In the previous article on knee pain we’ve identified 10 Causes Of Knee Pain in Runners. It would be helpful if you read that one first and then come back here.
Impact, or rather repetitive impact, is what causes injury in runners. Forces of about 2-4 times your body weight travel up through your leg, knee, thigh, hip, pelvis and up into your spine, each time your foot strikes the ground. The problem is not only the impact, but the fact that it’s repetitive.
These forces shake and disturb the tissues of your lower body just like an earthquake shakes the walls of a building. But just as some buildings remain standing while others fall, impact from running does not equally disrupt all the tissues they pass through. The damage is concentrated in a few areas of great susceptibility (Source: The Runner’s Body), knees being one of those areas.
I became very passionate, a bit obsessed some might say, with what caused my knee injuries (meniscus damage) as a young athlete Karate-ka. Over the past 5 years I’ve learnt a lot from my coaches, personal experience, books, and even clients about what causes knee pain, knee injuries and how to best manage them. I’m not a therapist or doctor, just a runner, athlete and personal trainer, who has been there, learnt about it, shared the information and got results, and now eager to share with those who cannot train directly with me. If you have an injury it is always best to consult a therapist or GP before anything else.
Don’t get me wrong I am aware that certain injuries never heal, in fact no injury ever heals to bring the body to where it was before, however, we can manage those injuries so we are not in pain and the injury doesn’t aggravate too fast, too soon. We also want to keep training and competing.
The body also finds ways to work around an injury so you can perform the same exercise, at the same intensity, even after injury. The body is amazing at adapting, so don’t lose hope.
In this article I will recap some of the advice from the previous article on knee injuries, but go more in depth with each one, as well as including information which was not previously mentioned in any other article.
Let’s understand why knee injuries or knee pain occurs, what to do and how to manage it so we can continue running.
1. “Lubricate” your joints. Do your pre-running warm up.
Movement lubricates the joints as oil lubricates the parts of your car so your car runs smoothly and you don’t worry about it breaking down on the road.
If a car would have no oil the components would grind against each other, wearing out faster. Well, it’s the same with your knees and any other joints.
Synovial fluid is the lubricant in your joints. You want this fluid to be present in the joints, everywhere, especially before you begin a physical activity, but not only. That’s why it’s important to take the joints through the whole range of motion on a regular basis.
One of the ways we do that here at The Merisoiu Technique Institute is through the full squat. All the way down. If you can’t go all the way down you may use a little wedge, such as a thin book or a little stick, just so you go all the way down.
If you do have a wedge under your heels, to not shift your bodyweight too much on your toes as this will transfer the weight and pressure on the knee joint, rather than the quads and glutes when standing up.
Ensure your heels are rooted into the ground throughout the squat.
When you squat, you bend your knees and go straight down as if you were going to sit on a small nursery chair placed right underneath you.
The full squat is not only good for the knees, it also takes your ankle and hip joints through the full range of motion. In the same time it activates the stability muscles, which are very important for runners, and not only. We will talk more about stability muscles later in the article.
Another exercise you could so is to lie face down on the floor and slowly bend your leg behind you at the knee, breathing out on the lift. I do that particular exercise before I go running, about 20 times each side. If you do this exercise standing it’s slightly different as the knees are not on the same line. Try both and observe the difference.
Warm-up is critical to reduce early joint wear and tear. Get those joints oiled and they will stay healthy for longer.
You didn’t see that coming, did you? Maybe you did. We think nutrition is only about recovery and weight loss, but it does more than that. Good nutrition means nutrients for the body, including your joints, and that includes your knees.
But it doesn’t really work from one day to another, it needs to be constant, so your body will absorb the nutrients, transport and deliver them in all corners of your body.
Some corners are more difficult to access, such as the medial knee meniscus. Knee meniscus is a cartilage, which is very durable and elastic. It’s like a shock absorber for the joint. It doesn’t have a blood supply, rather it gets oxygen and nutrients from the surrounding joint fluid.
