Subjective Interview:

This patient is a healthy, young female who presents with a primary complaint of bilateral anterior knee pain. These symptoms began shortly after beginning intensive training for a half-marathon, which she has been participating in for a few months now. In the beginning, the pain would not begin until the end of the run, then progressed to the middle of the run, and finally now is present throughout the entire run. She actually experiences pain during activities of daily living at this point as well. This pain is described as diffuse general knee pain that can vary between anterior and posterior knee regions with the right knee being more symptomatic than the left. The pain has not radiated distal or proximal to the knee region. There was no traumatic incident that brought on the symptoms. Additionally, she experiences pain during weight-bearing functional activities (squats, lunges, ect.) with increasing angles of knee flexion leading to increased pain. Her primary goal at the time of evaluation was to be pain-free and prepared to complete her half-marathon (~1 month away). Her primary care physician performed x-ray imaging and found minimal joint space narrowing of the medial tibiofemoral compartments bilaterally. There were no other significant findings from this radiological report.

Examination Findings:

Upon static observation, she demonstrates fairly significant genu varum, squinting patellae, and ‘toe-in’ bilaterally. Prior to beginning examination, fracture at the knee region was ruled out via the Ottawa Fracture Rules and prior radiological findings.

Movement analysis utilizing the lateral step-down and drop jump tasks showed several areas of concern. The lateral step down showed an uncompensated trendelenburg posture at the pelvis with a forward trunk lean. Additionally, the drop jump task showed decreased knee flexion with her knees extending well past her toes at impact. Both tasks elicited pain with the drop jump being most problematic.

During the physical examination, she stated tenderness to palpation of medial and lateral joint-lines bilaterally, but no significant findings with palpation to the soft tissue structures in the knee region.

Range of motion testing indicated a small deficit bilaterally in knee flexion/extension with increased pain associated with end-range knee flexion. There were no significant findings at either the hip or ankle in terms of ROM limitation. Crepitiation was noted throughout entire knee flexion/extension ROM. Accessory motion was WNL for tibiofemoral, patellofemoral, and tibiofibular motion.

Manual muscle testing results seem to indicate a bilateral limitation in hip abduction, external rotation, and extension strength with no deficits found in the musculature at the knee. She did experience pain with knee flexion and extension, but this pain did not implicate the hamstring or quadriceps musculature as the pain was once again a diffuse general knee pain and could not be localized to these specific muscle groups or their associated connective tissue.

Based on the prior examination findings, meniscal pathology seemed to be a likely hypothesis as 2 variables identified by Lowery et al to be indicative of a meniscus tear were present (pain with passive knee flexion and joint-line tenderness). With these 2 findings alone, they found that there was a specificity of 71.6%, sensitivity of 51.4%, and a positive predictive value of 65.5%. Unfortunately, no other factors were present in this patient to help increase the likelihood of this diagnosis (McMurray Test, pain with Modified Bounce-Home Test, and history of catching/locking were all negative). Patellofemoral special testing indicated a lateral pull of the patella and pain following the patellar compression test. Both of these implicate potential mal-tracking and subsequent altered patellofemoral contact area and articular cartilage damage. This suspected altered contact area did correlate well with the findings of the movement analysis and manual muscle testing.

So, if this was your patient, what would you hypothesize the underlying pathology to be? What else would you test? How would you move forward with treatment?

About the Author John Snyder, PT, DPT, OCS, CSCS

I am a Physical Therapist, a Board Certified Orthopaedic Specialist, a Strength & Conditioning Specialist, an Educator, and a Research Junkie. My goal is to provide resources for orthopedic and sports medicine clinicians to keep up to date with the current literature and allow them to translate it to their practice.


  1. All meniscal tests in isolation is fairly limited as a means of ruling in a meniscus tears. Further, joint line tenderness in isolation is such a non-specific finding. Given this patient’s symptoms, symptom onset/progression, as well as bilateral complaint make a meniscus pathology very, very small based on history alone.

    I do not see an underlying pathology per se in this case. Based on the information provided, this patient has non-pathologic knee pain exacerbated by running, progressed by increased mileage/intensity.

    Number one, I would encourage her that her imaging is essentially negative and there are no occult signs of “scary” pathology. Then, I would work on the impairments identified, assess her running gait and see if any changes in the way she moves/runs changes her main complaint, and get her moving in closed chain in new, novel, and relatively pain free fashion.


