Runner's Knee and Patellofemoral Pain: Why Hip Strength Matters

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. Hey everyone, it's your co-host Sebastian with the Restoring Human Movement podcast. Thanks for joining the show today. I thought I would do a podcast today on a little light reading that I did today between clients, and it is based upon evidence-based treatment options for common knee injuries in runners. This was a study that was done in 2019, and so this one was kind of nice to see, but I actually enjoyed the introduction more so than anything else.

So the introduction says, injury is a key barrier in many runners accounting for 19.4% to 79.3% of lower extremity injury rates. With over 40 million people in the U.S. running regularly, this percentage can represent a significant amount of runners with injuries. Nearly half of the 40,000 runners experience some type of pain or injury annually. The knee is the most common area in runners. The knee joint is affected by three main types of injuries, including patellofemoral pain syndrome, IT menfriction syndrome, and patella tendinopathy. Now, I'm going to stop right there, at least with reading off of the paper, because I think that's enough information to start talking about some stuff.

Maybe at a later date, I will cover what the paper says about different types of manual therapy and treatments. But I can tell you, at least from our experience here at Performance Place, what tends to work a lot with the missing link, at least in regards to rehab and exercise suggestion with runners, is they tend to lack glute strength. They tend to lack also support or core support, core endurance, core stability in the frontal plane, which is the side to side movements, not the forward backwards and not the transversal rotating. So I'll tell you the reasons why these things are significant for these knee conditions.

And you guys can feel free to look these things up on Google. But just know that we do have a link in the description for this podcast with a long format video on YouTube that Mandy Riehl did about patellofemoral pain syndrome, which is, I think, one of the most leading causes of knee pain with runners. IT man syndrome does exist. Patella tendinopathy is not quite as common. It's a little bit more with jumping athletes. But the prior two is fairly common. So I'm going to cover first the mechanics of what the knee likes and doesn't like. And I'm not going to say the diagnosis doesn't matter. The diagnosis do matter.

But the fact that they're coming from similar mechanics is very important. So the diagnosis that you have, the patellofemoral pain syndrome, the runner's knee, the conglomerate patella, the meniscal injuries, the IT man, a lot of it is a, we call it a power leak. And so it's where the weakest link is breaking. It starts to become symptomatic. And then you start to have a condition and a diagnosis. But the mechanics of the injury are very similar, if not trauma-based. So I'll start with first, with all runners, especially the endurance type, we need to consider the possibility of also fractures into the area.

It's not super common, but we do need to consider the possibility of having too much energy use compared to intake. It's not purposeful a lot of times with endurance athletes. They just don't think about how many calories they need to be taken in because of how many they're using. But that breakdown of the energy chain is important because it can leave you more susceptible to fractures, but also some of the soft tissue in the area can become problematic. Mandy Riehl did a podcast a long time ago about R-E-D-S, REDS, which is Relative Energy Deficit in Sports, which basically encompasses those people out there with overuse injuries who aren't getting any better.

You need to consider the energy intake parts. How are you supposed to get better if you don't have any materials to actually get better? Let's get on to the mechanical aspect of patellofemoral pain, which is oftentimes valgus collapse. So in the video that Mandy Riehl went over, she took two papers, I believe it was, another one, another two papers. So it was talking about the valgus collapse or knee dive in that is commonly associated to patellofemoral pain. Also, too, we found that with male runners, they actually have hip drop in correlation with that as well. Hip drop can be solved with single leg activities.

It can be solved with side bridges or side planks. Some of these things can be solved with single leg RDLs as well. So there's a strength treatment that you can do with it that can blend really well into also the preventative aspect of this injury that will probably come back at some point in time. So here's the mechanics that we know that the valgus collapse that happens or the inward knee dive, the knock knee, if you will, the knees coming inward, often it couples with other movements of the limb. It couples with collapse of the arch of the foot. So those of you who are dealing with plantar fasciitis or other types of foot conditions or other tendinopathies or conditions of the shin may be a part in this too, like those tibialis posterior people would be into this category because it makes those tissues overwork.

