Knee Swelling After Running: How a Runner in Her 30s Recovered

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hello, everybody, and welcome to the Restoring Human Movement podcast. This is your co-host, Dawne Costantino, and I have a friend here with me today. This is Garrett. Say hi. Hello, everyone. Garrett is an intern in our office. If you've been here before, you may or may not have worked with him. He'll be graduating in December, so I invited him to discuss a case study with me today of somebody that we've been working with together. Garrett has a strength training background, strength and conditioning background, so typically I'll do kind of the hands-on stuff with this patient, and then we will both discuss together what her program should look like out in the weight room, and then because he's so good, I just kind of leave him to it, so he'll have some input on this person's case today.

If you're new to the podcast, hello and welcome. We have tons and tons and tons of other podcasts that you can go check out on neck, shoulder, low back, hip. This specific case is about runners. We have Dr. Mandy in the office now, who is a running expert, so go back and listen to some of those running ones, all kinds of stuff. Just check it out. If you're returning, welcome back. We're going to hop right into it here. Case study. This is a female in her 30s who, at the beginning of the year, so this is May now, beginning of the year, she decided she wanted to get back into running. She kind of slowly got into it, but then really ramped it up to the point where she was doing about two to three miles, five to six days a week, whereas before, for years before that, she wasn't doing much.

Some strength training here and there. She was really stoked to get back into running. She presented in our office with a swollen left knee that really bothers her. She could run through it, but it was really starting to prevent her ability to push herself further if she wanted to. She described it as kind of painful in the joint, a feeling of swelling. The swelling will get better, but the moment she goes and runs again, it'll swell up right afterwards. She can't fully extend or flex the knee, so she noticed some mobility issues because of that swelling, pain would move around. It'd be on the back side, it'd be on the lateral side, it'd be on the medial side.

Nothing really else going on with her body at the time, but she did fill us in with, she has constantly had sciatica issues, sciatic flare-ups every few months on her opposite side, the right side, that usually occurs with deadlifting. So yeah, anything else that you can remember about her specifically that would be important to fill them in in the beginning? No. Yeah, that was pretty good, right? So in her examination, I'm not going to go super in-depth, but ultimately the major findings were obvious visible swelling, inability to contract the quad without pain, and really just didn't know how to do it.

The swelling was preventing her from being able to. She had some laxity that we found, maybe some instability in the knee that we found on the knee examination. But she also had some neural tension signs on both sides, really, the side that was involved and then the side that she has her old sciatic issues with. So we really took the approach of... Garrett, did we make her stop running? No. Okay. Why is that? For one, compliance purposes. Sure. That's what she wanted to do. That was going to keep her active and an active lifestyle. So we kept her running. We limited the volume, but we didn't want her to completely stop because once people stop moving, they don't get going again.

It's like the inverse of Newton's law. What would be a... We'll get back to the case, but I just kind of want to discuss a little bit more. What would be a reason we would make a runner stop running? Like this specific case, what would you have to find on her exam to be like, you got to stop? True, I would say, true swelling or like true structural damage. I'm thinking like stress fracture. Stress fracture. Completely, like you say, ruptured ligaments along with avulsion fractures as well. Things that actually get confirmed with imaging. That were like, yeah, once it's like, hey, yeah, this is...

We theorized this. Imaging confirmed it. It would behoove you to stop running as much because that is the thing that's driving this worse. Yeah, so if you are kind of new to running, you've increased your frequency, your duration feels like you might have slowly ramped up, but more likely than not, you didn't because nobody does it properly unless they're guided. It's really, really important to just go get an examination done by somebody that you know and trust to make sure that this isn't something like bone marrow edema, early signs of a stress fracture are already a stress fracture. When we increase activity too quickly and the tissue cannot tolerate it or can't, what's the word I'm looking for, compensate for the extra activity that quickly, then these types of injuries are what we're looking for.

So with her, thankfully, that is not what was going on, which is why we didn't need to take her out of running. We ultimately backed off a little bit. We went from five days to three days and I believe she had a threshold to when pain would set in, so I said stay under that threshold. So we didn't stop her completely, but we just needed to take a little step backwards. And I asked her about her warmup routine. Do you remember what her warmup routine was like? Pretty much non-existent. It was non-existent. She just, it was more for, just kind of helped with her mental state. So it's just, when I was ready to go run, I just went and ran.

