the runners knee

The Runners Knee Patella-Femoral Pain and Iliotibial Band Syndrome

‘Caught in the middle with nowhere to go’

This phrase from Physical Therapist Gary Gray, describes the knee’s

precarious position in the lower extremity. It is largely dependent on structures

above (pelvis / upper body) and the below (the foot), for its stability. Injuries or

weakness to these areas inevitably place the knee under increased mechanical

strain, eventually leading to injury. As all joints move in three planes of motion

knee alignment is dependent on muscles maintaining stability in these planes.

The neuro muscular skeletal system is best viewed as an integrated 3-

dimensional system. Loss of one dimension (or plane of motion) will place more

strain on the other two, e.g., if there is a loss of hip flexibility in the sagittal

plane (flexion / extension) then this will place more demand on the other two

planes (frontal and transverse), they have to make up for the loss of hip

flexibility. You will place more strain on the knee, foot, or both areas as a result.

Which structure will become symptomatic or ‘injured’ depends on the

individuals’ tissue / joint resilience.

This idea can be transferred to the tissue characteristics of flexibility,

strength, and endurance in any of the three planes.

The Three Planes of Motion

1. Sagittal – Flexion / Extension

2. Frontal – Abduction / Adduction

3. Transverse – Rotation.

The Runners Knee Patella-Femoral Pain and Iliotibial Band Syndrome A loss of flexibility, strength, and endurance will increase strain on structures

resulting in injury at some point. These losses are relative to the person

concerned, ‘one size’ does not fit all. When observing a patient performing an

active exam it is useful to observe muscle contraction during a movement eg

1. Concentric – contraction with shortening

2. Eccentric – contraction with lengthening

3. Isometric – contraction without movement.

Put simply, standing and flexing on one knee, muscles will be contracting by

Assessment

Firstly we all fall outside of the ‘norm’. We all have some musculoskeletal

dysfunction, but not all dysfunctions become symptomatic!

This photo circulated widely on the internet. This is Joshua Cheptegei of

Uganda who holds the world record for 10,000m in 26:11.00 !

As the knee is injured more often as a result of being in an upright position, it is

logical to try and do most of our assessment in a standing position. This may

not always be possible if the knee is very painful, and there is a risk of

aggravating the joint while the patient is upright.

Static Body Alignment

• You can’t change it

• Not always connected with running injuries

Shortening to flex knee (concentric) – Hamstrings

Lengthening to control flexion (eccentric) – Quadriceps

Maintaining Stability (isometric) – Gluteus Medius and Maximus

The Runners Knee Patella-Femoral Pain and Iliotibial Band Syndrome At this point it is worth noting what muscles take the most strain while running.

This is relevant to both injuries.

https://www.nature.com/articles/s41598-020-73742-5

Your initial case history should give you enough information on how your

patient became injured and your static exam should help you establish a

starting point in unravelling the injury aetiology.

Questions to ask are (for PFP and ITB):

Ask the right questions and listen to the answers

• How did the problem start?

• How often do you run / participate in sport

• How long have you been running?

• Have you had a break from sport?

• Do you understand what has happened to your Knee / ITB

• What else do you do?

Find out

• Why is running important to you?

• What is your goal? Eg 5k, marathon, lose weight, get fitter

• How are you when you cannot run? Eg mood etc

• How much time have you allowed for rest and recovery?

Gluteus Max 1.5 to 2.8 x Body Weight (BW) Force

Gluteus Medius 2.6 to 3.5 x BW Force

Gastrocnemius 2.5 x 3 BW Force

Soleus 6.5 to 8 x BW force

Quadriceps 4 to 6 x BW Force

https://www.nature.com/articles/s41598-020-73742-5

The Runners Knee Patella-Femoral Pain and Iliotibial Band Syndrome After your static exam, it is a good idea to introduce more active movements

like walking, jogging on the spot, slow jogging, lunges, hopping and running, as

these will help give clearer idea of the injury location and how it started.

There are many different approaches to what you should include in your

examination. The selection of assessments below will provide useful

information on both Patello-Femoral Pain (PFP) and Ilio-Tibial Band Syndrome

(ITBS) the cause of injury and how to start to treat your client. You are looking

for a link between pain, the pathology (PFP or ITBS) and results from

assessments.

Use these static and active tests to help you in your examination. The

Congress video will show examples of these.

1. Ankle dorsiflexion – Look at range with knee flexed and knee extended.

Tight soleus will reduce dorsiflexion at ankle. This requires all of the

muscles that reduce force in frontal + transverse plane (pronation) to

work harder eg Glut Max, GMed, QL.

