Why does my knee hurt when I run up and down stairs — and what is that crunching noise?

Knees, and the crunching noise they make, can be a pain for runners


Monday, November 14 2011, 11:17 AM

Ever since I can remember, my knees have made a crunching noise when they bend. So far, thank goodness, this is still only a noise and pain going down stairs.. I am 36 and started running about eight months ago on a treadmill. I am now up to six miles per run, four days per week, and my right knee is almost always stiff. Not painful, just stiff. So much so that at times, I can’t get past the stiffness to stretch my quads after a run. I want to train to run the NYC Marathon next year; it looks like such great fun. Should I be concerned about the area that seems swollen, even though there isn’t pain, only stiffness?. And what is it? – Sam J., Tampa, FL

“Runner’s knee” is the most common pain runners get. Sports doctors, orthopaedic surgeons, family doctors and internists see this in runners more than anything else. Understanding the real cause makes treatment easy and pain relief possible in a short period of time. It is also called “anterior knee syndrome,” “chondromalacia patella,” and “patellofemoral syndrome,” all names for the same thing.

When it comes to runner’s knee, biology is destiny: Blame your parents, they gave you feet like yours! Anyone whose foot rolls inward (pronation) during a stride is a candidate, but the real high risk for runners are people with extremely flat feet, a large, pronating forefoot, or a so-called “Morton’s foot” (where the second toe is longer than the first, causing an exaggerated pronation). Your parents gave you those feet — not your sport, your activity, or a specific injury.

Of all the aches and pains that one can get, this one’s probably the easiest to get rid of. If you were doing some serious running mileage over the summer, maybe getting ready for a fall marathon, or if pain came on “suddenly” without any apparent injury and your knee started to get sore when you walked up and down stairs, you feel clicking in the knee when getting up or you have felt stiff when you were sitting in a movie, you most probably have Runner’s Knee. It could have happened when you were 12, or 65. And the treatment, which is not complicated or extensive, is the same for everybody, from kids to grandparents.

It all starts with the kneecap. In a perfect world, it rides up and down in the V shaped groove just behind it as you walk, run, or cycle. More typically, though, your foot rolls in, or pronates, as you move from heel strike to toe off, and the kneecap ends up scraping along one side of the groove instead of sliding smoothly up and down the middle.

The cartilage there doesn’t much like getting sandpapered down that way, nor does the back of the kneecap, which begins to weep fluid that in turn produces a feeling of stiffness. The “crunching noise” is the rough cartilage rubbing. And though runners have named the condition, it crops up often in non-athletes, as well as among cyclists and those who play cleated-shoe sports like soccer and baseball, whose footwear can put sideways torque on the knee.

Physicians can diagnose this from the other side of the room: joint hurts, no particular injury caused it, worst going upstairs and downstairs (or walking down an incline or running down a hill which tightens the thigh muscle pulling the kneecap down into the groove causing a painful rubbing), stiffens after sitting awhile, like it needs to be stretched. That settles it.

Despite what you may have read, arthroscopic surgery helps perhaps one out of 100,000 sufferers. Mechanically smoothing the rubbing surface of the kneecap can last for six months or so, but unless your biomechanics have changed, it’s a borrowed time fix. Cutting the retinaculum, the connective tissue holding the kneecap in place to loosen it in the groove, is also only temporary. It eventually scars down tighter than it was before. Sooner or later, you’re back where you started.

Proper orthotics (full length, soft, controlling the forefoot) are the single most important step, since they prevent the roll that caused the scraping in the first place. Runners spend close to 80% of their time on their forefoot; an orthotic must control that area to be effective. The good news is that once you start wearing them, your knee cooperates quickly: The patella cartilage that’s been rubbed down is able to regenerate and heal itself. Just give it the chance. (Note: Orthotics that end mid-arch DO NOT WORK!)

But orthotics alone won’t do it. You need your other ally, the medial quad, the muscle in the front inside of your thigh that’s supposed to hold the kneecap in the center of the groove. The stronger it is, the better it can do its job. But there’s a rub: Leg extensions usually used to strengthen the quads also pull the kneecap back down into the groove and grind it up some more. No good. But terminal extension exercises (see below), which limit the motion to the last six inches of extension, don’t. Do them daily until the pain disappears, then twice weekly. Both legs, please (do one at a time), even if only one leg hurts. Your knees are a matched pair, and what’s already happened on one side is a good bet for the other some day.

In addition, physical therapy is initially needed to stretch the connective tissue that has tightened laterally, holding the kneecap on the side and not allowing the medial quad to hold it in the center of the groove. There is no substitute for a qualified physical therapist to stretch this retinaculum properly. Once stretched to allow that kneecap to stay centered, doing the exercises should hold it for life.

Knee sleeves, braces, straps, and ACE bandages are out. Think about it: If you compress the kneecap, every motion will press it into the groove. Keep it loose and free. Those devices are making money for someone, but not helping you in the long term.

Will all this cure you? No. You could have your orthotics Super Glued to your feet for a year, and if you took them off, a minute later your inherited biomechanics would resume — and eventually the pain right along with it. But make these exercises a part of your weekly routine, and you can rid yourself of this unnecessary pain forever.

Time for a Quad Job

(Not your usual leg extensions)

1. Sit up on a desk or high surface, stick your leg out straight, drop it about 6 inches and support it with a chair or stool.

2. Fill a gym bag or duffel with weights (books, soup cans, whatever) and strap it to the lower leg.

3. Lift only the last 6 inches (about 30 degrees) to full extension, hold for three seconds, then come slowly back down. Do five sets of 10 reps daily, with just enough weight that you get to five or six on that fifth set, and have to stop. Can’t get there? Take out some weight. Can do all 10? Add a book or some soup.

If you’re at a gym…

Use the leg extension weight machine. Do one leg at a time. Hold your one leg out to full extension with the weight. Then drop your leg down 6 inches and put the pin in to lock it at that point. (Every weight machine is different; have an instructor show you how your machine can limit your range of weight training.) Again, five sets of 10 with as much weight as it takes to get to five or six on the fifth set.

If you do leg presses, again only press away in the last 30 degrees of your knee motion. Bending your knee too far will bring the kneecap into the groove and grind it making you do damage to the knee as you strengthen the muscles!

If you’re a cyclist…

Raise your seat a bit higher than normal. As you pedal, that will help put you into the “good” range of motion above, rather than continuing to abuse your kneecap.

If you think you have runner’s knee, ask your physician:

1. Are my kneecaps tracking laterally?

2. Where can I find a full-length, flexible, soft leather orthotic locally?

3. Do you know of a local physical therapist who sees runners and knows how to stretch out my lateral retinaculum with soft tissue technique?

You can run once you’re in the orthotic. Stop only if the pain becomes so bad that it changes your running form. Once you’ve gotten the program under way (wearing orthotics and going to therapy three times a week), you will feel better within four weeks.


Lewis G. Maharam, better known as Running Doc™, is the author of the Running Doc’s Guide to Healthy Running and medical director of the Rock ‘n’ Roll Marathon series and the Leukemia & Lymphoma Society’s Team in Training program. He is past president of the New York Chapter of the American College of Sports Medicine. Learn more at runningdoc.com.

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