Injury Xchange Vol. 2: Runner’s Knee Explained and What to Do About It

Understanding Runner’s Knee

A runner with kneecap pain will quickly realize how important it is to keep the articular cartilage of the patella and the knee joint healthy.

Cross training is the way to go if you want to get fit and strong and prepare for your next mud run. Unfortunately, the incidence of Runner’s Knee for us multi-sports athletes is high as it is currently the #1 reported knee injury for runners over the age of 20 years old. In the sports medicine world, Runner’s Knee is diagnosed as either:

  1. Patellofemoral Pain Syndrome, which occurs when a runner experiences pain in the front of the knee involving the kneecap or patella, or
  2. Chondromalacia, which occurs when damage to the articular cartilage on the backside of the kneecap is suspected.

Signs and Symptoms of Runner’s Knee

Because of the high number of reps of knee bends associated with mud racers and runners, the articular surfaces of the knee become common locations of damage and pain. A runner with kneecap pain will quickly realize how important it is to keep the articular cartilage of the patella and the knee joint healthy. Abnormal biomechanics and high mileage commonly associated with distance runners will also result in tight IT bands and knee inflammation.

The tissues potentially injured with Runner’s Knee can include the patella tendon, the IT Band, the patellofemoral ligaments, the articular cartilage of the kneecap/knee, the patella fat pad, the quad tendon and the many bursas located around the knee. In addition, the vastus medialis muscle, the most distal and inner of the quad muscles, will usually become weak with any patella injury. With this inner quad weakness and resulting tightening of the outer knee structures, the laterally tracking patella pathology worsens.

The major symptoms of Runner’s Knee include:

  • Possible history of Osgood Schlatters disease or patella injury.
  • Noticeable atrophy or weakness of the quadriceps muscle when compared bilateral.
  • A complaint of weakness when running up hills and pain with an associated sensation of “giving way” around the knee when running down hills.
  • Discomfort and pain anywhere around the patella with prolonged sitting and/or activities involving resistive knee extension such as running and jumping.
  • Joint swelling may occurs after running.
  • “Crunching” and clicking sensation from behind the kneecap with squatting motion.  This may or may not be accompanied by pain.

Professional Treatment for Mudders with Runner’s Knee

  • Be consistent with the warm-up phase of the entire lower extremity.
  • Biomechanical analysis of the lower extremities bilaterally is an easy way to determine specific mechanical issues that are contributing to the Chondromalacia. Common factors are:
    • Leg length discrepancy
    • Poor lower extremity and low back flexibility
    • Excessive foot pronation or supination
    • Quad weakness
    • Weak abdominal musculature
  • Consistent use of rollers and massage to the entire thigh area including the lateral thigh, groin and hamstring muscles.
  • Implementing aggressive quad strengthening exercises that are pain-free with minimal patella grinding or noise present.
  • Full flexibility of the lower extremity and low back. The hip flexors, the IT band, the calves and, believe it or not, the big toe are commonly overlooked areas for mudders with chronic Runner’s Knee.
  • Aggressive manual therapy and modalities to decrease the pain while increasing the mobility of the soft tissue associated with the patella.
  • Ice, ice, ice….immediately after any activity.  

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to cross training:

  1. Does my mechanics and/or injury merit the need for orthotics?
  2. How badly damaged is the cartilage on the back of my kneecap and are there any activities that I need to avoid as I rehab this injury?
  3. What factors, such as poor flexibility or quad weakness, do you consider to be the main reasons for my injury?
  4. Is there a specific exercise(s) that I need to avoid in order for me to stay very active & healthy?
  5. To assist my efforts to return to cross training, do you have a detailed written rehabilitation protocol to assist my therapist and me?

Elite Sports Medicine Tips To Avoid Runner’s Knee

  • Common Sense – Clearly looking at both the changes with your workouts and your footwear can solve the mystery of kneecap pain 60% of the time.
  • Find the Real Problem – Kneecap pain is usually caused by a mechanical problem elsewhere in the body.  Start looking above, below, behind and in front of the kneecap to see if the Runner’s Knee is more of the symptoms not the source of the problem.
  • Change Now & Stay the Course – Scar tissue associated with patella injuries doesn’t just go away.  Plan on finding the problem, making the necessary changes and then stick to that plan for the long haul.
  • Ice is Your Friend – I preach this sermon often but it’s for good reason:  Ice hurts but it’s exactly what you need for this injury.  You need ICE and lots of it.
  • Father Time Has a Bum Knee – Flexibility typically decreases with age…..unless we spend the time to improve it.  Stretching takes a huge amount of stress off your knees, patella’s and low back. Get rid of the “I’m too busy to stretch” excuse.  Start stretching NOW and make your patella pain a thing of the past.

Mike Ryan FitnessMike Ryan, PT, ATC, PES is the Head Athletic Trainer/Physical Therapist for the Jacksonville Jaguars of the NFL and a 6 time Ironman triathlete. Mike is the founder of, a free sports medicine resource dedicated to keeping mature athletes healthy & active.


1 comment… add one
  • Pat Devine

    Good read Mike! Got anything on Anterior Compartment Syndrome? Dr. Ken is shaking his head at me for overdoing it and not sticking to his timeline! Took a week post-race for swelling to go down but still tender and sensitive. Need to smarten up my training! Thanks

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