I might've done some like leg swings, hamstring stretches, kind of dynamic stretching maybe. I might be making that up, honestly. I don't think she had a warmup routine. So what we found in her program that day became a part of her routine, which we'll fill you guys in on. So yeah, we had some neural tension signs, meaning as we tested her sciatic nerve, we noticed that it was different from side to side, wasn't presenting what we would call as like a normal hamstring stretch, which she would feel it from all the way from her back, all the way down to her foot. So I always like to take the approach.

This is just my preference. I don't know if other people think differently, but I always tell people, we can rehab you all day, but if you have neural tension signs and this isn't working properly, you're not going to respond well to rehab. So we've got to get these neural tension signs normalized first before we can then ask your muscles to start getting stronger around the injured area. So she was given, we have a slumps test, which is what was our outcome measure for the neural tension signs. Cobra poses ended up really normalizing that within the first session. And then within a week, I think two weeks, actually, all of that ended up getting a lot better for her.

So the goal was do some Cobras. And then what was the corrective exercises we gave her for that and the knee on the first day? Do you remember? Oh, it was, uh, we just, it was a corrective. We just limited to do that for both. And I believe we probably implemented some calf raises. Yeah, absolutely. It was super simple stuff. It really was like, we're not going to go crazy today. We're going to get your back and your nerve feeling better. We're going to support the knee. You're going to build this into your warmup routine and we're going to go from there. So yes, she was given glute bridges to a pretty fatiguing amount just to offload the knee.

She was given Cobra poses for that neural tension. We gave her calf raises to really start to support the lower limb there. And she came back pretty, pretty good. I'd say like 40% better within the first week. We continued that a bit with what did we add going from there? How else did we support around the knee there and around her back moving forward? For the knee, we implemented split squats. Actually, before we moved the knee, actually, we focused on the foot and the hip. We gave her like banded B stance or kickstand RDLs trying to get her core and glute stabilizing and getting her ankle to support her weight under load.

And we progressed load through there through various forms of split squats amongst tolerance and did a lot of basic hinging in all forms. We tried to progress single leg bilateral to see how she could load that extension pattern that we found that Cobra poses seemed to help with. Absolutely. The ultimate thing was this is a runner who's still running. And so most of the stuff that we want to do in here should, you know, kind of meet the demands of running. So when you're running, you're spending most of your time on a single limb. So it was important for us to get her to single limb exercises as soon as possible that she could tolerate.

And it was really important for her to want to strength train through this time, too. And she loves deadlifting. I don't think I mentioned that. That's actually deadlifting is what kept flaring up for sciatica in the past. I might have mentioned that. But so, yeah, I believe we were getting to a point where she had reported about 100% improvement with her knee. Her next follow up, sciatic flare up. Do you remember what happened there? She was deadlifting. Yeah. Deadlifting at home. She was deadlifting. So and this happens. This happens during our journey. We never expect a perfect trend in an upward direction when we are going through journeys like this.

There's going to be ups and downs. As long as the pattern is upward, we're doing the right things. So we were working on deadlifting with her in here with certain things that we have in the office. Kettlebells, hex bar, landmine, things of that sort. And then she had a barbell at home. So she went home and did a barbell version. And for some reason, that seemed to be different for her and did flare up her sciatic nerve. So we re-examined her on that flare up day. No issues in the low back, actually, really having to do with like a disc issue, pressing on a nerve or anything like that. It really was just something about her deadlift form.

Kept tensioning that nerve in a way that kept aggravating it. So I found a first aid for her, which ended up being child's pose, kind of sitting and rounding the low back. Really helped normalize some of the tension in that nerve for her again. And so then what did you see when you worked with her on her deadlift that day? On the day she came in with a flare up, were we deadlifting? Yes. Yeah. What kind did we do on the first day? The first flare up, we did trap bar. And there were real, no patterns of dysfunction with the trap bar. Everything seemed okay. And she was able to do it. Yep. No problem, right?

We loaded it up, moderately heavy for her, which is probably like 135 pounds. And it was, yeah, no issues. Absolutely. And so we really wanted to see symptoms come down before we went back to that really provoking one, which would have been the barbell deadlift. So on the second week, she was feeling pretty damn good in the sciatic nerve. So we said, let's look at your barbell deadlift today. And what did you see? A lot of the right, just ilium, was kind of tilted upwards, which we want to think about like a shoulder blade. Like when it's hiked up towards your neck. That's essentially what I was seeing with her right hip bone as she was deadlifting.

