10 Causes of Knee Pain in Runners

10-Causes-of-Knee-Pain-in-Runners

One of the most common injuries in running happens around the knee because of the impact they need to absorb. We put our knees under pressure with every step, when walking, sitting standing and, of course, running. What we do and how it do it, not only when we run but all the time (this is true for everyone not only runners) is essential for healthy knees.

The kinetic chain means that every part of the body is connected to another part of the body, in such a way that a problem in one area of the body may cause problems in another area are of the body. Nothing in the body is isolated and nothing happens in only one part of the body.

If you have an injured little toe be sure that your body is adjusting to that injury as you cannot use the little toe as you normally would. Those small adjustments can lead, in a few weeks, to tight muscles on the opposite side of your body, for example. Tight muscles will eventually affect your alignment and send pressure to joints, ligaments and tendons, which is not normally their job to do.

That is why an injury, no matter how small should be taken care of as soon as possible, so as to not allow the small problem to escalate and become a major problem.

MOVEMENT

Movement squeezes synovial fluid – joint “lubricant” – into the joint. This is why it’s important to take the joint through the full range of motion. For example, if you never take your knee into full flexion, the parts of the surface that don’t come into contact can degenerate more quickly.

We regularly practice full squats, a movement which besides strengthening stability muscles around and within the joints, it also take the ankles, knees and hips through their full range of motion.

MUSCLES

Muscles do the hard work, they are the workers in the body. The brain sends them information with instructions to contract and produce movement, by pulling on the bones.

Since they are connected to the bones, joints and ligaments, injuries (strains or pulls) or weakness in the muscles can cause the knees, and other joints, to take too much pressure, do more than their part of the job and degenerate faster. They basically say “that’s not my job!!”.

THE NERVOUS SYSTEM

The nervous system is the means by which your body components communicate. It’s the network that allows the brain to community with the muscles to produce movement. It’s also the communication channel for the body to send information of position in space to the brain, which then places the body in the best position to avoid injury.

For example, when you run into a ridge on the ground, your body send a message to the brain, which then sends a message back to the rest of the body to assume the best possible position to avoid injury. That includes the arms and head. When you lose balance your arms go the side straight away, that’s why.

Going back to the nerves, if there is a problem with one of the nerves, for example the dreaded sciatic nerve, the effected nerve can refer pain in another part of the body, and that includes the knee.

In the sciatic nerve example, if you have ever suffered by a trapped or irritated sciatic nerve, known as sciatica, you probably felt the sharp pain going down the back of the leg.

A nerve problem refers pain, it’s not usually localised.

RUNNING INJURIES

Running is more associated with chronic injuries than acute ones. That means that the knee injury happens gradually, through time, and symptoms just show up at a later stage.

It’s a build up of stressing certain areas of the body. The reason running is so hard on the joint, ligaments, tendons and muscles is repetitive impact.

Each time your foot touches the ground impact forces travel upward through your lower leg, knee, thigh, hip, pelvis and spine. It’s like an earthquake, shaking everything.

So our job here at The Merisoiu Technique Institute is to help you calm down that earthquake, reduce pressure on your joint and enable you to run stronger for longer.

CAUSES OF KNEE PAIN WHEN RUNNING

The topic of this article is knee injuries or almost any kind of knee pain (doesn’t necessarily have to be an injury for the knee to hurt).

There can be many, many reasons your knees hurt. In this article we mention some of the most common knee pain causes, but it’s not an exhaustive list. In subsequent articles we will take each one and see what we can do to prevent or treat the injury or, if it’s something serious, whom to talk to solve the problem.

Thus, here’s what may cause your knee pain:

1. Surfaces you run on

Let’s begin with the surface you run on. When you run on the same surfaces over and over again there’s a gradual accumulation of the same forces applied on the same areas of the body time and time again, over thousands of steps.

That is why it’s important to add variety to your running surfaces, concrete, off road, track etc. We will talk a bit more about this later in the article.

2. Your running shoes

The shoes you choose are critical to injury or injury prevention. If your shoes are too tight, or they don’t allow for a natural bend of the foot, or don’t allow for the toes to expand, or don’t give the support you personally need your stability can be compromised.

That compromised stability will cause instability in the knee as well. Remember the body sends signals to the brain, my means of the nerve network, to position the rest of the body (including spine, arms, neck and head) in the most efficient way to avoid injury. If the information is not accurate the brain can’t act in your best interest.