  2. Nick and Kyle,
    Thanks for the replies! Meniscal pathology was quickly ruled out as the negative tests began to pile up… I then moved on to the faulty running mechanics and ‘weak’ hip musculature that could potentially help contribute to the improper biomechanics. Additionally, her training regimen was not properly progressed from what I understood. She went from running once a month to running 4-8 miles daily. This could DEFINITELY be a contributing factor…


  3. John – Thanks for posting the case study. This is a fine example of how we have the potential to make a scenario far too complex – and prone to over-management – if we are not careful. The scientific literature on the etiology of running injuries would indicate that anywhere from 70 to 80% of running injuries are directly related to “training error” – oftentimes “too much, too soon”. The vast majority of running injuries are thus a situation in which the rate of application of training stimuli exceeds the rate of recovery and adaptation of the tissues. Most runners do not have activities in their training program (i.e. strength training) which help to promote recovery. With that said, there is little evidence to indicate a direct cause-and-effect relationship with biomechanical mal-alignments and similar clinical observations.

    I would utilize a mechanical assessment process (per MDT – repeated movement testing) to fully understand the effects of mechanical loading strategies – especially given that running is, in essence, repeated movement. Once a mechanical diagnosis is established, progressive mechanical loading strategies could then be applied, and training modifications implemented. Training and recovery strategies MUST be addressed as this is the root of the problem.


  4. I would also look at the foot and see how the mechanics look in a step forward position or a one legged stance position . Those are good ” running ” simulation positions to look at as running is a one legged activity for the most part!


  5. I think this the main point as Allan and Nick and John all mentioned:

    “She went from running once a month to running 4-8 miles daily”

    Simply, As Allan stated “training error” – oftentimes too much, too soon.”

    Also, quick clarification John. You mentioned “Meniscal pathology was quickly ruled out as the negative tests began to pile up” I would begin, and almost fully rule out the potential of meniscal pathology based on the history alone. If she did happend to have a meniscus tear in this exact clinical scenario, it is unlikely it happened traumatically, and very much likely an incidental finding, or incidental pathology IMO.


  6. A very nice, well documented case report. My compliments for that. This is the way we should report our findings on the patient. I definitely agree with most of the posts above. Increase of the activity is one of the causes. Has the patient a normal BMI ? Does she have good running shoes ? I also agree with to look at the whole chain, foot, knee, hip, lumbar spine. I don’t think that there is tissue damage, more a problem of overloading. Decrease the activity, minimally a day rest between two running sessions. Further i should do an ultrasound imaging examination. In the Netherlands we are allowed to do so, so i can be sure there is nothing on the tissues. Kind regards, Thom


  7. In all honesty, meniscal pathology shouldn’t have been a major competitor as a potential cause, but this was more a result of me being thorough due to the information collected through palpation and ROM testing. I fully agree with the unlikeliness of bilateral atraumatic meniscal pathology.

    Allan thank you for your input and expertise in dealing with running related injuries. “Too much, too soon” most definitely applies in this case and is the main exacerbating factor related to her current complaints. I believe that a biomechanical perspective in movement analysis can be a helpful examination in adjunct to the other factors evaluated. It can give your exercise prescription more focus not only in targeting specific tissues, but also in using the appropriate dosage in terms of the physiological demands of the activity. I agree it is not the end all be all treatment strategy and the pathoanatomical model has a lot to be desired, but in the correct situation, it can be very beneficial.

    That being said, the #1 change that should be made for this patient is a more tolerable and progressive training program. This is the first step in finding this patient relief and allowing her to achieve her goals.


  8. Good case study with details. I agree with all comments above re: training error, shoes, the whole LE biomechanical chain etc. I am curious whether you tested for ITB tightness? I often find ITB tightness a major factor causing altered patellar tracking in runners; and it is easy to be overlooked. even a mild tightness can cause tracking problems, pain etc.


  9. I agree with Thom, Nick and Kyle. Too much too soon. I was also concerned about glut weakness. Was your positive patellar test the patellar grind test? With genu varum, how was the patellar tracking – was it still lateral? quality of VMO – VMO atrophy or poor development? ITB/VL tightness or tenderness? foam rolling?
    Concerned about tracking
    Would like to hear answers before I attempt any specific treatement approach.

    Regardless, I would significantly decrease her activity to see if we can reverse her pain quickly. Otherwise she won’t reach her goal.


  10. Interesting case so far. 4ymptoms may be patellofemoral althouh the increased training might be suggestive of stress fracture not readily visible. I am also very suspicious of the rather profound hip weakness and the hip is known to be a potential scource of referred knee pain. Since tis is a case stugy, my comment would be to look further at the hip and/or lubar area


  11. Yes, she had a positive patellar grind test for retropatellar pain and crepitation. She also still tracked laterally in non-weight bearing (i.e. lateral pull sign) and neither thomas test nor Ober’s test indicated tightness of the iliotibial band. In terms of VMO… not my cup of tea as we’ve previously discussed, but there was no discernible asymmetry. Let me know your thoughts!

