runner's knee

Runner’s Knee And Fixing The Pain

In Sports Injury and Pain by Royce Bowman, PT, Director

Do you find yourself getting up and walking around a lot, but still feel like you’re being stabbed in the knee with every step? Or have you been told that it’s your IT band that is causing the knee pain? Does it feel like the knee pain is just starting to come back, even though you took a break from running for a few weeks?

If this sounds like you, then your condition may be runner’s knee.

This blog post will teach you what runner’s knee is and how it can slow down your life. We’ll talk about what causes runner’s knee and how physical therapy can help treat it.  (Please note that the terms “patella” and “knee cap” will be used interchangeably, but refer to the same small floating bone in the front of the knee).

What is runner’s knee?

You might hear your doctor call it Patellofemoral Pain Syndrome or Chondromalacia Patellae but all you want is for it to GO AWAY!

Runner’s knee occurs when cartilage under the kneecap becomes irritated and causes mild to moderate pain when running.

With this condition, your knees hurt

  • while you’re running,
  • when walking up and down stairs,
  • or after prolonged periods of sitting.

Causes of runner’s knee

First of all, you don’t have to be a long distance runner to develop runner’s knee. Much in the same way that you don’t have to play a lot of tennis to develop tennis elbow.

Often, runners who attempt dramatic increases in mileage or any high impact activity such as jumping may exceed the athlete’s current performance level. In turn, this equals overtraining.

Runners who run on sidewalks or streets end up with one leg on the downward or upward side because streets crown in the middle. A street slopes about seven degrees towards the gutter.

The sidewalk angles towards the street at anywhere from five to seven degrees. When you run on those surfaces, you get extra strain from improper alignment.

Foot problems – excess pronation leads to valgus at the knee. This happens during running and your landing places a strain on medial structures as well as the patellar and quad tendons.

Kneecap alignment – poor patellar tracking in the femoral groove leads to joint inflammation. Also,  additional strain on the quadriceps muscle can perpetuate knee pain.

Weak quadriceps – poor loading tolerance and eccentric quadricep strength during the repeated impact of running leads to abnormal and harmful positioning of the knee during running.

Tight Hamstrings/Calf muscles/Achilles tendons – too tight hamstrings and calf muscles restrict full hip extension. This leads to quadriceps compensating for the hamstrings. In turn, the overworked quadriceps put strain on the knee.

Often, a tight achilles tendon alters your gait. An abnormal distribution of weight occurs which causes knee pain.

Cartilage beneath knee cap – as cartilage wears down, you begin to expose underlying bone on bone, and that’s what creates inflammation and pain.

Changes to footwear or broken down footwear – Your foot mechanics determine what happens at the knee. Of course, foot mechanics are being supported by the shoe or footwear. Worn down shoes allow for bad or improper mechanics of the foot and ankle. Those poor mechanics contribute to poor knee mechanics. You increase wear and tear, further pain, swelling, and degradation of knee cartilage.

runner's knee

Symptoms of Patellofemoral Pain Syndrome/Runner’s knee

After running or high impact activity, you will likely experience an aching knee cap or pain in front of your knee. Often, your kneecap hurts when touched.

If you’re getting knee pain during running, it’s usually a mechanical problem.

If you’re getting knee pain after you run, it’s usually from an inflammation problem.  Runner’s knee often involves both.

Knee pain when bending 

In general, you’ll feel pain

  • when squatting,
  • lowering to a seated position such as a chair or toilet,
  • navigating up and down stairs.


The knee joint has a capsule of soft tissue around the joint. This particular capsule is the largest in the human body.

When extra fluid builds up due to inflammation, the knee feels stiff and range of motion feels tight.

While you’re running, there’s a phase of your gait when both feet are off the ground. The lead foot hits the ground, and the impact force to the foot is three and a half to almost four times your body weight. The impact affects your foot, ankle, and up toyour knee.

This creates shear forces on the cartilage especially between the patella and the femur. If the cartilage begins to wear thin, the wear and tear irritates the joint. You end up with pain and swelling.

What’s this popping sound I’m hearing?

Generally, the popping sound comes from the cavity of the knee joint. The cavity fills with fluid, thereby displacing other ligaments or tendons. These displaced ligaments and tendons snap over a bony prominence or some other feature in the joint.

