Q: I am a weekend warrior, I run a few hours to burn calories. Recently during my run, I developed pain at the front of the knee. The pain was very sharp and severe. What should I do? Any recommendations? Can I still run?

Anterior knee pain amongst runners and athletes is very common. It is sometimes referred to as “runner’s knee”. It is a symptom that should not be taken lightly or neglected. Being a “weekend warrior”, it is even more important to pay attention to this symptom as your muscles, tendons and ligaments may not be as well conditioned as that of an active professional athlete. 

There are several structures in the front of the knee, the most prominent of which is the patellar bone. This is also sometimes referred to as the kneecap. A tendon called the quadriceps tendon attaches above the patella & a tendon called the patellar tendon attaches below the patella. The patella glides in the front of the knee over the knee bone called the femur, making up the patella-femoral joint. 

As we run the muscles contract and move the kneecap in the front of the femur. If our thigh muscles are weak, the pull on this quadriceps tendon is not strong and the kneecap is not able to glide well in the front of the femur.  This abnormal gliding can give rise to mechanical knee pain as the patella knocks abnormally on the femur causing pain. Similarly the tendons above and below the knee cap could be inflamed from overuse causing pain. This is known as a tendinosis. 

The structures within the knee like the menisci or cruciate ligaments could also be injured to give the sharp pain. The most common structure to be injured within the knee is the meniscus. The meniscus is a type of cushion that protects the cartilage within the knee during impact. When we accidently twist the knee or land awkwardly while running, it’s possible for the meniscus to be injured. Sometimes the cartilage on the patella gets injured and the cartilage injury can cause severe pain, especially if there has been repetitive injury to the kneecap. The cartilage over the patella-femoral joint becomes thinned out and that condition is known as chondromalacia. However a cartilage injury of the patellar is uncommon.

It is best to seek an expert medical opinion with an orthopedic surgeon if the knee pain persists. Once a ligament or meniscus knee injury has been ruled out, physiotherapy can be started to strengthen the muscles. A structured physiotherapy program is useful to return a person to sports. Some patients do very well with knee taping and by changing their running pattern. Occasionally if there is structural damage to the knee and when physiotherapy has failed, surgery may be necessary. Knee surgery is usually done via arthroscopic (keyhole) surgery and there is minimal downtime following surgery.

Knee Structure and Injuries

Q: I run about 3-5km every 2 days. I press my fingertips along my shin, I spotted sharp pain but feel worse in the morning especially I try to lift my foot up to flex my foot.

Do I have shin splints? What is that?

The term “shin splints” refers to pain along the inner edge of the leg bone (tibia). Shin splints typically develop after physical activity. They are often associated with running or walking/marching for prolonged periods of time. A shin splint is an inflammation of the muscles, tendons and bone tissue around the tibia bone. In general, shin splints develop when the muscle and bone tissue in the leg become overworked by repetitive activity. 

Since shin splints are typically caused by overuse and they are self limiting. Standard treatment includes several weeks of rest from the activity that caused the pain. It may be advisable to switch to lower impact activities such as swimming or stationary biking. Shin splints usually resolve with rest. Before returning to exercise, you should be pain-free for at least 2 weeks. 

If the pain in the shin persists it is best to seek a medical opinion. Occasionally a stress fracture occurs in the tibia.  A stress fracture is a small crack in the tibia caused by overuse. Your specialist may sometimes order a bone scan or magnetic resonance imaging (MRI) study to pick up on stress fractures in the tibia. 

It is best to prevent the occurrence of a shin splint. It is important to make sure you wear shoes designed for your sport and they must be of the right fit. Slowly build your fitness level by engaging on a structured fitness program. Avoid bursts of exercise routines and consistency is the key to avoid any overuse injury to the tibia. 

Running Injuries in Knees

Q:  My 42 yr old aunty does a lot of running. She has a heel pain problem, the pain goes where the Achilles tendon attaches to the heel bones, which interfere her normal activities, particularly when she exercises.   What are the causes factors? What can she do? 

She most likely has Achilles tendon inflammation. There are two types of Achilles tendinosis (inflammation of the tendon), based upon which part of the tendon is inflamed- insertional tendinosis and non insertional. 

Pain occurring in the area where the Achilles tendon attaches to the heel bone is known as insertional Achilles tendinitis involving the lower portion of the tendon. This type of Achilles tendinosis is more common in the middle to older age group. A small group of patients may also have associated plantar heel pain (pain on the sole of the heel) due to plantar fasciitis (inflammation of the plantar fascia). 

In non-insertional Achilles tendinitis, fibers in the middle portion of the tendon have begun to degenerate. Tendinitis of the middle portion of the tendon more commonly affects younger people.

Bone spurs (extra bone growth) often form with insertional Achilles tendinosis as a response to repetitive stress to the tendon. The tendinosis is typically not related to a specific injury and is a chronic degenerative condition. The bone spur (extra bone growth) where the Achilles tendon attaches to the heel bone can rub against the tendon and cause pain.  Some patients experience pain and swelling that is present all the time and it gets worse throughout the day with activity. 

In most cases, nonsurgical treatment options will provide pain relief, although it may take a few months for symptoms to completely subside. A structured physiotherapy program helps to condition and strengthen the Achilles tendon. 

Surgery should be considered to relieve Achilles tendinosis only if the pain does not improve and it becomes difficult to wear shoes or perform simple day to day activities. It is best to discuss the options with your Orthopedic specialist. The specific type of surgery depends on the location of the tendinitis, amount of bone spurs and the amount of damage to the tendon. The goal of this operation is to remove any excessive bone spurs and repair the damaged part of the Achilles tendon. There are several techniques ranging from keyhole surgery to mini-open surgery for insertional Achilles tendinosis. 

Prepared by,

Dr K Kannan

MBBS (S’pore), MRCS (Edin), MMed (Orth Surg), FRCS (Edin) (Ortho & Trauma), FAMS (Ortho Surg)

Consultant Orthopedic Specialist Surgeon

Centre for Orthopedics