Injury Prevention

Runner's Knee Part 3: Training Modification & Self-Care

Over the last two weeks, we have discussed the ins and outs of what Patellofemoral Pain Syndrome is, the anatomy involved, how adjacent joints (hip and ankle) can lead to maltracking issues, and why runner’s are specifically susceptible to this common overuse injury.  You can read Part 1 & Part 2 here.  

Now it’s time to talk self-treatment and training modification.  Our goal is to maintain training (load) if possible when you find Runner’s Knee settling in, but more times than not,  rest and self-care is needed while also modifying our training volume and intensity until symptoms recede.

TRAINING MODIFICATION FOR RUNNER'S KNEE

Let's get the big one out of the way first!  One of the reasons many runners try to avoid visits to a doctors office about one pain or another is the fear that the physician will tell them to stop running.   Depending on the injury, how long it has been going on, current severity, and many other factors, some runner’s are able to continue training during treatment and rehab, albeit modified.  

Without getting too technical, we have to first understand the concept of 'load' and how it changes when we are injured.  As runners, we have a specific language so I am going to explain it in those terms. When our training is on and we are injury free and fit, long runs, speed work, tempo runs, and intervals go well and help us improve.  The amount of load on the knee (and other joints) is well handled and time is ample to recover. Now, let's say you decide to sign up for a race that is in 6 weeks and your training base is less than optimal. In hopes of having a good race, you ramp up quickly, performing hard days back to back, pushing it to your goal race pace over a good portion of your long run, etc., and now...BOOM, knee pain!  What has happened here is that you crossed over the load threshold of what your body will allow and recovery from.

For an interesting read, look into Scott Dyes work.  This is what is commonly referred to the ‘envelope of function’ in the coaching and physician world.

Jumping back in...now that we are injured, our load threshold is lower.  This is why a 5-mile run is painful halfway through when just 2 weeks ago, you were cruising through 10 miles with a few pickups.  If you continue down this path, patellofemoral pain can become so severe that just getting out of bed and navigating stairs are difficult.  When we encounter a runner in this position, we have to have a sit-down and talk training plan, race expectations, and our long-term goals.

While it is never our goal to shut a runner down in the middle of a training cycle, the long-term health and ability of the athlete is top of mind.  Because of this, when discussing training, we tend to cover three things.

Can we gradually ramp up training while continuing to respond to treatment?

When we begin treatment, we have to start with a baseline.  That may be 2 miles, 5 miles, or No miles before the pain sets in.  That is our starting spot. As we follow-through with the suggested treatment plan, this load threshold must also go up.  Rarely does pain go from 100 to 0, meaning, the pain goes from beginning at mile 2, then mile 4, then we find ourselves back up to 8-10 miles with no pain.  This is the progress we look for.

Initial volume should decrease by 50% for the first 2 weeks.

If you are coming to us for knee pain, make a conscious effort to dial it back for a few weeks. This allows you to keep training, but also a little more rest than normal while we get through the first few treatment session.  

Intensity, or pain provoking runs, need to take a full break until volume can increase without pain.

With runner’s knee, we find that the harder, hillier efforts cause the most problems.  While we want to maintain load on the knee while we treat, easy runs are the plan for the first few weeks.  Looking at what we just talked about with gradually ramping up, we need to make sure you can handle a good distance without pain before we start pounding out the speed-work and hill repeats.  And this goes for downhill too!

SELF TREATMENT OPTIONS FOR RUNNER'S KNEE

Now that we have discussed training modification, what can you start doing at home to help with Runner’s Knee?  Honestly, you should be doing all of this already, but pain is a much better reminder to break out the foam roller than a good run.  Your relationship with your foam roller needs to be strong. Your diet needs to be on point. Your bedtime needs to be early. Lastly, you need to realize that weight training is your friend.

Let's discuss a few of the easiest and most common self-treatment options.

Foam Rolling:

I don’t need to further detail my love for foam rolling over stretch or the benefits that regular foam rolling can provide for a runner.  As we address runner’s knee, rolling needs to be frequent, short bursts throughout the day. Meaning, roll the quadriceps, hamstrings, and posterior hip muscles 3-5 times per day.  Again, these are short 2-3 minute sessions. 10-15 rolls up and down over each area. Check the video!
 
 

Hip Mobility Drills:

As runner’s, our knee functions is highly influenced and controlled by what is happening at the hip.  If your hip range of motion is limited, this will eventually show up at the knee. Check the video!
 
 

Ankle Mobility Exercises:

As a practitioner, I’m typically a ‘ground-up’ person when it comes to runners.  While the hip controls the show, if the ankle does not move properly, it can not react properly or efficiently when the foot hits the ground causing problems up the chain.  Studies show that just a few degrees difference between ankles is a good indicator of future injury. Work on your ankle mobility - Check the video!
 
