8 Common Knee Pain Diagnosis – Treatments and Exercises Included

As a runner, chances are you know someone whom has experienced with a knee pain while running.

Some estimates show around 75% of runners experience at least one small knee injury every year.

It doesn’t have to be this way.

In this article, I will explain in-depth every knee injury that you could possibly experience as a runner.

You will learn what occurs with each injury, how they are rehabbed and how to prevent them

The injuries you will learn about are:

  1. IT Band Syndrome
  2. Runner’s Knee (Chondromalacia Patella)
  3. Plica Syndrome
  4. Patellar Tendonitis
  5. ACL injury
  6. Medial Meniscus Tear

I’m Dr. Sebastian Gonzales and I spent 21 hours of my life writing this guide so you can learn how to feel better.

Sebastian Gonzales DC

Chapter 1: IT Band Syndrome

Also known as Iliotibial Band Syndrome, this is extremely common in the running community. Learn how it’s treated.

Chapter 2: Patellar Tendonitis

Pain below the kneecap is extremely common in any athletic population. Learn how to treat and correct it here.

Chapter 3: Runner’s Knee (Patellofemoral Pain Syndrome)

AKA PFPS and Chondromalacia Patella, this “pain under the knee cap” is the #1 reason for doctors visits by athletes. Learn how we treat it.

Chapter 4: Pes Anserinus Tendonitis

Pain under the knee on the inner side? Maybe you have a Pes Anserius condition. Read about rehab and treatment.

Chapter 5: Plica Syndrome

Have pain on the inner part of the knee? Perhaps the plica could be the issue…

Chapter 6: ACL (Anterior Cruciate Ligament) Injury

Twist, “pop” and immediate swelling? You could be looking at an ACL injury. Learn more about this serious condition.

Chapter 7: Cysts of the Knee

Did your doctor say something about a cyst in your knee? This is the info you have been searching for…

Chapter 8: Medial Meniscus Injuries

Pain on the inside of the knee? Clicks, pops and maybe locks? Better read this!

CHAPTER 1: IT BAND SYNDROME (ILIOTIBIAL BAND SYNDROME)
  • Stinging pain on the outside of your knee?
  • Does your knee click?
  • Does the pain come back as you stop and start again?
  • Knee pain while running?

Watch this video before going on.

I go into almost everything you’ll need for ITBS. I cover anatomy, rehab, treatments and theory. I know it’s a long one but if you want to get better, you need to watch the entire thing.

Sit alone during your lunch break and spend the time.

I actually had IT Band Syndrome one time in my life for about a month.

It was unbearable.

I remember was training for a ½ marathon. On one of my runs around Back Bay in Newport Beach, I reached the section where you come to the neighborhoods on the north side where there are some traffic lights.

Red light.

Green light…this is where the stabbing pain began. There was pain with every step, or every landing to be more exact. It slowly dissipated over the next 50 yards.

I saw another light coming up and of course, hit another red light again.

Green light…the stabbing pain began all over again.

I began to walk and realized this was not normal.

Iliotibial Band Syndrome (ITBS or IT Band Syndrome) is an injury that can keep you down for months if you let it. I beat it and you can too. Let’s start by learning something about it.

IT Band Syndrome

What creates the pain associated with IT Band Syndrome?

The IT Band is a dense, fibrous band of tissue that runs from the outer hip down to the side of the knee. It sits right on top of the lateral quad muscle, and when it gets to the knee, it runs over a bursa. This bursa is normally located there to decrease friction between the IT band and the bone of the knee that lays deep to it.

Pain develops as the IT band is compressed into the bony area (lateral condyle) of the knee. It is commonly called a friction syndrome.

IT Band Syndrome

What causes the friction of the IT band on the bone?

The most common answer you’ll find on the web is “tightness of the IT band.”

But what is the truth?

It’s a combination of strength, coordination and endurance deficiencies of the core, hip and ankle. Some call the knee the “red-headed stepchild of the leg”. It’s never its fault, but it always gets blamed.

What’s the real story?

IT Band Syndrome

Not buying it yet?

Look at what the research says about IT Band Syndrome.

In 2010, an article from The Journal of Orthopedic & Sports Physical Therapy looked at the differences between the biomechanics of runners plagued by IT Band Syndrome and those who weren’t (so called non-injured/healthy runners).
In the study, they looked at and compared three things between the two groups:

  • Hip biomechanics
  • Knee biomechanics
  • Ankle biomechanics

In the past, researchers have theorized that IT Band Syndrome comes from any of the following: (Ferber 2010)

  • Excessive rearfoot eversion
  • Greater internal rotation of the tibia (where the band attaches)
  • Weakness of the hip adductors (on the sides) creating more adduction in running gait (crossing the leg past midline when looking head on)

Technical, I know, but hang in there. (I said we were going in-depth, didn’t I?)

