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Knee Pain in Women Runners
Why Is It So Common?
Knee pain is one of the top five running injuries impacting up to 2.5 million runners in the United States. There are many features of this common malady, some of which remain obscure. A number of risk factors have been cited over the years. Some of these factors affect women more so than men.

Female runners frequently experience knee pain on the front of the knee joint around their knee cap, known as the patella. The pain can be anywhere around the knee cap, on either side, above, or below.
This syndrome has been commonly called Runner’s knee. The more commonly accepted medial term is Patello-femoral Pain Syndrome. The femoral part of the description applies to the thigh bone or femur.

Symptoms include pain which occurs during or after running. Commonly the pain is worse when going down stairs or running down hills.

The patella (knee cap) is surrounded by the lower portion of the quadricep muscle on the front of the thigh. The quadricep muscle is actually made up of 4 different muscles (therefore the name). The under surface of the knee cap has a ridge which rides in a corresponding groove on the end of the thigh bone. When the knee bends, the knee cap (patella) should move and slide smoothly up and down in this groove, similar to a train on a track.
With Runner’s Knee or Patello-femoral Pain Syndrome, there is either a dysfunction or disruption of this smooth gliding, tracking motion.

There are several likely causes of this abnormal tracking. An imbalance in the strength or flexibility of the muscles surrounding the knee may be to blame. In runners with this type of knee pain, the muscles on the front and outside of the thigh (your I.T. band vastus lateralis) are often stronger and less flexible than the smaller muscles (vastus medialis) on the inside of the knee and thigh. Since the patella is a part of the quadricep complex, the larger outer muscles may pull the patella sideways and slightly off track.
This problem may be exacerbated in women due to the fact that the femur (thigh bone) is not in the optimal position as it descends down from the pelvis. Women often have wider hips resulting in a larger angle, called the Q angle, as the thigh meets the leg bone (tibia). This condition is commonly called “Knock Knee” or Genu Valgum.

Other reasons that Patello-femoral Pain Syndrome affects so many women, is that they have relatively weak hip muscles which can contribute to a weak core. Therefore, poor control form the hip muscles can cause faulty mechanics at the knee.
Other risk factors which can cause knee pain of this kind in women are abnormal patella shapes which are hereditary, a smaller or larger than normal patella, hyper mobility of the knee cap, tightness in the calf muscle and hamstrings may be a contributing factor as well. The knee cap can also be in an abnormal position in its relationship to the thigh bone groove (it may sit too high or too low in the groove).

Excessive abnormal pronation of the foot, a flattening of the arches of the foot in gait and running, can cause abnormal tracking of the knee cap to occur.
Over training, improper shoe selection, running on canted or uneven surfaces can also contribute to this syndrome.
What can you do to prevent and treat Patello-femoral Pain Syndrome?

Treatment options include core strengthening exercises, flexibility exercises of the hip, thigh, and calf. Custom made biomechanical insoles are helpful to realign the foot posture and protect the structures above form abnormal forces.
Other helpful tips include cross training on a bike, swimming, and an elliptical trainer. Try not to run until pain has subsided and you have corrected your abnormal mechanics. Simple rest alone would cure you but you must correct your abnormal biomechanics.

When you do return, use an easy graded return, avoid speed work, avoid downhill runs or walks, check your shoes to make sure they are the correct shoe for your foot type by checking with a running store nearest you.


Dear Friends and Colleagues,
In the past some of you have asked me podiatric sports medicine recommendations regarding shoes, biomechanics, and training techniques. I have decided to do a brief news letter on a quarterly basis to keep you informed on what’s new in the world of podiatric sports medicine. I hope you find this helpful. I promise to keep it short and sweet.

While there is no single best shoe, all my athletes have different needs. There are several key questions that I ask them about their training and running history. I also want to know height, weight, their basal metabolism rate if they know it. I also want to know exactly how much running they do and on what terrain they run on, how often they train and at what intensity they train. If they are having any type of injury or pain, I want to know if they’ve changed anything in their routine such as a shoe, a course of run, a type of surface, increased speed, anything that can give me a tip on why things are going wrong.

