Dr. Kevin Elder discusses runner's knee.
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Runner's Knee
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Dr. Elder is an affiliate associate professor at the University of South Florida and an affiliate assistant professor at Florida State University. He also serves as a volunteer faculty preceptor for Bayfront Medical Center and Morton Plant Mease family practice residencies primary care sports medicine fellowship programs.
Learn more about Kevin Elder, MD
Kevin Elder, MD
Dr. Kevin Elder is board certified in family practice with a Certificate of Added Qualifications in sports medicine. He completed his family practice residency and sports medicine fellowship at Bayfront Medical Center in St. Petersburg, Florida. Dr. Elder is currently the team physician for U.S. Soccer and the U.S. Ski Team. He served as the Tampa Bay Buccaneers team physician for five years and is still involved in a variety of professional, collegiate and high school programs.Dr. Elder is an affiliate associate professor at the University of South Florida and an affiliate assistant professor at Florida State University. He also serves as a volunteer faculty preceptor for Bayfront Medical Center and Morton Plant Mease family practice residencies primary care sports medicine fellowship programs.
Learn more about Kevin Elder, MD
Transcription:
Runner's Knee
Introduction: This is BayCare HealthChat, another podcast from BayCare Health System. Here's Melanie Cole.
Melanie Cole: Welcome. Today we're discussing runner's knee. Joining me is Dr. Kevin Elder. He's Board Certified in Sports Medicine and Family Medicine at BayCare. Dr. Elder, pleasure to have you with us today. We've heard this term runner's knee. What does that mean?
Dr. Elder: Runner's knee is a common condition that the term refers to a more complicated term that patients may hear, which is patellofemoral pain syndrome or the other term that can be used is chondromalacia patella, which are both pretty big words and terms, so runner's knee is a lot easier to say, but essentially what it is, is a condition which is very common where the cartilage essentially in the area of the knee generally underneath the patella or kneecap gets irritated or roughed up. And then the area where that cartilage, which is the cap that is on the bone that allows the smooth movement becomes this area where it grinds or clicks or makes noise and can cause pain.
Host: So then why does this happen? Do we know the causes? Are certain people, certain runners, more at risk? Are we blaming shoes, surfaces, anything about why this happens?
Dr. Elder: Absolutely. So we do know that there are factors associated with it. It is, as I mentioned, common, we can see it sometimes more commonly in women because of their natural alignment of their hips to their knee, to their lower ankle. And they can have what's referred to as an increased Q angle, which refers to the positioning, essentially of the kneecap relative to the pelvis and to their lower ankle. The knee cap, if it's somewhat improperly positioned or rides a little higher naturally from genetically just someone has that, or if it is tilted at a certain angle, which again naturally may be something that they have genetically, then this can lead to higher incidents of them having it. From the standpoint of certain activities such as running can accentuate that. So that's where the term runners knee comes in and what you can actually see is because of abnormal tracking or running where you might think that somebody would have always strong legs.
They may actually have strong legs, but they have an imbalance. So there can be an imbalance of the inside part of the quadriceps muscle called the VMO or vastus medialis oblique - VMO is the term a lot of runners would be familiar with. They may have a tight hamstring, they may have poor foot support, the muscle imbalances, there's various factors, and you mentioned shoe wear and certainly that could be a contributor as well because if the shoes are worn or improper fitting, it may accentuate or cause some of these factors. So in essence with this, there's some background factors that can affect it or cause it, but also activity can affect it and then shoe wear another. So there's really what you're doing when you see a patient like this is you're trying to determine what do they have, why do they have it? And then most importantly for the patient is how do we fix it?
Host: And before we talk about home care and how you can help us, sometimes when people go upstairs, they hear their knees grinding and popping or clicking. Even if they're not a runner and they assume arthritis maybe or you mentioned Q angle, I mean is that common?
