Why Your Knees Hurt When You Run (And Why Nobody’s Watching You Run)
Location First, Then Watch Them Run
When someone comes in with knee pain from running, the first thing we’re trying to figure out is where the pain actually is. Sometimes that location can be really telling — there might be some sort of structural irritation, like the meniscus or the medial or lateral collateral ligaments becoming very irritated.
But honestly, location is just the starting point. The next thing we’re looking for is how is this person running? One of the major steps people miss in evaluating pain is they don’t go watch the thing that’s creating the pain. If you’re having knee pain with running, we need to see you run. That sounds obvious. It almost never happens.
What We Look For When You Run
We have our own evaluation for this. The first thing we look at is running cadence — how quickly are the feet making contact with the ground. Then we’re looking for how much head motion is occurring and what kind. Is the head swinging side to side? Is there a lot of up and down vertical translation?
After cadence and head motion, the next thing we focus on is how someone is actually making ground contact — what part of the foot is hitting the ground first. All of this goes together. It’s really hard to have a mechanically efficient cadence if you have a strong heel strike pattern, because inherently there’s a point where you have to slow down to make the heel strike the ground.
Skipping Tells Us Almost Everything
Then we take them through a specific evaluation. First, we watch them skip. Skipping is actually a really great template for how to run. It shows us how they’re creating force, and people can usually fall back to a major running pattern in it. We need people to be using their hips to create hip flexion to run, and that usually shows up naturally in a skip. But sometimes it isn’t happening, and there’s a lot of drive coming from the calf and the quadricep — which is where we think a fair amount of this knee pain is coming from.
Then we’ll have them bounce up and down on their forefeet and watch what their body naturally does. We’re looking for around 180 beats per minute, but people are usually much slower than that. When they’re bouncing up and down on their forefoot, there’s usually a lot of knee bending happening, and they’re not letting the elastic tissue of the calf do the work. So most of the work is happening around the knee and the patellar tendon. That’s a major source of knee pain — they’re not allowing the calf to do the job the calf is supposed to do. And because they can’t sustain that kind of impact over and over through knee flexion quickly, the cadence stays really slow, around 120 beats per minute.
The Calf Is Suspension, The Hips Are The Motor
We had a patient recently who had almost no hip flexion in their skip pattern. What we really saw is that the entire force they were using to run was just pushing through their calves. And the problem is: the calf needs to function as a shock absorber, not a force generator. It needs to take in the energy of landing, send it through the elastic tissue of the Achilles, and redistribute that force back out. There’s a lot of mechanical efficiency in that. And it can’t happen if the calf is also trying to be the primary motor.
So we need the calf to be the suspension, and the hips to be the motor moving forward.
To help that patient feel it, we started with single leg hopping. When you stand on one leg and try to hop, it’s really hard to not use the opposite leg — the body naturally wants to use the leg that’s in the air to help create forward momentum. This patient wasn’t doing that. They were working really hard. Once we encouraged them to swing the elevated leg through, they started feeling how much easier the motion was and how much more momentum it created.
This usually happens in about an hour. Once someone can feel that it’s easier and it doesn’t hurt, they’re pretty happy to do it. The body is pretty accepting of that pathway. About 20 to 30 minutes is the evaluation and reteach. The next 15 minutes is how to actually do this when running right now. And the last 15 minutes, one of us will sometimes go running with them so they can pick up a natural stride and cadence and start to unconsciously mirror that pattern.
What Progress Actually Looks Like
Progress is an interesting word choice here. Week one, people are going to slow way down, because they’re learning a new thing. So we move into interval training — usually 10 to 14 rounds of running one block and walking three, to let the body learn how to move from a different energy source. Initially, output goes lower. But pain starts to recede, because the knee is no longer as involved in the mechanics.
About three or four weeks in, they return to their previous pace. They hover there for a while, and it takes another few weeks before speed really starts to increase — if that’s even the goal.
For most runners, the goal we’re working toward is between a seven and ten minute mile. There’s a lot of mechanical efficiency for humans at that pace. But it really depends on what the person wants. If they just want to run a few miles for fun without pain, pace isn’t a big deal. If they’re chasing a 5K time, or doing 200+ mile ultras like some of our patients, the conversation around cadence and training looks very different.
The Misconceptions We Keep Hearing
The biggest one: that running inevitably creates knee pain. The other one is that running is just bad for knees — but most of these patients only have pain in one knee, and you have to run with both legs in motion. That’s not mechanical. That’s a pattern problem.
Most runners we see in Portland are running on the roads in really thick foam shoes. The foam is often hiding their ability to heel strike and lose all their cadence and hip flexion — which is a source of running power. These are mostly weekend warriors — people with a strong connection to cardiovascular training, who want to run two to four times a week as a way to feel balanced and connected to movement. That’s where we see a lot of these issues.
For what it’s worth, Dr. Q runs barefoot, and that’s taught our team a lot about how running actually works. You can’t push and twist off the foot when you’re barefoot — it’ll just wear away the skin. So the down foot has to act like a big shock absorber, and it’s the leg off the ground that’s actually creating forward momentum. Totally different feeling. Totally different energy source.
What We Want You To Know
Even though Dr. Q runs barefoot, we don’t really care what you run in. What we want you to know is that how you run is extremely important, and it’s often the easiest source to get out of pain. We all of assume we have an inherent ability to run — and as kids we do — but that changes a lot as we grow up, for a lot of reasons.
And here’s the part that matters: when people are having knee pain, no one is really watching them run. When you come to Move Better, we will watch you run. If knee pain happens when you run, we’ll go run. Whatever movement is creating your pain, we’ll watch you do it as close to real life as possible. And if we can’t recreate it in the clinic — say it only happens at work — we’ll do our best to build that scenario here.
If you’re running through knee pain right now, or you’ve been told to just stop running, come see us. We’ll watch you move, and we’ll build a plan from there.