The athlete’s lower extremity biomechanics are a huge part of the process that I use for shoe selection and injury evaluation. I have seen three basic foot types in my practice. I classify these basic types through the medial longitudinal arch and its relationship to the transverse arch. I describe the longitudinal arch as the relationship for the rear foot to the mid foot and the transverse arch as the guide post for the mid foot to fore foot. There are three basic configurations. The rear foot arch could be in a high or elevated position or a low position. This is usually determined by clinical examination or by x ray evaluation of the calcaneal inclination angle. The calcaneal inclination angle is a bisection of the calcaneas on a lateral x ray view. This is measured, any angle which is over the normal 18 to 21 degrees is considered, in my opinion, a high arch rear foot. If you do not have access to an x ray this foot type can be noted by non weight baring position, the foot remains in a high arch position in the medial longitudinal arch and when you weight bare the foot remains in a similar position showing high arch rear foot and high arch fore foot. This foot type requires maximum amount of shock absorption and excellence I biomechanics in running. These athletes usually require a technique coach or a movement specialist to help decrease the shock that goes through their body.

The next foot type is the most common type that we see in the United States. This is a low arch rear foot and a low arch fore foot. Any angle measured through the calcaneas under 18-21 degrees is a relatively flat foot or pes planus foot type. These foot types absorb shock very well because they are flexible but they have a very hard time re supinating or becoming rigid for propulsion. This is where their problems develop. These foot types usually require some type of orthotic device, performance enhancement device, or just a stability or motion control running shoe.

So those two foot types comprise approximately 90% of all foot types that we see in athletics and in the general population. The tricky combination is the high arch rear foot and low arch fore foot because that athlete requires shock absorption on heel strike that can be provided through a neutral shoe but on take off or propulsion he needs stability. What does this all mean? This means he has a supinated rear foot and a pronated fore foot. This foot type will always give you trouble in diagnosing and in treatment. They may return to your office or training room for multiple issues. One problem resolves and another problem begins. We should be highly suspicious that an athlete has this specific foot type once they enter your training room for multiple problems in different sports. This foot type can be detected if you have the athlete seated, non weight baring on your training table and it appears that they have a high longitudinal arch. Once you place the athlete in a weight baring attitude the fore foot will appear to collapse and the heel may go into an everted or valgus position. This is the case that I described as a high, low foot type. Supinated on contact, lacking of shock, and pronated in take off. With this foot type we usually recommend a neutral cushioned shoe for shock absorption of rear foot and a custom made insole device for the control of pronatory forces in take off phase of gait.

Hope you find this helpful in your practice.


Pronation of the foot in running? What’s it all about?
Whenever we read an article about running the word pronation usually pops up. Most people think that pronation is a bad word like a four lettered bad word. I think the confusion is based on 2 different sources. The first is that there is a pronated foot type which just means a flatfoot deformity and the second source of confusion is the word pronation in the gait cycle or running cycle reference.

So let me try to clear some of this up for my new runner friends. The first thing one must know that some pronation is required in the running cycle during heel strike. A normal amount of pronation is required to attenuate the shock of heel contact. The problems and injuries occur in runners when there is too much pronation during the cycle. With excess pronation, the foot cannot convert to a rigid lever which is the necessary position for propulsion or take off. This conversion from pronation or (a lose bag of bones foot) to the supinated or (rigid lever foot) is delayed in the over-pronated foot and this results in abnormal muscle activity and bone irritation.

Some muscles and tendons are now working harder than they should be so they recruit other muscles which is where the term overuse injuries gets its meaning. Stress reactions and stress fractures result from the excessive muscle pulls on the bone. The more severe the pull the more likely the stress fracture occurs and vice versa.

Overuse injuries also increase in severity with the timing in which the over-pronation occurs. For example, if the over pronation occurs during propulsion it is more destructive to the foot and leg, than if the excess pronation occurs in the middle of the cycle. The reason being the abnormal forces are spread over a wider area at mid stance making propulsion delayed and sending a horrible torque through the great toe joint. So bad pronation is bad, and good pronation is helpful.


Muscle imbalances can cause lower back pain in runners
During the late propulsive stage of running (also called the take off stage) there is tension created in the psoas and ilacus muscle as well the rectus femoris muscle, your hip flexors located in the front of your hip and groin.

