Running and Knee Health: Recent Reports

– Derek M. Hansen – January 18, 2010

Once in a while, some of the major media outlets actually publish some interesting articles on the topic of exercise. Those of us that tire of reading headlines about the “Top 10 Exercises for Body Sculpting” or “How to Run Off that Spare Tire” are shocked when we see an article that can be of use to the general public. Time Magazine recently published an article by Adi Narayan titled “Is Running Bad for Your Knees? Maybe Not”.

In the Time article, Narayan initially presents the commonly held belief that excessive running is hard on your knees and can lead to osteoarthritis in later years. Procedures such as knee replacements or joint resurfacings seem more and more common amongst middle-aged adults and not just the elderly population. However, more recent research has shown that people who run regularly, even those that train vigorously, are at no greater risk for arthritis than those who do not run. In fact, study findings out of Australia suggested, “that people who exercised vigorously had thicker and healthier knee cartilage compared with their sedentary peers.” Narayan goes on to point out the fact that “arthritis is caused mainly by genes and risk factors like obesity (obese men and women are at least four times more likely to become arthritic than their thinner peers), rather than daily exercise or ‘wear and tear’ of joints.”

The article also includes a discussion of strategies to minimize running related injuries such as stress fractures. One suggestion was for runners to reduce their stride length (and, hence, air time) and increase stride frequency to reduce the braking forces created by landing out in front of their center of mass. Another suggestion was to simply minimize long periods of time away from running in an effort to keep the body in shape to absorb the ground forces associated with running. During the winter, when running outside is not an option for many people, the article suggests alternative means of maintaining activity such as treadmill running and indoor stair running. Thus, when the warmer weather does return, the body is not presented with the shock of hitting the pavement again.

I enjoyed the article for the simple fact that it presented some common sense information that all runners pretty much knew already but were afraid to boast about. Running can be one of the most basic means of getting the body in shape and staying healthy. We all know that running can be carried out in a manner that is unhealthy and destructive. However, many of the individuals who are running themselves into the ground are driven by behavioral problems (such as obsessive compulsive disorders) that make them exercise excessively. Running isn’t hurting people… people are hurting people.

I do have to include some general principles as part of my own article to give people something to think about when trying to avoid the pitfalls of running and associated knee problems. When performed properly, running is a great way to inexpensively improve and maintain personal fitness. However, common sense does not always prevail when people are in charge of their own health and well-being. This is where the unnecessary injuries become problematic, particularly for hips, knees, shins, ankles and feet. In general, many of the principles I have provided below apply to overall knee health for both athletes and the recreational fitness population.


1. Do not run through the pain.

I can’t even count how many times I’ve heard people say, “Well my knee problem started with a little pain on the outside of the knee and eventually led to it swelling up every time I run. Now I can’t even run.” Unless you are playing American football at the college or pro level, or competing in a combative sport such as boxing, mixed martial arts or amateur wrestling, you are not tough. Let’s face it. Having worked with all of these types of athletes and seeing what they go through week in and week out, I have come to the conclusion that I am also not tough. While their careers depend on the ability to fight through incredible pain and injury, the rest of us can take the time to listen to our bodies and take the necessary steps to rest and recover. So, do not try to tough it out. Running through pain can only lead to further problems in the form of inflammation, degeneration and compensation.


2. Keep your hips loose and limber.

A good majority of knee pain originates with tightness and poor mobility in the hips and glutes. Tight hips can create greater tension along the iliotibial tract leading to pain and irritation in and around the knee joint. High volumes of running can put greater impact stresses on the hip joint, leading to higher muscle tone and greater tension in the muscles around the hip. Simple passive static stretches for the glutes and piriformis can relieve a lot of the tightness in the hip joint and accordingly take stress off the knees. Additionally, massage of the gluteal muscles can help to reduce hip tension and knee pain.


3. Maintain supple quadriceps, calves and hamstrings.

All of the muscles around the knee joint must be kept supple and available for recruitment. If any of these muscles are knotted up and not firing properly, the knee will not be properly supported. As with the muscles of the hip, the muscles around the knee must be kept supple through static stretching and massage. When athletes report knee pain to me during training, a quick assessment typically reveals that they have a combination of quadriceps tightness and/or hamstring tightness. When I perform a simple light pass over these muscles with the palm of my hand or my thumb, the athletes often find it incredibly painful. It quickly raises their awareness of the causes behind the pain and a prescription of light static stretches and massage usually relieves the discomfort.


