How to recover from knee pain and start running again

As a chiropractor, the end of the year is really when I started to see knee pain cases from runners. There are two types of runners that I would typically see. Those who would come to me before the Singapore Marathon so I can help them get through the race. As well as those who would come to me after the race to fix their problems. Either way, knee pain is frustrating to work with and often doesn’t go away on its own. The good news? With the right approach, you can recovery and return to running without pain. In today’s post, we will discuss how to approach return to running when you have knee pain.

Common Causes of Knee Pain After Running

I wouldn’t be focusing too much on this because there is tons of information available online already. I think the problem with providing textbook answers to the causes of knee pain is that it can cause more harm than good. It encourages self-diagnosis and can often mislead people down the wrong rabbit hole. The end result is delayed recovery or worsening of a knee injury.

The standard answer to causes of knee pain from running include: runner’s knee (patellofemoral pain syndrome), ITBS (iliotibial band syndrome), patellar tendonitis, meniscus tears, etc. When self-evaluating, it is easy to match your symptoms to what is reported online. However, it is extremely common for runners to present with more than one injury at a time. As such, it is best to seek professional advice if you are looking for a diagnosis.

To give an example of multiple concurrent injuries, a client who had MRI of their knee found that there were at least ten potential contributing factors for their knee pain that was observable on their images.

If you were to match your symptoms, you will inevitably end up with one problem or diagnosis. This is problematic because it gives a false impression of the severity of the issue as well as the areas that need to be addressed for you to have a successful recovery.

Knee MRI can correlate poorly with knee pain

To make the matter worse, what you see on films may not actually be the reason why you are experiencing pain. This is a bit mind boggling so to better understand this, you should check out our old post on pain science.

The crux takeaway is that you can have pain without injury, and injury without pain. This is why diagnosis for knee pain can be challenging and why some people struggle to find good recovery results with their treatment.

A study of 230 knees found that 97% of people with PAIN-FREE knees had abnormalities in at least one knee structure on MRI. The most common structures involved are meniscus and cartilage of the knee. Those are always reported as the most common causes of knee pain among runners!

Here is the question: If so many people with non-painful knees have pathologies in their knee joint, is your MRI abnormality truly the cause of your pain?

To push it even further, is it possible that your meniscus tear or the likes were already present long before your pain started?

Knee surgery doesn’t always have the best track record.

It’s common to hear people associate running with wearing and tearing of the knee joint. First, that is not true. The correlation between running and degenerative knee disease is poor. Second, a lot of asymptomatic aka pain-free knees actually have observable degenerative knee findings on MRI. In other words, knee degeneration could be more of grey hair and wrinkles than actually problems that need to be fixed.

Regardless, I digress.

What I wanted to talk about is a big study published in 2017. The researchers found that knee arthroscopy was marginally better to no better compared to conservative care for both pain and function. This is something to keep in mind.

If the structural problem is the reason why people have knee pain then why does knee arthroscopy, where damaged tissue are literally removed or repaired, not work?

So, we have at least two (strong) arguments to why a root cause-based approach doesn’t work. First, a lot of people (97%) with pain-free knees have “root cause” problems in their knees on MRI. Second, knee surgeries that remove or repair damaged tissue doesn’t seem to work better than conservative care for both pain and function!

What is EBM aka evidence-based medicine?

This is an appropriate time to segue to talk about research and evidence. If you have been recommended for surgery, it may be a good idea to look up what are the studies available to support that particular procedure. If you can’t find any, you may want to clarify with the doctors you are working with on why it is a good idea and what is the research available to support their recommendation.

Evidence-based medicine is about “the application of the best available research to clinical care, which requires the integration of evidence with clinical expertise and patient values.”

A lot of people like to talk about chiropractors being quacks and how it is pseudoscience. Sure, I do see some dodgy chiropractors with questionable practices in Singapore so I will give you that. But why don’t we question mainstream medical procedures with the same rigor?

I am not saying that all knee surgeries don’t work. I am saying that sometimes knee surgeries are unhelpful and it is good to be discerning.

In God we trust, all others must bring data.

How to return to running when you have knee pain

I cannot emphasise it enough. Root causes are not as important as the greater society puts it out to be. You can recover from your knee pain without knowing the root cause at all. If you are serious about finding out what the root cause is, you 100% want to seek (evidence-based) professional help! Now that that is out of the way, how then can you get back to running with knee pain?

Rest

First, rest. I do agree, in theory, that rest is not necessary for everyone. However, in practice, I almost never meet clients who can’t benefit from some rest. In other words, if you have knee pain, rest is highly likely a good idea.

If you pain is acute (i.e., only just started a few days or weeks ago), resting allows your knee to settle down. The key is to not further aggravate the knee. You 100% can do some gentle stretches and mobilisation as long as they do not aggravate your knee condition.

I cannot emphasise this enough: Do not aggravate your knee.

If you have a hamstring strain, stretching your hamstrings may not be a good idea because stretching your hamstrings may worsening your pain. However, if you have meniscus pain, stretching your hamstring is perfectly acceptable.

This is congruent with current PEACE and LOVE guideline. Published in the British Journal of Sports Medicine in 2020, it is recommended to avoid activities and movements that increase pain in the first few days after the injury.

If you are self-managing, I will suggest being more conservative and avoid them for approximately two weeks before slowly reintroducing them again.

