Runner's Knee: Patellofemoral Pain Myths and How to Recover

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. And now, your host, Dr. Sebastian Gonzales. Hey everyone, it's Sebastian, your host with the Restoring Human Movement podcast. Thanks for joining the show and thank you for taking an interest in how to figure out how to make your body operate in a better fashion, to make sure you don't need things like surgeries or have chronic or long-standing pain. This is around episode 300, so we have lots of episodes in the past that cover various topics such as knees, hips, foot, ankles, proper core strengthening, proper leg strengthening, and various different types of conditions around the body.

So please go back and check those out. In this one, we're going to cover debunking some myths surrounding the condition called patellofemoral pain syndrome. We'll also cover some recovery tips with it. Tell you first what it is, as well as some of my experience working with it, but also, again, some of the mechanics associated to it. I think reasonably we can think this thing doesn't just pop up out of nowhere. It's not like you're destined to have it, and once you have it, it's going to continue forever and ever and get worse than a knee replacement. But I think a lack of good information about what current research says about it is kind of an issue because people aren't able to make very good informed decisions about how to deal with it if they don't have good relevant information.

So that is the goal of the podcast today, to give you a good insight of the information that is available currently, as well as some things that may probably not work as much so because they don't really identify risk factors. I think a good starting point for doing some of these podcasts is giving a rundown of what Dr. Google is talking about because that's where everybody starts when they have an issue. They say, you know what? I wonder what Dr. Google says about this thing. So I typed it up, and as always, AI takes over now when you type into Google, and this is what pops up that you guys will probably see as the first initial starting point.

And I'll tell you the things that I like and don't like in here because there are good and bad. Again, this is based upon old, and maybe AI is getting a little better about curing from actual research versus things that people write on the internet, but who knows? But hopefully this helps you make a better informed decision. So patellofemoral pain syndrome, also known as runner's knee, is a common condition that causes pain in the front of the knee around the knee cap. I would agree with that. It's typically associated to an increase in pain when squatting, running, jumping, climbing stairs, sitting for prolonged periods of time.

Yes, I would agree with all those. That's pretty common. Causes, it says, is structural defects. They're probably talking about in and around the knee, like old knee injuries. Certain ways of walking or running. I wouldn't say, let's just, let's chalk that up to more of gait, but gait is not something that you necessarily inherit. It's your way of bodies getting around stiffnesses or weaknesses that can be things that you can address. Overuse injuries. Yeah, I could say that probably happens. Weak thigh muscles. I would probably disagree there, but it does become a part. I'll explain this as we get into some of the research here.

Tight hamstrings. I wouldn't necessarily agree, but there's probably tight hamstrings that are going to be found with this condition. Poor foot support. I would chalk that up to maybe a poor foot that's poorly supporting itself. Doesn't necessarily need, you need, doesn't necessarily mean you need supports for your feet, but you maybe do a better job of getting your feet to do support. Malalignment in the kneecap. Yes, but no. And we'll cover that a little bit later. Treatments, it says. Resting, icing, compressing, elevation. I strongly disagree with this. I strongly, strongly, strongly disagree with this when it comes to a long-term treatment approach.

The long-term treatment approach is going to be much, much more than this, and it's going to be about identifying and reducing risk factors. Resting, icing, compression, elevation, yeah, those are okay in the short term, but usually about a 10-day period of time is probably where they start to strike out after that. I'm sure a lot of the runners I've talked to about having this condition is they use this approach. They do what a lot of people in sports do. They say, I shut it down. I shut it down. I did it for, I shut it down for like two to three weeks to see if I can like get it to cool down, and then I ran again, and you know what?

It's almost like the three weeks of not running didn't do a thing. It was still there, and that is very, very common. So, but yeah, it can cool down pain with local tissue irritation around the kneecap, but it doesn't necessarily stop the progression of the injury. Now, what typically happens with patellofemoral pain is going to be an irritation underneath the kneecap. So this is where, in the past, it became a little bit more popular to talk about how the quad was weak, especially the inner part of the quad, which is called the VMO, vastus medialis obliquus muscle, because they said that the vastus medialis obliquus was not necessarily pulling hard enough on the kneecap to pull it away from the outer side of the knee, called the lateral aspect, and it would start running into the underside of the kneecap would start running into the bony prominence underneath it, which is called the lateral femoral condyle.

