Why Your Knee Hurts When You Run And Why It Keeps Coming Back​

 

 

By Dr. Kendall Christensen, DO, CAQSM

 

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Dr. Christensen is a sports medicine specialist who has spent over a decade treating arthritis, joint pain, and sports injuries, with a focus on identifying what’s actually driving the pain. He uses precise, ultrasound-guided regenerative treatments to help patients improve without surgery or relying on steroids.

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I remember a patient that came to me when she was about to give up on her first half-marathon. She had been building her mileage when she developed knee pain that got worse every time she ran.

 

She cut her mileage down but it was still there, and she couldn't increase it without the pain worsening again. She iced it, took NSAIDs, saw her primary care doctor, her orthopedist, and went to PT for months but nothing was making it better other than rest. She was at the point where she either needed to increase her mileage or give up on the race.

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I've seen many patients in this situation, some with deadlines and others without, but so many had already seen their doctor, their orthopedist, done months of PT, and just weren't getting better. 

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The problem, in her case and most others, was that everyone was focused on the knee when the issue was coming from somewhere else. And just like her, most of them can continue to train at some level while we work on fixing the actual problem.

 

 

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The Knee Is Usually Not the Problem

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This is the thing that surprises most of my patients, especially younger runners: in active people building mileage, knee pain is rarely just a knee problem. The knee is where you feel it, but it's often not where it starts.

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When I evaluate a runner with knee pain I always evaluate their hips and feet. Specifically, I'm looking at the glute medius and glute minimus which are a very common driver of knee pain, especially when you are ramping up the mileage or adding elevation. These are two relatively small muscles on the side of the hip that play an enormous role in controlling how your leg moves through every stride. When they're weak or not firing properly, your femur (your thigh bone) rotates inward slightly with each step. That subtle rotation changes the mechanics of your entire lower leg, and the stress lands on your knee.

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Do that ten thousand times on a long run and you understand why the knee hurts.

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As runners age, true joint changes like early osteoarthritis can become part of the picture. But even then, the kinetic chain is almost always a contributing driver, meaning that addressing the hip and foot mechanics still matters, regardless of what's happening inside the joint.

The IT band gets blamed constantly for lateral knee pain, and it's not entirely wrong. The IT band is often tight, irritated and tender. But IT band issues are just another symptom of the real underlying cause. It gets irritated because the muscles that feed it are trying to pick up the slack for a glute medius and minimus that aren't doing their job. Foam rolling may provide temporary relief but it doesn't change the underlying mechanics driving the problem, and most people aren't targeting all the right structures anyway. When the IT band is irritated, the glutes are almost always a major part of the problem. That’s where much of the treatment needs to be focused.

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But It's Not Always the Hip

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I don't want to oversimplify this, because the kinetic chain runs in both directions. While the hip is the most common driver of knee pain in runners, the foot and ankle matter just as much.

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A dropped arch changes how force travels up the leg. An ankle that rolls inward, even subtly, creates rotational stress that accumulates at the knee over miles. Worn-out shoes that no longer provide the support they once did can turn a healthy runner into an injured one almost overnight.

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This is why I always evaluate the full chain (foot, ankle, knee, hip, and even the lower back) rather than just treating the painful spot. A runner who has been told they have IT band syndrome and has done months of hip strengthening without improvement often has a foot mechanics component that nobody looked at. Or vice versa.

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The point isn't that the diagnosis is wrong. IT band syndrome, patellofemoral pain, runner's knee — these are real conditions. The point is that the diagnosis describes where the pain is, not why it's there. And if you only treat where the pain is, you'll be treating it forever. Constantly chasing symptoms without addressing the underlying cause accelerates wear on the knee and surrounding structures. What starts as a mechanical problem can become a structural one if it's ignored long enough.

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What I Actually Do Differently

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I take time to watch you move, assess your strength and mobility through the full kinetic chain, and understand your training history, your footwear, your goals, and what you've already tried. By the time we're done I have a clear picture of not just what hurts but why, and that drives everything about the treatment plan.

