Why Runner’s Knee (Patellofemoral Pain Syndrome) Treatment Frustrates More Than Just Runners

by Michael Emmerling October 21, 2018

It’s commonly known as Runner’s Knee and clinically known as Patellofemoral Pain Syndrome (PFPS). The medical profession also refers to it as the “The Black Hole of Orthopedics” because treatment approaches that produce successful outcomes for those afflicted continues to elude them.

The research has been extensive. A myriad of treatment approaches exists. So why does a successful outcome for patients continue to be elusive? Are the current diagnosis and treatment approaches adequate? Are there any promising new approaches to treatment?

Let’s review some of the research and attempt to answer these questions.

The symptoms are described as a dull, aching pain around or behind the patella (kneecap). It can be debilitating to those afflicted and often becomes chronic. When stricken, active adults often struggle to maintain their active lifestyle. One recent study reports that ~75% of patients will be required to limit  sporting and physical activity. Another study reported that ~25% of recreational athletes diagnosed with PFPS will stop participating in sports altogether.

Less than one third of those afflicted will find long term relief. The condition often becomes chronic and can lead to patellofemoral osteoarthritis if left untreated.

Research indicates that PFPS is typically associated with activities that load (increase pressure on) the patella, such as ascending or descending stairs, jumping, running, and squatting. The research also identifies the primary cause of the condition as mal-tracking of the patella in the femoral groove. Excessive rubbing and pressure leads to irritation on the underside of the patella, known medically as chondromalacia.

With relative ease you can find a wealth of research on treatment options. Short term strategies can be used to relieve the pain and inflammation. Long term strategies recommend therapeutic approaches that correct the mal-tracking, stop the rubbing, and relieve the pressure.

Then why has relief been so elusive? Why are symptoms often persistent and chronic?

It begins with the fact that short term strategies only provide short term relief. They can relieve the pain and inflammation, but they won’t correct what caused the irritation in the first place.

Rest, ice, compression, and elevation (RICE) are advised as the first course of action. It’s recommended to let the symptoms subside before resuming activities that aggravate the condition. RICE begins the healing process, but it does not correct the underlying problem. When activity is resumed, the rubbing will resume, so it is likely the pain and inflammation will also resume.

Medication may also be used for short term relief. Oral anti-inflammatories (NSAIDS), topical gels, and patches can help reduce the pain and inflammation. In more extreme cases, corticosteroid or hyaluronic acid injections can be administered by a doctor. The later are reserved for patients who have significant inflammation that has not responded well to oral anti-inflammatories, ice, and rest. But once again, medication and injections do not correct the underlying problem. They can mask the pain and reduce inflammation, but the cause of the problem is still present.

Think about it, if medications and injections do not correct the problem, is it a good idea to resume activity once the irritation and pain subside? Doing so may cause further damage to the joint. That’s why doctors often advise their patients to stop activities until the underlying cause is corrected.  

Here’s the problem. The last thing an active person wants to hear is that they should stop doing an activity they enjoy. For some it’s devastating news. The race they’ve been training for, the goal they’ve set, the fitness they’ve gained must be put on hold.

Many will attempt to resume activity as soon as the pain subsides. The reality however is that until the underlying problem is corrected, the irritation will resume along with the intensity of their activity. 

There must be something that corrects the problem and allows for a quick resumption of activity. But what?

The research is clear. To achieve long term relief, the patella tracking problem must be corrected.  You must eliminate the rubbing and relieve the pressure on the underside of the patella. Until the underlying problem is corrected, the irritation, pain, and damage will continue.

The challenge begins with properly identifying the root cause of the rubbing. Correctly identifying the root cause requires an experienced clinician to conduct a thorough assessment. Several factors, including muscle weakness, tightness, and imbalances can throw off your alignment, driving the kneecap off track. Is it weak quadriceps? Is it your hips? Is it arthritis? Even flat feet can be the culprit.

Most often, the first course of treatment is targeted at strengthening the quadriceps muscle group. A successful outcome will require 4-8 weeks. It’s a challenging process because it must be achieved without applying excessive load or pressure on the patellofemoral joint.

Very often, the pain persists after weeks of therapy that has targeted the quadriceps. Why? There are many reasons. But one reason is that the underlying cause may not have been weak quadriceps. Will strengthening the quadriceps benefit someone with flat feet? The research concludes that no single intervention is superior to others and no particular program is effective for all patients. The reality is that unless the root cause is identified correctly, a successful outcome is unlikely. The symptoms will persist until the rubbing stops and the pressure is relieved.

What about commonly used bracing and taping products? Many products claim to provide relief of Runner’s Knee symptoms. They’re available in every pharmacy, sporting specialty, and big box store. Lots of runners can be seen wearing them. Do they work? The research reveals they don’t. Studies conclude that wearing a knee orthosis made no difference to knee pain (data from three studies) and function (data from two studies). Why is that?

Nearly all OTC products, such as knee sleeves and patella straps, use compression to treat the condition. Think about it. The irritation is being caused by rubbing and excessive pressure on the patellofemoral joint. Does it make any sense to apply compression, add pressure? Compression is the exact opposite of what is required to correct the problem. Compression based products are not the answer to the problem.

What about surgical options? Research concludes that there is a lack of evidence to support the efficacy of arthroscopy in patients with chronic PFPS. Operative interventions should always be considered a last resort.

Now let’s summarize. RICE and medication can provide short term relief, but they do not correct the underlying problem. Physical and exercise therapy can correct the underlying problem if the correct diagnosis is made. A successful outcome will require 4-8 weeks and avoidance of activities that cause discomfort. Commonly used braces and taping methods are ineffective. Compression based products should be avoided. And there is a lack of evidence supporting the effectiveness of surgical options.

So, what other options exist? Are there any supports or therapeutic strategies that offer promise? Here’s the good news. There’s a new product called NuNee that is proving to be very effective at relieving Runner’s Knee symptoms. It uses patent pending technology to relieve pressure on the patella during flexion. Think of it as a patella support that delivers relief by unloading the patella. It helps to relieve patellofemoral joint pressure and allows the patella to track properly in the femoral groove. Early testing has shown it can deliver immediate and significant relief for those afflicted with PFPS.

Physical therapists and medical practitioners are beginning to incorporate NuNee into their treatment plan. Dr. Ben Shatto, DPT and a running injury specialist says “NuNee has allowed the client to work harder and perform a greater volume of exercise without increased pain. This has allowed me to speed up their rehabilitation protocol. So far I have been impressed with the results.”

NuNee has shown that when it is combined with a physical or exercise therapy program it can lead to both a speedy and long-term recovery from PFPS.

Perhaps there’s finally been a breakthrough for navigating around the “Black Hole of Orthopedics”.

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