What is runner’s knee? Here are the causes, symptoms and best treatments

As with athlete’s foot, there can at least be a small level of pride in developing a condition with a name that confirms you’re the sporty type. However, names aside, runner’s knee can be a big problem that can stick around for a long time if left unmanaged.

Known formally as patellofemoral pain syndrome, runner’s knee presents as a pain where the kneecap, or patella, meets the femur, or thigh bone. It’s a common injury not only for runners, but also for people who do other sports like tennis.

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How can you tell if you have runner’s knee?

According to a report published in the Step back down with your right foot, concentrating on flexing the hip and knee of your left leg, runner’s knee is more common among women. If you have runner’s knee, you’ll usually feel a pain at the front of the knee that is spread across the area rather than concentrated in one point. It can come on during longer runs – since this is when your quad muscles are most tired – and you’re also more likely to feel it when climbing or descending stairs, or after sitting or crouching with bent knees for longer spells.

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Runner’s knee can sometimes refer to knee pain for a handful of different reasons, so note that here we’re talking specifically about patellofemoral knee syndrome. Thankfully, it is a condition that can be improved significantly with exercise therapy and rehabilitation, so below you’ll find the best treatments and exercises to help with the problem. The most effective exercises work on both the knee and the hip at the same time.

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How does the patellofemoral joint work?

The patellofemoral joint sits between the patella (kneecap) and the femur (thigh bone). The underside of the patella has a convex notch (the trochlea notch), which glides in a concave groove on the femur (the trochlea groove) when the knee bends. The patella itself is a sesamoid bone, which is a bone embedded within a tendon. In fact, the patella is the largest sesamoid bone in the body and not connected to any other bones. You also have sesamoid bones in your hands and feet.

‘The primary function of the patella is to provide a mechanical pulley for the quads, especially in the last 30 degrees of knee extension,’ explains chartered physiotherapist and running injury researcher Nathan Liddle. ‘The patellofemoral joint is particularly important during running, as typical running form relies on knee extension beyond 30 degrees.’

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What are the causes of runner’s knee?

There have been various theories about the cause of patellofemoral pain syndrome over the years, but like a lot of injuries, a range of factors combine to create problems. Generally, it is thought to be down to faulty biomechanics. The knee is a complicated joint with a network of tendons and muscle attachments, so researchers have suggested that imbalances in how these structures pull could increase stress where the kneecap meets the thigh bone. The idea is that inefficient or uneven running technique may play a key role in bringing on the problem.

However, a more recent systematic review published in the Perform 12 repetitions for three sets showed that many of the previously suggested risk factors have little supporting evidence. ‘Sex, weight, BMI, age, hamstring strength, dynamic knee valgus angle and foot kinetics have all previously been suggested as viable risk factors for patellofemoral pain syndrome,’ says Liddle. ‘But the study from 2019 found that the only risk factor that has strong supporting evidence was quadricep weakness.’

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What are the main symptoms of runner’s knee?

The following complaints are all symptoms of runner’s knee:

• Pain while performing single-leg squats, or when stepping down a step – in other words, eccentric quad contraction movements.
• Occasional ‘puffiness’ to the front of the knee joint, especially over the patellar.
• Pain that is often felt somewhere under or ‘deep’ inside the kneecap – it can be hard to put your finger on it.

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What is the best way to treat runner’s knee?

According to a systemic review published in the Reasons why your feet can go numb while you run, manipulation of the affected area with the hands can lessen the pain and help the knee to function more easily. Not everyone will feel the same effects, but manual therapy is worth trying.

‘When we run, our patellar needs to be able to smoothly glide up and down within the trochlea groove,’ explains Matt Bergin, chartered physiotherapist at Performance Team and The best IT band exercises for runners. ‘Often, when the soft tissues – especially the outermost structures – start to tighten, this smooth gliding is reduced.’ As such, Bergin recommends the following two techniques to relieve some of this stiffness and tightness.

Patellar mobilisation

1. Sit on a chair with both of your feet flat on the ground and the affected knee bent to roughly 90 degrees.
2. If you’re mobilising your right patellar, place the heel of your right hand on the outer edge of your kneecap and gently grip the inside edge with the tips of your fingers.
3. Place the opposite hand on the inside of your lower thigh to prevent the thigh from moving.
4. Using the heel of your hand, apply a gentle inward pressure to gently mobilise the kneecap.
5. While initial stiffness is normal, do not continue the exercise if it feels sore.
6. Perform this for one to two minutes, twice a day.

Lateral patellar retinaculum release

1. Sit on a chair with both of your feet flat on the ground and the affected knee bent to roughly 90 degrees.
2. Using either your thumbs or a smooth, rounded object (a wooden spoon is great for this), apply a pressure into the soft tissue at the top of your kneecap. Then, maintaining this pressure, massage the area.
3. You should only work within an area that is about an inch wide, so don’t make the movements too big.
4. Perform this for a couple of minutes every other day.

