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Front of Knee Pain with Running

The most common injury with running is knee pain and one of the areas the knee can be painful is in the front of the knee. Treatment for knee pain varies based on the location of the pain, so we’re tackling pain in the front of the knee separately from pain on the outside of the knee.

Throughout this blog post, we’re going to take you through some of the exercises we use with runners who present with pain in the front of the knee. If you’re more of a visual learner, feel free to watch the video below. Underneath the video, we’ll discuss the key content from the video. Feel free to watch, read, or both to get a better understanding!

Two Types of Pain in the Front of the Knee

When it comes to pain in the front of the knee, there’s two diagnoses we see most frequently – patellofemoral pain syndrome and patellar tendinitis. (Side note: Patellar tendinitis is actually typically a tendinopathy. Tendinopathy vs. tendinitis deserves to be discussed separately and as such is the topic of an entirely different blog post here.)

Patellofemoral pain syndrome and patellar tendinitis are treated similarly despite different parts of the front of the knee being irritated. In patellofemoral pain syndrome, the general patellar – or knee cap – area is irritated. For patellar tendinitis, the patellar or quadriceps tendon is the painful structure. However, a lot of the same contributing factors are at play in both of these diagnoses, which is why treatment looks similar. With both of these conditions, we often find strength deficits in the quadriceps and hip muscles as well as mobility deficits in the hip flexors, hamstrings, and calves.

Addressing mobility and strength limitations are important to get back to running without pain. However, runners who come into our clinic are typically already doing the mobility work. Even if they aren’t, nine times out of ten, their mobility limitations aren’t as significant as their strength limitations. Because of that, we spend more time on improving strength.

Two Strength Exercises for Pain in the Front of the Knee

At the beginning of the video, Dr. Sarah was doing a split squat while holding a kettlebell. Split squats and box step ups are two of our favorite exercises for reducing pain in the front of the knee for runners. We like both of these exercises because they mimic the action of running – a series of single leg squats. They are also efficient at strengthening the quadriceps and glute muscles while not typically worsening pain that is present.

Split Squats for Knee Pain

To do a split squat correctly, you want to spread your feet apart enough so that when you drop to the ground, the knee of your front leg stays still. The thigh of your back leg should be close to if not perpendicular to the ground at the bottom.

One of the mistakes we see people make with split squats is failing to have a wide enough stance. When your stance isn’t wide enough, the knee of your front leg travels forwards. The more forward that knee travels, the greater stress it puts on the knee. When there is pain in the front of the knee, that additional stress usually results in more pain.

Instead, keeping the front knee stationary while doing split squats will decrease the load on the knee joint while allowing you to strengthen the quadriceps. Once pain is low enough, we can start to let that knee move further forward. However, until then, it’s best to keep the shin vertical so that we can strengthen what needs to be strengthened without aggravating symptoms.

Box Step Ups for Knee Pain

For box step ups, we suggest performing them to the side instead of forward. This will have a better carryover to decreasing knee pain with running. The reason for this is the muscles on the outside of the hip are challenged more when you step up to the side than when you step up forwards.

Those muscles on the outside of your hip control how much your knee moves side-to-side while you’re running. Side-to-side movement of the knee while running is a common contributor to knee pain. So, the stronger the hip muscles are, the less ancillary movement that happens at the knee. And, the less ancillary movement that happens at the knee, the less knee pain you have. Therefore, we suggest doing side step ups instead of forward step ups.

The most common mistake we see with box step ups is individuals pushing off their bottom leg. Instead, you want to push down into the foot that is on the box. It’s harder to do that way, but more effective. Using the leg that’s on the box forces you to use your butt and thigh muscles, which is what we ultimately want to strengthen.

Pain in Front of the Knee Doesn’t Resolve Unless…

You load it. We’ll repeat that. You have to load these exercises. Yes, bodyweight is a great place to start, especially if the pain in the front of your knee gets aggravated with these, but you have to progress beyond that. (Side note: some pain is not a bad thing. In fact, some pain is often necessary and good in the healing process. See this blog post to learn more about how much pain is okay and how much is too much).

Intensity is Key

In order to make strength improvements, you have to load an exercise up. It shouldn’t feel easy. Instead, it should be challenging but not so challenging you can’t do it. On a scale of 0 to 10 where 0 is incredibly easy and 10 is unable to do another repetition, ideally you’re sitting at a 7-8 when it comes to strength training if you truly want to make progress.

There’s Also A Performance Bonus

Ultimately, we try to get individuals to utilize a barbell with weights or heavy dumbbells/kettlebells to strengthen their quadriceps and hips. (Do note that this happens over a period of multiple months and isn’t a couple week process. Strength takes time to develop). The reason we do this is because strength training – while it is incredibly effective at eradicating knee pain with running – is also one of the best things runners can do for their performance.

Contrary to popular belief, strengthening will not slow your running down. In fact, it improves performance while decreasing injury risk. Running is essentially a series of single leg squats. So, the more weight you can move with good technique while doing a single leg squat, the more powerful of a runner you are. The more powerful of a runner you are, the easier it is to run distances and pick up your pace. It also takes longer to get fatigued and you’re less likely to have your form break down. All of this results in superior performance on race day.

Wrapping Up Pain on the Front of the Knee

In conclusion, it doesn’t matter too much exactly which type of knee pain (patellofemoral or patellar tendinitis) you have on the front of your knee while running. What does matter is that you include strengthening in addition to mobility work. Two great strength exercises for runners are split squats and side box step ups because they mimic the running motion of single leg squats. Strengthening should respect the level of discomfort you have (no more than moderate pain) but it should also challenge you (a high moderate level of fatigue in the muscle).

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