Shore Footed Podiatry Ltd

Sports Injuries

Knee Complaints
Runner's Knee (Chondromalacia of the Patella)
The knee is a complex joint. It includes the articulation between the tibia and femur (leg
and thigh) and the patella (knee cap). The most common knee problems in running relate
to what is called the "patello-femoral complex". This is the quadriceps, knee cap and
patellar tendon. What is called runner's knee is a condition known to the medical
community as chondromalacia of the patella. This essentially means softening of the
cartilage of the kneecap. Cartilage does not have the same blood supply that bone does. It
relies on intermittent compression to squeeze out waste products and then allow nutrients
to enter the cartilage from the synovial fluid of the joint.
During running certain mechanical conditions may predispose you to a mistracking knee
cap. Portions of the cartilage may then be under either too much or too little pressure and
the appropriate intermittent compression that is needed for waste removal and nutrition
supply may not be present. This may result in cartilage deterioration, which at the knee
usually occurs on the medial aspect or inner part of the kneecap.

The symptoms of runners knee include pain near the kneecap usually at the medial
(inner) portion and below it. Pain is usually also felt after sitting for a long period of time
with the knees bent. Running downhill and sometimes even walking down stairs can be
followed by pain. The kneecap not tracking smoothly in its femoral groove causes the
condition. When the knee is bent there is increased pressure between the joint surface of
the kneecap and the femur (thigh bone). This stresses the injured area and leads to pain.

Factors that increase what is known as the "Q" (Quadriceps) angle increases the chance
of having runners knee. The Q angle is an estimate of the effective angle at which the
quadriceps averages its pull. It is determined by drawing a line from the Anterior
Superior Iliac Spine (bump above and in front of your hip joint) to the centre of your
kneecap and a second line from the centre of your kneecap to the insertion of the patellar
tendon (where the tendon below your knee cap inserts). Normal is below 12 degrees;
definitely abnormal is above 15 degrees. Many times adding to the strong lateral pull of
the bulk of the quadriceps is a weak vastus medialis. This is the portion of the quadriceps
that helps medially stabilize the patella. It runs along the inside portion of the thighbone
to join at the kneecap with the other three muscles making up the quadriceps. Some of the
mechanical conditions that may contribute to this include:

Wide Hips (female runners)

Knock Knees (Genu Valgum)

Subluxating Patella

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Patella Alta (high patella)

Small medial pole of patella or corresponding portion of femur

Weak Vastus Medialis

Pronation of the feet

Sports Injuries

Treatment of Runners Knee (Chondromalacia of the Patella)

At an early stage running should be decreased to lessen stress to this area and allow
healing to begin. It is important to avoid downhill running which stresses the patellofemoral complex. Exercises performed with the knee bent should be avoided. When the
knee is bent the forces under the kneecap are increased. Many people feel that the vastus
medialis muscle works only during the final thirty degrees of extension of the knee. This
is the muscle that helps stabilize the kneecap medially and prevents it from shifting
laterally and tracking improperly at the patello-femoral joint. Straight leg lifts strengthen
the vastus medialis and do not significantly stress the under surface of the knee cap. They
should be done 10 times on each side. Start with 5 sets of 10 and work your way up to 10
sets of 10. Straight leg lifts are best performed lying on a cushioned but firm surface, with
the exercising leg held straight and the non-exercising leg somewhat bent to take pressure
off of the back.

Tight posterior muscles should be stretched. In many cases tight calf muscles or
hamstrings lead to a "functional equinous" and make the foot pronate while running or
walking. This pronation is accompanied by an internal rotation of the leg which increases
the Q angle and contributes to the lateral subluxation of the knee cap. Running shoes that
offer extra support should be used. If further control of pronation is needed orthotics
should be considered. The late George Sheehan, M.D., sports medicine physician and
philosopher, was the first to popularise the notion that it was important to look at the foot
when runner's knee occurs. It is also important to rule out other knee problems when knee
pain occurs in runners and not just lump every pain as "runner's knee".

Iliotibial Band Syndrome

Symptoms of the iliotibial band syndrome are pain or aching on the outer side of the
knee. This usually happens in the middle or at the end of a run. A concomitant problem
may occur at the hip called greater trochanteric bursitis. During flexion and extension of
the knee the iliotibial band rubs over the femoral condlyle that leads to irritation. Factors

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Sports Injuries

contributing to this syndrome are genu varum (bow legs), pronation of the foot (subtalar
joint pronation), leg length discrepancy, and running on a crowned surface. Circular track
running may also contribute to this problem, since it stresses the body in a manner similar
to that of crowned surfaces and leg length differences. A tight iliotibial band aggravates
all of these factors. Changes in training frequently contribute to this problem. It is always
important to examine your training regimen and see what alterations have recently
occurred.
Anatomy The iliotibial band is a thickening of the lateral (outer) soft tissue that
envelopes the leg, which is called the fascia. In this area it is called the fascia lata. The
thickened band is called the ilio-tibial band. The muscles that insert into the proximal
(upper) portion of this band are the tensor fascia lata and a portion of the gluteus
maximus. At its insertion into the tibia it blends with the Biceps femoris and the Vastus
lateralis.

Self-Treatment:
Self-treatment for this problem should include:

Temporary decrease in training

Side Stretching

Avoid crowned surfaces or too much running around a track

Shorten your stride

Wear more motion control shoes to limit pronation

Carefully examine your training regimen (& running diary)

The side stretching is well illustrated in Runners World, February 1995. It is performed
while standing as follows: Place the injured leg behind the good one. If the left side is the
sore side, cross your left leg behind your right one. Then lean away from the injured side
towards your right side. There should be a table or chair that you can hold onto for
balance on that side. This stretch is the best of several that exist for this area. Be careful
not to overstretch. Hold for 7 to 10 seconds and repeat on each side 7 to 10 times.
If your self-treatment has not been completely successful than a trip to a sports medicine
specialist may include the additional treatment of possible orthotics. Treatment is usually
successful for this problem. So come in and see Jonathan Hagon at Shore Footed
Podiatry Ltd, at 22 Kitchener Road, Milford. Phone for an appointment on (09) 489
1011 6 days a week.