The runner’s toolbox : preventing and managing patellofemoral pain

May 1, 2019

Patellofemoral pain syndrome or “PFPS”  is a common problem for runners, so much so it is often referred to as “runner’s knee”. It’s a diagnosis by exclusion, meaning if someone has pain that fits a certain area and description, without falling into a number of specific structural causes, then the label of “PFPS” is given to their pain.  As far as diagnoses go it’s not terribly useful in describing specific causes of pain, it’s really just a complicated way of saying someone has pain around their knee cap. Despite the vagueness of the diagnosis, there are thankfully some very specific ways we can manage it!

Consistent with the last runner’s toolbox blog, these strategies fall into the categories of resistance training, load management, and supplemental recovery work.

Resistance training

Strength training can be useful for improving the overall load capacity of the knee specifically, while also increasing the strength of other muscle groups to help reduce the amount of unnecessary load the knee has to absorb. These exercises are designed to build movement skill, increase the overall load capacity of the knee, and strengthen the musculature around both the hip and the knee. While there are plenty of machine, barbell, and dumbbell variations that can be used to progressively load the lower body, here is a sample workout template with a few body weight variations that require minimal equipment and can be done just about anywhere.

Sample Template (2x/week)

A1. 3×12/side Glute bridge variation

A2. 3×6 Sissy squat variation

B1. 3×6/side Shrimp squat variation

C1. 3×8-10 Pistol squat variation

Sissy squat variations

Shrimp squat variations

Pistol squat variations

Glute bridge variations

Load management

The general load management guidelines apply to runners with PFPS, trying to keep any changes in running surface, cadence, footwear, training mileage and speeds as gradual as possible. That being said, there are also a few considerations that are specific to PFPS.

Foot strike – A more forefoot or midfoot striking pattern will load hips and ankles more significantly, while a heel strike will tend to increase knee loading. Fast transitions in foot strike technique are not advisable but recognize that a gradual transition from heel strike to forefoot strike might be an option if PFPS has been stubborn and is not responding to other management strategies.

Running Gradient – similar to forefoot vs heel-striking, running uphill will shift the load towards calves and the posterior chain, while running uphill will place greater load on the knees. A useful strategy to keep someone running with reduced pain may be to perform the bulk of their mileage on a treadmill going uphill, and progressively decreasing the incline as their symptoms settle down.

Non running aerobic work – maintaining overall fitness is a crucial part of rehab and will accelerate the return to previous levels of running. This may also be a temporary substitute for running mileage in order to let the knee settlee down and gradually reintroduce previous mileage. Low impact options include rowing, swimming, and sometimes biking.

Supplemental recovery work

The rule of thumb for this recovery work is that if it feels good, then go for it. While these won’t necessarily make or break long term results, if they can relieve symptoms and provide some relief then they can be of value.

Voodoo floss + squat or knee extension – the overall mechanism or long term benefits of this one are not really understood, but plenty of people tend to see short term improvements in pain and range of motion anecdotally.

Couch stretch – pain often comes along with reflexive muscle guarding and reduced range of motion. Spending a bit of time in couch stretch to improve hip and knee range will usually provide a bit of relief for those with PFPS whose quads and hip flexors have reduced extensibility.