The Clinic.

PAINFUL KNEE CAP WHEN RUNNING

I am 52 years old and have been running for 20 years, averaging 20 to 30 miles per week I also bike, swim, and lift weights regularly. I run several 5K and 10K races during the spring and summer and build up to run a fall marathon. This last fall I noticed a pain slightly below the knee cap when I ran. I especially noticed it when I tried to kneel or squat. This persisted even after I decreased mileage after my marathon training. I finally went to a doctor who diagnosed it as chondromalacia.

I have stopped running completely for about a month and I experience much less pain when I kneel or squat. I would like to start running again. What are my prospects for full recovery without recurrence?

Peter Hanamann

Neenah, WI

Knee cap pain is typically related to the patellofemoral joint. The term chondromalacia is less commonly used these days as it describes actual degeneration of the articular cartilage. If an x-ray confirmed that in your case, and arthritis has developed within the knee, it is difficult to treat. However, most cases of patellar pain are due to poor patellar tracking between the thighbone (femur) and the lower leg (tibia).

The first task is to address any factors that may contribute to maltracking. The most common cause of this kind of pain is an imbalance of the strength between the inner and outer heads of the quadriceps muscle causing the patella (kneecap) to be pulled off track during contractions of the quadriceps. Flexibility of the hamstrings, quadriceps, and the iliotibial band (tendons from the hip to the out-side of the knee) is also important. Excessive pronation due to a low arch may also contribute to patellar pain.

Patellofemoral pain caused by poor tracking of the patella usually responds very well to treatment. Physical therapy designed to build strength in the appropriate quadriceps muscles is the first line of defense. I generally recommend easy leg presses going from zero to no more than 50 degrees, single leg balance exercises squatting from zero to 30 degrees, and avoiding any leg extensions with weight at the ankle. Your best bet, since you have already stopped running for a month, is to get a referral to a physical therapist experienced with runners. A physical therapist can evaluate your foot and leg strength and teach you the exercises that will get you back on track and help you to avoid the problem once you start running again.

Michael Fredericson, MD.

Stanford, CA

Pain below the kneecap (in the soft part the doctor taps for a reflex), can also be patellar tendinitis. Make sure you see a sports medicine professional to receive an accurate diagnosis.

Mitch Goldflies, MD.

Chicago, IL

MEDICATION FOR HIGH CHOLESTEROL

I've had high cholesterol for years--it is about 240. The HDL to LDL ratio is fairly good, but the LDL is high (about 170). My doctor is recommending medication but I would rather use diet and exercise. Is medication necessary? Isn't high cholesterol a hereditary problem?

Robert J. Beck 

Houston,TX

Epidemiologic studies have shown that as cholesterol levels rise (both total cholesterol and LDL cholesterol) there is a graded increase in the risk for coronary artery disease, regardless of the source of the cholesterol. Controlled studies have also shown a reduction in heart attacks, deaths and strokes in patients with high cholesterol treated with drugs of the "statin" class. These drugs are generally very well tolerated and the benefit far outweighs the risk of side effects. Diet and exercise have been shown to lower cholesterol levels by zero percent to 20%, whereas statin therapy can be expected to lower levels by 25% to 60%.

Charles L. Schulman, MD.

Boston, MA

SHOULD YOU CORRECT HAGLUND'S?

I am 44 years old and have been running competitively for 15 years. After experiencing pain in the back of my right heel for several years I have been diagnosed with Haglund's deformity. My goal is not to return to the competitive level that I once ran, but merely to run recreationally and pain free. I would like to correct the problem permanently.

Mike Board

Merrick, NY

Haglund's deformity is a bony prominence on the back of the heel. It is often called a "pump bump" because of its prevalence among wearers of high heels. It can also be associated with bursitis and posterior heel spurs in some cases. It is usually caused by shoe irritation, the pull of the Achilles' tendon, a high arch, or foot biomechanics while running.

Conservative care consists of padding the back of the heel to reduce shoe irritation, in addition to wearing open-backed sandals when not running. Physical therapy, local cortisone injections into the bursa and anti-inflammatory medications can help.

Many patients respond to conservative care. However, if the Haglund's bump is very large, produces severe pain, or limits activities, surgery is a very viable option. Because it addresses the underlying bony problem, surgery may enable you to return to previous high levels of competitive running, even though at this point you have reduced your expectations.