    In my opinion, the weak hip musculature and related biomechanical abnormalities should be an area of concern and treatment.


  12. Enjoyed reading up on this case. Running form/shoe wear/ training programs regularity of stretch regiment after running and any dynamic warm ups etc prior to running also are thoughts. Knowing the poor weaning into longer, more frequent running, compounded with general weaknesses, etc, I can only imagine continued irritation, inflammation of knees began and were poorly managed, compounded by continued running, etc.


  13. I agree with Allan, instead of keep searching for a ‘specific tissue’ that causes the pain (like meniscus, cartilage, patella,…) It might be interesting looking for a mechanical diagnose.
    In my practice, I’ve seen a young basketball-player with bilateral knee pain diagnosed as ‘patella-tendinopathy’. After testing repeated movement (MDT McKenzie) I found that this patient had bilateral ‘knee derangement, extension-responder’. This patient was solved in 2weeks and is now playing basketball completely pain-free.
    Although the pain was gone, his doctor wanted to have an ultrasound display of both knees. UD’s were both negative…


  14. 1.Running 4-8 miles daily on a meniscal tear sufficient to cause consistent pain would almost certainly produce knee effusion 2. Bilateral meniscal tears without symptoms of an acute tear? not likely. Joint line pain on palpation as a test of meniscal pathology is predictively weak (think about the anatomy…) Patellar grind test is false-positive on about 80% of an active population – pretty much useless. Ober’s test far too insensitive and too difficult to stabilize proximal segments to be predictive with any but the tightest of ITB’s. Dollars to donuts this young woman has active trigger points throughout her vastus lateralis/ITB’s and poor quality VMO contraction. Clear these first (acupressure/foam rolling/deep tissue massage for lateral structures and max tetanic EMS to VMO to “re-boot” inhibition) and recheck pain-to-squat. I typically see 80-100% reduction in pain to 1/3 single squat in one effective treatment using above techniques. Once more local (knee) structures are cleared, then look to clean up proximal and distal (hip weakness, tib post weakness) issues. Definitely initiate hip ext/abd/ext rot strength ensuring minimal tibial progression during squat training (this may require increasing mobility of hips). Once pain free to squat, re initiate sensible running progression and maintenance soft tissue work.


  15. I agree with addressing the significant weakness at the hip, as this is really key in controlling the mechanics at the knee. ITB is almost always an issue in runners, so certainly address as per above. Did you look at her feet? If she is pronating, that would cause pain at the medial joint line and also create mechanical issues straight up to the hip. Did you look at lumbar, pelvic floor, and abdominal strength and stabilization? What is her posture like in stance and while walking or running? With such weakness at the hips, I would suspect some imbalance further up in the pelvis and spine, even shoulder girdles… it all matters when running. Patellofemoral dysfunction is often the result of lack of mechanical control above/below the knees. Aside from a direct hit to the patella, PF pain is not usually a pathology by itself. No doubt the swift increase in mileage was not good training practice, but the mechanical problem was already there. I would actually have her stop running while addressing the strength issues, foot mechanics, and work on proprioceptive activities. She could be cross training on a bike or in the pool for cardio while treating the knees. The inflammation being created behind the patellae (does she have just crepitus or is there a rub too?) needs a chance to calm down while you are helping her with strength and mechanics.


  16. Yes, a static and dynamic evaluation of her foot/ankle was conducted. There were no apparent abnormalities in terms of A/PROM, joint mobility, static alignment, or dynamic alignment (i.e. during lateral step-down). I agree that this is an area that can potentially cause a great deal of changes up the kinetic chain. Lumbar, abdominal, and general stabilization strength was exceptional and was never an area of concern. I will admit that pelvic floor strength was not assessed, but I can definitely see the merits in doing so.

    As I stated before, I agree that the meniscal pathology was unlikely to say the least. I was not thinking of a recent injury, rather a minor previous injury that may have been exacerbated by the recent increase in milage. It was quickly ruled out and I moved on to other, more likely, scenarios.

    As far as VMO training goes, once there is a study that confirms the ability to isolate this muscle, I will consider implementing those exercises into my treatment strategies. There, in my opinion, is not sufficient evidence to target the VMO in the treatment of potential PFPS patients. Please read and give me your thoughts.

    In terms of her running, my first words following the initial evaluation were to omit running from her training until her symptoms calmed down. She was hesitant, but agreed to stick to the stationary bike, elliptical, and pool.


