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Knee Pain in Runners: A Complete Guide to Management

Knee pain is one of the most common reasons runners aged 15–35 seek physiotherapy. Whether it’s a sharp twinge during a long run, a dull ache on hills, or a persistent niggle that flares in the first few kilometres, knee pain can quickly affect confidence, performance and the enjoyment of running.

At True Active Physiotherapy, we work with runners across every distance and level — from school-aged athletes and fun-run participants to competitive road runners, trail runners, triathletes and marathoners. Across all groups, the message is clear:
Knee pain is extremely common… and very treatable with the right plan.

This guide breaks down the key causes of knee pain in runners, explains why it develops, and outlines how evidence-based rehabilitation gets you back to running comfortably and consistently.

Why Knee Pain Is So Common in Runners

Running places repetitive load through the entire lower limb. With every step, runners absorb forces up to 2–3 times body weight, which accumulate over thousands of strides. The structures in the knee absorb around 5 times body weight alone.

Common running demands that load the knee include:

  • High-impact repetitive loading

  • Downhill running

  • Increased mileage

  • Speed work and hill efforts

  • Fatigue during longer runs

  • Suboptimal running mechanics

These forces stress the patellofemoral joint, patellar tendon, and surrounding stabilisers at the hip, thigh and ankle. When muscles fatigue or mechanically compensate, knee structures often absorb more load than they can tolerate.

Research consistently shows that hip strength, running gait, training load spikes and fatigue are key contributors to knee pain in runners.

Common Causes of Sudden or Sharp Lower Back Pain

People often describe their pain as “sharp,” “sudden,” or “I just couldn’t straighten up.”
Typical causes include:

  • Muscle strain or soft tissue irritation

  • Sudden twisting or awkward lifting

  • Prolonged sitting or poor posture

  • Reduced activity or deconditioning

  • Stress, fatigue or poor sleep (increasing pain sensitivity)

These causes are usually not serious — and respond very well to early movement and physiotherapy rather than rest.

The Most Common Causes of Knee Pain in Runners

1. Patellofemoral Pain (Runner’s Knee / kneecap tracking issues)

The most common form of knee pain in runners.

Typically felt:

  • Around or behind the kneecap

  • During running (especially downhill)

  • After prolonged sitting

  • With squatting, stairs or early in a run

Usually caused by an overload of the kneecap combined with reduced hip/knee control or weakness in the quads, glutes or calves.

2. Patellar Tendinopathy

Less common in steady-state runners but frequent in:

  • Sprinters

  • Interval runners

  • Hill runners

  • Athletes adding explosive training (e.g. plyometrics, jumping)

Pain occurs at the front of the knee and flares with:

  • Speed work

  • Hill repeats

  • Power-based sessions

3. Fat Pad Irritation

Pain at the front of the knee that worsens with:

  • Full knee extension

  • Downhill running

  • Faster paces

Caused by repeated compression of the fat pad beneath the kneecap.

4. Osgood–Schlatter Disease

A common issue in growing runners aged 12–17, causing pain at the top of the shin (tibial tuberosity).
Aggravated by:

  • Running

  • Jumping

  • Rapid training increases

  • Growth spurts

5. ITB Friction Syndrome (ITBFS)

A classic runner’s condition.

Pain occurs on the outside of the knee, often appearing:

  • After 2–5 km of running

  • During long runs

  • When increasing volume or hill work

Linked strongly to hip strength, stride mechanics and training loads.

Why Knee Pain Develops in Runners

Knee pain in runners rarely comes from a single incident.
It occurs when load > capacity over time.

Common triggers include:

  • Sudden increases in weekly mileage

  • Ramp-up of speed sessions or hills

  • Weakness in quads, glutes, calves or hamstrings

  • Increased downhill running

  • Running gait changes (conscious or unconscious)

  • Foot/ankle issues altering alignment

  • Fatigue reducing control

  • Returning to running too quickly after injury

Many runners report:

  • “It hurts early in the run but warms up.”

  • “It’s worse the day after a session.”

This is the knee signalling that the area is overloaded and needs structured adaptation.

Management & Rehabilitation for Runners

What Proper Treatment Looks Like

Effective knee rehabilitation for runners goes beyond rest and icing.
The best outcomes come from progressive strengthening, load management, and running-technique retraining.

1. Settle Irritation & Modify Load

The first step is calming symptoms without stopping running completely.

Examples of load modification:

  • Reducing weekly mileage temporarily

  • Swapping tough sessions for easier aerobic runs

  • Reducing downhill volume

  • Adjusting running surfaces

  • Avoiding deep knee flexion strength work early on

  • Manual therapy including soft tissue release and dry needling to settle symptoms and improve joint range of motion.

2. Restore Strength in the Quads, Glutes, Hips & Calves

Strength is one of the strongest indicators of running efficiency and reduced injury risk.

  • Quadriceps: absorb landing forces and control braking on descents.

  • Glutes/lateral hip muscles: maintain knee alignment during stance.

  • Calves: generate propulsion and shock absorption — critical for runners.

  • Hamstrings: assist with stride control and deceleration.

Runners with strong quads and hips show significantly fewer knee issues.

3. Improve Running Mechanics & Movement Control

Key technique factors influencing knee load include:

  • Overstriding

  • Excessive inward knee movement

  • Reduced hip extension

  • Poor cadence (taking too large of a step, or too slowly)

  • Trunk lean or crossover gait

Rehabilitation focuses on:

  • Cadence optimisation

  • Improving hip control in mid-stance

  • Reducing braking forces

  • Softening foot strike

  • Technique adjustments during fatigue

These subtle changes can dramatically reduce knee stress.

5. Using Force Plate Technology to Optimise Return to Running

At True Active Physiotherapy, force plates help us measure:

  • Plyometric capacity

  • Symmetry between left and right

  • Landing forces and control

  • Reactive strength

  • Stability under fatigue

This objective data ensures runners return safely and efficiently, with clear markers of readiness.

Returning to Running Safely

A successful, sustainable return includes:

  • Restored quad and hip strength

  • Strong calf endurance

  • Symmetrical landing and loading patterns

  • Efficient stride mechanics

  • Ability to tolerate training volume, pace and hills

  • Confidence in the knee

When these are achieved, runners typically return stronger than before the injury.

Long-Term Maintenance for Runners

Even once pain settles, maintaining strength is critical.

Just 20-30 minutes of targeted strength work 2-3 times per week can work alongside load management and good technique to reduce your injury risk.

Periodic check-ins can help catch early warning signs before they become injuries.

If Your Knee Has Been Sore Recently…

Knee pain in runners is common but manageable with the right plan.
Whether it’s a new niggle or something you’ve been managing for months, targeted rehabilitation can greatly improve your running performance and confidence.

If your knee hasn’t felt right lately, or if you’re unsure how to adapt your training without losing fitness, our team is here to help.
You don’t have to wait until it becomes a big issue. Even one session can give you clarity and direction.

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Tel: 03 7503 7657

Unit 6/25-41 Redwood Drive, Dingley Village

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