How to Avoid Runner’s Knee

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Your knees are put under a lot of stress, whether you’re running, playing basketball, dancing, or simply cleaning your house. Just using the stairs can put pressure on each knee equal to four times your body weight.

Functioning simultaneously as a hinge, lever, and shock absorber, the knee is the key to your ability to stand up, walk, climb, and kick. Yet it depends almost entirely on soft tissue—ligaments, tendons, and muscles—for stability. Because of its complexity and the great forces to which it is routinely subjected, the knee is susceptible to a host of injuries.

Of all chronic knee injuries caused by overuse, runner’s knee—more accurately called patellofemoral pain syndrome, or PFPS—is the most common.

Prevention is the key

PFPS typically occurs when a misaligned kneecap (patella) irritates the connective tissue supporting the knee. Characterized by dull pain in or around the kneecap, it is most noticeable when you go down stairs, run, or squat.

Nearly 30 percent of runners eventually develop this disorder. Skiers, cyclists, soccer players and people who participate in any high-impact activities are also prone to it.

Research has shed light on a variety of underlying factors that can contribute to PFPS. These include biomechanical problems such as a kneecap sitting too high or tilted in the groove in which it rests on the thighbone (femur); knees that turn in too much; feet that are very flat or very highly arched; and various muscle-related issues that affect how the kneecap moves. Genetics may predispose you to some of these factors.

Women are at greater risk for PFPS than men for anatomical reasons. For instance, they have a wider pelvis, which increases the angle of the quadriceps (the large four-part muscle group on the front of the thigh) to the knee. They also have smaller knees with less restraining tissue and weaker supporting muscle.

The best way to prevent runner’s knee is to strengthen and stretch the muscles that power knee movement, especially the quadriceps and hamstrings, which are located in the back of the thigh. (The exercises below will get you started.) A weakness or imbalance in the quads, hamstrings, and/or hip muscles can contribute to improper tracking of the kneecap.

If you’re a runner, your quadriceps are probably weaker than your hamstrings, so it’s a good idea to alternate cycling (a good way to strengthen the quads) with running. Walking up stairs or hills also helps strengthen the quadriceps.

To protect your knees, avoid the following:

  • Deep lunges or full squats
  • Downhill running
  • Cycling with the seat too low or in too high a gear
  • Taking large steps on the stairs or a stair-climbing machine
  • Full leg extensions with heavy weights and locked knees

In addition, do not exercise in worn-out shoes; don’t suddenly increase the intensity or length of your workouts; and don’t run on very hard, very soft, or hilly terrain. Don’t wear high heels, except on special occasions.

Treatment: what’s right for you?

If you have knee pain for more than a week or two, see your doctor. If you have PFPS, you should be referred to a physical therapist. There has been much debate about which treatments are best for PFPS.

Taping: One rehab technique for correcting a kneecap that doesn’t track properly is called McConnell taping, in which special tape is used to pull the cap into the correct position, thus reducing pain and allowing people to engage in rehab exercises. However, there is a need for large studies on taping techniques, and not all the findings have been positive. In addition, many people have trouble applying the tape properly.

Braces: There are special knee braces or sleeves that are supposed to correct knee biomechanics. The compression also stimulates skin and muscle receptors, thereby improving proprioception—that is, how you perceive the position of your knee in space. Improved proprioception may allow you to modify your movement in a way that puts less stress on the knee joint. A review in the American Family Physicianconcluded, however, that it’s not clear how effective the braces are.

Bottom line: If you have PFPS, it’s crucial to determine what’s causing it and get a personalized treatment plan. A skilled physical therapist—especially one who works with athletes and dancers—can then develop an exercise program to address your specific muscle weaknesses or imbalances and/or biomechanical problems.

Not everyone with PFPS has weak quads, hamstrings or hip muscles, for example. If it’s a biomechanical problem in the feet, you may need special shoe inserts. In rare cases, if nothing else helps, surgery may be an option.

(Originally published on Berkeley Wellness in November 2010. Updated April 2013.)

Running for Beginners: FAQ

How do I get started?
Start walking for a length of time that feels comfortable–anywhere from 10 to 30 minutes. Once you can walk for 30 minutes easily, sprinkle 1- to 2-minute running sessions into your walking. As time goes on, make the running sessions longer, until you’re running for 30 minutes straight.

Is it normal if running hurts?
Some discomfort is normal as you add distance and intensity to your training. But real pain isn’t normal. If some part of your body feels so bad that you have to run with a limp or otherwise alter your stride, you have a problem. Stop running immediately, and take a few days off. If you’re not sure about the pain, try walking for a minute or two to see if the discomfort disappears.

Can I run in sneakers?
Running doesn’t require much investment in gear and accessories, but you have to have a good pair of running shoes. Unlike sneakers, running shoes are designed to help your foot strike the ground properly, reducing the amount of shock that travels up your leg. They’re also made to fit your foot snugly, which reduces the slipping and sliding that can lead to blisters. Visit a specialty running store to find the right shoe for you.

How is running on a treadmill different from outdoor runs?
A treadmill “pulls” the ground underneath your feet, and you don’t face any wind resistance, both of which make running somewhat easier. Many treadmills are padded, making them a good option if you’re carrying a few extra pounds or are injury-prone and want to decrease impact. To better simulate the effort of outdoor running, you can always set your treadmill at a 1-percent incline.

Where should I run?
You can run anywhere that’s safe and enjoyable. The best running routes are scenic, well lit, free of traffic, and well populated. Think of running as a way to explore new territory. Use your watch to gauge your distance, and set out on a new adventure on each run. Ask other runners about the best local routes.

I always feel out of breath when I run–is something wrong?
Yes, you’re probably trying to run too fast. Relax. Slow down. One of the biggest mistakes beginners make is to run too fast. Concentrate on breathing from deep down in your belly, and if you have to, take walking breaks.

How do I prevent getting a side stitch when I run?
Side stitches are common among beginners because your abdomen is not used to the jostling that running causes. Most runners find that stitches go away as fitness increases. Also, don’t eat any solid foods during the hour before you run. When you get a stitch, breathe deeply, concentrating on pushing all of the air out of your abdomen. This will stretch out your diaphragm muscle (just below your lungs), which is usually where a cramp occurs.

Should I breathe through my nose or my mouth?
Both. It’s normal and natural to breathe through your nose and mouth at the same time. Keep your mouth slightly open, and relax your jaw muscles.

Should I be doing anything in the gym to build my fitness?
Working on stretching and flexibility is always helpful, especially to prevent injuries.

(Article originally published in Runner’s World)