American Council on Exercise by American Council on Exercise

runner's knee

It hurts to climb stairs. It hurts to squat. And sometimes, that soreness in your client’s knee is even severe enough to take the steam out of their training programs.

Chances are it could be Patellofemoral Pain Syndrome (PFPS), more commonly referred to as “anterior knee pain” or “runner’s knee.” The cause of 16% to 25% of all running injuries, PFPS can be a frustrating and often painful experience for clients, as it interferes with everything from training to just moving throughout the office.

It can stop even the most competitive athletes in their tracks. As it should.

Although the cause of runner’s knee can range from overuse to poor mechanics, the same training tactics can be used for most clients.

“Overuse results from making too big of a jump in training or not allowing enough recovery for the training stimulus,” said Todd Galati, ACE Director of Credentialing and ACE Advanced Health & Fitness Specialist. “Depending on the severity, program regressions may allow a person to continue training while others may need to stop the activity that caused the overuse issue. This may be difficult, but necessary, for some running enthusiasts.”

So how do you tailor an exercise regimen for clients following recovery from PFPS?

The first step would be to scale back exercise when knee soreness is present. Avoid aggravating activities like deep squats or running, make sure the client is wearing the right footwear and try using ice.

“Modify the client’s exercise program to a point where they’re challenged physically without resultant knee soreness,” Galati said. “Progressions should be conservative to allow the client to move toward goals while remaining pain free.”

The restorative exercise program should focus on three key areas:

The kinetic chain is a series of body segments connected by joints that favor either stability or mobility. Limited mobility in a more mobile joint (e.g., ankle, hip) will cause more stable joints (e.g., foot, knee) to sacrifice stability to allow the desired movement to be achieved. Instability in a more stable joint can cause mobile joints to sacrifice mobility to improve stability. Both scenarios can result in compromised mechanics and potential injury, such as PFPS.

How Flexibility Comes into Play
Clients may have some tightness in the hamstrings and calves due to compensatory patterns that develop in response to PFPS. For example, maybe they’ve developed a small limp or they’ve simply come to rely on their left side more to avoid using their right knee as a result of their stint with PFPS. Sometimes that sort of compensation is intentional; sometimes it’s just due to instinct. But either way, it can cause tightness that should be addressed through stretching and myofascial release (e.g. using a foam roller).

Increased flexibility can help to restore the mobility of the hip and ankle, allowing proper lower leg movement patterns to be restored. In addition, the lower fibers of the IT band attach directly to the proximal tibia and through fascial connections to the patella and biceps femoris, making the IT band a key target for flexibility exercises.

Restoring Strength Around the Knee
The knee isn’t made of a massive muscle. It’s a complicated network of bones, joints, ligaments and tendons – so a strengthening program should focus on areas surrounding the knee.

“The obvious muscles to strengthen around the knee include the quadriceps, hamstrings and calf muscles,” Galati said, “but don’t forget to strengthen the two-joint muscles of the hip and knee (e.g., sartorius, gracilis) and the muscles of the hip that insert on the IT band (tensor fasciae latae, gluteus maximus, gluteus medius), as the IT band provides the knee with lateral support. And remember, if it hurts don’t do it.”

Muscle soreness implies that sufficient physiological stress was applied to promote overload and progression. Knee soreness is different. It generally results when soft tissues around the knee are stressed beyond their limits. People who try to “push through” the soreness can end up with a painful injury.

Clients who have knee pain should be referred for medical evaluation, Galati said.

Transitioning Back to Functional Movement
Start with closed kinetic chain exercises in the sagittal plane, then progress functional integration by incorporating exercises in the frontal plane, followed by a combination of the two – starting with lower intensity exercises and working up. The table below lists lower limb exercises with appropriate progressions to improve stability, movement and functional integration.

Plane of Motion

Exercise Progression (Easy to Hard)

Sagittal Plane

Leg press machine 
stability ball wall squats
forward lunges
stair walking

Frontal Plane

Side stepping on level surface
side stepping on a step
side stepping with bands

Combined Planes

Multi-directional lunges
single-leg balance with multi-directional toe touch
multi-directional jumps (bilateral)

Using these exercises will keep clients progressing at an intensity level that fits their ability.

“Incorporating appropriate exercises and progressions will help restore joint stability and good movement mechanics to the joints of the lower limb, reducing stress on the knee and preventing re-injury,” Galati said.

Interesting in learning more about exercise progressions and specific rehabilitation techniques to serve clients recovering from common injuries including sprains and fractures? Check out our ACE Continuing Education Course, Post-Orthopedic Rehabilitation for Personal Trainers and earn 0.6 ACE CECs.

ACE® Pro Compass has arrived!

It's time to map out the career you want. ACE® Pro
Compass will steer you in the right direction across all
stages of your professional journey.