2. Single leg loading / Step down

Weak G Max and Med, soleus, vastus medialis, quads eccentric

strength, tight adductors,

3. Supine Bridge (Posterior Chain muscles) – gluteals and hamstrings,

abdominals

4. Glute Med – is it effective in maintaining pelvic stability?

5. Single leg rise – eg getting out of a chair. Quads, lumbopelvic stability

eg GMax and Med, QL

6. Running gait analysis – note cadence, narrow running gait, strike

pattern, ankle dorsiflexion, calcaneal eversion

• PFP and ITBS associated with increase in training volume

• Rapid increase of training volume (>30%) may increase injury risk.

• Recently added up and downhill running to training

• The less fit you are the more time is required for rest / recovery

• Explain pain – pain does not always mean serious damage


Patello-Femoral Pain (PFP)

PFP may occur after a sudden increase in activities like running or repeated jumping. Research suggests that PFP results from activity levels that are increased faster than the knee can get stronger. Other contributing factors to PFP may include:

• Weakness of essential muscle groups eg thigh muscles, pelvic muscles.

• Specializing in a single sport, which requires repeating the same movements again and again.

• Sedentary work postures eg driving or office work where knee is still and slightly flexed.

• Deconditioned people due to ill health who need to be active eg those living in a house, large garden, rural setting.

• Previous joint injury that was left to get better eg ankle inversion sprain

• Inadequate training / recovery in active people or those returning to sports activity after a lay off / injury.

• PFP and ITB will not go away on its own without treatment and return to

desired activity without guidance.

Inflamed area under patella

The Runners Knee Patella-Femoral Pain and Iliotibial Band Syndrome Your patient with PFP may experience pain:

• When walking up or down stairs or hills.

• With deep knee bending (squatting).

• When walking on uneven surfaces.

• With activity, but improving with rest.

• After sitting for long periods of time with the knee bent.

Diagnosis

• Through case history

• Location and nature of pain

• Provoked by deep squatting, coming downstairs in morning

• Tender around periphery of patella

• Link with running activity

• Link onset with starting running / return to running

The Track and The Train

How does a weak VMO (Vastus Medialis) contribute to PFP?

First thing to realise is that eccentric (contracting while lengthening) muscular

contractions are generally seen as the method used to steady or ‘stabilise’

movement, making sure it is a smooth activity while protecting other muscles

and joints, a bit like pulling the reins back while horse riding to steady the horse

(I do not ride by the way). Eccentric strength is also seen as the most energy

Patella – ‘the train’

Trochlear Groove – ‘the track’

Lateral lip of Trochlear groove

is higher than medial lip

Patella is ‘lifted’ to

show trochlear groove.

The Runners Knee Patella-Femoral Pain and Iliotibial Band Syndrome consuming so if your eccentric strength is not good (because you mostly train

concentrically) the controlling eccentric influence of Gluteus Maximus (to

control psoas flexing the hip , eg pulling the reins when riding) is fatiguing.

Quadriceps group of muscles also help control knee flexion by contracting

eccentrically, mainly VMO. As VMO gets pretty tired the Vastus Lateralis (VL)

gets overactive pulling the patella (the train) laterally right into the lateral ridge

of the trochlear groove ouch!

Just to add to this scenario Gluteus Maximus also eccentrically controls internal

rotation and adduction of the femur. Same scenario as above, this uncontrolled

motion causes the track to move medially allowing the laterally moving patella

(‘the train’, still with me?) to hit the trochlear groove even harder.

Keep this going and you have one way of developing PFP.

Suggested Treatment ideas:

• Soft tissue to the lower limb with joint articulation to the hip and foot

• Improved ankle dorsiflexion if required.

• Improved hallux (Big toe) mobility

• Distraction to the patella to improve patella mobility and glide.

• Attention to training / sports activity program.

• Give self help exercises eg ankle mobilising, gradual strengthening of

key muscle groups

• Train eccentric muscle function eg G Max, Quads calf.

• Increase step rate (Cadence)

• Decrease stride length if they are an overstrider.

• No sitting on sofa with legs tucked under and to one side.

• Supine sleeping with cushion under knees, helps in some.

• No HEAT

Summary of key points

• Help to balance training/ running load and capacity to manage that load

• Ensure treatment remains patient centred, not just about the knee!

• Assess their current knee load and ensure it’s at a manageable level

• Eccentric strength is very important

• Understand their beliefs about injury, why running is important and why they train the way they do.

• Hurt does not = harm, but people with chronic pain assume it does

• Empathise, educate, and explain


Ilio-Tibial Band Syndrome

Commonly seen in runners, it causes a stabbing or stinging pain along the

outside of the knee, just above the lateral femoral condyle. It is an overuse injury where the ITB and its insertion is put under a lot of strain as a result the forces involved in a flexing and extending knee. The tendon tissue will gradually strengthen to deal with the increased load. Acute inflammation is

The Runners Knee Patella-Femoral Pain and Iliotibial Band Syndrome necessary to help the healing process. However, chronic inflammation hinders healing, patients often do not realise this. A good reason to seek help early before an injury starts to turn chronic.

