If you’re reading this, you’re a keen runner, and I don’t blame you! Whatever your motivation; be it the accessibility of running, feeling of freedom, the mental and physical health benefits, the low cost, or the feeling of adding those miles and clocking the distances, for self-satisfaction or racing; running is very appealing and contrary to popular scaremongering it’s not bad for your joints!!

However, when an injury does occur it can be incredibly frustrating and persistent if not managed correctly.

Knee pain is the most common injury sustained by runners, making up 31% of all running related injuries in non-ultramarathoners. More specifically pain at the front of the knee around the kneecap (referred to patella femoral pain syndrome) accounts for most of these cases. (1)

So, let’s explore this condition first.

Patella Femoral Pain or Runners Knee

Patella Femoral Pain Syndrome (PFPS) is a clinical diagnosis rather than a structural one, indicating that there is tissue irritability but rarely damage. It is one of the conditions sometimes referred to as runners knee.

If you have PFPS you will have:

• Pain close around or behind the kneecap2

• Pain when squatting, climbing or descending stairs2

• Gradual onset of pain2

• Worsens through activity

What can be done?

There isn’t a one plan fits all for this condition. There will be a reason, unique to you, that your knee isn’t tolerating the load you are placing on it.

Usually this is due to a weakness in the musculature of the hip or less commonly ankle.

A progressive strength program, prescribed by a Sports Therapist or Physiotherapist, targeting the muscle or movement patterns that have been shown in assessment to be the source of the problem, is the recommended route. A common finding is weak quadriceps or hip musculature.

Tightness and shortness in musculature is often cited by my clients as a potential reason. Whilst not incorrect, frequently a tightening of muscle relates to either a direct weakness or overload because of weakness elsewhere.

See this blog for a more detailed explanation on ‘Why Stretching for Tightness Isn’t Always Effective’.

Imaging is not usually indicated. Unless you’re presenting with symptoms that might suggest there is significant structural damage (painful clicking, giving way, More information on imaging, pro’s and con’s can be found here

How long will it take for improvements to be made?

Muscular strength changes can take around 8 – 12 weeks of dedicated rehab to improve. However, improvements will often be noticed sooner with changes in movement patterning, advice for load management and an explanation of what is happening.

Illio-tibial band (ITB) syndrome

The ITB gets a lot of stick. It is most people’s favourite place to foam roll because ‘if it hurt’s it must be doing something’. So, what is it about this syndrome that makes the ITB get such a bad rapt and why do I think targeting this tough, fibrous band of tissue is like shooting the messenger. Let’s explore…..

The key to understanding it, is to understand it’s anatomy. The ITB is a very long dense, fibrous band of connective tissue, that is part of the fascia lata. Imagine the skin of a sausage & a part of that skin, down the length of the sausage is thicker, denser than the rest – that’s the ITB!

This thickening spans from the tendons of the Tensor Fascia Lata & Gluteus Maximus muscles around the hip, runs down the outside of the leg to a tubercle (bump) on the tibia, below the knee. On it’s way down it is anchored by further connective tissue to the thigh bone (femur).4

When the knee bends and straightens, tension in the band will shift from the front to back, dependent upon the angle of the knee & hip. At around 30-degree knee bend the ITB is at it’s most tense, it will dissipate pressure onto the fatty tissue between itself and the femoral condyle. This fatty tissue is very vascular (good blood supply) and innervated (full of nerves), thus meaning it will respond to increases in pressure above what it is accustomed.

So, contrary to the long-held view that the tendon is moving back and forth OVER the femoral condyle and the syndrome is a FRICTION generated by this movement, it is more like that there is an increase in pressure that the fatty tissue isn’t used to tolerating.

What can be done?

First up we must ascertain if the excessive load is external or internal.

External factors include increasing or changing activity too quickly. Have you:

• Recently increased run distance?

• Had a break in training but started again at the same distance?

• Changed terrain?

• Introduced hill work?

• Changed footwear?

These factors will increase the pressure on the fatty tissue, the fatty tissue will tell the brain it’s under more stress than usual and the brain will elicit a pain response as an attempt to stop you running.

External factors should always be addressed first, they’re the most common and simplest to fix.

Internal factors require a thorough assessment. I am usually looking for a movement pattern that will cause a lengthening or stretching of the ITB along with the muscles it originates from. This could be one or more of the following:

• Cross over gait. Foot striking on a central line or even crossing that line.

• Valgus knee movement. The femur rotates inwards, giving the appearance of the knee falling in during the stance phase.

• Hip drop. On stance phase the opposite hip will drop lower than the other on a horizontal line.

• Poor control of the foot arch.

