Bodyworks: Runner's Knee

How to recognise it, how to overcome it

by Patrick Milroy

The knee is basically a hinge joint, allowing backwards and forwards motion, but it is also able to rotate slightly in on itself. The bending and straightening is controlled by the hamstring and quadriceps muscles at the back and front of the thigh bone respectively, and their size and position affects the angles the legs move at, and particularly the way that the patella (kneecap) moves. Your anatomy and the patterns of your muscle use determine many of the injuries you will suffer.

‘Runner’s knee’ used to be known as chondromalacia patellae, but is now more often referred to as patello-femoral pain (PFP). It occurs when the patella fails to move smoothly and centrally through the femoral groove at the lower end of the thigh bones. This is sometimes due to muscle imbalance or abnormal anatomy, but it can also be the result of another injury which causes you to favour one leg in some way.

You’ll either suffer a persistent ache in the kneecap, which worsens with certain exercise, or you’ll feel a sudden, stabbing pain in the knee while running, which eases off when you rest. Sitting with your knees bent prior to a race can make things worse, as can running on hills or hard surfaces.

Despite the acute pain, your joint may look normal. Your knee may swell up, but this is more often due to other knee problems, such as a bursa or Hoffa’s syndrome, in which the fatty pads around the patella become swollen. You will probably have wasted inner quadriceps muscles (the vastus medialis), knock knees (genu valgum), overpronation, flattened longitudinal arches or a twisted tibia. More women suffer from the problem than men, and it often occurs in people with jobs which involve lots of sitting with knees bent.

Your doctor may try Clarke’s test, in which they’ll pull the kneecap towards your toes while inviting you to gently straighten your knee. You’ll feel pain; they’ll feel a roughness or grating as the uneven rear surface of the patella moves through the femoral groove. The doctor will also want to look at the wear of your running shoes.

Medical investigations
Sophisticated tests aren’t normally required. A ‘sunrise’ x-ray of the flexed knee will show if your patella is abnormal, roughened or displaced, and there is little need for scans. As many cases are the result of anatomical variations, having your running gait analysed may enable appropriate corrections to be made to alleviate the problem.

What else could it be?
While primary PFP is simply that, there may well be other influences. Disruption of the ligaments within and outside of your knee, arthritis in its many forms and ankle, shin, thigh and hip injuries may all affect knee movement and produce secondary PFP.

One factor in knee pain may be an inability to lock out the knee. Trying to do so stimulates the inner quadriceps muscles which strengthen and pull the patella straight. In most cases, little harm comes from performing this exercise, however it can make PFP worse if there is an imbalance in your quadriceps muscles and you perform knee extensions on a machine. You will therefore need to perform straight-leg exercises. Change your shoes if they have become worn, and correct any biomechanical abnormalities with orthoses or other appropriate aids.

Medical treatment
Thankfully, steroid injections and surgery aren’t often used to treat PFP. Some physiotherapists successfully tape the patella, drawing it back towards the mid-line, and can teach you how to do this yourself. Knee supports may effectively shift your patella towards the middle, but probably at some biomechanical cost which may itself cause injury. If our maker had wanted us to use knee supports, we would have been born with them. In fact, he did and we have; we have just forgotten how to develop and use them. Other forms of physiotherapy will ease PFP, but controlled exercises form the mainstay of treatment.

Can you run through it?/Recovery time
Within certain limits, the more you do the correct knee-strengthening exercises, the quicker your recovery will be. As for running through it, masochists will have no problem, though probably at the ultimate cost of a worn patella, potential arthritis and other injuries through favouring the limb. Treating the injury makes a lot more sense in the long run.

