A Physical Therapist-Approved Guide to "Runner's Knee" Pain

Runner’s knee is the pain you’re feeling around or under your kneecap during or after your run. 

It can be annoying, frustrating, and (most importantly) painful, so here’s some good news to know about runner’s knee upfront: 

1. In most cases, Runner’s Knee is not serious to overall health,
2. It can be treated with physical therapy depending on severity, and
3. There are a variety of at-home fixes you can get started on today!

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In this guide, our physical therapists reveal everything you need to know about Runner’s Knee - why it happens, what you can do about it, and how to prevent it in the future.

We’ll cover…

• Runner’s Knee Basics: What it is with answers to common questions.
• Runner’s Knee Causes: Why it’s happening based on your situation.
• Runner’s Knee Symptoms: How it is diagnosed by professionals. 
• Runner’s Knee Treatment: Explore a list of professional and at-home treatment options.
• Runner’s Knee Prevention: Physical therapist-approved exercises, gear, and form tips.

Runner’s Knee Basics

There are many misconceptions about what runner’s knee is and what to do about it, so let’s start with a physical therapist’s answer to: “What is Runner’s Knee?”

“Runner’s knee, or Patellofemoral pain syndrome (PFPS) is characterized by retro- or peripatellar pain. This is especially true during loading of the knee while in a flexed position, which causes high compressive forces between the posterior patella and the femur.”

• Meghan Taff, Physical therapist, Triathlon Coach, and Triathlete

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Simply put, runner's knee is pain located behind the kneecap, or in the soft tissue that surrounds the kneecap. Runner’s knee is common among athletes of all types: Marathon runners, triathletes, and just about any sport that includes running, squatting, jumping, and knee-loading as part of training.

Statistics you should know about Runner’s Knee

• Incidence rates vary between populations with 5.1%-14.9% of adolescent amateur athletes developing PFPS over 1 season.
• Females tend to be at greater risk for developing PFPS, most likely due to biomechanical differences (2.23 times more likely)
• The management as well as the prevention of PFPS warrants a closer look from athlete and PT alike due to alarmingly high recurrence rates of 70-90%. 
• Interestingly, many patients do not seek additional care after PFPS diagnosis despite exercise therapy reducing the risk of recurrent knee pain.  

Runner’s Knee Symptoms

Runner’s knee symptoms include…

1. Presence of retro-patellar (behind the kneecap) or peripatellar (top of the kneecap, or surrounding tissue) pain,
2. A reproduction of pain during kneecap/joint loading in the flexed position, plus,
3. The exclusion of other medical and musculoskeletal injuries like dislocation, tumors, meniscus injuries, tendinopathy, and more.

The variety of causes and symptoms of runner’s knee means seeking professional guidance is a priority. A physical therapist will have the expertise needed to decide if runner’s knee is the proper diagnosis in the first place.

How Physical Therapists Diagnose Runner’s Knee

Through “history-taking,” physical therapists diagnose runner’s knee based on a variety of information that has led you to this point.

Pain characteristics that PTs look out for include:

• Onset of pain: Typically gradual and slow, but can be acute. 
• Location of pain: Retro-patellar and/or peripatellar pain (as pictured above).
• Characteristics: Pain is often poorly defined by patients.
• Aggravating factors: Any loading of a flexed knee: squatting, prolonged sitting, running, jumping, ascending/descending stairs, etc.
• Timing: During activity or shortly after, sometimes the following day.

Overload characteristics that PTs look out for include:

• Changes in recent load compared to usual load (i.e. increased running mileage, ramping up speedwork),
• Changes in anything training-related, like
• Footwear,
• running surface,
• stress levels, and nutrition;
• Previous injury
• Best predictor for a new injury, especially if it’s closely related.

Clinical Examination of Runner’s Knee

The majority of clinical tests for runner’s knee are not accurate due to the variety of factors that play a role in its diagnosis and treatment. With that being said, physical therapists agree the most accurate test is the reproduction of pain during squatting. 

Additionally, other functional activities that load the PFJ in a flexed position like stair climbing or descending can be used. In addition, hypo-mobility demonstrated by the patellar tilt test can be used to support the diagnosis in combination with other findings.

Running Gait Analysis should be used as pain tolerance allows. If the patient is acute and/or limping, gait analysis should be performed when mechanics normalize.

Runner’s Knee Causes

Runner’s knee is caused by a deficiency in load management, muscle performance, movement coordination, or mobility. 

Overload is a primary cause of runner’s knee when athletes have been applying too much external stressors on their knee. This could include heavy-squatting, long-distance running, and more.

Muscle performance deficits such as not training Type 2 (fast twitch) muscle fibers as much as Type 1 (slow twitch) cause runner’s knee pain by not preparing the knees for the load being placed on them. 

