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Patellar tendonitis treatment can involve various options. In this article, we explain why we recommend the approach of relative rest and a graded strength training programme for treating patellar tendonitis to most of our patients. We also discuss what other treatment options could be used in addition to this, as well as the causes and symptoms of patellar tendonitis. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article are to pages where you can buy products discussed or mentioned here. We might earn a small commission on the sale of these at no extra cost to you. In this article: What’s the difference between patellar tendonitis and tendinopathy? What is patellar tendonitis? What causes patellar tendonitis? What happens to the tendon when you have patellar tendonitis? Patellar tendonitis symptoms - what does it feel like? Patellar tendonitis recovery time Patellar tendonitis treatment How we can help I've also made a video about the causes and treatment of patellar tendonitis/tendinopathy: What’s the difference between patellar tendonitis and tendinopathy? For all practical purposes, it means the same thing. But in 2019, a bunch of the world leading experts on tendons decided that the best terminology for this sort of problem would be tendinopathy, rather than than tendonitis. This is because '-itis' in the 'tendonitis' refers to inflammation, and researchers no longer think that inflammation is a key feature of this problem. In this article, we use the terms interchangeably. What is patellar tendonitis? Patellar tendonitis is an overuse injury that affects the patellar tendon. The patellar tendon is a thick tendon that runs over the front of your knee, from the lower edge of your kneecap (patella) to the front of the shin bone (tibia). It attaches your quadriceps muscles (front thigh muscles) to the shin bone. Any activity that activates or uses the quadriceps muscles also loads the patellar tendon. Patellar tendonitis is most commonly found in people who do sports and activities that require a lot of fast, repetitive, high-force contractions of the quadriceps muscles, e.g. football/soccer, volleyball, tennis, long jump, fell running, and CrossFit. What causes patellar tendonitis? Overuse Overuse injuries like patellar tendonitis develop when you either: Do an activity that is a lot more intense or harder than what you’re used to, e.g. playing in a tournament that results in six hours of high-intensity play when you’re used to two hours; Or you don’t allow your body enough recovery time between high-intensity training sessions. Whenever we train, our bodies (tendons included) sustain microdamage. If you allow enough recovery time, your body repairs this microdamage and as a result you grow stronger. But if you do another high intensity session before your body has fully repaired, the microdamage can accumulate and cause an overuse injury. Trauma The vast majority of cases of patellar tendonitis are caused by overuse, but sometimes a direct blow to the patellar tendon (e.g. someone kicks you or you bang your knee against something) can also cause the tendon to develop patellar tendonitis or tendinopathy. What happens to the tendon when you have patellar tendonitis? Healthy tendons are extremely strong structures. They are made up of mostly lots and lots of collagen fibres that are packed in parallel. They also have a few cells and some (not a lot) white, fluid-like substance between the fibres. The collagen fibres in healthy tendons are packed close together, in parallel. It’s the parallel structure of the collagen fibres that makes a tendon so strong. Remember that old experiment from school with the pieces of string? If you take one piece of string, it’s easy to snap. But as soon as you have ten pieces of string put together, it becomes impossible to snap them with your bare hands. When you develop a tendonitis or tendinopathy, it only affects a small portion of the tendon. For the patellar tendon, it most often affects the area where the tendon attaches to the lower edge of the kneecap. When you look at that injured part under a microscope, you’ll notice: In newly injured tendons - That the collagen fibres have started to move away from each other, there’s more of the fluid-like substance between them, and the cells have also changed. Microscopic image of a recently injured tendon (reactive tendonitis). If your patellar tendonitis has been dragging on for a month or two, you may notice that the collagen fibres in that area have totally lost their parallel structure, and there’s much more fluid-like substance. An ultrasound scan may also show new blood vessels growing into that area. Healthy tendons usually don’t have blood vessels growing into them. Microscopic image of an ongoing tendonitis/tendinopathy. The injured potion of the tendon has lost its parallel structure. Patellar tendonitis symptoms - what does it feel like? Where you feel patellar tendonitis pain The pain is felt over the front of the knee and most often in the area where the patellar tendon attaches to the lower edge of the kneecap. But it is possible to get it in other parts of the tendon. Most commonly the pain from patellar tendonitis is felt at the lower edge of the kneecap. Other conditions that can cause similar pain and are often mistaken for patellar tendonitis include quadriceps tendinopathy, infrapatellar bursitis, fat pad irritation, patellofemoral pain syndrome , meniscus tears , Osgood Schlatter’s (in children) and Sinding-Larsen-Johansson syndrome (in children). When does it hurt? It hurts whenever you do an activity that uses the quadriceps muscles (front thigh muscles). If your tendon is very irritated, even light activities like walking up and down stairs may hurt. If it’s not that irritated, then you may only feel pain when you do high-intensity activities like heavy squats, jumping, or running. You may find that your knee actually feels pretty good when you start with your activity, but then the pain slowly starts to build as you continue. Or you may have some pain when you start training, but then it actually goes away as you warm up, only to return much more intensely later on. If you’ve neglected your patellar tendonitis for a while and continued to train through the pain, you may find that it’s too painful to do sport. It is quite common to experience a delayed increase in pain, i.e. it is only 24 hours after doing an activity or training session that you suddenly experience an increase in pain. This is what makes tendon rehab so tricky - it usually doesn’t let you know at the moment when you’re overdoing things. That is why we teach our patients to monitor and interpret their 24-hour pain response rather than just focus on what they experience while they're doing their sport or activity. Patellar tendonitis can sometimes cause pain when you sit with your knee bent for a long period. This is because the injured patellar tendon is under a bit of stretch and compression when your knee is bent, and that can cause it to become irritated if the position is sustained for too long. However, this is also a common occurrence when you have patellofemoral pain syndrome and why it’s best to consult a physio who can help you figure out your correct diagnosis. Patellar tendonitis recovery time Patellar tendonitis, like all tendon injuries, can take a very long time to heal. Most people will recover and return to full sport within six months. But researchers have found that up to a third of athletes will take longer than six months to recover and often more than a year. This is why it’s important to seek help early on to ensure that you’re applying the most appropriate treatment plan for your specific case. Patellar tendonitis treatment The successful treatment of patellar tendonitis usually involves a combination of different activities and treatment modalities. We've included the most widely used and best researched ones in the sections below. 1. Relative rest Relative rest is different from complete rest in that you don’t have to stop all your activities. You can remain active as long as you reduce your activity intensity and volume to a level that doesn’t increase your pain. The aim is to allow your tendon to settle down, so that you can progress with your rehab and build the strength you need to go back to full sport. By how much you have to adapt your training will depend on how irritated your tendon is. For some athletes, this may mean that they have to stop all jumping and sprinting and just do low-load activities like walking or slow jogging. For others, it may mean that they just have to limit the volume, intensity, or frequency of their jumping and sprinting activities. We always aim to keep our patients as active as possible, as that helps to maintain their current tendon strength. But this is not an exact science and requires careful monitoring to get it right. Remember that relative rest should also take account of your normal day-to-day activities, and there are some everyday movements and positions that may aggravate your patellar tendon pain . Current recommendation You have to reduce the intensity of your activities to allow your tendon to calm down. Relative rest is superior to complete rest, as it not only allows the pain to settle but also retains more strength in the tendon. 2. Rehab for patellar tendonitis Strength training exercises There is very strong evidence that the best treatment for patellar tendonitis or tendinopathy is a structured strength training plan, consisting of exercises that specifically load the patellar tendon . This should not come as a surprise because, as we discussed earlier, when you injure your tendon it changes structure and loses some of its strength. The only way to trigger the body to produce new tendon fibres and restore its strength to the level you need is strength training exercises. What exercises you should do for patellar tendonitis is determined by your stage of healing, the sensitivity of your tendon, your sport, and your current strength. Recent research has shown that there’s a wide variety of strength exercises and programmes that could work for treating patellar tendonitis - we discuss them in detail in this article . In our experience, not everyone reacts equally well to the same exercises. Every case of patellar tendonitis differs in severity and irritability and people also have different end goals. So it’s important that the exercise programme is tailored to the individual and adapted as your tendon heals. Kinetic chain When we move, our bodies function as a kinetic chain which means that if something happens in one area, it also affects areas that are further away. A lack of flexibility or strength in one area may for instance cause another area to overwork or overstrain. Some areas in the kinetic chain that may affect your patellar tendon. There is evidence that lack of hamstring and quadriceps flexibility, restricted ankle dorsiflexion range (how well your foot bends up towards your shin), as well as reduced calf and glute function may increase your risk of developing patellar tendonitis. This is why we do a comprehensive assessment of our patients and don’t just focus on their painful knees. Biomechanics Biomechanics refers to the movement patterns we use when we do different activities. For patellar tendonitis, the landing mechanics from a jump has been shown to be of importance. Box jumps help to develop explosive strength and teach good landing mechanics. This is perhaps not something that needs to be addressed during the early stages of rehabilitation, as your biomechanics may be different when you are still in pain and these exercises can easily irritate the tendon. But it is definitely something that should be assessed during the later stages, once you’ve built some strength and your pain has settled. We’ll discuss the different exercise programmes and what an ideal exercise-based treatment plan for patellar tendinopathy should look like in a future blog post. Current recommendation Exercise remains the most effective treatment for patellar tendonitis, and several literature reviews have now confirmed this, but the exercise programme should be tailored to the individual needs of the patient and be adapted as their injury recovers. A one-size-fits-all approach is likely to aggravate the symptoms. 3. Ice Intermittent icing might help to reduce your pain because it numbs the nerve endings. This won't speed up the healing process as such, but it might make it easier for you to stick to your strength training exercises (see above) if they cause you pain. Current recommendation If your rehab exercises are painful, try applying ice before you do them. Aim for three applications of 10 minutes each, with 10-minute breaks inbetween. Don't ice your tendon directly after you've done your exercises; research has shown that you gain less from strength training if you regularly cool the tissue afterwards. You can read more about how to use ice for injuries in this article . 4. Shockwave Shockwave can be a useful tool to help reduce pain. However, a recent meta-analysis of the current research found that adding shockwave to an exercise-based treatment programme for patellar tendonitis added no extra benefit. Current recommendation If pain is preventing you from doing any exercises or from making progress with your rehab, it may be useful to try shockwave, as it may reduce your pain sufficiently to allow you to progress with your rehab. However, if you’re already able to tolerate your rehab exercises, you're not likely to gain any extra benefit from adding shockwave to your treatment regime. 5. Massage Massage may be useful to help reduce pain in the short term, but it doesn’t actually strengthen the tendon. Exercise has been shown to provide better short and long term results for pain reduction than cross-friction massage specifically. Current recommendation Don’t rely on massage alone for your recovery. You have to also follow a structured exercise-based rehab programme. 6. Anti-inflammatory medication Anti-inflammatory medications (NSAIDs) like ibuprofen or Naproxen are sometimes prescribed to help decrease your pain when you have patellar tendonitis. However, the research has shown that inflammation isn’t actually what causes the pain in ongoing tendonitis or tendinopathy. More importantly, research has also shown that anti-inflammatory medication may slow down the rate at which your body creates new collagen fibres in response to exercise. The whole point of doing the strength training exercises is to stimulate your body to produce new collagen fibres and to strengthen your injured tendon! Current recommendation Don’t use anti-inflammatory medication to treat patellar tendonitis. Discuss other options for pain management with your doctor. Paracetamol might be a better choice. Anti-inflammatory medication may reduce the benefits your patellar tendon is meant to gain from doing rehab exercises. 7. Topical glyceryl trinitrate There is some evidence that using topical (applied to the skin) glyceryl trinitrate in combination with an exercise plan may work better for reducing pain than exercise on it’s own. However, it does come with some side effects that may include skin irritation and headaches. Current recommendation Topical glyceryl trinitrate may be an useful adjunct to treatment if you’ve not seen any progress with your exercise programme after 12 weeks. 8. Platelet rich plasma (PRP) injections There is some evidence that PRP injections may be useful as part of the treatment for patellar tendonitis, but only when it is combined with an exercise plan. We are not yet sure what technique is superior or how many injections work best. They also don’t work for everyone. Current recommendation PRP injections on their own are not useful. They have to be combined with a graded strength training plan. It’s a treatment to consider if you’ve failed to make significant progress after 12 weeks of following a tailored exercise programme. PRP injections may be useful for treating patellar tendonitis, but corticosteroid injections should be avoided. 9. Steroid injections In the past, a steroid (corticosteroid or cortisone) injection was a standard treatment for any tendon injury, because it is pretty good at reducing the pain. However, now that a lot more research has been done, it has become clear that it might not be a good idea to inject a tendon with cortisone. Cortisone has been shown to slow healing and may predispose you to a tendon rupture. Steph discusses the use of steroid injections in more detail in this video. Current recommendation Do not use cortisone or steroid injections to treat patellar tendonitis/tendinopathy. 10. Patellar tendonitis strap or taping Some people find that using a patellar strap that applies pressure over the patellar tendon can reduce their pain while playing sport. Others find that tape can also provide some relief. There currently isn't much high-quality research available to back this up. A recent randomized controlled trial did show that both patellar tendon straps and tape can help to reduce pain, but they failed to show a significant difference between using a patellar tendon strap, applying a specific taping technique, and placebo tape (tape just stuck on in any way). Current recommendation A patellar strap may reduce your pain while playing sport, but this would likely be due to a placebo effect. Don't use this as a standalone treatment for patellar tendonitis. Make sure that you combine it with a comprehensive rehab plan. 11. Surgery Surgery should only be considered if you’ve followed a structured and progressive strength training programme for at least 12 months and not seen any progress. About 10% of patients with patellar tendinopathy seem to undergo surgery. There is currently no consensus on what type of surgery is best. Current recommendation Only consider surgery if you’ve failed to get results from a well-designed (tailored to you) exercise-based treatment plan for at least 12 months. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Burton, I. (2022). "Interventions for prevention and in-season management of patellar tendinopathy in athletes: A scoping review." Physical Therapy in Sport. Challoumas, D., et al. (2021). "Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies." BMJ Open Sport & Exercise Medicine 7(4): e001110. Christensen, B., et al. (2011). "Effect of anti-inflammatory medication on the running-induced rise in patella tendon collagen synthesis in humans." Journal of Applied Physiology 110(1): 137-141. Cook, J. L., et al. (2016). "Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?" British Journal of Sports Medicine 50(19): 1187-1191. de Vries, A., et al. (2016). "Effect of patellar strap and sports tape on pain in patellar tendinopathy: a randomized controlled trial." Scandinavian Journal of Medicine & Science in Sports 26(10): 1217-1224. Longo, U. G., et al. (2018). "Achilles Tendinopathy." Sports Medicine and Arthroscopy Review 26(1): 16-30. Magra, M. and N. Maffulli (2006). Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe, LWW. Malliaras, P., et al. (2015). "Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations." Journal of Orthopaedic & Sports Physical Therapy 45(11): 887-898. Virchenko O, Skoglund B, Aspenberg P. Parecoxib impairs early tendon repair but improves later remodeling. Am J Sports Med. 2004;32:1–5.