You will see it in

• repetitive activities, such as squatting, and endurance sports, such as running and cycling.

• Individuals who spend long periods of time in a specific position, such as sitting or standing for a long workday, climbing, squatting, or kneeling.

• Individuals who quickly start a new exercise regimen without proper warm-up or preparation.

With ITBS you may experience:

• Stabbing or stinging pain along the outside of the knee.

• A feeling of the IT band “snapping” over the knee as it bends and straightens.

• Swelling near the outside of your knee.

• Occasional tightness and pain at the outside of the hip.

• Continuous pain following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to standing position.

The ITB

• Will hurt at about 30° flexion.

• knee joint should have full flexion extension range of movement (ROM)

• knee should have no joint line tenderness.

• will not snap (although patients often say it feels like it will)

Pain is usually most intense when the knee is in a slightly bent position about 30°, right after the foot strikes the ground. This is the point where the IT band makes the most contact over the thigh bone. There is a theory that the ITB compresses the sensitive tissue underneath it just above the lateral femoral condyle (see diagrams above)

Tensor Fascia Lata – overuse of the TFL (look for hypertrophy or if very tight

foot may point outwards), creates anterior pelvic tilt, this increases the strain on

GMax and hence increases the strain on the lower leg. Patient must be able to

control their pelvic tilt by being able to isolate posterior and anterior rotation of

the pelvis. Look for cheating eg leaning forwards / backwards, bending knees,

scapula retraction, shoulder shrugging. If this happens you must teach them to

do a proper pelvic tilt with no muscle substitutions.


Useful Tests for ITBS Assessment

Noble Test

Ober test

Thomas test

Manual Pressure over insertion. (see accompanying video)

Treadmill

Good for reproducing symptoms and assessing patient progress

Observe for aggravating factors

• Narrow running style

• Heel striker

• Contralateral pelvic drop

• Knees almost touching

• Count combined number of steps / min (Cadence)

• ‘Bouncy or pogo stick’ style

Helpful assessments / exercises

• Single leg stance

• Single leg Dip

• Squat

• Lunge (see video)

Look for femoral medial rotation and knee valgus on affected side

during any of these tests. Persistently seeing this, is a factor in both ITB

and PFP. Be careful not to train the assessment. Demonstrate the

assessment for the patient but do not teach it. Let patient do the

required movement and watch how they do it. Better for them to repeat

it a few times to get an accurate idea of function. In ITBS allow knee to

flex beyond 30°to gage ITB improvement.

The Runners Knee Patella-Femoral Pain and Iliotibial Band Syndrome It can take months for these injuries to finally heal and the patient fully recover.

Manage patient expectations, by setting goals where symptoms decrease,

where they see the benefits of a gradual strengthening program.

You may initially want to see your patient x 2-3 over 2 to 3 weeks depending on

severity. Once symptoms decrease and your patient is doing well, leave them

for 2 to 3 weeks. Help maintain their progress by discussing with them

achievable goals.

Once they are over the injury

‘The objective of injury prevention / rehabilitation is to ensure tissue adaptation

stimulated from exposure to gradually increasing load keeps pace with, and

ideally exceeds the tissue damage’ Prof S McGill

Useful Training Tips for your PFP ITB patient

• 10% increase per week rule, generally works well.

• Incorporate recovery time into training / rehab program

• 80 – 20 Split between Low and High intensity

• Do not run your long runs too quickly.

Training Rehab

Make sure Muscles can cope (suggested simple exercises)

• Calf – raises should reach x30 (depending on age)

• Hamstrings – Nordic hamstrings, step ups, squats

• Glute Med – lateral lunges, single leg bridge

• Glute Max – single leg bridge

• Quads – lunges squats

• Adductors – lateral lunges, high knees

• The glutes, quads and calf are key to load absorption in runners.

The Runners Knee Patella-Femoral Pain and Iliotibial Band Syndrome Keep an eye out for

Last but not least

Thank you for ‘attending’ the FHT Virtual Conference 2021. I hoped you have

enjoyed it and also learnt from this presentation ! Looking forward to some

Face to Face teaching later in the year I hope.

Cameron Reid BSc(Hons)DO

Osteopath

Lower extremity stiffness

Mild stiffness morning after is OK – eases in morning

Stiffness affecting your movement next day = Too hard a session day

before

Summary of key points

• Help to balance training/ running load and capacity to manage that load

• Ensure treatment remains patient centred, not just about the knee!

• Assess their current knee load and ensure it’s at a manageable level

• Eccentric strength is very important

• Understand their beliefs about injury, why running is important and why they train the way they do.

• Hurt does not = harm, but people with chronic pain assume it does

• Empathise, educate, and explain

the runners knee

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