Elaine’s story – Knee pain

Elaine is a 29 year old solicitor whose training for a marathon had been disrupted by knee pain. When I first saw her she had 3 months to go until the marathon and was worried that she was not going to be able to do enough training to complete the course. She had raised considerable sponsorship money for charity and thought that she would be letting people down if she did not finish.

The pain was at the front of the knee – around and under the knee-cap. It had been niggling for a few months after running training but 1 month ago had gotten much worse immediately after a long run – 15K. She had tried resting for a few days and taking Ibuprofen and Paracetamol. These had all helped but she found that she got the pain again after running just 5K.

When I assessed Elaine, I found that she had flat feet. I videoed her running and noticed that each time her foot landed on the ground, it rolled into a flat-footed position and therefore caused the knees to jerk inwards. This was happening on both sides but was much more pronounced on the painful side. Further assessment demonstrated that the muscles at the front of the thigh – the Quadriceps were not adequately controlling the knee as it bent and were not strong enough to prevent this mal-alignment during running. There was also evident weakness of the gluteal muscles.

This type of knee pain – around the knee cap (patella) is usually called anterior knee pain or patella-femoral pain. Guidelines and research evidence indicate that in these cases where knee pain is related to the position of the foot, that inserts (orthotics) placed in the shoes should be considered. Because Elaine had never had this problem before and it only comes on after running for a considerable distance, I reasoned that she would not need orthotics. Rather, I advised that as a first line she should change her running shoes to supportive (anti-pronating) shoes. If this did not improve symptoms, I would consider referring for assessment for orthotics with a podiatrist.

There is also good research evidence for staying active, exercise therapy and also taping and manual therapy. I reasoned that as the pain was not evident until she had run for 20 minutes, that taping and manual therapy (pain relieving modalities) were not indicated in this case but that exercise therapy would be important.

Elaine’s physiotherapy had the following key phases:

1)     Change of footwear, maintenance of aerobic conditioning and initial rehabilitation

Elaine purchased a new pair of anti-pronating trainers. I also advised her to take three weeks off running. However to maintain her aerobic fitness so that she wouldn’t lose conditioning, we devised a training programme involving swimming and cycling – neither of which irritated her knee pain. I also taught her some basic quadriceps and gluteal exercises to initiate strengthening. Again these approaches are recommended in guidelines and by the better quality research.

Elaine’s concerns about losing fitness if she took a break from running were eased by the fact that she could train to a high intensity in the pool and on the bike. She carried out her exercises regularly and within 2 weeks was ready to progress to more functional and high level rehabilitation.

2)     Functional rehabilitation and re-introduction of running

The next phase of physiotherapy treatment was to commence exercises that used the Quadriceps and Gluteal muscles in functional positions – like squatting – re-educating their ability to control the position of the knee as it bent and straightened. Carrying out the exercises with the anti-pronating running shoes also helped to stabilise the position of the foot and provide a solid platform for movement.

Elaine also started to gently build up her running within the limits of her pain. She started with a 4 K run as she knew that she could easily tolerate this without pain. The rules were that she could increase gradually as long as she was sensible but if she got any pain that she stopped rested for a couple of days and go back a step. Also she was not allowed to run on consecutive days, could do a maximum of three runs per week and should have one longer run and two shorter easier runs per week. She also used ice on the knee after each run.

Elaine was progressing her distance steadily and had just one real setback when she overdid it a bit a few weeks later by doing two 10 K runs on consecutive days. She admitted that she had been foolish but had missed a few runs that week because of work and social commitments and was trying to “catch up”. This was enough of a wake-up for her to be sensible with her running progression from then on.

3)     Progression of running


The final phase of the rehabilitation involved further high level gluteal and quadriceps exercises in positions of increasing difficulty and higher level core stability exercise. She also continued to progress her running distance each week as during her long run. By 10 days before the marathon, she had tolerated her last long run (30K) and was ready to start tapering down her training before the big day. I am pleased to say that Elaine completed the marathon (in 4 hours 25 mins) and had no knee pain (she just ached all over for a few days!).