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Fun with flat feet, skinny legs and painful patellas

May 24, 2018

When I started running I was expecting a few aches and pains. I’d been fitted with the best shoes for my feet and embarked on an easy plan that wouldn’t finish me off before really getting started. Everything went well for a while but when I reached the point of doing regular 40 minute runs, aches and pains started to become a real problem.

I first noticed pain under the front of the right knee which would start as soon as I had finished running. This was accompanied by a pain which ran from the top of the right hip, extending down the the outside of the knee. I also began to feel niggling pains in my lower back approaching the end of a run. I figured it wasn’t caused by stress resulting from excess weight as I am a on the skinny side of light. Unfortunately I also have skinny, pencil like legs with a pronounced bow in them.

The final niggling pain occurred in the sole of the foot. This was something I had experienced on and off for years and was particularly noticeable after walking long distances or standing for a long time.

A visit to a the physiotherapist seemed like the only solution and after a thorough examination I was relieved to hear that my knees were OK. Since the worst pain was directly under the patella, this was the area I was most concerned with. I had also worried that bow legs prevented the patella tracking properly.

The physio noted two problems, the first being overpronation. I already knew I had flat feet and overpronated but didn’t realize that this could cause pain elsewhere. The pain in the sole of the foot was plantar fasciitis. The second problem was skinny legs. The muscles in the thigh that should stabilize the knee were small weak and insipid and so weren’t doing their job.

I was advised to stop running for a while and build up the quadriceps (thigh muscles) so that they would stabilize the knee joint. The condition is quite common in runners and is known as Runners Knee or patellofemoral pain syndrome (PFPS) and doesn’t just affect those with skinny legs!

Although I suffered with anterior knee pain the term runners knee is also used to describe lateral knee pain (pain along one side). This is often the symptom of an overuse injury and can be caused by iliotibial band syndrome (ITBS), rather than the muscle imbalance I suffered from. However, it has been suggested that muscle weakness can contribute to ITBS. The pain I felt from the outside of the hip to the knee was coming from the iliotibial band but was not the cause of the knee pain.

The physiotherapist felt I was a moderate overpronator but it was decided to deal with this later after strengthening the quadriceps. These are a group of muscles with the vastus medialis being important in stabilizing the knee or patella. This muscle is divided into the vastus medialis oblique (VMO) and vastus lateralis (VL). There is currently some debate about the extent to which each part stabilizes the patella. The vastus medialis is a muscle just above the knee.

Vastus medialis position

I was given an exercise program that focused on strengthening the muscles of the quadriceps and particularly the vastus medialis. I was taken through each exercise to ensure it was being performed correctly. The exercises were:

  • Walking Lunges: Standing upright, step forward with one leg landing on the heel, letting the knee bend to 90 degrees. The trailing leg drops close to the ground. Push off with the lead leg, bringing the trailing leg through and standing upright. Alternate between legs. This shows a walking lunge with dumbbells . I was advised to do these frequently during the day without any extra weight. They seemed to have the added benefit of improving balance.
  • Straight leg raises: These are performed sitting down and simply require one leg to be held straight, raised up and then lowered. As with the walking lunges, these were to be done frequently during the course of the day.
  • Bodyweight squats: These relied on the assistance of a sofa! The exercise involves standing with feet shoulder width apart and then squatting down to just touch the sofa (in a normal sitting motion) and then pushing up again. There were 15 repetitions performed three times. They were performed daily.
  • Step downs (AKA Reverse step ups): The step down requires a stable platform, low enough to step down from without too much imbalance or general wobbling around. I used a telephone directory to begin with. Standing with both feet on the step, step down with one leg and then return by pushing with the leg that is still on the step. This should be repeated with both legs. As strength increased the step height was increased.
  • Leg extension: As gym was nearby I was told to include four sets of twelve repetitions on the leg extension machine. Only a light weight was used.
  • Cross trainer: Since running was out of the question the cross trainer was used to maintain aerobic fitness.

The strengthening program seems to have worked well. I returned to running again after eight weeks and rarely suffer any knee pain. This really highlighted the importance getting the expert advice of a physiotherapist as soon as pains or problems starts to occur. Unfortunately I still have skinny legs and flat feet.

