Knee Pain while Running? This Advice Is For You!

In this episode of the Movaia Running Form Podcast, I welcomed back physiotherapist and expert running coach JP Gloria. Together, we dove into one of the most common running injuries: knee pain.

We talk about the different types of knee pain, strategies to manage and prevent it, and the role of running form, cadence, and footwear in mitigating stress on the knees.

We also discuss the importance of strength training for runners, how to balance training loads effectively, and why consistency matters more than complexity when it comes to exercises.

Plus, JP reflects on his own recent marathon experience, where things did not go quite as planned…

Dive right into the video below on Youtube, or listen to this podcast while running on Spotify. If you prefer to read, you’ll find the full transcript below:

Thomas Butter (00:07)
Hey, welcome to the Movaia Running Form podcast, where we’re discussing all things running or running form. My guest today, just as in the last episode, is JP Gloria, who’s a well-known physiotherapist and running coach and an expert on running form. Today we’ll be discussing one of the most common running injuries, knee pain.

But before we get into that, I would like to ask you JP, how did your recent marathon go?

JP’s Recent Marathon Experience

JP (00:39)
It was tough. You know, it’s very humbling, I’ll say. I got sick, I was under the weather, and maybe I should have not ran the race when you can’t really talk properly or breathe properly, but you put all that time into training.

Thomas Butter (00:49)
Mmm.

JP (00:55)
You don’t want to skip out on the marathon. But it was hard. I was already like out of breath at like mile three. And then what was it? Mile 15 to mile 16, I realized I had to pivot plans. just, no energy. It just had to adjust. Otherwise I’d probably die.

Literally, felt like it at least. But we made it through, I jogged rest of it. Wasn’t my best race, still finished under four hours though,
So I’ll take it when I’m at my worst possible shape. But no, it was humbling.

Thomas Butter (01:26)
Well done for finishing. I guess there’s probably two lessons in there, right? Number one, adjust your plans if you feel like today is not the day. And well, maybe consider another race to see if you’re feeling really terrible.

You had runners you were coaching also at the same race, right?

JP (01:41)
It was good seeing these people. I just know where some of these people were. Some of them couldn’t even run maybe even a few weeks prior and then to see them finish the race and finish strong without injuring themselves during the race. It’s always an amazing moment.

Marathons are hard. I think that’s one of the takeaways. No matter how fast you are, no matter how in shape you are, marathons are hard no matter what.

Thomas Butter (02:03)
For sure. I think that’s one of the nice things about coaching. It’s so cool if you see your athletes performing well and that just can make your day. All right.

Different Types of Knee Pain in Runners

Today’s topic is knees There’s a recent study actually where we see, these numbers where at any point in time, 16 % of the running population suffer from some sort of knee pain, So is that a pattern that you also see in your clinic?

JP (02:28)
Yeah, knee pain is one of the more common areas. it’s important to kind of decipher between the different types of knee pain. there’s anterior knee pain, the fancy term being patella femoral pain syndrome, versus something like patellar tendinopathy, which is when you have something going on the tendon. So it’s important to differentiate between those areas. But in terms of the pain in the knee, that’s something I commonly work with in the clinic.

Thomas Butter (02:55)
As a runner, how would you know if you’re suffering from one or the other and what would be the consequence of that?

JP (03:02)
Typically, the patelloformoral pain, typically it’s pain under the kneecap, feels like it’s kind of like deep in the knee per se. Typically feel it with any type of bending while putting weight on that leg. So it might be felt. With running, it could also be felt with stairs as well. With patellar tendon, depends on where it is. One of the common ones is distal, you’d touch the tendon, and they would feel pain in that area. So it was specifically on like that lower part, close, closer to the tibia. Also certain symptoms are a little different.

For example, with tendinopathies in general, there’s a little bit of a delayed effect that happens. let’s say you do run and you don’t feel anything initially, but maybe a few hours later, maybe the next day, that’s when you start feeling the soreness in that area.

Should you rest when feeling knee pain?

Thomas Butter (03:47)
When is it time to go see the specialist? Is there like a rough guideline there? Or is it really hard to put it down and very individual?