Deloading is about reducing load and merely changing activities

Just last year, a consensus statement on deloading was consolidated from expert strength and physique coaches. Deloading was defined as a period of reduced training stress designed to mitigate physiological and psychological fatigue, promote recovery, and enhance preparedness for subsequent training.

The key words that I want to highlight is “promote recovery”. When I advise clients to give running a temporary break so the needs have a chance to recover, they often ask if they can do other exercises such as hiking, circuit classes, trampoline workouts, etc.

The whole point of reducing load or load management is so the knee has a chance to recover. If we are looking at reducing load from running but yet increase load to the knees from other activities, then the deload may not achieve its objectives.

I understand the anxiousness in getting back to sports but it is important to understand the objective of resting and how appreciate the benefits it can bring you in the long run. As the Chinese saying goes, 休息是为了走更长的路 (rest is a preparatory step for a longer journey ahead).

Strength and conditioning

It’s very easy for people to say but I already squat or I already do leg press or I already stretch, etc. The truth of the matter is that if you have knee pain, what you are doing is simply inadequate.

I don’t mean insufficient in the sense that you need to squat heavier weight or more reps. But your choice of strength and conditioning is not preparing you enough for the demands of your running programme.

The solution therefore is to dig deep and find out what you have missed. Prioritise them based on what is most likely to help, and work on these areas accordingly.

This is why online bulletproof-your-knees training programme do not work for most people. Sure, some people can get better from following the programme but most don’t. We are different people, with different bodies, fitness levels, exercise history that there is simply just no perfect one-size-fit all approach.

Choose exercises that are not weight bearing first

Yes, running is definitely a load bearing exercise. You definitely need to be able to weight bear in order to go back to running. But of all strength and conditioning or rehabilitation you can do, choose the non-weight bearing ones first!

Why? Give your knees a change to rest.

You can go in hot and squat heavy from the get-go. It does work for some people but for most of us it will not. It will likely overload your knees and cause more pain, and delay your recovery.

By playing the long game and going slow and steady, you can get extremely good long-term results.

Gradual return to sport (pain is not acceptable)

When you decide to start running, forget about the mileage that you used to run. The reason is because that was the amount that was too much for you in the first place. We also cannot retrospectively figure out at what point it was too much because stress can be cumulative.

It’s much better to take reference from your current capacity. In order to do this, you will need a professional assessment. At Square One Active Recovery, we perform both biomechanical and functional assessments to ascertain how ready a person is to return to sport. If not ready, we can use these assessments to estimate how much work needs to be done and forecast when they can start running, and how much.

Without professional help, it is a good idea to start from zero.

A lot of injured runners use a run-until-it-starts-hurting strategy when they return to sport. They will run until they experience pain then stop. Rinse and repeat. Dear readers, this is a bad strategy!

In doing so, you are repeatedly aggravating your knee and it’s a recipe for disaster!

Run as little as you can then increase from there

If you are working on return to sports on your own, start with as little as possible. Very often, people will report the pain starting at approximately 1-2km mark at the start. For some, this initial pain will go away (i.e., no longer present as they continue to do more 1-2km runs). For others, the pain may persist or worsen.

For starters, if you are self-managing, 1km is a good conservative number to bring your knees for a test drive. Instead of trying to run the most you possible can, think of running the least you possibly can while still working on other areas of your recovery.

If 1km is doable for you, it makes more sense to run repeatedly 1km than to increase the distance per run straight away. You can start by once a week, then gradually increase to 2-3 times per week. Once that is achievable, you can consolidate your weekly mileage into a single long run to see how your knees cope. From there, you can gradually increase your mileage.

While this is indeed extremely conservative, it can help you avoid the vicious cycle of having your knee pain coming back over and over again. Sometimes what you need is to take extreme measures so you can have a breakthrough.

Cross-training

Something that is worth considering is that you don’t actually need to run to improve your running. When it comes to improving cardiorespiratory fitness, swimming can be helpful and is significantly less stressful than running.

Similarly, if you want to improve strength, you can do so by non weight-bearing exercises through gym machines. For example, leg extensions can be useful for training for quad strength while hamstring curls can help train your hamstrings. All of these exercises can be performed without you being weight bearing.

As much as possible, try to find what are the domains within running that you can work on through other exercises. They can help you improve your running capacity without actually requiring you to run on your knees.

Of course you cannot be a good runner from swimming alone. This is not what I am suggesting. What I am suggesting is that there are many training options for you to choose from. You don’t need to only run to get better at running.

Embrace yourself for setbacks

There is no magic cure that will get you back to running. No magic exercises you have to do. No miraculous treatments that work the way you would prefer.

Being pain-free without running is arguably easier than a full recovery with successful return to running. Wanting to keep running, which I appreciate is important to you, is an additional step once you are pain-free.

Running pain-free is more complex. It’s not just about healing the knee, but also about retraining your body to handle the impact and demands of running once again.

You will have small wins along the way. Similarly, you will also have setbacks. Unless you, or your choice of healthcare provider, can perfectly predict how your knee responds to every circumstances, it is inevitable that you may accidentally aggravate your knee even if you do everything right.

This is part of the recovery journey. It’s important to remain patient and resilient, understanding that healing isn’t linear and that progress often comes with bumps along the way.