Runner's knee AKA Patellofemoral pain syndrome is a complex topic. So Pat & Mike from That's Running Podcast helped me with providing the best advice for you and your knee pain. Some topics we discuss are: How we define PFJ pain & outdated terminology Why you should stop foam rolling your ITB Correct diagnosis before undergoing treatment What are the treatment options for you Common mistakes with PFJ pain Common training errors Is changing your shoes the answer? If you love hearing the boys and want to continue following them, head to their podcast or the links below: https://www.facebook.com/thatsrunning/ https://www.instagram.com/thatsrunning/ To follow the podcast joint the facebook group Becoming a smarter runner click on the link: https://www.facebook.com/groups/833137020455347/?ref=group_header To find Brodie on instagram head to: https://www.instagram.com/brodie.sharpe/ To work with Brodie Sharpe at The Running Breakthrough Clinic visit: https://breakthroughrunning.physio/
Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and let’s begin your run smarter journey.
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On today's episode, we're talking all things runner's knee with the boys from That's Running podcast. Welcome to the Run Smarter podcast, the podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger and smarter runner. My name is Brodie Sharp. I am the guy to reach out to when you finally decided enough is enough with your persistent running injuries. I'm a physiotherapist. the owner of the Breakthrough Running Clinic and your podcast host. I'm excited to bring you today's lesson and to add to your ever-growing running knowledge. Let's work together to overcome your running injuries, getting you to that starting line and finishing strong. So let's take it away. So we have the boys from That's Running and so we've got Pat and Mike and Brody from the Run Smarter podcast. And we thought we'd just come together, collaborate and kind of have a bit of a mastermind session about patellofemoral pain. So welcome boys. Thanks mate. Thank you for having us. Yeah, sweet. Thanks for reaching out and getting us on. Yeah, no problem. So we came up with the idea to talk about patellofemoral pain and you guys published this episode on Your podcast, I'll do the same with mine and just spread the wisdom, share the knowledge. Um, so I'm really excited to talk about today. What, where should we start? Oh, where should we start? I, I'll tell you what I want to start is the name of your podcast, which I quite like it's called Run Smarter. Yeah, it's very good. I, um, spent a bit of time coming up with it. We spent hours coming up with that's running. And then I ended up. I was never really that happy with it. We couldn't find anything else. So we just rolled with it. Oh, it works. I like the, um, the logo that you guys have put with the, the shape of the shoe. That was really nice. How'd you guys do that? How'd you do that? Um, I have a background in graphic design. So I was like, oh yeah, I'll chuck something together. Oh nice. To a running shoe. It's called that's running. Yeah. It's kind of funny that your podcast is called Run Smarter because the whole reason Mike and I do a podcast is cause runners are dumb. And so the recurring thing in everything we talk about is if you be less dumb, you'll like, you'll have a better time. So it's quite cool to, um, to chat with someone who has a podcast called Run Smarter. I love that. I feel exactly the same. And I know like sometimes you can't blame them because they just don't know these things. And it's, um, it's either, well, some of them do know it, but there's, there's two camps. There's the ones who choose to ignore. the smarter decisions because they just want to run fast. They want to run far and they just don't see the repercussions. But then you have the other ones who are none the wiser and they go onto Facebook groups and they just Google whatever questions they have and they either get a lot of misinformation or they just can't find the answers that they're looking for. And so it's kind of like bridging the gap between like, you know, when you go to a physio who's well-read and like really proficient with seeing runners and they educate them. How do you get that really wise education without seeing a physio? There's not really a lot of avenues that people can choose to take. You see people on Facebook groups, they post a question and the general population that gives them answers is so off the mark. It's just bridging the gap really. Sometimes I go on rants and I just go on all the Facebook groups and reply to all the questions with like what is good and right. But then I realized it's just like banging your head against the wall. Yeah, I've sometimes been like, I really want to say something, but I can't be fucked. Like there's so many people just giving this information and then there's my voice going, hey guys, maybe none of that is right and you should look into this. And then it just gets ignored. I'm like, okay, whatever. Yeah, but generally the stuff that works is the less sexy advice. Yeah. So maybe you should actually just run less and I don't know, do some squats. And people don't want to hear that. People want to hear you buy these new hawkers and then you do this and you take these electrolytes and then you're a bit sweet. Yeah. More salt, new shoes and you'll be sweet. It get, the waters get pretty murky when there's money involved in advertisement and you know, those sort of flashy ads. Yeah. Everyone's got like, everyone has their own agenda. And that's why we just try and be as transparent as we can. And I've come to realize that I make money through podcasting. So we're not, we're not doing this for any other reason other than to like, just throw some good news out there. Yeah. Better information, I suppose. Yeah. I should probably mention for my audience as well, that you guys did a day course about running and increasing education and becoming wiser. So how'd that go? Yeah, it was really good actually. We, um, we, we had what 20 people, so 20 came beans and we talked about, we probably crammed too much into one day, but we tried to talk about, um, injury reduction strategies, essentially. So a lot of strength, uh, strength work, training strategies, low monitoring, um, a bit on footwear, a bit on running technique, been on all the things that sort of contribute to, to like, I guess an increase in injuries and decreasing performance. So like, it was good. I think we went through all that. Yeah, we went through like four and a half hours of