Knee Pain: A Muscle Imbalance or Something More Serious


Just about every one who runs has experienced knee pain at one time or another. Whether it’s a mild discomfort, tolerable tightness, or a debilitating sharp pain that sidelines your training, knee pain is frustrating to deal with.

Why Knee Pain Occurs

With all the “parts” associated with knees— cartilage, menisci, patella, ligaments, muscles, tendons and the connective tissue that helps hold it all together— there is a lot of potential for something to go wrong. Most runners accept this risk and even expect that something will eventually start hurting. 

Experiencing knee pain, however, should not mean your running days are over. In fact, the majority of knee pain that occurs with running (and has no associated swelling) has more to do with a muscle imbalance than damage to the knee itself.

YES, there is hope for your knee; and no, you don’t need a knee replacement.

Imbalance puts excessive tension on the patella tendon or more commonly on a structure called the iliotibial (IT) band. The IT band spans from the hip to the knee along the outside of your thigh and causes excessive friction near the knee if it’s too tight. In addition to IT band friction syndrome, other common diagnoses for knee pain caused by muscle imbalances in runners are patella tendonitis and patella-femoral malalignment.


Most commonly, the majority of knee pain in runners results from the hip moving in a poor alignment pattern, which leads to discomfort or pain.


Here’s an analogy to help explain this better:

When a car has poor front end alignment, the tires begin to wear improperly. There is nothing wrong with the tires initially— the problem begins with the parts that are supposed to hold the tires in the proper alignment. If left unattended, the tires will wear beyond use and need to be replaced. 

Strengthening our hips is the equivalent to having our car realigned. If left unattended, knee pain will either cause the person to stop running or lead to actual damage to the knees. If your knee develops associated swelling in or around the joint, the muscle imbalance has progressed enough to cause irritation and in severe situations cause the patella to dislocate, in which case you should seek help from a physical therapist to correct it.

With a muscle imbalance, either the muscles are activated or recruited improperly (i.e. some muscles (quads) are overpowering other muscles (glutes)). Anyone who has a job that requires them to sit in a chair for the majority of the day (students included!) is at higher risk of developing this imbalance because the glutes are completely at rest while we sit. Sitting also stretches the glutes and shortens the hip flexors (front top of our thighs) further contributing to the imbalance.


Assessing an Imbalance


One way to assess an imbalance is when sitting in your chair at work, look at where your knees are in relation to your feet. 

Are they closer together than your feet? If so, your hips are in a position called hip internal rotation. One major role of the glutes is to externally rotate our hips. Keep your feet planted on the ground and move your knees away from each other and out over your toes.  Adjusting your position this way uses your glutes to do it. You may feel the arches in your feet rise up too.

Another way to assess your hip and knee alignment is to stand in front of a mirror wearing shorts or roll your pants up so you can see your knees. Notice which way your knee caps are facing, straight ahead or slightly toward the middle? 

Now, strongly tighten your glutes (aka: your butt muscles).  Hold for a second or two, then relax and closely watch your knees. 

Repeat. You should see your knees slightly rotating out as you tighten the muscles. If your knees are properly aligned, your kneecaps should be facing directly forward, which happens when you tighten your glutes. 

This self-assessment exercise allows you to see the correlation of hips, knees, and feet: movement at one end of the chain (hip), can positively or negatively affect something at the other end (knee, arch, low back, etc). By increasing glute strength, we don’t have to consciously think about using the glute muscles, and the alignment is maintained.


So, when is knee pain not from a muscle imbalance and, therefore, more serious? The following are reasons to suspect actual damage to the knee:

  • A sudden onset of a sharp pain. These kinds of injuries usually result from twisting, falling, almost falling, or jumping.
  • Any knee movement that feels like “something is in the way” and prevents full bending and/or straightening your knee. Knees should always move freely through their full range of motion.
  • Any noise (“pop” or “crack”) that is painful. Noisy knees without pain are common.
  • Your knee feels like it won’t hold you up, or other types of instability.

The best general advice for runners in regards to fixing/preventing knee issues is to strengthen your glutes. Exercises that focus on the glutes when done consistently will help prevent, decrease, or put an end to running-induced knee pain. 

There is a laundry list of exercises out there to help develop glute strength. The top exercises are lunges, hip extensions, squats, step-ups and bridging. Be wary of exercises with “dynamic,” “swinging,” “plyometric,” or “explosive” in their title. These exercises work, but are more advanced and have a higher possibility of injury if performed incorrectly. These types of exercises should be done under the watchful eye of a certified personal trainer or physical therapist to ensure safety and proper form.

Strength training takes 5 to 6 weeks of consistent work to have a positive effect on knee pain.  With physical therapy intervention, a decrease in knee pain can happen as early as 2 weeks.  Remember, knee pain from running does not need to end your running career.

Running is supposed to be fun; it helps clear our minds, build endurance, bond with others, and connect us with nature. A little time spent keeping yourself balanced will help prevent knee pain and allow you to enjoy the benefits of running.