JP (03:55)
It’s a case by case thing, but I’d say one thing that I try to do is keep the person running as much as possible. However, there are cases when it’s too flared up or too irritated that they need to stop. However, what I will mention across the board, besides like recent acute flare ups, especially with patellar tendon issues or conditions, is that absolute rest typically makes it worse.

You know, people will typically run and get, let’s say, pain in the knee and they decide, okay, I’m just not gonna run on it. They’ll just take a few days off, or a few days or a week off. And it’s one of those conditions where you take this time off and then you go back into running and it’s still there. Or maybe it’s even worse. Now it’s even stiffer than before, the symptoms come.

So we do need to take an active approach in managing it.

Thomas Butter (04:47)
So if a runner comes in with knee pain, would try to maybe reduce the volume or make some adaptations, but you try to keep them running. think that’s an important key takeaway. So is there like a common pattern in what causes these type of injuries? I think just this term multifactorial causes of injuries, what does it actually mean?

Balancing load and capacity of the knee to deal with it

JP (05:09)
Usually it’s not one thing. I find that it’s an accumulation of different factors coming together. So as you said, multifactorial. It’s not always physical too. There are psychological stressors that can actually increase irritation in the area or flare up the knee, let’s say.

But sometimes, we’re just trying to, find a balance between the body’s ability to adapt, versus what we impart on it, like in this case running. So it’s trying to strike a balance between those two. So from that one side, when we’re talking about that capacity aspect of things, we can make it stronger. We could build the resilience of, let’s say, the knee. But then we could also work on the other side of things, which is that biomechanical loading of the knee. So we could talk about ways that we could modify your running to reduce stress on that area and hopefully decrease irritation there. So we can approach it from both sides of the coin.

Risk Factors for Knee Pain in Runners

Thomas Butter (06:09)
So, I translate this into layman terms, this would make the knee stronger or other parts of the body that help the knee, right? Or change the way that you run, right? This would be two potential ways to deal with the issue. Just to come back a little bit to the previous question. things that you often hear about knee pain, that… people suddenly start running way more than they used to, or they have really old shoes, the way they run, right? Is there one that seems to be more common than the other,

JP (06:42)
I mean, there’s some themes. Typically, a spike in training load or volume is a thing. Could certainly talk about what that entails because something that gets brought up a lot in terms of spikes of training is people come to mileage. That’s why you think about the 10 % rule, which is increasing your mileage by 10%. I’d say that’s kind of helpful if the intention is to gradually build up one’s training.

But the issue with that, it only counts for volume. You know your mileage, but you also have to consider the intensity as well as the frequency of the runs as well. Because those would definitely play a factor and something that should be thought about when navigating certain injuries. But yeah, there’s a few things. There’s some interesting ones. For example,

Age plays a factor actually. when it comes typically with younger athletes, so you know, your teenagers or adolescents, the area that typically gets injured or irritated more so is the knee versus with older athletes, typically it’s more lower leg type things like your Achilles, calf, foot area.

So age is something to consider with that. Other things are, I guess weight is interesting. know, BMI, what’s interesting about that, it’s actually in the opposite way than people think. Because when people think, you know, people have knee pains, like, I just need to lose weight. When, what’s interesting about that is people with a higher BMA tend to, not have as much knee pain. usually have different issues, again, like lower limb stuff. And then obviously then the opposite when it comes to like people with lower BMI.

So it’s these things that I typically consider, also the biggest predictor for injury is if you had an injury there before, but all these things do matter because especially when trying to choose shoes or doing certain technique modifications or deciding training, maybe we could be a little bit proactive on addressing these areas.

So someone has a higher risk of having knee pain, perhaps we should already incorporate some modifications to minimize the chances of the knee flaring.

Running Form and Knee Pain

Thomas Butter (08:58)
You touched on three topics there, each one of them could probably be its own episode. You discussed running technique, we discussed also previously strengthening, and you also mentioned even running shoes. Pick the one that you want to start this, but really let’s go into running form first because that’s of course close to our heart. But then also touch on the other ones. Running form, what are the some of the things that potentially could cause this knee pain or how would you modify running foam to deal with knee pain?

JP (09:26)
There’s two ways to approach this from when I’m watching a runner versus what we so let’s actually start with the modification first, because it’ll make sense for the second thing I’m going to bring up.

