Runner’s Knee? Or Maybe Something More?

Wiping the sweat from my brow, I bend over and grab my knees. Training for Grandma’s Marathon on the outskirts of Duluth, I was struggling to extend past the 5-mile mark and the idea of finishing my first marathon was getting farther away.

Fortunate enough to participate in high school and collegiate sports, injuries were an expected part of sport. However, this time things were not getting better with rest.

Although I was a medical student at the time, the medical texts weren’t shedding any light on my recurrent knee pain. So I figured I’d get things checked out by a physician. After a brief clinic visit I was told I had “runner’s knee” or patellofemoral syndrome. I read up on it and, sure, the symptoms aligned… pain under the kneecap, exacerbated by running and other athletic activities. I was told to limit my mileage and given a prescription for Physical Therapy.

Feeling empowered by the diagnosis, I embarked on rehabilitation. Working closely with the therapist, we developed a running plan and leg strengthening program. Weeks passed and I was ready to challenge the Superior Trail again in anticipation to rejoin my training and achieve the 26.2 milestone.

Strapping on my trusty Reebok shoes I had been wearing since my high school track days, I felt refreshed and confident — however, as I breached my 5 mile mark I again felt the rub and creaks of my knees ailing in pain again. “What else can I do about this runner’s knee?” “I need an MRI” “Stick to the 5k” I thoroughly questioned my abilities and efforts.

Nearing defeat, my friend (OK, now my wife) suggested I join her to get new shoes for training. I reluctantly joined her but questioned her motivation. My shoes feel great on my feet, and besides, my feet feel fine. My old trusty Reeboks had myriads of track success and, despite their ragtag look, felt like heaven on my feet. My loyalty ran deep with those old friends on my feet.

Pulling into a small shoe store on the edge of Duluth, I ducked into the shop to check out the wall of colorful footwear. Checking out the look of the Nikes and Asics, my loyalty to my dingy sneakers waned and I warmed to the idea of giving a new pair of shoes a try.

I picked out a black and yellow pair of Nikes and found the casually dressed attendant. He asked my friend to stand on a pad which apparently mapped the pressure points on her feet so he could recommend the best shoe. She abided and was told she could pick just about any shoe on the wall. I was next and strolled onto the pad, standing up and resting back on my feet following his request.

His kind smile seemingly flattened. Concern filled his tone as he discerned my feet heat map picture on his screen. I pointed to those Nikes I liked so much, and he shook his head. “You have knee pain?” he asked. I was dumbfounded, I nodded my head. He went back behind his storage area and disappeared for minutes. It felt like forever as I watched my friend picking out her latest model of Asics, and I was excited to find my match.

Minutes later he brought out a box embellished with a brand that I couldn’t interpret. The box was dusty, I mean so dusty that he had to blow away the dust to avoid embellishing the box with his fingerprints. Handing me the box, I opened it to find the most hideous pair of shoes I’ve ever seen. A cross between ski boots and golfing shoes, these faded orange color shoes made me cringe. “These will fix your knee pain, I promise,” he boasted. Desperately, I laced them up and I felt like I was walking on water skis. I questioned him. “You have the flattest feet I’ve seen in a long time. These shoes will not only support your feet — they’ll fix your knee pain as well.”

Fast-forward to 26.2 miles: I found myself crossing the Canal Park finish line proudly in my orange shoes, winded by the length of the race and beating sun but unencumbered by my knee pain and newfound flat feet.

Runner’s knee, or “patellofemoral pain syndrome (PFPS)” is a well-established cause of anterior knee pain that runners, both novel and well-trodden, will often experience. PFPS is most often described as a dull pain under the kneecap that can become sharper with exercise, especially those that include flexing/bending the knee. Popping (crepitus) can often occur with offending activities. PFPS has a multitude of causes including muscular weakness, ligamentous laxity and malignment. Discussion of these is beyond the scope of this article; however, we’ll address an underrecognized cause. 

Pes planus, or flat feet, is a common condition in which the longitudinal arch flattens with pressure. Flat feet is most often seen in children until their arch develops around the age of 4-5 years of age. In adults, however pes planus can continue (those who are “born with it”) or develop (most often from injuries to the posterior tibial tendon or medial spring ligament).

The good news is that often pes planus is painless and no formal treatment is needed. However, for some patients the flat arch can cause the foot to move inward (or pronate) the foot which leads to increased stress, not only on the foot but can also disturb knee and even hip joints if malalignment occurs. For this reason, appropriate supportive shoes or arch support insoles can treat and prevent injuries.

As you are readying for your next run, take note of how your body is reacting to your stride. If you’re developing pain it’s important to not only understand the injury — but the problem behind the injury to keep your joints healthy now and beyond.

Perhaps my favorite part? My wife was right and I still haven’t told her that.