Updated: Apr 16, 2020
I have Kneecap Pain – should I run?
Written by Alison Low APA Specialist Sports Physiotherapist
Have you had persistent knee pain and been told by friends, family or even health professionals that you should stop running, it’s “bad for your knees”? This can be a heart breaking position to be in as a passionate runner – your heart may tell you to keep going whatever the cost but your head may be telling you to stop. This article will explore the latest scientific evidence in an attempt to answer the question “ I have kneecap pain – should I run?”
Runners know that running makes them feel great, connects them with communities and helps in managing weight and other chronic health conditions. Research here will back them up – a recent study has shown that runners live on average 3 years longer than non-runners and have a reduced risk of early mortality by 25—40%! (1)However up to 79% of runners will develop an injury and kneecap pain (known as patellofemoral pain) is one of the most common. (2)
Preliminary research (3 and 4)has connected persistent kneecap pain with ‘wear and tear’ changes shown on an MRI scans, these changes can be interpreted as early osteoarthritis – which is a pretty scary diagnosis. As MRI scans are getting cheaper and more accessible it is likely that many runners with ongoing knee pain are given a scan or may even request one when they are frustrated about ongoing pain. It is important that you have a discussion with your trusted health professional (ideally one who has experience with runners) about what changes may be found on the scan and how they relate to your current problem. There is good evidence in other parts of the body (shoulder and low back) that findings reported on scans are not always associated with pain and there is emerging evidence that this may also be the case with the knee.
If you do have a scan which shows early wear and tear what do we know about the risks of continuing to run? A large study in the Netherlands(5) has shown that 2 of the biggest risk factors for progression of osteoarthritis are a higher body mass index (BMI) and other health issues such as cardiovascular disease and diabetes – and we already know that running is a fantastic way of managing these. At the moment scientists have been unable to prove a link with running and increased osteoarthritis of the hip or knee (6). In fact a recent report (7)has found that recreational runners are less likely than their non-running friends to develop this condition and also less likely to have a total knee replacement if they do have degenerative changes. However scientists encourage these results should be interpreted with caution as they also found professional/elite or ex-elite runners showed slight increase in risk of knee osteoarthritis compared with non runners and runners were only followed up for 15 years.
So far research has been able to prove the benefits of running on general health and place doubt in the minds of those who believe running ruins your knees but should you run with kneecap pain? Currently the best available evidence(8 and 9)for managing kneecap pain includes an approach tailored to the individual runner including all, or a combination of, strengthening exercises for your hip muscles, thigh muscles/quadriceps or core, taping and orthotics/footwear modification. There is less evidence in favour of advice regarding stretching or massage but anecdotally this may also be effective. It is really important that the key drivers to your pain are identified and targeted rather than a scattergun approach. Choose a health professional that is used to working with runners and make sure that they communicate with you why they are choosing a particular management program. There is emerging evidence (10) that gait retaining in runners may also be effective. This is great news as it may provide an important window of allowing a runner to continue to not only safely run but run in a way that may be beneficial to their kneecap pain in a long term management plan.
How do you know what is right for you? In the early management of kneecap pain running load needs to be reduced. As a general guide it is advocated that you can run with some pain as long as that pain does is not greater than 2/10 (on a scale where 0 is no pain and 10/10 is the worst pain imaginable), the pain does not last more than 60 mins after completion of a run and there is no increase in symptoms the following day. It is important here that you are honest as the old saying goes if you are not “you are only cheating yourself”. Other ways of reducing loads but keeping on running include reducing speed (even considering a walk/run program), not running downhills or down stairs and reducing the distance of the run so you are not running in a fatigued state. Although it may seem counterintuitive kneecap pain can often be better managed with smaller but more frequent runs, this may be a strategy to keep weekly mileage up with less pain. However every runner is different so if shorter slightly faster runs seem to keep your pain within the guidelines outlined above then that may be a better strategy for you. This is why working with someone who is experienced with runners and writing a diary as to how your kneecap pain responds to running load is so very important.
If you are not strong enough especially through your core muscles, hip muscles or thigh muscles you may be sinking into too much knee or hip flexion whilst running. This can place greater forces through your kneecap joint. This is why your health professional will encourage you to add a strength training component to your training program. If you can maintain a better running position (especially when fatigued) it may reduce the forces going through the kneecap joint. The long term aim of a strengthening program is to improve your capacity to tolerate load and eventually do more running.
As mentioned previously exciting, emerging research(10 and 11) has suggested that running retraining focusing on technique changes including cues that increase cadence or encourage more forefoot landing can be effective in managing kneecap pain- to some extent this has been tied in with the minimalist footwear movement. It its true that these changes can reduce load going through the knee and reduce pain but it is important to note that the load is shifted elsewhere and that is normally to the foot and ankle so having strong and powerful calves is encouraged.
Once kneecap pain in under control it is important to gradually re-introduce loads to allow each runner to reach their potential. Currently it is recommended to increase these loads gradually (approximately 10% a week) to minimise any pain flares. When recovering from an injury it is advised to only change one component of training at a time eg volume or add speed or add hills so you can see how your painful knee reacts. Writing down your pain scores and time for recovery of pain post run in your training diary can help you see any emerging patterns related to training load.
To finish where we began with the question “I have kneecap pain should I run?” Emerging evidence suggests that running with minimal symptoms (less than 2/10) that settle quickly and show a trend for improvement, running is not only OK it may also be beneficial as part of a holistic management plan monitored by a health professional. By carefully managing you training volume , shifting the load away from your knee and improving your knee’s capacity to tolerate load you will get back to running pain free.
1.Lee D-C, Brellenthin AG, Thompson PD, Sui X, Lee I-M and Lavie CJ. Running as a key lifestyle medicine for longevity. Progress in Cardiovascular Diseases 2017;60:45-552.
2.Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002;36:95–101
3.Crossley KM. Is patellofemoral osteoarthritis a common sequela of patellofemoral pain? Br J Sports Med 2014;48:409-410
4.Collins NJ. Presented at APA national conference 2017