Runner's Knee: Why It Happens and How Physiotherapy Fixes It

You started running to get fit, and for the first few months it felt great. Then a dull ache appeared around your kneecap. It was manageable at first, maybe just noticeable at the start of a run. But now it hurts going up stairs, sitting for long periods, and the thought of your next run fills you with dread instead of excitement. This is runner's knee, and it is the single most common injury in recreational runners.

The frustrating thing about runner's knee is that rest makes it feel better, so you assume it has healed. Then you run again and the pain returns within a week. This cycle repeats because rest does not fix the underlying problem. This guide explains exactly what causes runner's knee, why standard advice often fails, and how a targeted physiotherapy programme resolves it for good.

What Exactly Is Runner's Knee?

Runner's knee, clinically called patellofemoral pain syndrome (PFPS), is pain around or behind the kneecap (patella) that worsens with running, squatting, climbing stairs, and prolonged sitting. It occurs when the patella does not track smoothly in its groove on the femur during knee bending, creating irritation of the cartilage and surrounding tissues. Despite its name, it is common in cyclists, hikers, and anyone who increases lower-body loading without adequate preparation.

The condition affects 25-30% of all runners at some point, making it the most prevalent running injury worldwide according to systematic reviews published in the British Journal of Sports Medicine. It is more common in women than men, likely due to wider hip angles and differences in neuromuscular control.

Why Does Runner's Knee Happen? The Biomechanical Causes

Runner's knee is rarely caused by a problem in the knee itself. It is almost always the result of how forces are transmitted through the leg during running. The knee sits between the hip and the foot, and when either of those joints is not doing its job properly, the knee absorbs the excess load. Understanding these causes is essential because treatment must target the source, not the symptom.

Weak Gluteal Muscles

The gluteus medius and maximus are the primary stabilisers of the pelvis and femur during single-leg stance, which is what running essentially is: a series of single-leg hops. When these muscles are weak, the femur rotates inward during the landing phase, pushing the patella against the outer edge of its groove. This is the single most common finding in runners with PFPS.

Poor Hip and Core Control

Core weakness allows excessive pelvic drop on the stance leg side, which further increases valgus (knock-knee) forces at the knee. This is visually apparent as a hip drop or a knee that dives inward with each step. It is often more pronounced during fatigue, which is why runner's knee pain typically worsens toward the end of a run.

Quadriceps Imbalance

The vastus medialis oblique (VMO), the inner portion of the quadriceps, plays a key role in keeping the patella centred. When the outer quadriceps (vastus lateralis) dominates, it pulls the patella laterally, increasing friction. This imbalance often develops from sedentary lifestyles where the inner quad becomes inhibited.

Training Errors

• Too much too soon: Increasing weekly mileage by more than 10% creates overload faster than tissues can adapt
• Hard surfaces: Running exclusively on pavement or concrete increases impact forces compared to trails or tracks
• Treadmill overuse: Treadmills encourage a shorter stride and different mechanics that can increase patellofemoral load
• Downhill running: Eccentric quadriceps loading during descent places significantly more force across the patellofemoral joint

What Does a 6-Week Physiotherapy Programme Look Like?

The following programme represents the evidence-based approach used at our sports rehabilitation clinic. It progresses from pain management and basic activation to full return to running over 6 weeks. Each phase should be mastered before progressing. Some patients progress faster, some slower, and the programme should be adjusted based on individual response.

Research from the Journal of Orthopaedic & Sports Physical Therapy demonstrates that hip-focused rehabilitation programmes are significantly more effective than knee-focused programmes for patellofemoral pain. The exercises above are designed to strengthen the hip stabilisers first and then progressively load the patellofemoral joint as strength improves.

How Can You Modify Your Running to Reduce Knee Pain?

Running form modifications can provide immediate pain reduction while you work on the underlying strength deficits. These changes reduce the load transmitted through the patellofemoral joint without requiring you to stop running entirely, which is important for both physical and mental health.

• Increase cadence by 5-10%: Taking shorter, faster steps reduces impact force per stride. Use a metronome app or music at the target BPM. If you currently run at 160 steps/min, aim for 168-176
• Lean slightly forward from the ankles: A gentle forward lean shifts loading away from the knee and toward the hip and glute muscles
• Avoid overstriding: Your foot should land under your centre of mass, not out in front. Overstriding acts as a brake and increases patellofemoral force
• Reduce downhill running: Until pain resolves, avoid steep descents or walk the downhill sections
• Run on varied surfaces: Alternate between pavement, track, and softer trail surfaces to distribute impact differently

What Shoes Should You Wear for Runner's Knee?

Shoe selection for runner's knee is often oversimplified. The right shoe depends on your foot mechanics, running style, and the surfaces you run on. There is no single "best shoe" for patellofemoral pain, but there are evidence-based principles to guide your choice.

• Cushioning: Moderate cushioning reduces impact forces compared to minimal shoes. However, excessively cushioned shoes can reduce proprioceptive feedback and alter landing mechanics
• Heel-to-toe drop: A lower drop (6-8mm) encourages midfoot landing and may reduce patellofemoral load compared to high-drop shoes (10-12mm)
• Stability features: If you significantly overpronate, a mild stability shoe can help. But most runners with PFPS do better addressing the problem through hip strengthening rather than shoe corrections
• Shoe rotation: Using 2-3 pairs of different shoes reduces repetitive loading patterns. A 2015 study found that runners who rotated shoes had 39% fewer injuries
• Replacement: Most running shoes lose significant cushioning after 500-800km. Track your mileage and replace accordingly

How Does Running in Dubai Affect Knee Pain?

Dubai's environment creates specific challenges for runners that are often underestimated. These factors do not directly cause runner's knee, but they increase vulnerability and can slow recovery if not managed properly.

• Heat and dehydration: Running in high temperatures causes faster muscle fatigue, which reduces the protective muscle activation around the knee. Dehydrated muscles are less elastic and more prone to strain
• Hard surfaces: Dubai's running routes (canal, marina, JBR) are predominantly paved, offering no shock absorption. Consider incorporating treadmill sessions or trail runs at Al Qudra for surface variety
• Seasonal patterns: Many Dubai runners drastically increase mileage in October-November when the weather cools, creating a classic too-much-too-soon overload after summer inactivity. Build gradually using the 10% rule
• Treadmill dependency: Summer months often mean treadmill-only running. The fixed belt speed and flat surface create different loading patterns. Vary incline and speed to simulate outdoor running diversity
• Race season: Dubai Marathon, Ras Al Khaimah Half Marathon, and various trail runs concentrate between November and March. Plan your training build-up to peak for your target race, not every race

Häufig gestellte Fragen

Getting Back to Pain-Free Running

Runner's knee is frustrating precisely because it feels like it should be simple to fix. The knee hurts, so surely the knee is the problem. But in almost every case, the solution lies in the hip, the core, and the way you run. Address those factors with targeted physiotherapy, and the knee pain resolves.

If you have been stuck in the rest-run-pain cycle, it is time to break it. A proper biomechanical assessment and a structured strengthening programme can transform your running from a source of pain into the healthy, enjoyable activity it should be.

Verfasst von

Dr. Hadi Komshi

Profil anzeigen

Specialist Internal Medicine

MD, DHA-Licensed

Dr. Hadi Komshi is a DHA-licensed Internal Medicine Specialist at Doctors Clinic Diagnostic Center in Dubai Healthcare City, with extensive experience in managing acute and chronic medical conditions including musculoskeletal pain and rehabilitation.

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