    1. Read the article, thanks. In-line with my thoughts. I have never been a believer in selective training of VMO to try and change the force vectors around the patella or timing of contraction. I don’t believe that a small muscle like VMO can be uniquely strengthened to the point it can effectively overcome/counteract the tight fascial force vectors produced by a tight VL/ITB/lateral retinaculum. However, joint pain produces reciprocal inhibition of muscles that lie closest to the joint (VMO wasting can be visually evident in large-muscled athletes within as little as 48 hours of an acute knee trauma). Thus it can be extrapolated that in chronic ant. knee pain patients there will be a degree of chronic inhibition of VMO so that VMO is not functioning even at it’s limited force-producing capacity. NMES to VMO literally “reboots”/removes the neurological inhibition to allow a forceful tetanic (non-inhibited) contraction to occur. All it takes is 15-20 reps of 8-10 second maximally tolerated VMO NMES contractions (I usually start with NWB supine positioning just for patient acceptance of NMES sensation and then work towards a FWB functional single leg 1/3 squat with NMES overlying the eccentric-concentric squat movement). One 5-minute treatment of above is used not to selectively strengthen VMO but to get it to function at it’s “normal” state.


  17. I know you are not keen on VMO strengthening because noone has done any research proper exercises for muscle activation. I am not so concerned about timing which has been researched. I learned a VMO exercise 20 years ago from Bob Mangine which correlates with anatomy and illicits visible fasciculations. Combine with NMES and I have gotten great results for 20 years. The easiests is to place patient in a static wall squat at 55-65 degrees – orientation of VMO fibers – i have a more advanced I think aI shared with you before.
    I also agree to check out VL and ITB with deep palpation – if tender – manual or foam roller to decrease lateral pull on patella And would definitily attack glut med


  18. The basketballplayer I was talking about had NO active or passive loss in ROM in both knees… I THOUGHT! This patiënt had minimum 10° hyperextension but when I mobilised to extension, I saw his ROM towards extension becoming even more! For this patiënt, his natural balance was from full flexion to 20° hyperextension. Afther the restauration of his natural balance, his pain was gone.
    In your case you have a young female athlete with only 2° hyperextension. Maybe is this not her natural balance? Is this patiënt overall stiff?


  19. I can definitely see the applicability of using NMES to disinhibit the VMO following a traumatic knee injury (as I believe David mentioned in our earlier conversations). I actually think it would be fascinating to see the results of a study comparing this NMES protocol + knee/hip strengthening v. only knee/hip strengthening in patients with PFPS. I do think there would be some level of benefit, but it’s hard to say whether there would be a significant effect.

    David, it’s not that there haven’t been studies done. There have been plenty of studies published examining countless variations of VMO exercises and none have shown significance or the ability to selectively activate. There are a large number of clinicians that want these exercises to work. In my opinion, if it was possible, a study would have been published by now.

    Lieve, the ROM ‘deficits’ were only seen in flexion and this limitation may not be clinically relevant… I have been taught that 0° of extension is ‘normal’. Have you been told differently? In your example, do you not believe 10-20° of hyperextension is a little excessive?


      1. I am not saying that I would attempt to decrease their ROM… I’m just having a hard time imagining someone with 20° of hyperextension and how this could be functional. Obviously, from the case presented, it was normal and ultimately decreased your patient’s symptoms and that’s our goal. Just evidence that every patient is different and each patient requires individualized treatment.


  20. Mark Comerford has done some VMO studies: a wall sit with the knee flexed to 60 degrees, 3 foot-lengths from the wall, feet straight, knees out so that you can see 2 toes inside of the knee. Also dominance of the TFL/ITB can contribute to tibial lateral rotation, patellar lateral glide, and genu valgus with medial joint line gapping. I agree with the foam roller working from the greater trochanter to the lateral knee, spending 2 minutes on each leg to allow for connective tissue lengthening. Decrease the TFL/ITB dominace by strengthening deep hip lateral rotators, glute max, posterior glute med, iliopsoas, and multifidi. Address movement patterns by working on squats and single leg stance, starting with the femur in neutral and not allowing increased femoral medial rotation.


  21. Improper muscular coordination and general weak/deconditioned hip lateral rotators and abductors definitely need addressed… I’m in complete agreement with that. Is there any way you could provide links to the studies published by Comerford? I have yet to come across these. Thanks!


  22. Try these:
    Comerford MJ – 1986
    Thesis: the development of dynamic radiographic measurements of patellar tracking and the documentation of normative values for asymptomatic males.
    Physiotherapy Thesis Library. University of Queensland
    Comerford MJ – 1986
    A review of the roles of vastus medialis obliquus and vastus lateralis and the implications of their integrated actions on patello-femoral pathomechanics.
    University of Queensland


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