By Dr. Dale Buchberger
Photo from “Runner’s World”
As the weather improves more and more recreational athletes will hit the road for their daily running sessions in an attempt to shed the winter pounds. Unfortunately, a large percentage of these individuals will have their exercise goals fall short do to injury. One of the most common injuries in the recreational runner is knee pain.
Commonly referred to as runner’s knee or patellofemoral pain syndrome (PFPS, this type of pain is worse with activity and improved with rest or stopping the running program. While the majority of runners knee can be resolved with a combination of physical therapy treatments and stability exercises there are occasional underlying problems with the patients anatomy that may slow progress. The faster the underlying problems are recognized the more efficiently the patient can be managed. Efficient management leads to faster resolution of their knee pain and return to their recreational running.
The knee is made up of four bones. The femur or thighbone above, the tibia and fibula below and lastly the patella or kneecap that sits in a groove on the femur. In the past, it was believed that the kneecap itself moved to the outside and this was the cause of pain in the knee. Today research has shown that it is not the kneecap that moves to the outside but, the femur moves to the inside giving the perception that the kneecap moves to the outside. This happens in large part do to weakness of the hip muscles that should contract and stabilize the femur at each step in the running or walking gait.
If you are experiencing simple runners knee because of poor mechanics from hip muscle weakness, exercises such as bridging, side leg lifts, and squats leaning into an exercise ball will be helpful in correcting that weakness and reestablishing correct mechanics on foot plant in the running gait. If your pain is not improving and you have received treatments such as ultrasound, electrical stimulation, ice, and knee exercises you should try alternative treatments and be evaluated for underlying conditions.
Several underlying conditions can be the cause of knee pain that fails to improve with comprehensive physical therapy. One of the more common conditions is known as a synovial plica band. This is basically an extra piece of tissue that remains in the knee from birth. Normally the plica is painless but, the stress of athleticism will irritate and thicken the plica turning it painful. Once the band becomes painful, ice and rest will usually reduce the pain. Returning to running often exacerbates the plica. Unfortunately, the most efficient treatment for a symptomatic plica band is arthroscopic surgical removal.
Here are some helpful clues to help differentiate a mechanical patellofemoral pain syndrome (PFPS) from synovial plica syndrome. Runners with a plica syndrome usually have pain with running in a very predictable time frame. For example, the pain usually comes on at a predictable time or distance into a run. Riding a stationary bike or using an elliptical are tolerable or even pain free. Sitting for long periods in a movie, car, plane, etc. cause pain and stiffness. This is referred to as cinema or movie sign. This is not commonly present in a mechanical PFPS. Riding a stationary bike and using an elliptical are usually pain free because neither requires you to be in single limb stance (standing on one leg) at any given point in time such as in running. It is the single limb stance that puts the most stress on the knee. While patients who have plica syndrome will get stronger with their strengthening program and their pain will subside with reduction or ceasing running activities, the pain returns with running in the same predictable manner as it did before the strengthening program. PFPS has a very good track record of resolution with a comprehensive program of manual soft tissue therapies, hip strengthening and balance training.
If you are a runner suffering from pain in the front of the knee and you have attempted self-care with a hip and knee program but continue to battle knee pain you should seek out an opinion of a healthcare provider with sports injury experience and training. A healthcare provider trained in the management of sports injuries and who is familiar with runners can let you know from a history and physical examination if a plica band should be suspected. Generally speaking, if the pain is present for 6-8 weeks and is not resolving to the point that you can return to your previous running routine a medical opinion is in order and will ultimately save you time, money and frustration. It won’t “just go away”.