A word of caution, today’s cushioned shoes mask the pain of running heavily and incorrectly. If you don’t believe be test it yourself. Take your shoes off and run 50m. You will notice how heavy you actually run. Don’t worry your body will soon begin to adjust and realign to reduce that impact. There’s an immediate foot-brain-body communication and the whole system will begin to adjust.

However, this doesn’t mean you should run barefoot, it only means you should learn the natural or barefoot running mechanics with the regular shoes one. It can be done, you can run with your shoes with less impact.

3. Your training

Same as with the running surfaces if you do the same routine over and over again you will stress the same areas of the body time and time again. If you also run the same route all the time then this is even more true.

Bring variety into your running training to reduce the risk of overuse injuries as well as to create adaptation and make progress.

It is worth, and actually important, to keep a running journal where, besides writing down distance and pace, you will note any niggles and pains during the sessions. You can then go back and maybe identify what caused the injury.

It may have been new running shoes, new route, change in speed, distance, too much, too soon and so on.

4. Change and speed

Increasing mileage, frequency or intensity by more than 10% per week can overload a body that’s not prepared for the effort, thus increasing the risk of running related injuries and, of course, knee injuries.

Running too fast while not prepared is another cause for injury. This is common when a runner transitions from distance running to interval running too quickly.

Distance running and interval running are two different types of running all together. Each requires different muscles and, actually, a different body. Just look at Mo Farah – a distance runner vs Usain Bold – sprinter.  Two different body types.

5. Running form

Your knees may hurt from continuous impact on landing and push off. That is why the running techniques we teach, with elements extracted from POSE Method, Chi Running and Natural Running, are meant to re-train your body to land softer, lighter and reduce the push-off – we pull, not push.

Since we’re talking about running technique, let’s talk about how you can address your running form to reduce the pressure on your knees as well as other joints throughout your body

 

a) Poor alignment when running

Alignment literally means arrangement in a straight line. That’s how you want to see and positions your body when you run. But most runners bend from the hips and they form this crocked line.

What’s stronger or more stable 20 bricks on top of each other on a line, or 20 bricks with just on brick sticking out?

A heel striker will bend from the hips even more pronounced because of the way the hip tilts to allow for the heel strike. If you kept your pelvis aligned you wouldn’t be able to comfortably heel strike.

 

b) Running gait – foot turnout

If your feet turn out as you run it can cause knee pain at any distance because it causes the knee to rotate inwards with every foot strike.

Consequently this will overwork the ligaments and tendons in the knee and lead to knee problems and pain.

See a more detailed explanation of a few knee injuries and conditions at point 4 below.

 

c) Heavy heel striking and landing ahead of the body (overstriding)

Pronounced heel strikers are more likely to develop patellofemoral pain syndrome, because impact forces are transferred more aggressively from the foot to the knee with this type of running.

Impact may can cause knee pain and heel strikers experience greater impact shock. However it can also be caused by excessive rotational forces, which come with a heel strike. A heel strike allows for the foot to rotate in either direction until the foot lands and grounds.

When you heel strike you are also probably landing in front of your body, it’s usually the case since you can’t comfortably heel strike if you land under your body/hips. When you land ahead of your body you are essentially breaking your forward momentum, you’re going against gravity, and you pay for it in the long run (no pun intended).

If your foot stops, as it does when you land in front of the body, and the body keeps moving, your knee becomes the transfer point for all the force. It takes more than its share.

Landing ahead of your body with a locked knee or ahead of your body with an over bent knee, both variations put a lot of stress on the knee join, tendons, ligaments and cartilage.

Also landing wide (with a wide space between your feet, wider than the hip width) ahead of the body with a locked knee and ankle can cause ITB (iliotibial band) pain.

You are landing outside your natural hip width (feet are too wide apart when landing), which causes the legs to bow out so you can move forward. This causes too much lateral movement and your hips need to compensate and adjust which stresses the IT band.

To reduce the impact on your knee join all you have to do is to pick up your feet and land under the body by leaning your body from the ankles, or run with your upper body in front of your foot strike (same thing said a different way).

 

d) Downhill running technique

Most think going downhill is actually better or easier than uphill. Think again. While running uphill your muscles burn, which means they take the load – remember muscles are the workers of the body – downhill muscles relax, and your knees take the load.

