Knee Pain in Runners: Are more proximal structures to blame?

Two of the most common injuries to present to the sports injury clinic in runners are iliotibial band friction syndrome (ITBFS) and Patellofemoral pain syndrome (PFPS) (Brukner and Khan 2007 and Ellis, Hing and Reid 2006).  ITBFS is characterized by pain and tenderness on the lateral aspect of the knee, which is usually due to repetitive flexion/extension movement where the iliotibial band pops over the lateral femoral condyle, causing increased friction (Pettitt and Dolski 2000). PFPS has been described as pain and tenderness on the anterior aspect of the knee, this is thought to be due to a maltracking of the patella as a result of tightness/weakness in the quadriceps muscle group (Crossley, Bennell, Cowan and Green 2004). The iliotibial band begins as an expansion of the gluteus maximus and tensor fascia late muscles and runs down the lateral aspect of the knee to insert in to the lateral aspect of the tibial condyle (Palastanga, Soames and Palastanga 2008). The Patellofemoral joint is the articulation between the posterior surface of the patella and the patellar surface of the femur and the architecture of this joint allows a mechanical advantage in the quadriceps (Vastus lateralis, medialis, intermedialis and the rectus femoris) (Palastanga et al 2008). The gluteus maximus, tensor fascia late and the rectus femoris are 2 joint muscles in that the act upon the hip and the knee, thus weakness within these muscles can impact the function of the knee joint (Hamill and Knutzen 2010).

Pain in both of these structures is common in runners, and may be due to training errors, incorrect footwear, and structural weaknesses/imbalances in the lower limb and pelvis (Brukner and Khan 2007).  For year’s therapist have tried to determine the best treatment for ITBFS and PFPS (Crossley et al 2004 and Ellis et al 2006). Recently researchers have begun to investigate the relationship the hip musculature in particular the abductors have with these two conditions (Ferber, Kendall and Farr 2011, Powers 2010 and Wilson, Kernozek, Arndt, Reznichek and Straker 2011). Weakness in the gluteus maximus, medius and tensor fascia late will impact on the ability to stabilize the pelvis while running (Burnet and Pidcoe 2009 and Powers 2010). Contraction of these muscles on the weight bearing side, keep the opposite side level, to avoid pelvis drop, which subsequently leads to a rotation at the femur and increased heel lift to ensure the foot clears the floor, thus placing additional stresses at the knee joint (Wilson, Kernozek, Arndt, Reznichek and Straker 2011). The forces experienced in the lower limb while running can be as great as 8X the body weight with each stride taken (Hamill and Knutzen 2010).

Individuals suffering from knee pain will generally experience pain either on the outside of the knee (Iliotibial Band) or the front of the knee (Patellofemoral joint). pain generally starts as a dull ache typically at a specific time or distance in the case of iliotibial pain and generally near the end of the run with patellofemoral pain, Correct diagnosis is essential in the management of either condition. examination typically involves testing the hip/knee joints, with treatment focusing on strengthening areas of weakness and stretching areas of tightness.

Unfortunately without treatment this type of pain will most likely recur, therefore it is essential to seek advice about the best way to manage this. below are a couple of preventative exercises that will assist in keeping your lower body strong and conditioned for running.

Squats with Band around the knee

Side Lying Leg Lifts


Hip Hikers

Single leg squats

Step ups

The above exercises can be done at home with minimal equipment and should be performed 2-3 times per week performing 2-3 sets of 10-15 repetitions per side where appropriate.

For anyone looking for more information on the above, I recently gave a presentation on the relationship gluteus medius weakness has on patellofemoral pain syndrome. I have attached this here.

Gluteus Medius Weakness and Its Relationship with Patellofemoral Pain Syndrome


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