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Discuss this article

Hi, All
Question on knee pain,
pain upon foot stike in the small hollow just below my left knee.
Have just upped milage.
Anyone else had this?
Advice please!
Posted: 14/08/2002 at 20:49

Sounds like something similar which happened to me too and the same knee! I just kept off it for a week then slowly jogged shorter distances for a week then it was sorted.After two weeks I could run normally again and increased the mileage more slowly!Never knew what caused it though,neither did the doctors but it might be an idea to get it checked out by a gp first to check no underlying tissue damage.Maybe it has something to do with weightbearing on one particular foot more than the other on longer distances?Hope you get it sorted.
Posted: 14/08/2002 at 23:00

Hi, Just been to Drs about pain in hollow of both knees. Told it is a knee cap problem.It insn't in the middle-its pulled more to the outside which is causing the pain.Dr very negative & advised me to give up running or be in a wheelchair by the time i'm 60 (I'm 32!!) Surely there is a way to solve this. PLEASE! CAN ANYONE HELP? I'm new to running (4 months) and have had this pain for most of this time.
Posted: 15/08/2002 at 08:03

Julie don't know if this helps but look at the injury section on knees for more information, but also have you considered going to a physio and getting your kneess looked at by them?

There is sometimes a biomechanical reason for why the kneecap moves (I believe but there are people on this site who are more knowledgable than me) which can be remedied. The important thing is to rest your knees, no running until this has been resolved.

Hope this is some use..
Posted: 15/08/2002 at 08:10


Currently in the middle of a knee pain thing (I can bore for England on this one). My pain is below the knee cap at the front of the knee. I went to my GP who was very helpful but after giving it a bit of a wiggle and a push sent me for an x-ray. The x-ray showed nothing. Doctor sent me to an Osteopath (sports orientated) who told me that it was due to biomechanical difficulties caused by a) too much running (more not enough cross training than too much mileage in itself) causing muscle imbalance: solution? more cross training especially cycling; and b) shortening of the hamstrings again caused by running; solution? More POST RUN stretching.

Ultimately I suspect he is right and that the solutions will work (I have implemented both) BUT I think the initial condition probably needs rest. At the moment I refuse to rest due to an impending marathon so am working around the problem.

So my advice? Get the problem properly diagnosed and then take a rest to give it time to recover.
Posted: 15/08/2002 at 09:36

Julie, it sounds as if your GP is scaremongering from a position of limited knowledge. I've never seen anyone confined to a wheelchair because of a patellar tracking problem yet!

Giving up running will certainly stop your knees from hurting, but that's not what you want, is it? And it's not the only solution.

You need to see a physiotherapist. It doesn't have to be a specialist sports physio - ask your GP for an NHS referral, or see a physio privately if the waiting list is long.

Meanwhile, cut your mileage down to no more than two-thirds of your current level, and don't try to run through the pain or take painkillers to allow you to run. If you have to alter your running gait to avoid pain, stop running as you'll end up injuring something else. Keep up your cardiovascular fitness by swimming (not breast-stroke as the froggy-leg movement is bad for sore knees), cycling, rowing, and you might find you can cope with the stair-climber or elliptical cross-trainer. Or just walk!

Patellar tracking problems are often the result of weakness of the vastus medialis (inner thigh) muscle relative to your other thigh muscles, and there are specific exercises which you can do to strengthen this muscle so that it can hold your knee-cap in its proper groove while you run.

Don't give up now, Julie. Injuries like this are very common in relatively new runners. Remember that running does not cause long-term knee damage - the biggest risk factor for knee arthritis is obesity.

Cheers, V-rap.

Posted: 15/08/2002 at 09:55

Thanks for the advice gang. Any one know any good books on running specific stretches? Or may be a web site, would need diagrams.
I'm not going to let this stop me, last time out after about an hour I had about 10 minutes "in the zone", bestfeeling I've had for along time. Hooked.
Posted: 15/08/2002 at 16:34

OK I too can bore for England on this one, ......

My desperately severe quad imbalances were causing muscle tears. The quad imbalances were becos of the excessive Q angle I have - which meant the vastus medialis was being completely overpowered by the other 3 quad muscles - and in addition the vm muscle itself was completely wasted because the knees didn't have proper extension. This was also the cause of the desperate shin splints I've suffered from all my life (& which are now just a nuisance rather than totally disabling.) I still get problems with the kneecap tracking and also a troublesome bursa - - but I know how to fix them now.