4. Choose softer surfaces for your running activities.

Heavy impacts on hard surfaces can not only create trauma within the knee joint, but also tighten up key muscles around the knee and hip. Where possible, avoid concrete and asphalt surfaces for longer runs. If you run several times per week, at least try to mix up your surfaces each day to give your body a break. Anything from sand to grass to wood chip trail will give your legs a break, while working on strengthening of the feet, ankles and knees.


5. Limit running downhill to a minimum.

Many recreational athletes love running on mountainside trails with varied terrain. While running uphill can be a good workout, running downhill can not only be hazardous, it can significantly multiply the impact forces on each stride. If you insist on running downhill, take it slow and easy. Additionally, maintain a higher stride frequency to reduce impact forces and keep a better grip on the terrain (as with anti-lock brakes). A cautious approach to downhill running is the best option, particularly on hard surfaces and steep grades.


6. If you are overweight, keep running distances and durations short and intermittent.

One of the most painful things to watch is how the trainers in “The Biggest Loser” have excessively obese individuals running on pavement as part of their training. The risk of damage to connective tissue and joint surfaces is much greater for for overweight individuals when running and performing high impact activities than for less heavy exercisers. While running is one of the more effective ways to burn calories, walking or working on a stationary bike is the best ways to introduce exercise to overweight individuals.


7. Choose running shoes that are appropriate for the surface on which you predominantly train.

Shoes that are too stiff or hard do not provide enough cushioning and flexibility. Shoes that are too soft can sometimes provide inadequate support. Unstable footwear can cause the muscles and tendons in the feet and lower legs to stiffen too much, resulting in harder impacts to the knees and hips. Obviously comfort is very important when purchasing a pair of running shoes. However, be aware of the types of shoes you are choosing (i.e. support vs. cushioning) and how your body is reacting to the shoes over their lifespan. Softer shoes may initially feel good, but over the long term may lead to more leg pain due to lack of support.


8. Don’t get caught up in the wonder cures of orthotics, knee braces and knee sleeves until the problem has been properly diagnosed.

People love to buy equipment to solve their ills. However, I would stress that you comprehensively examine all of your symptoms and running habits before you resort to orthotics or bracing devices. I see too many runners hobbling along with knee braces, but no one has taken the time to correct their poor running technique. Is this type of equipment bad? Absolutely not. In many cases I believe orthotics and braces are simply ill prescribed or overly prescribed. If you have taken the time to evaluate the situation and the appropriate sports medicine professionals have recommended that orthotics or braces are required, then go ahead and buy the gear. Hyper-mobility of the knee joint can be aided by a well-fitted brace. Knee sleeves can keep the joint warm, offsetting possible discomfort. And, orthotics can address foot-strike and alignment issues that may not be improved through physical therapy alone. Hopefully these types of equipment perform as advertised, reducing knee pain and improving your overall running experience.


9. Use anti-inflammatory medications sparingly and strategically.

Popping pills has always been a convenient remedy for the modern athlete. While I am personally not predisposed to using medications, I can say that strategic use of some anti-inflammatory medication can help to get you through some rough spots in your rehabilitation. Pain and inflammation has a sinister way of perpetuating the problem. Inflammation and fluid in the knee can impair proper muscle function in the vastus medialis portion of the quadriceps muscles. Pain can also lead to compensatory muscle firing patterns that perpetuate the problem. Appropriate use of certain medications – in coordination with many of the other strategies mentioned above – can help to get you over the hump and onto progressively better results in your rehabilitation.


10. Work on running technique and appropriate stride length.

As always, I have to include a recommendation on improving your running technique. As mentioned in the Time article by Adi Narayan, increasing stride frequency can reduce impact forces and the possibility of leg soreness and injury. Higher frequency striding will keep your foot-strike closer to a position directly under your center of mass, thereby reducing the braking forces of heel striking. It should direct forces to the mid-foot or forefoot, as opposed to on the heel which has less shock-absorption properties.


It is nice to read that running isn’t the primary cause of knee degeneration. I would hate to see running removed from our menu of safe and inexpensive activities for improving and maintaining health and fitness. For those of you who may be more predisposed to osteoarthritis, I would suggest that you follow all, if not several, of the recommendations provided above. As with automobiles, regular care and maintenance goes a long way to extending the life of its various parts and components.