First off, it’s important to know the IT Band does not stretch…maybe a tiny bit, but really not much at all. It is a structure of support just like the ACL. One of its functions is to provide lateral support to the hip and knee…so why would we even attempt to stretch it anyway?

I don’t know of any runner who spends their mornings trying to stretch their other joint-stabilizing structures like the ACL, PCL, and stiff ankle ligaments, which can often be sprained/torn.

IT Band Syndrome

Let’s start with the ankle

In this study, they found no correlation with IT Band Syndrome and rearfoot eversion (in laymen’s terms, some might call that “flat feet”). In fact, the IT Band syndrome group actually had less eversion (“pronation or flat feet”) than the non-injured group.

“How could that be?” you might ask.

They found that the IT Band group actually had higher activation of the opposing muscles of the ankle, which do the opposite motion, called inversion. Inversion would be like running on the outer parts of your feet.

Perhaps, this is a compensation mechanism…we don’t know for sure.

Even if ankle eversion was a significant finding in IT Band Syndrome cases, there is a lot of variability in how much eversion is too much. There is not a direct, one-to-one relationship in degrees of motion between rearfoot eversion and tibial rotation.

So if you’re wearing orthotics and you are still having IT band pain, perhaps we should look into the hip and then the knee itself.

Does the hip have a correlation with IT Band Syndrome?

Ferber’s study points to poor biomechanics of the hip as a reason for IT Band Syndrome due to significant increases in hip adduction or crossing the midline. Correction of this problem via strengthening of the hip abductors over a six-week course showed improvement in 22 out of 24 runners with IT Band Syndrome and knee pain while running (Fredicson 2000).

So, getting stronger hips is the answer?

Just six weeks of hip strength training resulted in pain-free running in 92% of runners.

For those of you interested in this study there is a reference in our resources.

IT Band Syndrome

If you have been studying causes of IT Band Syndrome then you have a run across the topic of internal tibial rotation.

Does internal tibial rotation cause IT Band Syndrome?

Studies have been indicating that it is not as big of an issue as we originally thought.

So am I saying there is no internal tibial rotation with IT Band Syndrome?

Not at all.

Internal rotation of the tibia is not something that just happens, but according to this research, ankle biomechanics is NOT the main cause in IT Band Syndrome. What is causing it to rotate is a different process altogether.

Why is all of this information important to you?

If the hip and ankle are factors in IT Band Syndrome, then it is more than a knee problem, correct?

So, there is more to it than just foam rolling till we are black and blue?

Definitely!

A rehab program for IT Band Syndrome encompasses core exercise, squats, lunges, hip band work, and ankle proprioception drills to name a few. I know it sounds complicated, but it really isn’t.

Here are a few exercises I start people on if they have knee pain while running:

There’s a few videos in this block. I would take the time to watch them all if you’re serious about your knee. The last one is provided by an awesome Jason FitzGerald at Strength Running.

Now on to the IT Band Stretches… Skye!

The sad reality is stretching the IT Band is old news. Study upon study over the past 10 years has shown when we improve core and hip function, majority of IT Band cases get better without stretching.

So is there a need for IT Band stretches at all?

Sure… they can assist with decreasing pain but that’s not the most important part of injury recovery. The most important part is FUNCTION. How do you function today? It really don’t matter a ton how you feel.

What will keep you running longer is improved function. Pain comes and goes but when it’s present it’s the best motivation factor you could ever ask for. Be thankful for it and allow it to improve your function for a longer running career.

Here’s some other treatments and/or factors that can assist you in recovering from IT Band Syndrome and decrease knee pain while running:

  • Active Release Technique
  • Deep Tissue Massage
  • Functional Neurology
  • Anti-inflammatory Injections
  • Prolotherapy
  • Chiropractic Adjustments or mobilizations
  • Strength training/rehab
  • PRICE therapy
  • Running gait training
  • New shoes
  • Better roads
IT Band Syndrome

Stop just foam rolling your IT Band and taking excessive time off. You can be moving towards your running goals during your downtime from running; but stretching and wishing you could run is not the best plan of attack.

Have someone assess what your problem is, get on a training plan, and get back to running within a few weeks. This will just be a hiccup on your path to becoming a healthier runner.

References:
Ferber, R. Noehren, B., Hamill, J., Davis, I. 2010, “ Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics”, Journal of Orthopaedic & Sports Physical Therapy, Vol. 40, pp. 52-58.

Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000;10:169-175.

CHAPTER 2: PATELLAR TENDONITIS
  • Pain just under the kneecap…on the tendon?
  • Painful and tight when you’re just standing up?
  • Scared of pain associated with stepping off of a curb?
  • Knee pain while running?

This does not have to be the injury that takes you out of running. This will not be your last race.

In this section of the article, you will learn the ins and outs of Patellar Tendonitis. More detailed and easier to understand then the last page you read…which was probably WebMD, huh?

Before we start into the text you NEED to watch this video… yes it’s another long one but it’s very comprehensive. I cover just about everything you need to know about patellar tendonitis in one video.

Don’t cheat you’re self. Find 30 minutes out of your day to watch the entire thing.

What is Patellar Tendonitis?

Patellar Tendonitis can feel like pain just below (inferior to) the kneecap at the inferior pole down to the tibia, but it can also be present at the top of the kneecap and run into the superior portion as well.

Looking at the anatomy of the patella, it is not hard to see it is a unique bone because it is encased in a tendon. It is called a sesamoid bone.

Its purpose is to create mechanical advantage as a tendon crosses a certain joint, in this case, the knee joint.

Patella Tendonitis

What causes Patellar Tendonitis?

  • Overuse
  • High intensity and frequent physical activity
  • Muscular/skeletal instability
  • Malignancy of bone
  • Tightness of the muscles surrounding the area
  • Obesity
  • Patella alta
Patella Tendonitis

What creates the pain associated with Patellar Tendonitis?

The patellar tendon is just like any other soft tissue structure of the body. If you demand too much from it, eventually it will fail.

This is exactly what happens. The tendon is exposed to too many miles, too much concrete, or too much improper running mechanics.

The tendon becomes irritated and starts to yell at you.

“Hey! You’re hurting me. Stop!”

Do most people stop?

No.

Patella Tendonitis

Typical treatment is an anti-inflammatory remedy such as pills or ice. Remember, inflammation is a natural process. Your body is telling you something.

What is your body telling you?

Change something because what you’re doing isn’t working.

Does this mean you have to stop running forever? Not at all, but you may have to decrease your mileage a bit to “cool the knee down” while you rehab.

Research has shown Patellar Tendonitis can be treated with rehab of the core, hip, thigh and ankle. Imbalances of the muscles of the pelvis and thigh would be my first guess as to what causes most cases of Patellar Tendonitis in the first place.

Usually, if we work from this assumption and move our way towards gait analysis later in the program, it goes fairly well. With Patellar Tendonitis, if you look at gait too, soon there will be false positives.

I know all of this information is cool, but you just want to know what can decrease the pain, right?

Isolated treatment of pain in the tendon is important though.

Patella Tendonitis

What are some options for Patellar Tendonitis treatment?

Treatment of the area of pain is critical in decreasing knee pain while running and rehabbing the area. All of these are great options:

  • Rest the area (72 hour max)
  • Stretching
  • Ice treatment
  • Non-steroidal anti-inflammatory medications
  • Chopat straps/braces
  • Active Release Technique®
  • Surgery
  • Corticosteroid injection
  • Massage
  • Platelet rich plasma

Here’s one of the ball mobilization exercises that really seems to free things up. Rolling out the quad group will decrease the amount of tension on the kneecap and the patellar tendon that’s attached to it.

Also in this collection is one of the rehab circuits I like to do with my runners as we advance. Everything can be scaled back, and the hardest part will be squatting. I know there is squatting in this circuit, and if done more in a box squat pattern, it will decrease the pain. Increasing height will assist as well.

What test can rule in the need for Patellar Tendonitis treatment?

  • X-ray’s will rule out if there is a problem in the bone
  • Definitive answer is an MRI
  • Diagnostic Ultrasound
  • Physical exam by a medical professional
CHAPTER 3: PATELLOFEMORAL PAIN SYNDROME (RUNNER’S KNEE)
  • Does your knee sound like a rusty door hinge?
  • Does it swell after a run?
  • Inner knee pain?
  • Thinking you’re just “getting old”?
  • Knee pain while running?
  • Pain on inside of knee (medial knee pain)?

This does not have to be the end. You don’t have to start cycling or swimming just yet.
You can run again with the right rehab.

Before you go to far, you should find 30 minutes to watch this video all about Runner’s Knee. I included many corrective exercises, assessments and treatments. It will answer many of your questions and you won’t even have to read the whole section.

For your convenience, I created some page jumps for the Runner’s Knee / Patellofemoral Pain Syndrome section.

