PFS/"Runners Knee"- Treatment
In last week's post on PFS or "runners knee" as it's sometimes referred to, we talked about what it actually is from an anatomy standpoint, what causes it and how to tell if this is what your have or what else it might be. During this post we're going to focus more on the actual treatment for it. This includes guidelines for the initial symptoms, how to use Self Muscle Massage to best loosen up the affected muscles, and specific stretches that will help improve and maintain mobility in the muscles themselves.
Post Injury (or when the symptoms start if there is no "injury")
Guidelines:
1) Runners knee will present itself in two ways. You will have the immediate pain in and around the knee cap (usually on the inside and on the outside just above it but this can vary) and you will have the muscular symptoms (stiffness, decreased mobility) that are causing it.
2) Use traditional R.I.C.E. for the knee cap symptoms. These include: rest, ice, compression and elevation. The immediate goal after injury is to decrease the symptoms (pain, swelling, etc) to allow for better mobility.
3) Use self muscle massage to loosen up the quadricep. In the first 48-72 hours, focus on the upper and middle portion of the muscle. As the knee cap sx lessen, you can move closer to the knee joint itself.
4) Use self muscle massage to target what is causing the actual injury (in other words, find the restrictions that shortening your stride and work on them so that the quad isn't getting cooked on every run).
5) Use stretching to gently improve and maintain this new found mobility.
Self Muscle Massage
Guidelines:
1) When using self muscle massage on Runners Knee, keep in mind that you need to work on two parts: a) what actually hurts- your Quads and b) what is causing the problem.
2) In the last post on PFS, we identified several restrictions that may lead to a shortened stride and decreased push up. They include:
a) decreased hip extension(this means you want to work on your hip flexors and glutes)
b) decreased knee extension (this means you will want to work on the hamstring and gastroc muscle)
c) decreased ankle mobility (this means that you will want to work on the calf and foot)
3) When working on the Quad itself, start easy and above the knee cap. Work your way closer to the joint as symptoms allow.
4) If you are unsure where the restriction may be, start with the most likely candidate- the hamstrings and calf. The majority of PFS patients that I see have extremely tight calves and hamstrings.
5) Ice following soft tissue work, especially the quad. This will help decrease pain and inflammation. 10-15 minutes is all you need.
Stretching
Guidelines:
1) Stretching should NEVER hurt. The goal is to only go as far as you can comfortably. Once you feel a pull or "stretching sensation" stop there. This way you can build on each stretch without risking injury.
2) You will always get more out of frequency (meaning daily or multiple times per week) instead of one killer session one time per week.
3) Shoot for 20-30 second holds and 3-4 repetitions.
4) Remember: muscles work in pairs. If one group is limited or tight, it will make the other group work harder. Stretch both for best results.
Why these stretches??
In the last post we showed you how runners knee can occur from possible variations in your stride (in particular, how it occurs as a result of poor push off). The four stretches detailed below have been chosen specifically to help correct those variations. The primary goal of these stretches is to restore mobility to the foot, ankle, knee and hip joints to allow for full push off. By doing so, the quad muscles will be able to share the work load with the larger glute muscles and the strain on the knee cap itself will be reduced.
#1 The Gastroc (large calf muscle)
Rationale: The gastroc (large calf muscle) runs from the back of your heel where the achilles inserts up the back of your leg and behind the knee joint. It crosses the knee joint. Why is this important?? You need to stretch both the ankle and knee joints to fully lengthen this muscle.
What you will need: a step or stool that you can step on and drop your heel off of.
Key points: 1) you want to keep your knee straight as a board (this means no bending at all at any point during the stretch; for most people this will limit how far you can bend forward and that is normal), 2) drop your heel off of the step, 3) bend forward at the waist , 4) only go as low as you can without bending your knee, 5) once you feel a light pull, hold for 20-30 seconds and repeat 4 times.
Where you should feel it: in the back of the calf (upper part), behind the knee joint and in the back of your thigh. If the muscles in the back of the leg are tight, you may also feel a pull in the back of your hip and buttock.
#2 Soleus
Rationale: While the larger gastroc muscle works while the knee is STRAIGHT, the smaller soleus muscle works while the knee is BENT. That's why this lower calf muscle can get cranky with hill running and cycling. For this reason, to fully stretch this muscle, the knee needs to be bent.
What you will need: nothing at all.