Typically, popping and grinding sounds (crepitus) accompany runner’s knee syndrome.

These noises can be a result of the swelling as described above or when the cartilage begins to degrade and becomes less smooth. Then  the sliding of the patella in the femoral groove begins to make noises.

If the knee continuously makes noises, hurts during and after activity and swells, you should make an appointment with an Orthopedic doctor for examination.

Patellar tendon pain lies beneath the kneecap, in the front of the knee. Your tendon is being overloaded by the eccentric impact of running. That means when your lead foot lands, your knee bends, but the quadricep still contracts. This overloads the patellar tendon, causes tendinitis,, and you develop knee pain.

Can runner’s knee cause pain in the back of the knee?

When swelling causes the “water ballooning” effect inside the knee cavity/capsule you’ll develop a bulge in the space behind the knee. In turn, the pressure pushes on sensitive nerves and blood vessels which leads to pain in the area.

Why is it common in young female athletes?

There is typically an anatomical difference between the male and female gender.

Females tend to have a wider pelvis. Since the femur bone attaches to the lateral side of the pelvis, it increases the angle of the knee joint. The increased angle adds extra stress to the knee’s soft tissues and how the patella tracks in the femoral groove.

So, when a young female athlete overtrains while running, they are more likely to develop runner’s knee than the male athlete.

This place has improved my quality of life! I have recommended several people. The staff is great and treatment is superb! My husband is in therapy here now and he has also improved. Royce has been my go to therapist for years! One couldn’t find anyone better. My husband himself has Aj and has had excellent care!Connie Harrison

Can you resolve runners’ knee without treatment?

It depends. If you continue to repeat the same patterns, your situation is likely to continue and worsen.

What do you do if knee pain persists long term?

First of all, consult with a professional. A physical therapist, orthopedic physician, or orthopedic surgeon can provide you with a detailed diagnosis of musculoskeletal issues.

More than likely, you’ll receive range of motion tests, strength tests, and then possibly, X-rays and/or MRI. X-Rays and an MRI help rule out other pathologies.

If you’re feeling limited in sports activities or, most importantly, the things you do on a daily basis like walking up and down stairs, seek help.

If you are continuing to run, you may need to stop and allow for healing and decreased inflammation of the knee. Also, until you consult with your therapist, you should limit your running while initially starting PT.

How does physical therapy help relieve pain from runner’s knee?

Because of the body’s kinetic chain, anything from foot, knee, hip and pelvic abnormalities can lead to runner’s knee. As a result, treatment areas can vary.

  • For the foot, flat foot or pronation can lead to stress at the knee. We work to strengthen the dynamic arch support of your foot. Plus, we want to strengthen the calf and musculature surrounding the foot. We work on increasing flexibility of the ankle/foot complex and provide advice on orthotics as well.
  • At the knee, we can provide taping to improve patella tracking in the femoral groove. We work to strengthen the quadriceps and hamstrings. Also we work to improve the eccentric loading tolerance (ability to accept weight through the leg while bending) to allow for return to running.
  • Just like the foot, the hip and pelvis can promote abnormal positioning at the knee and lead to pain. Weak gluteus muscles (primarily the gluteus medius) lead to internal rotation and valgus (knock-kneed position) at the knee. This causes strain as well. We work on strengthening and landing mechanics to avoid any compensations throughout the lower extremity.

Additional treatments which complement your recovery can include taping, bracing, icing, and more. We individualize your total care plan.

The physical therapy regime would be to improve flexibility, strength, and stability of the knee joint. The therapy helps support the knee during vigorous activity such as running.

Runner’s knee recovery time with physical therapy

You’re looking at temporarily reducing activities that exacerbate your symptoms.

And it’s all based on the initial evaluation, between the physical therapist. And you as an individual athlete or non athlete.

After that, you’ll begin a slow progression of working back to everything that you want to do.  In general, you’re looking at 6-8 weeks of

  • strength and muscle building
  • specific activity training through agility training or plyometrics
  • stretching exercises which develop stability and control of your knee joint biomechanics.

Once you’re healed and ready to return to running, we’ll provide you with a number of aftercare steps you can take to keep runner’s knee in check. This can include advising you on correct form, how to warm up, and more.

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Read more – How runners knee can lead to patellofemoral arthritis

About the Author

Royce Bowman, PT, Director