I had a similar problem that peaked when I ran a marathon on very little training (stupid, I know, but I'm a Marine so go figure).
Basically, the problem seemed to be an imbalance in muscle strength between the inner and outer quad causing the knee cap to track incorrectly. Here's what worked for me: I stopped running for 4 weeks and started riding a bike for cardio, I bought a pair of motion control insoles and one of those knee straps that go just below the knee-cap, I iced the affected knee as often as possible, and began taking Glucosamine and Condroitin supplements. I never did see a doc though I do recommend you see one. Regardless, my knee seems to be 100% again.
Good luck.
Article:
They go by many names--runner's knee, quadriceps insufficiency,
chondromalacia--and, like most overuse injuries, they are a result of
change. For a runner, it can be new shoes that change your gait. It can be
going from a pair that's badly worn at the heel to a new pair of the same
brand. It can be starting to run hills--when you run uphill you I shorten
your stride, because you run with more of a bent knee; downhill you
lengthen your stride, because the earth is falling away from you and your
foot doesn't hit the ground as quickly. It can be from training on a
track. About 60 percent of the usual quarter-mile track is curved, and
when you run on an unbanked curve, you bank yourself. For a dancer it
simply may be the result of working toward a new role, one that involves a
lot more jumping, say. For a gymnast it can be no more than changing
floors (and it doesn't have to be a bad floor; there's some evidence that
any kind of change, even from an awful floor--concrete, for example--to a
good, sprung wooden floor can do it).
Hikers often develop knee problems while trudging downhill rather than up.
The reason may be that it's harder on the muscles to constantly lengthen
than to contract. For example, it's easier to get out of a chair slowly
than it is to sit down in one slowly, and sitting down in a chair, so far
as the quadriceps is concerned, is what you're doing when you go downhill.
People who go camping in the mountains are often fine going up. They pitch
their tent, fish, cook out, and have a grand old time. But when they come
down they have fits. The Grand Canyon, into which you go down before
coming up, is notorious for causing people who may have had only minor
knee complaints to be in such difficulty by the time they reach the bottom
that they must resort to a burro to make it up to the top. And in
day-to-day living people will frequently complain that they can go up
stairs but can't come down. Ironically, fitness programs, whose purpose is
to make your knee stronger, can cause the extensor mechanism the injuries
they purport to prevent. So far as the quadriceps is concerned, lifting
weights by extending your leg is just like going downstairs. Essentially
what you're doing is hanging a weight on your foot and trying to
straighten out your knee against it--not a terribly natural thing to do.
People subject their knees to this kind of abuse because it's an effective
way to isolate muscles, but if the vastus medialis isn't strong enough to
hold your kneecap in place, and you hang seventy or eighty pounds on your
foot, your kneecap just may try to find a new groove.
Skiers who lift to get in shape at the beginning of the season often
experience just this problem. Their legs were hard as steel at the end of
spring, so they start big, lifting at a level that the large part of the
quadriceps may be able to handle but the vastus medialis, which falls out
of condition more quickly than the rest of the thigh, cannot tolerate. The
upshot: a sore and tender knee. It's important to build up slowly, with
weights light enough for the vastus, then gradually increase. Squats can
be the most harmful of all. At the least, a squat subjects the back of
your kneecap to about seven and a half times your body weight--around one
thousand pounds per square inch--but imagine the forces on the knees of
people who do their squats with 200 pounds of barbells on their shoulders.
And when you ski you're really in a semisquat--or you should be--and if
the vastus isn't strong enough, or if you start out in good shape but ski
too long and the muscle runs out of gas (and the first part to run out of
gas will invariably be the vastus because there isn't as much of it in the
first place), it's a solid bet you'll find yourself in the first-aid
station before long. So these changes can be type-of-activity changes,
level-of-activity changes, terrain changes, footwear changes, even changes
as well meant as trying to get in shape.
The pain of this kind of injury is like all overuse type pain in that it
creeps up on you. Frequently you first notice it after the activity. Then
you start noticing it toward the end of the activity, then earlier in the
activity, and pretty soon it's there all the time. Usually it hurts in the
front of the knee, but in a diffuse way. It's not like a torn cartilage
(which we'll get to later in this chapter), where you can put your finger
against a spot on the knee and say, "That's where it hurts, right there."
When you ask people where an extensor mechanism injury hurts, 75 percent
of them will rub a finger up and down along the inside of the kneecap. For
another 15 percent it will be on the outside of the knee, and the last 10
percent can't quite figure out where it is--just somewhere around the
front of the knee. It's worse with activity, better with rest. And as it
gets worse, you develop problems elsewhere. So if you would describe your
pain this way, you may have something else going on as well, but you
certainly have a problem with the vastus medialis and the kneecap. From
now on we'll call the injury chondromalacia. Chondro means "cartilage,
"malacia "wear"--to wit, cartilage wear. The kind of problem we're talking
about may not have anything to do with cartilage wear; nevertheless, the
term is used to describe it. (More on that later.) One of the next
tip-offs to appear, and the last to disappear, is what is called the
positive theater sign: you're unable to sit with your knees bent for a
long period of time. People with this problem are the ones you're always
tripping over in a crowded theater because they sit on the aisle and
stretch their legs out. These are the people who have a hard time in the
economy section of airplanes, or who can't take long rides in VWs. If
you're one of these people, and you've been sitting for a long time, you
may get up and discover that your knee just won't work. It might take four
or five steps to get it to straighten out. The knee isn't locking, really,
but doing something that's called gelling (as in "gelatin"--rubbery; hard
to move).