Having seen 3 physios, an osteopath,a sports masseur, a chiropractor, the Runners World Doctor and a podiatrist, of whom only one physio and the podiatrist were any good - (the osteopath wasn't far out)..if anyone wants to e-mail me seperately I'm sad enough to have prepared a word doc which I'll happily e-mail out with loads of corrective exercises in it - on the basis that I've already paid out more than enough in professional fees for all of us so am happy to share the advice I got which eventually worked for me.
Posted: 15/08/2002 at 17:02

Thanks to every one for their advice and encouragement. Going to make an appointment with a different G.P. Its nice to know I'm not alone with my problem.Now i've got over the shock and depression I'm more determined than ever to keep on running (I've a race in 2 weeks!) and prove the G.P wrong.
Posted: 16/08/2002 at 08:14

Wow, I think I've been having the same trouble. I'd got up to about 14K in my training for my first half marathon and I was getting pain just on the outside below both my knees. At first I thought I'd just carry on and see if it went away but after two weeks it was still there.

I decided to cross train and see if that helped which it did a bit but I noticed that after a fast 1K swim (half breast stroke trying not to use my legs too much, half crawl) that my knees were a little sore. Hadn't seen V-rap's advice about not doing breast stroke at that point.

I've been trying to keep up my fitness by swimming twice a week (1K each time) and cycling (doing two one hour sessions of an exercise bike program that does intervals over 15 miles) but I haven't been running in nearly a fortnight.

I've got jut over two weeks left before I'm due to run a half Marathon and I'm starting to wonder if I should:

a) give up because I don't want to permanently knacker my knees/ won't be ready

b) keep on cycling, swimming crawl (no more breast) and wait for the knees to feel 100% before running again....

c) Start running again on Monday and ignore the pain, which is really easy to do after the first few steps, the only reason I stopped running was because I didn't want it to get worse and stop me doing the half marathon.

Obviously I should see a doctor but I'm stuck in Brussels until the end of the month and I don't fancy paying for xrays and stuff out of my own pocket.
Posted: 16/08/2002 at 13:42

Hi guys I need some reasurance. Having gone through the problem of having a runners knee and got over it I now have got the problem back. I have already changed my shoes once! The problem is that I am hoping to join the army and I have to be in top condition. I went to my doctors the first time this happened and I am too scared to go again just incase he says I am not fit enough for the army! Will this problem keep coming back? Can I get arthrisis form it??? Will physio help? Please guys, I need some help!

Love Nessie
Posted: 02/07/2003 at 11:39

I had very bad knee pain (left Knee) and I went to a ortho Dr. and i have a condition very very common to runners called Chondromalacia>>>>softning of the cartilidge.. It will advance to arthritis if I do not take it easy on my running. His advice was cross training. If it comes back he said SURGURY!!! Not good news today.
Posted: 25/08/2004 at 22:12

An American chiming in......well I have been struggling with what up tilll now was a minor discomfort on the inside (sometimes middle and outside) knee, usually just under the knee protrusion. I noticed this occassional discomfort around 6- 8 monts ago, possibly...almost always post workout on my way down the subway stairs after leaving the gym, walking down hill etc. My workout has usually consisted of treadmill for 30 minutes to an hour 3 days a week and the other 3 days weight training (I stopped running outside about 2 years ago, ironically to save my knees). This past week after 2 days off from leg exercise I was doing my weekend thing laundry, running up and down my building stairs etc. Feeling great.....a million bucks...invincible. Leaving the flat later that day I was suddenly hit with the discomfort in the knee which haunted me all the way to the subway, down the steps and then leaving the train, up the stairs......well you get the picture.

Me and my body have always been on the same page so this concerned me. I booked an appointment with a Top Rated Sports Medicine Specialist here in NYC. After watching me run barefoot on the Treadmill and hearing of my symptoms it didn't take him long to diagnose me with Runners Knee. I had done some reasearch on the web about this ailment and was hoping it was something a bit less....destructive. I am now about to begin my journey of Physical Therapy. I kick myself in the head for foolishly listening to someone a year ago who told me that putting double arch supports (store ones over the ones included) in my sneakers was a bad idea. I am such an extreme overpronator that I think these had saved me up to this point.

So the goal now is to wear a temporary Orthopedic arch supports until a custom one is made and to go to physical therapy to re-allign my leg (apparently, like allot of runners I have strong outer quads and under-developed inner ones (VMOs) my Illoidial Band is probably too tight.

