If you run with poor technique or an injury which alters your posture and running gait, then you risk potentially damaging your knees due to stresses being put on the knees in a direction which they were not designed for. While the knee can cope with an awful lot, excessive miles with abnormal biomechanics over time may lead to damage.
Whether or not you will develop significant, symptomatic osteoarthritis (OA) in your knees has more to do with your genetics than how much you run. The truth is that we are all different. There’s no magic number for how many miles we can run and how much recovery we need, and there’s insufficient evidence to say that running will damage your knees. Remember: you are more likely to have problems with your knees if you are inactive than if you are a runner.
An interesting study done in 2019 took 82 middle-aged adults who were running their first marathon and scanned their knees six months before and two weeks after their marathon. During the four-month training programme 11 dropped out, but 71 went on to run their marathons. Six months before the marathon, most of them had some changes to their knee structures linked with the onset of osteoarthritis, even though they didn’t have any symptoms. After the marathon there was an improvement in some of these changes in the ends of the tibia and femur, and a worsening of the changes in the cartilage of the patella. Any worsening was still asymptomatic and we don’t know in the longer term whether these changes persisted or improved. Potentially, if we could counteract that patella damage in some way, perhaps with injury prevention exercises, then we could say that middle-aged runners who start running a marathon could protect their knees from future osteoarthritis.
Did you know?
There are over 206 bones in the adult body. Children have more, but many bones fuse together as they grow.
Q I’m overweight. Will running harm my joints?
A Running places much more impact onto a joint than walking. Joints are well-designed to carry load and absorb impact, but there does come a point at which excess weight will put strain on a joint and potentially lead to damage. Some exercise will always be better than no exercise and you are more likely to have joint problems if you are inactive. Being overweight doesn’t mean you shouldn’t run, but you do need to be careful, because it’s a high-impact activity and people who are overweight are at higher risk of osteoarthritis. Running can help you reach and maintain a healthy weight, if that’s your goal, but not every overweight person runs to lose weight and it’s important to acknowledge that. You do, however, need to take care of your joints to prevent damage and injury. You can do this by building up your distances gradually, and allowing rest and recovery time between runs to enable joint and muscle repair. Running with a good technique, and doing strength and conditioning exercises, is important too. Don’t ignore twinges. You are asking a lot of your body so become very self-aware, listen to it and take prompt action to avoid long-term problems.
Q I’ve got some osteoarthritis in my knees. Am I OK to keep running?
A Being told you have osteoarthritis (OA) by your doctor can be very upsetting, particularly if you are a runner, but it may not be as bad as you think. First of all, it’s important to know that what is seen on an x-ray may not correlate with what you feel. You can have quite significant pain from your knees and have an almost normal x-ray. Conversely, you can have marked arthritic changes on your x-ray and not experience any pain from your knees at all. How your knees actually feel is more important and doctors won’t usually order an x-ray when they suspect OA, because it can be unhelpful.
OA used to be called the ‘wear and tear’ arthritis, but this implies someone has worn out their joints through being active. Really it should be called the ‘wear and repair’ arthritis, because your joint is changing and adapting in order to keep it mobile and flexible. The worst thing you can do if you have OA is to avoid using your joint through fear of wearing it out further.
There’s good evidence that exercise should be used as a treatment for OA. Resistance exercises are particularly helpful for reducing pain and stiffness, and a training plan containing flexibility and aerobic exercise, as well as strength work, is most likely to improve pain and maintain function in the knee. All exercises need to be done consistently and regularly or the effect will wear off. Physical activity can work as well as, and in some cases better than, pain medications in OA, and is clearly a safer and better long-term option.
Exercise is definitely essential for your future joint health, but how your OA is going to affect your running depends on the severity of your condition and the degree of pain that you have. This is a very individual thing and you will need to discuss it with your doctor. If you have severe OA with little or no meniscus left (the menisci are the shock-absorbing pads in the knee joint) then effectively you have bone on bone contact and running may not be advised. If, however, you have mild disease with few symptoms then running, alongside lots of strength and flexibility work, may be a good way forward for you. Consider including some low-impact cross training such as cycling or swimming into your training plan, running off road when you can to reduce impact and adding in some extra recovery days. Be guided by any pain or swelling and increase or decrease your activities accordingly. Don’t immediately despair. With advice, trial and error and determination, a diagnosis of OA doesn’t always mean the end of your running career.
Real-life runners
When the surgeon told me I must not try to run again after a knee replacement, I didn’t disobey, I just sort of forgot. After three years of cautious build-up, I was winning my age-group again. Now, two and a half years after the other knee was replaced, I’m back to age-graded 80 per cent. It takes care, patience and a touch of stubbornness, but at 80 I’m a runner again. And the latest medical research agrees with me.
Roger Robinson, former England and New Zealand international, author of When Running Made History and winner of an award from the American Academy of Orthopaedic Surgeons for his writing about running on knee replacements
Did you know?
