We all seem to have the impression that running is bad for our knees, right? I remember before I started training for my first ultra, I was terrified about hurting my knees. I had heard so many stories of people whose running careers stopped almost as soon as they started due to knee pain. It seemed like you either were made to be a runner, or you weren’t. Sure enough, just a couple months into training as I ramped up my mileage, I was ground to a halt by my knees. My doctor told me if I didn’t stop then I wouldn’t be able to walk by the time I hit 30 (ahem, I’m 34 now and walking just fine). After doctor shopping a bit, I finally found one that diagnosed me with patellofemoral syndrome (described below). Basically, I was feeling knee pain because of muscle imbalances that were not allowing the kneecap to track properly. Running wasn’t bad for my knees – my lazy ass was.
I’ve since had a fundamental belief that too many people get discouraged by running because of this myth about the knees… but in order to back up my claim, I thought I would turn to the experts to get the real answer! Thanks to my friends at the Bowskill Clinic in London, as well as their trusted medical colleagues, we’ve got answers to some of the key questions runners have about their knees. This post will focus on:
- helping us understand the bigger picture of how running affects our knees;
- providing us with a simple test we can use to gauge how injury-prone we might be; and
- detailing the different types of injuries, conditions or running technique that might cause knee pain.
In the next post, we will explore what to do if you already have knee pain, and some stretches and exercises that might help runners’ knees! The information in these two posts have been researched and written wholly by them, specifically for you (us!), which is pretty awesome. Only minor edits (and a few cheeky comments) by me.
So, experts, help us out here: is running bad for our knees?
Understanding the full picture
Running is a dynamic and repetitive activity that relies on us being able to accept up to six times our body weight on each foot strike. The repetitive and relatively high amount of impact involved mean that if we do have particular structural issues, we may experience problems more quickly than we would with more varied activities. However, according to the team at the Bowskill Clinic, there is nothing inherently bad about running. Some people are just at higher risk of injury than others depending on a number of different factors. The key is understanding the risk factors for running, knowing which ones you might be exposed to, and to what degree.
“Most running injuries are not traumatic in nature [unless you fall or trip]”, says Dr Jonathan Rees, Consultant in Rheumatology and Sports and Exercise Medicine. “Instead, most running injuries occur as a result of too much load being placed on a part of the body in a repetitive manner. In this respect, an injury occurs when load is repeatedly greater than the body’s resilience to that load.”
Dr Rees tells us that the key to preventing a knee injury – and indeed any running injury – is to understand your own individual ‘intrinsic’ factors and ‘extrinsic’ factors, and how these make you more or less injury prone.
Intrinsic factors are things that are unique to us as individuals, such as age, genetic, previous injury history, and our biomechanics. Extrinsic factors are the things that are done to our body, such as running load, footwear, running surface, intensity of training, nutrition and rest. While we are stuck with the intrinsic factors, we are better able to control and change the extrinsic ones. (To learn more about these factors from Dr Rees, check out this article published in ‘Football Medic & Scientist’ Issue 15 Winter 2015/2016 here).
What factors may contribute to a higher risk of knee injury in some runners?
So we know that a runner’s risk of injury depends on a host of different factors – but how do figure out how these apply uniquely to us? The Bowskill Clinic has tried to simplify this down to an easy test of just five questions, which you can use to score yourself on a scale of 1-10.
0 is absolutely perfect – 10 is absolutely awful!
The closer your cumulative score is to 50, the higher your relative risk is of injury. It does not mean you can’t run, only that the odds are stacked less in your favour.
‘Biomechanics’ refer to the way in which your body is put together and the manner in which you move. Do your knees heavily drop in when you run? Do your feet either overly pronate or supinate? (See here for an explanation and video examples of each) Have a peek at the soles of your shoes – is there an uneven pattern of wear? If you look like Mo Farah when you run then you’re a zero – more Forest Gump then closer to a 10.
0 1 2 3 4 5 6 7 8 9 10
2. Physiological load
Physiological load means how much stress your body is currently under. If you are in bed by 10pm every night, don’t bother with alcohol or coffee, eat a healthy diet, live a stress-free life, are happy at work and happy at home, you are closer to a 0 (and, apparently, complete life fulfillment – please give the rest of us advice!) . If your life is rather a more turbulent mess of late nights, takeaways, long stressful hours of work, and a caffeine or wine drip, you’re closer to a 10.