Frankly I am a bit concerned about the long term effectivness....though I have been assured that is is quite common and curable. But isn't that relative to the damage that has already been done? Is this the same as Chondromalacia? Please.......I welcome any and all opinions /experiences on the matter.

Another Note I was told that Squatting, Lunges and Leg Extensions (the backbone on my leg strengthening) were bad ideas with my condition and that from now on I should not go beyond a 30 Degree bend when doing any of these. Has anyone been able to develop their muscles with such a limited range?
Posted: 22/01/2005 at 01:26


To regurgitate back what I have been told.......Physical Therapy is essential to getting your legs re-aligned, if in fact they are the cause. Also, if you fall on your foot due to overrpronation or other foot oddity this can affect your knee staying in the groove and consequently tear it up. I would not settle for new sneakers but be sure that your feet/ form are observed on a treadmill and that, IF OFF CENTER you get a custom orthopedic. It is not uncommon for someone to have one foot longer than the other for instance which could create an imbalance that puts more impact on one knee or causes the other foot to compensate in an odd way.

This is the info that I have received thus far and hope is of some small value to you.

All my best wishes,

Posted: 22/01/2005 at 01:38

lighter note

at 17 a doctor told me I had crumbling patela but I still got in the army(at the time I could run a 4:30 mile)
at 21 I damaged both my acl tendons playing footy and was told to slow down or risk permanent damage(phrase he used was wheelchair by 35)
at 28 I tore the cartlidge in my right knee
playing football(did not have surgery used balanced exercise to build the muscle around my knee and started running again)
this year I will be doing the comrades marathon.
ps. I am 35 this year and as yet have not booked my wheelchair

moral: at the end of the day you make the decisions in your life, choose wisely you only get one shot at having all this fun
Posted: 22/01/2005 at 01:57

I am suffering from runners knee at the  moment but find it at it's worst when I am on my bike.

Does anyone know why this would be?



Posted: 13/03/2010 at 08:23

hi im getting pains on the inside if my right knee, when im running and mainly high milage rested todayts hopefully be ok for run tomorrow for 20-22m dont know what to do
Posted: 13/03/2010 at 12:28

Hi, in last 4 weeks have started running again after birth of second child (3 months ago) and all of a sudden having sore knees as sooon as I leave the house!  Never had this problem before (not even after first child) and not sure what to do about it.  It's not very bad, just enough to slow me down and change my gait.  Knee supports a good idea or not?
Posted: 07/07/2010 at 21:37

I would be very grateful if you could mail me your knee strengthening excersises. Thank you.
Posted: 09/12/2010 at 17:29

Have any of you tried kinesiology tape? I found that worked for my runners knee. Originally I brought a full knee precut but now I just use a strip beneath my patella. It seems to remove a bit of the stress and the pain is certainly a lot less.
Posted: 17/02/2011 at 13:44

Hi there,

Thanks very much for your posting - please send me a copy of the document you mention.

I have pain at the top of my knee cap and think some strengthening exercises could help a lot. Hope your knees are in good shape these days.

Regards, ian. 

Posted: 08/05/2011 at 14:22

Hi there,

I've just read your post about corrective exercises for Runner's Knee. I've just discovered I have it, it made me pull up at 9 miles in a 13 mile run. Gutted, as I'm training for a half marathon. Really want to fix this over the next four weeks. Help!!! Any suggestions would be great. I've just bought a pair of Kayano 17 which I've been told are the champagne of supportive footwear for runners.

Kind regards,


Posted: 08/05/2011 at 17:18

2 Things ive learned about knee problems:

1) GP's dont know what they are talking about. Whether its because of the NHS or they hate anyone who trains hard, I dont know. Use them to get your physio referal (6 30 min sessions on the NHS are yours for the taking). I went in with a hip problem 6 weeks before a half marathon and the GP told me it was probably broken and I'd never run again (he didnt bother x-raying. but luckily I have bupa and the minor injury in the piriformis muscle was both diagnosed and fixed, via acupuncture within 2 weeks.)

2) See a proper sports physio and do everything you are told to do. 