But also if you look above the knee as well, you'll see that there is a internal rotation aspect of the femur, usually from poor glute activity. And this is usually glute max. That also couples with an anterior pelvic tilt, which also couples with lumbar extension. All of these movements kind of coupled together. And so this is a breakdown of the entire chain. Again, the diagnosis that comes out of it is going to be what symptomatic tissue becomes. It starts screaming first. And for patellofemoral pain, what we find is that there used to be a blame on the quad muscles being weak, especially the VMO or the medial quad, the inner quad.

I'm not going to say that doesn't have a part in it, but I think what we concluded is that most people have the start of the injury, if not traumatic based, from the pelvis and the hip, not doing their job. And then later they end up having knee pain, but the knee pain, when it hurts, people tend to not use their knee. They don't bend their knee. They don't do squatting. And then they have a related loss of quad strength on that side. That's what we believe is happening. But it's hard to say that the quad strength and the patellofemoral pain are not correlated. They probably are. But again, people who hurt their knee tend to not use their knee.

So how can we say that's the actual cause? The reason why I believe that the mechanics of the hip are the most important, I'm not saying that the foot mechanics aren't important. We can cover that at a later date. But the glute one is the biggest problem, I think, with most people. So if you look at knee mechanics, you'll see that this whole lateral tracking patellofemoral pain thing that people talk about, where they're saying that the side of the patella or the kneecap hits the side of the femur called the lateral femoral condyle and starts to rub away the undersurface, creating spurs and lack of cartilage and so on.

It's not incorrect. It's correct. But the way it happens, I think, has some bad information over the years. We used to believe that the inner quad muscle, the VMO, was weak enough to not be able to pull the kneecap to the midline, creating an excessive rub on the outer part. Or they thought that the outer quad was way too strong and it's pulling too hard. In the past, they did something called a lateral release of the vastus lateralis. I'm not sure the success rate on that, but I don't think they quite do that quite as much anymore. A lot of rehab exercise programs focuses strengthening the VMO.

They'll still have a part, but I think there's more to it. What you can actually consider here, and if you can imagine it in your mind's eye, is that the kneecap is not floating to the outside. It's that the femur is drifting rotationally inward and that couples with knee valgus or knee cave, and that's because the glute max is not resisting the inward rotation. It doesn't have enough stiffness and enough strength. Now, there's no internal rotators of the femur. They're mainly just lack of support to control internal rotation. The muscles up into the inside part of the hip, like the pectineus and so on, they're not strong enough to do that job.

They're not prime movers. That's kind of like the rotator cuff muscles of the hip. They are just there for support. But the glute max is highly related to having knee conditions. Like if you have a lack of glute strength or your lack of hip extension strength does not beat your ability to extend your knee or knee extension strength, then you have a risk factor for knee injuries, okay? There's a lot more that goes into it than this. There's dynamic knee valgus. There's cam angles. There's a bunch of other things you can look at. But I think from simple terms, most people, most runners lack hip strength.

Now, I can make a blanket scenario. I can make a blanket comment like that, and I would be wrong sometimes. I fully acknowledge that, but I think people like to have some certainty with these, so I'm giving you at least what I commonly see, if I had to guess. One reason is because they have the knee injury in general. There's a reason why therapists over the years give people glute medius exercises, a bunch of glute exercises, and side planks, and frontal plank stability, and all of it's good, right? But if we're finding it that commonly in research, maybe we just listen to the research and find out that that musculature is typically very weak in these individuals.

Now, another thing, too, is that I've worked with a lot of distance runners, and I'm not going to say that people don't have good exercise programs or strength training programs. They do, but I see a lot of them lacking in their ability to actually perform a hip-dominant pattern like a deadlift. They're very good at squats. They're very good at all their other exercises they're doing, but when you ask them to do a deadlift, their form is usually not very good. I see a lot of low back round. Now, people may argue with me about, well, it's okay to deadlift with a rounded lower back. Not if you want to bias the exercise to the hip.

Like, the whole point is it's called a hip hinge. It's not called a spinal hinge exercise, although there are spinal hinging exercises, which are fine in some scenarios. But if we want to bias and strengthen the hip, we need to make sure that we're actually doing the hip-dominant pattern. And same thing goes with single leg RDLs. I see countless people doing single leg RDLs with the weight that's too little to actually improve strength. But also because the weight is too little, the weight is too low. And for most runners, including myself, I'm not able to touch my toes very well. So, being able to reach for a low weight and expect your spine not to get into the mix of doing the lift for you is kind of ridiculous.

