Get off your Butt to manage your knee pain

In this article we will look at 3 common knee conditions- patella femoral pain syndrome, iliotibial band syndrome, and osteoarthritis of the knee. These are all non-traumatic injuries of the knee which can be affected by load. In most injuries we need to assess load as this directs our management. Do we need to manage the condition by reducing the load ordo we need to increase the body’s resilience to cope with the demand? Overuse injuries are caused by doing too much too soon- e.g. too much distance, too much speed, too many hills. All factors need to be taken into consideration when assessing overuse injuries –e.g. recent illness, change in medication, training equipment (shoes), posture and biomechanics, impact on our ability to deal with load.
We need to find the optimal loading. We often think of overuse injuries as doing too much, but likewise not doing enough also puts us at risk of injury. The weekend warrior is as much at risk as the high mileage runner. High mileage runners may need to work more recovery time into their training schedule and allow for some cross training. The weekend warriors often need to build and extra session or two during the week. Both groups need strengthening if not already included in their program.

Managing load in the runner- source

When looking at knee pain we need to consider the biomechanics of the entire limb and address strength and flexibility of muscles around the pelvis, hips, thigh and lower leg. Most knee injuries can be improved by strengthening around the hips and pelvis- your butt. We will look at strengthening exercises and some techniques you can work on while running to help deal with knee pain.

Iliotibial Band syndrome (ITB)

The large white area seen down the side of the leg. Image from Body World

ITB is typically seen when there has been an increase in training. Pain is on the outside of the knee and presents at the same time in training e.g. consistently at a certain distance or time into a long run. It is aggravated by running downhill, better on the up hills and eased by walking. The muscle imbalance that is often at play in ITB is – weakness in the gluteals and tight hip flexors. It may also be aggravated by changing a sport e.g. adding cycling. Cyclists use a lot more hip flexion which can cause the hips to be tighter, not allowing you to get the full hip extension when running.
What to do when you have ITB. You need to decrease your mileage. If the pain usually comes on at 10km into a run, you need to cut your distance down to where you can run without pain e.g. 7km.You must start a strengthening program. You can increase the intensity of your training to make up for the shorter runs. ITB does not like the monotony of the road, so running on off road surfaces can help- parks, Parkruns, running on the  pavement can be helpful.

Strengthening –Focus on glutes strengthening, and hip flexor stretching.
Stretching– Hip flexor stretching
Running form– Decreased step rate or a cross over gait can aggravate the ITB. Try to increase cadence and if you have a cross over gait then looking at widening your stance can help. It helps to think of running on either side of an imaginary line.

Patella femoral knee pain (PFP)
PFP is usually an ache over the front of the knee. The knee may be painful during a run, or after a run. A sustained bend of the knee e.g. while sitting, driving, sleeping in the foetal position, tends to aggravate the pain making it very difficult to then straighten the knee. Pain is often worse with running downhill or going down stairs. PFP syndrome may have been set off by a run with lots of downhill running or steep descents.

Strengthening– Strengthening of the quadriceps an around the hips and pelvis had the biggest effect in reducing patella femoral knee pain (Lack et al (2015))
Running form– Increasing step rate and altering foot strike pattern have been shown to decrease load on hips and knees, and increase hip muscle activation. By improving running form you can improve activation of gluteal muscles which can help prevent injury. Vannata et al (2017) found that instructing heel strikers to run with a forefoot strike pattern resulted in greater activation of gluteal and hamstring muscle.
Running barefoot decreases patellofemoral joint stress by 12% because it prevents over striding and heel striking (Bonacci et al (2014)). You can run barefoot or with minimalist shoes to reduce the load on the joint and to improve you running form. Running barefoot or in minimalist shoes does come with its own set of injuries e.g. stress fractures of the foot, Achilles and calf issues. So it is often done for short periods while working on running form.

Osteoarthritis (OA)
Osteoarthritis typically presents with a swollen knee, there is often stiffness first thing in the morning (less than 30minutes), or after a period of inactivity e.g. sitting in the day and then getting back up again. The knee will be painful and typically worse after a run. If you are an older runner, have had a history of trauma to your knee, or have an increased BMI you may be at risk of OA.

OA often presents as a painful swollen knee.

We all know running is good for our health, however we have all had the question “isn’t running bad for your knees?” New research published in the Journal of Sports physiotherapy (JOSPT) looked at exactly this question: “does running lead to higher rates of arthritis in knees and hips “. Their findings suggest that the difference in outcomes depends on the frequency and intensity of running. Recreational runners had 3.5% chance of developing hip or knee arthritis. A sedentary lifestyle- not running- or competing as an elite runner increases the risk of hip or knee arthritis by 10,2% and 13,3% respectively (Alentorn-Gell 2017). It has been suggested that high volume and high intensity running is a risk factor, a distance of more than 92km/week is considered high volume running. So the risk of knee osteoarthritis in the recreational runner is less than the sedentary population.
In managing osteoarthritis, diet and exercise are the two key things. If you have an increased BMI losing the extra weight will make a significant difference to the pain.
Strengthening– You want to improve the strength of quadriceps and gluteals.
Stretching– You need to consider the flexibility of hamstrings, quadriceps and calf muscles
Running form -In terms of running style we would use the same techniques as that used for PFP. You need to decrease the running activity while strengthening to reduce impact exercise. A run walk program is often a good way to keep running while reducing the load.

These are some of the most common knee conditions seen in runners. But often with the some strengthening they can be well managed and you can get back to many happy running miles.



1) Alentorn-Gell E, Samuelsson K, Musahl V, Green C, Bhandari M, Karlsson J (2017) “The association of recreational and competitive running iwht hip and knee osteoarthritis: a systematic review and meta-analysis” Journal of orthopaedic and sports physical therapy, volume 47 (6) p 373-390 doi:10.2519/jospt.2017.0505
2) Bonacci J, Vincenzo B, Spratford W, Collins P (2014) take your shoes off to reduce patellofemoral joint stess during running” British Journal of Sports medicine 2014; 48 407-407
3) Barton C.J, Lack S, Hemmings S, Tufail S, Morrissey D (2015) “The Best Practice Guide to Conservative Management of Patellofemoral Pain: incorporating level 1 evidence with expert clinical reasoning” British Journal of sports Medicine. 49:923–934. doi:10.1136/bjsports-2014-093637
4) Chang Z, Zhang JHW, Au I.P.H, An W.W., Sum G.L.K, Ng G.Y.F, Cheung R.T.H (2017) “Gait retraining lowers injury risk in novice distance runners: a randomized controlled trial” The American Journal of Sports Medicine.2017. In press. AMJSPORTS/2017/221127 DOI: 10.1016/j.clinbiomech.2016.03.010
5) Lack S, Barton C, Sohan O, Crossley K, Morrissey D (2015)” Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis” British Journal of sports Medicine
6) Reiman M, Bolgla L, Loudon J (2011) “A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises” Physiotherapy Theory and Practice, 28(4):257-268 DOI: 10.3109/09593985.2011.604981 · Source: PubMed
7) Vannatta CN, Kernozek TW (2014) “Patellofemoral Joint Stress during running with alterations in foot strike pattern DOI: 10.1249/MSS.0000000000000503 · Source: PubMed
8) Vannatta CN, Kernozek TW, Gheidi N (2017) “Changes in gluteal muscle forces with alternation of footstrike pattern during running” DOI: 10.1016/j.gaitpost.2017.08.005
9) Professor David Hunter talks osteoarthritis exercise therapies: better outcomes BKSM 17 Febraury 2017

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