like good fun. And it's good to have, normally we just took monologue at people and helped their lesson when now you can actually have a discussion and people ask questions and go, oh, what about this? What I do this? What do you think of that? And that's quite nice to have that. It's very interactive, which I appreciate it. Yeah, cool. And it's one of the reasons why I reached out to you guys, cause listening to some of your previous episodes, a lot of the information that you're putting forth is is really on the mark with where the research is now and what all the gurus are saying and we seem to be on the same wavelength in terms of the information that we're delivering and how we're delivering it. So yeah, I'm excited to bring this mastermind together and have a chat. So it'll be, actually on the course that Mike and I did the other day, one of the guys had a really interesting question. He said, Pat and Mike, is there anything you disagree on? And we kind of looked at each other and we're like, no. Not really. I'm going to disagree. And I think because a lot of what we do is based on, you know, recent firm science and it's current best practice. So there's nothing we really disagree on in that sense. Um, there are small finicky things, you know, with like, you know, mindset and running and maybe how you schedule training. Yeah, but that's more personal preference and disagree. Yeah. I was just about to say that you're absolutely right. It's good. It's good that that's where your head's at as well. So I want to hear what you have to say about knee pain. Cause it'll be, I know what I think, but I want to hear what you get. So like runners knee, right. Which is like officially is like patellofemoral pain, I suppose. Is that what you call it? Yeah. I like to officially call it patellofemoral pain, but it's very much a, the umbrella term I was trying to like, look at a good definition, um, because there's a, um, the topic of like, condromylacia that gets thrown around there and they kind of say that's runner's knee as well. And I'm kind of like, Oh, I've got patellofemoral pain. We've got that and runner's knee and it kind of like, just becomes this whole umbrella term, but it comes to gussing or like if I've got a client in front of me and I try and describe patellofemoral pain, um, I used to, when I was first out of uni use a lot of like maltracking weakness, tightness, pulling across and. doesn't sit in its groove properly. This conversation right now and hang up on you. Yeah, I know. Um, that was sort of how I was taught and it's now it's just more like really dethroning language and now we know it's not a lot of mal like tracking all that sort of stuff. It's just overload of the patella femoral joint. And if you just describe to people, okay, this is your patella femoral joint. This is how. Um, the kneecap moves, we've just overloaded it with, well, it's usually some sort of silly training error. And once we build up the structure and build up the capacity, we can slowly get back to where you were and, um, yeah, I tend to make it a bit more empowering language and something that they can understand and they're not like totally in fear of, oh no, now my kneecap is falling out or, you know, whatever they want. And that's it. That's so true. Like if you, and the words that you use are so profound. So there's such a huge difference between saying the groove in, you know, the end of your femur is too shallow. Therefore your kneecap doesn't sit correctly in that groove. Therefore it's going to be maltracking. Therefore you have knee pain. As a patient you're there like, Oh, fuck, how do I fix that? That's, I'm just stuffed now. I better get off the thought. It's like you can't fix a groove in your. Yeah. In your bone. So what do you do? You stop running or you forever tape it? Exactly. It keeps strapping tape. So it's, it's way better to say, yeah, you're, you've got a sore knee. So like literally I, you've got to kind of pick the person that you're talking with, right? For some people I'm like, sweet, your diagnosis is temporary. So I'm like, that's your diagnosis. Some people are like, if you have a temporary sore knee, you can fix that. And then you can become pain free fairly, fairly soon. But if you've got a maltracking kneecap and your groove is too shallow and all this, that's tight, that's weak, that whatever it's like, fuck, this is going to hurt for a long time. Yeah, absolutely. Cause then it's like, well, what can I do about it? And then that's where people get into, oh, you just need to foam roll your ITB or you just need to do these VMO strengthening. And that's where you start to fall down this like really mismanaged, uh, ineffective treatment plan. And that's the difference between someone who's up to date with the latest kind of running research and someone who went through uni 10 years ago and just continues to practice what they took on at uni. And that's the thing because I think that first thing you described that Brody is what a lot of people have done for many years and a lot of people are still doing. They're still giving that same description of it's maltracking, it proves to shadow and then comes the VMO rolling and the quote rolling and the VMO strengthening and the ITP shit. I find... as, as health professionals, we have a responsibility to be more informed than general public. Yes. Absolutely. I think a lot of people get this like ingrained diagnosis as well with Google and talking to mates and things, because I will in the, like in a session, I'd do all this dethroning language and talk to what we just talked about then. And then at the end of the session, I'm like, oh, so all that makes sense. And. some of them will recap and be like, yeah, so what you're saying is my kneecap is not sitting right and smell tracking. And I'm just like, Oh no, what have I done? And I think it's like, they just do their own research and then it's just ingrained in their mind and they don't want to deviate from that narrative. We're changing that Brody. That's why we're chatting today. So you guys are on the same page in terms of how you describe it. Do you like to? tweak it any other different way? I just, just say, ah, a bit of an irritated knee. Yeah. You've overloaded a bit. It's a bit irritated. That's calming down. That's back off on the load to get you running again. Cool. That way some of the common, uh, either, um, training errors or causes that you guys see, um, people with patella femoral pain being done. One-on-one cause. Mike puts this really well. He often says, oh, cool, you ran 10K and you got