Knee pain is one of the most common complaints among runners, but not all running-related knee pain is the same. Where the pain occurs, when it begins, and how it responds to activity can tell us a great deal about what may be causing it.
When a runner comes to Art of Physical Therapy with knee pain, I do not look only at the knee. I want to understand the runner’s training history, weekly mileage, running surface, recent changes, strength, mobility, running mechanics, footwear, and goals.
The goal is not simply to make the pain disappear temporarily. It is to determine why the knee is receiving more stress than it can currently handle and help the runner return to training with confidence.
Where Does Your Knee Hurt When You Run?
One of the first questions I ask is: Where exactly do you feel the pain?
The location of the pain can help differentiate between several possible causes. Pain in the front of the knee may indicate something different than pain on the outside of the knee or below the joint.
I also ask questions such as:
How long have you been running?
What does your weekly running routine look like?
How many miles are you running?
What surfaces do you normally run on?
Have you recently increased your mileage or intensity?
Have you added hills or speed work?
Have you changed your footwear?
Are you preparing for or recovering from a race?
Does the pain improve as you warm up?
How long does the pain last after running?
Many running injuries develop from repetitive, chronic overloading rather than one dramatic incident. Understanding the runner’s training program helps me determine whether the workload may have increased faster than the body’s ability to adapt.
Common Causes of Knee Pain in Runners
Several possible causes of running-related knee pain exist. Two of the most common conditions I see in runners are patellofemoral pain syndrome and iliotibial band syndrome.
Patellofemoral Pain Syndrome
Patellofemoral pain syndrome, commonly abbreviated as PFPS, usually causes pain in the front of the knee around or behind the kneecap. Some runners also feel pain along either side of the kneecap.
The pain may become noticeable during running, squatting, lunging, or using stairs. It often relates to how much load the knee is receiving and whether the muscles around the hip and knee can control that load effectively.
Iliotibial Band Syndrome
Iliotibial band syndrome, often called IT band syndrome, typically causes pain on the lateral, or outside, portion of the knee.
The pain may begin after running a certain distance or become more noticeable during longer runs. A runner’s training load, hip strength, lower-body control, and running mechanics may all contribute.
What Causes Running-Related Knee Pain?
Running knee pain rarely has one universal cause. In my experience, several contributing factors often overlap.
Increasing Mileage Too Quickly
One of the most common training mistakes is increasing mileage or intensity faster than the body can adapt.
Your cardiovascular system may feel ready to run farther before your muscles, tendons, joints, and bones are prepared for the additional workload. You may feel fit enough to increase your mileage while the tissues in your lower body are still catching up.
This does not mean running is bad for your knees. It means the training load needs to progress at a rate your body can tolerate.
Quadriceps and Glute Weakness
The quadriceps and gluteal muscles help the body absorb and control the forces produced during running. Weakness in these areas, especially poor eccentric control, may increase stress at the knee.
Eccentric control refers to a muscle’s ability to manage force while it lengthens. Runners need this control every time the foot hits the ground, the knee bends, and the body accepts weight.
Limited Hip or Ankle Mobility
A mobility restriction does not always cause pain at the restricted joint. Limited movement at the hip or ankle can alter lower-body mechanics and shift more stress toward the knee.
This is why an effective knee evaluation should examine the entire lower body rather than focusing only on the painful area.
Overstriding and Slow Cadence
Overstriding occurs when the foot lands too far in front of the body. This pattern, particularly when combined with a slower cadence, can increase braking forces and place additional stress on the lower extremity.
That does not mean every runner with knee pain needs to change their form. Evaluate running mechanics in the context of the individual runner’s symptoms, strength, mobility, experience, and goals.
A Runner With Knee Pain Six Months After a Sprain
One runner I treated had a mild knee sprain outside of running. Six months later, the symptoms had changed to pain in the front of the knee, and the pain was preventing the patient from running.
During the evaluation, most findings appeared normal. However, the affected leg had significant quadriceps weakness and considerable tenderness around the kneecap. Lunging and squatting also reproduced the pain.
These findings were consistent with patellofemoral pain syndrome.
We began with quadriceps activation and hip strengthening in positions the patient could perform without increasing pain. I also used taping techniques to help reduce stress around the kneecap.
Within one or two follow-up visits, the knee’s sensitivity had decreased. We then progressed to single-leg loading and eventually reintroduced running based on the patient’s tolerance.