 

Kinesio Taping:

This is a bit controversial.  As you will hear me say in the demonstration below, the effect of taping is hard to prove.  Don’t get me wrong, I love taping, in the short-term. It is by no means a long term fix for any injury!  With that, you can also find 500 runners at the upcoming Big Cottonwood Marathon or the St. George Marathon that have their knees, shins, hips, and ankles taped that will absolutely swear by it.  With all of that, I just don’t have solid evidence that proves any of that...but placebo is a powerful tool and I do appreciate taping as a means to help someone recovery and cue good movement patterns.  If anything, the tape is a visible reminder to roll, stretch, and rest more. Check the video!
 
 

Body-Mass Index:

BMI has to be briefly discussed her because whatever weight we are carrying around affects our knees!  Remember from the part of this series we mentioned that during running, the knee takes on 5-6 x’s your body weight during each step.  While many people us running for weight loss, and other avoid it due to weight, the fact is, those with knee pain will benefit from weight loss if they are in the higher BMI category.  I am not a dietician, we do not push weight-loss in our office, and I can’t tell you how many ‘Clydesdales’ category runners that can kick my tail in a race. Health is more than just pounds, but Runner’s Knee can be helped by a better BMI.  

Psychosocial Influences:

Lastly, psychosocial factors.  Runner’s are among the worst when it comes to injuries and the doom and gloom that comes with it.  Some are severe enough that I have referred out to a professional for guidance. This is not something to be ashamed of and can actually help your recovery and performance.  We now understand pain a bit better than we did 20 years ago, we still have a long way to go, but we know one thing to be true, if you do not think you will get better, you won’t.  You have to buy into the plan, think positive, take the little wins, and know that this will not last forever. Any injury will last longer than we want it to, but you have to realize that by pure running statistics, you will get hurt at some time if you are training consistently, but it will also pass.

Hopefully, this article cleared up a few things regarding your training and the ability to continue through treatment as well as a few ways to care for Runner’s Knee yourself.  Ideally, you can manage this yourself, learn from it, and prevent it from coming back again. As runner’s, we are prone to injury, that is just the way it is. But, we want to make sure you have the necessary knowledge and tools to help yourself before you give up, stop running, and then drag yourself into a sports physician office.  

LET'S REVIEW TODAYS INFORMATION

  • When faced with Runner's Knee, training modifications are a must.  We typically cut the volume by 50% and refrain from intense workouts (intervals, hills, tempo) for the first 2 weeks.

  • Self-care is a must.  It not only helps speed your recovery over your treatment plan but it can help prevent future injury.  

  • Self-care can be as simple as foam rolling a few times per day to running specific mobility, stability, and strength exercises.  

 
 

Stay tuned for part 4 where we will discuss when to seek treatment and how we treat Runner’s Knee in our office, as well as a few examples of our suggested rehabilitation exercises.  

Train smart, recovery well, race great!  


Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

What's The Deal With Hip Internal & External Rotation?

As I near my 2 year mark in clinical practice, you start to realize trends. Sometimes these trends solidify what we already know, align greatly with what we are already practicing, and allow us to continue down the beaten path.  However, there are things we begin to see as key indicators on how an injury occurred, things that are so simple, they often get overlooked in a treatment plan.  Today I want to briefly discuss an item that falls under both of these categories.  

Hip range of motion (ROM) is often taken for granted, until that time comes where one side is severely restricted and we are unable get up off the floor without the use of our hand, or the assistance from another.   As I have progressed clinically, hip ROM started as just something to jot down in a patients notes, but has quickly become one of the first areas I look to and address for nearly all of the low back pain** and lower extremity complaint (acute and overuse) patients that come into our clinic.  

The problem we see is that the restriction is never symmetrical, causing compensatory patterns that quickly lead to injuries and confused patients. While getting you out of pain is our job, our goal is education and prevention.  Below are some great stretches and mobility movements that are not only easy to perform, but effective is restoring symmetrical movement.  Enjoy.  

Learn, Practice, Perform!  

Level 1 Hip Internal & External Rotation

Internal Rotation Hang

Setup: Lie flat on back with knees bent and feet about 6 inches wider than shoulder/hip width.

Step 1: Allow knees to ‘hang’ inward, letting gravity to do the work.  We want to sit here for 1-2 minutes.  

Step 2: If you get bored, slowly and gently, swing the legs/pelvis back and forth to induce some extra motion into internal rotation.   

External Rotation/Mobilization Stretch

Setup: Lie flat on back with the leg being treated in a flexed hip position and the non-treated leg lying flat on the floor.  

Step 1:  Pull the foot of the flexed hip leg toward the mid-line and up toward the torso, you should begin to feel this over the posterior hip in the external rotators and glutes.  

Step 2: Pull the knee toward the OPPOSITE shoulder and hold for a 3-5 count, release and repeat 10 times on each side.  

 

Level 2 Hip Internal and External Rotation

Internal Rotation with band assistance.

Setup:  Our setup is the same as the ER exercise in level one.  This time with a band wrapped around the mid-foot and tracing the outside of the leg.  

Step 1:  The band provides a mechanical advantage and when pulled over the knee and across the body, provides assisted over-pressure into hip internal rotation.  

External Rotation: Pigeon Pose

Setup:  In a modified lunge position, externally rotate the treated leg and and sit back with the non-treated leg extended behind you.  