So when it comes to how you run, it could influence how stresses are imparted on different parts of the body. For example, when we talk about foot strike, You can land around kind of closer to the toes. So that would be considered the forefoot region. You can land close to the middle. That would be considered the midfoot region, or you can land closer to the heel region, which is typically more classified as the rear foot region. Now, depending on where you land can influence how stresses are imparted on that leg. So if you land closer to the forefoot region, minimize stress on the knee, but it would bias loads closer to that lower leg, so that calf muscle ankle complex; versus if you’re more of a rear foot striker, that bias loads more toward the knee. But it takes a little bit of pressure off of the calf ankle area. So this could play a role because let’s say if someone’s dealing with knee pain, maybe we could redistribute those forces a little bit more by having the person land closer to the forefoot area.

How Running Shoes Can Affect Knee Pain

And then, know, since we’re on this line of thought we could talk about shoes Maybe if someone has a lot of knee pain and they’re having difficulty running because of it perhaps we should opt for more of a Zero to we call it zero drop commonly zero drop but technically zero, you know the differential between the heel and toe Difference would be zero. So zero drop shoe might be more helpful because again that will bias loads more on the calf, you know, the calf muscle ankle complex, but it’ll put a little bit less pressure on the knee and that might make the knee feel better so the person can continue running.

Foot Strike and Knee Pain

But when you watch runners, it might tell a different story because I do a lot of run analysis on runners all, all around the world, essentially. And what’s interesting about that is that can be pretty counterintuitive if you don’t have as much experience with, you know, with gait analysis or run watching runners because initially we talked about how a forefoot strike landing close to the toes would win my stress on the knees.

However, I find that a lot of runners, typically already compensate or adapt for those things. So let’s say, you know, we use Movaia and we notice a different foot strike pattern of, wow, on the right foot they land more on the forefoot and on the left side they land closer to the rear foot or heel region. We notice that and then someone asks the question, which side is more likely to have pain? Or knee pain?

And a lot of people initially would say, that would be the left side, the one that’s heel striking because that puts more load on the knee. However, what I’ve found, is I found a lot of times, where it’s actually the opposite. It’s actually the side that has knee pain is the one that they’re already forefoot striking.

So they’re landing on the forefoot because the knee is already irritable, so it’s already trying to offload pressure around that area,

Thomas Butter (12:46)
That’s fascinating. Foot strike seems to be a key area when looking at knee pain. Are there any other go-to parameters to look at first? think hip drop is mentioned often or anything else that will be key to look into when dealing with knee pain.

Overstriding and Knee Pain

JP (13:02)
Yeah, there’s others. we could look at shank angle, it’s not just about how the foot lands. So, you know, which part of the foot lands on the ground, but rather where is that foot when you land in relation to the body. So something we look at is shank angle. We could look at that through Movaia. you know, most commonly we try to minimize overstriding, which is where that foot lands too far in front of the body. So if we could get that foot to land a little closer to the body, that would essentially reduce loading or stress with each step and may help.

Hip Drop and Knee Pain

You know if we could decrease load per step that might help with the knee irritation as well when running you know, you brought up the hip drop. That’s a it’s a very interesting. Because that’s almost like a chicken and egg scenario. So oftentimes when we look at hip drop

Sometimes we see that as the source of knee pain. You’re having knee pain. A lot of times when people see this hip drop, people say, because you have this knee, this hip drop, that’s why you have knee pain. However, what’s very fascinating is we could, it also happens the opposite way. So just by having knee pain can actually cause that hip drop to occur or as well. So.

It can go both ways, essentially.

Thomas Butter (14:18)
Yeah, I remember you mentioning a while ago that actually if you have no hip drop, almost zero hip drop, that this could be a protective adjustment of your body, while typically we like a stable hip, it might actually indicate issues in that area if I’m conveying that message correctly.