There is some evidence that there are “canal-like structures opening deep into the surface of the menisci” which may “play a role in the transport of fluid within the meniscus and may carry nutrients from the synovial fluid and blood vessels to the avascular [tissue which does not contain blood vessels or lymphatics] sections of the meniscus”. Further study is needed to pinpoint the “exact mechanism by which mechanical motion supplies nutrition to the avascular portion of the menisci”. (Source: The Basic Science of Human Knee Menisci – Structure, Composition, and Function – Alice J. S. Fox, MSc, Asheesh Bedi, MD, and Scott A. Rodeo, MD)
If this is true then nutrients can reach the menisci and other cartilages throughout the body which don’t contain blood vessels, as well as to everything else from bones, to tendons and joints.
The question is: what type of nutrients will your injuries receive? Bottom line…it’s in your hands, it’s a matter of choice.
Thus good nutrition = healthy joints
Ensure your stability muscles in and around the joints are strong. As my Sensei once told us: small muscles are sneaky, large muscles are lazy. Small muscles don’t want to work and “ask” large muscles to take on more work.
Those small, microscopic muscles are very, very important when it comes to joint stability. And I have my natural movement fitness coach Michael Cohen to thank for introducing me to this important aspect of training.
Thus it is important to ensure you train those small, microscopic muscles so they stabilise the knee joint, not letting it go out of alignment and wear too fast, too early.
To do this it’s not enough to do hundreds of squats, jump and run, you need to work on slowing down your movement, practice all sorts of balance, strength and body weight transfer exercises regularly, whether you do it as a standalone routine, in between your other exercises or while waiting for the train or brushing your teeth (careful with balance exercises, safety first), do it regular, be consistent and you will reap the rewards of a fit and strong runner.
Small muscles are important but so are larger muscles which keep the knee from maltracking, such as the adductors and abductors, inside and outside the thigh respectively.
An imbalance in the strength of the muscles in the inside and outside of the thigh causes maltracking of the knee cap (patella) which sits and moves in its groove. This maltracking leads to patellofemoral pain syndrome or anterior knee pain, as it’s most popularly known.
Besides the adductors and abductors another important muscle to look after is the gluteus medius, located up on the hip and on the outside of the thigh. We all focus on strengthening the gluteus maximum, the buttocks, but the medius and even the minimus are important in stability. The gluteus medius work with the other muscle to keep the leg and knee aligned, preventing it from roll in.
If the knee rolls in, the vastul medialis and gluteus medius are not working properly, so the TFL takes over. If the TFL is overworked it can pull in the ITB, increasing the lateral pull on the kneecap. Because the ITB connects to the outside of the patella, the lateral pull in the kneecap can cause this tissue to become sore and inflamed. (Source: Running Well by Sam Murphy and Sarah Connors). Quite a vicious cycle isn’t it?
Remember one important thing: if one thing goes wrong in any part of your body it will have consequences throughout your body. Nothing is isolated from the whole. And injury is never really localised, it’s sends ripples throughout the body.
Also if there is an imbalance in any of the other body systems – physical, mental, emotional, chemical – the other systems will take resources, which should be used for specific tasks, to address the emergency and thus those tasks are not completed. If the resources are re-directed for too long then the whole system is thrown off. Makes sense right? I can’t really tell you the source of this statement because I’ve read so many books and articles that this is more of an intrinsic type of knowledge.
Let’s take an example:
- You experience an injury in your right knee – physical
- Your body starts sending more nutrients to the right knee to help recovery – chemical
- Your mind starts paying particular attention how it’s moving, to protect the right knee from any further damage, so it takes some of the weight bearing responsibility usually met by the right knee, and places it on the left leg, causing you to limp – this is the mental / psychological system
- If you limp for too long the left leg muscles will begin to store tension and your hips and spine will begin to alter their movement and alignment as well
- If the injury lasts for too long, your mind is still busy with it, you can’t do much physical exercise, you can’t really run too much, you probably find it difficult even to go down the stairs. You begin to put on weight, you feel stressed, sad, maybe some signs of depression, anger, frustration etc – this is the emotional system affected by a physical injury
However we can’t avoid all injuries and this chain reaction, this just happens, it’s part of life. What I am trying to impress on you is that when injury happens you should take the necessary steps, even stop training for a week or two, to recover. Do not train through a serious injury, thinking you can “shake it off”. If you don’t recover properly you risk months of break from training instead of weeks.