So, we may as well elevate the weight. Get the weight higher. Make it so your hand only has to go down to about just below the knee. And you'll probably get a lot of bang to buck just like that. Your form will improve. Your hip will get stronger. You'll have less knee pain and so on. Now, I'm not going to spend the whole time talking about how to deadlift. But I think just understanding that, number one, your form has to be good. Number two is, if you're trying to build strength, I'm not talking about endurance. I'm talking about strength. And I'm not talking about toning. I'm talking about strength.

If we're talking about building strength, you have to perform heavier sets. You can't just do toning work. So, just realize that strength actually has a protocol. So, if your workouts are not strength-based, and that is part of the problem, that you have a weakness in the hip, you need to make sure it's strength-based or else you're just kind of wasting your time. And then once you get the right protocol involved, you actually might just start to feel better in your knee. Now, knee conditions that have been around for too long, yeah, they start to create structural deformities. And so, structural deformities would be like bone spurs, lack of cartilage underneath the knee, meniscal tears.

And so, these are things that tend to have more lasting effects. I've hit my knee many times diving for baseballs. I've irritated my T-band with running. And those don't have any lasting effects. Like, yeah, it hurt to do at the time. But I don't see any physical deformity. My MRI and x-rays are normal. Like, everything's good, right? Now, for those of you who actually have positive imaging, that's not to say you'll be in pain forever. But the progression of what's been happening, if not trauma, I keep saying that because trauma is a wild card. You can't control it. We're talking about controllable things today.

So, whatever you're doing, whether it be your mileage or your spikes of activity or poor exercise program or whatever it may be, is what's making your image present in the way it is today, if not trauma. So, we have a saying, you're some of your habits, okay? I know a great training coach who, he's very direct in what he suggests to people. He says in regards to diet, it's, you didn't, it's not what you, you're not what you eat. You are what you ate. So, it's what you did in the past. You're a reflection of what your past habits were. And so, low back pain, IT band syndrome that keeps coming back, structural deformities such as meniscal tears or bone spurs, osteoarthritis, things like that, those are a reflection of how you've been programming so far.

So, one easy suggestion to do is let's just take a play out of the research book and realize that knee mechanics, are related to hip and foot mechanics that are also related to core function. Not endurance, not strength, but function. And I can talk about that in a later podcast if you subscribe to the show. So, if you find that your knee caves when you're in single leg stance activities such as lunges or single leg RDLs or people notice, they can see you coming down the road or down the trail. They see your knee cave and when you're running, they know it's you because you have that atypical gait.

You have a higher risk factor for injury. If you continually have like a dump, like your belt line tends to dump to the side and you notice that you have something called hip drop, you, especially as men, you have a higher potential of knee injuries. I would say that at least from brass tacks, if you cannot hold a side plank for more than a minute, I'd say at least 90 seconds is typically the standard. Not any difference from side to side, more than five seconds. Then if you can't do that, then you're at a higher risk. And if you can't deadlift your body weight, I think you're getting into a higher risk category too.

So the, I will always reserve the right to change my mind. But at this point, I haven't seen that these have failed me over the past 15 years of practice. Generally, they're pretty accurate, but everybody is a little bit different. And I'd be lying if I said that everybody had the same exact remedy. They don't. Everybody's a little bit different and not everybody can do a deadlift. Nobody can do a single leg RDL. There's other ways to strengthen the hip, which you just got to get creative at as strength, the conditioning coach. So take advantage of that YouTube video that we have that covers a little bit more in detail of what these things look like.

Mandy even shows the model of how the knee is not actually lateral shifting or the patella isn't shifting to the side. It's actually the femur rotating in. And also too, we have telehealth sessions. We're licensed in many states and we can help you with telehealth. We help many people with telehealth that I've seen them in person. But if you want to come in and see us in person, we'd love to see you as well. Schedule a consultation with us and it is very affordable. and you'll walk away with more information than you ever thought possible. Subscribe to the show. We'll see you next time.