Strength exercises are crucial in managing runner’s knee pain, also known as patellofemoral pain syndrome. This condition is often caused by muscle imbalances, poor flexibility, and over-training, for example a rapid increase in running volume or intensity. By targeting specific muscles around the knee and hip to increase their strength, exercise can not only alleviate the pain but also enhance knee stability, reduce your risk of future problems, and improve running performance.
Incorporating strength training into your routine can significantly reduce knee pain due to running, and reduce your risk of future injuries. Exercises such as lunges, step-ups, and single-leg squat variations are highly effective in strengthening the muscles surrounding your hip and knee. Additionally, improving flexibility and mobility through stretching or using a mobility aid, for example a foam roller, trigger-point ball or massage gun, can improve your running mechanics.
Combining strength exercises with proper running technique and following the right running training program provides a comprehensive and effective approach to managing and preventing patellofemoral pain syndrome. Implementing these changes into your running training will keep you running pain-free for longer and enable you to minimise your risk of runner’s knee while improving your running performance.
Treatment For Runner’s Knee – Key Takeaways
- Strengthening exercises are essential for managing runner’s knee pain, and increasing the strength in both the knee and the hip muscles is more effective than knee strengthening alone
- Incorporate flexibility and mobility exercises as needed to allow improved biomechanics
- Proper running technique, following an appropriate running training program, and allowing adequate rest and recovery are also important for effective long-term management of runner’s knee pain
Anatomy of Runner’s Knee
Runner’s knee, or patellofemoral pain, is a common injury affecting many athletes. Understanding the key structures involved and how they function can help you understand and manage your pain, and help minimise your risk of future problems.
Knee Structure and Function
The knee joint consists of the kneecap, or patella, which rests on the front of the femur (thigh bone). The femur sits on top of the tibia, the shin bone, forming the main knee joint. The patella functions to protect the knee and improve the leverage of the quadriceps, the muscles in the front of the thigh, helping them to act more strongly across the knee joint.
Runner’s knee, or patellofemoral pain, is where pain is felt behind or around the kneecap. It often results from improper “tracking” of the patella, causing irritation. Tracking refers to how the kneecap moves up and down on the front of the femur. The quadriceps muscles play a crucial role in maintaining correct patella tracking, stabilising the knee and ensuring smooth movement of the patella. Weak quadriceps can exacerbate knee problems by allowing patella “mal-tracking”, i.e. where the patella doe not keep in correct alignment on the front of the femur. Strengthening the quadriceps muscles can significantly improve patella tracking and reduce pain.
The gluteal muscles, i.e. your butt muscles, also play a vital role in lower limb biomechanics, including knee mechanics and alignment. These muscles help stabilise the hip and pelvis during movement, for example when running they help stabilise your pelvis as you land on one leg and swing the other leg through. Weakness in the glutes can lead to poor movement control in the knee, increasing your risk of knee pain as well as many other common running injuries.
The gluteal muscles, i.e. your butt muscles, also play a vital role in lower limb biomechanics, including knee mechanics and alignment. These muscles help stabilise the hip and pelvis during movement, for example when running they help stabilise your pelvis as you land on one leg and swing the other leg through. Weakness in the glutes can lead to poor movement control in the knee, increasing your risk of knee pain as well as many other common running injuries.
Research Into Strength Exercises For Runner’s Knee Pain
Recent research suggests that combining hip and knee strengthening is the most effective in reducing pain and improving activity levels in individuals with patellofemoral pain (runner’s knee). Strengthening both the hip and knee muscles is more effective than strengthening the knee muscles alone. Strengthening the hips helps in maintaining proper overall lower limb alignment and movement control during activities, including running, and this is helps improve overall knee and patellofemoral joint mechanics and function.
Identifying and Addressing Muscle Imbalances
Recognising and correcting muscle imbalances is key for runners dealing with knee/patellofemoral pain. These imbalances may include strength imbalances as well as length and mobility issues. Identifying these imbalances is a critical first step in the process of developing an effective management plan, because it allows targeted exercises to be prescribed to restore correct muscles strength and length.