If you have a dog and you've given them a bone before, it's usually like a beef or bovine bone, and then you see these big old two knuckles on the end. Those are the condyles. And so in that little notch there runs your patella or your kneecap. And so that thing is intended to stay generally centered in there, but if it starts rubbing excessively on one side, it's going to irritate the underneath surface. Now, just to note, too, because some of these things are better seen visually, we do have a very detailed YouTube video that Dr. Mandy at our facility did on this. It released this year. I'll put a link in the description so you guys can look at it, because I think you'll get a better understanding there of how knee mechanics are associated to hip mechanics as we go through that and describe and talk a little bit more about the hip in this case here.

So there was some current research that we proposed on that video as well. And so this one was, I forget, it was from 2016, actually. So this was called Runners with patellofemoral pain have altered biomechanics, which targeted interventions can modify a systematic review and meta-analysis. So if you guys don't know much about research, a systematic review is a review of many different articles in the past. I don't know. I'd have to look back to see how many articles or research articles that this actual study analyzed to see a commonality associated to it. But sometimes they're in the hundreds.

Meta-analysis is also one of the higher levels of research. So this one is a systematic review and meta-analysis, so it's actually very good. So it's not like they studied just one person and came up with a conclusion. This is literally probably hundreds and hundreds and hundreds of people with different researchers, with different biases that they've excluded from these because they've been biased. So the highlight that we have is going to be increased peak hip adduction is a risk factor for patellofemoral pain to develop in female runners. Now, hip adduction is basically the knee crossy midline.

So if you're standing in single leg stance and you see your knee about to come together to the other knee and it drips further across midline than a normal knee would, that is the hip moving through adduction, ADD, which then brings the knee inward. It creates a scenario called knee valgus or the knee crosses over midline. You may be looking out and you see other runners having like one knee that kind of dives inward quite a bit as they start to stand on that leg. It's hard to see unless you start videotaping people, but you can see them doing it with simple things like single leg hinges or Y stance drills.

So you can see it. You can even see it with box jumps. But this is basically, this basically shows that there's an issue probably at the hip or the core or the foot or the ankle. And I know this talks about hip adduction on the study, but just know that I think as a general rule here, now that we know that there's a higher risk of having patellofemoral pain associated to a hip thing, we can also extrapolate to say that actually what happens from adduction of the hip is actually if you look down at your foot, when you adduct your hip in a single leg stance, you actually have a cave of the arch of the foot on that same side too.

So things like past foot injuries or past plantar fasciitis or weakness of the intrinsic or small foot muscles, these are all parts to this. So it's actually less related to the quad muscle than you actually think. Hey everyone, it's Sebastian. I'm going to hijack the show just for a second here to tell you about an opportunity that we have called the Discovery Session. A lot of people over the years have reached out to us from our YouTube channel because we have 150,000 YouTube subscribers at this point in time, probably more by the time you're listening to this. And we have a lot of people listen to this show and read our articles online.

They're frustrated. People are frustrated about not being able to get back to full activity. They're frustrated they can't really trust their body. They're frustrated that they have not found any long-term answers or things to make them happy. And so we're here to help. We may not be the ones to actually help you and we're okay with that, but we're hoping that if you are able to speak with us that we can maybe give you some insight of things that you potentially haven't tried yet. And if we know people, we'll suggest those people too. So if you want to take advantage of the Discovery Session, all you need to do is go to p2sportscare.com and find the Book Now button.

It's all in there. We have virtual or in-person options. You can go to the show notes for this show and find a link that will directly connect you to us. Or you can call us 714-502-4243. We'd love to help you the best that we can and we're always here to serve. Now back to the show. Now there was another study that was done and this one is 2015. This was lower limb control strength in runners with and without patellofemoral pain syndrome. They studied women and men. They found that female runners with patellofemoral pain showed an increase in hip adduction, which we just talked about, and hip internal rotation during single leg stance as compared to the people who didn't have it.

