Knee pain. Possible causes and treatment

Extract from a randomized, control trial, comparing the Jing Hip and pelvis clinical massage protocol versus the same protocol plus strengthening exercises in the treatment of patellofemoral pain in runners.

knee pain

Knee pain is a daily reality for many people. With a health system that doesn’t provide a clear treatment strategy to tackle the presentation, many end up putting up with the pain and having to permanently stop or adapt their lifestyle to their new reality.


In many cases knee pain can be resolved with the right treatment approach. 


In this article we’ll look into the findings of a randomised, control trial carried out in our clinic with recreational runners with knee pain. We’ll look into the main cause of knee pain and we’ll look at treatment options. We’ll close the article by explaining what the choice of treatment is at our clinic based on our research findings and the reason why we choose it over other treatment approaches. 


Enjoy the read!

Patellofemoral knee pain (knee pain at the front of the knee) in runners - Can manual therapy help? and... is it effective?

knee pain in runners

It wasn’t until the cultural revolution of the 1960’s and 1970’s that running “became a thing”. Up until the 1960’s amateur running in public spaces was widely frowned upon, running was therefore mainly if not exclusively practiced by athletes (Scheerder et al., 2015). This seems impossible to believe now a days; for example, a historic record was set by the number of runners who registered for a ballot place in the 2020 London Marathon alone, with almost half a million and counting (Ballot Entry, 2019).


Whereby the amateur running community has grown exponentially in the last 60-70 years so it has the number of running injuries. With a yearly incidence rate among recreational runners being between 37 and 56% (van Mechelen, 1992) running seems to also pay its toll. As per the same author, the majority of running injuries are located from the knee downwards (70-80%), between 50 and 75% of them appear to be due to constant repetition of a certain movement, with the knee being the most affected structure amongst all, amounting to 25% of the total of running injuries.


Amongst all knee conditions, Patellofemoral syndrome (PFS) or pain in the front and around the knee cap is one of the most common complaints among runners and the general adult population, showing to be one of the main running-related injuries -incidence ranging from 7.4% to 15.6% (Lopes et al., 2012). The complexity of the knee joint and the different possible aetiologies of this condition make it hard to establish a clear consensus regarding the terminology and treatment so in some cases it is referred to as “jumper’s knee” or “runner’s knee”.


In most cases, excluding anterior knee pain due to intra-articular pathology, peripatellar tendinitis or bursitis, plica syndromes, Sinding Larsen’s disease, Osgood Schlatter’s disease, neuromas and other rare pathologies, it is suggested that remaining patients with a clinical presentation of anterior knee pain could be diagnosed with patellofemoral pain syndrome (PFPS) (Lankhorst et al., 2012).

Most common PFS predisposing factors include, (1) bony abnormalities and or misalignment of the lower extremity and or the patella; (2) muscular imbalance and (3) overuse (Roque et al., 2012). 


Running motion is (and therefore walking as well), at the same time, affected by the dynamic force of muscles, the kinetic force of the moving body, gravity and ground reaction (Slocum and James, 1968). At present we know that the musculoskeletal system behaves as a tensegrity structure (Myers, 2014) meaning that it operates as a perfect engineering system and that any small imbalance in one of its structures would affect the biomechanics of the whole, causing vulnerable joints to operate out of balance and exposing them to injury.


Considering the place where the knee sits in the body and the forces to what it’s exposed, its complex anatomy and delicate uniaxial system -mostly limiting its movement to the sagittal plane (Blackburn and Craig, 1980) making it vulnerable against any misalignment- , as well as its highly impact-absorbing properties (Hoshino and Wallace, 1987) it’s not a surprise that the knee is found to be the most vulnerable and injured structure among runners.


Whilst gravity and ground reaction are static forces, the balance and biokinetics of the human body can’t be calculated into a single number; its complexity and impact on performance and injury prevention and rehabilitation cause it to be a hot topic still open to investigation and discussion amongst body therapists.


knee pain treatment in runners

When discussing balance or biokinetics, the word “fascia” necessarily emerges. Fascia is defined as ‘a connective soft tissue system in our body that forms a whole-body continuous three-dimensional matrix of structural support’ (Fascial Research Congress 2012).


Strain in one area of the fascial ‘silken body suit’ can be transmitted to elsewhere in the body (Fairweather and S. Mari, 2015). Not only that, relatively recent research suggests that muscle tissue belongs within that fascial webbing (Schleip et al., 2012), meaning that there is no discontinuity between muscles as previously thought.


