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Runners Knee Pain

By: | Tags: | Comments: 0 | February 22nd, 2023

Knee pain is a common complaint for runners. With the London marathon only a couple of months away many individuals have begun their training an it would be unfortunate for anyone to pick up injuries along the way that would force them out of the event.

We previously explored how mobility and strengthening of the ankle joint can significantly reduce the risk of knee pain. Knee pain and injury can originate from dysfunction at the ankle joint, hip joint, or a combination of both. In this post, we will explore how restrictions in movement at the hip joint can lead to knee injuries for runners.

Research has shown that one of the main predictors of injury is individuals with excessive internal rotation and adduction of the hip joint (1, 2, 3). This causes the knees to buckle inwards (see image below). The knee bow position places excessive pressure and wear and tear on the outside of the knee. Research has also indicated that knee bow-in increases the risk of Anterior Cruciate Ligament (ACL) injury.

This position of the knees in the image above, known as knees bow-in is also correlated with weakened gluteal muscles which oppose the knees bowing inwards (4-10). There is also specific research that shows improving gluteal strength reduces knee bow-in and the risk of knee pain during running (11-12).

What causes my knees to bow in?

Muscles which have become tight and restricted in the hip and knee joints due to compensation and daily movement patterns will play a big part. The primary culprits for this are the Tensor Fascia Latae (TFL), Gluteus Minimus, Adductors and Biceps Femoris (Hamstring) muscles. A lack of extensibility of these muscles will drive the knees inwards during motion and restrict optimal movement at the hip and knee.

What can we do?

Step 1: Release Techniques (VIDEO LINK)

TFL on Foam Roller/Ball

This post will focus on the mobility portion of correcting this dysfunction followed by a sequel post on strengthening. The first step in correcting this movement restriction is to use release techniques to address the over-activity in the tight muscles mentioned earlier. We use tools such as foam rollers, massage balls or massage guns (if you have one) to identify small adhesions called trigger points within the muscle. People may know these as ‘knots’.

These trigger points are areas in the muscle that feel tender and irritable when we apply pressure with a tool in those areas. They are small bundles of muscle fibres that have become contracted and act like roadblocks that hold the muscle in a shortened position. If we stretch a muscle without addressing those roadblocks these trigger points will only pull the muscle back to a shortened position. For simplicity, we will focus on the most likely significant muscle contributing to this dysfunction, the TFL muscle.

Step 2: Stretch (VIDEO LINK)

Kneeling Hip Flexor Stretch (TFL Modification)

Once the trigger points have been addressed this removes the ‘roadblocks’ in the muscle. We can now stretch the muscle to return it back to its optimal length without the muscle being pulled back into a shortened position by any trigger points. It is important to hold any stretch at the first point of tension known as the first resistance barrier and not apply excessive tension to the muscle. Once the initial tension diminishes, we can move further into the stretch to find and hold at the next resistance barrier.

Step 3: Activate

Gluteus Maximus Activation

Many individuals make the mistake of only focusing on the mobility portion when trying to correct movement restrictions. Once the mobility portion has been addressed it is essential that we immediately begin strengthening the underactive muscles to restore normal function.

The gluteus maximus is the most significant muscle in the human body. It is the primary hip extensor, an essential motion of daily function. Every stride we take during running the gluteus maximus provides the majority of the force. Additionally, the gluteus maximus is the largest contributor to many functional activities including, jumping, climbing stairs, getting in or out of a chair, squatting or deadlifting. In addition, the gluteus maximus is required to provide a significant amount of force to decelerate and prevent excessive knee valgus during the aforementioned functional activities. The inability to prevent excessive knee vagus has a high correlation with injury to the knee (7) Specifically injury to the anterior cruciate (ACL) and medial cruciate ligaments (MCL). Optimal gluteus maximus activity aids in optimising the amount of tension and positioning of the iliotibial band (ITB) by opposing the force generated on the ITB from the TFL. A short and overactive TFL can effectively pull the ITB tight if there is no counteracting force from the gluteus maximus. This may lead to conditions such as ITB syndrome (runner’s knee).