A lateral collateral ligament (LCL) tear is a knee injury that seldom happens in isolation. The force that causes it is usually so big that often something else also gets injured. This article explains how the LCL typically gets injured, what the symptoms are, how the injury is diagnosed and graded, what the treatment options are, and what the recovery times might be under various circumstances. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We may earn a small commission on sales at no extra cost to you. In this article: Anatomy of the lateral collateral ligament How the LCL gets injured What’s the difference between an LCL sprain and a tear? Lateral collateral ligament tear symptoms Lateral collateral ligament injury tests Grading LCL tears Do you need surgery for an LCL tear? LCL sprain recovery times LCL injury treatment without surgery How we can help We've alse made a video about this: Anatomy of the lateral collateral ligament The lateral collateral ligament of the knee (sometimes called the fibular ligament) runs over the outside of the knee from the lateral epicondyle of the knee to the head of the fibula. It’s main job is to stop the knee joint from gapping too much to the outside (resisting varus forces) or turning too far out and back. The popliteus tendon, cruciate ligaments, iliotibial band, biceps femoris tendon, and lateral (outer) gastrocnemius tendon all support the lateral collateral ligament in these tasks. The LCL differs from the medial collateral ligament (located on the inner border of the knee) in that it is more tubular (as opposed to fan-like) and doesn’t attach to the meniscus or the joint capsule. How the LCL gets injured LCL tears are usually caused by a strong force from the inner front of the knee, forcing the knee into extreme extension and causing it to gap on the outside. Examples are a rugby player falling on their knee or a tennis player pivoting quickly and forcefully. It takes a lot of force to injure the LCL, and this type of ligament tear is usually accompanied by injuries to other tendons and ligaments in that area (listed above). You may hear doctors say that someone has an injury to the posterior lateral (back outer) corner (PLC) of the knee – this means that they’ve torn more than one of these structures. When more than one of these structures are seriously injured, it causes the knee to be unstable and they usually require surgical repair. Isolated lateral collateral ligament injuries, where only the LCL is torn, are not that common, but when they do occur, they usually recover well without surgery. Tennis and gymnastics are two sports in which isolated LCL tears often occur. Isolated lateral collateral ligament tears most commonly happen in tennis. What’s the difference between an LCL sprain and a tear? Nothing. People often refer to a milder or minor LCL tear as a sprain, but this is not a medical diagnosis. Even the slightest LCL injuries involve a small tear. You can read more about the grading of LCL injuries below. In this article, we use the term LCL tears and LCL sprains interchangeably. Lateral collateral ligament tear symptoms LCL tear symptoms include: Sudden, sharp pain during a forceful movement or blow to the knee. Pain and mild swelling over the outside of the knee. If you’ve injured something else inside the knee (like a meniscus or cruciate ligament ) your knee may be very swollen. If the fibular nerve was also injured, you may feel a numbness or weird sensations over the outside of your lower leg or the top of your foot. If you have a Grade 3 LCL tear and/or have injured other ligaments around the knee, you knee may feel unstable when you walk and move. Lateral collateral ligament injury tests Varus Test for LCL tears This test is pretty easy to do and the results are used to predict if surgery is needed or not. The patient lies on their back on a bed. Always perform this test on the uninjured side first, so you know how much the patient’s knees normally gap. The examiner places their one hand under the knee so that the heel of that hand can apply force over the inner part of the knee. Their other hand holds the lower leg over the ankle. They then pull the ankle inward while pushing the knee out, trying to gap the outer knee joint. Be gentle - if the ligament is fully torn the knee will gap a lot. The test is first performed with the knee bent to 30 degrees. If the outer part of the injured knee gaps more than that of the uninjured one, the test is a positive indicator for an LCL injury and a potential PLC injury. The test is then repeated with the knee fully straight. If the injured knee gaps less when fully straight, it indicates an isolated LCL injury. If the knee gaps just as much as when it’s bent, it indicates that the LCL as well as other structures that make up the PLC of the knee have been injured. X-ray X-rays don’t show LCL injuries, but they are useful to rule out other types of injury. Because it takes so much force to tear the LCL, it is quite common to also fracture the head of the fibula, or to pull out a small piece of bone where the LCL attaches to the fibula (an avulsion fracture). MRI scan An MRI scan is the best way of fully assessing the LCL and the other ligaments, tendons, and menisci of the knee that may have been injured. Grading LCL tears LCL tears can be graded in two ways: According to how much instability or gapping is found when the Varus Test is performed. According to how much of the ligament appears to be torn on an MRI scan. Grading LCL tears according to the Varus Test Grade 1 – Stable: The Varus Test usually produces only pain, without any extra gapping or movement of the joint. Grade 2 – Decreased stability: There is usually a bit more movement when the Varus Test is performed on the injured leg vs. the uninjured leg (5 mm to 10 mm), but it is not excessive, and there is still something preventing the movement from going past a certain point. Grade 3 – Unstable: There is usually significant gapping of the outer knee joint when doing the Varus Test (more than 10 mm). Grading LCL tears according to MRI results Grade 1 – Minor tear or sprain: Very few fibres of the ligament are injured. Grade 2 – Partial tear: A significant portion of the ligament has torn. Grade 3 – Complete tear or rupture: The ligament is torn right through. The results of the Varus Test is used to decide whether an LCL injury requires surgery. Do you need surgery for an LCL tear? The results of the Varus Test should be used to decide whether surgery or conservative treatment is the best option. This means that, even if the LCL looks like it is fully torn on the MRI scan, it can still be treated using only a brace and progressive load bearing and exercise, as long as the Varus Test produces a Grade 1 or 2 result. Bushnell and colleagues found that NFL athletes who had an isolated Grade 3 lateral collateral ligament tear on an MRI scan recovered more quickly, while achieving an equal likelihood of return to play at the professional level, when they were treated conservatively rather than with surgery. Even fully torn lateral collateral ligaments can heal without surgery. There are also several case studies describing the successful treatment of isolated complete LCL ruptures, even with avulsion fractures, using only braces and rehab exercises in various types of athletes, including kids and adults, taking part in ju-jitsu, rock climbing, and soccer. It is only when you have also torn some of the other ligaments in and around the knee, like the anterior or posterior cruciate ligaments or other structures that make up the posterior lateral corner of the knee, that surgery may be the better treatment option. LCL sprain recovery times The current recommendation is that someone should only return to sports when they have full, pain-free knee range of motion, no tenderness on the outside of the knee, and no ligament laxity when the Varus Test is performed. With conservative treatment, the average recovery times are: Grade 1 LCL tear (sprain): Four weeks to slow, controlled types of exercise, and 4 to 6 weeks for sports involving quick changes of direction. Grade 2 LCL tear: Eight weeks to get back to easily controlled sports, but usually closer to 12 weeks to get back to sports with quick changes of direction Grade 3 LCL tears: About 6 months to get back to full, competitive sport involving twisting, turning, and sudden movements. Can be as soon as 8 weeks for sports that involve only controlled movements, e.g. yoga, as long as only the LCL was injured. If the person also bruised the knee joint’s cartilage or bone (resulting in a very sore and swollen joint), it may take 3 months to get back to controlled activities like yoga. Recovery times after surgery: Isolated LCL reconstruction: Six months to get back to full sport. LCL plus other ligament or tendon repair: Six to 9 months to get back to full sport. LCL injury treatment without surgery LCL knee braces and weightbearing If you have a Grade 1 LCL tear or sprain and no laxity in the Varus Test, you likely don’t need a brace, and you can usually walk as soon as it is comfortable. Grade 2 LCL tears do require a brace for about 6 weeks, but patients are usually allowed to move the knee and place as much weight on the leg as is comfortable from Day 1. Researchers recommend that Grade 3 LCL tears have to be immobilised in a brace for 2 weeks with the knee fully straight and no weight being placed on the leg. After that, the hinge of the brace is adjusted weekly over a period of 6 weeks with the aim to bend the knee at least 90 degrees before removing the brace. The brace can usually be removed after 8 weeks. However, research into the best way to treat LCL tears is thin on the ground, and I suspect that these recommendations may change to also allow some early movement and weightbearing, as with MCL tears. But for now, it’s best to stick to what we know works. We've written a detailed article about the type of knee brace needed for lateral collateral ligament injuries – here are some examples on Amazon. Crutches If you have a Grade 3 tear and been told that you aren’t allowed to place any weight through your leg, you will have to use crutches. Crutches are optional for other cases. They can be useful to help you move and recover better if your knee is quite painful to stand or walk on. It is always good to try and mimic your normal gait pattern when you use crutches , but this will only be possible once your brace allows your knee to bend. Rehab exercises for LCL strains and tears These exercises are only appropriate for cases that are managed conservatively. If you’ve had surgery for your LCL tear, you have to follow you surgeon’s suggestions, because the healing process is different. General guidelines Early movement within the pain-free range is good – never push through pain. If you have been told to wear a brace, you have to wear it whenever you do your exercises, stand, or walk. Find more detailed advice about braces for LCL tears here. Exercises for early LCL rehab These exercises activate and work the quads and hamstrings without placing strain on the LCL. Limit how far you move your leg to what you can do pain-free or to the restriction of your brace. Examples include: Knee flexion and extension: This gets the knee moving, helping with circulation and stiffness. Active straight leg raises: Tensing your quads and lifting your straight leg. Prone or standing leg curls: Start with no weight/resistance, and gradually add some. Exercises for mid-stage LCL rehab These exercises help you to regain your knee’s full range of motion and strength in controlled positions. Some examples include: Continue flexion and extension until full range Squats Balancing Bridges Exercises for later-stage LCL rehab It is now time to introduce more dynamic movements that load the knee and the LCL more forcefully. Your sport will guide the choice of exercises here – the final rehab for someone who just enjoys walking will be very different from that of someone who wants to run. Similarly, the rehab plan for a runner will look very different from that of a footballer. If you’re looking to get back to a sport like football, which requires quick changing of direction, your rehab will have to build up to this over time. Examples include: Lunges Single-leg squats Single-leg deadlifts Hopping and jumping exercises, if your sport requires it Easing into running – first in straight lines and then adding in changes of direction (if needed), also starting slow and building the speed over several weeks. LCL exercises to avoid Avoid doing exercises like side-leg lifts during early rehab – the weight your leg as you lift it can cause a strain on the LCL. You can usually start them once you’re allowed to remove your brace. Side planks, where you carry your full weight through the side of your leg and trunk, place a very large force through he LCL and should be avoided until much later in your rehab. Avoid doing exercise that load the LCL directly during the early stages of rehab. Examples are side-leg lifts and side planks. Medication You may benefit from pain medication if your knee is very painful. However, pain medication doesn’t speed up the healing, so only use it if it is really necessary. In most cases, it’s best to avoid anti-inflammatory medication , because it may interfere with healing. However, there are some instances where this medication is needed and beneficial, so speak to your doctor before you start or stop taking any medication. Ice Ice might provide temporary pain relief, but it won't necessarily speed up your healing. Don't apply it for more than 10 minutes at a time, and give it a rest of at least 10 minutes inbetween. You can read more about how to use ice for injuries in this article . How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Bushnell, B. D., et al. (2010). "Treatment of magnetic resonance imaging-documented isolated grade III lateral collateral ligament injuries in National Football League athletes." The American Journal of Sports Medicine 38(1): 86-91 . Davenport, D., et al. (2018). "Non-operative management of an isolated lateral collateral ligament injury in an adolescent patient and review of the literature." BMJ Case Reports 2018: bcr-2017-223478 . Petrillo, S., et al. (2017). "Management of combined injuries of the posterior cruciate ligament and posterolateral corner of the knee: a systematic review." British Medical Bulletin 123(1): 47-57 . Ramos, L. A., et al. (2019). "Treatment and outcomes of lateral collateral ligament injury associated with anterior and posterior cruciate ligament injury at 2-year follow-up." Journal of Orthopaedics 16(6): 489-492 . Sikka, R. S., et al. (2015). "Isolated fibular collateral ligament injuries in athletes." Sports Medicine and Arthroscopy Review 23(1): 17-21 . Yaras, R. J., et al. (2022). "Lateral collateral ligament knee injuries.” StatPearls Publishing .

A lateral meniscus tear doesn’t happen as easily as a medial one, and they tend to heal better when left alone. However, a lateral meniscus tear can take longer to heal after surgery. This article explains the symptoms of a lateral meniscus tear as well as the treatment options, the correct rehab exercise approach, expected recovery times, and why surgery should be the last resort. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article may be to pages where you can buy products or brands discussed or mentioned here. We might earn a small commission on the sale of these products at no extra cost to you. In this article: Anatomy How does a lateral meniscus tear happen? Lateral meniscus tear symptoms Does a lateral meniscus tear require surgery? Lateral meniscus tear treatment - conservative approach Lateral meniscus tear recovery time How we can help We've also made a video about this: Anatomy You have two menisci in your knee – one lateral and one medial. The lateral meniscus is on the outside of the knee and the medial on the inside. They are C-shaped discs made of cartilage, and their outer edges are thicker than the inner edges. This forms a concave surface that helps the femur (thigh bone) to sit better on top of the tibia (shin bone), contributing to the stability of your knee. The menisci also function as shock absorbers and help to distribute load more evenly through the knee joint. The medial meniscus is more securely attached to the ligaments and other structures in the knee than the lateral one and doesn’t move much when your knee moves. The lateral meniscus is more mobile and moves with the outer joint surface of the femur as you bend and straighten your knee; this is partly why it doesn’t get injured as often as the medial meniscus. The outer 25% to 30% of the menisci gets a blood supply. The inner portion does not have a blood supply; it depends on the synovial fluid in the joint to supply it with nutrients and oxygen and to remove carbondioxide and other by-products. This is why movement is important for the meniscus, because the change in pressure funnels the synovial fluid to and from it. How does a lateral meniscus tear happen? Meniscus tears are most often caused by movements that involve a forceful twisting or extreme bending of the knee. These actions can also injure other parts of the knee, and a lateral meniscus tear often occurs in combination with an anterior cruciate ligament (ACL) tear . Lateral meniscus tear symptoms The pain caused by a lateral meniscus tear is located over the outer edge of the knee, along the joint line. Depending on what part of the lateral meniscus is injured, it can be over the front part of the outer edge, directly on the outside, or more towards the back of the knee. The swelling can vary – from a bit of puffiness to having an extremely swollen knee. Most likely you will not be able to bend or straighten your knee fully, but this should improve within a few weeks. A physio will be able to tell whether your knee movement is recovering at a normal pace. You may experience a feeling of instability, clicking or “popping”, or that your knee wants to lock when you move. Walking can either be very uncomfortable, or it can be mostly fine until you try to walk up or down an incline or stairs. Walking on uneven terrain can often cause pain. Climbing stairs can often cause outer knee pain when you have a lateral meniscus tear Does a lateral meniscus tear require surgery? Very likely not. There is evidence that stable lateral meniscus tears heal by themselves in the vast majority of cases, and they tend to heal better than medial meniscus tears. Studies that followed the long-term progress of patients have shown that the recovery rates and results one year after the injury are very similar for people who have had surgery and those who underwent a conservative treatment plan. Surgery does not guarantee good results and may increase your chance of developing osteoarthritis in the knee, so it is currently advised that conservative treatment (consisting of relative rest and exercise – see below) should be the first choice for lateral meniscus tears. However, not all meniscus tears react equally well to conservative treatment, and if it is torn in a way that blocks your movement (e.g. a bucket handle tear), it may require surgery. Your doctor will consider the following factors when deciding whether you need surgery: The type of tear (stable vs. unstable, or blocking movement) How it affects your function – are there signs of improvement, or does it continue to severely affect your function several months later? How it reacts to conservative treatment – i.e. rehab exercises for at least 6 months, although full recovery can take up to 12 months. If surgery is required, meniscus repair surgery is the first option, but this is only feasible if the tear is in an area with good blood supply and if the meniscus is not too damaged. The next option is a partial meniscectomy, where they trim the injured part of the meniscus away. Meniscectomies often lead to poorer outcomes, including ongoing pain and swelling. They are also associated with an increased risk of early osteoarthritis. Lateral meniscus tears do worse after a meniscectomy than medial meniscus tears because of how the load of your weight is distributed in your knee. As an aside: Clinicians used to think that ACL tears should be repaired surgically as soon as possible to prevent further damage to the meniscus. However, there is new evidence that delaying or avoiding ACL surgery and following conservative treatment instead do not lead to further tearing of the meniscus. Lateral meniscus tear treatment – conservative approach The knee works as a unit, so the conservative treatment for meniscus tears, including what exercises you do, is exactly the same for lateral and medial meniscus tears. There are three phases: Phase 1: Treatments that decrease pain and increase movement This is for the very early stage of your rehab, when your knee is still very painful, swollen, and stiff. The main aim is to help your injury to settle down. Treatments that may be useful include: Icing your knee intermittently to reduce swelling and pain. Here’s more information on how to apply ice to an injury and what to avoid . Gentle movements and exercises to reduce pain and swelling and to start activating the muscles that support your knee. The movement also improves the supply of the much-needed synovial fluid to the injured meniscus. You can find examples of exercises used during this early stage of meniscus tear treatment here . Reducing the load on your injured knee, e.g. using a walking stick or crutches, or simply reducing the time you spend on your feet. For instance, don’t try to clean the house in one go. Rather break the task up in smaller parts and rest in between, or spread them out over several days. Pain medication can be useful if your pain is severe or your knee is badly swollen. There is some evidence that nonsteroidal anti-inflammatory medication (like ibuprofen) may not be that good for healing, so consider exploring other options with your doctor. However, if you use it for only a few days to reduce severe swelling, the benefits may outweigh the risks; it’s long-term use that may cause problems. Phase 2: Gradually restore your full strength and control The most important treatment during this phase is the right combination of relative rest and rehab exercises. Relative rest The aim with relative rest is to stay as active as possible without increasing the pain and swelling during the activity or in the 24 hours afterwards. Complete rest isn’t useful at this stage because, while it calms your pain down, it can actually make you lose even more strength and control. Relative rest helps you to maintain the strength, control, and endurance you currently have, and it also allows you to gradually improve these as you recover. For instance, if you go for a walk and it only feels mildly uncomfortable, but there’s no increase in pain or swelling later on, then it was fine to do that walk. On the other hand, if everything feels fine during the walk, but that evening or the next day your knee is significantly more painful and swollen, it was likely a bit too much. Use this approach for all your activities, including your rehab exercises. If your knee pain increases significantly after doing an activity, it's a sign that you should likely reduce the volume or intensity of that activity until your injury has had time to heal Rehab exercises These exercises will teach you good movement patterns and control. Initially, they involve low-load and very stable movements, e.g. a double-leg squat within a limited range of movement. It is important not to rush the rehab; for instance, you can make your injury worse if you try and squat too deeply at the start. However, as your injury heals, the exercises should gradually become more intense and complex to eventually restore the full strength and control you need for the types of activity or the sport you want to be doing. Here is our full guide for meniscus tear rehab, including what exercises to do (with demo pics and video clips) . Meniscus tear rehab exercises should start easy and gradually progress to more intense and complex ones Phase 3: Easing back into sport Once you’ve completed your rehab exercise programme, your meniscus won’t be ready yet to cope with a complete session of top-intensity match play or running. This is why it is important to ease back into your sport with a run-walk programme or half-effort training sessions to start with. If you resume your sport too soon or too intensely, you risk reinjuring your knee. A physio can help to assess whether you’re ready by setting you specific movement tests or exercise targets. Gradually easing back into sport allows your knee to regain the final strength it needs Lateral meniscus tear recovery time The recovery time for meniscus tears depends on the severity of the tear, what part of the meniscus is torn, your age, and whether surgery is needed. It can be anything from 8 to 12 weeks for simple tears in younger adults but up to 6 months to a year in other cases. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Gastaldo, M., et al. (2022). "High quality rehabilitation to optimize return to sport following lateral meniscus surgery in football players.” Annals of Joint, Vol 7. Van De Graaf, V. A., et al. (2018). "Effect of early surgery vs physical therapy on knee function among patients with nonobstructive meniscal tears: the ESCAPE randomized clinical trial." Jama 320(13): 1328-1337. Van der Graaff, S. J., et al. (2022). "Meniscal procedures are not increased with delayed ACL reconstruction and rehabilitation: results from a randomised controlled trial." British Journal of Sports Medicine. Published Online First: 22 September 2022. doi: 10.1136/bjsports-2021-105235 Lee, Yong Seuk, Lee, O-Sung, Lee, Seung Hoon. Return to Sports After Athletes Undergo Meniscal Surgery: A Systematic Review. Clinical Journal of Sport Medicine: January 2019 - Volume 29 - Issue 1 - p 29-36 doi: 10.1097/JSM.0000000000000500 Lavoie-Gagne OZ, Korrapati A, Retzky J, et al. Return to Play and Player Performance After Meniscal Tear Among Elite-Level European Soccer Players: A Matched Cohort Analysis of Injuries From 2006 to 2016. Orthopaedic Journal of Sports Medicine. 2022;10(1). doi:10.1177/23259671211059541 Englund M, Guermazi A, Gale D, et al. Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. New England Journal of Medicine 2008;359(11):1108-15. doi: 10.1056/NEJMoa0800777 Kise Nina Jullum RMA, Stensrud Silje, Ranstam Jonas, Engebretsen Lars, Roos Ewa M. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ 2016;354 :i3740 Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine (5th ed.) Vol 1: Injuries. (2017) McGraw-Hill Education. Borque, K. A., et al. (2021). "Evidence-based rationale for treatment of meniscal lesions in athletes." Knee Surgery, Sports Traumatology, Arthroscopy: 1-9.