What is Runner’s Knee?
What causes Runner’s Knee?
Runner’s Knee Symptoms?
Runner’s Knee Rehab
What are some options for Runner’s Knee treatment?

PATELLOFEMORAL PAIN SYNDROME (RUNNER’S KNEE)

In this section of the article, you will learn about the most common knee injuries experienced while running. You will learn about common treatments and rehab exercises.

But most of all, I want you to know you are not alone. Many runners have gone through this before and have come out fine. But with an injury like Runner’s Knee, you must understand one thing:

It is not a major injury in the beginning, but it can and will be the injury that stops you from running permanently if you don’t address the underlying causes.

I have had Runner’s Knee just like you. It was around five years ago.

I was in my prime. 31 years old and the fittest I’ve ever been.

It was a slow progression. I began noticing my symptoms for about a week before I realized and then considered the consequences of my neglect.

What is Runner’s Knee?

Pain felt deep in the knee can be a symptom of Chondromalacia Patella, also known as Patellofemoral Pain Syndrome (PFPS). The meaning of chondromalacia can be broken down to chondro, meaning cartilage and malacia, which means weakening.

Runners Knee and Patellofemoral Pain Syndrome are the same condition. I know it’s confusing since the names are different, but think of one as the athletic term and the other as a medical term.

In the past, the term “Runners Knee,” was used to describe pain around the patella or kneecap. Currently, most doctors recognize it as a “catch all, garbage term,” used to describe pain around the kneecap. The term is used so loosely it no longer has value and lacks description of the underlying reason for knee pain around the cap.

PATELLOFEMORAL PAIN SYNDROME (RUNNER’S KNEE)

Patellofemoral Pain Syndrome is a little bit more descriptive because it indicated the region or location of the irritation. However, it still doesn’t account for the mechanisms causing Patellofemoral pain. We will go into that later…

Let’s start with describing why it’s medically called “Patellofemoral Pain Syndrome.” The region of the knee in question is called the Patellofemoral complex, which is made of the kneecap (aka the patella) and the femur (aka the thigh bone). This region also has ligaments, cartilage, nerves, blood vessels, and tendons. It’s a complex joint when we look into the small parts but by no means is it as complex as the ankle.

The underlying fact that this is a cartilage injury is what makes it the kind of injury that could ultimately keep you from running. Cartilage does not heal as well as bones and muscles do.

Cartilage doesn’t have a direct blood flow supply (excluding the outer 1/3 of the meniscus) like other tissues of the body. It gets its nutrients through intermittent compression, pushing out the waste and sucking in the good stuff. Cartilage is just like the rest of your body in that respect.

You eat food and then get rid of the waste. This is no different except think of the cartilage is constipated. It sometimes needs to be squeezed. Constant squeezing however won’t allow for nutrients to come in. This eventually leads to slow cartilage degrade, resulting in Runners Knee.

Once you lose it, you lose it. Although with some experimental techniques, regeneration of cartilage is looking more and more possible in the future.

Do you need your cartilage?

Yes, you do. It provides a slick surface for bones to glide on one another. That grinding feeling you have is from the cartilage not being there or it being too soft to do its job.

If you suffer from this condition, you are not alone. In fact, it is the most common reason any athlete will report to a sports injury clinic. It affects up to 30% of all athletes.

What are the symptoms of Runner’s Knee?

  • Pain that is generally dull and constant
  • Clicking/popping of the knee upon motion
  • Swelling of the calf
  • Bruising of the muscle
  • Restricted motion
  • Dull achy pain around the knee cap
  • Pain walking downstairs
  • Pain running downhill
  • “Movie theater sign” (Pain after having the knee flexed for a period of time)
PATELLOFEMORAL PAIN SYNDROME (RUNNER’S KNEE)

The “Movie theater sign” or the bent knee position is an interesting one since it confusing many patients. The belief “rest will make it better” seems to not work in this bent knee position.

PFPS is a condition where two surfaces (the femur and the underside of the kneecap) are being irritated against each other and in this bent knee position they will rub more. Let’s look at some pictures.

What causes Runner’s Knee?

I hear “overuse” a lot.

I’m not going say that is 100% wrong, but I like to point out the obvious.

“Why does it only affect one of your knees, then?” you ask. “Don’t you run the same amount of steps with both legs?”

I am like everyone else. I too would like to think that I crushed so many miles this week, I just overused my body, but that is not the case.

Often after testing flexibility, core strength, hip strength, single leg balance and movement patterns like squatting and hip hinging, we find there are asymmetries.

PATELLOFEMORAL PAIN SYNDROME (RUNNER’S KNEE)

Studies in the past blamed a weak vastus medialis or inner quad muscle, but recently we have learned there is more to it than just that.