Gluteus Medius Activation

The gluteus medius is the primary stabiliser of the hip during running. Each time one foot is placed on the ground during each stride the gluteus medius functions to maintain a level pelvis and prevents the pelvis from elevating or ‘hiking’ to one side. This hiking is a sign of gluteus medius weakness as it is unable to adequately stabilise the hip the body shifts to the opposing side in order to compensate. Failure to adequately stabilise the hip joint on the side where the foot is in contact with the ground during running results in excessive knee valgus. The gluteus medius like the gluteus maximus requires adequate strength to decelerate the motions which contributes to knee valgus. 

Round Up

For more information on the techniques discussed in this post or to book an appointment to have your posture and running technique analysed please contact us by emailing reception@shawephysio.com or call us on 01992 451849.

  1. Ireland, M. L., Wilson, J. D., Ballantyne, B. T., & Davis, I. M. (2003) Hip strength in females with and without patellofemoral pain. Journal of Orthopaedic and Sports Physical Therapy, 33, 671-676
  2. Powers, C. M. (2003) The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. Journal of Orthopaedic and Sports Physical Therapy, 33, 639-646
  3. Powers, C. M., Ward, S. R., Fredericson, M., Guillet, M., & Shellock, F. G. (2003) Patellofemoral kinematics during weight-bearing and non-weight-bearing knee extension in persons with lateral subluxation of the patella: a preliminary study. Journal of Orthopaedic and Sports Physical Therapy, 33, 677-685
  4. Smith, J. A., Popovich, J. M., & Kulig, K. (2014). The influence of hip strength on lower limb, pelvis, and trunk kinematics and coordination patterns during walking and hopping in healthy women. Journal of Orthopaedic & Sports Physical Therapy, (Early Access), 1-23.
  5. Mauntel, T., Begalle, R., Cram, T., Frank, B., Hirth, C., Blackburn, T., & Padua, D. (2013). The effects of lower extremity muscle activation and passive range of motion on single leg squat performance. Journal Of Strength And Conditioning Research / National Strength & Conditioning Association27(7), 1813-1823.
  6. Padua, D. A., Bell, D. R., & Clark, M. A. (2012). Neuromuscular characteristics of individuals displaying excessive medial knee displacement. Journal of athletic training47(5), 525
  7. Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., & Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. The American journal of sports medicine33(4), 492-501.
  8. Dos Reis, A. C., Correa, J. C. F., Bley, A. S., Rabelo, N. D. D. A., Fukuda, T. Y., & Lucareli, P. R. G. (2015). Kinematic and Kinetic Analysis of the Single-Leg Triple Hop Test in Women With and Without Patellofemoral Pain. journal of orthopaedic & sports physical therapy, 45(10), 799-807.
  9. Noehren, B., Scholz, J., Davis, I. (2011) The effects of real-time gait retraining on hip kinematics, pain, and function in subjects with patellofemoral pain syndrome. Br Journal of Sports Medicine. 45:691-696
  10. Ireland, ML., Wilson, JD., Ballantyne, BT., Davis, IM. (2003). Hip Strength in Females With and Without Patellofemoral Pain. J Orthop Sports Phys Ther 2003. 33: 671-676
  11. Ramskov, D., Barton, C., Nielsen, R. O., & Rasmussen, S. (2015). High Eccentric Hip Abduction Strength Reduces the Risk of Developing Patellofemoral Pain Among Novice Runners Initiating a Self-Structured Running Program: A 1-Year Observational Study. journal of orthopaedic & sports physical therapy45(3), 153-161
  12. Snyder, K. R., Earl, J. E., O’Connor, K. M., & Ebersole, K. T. (2009). Resistance training is accompanied by increases in hip strength and changes in lower extremity biomechanics during running. Clinical Biomechanics24(1), 26-34