Okay. We used a simple cue because she had pain as she pulled. If you're in that position, all that musculature, all the structure, it doesn't matter what it is, it's going to be compressed. And then if you're going to try and pull from a compressed position, you have no strength. So it's going to leak somewhere else. So simple cue, I said, tuck your tail, like a dog tucks her tail between their legs. I said, tuck your tail before you get set up, grab tension to the bar and pull. And immediately relieved all pain. Not a quick fix, but it's a pattern fix. So I just used that cue and then she set up and we're able to pull that hip bone down and create capacity for those muscles to stabilize the spine.

Nice. So ultimately what he's saying here is that her strategy of deadlifting with a barbell was for some reason different with all the other implements that we were using. And so a cue of just kind of finding the lower abdomen a little bit better, putting your pelvis in a better position, utilizing more muscles to help get that barbell up. All of that seemed to really help with what she was feeling in her nerve. She came back today and she was like, I'm 100% better. Normally her sciatic flare-ups would last about four weeks. This time around, she was at 80% within one week and 100% within two weeks.

So that's huge improvement. Why do you think it was different this time around? I liked the words you used before we started recording. She had a strategy. Strategy to follow. Yeah, strategy to follow, strategy, things to execute when she had pain. I think that's one of the primary things that we use in this office is finding the first aid. So this time she had something that we knew that we helped her guide her way to finding something that relieved her of her pain. And we gave that to her. And that changed, I think, a little bit over time. But as long as that changes, as long as we have consistency, she had a plan to execute before she, before it got worse.

Absolutely. There's no way that we could know this, but I firmly believe that if she didn't have this strategy to execute on her own, it's the taking yourself away from the strength training and away from the running that would have made her flare-up last longer. Because she was able to stay active and just modify through the flare-up, it got better quicker. I firmly believe that. And it's something for y'all listening just to consider. Again, I think, and I say this a lot, rest is not sit your ass on the couch for six weeks. Rest is take a step back, listen to the body, find ways to modify the activity that you are doing, but still remain active.

So I thought that was a fun one to share because, you know, she was, I mean, it was an easy case, to be honest with you. She was very grateful today when she left. Runners are just, I think, a lot of times that there's a fear of being taken out of the sport. And most of the time, you don't need to be taken out. It's just finding ways to modify or taking one step back or finding some supplements to build in to help kind of support you along the way. We wanted to kind of discuss maybe some questions that she had along the way. So we might've already covered this, but let's make sure that we did.

Can she still, can I still run was actually her first question. So yes, obviously she could, right? Not as much. We stepped back on the frequency and the duration, but she was still able to, and now she's back to normal. Her normal running, I think it's been six weeks now. Yeah. Why does deadlifting keep hurting me? How would you have answered that for her? The same way I kind of just explained it. It was just her hip bone was a little higher up and we needed to actually cue it to pull down before she pulled. And there was why that also popped up when she would run in the past. I believe that was the original answer as if she was trying to extend the hip, but it was already pre-shortened an extension.

You have no room to go there. So musculature is out the window there. It's not going to work how it should. And you're just going to pull on structure, compress the nerve like we talked about. That's why the sciatica work. And I kind of gave her that breakdown too, because if it flares up in the future when she's running, it's important to understand that. But there's a reason why you'll deadlift for running, but why the injuries in the deadlift also can appear the same when they're running and how we can use those strategies that she's used to help kind of mitigate those flare-ups or get her back to what she's doing for more or even a mental state to give her confidence so she can get back to doing what she wants.

Absolutely. And it's going to be different for everybody, y'all. Like the deadlift form is different for everybody. Cues, the way that your brain will interpret those cues and execute the movement. Like it's all about just really finding that right coaching to get you to do the movement properly for your specific body and your specific injury. So don't be afraid to go ask somebody for help, please. I do. Garrett's helping me currently. I hate him for it because he really pushes me. But even with all that I know, I still ask for help when I'm in pain too. Common problems we see with things like knee swelling in runners or nerve tension in deadlifters.