Resection (removal) of the bony prominence on the heel can be performed by going through or around the Achilles' tendon. A portion of the Achilles' tendon may need to be resected and is re-attached upon completion of the bone procedure. New technology such as bone anchors, which better secure the tendon to the bone, has improved our results and the surgery is often quite successful. The foot must be immobilized for six weeks.

After healing, gradual non-weight bearing exercises such as swimming and biking can be performed as long as your recovery is uncomplicated. On average, patients return to running within three months.

Adam K Spector, D.P.M.

Silver Spring, MD

A word of caution about being too sanguine about any surgical treatment -- as a group, runners are very difficult to hold down and run a high risk of re-injury and chronic problems. Full rehabilitation is often complicated by this era of managed care in which the insurance carrier often limits physical therapy. Be your own best advocate. Respect the time necessary for healing and full rehabilitation.

Marvin Bloom, M.D.

Burlingame, CA

SHIN PAIN PROBLEMS

I am 50-years-old and have been running approximately four years. I run about 25 miles per week, on pavement. I usually run four to five days a weeks including a long run of about six to nine miles on Sundays. I usually rest on Monday. I alternate two pairs of good running shoes and retire them after 500 miles.

Since raising my mileage from twenty miles per week up to twenty-five, I have had a persistent pain along the front right side of my shin in my right leg when I run. Sometimes it is sorest at the bottom of the leg and sometimes it hurts most in the middle of the muscle. It tightens up shortly after I begin to run within the first half-mile. Sometimes it loosens after three or four miles if I keep running. My left leg never hurts. If I stop and walk, it stops hurting but as soon as I start back up, it hurts again. I have tried strengthening exercises but haven't noticed any difference.

Michael Quillen

Gate City, VA

Anterior leg pain (pain in the front of the leg) is a very common running malady, which is loosely labeled shin splints. This includes tendinitis, stress fracture, compartment syndrome and a condition called periostitis. Any of these conditions can result from moving up in mileage or intensity too quickly. The fact that you run on pavement might contribute to your leg pain, which sounds like an anterior shin splint.

Do you usually run on a canted road facing traffic? This can create a functional leg length difference. This mechanical imbalance can result in overload of the anterior musculotendinous structures and tendinitis can develop.

If you continue to run despite pain, a chronic tendinosis can develop, which can cause inflammation at the shinbone itself, called periostitis.

Just because your leg "loosens up" during a run, don't rule out the possibility of a tibial stress fracture. Compartment syndrome, which is a tightening of one of the muscle compartments in the lower leg, is less likely since this usually worsens with more running.

If reduction of your mileage doesn't solve your problem, I would suggest that you see a sports medicine specialist. It is imperative that a stress fracture be ruled out since this will have the greatest implications on your running. X-rays and possibly a bone scan may be required to determine this.

In the absence of a stress fracture, my recommendations include rest, ice, anti-inflammatory medication, physical therapy, massage, and a biomechanical evaluation to check for flaws in form and function. Cross training with water jogging would be ideal. Do not use a stair machine or bicycle because they would not provide rest for the affected tendons.

Once you are pain free, strengthening and stretching will help to prevent a recurrence. When you are ready to return to running, try to avoid the hard pavement. Choose a soft track or park trails. And always remember to give your body time to adjust to small increases in mileage and intensity. As we age there is a smaller margin for error before injury slows you down.

Jeffrey A. Ross, D.P.M.

Houston, TX

RELATED ARTICLE: ARE YOU BOTHERED BY AN INJURY? DO YOU HAVE A TRAINING OR DIET QUESTION?

Ask The Clinic, in care of The American Running Association. 4405 East West Highway. Suite 405. Bethesda. MD 20814. FAX [phone]. or e-mail at [e-mail]. Write a letter including as much relevant information as possible about you (age. weight. etc.) and your injury (type and location of pain), training schedule (typical weekly workouts, pace, surface), athletic and medical history sole wear, recent changes in training, etc. Type or print your letters. Hand-written FAXed letters cannot be accepted. All letters, even e-mail, must include your name, address and phone number. Responses usually take three to four weeks, but can take as long as five.