So that's that knee diving inward. We can see it. You can probably see it on all these different tests like dropping from a box, like hopping on one leg. All these can be found even in the absence of having any knee pain. So if your knee pain is coming back over and over again, assessing to figure out if these risk factors are still present is the magic. And that's why I kind of don't, I don't think rest, ice, heat, compress are really useful at all. They don't address these components. And it leads the person to believe that, you know what, my knee feels a lot better. I think I'll just keep running.

And you keep beating up that knee. And later on, you end up having longer standing problems like arthritic change, loss of cartilage in the knee, or the bone-on-bone scenario they talk about. And then it's a lot harder to deal with. So once you have like some of those structural changes, it's a little bit harder. But the first time you go through this, this is something that should be looked at. Now we're talking about male runners. Male runners that have patellofemoral pain syndrome exhibit increased contralateral hip drop and hip, increased hip adduction as compared to the controls. So that is also going to be that you'll see their belt line will also drop.

So if they're standing on the right leg, you'll see their left hip drop. And this is related also to the hip, but also to the core. So now that we know that the single leg stance component, at least from the hip, is a problem, I hope that we can all agree that the foot and ankle are probably going to be a part. Like if I dug through more research on things, I'm probably going to find a lot of references to foot, ankle stiffness, or instability as well that are going to be related to this as well. That's why they typically suggest things like arch support, which is a synthetic way of supporting the hip and also bringing that knee back into a better position.

So I'm not saying orthotics is a bad idea or inserts are a bad idea, but I think I'd rather have my body do the work versus give it a support for it because I think it makes it a little bit lazy. But either way, though, let's go back into that whole quad thing because I think this is something that's a little bit hard for people to grasp because it's been time and time again, people talk about how the weakness of their inner quad muscle, their VMO is associated to their knee, to their patellofemoral pain. I don't think it is. I do think there's weakness, but I don't think that was the cause. And let me rephrase that.

I know that when I've had knee pain in the past, I stopped using the knee. I stopped bending it. And I can see this with a lot of older people that we work with that they've had trouble with their knees over the years. When they get up from the ground, they actually lock their knees and just use their hands to push themselves to get up. Like they'll do anything in their power unknowingly to not use their knees. So what do you think is going to happen to their quad? All of their quad. The whole thing's going to get weak, right? And then, so we know that people who have chronic or ongoing knee pain have quad weakness, but that's not a contributor, but it certainly doesn't help.

So I think a bigger thing, especially if this is first, this is now plaguing you and this is a new thing. I think we need to consider up or below the knee risk factors. So how does your single leg stance look? Is your knee or hip adducting, is your knee diving in when you're in single leg stance or jumping down from a box? Does it happen when you're doing squats at the gym? When you're running as a man, do you have contralateral opposite side hip drop? If you do, these are risk factors. Let's deal with these things and let's deal with them soon. So we get you back running again soon. So your quad does not weaken.

And then you have a longer path to take with this. By the way, I'll put references to all these articles in the show notes. So on your podcast player, so you can read them if you'd like, they are, you'll probably get to see a lot of it, which is public domain. You don't have to actually purchase the studies. Now let's just consider what we got to do to reverse engineer these things. And I'm going to say this in like, in very simple terms, because I mean, people can, and oftentimes do solve a lot of their own problems. Like if you can identify a problem to solve, like I've contralateral hip drop, I have hip addiction, then yeah, there's, there are certain exercises and strategies and stretches you can do to help out with this.

A lot of people don't, don't know what they're doing though. This is their first time through it and not all runners, but some runners have never actually stepped foot in a gym before to do actual resistance training, which can really, really help. Resistance training builds up strength of the hip and the core and the entire leg. It makes it so we can mitigate that, that knee collapse or valgus collapse across. Without having to think about it, like, like changing your running gate should not be a conscious thing. I'm a strong believer in that. I know that if you tried to change the way that I brush my teeth, I've been doing it for 40 years.