Osteoarthritis is the most common form of arthritis. It affects around 8.5 million people in the UK and is one of the leading causes of pain and disability worldwide.
Q Will running help prevent osteoporosis?
A Weight-bearing exercises such as running are perfect for strengthening bones, because the jolt on impact with the ground stimulates bone production. Bones are constantly being made by cells called osteoblasts and broken down by osteoclasts, so we need to make sure that the formation exceeds the destruction in order to maintain our bone mass. Exercise is an ideal way to do this and as well as weight-bearing exercise, muscle-strengthening exercises will improve bone health too. When you’re using a muscle against resistance such as with a weight or resistance band, the tendon, which attaches the muscle to bone, tugs on the bone, which stimulates bone formation.
Osteoporosis is a condition that affects approximately one in three women and one in 12 men. When bone destruction exceeds bone formation, then bone mass reduces. Reduced bone mass is called osteopenia and, when it falls below a certain level, osteoporosis is diagnosed. The bones are weaker, more fragile and prone to fracture with minimal or no trauma. Common bones to break include the wrist, spine and hips, and all can have significant consequences on an individual’s life and future, including the possibility of long-term pain and reduced mobility, so we need to do all we can to prevent osteoporosis.
Q Is it OK to run if I have osteoporosis?
A Running is a great impact activity for maintaining bone mass, but if you have established osteoporosis then you will need to get individual advice from your doctor. Most people will be able to carry on running. Exercise is an important part of your treatment and by exercising more you may actually see an improvement in your bone mass. Occasionally, if you have more advanced disease, particularly in your spine, then your doctor may feel the risks of running outweigh the benefits and you will have to adapt what you do. There’s a great factsheet on exercising with osteoporosis ava
ilable online from the Royal Osteoporosis Society. It explains how important exercise is if you have osteoporosis and gives good advice about exercising safely.
Did you know?
By the age of 18 you will have 90 per cent of your bone mass. It reaches its peak strength around 30 with men reaching a higher bone mass than women. Bone mass then gradually declines as you age, with a sharp drop in women around the time of the menopause. Women tend to lose bone from a younger age and at a faster rate than men.
Q What are shin splints?
A The answer to this isn’t as straightforward as you may think, because we don’t actually know! Some runners, particularly beginners and those who have rapidly increased their mileage, develop pain and tenderness in the shin area on the front of their lower legs. Shin splints are also called medial tibial stress syndrome. The tibia is the name of the larger of the two bones in the lower leg and the medial side is the inner part where the pain is most often felt. The condition seems to result from an increase in stress in this area, but there’s confusion as to the cause, with some believing it results from tiny amounts of bleeding between the periosteum (the outer layer of bone) and where the muscles attach. Some studies using scans have found no actual changes to the bones or tendons that explain the symptoms of pain and tenderness. It certainly seems to be an over-use injury that starts gradually, is worse when running and is eased by rest.
While we may not fully understand the causes of the pain, there are certain factors that seem to make people more likely to get shin splints, and these can be addressed to help prevent them occurring and enhance recovery. People who are overweight are more at risk due to the increased load on the lower legs. Beginners are particularly vulnerable too, especially if they increase distance rapidly without allowing sufficient time for the lower leg muscles to adapt. If you’ve had shin splints before then you’re more at risk of getting them again and women are affected more than men. These two factors may well be linked to biomechanics and it seems that weaknesses or imbalances in the hip and core muscles may have a role to play. Interestingly, there’s also some evidence from a small study in high school athletes that running with a lower cadence (slow step rate) might put you at higher risk of shin splints than running with a higher cadence.
Q I’ve got shin splints. How long should I rest for?
A Rest is important and you need to wait until you are pain free with no tenderness on pressing your shins, and no pain on walking and jumping, before you begin to run again. You can apply ice to your shins (see here) and take pain killers such as paracetamol or ibuprofen if you need to. It will probably take between two to four weeks for the pain to go. During that time it’s thought to be OK to exercise if what you’re doing isn’t causing you pain. Cycling and swimming are ideal things to try.
If you think your shin splints were just due to increasing your distance too rapidly then you can manage your own gradual return to running. However, if you have had shin splints before or you think there may be an underlying cause, such as your running gait, then it would be advisable to seek an assessment from a physiotherapist with expertise in running. They will be able to look at the bigger picture, spot weaknesses that may be triggering your shin pain and devise a recovery programme for you. They may recommend that you are fitted with orthotics for your shoes to correct pronation of your feet as this can be a cause for some people, but it’s a little controversial as to how big an issue this is.
Returning to running gradually and slowly increasing the load on your tibia is the key. It’s a good idea to start on softer ground, such as grass, and consider doing some of your runs every week off-road in the future. Strengthening your calf muscles may reduce the recurrence of shin splints. Calf raises while holding weights in your hands is a simple exercise you can do at home.
