Answering the Knee Question

One major myth about distance running is that it will "ruin your knees". Many non-runners often wonder how the knees can withstand a marathon. Many of us have heard the question from a non-runner: "Don’t your knees hurt you after all that running?" This can be as annoying a question as "so how many miles was that marathon you did?" The good news is that unless you have had a significant previous joint injury, such as torn ligaments or cartilage, there is no evidence that beginning and continuing distance running will cause osteoarthritis or other traumatic injury. While the knee is the most frequently injured area in running, most of the injuries are of the overuse nature, and can be managed with correct treatment.

The knee is actually composed of two joints. One is the patellofemoral, between the kneecap (patella) and femur (thighbone), and the other is between the tibia (shinbone) and femur. Also nearby is the joint between the tibia and fibula (outer leg bone.) The patella attaches the quadriceps to the lower leg through the patella tendon. The knee joint lies between the foot and the hip/pelvis, and its status is dependent on proper alignment in those joints, which is one reason it is so frequently the site of pain. Thus the approach to keeping our knees healthy must include looking above and below the knee itself.

The two most common overuse injuries at the knee have been named patellofemoral/malalignment syndrome and iliotibial band syndrome, and they share some common causes and treatments. Patellar tendinitis is a related problem. Iliotibial band syndrome will be discussed next month.

Patellofemoral alignment syndrome usually involves pain at the front of the knee, around the kneecap, which may be from pain sensitive muscle (the quadriceps), tendon or both. Symptoms usually start with a dull ache either early or late in a run. Hill training may exacerbate. Besides running, pain may be felt going up or down stairs and after sitting. "Movie sign" is present when you feel more pain after sitting (as at the movies) and then straighten your legs to walk. Also, a "clicking" feeling may be present when flexing and extending your leg.

Irritation to the knee tissues occurs when the patella does not glide, or "track", properly along the femur as the knee flexes and extends (which may produce the clicking feeling). Tenderness is usually found where the muscle or tendon insert on the patella. As in all running injuries, a combination of extrinsic (training/equipment/technique) and intrinsic (structural/biomechanical) factors is causative, and all must be addressed. Intrinsically, both muscle imbalance and joint alignment can be to blame. The patella can be pulled laterally (outward) by a tight outer quadriceps overpowering a weaker inner quadriceps. Overuse causes adhesions and trigger points (knots) to form in the muscles, which can refer pain to the kneecap as well as put abnormal tension on the tendon. Restriction of motion in the lower back or hips, along with tight hamstrings and calf muscles can also put more pressure on the kneecap. The angle at which the femur and tibia meet, called the "Q-angle", can predispose to tracking problems if it is greater than normal. Many women have knee problems as their pelvis is shaped wider and creates a larger q-angle. Finally, an ankle and arch that overpronate (flatten too much upon wieghtbearing) can also cause abnormal tracking, as the lower leg and knee follow the foot inward.

Extrinsically, running on cambered roads will put the inner leg at risk, as the knee will be forced inward. Other extrinsic factors include a rapid increase in daily or total mileage and too much hill training.

Treatment must involve addressing both the acute pain, if present, and the underlying causes of either acute or chronic pain. Acute care includes ice, compression, and elevation to decrease any swelling and maintain as much range of motion as possible, as well as electric muscle stimulation for the same purpose. Isometric quadriceps exercises can begin almost immediately to improve strength of the inner quadriceps (vastus medialis).

Treatment must involve addressing both the acute pain, if present, and the underlying causes of either acute or chronic pain. Acute care includes ice, compression, and elevation to decrease any swelling and maintain as much range of motion as possible, as well as electric muscle stimulation for the same purpose. Isometric quadriceps exercises can begin almost immediately to improve strength of the inner quadriceps (vastus medialis).

Taping of the patella can help guide it back into a more pain-free position, support the involved muscles, and also relieve tension on the tendon if it is involved.

As with all overuse injuries, once the acute pain/swelling is controlled the biomechanical factors and any training errors can be addressed. The tight muscles mentioned above must be stretched. Office treatment with Active Release Technique(ART) of the involved soft-tissues is often a necessity, to relieve the pain-causing adhesions, trigger points and tightness, as well as spinal, hip and knee adjustments to restore proper joint motion. Next, the weak muscles must be strengthened. Straight leg raises are first added to the isometrics, and then exercises involving knee flexion can be added. These are the short-arc extensions, quarter squats, and step-ups. Elastic tubing or bands can provide additional resistance to the short-arcs and squats. A gradual return to running can start once these exercises can be performed pain-free, however orthotics may be needed to control overpronation.

To prevent re-occurrence, as well as to prevent first-time occurrence, all of the above exercises and treatments can be employed. This will ensure you don’t have to answer the knee question with "of course my knees hurt, I just ran 26.2 miles…"

This article is for informational purposes only, and should not be used as personal advice or diagnosis without first consulting a health-care professional. If you have, or suspect you have a health-care problem, then you should immediately contact a qualified health-care professional for treatment.