0 1 2 3 4 5 6 7 8 9 10
3. Training programme
This category has to do with how structured or unstructured your training programme might be (or, cough, whether you have a training programme at all). To score a zero here you need to be well organized, follow a periodised programme to manage load, understand heart rate or lactate thresholds, and be acutely aware of what every run or rest day is aimed at achieving (if this is you, I’m guessing you’re actually a triathlete in disguise, rather than an ultrarunner). On the other hand, if, say, you’ve recently ramped up your running after a long period of inactivity in the hopes of cranking out a half marathon on just a few weeks of training, you are much closer to the other end of the scale.
0 1 2 3 4 5 6 7 8 9 10
4. Previous history of injury
If you have managed to stay properly injury free from your pelvis down to your toes, you’re a zero (and, in my humble opinion, a hero…as in a fictional superhero). If you’ve had two hips replaced, an ACL repair from an old skiing injury and also a dodgy ankle you seem to keep rolling, put yourself closer to a 10!
0 1 2 3 4 5 6 7 8 9 10
If you have never touched your toes and would be pleased to reach your knees, congrats, you are a 10! If you are the most mobile person in your yoga class and can basically contort yourself into all kinds of pretzel shapes, you are also a hypermobile 10. To get a zero, you work regularly on stretching the areas where you are tight and probably use things like foam rollers and stretching tools. Regular massage or soft tissue work is also essential if you are going to get a zero here.
0 1 2 3 4 5 6 7 8 9 10
0-17 Good to go and relatively low risk
18-36 Can go in both directions – time to review some of your decisions
37-50 Time to get some expert advice and make some changes
I gave myself a score of 32, thanks to my growing injury history and lack of flexibility. How about you? Now that we know where we stand in terms of potential risk of injury, let’s take a look at what kinds of injuries we want to avoid….
What causes knee pain in runners?
Knee pain can be caused by a range of different things – from something as simple as tight muscles or overuse, which can be treated with proper stretches and rest, to something more complicated.
Andrew Jackson, senior Physiotherapist at the Bowskill Clinic has outlined below some of the major mechanical pain generators for runners’ knees and why they come about.
Patellofemoral pain syndrome (PFPS): This is also known as “runner’s knee,” or chondromalacia patella, is the most common overuse injury among runners. It occurs when a kneecap (patella) isn’t tracking properly and irritates the femoral groove in which it rests on the thighbone (femur). This can happen for many reasons including a worn meniscus between the knee joint, a high or low located patella, poor biomechanics and even flat feet. Look out for deep tenderness in the front of the knee, usually toward its center. You may feel pain toward the back of the knee, a sense of cracking or that the knee’s giving out. Steps, hills, and uneven terrain can aggravate PFPS.
Meniscus injury: This is an injury to the cartilage pad in the knee. It tends to be an indirect injury to runners mostly middle-aged and upwards as the meniscus naturally begins to wear, degenerate and lose its cushioning effect. Eventually this causes a degenerative tear. Look out for pain and joint swelling. The pain is usually along the joint line on one side of the knee (usually the inside) and can coincide with a locking sensation of the knee.
Iliotibial Band (ITB) Syndrome: The ITB is a dense, fibrous ligamentous band that runs down the outside of the thigh from the hip to the shin, attaching just below the knee. It works to stabilise the knee joint, but in runners it can typically become tight and inflamed as a result of lumbo-pelvic dysfunction (dysfunction of the lumbar spine/pelvis), medial/lateral rotational instability of the knee, weak medial quadriceps (the part of your quad muscle on the inside part of your knee) or poorly functioning feet (for me, it was my weak gluteus maximus aka a lazy butt). Look out for swelling and pain on the outside of the knee, particularly if you bend your knee at a 45-degree angle.
The patellar tendon is a short but very wide tendon that runs from your
patella (kneecap) to the top of your tibia. Its job is to absorb the loading forces on the knee via the large quadriceps muscles. This can inure the long strands of the tendons. This is often a result from a forward drawn posture with an anterior rotated pelvis, weak hamstrings and/or quad dominance. Look out for
a stiff feeling and eventually a sharp pain below your knee cap. Worse when going downstairs or downhill.
