that goes through the kneecap and thigh muscles with each step, reducing pain.
Don't forget to choose the right running shoes that fit well, give you stability, and feel comfortable - supportive shoes that meet your needs are crucial in managing load and preventing further injury.
Rebuilding strength throughout the kinetic chain not only reduces pain and resolves the root cause of your running knee pain, but also reduces the risk of recurrences.
Bonus point: strength in your lower body means you’ll be able to run faster, longer, and more frequently – and you’ll be protected against other kinds of running-associated injuries like Plantar Fasciitis.
Start with Instrument-Assisted Soft Tissue Mobilization: Massage the VMO muscle before and after runs to activate and relax the muscle.
Engage in Progressive Strengthening Exercises: Incorporate exercises that strengthen the entire kinetic chain, from your feet to your hips.
Manage Your Running Load: Gradually increase your running distance and intensity to avoid overloading your knees. Don't run when you can't do a small knee bend without pain!
Maintain Proper Running Form: Focus on running with good posture and technique to minimize stress on your knees.
Stay Consistent: Regularly perform your rehabilitation exercises and treatments to maintain progress and prevent recurrence.
Alleviate was founded by a patient-and-clinician duo to bring the effective chronic pain treatment from physical therapy offices to everyone's home.
Runner's Knee treatment that you can do yourself is at the center of our history: Rick, one of the co-founders, met Luke, the other co-founder, when he went to Luke's physical therapy clinic after years of dealing with Runner's Knee pain without much success. Luke fixed his knee in 6 weeks.
With Runner's Knee Essentials, you can use the Alleviate Method to recover from Runner's Knee at home, using the methodology Luke used on Rick's knee. No physical therapy training required!
Luke Ferdinands, Physical Therapist & Co-Founder
A New Zealand-trained physical therapist with over 20 years of experience, Luke developed the Alleviate Method to bring the gold standard of physical therapy care to everyone's home. Luke leads the development of physical tools and digital physical therapy content, focusing on driving clinical outcomes for people with chronic musculoskeletal pain conditions like Tennis Elbow, Plantar Fasciitis, Runner's Knee, and more.
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Runner's Knee Essentials
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