I know it’s difficult and frustrating, I have been in that situation numerous times. Sometimes I take breaks, other time I’m stubborn and I don’t. Something I take the correct decision, other times I pay for my stubbornness.
Although anti-inflammatories or RICE-ing the injury works, as a temporary solution, you must find out what caused the problem to occur. As mentioned in the previous article on knee pain, if you haven’t been in an accident, haven’t had a fracture, or any other obvious reason for your knee to hurt, it could very well be one of the following reasons:
- Foot overpronation
- Inward rotation of the hip
- Tight calf muscles
- Weak gluteus medius – which can cause the leg to internally rotate more
- Tight quadriceps – which can increase the loading of the patella, the shorter they are, the greater the pull over the knee
- Knocked knees – knees falling in
The best thing to do when you suspect injuries is, of course, to see a physio, a sport medicine expert or even a GP and assess your injury, running form, muscle strength and flexibility.
We’ve only mentioned the anterior knee pain above. In the previous article I went through a few other possible caused of knee pain. Make sure you check it out.
However, bottom line, seeking professional advice and strengthening your knee and rehabilitating after an injury is essential. Keep you stability muscles strong and you can reduce the risk of knee injuries.
In a future article I will give you some exercises that work to strengthen your stability muscles and stabilise the knee joint.
As we’ve seen in the previous article on knee injuries in runners there are muscles that connect to the knee cap.
Sometimes we experience knee pain because those muscles pull on the knee joint because they’re too tight, too short, because you don’t take the time to ensure they come back to their regular length through stretching and mobility exercises.
To help correct reduce the risk of knee injuries you have to stretch each part involved in stability, protecting or moving the knee. When you stretch have this list in front of you and follow it after a few runs. At a minimum you should stretch the following muscles:
- Adductors (inside of thigh)
- Hip flexor (from of thigh, at the hip joint)
- Tibial muscles
In the next article I will share with you our MoveWildTM post running stretch movements which will stretch almost every muscle in your body.
Ensure that your body is not only flexible but the joints are mobile and move smoothly through the whole range of motion. Remember the synovial fluid we talked about right at the beginning of this article, yes? Take the joint through the whole range of motion to “oil” the whole joint.
Besides the knee joint itself, particular for knee pain and knee injuries is the ankle joint. If the ankles are too stiff they can’t absorb part of the impact and it sends more of it to the knees.
If you are a minimalist runners your ankles should feel like they’re going through the whole range of motion – it depends on how you run of course.
If you are a heel striker chances are your ankles need a bit more mobility work.
This article is getting waaaay to long so in the next article on knee pain I will share with you a method of testing your ankle mobility and a few ways to improve your ankle mobility as well.
Running on the same route, same surface and same direction over and over again you place roughly the same stress on the same joints over and over again, thousands and hundreds of thousands of times. No wonder running is associated with knee injuries and not only. It’s the repepetitive stress the same way in roughly the same place that causes the problem.
- Change the surface you run on. Running on different surfaces will also challenge your musculoskeletal, neuromuscular and cardiovascular systems in different ways
- Change the route every once in a while
- If you run on a track change the direction you run in
- Run on grass or asphalt rather than concrete, where possible.
- If you run on the side of the road, run on the other side as well, balance it out, especially if it’s a cambered road
I emphasize to my clients to “balance it out”. Everything you do on or with one side of the body, do it on or with the other side of the body as well.
Try brushing your teeth with your other hand from time to time, challenge your body and brain to do things differently.
7. Nerve flossing
Nerves form the communication network between your brain and the rest of your body. They send information from the body to the brain, and vice versa, about movement, digestion, pain, injuries, body position and so on. They play a big role in your posture and perception of pain.