I am not going to do it. Like it will take literally forever. That's a deeply ingrained habit. It's not going to change. So it's very, very hard to actually change your running gate. It's easier to change the attributes that your body has. And then your running gate will be a reflection of what those attributes are. And if you have them, period, let me describe that in a different way. Cause this is a whole different way of looking at, looking at rehab and retraining how human movement happens. Uh, and it's foreign to a lot of people. So I just want to make sure to circle back to this one more time before we get into some exercises and things that we use and, and what the expectations could be by using those.

But so we have a, we can change human behavior, human movement by changing a scenario. And so if you look back into some research, they call this the dynamic, dynamic system theory. You basically can change three things, environment, internal constraints, or task. Okay. So one example is an environment. So if I were going to have you run a certain way and change your gate, the easiest thing to do is to give you your regular shoes and put you on ice. All of a sudden your gate will change. It doesn't matter how much I coach it or how much like, or how much I tell you to not do what you're doing, which is probably moving very slowly and carefully.

You're going to do it. And this is because the environment has changed. The surface has changed. So one thing you can do if you're having some knee pain, the way the, your body is deciding to take those movement strategies of letting the knee dive in and the hip drop because of the environment, it could be because of the environment you're in. So if you're a road or concrete runner or a track runner, maybe changing the environment, like going to the sand or maybe going to hills could be a really simple way of changing things as things start to settle down, you're reintroducing running back in.

The other thing you do is you can change the internal, the internal environment. And that's going to be something like stiffnesses and weaknesses. So if your body is not strong enough to stand on a single leg, and I did have a gentleman come in recently that he, he was very hard for him to stand on a single leg because he had a past knee surgery. How's your body going to do that over and over again, very quickly on with having to do it with, with some quickness on your stride. It's going to be very, very hard. So why don't we take that same person, build some strength and balance in that leg first over the course of a month and then put that same person and do the same workout that they were doing.

They'll probably fare better because now their body says, oh, I have some balance and strength in that leg. Now I can do things differently. Similar to like changing the, the, the surface, like the, the ice. Now it has a different internal environment to work with. Now, if you have a weak quad, heck yeah, let's strengthen that quad up, right? It'll be able to use the knee better. It's the capacity of the knee will be better, but if your core strength is weak, if you have a stiff ankle, if you have a stiff hip, you have a pinchy hip that doesn't allow the hip to actually operate well, assume it's going to not work well.

And the body is going to find ways around that deficiency. So when you're working with, with changing human movement, it comes down to like, like you can't really control the environment all the time. The task itself is running or squatting or whatever you want it to be. So it's harder to change those two, but what you can do and what's in your power is finding someone who can properly assess your deficiencies, your stiffnesses, your weaknesses, your poor work capacities, and make sure that those tissues or your body has those abilities. So then you can actually do the task that you want to do, which is running.

Okay. So now let's talk about how, how maybe that looks. And I'm only going to start from, I'm only going to talk from like a hip strengthening protocol because it's not going to be enough time in this podcast. And I want to make sure that everybody gets a bite-sized chunk here. If you have something unique that you want to talk to our office about, we can certainly help you. Just, just call us 714-502-4243 or check out performance place, which is going to be p2sportscare.com. All of our contacts in the description, but we customize plans for everybody. So with the hip strengthening protocol, usually the first thing that we want to do is make sure that the glute max has the ability to function and it's not lazy.

There's a lot of slang terms tossed around about sleepy glutes or glute inhibition or glute amnesia, which basically means that your glute is not very willing to help. It doesn't mean it's off. It doesn't mean it's not working at all. It is, but sometimes it has issues with coming in late to the party and it makes other tissues work a little bit harder. And so the purpose of some of those exercises that you've probably been given like clamshells and sideline adduction exercises, or sorry, abduction exercises rather, single leg glute bridges and things like that. It's to strengthen the glute or at least to change something about the glute.