Dr. Elder: Yes, it is very common and often we hear patients tell us, my kids laugh at me because my knees are making all this noise when I go up or downstairs, and so it is very common. The noise in of itself is not a problem. Some people are going to have that even in a younger person, if they're running or active, they'll notice they have some grinders, some noise, but it can be a sign that maybe some attention should be made on trying to not let some of these muscle imbalances continue or there will be more than just noise. There may be some pain and then some dysfunction and then the end of the day what we want people to do is move. So if it goes from, Hey, we have this little bit of noise or popping going up or down stairs to where we have a lack of ability to exercise, well, we don't want that. As far as is it arthritis, it is not the same thing as arthritis. Patellofemoral or runner's knee is not the same thing as arthritis. Now, some people can have both conditions, so it is not exclusive either, but in of itself, just the fact that somebody has popping in their knees or has issue, that doesn't necessarily mean they have arthritis that would be diagnosed based on the rest of their exam and certainly at least getting an x-ray to actually look at their joint space.
Host: So that's really important to note. And let's start with when they start to feel it. Runners, and runners generally wear good running shoes and usually they know if they're a pronator, supinator maybe they've got an orthotic. Maybe you're going to recommend that we look at our orthotics, but if we start to feel pain in our knee, what is the first line of defense? Is it activity modification? Do you like ice or heat, nsaids, what do you want us to do first? If we're just starting to feel that pain while we're out walking or running.
Dr. Elder: I think if you're just starting to feel the pain, the first step is to say, what am I doing? And is there an association with something, for example, a lot of runners do pay a lot of attention to, are they a pronator, supinator, arch. They know all of those things and they have pretty close attention to their body. On the other side of the coin, they might run the same route all the time and this might because of the uneven surface of the road over and over or whatever they're running on cause some increased symptoms. So I think if there's simple things we can modify like that to start with. For example, changing up the route that they run or changing up days, maybe doing some cross training, using some ice. There's no perfect answer for ice or heat. One is not magically better. Generally speaking, ice is better for pain acutely or swelling. And if we have muscle spasms, sometimes heat can be more helpful to bring in blood flow. But there's no perfect answer. Some people alternate. And then as far as nsaids, I think in the short term using nsaids or ibuprofen, Aleve or even Tylenol, those are fine. They may help. I think if somebody is taking these and they continue to have symptoms and it's affecting their ability to exercise, that's where it's time to come see the doctor
Host: Before we discuss what you might do for them. What about wrapping? A lot of times we see runners with wraps around their knee. Do you advise that or not a great idea?
Dr. Elder: I think that wraps have their purpose. Providing a little bit of compression can create what's called proprioception, so proprioception is basically a feedback from the muscle to the brain of where kind of everything is. If you ever put a wrap on your knee or ankle, you notice that when you put it on it feels real snug. But after a little while you don't even notice it's there. Kind of like putting on socks or something. And this is because the brain still knows it's there, but it's thinking about other things, but it's still providing some feedback. So I think it can be useful if somebody is having swelling in their knee and that's why they're using the wrap. Well, I think you want to first ask the question, why is there swelling? If they're having pain and it's always at the same place and they're treating that by using a wrap, well you're not answering the question, why is their pain? So I think that wraps, for example, have a place, I think you want to know what you're using them for and what's the actual underlying problem and then then it can be useful.
Host: So then if someone comes to see you and you've determined via x-ray and medical history, examination that this is what's going on, what are some treatments you might try? Do you look to cortisone shots? People always have questions about injections and what do you do for them?
Dr. Elder: So you mentioned of some of the conservative things, making sure their shoe wear is correct, modifying some of their activities. I don't tell people don't run anymore. It's bad for you because I don't think that's really accurate advice and no one wants to hear that. So I think sometimes it can be cases of somebody running too much, too many days a week or too much accelerating their say training too much, so we have to modify that, but just a blanket statement like running is bad for you. I think that's inaccurate. I think if anything, people who are less active are much less healthy, so I always try to reassure them with that. Then when we get into other treatments, we can use some wraps. We can use some braces. Physical therapy is a big part of the treatment in if they prefer giving them some home exercises to try first is very useful. Using some ice, using some pain relievers can help. As far as cortisone shots, my take on cortisone shots is you're masking the symptoms.
