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Training & advice

Andy Byrne - Anterior Knee Pain

Andy Byrne from David Roberts Physiotherapy looks at this common running injury

You know how it is - you're building up to that target race, making sure you get in all the training that you can and praying that you will not get injured.  I know from experience how devastating an injury at this point in training can be.  However, from my experience, this is the time we will see most people coming into the clinic with injuries as a result of the highest mileage, the amount of time the training has been going on for, and people's anxiety with regards to injury and not being able to complete the race.  One of the most common injuries that I see at this point prior to the London Marathon is anterior knee pain. Here I will discuss this, and will give you ways to try and settle it whilst continuing to taper your training as planned rather than cutting it short due to injury.

Anterior Knee Pain is probably the most common injury that I treat runners for.  The reason for this is that it covers a huge range of problems, all of which can cause a fairly non-specific pain in the front of your knee.  I cannot possibly go through all the possible causes for pain in this area, and my advice would be, as ever, to consult your Physio for an accurate diagnosis, but I will try to cover the most common causes here, and give ideas for their treatment.

At this stage in training, the most common injuries are over-use type injuries rather than purely biomechanical injuries, which would tend to cause problems earlier in the training programme.  The two main causes that we will discuss are Ilio-Tibial Band Dysfunction and Patella Tendinitis.

Ilio-Tibial Band (ITB) Dysfunction:

With ITB dysfunction, you will typically feel pain on the outside of your knee that will sometimes spread to feeling like it is deep under the knee cap.  It will tend to give you a sharp, stabbing pain which will generally come on after running for a short time, and will probably increase if you keep running.  Once you stop, you will generally have aching in the knee, particularly if you sit for a while after running and then try to walk again. You may also have pains as you walk downstairs if you have inflammation under your knee cap.

The pain is caused by the ITB being too tight, and pulling on the lateral structures of your knee (the ones on the outside) as well as altering how your knee cap moves, which then causes inflammation under the knee cap.

There are a number of things that you can do to settle this.  Firstly, stretch the ITB.  It is notoriously difficult to stretch and you will not necessarily feel a stretching sensation as you would with a muscle stretch, but if you hold the position, you will be having a stretching effect.  The best stretch for the ITB that I have found is as follows (there are a huge number of variations you can find):

Lie on your side with your bad leg on top.  Bend your bottom leg up a little so it is comfortable.  With your top leg, stretch as if you are doing a standard quads stretch, ie bend you knee up to your bottom and hold it there with your hand.  The ITB is stretched now by lowering your knee down towards the bed.  It is a bit of an awkward position but works well.


Hold for 45 seconds to a minute, and aim to do this stretch about 6 times a day plus as a warm up and cool down to any running you are doing.

Secondly, as well as stretching regularly, put ice on the outside of your knee for 20 minutes, twice a day.  This will help to reduce some of the inflammation. 

On top of the stretching and the ice, there are various other things you can try to settle the symptoms.  Firstly, when you are running, try widening your running style.  Ie. If you imagine running along a white line, if your feet would normally land on the line, try to imagine your feet landing either side of it instead.  This only really applies to those who have a very "narrow" running style, and I am not suggesting vastly altering how you run at this stage in the training, but a slight widening can be beneficial.

Secondly, try to bend your knee slightly more when you are running.  I have found from personal experience that this can sometimes relieve the pain, particularly if the pain is only coming on later in your training runs.  By doing this, you can sometimes loosen the lateral structures in the knee that are tightening due to the ITB, as you will be stretching them slightly more.

Thirdly, I would strongly recommend that you get a sports massage to try to loosen the ITB.  These are not nice massages but work very well. 

All of the above are designed to try and settle the symptoms of ITB dysfunction quickly to allow you to complete the marathon.  They do not address the cause of the problem.  This is normally weak glutes, weak trunk side flexors, or a biomechanical problem in the foot or ankle.  I will discuss ways of improving this in another article, as just a few weeks are not really long enough to rectify these problems.  However, any type of glutes strengthening such as lunges, or single leg bridges or "clam" exercises along with side planks, could be useful to try to improve the problem prior to the marathon.

Patella Tendinitis:

With Patella Tendinitis, you will generally have a sharp pain under the knee cap at the front of the knee, when running, but also as you go upstairs.  The pain is caused by the tendon being inflamed, but you can also have inflammation of the bursa (fat pad to stop the tendon rubbing on the bone) which will cause a similar pain.

Again, there are a number of things you can do to settle this.  Firstly, a lot of quads stretches! Each one held for the standard 20-30seconds to be repeated as often as possible throughout the day and as a warm up and cool down to any activity.

Secondly, apply ice to the front of your knee for 20 minutes stints, at least twice a day.  The best position for this is to sit with your legs up on the sofa, with your knee slightly bent, with a small rolled up towel underneath it.

Thirdly, I would recommend that you see your Physio.  There is a very simple taping technique that can be applied to your knee to take the pressure off the tendon that can work very well.  You can easily do this yourself once you know how.  You might have seen people like Rafael Nadal and Juan Sebastian Veron wearing a tape just under their knee...this is probably what it is for.

Whilst this article only covers two causes of knee pain, the advice is generally the same for most injuries at this point in training.  Ice, stretch, and see a Physio ASAP to settle the symptoms.  Then, once the marathon is done, then start on exercises and rehab to strengthen any weak muscles, often the glutes, to ensure that the same problem does not happen again.