Patellofemoral Pain Syndrome

Runners Knee!

“I have knee pain after I run.”

This is a very common issue for many people. “Runner’s knee” or “patellofemoral pain syndrome” to give it its proper name. This can be a frustrating injury for both you as a runner and us as physiotherapists.

It’s obvious why this is frustrating to you. Either it’s stopping you from running or you can run but the pain is worsening after each run. But why is it frustrating for physiotherapists?

Runner’s knee is frustrating for physios because there is no consensus on what exactly is the cause. Not knowing the exact cause can make it hard to explain the runner’s knee to you. But, thankfully, there are good treatment options, and having seen a lot of runners in our clinic we have gotten good at finding triggers to this kind of knee pain. Once we find the triggers we can address them and get your back running pain-free!

So what’s the best way to treat a runner’s knee? Well, the best way is to prevent it from happening in the first place. If you think you have a runner’s knee then skip to the next paragraph. But, if you are new to running and want some good prevention strategies for running injuries email us at for free beginners running plan. Or, if you want a more detailed at-home strengthening plan to improve your running and keep you injury-free you can CLICK HERE for our 12-week runner’s strength plan.

Patellofemoral Pain Syndrome responds well to rehab and adaptation of your training volume. Patellofemoral Pain Syndrome is typically a dull ache as opposed to sharp pain. This ache can last a long time and may not actually stop you from running. But, the ache may reduce the quality of your runs and interfere with your daily activities outside of running.

What is Patellofemoral Pain Syndrome

The first thing we need to address is the misdirect that is the name “runner’s knee” which has been attached to this injury. Much like “tennis elbow” or “golfers elbow”… “runner’s knee is not just for runner’s. Patellofemoral Pain Syndrome is common in cyclists, hikers, field sports like football or hurling and it is common with track and field athletes like sprinters or hurdlers.

Many people theorise that the movement of the patella may be the cause of Patellofemoral Pain Syndrome. There is no proof of this. Other’s believe that quadriceps weakness and its poor control of the patella is what causes Patellofemoral Pain Syndrome. This may be a contributing factor. But, weakness doesn’t mean poor control. Instead, strong quads are more likely to improve knee joint health than patella control.

Cartilage degeneration is another cause that is theorised but again there is very little evidence for this. Yes, knees with Patellofemoral Pain Syndrome often have cartilage degeneration in them. But, often both knees of one person have cartilage degeneration but only one has Patellofemoral Pain Syndrome. If cartilage degeneration was the main cause then wouldn’t both knees have pain?

If you are to simply go looking for a cause of Patellofemoral Pain Syndrome you won’t find one. Patellofemoral Pain Syndrome in your knee is likely your body’s way of telling you that your knee needs a rest from something. What exactly that something is we can help you find out. The good news is that Patellofemoral Pain Syndrome does not mean continuing to use your knee will lead to further damage or unrepairable damage.

How do I know if I have Runner’s knee?

The symptoms you should be looking out for with Patellofemoral Pain Syndrome are;

  • Dull achy pain on the front of or edges of the patella (kneecap)
  • Sometimes a sharp pain that feels like it’s deeper under the patella.
  • Increase in pain running uphill
  • Increase in pain walking upstairs
  • Pain after prolonged sitting
  • Tenderness when pushing on the patella

Patellofemoral Pain Syndrome Myths

Some kind of biomechanical issue is causing your knee pain!

Many physiotherapists get lazy and blame very normal body mechanics for your pain. “flat feet” get an awful time. Leg length discrepancy does too. And don’t get me started on the supposed Q-angle danger!

What’s your Q-angle? Your q-angle is found by drawing a triangle from your patella to two parts of your hips. Then you take the angle at the point of the triangle that forms on the center of your patella. The “good” angle to have is 15 degrees. But, apparently, just 5 degrees on either side is dangerous! Nothing has ever confirmed that this is an accurate claim. When you’re unsure as a physio it’s easy to blame something technical that the patient doesn’t know. Blaming the q-angle or some biomechanical issue is irresponsible. Your physio should tell you. This is Patellofemoral Pain Syndrome, we don’t know what causes it, but this is how to fix it.

Patellar tracking is causing your knee pain

Pain in the knee is often cited as being caused by the kneecaps inability to “track properly”

There is no clear connection between the movement of the patella and knee pain. The patella is more dynamic than you’d think. Your patella doesn’t just more in straight lines. In fact, if you lie your keg flat on your bed and play with your kneecap you will see that it moves in lots of different directions.

Like many body parts, there is no “normal” or “abnormal” movement for your patella. If your treatment for Patellofemoral Pain Syndrome focuses on alignment or tracking of the patella then it’s time to go elsewhere. IT band stretches, knee braces, and taping won’t work. Quad strengthening may be needed and useful for your knee pain but its focus should not be to change the alignment or tracking of your patella.

Cartilage damaging is causing Patellofemoral Pain Syndrome.

The first issue here is the cartilage under your patella does not have any nerves in it. The cartilage alone is relatively inert. You can’t hurt it if it doesn’t have any nerves. It’s more likely the synovial fluid in your knee is what is being irritated. In any case though it is extremely unlikely that there is structural damage when it comes to Patellofemoral Pain Syndrome.

Can I continue to run and train with Patellofemoral Pain Syndrome?

Running can for sure irritate and exacerbate your pain when you have Patellofemoral Pain Syndrome. But, that being said it I possible to continue to run, hike, cycle and train through the pain. You will not cause more damage by doing so. Just keep in mind it will continue to be uncomfortable if you keep training.

Usually, we make a decision on continued running/training based on your situation. There is no right or wrong answer here.

Take for example one person I saw 6 weeks out from the marathon;

They had Patellofemoral Pain Syndrome. It was dull, achy but didn’t stop them running. They would have soreness after runs that would last a few hours. After big runs, the pain would last until the next day. Stopping running would have helped their pain. But, they had trained since January for a marathon.

Their priority was completing the marathon as opposed to getting rid of the pain. In this case, we managed their running volume for 4 weeks with just two big runs (both 20 miles) these were key runs in their training. Then two weeks out from the marathon I used a two-week taper of relatively low volume to make sure they had two weeks without soreness. They then completed the marathon. This person had pain in their knee after the marathon, but, they had achieved their goal and then could focus on getting back fully pain-free with running.

Can Patellofemoral Pain Syndrome heal?

Yes definitely. Having pain-free knees is possible for sure. Often rest is given for patellofemoral pain syndrome. But, that’s the easy way out. As a physiotherapist, it is easy to tell you to stop running if that causes you pain.

Instead, in our clinic, we address the problem so you can get back doing the things you love. If you have Patellofemoral Pain Syndrome and we ask you to stop running it is only temporary. We want to work with you in order to reduce your pain and get you back running.

If you have any questions please don’t hesitate to contact us.

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Tommy Brennan

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