Getting a “Runner’s Knee” Back on Track

Fri, 4 Nov. 2011 - 9:31 p.m. MT
Credit: ARA Staff - American Running Association

By Bruce R. Wilk, PT, OCS
 
Every day patients get misdiagnosed, and the injured runner is no exception. Runners with complaints of knee pain, for example, are sometimes hastily diagnosed by non-sports medicine clinicians with that old favorite, patellofemoral syndrome. Also known as “runner’s knee,” this diagnosis too often follows quickly after the patient simply reports knee pain and mentions that they also distance run.
 
I want to share a recent case demonstrating how an inaccurate diagnosis and the wrong focus can get an injured runner way off the track to recovery. Eventually we found the underlying mechanism causing the injury, but it’s as complex as it is necessary to do so. To recover fully from running injury, treatment of the specific running-related dysfunction is paramount.
 
“Sean” is a runner who came to me after months of failed rehab at another clinic. Every time he gets 10 miles into his training, his knee blows up and he is unable to run. He even has trouble going up and down stairs for several days afterwards. Sean had previously gone to his physician and they diagnosed him with chondromalacia and a patellar tracking problem. The therapist told Sean his problem was due to weakness in his VMO muscle (i.e., the vastus medialis oblique muscle—a muscle on the inner side of the knee which is a part of the quadriceps).
 
The therapist had taught Sean all about his VMO and he happily shared with me all of the information his previous therapist had given him. Sean was convinced that the weakness in his VMO was the root of all his running problems. He had spent weeks working with the therapist to get his VMO big and strong. Sean was diligent with his therapy where he also received electrical stimulation and biofeedback in addition to gym exercises. Sean even boasted that he spent extra time in the weight room after work doing his therapy exercises. Overall, Sean was now very proud of his big and strong VMO. So what’s the problem?
 
Unfortunately, Sean was no more able to run with his newly developed VMO than before. His knee continues to blow up everytime he is deep into his training, and he is still left unable to negotiate stairs for several days afterwards. Essentially, nothing has changed except for his newly strengthened VMO—the dysfunction is still present.
 
When I examine Sean, I find tenderness and weakness lateral/inferior to his patella (knee cap). Sean’s problem isn’t chondromalacia with a tracking problem due to a weak VMO, but actually a lateral patellar tendonosis. Sean’s long term lateral patellar tendonosis had never been addressed, so every time he returned to running and his knee blew up, he then had lateral patellar tendonitis (“osis” refers to the condition of a tendon problem, while “itis” refers more to an acute inflammation of the tendon).
 
As with all running injuries, addressing Sean’s specific running-related impairments is critical, and his difficulty with stairs is a big clue. As I assess Sean on a step test and on the treadmill, Sean’s body isn’t balanced when he runs or steps and he has poor control of his knee movement through his range. Sean severely lacks body awareness and, despite his well developed VMO, is moving with very little lower extremity control.
 
I worked with Sean to teach him how to control his knee and balance it in relationship with the rest of his body. Once he was better able to control his knee and keep his body balanced for stepping, we transferred this concept into running. Sean had to once again learn how to properly run. He desperately needed increased body awareness and the ability to self correct his posture and mechanics, specifically related to his knee mechanics. By identifying Sean’s specific running dysfunction, it allowed us to properly address his training deficits, thereby allowing him to return to distance running.
 
In the end, it didn’t matter that Sean knew the name VMO or that it was big and strong. And it probably didn’t even matter that Sean understood the difference between a patellofemoral syndrome or a lateral patellar tendonosis. What matters is that Sean is a better runner now than before his injury. He knows how to control his knee and balance his body for stepping and running.
 
The healthcare provider needs to correctly identify the injury/deficit and this is why it’s important for runners to seek help from medical professionals with running expertise. It’s very much about addressing the specific problems affecting your running. Choose a healthcare professional who knows about running injuries to help you do this!
 
Bruce Wilk is a board-certified physical therapist, a certified running coach, and director of Orthopedic Rehabilitation Specialists in Miami, Florida.

(RUNNING & FITNEWS® January / February 2011 • Volume 29, Number 1)


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