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For most runners, correcting the mechanical drivers is the foundation. That means targeted work on glute activation and strength, addressing foot mechanics if needed, and in some cases a footwear or orthotic change. This isn't revolutionary but it has to be done right. I also use focused shockwave therapy and Class IV laser as part of most treatment plans to accelerate healing and address pain without masking it. Both can help calm down irritated tissue and get you back to running sooner.

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For more advanced cases involving osteoarthritis, glute tendinopathy, or longstanding issues, it may be necessary to directly address the tissue damage that has accumulated. That's where regenerative medicine comes in. Depending on what I find, I may recommend PRP (platelet-rich plasma), which uses your own blood's healing factors to stimulate tissue repair in damaged tendons, ligaments, or the joint itself. For more significant degeneration, MFAT (micro-fragmented adipose tissue, derived from a small amount of your own fat) provides a powerful regenerative signal that can address damage that PRP alone won't fully resolve.

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No steroids. No surgery referrals unless surgery is genuinely the right answer, which is less often than you might think. No pain medication to cover up a signal your body is sending for a reason.

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A Note on Cortisone and Steroid Injections

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This is vitally important to understand, and most runners that have seen someone before me have either already had a cortisone shot or been offered one.

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Corticosteroid injections are one of the most commonly used treatments in orthopedic and sports medicine. They reduce inflammation quickly and can provide meaningful short-term pain relief, but they often damage the tissue they are meant to treat.

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There is growing evidence that corticosteroids can negatively affect cartilage, tendon, and other soft tissues, particularly with higher doses or repeated use. These effects may persist for weeks to months, which is one reason many surgeons avoid operating within a few months of a steroid injection. A single corticosteroid injection has been shown to reduce cartilage thickness in the treated joint. It weakens tendon tissue, not just with repeated injections, but potentially after one. Tendon rupture is a documented complication. And when steroids are taken orally or absorbed systemically, which happens more than most patients realize, the effects extend beyond the injection site.

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This includes a serious condition called osteonecrosis, where bone tissue dies due to disrupted blood supply, sometimes leading to joint collapse and replacement surgery. While osteonecrosis is an uncommon complication, steroids are used often enough that I have seen this about 1-2 times per year in my clinic, including young patients who are far too young to need a joint replacement.

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I understand why it gets offered and why patients accept it, but you may be robbing Peter to pay Paul. You may be sacrificing the long-term health of your joint or tendon for the short-term benefit of pain relief.

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I go into much more detail on this in our ReForge Reveals article on steroids. I'd encourage you to read it before accepting a cortisone injection for any injury.

 

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What to Do Right Now

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If you're dealing with knee pain as a runner, here are the most important things you can do before you come see me or anyone else:

Check your mileage on your shoes. Most shoes only last 300 to 500 miles, which comes fast when you are training for marathon distances. If you are approaching that threshold and developing pain, try changing your shoes before anything else.

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Make sure your shoes match your mechanics. Go to a running specialty store, not a big box retailer. Have someone watch you walk and run. They may be able to help you determine whether you need a stability shoe or an orthotic.

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Address your glutes. Clamshells, side-lying hip abduction, and single-leg work. Glute weakness is almost always part of the picture and you can start on it today.

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Foam rolling the IT band alone is not enough. Rolling the IT band by itself is unlikely to get you far and is realistically affecting the lateral quad more than anything else. To actually address the muscle tension pulling on the IT band and patella you need to roll the IT band, lateral quad, glute max, and TFL together. Done thoroughly, that can temporarily improve the mechanics contributing to your pain and may reduce some of the cumulative stress on the tissue.

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Don't accept cortisone as a first-line treatment. Ask what's driving the pain. Ask what the injection will do to address that driver. If you can't get a clear answer, you deserve a second opinion.

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And if you’ve already tried conservative treatments and still can’t run without pain, you’re exactly who ReForge Health was built to help.

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