They are not actually treating the condition, so I feel like a cortisone shot is an isolated thing you might do. For example, if somebody has some significant knee pain, chondromalacia , let's say in there going on a trip with their friends and they're going to be hiking the Grand Canyon and their knee is killing them. Something like this. You're trying to help them for this occasion. I think as far as doing it and expecting it's going to cure the problem, it really doesn't. So I'm real big on using those. Sometimes if we have lingering chondromalacia or lingering cartilage involvement and we've done our workup, we've done an X Ray, we've done maybe other imaging such as MRI or musculoskeletal ultrasound in the office, and we know what we're dealing with, and we feel like all the conservative treatments haven't worked. Some of the options use presently such as the orthobiologics, PRP is used on occasion for these things and it can be helpful. So I think those kinds of things can be more helpful actually than cortisone shots.
Host: Well that is great information. So as you wrap up with your best advice about runner's knee, what would you like listeners to know about possibly preventing it and that yes, you said you don't want to activity modify, you want them to keep running. Maybe not to overdo it, but really what you'd like them to know about runner's knee and protecting those knees while they're out running.
Dr. Elder: I think the main things to know are that first of all activity and running specifically is not bad for you. You're not going to get an arthritic knee because you run, you probably more likely to get an arthritic knee because you don't run and are overweight and inactive. I think as far as treatment, again, it's common. I consider it most of the time to be a nuisance, so things that are a nuisance, we want to figure out how to deal with them and then move on with life. On occasion, if it's becoming more of a nuisance and we've tried to focus on activity modification, strengthening, icing, bracing, then we need to get it checked out. We need to come in for a visit and get it evaluated. We might have an opportunity to have an initial consultation with a patient in a virtual capacity, which might be their preference or seeing them in the office, in which case we can do a more detailed workup including x-ray and musculoskeletal ultrasound.
From there, I guess the biggest thing I'd want patients to know is there's a solution for this and that's the good news. When somebody has severe arthritis, there is not great solutions. We can manage the symptoms. But when we have patellofemoral syndrome, where we have runner's knee, there is a solution. There might not be an easy one or a snap of the fingers, but the good news is we can treat it and we have some tools. And again, if the simple things don't work, then we can move onto the more advanced things and considerations such as PRP, things like that. But the good news at the end of the day is this is something we should be able to fix and get somebody back on track.
Host: Thank you so much Dr. Elder, what great information and such usable tips for runners to take right now and use. So thank you again and that concludes this episode of BayCare HealthChat. Please visit our website at baycare.org for more information and to get connected with one of our providers. Please share this show with your friends on social media, other runners that you know because that way we all learn from the experts at BayCare together. Please remember to subscribe, rate, review, this podcast and all the other BayCare podcasts. I'm Melanie Cole.
Runner's Knee
Introduction: This is BayCare HealthChat, another podcast from BayCare Health System. Here's Melanie Cole.
Melanie Cole: Welcome. Today we're discussing runner's knee. Joining me is Dr. Kevin Elder. He's Board Certified in Sports Medicine and Family Medicine at BayCare. Dr. Elder, pleasure to have you with us today. We've heard this term runner's knee. What does that mean?
Dr. Elder: Runner's knee is a common condition that the term refers to a more complicated term that patients may hear, which is patellofemoral pain syndrome or the other term that can be used is chondromalacia patella, which are both pretty big words and terms, so runner's knee is a lot easier to say, but essentially what it is, is a condition which is very common where the cartilage essentially in the area of the knee generally underneath the patella or kneecap gets irritated or roughed up. And then the area where that cartilage, which is the cap that is on the bone that allows the smooth movement becomes this area where it grinds or clicks or makes noise and can cause pain.
Host: So then why does this happen? Do we know the causes? Are certain people, certain runners, more at risk? Are we blaming shoes, surfaces, anything about why this happens?
Dr. Elder: Absolutely. So we do know that there are factors associated with it. It is, as I mentioned, common, we can see it sometimes more commonly in women because of their natural alignment of their hips to their knee, to their lower ankle. And they can have what's referred to as an increased Q angle, which refers to the positioning, essentially of the kneecap relative to the pelvis and to their lower ankle. The knee cap, if it's somewhat improperly positioned or rides a little higher naturally from genetically just someone has that, or if it is tilted at a certain angle, which again naturally may be something that they have genetically, then this can lead to higher incidents of them having it. From the standpoint of certain activities such as running can accentuate that. So that's where the term runners knee comes in and what you can actually see is because of abnormal tracking or running where you might think that somebody would have always strong legs.