knee pain. So let's just try running 10K again and see if you get knee pain again. Like, oh, okay, I got knee pain. Let's just try running 10K again and see if it hurts again. When you say it like that, it's so dumb, but that's the way a lot of runners' brains kind of operate. They're like, oh, saw yesterday, I'll just try it again. Like that kind of... Yeah. Really make sense that, you know, then there's the classical, like we just went from 25 kilometers per week to 60 kilometers per week. Like that is just classic. Uh, I usually it's, there's always, I mean, everyone is so different. Every individual has their own reason why they get knee pain, whether it's just like poor movement patterns or like a poor running technique or whatever it might be, and then you double your running load, you got no chance. Do you see many people like How would someone know if they have these poor movement patterns? Well, that's, it's hard to self kind of diagnose that sort of stuff. It's a lot of people don't really know how they move in the first place. Um, and that's, that's tricky. And that's quite a lot of what like I do face to face is identifying what sort of movement puts the majority of the load through the knee joint. And essentially you can just, you can buy the way you move. You can and should eventually choose where you put the load. And so some people just with their normal movement patterns, which they've probably done their whole life, they tend to put a little bit more load in their knee, or they might put a little bit more load in their Achilles, or they might put a little bit more load in their glutes. So it's just working with the person to identify that. It's hard to sit here on a podcast and be like, this is what does it. There are some really like generic things like, like we know from the research, overstriding, slow cadence and heel strike all put load in the knee joint. We know that. But to... each individual person, it's to a different level. Yeah. And that might be fine if you've done that for years and years and you've been running 30k's a week. And you can tolerate that. You can tolerate that because of use of time. But then with those sort of patterns, you increase to 50k's a week and suddenly you go, that's not fun. And nothing has really changed. And it's not necessarily, oh, you have bad technique. It's more you went from your 30k with... that movement pattern 250k and that's just been too much on the net. And I shouldn't even say that technique because there's no, like, I hate that. That's, and that's that negative language. It's just, it's just a technique that tends to put more of the loading telecom, that's all it is. So if I can attempt to summarize, we've got a wide variety of runners and how they're running. And. there are certain biomechanical angles or positions that might put the knee at a greater load in some people more than others. And whether that be with cadence, overstriding, heel strike, whatever have you, it's not wrong. It's just how they run can put more load through the knee and less through other parts of their body. But then you're combining that with training overload or just load in general. And so some people, if they, have a certain way that they move and then combine that with increasing their mileage, they're more susceptible to sustaining these overload pains. Is that right? Yes, very much. That's well done. Yeah. We need you to just step into our podcast every 10 minutes or so and go, cool, the one minute recap of the last 10 minutes. I'm trying to break it down for people who don't understand like cadence and understand certain terminologies that we're doing. So. Um, I think, yeah, just general recaps here and there. So is there anything else we needed to cover with like general causes before we move on to say like symptoms or something? Yeah, no. Let's move on to symptoms. I would say maybe if someone is having knee pain and they're not too sure diagnosis-wise if it is patellofemoral, it might be something else. Is there a certain pattern of symptoms that you guys see commonly that might suspect that it's more patellofemoral pain than something else? Yeah, 100%. Well, one of the, I suppose if we're just, if we know someone has like knee pain that's related to running, I would want to know if it's more say sore at the start of a run and then tends to warm up and goes away, or if it's more during the run, they're not too bad, but then the next day they're pretty sore. Generally that's a bit of a giveaway that they have more patellofemoral related overload. It's like a next day thing or six hours later kind of thing. Um, if it's. during a run, then I might be thinking, is it something else, potentially like a tendon related thing? And also just the location of the pain too. Normally when someone struggles to put their finger on it, like is it quite vague, it's sort of around the kneecap, I can't poke it. Then I'm like, okay, it's probably patellofemoral pain. It's only a hurt sort of at the front and they rubbed their entire knee and it's like, oh, it's sort of there. And then they sort of. go, oh, it's under there and over there, and sort of not actually giving you a spot. They are, all right, so general knee pain. Yeah, 100%. And then if it's a patellar tendon issue, you get one finger and you can put it right on the sore bit. If it's like an ITB related issue, you can get one finger and you can put it on the sore bit. Whereas it's always very hard to point to. And generally, if it's more a knee joint issue, You don't have that so much more on the joint line or more so back of the knee or more when you go in the knee, but this is more from the knee. I find with the telephone. Yeah. So it doesn't feel really deep into the joint, but very hard to localize. It's very vague. Often see with clients, yeah, they'll, they'll point to the kneecap, but then like their finger will move around from the bottom of the kneecap to the side, either like to the outside, to the inside or over to the top. And it kind of just like. Yeah. They kind of just drift that finger all, all around the kneecap kind of region. And they know themselves, it's hard to really localize that pain. Yes, definitely. And if they can confidently point to the sorbit with one finger, it's probably not telephemeral pain. That's just generally what I'm trying to do. Yeah. I'll add with like symptoms. Um, the, if it gets to a level of irritation, um, like general day-to-day things start to become irritable, whereas some other diagnoses might, it might be fine. But if it is getting to that level of irritation, things