Knee Pain While Running: Where It Actually Starts and How to Get Rid of It

One of the most common presentations I treat is knee pain while running. I'm going to share my insights into how I typically see knee pain start, why it occurs, and how to get rid of it.

The Knee Joint Itself

First off, the knee is a modified hinge joint, meaning that it mostly bends and straightens with a small amount of rotation. It's not like the hip joint where you have a ball and socket with multiple planes of motion that can take on a lot of different ranges. The knee has ligaments like the ACL, MCL, LCL, and PCL that keep it stable, and a meniscus that absorbs shock and distributes force up through the femur and down through the tibia. But when restriction, pain, or injury sets in at the joints above or below, that shock absorption is then placed on the knee.

This matters because the knee is essentially stuck in the middle of the kinetic chain. It depends on the ankle below and the hip above to do their jobs. When those joints aren't pulling their weight, the knee pays the price.

Knee Pain Doesn't Always Start as Knee Pain

What I've noticed is that knee pain doesn't always start as knee pain. It shows up as small cues in the body that most people ignore, and then the knee becomes the thing that finally gets their attention. Like placing more stress on the knee during stairs, using your knee to kneel down for years, squatting with all the pressure on your knees… Sound familiar? 

Did you know that patellofemoral pain is the single most common running injury (front knee pain). Research shows it accounts for almost 40% of all knee problems seen in clinical settings, and among runners. So this isn't a rare complaint. It's the norm for runners who don't address what's happening above and below the knee.

The Ankle Connection

Almost every single knee pain client that I treat has a history of ankle instability, a history of ankle sprains, or really stiff ankles. When we walk or run and take that first step, if the ankle is not adequate to take on the load, it's going to put stress on the knee. Not only having stiff ankles, but having toes that don’t move and are stuck in the same position.

So that's one of the first things to look at: giving your ankles and toes a proper assessment and not ignoring the years of ankle dysfunction that are quietly putting stress on your knees. How many times have you heard someone go, “Oh, I just rolled my ankle, no biggie.” but, that’s exactly where you need to start treatment. Because when you roll the ankle, some ankle ligaments will stretch and some ligaments will lock up.

This is why I can treat knee pain in kid athletes so much quicker than adults, because they haven’t had the years of compensation from the knee injury. I can get right to the root cause and get them better by 1 to 2 sessions.

The Hip Connection

The next area is hips. What I often see is really tight hips. Remember when I said the hip has multiple different ranges because it's a ball and socket? That means you have to actually use those ranges. If you don't use it, you lose it. So getting your hips mobile is great for running because then your hips and pelvis have the ability to ascend and descend freely, and the knee doesn't have to compensate by taking on more mobility than it's designed for.

Research supports this too. Studies on runners with patellofemoral pain consistently show weaker hip abductors and external rotators compared to pain-free runners. When the hips can't stabilize and move through their full range, the forces get redirected, and the knee is the joint that absorbs the difference.

Too Much, Too Soon

Another way knee pain shows up is by placing too much stress on your knees too soon. This is actually when I see the majority of running-related knee pain. These runners also have pain going downstairs or walking down a hill. They don't have the proper muscular stability around the knee, so when they go to do something that works with gravity, they don't have the support to control the load. All that pressure then goes to the knee ligaments and tendons in the area instead of the muscles.

This is the load management piece. The tissues around the knee need to be progressively loaded to build tolerance. Jumping straight into high mileage or adding hills without building that base of strength first is one of the fastest ways to develop knee pain.

What to Do About It

So one of the best ways to decrease knee pain while running is taking a look at your ankles and taking a look at your hips.

Ankles: Make sure your ankles are stable but mobile. You should be able to use your big toe and all of your toes. Your arch should be mobile with strength behind it. You want to be using your full foot to push off, run, and plant. If you've had a history of sprains and you've never rehabbed them properly, your ankle is likely not giving your knee the foundation it needs.

Hips: You want your hips to be mobile in rotation, not just forward and back. You want to feel like your hips have the freedom to do a full stride. Make sure your hips are driving forward while you're running and your momentum is forward, not side to side or collapsing inward.

Movement patterns: To decrease pain in your knees while running, make sure you're not putting unnecessary stress on them during daily life either. When you're walking, running, doing squats, doing laundry, you want to be planting your feet and moving with your hips and core first, not leading with your knees. Getting less pain in your knees means putting the stability in other places, primarily the hips and core. You want the core to be the muscle group that drives your body forward and does the work for you. When pain and limitation set in, we start to compensate with joints like the knees, and that's when the cycle gets worse.

The Bottom Line

I've worked with many runners and the best tip I can give is to make sure you have freedom in your joints but stability and strength at the same time. The knee doesn't need to be patched up. It doesn't need complete rest. You want mobility that is strong. If you can change where you put stress on your system while you run and address the things that are actually driving the pain, that is the ultimate hack. That's what I work on with my runners so they can continue running without pain and even get shorter mile times.

If you have knee pain while running and want to address this so it doesn’t get worse. Reach out and we can set up a virtual or in person session to start running pain-free and hitting all of your milestones!