Referred pain: Pain can also be felt in the knee as the result of ‘referred’ pain (pain coming from an issue elsewhere). Pain may be referred to the knee area as a result of a degenerate hip joint, a stiff or mobile sacroiliac joint (the sacroiliac joint connects the sacrum – triangular bone at the bottom of the spine – with the pelvis on each side of the lower spine), or other areas.
Can my running style affect my knee pain?
, Musculoskeletal Podiatrist at the Bowskill Clinic explains, “the mechanism or process that leads to a running knee injury can in many cases be related back to how the knee moves and loads during the gait cycle. Since this is determined by how you run and your biomechanics, the simple answer is yes
However, it is important to consider all aspects when determining the cause of your knee pain to ensure that interventions lead to recovery and not a new injury! (The intrinsic and the extrinsic factors as described above!)
Some other factors to consider include the following:
- Continuous and repetitive running on uneven surfaces can place disproportionate stress on one side of the knee compared to the other, such as the camber of a road.
TIP: Always vary the course of your run to reduce the likelihood of any repetitive strain.
- Poor alignment of the knee (knocked knee) can occur due to weakness or imbalance of the muscles above the knee or an unstable foot below. (Exercises to address the muscle dysfunction will be included in Part Two of this post.) Foot control can be improved with correct running shoes and, when required, in-shoe orthotics.
TIP: It is important to remember there is no one ideal shoe to prevent knee pain as the requirements for each runner will vary.
- When done under supervision, re-training your running technique can play an important part in reducing knee pain. When reviewing your technique, some of the considerations are:
- Your stride length
- Which part of your foot hits the ground first
- Your cadence
- Do your feet cross over the midline of your body before they contact the ground?
TIP: When looking at running and technique and biomechanics it is imperative to consider the effect of fatigue and load tolerance for the individual. The results of a running analysis can be different if performed after a long run when your muscle groups are tired and perhaps when you are less likely to concentrate on your running technique.
In summary, there are many contributing factors to injuries in runners and the better you understand your own individual risk, the better able you will be to manage this. The most important factor in managing any aches or pains is to listen to your body and the signals that it is giving you. If you think you need further expert advice, get it early, ensuring the fastest possible diagnosis and recovery.
Now that we know a bit more about how knee pain may be caused and what to look out for, stay tuned for Part Two in which we’ll learn what to do when we do experience knee pain, as well as some stretches and exercises to help prevent injuries in the future!!
A huge thanks to the Bowskill Clinic
and their team of experts for providing us with all of this information. It’s no easy task to pull this all together. These guys are top notch, so I’m really stoked they agreed to do this! have the UltraRunnerGirl stamp of approval (they helped me overcome injuries in 2010 and again last year in 2016 before Tor des Geants
The Bowskill Clinic is an interdisciplinary centre specializing in rehabilitation of orthopaedic and sports injuries.
Jon Bowskill, Corrective exercise specialist / performance strategist, founder at Bowskill Clinic
Jon is an exercise specialist with a particular interest in creating bespoke strategies for rehabilitation and performance. He works with his team to bring together the right specialists to help resolve a range of different sports injuries.
Andrew Jackson, Musculoskeletal Physiotherapist at the Bowskill Clinic
Andrew is a specialist in physiotherapy and movement mechanics. He works closely with Jayesh to develop treatment and exercise prescription for runners.
Jayesh Thakrar, Musculoskeletal podiatrist at the Bowskill Clinic
Jay is a specialist in running biomechanics and uses the very latest VICON motion capture system along with in shoe pressure analysis to precisely understand runners’ needs.
To find out more of what our runners rehabilitation and management programmes involve contact firstname.lastname@example.org or see more of our physiotherapy and biomechanical gait assessments at www.bowskillclinic.com
Dr. Jonathan Rees, Consultant in Sports and Exercise Medicine and Rheumatology at the Fortius Clinic
Dr Rees is a specialist in sports medicine with a particular interest in running and tendon injuries. He was physician to the 2012 London Olympics and 2008 Team GB paralympic team.
Dr. Simon Blease, Consultant Musculoskeletal Radiologist
Dr Blease is a specialist in musculoskeletal imaging especially relating to sports injuries. He provides second opinions on scans for complex or non resolving issues.