This is proprioception – “sense of self” – which was developed by the nervous system to keep track of and control the different parts of the body.
Nerves can get sore and inflamed, just like muscles, and can affect movement. We cannot stretch the nerves as we would stretch muscles, but we can mobilise them. If there is anything bothering the nerve along the way, or the nerve gets stuck (as it can happen to the sciatic nerve which travels in and out of joints and muscles), “nerve flossing” or nerve mobilisation can help with that.
Of course it is always recommended to see a therapist or GP to ensure there isn’t a more serious case going on.
We can’t touch nerves as we touch muscles, to stretch and move them around. So we have to “floss” them instead. Nerve flossing means putting the nerve on tension and then move a structure of the body (i.e. the head) around, which moves the nerve in and out of the tensed position. It’s a sort of sliding or gliding motion that creates motion between the tissues.
Think about sliding the dental floss in between your teeth. If we compare the dental floss with the nerves and the teeth with the muscles, the difference is the dental floss (nerves) will be stationary, and the teeth (muscles) will move forward and back, essentially creating a similar movement.
However keep in mind that the nerve should never be held in a tensed position as it can damage it and the blood vessels supplying it. It is also important for the movements to be performed very slow. It’s better to perform the exercises slow and less of them, then fast and cause damage.
The two most important nerves for runners are the sciatic nerve and the femoral nerve (Source: Running Well by Sam Murphy and Sarah Connors). Both of them emerge from the vertebrae of the lower back.
I haven’t created any videos on nerve flossing myself but here are 2, one for the sciatic nerve and another for the femoral nerve, you can try:
Sciatic nerve flossing / mobilisation
Above the back of the knee the sciatic nerve divides into two nerves: the tibial and the peroneal nerves. The tibial nerve travels to the foot and innervates the heel and sole of foot. The peroneal nerve travels sideways along the outer part of the knee and into the upper foot. This is the connection with our knee discussion.
Femoral nerve flossing / mobilisation
The femoral nerve supplies the front of the thigh, quadriceps muscles. The quads assist with knee extension. All quadriceps attach to the patella (knee cap). If you have a non-specific knee pain it’s worth considering the femoral nerve. As always when it comes to nerves it’s best to see a therapist or GP.
These exercises can also be incorporated as post running stretches if you don’t already have a stretch routine or want to build on the one you have. Try them out and see how it goes.
8. Running form
Pronounced heel strikers are more likely to develop patellofermoral pain syndrome, just like new runners are more likely to suffer tibial bone strains because they have not achieved the bone adaptations yet. (Runner’s Body)
Heel strikers seem to experience greater impact shock than even the knocked knee runners – those whose knees rotate inwards as discussed above.
Overstriding can also be a possible cause of knee pain.
There is some evidence that altering a runner’s form and strengthening certain muscles (i.e hip abductros and hip external rotator) may reduce the degree to which impact forces concentrate in particular areas, in our case the risk of patellofemoral pain syndrome PFPS or runner’s knee. (Runner’s Body)
If reducing the impact is a mean to reducing the risk of knee pain then shortening your stride and landing with the foot flat under your hips instead of in front of your body is worth the work.
Nicholas Romanov’s Pose Method of Running and Danny Dreyer’s Chi Running technique take the same approach, shorter strides, landing under the body.
Using your quad muscles will lead to overstriding, heel striking and knee pain. Instead use the hamstrings to lift the ankle on a straight line under your hip and have a slight lean in the body (from the ankle). Here’s a video on how to “pull” your leg up under the body.
9. Stride frequency or optimum pace
The faster we change support the less we interrupt the gravitational pull and the faster we run as well.
A faster stride will keep your stride length short and enable you to land under the body, instead of ahead of the body as discussed above.
Furthermore as you land under the body the only way you can land is flatfoot. You can also land on your toes, but keep in mind that your heels touch the ground ever so slightly, just “kisses” the ground.
The less we counteract with the gravity and the less time we spend on the ground, the less load we place on joints, ligaments and tendons which in turn reduces the changes of injuries. For those running high mileage this is crucial.