Key points: 1) get into a lunge position with one leg forward and one leg back, 2) lean forward over the front foot with your body weight primarily over the big toe and your heel flat on the ground, 3) if you feel pressure in your ankle joint- stop and hold there. As the joint loosens, you will start to feel the muscular stretch in the lower part of your calf, 4) hold 20-30 seconds and repeat 4 times.
Where you should feel it: in the lower part of your calf between the large calf bulge and your heel. as stated earlier, if your ankle joint is tight, you may feel pressure there before you feel a stretch in the muscle. stick with it. as the joint loosens you will feel it.
#3 Hamstring 3-way Stretch
Rationale: The hamstring is actually made up of three different muscles. All three start at your sit bone and run down the back of your thigh before inserting on either side of the back of the knee. Two of these muscles insert on the inside of your knee and the third, larger muscle, inserts on the outside. With two different end points, it's important to full stretch out the hamstring muscles as a group. This means adding in a rotation component to the stretch.
What you will need: a step stool or something to prop your foot up on. Ideally you want something that is below waist height (this will place a LARGE amount of strain on the muscle and will be too much for most people).
Key points: 1) while performing this stretch you want to stand with one foot propped up and the knee straight (the ankle is relaxed during this), 2) you also want the knee of the leg you are standing on to remain straight with your toes pointed forward (it's very common for people to rotate this foot out for comfort; try to keep it straight!!), 3) the goal of this stretch is to feel it directly behind the knee....to do so place both hands on your knee cap and push straight down towards the floor, 4) most people assume that the goal of this stretch is to lean forward while trying to touch your head to your knee. this is incorrect. try to remember this- pressure on the knee first. forward lean second if at all., 5) hold 20-30 seconds and repeat 4 times.
Where you should feel it: directly behind your knee. initially, you may feel this in the back of your calf all the way to your hip. If you do, ease up on your forward lean and then push down with your hands without leaning.
Key points: 1) in this stretch, we are adding rotation to the previous stretch, 2) the starting point is exactly the same- knees straight, toes forward on both feet and ankle relaxed, 3) add downward pressure to your knee with your outside hand, 4) with you inside hand rotate your upper body like you are trying to touch the outside of your knee, or if you can, the outside of your ankle, 5) try not to rotate your hips; upper body only should be moving, 6) hold 20-30 seconds and repeat 4 times.
Where you should feel it: initially, you will feel this in a few places and that's normal. as the muscles start to loosen, you will feel this in the outer part of your hamstrings and lower leg. You may also feel it directly behind your knee.
Key points: 1) in this stretch, we are adding rotation to the first hamstring stretch, 2) the starting point is exactly the same- knees straight, toes forward on both feet and ankle relaxed, 3) add downward pressure to your knee with your inside hand, 4) with you outside hand rotate your upper body like you are trying to touch the inside of your knee, or if you can, the inside of your ankle, 5) try not to rotate your hips; upper body only should be moving, 6) hold 20-30 seconds and repeat 4 times.
Where you should feel this: initially, you will feel this in a few places and that's normal. as the muscles start to loosen, you will feel this in the inner part of your hamstrings and lower leg. You may also feel it directly behind your knee.
#4 Quad/Hip Flexor Combo Stretch
Rationale: The hip flexors originate on the lumbar spine, pass through the abdominal cavity and insert into the top of the femur (your long thigh bone). The quad muscles begin at the upper femur and then travel the rest of the way down the upper leg to the knee cap. Due to this proximity, both muscle groups work closely together. Like the gastroc muscle, the quadricep muscles cross two joints (the hip and knee). This means that to fully lengthen the muscle you must stretch both joints. As an added bonus, doing so will also stretch out your hip flexors.
What you'll need: nothing at all. you can do this one on the floor (preferable to your bed so that your back is fully supported).
Key points: 1) start by laying on your back with both of your knees bent and feet flat on the floor (hips and knees should be together at the start), 2) next rotate both your knees over to one side (keep your shoulders flat and both feet together), 3) then pull the top leg back and try to bring your heel towards your butt (try to keep your knee on the ground if you can but it’s okay if it stays in the air), 4) lastly push your hip up and away to increase the stretch (red arrow), 5) hold 20-30 seconds and repeat 4 times.
Where you should feel it: You may feel this stretch in a few places. Ideally, you want to feel it in the front of you hip and down the entire length of your quad.