This case shows why waiting for pain to disappear is not always enough. Six months had passed since the initial sprain, but the affected leg still had a significant strength deficit that needed attention.
What Can Runners Safely Try at Home?
For new or relatively mild knee pain, massaging and gently stretching the muscles around the knee and hip can be a safe place to start. These strategies may reduce discomfort, but they often do not prevent recurring pain on their own.
If the pain is related to repetitive loading, we still need to determine why the knee is receiving more stress than it can tolerate.
Basic strengthening exercises that may be helpful include:
Step-ups
Single-leg bridges
Controlled lower-body exercises
Pain-free hip strengthening
Pain-free quadriceps strengthening
These exercises should not significantly increase your pain. An exercise that helps one runner may not suit another runner or every type of knee injury.
Stretching, massage, foam rolling, taping, knee braces, or changing shoes may provide temporary symptom relief. However, none of these should automatically be treated as a complete solution. If the pain keeps returning, the underlying training, strength, mobility, or movement issue may not be fully addressed.
Should You Stop Running When Your Knee Hurts?
Most running-related knee pain does not automatically require you to stop running completely. Depending on the condition and severity, you may be able to adjust your mileage, pace, terrain, or workout intensity while beginning rehabilitation.
One condition that may require you to stop running is a possible bone stress injury. Pain from a tibial bone stress injury is often felt below the knee along the shin bone. It typically develops gradually and may not improve after warming up.
You should pause your training and schedule an evaluation if your pain:
Becomes constant
Takes more than a few hours to settle after running
Affects walking, squatting, or using stairs
Does not improve after warming up
Noticeably limits your running performance
Continues to worsen from one run to the next
Is sharply localized over a bone
Continues for longer than one or two days
You don't have to wait until you can no longer run to see a physical therapist. An early evaluation can help identify the contributing factors before the pain becomes more limiting or leads to a secondary injury.
Often, the sooner we can evaluate the problem, the sooner we can help you return to your activity with limited or no pain.
What Happens During a Running Knee Pain Evaluation?
My evaluations are detail-oriented because knee pain is rarely explained by one isolated test.
I assess lower-body strength, mobility, coordination, and control through both functional movements and isolated testing. This may include squatting, lunging, single-leg movements, and measuring quadriceps strength with a dynamometer.
A dynamometer provides an objective measurement of peak muscle strength. This can reveal meaningful differences between the legs that may be difficult to identify through observation alone.
Runners should bring their running shoes because I prefer to evaluate running form on the first day whenever symptoms allow. If the knee is too painful for running, we begin with symptom management and may use taping when appropriate.
A running knee pain evaluation may include:
A detailed review of your running and injury history
Hip, knee, and ankle mobility testing
Quadriceps and hip strength testing
Single-leg balance and movement assessment
Functional squatting and lunging
Running-form assessment
Review of cadence, stride, and foot placement
Discussion of footwear and running surfaces
Review of current mileage and training progression
Treatment Should Match the Runner’s Goals
Treatment should always be personalized. Two runners with similar knee pain may need different plans based on their symptoms, strength, training history, schedule, and goals.
A recreational runner without an upcoming event may have time to reduce training and rebuild gradually. Someone with a race approaching may not have enough time to become completely pain-free or make significant strength gains before race day.
In that situation, physical therapy can help the runner make informed decisions, adjust training, and manage symptoms until the event has passed. We can then address the longer-term contributing factors more fully afterward.
This is very different from telling every runner to stop running and rest.
Rest may calm the symptoms because it temporarily removes the load. However, rest alone does not improve strength, mobility, running mechanics, or training decisions. If those factors remain unchanged, the pain may return when the runner resumes the same workload.
Find the Cause Instead of Only Treating the Pain
The most important part of treating running-related knee pain extends beyond a list of exercises. Runners also need to understand how training volume, footwear, running gait, strength, recovery, and symptoms fit together.
At Art of Physical Therapy in Raleigh, we evaluate the entire runner, not just the painful knee. The goal is to identify the factors contributing to the problem, develop a plan around the runner’s goals, and help them return to running with as little unnecessary downtime as possible.
If knee pain is affecting your running or daily activities, a physical therapy evaluation can help you understand what may be causing it and what to do next.
Get Help With Running-Related Knee Pain in Raleigh
If knee pain is changing how far, how fast, or how comfortably you can run, you do not have to wait until it forces you to stop. Art of Physical Therapy provides detailed running injury evaluations in Raleigh to identify the factors contributing to your pain and build a personalized plan around your training goals.