like stairs, like sit to stands, even just sitting for long periods of time can start flaring it up. This is the higher levels of irritability. Have you guys identified any other activities throughout the day that might stir up the knee? Yeah, walking downstairs, walking downhill. Yeah. When it like a, usually a lunge. If someone has to lunge down to get something out of the bottom shelf or the fridge or lunch down to pick up their dog, just, you know, for instance, that will be uncomfortable and they'll just find themselves like favoring the other knee, um, little things like that. Uh, and then going to the gym and squatting heavy can just be a bit so different. I find lunging is generally what it's because generally when they're lunged, like they need to travels forward more than in it. standard like hip don't know squat. Yes. So when squatting and they go, oh yeah, it's a bit Hmm, but I want to learn you to like oh, yeah, you're not loving that. Yeah. I think there's certain movement patterns that will place that knee under more load and if it is Irritated because it's been overloaded Like you said going downstairs or doing a squat where your knees travel more forward just puts more and more load through that joint itself And therefore more pain Yeah, yeah, absolutely. All right, cool. Um, so if someone's listening and they're like, oh my God, this is me. What's our first line of defense? What can we do for treatment? We've got to, well, if you're going to treat something, you've got to know the factors that you're treating. So for me, I always with each individual, try and work out what the main reason they're having their pain is and then, you know, that's different for everyone. It can be. uh, the way you run, it might be your like running technique. You might be a really knee dominant runner, in which case the first thing to try and play around with is your running technique. It might be the fact that you've just gone from 30 kilometers per week to 60 kilometers per week, in which case your first line of treatment is decrease that. Or it might be because, uh, you know, for whatever reason, you're just really like tight, like really just tight and stiff through the glutes, through the quads, whatever I am. some manual therapy or a session with a massage therapist or a foam roller can kind of free you up a little bit. And ease it off a bit. So it's, I always, well the way I've started to approach these is, cool we know what the diagnosis is, let's pick out the main one or two factors for you and work on them today. Yeah, I've seen people who can't squat because their knees are so sore, and they're the people who are like, cool I'm just gonna rub you for 30 minutes, and they feel a million bucks. Yeah. There's the people who are. still running 40 Ks a week and they're like, Oh, my knees a bit sore. It might be a technique to chew for them. So once you identify that, then you go into it. Yeah. Like why I always try to just think of like, look at the things that we know irritated and reduce that. Yeah. If running irritates, we need to make, okay, let's back off and running for a bit to settle it. Yeah. And then investigate it into what Patty just said, like what's causing it exactly. What can we do to do? We need to change it. thing in technique or the work on some strength, how do we need to just decrease load of it or if it's not, because it's not only runners, it can be just people that are in the gym five, six days a week and they were supporting and lunging. And if lunging really bloody hurts, do less lunging to back off on rotating the joint. Yeah. Good point. I think, um, I think there's a, because everyone's totally individual with how they got it in the first place, but then. their normal training load during the week because there's so many different factors. It could be even they haven't changed any of their running, but they ran and then did a gym session or did the gardening or the combination of that in the same day. So you're not going to have the most effective treatment unless you identify those causes. And so I think what we're getting to is that there's not one answer, but a good starting point is identifying the correct factors, the aggravating factors. and what caused it in the first place. And physio doesn't need to be fancy. If you are like you're saying Mike, you've got those people who are just running high mileage and then they're starting to get a bit of knee pain just looking at their training load the last two weeks and said, oh, you've done three runs like in three consecutive days. Have you done that before? Oh, no, that was just something new because my work schedule has changed. Okay, it might just be as simple as let's give you a day or two off, joint time to settle down and then let's not run three consecutive days and see how it feels. It could just be a simple thought. What does it mean to run three consecutive days? It's funny how when you say it like that, it's like the most obvious thing in the world. But for a lot of people with knee pain, it's like a hard pill to swallow. But if you're sitting here listening to it and you don't have knee pain, you're like, of course, it makes sense. It's really interesting until you're in that situation, you're like, oh, but... Well, I tend to do as well is just grab that phone and go through their diamond or Strava and go cool, let's have a look at your last two weeks and show them the numbers and go are you going from here to here or you've gone from running two days a week to five days a week? Yes, maybe that might have done it and they go oh yeah, oh yeah, but they can see there's something there they can look at and go oh yeah that makes sense I've gone from 30 to 50k or I've gone from Wednesday, Saturday to Monday, Tuesday, Wednesday, Thursday, Friday. Yeah. True. Have you done any work around taping or stretches, anything like that? Taping? Yes. Some people really get like instant relief from taping. Usually I, I will try taping on someone if they have soreness. One of those day-to-day movements like if they squat or they lunge and they go, yeah, that was pretty sore Is the taking straight away takes 30 seconds and that can give decent relief Otherwise there's always Some like self-release work or foam roller work On the outside of quads and the glutes and that can also give like pretty reasonable relief to yeah. Yeah, I know I think for those So may go on you go I was going to say I've had patellofemoral pain in the past and I still get it here and there if I start increasing my mileage, but what I've found really works for me is