A high rate of stride frequency does not demand a huge muscular effort, on the contrary, you actually use less muscle. Of course at the beginning it will be difficult, any changes you make to anything will be difficult at the beginning until the body adapts.
To use less muscle we need to take advantage of the pull of gravity. Why work against gravity by pushing the whole body forward, when we can use gravity as free energy to PULL us forward. Being pulled by something is a lot easier than you pushing your body to move.
To take advantage of the pull of gravity we must understand how the lean works. It’s actually simple really:
- Stand facing a wall about 10 cm away
- Hold your body straight and look forward
- Hold hands in front of you to meet the wall
- Lean your WHOLE body from the ankle and catch yourself with your hand, letting your elbows bent as if you were doing a press-up against the all
- Push yourself back and repeat
- Then do the same on one leg only
- Then do the same but it a bent knee and bodyweight slightly distributed more on the ball of the foot (a little, as in 55% of your bodyweight, not too much)
- Your body alignment, do not stick your bum out behind or push your hips forward
- Avoid sinking your hips as you meet the wall, hold your abs tensed
- Don’t lift yourself on the heels. The heels come off the ground as a consequence of you leaning, you don’t lift your heel to push your body forward.
- Think about the leaning tower of Pisa – that’s how your lean should look like, at a smaller scale of course, we need to learn only a few millimetres to harness the power of gravity
The optimum pace or stride frequency is 180 steps per min (counting left and right) or around 90 steps counting only one side.
But hold one a second, won’t this be hard work? Yes, it will, going from 150 or less to 180 is quite a jump.
As a recreational runner the easiest way to do this is to get a stop watch or a metronome app and learn and practice the rhythm. Run with the metronome and count 1,2,3,4, 5,6,7,8 alongside the metronome. Develop a counting rhythm so that when you go for your regular runs you just count and don’t need to worry about turning the app on.
At times throughout your run pick two points (i.e. from where you are to a bench, a tree, the corner of the street etc) and run at 180 beats per minute to that point. Then run as you normally do. This is Fartlek training. Short bursts of faster runs. This will ensure a smooth and gradual transition to the new pace without burning yourself out.
For the more competitive runner, you can have a separate interval session. Run at 180 bpm for 30 sec or 1 min, or 5 min (depending on your fitness less and your current pace), then make the recovery run your regular pace. In time your body will learn the new pace as it gradually transition. Remember your goal is to get your body accustomed to the new pace. This will be your new comfort zone. So don’t make the intervals super difficult, it’s not that kind of running interval session.
10. RICE your injury
When you do get injured, injuries must be given the appropriate attention. Ensure you rest, ice it, compression (strap the joint) and elevate. Read this article on RICEing your injuries.
11. Anti gravity
Running in shallow and deep water as part of you running training reduces the impact on your joints.
Or better yet here is an antigravity treadmill
Have you had the opportunity to try an antigravity treadmill? ILeave a comment below and let us know how it is.
Of check out this underwater treadmill
These are all good ways to either recover from injuries or get a good workout without pounding the ground.
There you have it, how runners can manage their knee pain. There is much more I would have liked to cover here, but I hope it will give you a better idea of knee pain and injuries.
Keep in mind that I am not a therapist or medical professional, so take this article, and all article on running injuries, as general information. The author takes no responsibility for any injuries and damage occurred as a result of following the advice from their article and books.
- Donna Finando and Steven Finando “Trigger Point Therapy”
- Sam Murphy and Sarah Connors “Running Well”
- Danny Dreyer with Catherine Dreyer “Chi Running”
- Nicholas Romanov “POSE Method Of Running”
- Nicholas Romanov with Kurt Brungardt “The Running Revolution”
- Ross Rucker and Jonathan Dugas, Runner’s World “The Runner’s Body”
- Danny Abshire “Natural Running”
- Kinetic Health
- The Basic Science of Human Knee Menisci by Alice J. S. Fox, MSc, Asheesh Bedi, MD, and Scott A. Rodeo