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Expert Feature: Breaking Down Anterior Knee Pain


Posted by Heidi Mills of Sports Injury Clinic under Running, General on 26 July 2012 at 11:00 PM

Sports Injury Clinic is a specialist blog for educating about injury cause and prevention. They've written us a piece on one of the most common running injuries; anterior knee pain.

Injuries are a big concern for runners. Injuries to the feet, shins, knees and hips are common and largely due to the repeated impacts and movement patterns that running requires. In this series of articles we are going to look at the most common injuries suffered by runners. We will discuss what the injury actually is, what causes it, how it can be treated and most importantly how it can be prevented.

Anterior Knee Pain

Anterior knee pain has many names. You may have heard it called patellofemoral pain syndrome, or even runner’s knee (although this name is sometimes used for IT band syndrome).

In cases of anterior knee pain, the runner often complains of pain at the front of the knee, which is hard to pinpoint or may move around. The pain is often worst after running and also the next day and is at its worst when getting up after a period of rest and also when walking down stairs.

The cause of anterior knee pain tends to be patella mal-tracking. What this means is that the kneecap is moving excessively. What should happen at the joint is that the kneecap runs up and down in a groove at the front of the knee. When the patella mal-tracks, it moves out of alignment, usually to the outside of the joint when the knee is bent. This causes an aggravation of the articular cartilage lining the back of the kneecap where it is now rubbing against underlying bone. This doesn’t happen in a perfectly functioning knee. As the condition develops, more and more damage is done to this cartilage, which can result in a condition known as chondromalacia patellae.

The cause of this mal-tracking is usually a combination of biomechanical causes and muscle imbalances. This injury is far more common in female runners. The reason for that is the wider hip creates a larger angle at the knee which instantly creates an increased risk of mal-tracking. Factors which may add to this include weak hip abductor muscles (gluteus medius in particular), as this allows the knee to fall inwards because these muscles are not pulling the whole thigh outwards. Overpronation at the feet is another common causative factor as this causes the shin to rotate inwards and in turn, the knee. 

In terms of muscle imbalances, the usual scenario is that the quad muscles are imbalanced. There are four quad muscles which are found on the front of the thigh and cross the knee joint, contracting to straighten the knee. The Vastus Medialis muscle is the inner most of these four muscles and the lower fibres of this muscle (known as VMO) are important for controlling patella motion. However, in many cases, the VMO is weakened, or not firing quickly enough. Add in to the mix a tight IT band and lateral quad muscles and we have a muscle imbalance! The tight lateral muscles pull the kneecap outwards and the weak VMO isn’t strong enough, or quick enough, to counteract this pull.

Treatment of anterior knee pain is focused on correcting the cause of the injury. In the short-term, rest from aggravating activities, as well as ice and anti-inflammatories may well be helpful to get everything settled down. 

Firstly, look at the feet and the running shoes. These should be suitable for the foot type and not more than 400 miles old! If unsure, a gait analysis is recommended. 

Secondly, look at your squat. If the knees fall inwards giving a knock kneed appearance, then strengthening the gluteus medius muscle is advisable. This can be done with a clam exercise.

Next, look at quad muscle imbalances. Sit on the floor with the legs straight out in front and a small towel rolled up under the knee. Press two fingers into the quads, just above and to the inside of the kneecap (sometimes called the teardrop muscle). Then press the knee down into the towel - your foot should lift up. The muscles under your fingers should strongly contract the second you move your knee. As seen below: 

Often what actually happens is that the contraction is a little delayed. If you think this is you, then you can do this same test as an exercise to try to increase the strength and speed of this contraction. Squats using a ball between the knees are also great for strengthening this and the hip abductors.

Finally, work on your flexibility. Make sure your quads and IT band in particular are flexible. Stretches and myofascial release using a foam roller are ideal for this. Sports massage will also be beneficial.

Once you have addressed all of these issues and you are pain-free on a daily basis, try to return to running. Ensure this is a very gradual return and stop if you feel any pain. Continue with your exercises throughout your return. 

A knee support may be helpful to assist in this return and should be one with a hole at the front and padding surrounding the patella. If pain persists, make sure you visit a sports injury professional for a full assessment and suitable treatment.

Prevention of anterior knee pain is all about working on your glute strength, flexibility and making sure you have the right running shoes. This also includes changing them regularly so they don’t lose their support/cushioning! 400 miles is the point at which it is recommended to change your shoes.

Whilst getting out on the road (or treadmill) is a great form of exercise, it is important to also cross train. Firstly this allows the body a change in demands and as they say ‘a change is as good as a rest’. Secondly, it will work different muscle groups which may not be targeted as much when running. Being involved in lots of different sports and activities helps the body to become more well-rounded and strong in every sense. 

Weight training is also recommended for runners to improve the endurance strength of the leg muscles, especially the glutes (bum muscles) which are often ignored. Exercises such as clams, bridges, squats and lunges should be performed at least once or twice a week and can be a great way of preventing running injuries.

For more information on the treatment and rehabilitation of anterior knee pain, please visit

  • Encourage

    encouraged this.



    I noticed some pain on the outside of my knee developing when I started running more regularly - it would flare up whilst cycling but these tips of stretches and exercises really helped me!

    Joanne H and Heidi M encouraged this.


    Great article, thanks Hiedi! I've been using a foam roller a lot recently, glad to see its the right thing to do!

    Heidi M encouraged this.


    I think this article is going to help me tremendously...thanks so much!

    Heidi M encouraged this.


    Thanks Hiedi for this! I have actually always had knee injuries, but I have read it somewhere that you can just "run through the pain" where you body will eventually get used to it, and strengthen the joint itself...? Is this true? This has worked for me so far throughout the last few years (including a couple of marathons), Does anyone know if it is actually true?

    Heidi M encouraged this.


    Sounds exactly like what I have, good tips!


    Sean W - NO NO NO! Never run through pain. It will only make the problem worse and mean you have to take longer out to treat it. If you rest as soon as you feel pain and get it looked at, making sure you correct the contributing problems, then you shouldn't need long out at all!

    Search4hurt A and Adrian K encouraged this.

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