Role of Muscle Strength In Runner’s Knee Pain
Strong muscles support joints, provide stability and maintain correct movement mechanics. Key muscles for runner’s knee pain include the glutes, quads, hamstrings, and hip flexors. When these muscles are not equally strong, it can cause imbalances. It is worth noting that the calf muscles are also a critically important muscle group for distance runners in general. So, although they are not directly linked to runner’s knee pain, runners should always include calf strength in their program to help their running performance as well as reduce their risk of many running injuries.
Weak glutes can lead to overcompensation by other muscles, such as the hamstrings or TFL (tensor fascia lata, a muscle on the outside of your hip that attaches to your ITB). Weak glutes are also common in people who have tight hip flexors. These imbalances and compensations, over time, can lead to abnormal lower limb mechanics and mal-tracking of the patella, resulting in runner’s knee pain.
The patella (kneecap) is actually located within the tendon of the quadriceps (quads) muscles at the front of the thigh. This means that quads weakness or imbalance can significantly affect patella tracking and lead to patellofemoral/runner’s knee pain. We used to think that strengthening the quads muscles alone was the main focus of strength exercise for runner’s knee pain however, we now know that it is important to also target the hip and pelvis muscles for the most effective management.
Importance of Muscle Balance and Co-ordination For Runners
Muscle balance is about ensuring that different muscle groups have enough length and strength to allow them to work together and produce efficient and controlled movement. But that’s not the whole story! You also need to make correct use of the available length and strength of different muscles during movement. Put simply, it’s no good having enough length and strength in muscles if your brain doesn’t co-ordinate them together correctly.
Co-ordination or “motor control” is critical for correct movement, for example is achieving an efficient and economical running style. Think of it like a “movement habit”. If you’ve been running (or doing many other types of movement) in a certain way for years, your brain will have developed specific and very ingrained nerve firing patterns to recruit muscles to produce the movement in that way. So if you suddenly increase the length or strength of a muscle but don’t change the way your brain sends signals through your nerves to engage the muscles, there will often be little or no change in the way you move.
So, for the most effective management programs for runner’s knee (and many other running-related injuries), we need to restore muscle balance (length and strength) and also train your brain to use your muscles to produce more effective and economical movement. This means that as well as strengthening muscles in isolation, for example specific quads or glute strength exercises, we also need to be doing more functional or movement-specific drills. For runners this might include single-leg squat variations, which help co-ordinate muscles working together to keep stable with only one foot on the ground, and/or running coaching which improves your running gait economy and efficiency.
Essential Strength Exercises for Runner’s Knee Pain
For runners experiencing knee pain, focused strengthening exercises are effective in relieving pain, improving stability and helping you get back into training. Concentrating on the quadriceps, glutes, hamstring and calf muscles can make a significant difference in managing knee pain. These strength exercises are also effective in reducing your risk of future injury and improving your running performance. As well as strengthening specific muscle groups, your program should also include more functional exercises, for example squat variations and running-specific drills. This ensures that once you build strength you actually use that strength to improve your movement control and running gait.
There are way too many strength exercise options available to go through in this post. A few of the more common entry-level exercises that we use with runner’s knee pain are shown below. Generally start with 3 sets of 8-10 reps, performed 2-3 times per week. But remember that personalisation is the key, i.e. you need to get on the right program for you. This means your strength training should be based on an initial assessment that looks at your;
- strength and flexibility
- movement control and co-ordination
- current injury and symptom level
- injury history
- strength training experience
- running goals
- access to weights and time able to be committed to your training
Quadriceps (Quads) Strengthening
The quadriceps are vital for knee stability, and they are one of the most important muscles to strengthen for runners with knee pain. Squats and lunges are often effective for this muscle group.
Squats:
- Stand with feet shoulder-width apart. Use a weight that is challenging but able to be done with full range and correct form.
- Lower your body using a squatting motion, as if sitting in a chair, keeping knees over the middle of your feet – don’t let your knees roll inwards
- Hold for a few seconds, then return to standing
Lunges:
- Step forward with one leg, bend both knees until the back knee is just above the floor. Keep front knee over the middle of your feet – don’t let it roll inwards.
- Push through the front heel to stand back up
- Add weight as you can.