They may actually have strong legs, but they have an imbalance. So there can be an imbalance of the inside part of the quadriceps muscle called the VMO or vastus medialis oblique - VMO is the term a lot of runners would be familiar with. They may have a tight hamstring, they may have poor foot support, the muscle imbalances, there's various factors, and you mentioned shoe wear and certainly that could be a contributor as well because if the shoes are worn or improper fitting, it may accentuate or cause some of these factors. So in essence with this, there's some background factors that can affect it or cause it, but also activity can affect it and then shoe wear another. So there's really what you're doing when you see a patient like this is you're trying to determine what do they have, why do they have it? And then most importantly for the patient is how do we fix it?
Host: And before we talk about home care and how you can help us, sometimes when people go upstairs, they hear their knees grinding and popping or clicking. Even if they're not a runner and they assume arthritis maybe or you mentioned Q angle, I mean is that common?
Dr. Elder: Yes, it is very common and often we hear patients tell us, my kids laugh at me because my knees are making all this noise when I go up or downstairs, and so it is very common. The noise in of itself is not a problem. Some people are going to have that even in a younger person, if they're running or active, they'll notice they have some grinders, some noise, but it can be a sign that maybe some attention should be made on trying to not let some of these muscle imbalances continue or there will be more than just noise. There may be some pain and then some dysfunction and then the end of the day what we want people to do is move. So if it goes from, Hey, we have this little bit of noise or popping going up or down stairs to where we have a lack of ability to exercise, well, we don't want that. As far as is it arthritis, it is not the same thing as arthritis. Patellofemoral or runner's knee is not the same thing as arthritis. Now, some people can have both conditions, so it is not exclusive either, but in of itself, just the fact that somebody has popping in their knees or has issue, that doesn't necessarily mean they have arthritis that would be diagnosed based on the rest of their exam and certainly at least getting an x-ray to actually look at their joint space.
Host: So that's really important to note. And let's start with when they start to feel it. Runners, and runners generally wear good running shoes and usually they know if they're a pronator, supinator maybe they've got an orthotic. Maybe you're going to recommend that we look at our orthotics, but if we start to feel pain in our knee, what is the first line of defense? Is it activity modification? Do you like ice or heat, nsaids, what do you want us to do first? If we're just starting to feel that pain while we're out walking or running.
Dr. Elder: I think if you're just starting to feel the pain, the first step is to say, what am I doing? And is there an association with something, for example, a lot of runners do pay a lot of attention to, are they a pronator, supinator, arch. They know all of those things and they have pretty close attention to their body. On the other side of the coin, they might run the same route all the time and this might because of the uneven surface of the road over and over or whatever they're running on cause some increased symptoms. So I think if there's simple things we can modify like that to start with. For example, changing up the route that they run or changing up days, maybe doing some cross training, using some ice. There's no perfect answer for ice or heat. One is not magically better. Generally speaking, ice is better for pain acutely or swelling. And if we have muscle spasms, sometimes heat can be more helpful to bring in blood flow. But there's no perfect answer. Some people alternate. And then as far as nsaids, I think in the short term using nsaids or ibuprofen, Aleve or even Tylenol, those are fine. They may help. I think if somebody is taking these and they continue to have symptoms and it's affecting their ability to exercise, that's where it's time to come see the doctor
Host: Before we discuss what you might do for them. What about wrapping? A lot of times we see runners with wraps around their knee. Do you advise that or not a great idea?
