Video Case Study: Fixing Knee Pain During Running

"I have been running 5 out of the past 6 days between 7 and 10km and the knee has been holding up well. Very grateful to be able to do this....
Thanks for getting me back to running pain free!"


I don't know how else to say it. It really sucks when all of a sudden doing something that you love starts to cause your body pain. It feels like someone has taken away part of who you are.

This happened to one of my clients this past fall. Running went from being an enjoyable part of her life to something that caused almost immediate physical pain.

It took many months of training to get her back to running pain free. Here's an overview of how we did it.



Step-up fail: the knee caves in as the client performs the movement.

Step-up fail: the knee caves in as the client performs the movement.

Anytime a client tells me that they experience knee pain, the first thing I'm curious to assess is their single leg balance and knee stability. 

And, by the way, If you work with a coach or personal trainer who hasn't done a series of simple assessments with you, think about doing your training elsewhere. It really is THAT important. If a coach or personal trainer doesn't assess you, they have no idea how to develop a program that will be a good fit for you.


The most basic version of this assessment is as follows: can you do 10 step-ups per side to an 8-10" box with perfect form?

Yes or no.


After years of experience, I can tell you this: if you're a human with two functional legs, you need to be able to balance and perform a quality step-up. If you're experiencing knee pain, don't be a door knob. Get help from a good rehabilitation therapist (physio, chiro, etc.). Check out my article on How to Find a Good Physio for more information. If you're already using a rehabilitation therapist and they aren't teaching you enough to accomplish this basic standard, you need to find someone who can.  



If you can't do a simple movement with good form, how can you expect to perform more challenging movements with good form? When we add load, speed, or complexity, any weaknesses will only be amplified. 

These videos go from simple to more complex movements: deadlift (both feet on the floor) to step-up (only one support leg) to lunge (one support leg with greater movement) to jumping (adding high impact, power and speed). If you demonstrate a positioning problem in one, chances are it will show up in any similar movement of equal or greater difficulty.  



First, get help from a rehabilitation therapist. Then get strong enough to do what you want to do. Be prepared to have to re-teach yourself basic things like how to stand, walk and run with proper form/alignment.

The basic approach for a situation like this is pretty straightforward in theory:

  1. Find the weakness/limiting factor (in this client's case - glute and foot weakness). Figuring out the problem can be tricky, and consulting with a good rehabilitation therapist helps a lot.
  2. Move from simple exercises to more complex exercises as your ability improves.
  3. Ensure that proper form and positioning are maintained at all times so you retain good habits/technique through your exercise progressions.



There was a lot of variation in this client's program, but an example of a progression we used is this (videos below):

1. "Clams" to teach basic control of the glutes. (2 weeks)

2. "Single leg hip hinge holds" to work on single leg stability without introducing movement. (2 weeks)

3. "Single leg RDLs" with a slow tempo. (3-4 weeks)

4. "Side step-up" and other step-up variations, and double leg skipping. (3-4 weeks)

5. "Single leg skipping" with plenty of rest to ensure form is 100% (4-6 weeks).

In all cases, the key was to ensure that perfect foot/knee position was maintained during the drill, and that the glutes and foot muscles remained actively engaged.



If you get knee pain when running, passing the step-up test is a good start, but it isn't enough.

In this case, the goal was to get the client back to running 10km without pain. That's about 12,500 strides, which means it's a whopping 12,500 hard impacts that the foot, ankle and knee need to be able to handle.

So after we build basic strength and teach better positions with slow movements (step-ups, squats, etc.), we need to practice with drills that mimic the impact (i.e. ground reaction force) of running. 

Double leg box jumps and skipping (i.e. jump rope), while paying close attention to proper glute activation and foot/ankle position, are a great place to start. After a few weeks, we started doing single leg skipping (more challenging than double leg) and building up her strength and coordination there.

Then, all of this needs to be transferred to the skill of running and practicing maintaining good positioning of the foot/knee under increasing levels of fatigue over time. 



If you flunk the step-up test, get some help now before this leads to knee pain! Especially with running season around the corner, do some preventative maintenance. 

And view it as an opportunity to grab some low hanging fruit rather than something annoying that you have to deal with. When you fix it, I guarantee you will feel so much more solid and powerful.

Poor knee and ankle stability is one of the most common and detrimental movement deficiencies I regularly see with my clients, but it's usually not that hard to correct. It just takes some time, practice, and the right exercise progressions.

If you need help, drop me a line and I can send you more resources. 

And stay tuned. I'll be putting out a periodized running program later this spring/summer. You won't want to miss out on it!

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