The 3 most common types of knee pain in runners

It's Dr Mark here from Base Camp.

Knee pain sucks. Straight up. Almost every runner will experience an injury at some point. The knee is the most common running-related injury runners experience.

The good news is, for most runners, it doesn't have to stop you.

Most often, running-related knee pain from 1 of 3 different causes:

1. The Patellofemoral joint pain (the knee cap, the muscles, and the tendons associated with it)

2. The Iliotibial Band pain (aka the IT Band)

3. Osteoarthritis (inflammation of the knee joint)

All three of these injuries have their causes and specific solutions.

Despite that, they all come down to the same thing: doing too much, too soon.

Your body wasn't prepared for the demands you placed on it.

It happens.

BUT... if you don't want to end up in REHAB PURGATORY then take them seriously.

For runners, there are three types of knee pain you need to understand.

The first is Patellofemoral Pain (PFP) in the FRONT of the knee, and the second is Iliotibial Band (ITB) Pain on the OUTSIDE of the knee.

None of them are fun.

But they don’t have to be permanent or keep you from hitting your running goals.

In fact, chances are good if you are a runner that you will experience either PFP of ITB pain at some point in your running career.

The WRONG thing to do is ignore it, keep running at the same intensity and volume, and just hope it goes away.

Let’s talk a little bit about both types of pain and your first line of defence for both of them…

1. PATELLOFEMORAL PAIN (PFP)

Patellofemoral Pain (PFP) is pain that is located on the anterior aspect of the knee (the front).

The word sounds scary, but really it just means pain related to the patella (your knee cap) and your femur (your leg bone). Often, the tendon is involved and can be one of the primary pain generators for PFP. It tends to be MUCH more common in women (2-3 times as common in fact) and can take a long time to resolve (for some stubborn cases it can last more than a year).

Pain tends to come on slowly, and may or may not be present during every run.

In my experience, runs with a lot of downhill mileage are notorious for flaring up PFP. This is likely mainly due to the way the quad muscles need to contract to stabilize the knee while travelling downhill, even at moderate grades.

One of the most common symptoms of PFP is pain with ascending and descending stairs.

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2. Iliotibial Band Pain

Iliotibial Band Pain is pain that is located on the lateral aspect of the knee, where the Iliotibial Band (ITB) connects to the lower leg bone (the tibia, which is your shin bone).

Like PFP, ITB Pain tends to come on slowly, but once it comes it rarely goes away without a fight. The pain is often worse with early knee bending (when the knee is bent to about 30 degrees) and wreaks havoc on activities like cycling and downhill running.

The function of the ITB is to preserve force while we are walking or running, and stabilize the lateral knee. Pain comes on when the bursa (and fluid-filled sack) that is located deep to the ITB insertion becomes irritated.

ITB pain is often intense and debilitating.

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3. Osteoarthritis (OA)

The third type of knee pain is osteoarthritis-related knee pain.

A lot of people think that running is bad for your knees and causes OA. The reality is that osteoarthritis is LESS common in recreational runners, which means that it is actually PROTECTIVE from arthritis!

The key is to get the dosage right.

If you have already had a knee injury, there is a higher chance you will develop OA and OA-related knee pain, but it is not guaranteed.

When there is degeneration, joint changes, or arthritis in the knee, your knee is more sensitive to triggering pain. But… the dosage makes the poison. Over time, you can build up your running volume and run without pain, even if you have arthritis.

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WHAT TO DO ABOUT RUNNING KNEE PAIN?

THE TYPICAL CYCLE OF RUNNING INJURIES…

Unfortunately… most running injuries tend to follow this pattern:

Initial Injury from too much running volume

> Runner takes a couple of days off because of the pain

>> The pain gets better because the pain trigger (running) is absent, but because they took time off, their tissue fitness also decreased

>>> Runner returns to running at their usual pace and volume without building the tissue tolerance back up or following a progressive plan

>>>>> The runner gets injured AGAIN and starts the cycle all over.

Ready to BREAK THE CYCLE?

the better strategy:

Regardless of the type of knee pain, the approach remains pretty much the same, with some subtle tweaks.

The first step is to try and rule out something worse PFP or ITB Pain which are both ‘non-complex’ biomechanical conditions. We want to make sure it isn’t something more severe like a bone-stress injury (stress fracture), connective tissue injury like a meniscus tear or ligament damage, or infection/disease-related. We can’t always rule these things out, but we try and be as confident as possible that the pain is in fact something we can deal with conservatively (without drugs/injections or surgery).

Don’t misinterpret the above information though. Just because something isn’t ‘medically’ serious, doesn’t mean the pain isn’t severe or debilitating.

IF the pain does in fact fall into the category of either PFP or ITB Pain, we take a 3-step approach to managing, fixing, and preventing the condition from coming back.

Step 1: CALM STUFF DOWN

Step 2: BUILD BACK UP

Step 3: BRIDGE THE GAP

Step 1: CalM Stuff Down

The first thing we need to do with either knee pain condition is to calm down the pain so you can get back to running without making things worse.

Our first line of defence is some DELOAD work. This means taking a few days or weeks off. No runner likes to hear this. But some sort of deload is essential for calming the pain down. For some runners, that does not mean COMPLETELY stopping running. We try really hard to keep runners running, because we know one thing is true: RUNNERS LIKE TO RUN.

Step 2: Build Back Up

Once the pain has calmed down a bit, then we move into our Build phase. This focuses on building your strength, endurance, and tissue tolerance back up to handle the demands of running. This usually looks like some strength and cardio training BELOW symptom threshold.