And recovery will follow. I've made plenty of mistakes myself (I even taped the area up horizontally, which only put pressure on the IT band making it rub even more), used google as a doctor etc.

There are so many variables for what it could be, but seeing as ITBS is known as 'Runners Knee' and is bought on by increases in training, its usually a no brainer as the cause...but can be tight in different areas. Really just make sure you see someone who knows what they are doing, which in most cases is not some indian doctor who is trying to get you out of his office as quickly as possible. 

Posted: 08/05/2011 at 17:37

GP's is general medicine which is code for saying they no jack all about anything therefore go to GP or A&E and get a referral for a scan or physio, I tore my knee playing football and actually found the NHS brilliant just make sure u can see a specialist, ive just run shakespeare marathon and the pain in my heel and knee is pretty bad hopefully will subside thou!
Posted: 09/05/2011 at 14:21

I have developed a pain to the inside and below my knee.  It just feels stiff and like its seizing up.  What is strange though is that it hurts at rest (sitting/sleeping), but when I run the pain disappears, only to come back when I stop.  Doing Great Manchester Run on Sunday - any ideas?? 
Posted: 09/05/2011 at 18:03

WelshRunner66 wrote (see)
I have developed a pain to the inside and below my knee.  It just feels stiff and like its seizing up.  What is strange though is that it hurts at rest (sitting/sleeping), but when I run the pain disappears, only to come back when I stop.  Doing Great Manchester Run on Sunday - any ideas?? 
sounds like that could be MCL or menicus ive done MCL wasnt maje, i just had physio, ultrasound, acupunture, massage on it to get it fully sorted, had to build in rest periods thou, menicus can be a right pain thou (so I told) never done myself, good luck with 10k thou, smash it!
Posted: 10/05/2011 at 00:34

WelshRunner66 wrote (see)
I have developed a pain to the inside and below my knee.  It just feels stiff and like its seizing up.  What is strange though is that it hurts at rest (sitting/sleeping), but when I run the pain disappears, only to come back when I stop.  Doing Great Manchester Run on Sunday - any ideas?? 

sounds like that could be MCL or menicus ive done MCL wasnt maje, i just had physio, ultrasound, acupunture, massage on it to get it fully sorted, had to build in rest periods thou, menicus can be a right pain thou (so I told) never done myself, good luck with 10k thou, smash it

Many thanks for this Pete - I'll look into it if the pain persists.  Just resting now until Sunday! 

Posted: 10/05/2011 at 19:36

Hi,Would really apreciate a copy of your document on knee pain treatment.Please mail to: Many thanks,Ian. 
Posted: 26/04/2012 at 20:17

I'm 36. I had runners knee for over 10 years, from around 18 onwards.

The day after squash, football or running (typically 2k) my knees would ache if I kept them bent - if I straightened my knee the pain would go away only to return if I kept my knee bent. It gradually got worse until in my early 30's it would be slightly painful walking down stairs for a day or two after sport. So I kept sport to once a week to limit any damage.

I went to some top physios in the UK, they gave me custom orthotics, but they didn't help much.

2 years ago I tried running barefoot on a treadmill and was shocked that there was no pain the day after the run. 2 years on and now I run about 3k barefoot a day (I actually run with cheap Speedo water shoes which have a flat bottom which are around 2 or 3mm thick) and I don't feel any pain at all in my knees - even when I run on hard surfaces I feel nothing.

Just a word of caution. The adjustment to barefoot running is big and should be done gradually. I just went all out and in the first few months of barefoot running I developed achilles tendonosis and then patella tendonosis but once I self-diagnosed them and did the appropriate stretches they went away. Also I've had tons of blister, but now that my feet are used to it, I don't get them any more.

Posted: 11/06/2012 at 13:12

I had knee issues in the lead up to my marathon in April.  A physio diagnosed bad patella tracking caused by an incredibly tight IT band and after some excrutiatingly painful massage and foam rollering it went away.

So I'd definitely recommend seeing a good physio.

Posted: 14/06/2012 at 12:29

For those asking for a copy of the exercise list you might want to note that post was made a decade ago!

Posted: 15/06/2012 at 15:34

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