Next you may start to get some swelling in the knee. That causes the knee
to ache, usually in the back, where the capsule surrounding the knee is
softest and the fluid accumulates most readily. When you bend your knee,
the fluid squirts into the back, and it may feel as though there's an
orange stuck back there. At the least it will feel tight, as though
something's in the way. Something is indeed in the way: fluid. But people
usually don't realize that that's the problem. They just know that they
can no longer get into a squat. Not because the knee hurts so much, but
because it feels tight, full, sort of boggy. As the fluid continues to
accumulate, your knee will begin to look, as well as feel, different.
It takes quite a bit of fluid in the knee to call attention to
itself-about an ounce to an ounce and a half will just begin to make a
difference for most people. But if you really know how to look at your
knees, you can tell. Stretch them in front of you on the floor, or on top
of a coffee table, all the way out, without tightening up the muscles (if
you tighten your muscles you push all the fluid to the back of the knee).
Then check to see if both knees look the same. There should be hollows on
either side of your kneecap--look for them. If one knee is less delineated
than the other, then it's time to stop ignoring it. One thing leads to
another: now the pain in your knee may be sharper. If there's a lot of
fluid in your knee, your kneecap can't possibly be where it belongs. It
may have been displaced a bit to begin with; now it's more out of place,
pushed to the side by the fluid. It may start rattling around a bit,
making clicking sounds, or popping--repetitious noises. And now you're
using your knee differently. You're reluctant to straighten it--that's an
extreme motion and it hurts--and you're just as reluctant to bend it all
the way. In fact, you can't bend it all the way; it's stiff, as though
filled with gelatin. So you start limping, keeping your leg somewhere
between too straight and too bent. Which means that you must walk on your
toes, because your partially bent leg isn't long enough otherwise.
When you walk on your toes, your calf starts to hurt, as your calf muscles
are the ones that keep you up on your toes. The gastrocnemius muscle in
the calf begins above the knee, and the strain on it may itself cause more
knee pain. Or the hamstring muscles may begin to hurt where they connect
in the back of the knee, because they're helping to keep the knee
partially bent all the time. And your quadriceps aren't being used
normally, so they get weaker, especially the vastus medialis, which was
too weak in the first place. Then your knee may start giving way. It just
won't hold you up. You'll be walking and suddenly feel as though you
stepped into a hole, with nothing there for support. But before you fall
you catch yourself--until the next time. All these things feed on
themselves. The more problems you have, the less normally you're going to
use your knee. The less normally you use your knee, the weaker it gets.
The weaker it gets, the more likely you are to have problems. And once
this cycle gets started, it's not going to get better by itself,
especially because it sneaks up on you. Without thinking much about it,
you start altering your activity to fit your diminishing capabilities. You
used to run five miles a day; after a month you're down to two, then one.
You used to take aerobics class five times a week; now you go three times,
and a month later it's all you can do to take any classes at all. A month
after that you have trouble walking to the studio from the parking lot.
You always take the elevator now, and you drive around the block four
times just to find a parking place that's three blocks closer because it's
going to be hell walking down the hill to the office.
And all this time you figured it would just go away. Didn't it go away
last time, when you were ten years younger? Or, more likely, there was no
last time. You just haven't had to deal with something like this before.
The temple of your body has up to now remained inviolate, and you can't
quite believe that it's happening to you. Except that it's happening, all
right, and you'd better do something about it or it'll simply continue to
happen, and get worse.
Gutting it through is not the answer. Neither is simply stepping up your
activity rate. Some people figure, rightly, that if the knee is weak
there's only one thing to do: make it stronger. So they lift weights even
more than they used to, walk, run if they can, in spite of the pain. And
the knee simply doesn't come around. It's not that these activities aren't
making you stronger, it's that they're making both sides stronger at the
same time. So the bad side remains weak by comparison. You've got to do
something to get the bad side up to the level of the good one, otherwise,
the discrepancy will remain, along with the pain. You've got to do
something extra with the side that's bothering you. And that extra isn't
nearly as hard as you might think.
What to do about it
You must break the vicious circle, get rid of the pain so you can again
use the knee normally, get rid of the swelling, and build some muscle. The
solution (and, indeed, the solution for other problems as well) is to make
the quadriceps on the bad side, specifically the vastus medialis,
stronger. If you can cycle, one-legged cycling will make it stronger, but
frequently by this point you're no longer able to do weight exercises (and
cycling is really a weight exercise). Usually about the only thing to do
is tightening exercises.