Step 3: Bridge the Gap

Once we have built the tissue tolerance back up, we need to bridge the gap from rehab back to performance. Just because the tissue is strong, does not mean it is necessarily ready for the demands of the running you were doing before injury.

This process is collaborative and involves some trial and error. Too much too soon? We take two steps backwards.

While it is tempting to jump right back into your regular running routine because you are feeling so much better, it is a much better idea to gradually build your running volume back up.

Ok… but what does that actually LOOK like?

Fair question, that I wish I had a straightforward answer to. Unfortunately, everyone is different. There is no single exercise, stretch, or rehab plan that works for everyone.

If your knee pain is keeping you from running, or doing anything else you love, I HIGHLY recommend you seek out a qualified provider.

That said, if you want to take a shot at fixing your pain yourself from home, here are some of the exercises I often use with my patients.

PFP EXERCISES:

Tempo Squats (3-seconds down, 1-second hold, 1-second up, 0-second rest at the top)

Rear Foot Elevated Split Squats

Knees Over Toes Split Squat

KB Deadlifts

ITB Pain Exercises

Stationary Cycling (with your knee flexed to about 35 degrees at the bottom of the stroke. Move your seat forward and down to accomplish this).

Uphill Treadmill Walking (8-10 degrees incline)

Rear Foot Elevated Split Squats

Side Bridge

KB Deadlifts

Want 1-on-1, personalised rehab?

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Author: Dr Mark Murdoch, Chiropractor and Co-Founder at Base Camp Chiropractic and Sports Rehab in Vernon, BC.

Mark Murdoch is a Doctor of Chiropractic with a Master’s Degree in Sports Medicine.

www.BaseCampClinic.com

Contact: drmurdoch@basecampclinic.com

Instagram: Base.Camp.Doc

Dealing with a new knee injury

The first thing I recommend doing if you think you have injured your knee is to get a proper assessment. I can help you if you are looking for a sports medicine oriented chiropractor or physiotherapist in Vernon, BC.

Sometimes, though, getting in to see someone you trust can be a challenge. Your chiro doesn’t have an opening, your physio is off, or your athletic trainer is busy. It is helpful to have some strategies to manage your knee injury in the meantime.

IMPORTANT NOTE:

If you have severe swelling, heard a pop/snap followed immediately by pain, or you have any reason to suspect it is fractured, you need to get an x-ray as soon as possible. Visit your local emergency room or urgent clinic.

ACUTE knee pain just means that you had a recent injury that might be responsible for your pain. A slip and twist, or a fall and catching yourself. Even just a long day of skiing or hiking hard can lead to an incident of acute knee pain.

When a patient comes to me with acute knee pain, we have 3 goals:

1. Limit or reduce swelling

2. Maintain active range of motion

3. Preserve muscle mass and strength, especially in the quads (front of the thigh)

Managing Swelling

Swelling leads to pain and stiffness, which usually leads to inactivity, which always leads to loss of muscle mass and strength. So in essence, managing swelling is already starting to accomplish the other two goals.

Here is how we manage swelling with acute knee pain:

• Keep the joint in motion as often as possible within pain-free (or manageable pain) range of motion. Keeping the ankle and hip moving is also helpful in pumping out swelling.

• Elevation to take advantage of gravity to clear swelling

• Compression to increase clearing of fluid and limit swelling

VIDEOS: 

Maintaining Range of Motion

Motion is the lotion. You don’t use it, you lose it. Same same. We want to keep moving as much as possible, within reason, immediately following injury. That might mean you are literally moving your knee joint 5 degrees, or your knee doesn’t even move but you are pumping your ankle through range of motion. Do as much as you can within PAIN-FREE RANGE (or at least tolerable pain). 

Here are the exercises I recommend to my patients to maintain range of motion:

1. Quad Sets

2. Passive Range of Motion

Maintaining Strength and Muscle Mass

The key to maintaining muscle mass after an injury is: movement and nutrition. If left immobilized, the leg muscles can atrophy (i.e. shrink) by ~5% in a single week. Atrophy tends to slow over time (since there is less muscle to waste away), but it is not uncommon to have upwards of 15% muscle loss in a month of mobilization. That is a big deal.

Here are the first things we do to prevent as much muscle mass and strength loss as possible:

1. Nutrition:

   1. Immediately increase protein consumption. Your body NEEDS protein to heal your injuries, and even though your activity level may decrease, your protein needs often INCREASE

   2. Avoid highly inflammatory foods whenever possible (even though I know how tempting it is to finish that pint of ice cream to cope with the frustration)

2. Isometrics or low-load movements - keep the injured joint moving as often as possible with as much stress as you can handle.

   1. Isometrics: activates the muscle without moving the joint through range of motion, and is often tolerable even when in a lot of pain

   2. End range limited range of motion exercises like Quad sets

   3. Contralateral leg training: i.e. exercising with the OPPOSITE limb can actually maintain both muscle mass and strength (pretty cool, eh?)

Exercise for Acute Knee Pain:

Not sure where to start?

That is where a qualified Chiropractor or Physiotherapist in Vernon, BC can help. A good Chiro or Physio will put you through a thorough assessment and help identify the extent of your injury and your pain triggers. Then, they will help you put together a rehab plan to get you back in action.

Author: Dr Mark Murdoch, Chiropractor and Co-Founder at Base Camp Sport and Spine in Vernon, BC.

Mark Murdoch is a Doctor of Chiropractic with a Master’s Degree in Sports Medicine.

www.BaseCampClinic.com

Contact: drmurdoch@basecampclinic.com

Book an Appointment with Dr Murdoch: book here

Instagram: Base.Camp.Doc