 

It may not be necessary to observe gait, I will often watch a client run on the treadmill to confirm my thoughts from a comprehensive assessment. A single leg squat or hop, along with some strength and muscle length tests will usually be very informative.

The rehabilitation exercises I prescribe will be based upon my assessment findings. I will frequently recommend banded crab walks, single leg squats, side lying leg lifts plus a progressively heavier squat or deadlift. I am a big believer that runners should be lifting weights and provided there is a plan…. you cannot go wrong, by getting strong!

How long before I can run again?

Continuing to run whilst undertaking rehabilitation work is essential. I rarely suggest people stop running. Think back to the cause “increases in pressure above what it [the fatty tissue] is accustomed”. Stop running & the accustomed pressure reduces, start running again and the tissue will respond sooner to less pressure. The threshold for nerve activation reduces.

We may look to adapt you running distance, speed, terrain, particularly if you have identified a trigger. But continuing to run is important.

It is very unlikely with this syndrome that you are causing damage by running. Even actual tissue irritation (inflammation) is questionable. However, running through pain can have detrimental effects on your movement patterns (compensatory) and can also heighten nerve sensitivity. Just making it a little more stubborn to shift in some cases.

 Patella Tendinopathy

Tendinopathy is an overuse tendon injury. Sometimes referred to as ‘Jumpers knee’ you will see this frequently in jumping sports – funnily enough – but can also hinder runners, particularly those that do other sports too. The patella tendon is located below the kneecap and attaches onto the tibia (shin bone) & is the fixing point for the Quadriceps muscle group.

Tendinopathy usually occurs due to numerous bouts of acute overload without adequate recovery time. Think of this as sudden increase or change in your training, plus increasing how often you do it. Sudden increases in exercise or a lack of strength means the tendon fails to cope with the demands & results in the tendon to needing to make changes or undergo repair. Whilst these changes are taking place another acute bout of activity is undertaken, disrupting the adaptation or recovery process. If this cycle is repeated, the tendon becomes dysfunctional and unable to effectively restore healthy tissue to repair itself.

Typically, tendon pain will improve with gentle movement, known as the ‘warm up phenomenon’, but pain will increase immediately with high loads like hopping and disappear as soon as it is ceased. It may come on late in a run or you’ll find it very stiff when walking down stairs in the morning.

What can be done?

We must first ascertain what your exercise routine looks like, discuss any changes to your training program and the nature of your pain to ascertain the severity of the tendinopathy.

An assessment will consist of muscle length and strength tests, as well as determining what dose of aggravating activity (hopping) the tendon can tolerate. These tests will form the basis for the rehabilitation prescribed and what exercise is ok to keep doing and what should, temporarily, be avoided or reduced.

All tendon rehabilitation programmes will involve loading the tendon in a controlled manner. Rest will fail to improve this condition, despite improvements in pain whilst not exercising, the tendon requires stimulation to promote the collagen synthesis required for a functional manner.

How much load, frequency and type of exercise prescribed will depend on how irritable your tendon is, equipment you have access to and what your overall aims are.

How long before I can run again?

Patella tendinopathy is notoriously slow to respond. Studies have mostly been conducted on athletic populations, often without the ability to fully rest from aggravating activity, however these show many still having pain at 6 months and some remaining at 12 months.

It is important to follow a full rehabilitation program, that is pitched correctly for you and to adapt, not necessarily stop, running or other sports. Increasing recovery time (tendon collagen synthesis can be up to 72hrs post a high impact session).

Read more about what tendinopathy is and how to combat it.

 

Read more about how I approach knee pain here

Or if you would like to discuss your knee pain with me contact me via email or on Whatsapp to arrange a call.

 

1.        A systematic review of running-related musculoskeletal injuries in runners. Kakouris, N. Yener, N. Fong, D. 2021. Journal of Sport and Health Science. Volume 10, Issue 5.

2.        Patellofemoral pain. Crossley, K., Callaghan, M., Linschoten, R. 2016. British Journal Sports Medicine; Volume 50. Issue 4.

3.        Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M. Is iliotibial band syndrome really a friction syndrome? J Sci Med Sport. 2007 Apr;10(2):74-6; discussion 77-8. doi: 10.1016/j.jsams.2006.05.017. Epub 2006 Sep 22. PMID: 16996312.

4.        Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Phillips N, Best TM, Benjamin M. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. 2006 Mar;208(3):309-16. doi: 10.1111/j.1469-7580.2006.00531.x. PMID: 16533314; PMCID: PMC2100245.

5.        Mallinaras, Cook, Purdam, Rio. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations https://www.jospt.org/doi/10.2519/jospt.2015.5987