Running with Knee Pain
Hi all,
Just wanted to share why you might have knee pain while running. During my half marathon training this year, I noticed that my knee had been a bit more sore than usual. I wanted to share some of my insights about troubleshooting knee discomfort as both a runner and physiotherapist.
Where Does It Hurt?
This is one of the first questions a lot of physiotherapists will ask to find out what could be causing the pain.
Some common areas of discomfort include:
At the front of the knee
Behind the knee
Inner aspect of the knee
Outer aspect of the knee
Deep inside the knee
Structure of the knee and ligaments
Location allows a physiotherapist to narrow in on the root cause of the injury. We will often look at the joint, muscles, ligaments, and even nerves that travel through that area to help you find the fastest route to recovery. Physiotherapists are trained to know their anatomy and use special tests to determine which part of the knee could be injured.
Do I need Diagnostic Imaging before I come to physiotherapy?
The biggest concern when people with knee pain come in is whether their injury is irreparable or requires surgery. Many people are concerned about what’s happening inside the knee and often ask for imaging first. The options for the knee are an x-ray, ultrasound and MRI. An X-ray can show bone and joint spacing. An ultrasound will show soft tissue which includes the muscle belly, tendons and ligaments. An MRI can show soft tissue, bone, blood vessels and nerves.
Physiotherapy as the First Line of Defence
It’s often a misconception that imaging is necessary and that a physiotherapist needs it to treat the knee. However, imaging is not always necessary to diagnose an issue. There are specific tests that a physiotherapist can complete during your assessment to find the underlying cause and provide exercises to guide you back to recovery.
Ultimately, starting with physiotherapy helps us avoid the potential need for surgery. We want to start with conservative management — if there’s a chance to get your knee better without going under the knife, it reduces the risk of complications such as infection or unsuccessful surgery. Your family doctor will often recommend starting with conservative management for six weeks to see if there’s progress. Your physiotherapist at Break Free can give you an idea of how fast your knee is progressing. Once you’ve given physiotherapy a good shot but nothing is changing, it may be time for imaging and a referral to a specialist.
Anatomy of the Knee
Meniscus
The meniscus is a shock-absorbing structure that cushions your femur and tibia — two of the three long bones that make up your lower leg. It helps lubricate and provide nutrition to the joint when we move our knees. It also protects the surface of the bones that form the joint by absorbing shock and provides stability so that your femur and tibia can move well.
Ligaments
There are multiple ligaments in the knee:
Medial collateral ligament (MCL): inner aspect of the knee
Lateral collateral ligament (LCL): outer portion of the knee
Anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL): inside the knee
A model showing the structure of the knee from the rear with the meniscus and ligaments depicted.
Ligaments are structures that help stabilize the knee joint. They are tight collagenous tissues that prevent excessive movement. The MCL and LCL prevent side-to-side movement, whereas the ACL and PCL prevent shifting of the knee joint forwards and backwards.
Ligaments can be sprained due to sudden changes in direction during running or twisting motions. Collisions with other athletes are also a common reason for ligament sprains. Ligaments often need rest, followed by progressive loading to strengthen the knee.
Knee Cap
Your knee cap can also cause pain, which may feel like discomfort at the top or underneath the knee cap. It can cause clicking or a popping sensation as you go down stairs and may worsen when your knee is bent. Tight muscles in the front of the leg can increase tension on the knee cap, leading to pain and clicking. Muscular imbalances around your hip and ankle can also contribute.
It’s possible to dislocate or sublux the joint, which increases the chance of reinjury and causes instability. An assessment can determine which muscles are weak to help decrease the chances of pain or clicking.
Model depicting the knee cap in flexion
Is clicking a sign of a serious problem?
Clicking is not a sign of something serious. If there is pain associated with a click, it is important to let your physiotherapist or doctor know. Your health care practitioner will ask detailed questions to help determine if more testing needs to be completed. In some cases, weak muscle groups can lead to poor tracking of the patella leading to something called crepitus - this is the popping, clicking and cracking sound you hear when you bend your knee. I have had some clients who were able to strengthen their knees so that their knee-cap stopped clicking or popping. However this is not always guaranteed depending on how long the injury has been around for.
Pes Anserine
A group of muscles known as the pes anserine attach to the inside of the knee just below the joint line. This includes the sartorius, gracilis, and semitendinosus — three muscles that help support the knee and hip. These muscles can be weak or overused, leading to sensitivity on the inside of the knee.
Bursa
Bursae are fluid-filled sacs that act as anti-friction pads between muscles and bones. Muscular imbalance or overuse can increase friction in these areas, leading to inflammation, swelling, and pain.
Nerve from the Back
According to a 2019 study, 25% of knee problems can originate from the back as referred pain from the spine. Nerves exiting your back can affect the muscles that move your knee. Your physiotherapist at Break Free is skilled at identifying whether this is the main cause or a contributing factor. They will complete a lumbar spine screen to determine if the nerves in your lower back are involved.
Pain with Running
There are many factors that come into play when discussing knee pain. Running is a full-body movement, and many contributing parts are involved. When I was running this year, I completed a half-marathon and duathlon - both of these require heavy utilization of your legs. As a result, I developed pain on the inner aspect of my left knee. After my races, I had to take some time to recover and revamp my exercise program to ensure I was not causing more harm to my knees.
A Full-Body Approach
At Break Free Physiotherapy, our focus is to look at the body as a whole system.