“Should I go for meniscus tear surgery?” and “How long is the recovery time for a meniscus tear?” are two questions we often get asked. In this article, we explain what the meniscus does, how it gets injured, why surgery is not the automatic meniscus tear treatment option anymore, and how long this injury takes to recover. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains links to products relavant to the topic discussed here. We might earn a small commission on sales at no extra cost to you. In this article: What is a meniscus? What causes a meniscus to tear? Meniscus tear surgery vs. conservative treatment Will a meniscus tear heal? Meniscus tear recovery time Conservative treatment for a torn meniscus How we can help We've also made a video about this: What is a meniscus? A meniscus is a horseshoe-shaped piece of cartilage that forms part of your knee joint. It sits between the bottom end of your thigh bone (femur) and the top end of your shin bone (tibia). Actually, as you can see in the picture, you have two of them in each knee – one on the inside of the knee (medial meniscus) and one on the outside (lateral meniscus). Their function is to ensure that the two bones fit together comfortably, and they act as shock absorbers. What causes a meniscus to tear? A meniscus typically tears when the knee joint is subjected to a sudden, forceful twisting or a deep squat with a heavy load. In some cases, this is preceded by a gradual straining of the meniscus due to overuse – when you've really worked it hard in a way that it didn't want to be worked, over a long period of time, or by repetitive straining due to poor biomechanics. In these cases, it can be a very simple movement that finally does it. One of my patients was merely bending down to get logs out for the fire when it happened. But a healthy meniscus can also be injured by a sudden, traumatic movement, for example when you fall and twist your knee. Meniscus tear surgery vs. conservative treatment When I first started studying physiotherapy, at about the turn of the century, meniscus tears were regarded as something that always needed surgery. An arthroscopic partial meniscectomy is the most frequent procedure done by orthopaedic surgeons for meniscus injuries. They enter the knee through a few small incisions and, with the help of a camera, remove part of the meniscus. A meniscus is meant to absorb shock in your knee, but a meniscus of which a part has been cut away cannot do this as well as before. Research has shown that knees with a meniscectomy are more likely to get arthritis later on. Also, as soon as you remove a part of a meniscus, you're changing the biomechanics in the knee – how it carries your weight. A recent study followed people with meniscus tears who have had surgery and who have not had it over a two-year period. They found that there was no significant difference between the two groups after two years: some still had pain, others’ knees felt a bit iffy, and others had no pain. The researchers also tracked the progress of people who started out with just rehab and no surgery but, later during the two-year period, decided to have surgery after all; they didn’t find any extra benefit from it. So, surgery is not necessarily a silver bullet for meniscus tears. There is one exception, though, and this is if you have a bucket handle tear, where the tear in the meniscus turns back on itself, and then the knee gets stuck. If you haven't regained most of your range of movement within four to six weeks, you should definitely go and consult a surgeon to see whether surgery is needed. But if your knee regains most of its range of movement within the first four weeks, I would recommend that you first go for conservative treatment consisting of a good rehab programme for meniscus tears and follow that for three to six months. As long as you see small improvements, stick with it rather than having surgery. Will a meniscus tear heal? This is one of the more frequent questions we get asked. The reason many people ask is because they read on the Internet that a meniscus cannot heal because it has such poor blood supply. Well, nothing in a joint has a good blood supply, but joint injuries generally do heal. A joint relies on synovial fluid instead of blood to supply it with nutrients and take away waste products. And for the synovial fluid to do its thing, the joint needs to move. Therefore, you don't need a massive blood supply to get your meniscus functional again, you just need a graded exercise plan and the right nutrients (balanced diet). We don’t really know whether a tear in a meniscus always knits together again. People’s knees are usually only scanned shortly after they’ve been injured to see what the problem is. If it’s a meniscus tear, it isn’t scanned again later on to see whether it has healed. How well it has healed is judged based on how much your symptoms have improved. The evidence also suggests that a meniscus tear doesn't have to knit together for you to have a fully functional and pain free knee. Painless meniscus tears Meniscus tears are also very common in people who have no knee pain. In one study, researchers looked at MRI scans of 991 patients and found that 61% of them had meniscus tears but reported no pain or symptoms in their knees. So, it is possible to have a functional, pain-free knee despite the meniscus being torn. We’ve also observed this in our own patients. After we’ve rehabbed them successfully from a meniscus tear, they’ve gone back to doing their sport without any problem and then, years later, they get another injury, and when they’re scanned for that injury, it turns out that, by the way, their meniscus is still torn! So, try not to worry about whether it's healing or not healing. Rather go according to how your knee is functioning; how much more can you do today compared with what you could do yesterday or last week? Meniscus tear recovery time A meniscus injury can take a long time to get better. A mild meniscus tear – especially for younger people – can get better in about four to twelve weeks. But for older people – and unfortunately, I’m referring here to anyone over the age of 35 – it can usually takes three to six months, but often even longer. Something that can really increase your recovery time is if you’re trying to force the pace with your rehab. If you overdo it with how many repetitions you’re doing or using too much weight, you can actually aggravate your pain and delay your recovery. Therefore, it's quite important to get some guidance on the right level of exercise for you. So, the long and the short of it: Recovery times for meniscus tears can vary quite dramatically, but as long as you're seeing small improvements it means that rehab will likely work for you. Conservative treatment for a torn meniscus A well-rounded conservative treatment plan for meniscus tears has these elements: Relative rest Rehab exercises Cross-training Relative rest Relative rest – as opposed to total rest – involves starting to use your knee joint gently as soon as possible after you’ve injured it while avoiding movements that cause additional pain. This is because your joint needs some movement to get that synovial fluid in and out to help your meniscus recover. However, there are some movements and activities that are likely to increase your pain and delay recovery, and which we advise our patients to avoid during the early stages of recovery: Twisting movements of the leg. So, for example, if you want to swivel around while standing. Rather move your feet with your upper body. Deep squatting or kneeling. Walking on uneven terrain or steep downhills. Walking or standing for long periods. Your injured meniscus needs time to regain its strength and endurance and it won’t yet be able to tolerate long periods of weight bearing. If you find that your knee is significantly more swollen or uncomfortable in the late afternoons or evenings, then it may be that you’re doing too much. Ice for pain relief Ice might provide temporary pain relief, but it won't necessarily speed up your healing. Don't apply it for more than 10 minutes at a time, and give it a rest of at least 10 minutes inbetween. You can read more about how to use ice for injuries in this article . Rehab exercises Rehab exercises for meniscus tears should evolve and progress as your injury recovers. During the early stage of recovery, the exercises consist of low-load repetitive movements with the aim to feed the joint, improve range of motion, and activate the muscles that support the knee and control your leg. We have created a detailed article and a video demonstrating exercises that can be used during the first few weeks of meniscus tear rehab . In the later stages of rehab, once your knee can tolerate more load, the exercises should slowly increase in intensity and complexity until you’ve regained the full strength and control required by your sport. It should include exercises that: Strengthen the muscles around the knee. Strengthen the muscles that improve your leg control, e.g. gluteal and ankle muscles. Strengthen your core muscles. Improve your position sense, which is your brain’s awareness of and ability to control your leg without you having to look at it. We provide more detailed examples of exercises for later stage rehab for meniscus tears and how to progress them in the second part of this article. Cross-training Any activity that involves low-load, repetitive movements of the knee can be a useful cross-training option to help your recovery. The most common two are cycling and swimming. Cycling with a meniscus tear Cycling can be a good cross-training option if you have a meniscus tear, but it won’t suit everyone. If your knee feels uncomfortable, check whether it makes a difference if you adjust your saddle (higher is often better) or where you place your feet on the pedals. Often, the knee feels quite stiff and uncomfortable when you start pedalling and then improves as you continue. It's best to use a stationary bike during the early stages of meniscus tear rehab. If you have a relatively recent meniscus injury and want to try out cycling for cross-training, I would suggest that you use a stationary bike because: It is easier to control your movements and the resistance against which you pedal. You may reinjure yourself if you have to stop suddenly while cycling out on the roads. Your knee should not feel worse after you’ve cycled, and you should not experience actual pain while cycling. Swimming with a torn meniscus I’ve shared detailed advice on swimming with a meniscus tear in the video below, but in short: Do NOT do breast stroke – the circular movement of the legs will likely aggravate your injury. Squeeze a flotation device between your legs to prevent you from kicking if your knee feels uncomfortable when you kick. You can start doing freestyle once you feel your knee is fine with straight-line kicking. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References: Englund M, Guermazi A, Gale D, et al. Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. New England Journal of Medicine 2008;359(11):1108-15. doi: 10.1056/NEJMoa0800777 Kise Nina Jullum RMA, Stensrud Silje, Ranstam Jonas, Engebretsen Lars, Roos Ewa M. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ 2016;354 :i3740 Brukner, P, et. al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education.

An MCL sprain – an injury to the medial collateral ligament, on the inside of your knee – can be caused by a sudden impact to the leg, or it can develop over time due to the way you walk or run. This article explains how the MCL sprain treatment will depend on how the injury happened, as well as what the symptoms are and what the expected recovery times are. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. If you buy anything via these, we might earn a small commission at no extra cost to you. In this article: Anatomy of the medial collateral ligament Causes of MCL sprains MCL sprain grades MCL sprain symptoms MCL sprain recovery time Does an MCL tear require surgery? Conservative treatment for MCL sprains How do you know if your MCL is healed? How we can help We’ve also made a video about this: Anatomy of the medial collateral ligament In spite of the singular “ligament” in the name, the MCL consists of three parts, and one of them has been discovered only relatively recently! A: sMCL = Superficial Medial Collateral Ligament, POL = Posterior Oblique Ligament, B: Deep Medial Collateral Ligament. Picture credit: Wijdicks et al. 2010 These ligament parts are on the inside of your knee, and they attach the bottom end of your thigh bone (femur) to the top end of your shin bone (tibia). Their job is to prevent the inner part of your knee joint from separating as you move. When I studied physiotherapy about twenty years ago, we knew about the superficial MCL (sMCL in Picture A) and the deep MCL (the only ligament in Picture B). Since then, they have also discovered the posterior oblique part of the ligament (POL in Picture A). Causes of MCL sprains MCL sprains are caused by forces that want to make the knee collapse inwards and that are stronger than what the MCL can handle. It can be a sudden force or something more ongoing that sets in over time. Sudden MCL sprains These are typically caused by an impact to the outside of the leg that forces the knee joint inwards, causing an MCL sprain. A severe impact that also makes the knee rotate can cause an additional injury to the ACL (anterior cruciate ligament) and/or the medial meniscus . A sudden MCL sprain could also happen without an impact to the leg, for example if you step off the pavement awkwardly or step in a hole. Overuse MCL sprains These happen when there is something about the way you walk and/or run that causes the inside of the knee to take more strain than it is meant to, instead of having the forces of walking and running distributed more “fairly” throughout the whole joint. The most common examples are when you don’t have good stability around your pelvis due to weak gluteal muscles or when your foot collapses inwards too much (over-pronation). In both cases, this can cause your knee to turn in excessively and increase the strain on the MCL. For runners and walkers, the pain from this overuse type of MCL sprain develops slowly over time. It is quite important to understand what has caused an overuse MCL sprain, because you should address these causes during your rehab. MCL sprain grades Grade 1 is a very minor sprain. You will usually have some pain but the knee will be stable. Grade 2 means that a substantial number of fibres have been torn. You will have more pain and your knee will be a little less stable. Grade 3 means that the ligament is fully ruptured. Interestingly, Grade 3 tears are often less painful than Grade 2 ones, but your knee will be a lot less stable. MCL sprain symptoms Traumatic tears You feel a sudden, sharp pain on the inside of your knee while doing an activity. Depending on how severe your sprain is, you may struggle to fully bend or straighten your knee. The pain is located over the inner part of the knee and, when pressing on the MCL, you can find a painful portion in the ligament. Activities that cause your knee to turn in or gap on the inner part usually cause pain, e.g. walking on uneven terrain or soft sand, walking in unstable or too flexible shoes, or twisting around while your feet are planted. You may notice a bit of swelling over the inner part of your knee joint, in the area of the ligament. Isolated MCL sprains don’t cause much swelling. If your knee swells significantly, you’ve likely also injured something else inside your knee, e.g. your meniscus. If you’ve torn a significant part of your MCL, your knee may feel unstable when you walk. Overuse MCL sprains The pain usually develops gradually over time and you’re not aware of any specific moment when you injured your knee. The pain is also located over the inner joint line, and you can find a painful area in the MCL when you press on it with your fingers. You may be able to fully bend and straighten your knee without any pain. Your pain will be aggravated by activities that increase the strain on the MCL, e.g. walking on uneven terrain or in unsupportive or too flexible shoes. MCL sprain recovery time Fortunately, the MCL has a really good blood supply, especially the superficial part, so it heals quite quickly for a ligament. The recovery time for mild MCL sprains is about four to six weeks. Moderate to severe MCL injuries take about 12 weeks to fully rehabilitate. However, like I explained earlier, an MCL injury sometimes goes hand-in-hand with an injury to the ACL and/or the meniscus. In these cases, the rehab time will be longer. Another possible complication is bone bruising. This can happen if your injury was due to a sudden impact that also squashed the bottom end of the femur and the top end of the tibia together. Bruised bone takes longer to heal than ligaments – anything from two to four months. So, you may still have pain in the inner part of your knee even though the MCL has healed. This is why it could be useful to get a scan if you're not recovering as expected, as it might explain why your pain is persisting for longer than expected. Does an MCL tear require surgery? No, the research shows that even Grade 3 MCL tears do really well with conservative management, i.e. the right combination of rest and protection (to allow the MCL to repair) and rehab exercises to strengthen the MCL and leg muscles that support it. It is only in very specific cases that surgery may be required, like when the MCL has pulled away from the bone (avulsion fracture) and the muscles come between the two ends of the torn MCL. We've made a short video about this: Conservative treatment for MCL sprains Type of treatment depends on the cause of the MCL sprain The treatment approach for an MCL sprain should be informed by the cause and severity of your injury. In the case of an overuse sprain, the focus will be as much on strengthening the body area that was the cause of the sprain (e.g. weak glutes) to prevent it from happening again as it will be on rehab for the MCL itself. In the case of an acute MCL tear, on the other hand, the focus will be much more on protecting the knee and getting the MCL to heal. Issues such as hip stability would be secondary, because that is usually not what caused the injury. Braces for MCL sprains You may benefit from wearing a brace when you have an MCL sprain. Grade 1 sprains usually don’t require a brace, as long as you avoid activities that place strain on the MCL. More serious Grade 2 and definitely Grade 3 tears require braces that limit the side-to-side movement of the knee but allows your knee to bend and straighten. We have a detailed article explaining what type of brace is best for MCL sprains, and when and for how long to wear them . MCL sprain rehab exercises A well-rounded rehab plan for an MCL sprain should include exercises that: Restore the full range of motion in your knee. Strengthen your core, glutes, and lower leg muscles – this improves the stability in your leg and reduces the strain on the MCL. Challenge and develop your position sense and balance – these also improve your stability and control. Strengthen the muscles that directly control your knee joint, e.g. quads and hamstrings. The exercises should: Never be forced into pain. Start with stable, double-leg exercises (see examples below). They provide strength and help you develop good movement patterns in positions that don’t place much strain on the MCL. Be progressed to single-leg exercises that challenge your balance but maintain stable, straight lines. These exercises increase the work on the MCL but not excessively. Be progressed to include movements that challenge your knee in all directions and require more skill and control e.g. lunges into all directions. Include sport-specific exercises during the later stage of rehab, e.g. hopping and jumping or changing direction, if that is required by your sport. Slowly ease you back into your sport in the final stage of rehab. Your knee won’t yet have the full strength and endurance to cope with a full training session or competition; it’s important to build up to it over several weeks. How quickly you can progress through these exercises will depend on the severity of your injury. Your physiotherapist will guide you and help you test when you’re ready to safely move on to the next stage. Exercise examples Example of a range-of-motion exercise: Lying on your back and slowly bending and straightening you leg. Don't force it. Just go to where it feels comfortable. Example of double-leg exercises: Squats and bridges Examples of exercises that challenge your balance: Single leg balance, single leg squat, and single leg deadlifts. Examples of exercises that challenge your knee in all directions: Balancing on unstable surface and lunges into all directions. How do you know when your MCL has healed? We usually consider an MCL as healed when a patient can perform the following activities without experiencing pain or swelling during or in the 24 hours after: Move their knee fully into all directions Someone can push on the outside of your knee, trying to gap the inner joint, without it hurting or making your joint move more than your uninjured one Do exercises like lunges into all directions and at speed Walk and run on uneven surfaces. You should always gradually ease back into your sport to allow your MCL to regain its final level of strength. Your physio can help to guide you on this. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References In: Brukner P, Clarsen B, Cook J, Cools A, Crossley K, Hutchinson M, McCrory P, Bahr R, Khan K. eds. Brukner & Khan’s Clinical Sports Medicine: Injuries, Volume 1, 5e . McGraw Hill; 2017. Garvey, S. E., et al. (2013). "Current Best Practice for Management of Medial Collateral Ligament Injury." Wijdicks, C. A., et al. (2010). "Injuries to the medial collateral ligament and associated medial structures of the knee." JBJS 92(5): 1266-1280. Vosoughi, Farzad, et al. "Medial collateral ligament injury of the knee: a review on current concept and management." Archives of Bone and Joint Surgery 9.3 (2021): 255.