You may be thinking it’s from a laterally tracking kneecap. Yes, that has been a theory as well, and yes, it can cause rubbing on the outer aspect of the femur bone, which creates damage, but the reason why it is “tracking laterally” is not the fault of the quad group.

It is the core and hip’s fault.

It’s true! You knee injury is from the core and hip once again!

Dynamic “motion” MRIs of patellofemoral pain syndrome patients have found that the main reason the kneecap rides laterally is because the femur bone spins itself into contact. The spinning starts at the hip.

If the core and hip muscles are not doing their jobs, the femur bone rotates medially (inward) and contacts the kneecap leading to patellofemoral pain syndrome.

Am I saying the theory of the quad being the issue is not possible?

I’m not saying that at all. It’s just not as probable. Common practice in movement therapy is to stabilize regions proximal (closer to the midline) when we have a distal injury (further from midline). When we have a knee injury we check the core, breathing patterns, pelvis and hip function before we narrow our focus to the knee.

If we conclude the knee itself is the contributing factor the following are the first places we look:

  • Active Stabilizers: The Quad group
  • Passive Stabilizers: The ligaments and fascia around the knee complex
  • Static Stabilizers: The bony contours and surfaces

Any of these three groups could be the reason for knee pain. But again, we always have to assess above and below the knee first.

Here are a few things you can try to assess your midline stabilization. If these tests are positive then we have a need for core, pelvis, and hip rehab before we even waste time on the knee. When we correct these, often times the knee will unload the cartilage and allow healing.

  1. Trendelenburg Test (10 sec hold)
  2. Dynamic Trendelenburg Test (quality of motion assessment)
  3. Side Planks (1 min hold)

If you’re not rock solid on each of these then you have some work to do. I have some Runners Knee exercises I use in my office in the video at the top of this section… better watch the whole thing this time.

Side Plank Exercise

What does this mean for rehab?

If you have Runners Knee the first thing you should do is the exact thing you didn’t want to hear. Stop the mileage.

This doesn’t mean you can’t run ever again but you need to stop the mechanism of injury for the medial knee pain. You have to stop the compression remember. If all goes well in rehab you maybe able to build up again in a few weeks. With proper guidance, most people can keep a fraction of their mileage as a “base.”

Take this time to find your cardio through swimming, cycling (clipped in only), and high intensity weight training. All three of these activities independently can assist in your recovery by pumping nutrients into the cartilage and as a bonus they can all make you faster!! More on this later…

When you do start running again, you should consider beginning on flats with dirt. The harder the surface the more impact into the knee. This won’t yield the quickest speeds ever but you’ll be on hard surfaces in no time.

Just like all of the other knee conditions, we need to focus on the core, hip and thigh. I know this article is getting redundant, but it is true.

Here’s a circuit I use with my runners rehabbing Runner’s Knee. Remember, this is all scalable. More importantly, keep in mind I prescribe this circuit to a person whom I’ve tested and deemed it’s safe for them to use.

Other rehab exercises we often use are:

  • Proprioception exercises for the knee
  • Deadlifts
  • Multiplanar core stabilization
  • Pallof press variations

I strongly believe one of the worst things you can do when injured is to 100% rest the area… the knee is no different. There are ways to keep function and strength on the hips, core, knees and complex motions of the leg when injured.

Here’s a video on the concept of lifting around Runner’s Knee so you can recover and start running again sooner.

What are some treatments used to decrease the pain of Runner’s Knee?

These are all great treatment options for decreasing knee pain while running. Without a drop in pain it is hard to rehab the area and use exercises.

  • Rest and ice
  • Addressing the scar tissue formation with soft tissue manipulation
  • Active Release Technique and Graston
  • Rehabilitative strengthening exercises
  • Taping or bracing the knee
  • Anti-inflammatory pain medications
  • Surgery options of arthroscopy or realignment of osseous structures

To be clear, I do not agree with all of these, but they are used nonetheless.

Some image options that can assist in confirming the diagnosis are:

  • X-rays – rules out bone injury
  • MRI – way better image
  • Diagnostic Ultrasound – can see the soft tissue of the knee
  • Physical exam by a medical professional
PATELLOFEMORAL PAIN SYNDROME (RUNNER’S KNEE)

Works Cited

Staff, Mayo Clinic. “Definition.” Mayo Clinic. Mayo Foundation for Medical Education and Research, 05 Feb. 2013. Web. 06 June 2013. http://www.mayoclinic.com/health/chondromalacia-patella/DS00777

Endo, Yoshimi, Beth E. Shubin Stein, and Hollis G. Potter. “Abstract.” National Center for Biotechnology Information. U.S. National Library of Medicine, 30 Aug. 0005. Web. 06 June 2013. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445133/

CHAPTER 4: PES ANSERINUS TENDONITIS
  • Pain about an inch below the knee?
  • On the front but inside?
  • Pain climbing stairs?

