Monday, August 27, 2018

Preventing Runners Knee - Part III

With an increase in popularity of running, we are seeing more and more running related injuries.  This series is devoted to helping prevent one of the most common running injuries, runner's knee.  Although this is catch all diagnosis, last week we started a discussion around some common root causes for non-contact knee injuries and specifically started to discuss stretching.  This week we will continue that discussion on factors that add to poor running mechanics.

  • Faulty running mechanics – there are “a lot” of faulty movement patterns in runners that can result in problems in runner.  This week we will conclude this portion talking about another root cause for faulty running mechanics.
    • Weakness – weakness throughout the lower kinetic chain can add to an increase risk for runners knee.  What we have found in our research is that if you address the most common weaknesses seen in the majority of runners (≥80%) that most will not only have a dramatic reduction in runners knee but will also have a reduction in all lower limb injuries.  Further, we have found that if you train a runner in a fatigued state (low volume specific training done at the conclusion of a run), we not only see them run better (with less faulty mechanics) throughout their run (fresh and when tired) but they also get an improvement in their performance.  This was the inspiration for the development of the Run Safe App.  This is a free app that has a video for every exercise for runners to do prior to their run and immediately following their run.  The program is done 2-3 times per week and progressed to the next level once performance of the previous level of exercises are done with the technique described. 
  • What exactly is runner's knee? What are some of the signs and symptoms runner's should look for?
    • Runner’s knee is basically a general term which encompasses multiple diagnoses.  Some of the most common diagnoses that fall into runners knee category.
      • Patellafemoral pain syndrome (PFPS) – the patellafemoral joint is the articulation between the femur and the patella.  In this joint, the patella rides in a groove in the femur.  In some runners, the patella will move too much in that groove which will cause pain.  Some cases, the under surface of the patella will become worn and develop a rough surface.  If this is the case, you will typically hear crepitus (grinding) under the knee cap as you move your knee from flexion to extension or when doing a squatting motion.  In most cases with PFPS, the pain will be under the knee cap, more of a deep ache and you may experience some grinding.  
      • IT Band Friction Syndrome – this occurs on the lateral aspect (outside) of the knee and is where the ITBand attaches.  If this is tight it will rub on the lateral aspect of the knee as the knee moves from a flexed to extended position.  This will cause point tenderness on the outside of the knee and some cases where the bursa becomes inflamed you may see localized swelling.  In addition, if there is weakness in the hips and the femur moves into a internally rotated position at midstance, this can also place wear on the insertion of the IT band causing pain and irritation. 
      • Patellar tendonitis – this occurs on the front of the knee on the patellar tendon.  When this tendon becomes inflamed (known as tendonitis) it will become painful on the anterior aspect of the knee during squatting motions, ascending/descending stairs and prolonged sitting. In some cases, this pain may start at the beginning of the run but start to resolve as the run progresses or as you get warmed up.  This typically will come back a little worse after the run and after you have cooled down. 
      • Meniscal pain – the meniscus are the shock absorbing structures of the knee.  Minor tears or wear and tear can cause pain.  This will be more of a deep pain in the knee and you may or may not be able to palpate (touch) it.  If you can touch it, it can be on the inside (medial meniscus), outside (lateral meniscus) or posterior medial corner (back inside of the knee).  This type of pain can limit your running and can feel very sharp.  This will also bother you at the joint line after prolonged sitting.  This is sometimes referred to as movie goers knee because people usually notice this after sitting for a long time in a movie.
      • Fibular head instability – this is less common but seen in some cases.  This is felt on the outside of the knee and is commonly misdiagnosed as ITBand friction syndrome.  The fibular head is held in place by the annular ligament.  If this ligament is torn, then the fibular head will move back and forth during running causing the bursa in this area to become inflamed.  The common peroneal nerve also sits right there so runners with this injury may also report an intermittent "zinging" sensation. A simple stability test confirm or rule this out and it can be treated with a athletic training taping technique which provides stabilization to the joint.  
      • Runners knee does not typically include:
        • Bone bruises
        • Ligamentous tears (ACL, PCL, LCL, MCL)
        • Meniscal tears

  • What are some exercises and/or stretches people can do at home to treat runner's knee? 
    • First and foremost – ice.  Swelling and pain inhibit strength.  There is a neurophysiological and psychological impact that pain has on strength.  Therefore, the longer the pain and swelling persist, the more it will impact strength.  Two different types of icing we recommend based on the diagnosis.
      • Patellar tendonitis, ITBand friction syndrome, fibular head instability – ice massage.  Take a paper or Styrofoam cup and fill with water.  Freeze.  Peel the paper away leaving enough that you have enough paper to hold onto the ice cube but exposed area that you can rub on the painful area.  Rub the ice cube on the painful area of 5 mins.  This will create a layer of water between the skin and ice.  This conducts the cold much better but can only be used for tissues that are close to the surface of the skin (like above).  Do this 3-5 times per day until the pain goes away.  Ice until you get back to your normal running routine without pain.
      • PFPS and meniscal pain – use an ice bag for 15 min.  The ice needs to be cold enough to make you numb in 5 minutes but not so cold that it burns your skin.  Ice for 15 min 3-5 times per day until the pain goes away.  Ice until you get back to your normal running routine without pain.

We hope you are enjoying this series.  Next week we will start looking at additional stretches we can do to avoid runner's knee.  Stay tuned and please share with others you think might be interested.  #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent is also a competitive athlete in Brazilian Jiu Jitsu.