Knee pain is a common problem for runners, but often it is tricky to figure out what caused it. In this article, we’ll discuss the most common causes of knee pain in runners and how you can distinguish between them. We’ll also share the top three treatments that we find work best for dealing with each of these knee injuries. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. In this article: Inner (medial) knee pain Outside (lateral) knee pain Front (anterior) knee pain General knee pain How we can help We've also made a video about this: Inner (medial) knee pain when running Inner knee pain when running - Where you feel the main pain. Medial meniscus tear The pain from a medial meniscus tear is usually felt on the inside of the knee, along the inner joint line. It can also be located a bit more to the inner front or inner back of the knee, depending on which part you injured. It is usually caused by a sudden twisting movement or deep kneeling. It is often accompanied by some swelling, and it may be difficult to fully bend or straighten your knee. Meniscus injuries can feel very similar to bone bruising and medial collateral ligament tears, and these three injuries can often happen at the same time. Your physio or doctor can help you to distinguish between them. I've also made a video where I discuss meniscus tears and their treatment in detail: My top three treatment suggestions: Let it settle - Allow your knee three to seven days to settle before you start any serious rehab exercises. You don't need complete rest, but limit how much time you spend on your feet (standing and walking) - if your knee hurts more in the afternoon or evening, it may be a sign that you're doing too much. Use ice and gentle movement (bending and straightening your leg) to help your knee calm down and the swelling to reduce. inbetween. You can read more about how to use ice for injuries in this article . Follow a progressive rehab plan that includes exercises that strengthen your glute and thigh muscles and balancing exercises to restore your control and position sense . These have to start in positions that don't place a lot of load through your injured knee and then slowly increase in intensity and complexity as your knee recovers. Refrain from running until you have: Regained full range of motion, And full strength, And good balance and control. Looking at the knee from the front - the inside of the knee is on the right Medial collateral ligament (MCL) tear/strain The medial collateral ligament runs over the inside of the knee. It resists forces that try to gap the inner part of your knee joint and stops your knee joint from bending outward too much. You usually strain or tear it through a sudden movement, often involving a twisting action, very similar to the type of movement that injures the medial meniscus. But you can also develop an overuse MCL injury if your knee turns in excessively when you run or walk. Tears can vary from a mild strain to a significant tear that may require you to wear a brace. You usually feel a sudden sharp pain when you tear/strain your MCL. You may notice a bit of puffiness or swelling over the inner knee line, and you will be able to locate a painful area in the ligament when you press on it. Depending on the severity of the tear, you may not be able to fully bend or straighten your knee. MCL strains can often be misdiagnosed as meniscus injuries, but they can also occur together with a medial meniscus tear. I've also made a video where I discuss MCL tears and their treatment in detail: My top three treatment suggestions: Avoid activities that strain the ligament. This advice applies to the early stage of rehab; by avoiding activities that make your knee move inward, you give the ligament a better opportunity to repair the injured area. Examples of activities to avoid include running, walking on uneven or soft ground, walking in unsupportive shoes, and dancing. You may benefit from wearing a knee brace for a few weeks, but this will depend on the severity of your strain. If it is a minor strain, you may be OK if you're careful and just avoid certain movements. However, if you have a moderate to severe strain/tear or a job that forces you to move in ways that may strain your injured ligament, it is best to invest in a knee brace that limits the side-to-side movement in the knee as well as the last 30 degrees of knee extension (straightening your leg). This will allow the ligament to repair. Your physio or doctor will guide you with regards to this. Rehab exercises tailored to your specific needs. It's good to work on general strength and control in your core and legs, but you may want to focus on specific areas, depending on what your physio thinks contributed to your MCL strain. For instance, weak glute muscles or poor ankle stability can cause your knee to turn in more when you run, increasing the strain on your MCL. Reduced proprioception (position sense) can also predispose you to this injury. Position sense can easily be retrained through balancing exercises. Bone bruising (inner or outer knee) Bone bruising is actually a common injury despite not being talked about that much. It can develop over time due to repetitive low impacts – for example in endurance running. But it can also happen when a sudden movement squashes the bones that form the top (femur) and bottom (tibia) of your knee joint together. It is also common for the movements that injure the menisci or ligaments to cause bone bruising. Bone bruises can cause pain very similar to a meniscus tear or ligament strain. Bone bruises can only be diagnosed via scans. They can take quite a long time to heal fully. Here's a video with more detailed info and advice on bone bruising: My top three treatment suggestions: Reduce the load on the area that has the bone bruise. The extent of your injury will determine what you should do. For example, if your knee is very painful, you may have to use crutches for a while. If it's only a minor bone bruise, you may just have to avoid standing or walking for lengthy periods, or high-impact activities like jumping and running. Let pain be your guide - aim to cut out or reduce the intensity of all activities that cause pain during or after you've done them. Keep your body strong. It's important to maintain your muscle strength and control while you wait for your bruised knee to recover. Choose exercises that don't place a lot of force through your knee, e.g. clams with resistance bands, knee extensions, or curl machines in they gym, or bridges with weights. Cycling or swimming are good options for cardiovascular fitness during this time. Vitamins and minerals. You can help your bones recover by ensuring that they have all the vitamins and minerals they need. The main building block for bone is calcium (found in dairy products and other fortified products), but you can only absorb it if you have sufficient levels of vitamin D . Your doctor can test your vitamin D levels and suggest a supplement if needed. Outside (lateral) knee pain in runners Lateral meniscus tear Lateral meniscus tears are much less common than medial meniscus tears. The pain from a lateral meniscus tear is usually felt on the outside of the knee, along the outer joint line. It can also be located a bit more to the outer front or outer back of the knee depending on what part you injured. They are traumatic injuries that usually happen suddenly, like when you stumble or twist an ankle. Here's our full article on lateral meniscus tears . My top three treatment suggestions: The treatment for lateral meniscus tears is exactly the same as for medial meniscus tears. You can find a detailed explanation above , but it consists of: Relative rest to allow the injury to settle A progressive rehab plan Refrain from running until you have: Regained full range of motion, And full strength, And good balance and control. Lateral collateral ligament (LCL) strain/tear Lateral collateral ligament tears are not common in runners, because it usually takes a lot of force to tear your LCL. It is a traumatic injury with a clear cause, e.g. falling hard in an awkward way or taking a direct blow to the knee. I'm not going to suggest treatment options for this, because it usually happens in combination with other, more serious injuries (like posterior cruciate ligament tears) that dictate what treatment should be followed. IT band syndrome IT band syndrome causes pain where the IT band crosses over the outside of the knee joint. It's an overuse injury. It may start as only a slight niggle or discomfort during a run or after a run. But the pain then increases if you continue to train without having fixed the problem. We've done a detailed explanation of the causes and treatment of IT band syndrome . The main cause of IT band syndrome is thought to be linked to poor biomechanics (pelvis dropping, knee turning in, foot overpronating) when you run. There are several factors that can influence your biomechanics negatively, such as running on very tired legs, running on a cambered surface, having weak glutes, or poor ankle and foot strength and control. I've also made a video where I discuss the causes, symptoms and treatment of IT band syndrome in detail: My top three treatment suggestions: Rest it - All the research projects that investigated how to successfully treat IT band syndrome with rehab exercises asked their participants to take a break from running for six weeks to allow the tissue to calm down. But some people may be able to continue running if they reduce their training load; we discuss how you can decide whether you are OK to run with IT band syndrome here . Rehab - Depending on what caused your specific case of IT band syndrome, you may benefit from doing either IT band stretches , strength training exercises, control exercises , or a combination of these. This is why it is useful to have an assessment by a physio who can compile the most effective treatment plan for you. Gradual return to running - Once your IT band has calmed down and you've restored the strength and control you need, you have to ease back into running gradually. The injured tissue won't yet have the capacity to cope with all the running you might want to do, and it is important to build this up slowly. Front (anterior) knee pain from running Patellofemoral pain syndrome (runner's knee) Patellofemoral pain syndrome is an overuse injury affecting the underside of the kneecap. The most common causes of this include a sudden increase in running volume or running speed. But poor control and strength in the other muscles of your leg as well as your core may also play a role, as this can lead to greater forces working on the kneecap. Sometimes, non-running activities can be to blame, e.g. kneeling for a lengthy period in the garden or while tiling a floor, or doing lots of deep squats. The pain is usually felt over the front of the knee, but it can also cause pain to the sides of the kneecap, above, or below it. Often, it's not possible to find the painful spot when you try and push on it. It tends to develop gradually and increase in intensity as you continue to train. My top three treatment suggestions: Reduce your pain by: Avoiding aggravating activities Trying different taping techniques Using ice Include exercises that retrain the quadriceps muscles. It is important to start with these in positions that don't create large loads on the kneecap (avoiding deep knee flexion). It is also often better to start with isometric exercises and to avoid repetitive flexion and extension of the knee. Running technique - If you tend to land with your foot far out in front of your body or run with a narrow gait, the research shows that making changes to your running technique may help to settle your patellofemoral pain . Patellar tendonitis/tendinopathy Your patellar tendon is the thick tendon that runs from the lower edge of the kneecap to your shin bone (tibia). Patellar tendonitis or tendinopathy is usually caused by overuse that sets in slowly during one very hard session or over several sessions (ramping training up too quickly or not allowing enough recovery), but it can sometimes develop after getting hit on the tendon. If you felt a sudden sharp pain when you injured your knee, it's more likely that you've sustained a tear. You feel the pain from patellar tendonitis over the front of the knee, in the area just below the kneecap. There is usually a specific part of the tendon that feels painful to press on. It can easily be confused with fat pad impingement or patellofemoral pain syndrome. It tends to hurt when you do activities that use the quad muscles, e.g. jumping, running, or squatting. You may find that it feels OK or even better while you exercise, only for it to flare up worse the next day. I've also made a video where I discuss the treatment of patellar tendonitis / tendinopathy in detail: My top three treatment suggestions: Relative rest - Tendons don't require complete rest to recover. They often do better if you remain active but just cut down or adjust the activities that really aggravate them. Analyse your sport and all your daily activities. How much, or for how long, or at what intensity can you continue to run without making your tendon pain worse in the 24 hours after the run? This may require you to do only easy, short runs, and less often than usual. Strength training exercises - There is strong evidence to support the use of a progressive strength training programme as treatment for patellar tendonitis. There are two factors that such a programme should adhere to: It should start at the correct intensity for your tendon's current capacity. Injured tendons lose some of their strength, and if the exercises are too intense, they can actually make the tendon more sensitive. It should slowly be progressed until the exercises resemble the forces that your tendon will have to resist during your normal sport. This is important if you want to avoid reinjury. Include exercises that retrain landing mechanics - The patellar tendon works much harder when you land (either from a jump or while running) than when you push off. It is important to retrain that action and ensure that the other parts of the body (kinetic chain) are all accepting their part of the load. You can find a discussion of the other common treatments used for patellar tendonitis here . Quadriceps tendonitis/tendinopathy Your quadriceps tendon attaches your four quad muscles to the top of your kneecap. Like patellar tendonitis, quadriceps tendonitis is an overuse injury caused by an overload of activities that require the quadriceps muscles to work very hard eccentrically, e.g. heavy loaded deep squats, lots of jumping activities, or downhill running. The pain is felt above the kneecap in the area of the quadriceps tendon. It is usually most painful in positions where the knee is loaded in a flexed position (deep knee bend), e.g. at the bottom of a squat. My top three treatment suggestions: The treatment for quadriceps tendonitis is exactly the same as you would do for patellar tendonitis so have a look at the advice listed above for the details but in summary, it consists of: Relative rest Strength training Retraining biomechanics Fat pad impingement There's a fat pad just under the patellar tendon, in the area where the bottom of the thigh bone (femur) meets the top of the shin bone (tibia). The fat pad can get pinched between the kneecap and the thigh bone or between the shin bone and thigh bone. It is filled with nerve endings and can cause a lot of pain when pinched. Fat pad impingement is often caused by uncontrolled hyper-extension of the knee or after a direct blow to the knee that causes it to swell. The pain is felt over the front of the knee, below the kneecap and can be mistaken for patellar tendinopathy or patellofemoral pain syndrome. When you press in the area, the pain is usually located next to or behind the tendon instead of on it. It is typically aggravated by activities that fully extend the knee, e.g. straight-leg raises or standing for long periods. My top three treatment suggestions: Exercises that improve the control around the knee , especially end range extension. Include exercises that work the hamstring eccentrically, as it is they that must slow the knee extension down and prevent hyper extension. Limit your exercises to the pain free range and it's usually best to avoid full extension to start with. Consciously work on your movement patterns and habits. Incorporate this into your rehab but also your daily activities. Do you have a habit of locking your knees into hyper-extension when you stand for long periods? If so, adjust that position and teach yourself to stand in a more neutral position. Taping the kneecap. If your kneecap is the culprit, you may benefit from applying different taping techniques that adjust its position slightly. However, in my experience the effect of this is rather short-lived, so don't view this as a long-term solution. Referred pain from the hip This may sound a bit bizarre, but it is possible that your knee pain is actually coming from your hip, even if you don't have any pain up there. This is why it is important that your physio doesn't just check your knee when you have knee pain. They should always include screening tests for the joint above (the hip) and the joint below (the ankle). General knee pain after running If your knees are feeling generally achy after runs and the discomfort lingers for a day or two, it may be that you’re overloading them. Rather than getting a specific injury, the joint and some of the structures in and around it are becoming irritated because they are either being asked to work harder than what they currently have the strength for, or they are not being given enough time to recover. If this continues for too long, it can eventually cause an injury. My top three treatment suggestions: Yes, training errors are often to blame for this, but there may be other things you need to look at as well: Check that your running shoes are not too worn and that they provide enough support and cushioning. Are your leg muscles strong enough? Your muscles are meant to absorb much of the impact when you run, and if they aren’t strong enough it can force your knee joints to take more strain than they should. Review your training plan (not just running, but also strength training and other activities). Do you need to adjust it to allow more time for recovery? Are you ramping your training up too quickly? How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Aderem J, Louw QA. Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC Musculoskeletal Disorders 2015;16(1):356. Allen DJ. Treatment of distal iliotibial band syndrome in a long distance runner with gait re‐training emphasizing step rate manipulation. International Journal of Sports Physical Therapy 2014;9(2):222. Balachandar, V., et al. (2019). "Iliotibial Band Friction Syndrome: A Systematic Review and Meta-analysis to evaluate lower-limb biomechanics and conservative treatment." Muscles, Ligaments & Tendons Journal (MLTJ) 9(2). Barton, C. J., et al. (2016). "Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion." British Journal of Sports Medicine 50(9): 513-526. Brukner, P, et. al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) Dodelin D, Tourny C, Menez C, et al. Reduction of Foot Overpronation to Improve Iliotibial Band Syndrome in Runners: A Case Series. Clin Res Foot Ankle 2018;6(272):2. Friede, M. C., et al. (2021). "Conservative treatment of iliotibial band syndrome in runners: Are we targeting the right goals?" Physical Therapy in Sport. McKay, J., et al. (2020). "Iliotibial band syndrome rehabilitation in female runners: a pilot randomized study." Journal of Orthopaedic Surgery and Research 15(1): 188. Louw, Maryke, and Clare Deary. "The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners–A systematic review of the literature." Physical Therapy in Sport 15.1 (2014): 64-75. Phinyomark A, Osis S, Hettinga B, et al. Gender differences in gait kinematics in runners with iliotibial band syndrome. Scandinavian Journal of Medicine & Science in Sports 2015;25(6):744-53. Van der Worp MP, van der Horst N, de Wijer A, et al. Iliotibial band syndrome in runners. Sports Med 2012;42(11):969-92. Burton, I. (2022). "Interventions for prevention and in-season management of patellar tendinopathy in athletes: A scoping review." Physical Therapy in Sport. Challoumas, D., et al. (2021). "Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies." BMJ Open Sport & Exercise Medicine 7(4): e001110. Christensen, B., et al. (2011). "Effect of anti-inflammatory medication on the running-induced rise in patella tendon collagen synthesis in humans." Journal of Applied Physiology 110(1): 137-141. Cook, J. L., et al. (2016). "Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?" British Journal of Sports Medicine 50(19): 1187-1191. de Vries, A., et al. (2016). "Effect of patellar strap and sports tape on pain in patellar tendinopathy: a randomized controlled trial." Scandinavian Journal of Medicine & Science in Sports 26(10): 1217-1224. Longo, U. G., et al. (2018). "Achilles Tendinopathy." Sports Medicine and Arthroscopy Review 26(1): 16-30. Magra, M. and N. Maffulli (2006). Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe, LWW. Malliaras, P., et al. (2015). "Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations." Journal of Orthopaedic & Sports Physical Therapy 45(11): 887-898. Virchenko O, Skoglund B, Aspenberg P. Parecoxib impairs early tendon repair but improves later remodeling. Am J Sports Med. 2004;32:1–5. Agresta, C. and A. Brown (2015). "Gait retraining for injured and healthy runners using augmented feedback: a systematic literature review." Journal of Orthopaedic & Sports Physical Therapy 45(8): 576-584. Barton, C. J., et al. (2016). "Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion." British Journal of Sports Medicine 50(9): 513-526. dos Santos, A. F., et al. (2019). "Effects of three gait retraining techniques in runners with patellofemoral pain." Physical Therapy in Sport 36: 92-100. Noehren, B., et al. (2011). "The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome." British Journal of Sports Medicine 45(9): 691-696. Willy, R., et al. (2016). "In‐field gait retraining and mobile monitoring to address running biomechanics associated with tibial stress fracture." Scandinavian Journal of Medicine & Science in Sports 26(2): 197-205. Willy, R. W., et al. (2012). "Mirror gait retraining for the treatment of patellofemoral pain in female runners." Clinical Biomechanics 27(10): 1045-1051. Englund M, Guermazi A, Gale D, et al. Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. New England Journal of Medicine 2008;359(11):1108-15. doi: 10.1056/NEJMoa0800777 Kise Nina Jullum RMA, Stensrud Silje, Ranstam Jonas, Engebretsen Lars, Roos Ewa M Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. 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Iliotibial band syndrome (IT band syndrome) can be a pesky problem to get rid of, and its one of the few injuries that affect more male runners than females. I actually did my masters dissertation on this subject and found that, like with most sports injuries, IT band syndrome can have many causes. And the key to finding an effective treatment plan for your case lies in figuring out exactly what caused yours. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article are to pages where you can buy products discussed or mentioned here. We might earn a small commission on sales at no extra cost to you. In this article: Anatomy of the iliotibial band What does the IT band do? What causes IT band syndrome? Iliotibial band syndrome symptoms How long does IT band syndrome take to recover? What treatments work for IT band syndrome? We also made a video about this: Anatomy of the iliotibial band The iliotibial band (IT band or ITB) is made of thick fibrous fascia that is extremely strong. Facia is the white sinewy stuff that you find in meat. It may help to imagine it as the same material that a car’s safety belt is made of. It runs from the top of the pelvis over the side of the hip, down the side of the thigh and attaches to the outside of the knee and kneecap. The IT band itself is sinewy and not very flexible, and it’s not really possible to stretch it. I know! You’ve been taught stretches for the IT band in the past, but give me a moment to explain. There are several muscles that attach into the IT band, including the Glute Max, Tensor Fasciae Latae, and Lateral Quadriceps muscle. If these muscles become tight and inflexible, they pull the IT band taut and then people wrongly blame the IT band for being 'too tight'. In fact, it’s the fault of the muscles that are attached into the IT band. So, instead of trying to stretch the IT band, it works much better if you direct your stretches at the muscles that attach onto it. I’ll give you some examples later in the article. What does the IT band do? It helps to stabilise your pelvis (keeps it level) on your leg when you walk or run or jump. As mentioned above, the IT band itself cannot contract, but it can get pulled tight when the muscles that attach into it contract and tug on it. What causes IT band syndrome? IT band syndrome is caused when the IT band is pulled too tight over the outside of the knee, causing it to squash excessively against and rub on the bone as you bend and straighten your knee during running. Traditionally, IT band syndrome was described as being caused by excessive friction, but these days researchers think it may actually be due to excessive compression. This not only causes the IT band itself to become inflamed and sore, but also the fat pad and bursae between the IT band and the bone. A bursa is a small fluid-filled sac, and you find them everywhere in the body where tendons and bones are close to each other. Their job is to decrease friction, but they can become inflamed and very painful when exposed to excessive compression or friction. Interestingly, researchers have reported that when they scan the painful area of the IT band, they most often find that it is this tissue (fat pad and bursae) between the IT band and the thigh bone that shows signs of injury, rather than the IT band itself. Some of the reasons why the IT band may be pulled too tight include: If the muscles that attach into the IT band (glute max, TFL, lateral quad) are tight and pull it too taut. If your hip muscles aren’t strong and allow your pelvis to drop or your knee to turn in excessively as you run – the glute max and glute med muscles are usually the main culprits. Because the IT band attaches onto the pelvis and knee, it gets pulled tight when this happens. Weak glutes on one side will cause the pelvis to drop on the other side and/or the knee to turn in, pulling the IT band tight. Excessive pronation in your foot (when your foot rolls in) can cause your lower leg to turn in more. Because the IT band attaches onto the lower leg, this can potentially cause the IT band to pull tight and compress more against the outer knee. Excessive foot pronation can cause the knee to turn in and pull the IT band tight. If you’ve done a really tiring run, e.g. a long downhill race. You may normally have strong hip muscles, but if you tire them out a lot, they may not be able to stabilise the pelvis, also causing it to drop and pull the IT band taut. Downhill running can cause trouble. I’m often guilty of just letting go and plonking down a hill, but this can cause a lot more impact on your legs. Running on an incline or camber of a road can also cause the IT band on your one leg (the one at the top of the camber) to pull tight over the side of your knee. If your one leg is shorter than the other, it can cause the IT band of the longer leg to pull tight. Iliotibial band syndrome symptoms When you have IT band syndrome, you may feel a sharp or burning pain on the outside of your knee. It usually only hurts while you're running, but if it's very irritated, even walking may make it hurt. Iliotibial band syndrome causes pain on the outside of the knee. The point in the running gait cycle when the IT band compresses most against the thigh bone is just after your foot touches the ground and when your knee is flexed at about 30 degrees. So, you will likely experience the most pain at that point and then less during the rest of the movement. You will likely be able to locate a painful area in the lower part of the IT band close to where it attaches to the outer knee. A test we do in clinic to test for IT band syndrome involves us pressing down on the IT band (increasing compression) in the area of the knee and then repeatedly flexing the patient's leg through 30 degrees of knee flexion. This will usually elicit pain if their IT band and the structures under it are irritated. You may initially only feel the pain towards the end of a run or training session. But if you've ignored it for a while and continued to train through it, it may be painful right from the start of your run. You may notice a slight puffiness over the outside of the knee, but this is not the case for everyone. How long does IT band syndrome take to recover? If you’re lucky and you treat it right from the start, it will take between 6 and 12 weeks. If you neglect it and try to run through it for a while, it can take a lot longer. If you want it to recover quickly, get some guidance and a treatment plan early on from someone who knows what they’re talking about. What treatments work for IT band syndrome? As we have seen, IT band syndrome can have many causes, and that’s why there is no one-size-fits-all treatment for it. You have to identify your cause and work on that. Relative rest This is key to getting rid of IT band syndrome. You have to cut out all aggravating activities so that the irritated tissue can settle down. This doesn’t mean that you necessarily have to stop running. Some of our patients find that they just have to keep their runs short or play with their running style. For example, running up stairs is often tolerated better than running on the flat. If you find that you can’t run, you can try and maintain your fitness by doing other activities, like swimming with a pool buoy between your legs. Cycling is often not that well tolerated during the early stage of rehab, because it involves too much repetitive movement in the knee. Anti-inflammatory medication (NSAIDS) Using anti-inflammatory medication (like ibuprofen or naproxen) may be useful during the early stages of treatment, as it is thought to reduce the inflammation in the fat pad. Please discuss this with your doctor before you take any medication, because it may not be right for you and can cause other issues. This should not be seen as a cure. Medication may decrease your pain, but if you want to get rid of IT band syndrome and prevent it from coming back, you have to address the underlying causes discussed above. Ice Icing the painful area on the side of your knee may be a useful way to decrease pain and inflammation in the fat pad when you have IT band syndrome. Just like with anti-inflammatory medication, ice should not be seen as a cure. It might be a useful short-term solution to help calm the sensitivity down, but you still have to address the underlying causes. You can read more about how to use ice for sports injuries in this article . Strengthening exercises If you have poor hip stability , you may likely benefit from strengthening up your glute max and glute med . Make sure that you choose exercises that do not cause pain in your knee! Exercises like single leg squats or lunges are usually not useful at the start, when the IT band is still very sore. Leave them for later and choose exercises where the knee stays stationary (e.g. the clam or double leg glute bridge) to start with. Strength training alone may not be enough to improve your movement patterns when you run. Research has found that runners often have to do specific running style drills if they want to improve the way their legs move when they run. We discuss running tips for IT band syndrome in more detail in this article . IT band stretches Whilst the IT band itself cannot really be stretched (it's too sinewy), you may find benefit from stretching the muscles that attach onto the IT band . These include the glutes, TFL, and lateral quad. Stretching these muscles reduces their tone, which in turn reduces the pull on the IT band. Getting into the habit of stretching these areas after you've done a workout may be a useful way of preventing them from becoming overactive and tight. Just make sure that, during the early stages of rehab when your knee is still very painful, you choose stretches that don't put a lot of strain on the injured area. We'll discuss this in more detail in a future blog post. Massage and foam rolling Physios will often use massage as part of their treatment for iliotibial band syndrome or recommend that patients use a foam roller. This can be useful, as it can help reduce pain and relax the muscles that attach onto the IT band. But the positive effects, both from massage by a therapist as well as self-massage using a foam roller, are transient. So massage/self-massage can be useful during the early stages to help reduce pain and discomfort, but it too is not a cure. Please don't hammer the poor IT band when you foam roll. Remember, this injury is caused by too much compression, and you will make your symptoms worse if you are too aggressive. Rather massage all the muscles that attach onto the IT band (glute max, TFL, lateral quad). I discuss all the dos and don'ts of foam rolling the IT band and the relevant muscles in this article . Running style The research has shown that changing your running style to giving lighter, quicker steps can work well to treat ITB syndrome. Increasing your cadence (how many steps you take in a minute) by as little as 5% can significantly reduce the impact forces on your body when you run. We've written a whole article just about running with IT band syndrome where you can find more tips and advice about this. Orthotics or supportive insoles You may benefit from wearing some orthotics or supportive insoles if you have one leg shorter than the other or if your feet roll in too much (over-pronate) when you run. I would consult a podiatrist if you have a leg length difference, but below are some affiliate links to orthotics on Amazon that may help correct over-pronation. IT band straps/braces Some of my patients have found that using IT band straps or braces helped them. They work by changing how the IT band makes contact with the bone. For some people this can off-load the painful part and allow them to train pain-free. Are you causing more damage by using them? I usually advise people to see how they feel within the next 24 hours. If, when using the IT band support, they are pain-free during their run and their symptoms are no worse during the 24 hours after the run, they are very likely OK to use it. If, however, they find that their pain is significantly worse after their run or the next morning, I would say that they are better off not using the support. Below are some affiliate links to examples of IT band braces/straps on Amazon. In summary: Every person’s case of IT band syndrome will have a specific set of factors that caused it and your treatment plan needs to address all of them. How we can help Need more help with an injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ResearchGate . References Aderem J, Louw QA. Biomechanical risk factors associated with iliotibial band syndrome in runners: a systematic review. BMC Musculoskeletal Disorders 2015;16(1):356. Allen DJ. Treatment of distal iliotibial band syndrome in a long distance runner with gait re‐training emphasizing step rate manipulation. International Journal of Sports Physical Therapy 2014;9(2):222. Balachandar, V., et al. (2019). "Iliotibial Band Friction Syndrome: A Systematic Review and Meta-analysis to evaluate lower-limb biomechanics and conservative treatment." Muscles, Ligaments & Tendons Journal (MLTJ) 9(2). Barton, C. J., et al. (2016). "Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion." British Journal of Sports Medicine 50(9): 513-526. Dodelin D, Tourny C, Menez C, et al. Reduction of Foot Overpronation to Improve Iliotibial Band Syndrome in Runners: A Case Series. Clin Res Foot Ankle 2018;6(272):2. Friede, M. C., et al. (2021). "Conservative treatment of iliotibial band syndrome in runners: Are we targeting the right goals?" Physical Therapy in Sport. McKay, J., et al. (2020). "Iliotibial band syndrome rehabilitation in female runners: a pilot randomized study." Journal of Orthopaedic Surgery and Research 15(1): 188. Louw, Maryke, and Clare Deary. "The biomechanical variables involved in the aetiology of iliotibial band syndrome in distance runners–A systematic review of the literature." Physical Therapy in Sport 15.1 (2014): 64-75. Phinyomark A, Osis S, Hettinga B, et al. Gender differences in gait kinematics in runners with iliotibial band syndrome. Scandinavian Journal of Medicine & Science in Sports 2015;25(6):744-53. Van der Worp MP, van der Horst N, de Wijer A, et al. Iliotibial band syndrome in runners. Sports Med 2012;42(11):969-92.