JP (14:36)
I think one of the myths or misconceptions is that, you know, people construe, hip drop, that’s a bad thing. But there should be some range of hip drop that happens. It’s actually a natural part of running. And when I don’t see any movement at all, sometimes that could be, you know, almost

My antennas go up a little bit and I want to understand why is it so rigid on the side? Is it because of excessive guarding around that area because of a lot of pain somewhere on that leg? Or is there some type of mobility deficit or something, know, limited mobility around that area that we do need to look further into? So, yeah, I think the point is there should be some range of movement going on in the hip and

Having too much of it or not a lot of it can clue in on certain things going on in the body that we may need to address or not address.

Cadence and Knee Pain

Actually, maybe we’ll go back because there’s one thing I would want to always mention. Just because it’s one of the most well-researched things when it comes to changing the way you run or doing gate modifications, which would be talking about cadence, is how quickly you take steps.

And there is a study out there where a 5 to 10 % increase of your cadence or how quickly you take steps without changing how quickly you run, because that’s another thing. Just by having a higher cadence by 5 to 10 % can reduce loading on the knee by upwards of 20%. So that can be something helpful for someone to continue running, especially if they have knee pain.

Thomas Butter (16:15)
Yeah, thank you for that because I think that’s also one of the really easy to do modifications, right? To basically shorten your step and take quicker steps and really impactful. Okay, so that I think covers the topic of running form. So moving on to strength I think an area that many runners who just love to be out there and run, tend to not prioritize So, what can you tell us about strength as it relates to the knee?

JP (16:42)
Yeah, so I think one of the concepts we talked about was the idea that we’re kind of working from two sides of the coin. One is the capacity of the, let’s say the knee in this scenario versus the biomechanical loading of the knee when you’re running.

How to Build Your knee’s Capacity to Deal With Running

So as we were talking about recently, we were talking about ways to reduce the loading on the knee so that can balance out the scales so someone can continue running. However, we could also look at the other side, which is building the capacity of the knee so it can handle the demands of running. And I think that’s a really important thing to talk about

People run to get fit, right? People run to get in shape. you know, people wanna get fit and they’re gonna try to do it through running.

However, I think it’s very important to not underestimate the demands of running. So maybe we also need to get fit to run

Thomas Butter (17:44)
How would you go about this right? Say I want to get fit for running: Maybe I know that you know previously had any injury which would already make it riskier for me. Can you give me let’s say two or three exercises that would be your go-to? Exercises for people to do

JP (17:58)
In terms of exercises to do, it’s very individualistic to the person, right? Because something, know, an exercise that you do may be harder for someone else or may be way too easy for someone else where it doesn’t elicit the stimulus to build the capacity of let’s say the knee in this scenario.

However, if I were to give exercises, sometimes I wouldn’t even worry about all that nitty gritty. Listen, I get into it, figuring out very specific exercises for someone to help navigate pain and get them running as quickly as possible. But I think the most important thing is finding exercises that the person is consistent in doing.

And I think that’s always the big issue with New Year’s. I think it’s great that you get started, but do you actually follow through with the plan? so if consistency is the most important thing, we should probably start with exercises that are more simple. I found that if we go too complex then that’s actually a barrier to being consistent.

If we’re trying to, let’s say, build strength in the knee, something as simple as a wall sit, starting with a wall sit would not be a bad place to start. mean, wall sits are good, squats, we have Bulgarian split squats, but I would say start with a wall sit. Start to actually work on the area and be consistent about

I found sometimes it’s that simple. I’ve worked with certain ultra runners who run like, you know, 30, 50, 100, 200 miles and have had reoccurring knee pain. And as soon as they started getting consistent with something as simple as a wall sit, all of a sudden, you know, frequency of the complaints around the knee drastically dwindle just by incorporating a simple movement.

You know, three sets of doing a wall sit hold for like 20 to 30 seconds, two times a week. Just something as simple that just takes one minute, essentially one to two minutes of your time goes a long way in keeping you training again.

Thomas Butter (19:56)
Yeah, that sounds very realistic and achievable, I think, for most runners. So that’s good to see that you can, even with something as simple like this, achieve good results. I had a question which is totally not related to knee pain, but you mentioned New Year’s Do you normally see that, similar to a gym, right, that maybe two or three months after New Year, do you get this big surge in patients coming in that started running around New Year’s? Or is it not like that?