Hip and Glutes (Gluteal) Strengthening
Strong hips and glutes mean better knee overall leg mechanics and knee support, which are essential for runners. Good initial exercises to try are hip bridges and clamshells.
Hip Bridges:
- Lie on your back with knees bent, feet flat on the floor
- Lift hips towards the ceiling, squeezing the glutes (i.e. your butt muscles). Try to get your hips fully straight but don’t arch your back.
- Hold for a few seconds then Lower back down and repeat
Clamshells:
- Lie on your side with knees bent at a 90-degree angle.
- Keep feet together, lift the top knee towards the ceiling. Keep your pelvis vertical – don’t let it roll backwards as you lift your top leg.
- Hold for a few seconds, then lower back and repeat.
Calf Strengthening for Runners
Your calf muscles play a crucial role in middle and long distance running, for example marathons. We need to remember that we have two separate muscles that make up our “calf muscle” group – your gastroc and your soleus muscles. This is important because although they work closely together, we need to train them a little differently to ensure we improve strength in both muscles. Straight-knee and bent-knee single leg calf raises are usually a good place to start.
Single Leg Calf Raises – Straight Knee
- Stand on one leg with that knee straight, using a wall for balance
- Slowly rise onto the balls of your feet, pushing through your big toe as much as possible
- Hold for a few seconds, then lower back down under control
- As you feel stronger you can start adding weight by holding a dumbbell or other weight in the same hand as the leg you are standing on
Single Leg Calf Raises – Bent Knee
- This exercise is the same as the straight-knee version excpet that you keep your knee bent to about 40 degrees throughout the whole exercise
- Stand on one leg with that knee bent to about 40 degrees, using a wall for balance
- Slowly rise onto the balls of your feet, pushing through your big toe as much as possible
- Hold for a few seconds, then lower back down under control
- As you feel stronger you can start adding weight by holding a dumbbell or other weight in the same hand as the leg you are standing on
By consistently doing these targeted strengthening exercises, runners can reduce knee pain and improve their overall leg strength. However, please remember that these are just a small selection of lower-level strength exercises, and they shouldn’t cause significant pain while you do them. We always recommend having a proper assessment if you are feeling knee pain when you run, to ensure that you get on the right strength program that will be safe as well as effective for your particular condition. For more information you can read our blog post on strength training for marathon runners or email us a question.
Optimising Running Technique To Improve Runner’s Knee Pain
As well as working on your strength, improving running technique can also help reduce knee pain and enhance running performance. This is especially helpful if your knee pain is not resolving with just doing strength exercises, if it keeps coming back, or it feels like it will only let you run a certain mileage but then gets sore again if you try to increase your training.
Having a treadmill-based running assessment using video analysis is a great starting point because it allows you to breakdown your running gait and identify areas of weakness, tightness or poor movement mechanics. Once you have identified these issues, working with a running physio or coach will allow you to correct them and achieve long-term improved running performance with less risk of injury.
Assessing Your Running Gait
Evaluating running gait involves analysing how a person moves while running. This process identifies improper movements that can cause overuse injuries. Common issues include overstriding, a cross-over gait, excessive contra-lateral hip drop, knee valgus (rolling in), excessive vertical oscillation, heavy heel striking, and improper arm swing.
A running gait analysis is best performed on a treadmill. Your running physio or coach will use video recordings to record your running form the side and from the back. Using video allows the footage to be slowed down, replayed, and paused, meaning that poor movement mechanics can be clearly identified. Once we can see how you run, we can then dig down to work out what can be causing any technique problems. For example are they due to a lack of muscle strength or length, or are they purely down to co-ordination (motor control) issues.
Identifying the underlying cause of any running gait problems is essential because it changes the focus of your management program. If they are due to specific muscle weakness then strength exercises are likely form the foundation of your initial program. Similarly, if they are due to muscle tightness then mobility drills or stretching may be the primary focus. However, if on specific testing you have adequate strength and length to run with good form, then the issue may be purely down to co-ordination or motor control problems, in which case technique coaching and movement-specific drills to improve your mechanics will be more effective. You can read more about having a running gait assessment at Central Performance.
Strategy for Rest and Recovery For Runner’s Knee Pain
Balancing rest and active recovery is essential to manage runner’s knee. It’s crucial to understand the importance of giving the knee adequate time to heal and utilising effective recovery techniques to promote better outcomes.