Hoffa’s fat pad impingement syndrome (also known as infrapatellar fat pad impingement) occurs when a fat pad in your knee gets pinched between the bones of your knee joint. There are a variety of possible causes, and this painful condition often goes together with other problems in and around the knee. This article explains the causes, how to correctly diagnose fat pad impingement, and what the treatment options are. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We might earn a small commission on sales at no extra cost to you. In this article: Where is the infrapatellar fat pad? What happens when you have infrapatellar fat pad syndrome? How to diagnose fat pad impingement (syndrome) Fat pad impingement treatment options How we can help We've also made a video about this: Where is the infrapatellar fat pad? You have four main fat pads in and around the knee. Hoffa’s fat pad, the bad guy in this story (or the victim, depending on how you look at it), sits below your kneecap and behind the patellar tendon, which connects the muscles over the front of your thigh (quads) to your knee joint. The fat pad lies across the line where the bottom end of your femur (thigh bone) meets the top end of your tibia (main shin bone). The infrapatellar fat pad is located below the kneecap, across the knee joint line formed by the femur and tibia. The infrapatellar fat pad contains many nerve endings, which is why it can be so painful when it is pinched. These nerve endings are thought to send signals to your brain about your knee’s position and how it is moving, helping with position sense and balance. The fat pad is also thought to act somewhat like a shock absorber, helping to distribute forces going through your knee more evenly and stabilising the patellofemoral joint (kneecap). What happens when you have infrapatellar fat pad syndrome? Fat pad impingement is when your infrapatellar fat pad is pinched (impinged) between your kneecap and thigh bone or between your thigh bone and shin bone. The fat pad is meant to slide and move as you bend and straighten your knee, but sometimes its movement gets restricted due to swelling or thickening or scar tissue, causing it to get pinched when your knee is fully straightened. Researchers are not 100% sure why this happens, but some of the causes are thought to include: Getting hit on the fat pad or falling on it, causing it to swell. Repetitive trauma through hyper- or over-extending (straightening) the knee can cause the fat pad to become inflamed and swollen and thicken over time. There is evidence that high volumes of intense exercise (running in a wheel) can cause fat pad swelling in rats, but we don’t know whether or how this relates to humans. There is some evidence that suggests that the position or shape of your kneecap and bones may play a role. There also appears to be a link between osteoarthritis and fat pad impingement, but it’s not yet clear how this works. How to diagnose fat pad impingement (syndrome) Fat pad impingement as a primary diagnosis, where only the fat pad is injured, is not that common. It appears more often than not with other knee injuries, e.g. patellar tendonitis , patellofemoral pain syndrome , meniscus tears , osteoarthritis , and ACL injuries . This is why “syndrome” is often added to the diagnosis, meaning there is more than one thing at play here. To diagnose fat pad impingement correctly, your physiotherapist will combine information from how the injury started, where you feel your pain, and how the injury now reacts to specific situations and movement tests. If the physio is still unsure, an MRI scan can be useful, but in most cases you don’t need a scan to diagnose this type of knee injury. Common fat pad impingement symptoms include: Patients describe a burning or aching pain deep to and either side of the patellar tendon, near the lower point of the kneecap. The area below the tip of the kneecap usually looks puffy and a bit swollen. The pain is most commonly felt when you fully straighten your knee or do activities that involve straightening the knee, e.g. going up stairs. Sitting with your knee bent for a long time may also hurt, due to the patellar tendon compressing the fat pad against the thigh bone. The physio can usually reproduce the pain by taking the leg and pushing it straight all the way. Tightening up the quads with your knee fully straight usually also reproduces the pain. It often hurts to stand for long. Some people with fat pad impingement have a habit of standing with hyper-extended knees (knees pushed back super far), which means that they are not using their quad muscles to keep their legs stable, but rather hanging off the ligaments of their knee joints. It often hurts more to walk in flat shoes, because your knee has to go straighter. Your physio will test for fat pad impingement by pushing your knee straight all the way. Anterior knee pain is often misdiagnosed as fat pad impingement, because when people press on the fat pad, it causes pain, and then they think, “Oh, I have fat pad impingement!” But, as mentioned before, this fat pad has lots of nerve endings, and these can become sensitised and sore when other things close to the fat pad are injured. So, making a diagnosis based on just pressing on it is not really that accurate. Top tip: If activities that load the knee in a bent position (like the downward movement of a squat) hurt, then it is likely not the fat pad causing your pain. It may rather be the patellar tendon or the patellofemoral joint (kneecap) that has issues. Fat pad impingement treatment options We discuss 12 of the most useful treatments for fat pad impingement below. It is important to understand that we are all different, and our injuries are never 100% the same. If a treatment or exercise has worked for someone else, it does not necessarily mean that it is right for you. Always compare how you feel before and after the treatment to decide whether you should use it or not. The first step in fat pad impingement treatment is to try and reduce the irritation and swelling. 1. Avoid painful positions The best way to stop irritating the fat pad is to avoid positions that cause pain. One example is standing with your knee slightly bent rather than pushed all the way straight. However, these are temporary adjustments. Once your knee has recovered, you should start moving it through its full range of motion again, otherwise you may end up with other injuries. 2. Shoes and gait Flat shoes usually require your knee to extend more when you walk. By wearing shoes with a slight heel (like most running shoes) or placing heel-lifting insoles into your shoes, you may be able to reduce the pinching when walking, which will help your painful fat pad to calm down more quickly. Shortening your stride may also help. Here are some examples of heel-lifting insoles available on Amazon: 3. Taping Some patients find that taping their knees can make a significant difference. The tape is applied in such a way that it tilts the lower part of the kneecap up, which is thought to reduce the pressure on the painful fat pad. There is currently no research available to indicate whether taping is truly effective. My advice is to test it – if your knee feels more comfortable with the tape on, then it is likely worth it. You will need someone else to apply the tape for you, because it can be hard to relax your leg if you do it yourself. The white tape that is applied as the bottom layer is called Hypafix – it helps the top layer tape to stick better, but is also hypoallergenic and helps to protect the skin. Here’s a video demo on how to tape your knee to relieve fat pad impingement pain. What you’ll need: ● 5 cm / 2 inch Hypafix tape for the bottom layer ● 3.8 cm / 1½ inch zinc oxide tape for the top layer ● Scissors. 4. Ice Applying ice over the fat pad can help to reduce the pain, swelling, and inflammation. You can find instructions on how to apply ice safely here . 5. Anti-inflammatory medication (like ibuprofen) Anti-inflammatory medications like ibuprofen (tablets or gel) may be useful to help reduce the inflammation and swelling. Speak to your doctor before taking any medication, as it may not be appropriate for you. 6. Manual therapy Some patients with fat pad impingement may have a stiff kneecap that doesn’t move as freely as the one on the other leg does. In such cases, some clinicians recommend manual therapy, where the physiotherapist mobilises the kneecap. We don’t know whether this makes a difference, since there isn’t any research that has tested the effect of this versus no treatment and/or other treatments. 7. Stretching Stretching the quadriceps muscles is sometimes advised, since it is thought to help free up the kneecap. But this should only be tried once the acute pain has settled – stretching too early into your recovery usually makes the pain worse. You can foam roll your quads instead. Doing quad stretches too early in your recovery can irritate the fat pad due to the patellar tendon pressing against it. If you do use stretching as part of your treatment, check how your knee reacts. It is quite common for stretching to feel good in the moment and then cause increased pain later in the day. If your knee hurts more after stretching, leave it out. Top tip: Whenever you introduce something new to your treatment programme, add one thing at a time and observe the 24-hour pain response to see whether it reduces or increases your pain. 8. Strengthening exercises It is usually best not to crack on with exercises that work the quadriceps muscles too early in recovery, as this often aggravates the pain, but you can usually get going with other muscle groups, e.g. glutes and hamstrings, in the meantime. Muscles worth strengthening: Gluteal and core muscles: These can help to improve your movement patterns and reduce the strain on your knee when you walk and run. The clam exercise is usually a safe one to start with in the early stages of recovery. Hamstrings: The hamstrings help to control and prevent hyper-extension of the knee when you walk and run. The bridge exercise is usually a good option for early rehab. Foot and ankle muscles: They can help to improve your movement patterns by reducing excessive pronation. You can find examples of exercises to correct overpronation here . Quadriceps muscles: This is so you can control you knee better when it is fully straight and stop it from just passively flicking back into hyper-extension. Avoid the leg extension machine at first; once you’re ready to start with quad exercises, doing gentle isometric squats with the knee remaining bent is a good place to start. 9. Retraining movement patterns (if needed) This will not be necessary for everyone with Hoffa’s fat pad impingement. If your physio has found that a part of your problem is that you stand with your knee in hyper-extension or flick it back when you walk, they may teach you ways in which to unlearn those patterns. This can help you to avoid getting fat pad impingement again. 10. Orthotics If your foot rolls in excessively (over-pronation) when you walk or run and it is not correctable through exercise alone, you may benefit from arch-supporting orthotics. These orthotics, available on Amazon, would work well for supporting your foot arches: 11. Corticosteroid injections Corticosteroid injections can work very well to reduce pain, swelling, and inflammation. However, they also have unwanted side effects, the most important in this case being fat pad atrophy. This is when the steroid injection causes your fat pad to shrink, which can actually lead to even more pain. For this reason, corticosteroid injections are usually only considered as the penultimate option, with surgery being the final one, after you’ve tried everything else. Steroid injections can have unwanted side effects and should be left as a last resort treatment, just before surgery is considered. 12. Surgery Surgery should be left as the last resort, because it is not always successful. Keyhole surgery is recommended, where the surgeon goes in and only removes the scar tissue and thickened areas. The current recommendation is to leave the unaffected parts of the fat pad intact. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Abelleyra Lastoria, D. A., et al. (2023). "Predisposing factors for Hoffa’s fat pad syndrome: a systematic review." Knee Surgery & Related Research 35(1): 1-14 . Kitagawa, T., et al. (2022). "Effect of physical therapy on the flexibility of the infrapatellar fat pad: A single-blind randomised controlled trial." PLoS One 17(3): e0265333 . Mace, J., et al. (2016). "Infrapatellar fat pad syndrome: a review of anatomy, function, treatment and dynamics." Acta Orthopædica Belgica 82: 1-2016 . Hannon, J., et al. (2016). "Evaluation, treatment, and rehabilitation implications of the infrapatellar fat pad." Sports Health 8(2): 167-171 . Dragoo, J. L., et al. (2012). "Evaluation and treatment of disorders of the infrapatellar fat pad." Sports Medicine 42: 51-67 .

A Baker’s cyst or popliteal cyst forms in the back of the knee and gets its name from Dr. William Morrant Baker, the surgeon who first described it. In this article, we explain why treating a Baker’s cyst without addressing the cause is likely a waste of time and how to decide what treatment options may be right for you. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article may be to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. In this article: What is a Baker’s cyst? Baker’s cyst symptoms How to diagnose a Baker’s cyst How to treat a Baker’s cyst Baker’s cyst recovery times How we can help We've also made a video about this: What is a Baker’s cyst? Anatomy There are several tendons that cross over your knee joint on all sides. Wherever a tendon is close to a bone or another tendon, there is a bursa (a fluid-filled sac), which helps to reduce the friction and compression between the tendon and the bone or between the tendons. The bursa in the inner corner of the back of the knee is special – it is directly connected to the knee joint via a one-way valve. The synovial fluid that lubricates and feeds the knee joint can flow through this valve into the bursa, but not out again. MRI image of a Baker's cyst. Picture from Stefanou, N., et al. (2022). "Tibial Nerve Palsy: An Atypical Presentation of a Popliteal Cyst." Cureus 14(8) What causes a Baker’s cyst? When something in the knee joint is irritated and inflamed, it triggers an increase in synovial fluid production. Some of this extra fluid gets pushed into the bursa at the back of the knee, and as the pressure from the fluid increases, it causes the bursa to swell, forming what is known as a Baker’s cyst. Common conditions that can cause a significant increase in fluid inside the knee joint that may induce a Baker’s cyst include: Meniscus tears Anterior cruciate ligament tears Injuries to the cartilage Osteoarthritis Inflammatory arthritis, e.g. rheumatoid arthritis Baker’s cyst symptoms Not all Baker’s cysts cause trouble – in most cases there are no symptoms. When there are symptoms, it can be any of the following. A sensation of fullness or stiffness behind the knee. Achiness behind the knee. You may notice that the back of your knee looks swollen when you extend it fully. If the Baker’s cyst is very large, it may prevent you from fully bending your knee. It may compress the blood vessels in the back of your knee, causing your lower leg to swell, turn blue or red, and hurt a lot. These symptoms are similar to those of a blood clot (DVT), and you should consult a doctor immediately if you experience any of them. In rare cases, the cyst may compress a nerve (tibial or peroneal) in the back of your knee, causing numbness and/or loss of strength in the muscles in your lower leg. If a Baker’s cyst ruptures, it can cause severe pain and swelling in the calf that also resembles DVT. How to diagnose a Baker’s cyst Although X-rays don’t really show Baker’s cysts, they are still useful, as they can identify possible causes, e.g. joint arthritis or loose fragments of cartilage, bone, or meniscus. Ultrasound scans can be useful to identify a cyst, but they are not so good at distinguishing Baker’s cysts from other conditions, e.g. meniscal cysts or tumours, which can look very similar. They also don’t show up other conditions, like meniscus tears, which may be the cause of the Baker’s cyst. MRI scans are therefor seen as the gold standard for diagnosing Baker’s cysts and identifying other issues inside the knee that may have to be addressed to successfully treat the cyst. How to treat a Baker’s cyst To treat a Baker’s cyst, you have to understand what is causing the irritation inside your knee and take steps to address that. If you focus the treatment solely on the Baker’s cyst (like draining the excess fluid), it will likely just return. If a Baker’s cyst is pressing on a nerve or on the blood vessels (see symptoms listed above), it is currently advised that it should be removed surgically. All other cases are usually treated by following a three-step approach: First, conservative treatment, which may consist of medication, ice, load management, and/or exercises. If Step 1 does not produce good results, injections are used in combination with Step 1. If none of the above produces good results, surgery may be an option. Let’s look at each step in more detail. Step 1: Conservative treatment As mentioned earlier, a Baker’s cyst usually forms as a result of some other condition that is irritating the knee joint. The exact conservative treatment that may be right for you will very much depend on the cause. Medication If your doctor feels that your Baker’s cyst is in part being caused by an inflammatory condition (like arthritis), they may prescribe medication to help calm the inflammation down. Anti-inflammatory medication may be useful in some cases. Ice Ice can be a useful tool to reduce swelling and inflammation. When applying ice , always place a damp cloth between your skin and the ice pack to prevent the cold burning your skin. Apply the ice for no more than 10 minutes at a time, with 10-minute breaks. Don’t use ice if you have circulatory problems or an open wound. You can read more about how to use ice for injuries in this article . Load management and relative rest An injured knee joint is usually not able to tolerate the load placed on it during your normal daily activities (standing, walking, stair climbing, running, etc.). If you continue with these, you will usually end up making things worse. Then again, complete rest is also not useful, as it can make your knee feel even more stiff and sore. This is where relative rest comes in. With relative rest, the aim is to figure out what level of activity your knee is currently able to tolerate before it starts to feel worse. So, you remain as active as you can whilst reducing, adapting, or stopping the activities that actually make your knee worse. Keep an eye on your symptoms for 24 hours after an activity, as things may feel fine during or immediately after the activity, only for your knee to swell or hurt significantly more several hours later. A physio can help you figure out the best combination of activities for your specific situation. Exercises for Baker’s cysts The exact exercises you should do when you have a Baker’s cyst will depend on what the underlying cause is and where you are in the healing process, but most patients benefit from exercises that improve circulation and strength. Exercises that improve circulation Ever heard the expression “motion is lotion”? Your knee joint does not have arteries or veins going into it; it relies on the changes in pressure when you move your knee to push the old synovial fluid out and to get new fluid with nutrients and oxygen. This is why keeping it super still can make your knee feel stiffer and more uncomfortable. Low-load exercises, where you repetitively bend and straighten your knee, are brilliant for feeding the joint and getting rid of swelling. Examples include: Bending and straightening your knee while sitting or lying down. Feel free to use your hands to help if necessary, and don’t force the movement; just take it as far as you comfortably can (see video demo). Cycling on a stationary bike. Set the resistance to whatever is comfortable, and ensure that the seat is not too low. Your aim is to move and feed your joint, not cycle up a virtual Mont Blanc! (Cycling on the road is unpredictable; you may have to stop suddenly and might jar your knee when you place your foot hard on the road. It is also easier to control the resistance and effort on a stationary bike.) Cycling on a stationary bike feeds the joint, and you can adapt the bike to suit your knee. These exercises can usually be done every day. Running is not ideal because, although running also produces repetitive motion, it is seen as a high-load exercise and will likely irritate your knee further. You may be able to ease back into running once your knee has improved. Strength