There is up to 10 times your body weight with each step when running downhill (Source: Danny Dreyer with Catherine Dreyer “Chi Running”)

6. Structures around the knee

Besides running form, shoes and surfaces you run on, another reason you suffer from knee pain may have something to do with the structures around the knees (i.e ligaments, tendons, cartilage, muscles)

 

a) Patellofemoral pain syndrome (PFPS) or anterior knee pain (where it’s usually felt) is a classic and common chronic injury in runners. It accounts for roughly 20% of all running injuries (Source: Ross Rucker and Jonathan Dugas, Runner’s World “The Runner’s Body”)

The cause of anterior knee pain when or after you run can come from structures which are connected to the knee joint, such as muscles, tendons or ligaments.

If any of the structures around the knee pull incorrectly, or exert too much or too little force, the knee cap can be pulled out of alignment or out of line and it doesn’t roll smoothly as it should.

Misalignment can be caused by strength imbalance of the muscles on the inside (adductors) and outside (abductors) of the thigh, for example the gluteus medius which is a stabiliser muscle.

If the knee rolls in as a result of weak inner and outer thigh muscles, the gluteus medius (gluteus minimus can also be included here) and a muscle called vastus medialis obliquus, can’t do their job properly, so the tensor fasciae latae (TLF) takes over.

But if the TFL has to do more than the job it’s supposed to do it can pull on the illiotibial band (ITB), increasing the lateral pull of the knee cap, again pulling the knee out of the alignment.

A lot to take it isn’t it? The body is not formed of separate pieces, it’s a whole unit. Anything that happens anywhere in the body will have a ripple effect throughout the rest of the body.

If you just run for a bus from time to time you don’t need to know these things, although you should, as general knowledge. Most people know more about how their car functions than how their body works. Which is weird, since they’re driving their body 24/7.

However, if you are a runner and you want to continue running for many years to come, it is essential to understand the basics of running mechanics so you understand how to design your training, when to pull back and when to push on. There’s a difference between productive and destructive pain.

Sometimes the best strategy is to rest and be able to run in 2 weeks, than to push on and be off training for 3 months because of the escalating injuries.

Going back to patellofemonral pain syndrome or anteriot knee pain, to  solve this problem you must find out what is causing your knee to roll in, it could be:

  • Overpronation of the foot
  • Inward rotation of the hips
  • Tight calf muscles
  • Weak abductors
  • Tights adductors
  • Weak gluteus medius (that’s part of the abductors actually)
  • Other tight structures around, below or above the knee (see quadriceps at point 7)
  • Other causes

 

b) Iliotibial Band (ITB) Syndrome

The ITB runs down the outside of the leg and is a thickening of the normal fascia that surrounds the thigh.

To give you a short definition, fascia is a thin membrane that connects or attaches every structure, muscle, internal organs.

ITB attaches to the Tensor Fasciae Latae (TFL) at the front of the hip and to part of the gluteus maximus at the back of the hip.

The TFL goes down to the outside edge of the tibia and to the head of the fibula (the 2 bones forming your shin). It also attaches to the patella (knee cap). If there is any tightness or any problem with the TFL your knee will also be affected.

ITB syndrome is the second most common injury in runners. ITBS is usually felt as a localised pain on the outside of the knee when the leg is bent. It’s usually worse going up and down the stairs and running downhill.

ITB pain can be caused by biomechanical alignment problems such as:

  • Bow legs
  • Overpronation
  • Leg length different

ITB pain can also be caused by training, such as running on the camber of the road on the same side of the road for too long, or on a track when you don’t change direction and run the same way all the time. These 2 cases load one leg more than the other.

Another cause of ITBS can be weak hip stabilisers which increase tension on the IT band upon landing .

Patellofemoral pain syndrome (anterior knee pain) is common in runners with ITBS as the internal rotation of the thigh comes with the weak hip stabilisers.

So strengthening the adductors and abductors, as well as the glutes of course, can help both knee pain and IT band pain.

 

c) Patella tendonitis or tendinosis

Tendonitis is an inflammation, while tendinosis is degeneration of the tendon.

This pain is usually at the bottom of the kneecap. Causes of patella tendonitis:

  1. Microtrauma – tiny damage to the tendon fibres
  2. Excessive excrentric overload of the quads – overload while the muscles are lengthening – which can be caused by overpronation again, turning-in of the hips or knees or excessive tightness in the quads.

 

d) Bursitis or Pes Anserinus tendonitis

Problems with this tendon are not as common but they can happen. The cause is usually tight muscles on the inside of the legs, adductors.