7 responses to “Fun with flat feet, skinny legs and painful patellas”

  1. Amy says:

    Hello there,

    Great Info! I’m flat footed, have skinny legs and also bow legged. Was wondering if you found out if bow legs contributed to the tracking problem in your knee. Do you still have knee problems with your skinny legs? Thanks

  2. beginrunning says:

    @Amy – Nice to hear from a fellow sufferer! It seems that the knee tracking issue was caused by a weak vastus medialis (VMO), exacerbated by overpronation. The physiotherapist felt the the amount of bow in my legs wasn’t a contributing factor. I was surprised when he said that since I had always been very conscious of the bowing. I had even considered surgery as a teenager and an orthopedic surgeon said it was possible to straighten my legs by removing parts of the femur. Thankfully I didn’t go ahead with the surgery. I guess it’s a case of perceiving the bowing as worse than it really is and having skinny legs certainly makes the shape appear more pronounced – especially to me. I don’t have severe bow leggedness though.

    I still have occasional knee problems but they are fairly minor and more like discomfort than pain. Often this is due to running down hill too fast or just overdoing it. I’ve kept up the strengthening exercise so my legs aren’t quite a skinny as they used to be! I think this is the reason for improvement since I gave up using an expensive pair of custom orthotics now my legs are stronger. I still get iliotibial band syndrome even though stretching regularly and maybe keeping the orthotics would have helped here. It’s just part of life now and I’ve got used to having ITB syndrome after a strenuous run or spending a long time on my feet.

  3. zuber says:


    I am glad to hear that these exercises are working!
    I also am skinny legged, slightly flat footed and bow legged with mild to moderate over pronation… I was told this by the Saucony running shoes people today after having my gait analysed. He recommended that I buy a pair of shoes for over pronation. I would first like to try to correct the problem rather than compensate for it and your story about your knees and the strength of your legs strikes a chord with me. You have suggested some reps for some of the exercises, but not for others. Do you just do them till you can’t do anymore?

    My god… I just looked at the date of your blog! any update on your problems?


  4. beginrunning says:

    @Zuber – For some exercises the physio didn’t give fixed set/reps numbers. He recommended doing walking lunges and straight leg raises frequently during the day. He suggested doing walking lunges every time I went to make coffee or left my desk. An easy way of getting the exercises done but it could generate a few comments from co-workers, unless you work in the Ministry of Silly Walks. If you wanted to incorporate the exercises into a routine a good starting rep range might be 3 sets of 5 reps for walking lunges, 3 sets of 10 reps for Straight Leg Raises and 3 sets of 10 reps for the Step Downs. It’s worth going easy with lunges as they need to be performed correctly so you may want reduce the total number to begin with. The static ITB Stretch after running may also help .

    As you noticed, it’s been a while since I posted about these problems! Despite a slow return to running and exercise after an enforced break earlier this year I’ve not had any issues with ITB syndrome or Plantar fasciitis. I occasionally use lower, off road shoes with little support so the exercises must have helped. I’ve continued these and added other strengthening exercises, both weighted and body weight, although I sometime get a slight knee twinge after longer runs. For ideas I’ve found Mike Boyle’s book Functional Training for Sports
    really useful, although I had a couple of sessions with a trainer to ensure I was performing the exercises correctly. I’ve still got skinny legs although they’re not quite as skinny as they were a couple of years ago. Unfortunately they still don’t look too good in a pair of shorts but they do seem to work a lot better! Good luck correcting your problem.

  5. Dan says:

    I also have a soreness on my right knee immediately when I stop running. However, it goes away after I perform my 5-minute cool-down walk.

    I have developed a new issue. There is a popping sensation above my right knee cap that occurs about an hour after I complete my 30 minute run. It started shortly after I switched from an all-weather track to asphalt. It is completely painless and the popping usually dissipates within a day or two. Should I be concerned? I read somewhere that I should wear a patella strap on the knee to help stabilize the knee cap.

    I would rather try suggestions before spending money to visit a specialist.

  6. beginrunning says:

    @Dan – I always put off a visit to specialist, but it can end up being more expensive in the long run! At least there’s no pain with the popping and I know some peoples joints are more noisy than others. My personal preference would be to wear a patella strap only if recommended by a doctor or physiotherapist and also ask if they suggest any rehab / strengthening exercise to improve knee stabilization instead.

  7. Chris says:


    i’ve had that same problem since i was 11-years-old and i played soccer.

    i stopped sports for years after i was 12 and it wasn’t until i was 20 that i began playing racquetball regularly.

    when i started jogging, i would get that. not sure what it is but you aren’t alone!