It's simple: straighten out your leg in front of you. You can sit on the
floor, or sit in a chair and rest your leg on a coffee table, or even sit
on the edge of your chair and extend your leg, with your heel on the
floor, so that the knee is perfectly straight. Just make sure it's
relaxed. Then place your fingers about an inch above the top of your
kneecap and an inch to an inch and a half toward the inside of your leg
(toward the midline of your body) and tighten your thigh. If you're doing
it right, you should feel the small muscle below your fingers get
tight--really tight. If that's the case, you've found your vastus
medialis, and you're in business. Tighten up and hold it for six to eight
seconds, relax for a couple of seconds, tighten and hold for six to eight
seconds, relax for a couple. Do three or four of these sets ten to fifteen
times a day. Sometimes it may be difficult to tighten the muscle. You may
find that when you tighten your thigh much of the muscle is rock-hard but
the portion beneath your fingers remains soft. In that case it's a matter
of learning how to control the muscle in order to exercise it. One easy
method is to roll up a towel and place it beneath your knee. Then push the
back of the knee down into the towel. When you do that, you'll find that
the vastus medialis beneath your fingers tightens automatically. You can
accomplish the same thing by putting your fist underneath your knee and
pushing down. It really doesn't matter what you have to do to persuade the
muscle to work--you may have to put the dog under your knee to get it
right--a rock-hard contraction is the bottom line. Continue doing the
exercise in this way until you find you can tighten the vastus without
anything beneath your knee. Again, tighten for six to eight seconds, then
relax, tighten again, and relax, three or four times in all. And do these
sets ten to fifteen times a day. (If everything fails, you might want to
try an electrical muscle stimulator to help you figure out how to do the
exercise. The problem is that now you'll have medical bills--doctor,
physical therapist, machine rental--but it's better than not getting the
exercise at all.) It may sound horrible, but what we're really talking
about is no more than seven minutes of work--thirty seconds of exercise
ten to fifteen times a day. You can easily fit that much effort into your
schedule if you tie it to something you already do a lot. If you're in
school, do the exercise set every time the bell rings. If you're in the
office, do it every time the phone rings. (Do a set every time somebody
puts you on hold, and in a week you'll probably have a quadriceps that'll
lift buildings.) If you're at home watching the tube, do it at each
station break. Don't try to do fifty of these at a time, in line with the
theory that if four are good, fifty must be better. Not so. For one thing,
it's boring--doing fifty of these is like watching paint dry--and for
another, it's almost impossible to do more than a few really good-quality
tightening at one time. Don't worry, you'll be able to see the increase in
muscle in two to three weeks. And the odds are better than four out of
five that you' 11 get better. It takes the most discipline in the
beginning. Later, when your knee starts letting you know that it's
improving, doing the exercises is a pleasure.
Sometimes the kneecap is so badly out of alignment that it hurts even to
do the tightening exercises. If that's your case, pushing the kneecap
toward the center of your knee with your fingers can make the exercise
more comfortable. Some people prefer to wrap the knee with an Ace bandage
or wear a neoprene knee sleeve. Such sleeves are available at hospital
supply shops and some sporting goods stores. Pro and OrthoTech are the
names of a couple of good ones. They keep the knee warm and may help hold
the kneecap in place. Icing after activity helps knock down inflammation,
as will aspirin or other anti-inflammatory drugs. But all of these things
are no more than adjuncts. They may make life a little easier for you, but
you're not going to get rid of the problem--if you're going to get rid of
it at all--until you make the bad leg stronger.
You might discover that you're among the 15 percent or so of people who
just don't respond to this kind of treatment. It may be that the problem
has gotten so bad that the back of your kneecap is chewed up (see the
following section), or the capsule may have been scarred and has become
too tight. If the exercise hurts (and as a general rule you shouldn't try
to strengthen things that hurt), and displacing the kneecap with your
fingers or a bandage doesn't help, then maybe you should see somebody. The
exercise simply may not work for everyone. But if you've experienced the
symptoms we've described, and the swelling isn't too bad, and your knee
isn't locking or doing any other horrible things, and doing the exercise
doesn't hurt, then it won't harm you to back down on the pain-producing
activity and try the program for at least two to three weeks before you
think about going to a doctor. A doctor who deals with these kinds of
things regularly is going to give you the same advice, anyway. He may give
the knee a thorough exam, take X-rays, test your strength, but at the end
of the visit he's going to tell you to make the muscle stronger--and it'll
cost you $200. If you do the exercises and develop lots of good muscle and
it doesn't change things, then you're between a rock and a hard place. You
may have to do something more spectacular. Like seeing someone. As a last
resort, there is an operation that can help chondromalacia. It involves
detaching the ligaments that hold the kneecap to the outside of the knee
so that the vastus medialis can pull more effectively to the inside. But
most likely you'll never have to go that far. First things first. Try the
exercises. Odds are you'll have to do no more. And once back on the track,
or the court, or in the studio, keep the muscle strong. The vastus
medialis--so much depends on so little.