Dr. Elder: I think that wraps have their purpose. Providing a little bit of compression can create what's called proprioception, so proprioception is basically a feedback from the muscle to the brain of where kind of everything is. If you ever put a wrap on your knee or ankle, you notice that when you put it on it feels real snug. But after a little while you don't even notice it's there. Kind of like putting on socks or something. And this is because the brain still knows it's there, but it's thinking about other things, but it's still providing some feedback. So I think it can be useful if somebody is having swelling in their knee and that's why they're using the wrap. Well, I think you want to first ask the question, why is there swelling? If they're having pain and it's always at the same place and they're treating that by using a wrap, well you're not answering the question, why is their pain? So I think that wraps, for example, have a place, I think you want to know what you're using them for and what's the actual underlying problem and then then it can be useful.
Host: So then if someone comes to see you and you've determined via x-ray and medical history, examination that this is what's going on, what are some treatments you might try? Do you look to cortisone shots? People always have questions about injections and what do you do for them?
Dr. Elder: So you mentioned of some of the conservative things, making sure their shoe wear is correct, modifying some of their activities. I don't tell people don't run anymore. It's bad for you because I don't think that's really accurate advice and no one wants to hear that. So I think sometimes it can be cases of somebody running too much, too many days a week or too much accelerating their say training too much, so we have to modify that, but just a blanket statement like running is bad for you. I think that's inaccurate. I think if anything, people who are less active are much less healthy, so I always try to reassure them with that. Then when we get into other treatments, we can use some wraps. We can use some braces. Physical therapy is a big part of the treatment in if they prefer giving them some home exercises to try first is very useful. Using some ice, using some pain relievers can help. As far as cortisone shots, my take on cortisone shots is you're masking the symptoms.
They are not actually treating the condition, so I feel like a cortisone shot is an isolated thing you might do. For example, if somebody has some significant knee pain, chondromalacia , let's say in there going on a trip with their friends and they're going to be hiking the Grand Canyon and their knee is killing them. Something like this. You're trying to help them for this occasion. I think as far as doing it and expecting it's going to cure the problem, it really doesn't. So I'm real big on using those. Sometimes if we have lingering chondromalacia or lingering cartilage involvement and we've done our workup, we've done an X Ray, we've done maybe other imaging such as MRI or musculoskeletal ultrasound in the office, and we know what we're dealing with, and we feel like all the conservative treatments haven't worked. Some of the options use presently such as the orthobiologics, PRP is used on occasion for these things and it can be helpful. So I think those kinds of things can be more helpful actually than cortisone shots.
Host: Well that is great information. So as you wrap up with your best advice about runner's knee, what would you like listeners to know about possibly preventing it and that yes, you said you don't want to activity modify, you want them to keep running. Maybe not to overdo it, but really what you'd like them to know about runner's knee and protecting those knees while they're out running.
Dr. Elder: I think the main things to know are that first of all activity and running specifically is not bad for you. You're not going to get an arthritic knee because you run, you probably more likely to get an arthritic knee because you don't run and are overweight and inactive. I think as far as treatment, again, it's common. I consider it most of the time to be a nuisance, so things that are a nuisance, we want to figure out how to deal with them and then move on with life. On occasion, if it's becoming more of a nuisance and we've tried to focus on activity modification, strengthening, icing, bracing, then we need to get it checked out. We need to come in for a visit and get it evaluated. We might have an opportunity to have an initial consultation with a patient in a virtual capacity, which might be their preference or seeing them in the office, in which case we can do a more detailed workup including x-ray and musculoskeletal ultrasound.
From there, I guess the biggest thing I'd want patients to know is there's a solution for this and that's the good news. When somebody has severe arthritis, there is not great solutions. We can manage the symptoms. But when we have patellofemoral syndrome, where we have runner's knee, there is a solution. There might not be an easy one or a snap of the fingers, but the good news is we can treat it and we have some tools. And again, if the simple things don't work, then we can move onto the more advanced things and considerations such as PRP, things like that. But the good news at the end of the day is this is something we should be able to fix and get somebody back on track.
Host: Thank you so much Dr. Elder, what great information and such usable tips for runners to take right now and use. So thank you again and that concludes this episode of BayCare HealthChat. Please visit our website at baycare.org for more information and to get connected with one of our providers. Please share this show with your friends on social media, other runners that you know because that way we all learn from the experts at BayCare together. Please remember to subscribe, rate, review, this podcast and all the other BayCare podcasts. I'm Melanie Cole.