The anatomy trains concept of Myers follows the grain of muscle and fascia to see what links with what and stablishes 7 traceable meridians of myofascia through which stability, strain, tension, fixation, resilience and postural compensation are distributed (Myers, 2015).


This means that restrictions in a certain area or specific muscle would affect the whole respective myofascial meridian and, at the same time, affect the whole tensegrity system, in the same way as if we pulled a puppet string; this would cause imbalance in the system, and imbalance is, as mentioned above, considered a main predisposing factors of PFS.

myofascial release for knee pain

Another word that emerges when thinking about possible causes for structural imbalance is “Trigger Point”.


Necessary mention here to Dr Travell, who left a legacy in body therapy with her extensive work on Trigger Points (TrPs). Defined as a “hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band” (Travell and Simons, 1993), in trigger point formation, a group of sarcomeres, or smallest unit formation within a muscle fiber, are stuck in contraction and are unable to let go (Fairweather and S. Mari, 2015). 


Independently of the reason why they develop, which is an entirely separate topic for research, trigger points develop in the muscle tissue and therefore they are deeply embedded within the fascia webbing, causing restrictions.


Previous research suggests a higher prevalence of TrPs in muscles like Gluteus Medius (Gme) and Quadratus Lumborum (QL) in individuals presenting with PFS in relation with those with no history of PFS (Roach et al., 2013). TrPs can also directly give rise to characteristic referred pain – trigger points in muscles like Quadriceps Femoris, Sartorius or Gluteus Minumus can cause referred pain in the knee- (Travell and Simons, 1983) and therefore are an important element to take into account when looking at pain or structural imbalances affecting the distribution of biomechanical forces.


If muscle imbalance is considered to be a primary possible etiological cause for patellofemoral syndrome, then we also need to look at resistance training (RT) recommended as one of the most effective methods to improve muscle mass, strength, and power (Kraemer and Ratamess, 2004).


Research shows weaker hip abduction and late activation of Gluteus Medius in runners presenting with patellofemoral pain syndrome in relation to those running pain free (Willson et al., 2011; ) (Ferber et al. 2011). Supporting that data, research also shows a decrease in knee pain following a hip abduction strengthening program in participants presenting with patellofemoral syndrome (Nakagawa et al., 2008). 


All the above suggests that correcting imbalance and misalignment by addressing key fascial restrictions and trigger points around the hip and thigh structures together with the strengthening of hip and thigh muscles would cause a positive impact to the knee joint in this particular condition.

The conclusion of the previous research showed really positive results after treatment and specific exercise was given once a week over a period of 6 weeks with a steady average decrease in pain levels. 


Based on our own research on the topic and our own  randomised control trial with runners we choose and offer in our clinic a combination treatment approach of advanced techniques. We also include exercise rehabilitation as part of the treatment plan. It’s the mixture of techniques what makes our treatment method so effective in releasing pain. 


Some of the techniques we use during a treatment session are Trigger point,  myofascial release and advance stretching between others. 



Ballot Entry (2019). Available at:

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Ferber, R., Kendall, K. D. and Farr, L. (2011) ‘Changes in Knee Biomechanics After a Hip-Abductor Strengthening Protocol for Runners With Patellofemoral Pain Syndrome’, Journal of Athletic Training. National Athletic Trainers’ Association, Inc, 46(2), pp. 142– 149.

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Lankhorst, N. E., Bierma-Zeinstra, S. M. A. and van Middelkoop, M. (2012) ‘Risk Factors for Patellofemoral Pain Syndrome: A Systematic Review’, Journal of Orthopaedic & Sports Physical Therapy, 42(2), pp. 81-A12.


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About the author

Rocio Santiago

clinical massage brighton

MA in nursing, Dip. Soft Tissue Therapy

Ro began her career initially as a nurse. During a difficult life period, Ro decided to ‘stop everything’ and travel to India, where she joined a massage course. From then on her career took another course as she got increasingly more interested in pursuing a future as a soft tissue therapist. 


Following this, Ro went on to train at one of the leading soft tissue therapy schools in Europe, completing a 3 year degree level course and specialising in effective soft tissue manipulation for the treatment of musculoskeletal pain. 


Ro has been seeing clients as a soft tissue therapist for 7 years, successfully treating a wide range of conditions. Her background in the medical sector, passion for the anatomy, biochemistry and physiology of the human body and a questioning nature result in a treatment approach that is based in science. Her life experience has added the holistic understanding that results in a treatment where mind and body are addressed as one.


More about the author and INSIDE here