Less is More: Returning from Injury (Runner’s knee, Patellofemoral Pain Syndrome)


Runner's Knee

Less is More: Returning from Injury (Runner’s knee, Patellofemoral Pain Syndrome)

I love America, but we do everything here to the extreme.

We’ve always been taught more is better, but when it comes to training – less is more and better is better.

I get referred athletes in pain or have to consult with injured athletes trying to get back on the field too often. Sadly, a lot of these injuries could be avoided if more attention was paid to total training volume and feedback from the athletes!

*By the way, if you are having serious knee pain you should get it assessed in-person, by a professional that you trust.


Background: Track and field athlete

  • Program was incredibly high volume (up to 70+ miles a week!)
  • Little recovery (No off days)
  • Minimal weight training

Practically the entire team is hurt, no surprise right…

  • Told to keep running same program
  • Pain worsened until it became intolerable
  • Sent to see PT and Trainer at school

PT’s and Trainers at school see “knee pain” and say it’s due to tight IT bands. Certainly it’s not the running 70 miles a week with no off days.

“Roll IT band and we’ll do Cupping, Ultrasound, Stim.” Lol. Awesome, we’re back in the 90’s.

After some fresh cupping marks and quick stretches, it’s back out on the track tomorrow…

And right back to pain and being unable to continue after a few minutes of running.

This went on for weeks.

Outcome: Runner’s Knee or Patellofemoral Pain Syndrome (PFPS syndrome)


Here’s what we did to get her out of pain and back on the track:

Step 1: STOP RUNNING (aka eliminate the irritant)

This might seem like common sense, that’s because it is. But seriously, people miss this. You need to eliminate the stressor initially and break the pain cycle. That doesn’t mean you don’t train, because if you want it to heal quickly – you must train (intelligently).

BUT, you need to get away from the activity that is producing pain first.

So is running bad? No. It’s the load or the total volume of running that is the problem. In her case, this was an overuse injury. The body’s ability to tolerate and recover from this stressor (running) was exceeded. The result was pain. 

We can argue about why it happened – inefficient mechanics, lack of overall hip strength, poor knee stability, all fine and good. It doesn’t change the fact that whatever you were doing, clearly wasn’t working.

Time to start over.

I’m a firm believer that we truly can’t predict and prevent injuries (the research currently supports this)[1,2]. There are just too many variables at play, I prefer just focusing on the things we can control – proper training, nutrition, and smart load management.

We know there is some correlation between “knee pain or PFPS” and strength of hip musculature, or poor control of dynamic knee valgus, lack of strength in the extensor muscles (quadriceps), and so on…[3,4]

We can list all of the “risk factors,” but a solid training program should check all of these boxes regardless.

Step 2: Find Pain-Free ways to Train and Move

               Your body, or how you move, is your instant feedback into what’s happening. Pay attention to this. Remove the fear and anxiety attached to movements – this is huge when it comes to dealing with pain. A little bit of discomfort is ok, a ton of pain is not. Let pain be your guide and be smart.

In this case, a runner can still develop the proper energy system of their sport/event through other non-painful means. You can bike, use the pool, perform medball workouts, or various circuits. All of these can help you develop and maintain your fitness.

– Bike workouts:

  • Tempo intervals (aerobic development) – start here as these are lower intensity
  • Acceleration (alactic-anaerobic), higher resistance, shorter bouts of work, 6-10 seconds
  • Speed (lactic-anaerobic), higher seat height, low resistance, up to 30 seconds of work

*We also used continuous circuits (blend of lower/upper/ab workouts) for anaerobic training and circuits with recovery for more aerobic training. We used the bike for 2-3 weeks or until she could perform general movement patterns without pain.

– Strength/Movement Training

  • Safe, Purposeful, Active/Dynamic warm-up (to reintroduce pain-free movement and improve dynamic flexibility and stability)
  • Walking power-speed drills to maintain form – eventually progressing them
  • Upper-body training (use this time to get your upper body strong)
  • Lower-Body training with proper progressions (exercises you can comfortably tolerate)
  • Tempo runs (Charlie Francis)

Movement is important and can be restorative. This particular athlete needed strengthening of hip musculature and just overall development. The training is general in nature, the exercises you choose to use aren’t all that important. Find pain-free strengthening exercises and progress them.

These are what we used:

  • Eccentric leg press, Isometric and Iso-dynamic Peterson step-ups, TKE’s, single leg stability
  • Hip/glute strengthening (side-lying abduction, isometric band holds, bridges, reverse hyper single leg/bilateral etc.)
  • Re-groove squat/hinge patterns – We went – bodyweight squat -> goblet squat -> box squat -> barbell squat.
  • Forward/backward sled-walking
  • General hamstring training (train it as hip extensor AND knee flexor), split squat (ecc/iso), lunge patterns (fwd/bkwd/lateral/etc.)

Continue to progress strengthening exercises and then begin to teach/reinforce proper jumping and landing mechanics.

Step 3: Slowly Progress Running 

Re-introduce running while controlling total volume. DO NOT resume right where you left off. We used tempo runs, to control the volume and exposure, beginning with 15-30 seconds or 50-100m at 65-70% effort with ab work/walks in between runs as “recovery.”

Eventually we progressed this to 3,500m total volume with no pain. We started back with 6-8 runs and gradually increased.

She was one of 3 left who was healthy enough to run in the first meet (no shocker). She ran her best race of the year after doing significantly less total running for the weeks leading up and not even being sure if she could compete this weekend.

Take home points:

  • Devil is in the dose (control the amount of total work you are doing, you aren’t the terminator)
  • Stop doing what hurts (duh)
  • Maintain fitness through non-painful means
  • Progress slowly and don’t be afraid to regress if your body tells you to
  • Train to feel good, not exhausted
  • Allow yourself time to recover (off days, epsom salt baths, massages, soft-tissue work)
  • Less is more

1.)  Do Functional Movement Screen (FMS) composite scores predict subsequent injury? A systematic review with meta-analysis.

2.) http://bjsm.bmj.com/content/early/2016/04/25/bjsports-2016-096256.short?rss=1 – “Why Screening Tests to Predict Injury Do Not Work”

3.) https://www.sciencedirect.com/science/article/pii/S2095254617301084#f0010 – “Dynamic knee valgus kinematics and their relationship to pain in women with patellofemoral pain compared to women with chronic hip joint pain.”

4.) https://www.jospt.org/doi/pdf/10.2519/jospt.2012.3803?code=jospt-site – “Risk Factors for Patellofemoral Pain Syndrome: A Systematic Review.”

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