When Runners Should See a Physio for Knee Pain vs. When They Actually Do See a Physio

JP (20:21)
You always have to think about when these people come in. Because when I think about people coming in for, let’s say, an assessment, I understand that they’ve already tried working on it. It’s very unlikely that someone, a runner comes in, I have knee pain. I’m going to go to JP right away.

No, that’s not how it works, right? When you have some knee pain, what do you do? Or if you have like pain somewhere, what do you do? You try to rest it, you try to maybe ice it, you try to look up exercises already, you try to sort it out on your own first. and then if that doesn’t work, and you’ll probably try that for not a day or two, but rather a few weeks.

Then you try another option that’s, probably not as expensive and then maybe that doesn’t work and or it’s getting worse and they or they have a big race coming up already their own they already have a race coming up when it used to be so far away that’s when you come see an expert so if I were to dive into that there’s a few things to take away typically with injuries

A lot of people, they’ll stop running and they’ll start at the new year, right? And once the new year hits, new year, new me. So they go from no running to following, I don’t know, a random training plan online that has them doing, 10, 15, 20 miles, So now they go from no running to running 15 to 20 miles a week.

Now, does that person get injured right away? Not really. Because something to know about training spikes is the injuries don’t typically happen right after the spike of training. It typically happens a few weeks afterwards. There’s some actually pretty good research on this, especially with some cross-country runners, is the injuries peak three to six weeks after the training spike.

And that’s important to know because it’s not like, I survived this week, I’m good. Right? No, we have to be kind of cautious about how we progress someone. And we have to look past the few days to week before. We should be looking at least one month before. I’m trying to understand a runner’s situation or case when navigating injury, I don’t look just one to two weeks back. I look like four to six weeks back. And I want to understand the patterns that are going on there. So that happens.

But I would say for me, a very busy time of the year would be, you know, for speaking along this, is roughly around February, February and March and then roughly around April, May area. So, you know, because I feel like injury would start to happen, but people also don’t come in until a race is way too close.

So it’s very common for me to not see someone because they got injured at that moment, but because their race is so close already. It’s like already four to six weeks away that now they do need to see a professional because they still want to run that race. Does that make sense? It goes on both sides of spectrum of whether the injury happens as well as considering how close the race is.

Thomas Butter (23:17)
Yeah, that makes a lot of sense

JP (23:26)
Because if you think about it from like, you know, being rational about it, if I get injured but my race is in eight months, a lot of people won’t come in because, you know, if I just rested, it’ll get better. But sometimes I think you’re just wasting time. Anyway, yeah. Those are my thoughts.

Thomas Butter (23:42)
I’m glad I asked the question because that opened up a whole other gold mine of insight. So, yeah, thanks a lot for that. I think we covered a lot of topics. So maybe to recap briefly, right? We look at running forms, certain things that it can maybe try to modify load or maybe things just to look out for. We talked a bit about strengthening, Keep it simple, but be very consistent about it. And even what you can do in terms of shoes to help mitigate it a little bit.

Wrapping Up & Get in Touch

New Year is a great time to start running, but take it easy. Movaia can be a great first stop if you want to check your running form. So go to Movaia.com and check out our free option or one of our paid plans. I’ll also leave all the contact details and social media information for JP, in the show notes.

If you’re dealing with a certain running injury that we didn’t cover today, then also please let us know, drop a note to community at movaia.com and we’ll make sure to cover it in of our future episodes. So before I close, JP, do you already have a next marathon or maybe something shorter now in mind to train for?

JP (24:49)
I’m definitely going to be training for a half marathon, I’m going to wait I’m a little traumatized at the moment, but I will sign up. I know in this year that I’m going to do a marathon, but I just don’t want to think about it right now.

Thomas Butter (25:03)
Alright, that’s fair enough. I’m looking forward to see where that’s going to be. Thank you so much for sharing all the information with us today. looking forward to catch up again. see you soon. And thanks to all the listeners joining in. Thank you. Bye-bye.

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More about knee pain and exercises to fix it in runners: ⁠https://movaia.com/how-to-fix-my-knee-pain/⁠

Get your own running form analysis to see if running form could be a reason for knee pain: ⁠https://movaia.com⁠

More from JP Gloria: Youtube: ⁠ @JPGloria ⁠ Instagram: ⁠jpgloria.dpt⁠