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Runner’s Knee Rehab Rationale: Later Phase and Return to Run

Part 2 of this Clinical Pearl series on will focus on runners knee return to running implications. It is during these phases that there will be a larger emphasis on advanced strengthening, single limb loading that simulates running activity, reintegration of running, and power-based exercises! By this point, the runner should have lower symptom irritability, and a solid foundation of motor control, stability, and strength before progressing towards this part of rehab.


“This blog is one of our ‘clinical pearls’, which is designed to assist clinicians in understanding exercise progressions for various clinical conditions. Throughout each of these clinical pearls, you will learn multiple ways to attack similar issues we all see when treating our patients. We also highlight many of our personal exercise library videos throughout these pearls, all of which you can gain access to as an exercise library member!”


Why Do Runners Need Strength and Power Training?

What you will notice is that this runner’s knee clinical pearl places a heavy emphasis on strength training. Why is this important for runners? Simply put, it not only helps prevent injuries, but it also improves running efficiency. When rehabbing runners, you not only want to help them get back to the sport they love, but you also want them to become even better at it than they were before their injury! This is why we must not only implement strengthening exercises but also power-based exercises. If runners can improve their running economy, they will be able to run after faster speeds with a lower rate of perceived exertion (RPE).

If you think about the process of running, our feet are only in the contact with the ground for a split-second. It is a purely single limb stance sport! With strength training, muscles are able to adapt to running by increasing the RATE of force production, ultimately leading to increases in muscular contractions in a shorter amount of time.

Strength training will focus on heavier loads, whereas our power will incorporate load as well, but with an emphasis on speed! 



What About Return To Running?

The University of Delaware has developed the soreness rules that are great to utilize in rehab. Watch along in this video for an explanation on tips to keep in mind when initiating a return to running.

Some important tips to keep in mind:

  • Start on flat surfaces that are more forgiving, such as a track or trail, both of which will decrease ground reaction forces in comparison to road surface.


  • Based on the runner’s experience, that will dictate what volume threshold he or she will start with. For example, an experienced marathon runner may be able to start with jogging for a longer period of time versus a more novice runner who may need to start with a walk/run program


  • Ensure the runner has an understanding of symptom threshold and how to interpret soreness rules


Phase 3 Strengthening Exercises

In this phase, we place a further emphasis on single limb loading, eccentric control, posterior chain strengthening, and bulletproofing the lower body and core! We also will transition the runner to more plyometric-based exercises that promote more power.

Take the eccentric single leg squat to the next level by taking away hand support and purely relying on your own body weight, stability, eccentric strength, and joint proprioception. 


Our quads and hip abductors are 2 of the most used muscles during running. The lateral step down will help increase strength, control the knee joint, promote eccentric strength, and promote proper control in the frontal plane. 


You can progress the lateral step down by increasing the depth of your step down as well as incorporating single limb balance to further emphasize stability. 


The rear foot elevated split squat toe raise will promote strengthening of our glutes, quads, and hamstrings. In addition. the heel raise will incorporate calf strengthening, which is also very important for runners, especially for propulsion.

This is also a great alternative to back squats if your runner simply does not enjoy getting under the bar.


The eccentric hamstring curl is a great way to strengthening the posterior chain on an unstable surface. Focus on slow and controlled with this movement to promote the hamstring muscles time under tension


The single leg hamstring curl is an awesome progression to the exercise above


The Nordic Hamstring Curl is the gold standard for improving eccentric hamstring strength. However, this is an advanced eccentric strengthening exercise and extremely challenging for the average person to begin with.

To work up to the Nordic Hamstring Curl, use your arms to slowly lower yourself to the ground and to help you push up. As you get better at this exercise, incrementally reduce how much you depend on your arms!


The Ultimate Resource For Educating and Programming For Your Patients

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Are you searching for a better way to provide education and exercise programming for your patients? The [P]Rehab Exercise Library is the best library available to the public that can optimize the resources you are providing for your patients and clients! Click HERE to gain access today.


Phase 3 Power Exercises

Runner’s need great hip extension strength to improve their efficiency with swing though, promoting greater knee flexion angles, ultimately promoting improvements in speed


Pogos are a great way to promote stiffness through the gastrocnemius/soleus complex as well as the Achilles tendon, which is an often culprit of pain for runner’s.


Lateral bounding helps the runner improve propulsion in the frontal plane. You may think that because running is a sagittal sport, you should only train in the sagittal plane. However, it is still beneficial to work on running-based exercises in all planes of motion! 


A great exercise to work on power through the legs. You can even focus more on the power by working on continuous box jumps, as the runner gets back down from the box, they spring back up as quickly as possible, which promotes increases in type II muscle fiber recruitment.


This is a progression of the double leg box jump where the runner now works on power through one limb at a time! 




Closing Thoughts

In regards to runner’s knee, it is a complex diagnosis that is multifactorial. When first evaluating your runner, gather a detailed subjective that gives you a great background in regards to the runner’s history. When you first are starting rehab for your runner, ensure they are bought into the fact that he or she may not be able to run for a period of time to avoid further disruption at the knee! The progressive phases of rehab are focused not only on dynamic mobility initially, but largely focused on progressive strengthening, stability, and power-based exercises to not only promote increased stiffness of the tendons and other soft tissue but also improve the efficiency of the runner!



Sherif Elnaggar, PT, DPT, OCS

[P]Rehab Head of Content

sherif elnaggar the prehab guys

Sherif graduated from Temple University with a Bachelor’s of Science Degree and a concentration in Kinesiology. He then received his Doctorate of Physical Therapy Degree from DeSales University, graduating with honors of the professional excellence award and research excellence award. After his graduate studies, he served as Chief Resident of the St. Luke’s Orthopedic Physical Therapy Residency Program. Sherif is a Board Certified Orthopedic Clinical Specialist. Sherif focuses on understanding how movement impairments are affecting function while also promoting lifestyle changes in order to prevent recurrences of injury. His early treatment interests include running related injuries, adolescent sports rehab, and ACL rehab in lower extremity athletes. He also has been involved in performance training for youth soccer players. Outside of working as a physical therapist, he enjoys traveling, running and cycling, following Philadelphia sports teams, and spending time with his family.


Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.

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