Common Running Injuries Part 3: Patellofemoral Pain Syndrome

Put an end to your knee pain

Published in

Runner's Life

7 min readJan 21, 2021

Patellofemoral pain, often called runner’s knee, is one of the most common injuries I see in the office. It accounts for over 25% of all injuries seen in a sports clinic yearly.¹ Currently, the best evidence for treating this condition is through exercise. This article will explain what causes patellofemoral pain and provide exercises to help treat your knee.

What is Patellofemoral Pain Syndrome (PFPS)?

Signs and symptoms

Pain when the knee is bending — ex: squatting, kneeling, stairs.
Ache when sitting or standing in one position for long periods.
Pain around the kneecap or beside/underneath the patella tendon.
Pain is usually worse on harder surfaces vs softer surfaces — ex: pain worse when running on the road vs. treadmill.

Patellofemoral Pain Syndrome vs. Patellar Tendinopathy

It is important to differentiate between patellar tendinopathy and PFPS. Patellar tendinopathy has pain that is directly on the tendon itself. If you go immediately below the center of the kneecap and feel pain on the tendinous band compared to pain around the sides of the tendon, then it is more likely that you have patellar tendinopathy.

In addition, patellar tendinopathy is often painful at the beginning of exercise, eases up in the middle of exercising, and then aches afterward. It is fairly common to have both patellofemoral pain syndrome and tendinopathy.

Treatment for patellar tendinopathy is similar to my previous article about Achilles tendinopathy, except instead of heel raises, perform a decline squat.

Common Running Injuries Pt 2: Achilles Tendinopathy

Defining Achilles tendinopathy and providing evidence-based treatment.

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Risk factors for PFPS

Weakness in quadriceps and hips.
Decreased flexibility.
Chronic overuse or ramping up running mileage too quickly.
Poor running mechanics.
Recent fall or trauma.
Flat feet or excessive collapsing of feet while running.

Causes of PFPS

Patellofemoral Pain Syndrome is a catch-all term to describe diffuse pain around the knee and has many causes. I have them organized into four separate categories. It is important to keep in mind that you may fit into multiple categories.

Quad and hip weakness.
Poor flexibility throughout the entire leg — in particular the quads, calves, and hamstrings.
Excessive foot pronation — running with collapsed arches or flat feet.
Patella (kneecap) moving too much or too little.

Treating Patellofemoral Pain Syndrome

As mentioned above, there are many causes for PFPS. I am going to list out some exercises that cover all the different causes. If a particular stretch or exercise is easy, it may be a sign that you do not have that deficit. Focus your attention on the exercises and stretches that are difficult or tight for you.

Strengthening exercises — perform 3x/week

Quad strengthening exercises — start with 3x10 working up to 3x15 before increasing weight. Keep pain below a 4/10 at all times.

Beginner: Knee extensions

Intermediate: Decline Squats

Advanced: Single Leg Chair Squats

Hip strengthening exercises — start with 3x10 working up to 3x30 before increasing weight as we primarily use these muscles for endurance. Keep pain below a 4/10 at all times.

Beginner: Bridge

Beginner: Clamshells

Intermediate: Bridge Marches

Intermediate: Lateral walks

Advanced: Rotisserie Chicken Exercise

Advanced: Wall Monsters / Wall Sidelying Hip Abduction

Foot intrinsic exercises — these are good for those with flat feet. Perform for 3 minutes on each side.

Towel scrunches — keeping your foot on the floor, use your toes to scrunch a towel up.
Marble pickups — lay down marbles on the floor and pick them up with your toes, placing them in a cup.

Mobility exercises — perform 2x each day holding for 30–60 seconds

Quad stretch — use a strap or your hand to pull foot back and bend knee as much as possible. Should feel a stretch in front of your thigh.
IT band stretch — see picture below.

Hamstring stretch — sit at the edge of a chair with knee straight and lean forwards until stretch is felt in back of the upper leg.
Calf Stretch — Let foot drop off a step or curb until stretch is felt in the calf.

Manual therapy

Foam roll structures before stretching or running as this will increase blood flow to the area. I recommend doing each for 1–2 minutes. If an area feels tight or a little painful, keep pressure on the spot for 30–60 seconds until it loosens up. Try rolling back and forth in small motions at these spots.

Quads/Hamstrings — foam roll the front and back of your thighs.
IT Band — It is best to roll the Tensor Fascia Latae (TFL) muscle vs. the IT band itself. This muscle attaches to the IT band so when it gets tight, the IT band becomes tight. The muscle can be found on the front-outside area of your hip. Try to foam roll near the outside of your front pocket and this should hit the TFL.

Patellar (kneecap) mobilizations may be beneficial for those who have tight patella. I rarely recommend doing these at home as it is safer for a healthcare professional to do it, but if you notice your painful knee has a patella that does not move as much as the other try doing what the video states below.

Note: do not perform this if your kneecap moves a lot or the painful side moves as much as the non-painful side.

Modalities/Other

Taping — Using a rigid tape can be beneficial. This is something a physical therapist or other healthcare professional can perform for you. Ideally, there should be a 2 point drop in your pain on a 0–10 pain scale.

Blood Flow Restriction — Blood flow restriction (BFR) uses cuffs with air in them to help occlude or block some blood from entering/leaving your leg. It’s a relatively new technique that is gaining more research each year². Blood flow restriction allows your body to get a surge of beneficial hormones while using light weight vs. needing to use heavy weights that irritate your knee. Only some clinics have this technology, but if your pain is severe even with the exercises above, then finding a physical therapy clinic with this might be beneficial for you.

Running Tips

Run softly — over-striding can lead to an increased load on the knees. Running softly will decrease stride length and promote a mid-foot landing vs landing with the knee completely straight. Runners can naturally accomplish this by listening to their feet hit the pavement and trying to land as soft as possible.
Keep knees from rubbing against each other — while running, try to prevent the knees from collapsing in and rubbing each other. If you notice this happens to you, then focus on the hip-strengthening exercises above.

Key Takeaways

Patellofemoral Pain Syndrome is complex and can have many causes. Try the ideas above and pick and see which muscles feel tight and/or weak. Expect 6–8 weeks for the pain to improve.

Keep pain below 4/10 with all exercises.

From my experience, the ITB stretch, hip strengthening, and taping have been the most beneficial at reducing pain.

Disclaimer: This is an educational piece and is not specific medical advice. Please consult with your physician or physical therapist before trying the exercises above.

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