The Importance of Adequate Rest
Adequate rest is pivotal in recovery from runner’s knee, as it allows the tissues to heal and reduces inflammation caused by overuse. Reducing running mileage may be required to allow things to settle, then you can gradually build up again. In some more painful cases a complete rest from running may be required, although we try to avoid this whenever possible. If you have to reduce or stop running for a time, then cross-training is important to help maintain your overall strength and fitness.
During rest days, you can usually still engage in low-impact activities like swimming or cycling. These activities maintain fitness without putting significant stress on the knees. This strategy helps keep muscles active and engaged, which helps when you are able to return to running and build up your volume again.
Recovery Techniques For Knee Pain
One of the simplest but most under-appreciated recovery factors is sleep. Sleep is when the body repairs itself, and skimping on it can slow down recovery. Aim for at least 7-9 hours of quality sleep per night to facilitate healing. Similar to sleep, eating a healthy balanced diet also is a big factor in promoting healing that is often neglected by recreational runners.
If tightness or stiffness is contributing to your knee pain then keeping up a regular stretching and mobility routine can be helpful. While we generally find that strength (or weakness) is a bigger factor in runner’s knee pain than tightness, in some cases increasing flexibility is very beneficial. The muscle groups we often target include the quads, hip flexors, hamstrings and piriformis/glutes.
Physio For Runner’s Knee – Central Performance Sydney / Surry Hills
A dedicated running physiotherapist can give you a fast diagnosis of your knee pain, then expert advice and a tailored treatment plan to get you back on track. The Central Performance Sydney Running Centre provides everything a runner needs, from acute injury management and running gait assessments, through to personalised strength and conditioning programs for runners. We also work with some of the best sports physicians and imaging centres, so if you need further investigations we can get these organised quickly for you. Click below for more information, to ask a question, or to book a physio appointment online.
Runner’s Knee Pain – Frequently Asked Questions
Runners often have questions about how to treat and prevent knee pain. This section covers exercises, targeted muscle strengthening, and physio techniques to help keep knees strong and healthy.
What are the best knee strengthening exercises to perform at home for runners?
Some of the best early-stage exercises include squat and lunge variations, step-ups, bridges and clam shells. All exercises should be performed with correct form and at a slow controlled speed. Once you are feeling comfortable doing 3 sets of 8-10 reps of these you can progress by adding weights. However, these are only introductory exercises and you should also progress to more challenging exercises when you feel ready. Also, personalisation is key, so having a proper assessment with a running physio is really helpful to ensure you follow the correct strength program.
Which muscles should be targeted to prevent or manage runner’s knee?
Focusing on the quadriceps, glutes, calf muscles and hamstrings is usually important for runner’s knee pain. Strong hip and pelvis muscles help improve overall lower limb biomechanics, stability and movement control while running. Quads strength is vital for maintaining correct patella alignment (patella tracking), and strong calves have been shown to be important for many reasons in distance running.
Can strength training help relieve runner’s knee pain, and if so, how?
Yes, strength training is a major part of most programs used to manage knee pain in runners. Building strength helps by improving your biomechanics and running gait, supporting your knee and patellofemoral joint alignment/tracking, and helping stabilise your pelvis, hip and lower limb during your running gait.
Should I stop running if my knee hurts?
Reducing your running volume and/or intensity is often required early-on to allow runner’s knee pain to settle. However, we try not to stop clients running completely, although this is sometimes required in more advanced or severe cases. Generally, running with a small-moderate amount of pain is still ok, as long as it settles fairly quickly after your run and you don’t feel that it is changing your running gait or getting too sharp. As you improve you can gradually increase your running volume and intensity again.
How can I reduce the risk of getting runner’s knee pain?
Consistent strength training and following the right running training program, one that increases your running gradually at a pace that your body can adapt to, are the two most effective ways to reduce your risk of getting knee pain with running. Having your running gait assessed and improved can also be very helpful, especially for persistent or recurrent pain. Other things you can do may include mobility/flexibility exercises, doing proper warm-ups and cool-downs, maintain a healthy weight, get enough sleep and eat a healthy balanced diet.