Now I'm not a fan of clamshells at all, but clamshells can work, but it comes down to dosage. So just like everything in life, it comes down to doing the proper amount of dosage. I know if I take Advil, you know, half of them ain't going to cut it, but maybe two of them will. And so I need to make sure I have the minimal effective dose to get the job done. And I think the first mistake that most people make is they don't actually do enough. Okay. So reps and sets really don't matter is it's based upon the burn that you feel. And so if we're going to change the internal environment of getting the glute stiffer, by the way, I didn't talk about the importance of the glute, the glute attaches 70% of its fiber to the IT band.

The IT band controls internal knee dive. That is very important. Okay. The glute med. Yeah, it's cool. It's important. The glute minimus. Yeah, it's important. The glute max, super important. And if you stimulate the glute max, you will get all of the other glute muscles to follow suit as well. So I wouldn't bother trying to isolate the glute medius and minimus. I would try to, I would try to get the glute max on point. Now clamshells, again, not my idea of the best glute max strength and exercise. So don't hold me to that, but we're going to use that as an example since that's what a lot of you probably have familiarity to.

Now, ideally the glute max with the clamshell, the one that's most worked is actually the one on the bottom side. So although you're moving the up leg, the one on the bottom glute max is doing most of the work if you actually roll your body weight to your knee on the downside. So if I was laying on my right side and I was trying to traditionally work my left glute, I would actually roll further like I'm rolling towards my right knee so it gets firm on the ground. And then that movement of the left leg is going to make the right glute work like hell. And I would probably continue to move that upside leg until my right butt cheek felt like it was on fire, like so on fire, like I could barely do another.

And here's what this does. So traditionally we're talking about activating the glute. That is important, but also let's consider the idea of stiffness since we talked about change of internal environment. So stiffness can be good and bad. So if I had stiffness in my ankle, it's hard to squat down. If I had stiffness in my hip, it's hard to extend it and run. But what if I had stiffness in an area that lacked stiffness all by doing my rehab better and having a better dosage effect and getting the right tissues to stiffen? So stiffness can be a good thing. And so we even know from running injuries that if there's less ground contact time, that decreases potential of running injuries.

And that comes down to partially stiffness of the limb. Like you kind of want some stiffness, but you don't want it in the wrong areas. And so where most people with patellofemoral pain syndrome have issues with is they lack stiffness of the glute, glute max, which allows the inward knee dive because that is the only muscle that controls inward knee dive. The only one. There are no muscles in the inner part that are pulling inward. There are no adductors that are pulling excessively to create this issue. It's mainly that the glute max is not doing its job to control inward movement. Now, so I would do that to the point to where it's so stiff that it actually, actually changes internal environment.

The way I like to think of this is if I did a lot of bicep curls, like so many that it was like reckless to do the next day, I'd have a hard time moving my elbow through full range of motion because the area has more stiffness. In this case, maybe not the stiffness that I want, but with the glute max, it's stiffness that hasn't been there. And that stiffness could last for a week or so and actually automatically change your gait because you change the internal environment. I know it's a whole different way of looking at rehab, but I promise you that it's probably the more effective way. Now, how do you get the glute max to work so well?

Well, it's going to come down to core stabilization, usually down to something called intra-abdominal pressure increases. So there's a lot of people who have been doing glute exercises and they don't ever feel like their glute is working, no matter how much doses they put into it. They feel their hamstring or their TFL or their hip flex or their low back working. In this scenario, then you have to make sure that you are actually being coached or you have to make sure that you have prerequisite steps to make the glute actually be encouraged to work. And that's going to come down to internal pressure or core stabilization.

Now, I'd love to say that core stabilization is just planks and side planks and bird dogs. It's not. It actually comes down to internal pressure more so than anything else. The common term that we use is called IAP. IAP can be usually challenged with manual contacts. It is not sucking the belly button in. It is not hollowing. It is actually outward pressure. And so that helps stabilize and it helps encourage the glute max to work even more, which will make your job a lot easier. Now, let's just say we got the glute working via working core intra-abdominal pressure and then we did the right dosage.