Step 1:  Begin with the foot of the treated leg near mid-line (easier) and begin to bring your torso closer to the ground while maintaining a straight spine.  

Step 2:  As this movement becomes easier, our goal is to get the treated lower leg perpendicular to your torso and away from the pelvis. Again, push the torso down toward the ground with a straight spine.  

 

Level 3 Internal/External Rotation - 90/90 Get-up to 1/2 kneeling  

Setup:  Sitting up tall with a straight spine, the forward leg positioned in external hip rotation and the leg 'coming through' in internal hip rotation. The lead leg foot should be close to midline and near the other leg making this a closed position.  

Step 1:  Push into the ground with the outer knee of the forward leg and bring the rear leg around to the front, landing in a lunge/half kneeling position.

Step 2:  In a slow and controlled manner, return to the starting position...enjoying the eccentric phase.  

** A 2015 study out of the Shahid Beheshti University of Medical Sciences found that Asymmetrical and limited hip internal rotation ROM were a common finding in patients with LBP.  Another study from The Sahmyook University Department of Physical Therapy found that hip mobilization brings positive effects on pain, function and psychological factors for patients with chronic low back pain, causing them to strongly recommend hip mobilization as an effective treatment method in treating chronic low back pain. 

Break Up the Endurance Training With Some Strength!

Endurance athletes, especially runners, tend to shy away from strength training due to what I would consider a misunderstanding of what it can provide. After working with hundreds, probably thousands by now, of runners and triathletes over the last few years, I find very few have a regular strength plan. Some are afraid of getting hurt, some do not know how to effectively strength train, and some still have the ridiculous notion that if they lift weights they will get so bulky, the can no longer run!

Let’s address these, shall we?

STRENGTH TRAINING SAFETY

As with every sport, there is a calculated risk of injury when strength training.  What will surprise some is that it is often much lower than the risk associated with training for an endurance sport.  This can depend on whether you are single sport athlete (running only!) or have taken to the range that triathlon offers.  

More can be read about sports specialization HERE from Dr. Greg Schiable. While this article is focused on sports specialization in children, the same can be shown for adult athletes who only participate, practice, and focus on one sport….an explanation why overuse injury rates are lower in triathletes compared to strict runners.  

This morning, I read a great post from Chris Beardsley (CLICK FOR FULL ARTICLE)  discussing the relative safety of strength training, especially when compared to endurance sports.  This article launched me into, again, thinking about strength training for endurance athletes, and puts another feather in the cap of it being a great cross option to break up the often monotonous droning on that running provides.

We can show that single sport athletes are more prone to overuse injuries and burnout, as well as demonstrate the benefits strength training gives to endurance, injury prevention and movement efficiency.

An interesting point made...Beardsley writes,

In comparison to the overall rate of injury in strength sports of between 0.24 – 5.5 injuries per 1,000 hours of training, the rate of injury during long-distance running is around 2.5 – 12.1 injuries per 1,000 hours and the rate during triathlon is around 1.4 – 5.4 injuries per 1,000 hours training.

He goes on to state that many studies put running injuries on the higher side of the stated rate.  

 

GETTING SWOLE

Let’s talk about getting bulky, to the point where you start to lose speed and endurance because you are just too massive to run efficiently.  It used to be that this conversation was primarily had with female athletes, but more and more we find male runners of the same belief.  In short, this is non-sense! Why is that you ask?

GENETICS: 

As a younger male, I spend countless hours, day after day, month after month, for a number of years, trying to pack on muscle and reach the elusive 200 lb mark.  It was a stage in my life….enjoyable and very educational… I have since returned to my love of endurance training, but strength training remains a big part of what keeps me fit, injury free, and happy.  

ENERGY & FOCUS:

I never made it to that 200 lbs mark.  Mainly because I could not eat, sleep, and breath lifting weights and energy intake.  To go from a slim and trim 155 to 200 is a feat which requires a lifestyle shift and not much time for anything else.  As runners, we simply can not consume enough, or slow down enough to really pack on muscle.  To make that shift, one would have to take all the time invested in putting in the miles...almost completely stop...and replace it with lifting weights...Not going to happen!  Stop worrying about getting bulky and think of what a 10-20% increase in strength could do for you during those last miles of a long run or how you can conserve energy by moving more efficiently.

 

BUT GYMS ARE SCARY

Many endurance athletes just don’t know what to do when they end up in a gym.  Fortunately, popular running sites and magazines have jumped aboard the strength train (locomotive type), and there are countless exercises and routines available if one simply does a Google search.  

My personal advice is to first master your body weight, which allows you to more comfortably perform exercise at home or on a track after a run.  Begin with push-ups, pull-ups, squats, lunge variations and jumps.  Once you reach a point where sets of 10, 20 or even 50 feel ‘easy’, it may be time to add in some weighted movements like kettlebell swings (my #2), deadlifts (my #1), and overhead press and pull variations.  

 

If you feel like you have been in a rut this summer or have had more than your share of injuries lately, maybe it is time to try something new?  Change up the routine a little...it is likely that you will enjoy the change and be surprised by the outcome.