You just finished your hardest week of training, culminating in a perfect 20 mile run that seemed effortless, that is until around mile 15 when you began to feel a nagging pain in one or both knees. You grind through the final 5 miles, and hit the couch when you get home. When you stand up, that pain returns, and gets a little worse when you walk up and down the stairs. You pop a few Advil, hit the bed, and assume all will be well in the morning.

Also known as runner’s knee, patellofemoral pain syndrome is the most common injury afflicting runners – some 20 percent of all running injuries – and is something I want to help you fix. The primary symptom of PFPS is pain under the kneecap, which becomes progressively more intense when running. There have been several theories about the cause of the pain, most notably and incorrectly, that the kneecap is pulled laterally by an over-dominant lateral quadriceps and weak medial quadriceps. In fact, we now know through 3-dimentional studies that the culprit is actually an excess of internal rotation of the femur, the result being a chronic stimulation of the pain nerves in the knee, but with no significant tissue damage.

Because there is no significant tissue damage seen with PFPS, the primary goal of therapy is to eliminate the aberrant movements that cause the chronic irritation. The first thing that any runner must do is to avoid painful running. So, if your onset of pain occurs at around 10 miles, keep your runs to 5 or 6, and allow a few days of recovery or cross training in between. The second thing that needs to occur is a clinical running gait analysis to identify any biomechanical abnormalities in your stride. A common pattern I see is a lack or hip stability, causing a dipping of the hip and subsequent excess of internal rotation of the femur during the midstance phase of gait. Additionally, a simple single leg squat will usually show an inward collapse of the knee in runners suffering from PFPS – again due to a lack of dynamic stability of the hip.

So what should you do besides eliminating painful running when you experience the symptoms of PFPS? Ice is your friend after a painful run, and will help to both decrease pain and reduce any inflammation that may be present. This can be done immediately following your run for 15-20 minutes. The longer term solution is to eliminate the excessive internal femoral rotation discussed earlier. I have a somewhat unique approach to this with my runners, that includes not only the standard hip stabilization exercises (see them in my article on shin splints), but also through clinical gait retraining with real-time feedback.

It amazes me how often a runner comes to me stating that they have been working their hip stabilizers to death in the gym with no change in their running pattern, only to correct their gait in a few short sessions through verbal and video feedback. There is a tendency in sports medicine to blame poor movement patterns on weak muscles, tight muscles, etc., but in reality much of what we see as incorrect is just something that was never learned. Teach the correct movement pattern, don’t simply target the muscles in the gym and expect results.

So, if you are suffering from PFPS, don’t lose hope. Get yourself checked, train your gait, and you will be as good as new in no time.