The knee is the most commonly injured body part in distance runners, and patellofemoral pain (PFP) is the second most common injury in novice runners. It accounts for approximately 13-30% of medical appointments for running injuries (Taunton et al, 2002). So what is it?

What is patellofemoral pain?

According to the 2016 PFP Consensus statement, Patellofemoral pain is “pain around or behind the patella, which is aggravated by at least one activity that loads the patellofemoral joint during weight bearing on a flexed knee” (Crossley et al., 2016). In other words, it is aggravation around the kneecap when you bend your knee in weight bearing. This would include activities such as going downstairs, running, hopping, and/or jumping. Alongside knee pain, other signs and symptoms may include crepitus behind the knee (i.e. a “crunchy” sound as you bend and straighten), tenderness when you press on or around the kneecap, and swelling at the knee joint. While there is no definitive test for the diagnosis of PFP, clinical examination and assessment (such as by a physiotherapist) remains the best approach to correctly diagnose PFP and rule out other possible causes of anterior knee pain such as meniscal involvement, patellar tendinopathies, and patellofemoral osteoarthritis, among others. 

Causes of patellofemoral pain?

While we once thought that risk factors such as flat feet, the angle between the hip and knee, and weak hip muscles may contribute to patellofemoral pain, there is no evidence to show that this is the case (Esculier, 2020). However, we do know that intrinsic factors such as sleep quality, mental health, stress and anxiety are all related to PFP and running injuries as a whole.

Given this, current leaders in the field of PFP suggest looking holistically at intrinsic factors such as the ones stated above, as well as extrinsic training factors such as increases in distance, speed, and running gait in determining what may be contributing to the knee pain and how best to treat it.

Treatment of Patellofemoral Pain in Distance Runners:

Current best practices suggest that consulting a health care professional for education on load management as well as strengthening exercises is the best treatment for PFP in runners (Crossley et al., 2016; Esculier, 2020). For example, an important part of returning to running is understanding tolerable pain parameters. While a 2/10 pain during activity, and up to an hour after is okay and can help with necessary tissue adaptation, we want that pain to be back to baseline by the following morning. More than a 2/10 pain during activity, or pain that lingers, may overload the tissue and prolong recovery. A physiotherapist may also make specific recommendations for training, such as running more often but with less volume in each bout (most runners love this one!) doing run/walk intervals, and temporarily decreasing downhill running and speed work. If despite these factors, running is still causing more than a 2/10 pain, patients are encouraged to cross-train with activities that place lower load on the patellofemoral joint, such as deep water running, or cycling. 

Current best evidence encourages strengthening and good coordination of the trunk, hip and knee for patients with PFP. The physiotherapist will prescribe appropriate exercises based on an assessment of both strength and mobility. For example, if the patient has decreased strength in their gluteus medius muscle (one of the key muscles that keeps you stable in single leg stance), the physiotherapist may prescribe a controlled single leg step down, single leg bridge, side planks, and various single leg standing exercises.

Additional interventions such as taping the kneecap (see image above) and manual therapy techniques to improve patellar mobility (some examples can be seen in an Instagram post on April 8^th 2024) can help with short term pain relief of PFP. Manual therapy can also help to address other asymmetries in the kinetic chain that may be contributing to increased load on the patella, such as reduced knee, hip and/or ankle range of motion. These interventions need to be combined with exercise programs and education to achieve long term results (Logan et al., 2017).

Lastly, physiotherapists can also do Running Assessments, in which they will take an in depth look at your running gait on a treadmill. From here they can suggest changes that the runner can make to decrease load through the knee to influence pain and improve performance. Examples of this may include changing cadence, footwear recommendations, giving cues related to sensations a runner may feel in their body, or giving cues that have the runner imagining certain actions while running. 

We offer Running Assessments at our North Shore Winter Club and Downtown Plaza of Nations clinic locations. 

About the author: 

Natalie Marshall is a Registered Physiotherapist at the North Shore Winter Club Allan McGavin Sport Medicine Clinic. After growing up playing team sports, Natalie got into running in physio school as a way to destress! She now enjoys run clubs and training for half marathon distances. Natalie has completed the Running Clinics “Fundamentals of Running Injuries” as well as “Diagnosis of Lower Limb Injuries” in the past two years and offers running assessments at the North Shore Winter Club location. 

References: 

Crossley, K. M., Stefanik, J. J., Selfe, J., Collins, N. J., Davis, I. S., Powers, C. M., McConnell, J., Vicenzino, B., Bazett-Jones, D. M., Esculier, J.-F., Morrissey, D., & Callaghan, M. J. (2016). 2016 patellofemoral pain consensus statement from the 4th international patellofemoral pain research retreat, Manchester. part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures. British Journal of Sports Medicine, 50(14), 839–843. https://doi.org/10.1136/bjsports-2016-096384 

Crossley, K. M., van Middelkoop, M., Callaghan, M. J., Collins, N. J., Rathleff, M. S., & Barton, C. J. (2016). 2016 patellofemoral pain consensus statement from the 4th international patellofemoral pain research retreat, Manchester. part 2: Recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). British Journal of Sports Medicine, 50(14), 844–852. https://doi.org/10.1136/bjsports-2016-096268 

Esculier, J.-F., Maggs, K., Maggs, E., & Dubois, B. (2020). A contemporary approach to patellofemoral pain in runners. Journal of Athletic Training, 55(12), 1206–1214. https://doi.org/10.4085/1062-6050-0535.19 

Logan, C. A., Bhashyam, A. R., Tisosky, A. J., Haber, D. B., Jorgensen, A., Roy, A., & Provencher, M. T. (2017). Systematic review of the effect of taping techniques on patellofemoral pain syndrome. Sports Health: A Multidisciplinary Approach, 9(5), 456–461. https://doi.org/10.1177/1941738117710938 

Powers, C. M., Witvrouw, E., Davis, I. S., & Crossley, K. M. (2017). Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th international patellofemoral pain research retreat, Manchester, UK: Part 3. British Journal of Sports Medicine, 51(24), 1713–1723. https://doi.org/10.1136/bjsports-2017-098717 

Taunton, J. E., Ryan, M. B., Clement, D. B., McKenzie, D. C., Lloyd-Smith, D. R., & Zumbo, B. D. (2002). A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine, 36(2), 95–101. https://doi.org/10.1136/bjsm.36.2.95