How To Stay Active And Manage Your Knee Pain

So you’ve been trying to get back into shape and just when you caught stride your knees started to hurt. Now what!? There are a few key elements with handling this issue that include optimal exercise selection, smart programming, and activity modification. Here is a comprehensive approach on how to stay active and manage your knee pain regarding different physical activities including running and hiking.


Runner’s Knee

Running is one of the most popular physical activities in the world. Running can be performed anywhere and doesn’t require any equipment, thus it is a cheap way to exercise and burn calories! However, a common mistake people make is they try running to get back into shape. You should be fit to run, not run to get fit. Here is an awesome video that sums up everything you need to know to get back to running when dealing with a knee injury!


Return to Running Progression And The Soreness Rules

Thinking about getting into running again after a knee injury? Check out this Return to Running Progression from the University of Delaware as well as the Soreness Rules. When it comes getting back to running, it’s all about gradually applying the load and stresses to your body again – a term called graded exposure. By applying load/stress in a graded way, you not only give time for your body (and brain) to adapt to the demands, but you also allow yourself to objectively determine how much running you can actually handle.

If you’re injured, follow these guidelines to get back to running! Progress to the next level when you are able to perform the activity level for 2 miles without increased effusion or pain. Perform no more than 4 times in 1 week and no more frequently than every other day. Do not progress more than 2 levels in a 7-day period. Here is the link for the running protocol as well as the soreness rules


Accessory Exercises For Runners

Did you know the knee has been documented as the most common site for an injury in runners (1)? The knee-cap joint (patellofemoral pain syndrome) and IT Band (iliotibial band friction syndrome) specifically  are the most common. Whats important to understand is the patellofemoral joint and the IT Band are influenced by the hips. The glutes play a key role in controlling the position of knee because they control motion of the hips. The position of the knee and hip can also be influenced by the position of the upper body (often referred to as the trunk). Here is an article to learn more about the importance of the glute max and it’s role with controlling the knee.

Whether you are a recreational/casual runner or an elite cross country athlete, it is essential to implement a cross-training strengthening and conditioning program that incorporates glute, quadriceps, and core training. Below are a few exercises that every runner could benefit from.


Glute Strengthening


Core Training


Flexibility For Runners

For anyone that has started running for the first time, or for the first time in a long time – you tend to feel pretty sore and stiff in your legs. Below are some of our favorite stretches for common areas that tend to tighten up and feel stiff from running.


Runners Stretch


Hip Flexor & Quadriceps Stretch


Calf Stretching


IT Band


Knee Pain With Hiking

We surveyed our followers and one of the most common requests was how to manage anterior knee pain (front of the knee). Anterior knee pain with going downhill is not uncommon, especially for someone that is not use to doing this activity and ends up doing a lot in a short period of time. Also there is the chance that their performance and fitness level is sub-par.

Before we go any further there is something we should review – active vs. passive shock absorption. Simply put, every time you take a step with walking there are forces that are imposed on your knee. There are two ways your knee absorbs these forces (1) actively via eccentric muscle contraction, or (2) passively via bone and cartilage. Below are two videos in slow motion to appreciate the differences.


Passive Shock Absorption

Active Shock Absorption

As you would imagine, active shock absorption is optimal in efforts to promote longevity of our passive structures. However, active shock absorption for a long hike with a lot of elevation change requires significant muscular strength and endurance. Whether it is poor fitness, fatigue, or a poor strategy – some individuals may demonstrate more of a passive shock absorption strategy, which may lead to anterior knee pain due to passive structure irritation including bone, cartilage, joint, ligaments, or fat pads. On the other end of the spectrum, performing a significant amount of acute active shock absorption that a person’s body may not be use to could also lead to anterior knee pain if the quadriceps/patellar tendon is overloaded.


Improve Active Shock Absorption

Below are a few exercises to improve glute strength, quadriceps strength, and eccentric muscle control of the hips and knees.


Step Up & Step Down

If the step up exercise is bothering your knee – then try the eccentric step down portion with a small range while keeping all of your weight on the box. Lower down to what feels comfortable and then return to the starting position.


Slant Board Eccentrics

A staple amongst patellar tendon rehab exercises. Positioning your foot angled down on the slant board is going to increase the demand on the quadriceps, thus increase loading of the patellar tendon.


Patellar Tendon Management

Below are exercises and programs that we have used with our patients/clients and have found success with managing patellar tendon issues.


Early Quadriceps/Patellar Tendon Loading

Sample Patellar Tendon Rehab Programming

General Considerations

As previously stated, eccentric muscle action is essential for active shock absorption, which can cause a lot of muscle damage and associated soreness via Delayed Onset Muscle Soreness (DOMS). Paying attention to your exercise programming, volume, and listening to your body are simple ways to mitigate the risk of dealing with knee pain. When you’re managing symptoms or there is a movement that causes a lot of pain – take a break! You don’t want to keep poking the bruise, tissue healing takes time and modifying your activity for at least a short period of time can be beneficial.

Getting back into training and finding the perfect amount of volume can be tricky. A simple concept is the acute : chronic workload ratio. Simply put, we want to find the sweet spot when it comes to training volume. Too much training load in a short period of time compared to your long-term average can increase your risk of injury.



An easy way to measure acute : chronic training load is Sessional Rate of Perceived Exertion (sRPE), which is session time X RPE. An example of this would be 30 minutes of training X 7/10 intensity = 210 units. Acute workload can be looked at the number of training units over a seven day period and chronic workload will be your weekly average over a four week span of time. The equation we will look at is acute/chronic work load with the sweet spot being 0.8-1.3.

Say that your weekly average is 840 units a week and one week you did 700 units. That ratio would be 700/840 = 0.83, which is in the sweet spot. However, if you bumped up to 1700 units in one week, that would be 1700/840 = 2.02, which would be in the danger zone. Think about how often you ramp up  your training or slowly ramp up your hiking distance before a big hike? Consider this next time before you do a big hiking trip!

According to Tim Gabbett, “In terms of injury risk, acute:chronic workload ratios within the range of 0.8–1.3 could be considered the training ‘sweet spot’, while acute:chronic workload ratios ≥1.5 represent the ‘danger zone’. To minimise injury risk, practitioners should aim to maintain the acute:chronic workload ratio within a range of approximately 0.8–1.3. It is possible that different sports will have different training load–injury relationships; until more data is available, applying these recommendations to individual sport athletes should be performed with caution.”


Our Recommendations

If you have any doubt about what you’re dealing with and you have been experiencing long-standing knee pain – please see a medical professional. This information is not intended to be medical advice specifically for you. You should not leave your body up to a guessing game on your own – do yourself a favor and seek a skilled healthcare clinician that can assess and evaluate your knee(s). This skilled healthcare clinician should be someone that is familiar with orthopedics and sports injuries as well as someone that sees knee injuries often. With a thorough in-person assessment, you will be able to benefit from an individualized program that will be designed just for you. If you’re in California or the greater Los Angeles area, click here if you’re interested in working with us!



Tauton et al. 2002 “A retrospective case-control analysis of 2002 running injuries”

Gabbett TJ 2016 “The training-injury prevention paradox: should athletes be training smarter and harder?”

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