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Runners Knee



Runners knee is one of the most common causes of anterior (front) knee pain and attributes for 25% of all knee pains and injuries seen and treated in sports injury and physiotherapy clinics including Phoenix Rehab.

Also known as "Patellofemoral Syndrome" or "Anterior Knee Pain", it can also cause pain to be referred

  • under and
  • around

the patient's knee cap.

It is mainly caused and exacerbated by the way our knee cap moves that causes friction at the back of the knee. Unfortunately the symptoms of runners knee comes and goes depending on your activity levels...and runners knee doesn't only affect runners - it affects both active and sedentary people eg office workers, teachers, housewives, executives etc.

Causes of Runners Knee

Runners knee was originally thought to be caused by the way our patella (our kneecap) moves unnaturally, causing additional stress on the cartilage which leads to pain.

You see our kneecap rests/sits in a groove (medically termed as the patellar or trochlear groove) right in front of the knee on the femur (our thigh bone) and is lined with very thick layer of cartilage. The kneecap is quite mobile, it can:

  • glide
  • tilt and rotate upwards
  • glide upwards, downwards and sideways in this groove

There are a few reasons that can influence or stop the patella from moving properly, all of which increases the forces and friction going through the kneecap, causing and exacerbating patella femoral syndrome. 

These include:

  1. Muscle weakness

    Weakness in the muscles above and below the knee directly reduces the support around the knee. This causes more weight to go through the kneecap, straining it much more.

    Also, we have to note that if the muscles on one side of the knee are weaker than the muscles on the other side, naturally the kneecap will shift slightly to one side in the groove (the stronger side), resulting in increased friction

  2. Muscle Tightness

    If the muscles around the kneecap are tight, they will pull the kneecap in the direction of the tightness, usually upwards and sidewards slidely, again, leading to increased friction and then to knee cap pain

  3. Foot Position

    Abnormal foot position such as flat feet, will cause the foot to roll inwards/go internally as we walk, jog or run. This alters the way the forces go upwards through the knee, and increases abnormal pressure on our kneecap

  4. Q Angle

    The Q angle refers specificly to the angle of the thigh (femoral) bone. An increase in the Q angle puts more strain on the kneecap (increased angle = increased pressure)

  5. Anatomy

    If there is abnormality in the shape of the patellar groove and/or the kneecap that causes both of them to be mal-aligned or blocked, that can restrict the movement and cause friction, causing you to develop patellofemoral syndrome

Symptoms of Patellofemoral Syndrome

Runners knee doesn't tend to be a traumatic or sudden issue - it normally develops over time.

Most patients describe/report it as an ache near and around their kneecap, usually underneath or at the sides of the patellar.

In some cases, there may be also presence of "crepitus", which means

  • grating
  • scraping
  • grinding

which is caused by friction on the knee cap.

There are also instances of mild to moderate stiffness and swelling in the affected knee too.

Pain in runners knee tends to not always be there (comes and goes) but will worsen with:

  • Prolonged exercises or activities e.g. running long distances, sports, skiing especially when going downhill
  • Stairs climbing especially coming downstairs
  • Standing/moving about after sitting for long periods e.g. at the cinema, office workers, driving long distance.  The knee tends to be stiff and sore when you first get up and then movement and discomfort improves as you move around

Treatment Options

Physiotherapy treatment for Runners Knee aims to reduce the kneecap pain and swelling, and address any muscle imbalance in the leg. The most common physiotherapy treatments for patellofemoral syndrome are:

  1.  Strengthening Exercises

    People with Runners Knee often have weak glutes (buttocks) and quadriceps (front of thighs) muscles. Strengthening these muscles will support the knee better as well as reduce the weight going through the knee.

  2. Stretches

    Reducing any muscle tightness (especially those shortened/tight knots in the muscles around the knee) will also improve how the knee cap glides in the patellar groove reducing the friction on the kneecap.

  3. Knee Braces

    Braces can help to improve the support around the knee and the position of the patella reducing the pain associated with patellofemoral syndrome.

  4. Orthotics

    There are special insoles that can be worn on your shoes to correct your foot position and Q angle and therefore reduce the forces going through the kneecap.

  5. Rest and Pacing

    Runners Knee often develops after a sudden increase in activity levels.

    We recommend and advise for you to rest for a few days to let your knee pain settle down, and then gradually build up the amount of exercise you do, or switch to non-impact exercise such as swimming.

    Remember, pain doesn’t always come on during an activity, it often develops later that day or overnight, so start slowly and gradually increase.

  6. Ice / Cold Therapy

    Using ice for ten minutes after activity can help to reduce patellofemoral syndrome pain and swelling.

  7. Avoid Prolonged Postures

    If your knee pain comes on mainly after sitting or resting for long periods, try to avoid keeping your leg still. At work, get up and have a little walk around every thirty minutes or so or if that’s not possible, gently move your leg backwards and forwards a few times.

    Some of our patients place a ball under their desk which they can then use to move their feet around, keeping their foot, ankle and knees active.

    This keeps the joint loose and lubricated which can help reduce patellofemoral syndrome pain.

  8. Painkillers

    Over the counter painkillers and non-steroidal anti-inflammatories e.g. Advil/Ibuprofen can be useful to reduce the pain associated with Runners Knee especially during acute / fresh pains.  Always consult your doctor before taking medication - if you need us to refer knee specialists to you, we will be more than happy to.

  9. Surgery

    It is very rare that patellofemoral syndrome requires surgery. 

    However, if the above physiotherapy treatments do not work after a period of time, then maybe surgery may be indicated to release tight structures around the knee or to remove bits of bone that are irritating the knee cap.

    The correct treatment will depend on the cause of your patellofemoral syndrome, so it is always advisable to see your specialist physiotherapist or doctor who can accurately assess what is causing your problem.

The Recovery Process

Recovery for runners knee can take anything from 6 weeks to six months with physiotherapy.

In the early stages of physio, we will focus more on taking the pains away first, then focusing on strengthening and stretching to improve muscle strength, length and stability.

We also have to ramp up your strength over time, allowing your muscles to rest to grow in between sessions, so pacing and resting is equally important part of recovery too.

Between physiotherapy sessions, other than doing what our senior physios teach you to do, you can also participate in lower-impact exercises such as

  • swimming
  • cycling
  • aquarobics
  • etc

If you really want to run during this time, please ensure that you have a really good pair of running shoes and try to avoid hills/trains/terrains/hard concrete floor running as these increases the impact and strain on the knees.



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