just doing some quad stretches and I do like not a lot, maybe just 30 second holds and I do that before and after and it makes me feel a lot better throughout the day. So everyone is different. Everyone does get pain for like slightly different reasons and I agree with you Pat, there's sometimes... a presentation in the clinic where you get them to do a step down and they have severe pain but then you just either reposition the patella or tape it in a certain position and they just feel so much better. It's a really good pain relieving treatment to implement just while they're building back up their mileage and building up their tolerance to load. Yeah, it can be really good for the short term. Exactly. And there are some people who have knee pain, you, you strap their knee up and it makes no change. So don't, don't bother. There's always a little bit of kind of tinkering that you need to do. So like, if like, I guess the main reason for this question is if you're at home and you're like, yes, this is me, I'm that runner. Cool. You can try strapping it here and there. You can try doing some foam rolling usually on your quads and if not through the glutes. And if that is the thing that gives you decent relief, then. Cool. Do that heaps for the next couple of weeks until your knee gets better. Well, while you do all the other, while you do load management and strength. Like, just if you're that runner at home that goes, that's me, have a think about why that could be. I just tried to identify what you've done or what you've changed or what's different and then go from there. Yeah. That sounds wise. If what, looking at like the systematic reviews of patellofemoral pain, they're, pretty much talks what we're talking about here. Yes, it works sometimes. Taping stretching can be good. Soft tissue release can be good, but what's generic and what everyone tends to agree on is strengthening and building up the load tolerance for that joint to tolerate the load that is required for running or gym or gardening, whatever the population you want to work with. So do you guys have any really good starting exercises? for someone who is like really irritated, but, um, let's just say they're at a point where they're not running yet. It's too sore to run a starting point for them. Ooh, still there Brody. I think I may have just lost you with the internet. Did you hear my really long winded question? Oh, there you go. Sorry. I just lost you for like 10 seconds Brody. Can you say that again? I, I went with a really long winded question and, um, kind of lost my train of thought there's I was talking about strength. And we'll talk about strengthening and how it's like a general consensus around like the research, the evidence, how important strengthening is. But do you guys have a go to strengthening exercise you'd like to start with someone who is a little bit irritated and is too severe to start running? Yes, I do. If they can tolerate squats, everyone gets a squat. If they can't tolerate squats, because that hurts the knee joint, always some like lateral hip muscle strengthening. So something on one leg where you're not moving the knee too much, but you're getting some good, just what we call glute strength happening on the side. So something I call a lateral toe tap is like gold for these sorts of people, for sure. Because we know that the stronger your glutes are. essentially the more loads you can tolerate through your knee joint. Can you describe a lateral toe tap for people? With pleasure. So you're leaning on two legs and you've got a like a looped thera band around your knees just above your kneecaps. And what you do is you stand on one leg but with your bum stuck out behind you. So in what we'd call a hip dominant position. So once you're there standing on one leg, you with the leg that's in the air, you just go out to the side and you just tap the ground and you bring your foot back in and you tap close to your body. And then you tap out to the side and then you tap close to your body. So you're just tapping out on one side with your foot, not pressing into the ground with that leg whilst you keep all your body weight on the leg that you're standing on essentially. And so that band around your legs should put quite a bit of load through your hips as you're doing this. And you should feel a nice, really nice burn through your glute muscles. as long as you put that leg in the right position. So you've got to be standing in a hip dominant position, so sticking butt behind you. If you're not, you just won't feel it. Yeah, like I always try to add two things to that and go, when you tap hard and tap in, try to tap softly, like there's a baby chicken trying to crush it. And then you want to, the standing leg, you want to really control, so don't let that knee sort of cave in, and that, because you're putting pressure on that. in a medial way, you really want to keep that control and strong and stable. Yes. Cause that's the key of the exercise. Absolutely. And if you get yourself in the right position, it will like burn your glutes within five or six reps. It's really fantastic. Good point. And I think it's a good starting point if they are too irritated to move that knee, because when we talk about the, uh, strengthening evidence, it's not just the knee joint itself, we actually, uh, working that whole kinetic chain. So it's a very, very good start to at least be proactive doing something and strengthening the glutes, allowing the whole connect chain to start building while that knee is calming down. And then as it calms down, you can start incorporating some squats or just like wall sits that you're not going through movement. You're just holding that position and strengthening the load through there. Any other nifty exercise you'd like to implement once they are a bit uh, down the track with their rehab. Like I really like, like after a bit down the track and it can tour a bit more movement, like a single leg that lift is really nice. Um, again, you're more hip dominant there, not too much. Like it's more a Romanian that lift than a conventional that lift. And just again, strengthen that hip, really having to plant that foot and stabilize that knee. Yeah. So we're incorporating multiple joints now we're doing knee and hip and I guess it will get to a point where we're still doing strengthening, but then we start slowly implementing some running and see what they can tolerate. And just playing with the numbers a little bit that way until they are, I guess, back to the same level that they want to be at. Would you guys do anything