Knee pain runners



by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit


There are three types of pain syndromes that occur in runners.

The first is chondromalacia patella, also known as “runner’s knee.”



Chondromalacia



Chondromalacia is due wear and tear of the undersurface of the patella (kneecap). This area has a covering of smooth cartilage. Under normal circumstances, the cartilage glides in the center of a groove (trochlear groove) located at the end of the femur (upper leg bone). In some individuals, the patella rubs against one side of the groove, and the cartilage surface become irritated. The result is knee pain.

Chondromalacia is due to metabolic changes involving the deepest layers of cartilage.

Chondromalacia often affects young, otherwise healthy, athletic individuals. Women are more commonly affected.

Pain is felt behind the kneecap. One of the most common injuries among runners, chondromalacia, also known as "runner's knee", most often begins when runners run more than thirty miles per week on a consistent basis. Sometimes, a runner will rest their knees for a few days only to notice that the pain returns after a few miles into the next run. The pain tends to be aggravated by running downhill or walking down stairs, and the knee often becomes stiff after sitting for extended periods. Going up stairs and getting out of a chair also can be painful. Crepitus (crunching or clicking sounds) may occur with bending or straightening of the knee.

The reason runners develop runner’s knee is because of muscle imbalance. Running tends to increase the strength of the back thigh muscles (hamstrings) more than those in the front (the quadriceps).

Foot abnormalities can stress the knee. Overpronation (rolling the foot in) or supinating (turning it out too much) can both be detremental.

Runner's knee is aggravated by rapid increase in the number of miles or new hill work or speed work. Runner's knee can also be brought on by running on banked surfaces or a curved track. Running on a road that is banked at the sides leads to pronation of the “short leg”- the one that is running on the higher surface.

Pain relief can be obtained by icing the knees immediately after running. Ice packs should be placed on the knee for about fifteen minutes to reduce swelling. Ice should be used twice a day for fifteen minutes at a time.

Relief can also be obtained by resting the knee. Rest reduces inflammation.

Cross-training activities such as swimming, can allow an athlete to maintain their fitness while resting the knee. The next step is a physical therapy regimen that should emphasize strengthening and flexibility of the quadriceps and hamstring muscle groups. Use of nonsteroidal anti-inflammatory drugs is also helpful to relieve the pain associated with chondromalacia.

Surgery is not indicated for this condition.

Foot stabilization is critical.Consider custom orthotics or even a commercially made foot support.

Quadriceps strengthening exercises are important for protecting the knee. A simple quad set exercise consists of sitting in a chair, extending the leg out in front and holding it straight out for 10 seconds, then slowly bending the knee and letting the foot touch the floor. Start with 25 repetitions and move up to 50 repetitions.

Abnormal tracking of the patella (tracking is the movement of the patella within the trochlear groove of the femur) due to tight ligaments on the outside (lateral side) of the kneecap is also a cause of chondromalacia. A procedure known as a lateral release can be performed. The lateral release involves cutting the tight lateral ligaments to allow for normal position and tracking of the patella.

Doing the exercises daily is an important part of treatment.

A small percentage will not find relief even after rest and rehabilitation.



Osteoarthritis

This is a condition due to wearing away of cartilage. It may occur in the medial compartment of the knee (inside part of the knee) where the femur articulates with the tibia or the lateral compartment, again where the tibia articulates with the femur towards the outside part of the knee.



Pain is felt either along the inside or the outside part of the knee. This condition must be distinguished from both chondromalacia as well as iliotibial band syndrome. The pain is due to a number of factors. The first is irritation of nerve fibers surrounding the joint capsule of the knee. Low grade inflammation also plays a role. Pain is aggravated by prolonged inactivity and made better by activity. Pain is often present at night. Sometimes, inflammation can lead to fluid accumulation- called a knee effusion. The treatment consists of ice, non steroidal anti-inflammatory drugs, occasional injections of steroids, and viscosupplementation (lubricant injections.) Bracing occasionally helps. Runners with osteoarthritis must learn to balance rest and activity. Cross-training with low impact types of exercise is useful.

Runners with osteoarthritis of the knee may be candidates for stem cell therapy. Click here to learn more:
Stem Cells for Osteoarthritis



Iliotibial Band Syndrome

In cases of chronic lateral knee pain, iliotibial band syndrome (ITBS) is a likely cause. A runner with this complaint will experience sharp stinging pain on the outside of the knee, which may cause a limp. This is an overuse injury.

Lateral knee pain can be induced by squats, lunges, hamstring curls, extensions and any motion that involves repetitive flexion and extension of the knees. In runners it may occur as a result of running up and downhill and on banked surfaces. Proper diagnosis and treatment are vital.

The iliotibial band (ITB) is a long ligament-like structure running along the outside of the thigh. It connects the ilium of the pelvis, with the upper lateral part of the tibia (shinbone). When the knee is bent more than 30 degrees, the iliotibial band (ITB) lies on or behind the lateral femoral condyle, the bony prominence that makes up the upper and outer portion of the knee joint. When the knee is extended, the iliotibial band (ITB) lies in front of the lateral femoral condyle. Repetitive flexion and extension moves the ITB back and forth over the condyle.

When the ITB becomes irritated and inflamed, ITBS is the result. A number of factors can trigger ITBS. Any sudden increase in training intensity - whether that increase comes from extra weight, an increase in reps, greater distance or training on uneven ground - can lead to lateral knee pain. The problem can also be worsened by other structural problems including pelvic obliquity, sacroiliac joint abnormality, and foot pronation (foot turning inwards).

The runner will complain of knee pain brought on by repetitive flexion and extension and may have a limp following exertion. Swelling is usually not present and there is no history of trauma. Full weight bearing on the affected leg with the knee in 30-40° flexion will reproduce the pain, as the ITB comes in contact with the lateral femoral condyle.

Rest, mileage reduction, and frequent ice are a start of treatment. Mileage should be reduced. Cutting back on hill work, and running on even surfaces will help.

Ice packs applied for 15 minutes two to three times a day along with non-steroidal anti-inflammatory medication are helpful. Neuromuscular electrical stimulation is an effective form of therapy for relieving the pain of muscle spasm. Deep friction massage also may help.

ITB stretching can begin after pain control has been achieved.

Runners can continue to exercise as long as they avoid activities which aggravate the pain - and that includes running.

To avoid lateral knee pain from ITBS, a reevaluation of the training routine should be done. Proper warming up and cooling down is essential. Stretching is mandatory.





Baker's Cyst

A fourth possible problem is a popliteal cyst. Pain and swelling develops behind the knee, right at the junction where the upper leg meets the lower leg. It is due to fluid accumulating in a bursal sack behind the knee. It causes tightness behind the knee. It often occurs in people who have underlying arthritis.

Treatment consists of drainage using an ultrasound guided needle with injection of a glucocorticoid.




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