Here are some areas of your body that can contribute to injuries during running:
Shoulder mobility
Strength of key shoulder muscles
Trunk strength
Lower back mobility
Hip mobility
Hip strength and endurance
Knee range of motion
Muscular strength around the knee
Ankle mobility
Endurance and strength of muscles that attach to the ankle
Foot strength and endurance
Running requires your knee to propel your body forward using many muscles. Your shoulder, trunk, hip, and ankle muscles all work together to coordinate this complex movement. If certain muscles in any of these areas are tight, weak or painful, you may develop knee pain. Your physiotherapist at Break Free is skilled at identifying what your body needs to run farther and faster.
Shoes
Shoes are important — and also a grey area. In today’s world of endless options, it’s easy to feel anxious and fatigued when trying to find the right pair. I know the pressure of choosing a shoe that won’t cause pain or waste money is real.
Some simple tips to help you with shoe hunting:
Shoes come in many shapes and styles. If you’re having trouble deciding which is best for you, speak with your Physiotherapist!
Bring an older pair of shoes that have worked for you and bring them to the shoe store
Wear new shoes around the house or on a treadmill before committing
Bring your shoes to your physiotherapist so they can assess your running on a treadmill
There should be half to a full thumb width of space at the front of the shoe
Your shoes can be snug, but not so much that you are getting tingling - your feet swell later in the day
Running in shoes versus walking in shoes can feel very different - pick shoes that are suited for your activity
Shoes Aren’t the Only Thing
In my own running journey, I’ve found that sometimes the shoes weren’t the issue — it was the strength of my body. Depending on the shoe, it can make certain muscles work harder.
Many shoes now feature maximal cushioning, leading to a taller stack height and higher heel drop. That means more material under your feet and a greater difference between the heel and forefoot. This shifts stress to different muscles. If you’re weak in a certain area of your body and the shoe either accommodates or demands more from that muscle, injuries can develop.
For example, a shoe with a lower heel drop (e.g., 6mm) may encourage forefoot striking, which uses more of your calf, shin, and foot muscles. A higher heel drop (e.g., 10mm) engages more of your quadriceps, hamstrings, and glutes.
Keep in mind that everyone’s body is different. An assessment can help account for variability in your body, strike pattern, and other factors.
Your Lower Back
If you’ve read my blogs, you’ll hear this a lot: What about your back?
An irritated nerve root in your lower back can contribute to subtle changes in your lower extremities. If you have a sitting job or frequently bend forward, this can lead to a lower back issue that affects your running. For example, I’ve found that a compressed or irritated nerve can cause odd muscular imbalances — even in people who cross-train regularly. By identifying these back-related weaknesses, your strength training becomes much more effective.
I’ve spent 11 years of my career learning about these strange patterns and have passed that knowledge on to our staff at Break Free. Our physiotherapists are great at finding tricky injuries that don’t improve with conventional internet exercises.
Training Load
Going too far, too fast? I did something silly and signed up last-minute for a duathlon with my friend Tolu: a 2.5km run, followed by a 30km bike ride, and a 7km run to the finish. I finished — but paid for it later. I still have a young man’s mind in an older body.
It’s important to work up to something gradually rather than diving into the deep end. With proper, progressive training and a good cross-training routine, you’re more likely to reach your goal and enjoy the process.
Injured? Try Active Rest
Just because your knee is injured doesn’t mean you can’t train in other ways. You may need to temporarily reduce your running distance or take a break, but you can still maintain fitness and come back stronger. Consider these alternatives:
Swimming
Strength training using weights or resistance bands
Low-intensity cycling
Walking and light hikes
Elliptical
Yoga to improve mobility
Swimming can be a great way to stay active while limiting use of an injury.
Rather than going through cyclical better to worse phases with your injury, you want a natural straight curve towards your goal. Consider other forms of activity to help you get back to what you love.
Come see us!
If you are still unsure on whether physiotherapy is right for you, try reading more of our blogs here or send us a note to ask a question. There is a lot of information about injuries you can look up. Ultimately we want to help people find freedom through movement to avoid medications and surgery. Our goal is to empower you and give you tools so your body can naturally heal.
I hope that you get to meet our lovely team to learn more about your body and how to get better and stronger.
My Yearly Half Marathon Report
Every year I will post about a race I’ve done to remind myself not to take the health of my body for granted. I had a back injury that worsened to a point where I couldn’t stand without tingling and numbness in my left leg. You can read more about that journey here. But since then, I’ve recovered well and continue to offer help to anyone who is having back pain.
This year I did the Springbank Half-Marathon as it would have been hard to go somewhere else because our son Levi was 5 months at the time. It was really fun as Asher, my oldest son, was able to run across the finish line with me. The weather was great and I ran it with friends and family. Here are some pictures and my time.
Springbank Half Marathon
Time: 1:51:57
Pace: 5:19min/km
Corey and his family after the race
Corey and his running companion Tolu pose for a quick picture!
Corey, his sister, with friends and family celebrating after the race.
Corey Kim
Physiotherapist
Hey, my name is Corey, and I’m a co-owner of Break Free Physiotherapy and Wellness. I was born in Seoul, South Korea but grew up in London, Ontario. I finished both my Bachelor of Arts in Kinesiology and Master of Physical Therapy degrees at Western University. I’m passionate about helping people find pain relief through movement and believe in self-empowerment by sharing knowledge of the human body and its ability to heal. [full bio]