Now what? Well, the next thing you want to do is bring that up into the real world situation, which is single leg stance, which we already know based upon those studies, hip adduction or knee crossing midline and hip drop in men are kind of an issue. So why don't we stimulate the entire leg to work together in a non-moving way to maybe carry over into the moving way, which is running. That's going to be something like an isometric single leg hold, which is going to make that glute just die. It's going to make the leg die. It'll be more glute dominant than anything else. But the more knee bend you have, the more knee quaddi it's going to be, which is not a bad thing either.

Now, if you wanted to make this into an advanced exercise, it's called a single leg RDL, which a lot of people do really poorly, quite honestly. So I feel like historically working with runners, they really, really tend to lean towards the idea of having an exercise that looks like a runner exercise. Now they tend to lean towards the single leg exercises, which is not a bad idea, but they don't have enough weight, which makes it lacking the ability to create strength. Now we have something called a strength set. A strength set is going to be something that's generally challenging between five to eight reps.

Body weight's not going to cut it. You guys are much stronger than that. And so it's probably going to take you into probably the 40, 50, 60, 80 pound range at some point for some people. I had a 16 year old girl the other day that I didn't want her to pick up the 50 pound weight, but she picked up the 50 pound weight in a single leg pattern and had no problem with it. She's very strong, but also too. I mean, you guys are too. Let's make sure there's strength in the leg. So the reason why the strength, the strength set protocol is important is because it links up the musculature. It takes the attributes that you gave it, such as core stability and the ability to control hip adduction and internal rotation and opposite side hip drop.

And it makes them all link together. It's like hitting the save button on your computer when you did a long podcast like this to make sure you don't lose it. And strength sets do that. It won't make you bulky. It'll make you stronger. The pure reason why you won't get too bulky with this is because you are a runner. It's nearly impossible because your body is in a resource fight to be able to build. It won't get bigger because you burn so many calories with your cardiovascular endeavors, which is not a bad thing, but you'll still get some strength. So I tend to think the process is this, is we need to make sure to stimulate the abdominal region with intra-abdominal pressure.

Then we challenge the glutes. And then we do single leg stance isometrically. And then we do a weighted version, such as a single leg RDL or some version of that. Some people can get away with doing a double leg hinge, which is a deadlift, which is a, you can do a barbell, you can do a hex bar or a trap bar, you can do all that stuff. But if you have not done that before, I would not weight it super heavy, but at some point you probably will. Reason being, because there's endless stories of people hurting themselves doing certain activities. I don't know how many people I've met who have hurt themselves doing deadlift and back squat.

It's not to say they shouldn't do it, but perhaps they should have started with better form in the first place. There's, there's many different ways to mitigate risk in that. And there's so many benefits from it as well. So make sure that you've actually been coached before you start doing that, because there shouldn't be any low back rounding or movement during that activity, or else you're going to risk having a back injury as well. So just to recap on some things, ice, heat, elevation, icing, probably no bueno at this point, unless you're in the, probably the first five to 10 days of this, of, of this problem in that case, by all means, should you be running at this point?

Probably not. Should you do things that provoke it? Probably not. What else can you do in that meantime? Well, you can probably identify risk factors with a trained eye if you can't do it yourself and then address those risk factors, which takes work away from that area in underneath the kneecap, which is rubbing and wearing. And at some point, bony changes and cartilage changes will probably happen. I don't like scaring people at all, but I like to give them realistic expectations. If that keeps happening, your body will adapt in that location and it will try to do the best it can to not limit you in the process, but you're going to have bony buildup.

You will probably have less cartilage in that region and your knee will hurt more often and your quad will probably get weaker because you're not doing as much with the knee. You'll avoid knee bend. Okay. So I hope this was helpful to everybody to at least learn the basics of what research is showing in with patellofemoral pain syndrome of the knee, especially with runners here. If you're struggling with this, reach out to us. We do specialize in working with people with this condition as well as other types. And we love to give people things that they can do today and also not hold them back from their physical activity if we don't need to.

But I think there's a time and place for it as always. But if you're looking to be active as soon as you can, not take excessive rest to make that quad week, give us a ring. We'd love to help you out and make sure to subscribe to the podcast. Give us some feedback on your podcast player. We'll see you next time.