Be guided by pain. Don’t try to run through it. If it’s flaring up again, then return to your cross training and try again after another period of rest. If it’s recurrent, then seek an expert opinion to look for an underlying cause and to rule out a stress fracture.
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Healthy bones
It’s vital to take steps to maintain your bone mass, particularly if you are a women around menopausal age. Here are some simple things you can do to maximise your bone health:
• Run regularly. Weight-bearing exercise will strengthen bones.
• Add muscle-strengthening to your training plan. This helps to stimulate bone growth too.
• Stop smoking. Smokers have a higher risk of osteoporosis.
• Cut down on alcohol. People who drink a lot of alcohol have a higher risk of osteoporosis. Stick to a maximum of 14 units per week.
• Eat a healthy diet to give you all the vitamins and minerals needed for bone health. Include calcium rich foods such as dairy products, green leafy vegetables and almonds.
• Consider taking a Vitamin D supplement. We get most of our vitamin D from sunlight and it can be hard to get enough from our diet, so you may want to consider taking a daily 10 microgram supplement, especially in the winter months.
Q How do I know if I’ve got a stress fracture?
A Repeated over-use and overloading of bone can sometimes lead to stress fractures where bone has literally cracked from overwork. They account for 15 to 20 per cent of musculoskeletal injuries in runners and are most common in feet, shins, knees, hips and the pelvis. Women are affected more than men and if you have had a stress fracture before, or have osteoporosis, then you are at a higher risk of having one.
The pain from a stress fracture tends to come on suddenly, in contrast to the more gradual onset of shin splints pain. It will get worse when you run, whereas many musculoskeletal conditions seem to loosen up and ease once you’re running. It also tends to hurt when you aren’t running and pain at rest is a red flag that there’s something significant going on. Another red flag is that you can identify a point where the bone is tender. Shin splints tend to give a diffuse area of tenderness, but you can literally ‘put your finger on it’ with a stress fracture. You might also notice some swelling at the site of the tenderness or further down your leg.
Like shin splints, stress fractures tend to occur when people over do it, running long distances frequently, often without adequate recovery time. Whether certain running styles, such as heel striking or forefoot landing, put you at more risk is open for debate and needs more research. Similarly, it’s not possible to say whether cushioning in shoes is definitely protective either.
Stress fractures don’t always show up on an x-ray so may require more detailed scans, such as CT, MRI or bone scans. If a fracture is confirmed, then rest is essential. It will usually take around eight weeks for it to heal up. Going back to running too soon can cause more damage and lead to a more prolonged time off. Cross training that doesn’t trigger pain is allowed, so you can still maintain your fitness, but do check with your doctor what is suitable for you and when. A gradual return to running is essential and it’s advisable to see a physiotherapist for a biomechanical assessment, strength exercises and a graded return to exercise.
Knees
Q What is runner’s knee?
A Rather than being a single diagnosis, runner’s knee is the term given to a variety of conditions that cause pain in the knees of runners. You may hear it called patellofemoral pain syndrome (PFPS). It tends to affect beginner runners or those who are increasing their distance and frequency of running. The pain is felt in, behind or around the knee cap (patella) and is often worse when running downhill or squatting. Despite the location of the pain, the problem isn’t usually from the knee itself. Hip, thigh, calf, foot and even core muscle weaknesses, tightness and imbalances all affect the alignment and function of the knee, and can result in knee pain. For example, if you are sedentary for large parts of your day then you will probably have weak glute muscles, which can result in the knees moving towards a knock-knee position when you run. This is particularly true for women. A weak core
and poor stabilisation of your pelvis can lead to your hip dropping when you land, which puts an uneven stress on your knee too.
Treatment initially focuses on letting the acute pain settle and then correcting the underlying problem. You may need a physiotherapist assessment to instruct you. Working on core strength, and hip and leg muscle strength, is vital. Try exercises such as squats, glute bridges and clam shells, (see figure below) either with or without a resistance band.
If the issue is more to do with your foot mechanics, then get fitted for running shoes in a specialist store with a video analysis of your gait. Runner’s knee can be overcome, but it may take some determination to solve it. Don’t give up, though, and keep doing your strength exercises as part of a weekly schedule to stop it recurring.
Feet and ankles
Q I get pins and needles in my feet when I run long distances and they sometimes go completely numb. Why is that and how can I stop it?
A Pins and needles and foot numbness, either whole or partial, are surprisingly common complaints. Thankfully, the cause isn’t usually anything to worry about, but it’s a very odd sensation when you’re running and can’t feel your foot. The first thing to consider is how your shoes are laced. Tight lacing will stop your foot moving in your shoe and help prevent blisters (see here), but it can cause problems. Superficial skin nerves easily become compressed, resulting in tingling and numbness, particularly when feet swell on long distances. It may simply be a case of loosening your laces slightly or investigating different lacing techniques.
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