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Knee Pain Explained

Giles Gyer of Osteon Physical Therapy looks at how you can keep your knees happy.

Whether you're starting to run regularly for the first time or an experienced pro, your knees are one crucial bit of kit. Fail to look after them properly and you can end up with real problems.

There are many reasons why your knees might hurt, from patellafemoral pain, runners knee, ITB dysfunction, to swelling and bursitis, but let’s look at some sensible steps you can take to prevent some of these conditions happening.

We are also going to look at a few overuse injuries and how you can identify them.

A basic guide to pain-free knees
1 - Correct footwear

Make sure the running shoes you have are fitted for you, whether you have high or low arches, and seek advice from specialist

2 - Start your training sensibly

Most pain and injury is caused by doing too much too soon. If you’re new to running, then build up the mileage slowly, increase your mileage by 10% per week and let your body get use to the new demands you're putting on it.

3 - Never train through the pain

It's your body's way of telling you something's up, addressing issues early is much better than having to take a long lay off.

4 - Stretch

It sounds simple enough, but it's something we could all do more of, work on the muscles surrounding the knee joint, make sure you stretch evenly and consistently, and always both legs!

5 - Foam rolling

It hurts but it works. Focus on the Iliotibial tract (ITB); if this is tight it can cause patella mistracking, runner's knee, and several painful conditions that can literally stop you in your tracks.

Common knee pains in runners: how to treat pain

So you've been sensible, your footwear is good, you stretch like an acrobat, and you're foam rolling so much it's actually stopped making you cry, but you're still having knee pain. Let's cover knee pain locations and what that can mean to you.

Pain below the knee

Patella Tendonitis (Jumper's Knee)

This is an overuse injury where the athlete does a lot of twisting or turning at speed, jumping or heavy landing onto the legs. This causes trauma and small tears to the patella tendon. Pain is felt at the base of the knee cap.


Signs of this can be aching and stiffness after training, pain when you contract the quadriceps muscles, the patella tendon is painful to touch and it can also be associated with poor Vastus Medialis Obliquus (VMO) function.


  • Rest from training in mild and moderate cases
  • Cold therapy after any training
  • Knee straps, kinesiology tape can help reduce the pain and ease the strain on the tendon
  • Strengthening programme to improve strength on the surrounding muscles
  • See a sports injury therapist if pain persists


Patellofemoral Pain Syndrome

This is a generic term for pain at the front of the knee that comes on slowly and gradually gets worse. General patellofemoral pain syndrome happens when the patella does not move or there is a mistracking when the knee is being bent and straightened.


Aching at the front of the knee; swelling sometimes happens after exercise, pain increases when walking up or down hills or stairs, and the knee clicks or grinds on bending. Runners might notice tight muscles, such as the calf muscles, hamstrings and quadriceps.

Runners that over pronate are susceptible to getting patellofemoral pain syndrome and, if you suffer with tight or weak muscles or do a lot of long distance running or hill running, then watch out.


  • Rest until there is no pain.
  • Apply RICE (Rest, ice compression and elevation) after activity. This will help reduce pain and swelling.
  • Knee straps, kinesiology tape can help reduce the pain and a patella stabilising support to control excess movement.
  • Look at stretching and strengthening the leg muscles, focus on the VMO and ITB, and using single leg exercises to balance out any weaknesses.
  • If you over pronate then consider using orthotics, or trainers with arch supports.
  • See a sports injury therapist if pain persists.


Pain on the inside of the knee

Pes Anserine Tendinopathy / Bursitis

This is a repetitive strain condition can be easily mistaken for Medial Collateral Ligament (MCL) injury do to the close proximity.

In simply terms, the Pes Anserine is the point where the tendons of the semitendinosis (Hamstring), Satorius and Gracilis muscles meet and attach to the tibia on the inner part of the lower knee; this can become painful due to repetitive strain.

In this area there is also a bursa, called the anserine bursa which lies between this combined tendon and the Tibia bone underneath. This bursa may become inflamed due to repetitive friction in sports such as cycling, running.

Some symptoms of this condition are pain over the inner and lower knee, pain on climbing stairs, localised swelling, pain on contraction of the hamstrings, pain on stretching the hamstrings.


  • Rest until there is no pain
  • Use cold therapy to reduce the pain and inflammation
  • If you over pronate then consider using orthotics, or trainers with arch supports
  • The use of tape / kinesiology tape to help support the knee
  • Stretching the hamstrings, quads and groin muscles effectively.
  • Sports massage therapy may be useful to treat the hamstrings
  • See a sports injury therapist if pain persists


Pain on the outside of the knee (ITB Syndrome)

Ilio Tibial Band Friction Syndrome (ITBFS)

Or "Runner's Knee" is a common and painful overuse injury that mainly affects the out part of the knee.

This common problem has many causes, people who have weak hip muscles such as the gluteus medius, or if you overpronate you can suffer from this condition and runners who do excessive training or hill running can be very susceptible.

Common symptoms for ITBFS are suffering from Pain on the outside of the knee, Tightness in the iliotibial band, pain is normally aggravated by running, particularly downhill or during flexion or extension of the knee, made worse by pressing in at the side of the knee over the sore part.


  • Rest, or reduce the mileage
  • Avoid painful running, for example downhill running or running on uneven surfaces
  • Apply cold therapy or ice to reduce any inflammation
  • Iliotibial band stretches after training and throughout the day are important
  • Combine the stretches with the use of a foam roller for the ITB, calfs and quads
  • Self massage techniques can also be very helpful in correcting ITB tightness
  • See a sports injury therapist if pain persists


Pain behind the knee

Popliteus Strain

The popliteus muscle is a tiny muscle situated in the back of the knee joint, it assists with internal or medial rotation of the tibia and also helps unlock the knee when a runner initiates knee flexion, or bends the knee from a fully extended position.

This poor little muscle is at risk to over use injuries, and injuries that are causes by muscular imbalances around the knee, also if the knee is excessively hyper extended.

Some signs of a popliteus strain are: if the muscle is tender to the touch; if you get posterior knee pain on resisted knee flexion; if your hamstrings are excessively tight and knee extension is painful or uncomfortable.


  • Rest until there is no pain and, if you still train, avoid running down hills
  • Make sure you have correct footwear when training
  • The popliteus muscle is difficult to work on and responds well to massage therapy
  • Apply cold therapy or ice to reduce any inflammation
  • Strength programme to reduce any muscular imbalances in the leg
  • See a sports injury therapist if pain persists


Note: This is not an exhaustive list of knee conditions, but a guide to a few overuse injuries that are common in runners. This doesn't address direct trauma to the knee joint such as tears or ruptures as that's a whole other article. Above all, always seek medical advice from a qualified therapist if pain persists.