What are some other areas that we need to consider when we're looking at people like this? Lately, because I've, other than this case, I've had a couple other runners I've been dealing with at the school clinic. And it's honestly, it's how is the lower leg and the feet? How are those moving? How is the core? How is the core or how is core bracing? Are they able to brace and stabilize their core? Because if not, the pelvis isn't going to work. And the knee takes all the bracing. It's the connector flight that nobody wants to get on. So that's one thing I look at is how mainly is the tibia, lower leg, and the ankle and the foot stabilizing so it can work correctly because a lot of knee pain comes in the front.

You can get a lot of bang for your buck just looking into that. Absolutely. I think that was something that was in a discussion with her in the beginning too, wasn't she? She was trying to supinate her feet for some reason because she read somewhere that she was overpronating and probably could be causing flat feet. So she would, on a day-to-day basis and while working and standing, force her feet to roll outward into a supinated position. And she had been doing that for the past however many years. And so we saw that in a lot of her movements, right? Like we would say deadlift or split squat or whatever it was.

And we would just see that big toe come up, her feet roll outward. So that was something that we did need to correct fairly quickly. There was some mobility issues in one of her ankles on that sciatica side, the right side. So we worked on some of that ankle mobility. Her calf raises were kind of weird and off in the beginning too. So we kind of had to cue through how to properly just get the right activation there. There were some differences in her hip mobility too. What are some things we've been seeing with hip mobility? That commonly the side that doesn't have, it's been frequently commonly the side that doesn't have pain is the needs some more TLC.

And that might be not the answer, but it might be a rock to look under to solve pain for the other side. I think she was a perfect example for that. The sciatic therapy that she had in the past were dysfunction on that right side, I believe. And the knee pain on the left was because she could not perform what we call gait cycle when she was running efficiently. So she would load into that side more and more and more. And the outside of the knee was where the pain was, along with her rolling on the outside of her feet. And we're seeing these dots connected here. And so when we looked at the other side with context clue, it helps with the history of the sciatic flare-up.

But if one side's not working efficiently, the other side can kind of take the brunt. Totally. Yeah, Gary and I have been seeing this a lot. So this is kind of our PSA for the day. If you have hip pain, probably not the problem spot. There's times that that's the problem spot. There's pain there because there's a tissue that's generating the pain. Yes, but more often than not these days, it's kind of crazy how much we're seeing this. The opposite hip is the one not functioning well or something on the opposite side of the body is not functioning well. Maybe has a mobility issue, a strength issue, past injuries that we're compensating around.

And so the painful spot is the one just taking on all the load. So yes, it needs love. But long term, we're going to need to attack some of these other dysfunctions we're seeing to see some improvement. So yeah, we were going to make a whole podcast about that. But I think I mentioned it in multiple podcasts before this. So I didn't want to, you know, beat a dead horse. If you have something you've been dealing with for a while, whoever you're working with is only focusing on the pain spot and you don't feel like you're getting better or you have, you know, some moments of feeling better and then big steps backwards and we're not going anywhere.

You need to have somebody assess the full body and see what other areas maybe need some love, although they're not in pain. I don't know how often I'm having to describe that to somebody. We're not working on your pain spot today. We're working on these other spots. To piggyback off that, of course, in your history, if you're in to see a doctor for the first time, whether that's a PT, chiro, whoever you're seeing, and they ask about things, just let them all know. Let everything be detailed, I would say, about not everything's important, but it might be. So it's really important because if we didn't ask about the previous history of the static, we probably wouldn't have discovered that that was probably the issue.

I mean, we might end up there eventually, but it's important to know all the history. So even if you think it's unimportant as a patient, just tell us. We're trained to handle it. Yeah. Separate from musculoskeletal stuff too, right? Like other diagnoses you have going on, autoimmune disorders, gut issues. I have constipation on a weekly basis. Like things that you would probably go to your primary care for, for help, which you should. It's still important to let the person who is helping you with your musculoskeletal conditions know about this stuff because it all plays a role in your healing timeline.

It really does. So yeah. Anything else you think is important to fill people in on, Garrett, about this specific case or any other things we've discussed? Keep moving. Don't stop. When things are painful, do what you can. See somebody if you don't have the information you need, but keep moving. Find videos on our YouTube that can be helpful for you. A little shameless plug. But yeah. Just don't stop moving. The body will heal as long as we keep moving. Sedentary is never again. Absolutely. If you want to know if we can help you, we do discovery sessions virtually or in person. We can always just start the conversation and see where it goes from there.

We do telehealth services. So take advantage. Send us an email. Give us a call. Have a nice day, y'all.