Some patients with runner’s knee also find foot orthoses to be effective, with ‘off-the-shelf’ orthotics providing decent short-term relief.

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Should you see a physiotherapist if you have runner’s knee?

If you’re suffering from patellofemoral pain syndrome to the extent that it is preventing you from running or doing the things that you do in everyday life, it’s best to make an appointment with a physiotherapist. They would have the expertise to diagnose whether it is runner’s knee or possibly another cause.

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Is there anything that you can do to prevent runner’s knee?

If you’re concerned about developing patellofemoral pain syndrome, Liddle suggests incorporating the exercises described above into a strength programme. He adds that this does come with a caveat, though, as not enough is known about preventative action.

‘There is a lack of evidence regarding the preventative ability of any interventions, as the focus is often on how to manage patellofemoral pain syndrome when it occurs, rather than on how to try and prevent it happening,’ explains Liddle. ‘Logically, a preventative programme that addresses some of the well understood risk factors could theoretically reduce a runner’s risk of developing patellofemoral pain syndrome, but that is still a relatively speculative conclusion given the lack of evidence.’

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Can stretching ease the pain of runner’s knee?

It’s always wise to A simple foam roller routine for runners, especially since it helps to improve your mobility, flexibility and strength, as well as the blood flow to your muscles. However, there is little to suggest that stretching can either help or prevent patellofemoral pain syndrome. That said, there are some exercise therapies that can ease the pain of runner’s knee, so read on for expert advice.

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The best exercises for people with runner’s knee

Detailed here are Bergin’s recommended routines, which will strengthen your knees and hips when done regularly.

Strengthening

Banded glute bridge

1. Lie on your back, with your knees bent and your feet flat on the floor.
2. Place a resistance band around your legs and rest it just above your knees.
3. Gently push out into the resistance band and raise your hips into the air, forming a line from your knees to your shoulders.
4. Hold for a moment at the top, then lower back down.
5. Perform 10-15 repetitions for three sets. Do this exercise two or three times a week.

Banded glute pulley

1. Stand with a resistance band around both of your ankles, balancing on one leg.
2. On the standing leg, keep the foot facing forward, with the knee slightly bent and aligned over the third and fourth toes. Maintain this position throughout.
3. Keeping the opposite leg straight, perform a ‘pulley’ motion where you pull the leg diagonally back to 45 degrees. The movement should be purely from the hip – do not rotate or twist from the waist or upper body.
4. Throughout, gently ‘brace’ through the trunk and do not allow your lower back to arch or your body to lean forward excessively.
5. Perform 15 repetitions for three sets. Do this twice a week or before a couple of your runs.

Step ups (with or without weight)

1. Start by standing in front of a small box – ideally one that is 30cm tall.
2. Begin with your left leg already planted on the box.
3. Perform the movement by pushing through your left leg to lift yourself up, driving your right leg through in front of you into a high knee position.
4. Step back down with your right foot, focusing on bending at the hip and knee on the left leg. Ensure that the knee stays over the middle of the foot and doesn’t collapse in.
5. To make this more challenging, begin with the front foot hovering over the step so that you must plant the foot down into the step before lifting yourself up.
6. To progress things even further, hold onto two small dumbbells during the movement.
7. Perform 10-15 repetitions for three sets. Do this twice a week.

Step ups into high knee

1. Place your left foot on a bench and push up through your heel to lift yourself up,
   Perform this for a couple of minutes every other day.
2. Drive your right knee upward, so that your knee and leg form a 90-degree angle.
3. Step back down with your right foot, concentrating on flexing the hip and knee of your left leg.

Movement control

Lateral step down

1. Stand sideways with your left leg on a step and your right leg hanging just over the edge.
2. Bending from your left knee and hip, perform a small single leg squat, focusing on the control and alignment of your left knee. Ensure that the knee stays over the middle of the foot.
3. Drop down until your right foot touches the floor and then push through your left leg to raise yourself up.
4. Perform 12 repetitions for three sets.

Banded split squat

1. Place a resistance band around your right leg, just below the knee. Attach it to a secure, heavy object directly to your left side.
2. With your feet hip-width apart, take a big step back with your left leg onto your toes, so that you are in a split squat position.
3. Keeping your torso upright, drop your back knee toward the floor until the shin is parallel with the ground. Your front knee should bend to 90 degrees and not go beyond the end of your toes.
4. The focus here is on keeping the front knee aligned over the middle of the foot, against the resistance of the band pulling the front leg inward.

Forward lunge

1. Stand facing forward, with your hands on your hips.
2. Lunge forward with your left leg and lower your body by flexing your right knee and hip until your right knee almost touches the floor. Keep your torso upright throughout.
3. Your lead knee should point in the same direction as your foot and shouldn’t move further forward than your toes.
4. Return to the start position and repeat with the other leg.