This could be an injury to the Pes Anserine tendons or bursa.

Just like the other sections, please watch the following video for extremely comprehensive and actionable steps you can take if you have a confirmed diagnosis of Pes Anserinus.

Pes Anserine Bursitis

What is Pes Anserine Bursitis?

The Pes Anserine is the attachment point for three muscles and in the area of a bursa located about an inch below the inner part of the knee. It is on the tibia bone.

The three muscles that attach here are:

  • Gracilis
  • Sartorius
  • Semitendinosus (medial hamstring)

Pes Anserine pain is normally due to inflammation of the bursa at the location, but it can also be from the tendons…making it a tendonitis.

A bursa is a naturally occurring fluid filled sac designed to limit friction as soft tissue structures pass by an area.

Who gets Pes Anserine Bursitis?

Pes Anserine Bursitis is one of the less common running injuries, but it can happen. The more common injuries you will encounter are runner’s knee, meniscal injuries and tendonosis.

Pes Anserine Bursitis can be present in athletes such as runners, cyclists and triathletes. On the flip side, I have seen many normal sedentary people who have it as well.

Pes Anserine Bursitis

How does Pes Anserine Bursitis happen?

It is no mystery there is a connection to the hip and core. All three of the muscles attaching to the Pes Anserine come from the hip.

Hip strength and endurance are directly connected to how well the core functions.

The core is the trunk as a whole…not just the six pack muscles.

Just like any other muscle/tendon injury, if you over stretch it, it goes beyond its optimal range. Think of a spring.

It has a length that it functions at best. Muscle and tendons are the same. When they are outside of these ranges, they are less effective at their job…so they become damaged.

Why is this important?

If the tendons become damaged, they also become inflamed. Inflammation creates a local chemical process, which then irritates the local bursa and leads to pain.

Pes Anserine Bursitis

How is Pes Anserine Bursitis treated?

  • Self massage of quads and hamstrings
  • Active Release Techniques
  • Graston or other tool assisted tissue work
  • Stretching of the hip, thigh and ankle
  • Deep tissue massage
  • NSAID
  • PRP
  • Prolotherapy
  • Rehab exercises for the core, hip, knee and ankle

When can you start running again?

It really depends on when you want to risk it.

In a perfect world, I would not have anyone run more than 5 miles at a time until they have successfully passed a battery of core and hip testing.

A decrease in pain has no correlation with if you can pass these tests or not. It just means that the area has calmed down. Simply resting it will calm it down, but that doesn’t mean your core, hips and knee are any more stable.

Pain can decrease within a matter of weeks, but building strength and endurance will take months to achieve.

CHAPTER 5: PLICA SYNDROME
  • Clicking on the inside of the kneecap?
  • Small swelling in the area?
  • Pain with running?

Plica Syndrome is a less common cause of knee pain in runners, but it is always on the list of possibilities.

It’s kind of funny this small tissue can create pain since it is not really a functioning part of our anatomy.
Just like the other sections, please watch the following video for extremely comprehensive and actionable steps you can take if you have a confirmed diagnosis of Plica Syndrome.

What is the Plica?

It is remnant tissue from our development. The main function of the plica is to provide glide for the knee joint.

Anatomically, the plica is thin layer of vascular synovial tissue found within the joint line of the knee. The plica is remnant tissue from fetal development that is diminished in size; it also known as a synovial fold.

Plica Syndrome of the Knee

What is painful in Plica Syndrome?

The plica itself is inflamed and irritated. It can become caught during motion of the knee due to poor running gait or in certain movement patterns such as squatting. The plica can be more prominent in some than in others, which increases the likelihood of it becoming irritated more easily.

Remember, it is a remnant of our development. It should have gone away just like our tails did.

What does Plica Syndrome feel like?

  • Dull and achy pain in at the inner (medial) knee joint that increases with activity
  • Catching or clicking of the knee upon flexion and extension
  • Swelling of the knee joint
  • Restricted motion
  • Pain going up and down stairs
  • Pain with squatting, bending, or getting up from a chair
Plica Syndrome of the Knee

What else is Plica Syndrome misdiagnosed as?

  • Meniscal tear
  • Patellar tendinitis
  • Stress fracture of the tibia

How can you treat Plica Syndrome?