as a warm-up? Pardon? You do. What's your cover of one or two go-to strength things? Um, Like in the initial stages, I usually like the wall sits. Um, I think they're quite nice. If we're doing, let's just say, if it's a, um, someone who's really irritated, I like to work on their step up, step down, like a single leg step down and working on a bit of control, a bit of hip control, um, and then adding in. Uh, a TheraBand is quite similar to what you guys are talking about. Say like a TheraBand around the knees, applying tension there while they're slowly stepping down the step. Um, and then just depending on what they need to get back to, I do like, um, the single leg dead lifts with like a kettlebell in the opposite hand to it. Progress people is usually really nice. Um, I really like crab walks if they are not tolerating going through knee flexion extension and they want to start incorporating a little bit more, um, lateral, like glute strength. Um, I, almost give crab walks to everyone's like one of my favorite go-tos. Um, I think that's it. I think like that would be enough. And if they're getting into the single leg deadlifts and they're getting into their squats and then maybe single leg squats, um, they're more than capable of returning to running. And if that's still flaring them up, then probably doing some plyometrics, doing some skipping hopping, like plyo lunges or something, um, before making that general, like just. really slow transition back to running. Agreed. Anything you guys want to add? Hopping, whatever it might be. You're pretty close to getting back to running anyhow. Yeah. Agreed. Um, anything that they should be avoiding when they are into their rehab and slowly getting back into running any like mistakes people make anything you can, you guys can think about? Um, yeah, don't blame your shoes. Good one. We were going, I got knee pain, I was going to buy new shoes, I'll fix it. And I'm like, mate, no, you just got no shoes, which is right. What's wrong with that? Why don't you want to fix your knee pain? That's why they're listening to Facebook groups and listening to just the general population. I think that's one of the answers that would come up. Absolutely. I think heels, heels we know will be a bit more aggravating on a, on a irritable knee, especially down heels. So. Uh, I would just be avoiding heels and stairs. I'm really, when you're getting back into running the flight of the better. And generally like speed work is okay. Uh, on a, on telephemeral pain, it's just, um, healy stuff is probably the main thing to avoid. Yeah. It's interesting to talk about that because usually when people increase speed, they're transitioning more to that forefoot running, which decreases load on the knee and then just increases load through the foot calf ankle, all that. Um, So it's a good point that you make. Often, if we're talking earlier in the rehab, one of the big things that people should be avoiding and the mistakes that they make is just complete rest and just saying, Oh, I'll just have a week off and then see how I feel next week. I'll just, I'll still irritate. I'll just take two weeks off and then see how things feel. Um, they get into real trouble there with trying to return back and it's just. the structures is getting weaker and more and more irritated with lower loads. And then they find themselves in a really tricky position. They have to really climb their way back up with some really low, slow, um, progressions through their strengthening. And the other thing I would say for a runner, if we're talking about making smarter decisions, it seems quite simple on paper, but just don't run through patella femoral pain. And a lot of runners will be like, Oh, it's starting to come on at say the 5k mark, but I just wanted to see how it'd go with it. As soon as you start to notice symptoms, definitely start backing off and because it's going to start causing more irritation. The only time I'm okay with having a complete stop in load is for like maybe two days, you can like completely rest for a couple of days. And generally speaking, that allows things to sail and breathe for a little bit. But if you're stopping for more than like four or five days, then that's where I start to get an issue because everything else starts to get a little bit weaker, a bit more day conditions, and then you have to go into this rebuilding phase. But I would say, don't be afraid to just literally completely stop for like just a couple of days. Cause that is quite often super beneficial. Don't stop for two weeks cause then you're starved. Yeah. Good. So, um, Pat, I'm a, I'm a client who's had knee pain for three weeks and I'm getting pain. Um, now going up and down stairs. Um, how long till I get better? Go to a different physio. Cause if you've been treated for three weeks and you're getting pain going up, there's been some wrong. Um, so you will probably never get better. You should come and see me or Brody. All right. Good role play there. I liked that. Uh, you can't put a timeframe on patella femoral pain. If you, usually if you've had it, for like a week, man, you just, you'll be sweating a couple of weeks. Like we'll be able to treat the factors pretty quick. Calm it down. You'd be all right. If you had knee pain for four years, then like, okay, this will be something. So it'd be like a journey that we go on. You have to work through it for a little while, really look into all the factors that could be at play. So yeah, man, hard to say. How long is a piece of string? Not sure. I've written down here some like, if we needed to do any gate retraining, considerations or talk about if someone needs to change their running style. Um, anything you guys want to comment? Oh, yes. Yeah. Um, with gate ready training, we know we're not, would you have a role risk? And what we are doing is just changing where the load goes in your body. So the cool thing about this is, is if everyone looks at them and goes about four or five centimeters lower. down. So we're talking right at the top of your calves. Put your hands there and ask yourself, do you want all the load to go below that line or do you want all the load to go above that line? So essentially you can put all the load in your knee upwards or basically in your calf and down from there. So to do that, we know increasing cadence will move the load lower. We know that going from a heel strike to a forefoot strike will move the load lower. There's one other thing I was going to say but I've just forgot it. Essentially you can move the load up and down and it's nice to know