These muscles also help to extend the lumbar spine and tilt the pelvis forward. To protect against these potentially injurious motions, the external obliques, and the rectus abdominus (2 of your important abdominal muscles which help with core strenght) pulls the pelvis upwardly counteracting forces caused by the hip flexors and allowing the spine and pelvis to function as a stable anchor.

So if your hip flexors are tight and over-developed this anterior or forward tilt of your pelvis can cause lower back pain.

To counteract this you must stretch your hip flexors and strengthen the abdominal muscles. This will reduce pelvic tilt and decrease the chance for low back pain to develop. Also, strengthening the low back can improve the balance between the muscles of the hip region.

Helpful Hints For Every track and Cross Country Coach.

  1. All runners are not created equally some will break down once in awhile, and some will break down all the time.
  2. All Runners on the team should receive a preseason biomechanical screening. This can be done in a matter of minutes per athlete.
  3. If major defects show up in this screening a more involved exam should be performed.
  4. Most injuries are predictable if you know your athletes mechanics.
  5. Most common injuries occur due to doing to much to soon, poor mechanics, changing of running surfaces, improper shoe selection, improper training.
  6. Training programs should be based on past medical histories, and all abnormalities should be corrected before progressing your athletes.
  • Dr. Cohen Lectures at STRIVE Physical TherapyDoing_it_right_0914
  • Dr. Cohen Lectures at STRIVE Physical Therapymoorestown running company screen shot

Dr. Lee and Unequal Technologies
unequal2Dr. Cohen has been named medical advisory board director of sports medicine for Unequal technologies. Dr. Cohen will be responsible for hiring everyone from doctors ,athletic trainers, and medical sports equipment specialists. These specialists will Dr. Lee and Unequal Technologiestrain staff at schools in the proper use of Unequal Technologies new shock suppression gear. This exciting new gear ranges from cushioned footwear to headgear that resists concussions. Dr. Cohen is glad to be affiliated with a company that puts out such quality products. To check out these products visit http://www.unequal.com/.

Dr. Cohen at the Healthplex
Dr. Cohen delivered a lecture on sports medicine at the Healthplex in Springfield hospital. He will deliver the speech to the sports medicine department and will speak on running injuries as well as the use of custom insoles in minimalist and traditional running. The people at Springfield hospital were happy to hear about the many things Dr. Cohen still picks up on while working with elite athletes.

Dr. Cohen Helped Philly Favorite Brandon Duckworth Get Back to Form
photoduckworthDDr. Cohen Helped Philly Favorite Brandon Duckworth Get Back to Formuckworth, best known in Philly for his outfield accolytes in the Duck Pond, has been struggling with heel pain for the past nine months. This pain has hampered the pitchers career, keeping him in the minors last year. With the help of Unequal Technologies Dr. Cohen fitted Duckworth with a custom Unequal Technologies insole that allowed him to run, train, and pitch pain free just in time for pitchers and catchers camp on Wednesday. Duckworth’s newfound insoles will help him in his attempt to join the Boston Red Sox staff this spring. Good Luck Brandon!

Dr. Cohen Visits Heinz Feild with Unequal Technologies
Dr. Cohen recently took a trip to Heinz field with Unequal Technologies to fit the Pittsburgh Steelers with their state of the art Kevlar grade shock suppression gear including new helmets, thigh pads, and foot insoles. His next stop around the league is Dallas, Texas to continue helping the NFL keep their athletes safe. Dr. Cohen is thrilled to be working with Pennsylvania based Unequal Technologies as he as plenty of experience recommending their shoes and other foot products to athletes. Unequal Technologies, who recently signed Michael Vick to an endorsement deal, makes quality sports footwear, insoles, and body padding that has been proven to help reduce shock from sports hits. Follow the link to see Heinz Feild pictures from Dr. Cohen’s trip.

NBA players visit Dr. Cohen
Due to the NBA lockout many professional basketball players are forced to play in Europe during the upcoming season. Being the team podiatrist for the 76ers has given Dr. Cohen the chance to get to know the players and some have come to his office for a final evaluation before leaving for Germany, France, or Spain. While he enjoys seeing the players he is going to miss being with the team this year.