Case Study 2-Runner with Chronic Knee Pain

Case Study 2-Runner with Chronic Knee Pain
July 19, 2011 Dr. Phillip Snell

Our 2nd installment to this area of the blog focuses on medial collapse of the knee.  Many of the most common running-related injuries stem from this excessive aberrant motion (Milner, et al, 2010; Ferber, et al, 2010).  Interestingly, in runners at least, the root of this problem is more software related than hardware related.  Early studies investigating anterior and lateral knee pain in runners, found excessive hip adduction and tibial torsion during gait analysis to be positively correlated with pain in the knee. (Dierks, et al, 2008; Souza et al, 2009)  It was theorized that runners with knee pain would exhibit gluteal weakness and that was born out in subsequent studies.  However, follow-up studies attempting to treat by strengthening the glutes showed that despite improvement in gluteal strength after training, these runners still had knee pain when they ran.(Blønd, et al, 1998)  It wasn’t until 2011, that significant success was found in these runners when they received real-time coaching + biofeedback to correct the valgus collapse.  (Noehren et al, 2011)  My feeling over the years has been that a glute strengthening program that targeted functional movement on 1 leg and, coupled with the verbal cues for gluteal integration while running, would improve outcomes in runners with knee pain.  Some recent studies have born that out and we’ve also seen good effect with that approach.(Earl et al, 2011; Dolak et al, 2011)  Below is a good example.





Bryan, 21 year old college XC runner, presented with chronic, episodic left anterolateral knee pain while running.  Pain began in his freshman year of high school and usually became more noticeable each year toward the end of the XC season.  He felt that the pain, while not severe enough to place him on the injured list, was sufficient enough to limit his performance by limiting his high intensity training.  He had had extensive physical therapy, which he attributed with keeping him able to run, but not to run pain-free.  He had limited experience with weight training, but had done bodyweight core training in the past 2 years and found some benefit in his pain incidence after.  He arrives between seasons on the advice of his coach, and only experiences knee pain on his long days when mileage exceeds 12-13 miles.  He had no prior direct trauma to the knee.



On ortho assessment, Ober’s and Nobles test confirmed shortened and painful ITB on the involved side.  Hip adductors were shortened and Thomas-Gaenslen’s indicated shortening of the hip flexors.  Palpation over the distal 1/3 of the ITB and medial and lateral peripatellar retinaculum reproduced CC pain.  No patellar malalignment was noted on static exam.  On movement exam, deep squat was painful in the medial patellar region and showed quad dominance and slight valgus collapse.  With manual cueing to activate the glutes, he squatted without pain.  Squat depth was markedly improved with a 2/4 “cheater board”.  Dorsiflexion of the ankle was limited bilaterally.  Lunge also produced slight pain, marked crepitus and valgus collapse.  Seated slump test produced no nerve tension signs, SLR was 80 deg bilaterally.  Structural diagnosis of patellofemoral syndrome was rendered and the functional exam to shed light on the cause was initiated.


Functional assessment findings were as follows:


Stecco Movement Verification:  Given mobility issues raised in the ortho exam, we started here and found painful Centers of Coordination at ante-genu, media-genu, lateral-genu, lateral coxa, media-coxa and ante-coxa.

Stecco movement verification screen for ante-genu.












Janda Key Movement Assessment:  Hip extension was delayed in glute max activation and strength was +4/5 on the involved side.  Hip abduction revealed hip flexor dominance and +4/5 glute med strength on manual challenge.



Janda's hip extension movement pattern test

















Mag 7:  1 leg stand was normal on time bilaterally, but demonstrated ankle eversion on the involved side and lateral pelvic tilting.  1 leg squat was painful

with valgus collapse of the knee and again showed lateral pelvic tilt.  Wall Angel revealed T4 mobility deficits.



Dr. Craig Liebenson demos Wall Angel test at Continuum of Care seminar, Seattle, 2011.
















At this point, I felt comfortable enough with the findings to render a functional cause of the PFS as shortening of the hip flexors and adductors with resultant gluteal inhibition…lower crossed syndrome.  We performed PIR and Fascial Manipulation to the hip flexors (AN-PV) and re-tested the hip extension KMP and found better strength in the glute max and improved firing order.  Repeat of the painful lunge pattern was still painful though.  Fascial manipulation to AN-GE resulted in ability to lunge painlessly.  Time constraints forced us to end this first session, so patient was briefly shown lunge stretches and goblet squats for hip mobility.  However, patient’s T4 mobility deficits forced a peel back to tactical frogs for hip mobility.  He was referred to for follow up tutorial videos on those exercises.