training exercises When we walk, our muscles are meant to absorb most of the shock and to stabilise our joints. For the knee joint, your front thigh muscles (quadriceps) are especially important. Most knee injuries or conditions like arthritis can be improved by strengthening the quads. However, you can make your symptoms worse by doing exercises that are too advanced for you, so please check with your physio before trying any exercises. Strength training exercises that may be useful to start with: Slow, controlled sit-to-stands from a chair (also known as box squats). Adjust the height of the chair so you can do it pain free – a higher chair is usually better. Isometric wall sits. The more you bend your knees, the harder these are, so start with very high ones where your knees are only slightly bent. Leg press machine in the gym. Limit the weight and how far you bend and straighten your knee to what you can do pain-free. Here’s more info on how to use the leg press for knee rehab . Knee extension machine in the gym. Strength training exercises should usually be done only two or three times per week and never on consecutive days, because your body needs some time to rest and recover after these sessions. Step 2: Injections If you’ve followed the advice in Step 1 for more than four weeks without getting results, you may benefit from a corticosteroid injection to help reduce the swelling by calming down the inflammation in your knee. Your doctor may advise that you skip Step 1 and go straight for an injection if your Baker’s cyst is very big and causes severe symptoms. These injections can be done into the knee joint or directly into the Baker’s cyst under ultrasound guidance. In some cases, the doctor may decide to drain some fluid from the cyst before injecting the corticosteroid. Corticosteroid injections appear to get good results but take several weeks to have an effect. It is quite normal to have a significant increase in pain the day after the injection, so ask your doctor what you should do if this happens. Corticosteroid injections can help you recover from a Baker's cyst. Once your knee is feeling better, it is important not to ramp up your activities too quickly, especially if you’ve not done much in the weeks leading up to the injection. Your knee and muscles will need time to adjust to being more active, so it’s best to ease into being active again. You may also have to do some exercises (such as those in Step 1) to help you regain full strength and control. A physio can advise on a safe plan. Step 3: Surgery for Baker’s cyst Research has shown that if you remove the Baker’s cyst without doing anything about the injury or condition that caused it (e.g. meniscus tear or arthritis), it usually just ends up coming back. Therefore, surgery should rather be directed at fixing or improving whatever is causing the irritation in the knee, e.g. doing a meniscectomy or trimming frayed cartilage. In severe cases of advanced osteoarthritis, a joint replacement may even be appropriate. Your surgeon should explain what is likely to provide the best outcomes for you. If your Baker’s cyst is affecting the blood flow in your leg or it is pressing on a nerve, surgery may be the preferred choice of treatment, and it’s often done sooner rather than later (skipping Steps 1 and 2) to prevent complications. Baker’s cyst recovery times Recovery times differ widely because a Baker’s cyst can have so many different causes and vary so much in severity. Most studies that looked into the efficacy of corticosteroid injections as treatment for Baker’s cysts reported good outcomes after four to six weeks. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References: Van Nest, D. S. et al. (2020). "Popliteal Cysts: A Systematic Review of Nonoperative and Operative Treatment." JBJS Reviews 8(3): e0139 Frush, T. J. and F. R. Noyes (2015). "Baker’s Cyst: Diagnostic and Surgical Considerations." Sports Health 7(4): 359-365

This article discusses various types of knee brace for meniscus tears. Not everybody with a meniscus tear will need a knee brace, so I’ll tell you when they can actually be useful. I will also point out some warning signs that you must remove your knee brace immediately. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We may earn a small commission on sales at no extra cost to you. In this article: Who needs a brace for their meniscus tear? Soft knee braces for meniscus tears Unloader braces for meniscus tears Hinged support braces for meniscus tears When to remove your meniscus tear brace immediately How we can help We’ve also made a video about this: Who needs a brace for their meniscus tear? Not everybody with a meniscus tear needs a brace.   Unlike ligaments, which help to stabilise your knee and which often need a brace for added stability when they are injured, your meniscus doesn’t play that big a part in knee stability. So, if the ligaments are fine, a knee with a torn meniscus is quite stable.   The most important treatment for meniscus tears is to reduce the load through the knee for a while so that the meniscus can recover and doing gentle exercises to strengthen the knee. (Read more about lateral meniscus tear treatment , medial meniscus tear treatment , and rehab exercises for meniscus tears .) However, there are specific instances where a brace may be useful: Providing the confidence to move If your knee is very swollen and painful, it can feel as if it wants to give way even though it isn't structurally unstable. In such cases, wearing a brace can just give it that extra bit of support and make it feel more comfortable – as if you can trust it a bit more – and that can help you to move around more easily.   Movement is very important for the meniscus because it helps with the healing process. So, anything that helps you to move around with more confidence is good.   Signalling to others that you’re injured A brace signals to other people that you knee is injured. This is especially useful when you're in crowded places.   I once had to walk through London’s very busy Victoria Station with an injured knee, and it wasn’t fun being jostled all the time. If I had a brace, people might have noticed and been more considerate. A knee brace can signal to others to move carefully around you. Note to self … A knee brace can act as a reminder to yourself that your knee is injured.   People are often not aware of what types of movement can be painful for an injury. For instance, you may be doing housework and having to squat, not realising that it will hurt your injured knee until it’s too late.   A brace can make you think twice when doing certain movements and realise that, “Ah, I shouldn't be doing that right now.”   When a knee ligament is also injured If you have injured one of the major ligaments in your knee in addition to your meniscus, it might mean that your knee is somewhat unstable. This can place extra strain on the meniscus and hinder its recovery.   In that case, a brace can provide extra stability, and then the meniscus can recover better. Soft knee braces for meniscus tears   Soft knee braces typically just wrap around the knee; they don't provide that much stability. So, if you also have a ligament injury, they're not appropriate. But if it's just an isolated meniscus tear, they can be useful. A soft knee brace with velcro can easily be adjusted if your meniscus injury causes your knee to swell more. Typical uses: To provide support if you've got a painful, swollen knee, because they're easy to adjust for the amount of swelling you've got. They give you a bit of security to have the confidence to move. If you are doing something active, they will allow you to bend and straighten your knee but avoid those extreme ranges of motion that can hurt your knee. They indicate to other people in crowded places that you have a knee injury. They act as a reminder to yourself that you've got a knee that needs looking after.   I prefer a soft knee brace that wraps around and fastens with Velcro , because you can adjust it if your knee swells during the day, as is sometimes the case with a meniscus injury, and tighten it up again when the swelling goes down. If the support is too tight, it can cut off your circulation. A brace that just pulls on over your leg can’t be adjusted, and this will be bad for your circulation if your knee swells.   Three good soft knee braces for meniscus tears available on Amazon:   Unloader braces for meniscus tears   Unloader braces are a lot sturdier that the soft ones. They’re called that because they can be adjusted to unload/relieve the pressure in a specific part of the knee. They are typically used by people with osteoarthritis in a part of their knee. The idea with a meniscus tear is that it can be adjusted to relieve pressure on either the inside or the outside of the knee, depending on where the tear is, to make walking and other activities a lot more comfortable.   Unloader knee braces can be adjusted to reduce the pressure on specific parts of the meniscus. However, whether it works as it is thought to work for meniscus tears has only been tested on cadavers (dead people). So, although the researchers have found that it seems to work in this way, this does not necessarily mean that it works in real life. Also, the study was funded by a manufacturer of these braces.   So, we’ll have to wait for some more research before can say for sure that unloader braces work for meniscus tears. It’s not my first choice of brace for a meniscus tear, but if you’ve done everything right and your meniscus is still painful, you could consider giving it a go.   The braces below are specifically for the left knee or the right knee, so if you order one, take care to select the correct side.   Hinged support braces for meniscus tears   These braces have hinged metal rods on the sides, and you can adjust them to allow the knee to move only in a certain range of motion. They provide the most support. Hinged knee braces are only needed if you've also injured a ligament. You probably won’t need one of these if it’s only your meniscus that’s injured. But they will contribute to your meniscus’s healing process if you have also injured a ligament in your knee and now your knee is unstable because of that.   The specific type of brace will rather depend on your ligament injury and not your meniscus injury. You can find more advice on the various types of knee brace in our articles on medial collateral ligament injuries  and lateral collateral ligament injuries . When to remove your meniscus tear brace immediately   Some people feel that they should wear a brace at all costs and not take it off even if it's uncomfortable. That is just not the case. If a brace is uncomfortable, it's not doing its job.   And if it's causing weird symptoms, it could mean that it's squashing your nerves or it's cutting off your blood supply, and that's not good at all.   Please remove your brace immediately if you have any of these symptoms. If the symptoms persist for more than 10 minutes after taking your brace off, please see your doctor. Significant swelling either above or below the brace. Your leg below the brace or your foot turns blue. Tingling, pins-and-needles, or numbness in the leg with the brace. A throbbing or burning sensation anywhere in that leg. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . Reference Kalra, M., Bakker, R., Tomescu, S. S., Polak, A. M., Nicholls, M., & Chandrashekar, N. (2019). The effect of unloader knee braces on medial meniscal strain. Prosthetics and Orthotics International, 43(2), 132-139 .

Metatarsalgia treatment consists mostly of focusing on the things you can control, such as getting the right metatarsalgia insoles and shoes, and adapting your activities to reduce your metatarsalgia pain. This article also discusses some underlying causes of metatarsalgia that we can’t do much about, such as the shape of your foot and lax ligaments, as well as recovery times. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We might earn a small commission sales at no extra cost to you. In this article: What is metatarsalgia? Some causes of metatarsalgia Metatarsalgia symptoms Recovery times for metatarsalgia Treatment for metatarsalgia Exercises for metatarsalgia? Running with metatarsalgia How we can help I've also made a video about this, where I discuss my own experience of metatarsalgia in some more detail: What is metatarsalgia? Metatarsalgia refers to pain in the ball of your foot. In the X-ray image below, you can see the metatarsal bones coming down from the mid-foot towards the toes, ending in the metatarsal heads, which are circled in red. It is this area that get injured when you have metatarsalgia. Picture adapted from Chahal, G. S., et al. (2020) The metatarsal heads form the ball of your foot. They take most of your weight as you roll forwards on your foot to propel yourself when walking or running. It also shares bearing your weight with your heel when you’re standing. When you look at a scan of a foot with metatarsalgia, you can usually see several things that cause the patient pain, which might include bone bruising and swelling (bone oedema) as well as inflammation and thickening of the soft tissue (ligaments and joint capsules). There may also be damage to the ligaments, or plantar plate, which are meant to support and protect the metatarsal heads. Some causes of metatarsalgia This condition is caused when the metatarsal heads take too much strain when you're walking or running, and then they become injured. Often, there’s an underlying issue which doesn’t cause metatarsalgia on its own but predisposes you to get it when something else changes, which then triggers it. Examples of issues that can predispose you to metatarsalgia Foot shape The shape of your foot may predispose you to this condition. The foot in the X-ray above has a high-arched, rigid midfoot, which causes the metatarsal heads to make contact with the floor more than would be the case for a less rigid or lower arched foot. Lax ligaments People with lax ligaments (severe cases of this are referred to as hypermobility syndrome) are prone to metatarsalgia, because the foot arch is not as stiff as those of other people, causing the foot to “collapse” when they run or walk. This can increase the impact on the metatarsal heads. Conditions like hypermobility syndrome may also mean that your ligaments are not very strong and damage more easily, which can also contribute. Long second toe or short big toe Some people have a really long second toe or a very short first toe; this can cause the metatarsal heads of the mid-portion of the ball of the foot to take more strain. A longer second toe can predispose you to getting metatarsalgia. Examples of changes that can trigger metatarsalgia These underlying issues can remain dormant, without causing any problems, until something changes that triggers the metatarsalgia. Change in footwear If you’re used to wearing shoes with softer soles, such as trainers, and then you change to wearing sandals or flip-flops, it can increase the strain on your metatarsal heads. The same applies if you change from cushioned running shoes to minimalist shoes or running barefoot. Change in the surface on which you walk or run If you usually walk on carpets or wooden floors when indoors, and then there’s a change to your living or work environment where the surface you walk on is tiles or concrete, it will cause more pressure on the metatarsal heads. The same might happen if you’re used to trail running or running on a treadmill or tartan track and then change to running on asphalt or tarmac. Activities (type or intensity) that your feet aren’t used to Examples would be if you take up running or hillwalking and overdo it right from the start by not allowing your body and feet enough time to adapt, or you change jobs and the new job requires you to now walk long distances. A good way to avoid injuries like metatarsalgia is to gradually ease into new activities over several weeks or months. It often takes a combination of factors to cause metatarsalgia, e.g. a certain foot shape + shoes that lack cushioning + sudden increase in time on feet. Often, several of the factors above conspire together. An example would be if you have lax ligaments and it has not caused you any trouble. But then, you go on holiday and change from usually wearing trainers in a carpeted environment to walking miles and miles in flip-flops on hard roads, day after day, to do some sightseeing. Arthritic conditions Certain arthritic-type conditions like rheumatoid arthritis or any inflammatory joint disease can predispose you to metatarsalgia. Also, arthritis can change the shape of your feet and your bones, causing the metatarsal heads to take more pressure when you’re walking or running. In these cases, the arthritis has to be treated in the first place, which is not the focus of this article. Metatarsalgia symptoms Initially, it feels like there’s a pebble under the ball of your foot. This is because the bone, ligaments, and tendons in that area have become thickened and swollen, and there’s more fluid than usual. You can also get sharp pains and even something that feels like an electric shock if the nerves that run next to the metatarsals are affected. Later on, if it’s not treated in time, it can become very painful just to be on your feet, especially first thing in the morning and when you try to walk after sitting still for a long period. However, there are other conditions that can cause similar symptoms, such a lower back pain with refers pain into that area, tarsal tunnel syndrome, and a stress fracture. Diagnosing metatarsalgia is quite easy. An experienced physiotherapist, podiatrist, or doctor will be able to diagnose it for you, usually without needing scans. The pain from metatarsalgia is in the ball of the foot. Recovery times for metatarsalgia A mild case that is caught early enough can be resolved within as little as six weeks. If you ignore the condition and soldier on regardless, it can take several months. Treatment for metatarsalgia The most obvious thing to do is to minimise the pressure on your metatarsal heads. Reduce aggravating activities This doesn’t mean you have to sit with your feet up all day long, but you have to do what you can to reduce the amount of walking and the amount of time you spend on your feet (standing and walking) on hard surfaces to a level that does not cause you pain. I realise this can be hard to do when even walking short distances hurts. Wear soft shoes Due to life and work getting in the way, reducing our activities is not always possible to the extent that we would like. However, choice of footwear is something over which we have more control. So, get shoes with soft soles. I had metatarsalgia a few years ago and got myself a pair of Crocs (Literide Clogs) . The soles felt like marshmallows, and I was able to walk indoors in these without pain. For outdoors, I found Hoka running shoes (Cliftons with wide toe box) quite comfortable. Orthotics Don’t get just any old pair of orthotics or gel pads; they will likely just increase the pressure on your metatarsal heads. You need to get orthotics with a metatarsal dome, which sits behind the metatarsal heads and lifts the shafts of the metatarsals up (together with their heads) to take the pressure off the painful area. You can get orthotics on Amazon that include a metatarsal dome , but I have never found them a good fit. My podiatrist made me a custom pair of orthotics with memory foam under my metatarsal heads and a metatarsal dome that worked like a charm. Exercises for metatarsalgia? In my experience, getting the right shoes, supportive insoles, and managing how much you stand, walk, and run is much more important than doing specific exercises. You may benefit a bit from doing calf stretches or foot strengthening exercises, but these will have little effect if your ligaments or the shape of your foot is part of the problem. Running with metatarsalgia If you’re a runner and the metatarsalgia is mild, you may find that running is actually less painful than walking. This is because when you try to walk, and especially if you're trying to walk fast, you tend to push through the front of your foot to propel yourself forwards, and that force just makes things worse. When you run, you can focus on propelling yourself forwards using your larger leg muscles more than your foot. If you’re lucky enough to be able to run while you have this injury, take care to practice load management. So, how much you run, combined with your other daily activities, must not make your feet feel worse the next morning compared to how things were before the run. If you can, avoid running up hills or doing sprint drills, because that will increase the pressure on the ball of your foot. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Chahal, G.S. et al. (2020). "Treating metatarsalgia: current concepts." Orthopaedics and Trauma 34(1): 30-36 .