  • RICE (rest, ice, compress, elevate)
  • Surgery based on the severity of the inflammation of the plica tissue
  • Lidocaine injections
  • Addressing the scar tissue formation
  • Stretching
  • Rehabilitative strengthening exercises
  • Active Release Technique

How to rehab Plica Syndrome

Rehab exercise is one of our focal points with Plica Syndrome treatment.
Normally, we focus on strengthening the entire kinetics chain, which includes:

  • Core
  • Spine
  • Hips
  • Thigh
  • Knee
  • Ankle
  • Foot

Sounds like everything in the leg, right? It is!

Leg and knee injuries are issues with the entire leg and core. Therefore, in rehab we can leave no stone unturned.

Works Cited

Griffith, Chad J., and Robert F. LaPrade. “Abstract.” National Center for Biotechnology Information. U.S. National Library of Medicine, 27 Nov. 2007. Web. 25 June 2013. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684145/>.

Cluett, Jonathen, MD. “Plica Syndrome.” About.com Orthopedics. About.com, 21 July 2008. Web. 25 June 2013. <http://orthopedics.about.com/cs/otherinformation1/a/plica.htm>.

“Synovial Plica Syndrome.” Synovial Plica Syndrome. N.p., 2011. Web. 25 June 2013. <http://www.osmsportsmed.com/OSM/Synovial_Plica_Syndrome.html>.

Nottage, Wesley M., MD, Norman F. Sprague, MD, Burt J. Auerbach, MD, and Hesmet Shahriaree, MD. “Plica Syndrome.” Plica Syndrome. The American Journal of Sports Medicine, 01 Sept. 1990. Web. 25 June 2013. <http://members.optushome.com.au/physio/plica.html>.

CHAPTER 6: ACL INJURIES
  • Have you every twisted your knee?
  • Did it “pop”?
  • Did it swell immediately?

You could have had an ACL injury in your past.

Why does the past matter?

An ACL injury is a huge predictor of future knee injuries for one reason… Your knee is probably still “loose.”

The knee is intended to bend a lot in two motions: flexion and extension. It is not intended to rotate and bend laterally.

How does the knee stop itself from rotating and laterally bending?

Bony architecture, ligaments, muscles and tendons help to keep the knee stable. One of the larger contributors is the ACL.

What is the ACL?

The ACL, also known as the Anterior Cruciate Ligament, is one of four ligaments that allow your knee to function properly. It forms an “X” shape with another ligament in between the tibia and the femur.
The ACL is the ligament that prevents forward movement of the tibia from underneath the femur.

Who gets ACL injuries?

Females are are at a higher risk of ACL knee injuries.

How much more?

About ten times more! Pretty unfair, huh?

You can prevent ACL injury and even rehab one if you do the right exercises. The American College of Sports Medicine claims significant improvements in knee control can be seen after just eight weeks of proper training.

What exercises are good for prevention and rehab?

ACL injury prevention programs must contain a few aspects:

  • Core training
  • Hip Strengthening (squatting and deadlifting)
  • Hip Stretching
  • Proprioception exercise for the hip and knee
  • Single leg training (lunges, ½ one leg squats etc.)
  • Landing plyometric training
  • Acceleration, deceleration, change of direction training
  • Knee rotational and lateral bend stabilization exercises

I know it sounds like a lot, but it’s not. If programmed properly, it can all be done in less than 30 minutes a day.

How many days a week should ACL prevention training be done?

I like three as the magic number, but here is the thing: once you stop, you will once again be at high risk of injury within about a month or so.

It’s not a scam; it’s the truth.

If you don’t use it, you lose it.

What if I already have an ACL tear…what can I do now?

If you have a tear and it has not been repaired, you will need to do a lot of the same work as someone who’s preventing an ACL injury, BUT you need to understand your knee is inherently unstable and very susceptible to swelling and injury.

I always suggest athletes with past ACL injuries have one on one instruction with a strength coach or a sports therapist.

Will you have to spend money?

Yes, but it is very much worth the cost!

CHAPTER 7: CYSTS OF THE KNEE

This section is only video currently. This video topic was in response to a Youtube questions I received. There are four major types of cysts you will hear about in the knee region. There are more but these are the strong majority.

These types of knee cysts are often incidental findings and don’t need direct treatment. They are often a sign of other injuries to the knee… such as the ones above this section.

CHAPTER 8: MEDIAL MENISCUS INJURY
  • Pain on the inside of the knee?
  • Minor clicking in the knee?
  • Minor knee swelling after running?

Medial Meniscus tears are extremely common and very manageable when people get early care. If not managed early in the injury process, it can lead to a surgical correction down the road.