Tendonitis happens when the tension on the area is too great, causing inflammation of the tendon and the underlying bursae.

The pes anserinus tendon runs along the inside of the knees and is a combination of the 3 tendons of the sartorius, gracilis and semitendinosus muscles.

The semitendinosus muscle is part of the 3 muscles that form the hamstring. The other two are biceps femoris and semimembranosus.

The actions of the semitendinosus and semimembranosus is extension of the thigh and flexion of the leg, as well as assisting in the internal rotation of the leg at the knee. Problems with these 2 muscles, tightness, trigger points, injury can send pain to the back of the thigh and knee and well as a portion of the calf.

Since we are talking about hamstrings, excessively tightened hamstring muscles can overload the quadriceps, which, in turn, can refer pain to different areas of the knee. Which leads us to…

7. Quadriceps

All four muscles that form the quadriceps attach to the patella (kneecap) through a common tendon via the patellar ligament to the tibia. Well that’s a mouthful.  Just remember the quads attach to the kneecap.

The four quadriceps muscles and pain associated with them:

  1. Rectus femoris – may cause anterior knee pain
  2. Vastus lateralis – pain may be referred to the back of the knee; pain can go all the way up to the hip on the outside of the thigh
  3. Vastus medialis – can refer pain on the front towards the inside of the knee, going up the thigh as well; may cause buckling of the knee
  4. Vastus intermedius – pain over the front of the thigh; no direct knee pain, but it can affect the other muscles which then cause knee pain

Of course the muscle-pain correlation is not isolated. It’s more to give you an idea of which muscle may cause which pain and where you’d feel it. There may be one or more causes of your knee pain, as we’ve seen above.

I added the quadriceps as a separate bullet point because it’s often overlooked by runners as a cause of knee pain.

Many, if not most, runners forget to stretch and massage their thighs and if they suffer from knee pain the cause may not always be a problem like tendonitis or anything structural, it might actually be very tight quadriceps.

That is why stretching is important, among many other reasons. If you do experience any knee pain, you know, at least, you can exclude one of the possible causes.

By the way, you can overload the quadriceps due to excessively tightened hamstring muscles. So stretch those hamstrings and quadriceps.

Sudden overload through misstep or fall can also overload the quads. But this is less of a repetitive running injury, it’s a sort of accident injury. The later can’t always be avoided, no matter how much you train, it’s part of the game.

8. Cartilage problems

The menisci can be damaged or torn by low level twists. There is usually a clicking in the knee, and pain when squatting. The knee may also lock or give way. The pain is usually felt on the inside of the knee with the knee bent.

I have to add I have first-hand experience with the menisci. Since the age of about 12, because of high intensity training in karate during the growth spurt, both my knee menisci damaged (grade 3 damage) to the point where I could barely walk.

Fast forward, natural movement fitness helped re-align, re-adjust and re-educate my body and body mechanics, to the point where today I can run, jump and practice karate without knee pain 95% of the time. The damage is still there, but their pain isn’t, so I dodged the surgery and I’m able to do everything I want without pain.

It all boiled down to perfecting the art of movement. Perfecting is not quite the correct word, there’s no such thing as perfect mechanics, it’s more like fine tuning.

By the way this doesn’t mean you should ignore your doctor. Everything I write in this article and on this website is not meant to replace any medical treatment or specialised advice.

9. Nerve referring pain

This is a very, very complex situation and only an expert can give you any advice here. All I can say is that if you feel pain travelling it may have something to do with the nerves. When a nerve is damaged, trapped or injured in any way it’s not usually localised, it refers pain in another part of the body.

10. Accidents

A twisting injury or a fall can cause damage to the knee’s structure. You should get an immediate diagnosis.

 

All the underlined topics will have their own articles so look out for them.

 

Sources:

  1. Donna Finando and Steven Finando “Trigger Point Therapy”
  2. Sam Murphy and Sarah Connors “Running Well”
  3. Danny Dreyer with Catherine Dreyer “Chi Running”
  4. Nicholas Romanov “POSE Method Of Running”
  5. Nicholas Romanov with Kurt Brungardt “The Running Revolution”
  6. Ross Rucker and Jonathan Dugas, Runner’s World “The Runner’s Body”
  7. Danny Abshire “Natural Running”

Disclaimer: information in this article and on this website is not meant to replace any medical or expect advice; you should always check with your doctor.