The correct tennis elbow treatment depends on what stage your injury is in , and there is no one-size-fits-all recipe. Get it wrong, and the treatment will be ineffective or even make your elbow pain worse. This article explains what tennis elbow home treatments work best for each stage and shares specific advice for office workers and gym goers. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We might earn a small commission on sales at no extra cost to you. In this article: Can tennis elbow heal by itself? The stages of tennis elbow Using pain to guide your treatment Load management – The most important treatment for all stages of tennis elbow Treatments for short-term tennis elbow pain relief Rehab exercises – the best treatment for long-term pain relief Tennis elbow recovery times with conservative treatment If conservative treatment doesn’t work How we can help References We've also made a video about this: With tennis elbow, the tendons that attach the wrist extensor muscles in your forearm (the muscles that bend you wrist back) to the outer elbow bone are injured. You can find a detailed discussion about what causes tennis elbow and how to diagnose it here . Can tennis elbow heal by itself? Yes, absolutely. Several studies  have reported that many cases of tennis elbow can recover without active treatments (e.g. massage, exercises, and injections). 👉 However, this does not mean that you can just carry on as normal and expect your tennis elbow to heal. You do have to reduce the load on that area temporarily – I discuss this in more detail below, under load management. The stages of tennis elbow Overuse tendon injuries, like lateral elbow tendinopathy, can be in one of three stages: Reactive stage – this is when your symptoms have been present for only a few days or weeks, and the tendon’s structure has not changed. Dysrepair stage – the symptoms have been present for a few months, and there are some changes to the tendon structure. Degenerative stage – the symptoms have been present for quite a few months or perhaps even years, and the injured part of the tendon has undergone significant changes in structure. You can read more about these stages and what it means for healing here . I’ll highlight below which treatments are most effective for each stage. The stage of your lateral elbow tendinopathy will determine what combination of treatments works best. However, it’s worth noting that there is no universally effective treatment that works equally well for all cases in a given stage of injury. Tennis elbow treatment is more likely to be effective if it is tailored to the individual and adapted from time to time according to how the injury responds to the treatment. If you’ve used a treatment for six weeks without seeing any improvement, you should try something else. In most cases you can expect very slow improvement , and that still counts. It is no improvement that means a change of treatment may be warranted. This is why it can be useful to work with a physiotherapist who will help you to figure out the best treatments for you. Using pain to guide your treatment The current research suggests that tennis elbow treatments are most effective when they don’t cause a significant increase in a patient’s pain during and in the hours after the treatment. So, regardless of the type of treatment: it is OK if you experience a slight increase in discomfort during or after the treatment (you’re just a bit more aware of it than normal) but it should not increase your pain significantly, and any increased pain must settle back to its previous levels within 24 hours. 🏆 Load management – The most important treatment for all stages of tennis elbow Load management consists of two overlapping elements: Relative rest: For your injury to settle and start healing, you must temporarily reduce the loads or forces that go through that area. But you usually don’t have to rest it completely – more on this below. Careful reloading: As your pain starts to calm down and settle, you gradually start using the arm more. This helps to restore the strength and function of the injured tendon and related muscles. It includes your daily activities as well as your rehab exercises (see below). Mistakes that people often make are: They don’t rest their elbow enough – they read on the Internet that they should do exercises and start these when the injury isn’t yet ready for it, or they over-protect their elbow by resting it too much and for too long, which leads to unnecessary loss of strength plus increased pain in the long run, or they ramp up activity too quickly once the pain has calmed down, and this causes a flare-up in pain (we call this a boom-and-bust cycle). 👉 What you want to do instead is to reduce or adapt the activities that aggravate your elbow pain. If adapting them doesn’t work, you may have to cut them out altogether for a short while. Then, once your tennis elbow pain has settled down, you gradually start easing back into those activities, testing short sessions or durations and observing how it affects your elbow. Simple adjustments, like carrying your shopping bag on the uninjured side, can help your tennis elbow pain to settle and healing to start. Simple adjustments that can help your elbow “rest” throughout the day include: Lifting things with your thumb or palm facing up – these positions use your wrist flexor muscles rather than your wrist extensors. Limiting repetitive movements. Not carrying things with the injured side – even low-level gripping (e.g. light shopping bags) can aggravate tennis elbow pain if you carry it for a long period. Using your other hand to lift, push, or pull things if possible. If playing backhands in tennis hurts but other strokes are OK, continue playing but leave the problematic ones out for now. 💻 Load management for office workers If working on a computer or using a mouse aggravates your tennis elbow, resting it completely is usually not an option because you’ve got to work. However, adapting your work set-up can make a significant difference: Get an ergonomic mouse – using a mouse with your wrist turned outwards uses different muscles than the traditional palm down position (which uses your wrist extensors). Switching to an ergonomic upright mouse can also help if you usually use the trackpad on your laptop. Have your keyboard slightly lower (make your chair higher or table lower) so your wrists don’t have to extend (bend up) as you type but rather stay in a neutral position or bend slightly downwards – this reduces the amount of work your wrist extensor muscles have to do. Get the right size keyboard for your body size – if your keyboard is too wide or too narrow, it will require you to do excessive repetitive wrist movements when typing, which can make things worse. Take regular breaks to move and stretch – even the perfect office set-up will not be enough to solve your elbow pain if you work hours on end without taking a break. You can find more advice on the best desk and chair set-up for office workers here . 💪 Load management for gym goers The problem with doing weight training is that every single exercise that requires you to grip a weight works the muscles that are attached to the injured tendon in tennis elbow. So, you have to keep in mind the total volume of exercise you do as well as the specific exercises. 👉 Your first aim is to see whether you can find a volume of exercises that does not increase your pain during or after you’ve done them. Adjustments that might help include: Cutting out all the exercises that require very strong gripping and where you can’t adjust the weights; bodyweight pull-ups, for example. Reducing the number of arm exercises and also the weights you use. E.g. instead of doing six exercises for your upper body, do two or three and make the weights much, much lighter. All exercises that require gripping, pushing, and pulling work the wrist extensor muscles, so it's crucial that you consider the total workload in a training session and not just individual exercises. If your elbow pain increases even with very light exercises, you will have to stop all exercises that require you to grip, push, or pull until your elbow has recovered somewhat. Once you feel ready to restart your training, test it carefully by adding only one or two exercises, and make the weights much lighter than normal – you know you’re doing it right if you feel slightly embarrassed to do such light weights in the gym. Then gradually increase your training load over time , taking care not to aggravate your symptoms. View this as rehab rather than fitness training – ramping the intensity up much more gradually than when you’re simply training for fitness usually works best. Treatments for short-term tennis elbow pain relief The treatments in this section can help to reduce your pain. However, they don’t bring about healing. 🤷So, why bother? Pain can make your life miserable and interfere with your sleep, work, and social life. It can also stop you from doing the things that are needed for healing , e.g. your rehab exercises. So, despite not being strictly necessary for healing, these treatments can be super useful as part of a comprehensive treatment plan. Test them and see what works best for you. Sleep and sitting position Sleeping with your elbow straight is usually a gamechanger. There is something about keeping the elbow bent for long periods that irritates tennis elbow and makes the pain worse. It can be a bit challenging to figure out how to keep your elbow straight while tossing and turning in bed, but my patients who manage this report big improvements in their pain. The same goes for sitting with your elbow bent – if you can avoid having it very bent up during the day, it can help reduce your elbow pain more quickly. If you can temporarily train yourself to sleep and sit with your elbow straight most of the time, it will help the pain to calm down quicker. Massage for tennis elbow Massage can help relax your wrist extensor muscles and reduce your pain. However, you can also make your elbow pain worse if you’re too aggressive. For newly flared up tennis elbow (in the reactive stage), avoid hard massage or using a massage gun over the tendons. At this point, the tendons are really irritated, and strong pressure over them usually just makes it worse (like pressing on a new bruise). For chronic tennis elbow pain (when it has been present for a long time), you usually can use stronger pressure and massage or use a massage gun over the tendons as well. Aim for a “comfortably uncomfortable” pressure – if you’re too aggressive or cause too much pain during the treatment, it can also cause a flare-up in pain. For massage guns, I recommend: Using low frequencies – 2,400 percussions per minute or lower. Doing it for only 2 to 3 minutes , covering the whole area. Applying “comfortably uncomfortable” pressure. Leaving at least 48 hours between treatments to allow your body to adapt and recover.   Here are some massage guns available on Amazon: I’ve previously discussed when it is better not to use a massage gun . 🤷 What about “breaking down the adhesions” with massage tools? There is currently no evidence that this works , and for every person who swears by it, I’ve seen at least one whose tennis elbow pain was much worse after. The research clearly shows that the main problem in the tendon is that it degrades and loses strength. Hence, I favour treatments that are well-researched and help restore the strength and tendon structure and are less likely to flare my patients up. Braces and straps There are three types of brace or support that people use for tennis elbow: Wrist splints – These force you to rest your wrist extensor muscles and are particularly useful for very painful cases. The research shows they work. Tennis elbow straps – These reduce the pull on the injured part of the tendon, thereby reducing your pain. The research shows that they can be very effective for some people but make others worse. Soft elbow sleeves – These have not been researched and are not that useful in my opinion. Tennis elbow braces can work really well for some people but not for others. 👉 You can find a detailed discussion about the different types of tennis elbow brace, how to decide which type to use, and when to wear them here. Taping So far, researchers have identified two taping techniques that can reduce tennis elbow pain. One uses kinesiology tape and one rigid zinc oxide tape. 👉You can find a step-by-step explanation on how to apply these taping techniques for tennis elbow here . Reapplying the tape repeatedly can be a bit of a pain, so I prefer using a brace or strap. However, if you have some tape lying around, this is definitely something you can try. Ice or heat for tennis elbow? There is no evidence that either ice or heat speeds up healing. However, it might help reduce your pain in the short term. It’s usually better to use ice if your tennis elbow pain only started a few days ago, as heat might make it worse if your case has an inflammatory component (not all cases have). Ice is usually the better option during the early stages of tennis elbow. You can usually use heat or ice for ongoing cases that have been painful for longer than a couple of weeks. However, overcooling or overheating tissue can be counterproductive, so only apply the ice or heat for 10 minutes at a time and don’t use extreme temperatures. Medication Anti-inflammatory medication may help to reduce pain in reactive tendinopathy. However, these type of drugs must only be used: If really needed for pain relief – they do not actually help healing. For a very short period – they can have negative effects on your stomach. For acute cases (reactive tendinopathy) – it is not useful in ongoing cases and may reduce the effectiveness of your rehab exercises. Where pain is severe in ongoing cases (that have been present for several months), your doctor may prescribe drugs that work on the central nervous system (e.g. antidepressants or antiepileptic drugs) since it can help to calm the general pain system. Dry needling and acupuncture Acupuncture and dry needling both use the same type of thin sterile needle. The main (and simplified) difference is that with acupuncture, the needles are inserted into “energy points”, while with dry needling they are inserted into painful spots (also called trigger points) in the muscles. Two recent reviews of the literature agree that dry needling can benefit tennis elbow. Navarro-Santana et al. (2020)  focused only on trigger point dry needling while Ma et al. (2024)  also included other types. Ma concluded that trigger point dry needling was more effective at reducing pain than other types and that the ideal frequency of treatment appeared to be two to three times per week. In my experience, once a week also gets good results. For acupuncture , two recent reviews also reported that it appears to be an effective treatment for reducing pain compared to placebo and other treatments like medication. 👉 However, all of these reviews rated the level or quality of evidence of the included studies as low to moderate, which suggests these treatments might be useful, but we can’t be 100% certain. Electrotherapies Despite physios and other clinicians regularly using electrotherapy treatments in clinic, many of these methods are supported by very little evidence or low-quality evidence. So, bear this in mind when reading this section. High-intensity laser has been shown  to reduce pain. Low-level laser therapy may be of benefit, but the research supporting it is not of good quality. TENS does not seem  to be effective. Ultrasound – The evidence for ultrasound is conflicting and of low or very low quality. Joint mobilisation There is evidence that manual therapy techniques where your physiotherapist moves your joints can help to provide short-term pain relief. Your physio may use joint mobilisation on your elbow as well as your neck and upper back if their assessment identified those areas as part of the problem. Joint mobilisation is not the same as joint manipulation (the typical cracking of a neck with a quick thrust movement) – the former is gentler and done with more control. Personally, I am not a fan of joint manipulations since they can cause serious injuries  and I don’t feel the reward (short term pain relief) is worth the risk. 🏆 Rehab exercises – the best treatment for long-term pain relief There are quite a few types of exercise that can be used for tennis elbow treatment. Your stage of tendinopathy, pain levels, and physical assessment will determine what exercises are most appropriate for you. The biggest mistake people make with rehab exercises for tennis elbow is to jump in too quickly and overdo things, and then it just makes the injury worse. The best treatment for a very painful tennis elbow that recently flared up is relative rest, not exercise. We discuss the various types of exercise for tennis elbow (with examples)  in detail in another article, but here’s a quick summary. 👉 Exercises that might be useful for all stages of lateral elbow tendinopathy: Stretches for the wrist extensors – reduce muscle tension and help the muscles relax. Mobility exercises for the rest of the arm and neck – these are especially useful in ongoing cases or if your physiotherapist suspects that those areas may be part of the cause of your elbow pain. Neural mobilisation (exercises that slide the nerves) – helps the radial nerve (that runs along the outer elbow) to slide and move more freely. Most people can start with gentle stretches during the early stage of tennis elbow. 👉 Exercises that should usually only be started in the dysrepair and degenerative stages: Strength training exercises for the wrist extensors – these can help to restore the tendon structure and reduce the load on the injured part of the tendon by strengthening the rest of the tendon. 👉 For sportspeople: Technique drills specific to your sport. Making sure all the parts of your kinetic chain is strong and can move freely. Shoulder stability exercises. Tennis elbow recovery times with conservative treatment The research shows that the vast majority of tennis elbow cases recover within 3 to 12 months with conservative treatments (so, the treatments explained above), but for some people it might take longer. If conservative treatment doesn’t work The treatments discussed below should only be used if you’ve tried at least 12 weeks of load management and some of the other treatments mentioned above without making much progress. Shockwave The evidence suggests that shockwave therapy may be more effective than injections for tennis elbow. However, it doesn’t work for everyone. Shockwave should only be considered for tennis elbow cases that have entered the dysrepair or degenerative stage – it will very likely flare your injury up if you use it in the reactive stage. Shockwave treatment can help for chronic cases of tennis elbow, but it doesn't work for everyone. Injections Here’s what the research has found about the types of injection typically used for tennis elbow: ❌ Steroid injections Corticosteroid injections are thought to work by reducing inflammation. However, we’ve seen that inflammation is only really present during the first few weeks of tennis elbow, and in any event, it is thought to be part of the healing process rather than the cause. These days researchers seem to agree that it’s best to avoid steroid injections for tennis elbow . Despite providing good short-term pain relief, they can actually lead to poorer long-term recovery. Platelet rich plasma (PRP) and autologous blood injections These injections use the person’s own blood. For PRP injections, the blood is spun at high speeds to separate out the platelets. The theory is that by injecting a person’s own blood into the affected tendon you can stimulate the healing process. Current research reports contradictory results for these types of injection – some reviews show that they are effective while others  can’t find any difference between them and placebo injections. This is also what I observe in practice – some of my patients find them extremely helpful while others are no better off. Importantly, they don’t seem to have any lasting negative effects. When they do bring about positive change, the improvement is usually gradual and most noticeable after about six weeks. Hypertonic dextrose injections Substances like hypertonic dextrose (prolotherapy) is thought to bring about healing by artificially irritating the injury site, causing inflammation, which then triggers tendon repair and healing. There is also evidence that it can reduce pain by affecting the nerve endings in that area. The current research  suggests that dextrose injections can reduce pain but likely does not improve function. So, they are best used in combination with other treatments (like strength training exercises) that can help to improve tendon and muscles strength and function. Botox injections Botox (botulinum toxin) is a protein that temporarily paralyzes muscles. Botox may work in one of two ways: It is thought that by temporarily paralyzing the wrist extensor muscles it allows them to rest and helps the tendons to recover. But there is also evidence that your body releases certain substances in reaction to the injection that might help with pain relief. The current research  shows that Botox may provide pain relief for up to six months but does not bring about changes in strength. Stem cell injections The theory behind stem cell injections is that they are meant to stimulate healing. There is currently very little research available, and where it does exist, the studies used very small sample sizes. So, we don’t know whether it is truly effective. Hyaluronic acid injection Hyaluronic acid is the primary component of synovial fluid and provides lubrication and shock absorption for joints. It’s not clear how it is meant to help with tendinopathies. There is also a lack of quality research into the effectiveness of hyaluronic acid injections and the studies that do exist show contradictory results. Surgery It has been reported  that only about 5% of tennis elbow cases require surgery. The research shows that open surgery, arthroscopies, as well as minimally invasive techniques , i.e. percutaneous ultrasonic tenotomy (Tenex), can help to reduce tennis elbow pain but do not necessarily lead to complete recovery. A benefit of the less invasive techniques is that they might allow you to return to work more quickly than open surgery would. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. 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