how to do that, when to do that. Cadence, this is the number one foot strike, like forefoot heel strike would be the other. Shoes can influence it but they're not that key. I reckon cadence is the easiest one for people at home. Oh yeah, you can measure it yourself, you can implement that yourself. Yeah, I think there'd be a lot of runners who will benefit a lot from that. Um, but it also depends on how low their cadence is to start with. So if they're already in like within a healthy range, say between, um, 170 and 180, um, it's probably less of a priority if they're below 165, 160, then it could be a huge game changer for people, even just, I guess, maybe just increasing 10% would, um, Well has been shown to reduce knee loads. Um, and yeah, I agree with you, Mark. It's probably the simplest thing to implement. Yeah, absolutely. Yeah. I think the thing to say there is you don't want to increase it too much. Yep. Um, because like if you're at one, let's say at one 60 at the moment, are you bumping up to one 80, you'll probably just run a lot faster. Yes. Um, plus it'll just destroy your aerobically. Yeah. Yep. You can't maintain that. Yeah, you have much higher metabolic demand if you increase your cadence by more than 10%. So it'll feel better on your knee, but you won't be able to sustain that. And the biggest and most important thing there is if you're going to increase your cadence, you want to not increase your speed, because as your speed increases, your cadence will become quicker. Yep. So if you normally run at, let's say, a six-minute pace, You want to still run a six minute pass and not just run a five minute pass and go, Oh, I've increased my cadence. No, you're just running faster. Yeah. Cause the change for your longer runs where you are running at your normal pass exactly. Yeah. Good point. Um, I think treadmills can be quite nice in that sense, just for training purposes because the belt of the treadmill stays the same and you can, um, just work out your cadence there and. I guess with, yeah, if you're outside and you're not like constantly just looking at your pace the entire time, some people might not be aware that they're slowly speeding up. Um, but yeah, it's a good one. I was going to talk to, if we're talking about gate retraining, um, there might be a population, particularly females with wider hips that, uh, do have a little bit of a crossover gate and they're sort of contacting their foot across their midline, which can put. the patelloframinal joint at a little bit of a disadvantage and sometimes just widening the step width a little bit can be really effective. But I guess that's really for a small percentage of those type of runners. Would you agree with that? Yeah, 100% definitely. And something I also have found is that if you have someone and yeah, Typically it is females with wider hips. It just mechanically, it puts your legs in a position where they'll want to have a narrow gait. Quite often increasing cadence there means your gait will be wider because you don't have as much time in front of your body and across your body to land. So sometimes it happens automatically, but sometimes it can be, I sometimes say to people, we just like, just have a little bit more daylight between your thighs and. And there you go, they feel that difference in their knee. Um, but if you're quite a slender male, probably won't have much of an impact on you unless you're doing something funny in your technique where you are crossing over. Yeah. I often tell some people who are running and their knees rub together to stop rubbing their knees together, but a lot of times they don't even know. And, um, it's really hard unless they have a mirror to actually look at, um, widening that, um, stance. And if you do widen it, it's very subtle. Yes. Oh, good point. Very good point. I often tell people, okay, you need to just slightly widen it and then they go again and then like hopping side to side and they just made the biggest adjustment. I'm like, no, no. Um, yes. Very good point. Um, yes. And then there's, I guess if you're talking, running, retraining, there's like, um, heel strike, four foot. And we know that you put less load into the knee joint. when you run mid-foot or forefoot compared to heel strike. But when you change that around, you massively decrease the load going into knee, but increase the load going into your calves. And from time to time, I have had patients of mine who I've changed that with, they'll say, oh man, my knee feels so good, but I can't walk because my calves are staffed. Yeah, definitely. And so you've just gotta be mindful of that too. Because you're not decreasing the load over all your body, you're just moving it. So less loading your knee, which is great, then more on your calves. And if your calves can tolerate that, sweet, you're all good. If your calves, if that's new for your calves, then you won't be able to walk next day because your calves are tight, which is funny. Absolutely. Um, anything else we need to cover? Like when it comes to my dot points here, I've, um, pretty much, I think we've covered a lot of the things I want to talk about, anything you guys have written down? Just footwear. Because I know people listening to this will be like, I reckon it's my shoes and like Mike said, it's not, or it's very rarely shoes are the number one reason, but they do contribute. So the way I kind of look at this is the thicker, more cushioned, more stable, more supportive, the more shoe that you have, the more it feels comfortable to run. with a lower cadence, more of an over stride and come down heavier on your heel. But in saying that, you can also run really, really nicely in quite supportive heavy, cringing shoe. On the flip side is if you're in more of the minimal sort of shoe, lightweight, flexible, less cushion, it's not very comfortable to over stride with a slow cadence and land down on your heel. It kind of forces you to have like a really nice, sharp, quick, high cadence technique. So footwear. for some people is a factor because of the way it influences your running style. Not because the shoe injured you, because the shoe made you run a certain way. So I've noticed this myself. I tend to wear like reasonably lightweight, you know, somewhat minimal shoes and I, you know, I've run in a certain way and then I, I recently ran in a pair of Essex Nimbus, which are quite heavy, quite stiff, quite good cushions. And I felt myself running with a much slower cadence, I felt heavier. I felt more sluggish. And I was running in them going, oh, this is how people run and they