Updated: Oct 3, 2019
Patellofemoral pain syndrome is well known amongst runners. So well-known it’s been nicknamed “Runner’s knee”. Patients often describe it as dull pain behind or around the knee cap, aggravated by activities such as squatting, running, or going downstairs for instance. PFPS has been long thought to be caused by the knee cap lying slightly wonky in the femoral grove underneath it. For quite some time, the only answer to PFPS would be to “strengthen the VMO”, this specific part of the quadriceps muscle which was thought to “pull” the kneecap back in. Problem is, most recent research shows it’s almost impossible to target the VMO on its own through exercise, and that positive results were likely due to increasing quads strength overall. Recent studies suggest that the problem may not be the kneecap going outwards but in fact the femur underneath it turning inwards. And what causes the femur to rotate inwards? Well, simple low of physics: weakness in the muscles that do the opposite (turn the femur outwards), hip abductors and external rotators, i.e. glutes and co.
When in doubt, strengthen the glutes they said.
IT Band Syndrome (which sounds like the name of an emo rock band the guys in the IT department would be in) – is thought to be the second most common injury in runners after PFPS. The Ilio-tibial Band, like its full name suggests, is a thick fibrous band that runs from the iliac crest down the outside of the leg and across the knee joint to the tibia, attaching to the outside of the kneecap on the way too. ITBS pain, which comes on when running and is often stabbing in nature, usually occurs when the distal insertion of the ITB becomes inflamed (some studies says it’s more a fat pad underneath that insertion actually, but that doesn’t really matter for now). Common causes include things like a sudden increase in your training or muscle weakness in - you guessed it - the glutes!
Let me explain quickly: a weak glute med will usually mean that the Tensor Fascia Latae (the TFL muscle, sounds less like a Starbucks drink) will try to take over in abducting the leg. Problem is, the TFL is attached to the ITB, and as it becomes more active then starts putting tension on it. So in theory, the weaker your glute med, the more tension placed on the ITB by the TFL, and the more chances to get ITBS. It’s important to note that glute med usually gets tired the longer you run, this may explain why we see ITB issues more frequently in long-distance runners.
As well as its mate the glute med, glute max also attaches to the ITB; and the good old quads, by control the position of the knee when the foot hits the ground, will have an indirect effect on the ITB too. It therefore makes sense to spend some time getting these guys up to date too.
‘Shin Splints’ / Medial Tibial Stress Syndrome
Shin splints is a diagnosis that can get quite confusing. If you open a medical dictionary, you won’t find shin splints in it, but you may find terms like Medial Tibial Stress Syndrome (MTSS), Posterior Tibialis tendinopathy or Compartment Syndrome. All these terms, although different conditions in themselves, can refer to pain felt along the inside part of your shin, thus likely to be described as “shin splints”. I’m going to go over MTSS in this article as I’ve found it’s the most common diagnosis I’ve made on runners coming in complaining of medial shin pain (only my own experience though).
We haven’t yet got a full grasp around the pathophysiology behind MTSS; some say it’s a step before a stress fracture, some say it has nothing to do with it, but we know that it very likely involves inflammation of the lining of the tibia in response to too much stress / force put through it.
When a bone like the tibia gets loaded, its first response is to increase its own density by creating new bone cells. It can do that to a certain extent and for a certain period, but if the stress continues and new bone cells are constantly needed, the bone gets too “stressed out” and inflammation occurs. This can then lead to “stress” fractures. In MTSS, the current thinking is that that process gets stuck at the inflammation bit (we’re not too sure why), just before the fracture. With runners, this can be caused by running too much, weakness of the surrounding calf muscles or poor footwear for instance.
MTSS is often described as diffuse pain, along the length of the bone, as opposed to focal pain which would then be the sign of a stress fracture. That’s where it gets tricky and why we’d advised to get any medial shin pain properly assessed, as an untreated stress fracture can turn nasty quite quickly.
In MTSS, rehab is all about load. We want to help our tibia take on stress (loading force) so it doesn’t have to constantly fight for it. A few muscles are important in that role: the soleus will reduce the load put through the tibia during ground impact (start of the“stance phase”, see diagram below); glutes will contribute to stability and will absorb load during that phase too; and lastly, the hamstrings and quads by both attaching to the tibia and both contracting together (co-contraction) will also help the tibia during the loading phase.
So what exercises should I do then ?
If we look back at our three injuries, we can identify a few key muscle groups worth spending our time on: glutes (med and max), quads, hamstrings and soleus. Of course, let’s not fall into the overly simplistic trap here: it’s not just about strengthening a muscle, it’s about doing so in the right conditions, in functional ways when possible, tailored to your own training and running style. That said, here are 3 exercises which I often like to give out in my training plans / rehab programmes as I feel they fulfil those criteria pretty well (they will of course need to be part of a more comprehensive and holistic plan).
Start simple with some step ups that will target your glutes (both max and med) (Reiman et al. 2012) and challenge your proprioception too. I like this exercise as it’s so easy to progress by just adding some weights or increasing speed for instance.
Single leg Romanian deadlifts
Single leg Romanian Dead Lifts are awesome to strengthen hamstrings in a way that is both functional and mimics running conditions: as well as strength, you will need good balance as well as good coordination and proximal control (control around you hip and pelvis area). Key skills for an injury-free running experience!
Soleus isometric squat
Kill two birds with one stone with this bad boy: quads and soleus, as we mentioned before, 2 vital muscles to help absorb load during running. The isometric contraction required here will recreate conditions of the stance phase of running. This will also be a nice exercise to build up calf strength and prevent Achilles tendinopathies.
As well as these, it’s good practice to get your running gait properly assessed. There’s many easy ways to alter your running gait to reduce pain, for instance reducing patellofemoral pain by increasing step rate and reducing stride length. Hobara et al. (2012) Above all, remember it takes time and dedication to see results - listen to your pain: any sharp pain is probably a good sign that you should stop what you're doing and come to see us. ;)