Can running cause knee injuries in individuals with or without a history of knee problems, such as osteoarthritis?

Can Running Injure Your Knees?

No, running does not inherently injure knees in healthy individuals and may actually be protective against knee osteoarthritis, but improper training progression and biomechanical errors significantly increase injury risk. 1, 2

Evidence on Running and Knee Health

Running Does Not Cause Osteoarthritis

• Runners demonstrate lower rates of symptomatic knee osteoarthritis compared to non-runners, with adjusted odds ratios of 0.64 for current runners versus those who never ran 2
• A systematic review of 7,194 runners found significantly higher prevalence of knee pain in non-runners (P < 0.0001), with no significant differences in radiographic knee OA or cartilage thickness between runners and non-runners 1
• Non-runners had a significantly higher risk of knee OA progressing to total knee replacement (4.6% vs 2.6%; P = 0.014) compared to runners 1
• In individuals without pre-existing OA, running does not appear detrimental to the knees 2

When Running Does Cause Knee Injuries

Training errors account for two-thirds of all running injuries, with rapid transitions in training being the primary culprit 3, 4

High-Risk Training Behaviors:

• Rapid mileage increases that violate conservative progression principles contribute to the highest injury rates 5, 6
• Approximately one-third of serious runners will incur an injury annually, with one-third of those injuries involving the knee 3
• Prior bone stress injury increases recurrence risk sixfold in females and sevenfold in males, highlighting the importance of proper rehabilitation 5, 6

Biomechanical Risk Factors:

• Excessive hip adduction during running gait is a predictor of tibial bone stress injuries in female runners 7, 6
• Reduced lower extremity muscle strength removes the protective shock-attenuation mechanism that normally reduces loads on the knee 7, 6
• Poor core and proximal strength leads to suboptimal lower extremity biomechanics that overload knee structures 7, 6
• Increased rearfoot eversion angles contribute to abnormal loading patterns 7

Sex-Specific Considerations

• Female athletes experience 1.7-2.2 times higher injury rates than males performing identical training in military studies 5
• Females demonstrate higher tibial bone stresses across all running speeds and benefit from more conservative progression 7, 6
• Low energy availability and amenorrhea in females result in 4.5-fold higher rates of musculoskeletal injuries 7, 8, 6
• Low testosterone in males similarly increases injury risk 4.5-fold 7, 8

Critical Training Parameters to Prevent Injury

Progression Guidelines:

• Progress mileage by no more than 10% weekly, though this rule lacks strong evidence and individual tolerance varies 5, 6
• Increase distance before speed or intensity in all return-to-running protocols 5, 6
• Train on alternate days initially to allow tissue mechanosensitivity recovery and adaptation 5, 8
• Include rest days during progression to prevent cumulative microtrauma 5

Strength Training Requirements:

• Address reduced lower extremity muscle size and strength through resistance training, which shows positive effects on bone strength particularly in female runners 6
• Implement core and proximal strength training to optimize lower extremity biomechanics and control excessive hip adduction 7, 8, 6
• Combine eccentric and plyometric exercises for superior functional outcomes compared to either method alone 8

Gait Modification:

• Running gait analysis and retraining address root causes of knee injuries 6
• Reducing stride length or increasing cadence reduces tibial stress 6

Common Pitfalls to Avoid

• Ignoring training errors: Two-thirds of injuries stem from improper training progression, particularly rapid transitions 3, 4
• Relying on external supports alone: Taping or bracing without addressing underlying biomechanical issues leads to recurrence 6
• Returning to running too quickly: This contributes to the exceptionally high recurrence rate of running-related injuries 5, 6
• Overlooking sex-specific needs: Females require more conservative progression due to higher tibial bone stresses 7, 6
• Neglecting strength training: Reduced muscle strength removes protective mechanisms against knee injury 7, 6

Public Perception Versus Evidence

• 86% of healthcare professionals perceive regular running as healthy for knees, compared to only 68% of the general public 9
• The general public incorrectly believes running frequently (29%), long distances (54%), and on hard surfaces (60%) increases KOA risk more than healthcare professionals recognize 9
• Most healthcare professionals recommend modifying training parameters rather than quitting running for those with existing knee OA 9