get knee pain. So the shoe did influence my technique and I actually felt the load in my knee, which is super interesting. So for some people, you change their shoe and it does really change how they run. But for some people, their running technique is so ingrained that a change in shoe will do nothing to them. So it's not about... the level of support it gives you. It's more about how it influences your whole greater technique. Yeah. And I think when we are summarizing the causes of patella femoral pain, when we're talking about biomechanics and overload and the relationship between the two, I think the shoes and the technique can kind of go into that biomechanical label and when you're talking about footwear, yes, changing footwear might be, might, well, can be implemented, but we're talking the smaller percentages, you know, that's like a 5% to 1% kind of change in terms of overcoming patellofemoral pain. Whereas the bigger percentages would be overcoming, well, identifying your training errors and addressing that. And then, okay, we've addressed that. If you're still getting knee pain, let's have a look at some considerations with gait retraining and yeah, take it from there. We don't need to go into the 1% as just yet. Yeah, exactly. Exactly. But it's. But I think people see it as a quick fix. Like if I just buy a new shoe, will I be sweet? And that requires so much less effort than analyzing your training areas, then doing a bit of strength work and doing gateway training and running less, running less. Yeah. The shoot shoes are seen as a silver bullet, which is not true. Yeah, absolutely. Anything else you have written down, Pat? Uh, no, just don't be dumb. If you have. like recent onset knee pain, it's usually not that tricky, not that complicated to fix. So it does frustrate me when I see someone who had a bit of a niggle in their knee and they did not address it and they just ran through it, ran through it, ran through it. And then all of a sudden they've had knee pain for three or four months and now it's going to be a little bit harder to fix. Well, actually I shouldn't say that. It's going to be significantly harder to fix. Whereas if you just, you know, If you had a sore knee for a few days or a week, you take a look back at yourself and see what can I do to address it? I say, just get onto it early. It's so easy. It's so easy to fix knee pain. If you get it in week one or week two, it's so hard if you get it in four months, six months, 12 months. I, um, I often talk about, well, you've said that, but it's like with every injury as well. I, I talk about this downward spiral. It's like, when am I seeing this person? Because. you can make silly decisions and be misguided of how to manage it. And then they just get so irritated and either weak or like they just aren't tolerating, well, they're tolerating less and less and less. And the further you go down that downward spiral, the harder it is to crawl your way back up and the more patient you need to be and the more things that need to be implemented. But if you catch it really early and you see a physio and you're, you know, you're just starting that downward spiral. It's a lot easier to work your way back up. You can say that with almost every injury. Oh yeah, absolutely. Yeah, definitely. Yeah. And if your physio starts to say your patella is not tracking, you say thank you very much and you walk out. Yes. And ask for a refund. Yeah. Yeah, but no, that's it. I reckon we've touched on it all, man. Mike, anything to add? No, I think I was gonna add what you just added. So, sweet. Yeah. Like I said, we're all on the same page here. So, um, it is a really good mastermind session. So I'll probably just recap. If there's, um, any like causes into patellofemoral pain, it's, you know, stop being dumb. First of all, um, stop doing the same thing over and over. If there is something that's flaring up the knee, just don't go back to that same thing. You might need to tweak it. Um, I guess we've talked about the causes being overload and a bit of biomechanics in the relationship between the two could be or could not be poor movement patterns that could just be overload. Symptom-wise either next day soreness or usually just pain around the kneecap, hard to localize. And then just when it comes to treatments, just making sure you're identifying the right aggravating factors, addressing those. And then if you need to use those 1% as of taping, stretching, soft tissue release, That's all great, but it seems addressing the overload and building up strength to tolerate that, to bring on that load or tolerate that load is the best thing for it. So then we just touched on the gate retraining, which don't, if there's a crossover gate or your cadence is quite low or if you're overreaching with your heel, can be something that may need to be addressed. So yeah, a nice recap there. Thanks guys, it's been good. I think like I said, just combining this mastermind session is always good and cross promoting audiences and getting the right wisdom is always a good thing. So yeah, thanks for coming on, having a chat. It's quite refreshing to hear someone who thinks the same way. I like it, it's good. Yeah, we should talk to someone who thinks the opposite way. Yeah, we should. That'd be good. severe disagreed with everything we just said. And let's see how that goes down. That'd be fun. Find someone in like a Facebook group and I'll send them your links. Yes, get them one. Stitch them up. Thanks Brody, man. It was a good chat. Yeah, sweet. So this is Brody and it's the Run the Smart Podcast for everyone listening. He knows what he's talking about. Likewise, you guys. So if you're a part of my group and you guys want to jump across to that's running, um, you guys are pretty much like on every platform. They just search where they're finding their podcasts. Yeah. There's Spotify and iTunes and I don't know wherever you get them. Yeah. You guys are on Instagram as well. What's your Instagram handle? Um, that's right. That's running. Nice. Very smart. Okay. Cool. Um, thanks guys. Let's finish up there. Thanks for listening to another episode of the Running Smarter Podcast. I hope you can see the impact this content will have on your future running. If you want to continue expanding your knowledge, please subscribe to the podcast and keep listening. If you want to learn quicker, jump into the Facebook group titled Become a Smarter Runner. If you want tailored education and physio rehab, you can personally work with me at brea Thank you so much once again and remember, knowledge is power.