Runner’s Knee – The Latest
Runner’s Knee – technically known most commonly as patellofemoral pain syndrome (PFPS) – remains the most common ailment affecting the knee area in just about any athletic activity that involves running or jumping. At other times referred to as “anterior knee pain” or “chondromalacia patella,” the prevalence of this condition is the number one reason so many still believe that running is harmful and will inevitably lead to premature knee arthritis, though as I’ve explained previously, these folks are confusing the patellofemoral joint (kneecap/thigh) with the tibiofemoral (shin/thigh) joint, which is the most common site of osteoarthritis and, according to the best evidence, generally not adversely affected by running.
PFPS is an irritation of the back of the kneecap that can lead to pain, swelling, and decreased function for activities that include running, jumping, stair-climbing, and even prolonged sitting, such as in a car or at work. ( I’ll refer you to these previous articles for a more extensive review of this condition: 15, 72, 89, 103, 122 )
As a look at these earlier columns will indicate, finding the most effective non-invasive, non-surgical treatments for this problem has been a quest of physical therapists for decades. As expected, there has been a considerable amount of variation in the approaches taken, as individual studies were published recommending this or that intervention strategy, only to be replaced later by new ideas. This variability has led to a fair amount of frustration on the part of therapists as well as patients. (In fact, not too long ago a New York Times journalist wrote of her experience seeing 5 different physical therapists for her Runner’s Knee condition and receiving 5 completely different treatment regimens.)
Recently, the Academy of Orthopedic Physical Therapy (a special interest section of the American Physical Therapy Association) published Clinical Practice Guidelines for physical therapists to use when examining, diagnosing, and treating PFPS. These guidelines are based on an extensive and exhaustive review of the large body of medical literature on the subject. Recommendations for or against the various examination tests and treatment interventions evaluated by the CPG authors are graded according to the strength and type of evidence found.
The following is a summary of this extensive document’s recommendations regarding the most commonly used interventions, along with an assessment of what this means for you should you require PT for PFPS.
- Exercise programs targeting specific (posterior and lateral) hip muscles, along with knee extensor (quads) muscles.
- Foot orthoses (prefabricated!) for patients with greater-than-normal foot pronation. However, this is recommended for only short-term (6 weeks) use and only in combination with exercise therapy. There is insufficient evidence to support custom-fitted orthoses.
- Manual Therapies, including lumbar or knee manipulation/mobilizations, should not be used in isolation, but may be an adjunct to exercise therapy.
- Dry Needling should not be used to treat PFPS. (This is not currently legal in NYS anyway.)
- Patellar Taping – may be used in conjunction with exercise programs to help reduce pain during exercise, but only in the short-term (4 weeks).
- Biofeedback – clinicians should not use any of the variety of such techniques designed to enhance specific muscle facilitation.
- Biophysical Agents – none of the most commonly used modalities – ultrasound, electrical stimulation, laser therapy, phono- and iontophoresis, cryotherapy (cold) – is recommended as a useful intervention for PFPS.
- Bracing – clinicians should not use or prescribe knee braces, sleeves, or straps for this condition.
- Running Gait Retraining – clinicians may use cueing techniques to facilitate a more effective foot strike pattern, step cadence, or other joint angle movements.
- Acupuncture – clinicians may use (where permitted) or refer for this intervention, but this recommendation is qualified, as the evidence still does not clearly indicate it is superior to placebo treatments.
My intent in summarizing these guidelines is to help you to be a more informed consumer should you seek the assistance of a physical therapist (or other healthcare provider) to address Runner’s Knee. The bottom line is that targeted exercise is the most effective intervention identified to date. There are other treatment options that can help in conjunction with exercise, but that should not be used in isolation. And perhaps most important, you should understand that many of the most commonly used physical agent interventions have failed to show any utility in treating PFPS. If these are recommended to you, by all means respectfully question why this is so and then make an informed decision on whether to consent to spend your time and money on something that experts strongly recommend against.