Lunge stretch video at Members may click and view video.

Tactical frog video from Members may click to view videos.










At the next visit, Bryan reported slightly less pain during runs the previous week.  We addressed the collapse at the distal end of the kinetic chain with the Vele’s Lean + Short Foot exercise and patient was instructed to perform prior to runs along with dynamic stretching of the hip flexors and adductors.  We also tested the previously observed lateral pelvic tilt in single leg positions with static side plank and patient showed endurance values of 80/95 sec on the involved side and 70/99 on the contralateral side.  QL was tender to palpation on the contralateral side and patient recalled that he ofter felt fatigue in that area on very long days.  no pelvic obliquity was noted on exam.  For manual therapy, I made a judgement call based on previous experience, and performed Graston Technique soft tissue manipulation to the tender peripatellar retinaculae.  While I don’t generally go directly to the painful area, I’ve found that with PFS of such longstanding history, the painful scarring of that tissue sometimes represents a space occupying lesion that may need to be addressed.  HVLA manipulation of the T4 area into extension was also performed as well as hip long axis distraction manipulation.  Bryan was able to squat and lunge without pain after.

Vele's Lean/Short Foot video at Members may click to view video.








At next visit, patient only had knee pain on the long runs and reported decreased severity when it occurred.  We had no provocative movements to assess in the clinic and were left with ADLs and objective movement quality measures.  Single leg squat was not painful but demonstrated valgus collapse.  Patient was shown Bulgarian split squats to replace the lunges and was now able to perform Goblet squats which replaced the tactical frogs.  RNT challenge was added to the Bulgarians.  We also repeated Graston to the peripatellar retinaculae, which were less painful during treatment.  T4 extension manipulation was once again performed.


Bulgarian Split Squat video at Members may click to view.

Goblet squat video at Members may click to view.












The following visit, Bryan reported he was now able to run 13 miles without knee pain.  With ADLs and clinical provocative tests now painless, we turned toward longer term training to be done at home.  Patient was shown progression pattern for adding weight to the Bulgarians, and was shown single leg deadlift using cross body pattern.  He was also shown single leg Pallof presses to integrate the anti-rotation training of the digital flexors.  We discussed findings of previous studies in distance runners involving heavy weight half squats and he was given copy of one study to share with the trainer at school.  This allowed this patient who was naive to weight training to integrate this training under supervision.  Lumbar FCE was performed and patient was WNL on all quadrants in the core test.


Single leg DL video at Members may click to view.






Bryan was seen a few more times during the course of the following season, but only to address neck and shoulder stiffness around exams.  He ran painlessly for the first season in his running career that year and PR’d twice.  He was chosen for the XC team that competed at NCAA nationals a goal he had not been able to accomplish previously.  Note that we intentionally did not attempt to take the patient into deep squats and to “correct” the ankle dorsiflexion deficits.  This was a judgement call given the research the shows inverse correlation between ankle dorsiflexion ROM and performance in elite distance runners.  This patient was seen only 5X to get resolution of his longstanding complaint, by using a functional approach.  Removing the energy leaks in his gait by stabilizing the core, and improving transverse plane control via the foot and hip allowed him to balance his musculoskeletal system to train with higher volume and intensity.  This allowed him to not only run injury free for the first season in his life, but also to run faster than before.


The exercises featured here are part of the membership-only area of  Members can use the extensive library of functional exercise tutorials to help improve patient care and to reduce time necessary to train patients.  The service is only $9.99 monthly, and those interested may trial the service risk-free for 30 days for only $1.  Click on the link below for more info.


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Milner CE, Hamill J, Davis IS. Distinct hip and rearfoot kinematics in female runners with a history of tibial stress fracture. J Orthop Sports Phys Ther. 2010 Feb;40(2):59-66.


Ferber R, Noehren B, Hamill J, Davis IS. Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics. J Orthop Sports Phys Ther. 2010 Feb;40(2):52-8.


Dierks TA, Manal KT, Hamill J, Davis IS. Proximal and distal influences on hip and knee kinematics in runners with patellofemoral pain during a prolonged run. J Orthop Sports Phys Ther. 2008 Aug;38(8):448-56. Epub 2008 Aug 1.


Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther 2009;39:12–19.


Blønd L, Hansen L. Patellofemoral pain syndrome in athletes: a 5.7-year retro- spective follow-up study of 250 athletes. Acta Orthop Belg 1998;64:393–400.


Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. Br J Sports Med. 2011 Jul;45(9):691-6. Epub 2010 Jun 28.