Here’s a video that will greatly assist you in understanding your medial meniscus tear. It’s a long video but very comprehensive. Sit down, get some popcorn for this one… it’s worth it!

MEDIAL MENISCUS INJURY

What is a Medial Meniscus tear?

The medial meniscus is a type of cartilage in the knee. This cartilage can become frayed, torn or caught at times. There are many different grades of medial meniscus tears, yet not all of them produce knee pain.

The medial meniscus is composed of fibrocartilage, which is different than the articular cartilage on the bones of the knee joint. One unique aspect of the meniscus is the outer third is the only vascular cartilage in the body, this means it has the potential of healing at a faster rate than most cartilage injuries such as Runner’s Knee.

What are the symptoms of a Medial Meniscus tear?

  • Clicking
  • Popping
  • Catching
  • Swelling
  • Pain with twisting
  • Pain with partial squatting
  • Pain with running

Interestingly, not all meniscus tears are painful.

I’ll give you an example… I had a patient about a year ago who came in with the chief complaint of medial knee pain (inner knee pain) after running. I conducted a series of tests to see if the medial meniscus was torn.

These tests included but we’re not limited to:

  • Thessaly’s Test
  • Apley Compression Test
  • Medial joint line tenderness

These were all positive tests so we worked off the diagnosis of a medial meniscus tear, of a minor grade.

After a few weeks of rehab, she asked if we can confirm if her pain source was from a new meniscus tear or not. So I said “sure let’s take a look.”

We utilized a diagnostic ultrasound to visualize the medial joint space on the symptomatic knee and we found there in fact some meniscus changes.

But here’s the interesting part… we took a comparative study on the other knee, which was not painful and it too had very similar changes as a painful knee. What does this mean?

This brings to light the possibility that her knee pain was not solely from changes within the medial meniscus. Perhaps the medial meniscus findings were incidental and the real root cause of knee pain was something else… such as how she moved her body on top of her knee, her gait mechanics, or the way she walked, squatted or perform daily activities.

We call this method of finding the main trigger “Root Cause Analysis,” if I can steal the term from a colleague Dr. Scott Mills.

The takeaway is this… although you have positive meniscal imaging and test, it’s always important to find the root cause of your pain before starting a treatment plan.

What causes a Medial Meniscus tear?

In textbooks, meniscus tears are created with knee cave (valgus force) and twisting of the knee. While in stance phase of running, knee caves and twisting occurs from the hip in the form of internal femoral rotation. Internal femoral rotation comes often comes from an athlete’s poor ability to keep the hips level when running. This hip drop comes from poor function of the stance leg gluteus medius and the swing side quadratus lumborum. A simple exercise that can assist in preventing hip drop is a fatigued state Farmer’s Carry.

We can say there’s deficiencies in a “functional core” or the midline of the body doesn’t have the ability to keep optimal position when running. Keeping form when under exhaustion is way harder than when fresh by the way.

Rehab for a Medial Meniscus tear

I like to start by showing patients their knee pain can be dramatically affected by avoiding their pain triggers. Pain triggers can be extremely simple to point out (twisting) or it can a little bit more investigation and history taking. For this reason you may want to see a professional who can spend more than 10 minutes in your initial exam. Each case is unique and it’s impossible to suggest care if you haven’t been examined thoroughly.

If we can identify the patient’s pain triggers, we can also correct the person’s movement so the medial knee pain no longer is sensitive. I’ll say that another way… we need to decrease the motions creating pain so the knee become desensitized in the region of injury.

In some cases, there could be something structurally wrong with the knee. In these cases, specific manual therapy applied directly to the region can provide some immediate relief and often times results in better quality corrective exercise.

Over the years some of the treatment of choice that I’ve use are:

  • Active release
  • Cross friction massage
  • Deep tissue work
  • Joint Mobilization

I know I probably sound extremely vague in describing how to rehab the knee but honestly each case is extremely unique in its own way and we need to first evaluate to find with the person’s deficiencies are before we recommend a correction.

Some of the most common deficiencies that I often find with runners with a medial meniscus tear are:

  • Hip drop
  • Low core endurance
  • Neuromuscular fatigue during training

Treatment options for a Medial Meniscus tear

Here are some other treatments and/or factors that can assist you in recovering from a Medial Meniscus Tear and decrease knee pain when running:

  • Active Release Technique
  • Deep Tissue Massage
  • Anti-inflammatory Injections
  • Prolotherapy
  • Chiropractic Adjustments or mobilizations
  • Strength training/rehab
  • Core Stabilization/ Endurance
  • PRICE therapy
  • Running gait training
  • New shoes
  • Better roads

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