Movement coordination deficits such as difficulties with activating the core and hip musculature can cause runner’s knee by making the thigh muscles (such as the quad) work overtime. Also, if you’re not performing drill work to help with running form cues, this can also perpetuate the deficiencies in certain muscles activating.

Mobility impairments such as tight hips or ankles, can cause runner’s knee by putting more stress through the knee vs dispersing the ground reaction forces (GRFs) more evenly as the foot hits the ground during the running gait cycle

Runner’s Knee Treatment

If you’re suffering from runner’s knee, chances are finding treatment is at the top of your to-do list. Because this condition has variable causes and symptoms, we’ve created a matrix to showcase the typical treatment required depending on your case.

Select a treatment based on your cause of pain

1. Overload: When the cause of your knee pain has been identified as “overload,” your treatment should center around load management. Load management is the practice of purposely reducing external stress on your muscles and joints to recover.
2. Muscle performance deficits: Your focus should be on exercise therapy that targets hip rotation and loosening, as well as knee-targeted exercises. Weight-bearing (resisted squats) or non-weight-bearing (resisted knee extension) are both recommended. 
3. Movement coordination deficits: If coordination is your problem, look to improve your running form and technique. Common solutions include gait training and movement re-education. 
4. Mobility impairments: Oftentimes your muscles are too tight. Stretching and strengthening the affected muscles will be the best treatment for you.

Other treatment solutions for runner’s knee include...

• Foot orthoses
• Manual therapy
• Dry Needling
• Taping
• Knee Orthoses
• Biofeedback
• Biophysical agents
• Gait retraining
• Acupuncture
• Patient education
• Blood flow restriction

Runner’s Knee Prevention

Athletes should be proactive in their care to prevent runner’s knee, replicating a routine that you would find with in-person PT care. 

The first step in any injury is to try and get the soft tissue to calm down (or release). Pain causes the muscles to tense, which prohibits good mobility around the joint, as well as the brain being able to connect to the muscles. Compensatory movement patterns form due to these physiologic changes. 

Once the soft tissue is more relaxed, perform self-joint mobilizations, including hip, ankle, and lumbar spine mobilizations. 

Our 3-Stage Approach to Getting Back to Running

Stage One: “I have not been running, or I’ve been running a little bit with pain.”

A. Pre-Run Routine (10-15 min)

1. B LE foam rolling, trigger point ball release as tolerated
2. Postural foam rolling (pecs, shoulders), trigger point ball release (pecs, scaps, back) as tolerated
3. Joint mobs to hips/ankles, spine
4. Muscle activation: core, post chain, glutes/hips, calves (might be more isometric initially)

B. Cardio/load modification

1. Swimming, cycling, elliptical: duration agreed upon by Patient and PT
2. Walk and/or walk/jog ratio: duration agreed upon by Patient and PT
3. Use of kinesio taping and/or bracing as needed during activity

Stage Two: “I can run for 15-20 min with minimal or manageable discomfort”

A. Pre-Run Routine (10-15 min)

1. B LE foam rolling, trigger point ball release
2. Postural foam rolling (pecs, shoulders), trigger point ball release (pecs, scaps, back)
3. Joint mobs to hips/ankles, spine
4. Muscle activation: core, post chain, glutes/hips, calves (moving towards more dynamic movements)

B. Cardio/Load modification

1. Swimming, cycling, elliptical, hiking: duration agreed upon by Patient and PT
2. Walk and/or walk/jog ratio, jogging: duration agreed upon by Patient and PT
3. Use of kinesiotaping and/or bracing as needed during activity

Stage Three: I can run 30+ min with minimal to no discomfort

A. Pre-Run Routine (15-20 min)

1. Full-body foam rolling/trigger point ball release
2. Joint mobs to hips/ankles, spine
3. Muscle activation: core, post chain, glutes/hips, calves (dynamic running movements)
4. Dynamic stretching/warm-up: Routine agreed upon by Patient and PT
5. Drill work and training to improve running form: routine agreed upon by Patient and PT

B. Cardio/Load modification

1. Swimming, cycling, elliptical, hiking: PRN
2. Jogging/running: duration, intensity, load agreed upon by Patient and PT
3. Use of kinesio taping and/or bracing as needed during activity

In conclusion 

There is no one-size-fits-all approach to diagnosing, treating, and preventing Runner’s Knee. As such, a personalized approach created by a physical therapist is important for a speedy recovery. If you’re looking for help navigating this process, Netic has specialized physical therapists ready to help you get back into race shape. 

Get matched with your Perfect PT for free today.

Before we end our guide, here are a few things to remember about runner’s knee:

• Runner’s knee can be “cured” given proper recovery time and rehabilitation
• Runner’s knee is often not serious to longevity but should be treated with care
• Symptoms include pain underneath the kneecap, as well as on top of, and around the kneecap soft tissues 
• Consult your physical therapist before starting a treatment plan

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